Every finding on record at Cypress at Lake Providence

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 6 (#5, #43, #52, #54, #55, #62) of 7 residents sampled for environment. The facility failed to ensure:1. Resident #5's bathroom sink was maintained in good repair2. Resident #43's room walls were free of holes;3. Resident #52's geri chair was clean and in good repair;4. Resident #54's air conditioner unit was clean; 5. Resident #55's electrical outlets were intact;6. Resident #62's floor was free of tearing and toilet seat in good repair.Findings: Resident #43 Observations on 07/13/2026 at 11:30 a.m. and 07/14/2026 at 8:50 a.m. of Resident #43's room revealed a large hole in the drywall behind the bedframe at the resident's head of bed. Resident #52 Observations of Resident #52's geri chair on 07/13/2026 at 9:10 a.m. and 07/14/2026 at 9:30 a.m. revealed Resident #52 was observed up in a geri chair in the hall with a cracked armrest on the left side. A brown substance was observed on the left side of the geri chair. Resident #54 Observations on 07/13/2026 at 11:15 a.m. and 07/14/2026 at 9:25 a.m. of Resident #54's room revealed the air conditioner vent had a buildup of a black grimy substance. Resident #55 Observations on 07/13/2026 at 11:15 a.m. and 07/14/2026 at 9:35 a.m. of Resident #55's room revealed a broken electrical outlet plate was observed on the wall right next to the resident's bed. Resident #62 Observations on 07/13/2026 at 9:00 a.m. and 07/14/2026 at 9:30 a.m. of Resident #62's bathroom revealed a large tear in the vinyl flooring in the bathroom near the shower, another smaller tear in the vinyl flooring by the entrance to the bathroom, and the toilet seat was not firmly affixed to the toilet. Observations on 07/14/2026 at 3:15 p.m. with S1Administrator revealed the following: Resident #43's room revealed a large hole in the drywall behind the head of the bed; Resident #52's armrest on left side of her geri chair was cracked and open the length of the armrest, and the left side of the geri chair was dirty with brown spots observed; Resident #54's room revealed a buildup of a black grimy substance observed in the air conditioner vent; and Resident #55's room revealed an electrical outlet plate was broken on the wall right next to the resident's bed; and Resident #62's room revealed a large tear in the vinyl flooring near the shower in the bathroom, a smaller tear noted at the entrance into the resident's bathroom, and the toilet seat was not secured to the toilet. An interview with S1Administrator at this time confirmed that all of these issues were observed and needed to be repaired. Resident #5 On 07/13/2026 at 9:35 a.m. and 07/14/2026 at 8:40 a.m., observations of Resident #5's bathroom sink revealed the sink to have an approximate 1 inch gap from the wall and was sagging on the left side. Further observation revealed the sink was attached loosely to the wall and moved when slight pressure was applied. On 07/14/2026 at 3:05 p.m., an observation conducted with S1 Administrator confirmed Resident #5's bathroom sink was not securely attached to the wall and in need of repair.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible by allowing cats to remain in the facility courtyard, resulting in residents sustaining scratches. Findings:On 07/13/2026 at 10:30 a.m., during a Resident Council meeting with a surveyor present, several residents voiced concerns regarding the large number of cats in the courtyard. Residents reported the cats would jump on them, causing scratches, and would defecate in the courtyard.On 07/13/2026 at 11:20 a.m., an interview with Resident #16 revealed he had been scratched on multiple occasions by cats in the facility courtyard. He reported S1Administrator had been stating for several months that the cats would be removed.On 07/13/2026 at 12:00 p.m., observation of the facility courtyard revealed 18 cats in the area.On 07/13/2026 at 2:50 p.m., an interview with a resident who wished to remain anonymous revealed she had been scratched by a cat approximately six weeks earlier. She reported S1Administrator had been stating for at least two months that the cats would be removed.On 07/13/2026 at 3:00 p.m., an interview with a resident who wished to remain anonymous revealed he had been scratched by a cat the previous week. Observation of his right forearm revealed what appeared to be scratches. He reported S1Administrator had been stating for months that the cats would be removed.On 07/13/2026 at 3:20 p.m., an interview with S4LPN revealed Resident #48 reported being scratched by a cat in the courtyard a few weeks earlier. S4LPN reported treating the scratches and completing an incident report. Review of the incident report for Resident #48 revealed that on 06/25/2026, the resident approached the nurses' station and stated a cat had scratched her. The incident report documented that the wound was treated and that the scratches were located on the fingers of the resident's right hand.Review of the Resident Council meeting minutes dated 07/08/2026 revealed that removal of the cats was identified as an area of concern.On 07/14/2026 at 3:00 p.m., interview with S1Administrator confirmed he was aware the cats were a problem that needed to be addressed.

Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment by failing to ensure: 1. The air conditioner in the laundry room was properly working;2. The sinks in the laundry area were in working order;3. The laundry building's interior walls were intact and free of holes;4. Chemical containers and boxes were not stored on the floor and;5. The area behind the washing machines were free of dirt and grime. Findings:On 07/14/2026 at 3:05 p.m., a tour of the facility's laundry room revealed the room to be warm. Interview with S13 Laundry Aide revealed the air conditioning in the laundry building cannot be operated when the dryers are running due to a breaker tripping when both are operated. Observation of a plug the air conditioning unit plugs into revealed the plug to have brown discoloration and appeared slightly charred around prong insertion holes. Further observations of the laundry building revealed the sinks did not operate when faucets were opened, chemicals and boxes were stored directly on the floor, holes in the wall paneling, and dirt/grime behind the washing machines. On 07/14/2026 at 3:10 p.m., observations of the laundry building with S1 Administrator and S8 Clinical Operations confirmed the air conditioning, sinks, and walls were in need of repair. S1 Administrator and S8 Clinical operations also confirmed the chemical containers and boxes should be stored off of the floor and area behind the washing machines were in need of cleaning.

Based on interview and record review, the facility failed to ensure each resident was informed of the risks and benefits of medications by failing to obtain informed consent for psychotropic medications for 1 (#7) of 5 sampled residents reviewed for unnecessary medications. Findings:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and insomnia.Review of the July 2026 physician's orders revealed Resident #7 was prescribed Olanzapine (antipsychotic), Trazodone (antidepressant) , and Clonazepam (benzodiazepine).Review of the electronic health record revealed there was no documented evidence that informed consents had been obtained for these psychotropic medications.On 07/15/2026 at 9:00 a.m., an interview with S8Clinical Operations confirmed there was no documented evidence that informed consents had been obtained for these three psychotropic medications.

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications by failing to monitor for edema and bleeding precautions for 1 (#16) of 5 residents reviewed for unnecessary medications. Findings:Review of the medical record for Resident #16 revealed he was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and localized edema.Review of the July 2026 physician's orders revealed Resident #16 received Eliquis (anticoagulant) and Bumex (diuretic).Review of the electronic health record revealed there was no documentation that Resident #16 was monitored for bleeding precautions or edema.On 07/14/2026 at 1:25 p.m., an interview with S8Clinical Operations confirmed that Resident #16 was not monitored by staff for bleeding precautions or edema.

Based on observations, record reviews, and interviews, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for the residents needs for 2 (#3 and #50) of 2 sampled residents. The facility failed to 1) obtain orders for PICC line care for Resident #3, and 2) provide and document PICC line site care including dressing changes for Resident #3 and #50. Findings: Resident #3 Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease, bladder neck obstruction, urinary tract infection, and schizophrenia. Review of Resident #3's significant change MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of Resident #3's active July 2026 physician's orders revealed no orders for PICC line care or management. Review of Resident #3's active plan of care revealed the resident has a PICC line for IV therapy to right arm and is at risk for complications such as infection, occlusion, or dislodgement. Further review of the plan of care revealed staff should perform dressing changes per facility protocol (commonly every 7 days or if soiled/loose). On 07/13/2026 at 10:00 a.m. and 07/14/2026 at 8:25 a.m., observations of Resident #3 revealed he had a PICC line in his right upper arm with a dressing dated 07/01/2026. On 07/14/2026 at 1:50 p.m., interview with S6LPN confirmed there were no orders in the electronic medical records for Resident #3's PICC line care or maintenance. Review of June and July 2026 MAR and TAR for Resident #3 revealed no documented evidence that PICC line care was provided including dressing changes. On 07/14/2026 at 1:56 p.m., interview with S8Clinical Operations confirmed Resident #3 had no active orders for PICC line care and maintenance and no documented evidence of PICC line site care was provided including dressing changes. Resident #50 Review of the record for Resident #50 revealed an admission date of 06/05/2026 with diagnoses including methicillin resistant staphylococcus aureus, pain in left knee, and arthritis due to other bacteria unspecified joint. Review of Resident #50's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Review of the July 2026 physician orders for Resident #50 revealed the following: Change PICC line caps and dressing, measure, and document PICC line from gray hub to skin and arm circumference three centimeters above the insertion site as needed every day shift every 7 day(s) for PICC line. This order was written on admission on [DATE]. Review of the care plan for Resident #50 revealed to ensure that the PICC insertion site remains clean, dry, and intact. Further review of the care plan revealed to assess insertion site every shift for redness, swelling, drainage, or tenderness, observe dressing every shift and change dressing and record observations site. Review of the June 2026 TAR for Resident #50 revealed no documentation that PICC line caps and dressing were changed. Further review revealed no documentation on treatment record that dressing was changed in July 2026. Observation on 07/13/2026 at 9:34 a.m. revealed Resident #50 was sitting up in a wheelchair in his room. Further observation revealed antibiotic intravenous therapy in progress via PICC line in right upper arm. The dressing covering the PICC line was dirty and no date of when last changed. Interview with resident #50 at this time revealed that the dressing has never been changed since he has been admitted . Interview with S6LPN on 07/13/2026 at 9:40 a.m. revealed that she cannot change the PICC line dressing and that S3ADON was responsible for changing the PICC line dressing for Resident #50. S6LPN confirmed that the PICC line dressing was not dated and in need of being changed for Resident #50. Interview with S3ADON on 07/14/2026 at 3:30 p.m. revealed that she changed Resident #50's PICC line dressing on 07/14/2026 and confirmed that the dressing she removed was dirty and not dated. Further interview with S3ADON revealed that she had not changed Resident #50 PICC dressing prior to today. S3ADON confirmed that the physician orders for Resident #50 are to change PICC line dressing every 7 days and as needed. S3ADON confirmed that no documented evidence that PICC line dressing was changed for Resident #50 since he was admitted on [DATE].

