Every finding on record at Guest House Nursing and Rehabilitation

Based on record reviews and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #2) of 3 sampled residents. The facility failed to assess, monitor, and document edema in accordance with the physician's orders and/or the comprehensive plan of care.Findings: Resident #1Review of resident #1's records revealed diagnoses that include edema, permanent atrial fibrillation, chronic right heart failure, hypertension, restless legs syndrome, disorder of peripheral nervous system and diabetes.Review of resident #1's Physician's Orders revealed an order dated 04/17/2026 for Lasix oral tablet 20 mg (milligrams). Give 1 tablet by mouth every 24 hours as needed for edema.Review resident #1's Comprehensive Plan of Care revealed resident has diagnosis of chronic kidney disease Stage II- risk for excess fluid volume, decreased urine output, and sodium retention. Monitor for generalized edema.Review of resident #1's April 2026 MAR (medication administration record) failed to reveal documentation of assessment or monitoring for edema was completed.Resident #2Review of resident #2's records revealed diagnoses that include rheumatoid arthritis, functional urinary incontinence, sarcoidosis of lung, age related physical debility, chronic kidney disease, and localized edema.Review of resident #2's Physician's Orders revealed an order dated 10/15/2025 Lasix oral tablet 20 mg. Give 1 tablet by mouth every 24 hours as needed for bilateral lower extremities edema.Review resident #2's Comprehensive Plan of Care revealed resident takes diuretic-at risk for dehydration. Intervention listed was to assess and record edema. Administer medication as ordered by physician. Assess and record edema.Review of resident #2's May 2026 MAR failed to reveal documentation of assessment or monitoring for edema was completed.During an interview on 05/13/2026 at 11:40 a.m. S1 ADON (Assistant Director of Nursing) reported if a resident is to be assessed or monitored for edema the nurses should document on the resident's MAR. S1 ADON checked resident #1 and #2's records and was unable to provide documentation that edema checks had been completed. S1 ADON agreed resident #1 and #2 should have been assessed for edema and they were not.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#38, #100,) of 2 (#38, #100) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.Findings:Resident #38 Review of Resident #38's record revealed an admit date of 01/04/2023 with diagnoses including chronic diastolic (congestive) heart failure, left knee primary osteoarthritis and chronic kidney disease. Further review of records revealed a quarterly Minimal Data Set (MDS) assessment dated [DATE] documented Resident #38 utilized a wheelchair for mobility and required moderate assistance with transferring.On 07/28/2025 at 9:53 a.m. and 07/29/2025 at 8:50 a.m., observations of Resident #38's wheelchair revealed the wheelchair arm padding to be cracked and torn.On 07/29/2025 at 9:50 a.m., an observation conducted with S2Director of Nursing (DON) confirmed that Resident #38's wheelchair armrest padding was cracked and torn. Resident #100 Review of Resident #100's medical record revealed an admit date of 01/01/2025 with diagnoses including other Alzheimer's disease, arthritis, asthma and cardiac arrhythmia. Further review of Resident #100's medical record revealed a quarterly Minimal Data Set (MDS) assessment dated [DATE] documented Resident #100 was mobile per wheelchair and required moderate assistance with transfers.On 07/28/2025 at 9:56 a.m. and 07/29/2025 at 8:55 a.m., Resident #100 was observed sitting a wheelchair that had cracked and torn arm padding.An observation on 07/29/2025 at 9:50 a.m. with S2DON confirmed that Resident #100's wheelchair arm padding was cracked and torn.

