Every finding on record at Deridder Retirement & Rehab Center

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 58 residents who consumed food from the kitchen. The facility failed to ensure: 1. Expired food items were discarded and not available for usage:2. Food items were properly stored, labeled, and dated;3. Dishware were properly clean and sanitized in accordance with food safety;4. Dietary staff worn hair/facial hair restraints while in the kitchen; and 5. Food temperatures were checked before meal services.Findings:Review of an undated facility policy on 12/15/2025 at 12:39 p.m. titled, References revealed the following in part .Sink: Solution 200PPM.Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Storage: Dry Food revealed the following in part .3. Discard any expired foods. Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Sanitation Room revealed the following in part .Work Surfaces: Dish room work surfaces must be maintained in a clean and sanitary condition. 1. Wash the soiled areas, rinse, sanitize according to manufacturer's instructions, allow to air dry. Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Daily Food Temperature Control revealed the following in part .Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within the acceptable ranges. 2. Prior to meal service, the cook shall take the temperature of all hot and cold foods. 3. Temperatures are recorded on the Temperature Log.Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Storage: Freezer revealed the following in part .1. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 3. Label and date all items. Review of a facility policy on 12/16/2025 at 3:26 p.m. titled, Infection Control-Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices with a revised date of 01/2025 revealed the following in part .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Observation on 12/15/2025 at 8:46 a.m. of the facility kitchen accompanied by S1 Administrator revealed the following: Walk-In Dry Storage Pantry: 1. Five 32-ounce plastic bags of unopened coconut shredding with an expiration date/best by date of 12/10/2025. Three Refrigerators (A, B, and C):1. Refrigerator A revealed one opened carton of orange juice with an expiration date of 11/27/2025. Three Freezers (A, B, and C):2. Freezer A revealed one opened, undated, and unsealed plastic bag of biscuits in a cardboard box (over 100 individual loose biscuits).2. Freezer B revealed one opened, undated, and unsealed plastic bag of okra in a cardboard box (over 100 individual loose pieces of okra). One 3-Compartment Sink Station:3. On 12/15/2025 at 9:24 a.m., S11 [NAME] performed the sanitizer testing check for the 3-compartment sink and resulted with a reading of 100PPM (parts per million).3. On 12/15/2025 at 9:50 a.m., S11 [NAME] performed a retesting of the sanitizer for the 3-compartment sink and resulted with a reading of 100PPM.3. On 12/15/2025 at 12:20 p.m., Auto-Clor Representative serviced the facility 3-compartment sink and revealed the sanitizer was tested low at 100mm. Auto-Clor Representative revealed proper sanitation of dishware should had been reading 200PPM at a minimum. 3. S1 Administrator present at all times of the above procedures. Hair/Facial Hair Restraints:4. Observation of S11 [NAME] with a red curly, goatee, with multiple fly away hairs on his chin. S11 [NAME] was observed not wearing facial hair restraints during the entire kitchen observation. S11 [NAME] was observed washing dishes, prepping food items, and walking throughout the kitchen areas without a facial hair restraint.4. In an interview on 12/15/2025 at 9:32 a.m., S11 [NAME] revealed he was aware he should wear a beard/facial hair restraint while in the kitchen but was not because they ran out of facial hair nets and was just not going to wear one today. S1 Administrator was present throughout all of the above findings during the kitchen observation and confirmed the above findings. S1 Administrator confirmed there should not have been any expired foods available for use and food items should have been dated/labeled and sealed in a bag once opened, but were not. S1 Administrator stated the food items should have been discarded, but were not. 5. Review of the facility Food Temperature Logs and Sanitizer Logs revealed the following in part .10/2025: Daily Food Temperature Logs and Sanitizer Logs revealed multiple days where the dish sanitizer solution was tested below 200 PPM and/or food temperatures for meal service were not completed. 11/2025: Daily Food Temperature Logs and Sanitizer Logs revealed multiple days where the dish sanitizer solution was tested below 200 PPM and/or food temperatures for meal service were not completed.12/2025: Daily Food Temperature Logs and Sanitizer Logs revealed multiple days where the dish sanitizer solution was tested below 200 PPM and/or food temperatures for meal service were not completed. S1 Administrator confirmed the above findings in regard to daily temperature logs and sanitizer logs, during the record review. In an interview on 12/16/2025 at 2:19 p.m., S4 DM revealed she was aware the dish sanitizer readings should be at a minimum of 200 PPM and expected her staff to notify her if the test readings were below 200 PPM. S4 DM revealed she expected all dietary staff to check the temperature of food items prior to serving and log temperatures on the daily temperature logs for each meal. S4 DM revealed she expected all dietary staff to label food items with an opened date once opened and then place the items into a seal Zip-Lock bag once opened. S4 DM revealed that a best by date is the equivalent to an expiration date and all expired food items should be disposed of and not available for use. S4 DM revealed she expected all dietary staff to wear hair restraints and/or facial hair restraints while in the kitchen and stated there was plenty of hair/facial restraint supplies for use. S4 DM acknowledged there was an issue with the dietary staff not labeling food items, sealing food items, checking food temperatures prior to serving, testing the sanitizer appropriately, and wearing hair/facial hair restraints while in the kitchen.

Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. Enhanced Barrier Precaution procedures were followed for Resident #54 and Resident #44. 2. Staff decontaminated reusable medical equipment between uses on different residents. Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Enhanced Barrier Precautions revealed the following in part .It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 2. Enhanced Barrier Precautions- Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: i. Wounds and/or indwelling medical devices (central lines, hemodialysis, catheters, urinary catheter etc.) even if the resident is not known to be infected or colonized with a MDRO. 4. High-contact resident care activities include: dressing, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use: central lines, urinary catheters, feeding tubes, etc. 7. EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Enhanced Barrier Precautions revealed the following in part .Providers and staff must also: wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube. Do not wear the same gown and gloves for the care of more than one person. Resident #54 Review of Resident #54's medical record revealed an admission date of 12/18/2024 and diagnoses of Osteomyelitis, Encounter for Orthopedic Aftercare Following Surgical Amputation, Type 2 Diabetes Mellitus without Complications, and Chronic Kidney Disease. Review of Resident #54's Quarterly MDS with an ARD date of 09/26/2025 revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident #54 required substantial/maximum assistance with bathing, upper body dressing, and personal care and was dependent on staff for transfers. Review of Resident #54's current physician orders revealed the following in part . Start date (04/01/2025) Enhanced barrier precautions related to wounds; and Start date (12/01/2025) Foley catheter: 12 French/30ml bulb, change catheter every 21 days and PRN due to leakage, occlusion, and dislodgement for urinary retention. Review of Resident #54's current care plan revealed the following in part .Focus: The resident has a 12French/30ml indwelling Foley catheter related to vesical fistula (date initiated 12/02/2025). Intervention: Catheter change every 21 days, 12 French/30ml indwelling Foley catheter (date initiated on 12/02/2025). Observation on 12/15/2025 at 10:13 a.m. revealed Resident #54 had an indwelling catheter. Observation on 12/16/2025 at 9:40 a.m. revealed S9 CNA entered Resident #54's room with clean linen and closed the door behind her. No observation of S9 CNA acquiring a gown/gloves upon entering the resident room. Observed Enhanced Barrier Precaution signage posted on the resident's door, which stated a gown and gloves should be used when providing hygiene, linen change, and brief changing. Observed a door hanger caddy placed on the resident's door with gown and gloves available for use. Observation on 12/16/2025 at 9:55 a.m., revealed S9 CNA exit Resident #54's room and place dirty linen into a linen barrel. No observation of dirty PPE, including a gown, at this time. In an interview on 12/16/2025 at 9:59 a.m., S9 CNA revealed she was assigned to Resident #54 and he had a Foley catheter for about a month. S9 CNA revealed she just provided personal care to Resident #54, which included a bed bath, incontinent care, linen change, dressing, repositioning, catheter care, and emptied the catheter drainage bag. S9 CNA confirmed she had only worn gloves when she provided care to Resident #54. Review of Resident #54's door signage with S9 CNA, at this time. S9 CNA stated she was aware Resident #54 required Enhanced Barrier Precautions due to his Foley catheter and she did not wear a gown when providing care to him, but should have. In an interview on 12/16/2025 at 10:20 a.m., S10 CNA revealed she was assigned to Resident #54 and he had a Foley catheter. S10 CNA stated she was aware Resident #54 does require EBP, but S10 CNA had only worn a gown when the resident had a big bowel movement. S10 CNA stated she does not wear a gown any other time when providing care to Resident #54. In an interview on 12/17/2025 at 10:45 a.m., S7 MDS revealed she was working as a floor nurse and assigned to Resident #54. S7 MDS stated she was familiar with Resident #54's care and he required EBP due to his Foley catheter, urostomy, and unhealed surgical wound. S7 MDS stated that all staff should wear a gown and gloves when direct care is provided, such as incontinent care, bathing, dressing, catheter care, etc. In an interview on 12/17/2025 at 2:06 p.m., S2 DON revealed residents who have a chronic wound, indwelling catheter, immune deficiency, or other indwelling devices, etc. required the need for EBP procedures. S2 DON revealed she expected staff who are caring for a resident with EBP to wear both gloves and gown when direct care was provided. S2 DON confirmed Resident #54 required EBP and staff should have worn both a gown and gloves when direct care was provided. Resident #44 Review of Resident #44's electronic medical record revealed an initial admission date of 11/12/2025 and a re-entry admission date of 12/11/2025 with a diagnoses that included in part. Intracranial Abscess and Granuloma, Other Post-procedural Complications and Disorders of the Nervous System, Hydrocephalus Unspecified, Other Disorders of the Pituitary Gland, and Unspecified Adrenocortical Insufficiency. Review of Resident #44's admission MDS with ARD of 11/28/2025 revealed a BIMS Score of 10, indicating moderate cognitive impairment. Resident #44 required partial to moderate assistance with showering, bathing, and personal hygiene. Review of Resident #44's December 2025 orders revealed in part. Vancomycin HCl Intravenous (IV) Solution (Vancomycin HCl) - Use 750 mg intravenously two times a day related to Intracranial Abscess and Granuloma. Flush 10 milliliter (mL) before and after infusion. Ceftazidime Intravenous Solution Reconstituted 2 gram (GM) – Use 2 gram intravenously every 8 hours related to Intracranial Abscess and Granuloma. Other post-procedural complications and disorders of the nervous system. Flush with 10 mL before and after infusion. Review of Resident #44's care plan with initiation date of 11/13/2025 revealed Resident #44 received IV medications through right arm PICC (Peripherally Inserted Central Catheter) line. On 12/16/2025 at 09:15 a.m., observation revealed Resident #44's room did not have any evidence that Resident #44 required enhanced barrier precautions. In an interview on 12/16/2025 at 09:15 a.m., S8 RN confirmed that Resident #44 had a PICC line in his right arm and did not have enhanced barrier precautions in place. S8 RN revealed she had just accessed Resident #44's PICC line to administer his morning dose of IV Vancomycin and did not wear a disposable gown. S8 RN confirmed Resident #44 did not have enhanced barrier precautions in place, and should. S8 RN confirmed she did not wear a gown when accessing Resident #44's PICC line this morning and should have. In an interview on 12/16/2025 at 09:29 a.m., S3 ADON accompanied the surveyor to Resident #44's room. S3 ADON revealed any resident with an indwelling medical device required enhanced barrier precautions. S3 ADON confirmed enhanced barrier precautions were not in place for Resident #44, and should have been. Observation on 12/16/2025 from 9:03 a.m. until 9:47 a.m. revealed S5LPN using an arm BP monitor, a wrist BP monitor, and a pulse oximeter to monitor the vital signs of multiple residents without sanitizing the equipment between uses on different residents. Interview with S3ADON on 12/16/2025 at 12:00 p.m. revealed staff were to decontaminate reusable medical equipment between uses on different residents. Interview with S5LPN on 12/16/2025 at 12:05 p.m. confirmed she did not decontaminate reusable medical equipment between uses on different residents, but should have.