Based on observation, record review, and interview, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for 2 (#16 and #34) of 2 residents reviewed for respiratory care. The facility failed to ensure: 1) Resident #16's respiratory equipment was stored appropriately, and 2) Resident #34 received oxygen at the prescribed flow rate. Findings: Review of the facility's Respiratory Equipment Management Policy dated 05/2026 revealed, in part, under Section 5. Storage: Respiratory equipment should be stored in a clean, dry manner consistent with infection prevention practices. Resident #16 Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with a diagnosis of COPD. On 07/13/2026, observation of Resident #16's room revealed a nebulizer mask was stored inside a drawer. The mask was not stored in a bag, and there was no date documented on the mask or tubing. On 07/13/2026 at 11:21 a.m., an interview with S4LPN, confirmed the nebulizer mask was not stored appropriately. S4LPN reported that weekend staff were responsible for changing the tubing weekly on Sundays and dating the storage bag. On 07/14/2026 at 2:15 p.m., an interview with S2DON, confirmed the nebulizer mask for Resident #16 should have been stored in a plastic bag and that the bag should have been labeled with the date. Resident # 34 Review of medical records for Resident #34 revealed an admission date of 10/12/2023 with diagnoses including chronic obstructive pulmonary disease, pulmonary fibrosis, chronic kidney disease stage 4 (severe), and shortness of breath. Review of the current physician's orders dated 05/18/2026 revealed Resident #34 had an order for O2 at 2 liters per nasal cannula Q HS. Review of the current plan of care revealed Resident #34 was receiving oxygen therapy related to chronic obstructive pulmonary disease. On 07/13/2026 at 9:30 a.m., 07/14/2026 at 8:38 a.m., and 07/15/2026 at 9:29 a.m., observations of Resident #34 revealed the resident was sleeping in his bed. Further observations on these dates revealed Resident #34 was wearing his nasal cannula and his oxygen flow rate was set to 4 liters per minute. On 07/15/2026 at 9:30 a.m., observation conducted with S12LPN confirmed Resident #34 had his oxygen flow rate set to 4 liters per minute and the flow rate should be at 2 liters per minute per the physician orders. On 07/15/2026 at 9:45 a.m., S2DON and S8Clinical Operations were informed Resident #34's oxygen had not been set to the ordered rate of flow.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (#43) of 1 resident sampled for pressure ulcers.Findings: Review of the facility's Pressure Injury Prevention and Management policy and procedure, revised 06/2026, revealed the following, in part:Policy Explanation and Compliance Guidelines:c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented.d. Assessments of pressure injuries will be performed by a licensed nurse and documented in the EMR. The staging of pressure injuries will be clearly identified. Review of Resident #43's record revealed an admission date of 03/20/2025 with diagnoses including unspecified injury to Lumbar1 level of lumbar spinal cord, paraplegia, pressure ulcer of sacral region stage four, pressure ulcer right buttock stage four, and acquired absence of left leg and right leg below knee.Review of Resident #43's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Further review of the MDS revealed resident had two pressure ulcers.Review of the July 2026 Physician's Orders revealed an order dated 04/14/2026 for wound care to sacrum/buttock and right ischium/buttock daily and as needed. Review of the resident's current care plan revealed pressure ulcers to right ischium and gluteal cleft. Further review of the care plan revealed the following Interventions were included -Monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration to the doctor; and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.Review of the record revealed weekly wound assessments were not documented for two weeks during June 2026 for Resident #43's pressure ulcers. An interview on 07/15/2026 at 8:00 a.m. with S8Clinical Operations revealed that Resident #43's pressure ulcers should have wound assessments completed weekly. Interview on 07/15/2026 at 9:35 a.m. with S8Clinical Operations confirmed the facility failed to complete weekly wound assessments on Resident #43's pressure ulcers for two weeks during June 2026.

Based on interview and record review, the facility failed to ensure MDS assessments were completed and transmitted to the state in a timely manner for 1 (#35) of 1 resident reviewed for resident assessments.Findings:Review of the medical record revealed Resident #35 was admitted to the facility on [DATE].Review of the progress notes dated 04/19/2026 revealed the resident left the facility and was admitted to the hospital.Review of Resident #35's MDS assessments revealed there was no discharge MDS assessment completed and submitted.On 07/15/2026 at 9:10 a.m., an interview with S10Regional MDS Coordinator confirmed the facility failed to complete and submit a discharge MDS assessment for Resident #35 in a timely manner (within seven days) to the state.

Based on interviews and record reviews, the facility failed to ensure residents were free from chemical restraints for 1 (#16) of 5 sampled residents reviewed for unnecessary medications. The facility failed to monitor for side effects and behaviors for Resident #16 who received psychotropic medications.Findings:Resident #16Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and depression.Review of the July 2026 physician's orders revealed Resident #16 was prescribed Quetiapine (antipsychotic) and Duloxetine (antidepressant).Review of the electronic health record revealed there was no documentation that Resident #16 was monitored for potential side effects and behaviors while taking antipsychotic and antidepressant medications.On 07/14/2026 at 1:25 p.m., an interview with S8Clinical Operations confirmed there was no documentation that staff were monitoring Resident #16 for potential side effects and behaviors.

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#25) of 1 sampled residents observed for medications available at the bedside. Findings: Self-Administration of Medication Policy dated 06/2026:Policy StatementResidents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy interpretation and Implementation1. If a resident voices or informs staff they wish to self-administer their medications, the resident will be assessed to determine whether self-administering medications is safe and clinically appropriate for the resident.2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident:a. The medication is appropriate for self-administration;b. The resident is able to read and understand the medication labels;c. The resident can follow directions and tell them when to take or administer to self the medication;d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects, and when to report these to the staff;e. The resident has the physical capacity to open the medication bottles, remove medications from a container and to ingest, swallow, (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with exacerbation, other seasonal allergic rhinitis, mild cognitive impairment of uncertain or unknown etiology, and tobacco use.Review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS score of 15 indicating Resident #25 was cognitively intact.Review of Resident #25's active physician's orders revealed an orders dated 10/09/2025 for albuterol Sulfate HFA aerosol solution 108 (90 base) mcg/act inhale 90 mcg orally every 4 hours as needed wheezing and symbicort inhalation aerosol 160-4.5 mcg/act 2 puffs inhale orally two times a day. Further review revealed an active physician order dated 05/26/2026 for ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml give 1 inhalation by mouth every 6 hours for shortness of breath. Physician's orders revealed these medications were ordered as self-administered.On 07/13/2026 at 9:10 a.m. and 07/14/2026 at 8:35 a.m., an albuterol sulfate inhaler and Breyna inhaler was observed in Resident #25's room next to his bed. Further observation revealed albuterol/atrovent nebulizers were in Resident #25's closet. Resident #25 stated he keeps the medications in his room and self-administers the medications.On 07/14/2026 at 1:10 p.m., an interview with S6LPN revealed Resident #25 self-administers his inhalers and nebulizers and lets staff know when he takes the medications for documentation in the medical records.On 07/14/2026 at 3:45 p.m., interview with S2DON confirmed Resident #25 did not have an assessment to determine if the Resident was safely able to self-administer the medications.

Based on record review, and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (#24) of 1 sampled residents reviewed for dignity. The facility failed to ensure that residents wore incontinence briefs that were properly fitted.Findings:Review of the record for Resident #24 revealed a [AGE] year old female with an admission date of 01/29/2016 with diagnoses of morbid obesity, urinary tract infection, and rash. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated the resident was cognitively intact for daily decision making. Further review of the MDS for Resident #24 revealed resident is always incontinent of bowel and bladder. Interview with resident #24 on 07/13/2026 9:23 a.m. revealed resident to be alert to person, place, time, and situation. Further interview revealed that staff sometimes have put incontinent briefs on her that are too small instead of the correct size. Resident #24 reported that the smaller brief is uncomfortable and irritates her skin. Resident #24 stated that the smaller brief also do not absorb as much urine and leak out onto her bed which causes an odor and upsets her. Resident #24 stated aides tell her they are out of the larger briefs that fit her so they have to use the smaller ones. Interview with S7 CNA, on 07/13/2026 at 10:00 a.m. revealed that she provided incontinent care for Resident #24. She reported that facility sometimes runs out of the large incontinent briefs and have to use a smaller brief on Resident #24. She stated that Resident #24 has complained that the brief is too tight and irritates her skin when they have to use them. She further stated that she has reported this to CNA supervisor. Interview with S9 CNA, on 07/14/2026 at 1:00 p.m. revealed that she frequently takes care of Resident #24 and has assists her with incontinent care. Further interview revealed Resident #24 required a larger brief and that sometimes the larger briefs are not available so staff has to use smaller briefs that are tight on resident. S9 CNA reported Resident #24 has complained to her of the small brief irritating her and leaking. S9 CNA stated she reports to CNA supervisor when they do not have enough of the larger briefs. Interview with S5 Wound Care Nurse, on 07/14/2026 at 3:00 p.m. revealed she is responsible for ordering briefs for the facility. She reported that she orders bariatric size briefs plus regular size briefs. S5 Wound Care Nurse reported facility runs out of the bariatric (large) briefs at times and reordering can sometimes be delayed. She reported that she is aware of residents having to wear briefs that do not properly fit but was not been made aware specifically of Resident #24. Interview with S3 ADON (CNA Supervisor) on 07/14/2026 at 3:30 p.m. confirmed that facility does sometimes run out of the large, bariatric briefs due to an ordering delay. S3 ADON confirmed S5 Wound Care Nurse is responsible for ordering incontinent briefs. S3 ADON stated was unaware Resident #24 had reported a problem with incontinence briefs. Interview with S2 DON on 07/15/2026 at 11:30 a.m. confirmed that she is aware of bariatric sized incontinent briefs are sometimes not available for residents due to an ordering issue. S2 DON reported she was unaware that Resident #24 reported a problem with incontinence briefs.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#2 and #3) of 3 sampled residents reviewed for environmental concerns. The facility failed to ensure: 1) Resident #2's bed frame, bed rails, over-bed table, air conditioner, and nightstand were kept clean and in good repair; and 2) Resident #3's bed frame, bed rails, over-bed table, and floor were kept clean and in good repair. Findings:Resident #2 Review of Resident #2's record revealed an admit date of 10/31/2024 with diagnoses including schizoaffective disorder, legal blindness, type 2 diabetes mellitus, peripheral vascular disease, seizures, and depression. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 which indicated no cognitive impairment. On 03/11/2026 at 9:50 a.m., dirt and grime were observed on Resident #2's bed frame, bed rails, over bed table frame, and top of her nightstand. Further observation also revealed the top drawer was missing from the night stand and a white powdery substance covered the air conditioner vent. On 03/11/2026 at 10:15 a.m., an observation conducted with S1Administrator confirmed Resident #2's bed frame, bed rails, over bed table frame, and night stand were dirty and stained. Further observation with S1Administrator also confirmed that Resident #2's top drawer was missing from the nightstand and the resident's air conditioner vent was covered with a powdery white substance. Resident #3 Review of Resident #3's record revealed an admit date of 12/10/2018 with diagnoses that included paraplegia, generalized muscle weakness, hypertensive heart disease with heart failure, and multiple myeloma not having achieved remission. Further review of records revealed a quarterly MDS assessment dated [DATE] documented Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment with daily decision making. On 03/11/2026 at 9:00 a.m., dirt and stains were observed on Resident #3's bed frame, bed rails, over bed table frame, and floor. Further observation revealed exposed particle board on the over-bed table with broken and missing veneer. On 03/11/2026 at 10:20 a.m., observation conducted with S1Administrator confirmed Resident #3's: 1) bed frame, bed rails, over-bed table frame, and floor were dirty and stained; and 2) over-bed table contained exposed particle board due to broken and missing veneer.

