Every finding on record at Ferncrest Manor Living Center

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program.Findings:Review of the facility's Pest and Insect Control Policy & Procedure revised August 2025 revealed, in part, an effective, regular basic pest control program was maintained so the facility may be free of pests and rodents. Further review revealed the following:All garbage and refuse was to be disposed of properly. The garbage storage area was to be maintained in a sanitary condition to prevent harborage and feeding of pests. Garbage containers are covered when removed from the kitchen area to the disposal area. All garbage should be brought out after every meal. The waste disposal company was responsible for dumpster pick up. Pest control contractors were to come to the facility once a month. If needed, the contractor would come to the facility more frequently or in an emergency. Maintenance employees were to check for pests, rodents and insects during walk throughs, and bug light trap pads should be changed every Tuesday. When there was a report of any type of pest or insect in the facility or on grounds, maintenance must be notified. Maintenance would then coordinate with the pest control contractor to come and treat the facility/grounds and look at preventative measures for the future. Observation on 06/15/2026 at 9:25AM of Hall A revealed 1 fly was noted flying in the hall.Observation on 06/15/2026 at 9:26AM of Hall B revealed 2 flies were noted flying in the hall. In an interview on 06/15/2026 at 9:28AM, S3Registered Nurse (RN) stated she was assigned Hall A. S3RN further stated she noticed numerous flies in the facility during the months of April and May 2026 and had noticed a few so far in the month of June 2026. Observation on 06/15/2026 at 9:35AM of Hall C revealed 2 flies were noted flying in the hall.Observation on 06/15/2026 at 9:45AM of Hall E revealed 1 fly was noted flying in the hall.In an interview on 06/15/2026 at 10:00AM, S5Licensed Practical Nurse (LPN) stated she was assigned to residents residing on part of Hall B and Hall C. S5LPN further stated last month, there was an issue with flies in the facility, including in residents' rooms. In an interview on 06/15/2026 at 10:15AM, S6LPN stated last month, S6LPN noted flies in the facility including in the residents' rooms. In an interview on 06/15/2026 at 10:25AM, S7Housekeeping stated last month, the flies were bad in the facility. S7Housekeeping further stated she counted about 20 flies in one day. S7Housekeeping further stated S7Housekeeping still sees a few flies a day now. Observation on 06/15/2026 at 1:30PM of the interior and the exterior of the facility with S2Plant Operations Manager revealed immediately on the outside of Hall C's exit door near the dining room, there was a large bin on wheels with a large amount of clear/white plastic bags containing garbage. Further observation revealed 2 large gray garbage bins were uncovered. Further observation revealed one of the mentioned gray garbage bins contained used gloves, 2 empty water bottles, and loose papers, all of which were not contained in a garbage bag. Further observation revealed the other gray garbage bin had loose paper, loose gloves, and an open carton of a protein supplement, all of which were not contained in a garbage bag. Further observation revealed 4 to 5 flies were noted flying around the outside of Hall C's exit door. Observation on 06/16/2026 at 8:49AM of Hall A revealed 1 fly was noted flying in the hall.Observation on 06/16/2026 at 8:50AM revealed immediately on the outside of Hall C's exit door near the dining room, 2 large gray garbage bins, uncovered. Further observation revealed 1 of the mentioned gray garbage bins contained used gloves, 2 empty water bottles, and loose papers, all of which were not contained in a garbage bag. Further observation revealed the other gray garbage bin had loose paper, loose gloves, and an open carton of a protein supplement, all of which were not contained in a garbage bag. Further observation revealed 4 to 5 flies were noted flying around the outside of Hall C's exit door and landing on cement. Further observation revealed 1 hanging fly strip full of dead flies.In an interview on 06/16/2026 at 8:51AM, S8Maintenance stated Hall C's exit door near the dining room was opened 5 to 7 times a day to bring trash to the dumpsters. S8Maintenance further stated the 2 large gray trash bins should not have loose garbage in them and should be covered. S8Maintenance further stated the flies were an ongoing issue at the facility during this time of the year.Observation on 06/16/2026 at 9:15AM of Hall C revealed 2 flies were noted flying in the hall.In a telephone interview on 06/16/2026 at 9:24AM, the facility's contracted pest control company's staff member stated on 05/26/2026, he was at the facility and provided his normal monthly pest control services, which included spraying for crawling insects only. The facility's contracted pest control company's staff member further stated no one from the facility informed him there was an issue with the flies or that the facility needed additional treatment. The facility's contracted pest control company's staff member further stated he noted flies in the facility but only a few during his visit. The facility's contracted pest control company's staff member further stated the facility had issues with fly infestation during this time of the year. The facility's contracted pest control company's staff member further stated he talked with S1Administrator approximately 2 months ago and offered to put out fly bait but, S1Administrator had never responded to his suggestion. In an interview on 06/16/2026 at 10:30AM, S9Director of Nursing (DON) stated the flies were bad inside and outside of the facility in April and May 2026, and S9DON was still noticing a few in the facility at this time. Observation of the smoker's patio on 06/16/2026 at 11:30AM revealed several flies flying around. Further observation revealed 2 residents in wheelchairs entered the facility through an automatic door, and 1 fly was observed entering the facility through the automatic door. In an interview on 06/16/2026 at 12:21PM, S1Administrator stated the facility should have maintained a pest free environment.

Based on observation and interviews, the facility failed to provide silverware at meal service.Findings:Observation on 05/19/2026 at 11:28AM revealed 15 unidentified residents ate lunch in the dining room. Further observation revealed the 15 residents were provided with disposable cutlery.On 05/19/2026 at 10:30AM a Resident Council meeting was held with Resident #11, Resident #27, Resident #55, Resident #89, and Resident #136.In an interview on 05/19/2026 at 10:57AM, Resident #11 indicated they were almost always provided disposable cutlery for meal service.In an interview on 05/19/2026 at 10:58AM, Resident #136 indicated they were almost always provided disposable cutlery for meal service.In an interview on 05/19/2026 at 10:58AM, Resident #11 indicated he did not like to use a disposable knife during meals. Resident #11 further indicated it was difficult to cut food with a disposable knife.In an interview on 05/19/2026 at 11:00AM, Resident #136 indicated she did not care to use disposable cutlery for meals. Resident #136 indicated there have been times when the disposable fork had cracked in half during her meal.In an interview on 05/20/2026 at 9:55AM, S12Dietary Supervisor indicated the residents were provided with disposable cutlery at least 1 to 2 days a week because the silverware was not returned to the kitchen in a timely manner. In an interview on 05/20/2026 at 10:10AM, S1Administrator indicated the facility had to use disposable cutlery at times because the silverware was either thrown away by residents and staff or the silverware was not returned to the kitchen. S1Administrator indicated the use of disposable cutlery was a dignity concern.

Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 sampled medication carts reviewed for controlled substance documentation requirements. Findings:Review of the facility's Controlled Substances policy and procedure, dated 09/01/1994, and revised on 06/11/2025, revealed, in part, controlled medications were counted at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty determined the count together. Review of the facility's May 2026 Medication Cart a Narcotic Nurse Sign Off Log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart a's controlled substances with the oncoming nurse on:- 05/06/2026 for the 7:00PM to 7:00AM shift; - 05/10/2026 for the 7:00AM to 7:00PM shift; and,- 05/12/2026 for the 7:00AM to 7:00PM shift.Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 05/15/2026 for the 7:00PM to 7:00AM shift.In an interview on 05/19/2026 at 8:40AM, S11Licensed Practical Nurse (LPN) indicated the Narcotic Nurse Sign Off Log should have been signed by the off going and oncoming nurse during shift change daily to indicate a correct and accurate count of all controlled substances.Review of the facility's May 2026 Medication Cart b Narcotic Nurse Sign Off Log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on:- 05/04/2026 for the 7:00PM to 7:00AM shift; - 05/08/2026 for the 7:00AM to 7:00PM shift;- 05/09/2026 for the 7:00AM to 7:00PM shift;- 05/09/2026 for the 7:00PM to 7:00AM shift;- 05/10/2026 for the 7:00AM to 7:00PM shift;- 05/12/2026 for the 7:00AM to 7:00PM shift;- 05/13/2026 for the 7:00AM to 7:00PM shift;- 05/13/2026 for the 7:00PM to 7:00AM shift;- 05/14/2026 for the 7:00AM to 7:00PM shift;- 05/18/2026 for the 7:00AM to 7:00PM shift; and,- 05/18/2026 for the 7:00PM to 7:00AM shift.Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart b's controlled substances with the off going nurse on:- 05/08/2026 for the 7:00AM to 7:00PM shift;- 05/09/2026 for the 7:00AM to 7:00PM shift;- 05/10/2026 for the 7:00AM to 7:00PM shift;- 05/12/2026 for the 7:00AM to 7:00PM shift;- 05/13/2026 for the 7:00AM to 7:00PM shift;- 05/14/2026 for the 7:00AM to 7:00PM shift; and,- 05/18/2026 for the 7:00AM to 7:00PM shift.Review of the facility's May 2026 Medication Cart c Narcotic Nurse Sign Off Log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart c's controlled substances with the oncoming nurse on:- 05/05/2026 for the 7:00AM to 7:00PM shift.- 05/12/2026 for the 7:00PM to 7:00AM shift; - 05/14/2026 for the 7:00AM to 7:00PM shift; and,- 05/17/2026 for the 7:00AM to 7:00PM shift.Review of the facility's May 2026 Medication Cart d Narcotic Nurse Sign Off Log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart d's controlled substances with the oncoming nurse on:- 05/04/2026 for the 7:00AM to 7:00PM shift;- 05/05/2026 for the 7:00AM to 7:00PM shift;- 05/12/2026 for the 7:00AM to 7:00PM shift;- 05/13/2026 for the 7:00AM to 7:00PM shift;- 05/14/2026 for the 7:00AM to 7:00PM shift;- 05/16/2026 for the 7:00AM to 7:00PM shift;- 05/17/2026 for the 7:00AM to 7:00PM shift;- 05/17/2026 for the 7:00PM to 7:00AM shift; and,- 05/18/2026 for the 7:00AM to 7:00PM shift.Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart d's controlled substances with the off going nurse on:- 05/06/2026 for the 7:00AM to 7:00PM shift;- 05/09/2026 for the 7:00AM to 7:00PM shift;- 05/13/2026 for the 7:00AM to 7:00PM shift; and,- 05/18/2026 for the 7:00AM to 7:00PM shift.In an interview on 05/20/2026 at 1:30PM, S2Director of Nursing (DON) confirmed off going and oncoming nurses were required to perform a count of the controlled substances at shift change together and sign the Narcotic Nurse Sign Off Log to indicate the medication cart's controlled substance count was conducted and there were no discrepancies.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure insulin (a medication that lowers blood glucose) multi-dose flex pens were dated when opened and/or removed from refrigerated storage or discarded as required (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d); and,2. Ensure opened, unpackaged, and/or unlabeled medication was not stored inside a medication cart (Medication Cart a).This deficient practice was identified for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 sampled medication carts observed for medication storage requirements. Findings:1.Review of the facility's Administering Medications policy and procedure, dated [DATE] and revised on [DATE], revealed, in part, when opening a multi dose container, the date the medication was opened should be recorded on the container. Review of the facility's Insulin Pen Administration policy and procedure, dated [DATE] and revised on [DATE], revealed, in part, opened insulin pens could only be kept at room temperature for up to 28 days. Further review revealed the opening date should be marked on the insulin pen to track expiration. Observation of Medication Cart a on [DATE] at 8:30AM revealed the following:-Resident #71's open insulin Lispro (a fast-acting insulin medication) multi-dose flex pen did not have an open date documented; -Resident #71's open insulin Lantus (a long-acting insulin medication) multi-dose flex pen did not have an open date documented;-Resident #131's open insulin Lantus multi-dose flex pen did not have an open date documented; and,-Resident #131's open insulin Novolog (a fast-acting insulin medication) multi-dose flex pen did not have an open date documented. In an interview on [DATE] at 8:40AM, S11Licensed Practical Nurse (LPN) indicated the above-mentioned multi-dose flex pens of insulin were opened, stored at room temperature, and should have been labeled with an opened date. S11LPN further indicated she did not know when the above-mentioned multi-dose flex pens of insulin were opened; therefore, the above-mentioned multi-dose flex pens of insulin in Medication Cart a should have not been available for resident use. Observation of Medication Cart b on [DATE] at 9:15AM revealed the following:-Resident #22's open insulin Novolog multi-dose flex pen did not have an opened date documented; and,-Resident #72's open insulin Novolog multi-dose flex pen did not have an opened date documented. In an interview on [DATE] at 9:20AM, S9LPN indicated the above-mentioned multi-dose flex pens of insulin were opened, stored at room temperature, and should have been labeled with an opened date. S9LPN further indicated she did not know when the above-mentioned multi-dose flex pens of insulin were opened; therefore, the above-mentioned multi-dose flex pens of insulin in Medication Cart b should have not been available for resident use. Observation of Medication Cart c on [DATE] at 9:40AM revealed the following:-Resident #127's open insulin Lantus multi-dose flex pen had an open date of [DATE] documented; and,-Resident #134's open insulin Novolog multi-dose flex pen did not have an opened date documented. In an interview on [DATE] at 9:45AM, S7LPN indicated Resident #127's insulin medication was opened, stored at room temperature, expired, available for use, and should not have been. S7LPN further indicated Resident #134's opened and undated insulin should not have been available for use. Observation of Medication Cart d on [DATE] at 9:54AM revealed Resident #90's open insulin Lantus multi-dose flex pen did not have an open date documented. In an interview on [DATE] at 10:00AM, S8LPN indicated Resident #90's multi-dose flex pen of insulin was opened, stored at room temperature, and should have been labeled with an opened date. S8LPN further indicated Resident #90's above-mentioned multi-dose flex pen of insulin should have not been available for resident use. In an interview on [DATE] at 1:30PM, S2Director of Nursing (DON) confirmed the above- mentioned insulin multi-dose vials should have been dated when opened and discarded 28 days after opening per the nursing standards of care. 2. Review of the facility's Storage of Medications policy and procedure, dated [DATE] and revised on [DATE], revealed, in part, drugs and biologicals should be stored in the packaging, containers, or other dispensing systems which they were received. Further review revealed, drugs that had missing, incomplete, or incorrect labels were to be returned to the pharmacy for proper labeling before storing. Observation of Medication Cart a on [DATE] at 8:30AM revealed 1 large oval white tablet and 1 small round off white pill stored in a medicine cup in the top left drawer of Medication Cart a.In an interview on [DATE] at 8:40AM, S11LPN indicated she did not know what the 2 uncontained and unidentified pills found in Medication Cart a were. S11LPN further indicated the 2 unidentified pills should not have been uncontained and unlabeled in Medication Cart a.In an interview on [DATE] at 1:30PM, S2Director of Nursing (DON) confirmed opened, unlabeled, loose medication should not have been stored in Medication Cart a.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure staff wore proper Personal Protective Equipment (PPE) while performing care for residents on Enhanced Barrier Precautions (EBP) (Resident #4, Resident #37); and,2. Ensure staff completed hand hygiene and wore proper PPE during the administration of an injection (Resident #131).This deficient practice was identified for 3 (Resident #4, Resident #37, Resident #131) of 6 sampled residents observed for infection control practices. Findings:Review of the facility's Enhanced Barrier Precautions policy and procedure, dated 04/01/2024 and revised on 05/05/2025, revealed, in part, EBP was utilized to prevent the spread of multi-drug resistant organisms to residents. Further review revealed EBPs employed targeted gown and glove use during high contact resident care activities when contact precautions did not otherwise apply. Further review revealed examples of high contact resident care activities which required the use of gown and gloves included changing linens, changing briefs or assisting with toileting, and device care such as a urinary catheter care. 1.Resident #4Review of Resident #4's May 2026 physician's orders revealed, in part, an order dated 03/09/2026 for EBP. Observation of Resident #4's room door on 05/18/2026 at 9:25AM revealed EBP signage which indicated gowns were required for high contact care activities such as incontinence care and changing linens. Observation on 05/18/2026 at 9:42AM revealed S18Certified Nursing Assistant (CNA) and S19CNA performed Resident #4's incontinence care and linen change without either S18CNA or S19CNA wearing a gown. In an interview on 05/18/2026 at 10:00AM, S18CNA indicated she did not wear a gown when she performed Resident #4's incontinence care and should have. In an interview on 05/20/2026 at 1:30PM, S2Director of Nursing (DON) indicated S18CNA and S19CNA should have worn a gown when incontinence care and the linen change was provided to Resident #4. Resident #37Review of Resident #37's record revealed, in part, Resident #37 was admitted to the facility on [DATE] with a diagnosis of dependence on respirator with a tracheostomy. Review of Resident #37's May 2026 physician's orders revealed, in part, an order dated 04/27/2026 for EBP. Observation of Resident #37's room door on 05/18/2026 at 9:39AM revealed EBP signage which indicated gowns were required for high contact care activities such as incontinence care and changing linens. Observation on 05/18/2026 at 9:39AM revealed S22CNA drained urine from Resident #37's urine collection bag without S22CNA wearing a gown. In an interview on 05/18/2026 at 9:40AM, S22CNA indicated the EBP sign on Resident #37's door was not for Resident #37, so there was no need to wear a gown. 2. Resident #131Review of the facility's Handwashing/Hand Hygiene policy and procedure, dated 09/01/1994 and revised on 05/11/2025, revealed, in part, single use disposable gloves were indicated before aseptic procedures and when anticipating coming into contact with blood or bodily fluids. Further review revealed hand hygiene was required to be performed prior to medication administration. Observation on 05/19/2026 at 8:21AM revealed S11Licensed Practical Nurse (LPN) administered Resident #131's Novolog (an insulin medication injected into the body to lower blood sugar) Novolog flex pen injection without performing hand hygiene and/or wearing gloves. In an interview on 05/19/2026 at 8:25AM, S11LPN indicated she did not perform hand hygiene and/or wear gloves to administer Resident #131's Novolog flex pen injection. S11LPN further indicated she did not normally wear gloves to administer an insulin injection to residents.

Based on observations, interviews, and record review, the facility failed to ensure residents' tube feeding pumps were clean and sanitary for 3 (Resident #4, Resident #35, Resident #106) of 33 sampled residents reviewed for environmental concerns during the initial pool observations. Findings: Review of the facility's Homelike Environment policy and procedure, dated [DATE] and revised on [DATE], revealed, in part, residents were provided with a clean, comfortable, and homelike environment. Further review revealed the facility staff maximized to the extent possible, a clean, sanitary and orderly environment. Resident #4 Observation on [DATE] at 1:20PM revealed the base of Resident #4's tube feeding pole and the surrounding floor was covered with an unidentified dried tan substance. Further observation revealed an unidentified dried sticky tan substance was present on the side and top of Resident #4's tube feeding pump. Observation on [DATE] at 10:40AM revealed numerous spots, varying in size, of an unidentified dried sticky tan substance on the base of Resident #4's tube feeding pole. Further observation revealed an unidentified dried sticky tan substance was present on the side and top of Resident #4's tube feeding pump. Observation on [DATE] at 9:00AM revealed numerous spots, varying in size, of an unidentified dried sticky tan substance on the base of Resident #4's tube feeding pole. Further observation revealed an unidentified dried sticky tan substance was present on the side and top of Resident #4's tube feeding pump. Resident #35 Observation on [DATE] at 1:00PM revealed the base of Resident #35's tube feeding pole and surrounding floor was covered with an unidentified dried tan substance. Further observation revealed an unidentified dried sticky tan substance was present on the sides of Resident #35's tube feeding pump. Observation on [DATE] at 10:30AM revealed numerous spots, varying in size, of an unidentified dried sticky tan substance on the base of Resident #35's tube feeding pole. Further observation revealed an unidentified dried sticky tan substance was present on the sides of Resident #35's tube feeding pump. Observation on [DATE] at 8:45AM revealed numerous spots, varying in size, of an unidentified dried sticky tan substance to the base of Resident #35's tube feeding pole. Further observation revealed an unidentified dried sticky tan substance was present on the sides of Resident #35's tube feeding pump. In an interview on [DATE] at 1:30PM, S2Director of Nursing (DON) confirmed Resident #4's and Resident #35's tube feeding pole bases and pumps had a dried sticky substance on it and were not maintained in a sanitary manner as required. S2DON further indicated resident equipment should be maintained in a clean and sanitary manner at all times. Resident #106 Observation on [DATE] at 9:11AM revealed an unidentified dried sticky tan substance was present on the side and top of Resident #106's tube feeding pump. Observation on [DATE] at 1:05PM revealed an unidentified dried sticky tan substance was present on the side and top of Resident #106's tube feeding pump. In an interview on [DATE] at 10:58AM, S4Registered Nurse (RN) indicated it was the responsibility of the nurse to ensure the resident's feeding pump was kept clean. S4RN confirmed Resident #106's tube feeding pump had a dried sticky tan substance on the side and top. S4RN indicated Resident #106's tube feeding pump needed to be tidied up.