Based on interview and record review, the facility failed to complete a Quarterly MDS assessment as required for 1 (Resident #4) of 28 sampled residents.Findings: Review of Resident #4's EMR revealed an admission date of 08/19/2019 with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Diabetes Mellitus, Type II. Review of Resident #28's MDS record revealed a Quarterly MDS with ARD of 11/01/2025 was exported on 12/15/2025. An interview on 12/17/2025 at 12:20 p.m. with S12 LPN confirmed Resident #4's Quarterly MDS with ARD of 11/01/2025 should have been submitted by 11/15/2025, but was not.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #53) of 2 residents reviewed for respiratory care. The facility failed to ensure oxygen was administered at the prescribed flow rate.Findings: Review of Resident #53's EMR revealed an admission date of 11/17/2022 with diagnoses including Asthma and COPD.Review of Resident #53's physician's orders revealed the following, in part.O2 (Oxygen) at 2 LPM via NC PRN O2 sat <92% dated 02/15/2023.Observation of Resident #53 on 12/15/2025 at 10:30 a.m. revealed O2 at 4 LPM via NC.Observation of Resident #53 on 12/16/2025 at 9:54 a.m. revealed O2 at 4 LPM via NC.Observation of Resident #53 on 12/16/2025 at 11:38 a.m. accompanied by S5 LPN revealed O2 at 4 LPM via NC. Interview with S5 LPN during the observation confirmed Resident #53's O2 should have been administered at 2 LPM, but was not.

Based on record review, observation, and interview the facility failed to maintain a medication error rate below 5%. The facility had a 7.41% medication error rate with 2 medication errors out of 27 opportunities. The facility failed to ensure:1. The correct topical medication was applied, in the correct site, and at the correct time for Resident #67; and2. Failure to ensure IV Vancomycin was infused at the correct infusion rate for Resident #44. Findings Observation of medication administration with S5LPN on 12/16/2025 at 9:16 a.m. revealed Desonide 0.05% Cream was applied to Resident #67's Right AKA stump. Review of Resident #67's physician's orders revealed the following, in part. Desonide 0.05% Cream - apply to face topically at bedtime, dated 12/04/2025; and Lidocaine External Cream 5% - apply to right stump area topically one time a day, dated 12/04/2025. Interview with S5LPN on 12/16/2025 at 11:17 a.m. confirmed she applied the wrong medication (Desonide Cream), to the wrong body site (Right stump), at the wrong time (AM), but should not have. Resident #44Review of Resident #44's electronic medical record revealed an initial admission date of 11/12/2025 and a re-entry admission date of 12/11/2025 with diagnoses that included in part. Intracranial Abscess and Granuloma, Other Post-procedural Complications and Disorders of the Nervous System, Hydrocephalus Unspecified, Other Disorders of the Pituitary Gland, and Unspecified Adrenocortical Insufficiency.Review of Resident #44's admission MDS with ARD of 11/28/2025 revealed a BIMS Score of 10, indicating moderate cognitive impairment. Review of Resident #44's December 2025 orders revealed in part. Vancomycin HCl Intravenous Solution (Vancomycin HCl) - Use 750 mg intravenously (IV) 2 times a day related to Intracranial Abscess and Granuloma. Flush 10 milliliter (mL) before and after infusion. In an interview on 12/16/2025 at 09:15 a.m., S8 RN revealed she just began Resident #44's 10 a.m. dose of IV Vancomycin. Observation at this time of Resident #44 revealed IV Vancomycin 750mg/150mL bag hanging on IV pole next to Resident #44 bed. IV Vancomycin infusing via dial flow tubing. Dial flow observed set at 150mL/hr. S8 RN confirmed IV Vancomycin was infusing at 150 mL/hr. Review of IV Vancomycin packaging at this time with S8 RN revealed a pharmacy label that read. Infuse 750mg IVPB over 90 minutes 2 times a day. S8 RN confirmed IV Vancomycin was infusing at the incorrect rate. S8 RN confirmed IV Vancomycin should be infusing at 100 mL/hr, and was not.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to ensure:1. Unattended treatment cart (Cart C) was locked appropriately;2. Expired medications were not available for use; and3. Drawers containing emergency medications were locked when not in use. This deficient practice had the potential to affect all 63 residents who currently resided in the facility. Findings: Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Medications-Storage revealed the following in part .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of an undated Facility policy on 12/16/2025 at 8:48 a.m. titled, Medication Cart Security revealed the following in part .1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must be securely locked at all time when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. Observation on 12/16/2025 at 10:09 a.m. of the entrance of Hall Z revealed a medication/treatment cart (Cart C) unlocked. Observation revealed Cart C was placed at the entrance of a busy hallway, Hall Z, with the cart doors facing outwards into the hallway. This Surveyor observed for approximately 10 minutes (until 10:19 a.m.) the unattended, unlocked cart. Observed 4 residents ambulate in front of the unlocked cart, 22 staff members ambulated in front of the unlocked cart, and 2 wheelchair bound residents wheeled themselves in front of the unlocked cart. At 12/16/2025 at 10:24 a.m., S3 ADON accompanied this surveyor to Cart C located on Hall Z. S3 ADON confirmed Cart C was left unattended and unlocked on a busy hallway, Hall Z. S3 ADON confirmed that Cart C was placed where the drawers of the cart were facing in the direction of the hallway were residents and others could access the contents inside the cart. S3 ADON opened the drawers to the cart (no key needed due to unlocked) and revealed it was the treatment cart, which contained medicated creams, ointments, dressings, and other medical supplies. S3 ADON revealed that all nurses are fully aware to lock their carts when left unattended. S3 ADON confirmed Cart C was unattended and unlocked, but should not had been. In an interview on 12/17/2025 at 2:11 p.m., S2 DON revealed she expected all nurses to lock their medication/treatment carts when not in use or left unattended. Review of the facility's undated policy titled Medications – Storage revealed, in part.the facility shall not use outdated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation of room [ROOM NUMBER] on 12/16/2025 at 11:45 a.m. with oversight from S6LPN revealed: Arformoterol Tartrate inhalation Solution 15mcg/2mL – 7 packages containing 5 vials each with expiration dates of 12/2024; Formoterol Fumarate Inhalation Solution 20mcg/2mL – 1 package with an expired date of 04/2025; Tropicamide 1% Phenylephrine 2.5% Ophthalmic Solution – 1 vial with beyond-use date of 11/15/2025; and Multiple unlocked Emergency Medication Storage drawers. Interview with S6LPN during observation revealed expired medications should not be available for use. Interview with S3ADON on 12/16/2025 at 12:00 p.m. confirmed expired medications were available for use, but should not have been. S3ADON confirmed Emergency Medication Storage drawers were to be locked when not in use, but were not.

Based on interview and record review the facility failed to employ staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition services by failing to ensure the dietary manager met the minimum qualifications of a certified dietary manager. This deficient practice had the potential to affect all 58 residents who consumed food from the kitchen. Findings:Review of an undated facility policy on 12/16/2025 at 3:36 p.m. titled, Food Service Manager revealed the following in part .Education: Dietary Manager certification is required. Qualifications: 1. Must be either a Dietary Assistant, Certified Dietary Manager, or Registered Dietitian. In an interview on 12/16/2025 at 2:19 p.m., S4 DM revealed she was hired in 08/2025 and has not worked in a nursing home setting before. S4 DM stated she has not obtained any certifications since she has been hired as the Dietary Manager, including the Serve Safe Certification. S4 DM revealed she has received guidance from the Registered Dietician and a Chef, who were both facility contracted individuals and worked part-time. S4 DM was unaware of a deadline to complete the Safe Serve Certification and should be starting the course in the middle of 01/2026.In an interview on 12/16/2025 at 4:00 p.m., S1 Administrator revealed S4 DM did not have any prior or current certifications in her personnel file. S1 Administrator confirmed he did not have any food service certifications. S1 Administrator confirmed that no other facility staff acquired the Serve Safe certification or other food service certifications for dietary management.In an interview on 12/17/2025 at 2:35 p.m., S1 Administrator revealed that upon hiring of S4 DM in 08/2025, S1 Administrator was aware S4 DM's certification was expired. S1 Administrator confirmed S4 DM did not have an associate or bachelor's degree of any kind. S1 Administrator confirmed the Registered Dietician and Chef were both contracted personnel and did not work every day at the facility.

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 63 residents who resided in the facility. Findings:Review of an undated facility policy on 12/16/2025 at 8:48 a.m. titled, Trash revealed the following in part .1. All waste must be place in sealed containers. All garbage and trash will be place in a dumpster in a convenient area near the facility. The lid to the dumpster is to be kept closed at all times. Observation on 12/15/2025 at 9:38 a.m. of the facility dumpsters accompanied by S1 Administrator revealed two facility dumpsters (Dumpster A and Dumpster B). Observation of Dumpster A revealed an opened side lid to the dumpster. S1 Administrator stated he expects all staff to close the dumpster doors/lids when they were finished taking the trash out. S1 Administrator confirmed Dumpster A had an opened side lid and it should have been closed at all times when not in use, but was not.

Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from sexual abuse by another resident for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for abuse. The facility failed to protect Resident #1 from being sexually abused by Resident #2. This deficient practice resulted in an immediate jeopardy situation on 11/22/2024 at 7:50 a.m., when Resident #2, who was cognitively intact, and had a history of inappropriate sexual behaviors entered the room of a cognitively impaired resident (Resident #1), and was found with his mouth on her mouth and his hand in her brief. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's undated policy on 12/04/2024 titled Abuse Prevention and Investigation revealed in part .Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation and any physical or chemical restraints not required to treat the resident medical symptoms. Residents will not be subjected to abuse by anyone. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse is non-consensual if the resident either appears to want the contact to occur, but lacks the cognitive ability to consent or does not want the contact to occur. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], with the following diagnoses: Cerebral Palsy, Encephalopathy, Aphasia, Dysphagia, Unspecified Convulsions, and Major Depressive Disorder. Review of Resident #1's Quarterly MDS with an ARD of 10/07/2024 revealed a BIMS score of 99, indicating Resident #1 was unable to complete assessment due to impaired cognition and is total care, dependent on staff for all activities of daily living. Review of Resident #1's care plan with a review date of 01/06/2025 revealed a communication impairment with a diagnosis Aphasia related to Cerebral Palsy. Interventions included in part .ask direct yes and no questions, anticipate and meet needs, monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included: Malignant Neoplasm of upper left lung, Cognitive Communication Deficit, Paranoid Schizophrenia, Major Depressive Disorder, Hypertensive Heart Disease, Other Anxiety Disorders, and Other Sexual Disorders. Review of Resident #2's Quarterly MDS with an ARD of 08/26/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2 required staff physical assist with transfers, locomotion on/off unit, toileting, dressing, and personal hygiene. Review of Resident #2's care plan with a review date of 02/20/2025 revealed the following problems in part . The resident has a behavior problem related to inappropriate sexual behavior towards others: Interventions included in part . Monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations. Document behavior, potential causes, and notify MD. 04/10/2024- Resident asked facility staff if she wanted private time with him, redirected resident and notified NP related sexual behaviors 06/24/2024-facility staff witnessed Resident #2 sitting in his wheelchair outside a female resident room telling her he loved her and wanted to have sex with her. Redirected resident brought to front lobby. Notified MD with new medication ordered: Zyprexa 10mg daily. 09/08/2024- Resident approached female resident and attempted to touch inappropriately. Targeted resident blocked attempts until facility staff intervened. Resident not easily redirected and placed 1:1 at this time. Notified MD and Psych NP, inpatient psych services for behavioral management requested for medication review and changes for better control of impulses. Remained 1:1 until leaving facility on 09/09/2024. 11/22/24- Resident was found in another resident's room kissing her with his hand under the cover. Staff immediately place resident on 1:1 supervision, MD/RP notified, Resident admitted to inpatient psychiatric facility on 11/22/2024. Observation of facility video footage on 12/03/2024 at 9:30 a.m. revealed on 11/22/2024 at 7:43 a.m. Resident #2 was observed propelling himself of out his room and sitting in his doorway in his wheelchair until 7:45 a.m. Resident #2 then propelled himself out of the room towards the nurses station. At 7:47:40 a.m. Resident #2 was observed propelling himself into Resident #1's room. At 7:50:32 a.m., S3 CNA was observed walking into Resident #1's room. Interview on 12/03/2024 at 9:50 a.m. with S3 CNA revealed while working the morning shift of 11/22/2024 she observed Resident #2 in Resident #1's room. S3 CNA stated she walked into Resident #1's room immediately and observed Resident #2 sitting in his wheelchair with his mouth on Resident #1's mouth and his hand in her brief. S3 CNA stated she removed Resident #2 from Resident #1's room and immediately notified management staff. Interview on 12/03/2024 at 12:31p.m. with S2 DON revealed she was notified of the incident immediately after it occurred on 11/22/2024. S2 DON stated staff immediately placed Resident #2 on 1:1 supervision, a body audit was conducted on Resident #1 and all cognitively impaired residents in the facility, and an abuse questionnaire was completed on all cognitively intact residents. S2 DON revealed an inservice for all staff on abuse was initiated within an hour of the incident and the Medical Director came to the facility and assessed Resident #1 and Resident #2. The Medical Director signed a Physicians Emergency Certificate, and Resident #2 was sent to a local hospital on 11/22/2024. Interview on 12/03/2024 1:20 p.m. with S1 Administrator revealed after the 11/22/2024 incident occurred with Resident #1 and Resident #2 she began the investigation. S1 Administrator stated the facility immediately placed Resident #2 on 1:1 supervision until he was sent out to the hospital. Body audits were completed for Resident #1 and Resident #2. The Medical Director assessed Resident #1 and Resident #2 on 11/22/2024 with no concerns. All cognitive resident were interviewed and questioned about abuse and a body audit was conducted for all resident with impaired cognition with no notification or signs of abuse. S1 Administrator revealed abuse in-servicing was initiated on 11/22/2024. Resident #1's family was notified and made the decision not to send her to the hospital for evaluation. Local police came out to investigate and determined Resident #1 and Resident #2 would not be fit to stand trial. S1 Administrator revealed that Resident #2 had plans to be discharged from the inpatient behavioral hospital on 12/06/2024, and had been accepted into a different nursing facility with an all male unit. Interview on 12/03/2024 at 3:00 p.m. with S2 DON revealed Resident #1 is cognitively impaired and cannot make decisions, including giving consent on her own. S2 DON confirmed Resident #2 kissed and inappropriately touched Resident #1, but should not have. The facility has implemented the following actions to correct the deficient practice: 1. Resident #2 was removed and immediately placed on 1:1 supervision. 2. On 11/22/2024 the Medical Director was notified and made rounds on both residents; Physician Emergency Certificate was signed for Resident #2. 3. Body Audits were conducted on Resident #1 and all resident with impaired cognition in the facility with no concerns on 11/22/2024. 4. Resident #1's Care Plan was updated to consult with Pastoral Care, Social Services, and Psyche services after the incident. 5. All cognitive residents were interviewed and questioned about abuse with no concerns on 11/22/2024. 6. Abuse in-servicing was initiated for all staff on 11/22/2024 and was completed on 11/23/2024. 7. Resident #2 was sent to a local hospital on 11/22/2024, then transferred to an inpatient behavioral hospital. 8. Weekly abuse monitoring for 8 random residents x 8 weeks was initiated on 11/22/2024. 9. Administration initiated morning rounds for all residents to questions about abuse on Monday- Friday indefinitely. 10. QA on abuse was updated and is being reviewed weekly. QAPI for abuse will be reviewed daily during morning meetings As of 11/23/2024 the past noncompliance was considered to be corrected.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for Behaviors for 1 (#2) of 3 (#1, #2 and #3) sampled residents. The facility failed to accurately capture Resident #2's inappropriate behavior against Resident #3 during the lookback period. Findings: Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included: Malignant Neoplasm of upper left lung, Cognitive Communication Deficit, Paranoid Schizophrenia, Major Depressive Disorder, Hypertensive Heart Disease, Other Anxiety Disorders, and Other Sexual Disorders. Review of Resident #2's Quarterly MDS with an ARD of 08/26/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2 required staff physical assistance with transfers, locomotion on/off unit, toileting, dressing, and personal hygiene. Review of Resident #2's Discharge MDS with an ARD of 09/09/2024 revealed there were no physical behaviors exhibited that were directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually.) No verbal behaviors exhibited that were directed toward others (threatening others, screaming at others, cursing at others.) No other behaviors exhibited not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Review of Resident #2's care plan with a review date of 02/20/2025 revealed the following problems in part . The resident has a behavior problem related to inappropriate sexual behavior towards others: Interventions included in part . Monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations. Document behavior, potential causes, and notify MD. Review of the Nurses' notes/incident report revealed the following: 09/08/2024- Resident #2 approached female resident and attempted to touch inappropriately. Targeted resident blocked attempts until facility staff intervened. Resident #2 not easily redirected and placed 1:1 at this time. Notified MD and Psych NP, inpatient psych services for behavioral management requested for medication review and changes for better control of impulses. Remained 1:1 until leaving facility on 09/09/2024. Signed by S2 DON. Interview with S6MDSLPN; S2DON and S1Administrator on 12/04/2024 at 5:31 pm revealed Section E- Behavior on Resident #2's MDS with an ARD of 09/09/2024 was not accurately coded and did not capture the inappropriate behavior that he exhibited toward Resident #3 on 09/08/2024 and it should have.