Based on interviews, observations, and record reviews, the facility failed to ensure Residents remained as free of accident hazards as possible for 2 (#13 and #61) of 4 (#13, #19, #61 and #62) Residents reviewed for accidents. The facility failed to ensure: 1) an appropriate intervention was attempted after each fall for Resident #61, and 2) new interventions were attempted after each fall for Resident #13 and #61. Findings: Review of the facility's Accident Hazards/Supervision/Devices policy dated 03/2023 revealed in part: Purpose: To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents. Policy: The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to Residents to avoid preventable accidents. 5. Facility data will be used to aid in identification of potential hazards, risks and solutions. 10. Interventions will be based on the results of the evaluation and analysis of information related to hazards and risks. Interventions will be consistent with professional standards. 13. Monitoring and modification process may include: a. Verifying that interventions are implemented as planned; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed, and; d. Evaluating the effectiveness of new interventions. Resident #61 Review of Resident #61's record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Further review of the MDS revealed the Resident required assistance with activities of daily living. Section J of the MDS revealed no falls documented for Resident #61. Review of the facility's incident/accident log revealed falls for Resident #61 on 04/22/2025, 04/23/2025, 05/13/2025, and 05/18/2025. Review of Resident #61's Incident and Accident reports revealed the following: 04/22/2025- staff were walking by Resident's room and heard something hit the floor and saw Resident #61 fall on her bottom with no injuries; 04/23/2025- nurse received report from certified nursing aide (CNA) that the resident lost her balance and hit her head on the door frame, and the CNA caught the resident before she fell , was going to bathroom and lost her balance, no injuries; 05/13/2025- nurse was notified by CNA that Resident #61 had slid out of her wheelchair onto the floor, no injuries; and 05/18/2025- Resident was found on the floor, resident had rolled out of the bed, no injuries. Review of Resident #61's current care plan revealed Resident #61 had actual falls with unsteady gait. Further review of the care plan revealed Resident #61 had a fall on 04/22/2025, 04/23/2025, 05/13/2025, and 05/18/2025. Review of the interventions for the fall on 04/22/2025 revealed staff education to ensure Resident's wheelchair is within reach. Review of the interventions for the fall on 04/23/2025 revealed to remind Resident to call for assistance with any transfers or getting from one place to the other. Falls on 05/13/2025 and 05/18/2025 were not added to the fall care plan. An interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) confirmed the intervention (reminding the Resident to call for assist with transfers or getting from one place to another) for Resident #61's fall on 04/23/2025 was not appropriate due to resident's cognition. S2DON confirmed that the facility failed to identify and implement interventions for Resident #61's falls on 05/13/2025 and 05/18/2025. 18118 Resident #13 Review of the medical record for Resident #13 revealed an admitted [DATE]. Resident #13 had diagnoses including heart disease, chronic obstructive pulmonary disease (COPD), depressive disorder, diabetes mellitus, paranoid schizophrenia, muscle wasting, cognitive communication deficit, and moderate intellectual disabilities. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 14 which indicated the resident had intact cognition for daily decision making and required partial to moderate assistance with toileting and bathing. Review of the Fall Risk assessment dated [DATE] revealed Resident #13 was at risk for falls. Review of the Incident/Accident report dated 04/22/2025 at 9:10 a.m. revealed Resident #13 was found sitting on the floor in front of his wheelchair alert and oriented. Review of the current care plan revealed the Resident had limited physical mobility. Further review of the care plan revealed the fall on 04/22/2025 was not addressed on the care plan. Review of the medical record revealed no documented evidence of an intervention attempted after Resident #13 was found on the floor on 04/22/2025. On 05/21/2025 at 11:55 a.m. S2DON confirmed no new interventions were attempted after Resident #13 had a fall on 04/22/2025 and also confirmed the fall on 04/22/2025 was not addressed on the care plan.

Based on observations, interviews and record reviews, the facility failed to ensure Residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene by failing for provide adequate bathing and nail care for 4 (#27, #3, #40, #52) of 4 (#27, #3, #40, #52) Residents reviewed for activities of daily living. Findings: Resident #52 Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease and major depression. Review of the 02/24/2025 Minimum Data Set (MDS) assessment revealed Resident #52 had a Brief Interview for Mental Status Score (BIMS) of 14 indicating he was cognitively intact. The MDS assessment also indicated Resident #52 needed assistance with personal hygiene. On 05/19/2025 at 10:17 a.m., observation and interview of Resident #52 revealed he had long dirty fingernails that were in need of care. Resident #52 reported he had asked staff to trim his fingernails recently. On 05/20/2025 at 1:10 p.m., interview with S4Licensed Practical Nurse (LPN) revealed resident #52 was a good historian and would tell the truth when recollecting. At that time S4LPN observed the fingernails of resident #52 and confirmed the fingernails were long and dirty and needed to be trimmed and cleaned. 41829 Resident #27 Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses that included morbid (severe) obesity, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, primary pulmonary hypertension, and shortness of breath, atrial fibrillation, generalized muscle weakness, muscle wasting and atrophy multiple sites, and abnormalities of gait and mobility. On 05/19/2025 at 8:30 a.m., an interview with Resident #27 revealed she did not receive a bed bath on Friday (05/16/2025). Resident #27 reported she was to receive bed baths on Monday, Wednesday, and Friday. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #27 was cognitively intact. Further review revealed Resident #27 required substantial/maximal assistance with toileting, shower/bathe, dressing, bed mobility, and personal hygiene. Review of care plan revealed Resident #27 had an Activities of Daily Living (ADL) self-care deficit. An intervention listed was to provide bed bath on scheduled bath days with maximal assist x 2. Review of the April 2025 Documentation Survey Report v2 revealed Resident #27 was to receive a shower/bath on Monday, Wednesday, and Friday. Further review revealed documentation Resident #27 only received shower/bathe on 04/07/2025. Review of the May 2025 Documentation Survey Report v2 revealed Resident #27 was to receive Shower/bathe on Monday, Wednesday, and Friday. Further review revealed documentation Resident #27 only received shower/bathe on 05/05/2025, 05/12/2025, and 05/19/2025. On 05/20/2025 at 3:22 p.m., an interview with S17LPN revealed she was never notified by any of the aides that Resident #27 had refused a bed bath. On 05/21/2025 at 12:15 p.m., surveyor informed S2Director of Nursing (DON) that Resident #27 reported she did not receive a bed bath on Friday (05/16/2025). S2DON confirmed there was no documentation that Resident #27 received a bed bath on Friday (05/16/2025). Resident #40 Record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #40 diagnoses included unspecified dementia, generalized anxiety disorder, schizoaffective disorder, muscle wasting and atrophy multiple sites, generalized muscle weakness, lack of coordination, and abnormalities of gait and mobility. Review of quarterly MDS assessment dated [DATE] revealed BIMS score of 8 which indicated Resident #40 was moderately cognitively impaired. Further review revealed Resident #40 required substantial/maximal assistance with personal hygiene, dressing upper and lower body, shower/bathe, and toileting. Review of the care plan revealed Resident #40 had an ADL self-care deficit. An intervention listed was maximal assistance x1 with personal hygiene. On 05/19/2025 at 10:28 a.m. and 05/20/2025 at 10:10 a.m., observations of Resident #40 revealed fingernails on both hands were very long. On 05/21/2025 at 9:15 a.m., an observation conducted with S2DON in Resident #40's room revealed Resident #40's fingernails on both hands were very long. S2DON confirmed Resident #40's fingernails were long and needed to be trimmed. 52271 Resident #3 Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, psychosis, schizophrenia, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #3 was cognitively intact. The MDS also indicated that Resident #3 required substantial/maximal assistance with personal hygiene. On 05/19/2025 at 1:35 p.m. it was noted that Resident #3 had lengthy facial hair below the nose and on the chin. On 05/20/2025 at 11:30 a.m., Resident #3 was observed in her room with lengthy facial hair below the nose and on the chin. On 05/20/2025 at 11:52 a.m. an interview with S5Certified Nursing Assistant (CNA) revealed that Resident #3 should receive baths on Monday, Wednesday, and Friday. Review of the April and May 2025 Documentation Survey Report v2 revealed Resident #3's bath days were scheduled for Tuesday, Thursday, and Saturday. Further review of the report revealed the only documentation of bathing was completed on 04/07/2025, 05/05/2025, and 05/19/2025 for the months of April and May 2025. On 05/21/2025 at 12:06 p.m., S2DON confirmed that Resident #3 did not have baths documented.

Based on interviews and record reviews, the facility failed to ensure the assessments accurately reflected the Residents' status by failing: 1. to ensure Minimum Data Set (MDS) assessments documented falls for Resident #61 and a pressure ulcer for Resident #35 and #62; 2. to ensure MDS assssment was accurate regarding falls for Resident #19; 3. to ensure risk assessments for skin were completed for Resident #35 quarterly; and 4. to ensure risk assessment for falls were completed for Resident #61 quarterly. Findings: Review of the facility's undated Skin and Wound Management Guidelines Policy and Procedure revealed the following, in part: Purpose: To provide guidance to prevent alteration in skin integrity, when possible; To identify and address risk factors for avoidable skin breakdown; To provide a process for managing pressure related and non-pressure related skin issues. Admission/Readmission 2. Wound Care Nurse b. Within 72 hours of admission, verify the Braden that was completed upon admission. Complete a Braden Scale Assessment quarterly. Resident #35 Review of the record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including other sequelae following unspecified cerebrovascular disease, other idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, major depressive disorder, aphasia, hypothyroidism, dementia in other disease classified elsewhere moderate with mood disturbance, anxiety disorder, unspecified psychosis, flaccid neuropathic bladder, mild cognitive impairment, hypertension, transient ischemic attack, and hyperlipidemia. Review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #35 required assistance with activities of daily living (ADLs). Review of the skin condition section of the MDS revealed Resident #35 had no risk of pressure ulcers and had no current pressure ulcers. Review of the record revealed Resident #35 had a stage 3 pressure ulcer to her rear left malleolus that was facility acquired on 07/25/2024. An interview on 05/20/2025 at 10:00 a.m. with S13Licensed Practical Nurse (LPN)/Treatment Nurse revealed Resident #35 had a stage 3 pressure ulcer to her rear left malleolus that was facility acquired on 07/25/2024. S13LPN/Treatment Nurse reported that Resident #35's pressure ulcer to left malleolus was healed on 05/19/2025. Review of Resident #35's last Braden scale for predicting Pressure Sore Risk for resident dated 09/04/2024 revealed a score of 18 indicating Resident #35 was at risk for pressure ulcers. No documented evidence of pressure sore risks assessments completed for Resident #35 since 09/04/2024. An interview on 05/21/2025 at 10:00 a.m. with S15LPN/Minimum Data Set (MDS) confirmed she did not mark Resident #35 as having a stage 3 pressure ulcer on the 04/28/2025 quarterly MDS. S15LPN/MDS reported she does not do the Braden scale risk assessments for the Residents but the hall nurse/treatment nurse does the Braden scale risk assessments quarterly. An interview on 05/21/2025 at 10:30 a.m. with S14Clinical Reimbursement Specialist confirmed Resident #35's last Braden Scale for predicting pressure sore risk was completed on 09/04/2024. S14Clinical Reimbursement Specialist confirmed the Braden scale for predicting pressure sore risk assessment should be done quarterly by the hall nurse or the treatment nurse. S14Clinical Reimbursement Specialist confirmed Resident #35's MDS from 04/28/2025 did not identify that Resident #35 had a stage 3 pressure ulcer resulting in inaccuracy of the MDS assessment completed by S15LPN/MDS. Interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) confirmed that Resident #35's quarterly MDS was inaccurate and failed to identify Resident's stage 3 pressure ulcer. S2DON confirmed the Braden scale for predicting pressure sore risk assessment was last completed on Resident #35 on 09/04/2024, and should be completed quarterly by the hall nurse or treatment nurse. Resident #61 Review of Resident #61's record revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living. Section J of the MDS revealed no falls documented for Resident #61. Review of the facility's incident/accident log revealed Resident #61 had falls on 04/22/2025 and 04/23/2025, which were prior to her quarterly MDS on 05/01/2025. An interview on 05/21/2025 at 10:00 a.m. with S15LPN/MDS confirmed Resident #61 had falls on 04/22/2025 and 04/23/2025. S15LPN/MDS confirmed she did not document falls on Resident #61's 05/01/2025 quarterly MDS. Review of Resident #61's last fall risk assessment was completed on 12/30/2024. An interview on 05/21/2025 at 10:30 a.m. with S14Clinical Reimbursement Specialist confirmed Resident #61 had falls on 04/22/2025 and 04/23/2025. S14Clinical Reimbursement Specialist confirmed that S15LPN/MDS failed to identify Resident 61's falls on the quarterly MDS on 05/01/2025, and confirmed the inaccuracy of the MDS. S14Clinical Reimbursement Specialist confirmed fall risk assessments should be completed quarterly, and confirmed Resident #61's last fall risk assessment was completed on 12/30/2024. An interview on 05/21/2025 at 11:45 a.m. with S2DON confirmed S15LPN/MDS failed to identify falls on Resident #61 on the quarterly MDS dated [DATE]. S2DON confirmed the last fall risk assessment on Resident #61 was on 12/30/2024. S2DON confirmed the facility failed to complete the fall risk assessment quarterly for Resident #61. 18118 Resident #19 Review of the medical record for Resident #19 revealed an admitted [DATE]. Resident #19 had diagnoses including hypertensive heart disease, pain, dysphagia, anxiety, depressive disorder, moderate intellectual disabilities and psychosis. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 which indicated Resident #19 had severe cognitive impairment for daily decision making and required assistance with activities of daily living (ADL). Further review of the MDS revealed the number of falls since admission or prior assessment with no injury - 2 or more and the number of falls since admission or prior assessment with injury (except major) - none Review of the Incident/Accident report dated 04/19/2025 at 9:05 a.m. revealed a Certified Nursing Assistant (CNA) reported to the nurse that the Resident was lying on the floor near his wheelchair face down. Nurse noted blood near resident. Laceration to right brow was cleansed with wound cleanser and bandaged. Review of the nurses notes dated 04/19/2025 revealed the Resident returned to the facility at approximately 1:20 p.m. via ambulance from the hospital. The Resident had 5 stitches to middle of his forehead. Review of the current care plan for Resident #19 revealed the Resident had an actual fall on 04/19/2025. On 05/21/2025 at 10:06 a.m. interview with S15LPN/MDS revealed the MDS should have had the number one on the MDS for injury (not major) when Resident #19 received stitches to his forehead on 04/19/2025. On 05/21/2025 at 11:15 a.m. S2DON was notified of the inaccurate assessment for falls on the MDS. 51983 Resident #62 Review of Resident #62's medical record revealed an admitted [DATE] and diagnoses which include in part: osteomyelitis, diffuse traumatic brain injury, unspecified intracranial brain injury with loss of consciousness, depression, nontraumatic subarachnoid hemorrhage, other reduced mobility, and encephalopathy. Review of quarterly MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 10 which indicated moderate cognitive impairment. Further review of section M of the MDS assessment reveals that Resident #62 did not have a pressure ulcer/injury over a bony prominence and no unhealed pressure ulcers/injuries. On 05/19/2025 at 7:45 a.m., interview with Resident #62 revealed that he had a wound on his right hip. On 05/20/2025 at 10:12 a.m., Resident #62 observed laying in his bed on his left side watching television. A dressing dated 05/19/2025 was noted to his right hip. On 05/20/2025 at 3:24 p.m., interview with S13 LPN/Treatment Nurse revealed that an outpatient wound consultant currently comes to facility to treat Resident #62's right hip and sacral wounds every Monday and Thursday. On 05/20/2025 at 3:24 p.m., record review revealed Resident #62 had the pressure ulcers to his right hip and sacrum on admission. On 05/21/2025 at 10:00 a.m., an interview conducted with S15LPN/MDS confirmed that Resident #62 did not have an accurate MDS skin assessment on quarterly MDS assessment dated [DATE]. On 05/21/2025 at 10:21 a.m., interview with S2DON confirmed that Resident #62 did not have any wounds documented on the quarterly MDS assessment dated [DATE].