Based on interviews and record reviews the facility failed to ensure certified nursing assistants (CNAs) were provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S13CNA, S14CNA, S15CNA, S16CNA, S17CNA) of 5 sampled CNAs reviewed for QAPI training requirements.Findings:Review of facility's training policy and procedure, with a revision date of 05/05/2025, revealed, in part, upon hire and prior to performing any functions of their position, each new employee and volunteer will be trained and oriented in accordance with state and federal regulations, as well as company policy and procedure. Review of S13CNA's personnel file revealed, in part, S13CNA had a hire date of 01/12/2026. Further review revealed no documented evidence S13CNA had received QAPI training, as required. Review of S14CNA's personnel file revealed, in part, S14CNA had a hire date of 02/25/2026. Further review revealed no documented evidence S14CNA had received QAPI training, as required. Review of S15CNA's personnel file revealed, in part, S15CNA had a hire date of 09/30/2025. Further review revealed no documented evidence S15CNA had received QAPI training, as required. Review of S16CNA's personnel file revealed, in part, S16CNA had a hire date of 10/25/2016. Further review revealed no documented evidence S16CNA had received QAPI training, as required. Review of S17CNA's personnel file revealed, in part, S17CNA had a hire date of 04/25/2023. Further review revealed no documented evidence S17CNA had received QAPI training, as required. On 05/19/2026 at 3:00PM, the surveyor requested QAPI trainings for the above-mentioned CNAs from S2Director of Nursing. On 05/20/2026 at 9:00AM, the surveyor requested QAPI trainings for the above-mentioned CNAs from S2Director of Nursing. In an interview on 05/20/2026 at 11:40AM, S2Director of Nursing indicated the above-mentioned CNAs did not have any QAPI trainings provided, as required.

Based on observations, interviews, and record reviews, the facility failed to provide privacy for a resident during incontinence care for 2 (Resident #4, Resident #95) of 2 sampled residents observed during incontinence care. Findings:Review of the facility's undated Resident Rights policy and procedure revealed, in part, employees should treat all residents with respect and dignity. Further review revealed all residents had the right to privacy and confidentiality. Resident #4Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2026 revealed, in part, Resident #4 did not have a Brief Interview for Mental Status (BIMS) score completed due to Resident #4 not being able to be understood or understand others. Further review revealed Resident #4 was dependent on staff assistance for toileting hygiene. Observation on 05/18/2026 at 9:42AM revealed S18Certified Nursing Assistant (CNA) and S19CNA entered Resident #4's room to perform incontinence care while Resident #4's roommate, Resident #95, remained in the room. Further observation revealed S18CNA and S19CNA did not close Resident #4's bedside privacy curtain and proceeded to remove Resident #4's pants, remove Resident #4's incontinence diaper and perform Resident #4's incontinence care. Further observation revealed Resident #4's genitalia remained uncovered and exposed to Resident #95 during the entire incontinence care process. Resident #95Review of Resident #95's MDS with an ARD of 04/23/2026 revealed, in part, Resident #95 had a BIMS score of 11, which indicated Resident #95 had moderate cognitive impairment. Further review revealed Resident #95 was dependent on staff assistance for toileting hygiene. Observation on 05/18/2026 at 9:37AM revealed S18CNA and S19CNA entered Resident #95's room to perform incontinence care while Resident #95's roommate, Resident #4, remained in the room. Further observation revealed S18CNA and S19CNA did not fully close Resident #95's bedside privacy curtain and proceeded to remove Resident #95's pants, remove Resident #95's incontinence diaper and perform Resident #95's incontinence care. Further observation revealed Resident #95's genitalia remained uncovered and exposed to Resident #4 during the entire incontinence care process. In a Resident Council meeting interview on 05/19/2026 at 10:57AM, Resident #11, Resident #22, Resident #27, Resident #31, and Resident #55 indicated they often saw residents receiving personal care with the doors open. In an interview on 05/20/2026 at 1:30PM, S2Director of Nursing indicated S18CNA and S19CNA should have ensured Resident #4's and Resident #95's privacy curtains were pulled while their respective incontinence care was performed.

Based on observations, interviews, and record reviews, the facility failed to ensure fall risk assessments were completed and new individualized fall prevention interventions were implemented to prevent future falls for 3 (Resident #108, Resident #112, Resident #142) of 3 sampled residents investigated for falls. Findings: Review of the facility's Resident Incident/Accident/Falls policy and procedure, dated 09/01/1994 and revised on 05/13/2025, revealed, in part, if falling occurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. Further review revealed the nursing supervisor on duty at the time should compete an incident report for resident falls no later than 24 hours after the fall occurred. Further review revealed when a resident fell, a falls risk assessment and the appropriate interventions taken to prevent future falls would be recorded in the resident's medical record. Review of the facility's Fall Risk Assessment form, revised on 12/2003 revealed, in part, upon admission and quarterly, at a minimum, a resident's fall risk should be assessed. On 05/19/2026 at 3:00PM, S2Director of Nursing (DON) was provided with a request for all Fall Risk Assessments for Resident #108, Resident #112, and Resident #142. On 05/20/2026 at 11:00AM, S5Minimum Data Set (MDS) Nurse was provided with a request for all Fall Risk Assessments for Resident #108, Resident #112, and Resident #142. Resident #108Review of Resident #108's medical record revealed, in part, Resident #108 was admitted to the facility on [DATE] with diagnoses which included pain, stroke, and seizures. Review of Resident #108's nurses' notes, dated 05/15/2026 at 2:52AM, revealed, in part, S24Licensed Practical Nurse (LPN) documented Resident #108 sustained an unwitnessed fall. Review of Resident #108's record revealed, in part, no documented evidence a Fall Risk Assessment was performed upon admission, quarterly, and/or after Resident #108's above- mentioned fall. Review of the facility's 2026 Fall List, updated and provided by S1Administrator on 05/18/2026, revealed, in part, no documentation Resident #108 sustained a fall incident on 05/15/2026. Review of Resident #108's care plan, with a start date of 09/10/2024 and a goal date of 07/07/2026, revealed, in part, Resident #108 had a potential for falls related to physical and cognitive limitations. Further review revealed an intervention for the facility to complete a Fall Risk Assessment per facility protocol. Further review revealed Resident #108's care plan was not updated with new individualized interventions and/or had supervision increased to prevent future falls after Resident #108's fall on 05/15/2026. Resident #112Review of Resident #112's medical record revealed, in part, Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, pain, insomnia, and nightmare disorder. Review of the facility's 2026 Fall List, updated and provided by S1Administrator on 05/18/2026, revealed, in part, Resident #112 sustained unspecified falls on 01/26/2026, 01/27/2026, 01/28/2026, and 02/14/2026. Review of Resident #112's care plan, with a start date of 01/03/2025 and a goal date of 07/21/2026, revealed, in part, Resident #112 had a potential for falls related to physical and cognitive limitations. Further review revealed an intervention for the facility to complete a Fall Risk Assessment per facility protocol. Further review revealed Resident #112's care plan was not updated with new individualized interventions and/or had supervision increased to prevent future falls after the above-mentioned falls occurred. Review of Resident #112's records revealed, in part, no documented evidence a Fall Risk Assessment was performed after Resident #112's above-mentioned falls. Resident #142Review of Resident #142's medical record revealed, in part, Resident #142 was admitted to the facility on [DATE] with diagnoses of, in part, muscle weakness, dementia, unsteadiness on feet, lack of coordination, and cognitive communication deficit. Review of the facility's 2026 Fall List, updated and provided by S1Administrator on 05/18/2026, revealed, in part, Resident #142 sustained unspecified falls on 03/05/2026, 03/13/2026, 03/24/2026, and two falls on 04/05/2026. Review of Resident #142's care plan, with a start date of 03/05/2026 and a goal date of 06/12/2026, revealed, in part, Resident #142 had a potential for falls related to unsteady gait, muscle weakness, and medications. Further review revealed an intervention for the facility to complete a Fall Risk Assessment per facility protocol. Further review revealed Resident #142's care plan was not updated with new individualized interventions and/or had supervision increased to prevent future falls until after the two falls on 04/05/2026 occurred. Review of Resident #142's records revealed, in part, no documented evidence a Fall Risk Assessment was performed upon admission, quarterly, and/or after Resident #142's above-mentioned falls. In an interview on 05/18/2026 at 2:30PM, S18Certified Nursing Assistant (CNA) indicated she was assigned to care for Resident #142. S18CNA further indicated she was not aware if he was a fall risk. In an interview on 05/20/2026 at 11:07AM, S3Assistant Director of Nursing (ADON) indicated fall assessments should be completed upon admission by the MDS nurse. In an interview on 05/20/2026 at 11:21AM, S5MDS Nurse indicated Fall Risk Assessments were not completed on the above-mentioned residents and should have been. S5MDS Nurse further indicated she was unaware a Fall Risk Assessment should have been completed after each fall and that new individualized care plan interventions were required after each fall. In an interview on 05/20/2026 at 1:30PM, S2DON confirmed the above-mentioned residents did not have Fall Risk Assessments completed as required. S2DON further indicated the above-mentioned residents should have had new individualized care plan interventions and/or had supervision increased to prevent future falls.

Based on interviews and record reviews, the facility failed to ensure residents who received psychotropic medications were monitored for potential adverse consequences associated with the use of psychotropic medications for 3 (Resident #10, Resident #115, Resident #149) of 5 sampled residents investigated for unnecessary medications. Findings: Review of the facility's Psychotropic Medication Use policy and procedure, dated 09/01/1994 and revised on 05/13/2025, revealed, in part, psychotropic medications were any medication that affected brain activity associated with mental processes and behavior. Further review revealed the following medications were considered psychotropic medications and were subject to monitoring: antipsychotics, antidepressants and antianxiety medications. Further review revealed psychotropic medication management involved the adequate monitoring for efficacy and adverse consequences. Further review revealed residents receiving psychotropic medications were monitored for side effects and the response to treatment was documented daily. Resident #10 Review of Resident #10's record revealed, in part, Resident #10 was admitted to the facility on [DATE] with diagnoses of, in part, anxiety, unspecified dementia without behavior disturbances, psychotic disturbances, mood disturbances, and bipolar disorder. Review of Resident #10's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/2026 revealed, in part, Resident #10 was on an antipsychotic medication which was assessed as a high risk medication.Review of Resident #10's care plan with a goal date of 08/21/2026 revealed, in part, Resident #10 received psychotropic drugs. Further review revealed an intervention for the facility to monitor Resident #10 for negative side effects related to Resident #10's psychotropic medication use.Review of Resident #10's May 2026 physician's Orders from 05/01/2026 to 05/20/2026 revealed, in part, an order for Resident #10 to be administered risperidone (a medication used to treat bipolar disorder) 1 milligram (mg) by mouth daily, with a start date of 05/06/2025. Further review revealed an order to monitor for side effects of antipsychotic medication, with a start date of 05/06/2025.Review of Resident #10's Medication Administration Record (MAR) dated 05/01/2026 to 05/20/262026 revealed, in part, risperidone 1mg was administered to Resident #10 daily from 05/01/2026 to 05/20/2026 as ordered. Further review revealed Resident #10 was not monitored for negative side effects related to risperidone use.In an interview on 05/20/2026 at 9:35AM, S2Director of Nursing (DON) indicated the documentation of psychotropic monitoring should be completed on the resident's MAR. S2DON further indicated there was no side effect monitoring completed for Resident #10's risperidone. Resident #115 Review of Resident #115's record revealed, in part, Resident #115 was admitted to the facility on [DATE] with diagnoses, in part, of schizophrenia, insomnia, and depression.Review of Resident #115's MDS with an ARD date of 05/05/2026 revealed, in part, Resident #115 was on antipsychotic and antidepressant medications, which were assessed as high risk medications.Review of Resident #115's care plan with a goal date of 08/04/2026 revealed, in part, Resident #115 received psychotropic drugs. Further review revealed an intervention for the facility to monitor Resident #115 for negative side effects related to Resident #115's psychotropic medication use.Review of Resident #115's May 2026 physician orders revealed, in part, an order for Resident #115 to be administered olanzapine (a medication used to treat schizophrenia) 2.5mg by gastric tube once in the evening, with a start date of 04/28/2026. Further review revealed an order or Resident #115 to be administered trazadone (a medication used to treat insomnia) 50mg daily at bedtime, with a start date of 04/28/2026.Review of Resident #115's MAR from 04/28/2026 to 05/20/2206 revealed, in part, olanzapine 2.5mg and trazadone 50mg were administered to Resident #115 from 04/28/2026 to 05/19/2026 as ordered. Further review revealed Resident #115 was not monitored for negative side effects related to olanzapine and trazadone use.In an interview on 05/20/2026 at 2:28PM, S2DON indicated there was no monitoring for negative side effects related to Resident #115's olanzapine and trazadone use. Resident #149Review of Resident #149's record revealed, in part, Resident #149 was admitted to the facility on [DATE] with diagnoses, in part, post-traumatic stress disorder and anxiety.Review of Resident #149's MDS with an ARD date of 05/15/2026 revealed, in part, Resident #149 received antipsychotic and antianxiety medications, which were assessed as high risk medications.Review of Resident #149's care plan with a goal date of 08/14/2026 revealed, in part, Resident #149 received psychotropic drugs. Further review revealed an intervention for the facility to monitor Resident #149 for negative side effects related to Resident #149's psychotropic medication use.Review of Resident #149's May 2026 physician orders revealed, in part, quetiapine (atypical antipsychotic used to relieve symptoms to treat mental disorders) 50mg by mouth at bedtime, with a start date of 05/14/2026. Further review revealed an order for Resident #149 to be administered lorazepam 0.5mg by mouth twice a day, with a start date of 05/07/2026. Further review revealed an order to monitor Resident #149 for the side effects associated with antipsychotics and antidepressants, with a start date of 05/07/2026.Review of Resident #149's MAR from 05/01/2026 to 05/19/2026 revealed, in part, lorazepam 0.5mg and quetiapine 50mg were administered to Resident #149 from 05/08/2026 to 05/19/2026 as ordered. Further review revealed Resident #149 was not monitored for the negative side effects associated with the administration of lorazepam or quetiapine.In an interview on 05/19/2026 at 3:34PM, S2DON indicated there was no monitoring for negative side effects related to Resident #149's lorazepam and quetiapine use.

Based on observations, interviews, and record reviews, the facility failed to maintain a resident's wheelchair in a safe working condition for 1 (Resident #91) of 5 residents reviewed for environment.Findings:Review of Resident #91's records revealed, in part, an admit date of 05/19/2025. Review of Resident #91's diagnoses revealed, in part, Resident #91 was diagnosed with lack of coordination, morbid (severe) obesity, right heart failure, and shortness of breath. Review of Resident #91's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2026 revealed, in part, Resident #91 required the use of a manual wheelchair. In an interview on 05/18/2026 at 9:00AM, Resident #91 indicated his wheelchair tires were extremely damaged with the rubber peeling off of the wheels. Resident #91 further indicated due to the damaged wheels on his wheelchair, the wheels on the wheelchair did not properly lock.Observation on 05/19/2026 at 12:00PM revealed Resident #91's wheelchair had multiple areas of rubber missing off the wheelchair's wheels. In an interview on 05/19/2026 at 12:02PM, Resident #91 indicated his wheelchair was not safe because it did not lock properly.In an interview on 05/19/2026 at 12:21PM, S8License Practical Nurse (LPN) indicated Resident #91 was missing rubber off of his wheelchair's wheels.In an interview on 05/19/2026 at 12:25PM, S2Director of Nursing (DON) confirmed Resident #91's wheelchair was not safe as a result of the damaged wheels that caused the wheelchair's left wheel to not lock properly. Observation on 05/20/2026 at 9:59AM revealed Resident #91's damaged wheelchair was present in Resident #91's room, available for Resident #91's use.In an interview on 05/20/2026 at 10:00AM, Resident #91 indicated his wheelchair's wheels were still damaged.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident was positioned as ordered while receiving enteral feedings (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) (Resident #2); 2. An enteral feeding administration set (tubing used to administer a resident's enteral feeding) for a resident's enteral feeding was changed every 24 hours per the facility policy and physician's order (Resident #2); and, 3. Only qualified staff placed a resident's enteral feeding on hold and/or restarted a resident's enteral feeding (Resident #R4). This deficient practice was identified for 2 (Resident #2, Resident #R4) of 3 (Resident #1, Resident #2, Resident #R4) residents reviewed for enteral feeding maintenance. Findings: Review of the facility's Enteral Feedings-Safety Precautions, last revised on 10/01/2024 revealed, in part, Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) were the personnel responsible for preparing, storing, and administering enteral feedings. Further review revealed the personnel would be trained, qualified, and competent in his/her own abilities. Further review revealed personnel should change a resident's enteral feeding administration sets at least every 24 hours. 1. Review of Resident #2's June 2025 physician's orders revealed, in part, an order dated 06/04/2025 for the head of Resident #2's bed to be elevated to 45 degrees at all times except during care. Observation on 06/23/2025 at 4:12PM revealed Resident #2's enteral feeding was infusing at 20 milliliters (ml) per hour (ml/hr), and the head of Resident #2's bed was elevated to 30 degrees. Observation on 06/23/2025 at 4:51PM revealed Resident #2's enteral feeding was infusing at 20 ml/hr, and the head of Resident #2's bed was elevated to 30 degrees. Observation on 06/24/2025 at 7:33AM revealed Resident #2's enteral feeding was infusing at 20 ml/hr, and the head of Resident #2's bed was elevated to 30 degrees. Observation on 06/24/2025 at 9:45AM revealed Resident #2's enteral feeding was infusing at 20 ml/hr, and the head of Resident #2's bed was elevated to 30 degrees. In an interview on 06/24/2025 at 11:23AM, S2Director of Nursing (DON) indicated the head of Resident #2's bed should have been elevated to 45 degrees as ordered. 2. Review of Resident #2's June 2025 physician's orders revealed, in part, an order dated 01/22/2025 for staff to change Resident #2's enteral feeding administration set (tubing) every day. Observation on 06/24/2025 at 11:20AM revealed the administration set for Resident #2's enteral feeding was dated as changed on 06/23/2024 at 12:00AM. Further observation revealed 400-500 ml of Resident #2's enteral feeding had already been infused. In an interview on 06/24/2025 at 11:22AM, S2DON confirmed Resident #2's enteral feeding administration set was dated 06/23/2025 at 12:00AM. S2DON further indicated enteral feeding administration sets should be changed every 24 hours. 3. Observation on 06/24/2025 at 9:43AM while S3Certified Nursing Assistant (CNA) was performing incontinence care to Resident #R4, the alarm to Resident #R4's enteral feeding pump (equipment used to administer a resident's enteral feeding at a set rate) was alarming. Further observation revealed a minute later, the alarm stopped. In an interview on 06/24/2025 at 9:44AM, S3CNA indicated the alarm to Resident #R4's enteral feeding pump was alarming because she had placed Resident #R4's enteral feeding on hold (stopped the infusion of the enteral feeding) while she was performing Resident #R4's incontinence care. S3CNA further indicated Resident #R4's enteral feeding pump had stopped alarming when S3CNA restarted the infusion of Resident #R4's enteral feeding. In an interview on 06/24/2025 at 11:22AM, S2DON indicated S3CNA should not be have placed Resident #R4's enteral feeding on hold or restarted Resident #R4's enteral feeding. In an interview on 06/24/2025 at 12:25PM, S1Administrator indicated it was not in a CNA's scope of practice to place a resident's enteral feeding on hold and/or restart a resident's enteral feeding.

Based on interview and record reviews, the facility failed to maintain accurate records for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accurate documentation. Findings: Review of the facility's Charting and Documentation policy, last revised on 10/01/2024, revealed, in part, all services provided to a resident shall be documented in the resident's medical record. Review of Resident #2's June 2025 physician's orders revealed, in part, an active order dated 01/22/2025 for staff to check the residual amount of Resident #2's enteral feeding (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) every 4 hours at 12:00AM, 4:00AM, 8:00AM, 12:00PM, 4:00PM, and 8:00PM. Further review revealed an active order dated 05/22/2025 for staff to administer Jevity 1.5 (an enteral feeding) to Resident #2 at a rate of 40 milliliters/hour (ml/hr) continuously. Further review revealed an additional active order dated 05/26/2025 for staff to administer Jevity 1.5 at a rate of 20 ml/hr continuously. Review of Resident #2's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, no documented evidence Resident #2's enteral feeding residual was checked on 06/08/2025 at 12:00PM, 06/08/2025 at 4:00PM, 06/21/2025 at 8:00AM, and/or 06/22/2025 at 8:00AM. In an interview on 06/24/2025 at 11:23AM, S2Director of Nursing (DON) indicated there should not have been two different physician's orders for the rate of Resident #2's Jevity 1.5 enteral feedings. S2DON further indicated the facility's nurses should have documented when they checked Resident #2's enteral feeding residual in Resident #2's eMAR and had not.