Based on observation, interviews and record reviews, the facility failed to ensure each resident received adequate assistance to prevent accidents for 1 Resident (Resident #43) of 2 (Resident #12 and Resident #43) sampled residents, a total sample of 21. This deficient practice resulted in an actual harm for Resident #43 on 04/28/2024 at 9:15 p.m., when S5 CNA failed to use 2 person assistance, when she transferred Resident #43 from the wheelchair to the bed. S5 CNA dropped Resident #43 onto the floor during transfer. On 04/29/2024 at 8:00 a.m., Resident #43 complained of pain to the left elbow. On 04/29/2024, X-rays were obtained, and Resident #43 was diagnosed with an Impacted Humeral Head Fracture, Acute with Osteopenia. Findings: Review of the facility's policy and procedure dated, and titled Safe Resident Handling/Transfers read in part . Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury, and provide and promote a safe, secure and comfortable experience for the resident, while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves, and the employees that assist them. Compliance Guidelines: Resident lift and transferring will be performed according to the resident's individual plan of care. Review of Resident #43's medical record revealed an admitted [DATE], with diagnoses that included in part . Cardiomegaly, Chronic Obstruction Pulmonary Disease, Hemiplegia following Cerebra Infarction, Type 2 Diabetes Mellitus, Non-Displaced Fracture of Greater Tuberosity of Left Humerus, and Major Depressive Disorder. Review of Resident #43's Quarterly MDS with an ARD of 04/19/2024, revealed a BIMS score of 15, indicating intact cognition. The MDS revealed Resident #43 required 2 person extensive assistance with bed mobility and transfers. Resident #43 had ROM impairment on one side to upper and lower extremities, and used a wheelchair for mobility. Review of Resident #43's care plan, with a Target date of 11/01/2024, revealed in part . 1. Physical mobility impaired related to left side Hemiplegia after CVA; Requires extensive assist with bed mobility and transfers (X2), does not ambulate; with approaches that included: Assistance as needed with all transfers. 2. At Risk for falls related to weakness, needs assist with ADL's, and requires 2 person assist with transfers. Approaches included: Monitor for signs/symptoms of increased weakness and tolerance. Interview on 08/19/2024 at 9:57 a.m. with Resident #43 revealed that S5 CNA had transferred her with no assistance on 04/28/2024 and had dropped her onto the floor. Resident #43 revealed she had informed S5 CNA she required a two person assist with transfers. Resident #43 revealed she had a fractured left shoulder due to the fall. Review of an incident report prepared by S6 LPN, and dated 04/28/2024 at 9:15 p.m., read in part .S5 CNA was transferring Resident #43 to a bed from a wheelchair. S5 CNA and Resident #43 slipped and fell to the floor. Resident #43 landed on her left arm and hip. Resident #43 sustained a left elbow hematoma. Review of a progress note dated 04/29/2024 at 8:08 a.m., and documented by S1 DON, revealed in part .Spoke with Resident #43 concerning fall. Resident #43 reported continued pain to her left arm, and stated that she had refused to go to the emergency room after the fall the night before. The progress note revealed Resident #43 did not want to go to the emergency room this morning, but did agree to have x-rays completed at the facility. Review of a progress note dated 04/29/2024 at 1:17 p.m. revealed in part .Resident #43 had a follow-up appointment on 05/01/2024 with Orthopedic Doctor for Left Humerous Fracture. Reviw of a progress noted dated 05/01/2024 read in part .Resident #43 reported moderate pain and received Tylenol 650 MG. Review of an X-ray report dated 04/29/2024, read in part . Procedure: Examination of the Left Shoulder. Indication: Pain Impressions: Impacted Humeral Head Fracture, Acute with Osteopenia. Interview on 08/20/2024 at 10:15 a.m., with S1 DON, revealed on 04/28/2024 at approximately 9:00 p.m., S5 CNA transferred Resident #43 from a wheelchair to a bed by herself, and S5 CNA and Resident #43 slipped to the floor. S1 DON revealed Resident #43 complained of pain to her left side, but refused to go to the emergency room for evaluation. S1 DON revealed Resident #43 continued to complain of pain to her left elbow, and agreed to have X-rays done at the facility on 04/29/2024. S1 DON revealed the X-rays showed Resident #43 had a fracture to her Left Humerous. S1 DON confirmed S5 CNA should not have attempted to transfer Resident #43 by herself. Telephone interview on 08/21/2024 at 10:00 a.m., S5 CNA, revealed on 04/28/2024 at approximately 9:00 p.m., she transferred Resident #43 from a wheelchair to a bed. S5 CNA revealed during the transfer, both she and Resident #43 slipped and fell on to the floor. S5 CNA revealed Resident #43's left elbow had started to swell. S5 CNA confirmed she transferred Resident #43 without a 2 person assistance, and shouldn't have.

Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 3 (#17, #32 and #52) of 3 (#17, #32 and #52) Residents reviewed for ADL's. The facility failed to ensure a Resident's (#17, #32 and #52) received nail care. Findings: Review of the facility's undated policy titled Nail Care revealed the following: The purpose of this policy is to provide guidelines for provision of care to a resident's nails for good grooming and health . 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . Resident #32 Record review revealed Resident #32 was admitted to the facility on [DATE] with the following diagnosis that included Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Chronic Pain due to Trauma and Muscle Weakness. Review of the Admission MDS with ARD of 07/31/2024 revealed Resident #32 had modified independence for cognitive skills for daily decision making, required substantial/maximum assistance for personal hygiene and dependent on staff for bathing. Observations on 08/19/24 at 10:27 a.m. revealed Resident #32 lying in bed partially covered. His fingernails was approximately 1/8th of an inch past his fingertips with a dark substance under the nail bed. During an interview with Resident #32 at that time revealed he wanted his nails cleaned and cut. He stated that he could not cut or clean his own nails. Observations on 08/20/24 at 8:45 a.m. revealed Resident #32 is lying in bed. His fingernails were still uncut with a dark substance under the nail bed. At that time, Resident #32 reported that he does not know how his fingernails gets dirty underneath, he said they are crusty. Observations on 08/20/24 at 9:48 a.m. was made with the DON of Resident #32's nails. The DON indicated that Resident #32's finger nails were dirty and needed to be cut and cleaned. The DON indicated that Resident #32 requires staff assistance for nail care, and his nails should have been cleaned and cut when he was showered. Resident #52 Record review revealed Resident #52 was admitted to the facility on [DATE] with the following diagnosis that included Encounter For Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Left Leg Below Knee, Peripheral Vascular Disease, Acquired Absence of Right Leg Above Knee and Muscle Weakness. Review of the Admission MDS with ARD of 05/24/2024 revealed Resident #52 had a BIMS of 14 (cognitively intact) and is dependent on staff for bathing. Record review of Resident #52's care plan with a start date of 05/21/2024 read in part: Requires assistance with ADL's .assist as needed . Observations on 08/19/24 at 9:35 a.m. revealed Resident #52 siting in bed. His fingernails were observed to be about 1/4 inch past his fingertips. During an interview with Resident #52 at that time he reported that he would like his nails cut. Observations on 08/20/24 at 8:35 a.m. revealed Resident #52 siting in his wheelchair. His fingernails were observed to about 1/4 inch past his fingertips. Observations on 08/20/24 at 9:45 a.m. was made with the DON of Resident #32's nails. The DON indicated that Resident #52's finger nails needed to be cut. The DON indicated that Resident #52 requires staff assistance for nail care, and his nails should have been cut when he was showered. 46773 Resident #17 Review of Resident #17's medical record revealed an admitted [DATE] with diagnoses that included Anxiety Disorder, Epilepsy, Hypertensive Heart Disease, Cerebral infarction and Dysphagia. Review of Resident #17's Quarterly MDS with an ARD of 06/05/2024 revealed a BIMS score of 11, which indicated moderate cognition impairment. The MDS revealed Resident #17 required substantial/maximum assistance with personal hygiene. Review of Resident #17's care plan with a review date of 09/04/2024 read in part . Assist with activities of daily living as needed. Observation on 08/19/2024 at 9:48 a.m. revealed Resident #17's fingernails were 1/2 inch long with brown substance observed under nails. Resident #17 revealed that staff clean and cut his nails for him and that he would like for them to be cleaned and cut but had not been recently. Observation on 08/20/2024 at 9:58 a.m. revealed Resident #17's fingernails were 1/2 inch long with brown substance under the nails. Interview on 08/20/2024 at 10:00 a.m. with S3 LPN revealed Resident #17's nails were long and had brown substance under them and should have been trimmed and cleaned but had not been.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #22) of 2 (Resident #4 and Resident #22) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored and labeled. Findings: Review of Resident #22's Clinical Record revealed an admitted [DATE] with diagnoses which included: Acute and Chronic Respiratory Failure, Pneumonia, and Chronic Obstructive Pulmonary Disease. Review of Resident #22's care plan with a review date of 07/19/2024 revealed in part .Potential for Ineffective Breathing Pattern related to Chronic Obstructive Pulmonary Disease, Pulmonary Edema with Shortness of Breath upon exertion and while lying flat, which interventions that included administer oxygen therapy as ordered and change tubing per protocol. Observation on 08/19/2024 at 9:30 a.m. revealed Resident #22 was in his room with a family friend at bedside. Oxygen tubing connected to oxygen concentrator with a date of 07/07/2024. Oxygen tubing connected to oxygen tank on Resident #22's wheelchair was not covered or dated. Resident #22 and family friend confirmed he used the oxygen. Observation on 08/19/2024 at 2:25 p.m. revealed Resident #22 lying in bed, sitter at bedside. Sitter for Resident #22 revealed Resident #22 wore oxygen at times. Sitter revealed she had recently seen Resident #22 with oxygen on. Resident #22's oxygen tubing connected to oxygen concentrator with a date of 07/07/2024. Oxygen tubing connected to oxygen tank on Resident #22's wheelchair was not covered or dated. Observation on 08/20/2024 at 9:16 a.m. revealed Resident #22 lying in bed talking to a friend. Oxygen tubing connected to oxygen concentrator with a date of 07/07/2024. Oxygen tubing connected to oxygen tank on Resident #22's wheelchair was not covered or dated. Resident #22's friend revealed Resident #22 had used his oxygen three days ago and used the oxygen tank on his wheelchair, when he went to doctor's appointments. Observation and Interview on 08/20/2024 at 9:25 a.m. with S7 LPN confirmed Resident #22 had an order for oxygen to be used PRN. S7 LPN revealed the night nurse on the weekend was responsible for storing/changing and labeling oxygen tubing weekly. Interview on 08/20/2024 at 9:36 a.m. with S8 ADON revealed oxygen equipment should be stored in a bag and labeled. S8 ADON revealed the weekend night nurse was responsible for changing oxygen tubing weekly on Saturday or Sunday. Observation with S8 ADON confirmed Resident #22's oxygen tubing connected to concentrator had a date of 07/07/2024 and should have been changed out. S8 ADON confirmed Resident #22's oxygen tubing to his tank should have been covered and dated and it had not been. Interview on 08/20/2024 at 11:00 a.m. with S1 DON confirmed that all oxygen equipment should have been changed and dated every weekend by the night nurse.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #59) of 1 (Resident #59) resident sampled for pain. The facility failed to ensure Resident #59 who displayed verbal and/or nonverbal indicators of pain received the ordered interventions to alleviate pain. Findings: Review of the facility policy titled, Pain Management revealed in part . Optimum and effective pain management is only successful through a systematic and total team effort. Continual monitoring, assessment and evaluation, resident education and utilization of scheduled medications and modalities is crucial to the success of each resident's pain management plan. Review of Resident #59's clinical record revealed an admitted [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Pain, Secondary Osteroarthritis, Complete Rotator Ruff Tear/Rupture of Left Shoulder. Review of Resident #59's 08/2024 Physician orders read in part . 08/08/2024 -Belbuca 300 mcg film Give 1 patch buccally to inside of cheek Q12 hours related to pain. 08/08/2024-Tramadol 50 mg give 1 tab po Q6h prn pain Review of Resident #59's Care plan with review date of 9/01/2024 revealed in part . Potential for alteration in comfort: Interventions: Monitor for worsening of pain symptoms and notify Physician of any changes Assess Pain Q shift using 1-10 scale Administer Pain medication as needed and monitor effectiveness Assess and document pain characteristics: Location, Duration. Frequency, aggravation and alleviating factors, intensity. 08/08/2024 -Returned from Orthopedic appointment with new orders as followed: Rest arm x2 days then resume, Belbuca 300mcg 1 film buccally Q12hrs, Tramadol 50mg po Q 6h PRN pain. Diagnosis: Left shoulder cuff tear. Review of Resident #59's Electronic Medication Administration Record for 07/2024 and 08/2024 revealed Resident #59 received prn Tramadol 1-2 times daily with pain levels ranging from 5-8 on pain number scale. Interview on 08/20/2024 at 8:30 a.m. with S4 LPN revealed Resident #59 has Belbuca 300mcg 1 film buccally Q12hrs ordered for left should pain. S4 LPN revealed the prescription was sent over to the pharmacy but she was unsure why the medication had not come in yet. Interview on 08/20/2024 at 08:35 a.m. with Resident #59 revealed she went to the Orthopedic specialist about 3 weeks or so ago and the Doctor suggested the medication Belbuca to help manage the left should pain because the Tramadol was not enough to manage the pain. Resident #59 stated after she received Tramadol her pain level goes down to a scale of 5. Resident #59 stated she thought the facility cancelled the prescription for the Bulbuca because she had not heard anything about it. Interview on 08/20/2024 at 10:30 a.m. with S2 DON revealed the pharmacy had sent over an authorization form via fax on 08/08/2024 to the facility prior to filling the medication. S2 DON stated the pharmacy had the wrong number so the facility did not receive the letter. S2 DON confirmed the medication was missed and should have been followed up on but had not been.

Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from sexual abuse by another resident for 1 (Resident #1) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents. The facility failed to protect Resident #1 from being kissed by Resident #2. Findings: Review of the facility's policy titled Abuse Prevention and Investigation revealed in part . It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual abuse is non-consensual sexual contact of any type with a resident. Review of a facility investigation report revealed in part . On 8/24/2023 at 3:24 PM S1 Administrator wrote: During the investigation, it appears as through Resident #1 is reciprocating the kiss from Resident #2. Resident #1 is a staff assessment, rather than a BIMS because she is rarely able to make her needs known. Resident #2's BIMS was a 15 at the time of the incident. For this reason, we substantiated the abuse. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], with the following diagnoses: Cerebral Palsy, Encephalopathy, Aphasia, Dysphagia, Unspecified Convulsions, and Major Depressive Disorder. Review of Resident #1's Quarterly MDS with an ARD of 07/21/2023 revealed a BIMS was not conducted, as Resident #1 was rarely/never understood, and Resident #1 had severely impaired skills for daily decision making. Resident #1 required 2+ persons physical assist with transfers, and required 1 person physical assist with locomotion on/off unit, eating, and personal hygiene. Resident #1 had bilateral ROM impairment of upper and lower extremities. Review of Resident #1's care plan with a target date of 10/20/2023 revealed a problem of verbal communication impaired related to confusion, speech unclear, diagnosis Aphasia. Interventions included in part .speak slowly, distinctively, and concisely facing the resident while speaking; encourage self-expression in any manner that provides information to staff/family to ensure needs are being met; keep explanations simple, ask questions with yes/no answers as appropriate, and offer encouragement and guidance daily as needed with decision making. Review of an incident report dated 08/17/2023 at 10:45 a.m. for Resident #1 revealed in part . Resident was seen being kissed in Area A by another resident. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included: Paranoid Schizophrenia, Major Depressive Disorder, Hypertensive Heart Disease, Other Anxiety Disorders, and Other Sexual Disorders. Review of Resident #2's Quarterly MDS with an ARD of 05/26/2023 revealed a BIMS score of 13, indicating intact cognition. Resident #2 required one person physical assist with transfers, locomotion on/off unit, dressing, and personal hygiene. Review of Resident #2's care plan with a target date of 09/25/2023 revealed the following problems in part . 1. Psychotropic medication usage daily, receives: Paxil, clinical indications: hypersexual behaviors. Interventions included in part . medications as ordered, behavior monitoring per facility protocol, and notify MD of any complications. 2. I display socially inappropriate behavior/disruptive behavior. Interventions included in part .monitor and document my behavior, administer behavior medications as ordered by physician, remove me from public area when behavior is disruptive and unacceptable, and 08/17/2023 personal contact with another resident - resident noted by staff deep kissing another resident that is unable to consent for herself, resident separated from female resident, NP and Psych NP notified, resident placed on 1:1, and inpatient psych stay ordered. Review of an incident reported dated 08/17/2023 at 10:45 a.m. for Resident #2 revealed in part . Was reported to staff that this resident was seen deep kissing another resident that is unable to consent in Area A. Observation on 09/12/2023 at 12:57 p.m. revealed Resident #1 in Area A seated upright in a geri-chair. Resident #1 was noted opening and closing her mouth, and making movements with her tongue. Interview at that time with Resident #1 was unsuccessful, Resident #1 responded to questions with incomprehensible vocalizations. Resident #1 did not shake her head yes or no to answer questions. Interview on 09/12/2023 at 1:14 p.m. with Resident #2 revealed he went out to the hospital recently for nerve trouble. When asked what kind of nerve trouble he had, Resident #2 stated it was sex trouble. Resident #2 reported he had this trouble in the past and his nerves were working too much. Resident #2 stated he never touched or kissed another resident in the facility. Interview on 09/13/2023 at 11:19 a.m. with S1 Administrator revealed she reviewed the video surveillance after the incident on 08/17/2023 at 10:45 a.m. with S2 DON, S3 MDS, and the Nurse Practitioner. S1 Administrator reported Resident #1 was sitting in Area A near the middle, and Resident #2 was sitting near the couch. S1 Administrator reported Resident #2 wheeled himself over to Resident #1, who was sitting in a geri-chair, and Resident #2 kissed her on the lips for a few seconds. S1 Administrator stated Resident #2 then came up, and then he kissed her again the same way for a few seconds. S1 Administrator confirmed Resident #1 was cognitively impaired and could not make decisions or give consent, and Resident #2 should not have kissed her. Interview on 09/13/2023 at 11:40 a.m. with Resident #1's Primary Care Physician revealed Resident #1 does not have the ability to consent, nor the ability to fend anyone off. Interview on 09/13/2023 at 12:12 p.m. with S3 MDS Nurse, revealed she was in her office when she was notified by S4 Sunshine Aide on 08/17/2023 that she saw Resident #2 picking up his head from Resident #1's face. S3 MDS Nurse reported she watched the video surveillance of the incident. S3 MDS Nurse stated Resident #2 wheeled up to Resident #1, looked at her, and leaned in and kissed her. S3 MDS Nurse reported there were 2 kisses that each lasted less than a minute. S3 MDS Nurse stated she could not see Resident #2's mouth on the video, but Resident #1 had her mouth open a lot, and it was like a real kiss. She reported Resident #1 opened her mouth a lot related to Cerebral Palsy. Interview on 09/13/2023 at 1:30 p.m. with S4 Sunshine Aide revealed on 08/17/2023, she was walking toward Area A and saw Resident #2 picking up his head from Resident #1's face in Area A. S4 Sunshine Aide reported she saw no contact, but it looked suspicious, so she went over to him to ask him what he was doing. S4 Sunshine Aide stated Resident #2 said he was not doing anything. Telephone interview on 09/15/2023 at 12:20 p.m. with Resident #1 and Resident #2's Nurse Practitioner revealed she reviewed the video surveillance from 08/17/2023. She reported Resident #2 was by the couch, and he went over to Resident #1, who was sitting in her geri-chair, and kissed her. She stated the kiss was brief and she thought it was only one, but it was a while ago. Interview on 09/15/2023 at 12:46 p.m. with S2 DON revealed she watched the video surveillance of the incident that occurred on 08/17/2023 with Resident #1 and Resident #2. S2 DON reported Resident #2 wheeled in his wheelchair over to Resident #1, he spoke to her, and then leaned in and kissed her. S2 DON reported the kiss lasted about 5 seconds or so. S2 DON stated it was more than a peck. S2 DON stated she saw Resident #2's head lean down to Resident #1's face a second time, but she could not see what happened that time. S2 DON reported Resident #1 cannot give consent, and confirmed Resident #2 should not have kissed Resident #1. Interview on 09/15/2023 at 1:16 p.m. with S1 Administrator revealed she substantiated sexual abuse because Resident #1 was unable to consent to Resident #2's kisses.

Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to prevent the development and transmission of infection, by failing to ensure that ice chests used to serve the residents ice were appropriately cleaned and disinfected. This deficient practice had the potential to affect 62 residents who are served ice by the nursing staff. Findings: Review of the facility's policy titled Ice Pass, Water Pitchers & Ice Machine revealed in part . 8. Ice chest and carts should be cleaned daily by nursing assistant and sanitized weekly by the Housekeeping Department unless the Administrator has reassigned these duties. Observation on 08/01/2023 at 9:55 a.m. revealed S3 CNA passing ice from an ice chest on Hall A. Observation on 08/01/2023 at 10:00 a.m. revealed a 48 quart Igloo ice chest located on Hall A filled with ice. A reddish substance with scattered black specks in the inner gasket and inside the rim of the ice chest was observed. The ice was accessible and available for residents' use. Observation on 08/01/2023 at 10:03 a.m. revealed a 48 quart Igloo ice chest located on Hall B filled with ice. The ice chest's inner rim was noted to have a reddish substance with scattered black specks in the inner gasket and inside the rim of the ice chest. The ice was accessible and available for the residents' use. Observation on 08/01/2023 at 10:42 a.m. accompanied by S2 DON, after inspecting the ice chests on Halls A and B, confirmed the ice needed to be emptied and the ice chests were unsanitary and needed to be cleaned and disinfected. S2 DON stated it is the responsibility of the CNAs to fill the ice chest at the beginning of each shift. S2 DON stated the CNAs are to inspect the ice chest before filling them. SD2 DON stated the process for cleaning the ice chest included the CNAs taking the ice chests out to the back of the facility, spraying it with a pressure hose, and drying the inside and outside of the ice chest. S2 DON stated she was not certain what solution, if any, was used by the CNAs when pressure washing the ice chest. S2 DON stated the dietary department sanitized the ice chest with a specific disinfectant, and named the disinfectant. S2 DON immediately had housekeeping remove both ice chests from the halls. Interview on 08/01/2023 at 11:52 a.m. with S3 CNA revealed the ice chests are placed out by the 10:00 p.m. - 6:00 a.m. shift, and changed out as needed. S3 CNA stated the ice chest are supposed to be wiped inside and out before filling with ice. S3 CNA stated she never had to refill the ice chest, and was not familiar with how to clean the ice chests. S3 CNA stated she passed out ice from the ice chest on Hall A to 3 or 4 residents after breakfast this morning. S3 CNA stated she never looked in the ice chest before passing out ice to the residents. S3 CNA stated she was not aware that the ice was in an uncleaned ice chest. Interview on 08/01/2023 at 12:15 p.m. with S6 CNA revealed the night shift CNAs fill the ice chest. S6 CNA stated day shift CNAs do not refill the ice chests if the ice has not melted. S6 CNA stated there have been times she has noticed that the ice chests were filled with ice, and they were nasty, the inside cover was not cleaned, and the insides of the ice chests were dirty. S6 CNA stated whenever she noticed the ice chest being dirty inside, she would dump the ice out, wipe the inside with a rag, then refill the ice chest(s) with ice. S6 CNA stated she was rehired by the facility in 09/2022, and has never taken an ice chest out and sprayed it out to clean it. S6 CNA stated each shift is responsible for filling the ice chest, and she was not certain who was responsible for keeping the ice chests cleaned. Interview on 08/01/2023 at 12:20 p.m. with S7 CNA revealed she is an Agency CNA, and has been assigned to the facility for approximately 1 year and works 6:00 a.m.- 2:00 p.m. S7 CNA stated that the ice chests are filled every shift by the CNA(s). S7 CNA stated she was not certain who cleaned the ice chests, or and how they were cleaned because she never had to refill an ice chest. S7 CNA stated she was never instructed on the policy and procedure of cleaning the ice chests prior to filling them with ice for use by the residents.

Based on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#55) of 19 sampled residents. The facility failed to accommodate Resident #55's choice to get out of bed and to have a shower instead of a bed bath. Findings: Review of Resident #55's clinical record revealed an admitted [DATE] with diagnoses that included: Obesity, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, Essential Hypertension, Chronic Congestive Heart Failure and Chronic Kidney Disease Stage 3. Review of Resident #55's Quarterly MDS with an ARD of 07/05/2023 revealed a BIMS of 15 (cognitively intact). Resident #55 required two-person physical assist with bed mobility, transfers, dressing, personal hygiene and bathing. Review of Resident #55's Care Plan with a Target Date of 10/04/2023 revealed Resident #55 required assistance with ADLs. Interventions included in part: assist with ADLs as needed, allow rest breaks between tasks, refer to OT/PT/ST if needed and transfer x2 person assistance with a lift. Review of Resident #55's Care Conference Summary dated 03/2023 revealed Resident #55 typically received a bed bath but requested to get out of bed for a shower and S8 SSD was to make sure Resident #55 got out of bed for a shower. A Review of Resident #55's ADL flow chart from 06/2023 - 07/2023 revealed Resident #55 received a bed bath on his scheduled bath days. A review of Resident #55's Nurses notes from 06/2023 - 08/2023 revealed no documentation of Resident #55 refusing to get out of bed. An observation on 08/01/2023 at 11:03 a.m. revealed Resident #55 in bed. Interview at that time with Resident #55 revealed he wanted to get up out of bed. Resident #55 stated that he had asked staff to get him out of bed into a wheelchair on several occasions but staff gave him various reasons as to why he could not get out of bed. Resident #55 reported the wheelchair the facility provided had been missing from his room for the last 3 months and he felt like that was partially the reason he was not allowed to get out of bed. Resident #55 stated he was told by staff that since he has pressure ulcers to his backside getting up would be counterproductive for healing. An interview on 08/01/2023 at 11:50 a.m. with S3 CNA revealed that Resident #55 used to get out of bed when therapy was working with him but he no longer gets out of bed. S3 CNA stated it had been a while since she has asked Resident #55 if he wanted to get out of bed because of the wound on his backside. S3 CNA reported she had been told (unsure by who) Resident #55 should not get out of bed because of his wounds. An interview on 08/01/2023 12:00 p.m. with S9 LPN revealed Resident #55 only gets out of the bed for MD appointments. S9 LPN stated she has not offered to assist Resident #55 with getting up out of bed in a while. An interview on 08/02/2023 at 9:10 a.m. with S10 CNA revealed she has never offered to get Resident #55 up out of bed because she did not know where his wheelchair was and that he was too big to get up with the lift. An interview on 08/02/2023 at 10:20 a.m. with S8 SSD revealed after the 03/2023 care conference meeting with Resident #55, she notified the management team that Resident #55 wanted to get out of the bed for a shower instead of a bed bath. S8 SSD stated she observed therapy getting Resident #55 up for a shower to demonstrate to staff on one occasion after the management team was notified of Resident #55's wishes to get up for a shower. An interview on 08/02/2023 at 10:55 a.m. with S11 Treatment Nurse revealed she told staff it was best not to get Resident #55 up out of bed without consulting with the physician because she felt his wounds wound deteriorate. An observation on 08/02/2023 at 1:25 p.m. in Resident #55's room revealed Resident #55 lying in bed telling S2 DON that he would like to get out of the bed and into the shower. An interview on 08/02/2023 at 1:25 p.m. with S2 DON confirmed that staff should have gotten Resident #55 out of bed when he asked, but it had not been done.

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents' care equipment was maintained in a clean and sanitary condition for 1(Resident #45) of 19 sampled Residents. Findings: Review of the Facility's Policy/Procedure title Cleaning and Disinfection of Resident-Care Equipment read in part: Policy: Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected . current CDC recommendations to break the chain of infection. 2. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable). Review of Resident #45's EHR revealed he was admitted to the facility on [DATE], admitting Diagnoses included Type 2 Diabetes Mellitus, Malnutrition, Heart Failure, Hypertension, and Arterial Fibrillation. Review of Resident #45's August 2023 Physician orders revealed: Diabetisource 80 ml/hr. with 30 ml/hr. H2O auto flush continuous feedings. Review of Resident #45's Quarterly MDS with an ARD of 05/25/2023 revealed Resident #45 had a BIMS of 13 (cognitively intact). Observation of Resident #45 on 07/31/2023 at 10:30 a.m. revealed an enteral feeding of Diabetisource at 80 ml/hr. delivered by enteral pump on a pole. There were large amounts of a dried yellowish/brown substance noted on the back, knob and front facing of the enteral pump with dripping of the substance going down the pole. Interview on 07/31/2023 at 10:32 a.m. with Resident #45 revealed he had a peg tube and he received Diabetisource. Observation of Resident #45 on 07/31/2023 at 12:00 p.m. revealed an enteral feeding of Diabetisource at 80 ml/hr. continued, with yellowish/brown substance noted on the back, knob and front of the enteral pump with dripping of the substance going down the pole. Observation of Resident #45 on 08/01/2023 at 7:24 a.m. revealed an enteral feeding of Diabetisource at 80 ml/hr. continued with yellowish/brown substance noted on the back, knob and front of the enteral pump with dripping of the substance going down the pole. Observation of Resident #45 on 08/01/2023 at 9:45 a.m. revealed the enteral feeding of Diabetisource at 80 ml/hr. with the enteral pump and pole with yellowish/brown substances on both. Interview on 08/01/2023 at 9:45 a.m. with Resident #45 revealed he noticed the front of the enteral pump with something on it but was not certain how long it had been present. Observation on 08/01/2023 at 10:39 a.m. of Resident #45's enteral pump and pole accompanied by S2 DON who identified the dried substance as enteral feeding (Diabetisource). S2 DON confirmed the enteral feeding pump and pole were unsanitary and should have been cleaned and wasn't. S2 DON stated the nurse(s) should have immediately wiped the machine and pole of any spills and not allowed them to dry on the machine and the pole.