Based on record review and interview, the facility failed to ensure a resident was free from misappropriation of personal property for 1 (#11) of 1 resident reviewed for personal funds. Findings:Review of the facility's undated Abuse and Neglect Prohibition policy revealed the following in part:Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, seizures, personal history of transient ischemic attack, cerebral infarction without residual deficits, chronic respiratory failure with hypoxia, pulmonary fibrosis, chronic kidney disease, other mixed anxiety disorders, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the Facility's Reported Incident revealed an allegation of misappropriation of funds/exploitation was reported to the facility on [DATE] by Resident #11 related to his Electronic Banking Transfer (EBT) card having an unauthorized charge on 07/07/2025. S7Certified Nursing Assistant (CNA) was identified as the staff member that had made unauthorized purchases with Resident #11's EBT card on 07/07/2025 and 07/11/2025. The investigation by the facility revealed the allegation was substantiated.Interview on 07/28/2025 at 3:30 p.m. with Resident #11 revealed he had allowed S7CNA to purchase items for him using her grocery store account using his EBT card a couple times in June 2025. Resident #11 further reported that someone had made purchases using his EBT card 2 times during July 2025 on 07/07/2025 and 07/11/2025 and he notified S8Social Services Director (SSD). Resident #11 reported S7CNA was terminated at the end of June 2025. Resident #11 reported he had 2 unauthorized charges of $225.32 and $88.35 in July 2025 on his EBT card. When Resident #11 reported this to the S8SSD, they were able to printout a list of his transaction history for his EBT card from 06/28/2025 through 07/10/2025, the charge for 07/07/2025 was made at a grocery store in the amount of $225.32. Resident #11 reported S8SSD helped him to deactivate his EBT card and setup online account information to help the resident track his purchases. Resident #11 had another unauthorized charge of $88.35 on 07/11/2025. Interview with S8SSD on 07/30/2025 at 8:00 a.m. revealed he was notified by Resident #11 on 07/08/2025 around 10:00 a.m. regarding a CNA from the facility making charges on his EBT card on 07/07/2025 for $225.32. S8SSD reported that Resident #11 had given his EBT card information to a CNA to purchase items for him to be delivered to the facility from a grocery store. S8SSD reported he notified S1Administrator on 07/08/2025 of the allegation of misappropriation of funds/exploitation made by Resident #11. S8SSD reported he and Resident #11 called the EBT program support on 07/09/2025. S8SSD was able to get a printout of Resident #11's transaction history on EBT card from 06/28/2025 through 07/10/2025 and identify the charge on 07/07/2025 in the amount of $225.32 was made at a grocery store. S8SSD reported Resident #11 confirmed he did not authorize this purchase. S8SSD reported they deactivated the resident's card at this time, but Resident #11 reported on 07/12/2025 he found another charge of $88.35 that was unauthorized on his EBT card again. S8SSD and Resident #11 called EBT program support back and cancelled the resident's EBT card, police were notified and a report was initiated by the police on 07/12/2025 after the second unauthorized purchase was made. S8SSD reported that the police only have a preliminary report and have not made any arrest at this time. S8SSD reported they were unable to print another history of transactions on this card due to it now being deactivatedAn interview with S1Administrator on 07/30/2025 at 8:30 a.m. revealed he was notified on 07/08/2025 by S8SSD of the allegation of misappropriation of funds/exploitation reported by Resident #11 by a CNA on his hall. S1Administrator reported he interviewed Resident #11, they were able to identify that the accused was S7CNA and she had obtained information from Resident #11's EBT card to purchase items for this resident from a grocery store.Review of Resident #11's Transaction History for his EBT card transactions from 06/28/2025 through 07/10/2025 revealed a purchase was made to a grocery store in the amount of $225.32. An interview on 07/30/2025 at 11:10 a.m. with S9CNA revealed she was working a few months ago and Resident #11 had a grocery store order delivered, but the driver from the store needed a pin number for the delivery. Resident #11 told her that S7CNA had the code for his order. S9CNA had to get the delivery code from S10Ward Clerk to give to the driver, but was unsure of the date this happened. An interview on 07/30/2025 at 11:30 a.m. with S11CNA confirmed he did have to get a code from S7CNA for a grocery store delivery order for Resident #11 while he was working with Resident #11 but unsure of the date.An interview on 07/30/2025 at 11:40 a.m. with S10Ward Clerk revealed S7CNA sent her a code to give to the staff for a grocery store delivery for Resident #11, but unsure of the exact date. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to ensure Resident #11 was free from misappropriation of funds/exploitation by S7CNA. S1Administrator confirmed S7CNA made two unauthorized purchases on Resident #11's EBT card in July 2025.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#16) of 1 residents reviewed for restraints. The facility failed to have documented evidence of releasing the lap tray every two hours for range of motion. Findings:Use of Restraint Policy dated April 2017Policy Interpretation and ImplementationPhysical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint.Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove.Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: c. placing a resident in a chair that prevents the resident from rising.Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. treat the medical symptom; b. protect the resident's safety; and c. help the resident attain the highest level of his/her physical or psychological well-being.11. The following safety guidelines shall be implemented and documented while the resident is in restraints:d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.e. Restrained residents must be repositioned at lease every two (2) hours on all shifts. Review of the medical record for Resident #16 revealed an admission date of 01/02/2025 with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations; unspecified psychosis not due to a substance or known physiological condition; restlessness and agitation and generalized anxiety disorder.Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment for daily decision making. The facility was unable to obtain a Brief Interview for Mental Status (BIMS) score. Further review also revealed Resident #16 was mobile via wheelchair and required partial/moderate assistance with transfers.Observations made on 07/28/2025 at 12:45 p.m., 07/29/2025 at 8:13 a.m., 07/29/2025 at 11:10 a.m., and 07/29/2025 at 3:00 p.m. revealed Resident #16 was sitting in a geri-chair with a lap tray in place.On 07/29/2025 at 12:00 p.m., a review of Resident #16's active July 2025 physician's orders revealed there was no order for the release of the geri-chair lap tray every two hours. Further review of Resident #16's records revealed there was no documentation of the release of the lap tray every two hours.On 07/29/2025 at 1:10 p.m., an interview with S6Certified Nursing Assistant (CNA) was conducted. S6CNA stated Resident #16 could not release the lap tray herself and she was also unaware that Resident #16's lap tray should be released every two hours.On 07/29/2025 at 1:15 p.m., an interview with S5Licensed Practical Nurse (LPN) was conducted. S5LPN stated there was no active order to release Resident #16's lap tray every two hours.On 07/29/2025 at 1:25 p.m., an interview was conducted with S2Director of Nursing (DON), S4 Corporate Consultant, and S3Registered Nurse (RN)-Admin confirmed that there was no order or documentation for releasing the geri-chair lap tray every two hours.