Based on observation and interview, the facility failed to ensure it posted the results of the most recent surveys of the facility by failing to post the results of 3 surveys that occurred after the facility's last annual survey on 05/08/2024. Findings: On 05/21/2025 at 11:35 a.m., observation of the facility posted surveys revealed the results of the annual survey dated 05/08/2024 were accessible to residents in a survey results binder. The facility was also surveyed on 09/26/2024 resulting in 2 deficiencies, on 04/01/2025 resulting in 2 deficiencies and on 04/23/2025 resulting in 3 deficiencies. The results of the 3 surveys were not posted. On 05/21/2025 at 1:45p.m., interview with S1Administrator confirmed the results of the 3 surveys conducted after the annual survey of 05/08/2025 were not posted.

Based on record reviews, and interviews the facility failed to ensure Residents were informed of the risks, benefits and side effects of an antipsychotic medication for 5 (#3, #32, #36, #61 and #63) of 5 (#3, #32, #36, #61 and #63) Residents reviewed for unnecessary medications. Findings: Resident #32 Review of the medical record for Resident #32 revealed he was admitted on [DATE] with diagnoses which included bipolar disorder and depression. Review of the physician orders revealed the Resident received the psychotropic medications Haldol and Seroquel for the treatment of bipolar disorder and Escitalopram for the treatment of depression. Review of the medical revealed there was no consent by the Resident for the psychotropic medications. On 05/20/2025 at 3:15 p.m., interview with S2Director of Nurses (DON) confirmed there were no consents for the psychotropic medications Haldol, Seroquel and Escitalopram. 18118 Resident #63 Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, depression, psychoactive substance induced psychotic disorder, hyperlipidemia, and hypertension. Review of the May 2025 physician orders revealed an order dated 01/03/2025 for Zyprexa (antipsychotic) 2.5 mg to be given at bedtime Review of the medical record for Resident #63 revealed no documented evidence of a psychoactive medication consent for the resident to receive Zyprexa. On 05/21/2025 at 12:00 p.m. interview with S7Regional Director of Clinical confirmed Resident #63 did not have a medication consent for Zyprexa. 43405 Resident #61 Review of the record for Resident #61 revealed an admitted [DATE] with diagnoses which included dementia with other behavioral disturbances. Review of the May 2025 Physician Orders revealed the following orders for psychotropic medications for Resident #61: 04/18/2025- Seroquel (antipsychotic) oral tablet 50 milligrams (mg) give 1 tab by mouth (po) in afternoon and Seroquel oral Tablet 50 mg give 1 tablet by mouth one time a day ; and 04/17/2025- Seroquel Oral Tablet 200 mg give 1 tablet by mouth at bed time, and Clonazepam (antianxiety) oral Tablet 0.5 mg give 1 tablet by mouth three times a day. Review of the record revealed no documented evidence of a pyschotropic medication consent for Resident #61 to receive Seroquel and Clonazepam. On 05/21/2025 at 1:40 p.m., interview with S7Regional Director of Clinical confirmed there were no consents for the use of psychotropic medications Seroquel and Clonazepam on Resident #61. 52271 Resident #3 Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, psychosis, schizophrenia, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #3 was cognitively intact. The MDS also indicated that Resident #3 was prescribed a/an: antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the May 2025 Medication Administration Record (MAR) revealed that Resident #3 received Divalproex for the treatment of schizophrenia, Clozapine for the treatment of psychosis, Mirtazapine for the treatment of depression, and Lorazepam for the treatment of restlessness/agitation. Review of the medical record revealed that there was no consent by Resident #3 for the psychotropic medications. On 05/21/2025 at 12:06 p.m., S7Regional Director of Clinical confirmed that there was no consent for the psychotropic medications: Divalproex, Clozapine, Mirtazapine, and Lorazepam. Resident #36 Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses that included Parkinson's disease, dysphagia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, and seizures. Review of the Medicare 5 day MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #36 was cognitively intact. The MDS also indicated that Resident #3 was prescribed a/an: antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the May 2025 MAR revealed that Resident #36 received Seroquel for the treatment of schizoaffective disorder, Sertraline for the treatment of bipolar disorder, Depakote for the treatment of schizoaffective disorder, Clonazepam for the treatment of generalized anxiety disorder, and Geodon for the treatment of mood. Review of the medical record revealed that there was no consent by Resident #36 for the psychotropic medications. On 05/21/2025 at 12:06 p.m., S7Regional Director of Clinical confirmed that there was no consent for the psychotropic medications: Seroquel, Sertraline, Depakote, Clonazepam, and Geodon.

Based on record review and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each Resident by having staff fail to follow physician orders for 1 (#32) of 5 (#32, #3, #36, #63, #61) reviewed for unnecessary medications. Findings: Review of the medical records revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of the physician orders revealed Resident #32 was to receive accu-checks four times daily. If the results were 401 or greater, staff were to administer 10 units of insulin and call the physician. Review of the accu-check results revealed the following: On 05/02/2025 at 10:00 a.m., Resident #32 had an accu-check of 434. There was no documentation that the physician was notified. On 05/03/2025 at 10:00 a.m., Resident #32 had an accu-check of 407. There was no documentation that the physician was notified. On 05/11/2025 at 10:00 a.m., Resident #32 had an accu-check of 455. There was no documentation that the physician was notified. On 05/16/2025 at 10:00 a.m., Resident #32 had an accu-check of 410. There was no documentation that the physician was notified. On 05/17/2025 at 10:00 a.m., Resident #32 had an accu-check of 423. There was no documentation that the physician was notified. On 05/20/2025 at 3:15 p.m., interview with S2Director of Nursing (DON) confirmed there was no documentation that the staff notified the physician when Resident #32 had an accu-check of 401 or greater.

Based on record reviews, observations, and interviews, the facility failed to: 1) assess Residents for risk of entrapment from bed rails prior to installation of bed rails, 2) obtain informed consent from the Resident or Resident's responsible party for bed rail use, 3) ensure a physician's order for bed rail use, and 4) ensure care plan reflected the use of bed rails for 3 (#8, #18, #321) of 3 (#8, #18, #321) Residents reviewed for bedrails. Findings: Review of the facility's Quality of Care Bedrails policy dated 03/20203 revealed: Purpose: To provide for resident safety if bed rails are used. Policy: The facility will attempt to use alternatives prior to installing a bed rail, including side rails, grab bars, and other assist rails. Prior to implementing a bed rail, the facility will assess the resident for entrapment, inform the resident and or representative of the risk and benefits of bed rails and obtain consent and verify that the bed is suited to the resident's size and weight. Manufacturer's recommendations will be followed when installing bed rails. Guidelines: 1. Prior to utilizing a bed rail, alternative measures will be attempted to meet the resident's needs and provide for his/her safety. 2. The resident will be assessed for risk of entrapment and possible benefits of bed rails, if it is determined that alternative measures are not effective. 3. The resident and/or representative will be informed of the risk and benefits of bed rails and informed consent will be obtained prior to instillation of bed rail. 4. Bed rails will be maintained and installed according to manufacturer recommendations. 5. Bed rails will be compatible with the bed frame and mattress in use by the resident. 6. Bed rails that are in use will be checked routinely to verify condition and installation security. 7. If a bed rail is implemented, the resident will re-assessed at routine intervals to verify the on-going need for the bed rail. 8. A bed rail will be used for the shortest time necessary to meet the needs of the resident. 9. Use of a bed rail will be reflected in the resident care plan. Resident #8 Record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #8's diagnoses included type 2 diabetes mellitus, generalized muscle weakness, hypertension, heart failure, chronic kidney disease, pain unspecified, and repeated falls. Review of active May 2025 Physician orders revealed there was no order for Resident #8 to have bilateral quarter bed rails. On 05/19/2025 at 9:40 a.m., 05/20/2025 at 9:00 a.m., and 05/21/2025 at 8:00 a.m., observations of Resident #8 revealed he was lying in bed with head of bed elevated up 15 degrees, quarter bed rails times 2 at the head of bed were in the upright position. Review of the care plan revealed Resident #8's plan of care did not include the use of bilateral quarter bed rails. Further record review revealed no documentation Resident #8 was assessed for the risk of entrapment from bed rails prior to the installation of bed rails or an informed consent was obtained for bed rails. On 05/21/2025 at 9:45 a.m. an interview with S7Regional Director of Clinical confirmed Resident #8 had not been assessed for bed rails, assessed for entrapment prior to the installation of bed rails, obtained an informed consent for bed rails, obtained an order for bed rails, or added bed rails to the care plan. Resident #18 Record review revealed Resident #18 was initially admitted to the facility 12/20/2023 and readmitted to the facility on [DATE]. Resident #18's diagnoses included acute necrotizing hemorrhagic encephalopathy, unspecified pain, paranoid schizophrenia, generalized anxiety disorder, generalized muscle weakness, seizures, and lack of coordination. Review of active May 2025 Physician orders revealed there was no order for Resident #18 to have quarter bed rail. Review of the care plan revealed Resident #18's plan of care did not include the use of a quarter bed rail. Further record review revealed no documentation Resident #18 was assessed for the risk of entrapment from bed rails prior to installation of bed rails or an informed consent obtained for bed rails. On 05/19/2025 at 10:45 a.m., an observation of Resident #18 revealed he was lying on his right side with right quarter bed rail in the upright position at the head of the bed, and left side of the bed was positioned next to the wall. On 05/21/2025 at 9:45 a.m. an interview with S7Regional Director of Clinical confirmed Resident #18 had not been assessed for bed rails, assessed for entrapment prior to the installation of bed rail, obtained an informed consent for bed rails, obtained an order for bed rails, or added bed rail to the care plan. 51983 Resident #321 Review of Resident #321's medical record revealed an admitted [DATE] with diagnosis which included in part: anemia, syncope and collapse, adult failure to thrive, and subluxation of cervical vertebrae. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #321 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #321 was cognitively intact. Further review of MDS revealed that Resident #321 was able to transfer self with standby assist. Observations on 05/19/2025 at 7:30 a.m., 05/20/2025 at 10:10 a.m., and 05/21/2025 at 8:12 a.m. of Resident #321's right upper quarter bedrail was observed on bed in the up position while the Resident was laying in it. On 05/20/2025 at 11:08 a.m., record review reveals that Resident #321's record did not have a physician's order for bed rail use, care plan, or bed rail assessment. On 05/21/2025 at 9:45 a.m., interview with S7Regional Director of Clinical confirmed that the facility did not assess Resident #321 for bed rails or risks of entrapment prior to the installation of bed rail. S7Regional Director of Clinical also confirmed that Resident #321 did not have a physician's order, consent, or care plans for bed rails.

Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to protect resident #1 from being sexually abused by resident #2. The facility failed to provide 1:1 (one to one) supervision to resident #2 after an allegation of sexual abuse. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2025 at 12:33 a.m. when resident #2 returned to the facility and was not monitored 1:1. Resident #1 alleged resident #2 entered her room and touched her breast on 03/14/2025 at 10:44 p.m. Resident #2 was removed from the facility by law enforcement and returned on 03/15/2025 at 12:33 a.m. Resident #2 was placed on 1:1 observation at that time. The facility failed to implement the 1:1 observation; therefore resident #2 entered resident #1's room a second time on 03/15/2025 at 4:47 a.m. and resident #1 alleged resident #2 touched her genitals over her underwear. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/26/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy on Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed the following: When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect resident from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. Review of the facility's One to One Resident Care Guidelines (undated) revealed the following: A resident that requires one to one care means that this resident must be visually monitored every minute of every day until it is identified by the management team that one to one is no longer necessary. This means you may not leave the resident unobserved for any length of time. Review of the medical record of resident #1 revealed she had an admitted [DATE]. Resident #1 had diagnoses which included hemiplegia to one side upper extremity, hemiparesis, aphasia, acute hepatitis C, history of a traumatic brain injury and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the medical record of resident #2 revealed he had an admitted [DATE]. Resident #2 had diagnoses which included Parkinson's, schizoaffective bipolar type, vascular dementia and insomnia. Review of the MDS dated [DATE] revealed he had BIMS score of 9 indicating moderate cognitive impairment. Review of the facility's investigation dated 03/14/2025 revealed on the night of 03/14/2025 at 10:50 p.m., resident #1 reported resident #2 entered her room and grabbed her breast. In the early morning hours of 03/15/2025, resident #1 reported resident #2 entered her room a second time and touched her genitals over her underwear. Review of the progress notes dated 03/14/2025 at 10:50 p.m. revealed S5Licensed Practical Nurse (LPN) documented that a staff member came to the desk and reported that resident #1 alleged resident #2 entered her room. When she sat up her breast fell out of her shirt. Resident #2 grabbed her breast and said he would like to suck on it. Resident #2 then left the room. Resident #1 activated the call light and when staff arrived she reported it to them. Review of the progress notes dated 03/14/2025 at 11:20 p.m. revealed resident #2 was escorted from the building by law enforcement. Review of the progress notes dated 03/15/2025 at 12:33 a.m. revealed resident #2 was returned to the facility by law enforcement. Review of the progress notes dated 03/15/2025 at 5:10 a.m. revealed S5LPN wrote a Certified Nurse Aid (CNA) told her that resident #1 alleged resident #2 entered her room a second time, but that she may have dreamt it. S5LPN spoke with S3CNA who had been assigned to monitor resident #2 one to one. S3CNA reported that resident #2 did not enter the room of resident #1 a second time. Review of the progress notes dated 03/16/2025 at 11:58 a.m. revealed S2Director of Nursing (DON) documented she was speaking with resident #1. Resident #1 reported to her that she initially thought she may have dreamt resident #2 entered her room a second time early in the morning of 03/15/2025, but it wasn't a dream. Resident #1 alleged resident #2 touched her panties at her groin. On 03/27/2025 at 2:50 p.m., interview with S3CNA revealed on 03/15/2025 after resident #2 was returned to the facility by the police, she was instructed to monitor resident #2 one to one by S2DON. S3CNA reported that while she was monitoring resident #2, she also responded to call lights on hall A. On 03/27/2025 at 3:30 p.m., interview with S5LPN revealed on 03/14/2025 shortly before 11:00 p.m., S6CNA approached the nurse's station and reported resident #1 alleged that resident #2 entered her room and grabbed her breast. She went to the resident's room, assessed resident #1, found no injury and resident #1 was not upset. S2DON and the police arrived shortly afterwards. The police escorted resident #2 from the facility. About 1-2 hours later the police returned resident #2 to the facility. After resident #2 returned, S3CNA was assigned to monitor the resident one to one. On the morning of 03/15/2025 around 5:00 a.m., S6CNA approached the nurse's station and reported that resident #1 alleged resident #2 entered her room a second time. The resident was assessed and no injuries were found. Resident #1 said she may have dreamed the incident. After leaving the resident's room, S5LPN asked S3CNA if resident #2 entered the room of resident #1 a second time. S3CNA told her resident #1 did not enter the room of resident #2 a second time. On 03/31/2025 at 12:00 p.m., interview with S1Administrator and S2DON revealed after resident #1 alleged resident #2 entered her room on 03/14/2025 and grabbed her breast, the police were called. When they arrived at the facility, resident #2 was arrested and escorted from the building. The police did not say that they would be returning the resident after processing. S2DON reported she was still in the building when resident #2 was returned by law enforcement. S2DON assigned S3CNA to monitor resident one to one for the remainder of the shift. S1Administrator and S2DON reported the investigation of the allegations indicated resident #2 did enter the room of resident #1 twice, once late in the night of 03/14/2025 and again early in the morning of 03/15/2025. They confirmed S3CNA did not monitor resident #2 one to one and failed to protect resident #1 from potential abuse. A review of the video footage was conducted. The following was observed: On 03/14/2025 at 10:44 p.m., resident #2 entered the room of resident #1. At 10:48 p.m., resident #2 exited the room. At 10:52 p.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. On 03/15/2025 at 4:47 a.m., resident #2 entered the room of resident #1. At 4:50 a.m., resident #2 exited the room of resident #1. At 4:54 a.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. Resident #2 was alone and there was no staff monitoring the resident one to one. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/18/2025: Corrective Action: 1) Full body assessment completed on the resident #1 on 03/14/2025. 2) Resident # 1 was offered to be evaluated at the emergency room and declined on 03/14/2025 3) Police notified and the accused resident #2 was taken into custody on 03/14/2025. 4) Accused resident #2 was placed on 1:1 upon return to facility on 03/15/2025. 5) DON/Designee has put daily monitors in place on 03/15/2025 for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited. 6) DON/Designee has in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbally returned demonstrations of types of abuse, signs and proper reporting procedures. 7) A Statewide Incident Management System (SIMS) report was initiated on 03/14/2025 Identification of others at risk: 1) All residents had the potential to be affected. 2) DON/Designee has interviewed all residents with a BIMs of 8 or greater -03/15/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 3) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings 03/15/2025. Systemic Change: 1) DON/Designee in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on the care expectations of a resident in 1:1 care, abuse, noting sexual and verbal abuse, the proper reporting procedure, and how to identify abuse and signs of abuse. Employees gave verbal return demonstrations of types of abuse, signs, and proper reporting procedures. Monitoring 1) The DON or designee will complete interviews with residents with a BIM score of 8 or greater weekly until they are compliant by 03/18/2025. 2) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings weekly until compliant-compliant 03/18/2025. 3) A regional team or corporate office nurse has been onsite since 03/17/2025 and will contact the facility daily for 2 weeks by phone or onsite to review audits and any new allegations of abuse. Then weekly for 1 month. The nurse(s) from the regional team or home office assist with investigations, observe the treatment of residents, perform chart audits, and provide oversight and consultation. 4) On 03/18/2025, the DON/Designee will perform walking rounds in which 10 residents (5 with BIMs >8 and 5 with BIMs <8) will be visited by the department head. Five residents will be interviewed regarding abuse for those who can be interviewed. At the same time, a skin check will be completed by a nurse for those residents unable to be interviewed to identify any abuse concerns for 2 weeks. This will then continue with 6 residents (3 with BIMs >8 and 3 with BIMs <8) daily for 4 weeks. Results from the resident interviews, assessments, and staff questionnaires will be reported to the QA committee weekly to assess the ongoing need for continued education or revisions to the plan. At that time, based on evaluations, the QA committee will determine the frequency at which resident interviews, assessments, and staff questionnaires should continue. Any concerns identified will be corrected immediately and reported to the administrator. 5) The Director of Nursing or a regional staff member will review all resident interviews and assessments daily for grievances/concerns. Starting on 03/15/2025, investigations will be initiated upon receipt. 6) The Director of Nursing and Administrator will review and discuss all resident-to-resident altercations daily, starting on 03/15/2025, to ensure that the resident is protected, the perpetrator is removed from the resident care area, reports to the Regulatory entities are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Regional [NAME] President, Director of Clinical Operations, Regional Controller and or Regional Nurse Consultant will review the investigation to ensure protection of the resident, that the perpetrator is removed from the resident care area that reports are filed timely, and a thorough investigation has been completed. This will occur daily for 2 weeks. After 2 weeks, it will be discussed in the Quality Assurance Performance Improvement committee meeting, at which time it will be determined at what frequency the audits need to continue. 7) The Regional Nurse Consultant, Regional Controller, or corporate staff member will complete administrative oversight of the facility daily for two weeks beginning 03/15/2025, then weekly for four weeks, then monthly. 8) A Quality Assurance meeting will be held weekly until immediacy is removed beginning on 03/18/2025, then for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A Quality Assurance meeting was held on 03/19/2025, and an action plan was formulated and implemented. On 03/26/2025, a second Quality Assurance meeting was held to review the current plan for any needed revisions, compliance, and/or further education. At that time, based upon evaluation, the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being, identify facility concerns, and implement a correction plan to involve all facility staff. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Regional Nurse of Clinical or a member of the regional staff daily until the removal of immediacy beginning 03/15/2025, then weekly for 4 weeks, then monthly.