Based on observation, interview and record review, the Facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The Facility failed to provide baths/showers for 2 (Resident #59 and Resident #60) of 19 sampled residents for ADL care. Findings: Resident #59 Review of Resident #59's medical record revealed an admitted [DATE] with diagnoses that included Type 2 DM, ESRD, Dependent of Renal Dialysis, Hypertensive Heart Disease with Heart Failure and Unilateral Primary Osteoarthritis of Left Hip. Review of Resident #59's Quarterly MDS with an ARD of 06/13/2023 revealed a BIMS score of 12. Resident #59's MDS revealed behaviors not exhibited for rejection of care. Resident #59 required one person assistance for bathing and supervision with personal hygiene. Review of Resident #59's Care Plan with a target date of 09/12/2023 revealed Resident #59 required assistance with ADLs with goal for increased independence. Approaches included in part . to assist with ADLs as needed. Review of Resident #59's Completed Shower log for 07/2023 - 08/2023 revealed no documentation that Resident #59 received showers on the following scheduled dates: Tuesday, 07/18/2023; Thursday, 07/20/2023; Saturday, 07/27/2023; Tuesday, 07/25/2023; Thursday, 07/27/2023; Saturday, 07/29/2023 and Tuesday, 08/01/2023. Interview on 07/31/2023 at 3:55 p.m. with Resident #59 stated he had just returned from dialysis and he had last received a shower on Thursday, 07/27/2023. Resident #59 stated he preferred showers and asked for a shower this past weekend but did not get one. Observation of Resident #59 revealed he was wearing a maroon shirt, black pants and gray tennis shoes. Interview on 08/01/2023 at 09:51 a.m. with Resident #59 stated that last Thursday (07/27/2023) was the last time he had received a shower and he had been asking every day since Saturday (07/29/2023) to get a shower but had not received a bath or shower. Resident #59 stated he had not refused to get a bath or shower. Observation of Resident #59 revealed he was wearing a maroon shirt, black pants and gray tennis shoes. Interview on 08/01/2023 at 4:11 p.m. with S7 CNA stated that Resident #59 was able to wash and dress himself and able to transfer to and from his wheelchair by himself. S7 CNA stated she was not assigned to him and had not given him a shower. Interview on 08/02/2023 at 09:10 a.m. with Resident #59 stated he had not received a bath or shower last night. Resident #59 stated he goes to dialysis today and was hoping to get a shower before he goes. Observation at this time revealed Resident #59 wearing the same black pants as he had worn on the previous days. Resident #59 stated that he had changed his own shirt yesterday. Interview on 08/02/2023 at 10:01 a.m. with S4 CNA stated Resident #59 and Resident #60 were scheduled to get baths 3 times a week on Tuesdays, Thursdays and Saturdays. S4 CNA stated she had not had a chance to catch up on the residents who needed baths that were not done yesterday. Interview on 08/02/2023 at 10:25 a.m. with S2 DON stated S3 CNA was assigned to bathe Resident #59. S2 DON confirmed S3 CNA did not bathe or shower yesterday on 08/01/2023 on the 2-10 shift and should have. Resident #60 Review of Resident #60's medical record revealed an admitted [DATE] with diagnoses that included Lack of Coordination, Acquired Absence of Left Leg Below Knee, Orthopedic After Care following Surgical Amputation, Type 2 DM, Generalized Muscle Weakness, Difficulty in Walking, Unsteadiness on Feet, Limitation of Activities due to Disability, Personal History of TIA and Cerebral Infarction. Review of Resident #60's Quarterly MDS with an ARD of 06/15/2023 revealed a BIMS score of 12. Resident #60's MDS revealed behaviors not exhibited for rejection of care. Resident #60 required extensive assistance with one person assistance for bathing and toileting and required limited assistance for bed mobility, transfers, dressing and personal hygiene. Resident #60's functional limitation in ROM without impairment to upper extremities and impairment on one side of lower extremities. Resident #60 had indwelling urinary catheter, and occasionally incontinent of bowels. Review of Resident #60's Care Plan with target date of 09/14/2023 revealed Resident #60 required assistance with ADL's with goal for increased independence. Approaches included in part . to assist with ADL's as needed. Review of Resident #60's Completed Shower log for 07/2023 - 08/2023 revealed no documentation that Resident #60 received a shower on his scheduled dates of Thursday, 07/20/2023 and Tuesday, 08/01/2023. On Saturday, 07/29/2023 was documented as Resident #60 refused. Observation on 07/31/2023 at 10:38 a.m. of Resident #60 awake sitting up in his bed wearing a black t-shirt with a small hole in the front and gray pants. Interview on 08/01/2023 at 8:47 a.m. with Resident #60 stated he should have received a bath 2 days ago and had not gotten a shower yet. Resident #60 stated he had not refused to get a bath or shower. Observation of Resident #60 revealed he was wearing a black t-shirt with one small hole in the front and gray pants. Interview on 08/01/2023 at 4:11 p.m. with S6 CNA stated that Resident #60 was able to transfer to and from his wheelchair by himself. S6 CNA stated she was not assigned to him and had not given him a shower. Interview on 08/02/2023 at 9:18 a.m. with Resident #60 stated he had been wanting a shower since Sunday (07/30/2023). He stated he had been waiting all morning and was ready for a shower. Resident #60 stated he put his clean clothes on his bed to change into after. Observation of Resident #60 revealed he was wearing a black t-shirt with a small hole in the front and gray pants. Interview on 08/02/2023 at 10:40 a.m. with S2 DON revealed Resident #60 was wearing the same black t-shirt with a hole in the front for 3 days. S2 DON confirmed the daily staffing schedule with shower/ bath assignments indicated no documentation for Resident #60 on 08/01/2023. S2 DON confirmed that both Resident #59 and Resident #60 needed to be bathed and were scheduled to receive showers. S2 DON confirmed that Resident #59 and Resident #60 did not receive showers and should have.