Based on observation and interview, the facility failed to ensure a resident's privacy during incontinence care for 1 (Resident #R4) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents observed for residents' rights. Findings: Observation on 06/24/2025 at 9:43AM revealed S3Certified Nursing Assistant (CNA) was providing incontinence care to Resident #R4 and did not announce that she was providing care to Resident #R4 when the surveyor knocked on the door to Resident #R4's room before entering. Further observation revealed Resident #R4's limbs and incontinence brief could be visualized from the doorway of Resident #R4's room. Further observation revealed that the privacy curtain in Resident #R4's room was not drawn to obstruct visualization of Resident #R4 from Resident #2 (Resident #R4's roommate) while S3CNA provided incontinence care to Resident #R4. In an interview on 06/24/2025 at 11:23AM, S2Dirctor of Nursing (DON) indicated S3CNA should have pulled Resident #R4's privacy curtain and/or provided privacy to Resident #R4 when she provided incontinence care to Resident #R4.

Based on observations, interviews, and record reviews the facility failed to ensure: 1. The facility's dining room was kept in a clean/sanitary manner; and, 2. The facility's hallways were kept in a clean/sanitary manner and in good repair for 3 (Hallway a, Hallway b, Hallway c) of 3 (Hallway a, Hallway b, Hallway c) hallways observed for physical environment. Findings: Review of the facility's Maintenance Service policy and procedure, with a revision date of 05/2024 revealed, in part, the functions of the facility's maintenance personnel included maintaining the building in good repair. Review of the facility's Environmental Services policy and procedure, with a revision date of 05/2024 revealed, in part, floors shall be maintained in clean, safe and sanitary manner. 1. Observation of the dining room on 05/27/2025 at 11:30AM revealed the following: - 16 windows had a total of 85 dead insects, between them, on the window sills; - five of the output air vents, on the ceiling above the area where the dining room tables were, had an unknown light gray substance surrounding them; and - 2 areas of wallpaper on the right side of the dining room wall leading from the entrance way, were peeling from the top of the wall, down the seam. Observation of the dining room on 05/29/2025 at 8:35AM revealed the following: - an unknown black/brown/gray particle build-up around the entrance way door jams; - a build-up of settled black/brown particles along an approximately 1 inch (in) ledge, located on the wall to the right near the entrance door, inside the dining room; - 1 dead insect and a severed tail, resembling the tail of a reptile, in 1 window sill located on the right wall leading from the entrance of the dining room; - five of the output air vents, on the ceiling above the area where the dining room tables were, had an unknown light gray substance surrounding them; and - 2 areas of wallpaper on the right side dining room wall leading from the entrance way, were peeling from the top of the wall, down the seam. In an interview on 05/29/2025 9:00AM, S7Housekeeping Supervisor/Dietary Manager confirmed the above observations and further indicated there should not be any dead insects or severed reptile tails in the window sills of the dining room or particle build up on the ledge inside the dining room door or around the dining room door jams. Observation of the dining room on 05/29/2025 at 12:10 PM revealed the following: - 1 dead insect and a severed tail, resembling the tail of a reptile, in 1 window sill located on the right wall leading from the entrance of the dining room; - five of the output air vents, on the ceiling above the area where the dining room tables were, had an unknown light gray substance surrounding them; and - 2 areas of wallpaper on the right side dining room wall leading from the entrance way, were peeling from the top of the wall, down the seam. In an interview on 05/29/2025 12:12 PM, S8Plant Operations Manager confirmed the above observations of the dining room. S8Plant Operations Manager further indicated the above findings did not present a clean homelike environment. 2. Observation of Hallway b on 05/27/2025 at 9:45AM revealed the following: - an accumulation of unknown black/brown/gray particles that began at Hallway b's front entry door jambs, continued along Hallway b's baseboards where they met the floor, surrounded the door jambs of the resident's rooms on Hallway b, and covered the lower portion of multiple resident's room doors on Hallway b; and - multiple areas of an unknown dried brown substance in a splatter and drip pattern on the walls of Hallway b; and - multiple areas of missing or damaged sheet rock on the walls throughout Hallway b. Observation of Hallway a on 05/28/2025 at 12:35PM revealed the following: - an accumulation of unknown black/brown/gray particles that began at Hallway a's front entry door jambs, continued along Hallway a's baseboards where they met the floor, surrounded the door jambs of the resident's rooms on Hallway a, and covered the lower one-sixth portion of multiple resident's room doors on Hallway a. Further observation revealed the above accumulation of black/brown/gray particles affected more than 50 percent (%) of the baseboards and 50% of the 36 resident's doors and door jambs located on Hallway a. - 5 areas of an unknown dried brown substance in a splatter and drip pattern on the walls of Hallway a; and - more than 50 areas of missing or damaged sheet rock on the walls throughout Hallway a. Observation of Hallway c on 05/28/25 at 4:30PM revealed the following: - an accumulation of unknown black/brown/gray particles that began at Hallway c's front entry door jambs, continued along Hallway c's baseboards where they met the floor, surrounded the door jambs of the resident's rooms on Hallway c, and covered the lower one-sixth portion of multiple resident's room doors on Hallway c. Further observation revealed the above accumulation of black/brown/gray particles affected more than 50% of the baseboards and 50% of the 35 resident's doors and door jambs located on Hallway c. - an unknown dried brown substance in a splatter and drip pattern on the 9 areas of the walls of Hallway c; and - more than 50 areas of missing or damaged sheet rock on the walls throughout Hallway c. Observation of Hallway b on 05/28/2025 at 4:36PM revealed the following: - an accumulation of unknown black/brown/gray particles that began at Hallway b's front entry door jambs, continued along Hallway b's baseboards where they met the floor, surrounded the door jambs of the resident's rooms on Hallway b, and covered the lower one-sixth portion of multiple resident's room doors on Hallway b. Further observation revealed the above accumulation of black/brown/gray particles affected more than 50% of the baseboards and 50% of the 29 resident's doors and door jambs located on Hallway b. - an unknown dried brown substance in a splatter and drip pattern on the 7 areas of the walls of Hallway b; and - 50 areas of missing or damaged sheet rock on the walls throughout Hallway b. Observation on 05/29/2025 at 9:00AM revealed the bottom of the metal exit door near the facility's dining room was rusted and cracked and had a scattered pattern of rust spots on the bottom one-half of the door. In an interview on 05/29/2025 at 9:00AM, S7Housekeeping Supervisor/Dietary Manager confirmed the above observations of Hallway a, Hallway b and Hallway c's walls, baseboards, door jambs, and resident's doors. S7Housekeeping Supervisor/Dietary Manager further acknowledged the above mentioned areas were not maintained as required. S7Housekeeping Supervisor/Dietary Manager further confirmed it was the facility's housekeeping department's responsibility to clean floors, door jambs, baseboards and walls, and the facility's maintenance department's responsibility to repair sheet rock, walls, and handrails. In an interview on 05/29/2025 at 9:10AM, S8Plant Operations Manager confirmed above observations of Hallway a, Hallway b and Hallway c's walls, baseboards, door jambs, and resident's doors and exit door near dining room. S8Plant Operations Manager acknowledged the door jambs, baseboards/floor junctions, resident's doors and hallway's walls should be clean and the sheetrock to Hallway a, Hallway b and Hallway c should have been repaired and was not. S8Plant Operations Manager acknowledged the above mentioned observations did not present a clean/homelike environment at present. S8Plant Operations Manager further acknowledged the building had a lot of needed maintenance repairs. In an interview on 05/29/2025 at 10:36AM, S1Administrator acknowledged Hallway a, Hallway b and Hallway c's walls, baseboards, door jambs, and resident's doors should have been clean and the sheetrock to Hallway a, Hallway b and Hallway c should have been repaired and was not. S1Administrator further acknowledged the above mentioned observations did not present a clean/homelike environment at present.

Based on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS) Assessment was transmitted within the required timeframe after completion for 1 (Resident #69) of 1 (Resident #69) sampled resident reviewed for assessment transmission. Findings: Review of Resident #69's annual MDS Assessment Section Z - Assessment Administration revealed, in part, Resident #69's annual MDS Assessment was completed and electronically signed by the Registered Nurse (RN) Assessment Coordinator on 04/17/2025. Review of the Final Validation Report dated 05/29/2025 revealed, in part, Resident #69's annual MDS Assessment was not submitted to the Centers for Medicare & Medicaid Services (CMS) database until 05/29/2025. In an interview on 05/29/2025 at 8:24AM, S11Registered Nurse (RN) indicated Resident #69's annual MDS Assessment was completed on 04/17/2025 but was not transmitted until 05/29/2025. S11RN further indicated that the assessment should have been transmitted within 7 days of the completion date but was not as required.

Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's May 2025 Medication Cart a Narcotic Nurse Sign on/off log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart a's controlled substances with the oncoming nurse on: - 05/01/2025 for the 7:00PM to 7:00AM shift; and, - 05/22/2025 for the 7:00AM to 7:00PM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 05/01/2025 for the 7:00PM to 7:00AM shift. Further review on 05/29/2025 at 1:57PM revealed S13Licensed Practical Nurse's (LPN) signature that indicated Medication Cart a's controlled medications had been reconciled by the off going nurse on 05/29/2025 for the 7:00PM to 7:00AM shift There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart a for the above mentioned dates and/or times. Review of the facility's May 2025 Medication Cart b Narcotic Nurse Sign on/off log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on: - 05/13/2025 for the 7:00PM to 7:00AM shift; - 05/14/2025 for the 7:00PM to 7:00AM shift; - 05/18/2025 for the 7:00PM to 7:00AM shift; - 05/27/2025 for the 7:00AM to 7:00PM shift; and, - 05/29/2025 for the 7:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart b's controlled substances with the off going nurse on: - 05/15/2025 for the 7:00PM to 7:00AM shift; - 05/27/2025 for the 7:00AM to 7:00PM shift; and, - 05/28/2025 for the 7:00PM to 7:00AM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart b for the above mentioned dates and/or times. Review of the facility's May 2025 Medication Cart c Narcotic Nurse Sign on/off log revealed, in part, there was not a signature of both the off going nurse and on oncoming nurse indicating the off going and oncoming nurses had reconciled Medication Cart c's controlled substances together on: - 05/01/2025 for the 7:00AM to 7:00PM shift; - 05/01/2025 for the 7:00PM to 7:00AM shift; - 05/02/2025 for the 7:00AM to 7:00PM shift; - 05/02/2025 for the 7:00PM to 7:00AM shift; - 05/03/2025 for the 7:00AM to 7:00PM shift; - 05/03/2025 for the 7:00PM to 7:00AM shift; - 05/04/2025 for the 7:00AM to 7:00PM shift; - 05/04/2025 for the 7:00PM to 7:00AM shift; - 05/05/2025 for the 7:00AM to 7:00PM shift; - 05/05/2025 for the 7:00PM to 7:00AM shift; - 05/06/2025 for the 7:00AM to 7:00PM shift; - 05/06/2025 for the 7:00PM to 7:00AM shift; - 05/07/2025 for the 7:00AM to 7:00PM shift; - 05/07/2025 for the 7:00PM to 7:00AM shift; - 05/08/2025 for the 7:00AM to 7:00PM shift; - 05/08/2025 for the 7:00PM to 7:00AM shift; - 05/09/2025 for the 7:00AM to 7:00PM shift; - 05/09/2025 for the 7:00PM to 7:00AM shift; - 05/10/2025 for the 7:00AM to 7:00PM shift; - 05/10/2025 for the 7:00PM to 7:00AM shift; - 05/11/2025 for the 7:00AM to 7:00PM shift; - 05/11/2025 for the 7:00PM to 7:00AM shift; - 05/12/2025 for the 7:00AM to 7:00PM shift; - 05/12/2025 for the 7:00PM to 7:00AM shift; - 05/13/2025 for the 7:00PM to 7:00AM shift; - 05/14/2025 for the 7:00AM to 7:00PM shift; - 05/14/2025 for the 7:00PM to 7:00AM shift; - 05/15/2025 for the 7:00AM to 7:00PM shift; - 05/15/2025 for the 7:00PM to 7:00AM shift; - 05/16/2025 for the 7:00AM to 7:00PM shift; - 05/16/2025 for the 7:00PM to 7:00AM shift; - 05/17/2025 for the 7:00AM to 7:00PM shift; - 05/17/2025 for the 7:00PM to 7:00AM shift; - 05/18/2025 for the 7:00AM to 7:00PM shift; - 05/18/2025 for the 7:00PM to 7:00AM shift; - 05/19/2025 for the 7:00AM to 7:00PM shift; - 05/19/2025 for the 7:00PM to 7:00AM shift; - 05/20/2025 for the 7:00AM to 7:00PM shift; - 05/20/2025 for the 7:00PM to 7:00AM shift; - 05/21/2025 for the 7:00AM to 7:00PM shift; - 05/21/2025 for the 7:00PM to 7:00AM shift; - 05/22/2025 for the 7:00AM to 7:00PM shift; - 05/22/2025 for the 7:00PM to 7:00AM shift; - 05/23/2025 for the 7:00AM to 7:00PM shift; - 05/23/2025 for the 7:00PM to 7:00AM shift; - 05/24/2025 for the 7:00AM to 7:00PM shift; - 05/24/2025 for the 7:00PM to 7:00AM shift; - 05/25/2025 for the 7:00AM to 7:00PM shift; - 05/25/2025 for the 7:00PM to 7:00AM shift; - 05/26/2025 for the 7:00AM to 7:00PM shift; - 05/26/2025 for the 7:00PM to 7:00AM shift; - 05/27/2025 for the 7:00AM to 7:00PM shift; - 05/28/2025 for the 7:00AM to 7:00PM shift; - 05/28/2025 for the 7:00PM to 7:00AM shift; and, - 05/29/2025 for the 7:00AM to 7:00PM shift. Further review revealed there was no signature that indicated Medication Cart c's controlled medications had been reconciled on: - 05/13/2025 for the 7:00AM to 7:00PM shift; and, - 05/27/2025 for the 7:00PM to 7:00AM shift. Further review on 05/29/2025 at 1:45PM revealed a nurse's signature that indicated Medication Cart c's controlled medications had been reconciled on 05/29/2025 for the 7:00PM to 7:00AM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart c for the above mentioned dates and/or times. Review of the facility's May 2025 Medication Cart d Narcotic Nurse Sign on/off log revealed, in part, there was not a signature of both the off going nurse and on oncoming nurse indicating the off going and oncoming nurses had reconciled Medication Cart d's controlled substances together on: - 05/01/2025 for the 7:00AM to 7:00PM shift; - 05/01/2025 for the 7:00PM to 7:00AM shift; - 05/02/2025 for the 7:00AM to 7:00PM shift; - 05/02/2025 for the 7:00PM to 7:00AM shift; - 05/03/2025 for the 7:00AM to 7:00PM shift; - 05/03/2025 for the 7:00PM to 7:00AM shift; - 05/04/2025 for the 7:00AM to 7:00PM shift; - 05/04/2025 for the 7:00PM to 7:00AM shift; - 05/05/2025 for the 7:00PM to 7:00AM shift; - 05/06/2025 for the 7:00PM to 7:00AM shift; - 05/07/2025 for the 7:00AM to 7:00PM shift; - 05/07/2025 for the 7:00PM to 7:00AM shift; - 05/08/2025 for the 7:00AM to 7:00PM shift; - 05/09/2025 for the 7:00AM to 7:00PM shift; - 05/09/2025 for the 7:00PM to 7:00AM shift; - 05/10/2025 for the 7:00AM to 7:00PM shift; - 05/10/2025 for the 7:00PM to 7:00AM shift; - 05/11/2025 for the 7:00AM to 7:00PM shift; - 05/11/2025 for the 7:00PM to 7:00AM shift; - 05/12/2025 for the 7:00AM to 7:00PM shift; - 05/12/2025 for the 7:00PM to 7:00AM shift; - 05/13/2025 for the 7:00AM to 7:00PM shift; - 05/13/2025 for the 7:00PM to 7:00AM shift; - 05/14/2025 for the 7:00AM to 7:00PM shift; - 05/14/2025 for the 7:00PM to 7:00AM shift; - 05/15/2025 for the 7:00AM to 7:00PM shift; - 05/15/2025 for the 7:00PM to 7:00AM shift; - 05/16/2025 for the 7:00AM to 7:00PM shift; - 05/16/2025 for the 7:00PM to 7:00AM shift; - 05/17/2025 for the 7:00AM to 7:00PM shift; - 05/17/2025 for the 7:00PM to 7:00AM shift; - 05/18/2025 for the 7:00AM to 7:00PM shift; - 05/18/2025 for the 7:00PM to 7:00AM shift; - 05/19/2025 for the 7:00AM to 7:00PM shift; - 05/19/2025 for the 7:00PM to 7:00AM shift; - 05/20/2025 for the 7:00AM to 7:00PM shift; - 05/20/2025 for the 7:00PM to 7:00AM shift; - 05/21/2025 for the 7:00PM to 7:00AM shift; - 05/22/2025 for the 7:00PM to 7:00AM shift; - 05/23/2025 for the 7:00AM to 7:00PM shift; - 05/23/2025 for the 7:00PM to 7:00AM shift; - 05/24/2025 for the 7:00AM to 7:00PM shift; - 05/24/2025 for the 7:00PM to 7:00AM shift; - 05/25/2025 for the 7:00AM to 7:00PM shift; - 05/25/2025 for the 7:00PM to 7:00AM shift; - 05/26/2025 for the 7:00AM to 7:00PM shift; - 05/26/2025 for the 7:00PM to 7:00AM shift; - 05/27/2025 for the 7:00AM to 7:00PM shift; - 05/27/2025 for the 7:00PM to 7:00AM shift; - 05/28/2025 for the 7:00AM to 7:00PM shift; - 05/28/2025 for the 7:00PM to 7:00AM shift; and, - 05/29/2025 for the 7:00AM to 7:00PM shift. Further review revealed there was no signature that indicated Medication Cart d's controlled medications had been reconciled on: - 05/05/2025 for the 7:00AM to 7:00PM shift; - 05/06/2025 for the 7:00AM to 7:00PM shift; - 05/08/2025 for the 7:00PM to 7:00AM shift; - 05/21/2025 for the 7:00AM to 7:00PM shift; and, - 05/22/2025 for the 7:00AM to 7:00PM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart d for the above mentioned dates and/or times. Review of the facility's May 2025 Medication Cart e Narcotic Nurse Sign on/off log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart e's controlled substances with the oncoming nurse on: - 05/13/2025 for the 7:00AM to 7:00PM shift; - 05/16/2025 for the 7:00AM to 7:00PM shift; - 05/19/2025 for the 7:00PM to 7:00AM shift; - 05/22/2025 for the 7:00AM to 7:00PM shift; - 05/24/2025 for the 7:00PM to 7:00AM shift; - 05/26/2025 for the 7:00AM to 7:00PM shift; - 05/27/2025 for the 7:00AM to 7:00PM shift; - 05/28/2025 for the 7:00PM to 7:00AM shift; - 05/28/2025 for the 7:00AM to 7:00PM shift; and, - 05/29/2025 for the 7:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart e's controlled substances with the off going nurse on: - 05/01/2025 for the 7:00PM to 7:00AM shift; - 05/13/2025 for the 7:00AM to 7:00PM shift; - 05/18/2025 for the 7:00PM to 7:00AM shift; - 05/23/2025 for the 7:00PM to 7:00AM shift; - 05/27/2025 for the 7:00PM to 7:00AM shift; and, - 05/28/2025 for the 7:00PM to 7:00AM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart e for the above mentioned dates and/or times. Review of the facility's May 2025 Medication Cart f Narcotic Nurse Sign on/off log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart f's controlled substances with the oncoming nurse on: - 05/12/2025 for the 7:00PM to 7:00AM shift; - 05/12/2025 for the 7:00AM to 7:00PM shift; - 05/13/2025 for the 7:00PM to 7:00AM shift; - 05/13/2025 for the 7:00AM to 7:00PM shift; - 05/14/2025 for the 7:00AM to 7:00PM shift; - 05/21/2025 for the 7:00PM to 7:00AM shift; - 05/22/2025 for the 7:00PM to 7:00AM shift; - 05/24/2025 for the 7:00AM to 7:00PM shift; - 05/25/2025 for the 7:00PM to 7:00AM shift; - 05/25/2025 for the 7:00AM to 7:00PM shift; and, - 05/27/2025 for the 7:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart f's controlled substances with the off going nurse on: - 05/12/2025 for the 7:00PM to 7:00AM shift; - 05/13/2025 for the 7:00PM to 7:00AM shift; - 05/24/2025 for the 7:00PM to 7:00AM shift; - 05/28/2025 for the 7:00PM to 7:00AM shift; and, - 05/29/2025 for the 7:00AM to 7:00PM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart f for the above mentioned dates and/or times. In an interview on 05/29/2025 at 1:40PM, S12LPN indicated the Medication Cart b Narcotic Nurse sign on/off log was not completed as required. S12LPN further indicated the off going and oncoming nurses should have reconciled the controlled medications at shift change together and each signed the Narcotic Nurse sign on/off log to verify the controlled substances count was accurate. In an interview on 05/29/2025 at 1:48PM, S14LPN indicated she could not provide any documentation Medication Cart c and Medication Cart d's controlled substances were reconciled on the above mentioned shifts by the oncoming and off going nurses and should have been. In an interview on 05/29/2025 at 1:57PM, S13LPN indicated she signed Medication Cart a's Narcotic Nurse sign on/off log as having performed the end of shift reconciliation of Medication Cart a's controlled substances at the beginning of her shift and should not have. There was no documented evidence and the facility did not present any documented evidence to dispute the above mentioned deficient practice. In an interview on 05/29/2025 at 2:00PM, S2Director of Nursing (DON) confirmed the above mentioned Narcotic Nurse Sign on/off logs were not completed with a nurse's signature at the beginning and/or at the end of the nurse's shift as required and should have been. S2DON further indicated the nurses assigned to Medication Cart c and Medication Cart d did not use the facility's approved Narcotic Nurse sign on/off log for the reconciliation of Medication Cart c and Medication Cart d's controlled substances and should have.