Based on observation, interviews and record reviews, the facility failed to ensure it implemented written policies and procedures that prohibited the abuse of residents for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to implement their Abuse and One to One Monitoring policies. The facility failed to provide one to one (1:1) supervision to resident #2 after an allegation of sexual abuse. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2025 at 12:33 a.m. when resident #2 returned to the facility and was not monitored 1:1. Resident #1 alleged resident #2 entered her room and touched her breast on 03/14/2025 at 10:44 p.m. Resident #2 was removed from the facility by law enforcement and returned on 03/15/2025 at 12:33 a.m. Resident #2 was placed on 1:1 observation at that time. The facility failed to implement the one to one observation; therefore resident #2 entered resident #1's room a second time on 03/15/2025 at 4:47 a.m. and resident #1 alleged resident #2 touched her genitals over her underwear. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/26/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy on Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed the following: When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect resident from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. Review of the facility's One to One Resident Care Guidelines (undated) revealed the following: A resident that requires one to one care means that this resident must be visually monitored every minute of every day until it is identified by the management team that one to one is no longer necessary. This means you may not leave the resident unobserved for any length of time. Review of the medical record of resident #1 revealed she had an admitted [DATE]. Resident #1 had diagnoses which included hemiplegia to one side upper extremity, hemiparesis, aphasia, acute hepatitis C, history of a traumatic brain injury and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the medical record of resident #2 revealed he had an admitted [DATE]. Resident #2 had diagnoses which included Parkinson's, schizoaffective bipolar type, vascular dementia and insomnia. Review of the MDS dated [DATE] revealed he had BIMS score of 9 indicating moderate cognitive impairment. Review of the facility's investigation dated 03/14/2025 revealed on the night of 03/14/2025 at 10:50 p.m., resident #1 reported resident #2 entered her room and grabbed her breast. In the early morning hours of 03/15/2025 resident #1 reported resident #2 entered her room a second time and touched her genitals over her underwear. Review of the progress notes dated 03/14/2025 at 10:50 p.m. revealed S5Licensed Practical Nurse (LPN) documented that a staff member came to the desk and reported that resident #1 alleged resident #2 entered her room. When she sat up her breast fell out of her shirt. Resident #2 grabbed her breast and said he would like to suck on it. Resident #2 then left the room. Resident #1 activated the call light and when staff arrived she reported it to them. Review of the progress notes dated 03/14/2025 at 11:20 p.m revealed resident #2 was escorted from the building by law enforcement. Review of the progress notes dated 03/15/2025 at 12:33 a.m. revealed resident #2 was returned to the facility by law enforcement. Review of the progress notes dated 03/15/2025 at 5:10 a.m. revealed S5LPN wrote a Certified Nurse Aid (CNA) told her that resident #1 alleged resident #2 entered her room a second time, but that she may have dreamt it. S5LPN spoke with S3CNA who had been assigned to monitor resident #2 one to one. S3CNA reported that resident #2 did not enter the room of resident #1 a second time. Review of the progress notes dated 03/16/2025 at 11:58 a.m. revealed S2Director of Nursing (DON) documented she was speaking with resident #1. Resident #1 reported to her that she initially thought she may have dreamt resident #2 entered her room a second time early in the morning of 03/15/2025, but it wasn't a dream. Resident #1 alleged resident #2 touched her panties at her groin. On 03/27/2025 at 2:50 p.m., interview with S3CNA revealed on 03/15/2025 after resident #2 was returned to the facility by the police, she was instructed to monitor resident #2 one to one by S2DON. S3CNA reported that while she was monitoring resident #2 she also responded to call lights on hall A. On 03/27/2025 at 3:30 p.m., interview with S5LPN revealed that on 03/14/2025 shortly before 11:00 p.m., S6CNA approached the nurse's station and reported resident #1 alleged that resident #2 entered her room and grabbed her breast. She went to the resident's room, assessed resident #1, found no injury and resident #1 was not upset. S2DON and the police arrived shortly afterwards. The police escorted resident #2 from the facility. About 1-2 hours later the police returned resident #2 to the facility. After resident #2 returned, S3CNA was assigned to monitor the resident one to one. On the morning of 03/15/2025 around 5:00 a.m., S6CNA approached the nurse's station and reported that resident #1 alleged resident #2 entered her room a second time. The resident was assessed and no injuries were found. Resident #1 said she may have dreamed the incident. After leaving the resident's room, S5LPN asked S3CNA if resident #2 entered the room of resident #1 a second time. S3CNA told her resident #1 did not enter the room of resident #2 a second time. On 03/31/2025 at 12:00 p.m., interview with S1Administrator and S2DON revealed after resident #1 alleged the resident #2 entered her room on 03/14/2025 and grabbed her breast, the police were called. When they arrived at the facility, resident #2 was arrested and escorted from the building. The police did not say that they would be returning the resident after processing. S2DON reported she was still in the building when resident #2 was returned by law enforcement. S2DON assigned S3CNA to monitor resident one to one for the remainder of the shift. S1Administrator and S2DON reported the investigation of the allegations indicated resident #2 did enter the room of resident #1 twice, once late in the night of 03/14/2025 and again early in the morning of 03/15/2025. They confirmed S3CNA did not monitor resident #2 one to one and failed to protect resident #1 from potential abuse. A review of the video footage was conducted. The following was observed: On 03/14/2025 at 10:44 p.m., resident #2 entered the room of resident #1. At 10:48 p.m., resident #2 exited the room. At 10:52 p.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. On 03/15/2025 at 4:47 a.m., resident #2 entered the room of resident #1. At 4:50 a.m., resident #2 exited the room of resident #1. At 4:54 a.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. Resident #2 was alone and there was no staff monitoring the resident one to one. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/18/2025: Corrective Action 1) Resident #2 remained on 1:1 care and was sent to in-patient psych on 03/15/2025. 2) Resident #1 was offered to be evaluated at ER and declined on 03/15/2025 3) Police notified of the second occurrence on 3/15/2025. 4) Full body skin assessment of Resident #1 completed on 03/15/2025. 5) DON/Designee has put daily monitors in place on 03/15/2025 for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited 6) DON/Designee has in-serviced all employees and agency personnel starting on 03/15/2025 and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures. 7) Staff involved received disciplinary action 03/15/2025 and resigned from her position at the facility. Identification of others at risk 1) All residents had the potential to be affected 03/15/2025. 2) DON/Designee has interviewed all residents with a BIMs of 8 or greater 03/15/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 3) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings 03/15/2025. Systemic Changes 1) DON/Designee in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on the care expectations of a resident in 1:1 care, abuse, noting sexual and verbal abuse, the proper reporting procedure, and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs, and proper reporting procedures. 2) The Regional Director of Clinical (RDC) educated the DON and Administrator on the policies and procedures for Abuse, including immediate provisions to protect residents in abuse situations. This was completed on 03/16/2025. Monitoring: 1.) DON/designee to complete interviews with residents of a BIMs of 8 or greater and weekly until compliant 03/15/2025. 2) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings weekly until compliant. 3) A regional team or corporate office nurse has been onsite since 03/17/2025 and will contact the facility daily for 2 weeks by phone or onsite to review audits and any new allegations of abuse. Then weekly for 1 month. The nurse(s) from the regional team or home office assist with investigations, observe the treatment of residents, perform chart audits, and provide oversight and consultation. 4) On 03/18/2025, the DON/Designee will perform walking rounds in which 10 residents (5 with BIMs >8 and 5 with BIMs <8) will be visited by the department head. Five residents will be interviewed regarding abuse for those who can be interviewed. At the same time, a skin check will be completed by a nurse for those residents unable to be interviewed to identify any abuse concerns for 2 weeks. This will then continue with 6 residents (3 with BIMs >8 and 3 with BIMs <8) daily for 4 weeks. Results from the resident interviews, assessments, and staff questionnaires will be reported to the QA committee weekly to assess the ongoing need for continued education or revisions to the plan. At that time, based on evaluations, the QA committee will determine the frequency at which resident interviews, assessments, and staff questionnaires should continue. Any concerns identified will be corrected immediately and reported to the administrator. 5) The Director of Nursing or a regional staff member will review all resident interviews and assessments daily for grievances/concerns. Starting on 03/15/2025, investigations will be initiated upon receipt. 6) The Director of Nursing and Administrator will review and discuss all resident-to-resident altercations daily, starting on 03/15/2025, to ensure that the resident is protected, the perpetrator is removed from the resident care area, reports to the Regulatory entities are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Regional [NAME] President, Director of Clinical Operations, Regional Controller and or Regional Nurse Consultant will review the investigation to ensure protection of the resident, that the perpetrator is removed from the resident care area that reports are filed timely, and a thorough investigation has been completed. This will occur daily for 2 weeks. After 2 weeks, it will be discussed in the Quality Assurance Performance Improvement committee meeting, at which time it will be determined at what frequency the audits need to continue. 7) The Regional Nurse Consultant, Regional Controller, or corporate staff member will complete administrative oversight of the facility daily for two weeks beginning 03/15/2025, then weekly for four weeks, then monthly. 8) A Quality Assurance meeting will be held weekly until immediacy is removed beginning on 03/18/2025, then for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A Quality Assurance meeting was held on 03/19/2025, and an action plan was formulated and implemented. On 03/26/2025, a second quality assurance meeting was held to review the current plan for any needed revisions, compliance, and/or further education. At that time, based upon evaluation, the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being, identify facility concerns, and implement a correction plan to involve all facility staff. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Regional Nurse of Clinical or a member of the regional staff daily until the removal of immediacy beginning 03/15/2025, then weekly for 4 weeks, then monthly.