Based on interview, observation, and record review the Facility failed to develop and implement written policies and procedures to protect Residents from abuse, neglect, exploitation and misappropriation of their property by failing to screen Agency/Contract Staff's background prior to allowing 2 of 2 unlicensed sampled (S7 Agency CNA and S8 Agency CNA) Agency/Contract Staff to work in the Facility. This practice had the potential to affect all Residents in the Facility. Findings: Interview on 11/15/2022 at 11:40 a.m. with S1 DON revealed the provider had not developed a written policy concerning the completion of criminal history background checks for unlicensed Agency staff. S1 DON confirmed that she did not have documentation of unlicensed Agency Staff background checks prior to allowing them to work in the Facility. The DON also stated they did not keep records on Agency Staff that worked in the Facility. She stated the Facility used a computer program that allowed them to visualize Agency Staff background checks at any time. She further revealed she was the only staff member who had access to this information but she was unaware she needed to screen Agency/Contract Staff prior to them working in the Facility. Observation on 11/15/2022 at 11:40 a.m. revealed S1 DON demonstrated their process using the computer system to pull up S7 Agency CNA and S8 Agency CNA background check information. Record review during the above observation only revealed S7 Agency CNA's background check was performed 09/26/2022 and S8 Agency CNA's was performed 08/07/2022 and that both had passed. There was no documentation provided which evidenced criminal history background checks had been completed by authorized providers. Interview on 11/18/2022 at 9:36 a.m. with S1 DON revealed S7 Agency CNA's first day to work in the Facility was 07/22/2022 and S8 Agency CNA's first day was 08/11/2022. Review of the Facility's Use of Outside Resources/Contract Staff Policy revealed in part, the following: 2. The facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services. 3. Individuals/Agencies who provide individuals performing services on a contract basis will be required to adhere to State and Federal regulations governing the facility as well as to remain in compliance with their licensing board.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 residents (#264 and #43), in a total sample of 64 residents. The facility failed to: 1. Immediately consult with the physician after Resident #264 sustained a fall, and was assessed by licensed staff to complain of pain to the left hip. 2. Ensure a delay in treatment did not occur for a resident (#43) who was discovered to have a bruise to his right arm. This deficient practice resulted in an actual harm situation for Resident #264 on 06/26/2022 at approximately 11:51 p.m., when S10 LPN received report that Resident #264 had fallen on the floor. S10 LPN assessed Resident #264 on 06/26/2022 at 11:51 p.m., with findings that Resident #264 complained of pain to his left hip when he was transferred from the floor to his bed, and did not notify the physician. Resident #264 continued to complain of pain to his left hip throughout the night, when he was turned and repositioned. The physician was not notified. Resident #264 continued to complain of pain when he was assessed by S11 LPN on 06/27/2022 at 8:27 a.m. S11 LPN contacted the physician on 06/27/2022 at 8:27 a.m. and received orders for portable x-rays. The x-ray results dated 06/27/2022 at 10:40 a.m. read that there was a visible fracture to Resident #264's left hip. Resident #264 was transferred to a local hospital on 06/27/2022 at 11:22 a.m. where x-rays revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #264 was transferred to another hospital on 06/27/2022 where he received surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Resident #264 Review of Resident #264's Medical Record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #264's Minimum Data Set, dated dated dated [DATE] revealed a BIMS (Brief Interview for Mental Status) Score of 10, indicating the resident was moderately impaired cognitively. The MDS revealed Review Resident #264 required extensive 2+ persons physical assistance for bed mobility and transfers; extensive assistance of 1 person for locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Review of Resident #264's Comprehensive Plan of Care with a target date of 08/18/2022 revealed Resident #264 was care planned for being at risk for falls. On 06/26/2022 a new intervention was put in place after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's note dated 06/27/2022 at 6:30 a.m. documented by S10 LPN revealed the resident was heard yelling for help. Upon entering the room the resident was laying on the floor. When asked what he was doing, he stated I was trying to get my feet untangled. The resident denied hitting head, but does complain of left hip pain. Further documentation revealed there were no visible injuries noted, but the resident experienced pain during ROM. Resident #264 had a small scrape to left arm noted and he was in stable condition. The resident's vital signs were WNL. Administered PRN [MEDICATION(S)] (muscle relaxer), and physician and RP were notified. Review of nurses' notes dated 06/27/2022 at 8:27 a.m. documented by S11 LPN revealed the resident complained of left hip pain and the physician was notified with new orders for portable x-rays of the left hip, femur, knee and tib/fib. At 8:45 a.m. S11 documented she attempted to contact the wife of the fall, but there was no answer. At 10:40 a.m. a portable x-ray present to obtain x-rays. The resident complained of left hip pain with movement while attempting imaging. The x-ray of the left hip showed a visible fracture was noted. The physician was notified and the resident was sent by ambulance to the hospital. Review of results of the portable x-ray of the left hip, unilateral with pelvis dated 06/27/2022 at 2:14 p.m. revealed an acute appearing femoral neck fracture was present, with mild displacement and moderate shortening deformity. Interview with S2 DON on 08/17/22 12:25 p.m. confirmed there was no documentation in the nurses' notes regarding a fall on 06/26/2022. S2 DON revealed the following process: if they don't hear back from the physician the next day, then it is assumed the physician did not want any new orders. S2 DON stated the staff do not call back the next morning to ensure the physician received the fax, or if there were new orders. S2 DON stated there was an incident and accident form for Resident #264 that was completed for another fall that occurred on 06/26/2022 at 11:31 p.m. However, S2 DON stated there was no documentation that the physician was faxed or called regarding the fall that occurred on 06/26/2022 at 11:51 p.m., and that Resident #26 complained of pain to his left hip. S2 DON stated that an order was received on 06/27/2022 at 8:27 a.m. after S11 LPN reported to the physician that Resident #264 still complained of left hip pain. Interview with Resident #264's physician on 08/17/2022 at 12:43 p.m. revealed that the nursing home notifies him of an issue regarding one of his residents via fax. The physician stated when a fax go to his office, he looks at them the next morning. The physician stated he had an understanding with the nursing home, that if a resident had an injury and complained of pain, they were to send the resident to the hospital. The physician stated the nurses do their own assessments and determined whether they should fax or send the resident to the emergency room . The physician stated there are times when staff will call him, but most of the time he was contacted by fax. The physician stated if he had received the call that Resident #264 had fallen and was complaining of pain, he would have sent him to the emergency room for an evaluation. The physician stated the nurse should have sent him to the emergency room . Interview with S11 LPN on 08/17/2022 at 4:15 p.m., revealed she worked on the 7:00 p.m. to 7:00 a.m. shift on 06/27/2022, and when she came into work, she collected the morning packets, which included the Incident and Accident reports. S11 LPN stated when she read the reports she saw where Resident #264 complained of pain, and knew immediately she needed to do an assessment on Resident #264. S11 LPN stated Resident #264 complained of pain to his left hip when she assessed him. S11 LPN revealed she contacted the resident's physician and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S11 LPN stated that when Resident #264 complained of pain to his left hip immediately after the fall, the nurse should have sent Resident #264 to the emergency room , and/or contacted the physician by phone, but didn't. Review of the 06/2022 eMAR revealed on 06/27/2022 at 12:00 a.m., S10 LPN administered [MEDICATION(S)] 10 mg one by mouth to Resident #264 for muscle spasm that was rated as a 5, on a pain scale of 1-10 with 10 being most severe muscle spam. During an Interview with S2 DON on 08/17/2022 at 4:50 p.m., she stated an in-service was done on 06/27/2022 regarding reporting incidents to the MD timely and to the DON. S2 DON stated the in-service did not include the agency nurses. S2 DON stated she did not think about doing an in-service with the agency nurses. S2 DON revealed there was a binder for staff to review communications reports, but was not sure if the agency staff reviewed it. S2 DON stated the nurse who worked on 06/26/2022 was an agency nurse, and if there had been a facility staff present, they could have helped guide the agency nurse in the correct procedure. Interview with S8 CNA on 08/18/22 at 8:25 a.m. revealed she worked from 7:00 p.m. to 7:00 a.m. on 06/26/2022. S8 CNA stated she was in the dining room when another CNA came in and told her to come help get Resident #264 off the floor. S8 CNA stated when she arrived at the room, Resident #264 was lying on the floor next to his closet. S8 CNA stated she helped S10 LPN pick Resident #264 up and placed him back in bed. S8 CNA stated Resident #264 complained of left hip pain at the time he was placed back in his bed. S8 CNA stated Resident #264 had not complained of hip pain prior to the incident. S8 CNA stated each time she went into his room to check, change and reposition him, (every 2 hours) he complained of pain to his hip. S8 CNA stated she reported it to his nurse (S10 LPN). Interview with S10 LPN on 08/18/2022 at 08:35 a.m. revealed she worked the 7:00 p.m. - 7:00 a.m. shift of 06/26/2022, as an agency nurse and cared for Resident #264. S10 LPN stated that a CNA came and told her Resident #264 had fallen. S10 LPN stated that when she went into the room, Resident #264 was lying on the floor. S10 LPN stated Resident #264 complained of pain to his left hip when she assessed him. S10 LPN stated she faxed the physician regarding Resident #264's fall and complaint of pain. S10 LPN stated she thought the physician may have wanted to order an x-ray. S10 LPN stated on the weekends and after hours she never calls the physician, she just faxed him. S10 LPN revealed that the CNA did report that Resident #264 complain of pain to his left hip when they reposition him. S10 LPN stated she just did know whether to send out or not, so she didn't. S10 LPN stated she had not received any training on when to call the physicians for emergencies, and had not been in-serviced since that incident on 06/26/2022 regarding when to contact the physician after an incident/accident occurred. Interview with S2 DON on 08/18/2022 at 9:14 a.m. revealed that S10 LPN had not been in-serviced after the incident that occurred on 06/26/2022, and should have. Observation on 08/18/22 at 1:30 p.m. revealed the resident was lying in bed. It was noted that the bed was not in the lowest position, 1/4 SR were up, there was no bed alarm was on the bed, and there was only one fall pad on the floor, to the resident's right side. Resident #43 Review of Resident #43's clinical record revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Quarterly MDS with an ARD of 06/27/2022 revealed a BIMS of 13 (indicating the resident was cognitive). The MDS revealed Resident #43 exhibited rejecting care during the assessment period. The MDS revealed the resident required extensive assistance of 2+ persons for personal hygiene; extensive assistance of 1 person with dressing; and extensive assistance with 1 person for bed mobility and extensive assistance 2 persons for transfers, and extensive assistance of 1 person for toileting. MDS revealed Resident #43 had no upper and lower extremity ROM impairments. Review of Resident #43's Care Plan with a Target Date of 05/31/2022 revealed a problem of noncompliance r/t refusal to allow staff to assist with ADL's, assist with transfers, and refusal of medication and meals. Interventions included: counseling as needed for noncompliance or inappropriate behavior. The Care Plan revealed on 04/26/2022 that Resident #43 refused wound care, resident stated We will do treatments tomorrow. Review of the nurses' notes for Resident #43 documented by S5 LPN revealed in part .07/06/2022 at 4:01 a.m. Resident #43 was sent to a local hospital emergency room via med express. Resident #43's right arm was swelling, warm and hard to touch, and purple/reddish discoloration around upper extremity/armpit area. Review of the referral record for Resident #43 documented by S5 LPN revealed in part .07/06/2022 at 5:48 a.m., Resident #43 had right upper arm swelling, discoloration, and warmth from shoulder to elbow. Review of the facility transfer log revealed Resident #43 left the faciity on [DATE] at 6:31 a.m. Review of Resident #43's hospital records dated 07/07/2022 revealed in part . Resident #43 complained of right upper arm pain and swelling. The CTA showed a large hematoma throughout the axillary region and upper arm, within deep facial planes. Resident #43 was diagnosed with a Pseudoaneurysm. Further review of hospital records revealed Resident #43 was taken to surgery on 07/07/2022 for I & D of Right Upper Extremity and 500 cc old clot was removed. Observation and interview with Resident #43 on 08/16/2022 at 8:55 a.m. revealed him lying in bed, alert, and oriented to person, place and time. Resident #43 was observed to have a bandage on his right upper arm. Interview with Resident #43 on the above date and time revealed S7 CNA hurt his right arm, when she grabbed his left upper shoulder and flipped him over on his right side, and He pushed her off of him. Resident #43 stated S5 LPN was in the room also, and wanted to look at an area on his head, and he (Resident #43) refused the assessment. Resident #43 stated that's when S7 CNA flipped him over. Resident #43 revealed the next morning his arm was black and blue, and he was sent to the hospital. Review of a written statement documented by S5 LPN revealed in part .Upon med pass (no documented date or time), I, (S5 LPN) noticed Resident #43 had a bruise to right upper extremity. At the 4:00 a.m. medication pass, staff alerted this nurse (S5 LPN) to assess Resident #43's arm because the arm had become swollen. S5 LPN assessed Resident #43's right arm to be visibly swollen, hard, warm to touch and discolored. S5 LPN sent Resident #43 to the emergency room . Review of a written statement documented by S6 LPN revealed in part . When this nurse (S6 LPN) arrived to work on 07/06/2022 at 5:30 a.m., S5 LPN asked me (S6 LPN) to assess Resident #43's right arm. S6 LPN documented bruising to Resident #43's right arm, right elbow, right shoulder, and under his armpit. S6 LPN advised S5 LPN to send Resident #43 out to be safe. Interview on 08/16/2022 at 4:13 p.m. with S5 LPN revealed she worked the 7:00 p.m. to 7:00 a.m. on 07/05/2022, and during the 7:00 p.m. medication pass, she noticed a bruise to Resident #43's right arm. S5 LPN revealed she asked Resident #43 what happened to his right arm, and Resident #43 stated He may have bumped his arm. S5 LPN stated she was called to Resident #43's room on 07/06/2022 at 4:00 a.m. by S7 CNA or S8 CNA to observe Resident #43's right arm. S5 LPN revealed Resident #43's right arm was swollen, hard, and warm to touch. Interview on 08/17/2022 at 8:17 a.m. with S7 CNA revealed on 07/05/2022 (she could not remember the time) S5 LPN wanted to assess Resident #43's arm and shoulder because it was red and swollen. S7 CNA stated she tried to hold Resident #43 up by his hips so S5 LPN could assess the back of his arm. Interview on 08/17/2022 at 9:45 a.m. with S5 LPN revealed she could not remember if the previous nurse told her anything about Resident #43 having a bruise to his left arm or shoulder. S5 LPN stated during the medication pass around 8:00 p.m. or 9:00 p.m. on 07/05/2022, she (S5 LPN) noticed a bruise on Resident #43's right arm. S5 LPN stated on 07/06/2022 around 4:00 a.m., S7 CNA or S8 CNA asked her if she could observe Resident #43's right arm again. S5 LPN revealed Resident #43's right arm was warm, hard, swollen, and a reddish/purple color. S5 LPN stated she should have documented her assessment and notified S2 DON for further instructions, but didn't. Interview on 08/17/2022 at 8:54 a.m. with S8 CNA revealed when she arrived to work on 7/5/2022 at 8:30 p.m., she heard a lot of loud noise coming from Resident #43's room. S8 CNA revealed Resident #43 asked her to come into his room when he heard her voice, and he put everyone else out of his room. S8 CNA stated Resident #43 had a bruise on his right arm. S8 CNA stated she asked Resident #43 what happened to his arm, and he stated he did not know. Interview on 08/18/2022 at 7:50 a.m. with S6 LPN she worked from 7:00 a.m. to 7:00 p.m. on 07/06/2022. S6 LPN stated on 07/06/2022 (could remember a time) S5 LPN asked her to assess Resident #43's right arm. S6 LPN stated Resident #43's right arm was swollen, hard, and warm to touch. S6 LPN revealed she told S5 LPN to send Resident #43 to the emergency room to be safe. Interview on 08/18/2022 at 9:27 a.m. with S5 LPN revealed when S6 LPN, came to work on 07/06/2022 at 5:30 a.m., she asked her to assess Resident #43's arm. S5 LPN revealed S6 LPN advised her to send Resident #43 out for an evaluation. Interview on 08/18/2022 at 9:31 a.m. S6 LPN revealed when she came to work on 07/06/2022 at 5:30 a.m., S5 LPN asked her to asses Resident #43's arm. S6 LPN revealed Resident #43's arm was swollen and bluish in color. S6 LPN revealed she advised S5 LPN to send Resident #43 out to the hospital for an evaluation. Interview on 08/18/2022 at 3:00 p.m. with S2 DON revealed S5 LPN should have notified her when the bruise was found on 07/05/2022 at 8:30 p.m. medication pass. S2 DON confirmed Resident #43 did not receive medical attention timely.