Based on observation and interview, the facility failed to ensure a nurse secured medications when unatteneded for 1 (Medication Cart b) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for medication storage. Findings: Observation on 05/27/2025 at 12:22PM, revealed Medication Cart b was left unlocked and unattended. Further observation revealed the following medications were present on the top of Medication Cart b and unsecured: 55 tablets of metoprolol tartrate (a medication used to treat high blood pressure and chest pain) 25 milligrams (mg) and two vials of Zosyn (a medication used to treat infections) 4.5 grams. Further observation revealed S16Licensed Practical Nurse (LPN) (the nurse responsible for Medication Cart b) was sitting at the nursing desk with her back turned to Medication Cart b. Further observation revealed Medication Cart b was left unattended by S16 LPN for 10 minutes. In an interview on 05/27/2025 at 12:33PM, S16LPN acknowledged she should not have the above mentioned medications and Medication Cart b unattended with the medications unsecured without proper supervision. In an interview on 05/29/25 at 8:35AM, S3Director of Nursing (DON) indicated the above mentioned medications should not have been left on top of Medication Cart b and unattended by the nurse. S3DON further indicated Medication Cart b should have been locked when not supervised.

Based on observation, interview, and record review the facility failed to: 1. ensure food stored in the facility's walk in cooler was properly dated and labeled, 2. ensure the dishwasher temperature and sanitizer log was properly maintained. Findings: 1. Review of the facility's policy for Food Receiving and Storage, with a revision date of 05/2024 revealed, in part, refrigerated foods are covered, labeled, and dated. An initial kitchen observation on 05/27/2025 at 8:25AM revealed the following: - 1 container of cooked carrots in a container covered with saran wrap not dated, - 1 container of barbeque sauce covered with saran wrap not dated and, - 14 styrofoam containers of chicken noodle soup were not dated In an interview on 05/27/2025 at 8:28AM, S7Dietary Manager confirmed the above mentioned containers of food should have been labeled and dated but were not. 2. Review of the facility's policy titled Dishwashing Machine Use, with a revision date of 10/01/2024 revealed, in part, a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [ppm]) after filling the dishwashing machine. Concentrations will be recorded in an approved facility log. Further policy review revealed the operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. An observation on 05/29/25 at 8:13AM, revealed the facility's dishwashing water temperature/sanitizer record was last documented on 05/20/2025 under the column listed for lunch. Further review revealed there was no documentation that the water temperature or sanitizer was checked prior to dishwashing after dinner was served on 05/20/2025. In an interview on 05/29/2025 at 8:26AM, S7Dietary Manager indicated the dishwashing temperature/sanitizer record should be documented on prior to dishwashing after breakfast, lunch, and dinner daily. S7Dietary Manager also confirmed the facility's dishwashing water temperature/sanitizer record was not documented from 05/20/2025 at lunch until 05/29/2025 at breakfast and it should have been. In an interview on 05/29/2025 at 8:40AM, S1Administrator indicated, the dishwasher water temperature/sanitizer record should have been completed on 05/20/2025 prior to dishwashing after dinner through 05/29/2025 but was not.

Based on interview and record review, the facility failed to: 1. Ensure the Quality Assurance and Assessment (QAA) committee met at least quarterly; and 2. Ensure the designated Infection Preventionist participated in the quarterly QAA meeting. Findings: 1. Review of the facility's QAA meeting sign-in sheet revealed the most recent QAA committee meeting was held on 04/09/2025. Further review revealed the prior QAA committee meeting was held on 10/09/2024. There was no documentation of a QAA meeting being conducted during the 1st quarter of 2025 (January-March) and the facility did not present any documented evidence a QAA meeting was held for the period of Jan-[DATE]. 2. Review of the Quarterly QAA meeting minutes dated 04/09/2025 revealed the Infection Preventionist (IP) was not documented on the sign-in sheet as being in attendance at the meeting. In an interview on 05/28/2025 at 3:01PM, S3Director of Nursing (DON) indicated the Infection Preventionist did not attend the 04/09/2025 QAA meeting. S3DON further indicated the committee failed to meet during the 1st quarter of 2025 and should have as required.

Based on record reviews, interviews, facility document reviews, and facility policy reviews, it was determined that the facility failed to keep a resident free from staff physical and verbal abuse for 1 (Resident #1) of 3 sampled residents reviewed for abuse. This deficient practice resulted in an actual harm on 11/19/2024when Resident #1 was physically abused by S2Maintenance and sustained injuries to his right face and left hand, which resulted in pain. Findings included: Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised on 07/25/2023 revealed, in part, residents have the right to be free from verbal, mental, and physical abuse. Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1 had diagnoses, which included, blindness to both eyes and a conduct disorder (a behavioral and emotional disorder that presented as repetitive, disruptive and violent behavior). Review of Resident #1's Minimum Data Set, dated dated dated [DATE] revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 used a wheelchair for mobility. Review of the facility's Incident/Accident report dated 11/19/2024 revealed, in part, Resident #1 was involved in a verbal and physical altercation with an employee. Further review revealed Resident #1 indicated that he was pushed by the employee and fell out of his wheelchair. Further review revealed a body audit was completed and Resident #1 had a pinpoint open area of the skin to the right side of his face and on the top of his left hand. Review of the facility's investigative report for physical abuse dated 11/21/2024 revealed, in part, on 11/19/2024 at 2:00 p.m., S1Administrator received a report of an altercation between S2Maintenance and Resident #1 which had occurred outside of the building in the smoking area. Further review revealed S2Maintenance stood up over Resident #1, who was sitting in a wheelchair, and started to point at him. Further review revealed S2Maintenance told Resident #1 to go dig up his dead mother and that Resident #1's girlfriend had a d*ck he had been sucking on. Further review revealed Resident #1 swung at S2Maintenance, and S2Maintenance attempted to block Resident #1's swings. Further review revealed Resident #1 flipped out of his wheelchair after he grabbed S2Maintenance's chains and both Resident #1 and S2Maintenance fell to the ground. Further review revealed the allegation of physical abuse was substantiated. Review of the facility's New Employee Request/Termination sheet dated 11/21/2024 revealed, in part, S2Maintenance was terminated on 11/20/2024 for a Code of Conduct violation, and was not eligible for re-hire. Review of the facility's Employee Disciplinary report dated 11/19/2024 revealed, in part, S2Maintenance failed to walk away from a situation that led to verbal abuse and physical abuse of a resident. Review of Resident #1's progress notes dated 11/19/2024 at 3:53PM revealed, in part, S5Director of Nursing (DON) was notified at approximately 2:00PM on 11/19/2024, an incident had occurred between Resident #1 and an employee. Further review revealed Resident #1 indicated he was pushed by the employee. Further review revealed a pinpoint open area was present to Resident #1's left hand and the right side of Resident #1's face. Review of Resident #1's progress notes dated 11/20/2024 at 3:54PM revealed, in part, on the morning of 11/20/2024, Resident #1's right eye was observed to be blood shot (eye redness from irritated or inflamed blood vessels on the surface of the white part of the eye) and slightly swollen. Further review revealed Resident #1 indicated his right eye was tender to the touch. Further review revealed Resident #1's left hand was observed to be swollen and Resident #1's left hand grip was not as strong as his right hand grip. Resident #1 further indicated his left hand hurt. Further review revealed the physician ordered a cool compress for five days to the right eye, twice a day for ten minutes, and the administration of one (1) drop of artificial tears to Resident #1 right eye, three times a day for seven days. In an interview on 11/22/2024 at 11:18AM, Resident #1 indicated he had a fight with S2Maintenance on 11/19/2024. Resident #1 further indicated S2Maintenance was speaking about his girlfriend and his mother in a derogatory manner. Resident #1 further indicated S2Maintenance hit him. Resident #1 further indicated he was having some swelling and tenderness to his left hand. In a telephone interview on 11/22/2024 at 11:48AM, S3Smoking Aide indicated on 11/19/2024, Resident #1 was outside in the smoking area and began to curse at S2Maintenance. S3Smoking Aide further indicated, as S2Maintenance was walking away from Resident #1, Resident #1 stated to S2Maintenance, I dare you to come closer. S3Smoking Aide further indicated that S2Maintenance should have walked away from Resident #1 when Resident #1 dared him to come closer. S3Smoking Aide further indicated S2Maintenance instead turned around and went back towards Resident #1. S3Smoking Aide also indicated both Resident #1 and S2Maintenance were talking about each other's family members in a derogatory manner, were using profanity, and were yelling at each other. S3Smoking Aide further indicated she told them Resident #1 and S3Maintenance to calm down and also left to go and get assistance. In an interview on 11/22/2024 at 12:02PM, S4Social Worker indicated while in her office, she looked out of her window and saw Resident #1 and S2Maintenace arguing with each other. S4Social Worker further indicated she heard S2Maintenance tell Resident #1 he could go dig his own mother out of the grave. S4Social Worker further indicated S2Maintenance told Resident #1 that his girlfriend was a man. S4Social Worker further indicated that both Resident #1 and S2Maintenance were calling each other a b*tch and telling each other f*ck you. S4Social Worker further indicated when she got closer to the smoking area, she saw S2Maintenance was standing over Resident #1 and pointing his finger in Resident #1's face. S4Social Worker further indicated Resident #1 swung and hit S2Maintenance's hat. S4Social Worker further indicated S2Maintenance then looked at her and told her that he (S2Maintenance) would be wrong if he hit Resident #1, while S2Maintenance made a punching arm gesture. S4Social Worker indicated she was unsure if S2Maintenance hit Resident #1. S4Social Worker further indicated Resident #1's right eye was redder than normal after the incident and Resident #1's left hand was swollen the next day. In an interview on 11/22/2024 on 12:45PM, S5DON indicated she was notified an incident had occurred on 11/19/2024 around 2:00 p.m. between Resident #1 and S2Maintenance. S5DON further indicated when interviewing Resident #1 after the above mentioned incident, Resident #1 indicated S2Mainteance had hit him and pushed him out of his wheelchair. S5DON further indicated Resident #1 also indicated that S2Maintence had told him his girlfriend was a man and had spoken about his mother. S5DON further indicated, during the post incident assessment, she noted a pinpoint open area of skin to the top of Resident #1's left hand and the right side of Resident #1's face. S5DON further indicated on 11/20/2024, she checked on Resident #1 and noted that his conjunctival sac (the small fluid filled space between the eyelid and the white part of the eye) to his right eye was swollen and his left hand was swollen. S5DON further indicated she asked Resident #1 if he was hit in the right eye, and Resident #1 indicated that he was hit in the right eye. S5DON further indicated Resident #1 indicated that he was so upset yesterday (11/19/2024) that he did not tell her anything about it. S5DON further confirmed what S2Maintenance said to Resident #1 in the above documented incident was verbal abuse. Review of the provider's surveillance footage from 11/19/2024 revealed, in part: -At 1:54:37PM, S2Maintenance walked up toward Resident #1, made a pointing hand gesture towards Resident #1's head, and continued to walk past Resident #1. Further observation revealed S3Smoking Aide was also present. -At 1:54:48PM, S2Maintenance stopped walking and turned around and started to speak to Resident #1. Further observation revealed Resident #1 then appeared to become agitated. -At 1:54:59PM, S2Maintenance walked briskly towards Resident #1 and then started to hover over Resident #1, who was sitting in a wheelchair, while speaking to Resident #1. -At 1:55:09PM, S2Maintenance pointed his finger very close to Resident #1's face. Further observation revealed Resident #1 and S2Maintenance appeared to be speaking in a loud manner to one another. - At 1:55:17PM, S2Maintenance closed the distance between himself and Resident #1 and S2Maintenance's head was hovering over Resident #1's shoulder. Further observation revealed, Resident #1 then swung his arm and hit S2Maintenance. -At 1:55:19PM, S2Maintenance continued to hover over Resident #1, appeared to be shouting at Resident #1, and pointed his finger in Resident #1's face. -At 1:55:33PM, Resident #1 again swung at S2Maintenance, but did not hit S2Maintenance -At 1:55:37PM, S2Maintenance began to walk away from Resident #1, but turned towards Resident #1 and appeared to be shouting. Further observation revealed S2Maintenace continued to hover over Resident #1, appeared to be shouting at Resident #1, and pointed his finger in Resident #1's face. -At 1:55:42PM, Resident #1 swung at S2Maintenace as S2Maintenance was turning around to walk away, but did not hit S2Maintenance. -At 1:55:45PM, S2Maintenance turned back towards Resident #1. Further observation revealed S2Maintenance appeared to be shouting at Resident #1 and was hovering over Resident #1. -At 1:55:53PM, S2Maintenance appeared to walk away from Resident #1, but then immediately turned around and started to speak to Resident #1. Further observation revealed S2Maintenance was hovering over Resident #1 and made pointing hand gestures towards Resident #1's shoulder and then face. -At 1:55:56PM, Resident #1 swung his left arm near S2Maintenance's head and then swung his left arm at S2Maintenance's right shoulder. Further observation revealed S2Maintenance appeared to hit Resident #1's arm away to prevent Resident #1 from striking him, and then grabbed Resident #1's left hand. -At 1:55:59PM, Resident #1 pulled his left hand out of S2Mainteance's grip and swung at S2Maintenance with his left hand. Further observation revealed S2Maintenance's then grabbed Resident #1's left hand and they appeared to struggle with each other, which resulted in Resident #1's left arm being extended back over his wheelchair and slightly behind his body. -At 1:56:05PM, Resident #1 appeared to place his cigarette in his mouth with his right hand, and then grabbed S2Maintenance with his right hand, which caused S2Maintenance to let go of Resident #1's left hand. Further observation revealed S2Maintenance immediately grabbed Resident #1's left hand as Resident #1 and S2Maintenance continued to struggle with each other. -At 1:56:18PM, an unknown object fell to the ground and S2Maintenance released Resident #1's hand and stepped back from Resident #1. Further observation revealed S2Maintenance continued to speak to Resident #1 and then stepped towards Resident #1. -At 1:56:25PM, S2Maintenance pointed his finger at the side of Resident #1's face and it appeared that S2Maintenance's finger made contact with Resident #1 face, as his head appeared to jerk back. Further observation revealed Resident #1 swung his left arm at S2Maintenance. Further observation revealed Resident #1 and S2Maintenance continued to argue with S2Maintenance walking away and coming back to hover over Resident #1 multiple times. -At 1:56:39PM, S2Maintenance pointed his finger at the side of Resident #1's face and it appeared that S2Maintenance's finger made contact with Resident #, as his head appeared to jerk back. Further observation revealed Resident #1 swung his left arm at S2Maintenance. -At 1:56:43PM, S2Maintenance put his hands out, with palms up, and motioned his fingers towards his own body as Resident #1 and S2Maintenance continued to appear to argue. Further observation revealed S2Maintenance continued to transition from walking away from Resident #1 to returning to hover over Resident #1. -At 1:57:08PM, Resident #1 appeared say something to S2Maintenance and S2Maintenance moved his face closer to Resident #1's face. Further observation revealed S2Maintenance then banged on his own chest with his hands and then pointed toward the ground. Further observation revealed S2Maintenance and Resident #1 appeared to continue to argue with S2Maintenance continuing to hover over Resident #1. -At 1:57:56PM, S4Social Worker walked into frame, and S2Maintenance then started to walk away from Resident #1, but returned and pointed his finger in Resident #1's face. -At 1:58:07PM, Resident #1 swung at S2Maintenance and appeared to hit him on the rim of his baseball cap. Further observation revealed S2Maintenace then turned towards S4Social Worker, and made a gesture with his closed fist towards Resident #1. Further observation revealed S2Maintenance then appeared to push his fist onto the side of Resident #1's face as evidenced by Resident #1's head pushing back. Further observation revealed Resident #1 and S2Maintenance continued to appear to be shouting at each other. -At 1:58:16PM, S2Maintenance pointed his finger into Resident #1's face and Resident #1 swung at S2Maintenance and grabbed S2Maintenance with his left hand. Further observation revealed S2Maintenance then tried to use his right arm to remove Resident #1's left hand from his person, and in the process, Resident #1 swung and hit S2Mainteance's right arm, causing S2Maintenance's right arm to knock back into Resident #1. Further observation revealed at this point, Resident #1 toppled over backwards in his wheelchair and hit the ground. In an interview on 11/22/2024 at 1:41PM, S1Administrator indicated he substantiated physical and verbal abuse had occurred for the above mentioned incident. S1Administrator further indicated Resident #1 was harmed by the above mentioned incident because Resident #1 had a scratch under his eye and was complaining of tenderness to the area of the scratch. In an interview on 11/25/2024 at 1:50PM, S4Social Worker indicated she called her supervisor to contact S5DON when she saw the above mentioned altercation between Resident #1 and S2Maintenance. S4Social Worker further indicated she was scared of getting hit if she got in the middle of Resident #1 and S2Maintenace because both were large men, and Resident #1 was swinging his arms, but could not see what he would have been hitting. In an interview on 11/25/2024 at 2:29PM, S5DON confirmed S2Maintenance made physical contact with Resident #1's head at 1:58:07PM on 11/19/2024 per the facility's surveillance video. S5DON further indicated Resident #1 was both physically and verbally harmed by the above mentioned incident.

Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including Cardiopulmonary Resuscitation(CPR) per the facility's policy and procedure, to a resident requiring emergency care according to the resident's advance directive and physician's order for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents. On [DATE], at approximately 11:48 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code, did not receive CPR upon being found pulseless, breathless, and unresponsive. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from 11:48 p.m. through [DATE] at 12:03 a.m. revealed S4RespiratoryTherapist (RT) and S5RegisteredNurse(RN) were present in Resident #1's room throughout his medical emergency and chest compressions were not initiated until [DATE] at 12:03 a.m. Resident #1 was transported to the hospital and was admitted . Hospital records, dated [DATE], revealed Computed Tomography (CT) findings of anoxic encephalopathy (a process that begins with the cessation of cerebral blood flow to brain tissue), and Emergency Department physician's impression was ischemic bowel related to post cardiac arrest hypo-perfusion (low blood flow). The resident did not regain consciousness, was removed from life support, and expired on [DATE] at 6:09 p.m. The Immediate Jeopardy continued when S4RT and S5RN failed to take immediate action to ensure Resident #1's code status was acted on according to their advance directives, the physician's order, American Heart Association Guidelines, and the facility's policy and procedures. S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:46 p.m. The Immediate Jeopardy was removed on [DATE] at 6:59 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice had the likelihood to cause more than minimum harm to the remaining 26 residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21,#22, #23, #24, #25, and #26) who were in the care of S5RN and S4RT on Hall Z identified as residents with an advanced directive that indicated staff would need to provide basic life support. Findings: Review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation (CPR) policy revealed, in part, the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Review revealed, if an individual was found unresponsive, the resident should be briefly assessed for abnormal or absence of breathing. If sudden cardiac arrest was likely, CPR should be initiated. Review revealed, The facility's procedure for administering CPR incorporated the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Career facility basic life support (BLS) training material. Further review revealed, the basic life support sequence of events was referred to as C-A-B (chest compressions, airway, and breathing). Review of 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Career facility BLS training manual revealed, in part, chest compressions should be started immediately. Review revealed, opening an airway and providing ventilation may cause significant delay. Review revealed, without effective chest compressions oxygen flow to the brain and the heart stops. Review of MedlinePlus.gov's online article CPR - Adult and Child after Onset of Puberty dated [DATE] revealed, in part, time is very important when an unconscious person is not breathing. Further review revealed, permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6 minutes later. Review of Resident #1's medical record revealed, in part, an admitted [DATE] with diagnoses that included: Acute Respiratory Failure, Hypoxia, and Tracheostomy Status. Review of Louisiana Physician Orders for Scope of Treatment (LaPost) dated [DATE] revealed, in part, if Resident #1 was unresponsive, pulseless and was not breathing, CPR or an attempt at resuscitation should be performed. Further review revealed, Resident #1's financial and medical power of attorney (POA) signed and dated the form on [DATE]. Review of Resident #1's [DATE] physician orders revealed, in part, an order dated [DATE] for Code Status: Full Code. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of [DATE] revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #1 was severely cognitively impaired. Review revealed, Resident #1 had no behaviors of rejection of care, and was dependent with moderate to maximal assistance with activities of daily living. Further review revealed Resident #1 had an active diagnosis of Tracheostomy Status. Review of Resident #1's Comprehensive Plan of Care with a Target Completion Date of [DATE] revealed, in part, Resident #1 was a full code. Further review of Resident #1's Plan of Care with a Target Completion Date of [DATE] revealed, in part, a Resident #1's tracheostomy tube and airway would be maintained. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from approximately 11:48 p.m. through [DATE] at approximately 12:03 a.m. revealed, in part, Resident #1 lying supine with his tracheostomy (a device surgically inserted into the trachea to allow air to fill the lungs) lying on Resident #1's right side on top of his blanket. S4RT entered Resident #1's room, applied gloves, and attempted to replace Resident #1's tracheostomy into his stoma (an opening in the neck where the tracheostomy is inserted). After being unsuccessful, S4RT opened a new tracheostomy kit, inserted the tracheostomy into Resident #1's stoma, and secured the tracheostomy around Resident #1's neck. S4RT obtained an Ambubag (a hand held device used to provide positive pressure ventilation to residents who are not breathing) and began bagging (imitation of positive pressure ventilation to an individual with insufficient breathing) Resident #1. S4RT stopped bagging Resident #1, shook Resident #1, exited Resident #1's room, and returned with a pulse oximeter (a device used to measure oxygen saturation in the blood). S4RT placed the pulse oximeter on Resident #1's finger and then exited Resident #1's room, leaving Resident #1 alone. S5RN passed Resident #1's door and S4RT reentered Resident #1's room with a portable oxygen cylinder. S5RN then entered Resident #1's room, placed her hands on Resident #1's chest, immediately removed her hands from Resident #1's chest, and exited Resident #1's room. S4RT then connected the portable oxygen cylinder to the Ambubag. At this time, S26Certified Nursing Assistant was observed passing Resident #1's door. S4RT placed the Ambubag on Resident #1, and began bagging Resident #1. S4RT exited Resident #1's room again, leaving Resident #1 unattended. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from 12:03 a.m. through [DATE] at approximately 12:10 a.m. revealed S4RT reentered Resident #1's room with S5RN, S26CNA, and S27CNA and S5RN started chest compressions. S5RN, S26CNA, and S27CNA alternated performing chest compressions until the fire department arrived. Further review revealed, the fire department entered Resident #1's room, immediately placed him on the floor, and began chest compressions. Review of Resident #1's nursing progress noted dated [DATE] at 11:49 p.m. written by S5RN revealed, in part, S5RN was called to Resident #1's room by S4RT. Further review revealed, Resident #1 was found unresponsive with no pulse, no respirations, and no blood pressure. Further review revealed, S4RT stated Resident #1 pulled out his tracheostomy tube, and S5RN initiated CPR and called 911. Further review revealed S5RN continued with CPR until the arrival of EMS on [DATE] at 12:15 a.m. when Resident #1 was transported to the hospital for evaluation and treatment. Review of Resident #1's respiratory progress note dated [DATE] at 12:48 a.m. written by S4RT revealed, in part, at 11:30 p.m. Resident #1 was found apneic (absence of breathing) and without a pulse with his tracheostomy tube completely pulled out. S4Respiratory Therapist inserted tracheostomy tube back in the trachea and began bagging Resident #1. The nurse called 911 and Certified Nursing Assistant (CNA) helped with compressions. The firemen and emergency medical technicians (EMTs) arrived and performed machine compressions, gave epinephrine, and were able to regain a pulse back. Resident #1 was sent to the hospital. Review of Resident #1's hospital records revealed a computerized tomography (CT) scan dated [DATE] at 2:04 a.m. with results that read, concerning for anoxic encephalopathy (a process that begins with the cessation of cerebral blood flow to brain tissue). Review of Resident #1's emergency room records revealed a physician's note dated [DATE] at 2:25 a.m. that read suspected bowel ischemia (evaluated by gastrointestinal team) and related it to a post cardiac arrest hypoperfusion (lack of blood flow) state. Review of Resident #1's hospital physician progress note dated [DATE] at 1:13 p.m. revealed, the physician notified Resident #1's family of concerning findings on head CT which showed an anoxic brain injury. Review of Resident #1's hospital respiratory progress note dated [DATE] at 11:33 a.m. revealed, in part, Resident #1 was placed on comfort care and his ventilator was turned off at 11:00 a.m. Review of Resident #1's death certificate revealed, in part, an expiration date of [DATE] at 6:09 p.m. In an interview on [DATE] at 9:40 a.m., S5RN stated she was the nurse responsible for Resident #1 on [DATE] from 7:00 p.m. to 7:00 a.m. S5RN stated after reviewing the above mentioned camera footage, on the night of [DATE], S5RN was notified by S4RT, that Resident #1 was pulseless and unresponsive. S5RN stated upon entering Resident #1's room, she instructed S4RT to initiate chest compressions. S5RN stated she did not start chest compressions on Resident #1 because her main priority was to call 911. S5RN stated the facility's protocol was to yell out for help and immediately start CPR. S5RN confirmed CPR should be performed on a hard surface or a CPR board should be used. S5RN confirmed chest compressions should have been started on Resident #1 immediately. S5RN further confirmed anyone in the facility can call 911 and her priority should have been Resident #1. In an interview on [DATE] at 10:13 a.m., S4RT stated he was the Respiratory Therapist caring for Resident #1 on [DATE] from 7:00 p.m. to 7:00 a.m. S4RT stated after reviewing the above mentioned camera footage, when he entered Resident #1's room at approximately 11:48 p.m., Resident #1 was pulseless and breathless. S4RT stated he visualized Resident #1's tracheostomy tube was not in place and he immediately attempted to replace it. S4RT stated during the above mentioned time frame, he was doing the tasks he was capable of doing while he was by himself in Resident #1's room. S4RT further stated because he was the respiratory therapist, his main focus was Resident #1's airway. S4RT confirmed following the initial assessment of Resident #1, he should have immediately begun chest compressions and he did not. S4RT further confirmed he should not have left Resident #1 alone at any time. In an interview on [DATE] at 4:00 p.m., S2Director of Nursing (DON) stated after reviewing the above mentioned video footage, S4RT and/or S5RN failed to perform chest compressions for Resident #1 for approximately 15 minutes. S2DON stated the above action by S4RT and S5RN was against the facility's policy and procedure for emergency procedures related to CPR, which was to begin chest compressions immediately. S2DON further stated S4RT and S5RN's actions left the remaining 26 residents on Hall Z who had an advanced directive status of full code at risk for serious injury, harm, or death. In an interview on [DATE] at 11:30 a.m., S1Adminstrator stated after reviewing the above mentioned video footage, S4RT and S5RN failed to perform chest compressions for Resident #1 for approximately 15 minutes. S1Adminstrator further stated the above actions by S4RT and S5RN were against the facility's policy and procedure for emergency procedures related to CPR, which was to begin chest compressions immediately.

Based on record review, observations, and interviews, the facility failed to implement their abuse policies and procedures to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to: 1. Ensure staff who had convictions that barred employment were not allowed to work in the facility for 1 (S32Laundry) staff; 2. Ensure staff who had charges that barred employment with no final disposition were not allowed to work in the facility for 2 (S13CNA and S14Housekeeper) staff; 3 Ensure staff who worked in the facility had a completed criminal background check prior to hiring for 7 (S6CNA, S15Dietary Cook, S29CNA, S31CNA, S33Housekeeper, S34Housekeeper, and S35Housekeeper) staff and, 4. Ensure staff who worked in the facility had a completed National Sex Offender registry check prior to hire for 23 (S6CNA, S11CNA, S13CNA, S14Housekeeper, S15Dietary Cook, S16Laundry, S17Laundry, S18Housekeeper, S19Dietary Aide, S20CNA, S22CNA, S23Housekeeper, S24CNA, S25CNA, S26Transportation, S27Housekeeper, S29CNA S30CNA, S31CNA, S32Laundry, S33Housekeeper, S34Housekeeper, and S35Housekeeper) of 27 (S6CNA, S11CNA, S12Housekeeper, S13CNA, S14Housekeeper, S15Dietary Cook, S16Laundry, S17Laundry, S18Housekeeper, S19Dietary Aide, S20CNA, S21Housekeeper, S22CNA, S23Housekeeper, S24CNA, S25CNA, S26Transportation, S27Housekeeper, S28CNA, S29CNA S30CNA, S31CNA, S32Laundry, S33Housekeeper, S34Housekeeper, S35Housekeeper, and S36CNA) employee personnel files reviewed. This deficient practice resulted in an Immediate Jeopardy situation on 05/01/2023 at 7:14 a.m. when the facility failed to screen all employees and allowed staff who had convictions that barred employment, staff with no final dispositions on charges, staff with no criminal background check and staff with no National Sex Offender registry check access to all 109 vulnerable residents placing them at risk for abuse/neglect/exploitation/misappropriation of property in and around the entire facility. The deficient practice had the likelihood to cause serious injury, harm, impairment, or death to all 109 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. S1Administrator was notified of the Immediate Jeopardy on 07/21/2023 at 12:40 p.m. The Immediate Jeopardy was removed on 07/25/2023 at 1:14 p.m. after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit which included in part: developing and implementing policies and procedures for screening employees that ensured all 109 residents were free from potential abuse, neglect, exploitation, and misappropriation of property; auditing employing files; completing background checks; and termination of 6 employees with convictions that barred employment. Findings: Review of Louisiana R.S. (revised statute) 40:1203.3 revealed, in part, no employer shall hire non-licensed person when the results of a criminal history check reveal that non-licensed person has been convicted of any of the following offenses: distribution or possession with the intent to distribute controlled dangerous substances as listed in Schedules I through V of the Uniform Controlled Dangerous Substances Act. Further review revealed, the felony offense involving theft, pursuant to R.S. 14:67, or theft of assets of an aged person or person with a disability, pursuant to R.S. 14:67.21 in excess of five hundred dollars or in any case in which the offender has been previously convicted of theft, pursuant to R.S. 14:67, or theft of assets of an aged person or person with a disability, pursuant to R.S. 14:67.21, regardless of the value of the instant theft. Further review revealed, if the results of a criminal history check reveal that a non-licensed person had been convicted of any of the offenses listed, the employer shall immediately terminate the person's employment. Review of the facility's Risk Areas for Fraud and Abuse policy revealed, in part, the facility would have policies and procedure in place to prevent abuse, neglect, exploitation or misappropriation of resident property. Further review revealed, in part, individuals would not be employed who had been found guilty of abuse, neglect, exploitation or misappropriation of resident property. Review of the facility's policy regarding the Seven Components of Abuse Prevention revealed, in part the facility will screen employees to determine if potential or current employees had records or abuse. Further review revealed, no documentation of any procedures for completing state approved criminal background checks or National Sex Offender registry checks, and how the results of a state approved criminal background checks or National Sex Offender registry checks would affect the hiring process. Review of the facility's Coordinating and Implementing Abuse, Neglect, and Exploitation Policies and Procedures revealed, in part, policies were in place that prevented resident abuse, neglect, exploitation and misappropriation of resident property. Further review revealed that the facility would have policies that address employee screening as part of abuse, neglect, exploitation and misappropriation prevention. Review of the facility's Hiring Policy and Procedure revealed, in part, all employees will be screened and references obtained. Further review revealed, all applicants will be subject to employment investigations into their work backgrounds, their personal references, and verification of criminal record shall be conducted. Further review revealed, no documentation of any procedures for completing state approved criminal background checks or National Sex Offender registry checks, and how the results of a state approved criminal background checks or National Sex Offender registry checks would affect the hiring process. Review of the facility's Employee Conduct and Work Rules policy revealed, in part, conviction of a crime, whether following a trial or a plea of guilty, that indicated unfitness for the job or a risk to the safety or well-being of the residents, will result in corrective action up to and including termination. Review of the facility's Background Screening Investigations Policy and Procedure revealed, in part, background and criminal checks are to be initiated for non-licensed employees prior to the first day of work and that non-licensed employees were allowed to begin working until their results were received. In an interview on 07/19/2023 at 11:00 a.m., S37Human Resources Director (HR) stated approved criminal background checks were submitted on hire for all staff. S37HR further stated on occasion, the state approved criminal background check company required fingerprints for newly hired employees, and the state approved criminal background checks for newly hired employees sometimes took 30 to 45 days to be completed. S37HR further stated that the Louisiana state law allowed the facility to allow newly hired employees to work in the facility until their criminal background checks were received as long as the request for the criminal background checks were submitted to the state agency within 72 hours of hire. S37HR also stated newly hired employees that were allowed to work without a state approved criminal background check would be fired immediately if the employee's criminal background check listed a conviction that barred employment. 1. S32Laundry Review of S32Laundry's employee record revealed, in part, S32Laundry was hired on 06/07/2023, and a state approved criminal background check report was not completed until 06/27/2023. Further review of S32Laundry's background check revealed, in part, S32Laundry had two convictions of theft between $100 and $500, which barred employment. Further review revealed the facility allowed S32 Laundry to work multiple shifts for 26 days. In an interview on 07/20/2023 at 3:39 p.m., S37HR stated S32Laundry's criminal background check revealed he was guilty of two thefts between $100 and $500, which were convictions that barred employment. S37HR further stated that S32Laundry's employment at the facility should have been terminated when facility received S32Laundry's state approved criminal background check report on 06/27/2023. S37HR also stated S32Laundry should not have been allowed to continue to work at the facility putting the facilities residents under unnecessary risk In an interview on 07/21/2023 at 9:44 p.m., S43Housekeeping Supervisor stated that facility's residents were put under unnecessary risk due to S32Laundry working in the facility with charges that barred employment. In an interview on 07/21/2023 at 10:13 a.m., S1Administrator stated S32Laundry's state approved criminal background check had convictions that barred employment, and that S32Laundry should have been terminated as soon as their state approved criminal background check report came in, but was not. S1Administrator further stated that allowing an employee with charges that barred employment to work in the facility put all residents at a risk for abuse, neglect, and misappropriation of property. 2. S13CNA Review of S13CNA's employee record revealed, in part, S13CNA was hired on 05/17/2023 with no state approved criminal background check completed until 06/15/2023.The background check revealed S13CNA had a charge of Manufacturing, Distribution, or Possession of a Scheduled I; Possession Marijuana with no final disposition. Review of S13CNA's timecard revealed S13CNA was allowed to work 12-hour shifts with all 109 vulnerable residents' for 34 days. S14 Housekeeper Review of S14Houskeeper's employee record revealed, in part, S14Housekeeper was hired on 05/01/2023 with no state approved criminal background check until 06/02/2023. The background check revealed S14Housekeeper had three charges of misdemeanor with no disposition noted. Review of S14Houskeeper's Time Card Report revealed, in part, S14Houskeeper was allowed to work throughout the facility as a [NAME] for 49 days working multiple shifts and times exposing all 109 residents to risk. In an interview on 7/20/2023 at 3:39 p.m., S37HR confirmed S13CNA and S14Housekeeper had charges that barred employment, and the facility had no final disposition of the charges. S37HR further stated, she was not aware that S14Housekeeper's three charges of misdemeanor theft would have barred him from employment if no disposition was available. S37HR further stated that S13CNA and S14Housekeeper should not have worked in the facility with no final disposition of charges that barred employment. S37HR further stated that because S13CNA's and S14 Housekeeper's employment continued at the facility, the facility's residents were put under unnecessary risk for abuse, neglect, and misappropriation of property. In an interview on 07/21/2023 at 10:13 a.m., S1Administrator stated S13CNA and S14Houskeeper had charges that if convicted, barred employment on their state approved criminal background check reports with no final disposition of the charges. S1Administrator further stated S13CNA and S14Houskeeper should have been terminated as soon as their state approved criminal background check report came in, but were not. S1Administrator further stated that allowing employees with charges that if convicted would bar employment on their state approved criminal background check with no final disposition noted to work in the facility, put residents at potential risk for abuse, neglect, and misappropriation of property. 3. The following 7 employees were allowed to work throughout the facility with all 109 residents with no state approved criminal background check completed prior to hire as follows: S6CNA was allowed to work 12 hour shifts throughout the facility for 10 days from 06/29/2023 to 07/21/2023. S15Dietary Cook was allowed to work in the facility's kitchen on multiple times of the day for 10 days from 07/13/2023 to 07/21/2023. S29CNA was allowed to work 12 hour shifts throughout the facility for 14 days from 06/26/2023 to 07/21/2023. S31CNA was allowed to work multiple shifts throughout the facility for 20 days from 06/27/2023 to 07/21/2023 S33Houskeeper was allowed to work 8 hour shifts throughout the facility for 12 days from 07/03/2023 to 07/21/2023. S34Houskeeper was allowed to work 8 hour shifts throughout the facility for 12 days from 06/30/2023 to 07/21/2023. S35Houskeeper was allowed to work multiple shifts throughout the facility for 22 days from 06/20/2023 to 07/21/2023. In an interview on 07/20/2023 at 11:57 a.m., S37HR stated that she did not have completed background checks on S6CNA, S15Dietary Cook, S29CNA, S31CNA, S33Housekeeper, S34Housekeeper, and S35Housekeeper. In an interview on 07/21/2023 at 8:44 a.m., S2DON stated allowing employees to work in the facility without a completed state approved criminal background check could potentially put the facility's residents in jeopardy of abuse. In an interview on 07/21/2023 at 9:44 a.m., S43Housekeeping Supervisor stated allowing S33Housekeeper, S34Housekeeper, and S35Houskeeper to work in the facility without having their state approved criminal background checks completed put the facility's residents at risk. In an interview on 07/21/2023 at 9:53 a.m., S44Dietary Manager stated that because S15Dietary Cook did not have a state approved criminal background check completed, he put the facility's residents under an unnecessary risk for abuse. In an interview on 07/21/2023 at 10:08 a.m., S37HR stated that employees working in the facility without completed state approved criminal background checks put residents at risk for abuse, neglect, and misappropriation of property. S37HR further stated when prospective employees are not screened properly before hire, the facility does not know if the prospective employees have a criminal history, and that puts the facility's residents at risk. In an interview on 07/21/2023 at 10:13 a.m., S1Administratior stated the facility's residents were not adequately protected due to staff being allowed to work in the facility without a completed approved criminal background check. 4. The following 23 employees were allowed to work throughout the facility with all 109 residents without a completed National Sex Offender registry check. S6CNA was allowed to work multiple shifts throughout the facility for 10 days from 06/29/2023 to 07/21/2023. S11CNA was allowed to work on multiple day shifts throughout the facility for 7 days from 07/11/2023 to 07/21/2023. S13CNA was allowed to work multiple day shifts throughout the facility of 34 days from 05/17/2023 to 07/21/2023. S14Housekeeper was allowed to work on multiple shifts throughout the facility for 56 days from 05/01/2023 to 07/21/2023. S15Dietary Cook was allowed to work in the facilities kitchen on multiple times of the day for 7 days from 07/13/2023 to 07/21/2023. S16Laundry was allowed to work on multiple shifts with access to all residents for 41 days from 05/31/2023 to 07/21/2023. S17Laundry was allowed to work on multiple shifts with access to all residents for 15 days from 06/20/2023 to 07/21/2023. S18Houskeeper was allowed to work multiple shifts throughout the facility for 39 days from 05/16/2023 to 07/21/2023. S19Dietary Aide was allowed to work multiple shifts in the facility's kitchen for 12 days from 07/03/2023 to 07/21/2023. S20CNA was allowed to work multiple shifts throughout the facility for 16 days from 07/07/2023 to 07/21/2023. S22CNA was allowed to work multiple shifts throughout the facility for 34 days from 05/21/2023 to 07/21/2023. S23Houskeeper was allowed to work multiple shifts throughout the facility for 28 days from 05/30/2023 to 07/21/2023. S24CNA was allowed to work multiple shifts throughout the facility for 32 days from 05/17/2023 to 07/21/2023. S25CNA was allowed to work multiple shifts throughout the facility for 49 days from 06/02/2023 to 07/21/2023. S26CNA was allowed to work multiple shifts throughout the facility for 30 days from 05/02/2023 to 07/21/2023. S27Housekeeper was allowed to work multiple shifts throughout the facility for 42 days from 05/16/2023 to 07/21/2023. S29CNA was allowed to work multiple shifts throughout the facility for 14 days from 06/26/2023 to 07/21/2023. S30CNA was allowed to work multiple shifts throughout the facility for 31 days from 06/07/2023 to 07/21/2023. S31CNA was allowed to work multiple shifts throughout the facility for 20 days from 06/27/2023 to 07/21/2023. S32Laundry was allowed to work multiple shifts throughout the facility for 28 days from 06/07/2023 to 07/21/2023. S33Housekeeper was allowed to work multiple shifts throughout the facility for 11 days from 07/03/2023 to 07/21/2023. S34Housekeeper was allowed to work multiple shifts throughout the facility for 12 days from 06/30/2023 to 07/21/2023. S35Housekeeper was allowed to work multiple shifts throughout the facility for 24 days from 06/20/2023 to 07/21/2023 In an interview on 7/20/2023 at 3:39 p.m., S37HR stated allowing employees without a national sex offender registry check work in the facility put the facility's residents at risk for harm, and that employees without a national sex offender registry check, should not be working in the facility. In an interview on 07/21/2023 at 8:44 p.m., S2DON stated it was important for the facility to run National Sex Offender Registry checks on all employees prior to hire. S2DON further stated if the facility was not aware of what employees had been convicted of, the facility did not know what the employees could potentially do the facility's residents. In an interview on 07/21/2023 at 9:43 a.m., S49Assistant Administrator stated she was unsure if any employee employed by the facility had been checked against the National Sex Offender Registry due to a problem with the facility's contracted state approved background check agency. S49Assistant Administrator further stated she spoke to the facility's contracted state approved background check agency, and S49Assistant Administrator confirmed that the state approved background check agency was not performing National Sex Offender Registry checks on employees as part of their criminal background check. In an interview on 07/21/2023 at 10:13 a.m., S1Administrator stated the facility was not following the Abuse Prevention policies during the hiring process. S1Administrator further stated the facility's screening process was not adequate to protect residents in the facility. S1Administratior stated 37HR was not aware national sex offender registry checks were not being completed on the facility's employee's before they were hired and allowed to work in the facility, and S37HR should have ensured the National Sex Offender Registry was assessed for all staff. S1Administrator further stated that because facility was not screening new employees correctly before allowing them to work in the facility, the facility's residents were put at risk for abuse, neglect and exploitation. 47500

Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being by failing to: 1. Ensure a system was in place for staff to identify residents as unsafe smokers,supervise residents who displayed unsafe smoking habits, and ensure smoking material and/or cigarettes were not in resident possession (Resident #24, and Resident #80, Resident #83. Resident #85); and, 2. Ensure all residents were free from resident to resident sexual and physical abuse; and 3. Develop and implement policies and procedures for screening employees to prevent resident abuse, neglect, exploitation, and misappropriation of property. This lack of Administrative oversight resulted in an Immediate Jeopardy that could affect the lives and well-being of all residents residing in the facility and the likelihood to cause serious injury, harm, impairment, or death to all 109 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. S1Administrator was notified of the Immediate Jeopardy on 07/21/2023 at 12:40 p.m. The Immediate Jeopardy was removed on 07/25/2023 at 2:15 p.m. after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit which included, in part: S63Owner will be overseeing S1Administrator and the facility department heads in the implementation of the interventions put into place to ensure they are enforced for unsafe smokers. S63Owner will observe the smoking area and check the list of unsafe smoking residents weekly. S63Owner held an in-service that began on 07/24/2023 with department heads that covered new implementations, which included unsafe smoker's lists and how to protect residents from unsafe smoking habits. S63Owner will meet with S1Administrator weekly for 3 months until 10/21/2023 to review the facility's policy and procedures, including unsafe smoking and smoking policies. S1Administrator and S63Owner will be reviewing that every perspective employee's references and background checks are completed before hire for the next 6 months. S1Administrator will periodically review new employee files quarterly for reference checks and background checks thereafter. S1Administrator in-serviced all staff on the new abuse policy. S63Owner, S37Human Resources, S49Assistant Administrator, and all facility department heads were in serviced on the new hiring policy. Facility will not allow any perspective employees to work in the facility until background checks and reference checks are completed and free of any convictions that barred employment. The Facility will be contracted with a new state approved background check company that will be able to produce reports more quickly. S63Owner stated she will maintain oversight for Administration and Administrative Staff. Findings: Cross-Reference Findings at F-689 In an interview on 07/20/2023 at 11:45 a.m., S1Administrator stated Resident #24. Resident #80, Resident #83, and Resident #85 should not have been allowed to smoke without staff supervision. S1Adminstrator further stated Resident #80 should have been deemed an unsafe smoker after he was caught smoking in his room, he should have been provided direct supervision when he was smoking, and his smoking material should have been removed from his person following the incident. S1Adminstrator stated Resident #83 should have been deemed an unsafe smoker after she was visualized during her assessment disposing of ashes improperly. S1Administrator stated S60SSD should have notified him or S2DON following the incident, and Resident #80 should have been reassessed immediately. S1Adminstrator further stated Resident #24 and Resident #85 should have staff supervision when smoking and Resident #24 should have a smoking apron on at all times. Cross-Reference Findings at F-600 In an interview on 07/19/2023 at 10:13 a.m., S1Administrator stated when Resident #100 displayed inappropriate sexual behaviors, Resident #100 should have been placed on 1 on 1 supervision, Resident #100's physician should have been contacted, and a discharge/transfer plan should have been started. S1Administrator stated Resident #100 had the potential to have inappropriate sexual behaviors with other residents when not on 1 on 1 supervision and residents were not safe. In an interview on 07/25/2023 at 11:30 a.m., S2DON confirmed Resident #21 physically abused Resident #8 on 04/01/2023. S2DON further confirmed new interventions were not put into place after new episodes of abusive behaviors on 08/18/2022 and 04/01/2023. S2DON further stated Resident #21's care plan should have included new interventions after each new abusive behavior episode. In an interview on 07/25/2023 at 11:50 a.m., S63Owner confirmed Resident #100 sexually abused Resident #27 on 06/01/2023. S63Owner further stated once Resident #100 returned to the facility, there should have been a plan in place for monitoring of Resident #100's inappropriate sexual behaviors and if inappropriate behaviors were noted, S2DON and S1Administrator should have been notified of Resident #100's sexually inappropriate behaviors. S63Owner confirmed all residents were at risk for sexual abuse. Cross-Reference Findings at F-607 In an interview on 07/21/2023 at 9:43 a.m., S49Assistant Administrator stated she was unsure if any employee employed by the facility had been checked against the National Sex Offender Registry due to a problem with the facility's contracted state approved background check agency. S49Assistant Administrator further stated she spoke to the facility's contracted state approved background check agency, and S49Assistant Administrator confirmed that the state approved background check agency was not performing National Sex Offender Registry checks on employees as part of their criminal background check. In an interview on 07/21/2023 at 10:13 a.m., S1Administrator stated the facility was not following the Abuse Prevention policies during the hiring process. S1Administrator further stated the facility's screening process was not adequate to protect residents in the facility. S1Administratior stated 37HR was not aware national sex offender registry checks were not being completed on the facility's employees before they were hired and allowed to work in the facility, and S37HR should have ensured the National Sex Offender Registry was assessed for all staff. S1Administrator further stated that because facility was not screening new employees correctly before allowing them to work in the facility, the facility's residents were put at risk for abuse, neglect and exploitation. 47487 47500

46683 47487 47500 Based on observations, interviews, and record reviews; the facility failed to protect residents' right to be free from abuse for 3 (Resident #8, Resident #27, and Resident #104) of 7 (Resident #8, Resident #21, Resident #27, Resident #82, Resident #83, Resident #100, and Resident #104) residents investigated for abuse. The facility failed to protect: 1. Resident #27 from sexual and psychosocial abuse by Resident #100; 2. Resident #104 from sexual abuse by Resident #100; and 3. Resident #8 from physical abuse by Resident #21. This deficient practice resulted in an Immediate Jeopardy situation on 06/01/2023 at 12:50 p.m. when Resident #100, a cognitively impaired resident, lifted Resident #27's shirt and attempted to put his face to Resident #27's breast causing Resident #27 to have increased anxiety when anyone enters her room. The Immediate Jeopardy situation continued for the following: on 07/13/2023, S5LPN witnessed Resident #100 pucker his lips and attempt to kiss Resident #27 and on 07/17/2023, S6Certified Nursing Assistant (CNA) witnessed Resident #100 sexually abuse Resident #104 by attempting to touch Resident #104's genital area. S1Administrator was notified of the Immediate Jeopardy on 07/19/2023 at 12:45 p.m. The Immediate Jeopardy was removed on 07/22/2023 at 12:21 p.m., after it was determined through observation, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included in part; notifying residents responsible parties, in-service staff on reporting sexually inappropriate behavior to management immediately upon witnessing. Began abuse training with staff on identifying and preventing abuse with Staff unable to work until they had been in-serviced on reporting sexually inappropriate behavior and abuse training. Resident #100 was placed 1:1 supervision with S24Certified Nursing Assistant (CNA), due to the potential to cause harm to other residents until Resident #100 was sent to hospital for psych evaluation and treatment due to sexually inappropriate behavior. The deficient practice had the potential to cause serious harm or injury to all 109 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Review of the facility's Abuse, Neglect, Exploitation and Misappropriation policy, revised March 2023, revealed, in part, resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #27 Review of the facility's incident report list dated 2023 revealed, in part, no incident report for Resident #27. Review of the facility's Statewide Incident Management System report dated 06/01/2023 revealed, in part, Resident #100 went into Resident #27's room and placed his tongue into her mouth. Resident #100 was trying to touch Resident #27 but unsuccessful. Further review revealed a follow-up was conducted with three female residents on the unit and there was no evidence of any previous incidents with Resident #100. The appropriate amount of staff was on the unit at the time of the incident, 2 nurses and 4 CNAS. The police were not notified as Resident #27 requested not to do so. S2Director of Nursing (DON) would follow-up with the nursing staff on Resident #100's behaviors for 3 months. Review of Resident #27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/2023 revealed, in part, Resident #27 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #27 was severely cognitively impaired. Review of Resident #27's progress note dated 06/01/2023 at 1:33 p.m. revealed, in part, S2DON was notified at 12:50 p.m. that a male resident was found in Resident #27's room, Resident #27 stated the male resident kissed her and attempted to touch her pointing to her vaginal area, provider was notified. Observation on 07/18/2023 at 9:37 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? In an interview on 07/18/2023 at 9:37 a.m., Resident #27 stated a man entered her room several weeks ago, fondled my breast. Resident #27 stated she started waving her arms while yelling I don't want that, stop and then he went away. Resident #27 further stated she now becomes anxious when anyone enters her room. In an interview on 07/18/2023 at 2:00 p.m., S56Licensed Practical Nurse (LPN) stated Resident #27 voiced being scared of a man who entered her room and touched her. In an interview on 07/18/2023 at 3:09 p.m., S4Certified Nursing Assistant (CNA) stated she entered Resident #27's room and saw Resident #100 had lifted Resident #27's shirt trying to put his mouth on her breast. S4CNA further stated Resident #27 began to fight him by trying to push him away with her arms. S4CNA stated she removed Resident #100 from Resident #27's room. S4CNA further stated she reported the incident to S40LPN. In an interview on 07/19/2023 at 9:40 a.m., S39Social Worker stated on 06/01/2023 she was notified that Resident #100 kissed and attempted to touch Resident #27. S39Social Worker stated since the incident, Resident #27 was scared and nervous. S39Social Worker stated when staff entered Resident #27's room she would immediately ask Who was present in her room and why they were entering her room? S39Social Worker stated after the incident when Resident #100 kissed Resident #27, staff were educated to knock and identify self and why they are entering Resident #27's room and to close the door upon exiting the room. S39Social Worker stated staff should report any inappropriate sexual behaviors to social services. S39Social Worker stated when these behaviors occur immediate action should be taken. S39Social Worker stated she was not aware of Resident #100 touching Resident #104 and immediate action should have been taken. In an interview on 07/19/2023 at 11:25 a.m., S40LPN stated on 06/01/2023 S4CNA reported she witnessed Resident #100 attempting to touch Resident #27's breast with his mouth. Observation on 07/20/2023 at 9:37 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? In an interview on 07/21/2023 at 12:04 p.m., S39Social Worker stated she did not complete any follow-up assessments with Resident #27 after the incident that occurred on 06/01/2023 with Resident #100. In an interview on 07/21/2023 at 12:20 p.m., S2DON stated she spoke with Resident #27 on several occasions to assess Resident #27's emotional state. S2DON stated she did not have any documentation of follow-up assessments completed for Resident #27 after the incident of sexual abuse that occurred on 06/01/2023 with Resident #100. S2DON further stated she did not have any documentation of staff education completed following the incident that occurred on 06/01/2023 when Resident #100 placed his tongue into Resident #27's mouth. Observation on 07/22/2023 at 11:00 a.m. revealed as surveyor entered Resident #27's room Resident #27 began to ask who is here, why are you here? Resident #100 Review of Resident #100's MDS with an ARD of 04/13/2023 revealed, in part, a BIMS was not conducted because Resident #100 was rarely or never understood. Review of Resident #100's progress note dated 06/01/2023 at 12:30 p.m., revealed, in part, Resident #100 was displaying inappropriate behavior with residents and staff by touching them in sexual ways, kissing, and wandering into female resident's rooms. Review of Resident #100's progress note dated 07/13/2023 revealed, in part, Resident #100 displayed inappropriate behaviors the entire shift by touching female staff members and puckering his lips wanting to kiss Resident #27. Review of Resident #100's progress notes dated 07/13/2023 revealed, in part, Resident #100 was able to propel himself via wheelchair throughout the facility. Review of Resident #100's care plan last updated on 05/15/2023 revealed, in part, no documented evidence and the facility did not present any documented evidence that a plan of care was developed with goals and/or interventions related to Resident #100's sexually inappropriate behaviors after the above mentioned 06/01/2023 incident or after Resident #100's above mentioned behaviors on 07/13/2023. Review of Resident #100's July 2023 physician's orders revealed, an order with a start date of 06/13/2023, to monitor Resident #100 for inappropriate behaviors every two hours and document any inappropriate behaviors noted. Review of Resident #100's June 2023 electronic medication administration record (eMAR) revealed, in part, no documentation that behaviors were monitored at 12:00 a.m. on 06/15/2023, 06/19/2023, 06/24/2023, 06/28/2023; 2:00 a.m. on 06/16/2023; 4:00 a.m. on 06/16/2023; 6:00 a.m. on 06/16/2023 and 06/27/2023; 8:00 a.m. on 06/14/2023 and 06/18/2023; 10:00 a.m. on 06/16/2023 and 06/22/2023; 12:00 p.m. on 06/16/2023, 06/22/2023, and 06/26/2023; 2:00 p.m. on 06/13/2023; 4:00 p.m. on 06/13/2023; and 6:00 p.m. on 06/13/2023 and 06/16/2023. Review of Resident #100's July 2023 eMAR revealed, in part, no documentation that Resident #100's inappropriate behaviors were monitored at 12:00 a.m. on 07/02/2023, 07/03/2023, 07/06/2023, 07/07/2023, 07/11/2023, 07/15/2023, 07/16/2023, 07/17/2023, 2:00 a.m. on 07/18/2023, 6:00 a.m. on 07/05/2023 and 07/14/2023, 8:00 a.m. on 07/14/2023, and 6:00 p.m. on 07/02/2023. Review of Resident #100's June and July 2023 eMAR revealed in part, Resident #100 displayed inappropriate sexual behaviors on the night shift 7:00 p.m. to 7:00 a.m. on 06/20/2023, and displayed inappropriate behaviors on 07/11/2023 at 12:00 p.m There was no documented evidence, and the facility did not present any documented evidence of supporting documentation of the facility acting upon Resident #100's inappropriate behaviors displayed on 06/20/2023 and 07/11/2023. In an interview on 07/18/2023 at 4:00 p.m., S48LPN stated Resident #100 was monitored every two hours for inappropriate behaviors due to a previous incident with Resident #27. S48LPN further stated Resident #100 should have one on one supervision by staff. In an interview 07/18/2023 at 4:22 p.m., S53CNA stated she was unaware Resident #100 had inappropriately touched Resident #27. S53CNA was unaware that he was supposed to be monitored for inappropriate behaviors In an interview on 07/18/2023 at 5:50 p.m., S2DON stated Resident #100 was the perpetrator in an incident of sexual abuse on 06/01/2023 with Resident #27. S2DON stated since Resident #100's return to the facility on [DATE]. Resident #100 should have been monitored by staff every hour for inappropriate sexual behavior. S2DON further stated staff had not reported Resident #100 had displayed sexually inappropriate behavior or had any additional instances of sexual abuse. In an interview on 07/19/2023 at 9:13 a.m., S45Assistant Director of Nursing (ADON) stated Resident #100 can move around the facility freely. S45ADON stated staff did not report any sexually inappropriate behavior from Resident #100 since his return from the psychiatric hospital on 06/09/2023. S45ADON stated Resident #100 should have been monitored every 2 hours for sexually inappropriate behaviors. S45ADON stated Resident #100 was monitored because of an incident where he tried to kiss Resident #27 and touched her breasts. S45ADON stated all staff that worked with Resident #100 should have been aware that Resident #100 had to be monitored for sexually inappropriate behaviors. S45ADON further stated Resident #100 needed one on one monitoring in order to keep other residents free from sexual abuse. In an interview on 07/19/2023 at 9:57 a.m., S2DON stated Resident #100's care plan should have been updated when Resident #100 first displayed inappropriate sexual behaviors. S2DON stated Resident #100's care plan should have been updated with each inappropriate sexual behavior. S2DON stated Resident #100's eMAR should have documentation every 2 hours of Resident #100's sexually inappropriate behaviors. S2DON further stated blank documentation indicates the monitoring was not done. In an interview on 07/19/2023 at 10:13 a.m., S1Administrator stated when Resident #100 displayed inappropriate sexual behaviors, Resident #100 should have been placed on 1 on 1 supervision, Resident #100's physician should have been contacted, and a discharge/transfer plan should have been started. S1Administrator stated Resident #100 had the potential to have inappropriate sexual behaviors with other residents when not on 1 on 1 supervision and residents were not safe. In an interview on 07/19/2023 at 9:10 a.m., S5LPN stated Resident #100 was known for trying to touch staff. S5LPN stated Resident #100 had to be monitored due to trying to touch other residents inappropriately. S5LPN stated that her nursing note on 07/13/2023 was in regards to Resident #100 trying to get close to Resident #82 puckering his lips at her. S5LPN stated that neither Resident #82 nor Resident #100 had the mental capacity to consent to sexual behavior. S5LPN stated Resident #100 can roll himself backwards in his wheelchair to get off of the unit to go smoke by himself. S5LPN stated she monitored Resident #100 every two hours while he was on unit for inappropriate behaviors. S5LPN further stated that she had not reported the sexually inappropriate behaviors to S45ADON or S2DON. In an interview on 07/19/2023 at 10:46 a.m., S47LPN stated Resident #100 tried to kiss other residents, especially Resident #82. S47LPN stated her documentation of inappropriate behaviors on 06/20/2023 was in regards to Resident #100 puckering at Resident #82, trying to get close to her, and having to be separated. S47LPN further stated that she had not informed S45ADON or S2DON of Resident #100's behavior. Resident #104 Review of Resident #104's MDS with an ARD of 06/22/2023 revealed, in part, Resident #104 had a BIMS of 14, which indicated Resident #104 was cognitively intact. In an interview on 07/18/2023 at 1:45 p.m., Resident #104 stated Resident #100 tried to grab her private area on 07/17/2023. Resident #104 further stated she told Resident #100 to stop touching her. Resident #104 stated S6CNA was present when Resident #100 tried to grab her private area. In an interview on 07/18/2023 at 2:53 p.m., S6CNA stated on 07/17/2023 she witnessed Resident #104 sitting in her wheelchair by the desk when Resident #100 rolled his wheelchair by Resident #104 and attempted to touch Resident #104. S6CNA further stated Resident #104 told Resident #100 to stop touching her. S6CNA stated she then instructed Resident #100 to move away from Resident #104. In an interview on 07/19/2023 at 9:57 a.m., S2DON stated Resident #104 informed her this morning that Resident #100 attempted to touch her in between her legs on Monday 07/17/2023 and staff was present when it happened. S2DON stated the staff that were present when Resident #100 attempted to touch Resident #104, should have notified her immediately. S2DON stated Resident #100 should have been placed on 1 on 1 supervision and Resident #100's physician should have been notified. S2DON stated because she was not informed of Resident #100 touching Resident #104, Resident #100 was not placed on 1 on 1 supervision and Resident #100 was able to continue to have inappropriate sexual behaviors toward and with female residents. Resident #21 Review of Resident #21's MDS with an ARD of 05/11/2023 revealed, in part, Resident #21 had a BIMS score of 12 which indicated Resident #21 had moderate cognitive impairment. Review of Resident #21's Care Plan initiated on 04/29/2021 revealed, in part, Resident #21 exhibited abnormal behaviors which included cursing staff and playing with her feces with interventions initiated on 05/20/2021 to include: approach resident in a calm and non-judging manor, notify physician and family of behaviors, attempt to divert attention during outburst, remove Resident #21 from area of agitation, attempt to find causes of agitation, psychiatric evaluation as needed, and smile and talk with Resident #21 when approaching and/or giving care. Further review of Resident #21's Care Plan initiated on 04/01/2023 revealed, in part, Resident #21 entered Resident #8's room and began hitting Resident #8 while Resident #8 was in his bed. Resident #21 was removed from Resident #8's room and staff redirected her behavior. New orders given to send to emergency room for psych evaluation. Further review of Resident #21's Care Plan revealed no documentation of new goals or interventions Resident #21's return to the facility from an admissions to a psychiatric facility on 08/18/2022 and 04/01/2023. Review of Resident #21's progress notes revealed, in part, an entry dated 08/18/2022 at 11:00 a.m., read Resident #21 was observed in another resident's room destroying their personal property and throwing the bed mattress on the floor. Review of Resident #21's progress notes revealed an additional entry date of 04/01/2023 at 8:19 a.m. entered by S57LPN which read, Resident #21 up in wheelchair observed going toward Resident #8's door way fussing. S57LPN walked and closed the door to avoid confrontation. Further review of Resident #21's progress notes revealed an additional entry dated 04/01/2023 at 12:38 p.m. entered by S57LPN which read, monitoring Resident #21's activity on the unit. Resident #21 complained that Resident #8 was a devil and trying to attack her mind. Further review revealed, in part, an additional entry dated 04/01/2023 at 3:15 p.m. entered by S57LPN which read, called to Resident #8's room where Resident #21 was seen hitting Resident #8 while he was in his bed. Nurse rolled Resident #21 to her room. Resident #21 was angry and stated she does not like to be lied too. Resident #21 said when she is mad she would hurt someone. Review of a Statewide Incident Management Systems report dated 04/03/2023 revealed, in part, on 04/01/2023 at 2:00 p.m., S61CNA witnessed Resident #21 enter Resident #8's room and punch Resident #8 in his arm and side of chest. Resident #21 was removed from room immediately and placed under one-on-one supervision. The Nurse Practitioner, responsible party and S2DON were immediately notified. Interviews were conducted by S1Administrator. Resident #8 was assessed and no redness, bruising or swelling noted. Resident #8 stated he felt safe and did not have any complaints at that time. Resident #8 could not give a description of why the incident occurred. Further review revealed Resident #21 was removed from Resident #8's presence and returned to her room while Resident #8 was assessed and medical doctor and nurse practitioner were notified. Orders were given for Resident #21 to be sent out for a psych evaluation at the emergency department and she left the faciity on [DATE] for psych evaluation. Further review revealed upon Resident #21's return to the facility more frequent nursing rounds would be scheduled, and a care plan for Resident #21 would be completed on her behaviors. In an interview on 07/18/2023 at 2:40 p.m., Resident #21 stated she gets angry with Resident #8 at times and she had hit him in the past. In an interview on 07/18/2023 at 2:50 p.m., S3LPN stated she had observed Resident #21 fuss and curse at Resident #8 and other residents. S3LPN further stated Resident #21 had previously went into Resident #8's room and pulled the mattress for Resident #8's bed on the floor. S3LPN also stated Resident #21 threw Resident #8's personal items on the floor because she was angry with him. In an interview on 07/19/2023 at 3:05 p.m., S57LPN stated on 04/01/2023 at 3:15 p.m., Resident #21 was angry with Resident #8 and hit him. S57LPN further stated the CNA who witnessed Resident #21 hitting Resident #8 removed Resident #21 from Resident #8's room and brought Resident #21 to her room. S57LPN stated she notified S2DON and the physician of the occurrence. S57LPN stated the physician ordered Resident #21 for a psychiatric consult. S57LPN further stated Resident #21 was visually supervised by staff until she left the facility for a psych consult at the emergency department on 04/01/2023 at 4:53 p.m. S57LPN stated Resident #21 was admitted for psychiatric treatment following that occurrence. In interview on 07/21/2023 at 3:00 p.m., S3LPN stated when Resident #21 returned to the facility from her psych admission, no new approaches or interventions such as, increased supervision, were ordered. In an interview on 07/25/2023 at 11:30 a.m., S2DON confirmed Resident #21 physically abused Resident #8 on 04/01/2023. S2DON further confirmed new interventions were not put into place after new episodes of abusive behaviors on 08/18/2022 and 04/01/2023. S2DON further stated Resident #21's care plan should have included new interventions after each new abusive behavior episode. In an interview on 07/25/2023 at 11:50 a.m., S63Owner confirmed Resident #100 sexually abused Resident #27 on 06/01/2023. S63Owner further stated once Resident #100 returned to the facility, there should have been a plan in place for monitoring of Resident #100's inappropriate sexual behaviors and if inappropriate behaviors were noted, S2DON and S1Administrator should have been notified of Resident #100's sexually inappropriate behaviors. S63Owner confirmed all residents were at risk for sexual abuse.