Based on observation, record review and interviews the facility failed to protect a residents' right to be free from physical and psychosocial abuse by a Certified Nursing Assistant (CNA) for 1 (#16) of 4 (#10, #16, #63, and #73) residents reviewed for abuse. The deficient practice resulted in an actual harm for resident #16 (who was cognitively impaired) on 04/28/2024 during the day shift between 6:00 a.m. - 2:00 p.m. when S4CNA was observed by S5CNA and S6CNA punching resident #16 in the face, chest and side several times with a closed fist. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be treated in this manner in her own home or health care facility. Findings: Review of the facility's policy and procedure for Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed: Purpose: To keep residents free from abuse, neglect, and corporal punishment of any kind by any person. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root disorder, insomnia, anoxic brain damage, delusional disorder, psychotic disorder with delusions due to known physiological condition, dementia with behavioral disturbance, impulse disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #16 had severe cognitive impairment for daily decision making and required extensive assistance with activities of daily living. Review of the physician orders dated 11/01/2023 revealed an order for resident #16 to have one on one care at all times. This physician order continued each month up to the present date of the survey. Review of the current plan of care revealed resident #16 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Resident #16 has a self-care performance deficit and required assistance with activities of daily living. Resident #16 required 1:1 care 24 hours a day. Review of the facility's Investigation Report dated 04/28/2024 at approximately 2:30 p.m. revealed S7CNA was the oncoming CNA assigned to resident #16's hall. Another aide, S8CNA asked for assistance in getting resident #16 to her room. S9CNA, S8CNA and S7CNA noticed a bruise on resident #16's face. The incident was immediately reported to S3Licensed Practical Nurse (LPN). Review of the nurses' notes dated 04/28/2024 at 4:40 p.m. revealed the staff reported that resident #16 had bruising and scratches on her body. The CNA brought the resident to the nurse to assess. The resident was sitting upright in a wheelchair, awake and alert. Upon assessment, the resident was noted to have bruising to the right eye, scratches to the left breast and one scratch to left posterior shoulder. Review of the Incident Report dated 04/28/2024 at 3:31 p.m. revealed resident #16 was noted to have bruising of the right eye, a scratch to the left breast and one scratch to the posterior shoulder. The resident was unable to give any description of incident. Further review of the Incident Report revealed everyone involved in the care of the resident was immediately suspended pending further investigation. On 05/06/2024 at 11:00 a.m., observation of resident #16 revealed she was in the hall sitting in a wheelchair with the 1:1 staff member next to her. Resident #16 was noted to have a bruise under her right eye. On 05/07/2024 at 4:30 p.m., an interview with S9CNA revealed she worked on 04/28/2024 from 2:00 p.m. - 10:00 p.m. and she noticed a bruise to resident #16's right eye and she informed S13ADON (Assistant Director of Nursing). On 05/06/2024 at 3:30 p.m., an interview with S13ADON revealed she was working on 04/28/2024 when the CNAs for the 2:00 p.m. - 10:00 p.m. shift came into work, they noticed that resident #16 had a bruise to her right eye. S13ADON further revealed that she assessed resident #16 and saw a bruise to her right eye and a scratch to her left chest and left shoulder. On 05/07/2024 at 10:30 a.m., an interview with S13ADON revealed on 04/28/2024 S4CNA had already completed her shift and had left the nursing home. S4CNA was called to come back to the nursing home to provide a statement of events when she worked with resident #16 on 04/28/2024. S4CNA returned to the nursing home, provided a statement and denied any issues regarding resident #16 during her shift on 04/28/2024. Further interview with S13ADON revealed she attempted to contact S5CNA and S6CNA on 04/28/2024 without success. S5CNA and S6CNA were the other two aides that assisted in the care of resident #16 on 04/28/2024. S13ADON revealed S5CNA and S6CNA came to the nursing home on 04/29/2024 and provided a statement. S5CNA and S6CNA revealed they saw S4CNA hit resident #16 in the face, chest and side multiple times on 04/28/2024. The facility notified the local Sheriff's department and the Sherriff's department started an investigation on 04/29/2024. Review of the statement provided by S5CNA revealed on 04/28/2024, S4CNA asked if S5CNA could help change resident #16. Resident #16 grabbed S4CNA's necklace and S4CNA got mad and began punching resident #16 repeatedly everywhere. Review of the statement provided by S6CNA revealed on 04/28/2024, S4CNA asked if S6CNA could help change resident #16. During the care resident #16 began to grab S4CNA and once she grabbed her S4CNA punched her in the face several times. Resident #16 broke S4CNA's necklace and S4CNA got mad and punched resident #16 in the face, chest and side multiple times. Review of the Sheriff's Department Investigation Report revealed on 04/29/2024 at approximately 4:48 p.m. S4CNA confirmed she did hit resident #16 with a closed fist on the shoulder and back. S4CNA was arrested on 04/29/2024. On 05/07/2024 at 11:00 a.m., an interview with S3LPN revealed on 04/28/2024 at 2:10 p.m., S7CNA came and informed her that resident #16 had a bruise on her left eye. S3LPN revealed S13ADON and she assessed the resident and she was observed to have a bruise to her right eye and a scratch to her left breast and left shoulder. On 05/08/2024 at 6:15 p.m., an interview with S1Administrator confirmed resident #16 was physically abused by S4CNA and it was everyone's responsibility at the nursing facility to ensure residents are free from abuse.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that the each resident received adequate supervision to prevent accidents for 4 (#13, #19, #26, #49) of 7 (#13, #19, #26, #28, #49, #61, #366) residents reviewed for accidents by: 1. Allowing resident #19 to smoke while wearing his nasal cannula with his oxygen canister on his wheelchair, 2. Allowing residents #13, #26, and #49 to smoke without wearing a safety apron and to smoke without adequate supervision, and 3. Failing to counsel and educate these residents on unsafe smoking practices. The immediate jeopardy began on 8/14/18 at approximately 11:45 a.m., when resident #19 was observed for 3 - 4 minutes smoking near the front doors of the facility while wearing his nasal cannula with his oxygen canister on his wheelchair. During this observation, resident #26 was also present along with other non-sampled residents who were also smoking in this area. There were no staff members present at this time. S3Administrator was notified of the Immediate Jeopardy situation on 08/14/18 at 3:42PM. A plan of removal was submitted by S3Administrator which included the following: 1. After thorough assessment of all smokers for safety practices, residents noted unsafe were counseled regarding specific unsafe practices, risk/dangers were reviewed, and smoking accessories were surrendered to staff. Unsafe smokers will be supervised 24 hours a day, 7 days a week to ensure safety for all residents, staff, and visitors. Supervision will be provided by trained staff members with specific consideration being given to designated smoking locations, close observance of potential hazards and safety measures/interventions that may apply. Staff members working specific positions on specific shifts will be assigned smoking supervision duties, however, other members of staff will be trained/in-serviced to not only supervise unsafe smokers, but recognize smoking characteristics that may jeopardize ones safety. 2. It was agreed by facility and resident #19, that when resident #19 desires to smoke, he will surrender his E-tank to staff at the nurse's station. A single tank rack has been placed at the nurse's station to hold resident #19's tank while he smokes. A smoking monitor will provide resident #19 with smoking accessories only when oxygen tank is not present. 3. All staff members will be educated regarding the supervision of unsafe smokers per company policy. In addition, staff members will be tested following in-service to ensure understanding of policy. 4. Quality Assurance and Performance Improvement (QAPI) will evaluate the effectiveness of this program. Administrator, DON, and/or ADON will monitor three times weekly for 3 months, then randomly thereafter, to ensure all unsafe smokers are supervised and safety measures are followed. S3Administrator was notified that the Immediate Jeopardy situation was removed on 08/14/18 at 3:45PM when an acceptable plan of removal was presented. This deficient practice continued at a potential for more than minimal harm for all 66 residents in the facility, as well as for staff and visitors. Resident #19 A review of resident #19's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of resident #19's current physician's orders [REDACTED]. A review of resident #19's Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of resident #19's current care plan revealed a problem of noncompliance related to refusal to allow staff to assist with activities of daily living, use call light for transfers, refusal of medications, refuses to put [MEDICAL CONDITION] (Continuous Positive Airway Pressure) / Oxygen tubing back in bag once he is done using it; refuses to remove oxygen when smoking. Approaches listed included counseling as needed for noncompliance or inappropriate behavior and discuss with family history of behavioral changes. A further review of resident #19's current care plan revealed a problem of Resident is a cigarette smoker; Safe smoker noted at this time. Goal and target date (11/10/18): Compliance to smoking policy and resident's safety will be maintained with smoking over the next review. Approaches listed included: -Provide education to resident and reminders as needed on facility's smoking policy and designated smoking area for safety. Monitor every shift for compliance. Notify physician, administration and family if noncompliance noted. -Inform resident of plan of care for safety with cigarette smoking. Monitor every shift for compliance. Notify physician, administration, and family if noncompliance noted. -Staff to maintain resident's smoking supplies at nurse's station for safety. Provide resident with supplies upon request to smoke. -Monitor resident during smoking for safety. Notify physician, administration, and family if signs or symptoms of decline in status noted or if risk for injury noted secondary to smoking. -Safe smoking assessment to be completed quarterly and with significant changes in status noted. Provide plan of care for safety with smoking as indicated per smoking assessment. -Monitor every shift for signs and symptoms of decline in status secondary to smoking and notify physician if noted. -Monitor resident every shift for signs and symptoms of [MEDICAL CONDITION] clothes, personal items, or skin. Notify physician, administration, and family if noted. -Staff to provide assist with lighting cigarette, provide smoker's apron, and provide supervision while smoking cigarettes for safety. A review of resident #19's Safe Smoking assessment dated [DATE] revealed resident #19 is determined to be a safe smoker. The first question on the assessment asked: Can the resident light and smoke cigarette, cigar, or pipe using safe technique for putting out the match or lighter, cigar, cigarette, or pipe, and disposing of ash? It was answered, Yes. On 08/14/18 at approximately 11:45AM, resident #19 was observed for 3-4 minutes sitting in his wheelchair outside the front door smoking with resident #26 and multiple other non-sampled residents while wearing his nasal cannula with his oxygen canister in the holder on the back of his wheelchair. There were no staff members observed with the residents during this time. An interview was conducted with the S1DON (Director of Nurses) at 12:20PM on 08/14/18. She stated she had educated resident #19 multiple times, informing him that smoking with his oxygen was putting himself and others in danger. However, the S1DON confirmed that resident #19 continued to smoke while his oxygen canister was in place. An interview was conducted with S2ADON (Assistant Director of Nurses) at 1:00PM on 08/14/18. She stated resident #19 had been going out with his oxygen canister since two hospitalization s ago. She confirmed he is deemed a safe smoker, allowed to keep his cigarettes and lighter, and does not require supervision. She stated sometimes he takes the oxygen off and sometimes he doesn't. She later confirmed two hospitalization s ago was in (MONTH) (YEAR). An interview with S3Administrator at 1:35PM on 08/14/18, revealed he was aware resident #19 smoked with his oxygen on, but stated resident #19 turned his oxygen off when he smoked. When asked about the facility's smoking policy which indicated that it may be necessary to restrict an individual resident's smoking privileges because of safety reasons, the Administrator said he thought it was okay because the resident was turning his oxygen off. He confirmed staff had not been checking to ensure that the oxygen canister was turned off when resident #19 went out to smoke. An interview was conducted with S4CNA (Certified Nursing Assistant) and S5CNA on 08/14/18 at 1:40PM. Both stated they worked on resident #19's hall. They both stated that the resident goes out several times a day to smoke. They further indicated that the resident kept his oxygen canister on the back of his chair and his oxygen tubing in his nose while smoking. In an interview on 08/14/18 at 1:50PM, resident #26 stated the resident #19 comes outside all day and night and always has his oxygen with him. At 1:55PM on 08/14/18, an interview was conducted with S6CNA. She stated resident #19 comes outside to smoke all the time and he turns his oxygen off, but doesn't take the nasal cannula off. In an interview with Resident #19 at 2:00PM on 08/14/18, he stated that he turns his oxygen off when he smokes, but the oxygen canister remain in his presence. When the resident demonstrated how he turned the oxygen off, the shut off valve on the canister was observed to read 2 liters. An interview was conducted with S1DON at 2:45PM on 08/16/18 who confirmed there was no documentation of counseling resident #19 regarding the danger of smoking with oxygen. Resident #26 Record review for Resident # 26 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had a BIMS of 11. Review of the comprehensive risk assessment for safe smoking dated 06-19-18 revealed the resident was assessed to be an unsafe smoker due to burn holes in clothing. Review of the care plan revealed an intervention dated 01/19/18 for a smoking apron to lap while smoking and cigarettes to be kept at the nurse's station. Further review of the care plan revealed noncompliance r/t refusal to wear smoking apron --notify md/rp (medical doctor/responsible party) with any complications --counsel resident regarding importance of compliance. --Check on resident frequently for needs On 08/13/18 at 9:30AM, Resident #26 was observed smoking on the front porch area. The resident was not wearing a smoking apron and there were no staff present. On 08/14/18 at 01:28 PM, Resident #26 stated she kept her cigarettes and lighter in her purse. She stated that she has never burned her clothing, and she told them she would not wear an apron. On 08/15/18 at 10:00AM, Resident #26 was outside smoking and not wearing a smoking apron. On 08/16/18 at 02:34PM, an interview with the S2ADON confirmed the resident kept her own cigarettes and smoked outside without a smoking apron. She stated there was no documentation the physician was notified of the non-compliance, no documentation the resident was counseled regarding the non-compliance, nor that there was an increase in the monitoring of the resident. The care plan was not revised to include new interventions for monitoring the resident who refused to wear the smoking apron and who was non-compliant with safe smoking practices. Resident #13 Review of the medical record revealed sample resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed the resident is moderately impaired and requires extensive assistance with all activities of daily living and set up help with meals. Review of the physician's orders [REDACTED]. Review of the Smoking assessment dated [DATE] revealed sample resident is assessed to be an unsafe smoker due to the resident not demonstrating that she will not avoid giving cigarettes or smoking paraphernalia to other residents who may be unsafe or lighting cigarettes. Review of the care plan revealed that sample resident #13 was care planned to be an unsafe smoker due to her refusing to wear smoking apron. Interventions were to counsel the resident as needed for noncompliance or inappropriate behavior. Observation on 08/13/18 at 10:15AM revealed the resident was sitting on the front porch smoking without a smoking apron on and no staff was present. Observation on 08/14/18 at 9:30AM revealed sample resident #13 was sitting on the front porch smoking without an apron on. Observation on 08/14/18 at 2:30PM revealed sample resident #13 was sitting on the front porch smoking without an apron on. Interview with the S1DON (Director of Nursing) at 2:47PM on 08/16/18, revealed the resident had not been counseled as per the care plan and the care plan had not been revised to include new interventions for supervision of this resident that was an unsafe smoker, and who had unsafe smoking practices that included not wearing a smoking apron. Resident #49 Review of the medical record for resident #49 revealed the resident had [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set) dated 07/25/18 revealed the resident scored a 9 (moderate impaired cognition) on the BIMS. Review of the smoking assessment dated [DATE] for sampled resident #49 revealed the resident had not demonstrated that he would avoid giving cigarettes or smoking paraphernalia to other residents. Resident #49 was assessed to be an unsafe smoker. Review of the current care plan revealed the resident was assessed to be a safe smoker. On 08/13/18 at 12:00PM observation of the resident revealed he was walking in the hallway and the resident showed two surveyors a pack of cigarettes and a lighter he had rolled in his shirt sleeve. Further observation revealed he was wearing a long sleeve red shirt and it had burn holes in the chest area of the shirt. On 08/13/18 at 12:15PM observation of the resident revealed he was outside smoking without staff present and the resident was not wearing a smoking apron. On 08/16/18 at 2:10PM S2Assistant Director of Nurses (ADON) and S3Administrator confirmed the resident was deemed an unsafe smoker on the smoking assessment and should have been monitored by staff while smoking.