Based on record review, observations, and interviews, the facility failed to: 1. Ensure staff identified and supervised residents (Resident #24, Resident #80, Resident #83, and Resident #85), who displayed unsafe smoking habits, as unsafe smokers; and, 2. Ensure residents, who displayed unsafe smoking habits, did not have access to smoking materials and/or cigarettes was not in their possession for 4 (Resident #24, Resident #80, Resident #83, and Resident #85) of 4 (Resident #24, Resident #80, Resident #83, and Resident #85) smokers reviewed for safe smoking. The facility documented 16 residents who were smokers. The deficient practice resulted in an Immediate Jeopardy situation for Resident #80 on 07/17/2023 at 10:10 a.m. when Resident #80, a resident who previously displayed unsafe smoking habits, was sitting in his wheelchair in the designated smoking area smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #80 was observed smoking a cigarette with visible ashes noted falling on Resident #80's shirt, shorts, and hoyer pad. The Immediate Jeopardy situation continued for the following: On 07/17/2023 at 10:12 a.m. when Resident #83 was smoking a lit cigarette with ashes falling onto her shirt and right arm. Resident #83's geri chair was observed with black ash marks to the right armrest and ashes noted to the foot rest. On 07/17/2023 at 10:19 a.m., Resident #24, a visually impaired resident, was smoking a lit cigarette outside without supervision of staff and without a smoker's apron in place. Resident #24 was observed with a lit cigarette in his hand with visible ashes noted on Resident #24's right upper leg. On 07/18/2023 at 11:01 a.m., Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. S1Administrator was notified of the Immediate Jeopardy on 07/18/2023 at 4:30 p.m. The Immediate Jeopardy was removed on 07/20/2023 at 4:09 p.m., after it was determined through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included in part: *All residents who smoke were reassessed for smoking safety. Smoking assessments will be done on admit, quarterly and as needed. *All staff were in-serviced on the smoking policy,(a copy of the policy given to all staff), at risk residents, smoking times for unsafe residents and what to do with non-compliant residents, to ensure all smoking materials are not left with unsafe smokers and to report to management immediately. No resident is allowed to smoke after 8pm. Staff were not allowed to work their next assigned shift until they have been in-serviced on the above. *The facility assigned a staff member in place to monitor residents while smoking in the east court yard (assigned smoking area) to ensure that the residents smoking are safe until 8:00 p.m. *Care plans were updated to reflect if the resident was safe or unsafe while smoking and update as needed. *S2DON/designee will monitor compliance of interventions of unsafe smokers randomly at least once a day x 4 weeks beginning 07/19/2023 until 08/20/2023. Random checks of smoker's rooms to ensure no lighters are available 3 times a week for 4 weeks. Families notified that no resident is allowed to have a lighter and that the facility will provide lighters. *A meeting was held with all 16 residents that smoke to inform them of the smoking hours (7:00 a.m.-8:00 p.m.), smoking policy, and educate them on the possibilities of infection with sharing cigarettes. Findings: Review of the facility's Smoking and Lighters Policy and Procedure revealed, in part Smoking is not permitted in the resident's room. If resident is caught smoking in a non-designated area, the social worker will counsel the resident on risks and safety factors. Lighters, matches, or other items that ignite a fire are not allowed in resident rooms. Any such items found in a resident's room will be confiscated. Residents who are deemed safe to smoke will be allowed to keep their cigarettes in their room. Residents who need assistance to smoke will be required to leave their cigarettes at the station with their nurse. The facility's employees on Nurse's Station g and Nurse's Station f will be supplied with lighters purchased by the facility. Any resident who would like to go smoke in the designated smoking area must retain one of these employees to go outside with them and light their cigarette. Review of the facility's smoking list revealed Resident #24, Resident #80, Resident #83, and Resident #85 were smokers. In an interview on 07/17/2023 at 9:38 a.m., S1Adminstrator stated all the smokers in the facility are safe smokers. 1.) Resident #80 Review of Resident #80's face sheet revealed, in part, Resident #80 was admitted on [DATE] with diagnosis that included: Tobacco abuse counseling and Nicotine Dependence. Review of Resident #80's Minimum Data Set with an Assessment Reference Date of 05/15/2023 revealed, in part, Resident #80's Brief Interview for Mental Status Score was 6 which indicated Resident #80 had severe cognitive impairment. Review of Resident #80's Comprehensive Care Plan, with a start date of 03/31/2023, revealed, in part, Resident #80 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #80 and/or Resident #80's family were to provide Resident #80's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident is properly dressed for weather conditions when outside in smoking area, encourage resident not to spend extended time in smoking area related to excessive heat or cold, assure/encourage resident to be well hydrated when spending time in smoking area, assist resident to smoking area, encourage resident to stay out of direct sunlight, and provide a smoking jacket as needed. Review revealed an additional intervention was added on 05/18/2023 to include staff were to make rounds every hour while in smoking area and as needed. Further review revealed Resident #80's care plan was last reviewed and/or revised on 05/22/2023 at 11:01 a.m. by S7Careplan Nurse. Review of Resident #80's nurses' notes revealed, in part, a nurse's note with a date of 07/13/2023 and time of 5:55 p.m. written by S7LPN which stated Resident #80 was noted smoking in his room. Further review revealed Resident #80's mother was notified by her answering machine and the social services department would be notified. Review of Resident #80's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #80. Review of Resident #80's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #80. Review of Resident #80's current Physician Orders revealed an order with a start date of 01/15/2023 that read Resident #80 was to be up out of bed in his wheelchair daily and he was to be brought outside. Review of Resident #80's Safe Smoking Assessment Form with a completion date of 05/15/2023 revealed, in part, Resident #80 was safe to smoke unsupervised. Review revealed incomplete questions that consisted of- The resident requires 1:1 supervision while smoking, the resident requires a fire proof smoking apron while smoking, and all smoking material will be kept at the nurse's station. Further review revealed staff were to round on Resident #80 every hour and as needed. Review of Resident #80's medical record revealed no documented evidence and the facility did not present any documented evidence of a Safe Smoking Assessment completed after Resident #80 was observed smoking in his room on 07/13/2023. Review of Resident #80's Social Services Notes revealed no documented evidence of counseling or education provided to Resident #80 after Resident #80 was observed smoking in his room on 07/13/2023. Observation on 07/17/2023 at 10:10 a.m. revealed, Resident #80 gave Resident #83 a cigarette. Further observation revealed Resident #83 lit Resident #80's cigarette with her lighter and Resident #80 began smoking a lit cigarette in his wheelchair with cigarette ashes falling onto his shirt, blue hoyer pad, and khaki shorts. In an interview on 07/17/2023 at 10:13 a.m., Resident #80 stated he smoked cigarettes on a daily basis. Resident #80 stated he does not wear an apron, he does not need staff to supervise him when he smokes, and he keeps his own smoking materials. Resident #80 stated he is also able to keep his own lighter, but if he does not have his lighter he will get a light from Resident #83 or other residents on the smoking patio. Resident #80 further stated he got caught smoking a lit cigarette in his room last week, but the facility told him he can still keep his smoking material. In an interview on 07/17/2023 at 10:20 a.m., Resident #83 stated her and Resident #80 smoke every day together in the designated smoking area. Resident #83 stated Resident #80 has his own cigarettes and lighter. Resident #83 stated if Resident #80 does not have his lighter, she would light his cigarette for him. Resident #83 stated Resident #80 does not have to be supervised by staff when smoking or wear a smoking apron. Resident #83 stated staff does not have to supervise any of the smokers. Resident #83 stated when any of the residents smoke, they are usually by their self. In an interview on 07/17/2023 at 11:30 a.m., S10CNA stated Resident #80 goes outside and smoked frequently in the designated smoking area. S10CNA stated Resident #80 does not require supervision when he smokes and he was allowed to keep his smoking material. S10CNA stated Resident #80 needed assistance to the smoking area, but once he was outside he liked to sit outside, smoke, and socialize with other residents. In an interview on 07/17/2023 at 12:38 p.m., S3LPN stated she had multiple smokers on her hall. S3LPN stated Resident #40, Resident #61, Resident #68, Resident #73, Resident #80, Resident #83, and Resident #85 were all smokers and were allowed to keep their smoking materials. S3LPN stated when Resident #80 needed his cigarette lit, he would go outside and get another resident to light his cigarette. S3LPN stated Resident #80 did not require supervision when smoking nor did he require a smoking apron when smoking because he was not an unsafe smoker. In an interview on 07/17/2023 at 1:21 p.m., S11CNA stated she had been working at the facility about 2 weeks and the facility had not informed her of any residents on her hall that were unsafe smokers or that needed to be supervised when smoking. S11CNA stated Resident #80 kept his smoking material on his person and he smoked multiple cigarettes throughout the day. S11CNA stated Resident #80 goes outside with Resident #83 and Resident #85 to smoke. S11CNA stated Resident #80 can smoke unsupervised and does not require a smoking apron because he is not an unsafe smoker to her knowledge. Observation on 07/17/2023 at 3:30 p.m., revealed Resident #80 lying in his bed with a green pack of [NAME] cigarettes on his bedside table. In an interview on 07/18/2023 at 2:00 p.m., S58CNA stated Resident #80 was a safe smoker. S58CNA stated Resident #80 could go outside without supervision and smoke. S58CNA stated Resident #80 had never had any incidents that warranted him being an unsafe smoker. S58CNA further stated Resident #80 had to be assisted outside by staff to the designated smoking area, but once Resident #80 was outside he could smoke unsupervised. In an interview on 07/17/2023 at 3:32 p.m., Resident #80 stated he kept his packs of cigarettes in his two drawer dresser next to his bed. Observation on 07/17/2023 at 3:34 p.m. revealed, Resident #80 had two packs of green [NAME] cigarettes in the two drawer dresser located next to his bed. In an interview on 07/18/2023 at 10:00 a.m., S3LPN stated she was the nurse for Resident #80 when he was observed smoking in his room. S3LPN stated she removed a lit cigarette and a lighter from Resident #80's possession, but she allowed him to keep his smoking materials in his possession because she assumed without a lighter, Resident #80 could not smoke in his room. S3LPN further stated she notified Resident #80's mother and S2DON. Observation on 07/18/2023 at 11:01 a.m. revealed, Resident #80 gave Resident #85 a cigarette. Observation revealed Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. Observation revealed Resident #80 began to smoke the lit cigarette dropping ashes onto his shirt. Observation revealed circular piles of gray ash noted on Resident #80's pink fleece blanket lying on his lap and his blue hoyer pad. Further observation revealed a green pack of [NAME] cigarettes with two cigarettes in the pack lying in the crease of Resident #80's left arm. In an interview on 07/18/2023 at 11:05 a.m., S64Housekeeper stated the facility does not have a smoking aide. S64Housekeeper stated the residents in the facility do not require supervision when smoking. In an interview on 07/18/2023 at 11:18 a.m., S60SSD stated she did not counsel Resident #80, file an incident report, notify the DON or Administrator, or educate any staff after she was notified Resident #80 was smoking in his room. S60SSD stated she should have counseled Resident #80 and notified S2DON or S1Administrator of the incident. In an interview on 07/18/2023 at 1:18 p.m., S7Careplan Nurse stated she was responsible for performing smoking assessments and updating careplans for residents who smoke. S7Careplan stated when she completed Resident #80's smoking assessment, she interviewed the CNA that was assigned to Resident #80 that day. S7Careplan Nurse further stated any questions the CNA was not able to answer, she would ask Resident #80. S7Careplan Nurse stated she did not visualize Resident #80 smoke when she completed his smoking assessment. S7Careplan Nurse stated a resident should be deemed an unsafe smoker if they drop ashes on themselves while smoking, if they attempt to smoke in area that was not a designated smoking area, if they cannot dispose of their ashes properly, and/or if the resident has had any accidents/incidents while smoking. S7Careplan Nurse stated she was not informed Resident #80 was observed smoking in his room so a smoking assessment was not completed. S7Careplan Nurse further stated Resident #80 should have had a smoking assessment done on 07/13/2023 when Resident #80 was observed smoking in his room, Resident #80 should have been care planned to be an unsafe smoker, and Resident #80 should not have been allowed to have smoking materials at any time. In an interview on 07/18/2023 at 2:30 p.m., S39Social Worker stated she was not informed of the incident that occurred on 07/13/2023 when Resident #80 was observed smoking in his room. S39Social Worker stated Resident #80 should have had a one on one counseling, S2DON and S1Administrator should have been notified, and a plan to ensure safe smoking should have been implemented. In an interview on 07/18/2023 at 2:38 p.m., S2DON stated she was notified today that Resident #80 was caught smoking in his room on 07/13/2023. S2DON stated Resident #80 should have been reassessed after that incident, his careplan should have been updated, and the interdisciplinary team should have been notified following the incident and they were not. S2DON confirmed Resident #80 was in possession of his smoking material and he should not have been allowed to keep his smoking material, he should have been made an unsafe smoker, and all of the facility's staff should have been educated and they were not. 2.) Resident #83 Review of Resident #83's face sheet revealed, in part, Resident #83 was admitted on [DATE] with diagnosis that included: Bipolar Disorder, Schizophrenia, Cocaine Abuse, Altered Mental Status, and Major Depressive Disorder Review of Resident #83's Minimum Data Set with an Assessment Reference Date of 06/05/2023 revealed, in part, Resident #83's Brief Interview for Mental Status Score was 14 which indicated Resident #83 was cognitively intact. Review of Resident #83's Comprehensive Care Plan, with a start date of 03/13/2023, and a revision date of 06/05/2023, revealed, in part, Resident #83 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #83 and/or Resident #83's family were to provide Resident #83's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident was properly dressed for weather conditions when outside in smoking area, encourage resident not to spend extended time in smoking area related to excessive heat or cold, assure/encourage resident to be well hydrated when spending time in smoking area, assist resident to smoking area, encourage resident to stay out of direct sunlight, and provide a smoking jacket as needed. Review revealed an additional intervention was added on 05/18/2023 to include staff were to make rounds every hour while in smoking area and as needed. Review of Resident #83's Safe Smoking Assessment Form, with an original completion date of 02/01/2022 and a reassessment date of 06/05/2023, revealed, in part, Resident #83 was unable to light her smoking material independently, Resident #83 was unable to dispose of ashes appropriately, and Resident #83 was unsafe to smoke unsupervised. Review of Resident #83's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #83. Review of Resident #83's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #83. Observation on 07/17/2023 at 10:12 a.m. revealed, Resident #83 lit Resident #80's cigarette with her lighter. Observation revealed Resident #83 then lit her cigarette and began to smoke with ashes falling to her shirt and right arm. Observation further revealed Resident #83's right gerichair arm with black marks and visible burn marks. Observation further revealed ash noted to the foot rest on Resident #83's gerichair. In an interview on 07/17/2023 at 10:12 a.m., Resident #83 stated that she was allowed to smoke without staff supervision. Resident #83 stated she was allowed to keep her own cigarettes and lighter. Resident #83 stated the marks noted to the right arm of her gerichair were from when she used her gerichair to tap her ashes off of her cigarette because she cannot reach the ashtray. Resident #83 further stated she assisted other residents that come outside with lighting their cigarettes, if they do not have a lighter. Resident #83 stated Resident #24, Resident #80, and herself are allowed to smoke unsupervised. Resident #83 stated to her knowledge none of the residents who smoke have to be supervised and staff only come into the smoking area if they smoke. Resident #83 stated she did not use a smoking apron and she had never seen Resident #24 or Resident #80 use a smoking apron. In an interview on 07/17/2023 at 1:30 p.m., S11Certified Nursing Assistant (CNA) stated she has been working at the facility about 2 weeks and the facility has not informed her or educated her on any residents on her hall that were unsafe smokers or that needed to be supervised while smoking. S11CNA stated Resident #83 has to be put in her geri-chair and brought outside. S11CNA stated she kept her smoking material on her person and she smoked throughout the day. S11CNA stated Resident #83 could smoke unsupervised and does not require a smoking apron. S11CNA further stated Resident #83 was not an unsafe smoker to her knowledge. Observation on 07/18/2023 at 9:20 a.m. revealed, Resident #83 outside smoking a lit cigarette with ashes falling onto her left arm. Observation on 07/18/2023 at 11:05 a.m., revealed Resident #83 smoking a lit cigarette. Further observation revealed Resident #83 scraped the lit cigarette across the right arm of her gerichair to discard her ash. Observation further revealed ash dropping onto Resident #83's right leg and inside of the right side of Resident #83's gerichair. In an interview on 07/18/2023 at 1:20 p.m., S7Careplan Nurse stated she was responsible for performing Resident #83's smoking assessments and updating Resident #83's smoking careplan. S7Careplan Nurse further stated Resident #83 could not dispose of ashes properly upon assessment and should have been an unsafe smoker. In an interview on 07/18/2023 at 2:40 p.m., S2Director of Nursing (DON) confirmed Resident #83's right arm on her gerichair had ash and burn marks. S2DON confirmed Resident #83 was using the right arm of her gerichair to extinguish her lit cigarette. S2DON stated Resident #83 should have been deemed an unsafe smoker on 06/05/2023 when her re-assessment was completed. S2DON stated Resident #83 should not have been allowed to smoke unsupervised at any time and she should have had a smoking apron in place when smoking. S2DON further stated Resident #83 should not be allowed to have a lighter on her person at any time. 3.) Resident #24 Review of Resident #24's face sheet revealed, in part, Resident #24 was admitted to the facility on [DATE] with diagnoses that included: blindness of both eyes. Review of Resident #24's Minimum Data Set with an Assessment Reference Date of 06/05/2023 revealed, in part, Resident #24's Brief Interview for Mental Status Score was 15 which indicated Resident #24 was cognitively intact. Review of Resident #24's Comprehensive Care Plan revealed, in part, a category of safe smoking with a start date of 09/10/2020. Further review revealed interventions that included: the staff should interview Resident #24 to assure the safety of smoking, monitor Resident #24's room for indication of smoking such as burn marks, cigarette butts, burned matches, educate Resident #24 on smoking safely, inform Resident #24's family of any problems with smoking noncompliance with facility's smoking safety protocol, provide a smoking vest if needed for Resident #24's safety, and the family and/or Resident #24 was to provide their cigarettes and lighters. Review of Resident #24's physician orders for June and July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of the facility's smoking list revealed Resident #24 was a smoker. Review of Resident #24's electronic Medication Administration Record (eMAR) for June and July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of Resident #24's Activities of Daily Living record for July 2023 revealed no documentation of Resident #24 being monitored while smoking. Review of Resident #24's Assessment for Safe Smoking with a date of completion of 06/05/2023 revealed, in part, Resident #24 was safe to smoke unsupervised. Review of this assessment revealed Resident #24's visions was impaired, but he was able to smoke safely. Observation on 07/17/2023 at 10:19 a.m. revealed, Resident #24 smoking a lit cigarette outside without supervision of staff and without a smoker's apron in place. Observation revealed Resident #24 had a lit cigarette in his hand with visible ashes noted on Resident #24's right upper leg. In an interview on 07/17/2023 at 10:19 a.m., Resident #24 stated that he is blind in both eyes. Resident #24 stated he was allowed to smoke without staff supervision. Resident #24 further stated he was allowed to keep his cigarettes and lighter at all times. Observation on 07/18/2023 at 9:20 a.m. revealed, Resident #24 sitting outside in his wheelchair in the designated smoking area without staff present. Further observation revealed, Resident #24 with a small pile of ashes on his right upper thigh and left mid-thigh. Observation on 07/18/2023 at 10:45 a.m. revealed, Resident #24 sitting outside in his wheelchair smoking a lit cigarette in the designated smoking area without staff present. Observation revealed, Resident #24 had a small piece of ash noted to his left upper thigh. Further observation revealed ashes scattered on his right and left thigh. In an interview on 07/18/2023 at 11:33 a.m., S28CNA stated Resident #24 could smoke without staff supervision. S28CNA stated that she was unaware if Resident #24's cigarettes needed to be kept on the nurse's medication cart. S28CNA further stated that she was unaware of the facility's process on notifying the staff of resident's smoking status. S28CNA stated she used her best judgment to determine if a resident should be supervised based off of their cognitive status and their mobility needs. In an interview on 07/18/2023 at 11:44 a.m., S62LPN stated she was unaware that unsafe smoker's smoking material should be kept on the nursing cart. S62LPN stated she does not know the facility's process for identifying if a resident was a safe or unsafe smoker. S62LPN further stated she was unaware of the process for a resident's smoking assessment. In an interview on 07/18/2023 at 12:30 p.m., Resident #24 stated he was currently in possession of his lighter and his cigarettes. Resident #24 further stated that he kept his cigarettes in his pocket. In an interview on 07/18/2023 at 1:06 p.m., S62LPN stated she was unaware of Resident #24's smoking status. S62LPN stated that she had witnessed Resident #24 borrow cigarettes from other residents, but she had never seen him with some of his own smoking material. S62LPN further stated if a resident was smoking in their room, holding a cigarette close to their person, falling asleep while smoking, if ashes are falling onto their clothing while smoking, or if burn holes were noted to the resident's clothing, then the resident should be considered an unsafe smoker. In an interview on 07/18/2023 at 1:10 p.m., S2DON stated Resident #24 was an unsafe smoker due to dropping ash on himself. S2DON further stated Resident #24 should have staff supervision when smoking. In an interview on 07/18/2023 at 1:11 p.m., S1Administrator stated Resident #24 was an unsafe smoker due to dropping ash on himself. S1Administrator further stated Resident #24 should be monitored when smoking due to displaying unsafe behaviors. In an interview on 07/19/2023 at 8:27 a.m., S7CarePlan Nurse stated she interviews the nursing staff and the CNA staff to obtain information to complete safe smoking assessments. S7CarePlan Nurse further stated that she does not go outside to observe residents smoking directly because she has a problem with her lungs and the smoke irritates them. S7CarePlan Nurse stated she used the window in the center of the building to assess residents who are smokers. Observation on 07/19/2023 at 8:50 a.m., surveyor walked the distance from the above indicated window to the area Resident #24 has been observed smoking and it was approximately 125 feet. 4.) Resident #85 Review of Resident #85's face sheet revealed, in part, Resident #85 was admitted to the facility on [DATE] with diagnoses that included: Nicotine Dependence Review of Resident #85's Minimal Data Set with an Assessment Reference Date of 06/12/2023 revealed, in part, Resident #85's Brief Interview for Mental status Score was 15 which indicated Resident #85 was cognitively intact. Review of Resident #85's Comprehensive Care Plan, revealed, in part, Resident #85 would be free from complications and/or injury from smoking. Review revealed interventions that included: Resident #85 and/or Resident #85's family were to provide Resident #85's cigarettes and lighters, smoking assessments were to be done upon admission to the facility, quarterly, and as needed, staff are to remind/encourage resident to only smoke in designated smoking area, assure that resident is properly dressed for weather conditions when outside in smoking area, and provide a smoking jacket as needed. Review of Resident #85's physician orders revealed no documentation for smoking or one hour monitoring. Review of Resident #85's electronic Medication Administration Record (eMAR) revealed no evidence of documentation of one hour monitoring of Resident #85. Review of Resident #85's Activities of Daily Living (ADL) documentation revealed no evidence of documentation of one hour monitoring of Resident #85. Review of Resident #85's Safe Smoking assessment dated [DATE] revealed, in part, resident was safe to smoke unsupervised at this time. Observation on 07/18/2023 at 11:01 a.m. revealed, Resident #80 gave Resident #85 a cigarette. Observation revealed Resident #85 put Resident #80's cigarette to his mouth, used his orange lighter to light the cigarette, then gave the cigarette back to Resident #80. In an interview on 07/19/2023 at 8:27 a.m., S7Careplan Nurse stated she interviewed Resident #85's nurse and CNAs in order to get information regarding Resident #85's smoking habits to completed his safe smoking assessment. S7Careplan Nurse further stated she would also view Resident #85 and additional residents through the window in the center of the building to assess residents who smoke.S7Careplan Nurse stated she was unsure if she could see exactly how residents were disposing of ashes from the window in the center of the building. Observation on 07/19/2023 at 8:50 a.m., surveyor walked the distance from the above indicated window to the area Resident #85 has been observed smoking and it was approximately 125 feet. In an interview on 07/20/2023 at 11:45 a.m., S1Administrator stated Resident #24. Resident #80, Resident #83, and Resident #85 should not have been allowed to smoke without staff supervision. S1Adminstrator further stated Resident #80 should have been deemed an unsafe smoker after he was caught smoking in his room, he should have been provided direct supervision when he was smoking, and his smoking material should have been removed from his person following the incident. S1Adminstrator stated Resident #83 should have been deemed an unsafe smoker after she was visualized during her assessment disposing of ashes improperly. S1Administrator stated S60SSD should have notified him or S2DON following the incident, and Resident #80 should have been reassessed immediately. S1Adminstrator further stated Resident #24 and Resident #85 should have staff supervision when smoking and Resident #24 should have a smoking apron on at all times. 47487