Based on observation, record review, and interview the facility failed to ensure the resident was free from any physical restraints not required to treat the resident's medical symptoms for 1 (#23) of 1 (#23) resident reviewed for restraints out of a total of 32 Stage 2 sampled residents. The facility failed to: 1.) ensure that a pre-restraint assessment was conducted before initiating a restraint, 2.) ensure that a resident was not placed in the wheelchair with the self-releasing soft belt restraint after the resident was found with the soft belt across her chest, 3.) assess her for the least restrictive measures possible, and 4.) document the specific medical condition that made the restraint necessary. Resident #23 was placed in an Immediate Jeopardy situation on 07/23/15, when the facility placed the resident back in the wheelchair and applied the self-releasing soft belt restraint after finding her slid down in her wheelchair with the lap belt intact, across her chest. The facility did not have a system in place to assess the resident for the appropriateness of the restraint, assess for a medical indication, or least restrictive restraint. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 08/27/15 at 11:15AM and a plan of removal was accepted on 08/27/15 at 1:50PM. The plan of removal dated 08/27/15 submitted by the facility revealed the facility will ensure that a comprehensive assessment is performed for each resident. All residents will be assessed for safety and appropriateness before a device/restraint is initiated for any resident. All residents are and will be reassessed after an incident and changes made to the plan of care as needed. All residents are assessed at least quarterly and with significant changes for need for a restraint. Staff will be trained on the use and application of any restraints or devices used. Staff will be re-inserviced on all of the above starting 08/27/15. All residents in the facility will be reviewed to ensure compliance. S1Administrator/S2DON/Designee will monitor at least 5 residents per week for 12 weeks then randomly to ensure compliance. The Immediate Jeopardy was removed on 08/19/15 at 3:00PM, when the self-releasing soft belt on resident #23 was immediately removed and she was placed in a specialized wheelchair. The deficient practice remains at a potential for more than minimum harm for resident #23. No other residents in the facility were in any type of restraints. Findings: Review of the medical record revealed resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #23's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 3 which indicated she was severely cognitively impaired. Further review revealed there were no restraints being used for the resident during the assessment period. Review of the August 2015 Physician order [REDACTED]. Review of the Incident Accident Report dated 07/23/15 at 10:03AM revealed resident #23 slid out of her wheelchair with the lapbelt still intact across her chest. The resident vomited on her clothes and there were lapbelt marks across her chest. There were no apparent injuries noted. Further review revealed there was no documentation that the facility addressed the potential safety issues with continuing to use the soft belt for the resident. On 08/19/15 at 2:00PM, an interview with S2DON revealed during the incident investigation it was determined that the resident was trying to get in her bed unassisted because she wanted to go to bed after meal time. Review of resident #23's care plan revealed the facility had identified she was at risk for injury related to generalized weakness and bilateral AKA. The above incident was documented on 07/23/15 with a new intervention initiated to counsel the CNAs to assist resident to bed after each meal. Further review of resident #23's medical record revealed the resident had not had any other occurrences related to sliding out of her wheelchair. There was no documentation of a pre-restraint assessment prior to initiating the self-releasing soft belt for the resident. Further review revealed there was no re-assessment after the incident for the continued use of the above restraint. Review of the July 2015 and August 2015 nurse's notes revealed there was no documentation that resident #23 had any occurrences of unfastening her self-releasing soft belt. On 08/19/15 at 10:00AM, an observation of resident # 23 revealed she was in her wheelchair with a self-releasing soft belt on. An attempted interview with the resident at this time revealed she was confused and was not able to unfasten her soft belt. On 08/20/15 at 9:00AM, an interview with S6CNA, revealed she has worked with resident #23 for 2 years. She confirmed she has never seen her unfasten the self-releasing soft belt without assistance. S6CNA stated the resident was confused most days. On 08/20/15 at 9:15AM, an interview with S4LPN, revealed she has worked with the resident about 1 year. She confirmed the resident was confused at times and she has never witnessed her unfasten the self-releasing soft belt. The facility had a policy and procedure regarding physical restraints which included using the least restrictive measures possible, documenting the specific medical condition that makes the restraint necessary, protecting the resident's safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. On 08/19/15 at 2:00PM, an interview with S2DON confirmed there was no pre-restraining assessment completed before initiating the soft self-releasing belt. She also revealed they failed to address the potential safety issues with continuing to use the soft belt for the resident after the 7/23/15 incident when the resident slid out of her wheelchair with the lapbelt still intact across her chest.

I. Based on observation, record review, and interview, the facility failed to conduct a periodic comprehensive, accurate assessment of the resident's needs for 1 (#23) of 1 (#23) resident reviewed for restraints out of a total of 32 Stage 2 sampled residents. The facility failed to: 1.) assess the resident for the appropriateness of the restraint, 2.) assess for a medical indication, and 3.) assess for the least restrictive restraint. Resident #23 was placed in an Immediate Jeopardy situation on 07/23/15, when the facility placed the resident back in the wheelchair and applied the self-releasing soft belt restraint after finding her slid down in her wheelchair with the lap belt intact, across her chest. The facility did not have a system in place to assess the resident for the appropriateness of the restraint or assess for a medical indication or least restrictive restraint. S1Administrator and S2DON were notified of the Immediate Jeopardy situation on 08/27/15 at 11:15AM and a plan of removal was accepted on 08/27/15 at 1:50PM. The plan of removal dated 08/27/15 submitted by the facility revealed the facility will ensure that a comprehensive assessment is performed for each resident. All residents will be assessed for safety and appropriateness before a device/restraint is initiated for any resident. All residents are and will be reassessed after an incident and changes made to the plan of care as needed. All residents are assessed at least quarterly and with significant changes for need for a restraint. Staff will be trained on the use and application of any restraints or devices used. Staff will be re-inserviced on all of the above starting 08/27/15. All residents in the facility will be reviewed to ensure compliance. S1Administrator/S2DON/Designee will monitor at least 5 residents per week for 12 weeks then randomly to ensure compliance. The Immediate Jeopardy was removed on 08/19/15 at 3:00PM, when the self-releasing soft belt on resident #23 was immediately removed and she was place in a specialized wheelchair. The deficient practice remains at a potential for more than minimum harm for resident #23. No other residents in the facility were in any type of restraints. Findings: Review of the medical record revealed resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #23's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 3 which indicated she was severely cognitively impaired. Further review revealed there were no restraints being used for the resident during the assessment period. Review of the August 2015 Physician Orders for resident #23 revealed an order dated 07/09/15 for a self-releasing soft belt for her wheelchair. Review of the Incident Accident Report dated 07/23/15 at 10:03AM revealed resident #23 slid out of her wheelchair with the lapbelt still intact across her chest. The resident vomited on her clothes and there were lapbelt marks across her chest. Further review revealed there was no documentation that the facility addressed the potential safety issues with continuing to use the soft belt for the resident. On 08/19/15 at 2:00PM, an interview with S2DON revealed during the incident investigation it was determined that the resident was trying to get in her bed unassisted because she wanted to go to bed after meal time. Review of resident #23's care plan revealed the facility had identified she was at risk for injury related to generalized weakness and bilateral AKA. Further review of resident #23's medical record revealed the resident had not had any other occurrences related to sliding out of her wheelchair. There was no documentation of a pre-restraint assessment prior to initiating the self-releasing soft belt for the resident. Further review revealed there was no re-assessment after the incident for the continued use of the above restraint. Review of the July 2015 and August 2015 nurse's notes revealed there was no documentation that resident #23 had any occurrences of unfastening her self-releasing soft belt. On 08/19/15 at 10:00AM, an observation of resident # 23 revealed she was in her wheelchair with a self-releasing soft belt on. An attempted interview with the resident at this time revealed she was confused and was not able to unfasten her soft belt. On 08/20/15 at 9:00AM, an interview with S6CNA, revealed she has worked with resident #23 for two years. She confirmed she has never seen her unfasten the self-releasing soft belt without assistance. S6CNA stated the resident was confused most days. On 08/20/15 at 9:15AM, an interview with S4LPN, revealed she has worked with the resident about one year. She confirmed the resident was confused at times and she has never witnessed her unfasten the self-releasing soft belt. The facility had a policy and procedure regarding physical restraints which included using the least restrictive measures possible, documenting the specific medical condition that makes the restraint necessary, protecting the resident's safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. On 08/19/15 at 2:00PM, an interview with S2DON confirmed there was no pre-restraining assessment completed before initiating the soft self-releasing belt. She also revealed they failed to address the potential safety issues with continuing to use the soft belt for the resident. II. Based on observation, interview and record review the facility failed to conduct an accurate and comprehensive admission assessment for 1 (#36) of 1 (#36) by failing to assure a resident had access to emergency transportation in a total of 32 Stage 2 residents. Findings: Review of the record revealed Resident #36 was admitted with [DIAGNOSES REDACTED]. Review of the admission assessment revealed the resident's weight was 829 pounds. S2DON stated that there was no ambulance service in the parish with equipment to transport the resident due to his weight. Resident #36 was transferred to the hospital in a neighboring parish on 05/15/15 [MEDICAL CONDITION] related to a wound on his leg. S2DON stated that it took several days to arrange transportation for the resident and they had to use an ambulance service from another parish. The resident returned to the facility on [DATE]. S1Administrator confirmed that she completed the admission assessment on Resident #36. She stated that she did not consider that the parish ambulance service could only service up to 750 pounds with its stretchers when the resident was admitted to their facility. She confirmed that the facility was not able to meet the needs of this resident because the parish ambulance service had no means to provide emergent transportation for the resident. III. Based on observation, record review, and interview the facility failed to ensure a comprehensive assessment was conducted for 1 (#37) of 1(#37) resident who received [MEDICAL TREATMENT] services out of a total of 32 Stage 2 sampled residents. Findings: Review of the medical record revealed resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/20/15 at 9:30AM, an interview with resident #37 revealed she goes to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. She stated she began [MEDICAL TREATMENT] about a month ago. Resident #37 revealed the nurses at the [MEDICAL TREATMENT] center take care of her vascular access for [MEDICAL TREATMENT] (Shiley left chest). She confirmed that she has not had any concerns with her Shiley access since she started [MEDICAL TREATMENT]. Review of the August 2015 MD orders for resident #37 revealed there were no orders for [MEDICAL TREATMENT] treatment or care/monitoring of the resident's Shiley access. Review of resident # 37's medical record revealed there was no documentation of care/monitoring of the resident's Shiley access. On 08/20/15 at 10:50AM, an interview with S4LPN revealed she has worked with the resident since she was admitted . She stated the resident started [MEDICAL TREATMENT] about 3 weeks ago and stated she has a [MEDICAL TREATMENT] access located in her left chest. S4LPN revealed she checks the resident's dressing, assesses for signs and symptoms of infection/bleeding. She stated she documents the above in the nurses's notes. She confirmed the resident has not had any complications since starting [MEDICAL TREATMENT]. Review of the August 2015 Nurse's Notes revealed documentation when resident #37 left the facility for [MEDICAL TREATMENT] services and when she returned. Further review revealed there was no documentation regarding an ongoing assessment of her Shiley which included monitoring for sign/symptoms of infection or bleeding at the site. On 08/20/15 at 11:00AM, an interview with S7CNA revealed she takes the resident's blood pressure in her right arm due to the access in her left chest. She confirmed the resident has not had any complications since starting [MEDICAL TREATMENT]. On 08/20/15 at 9:10AM, an interview with S2DON confirmed there was no physician orders for [MEDICAL TREATMENT] services and monitoring of the resident's Shiley access. She also confirmed there was no documentation between the facility and the [MEDICAL TREATMENT] center regarding the resident's [MEDICAL TREATMENT] care.