Based on observation, record review and interview, the facility failed to: a) Ensure that a resident receiving tube feedings did not develop dehydration for 1 of 5 sampled residents (Resident #3). This failed practice resulted in actual harm for Resident#3 when the facility failed to monitor the resident ' s hydration status. Resident #3 was admitted to the hospital and placed in the Intensive Care Unit for [DIAGNOSES REDACTED]. This failed practice had the potential of affecting all residents in the facility receiving tube feedings which totaled 26 according to the Resident Census and Conditions of Residents. b) Ensure that a resident who is dependent on staff for feedings and hydration if offered fluids during and after meals and at sufficient intervals to ward off thirst, for 1 of 5 sampled residents (Resident #2). The facility failed to have a system in place to monitor that fluids are offered to residents who are dependent for feeding. This failed practice had the potential to affect all residents who were dependent with feeding which totaled 31 according to the Resident Census and Conditions of Residents report. Findings: Resident #3. Observation of Resident #3 on 6/2/11 at 11:00am revealed Resident #3 lying in bed, responding to verbal stimuli by looking at speaker. Resident was observed with a tracheotomy and was ventilator dependent. Resident was receiving continuous tube feedings at 35cc/hr. Observation of Resident #3 on 6/6/11 at 4:00pm revealed resident alert, responding to verbal stimuli by mouthing words and responding to known staff by smiling and eye contact. Record review of Resident #3 ' s Nurses Notes revealed an entry dated 5/16/11 at 4:30am which noted that the resident was found very lethargic and unresponsive to verbal calls. The physician was notified and an entry dated 5/16/11 at 5:20am revealed that resident was transported to the local hospital. Record review of physician's order [REDACTED]. Record review of Tube Feeding Record dated 4/11 (April 2011) revealed written documentation that resident received 200cc of water tube feed flush from 4/5/11 through 4/13/11. There was no documentation for the 3-11 shift which indicated that Resident #3 received 200cc of tube feeding water flush on 4/7/11, 4/8/11 4/9/11 and 4/12/11. There was documentation that resident received 200cc flushes on the 11-7am shift from 4/4/11 through 4/13/11. Further review revealed orders for 5/1/11 through 5/31/11 for tube feeding (nepro) at 40cc per hour and flush for 150cc every shift. Record review of Tube Feeding Record dated May 2011 revealed daily documentation of resident receiving 150cc of water-tube flush for the 7-3 shift, the 3-11 shift and the 11-7 shift from May 1st though May 15th when resident went into the hospital. This record was presented by the facility on 6/3/11 in the afternoon. The original record was not in the chart at the time of the investigation. Record review of Resident #3 ' s care plan with an onset date of 3/22/11 and a review date of 6/20/11 indicated a problem of: Feeding tube must be utilized to maintain nutritional status. Approaches listed included a) monitor intake and output every shift, and b) monitor lab value as ordered. Further review of the care plan revealed another problem of: Fluid volume, hx of dehydration and approaches included a) flush peg tube as ordered, b) labs as ordered and notify physician of any abnormal labs, c) monitor vital signs, and d) monitor output. A review was done of Resident #3 ' s labs while at the nursing facility and pre-hospitalization . Review revealed the following results: Labs drawn on 1/26/11: BUN 77 (H) (reference range 5-26), Creatinine 1.5, BUN/Creatinine ratio 52 (H) (reference range 8-27). Labs drawn on 2/23/11: BUN 60 (H) (reference range 5-26), Creatinine 1.2, BUN/Creatinine ratio 50 (H) (reference range 8-27). Labs drawn on 3/23/11: BUN 117 (H!) (reference range 5-26), Creatinine 1.7 (H) (reference range 0.5-26), BUN/Creatinine ratio 71 (H) (reference range 8-27). Labs drawn on 4/25/11: BUN 51 (H) (reference range 5-26), Creatinine 1.3, BUN/Creatinine ratio 40 (H) (reference range 8-27). Review of the laboratory documents listed above revealed that the labs were faxed to the physician ' s office on the dates listed. There was no documentation, however, that indicated that any follow-up was done to ensure that the abnormal labs were reviewed by the physician. Interview with S5 LPN on 6/6/11 at 4:10pm indicated that Lab results are faxed to the physician and an office communication filled out. S5 LPN revealed that she would call the MD ' s office the following day if there were no follow-up instructions. Interview also revealed that Resident #3 was not on fluid restriction. Resident #3 got a set amount of water for flush which was to be recorded on resident's intake and output sheet. Intake and output was to be done each shift. Interview with S1 DON on 6/6/11 at 2:00pm indicated that Resident #3 ' s labs were faxed to MD ' s office. S1 DON indicated that there is a communication book for responses from physician. S1 DON stated that she would investigate physician follow-up but did not return with a response. Record review of the emergency room Visit Report by the local hospital revealed an entry with an admitted [DATE] dictated by the physician describing the course of treatment for [REDACTED]. The notes revealed that upon arrival to the emergency department, Resident #3 was febrile at 100.4 and mildly [MEDICAL CONDITION]. (These can be symptoms of dehydration). Resident #3 was started on intravenous saline. The conclusion of this record revealed that Resident #3 appeared very volume depleted and one of the admitting [DIAGNOSES REDACTED].#3 ' s sodium was 167 and noted as exceeding critical levels (reference range 134-144). Resident #3 also had elevated BUN and Creatinine levels, 152 and 3.2 respectively. The reference range for BUN was 5-23 and for Creatinine 0.6-1.0. Record review of Nurse ' s Notes dated 5/20/11 at 5:00pm revealed that Resident #3 was readmitted to the facility and was awake and alert. Resident #2 Observation of Resident #2 on 6/2/11 at 2:00pm revealed resident lying in bed, awake and alert. Resident was cognitively intact and fluent in conversation. Resident was noted to be a quadriplegic with minimal movement of upper extremities. Resident was not able to lift her arms to feed self. Interview with Resident #2 on 6/2/11 at 2:00pm indicated that resident did not get water as much as she would like to. Resident further revealed that she did not get water after breakfast or after lunch. Resident #2 stated that she does not take water until after she finished eating as that was a practice taught by her mother. Interview revealed that the CNAs are usually in a hurry to clear the meal trays and leave and she is usually not offered water. Furthermore, when the CNAs come in to replenish the pitchers they leave without offering her a drink. Resident #2 indicated that she was thirsty at the time of the interview. Record review of care plan dated with an onset 2/4/10 with a problem of nutrition related to potential for inadequate nutritional intake r/t feeding deficit. Another problem noted that resident had limited ability for self-positioning due to contractures. Included in the approaches is to ensure adequate fluid and food intake daily. Interview with S4 CNA Supervisor on 6/3/11 at 11:30am indicated that residents who are paralyzed are offered hydration throughout the day. S4 CNA Supervisor conceded that there was no monitoring as to whether hydration was given to dependent residents.

Based on observation, record review and interview, the facility failed to: a) Ensure that a resident receiving tube feedings did not develop dehydration for 1 of 5 sampled residents (Resident #3). This failed practice resulted in actual harm for Resident#3 when the facility failed to monitor the resident ' s hydration status. Resident #3 was admitted to the hospital and placed in the Intensive Care Unit for [DIAGNOSES REDACTED]. This failed practice had the potential of affecting all residents in the facility receiving tube feedings which totaled 26 according to the Resident Census and Conditions of Residents. b) Ensure that a resident who is dependent on staff for feedings and hydration if offered fluids during and after meals and at sufficient intervals to ward off thirst, for 1 of 5 sampled residents (Resident #2). The facility failed to have a system in place to monitor that fluids are offered to residents who are dependent for feeding. This failed practice had the potential to affect all residents who were dependent with feeding which totaled 31 according to the Resident Census and Conditions of Residents report. Findings: Resident #3. Observation of Resident #3 on 6/2/11 at 11:00am revealed Resident #3 lying in bed, responding to verbal stimuli by looking at speaker. Resident was observed with a tracheotomy and was ventilator dependent. Resident was receiving continuous tube feedings at 35cc/hr. Observation of Resident #3 on 6/6/11 at 4:00pm revealed resident alert, responding to verbal stimuli by mouthing words and responding to known staff by smiling and eye contact. Record review of Resident #3 ' s Nurses Notes revealed an entry dated 5/16/11 at 4:30am which noted that the resident was found very lethargic and unresponsive to verbal calls. The physician was notified and an entry dated 5/16/11 at 5:20am revealed that resident was transported to the local hospital. Record review of physician's order [REDACTED]. Record review of Tube Feeding Record dated 4/11 (April 2011) revealed written documentation that resident received 200cc of water tube feed flush from 4/5/11 through 4/13/11. There was no documentation for the 3-11 shift which indicated that Resident #3 received 200cc of tube feeding water flush on 4/7/11, 4/8/11 4/9/11 and 4/12/11. There was documentation that resident received 200cc flushes on the 11-7am shift from 4/4/11 through 4/13/11. Further review revealed orders for 5/1/11 through 5/31/11 for tube feeding (nepro) at 40cc per hour and flush for 150cc every shift. Record review of Tube Feeding Record dated May 2011 revealed daily documentation of resident receiving 150cc of water-tube flush for the 7-3 shift, the 3-11 shift and the 11-7 shift from May 1st though May 15th when resident went into the hospital. This record was presented by the facility on 6/3/11 in the afternoon. The original record was not in the chart at the time of the investigation. Record review of Resident #3 ' s care plan with an onset date of 3/22/11 and a review date of 6/20/11 indicated a problem of: Feeding tube must be utilized to maintain nutritional status. Approaches listed included a) monitor intake and output every shift, and b) monitor lab value as ordered. Further review of the care plan revealed another problem of: Fluid volume, hx of dehydration and approaches included a) flush peg tube as ordered, b) labs as ordered and notify physician of any abnormal labs, c) monitor vital signs, and d) monitor output. A review was done of Resident #3 ' s labs while at the nursing facility and pre-hospitalization . Review revealed the following results: Labs drawn on 1/26/11: BUN 77 (H) (reference range 5-26), Creatinine 1.5, BUN/Creatinine ratio 52 (H) (reference range 8-27). Labs drawn on 2/23/11: BUN 60 (H) (reference range 5-26), Creatinine 1.2, BUN/Creatinine ratio 50 (H) (reference range 8-27). Labs drawn on 3/23/11: BUN 117 (H!) (reference range 5-26), Creatinine 1.7 (H) (reference range 0.5-26), BUN/Creatinine ratio 71 (H) (reference range 8-27). Labs drawn on 4/25/11: BUN 51 (H) (reference range 5-26), Creatinine 1.3, BUN/Creatinine ratio 40 (H) (reference range 8-27). Review of the laboratory documents listed above revealed that the labs were faxed to the physician ' s office on the dates listed. There was no documentation, however, that indicated that any follow-up was done to ensure that the abnormal labs were reviewed by the physician. Interview with S5 LPN on 6/6/11 at 4:10pm indicated that Lab results are faxed to the physician and an office communication filled out. S5 LPN revealed that she would call the MD ' s office the following day if there were no follow-up instructions. Interview also revealed that Resident #3 was not on fluid restriction. Resident #3 got a set amount of water for flush which was to be recorded on resident's intake and output sheet. Intake and output was to be done each shift. Interview with S1 DON on 6/6/11 at 2:00pm indicated that Resident #3 ' s labs were faxed to MD ' s office. S1 DON indicated that there is a communication book for responses from physician. S1 DON stated that she would investigate physician follow-up but did not return with a response. Record review of the emergency room Visit Report by the local hospital revealed an entry with an admitted [DATE] dictated by the physician describing the course of treatment for [REDACTED]. The notes revealed that upon arrival to the emergency department, Resident #3 was febrile at 100.4 and mildly [MEDICAL CONDITION]. (These can be symptoms of dehydration). Resident #3 was started on intravenous saline. The conclusion of this record revealed that Resident #3 appeared very volume depleted and one of the admitting [DIAGNOSES REDACTED].#3 ' s sodium was 167 and noted as exceeding critical levels (reference range 134-144). Resident #3 also had elevated BUN and Creatinine levels, 152 and 3.2 respectively. The reference range for BUN was 5-23 and for Creatinine 0.6-1.0. Record review of Nurse ' s Notes dated 5/20/11 at 5:00pm revealed that Resident #3 was readmitted to the facility and was awake and alert. Resident #2 Observation of Resident #2 on 6/2/11 at 2:00pm revealed resident lying in bed, awake and alert. Resident was cognitively intact and fluent in conversation. Resident was noted to be a quadriplegic with minimal movement of upper extremities. Resident was not able to lift her arms to feed self. Interview with Resident #2 on 6/2/11 at 2:00pm indicated that resident did not get water as much as she would like to. Resident further revealed that she did not get water after breakfast or after lunch. Resident #2 stated that she does not take water until after she finished eating as that was a practice taught by her mother. Interview revealed that the CNAs are usually in a hurry to clear the meal trays and leave and she is usually not offered water. Furthermore, when the CNAs come in to replenish the pitchers they leave without offering her a drink. Resident #2 indicated that she was thirsty at the time of the interview. Record review of care plan dated with an onset 2/4/10 with a problem of nutrition related to potential for inadequate nutritional intake r/t feeding deficit. Another problem noted that resident had limited ability for self-positioning due to contractures. Included in the approaches is to ensure adequate fluid and food intake daily. Interview with S4 CNA Supervisor on 6/3/11 at 11:30am indicated that residents who are paralyzed are offered hydration throughout the day. S4 CNA Supervisor conceded that there was no monitoring as to whether hydration was given to dependent residents.