Based on interview and record review, the facility failed to ensure a thorough investigation was completed for an allegation of misappropriation of property/exploitation for 1 (#7) of 1 resident reviewed for personal funds.Findings:Review of the facility's undated Abuse and Neglect Prohibition revealed the following in part:Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Investigation:1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, other seizures, personal history of transient ischemic attach, cerebral infarction without residual deficits, chronic respiratory failure with hypoxia, pulmonary fibrosis, chronic kidney disease, other mixed anxiety disorders and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the Facility's Reported Incident revealed an allegation of misappropriation of funds/exploitation was reported to the facility on [DATE] by Resident #11 related to his Electronic Banking Transfer (EBT) card having an unauthorized charge on 07/07/2025. S7Certified Nursing Aide (CNA) was identified as the staff member that had made unauthorized purchases with Resident #11's EBT card on 07/07/2025 and 07/11/2025. The investigation by the facility revealed the allegation was substantiated.Interview on 07/28/2025 at 3:30 p.m. with Resident #11 revealed he had allowed S7CNA to purchase items for him using her grocery store account using his EBT card a couple times in June 2025. Resident #11 further reported that someone had made purchases using his EBT card 2 times during July 2025 on 07/07/2025 and 07/11/2025 and he notified S8Social Services Director (SSD). Resident #11 reported S7CNA was terminated at the end of June 2025. Resident #11 reported he had 2 unauthorized charges of $225.32 and $88.35 in July 2025 on his EBT card. Resident #11 reported this to the S8SSD and they were able to printout a list of his transaction history for his EBT card from 06/28/2025 through 07/10/2025, the charge for 07/07/2025 was made at a grocery store in the amount of $225.32. Resident #11 reported S8SSD helped him to deactivate his EBT card and setup online account information to help the resident track his purchases. Resident #11 had another unauthorized charge of $88.35 on 07/11/2025. Interview with S8SSD on 07/30/2025 at 8:00 a.m. revealed he was notified by Resident #11 on 07/08/2025 around 10:00 a.m. regarding a CNA from the facility making charges on his EBT card on 07/07/2025 for $225.32. S8SSD reported that Resident #11 had given his EBT card information to a CNA to purchase items for him to be delivered to the facility from a grocery store. S8SSD reported he notified S1 Administrator on 07/08/2025 of the allegation of misappropriation of funds/exploitation made by Resident #11. S8SSD reported he and Resident #11 called the EBT program support on 07/09/2025. S8SSD was able to get a printout of Resident #11's transaction history on EBT card from 06/28/2025 through 07/10/2025 and identify the charge on 07/07/2025 in the amount of $225.32 was made at a grocery store. S8SSD reported Resident #11 confirmed he did not authorize this purchase. S8SSD reported they deactivated the resident's card at this time, but Resident #11 reported on 07/12/2025 resident found another charge of $88.35 that was unauthorized on his EBT card again. S8SSD and Resident #11 called EBT program support back and cancelled the resident's EBT card, police were notified and a report was initiated by the police on 07/12/2025 after the second unauthorized purchase was made. S8SSD reported that the police only have a preliminary report and have not made any arrest at this time. S8SSD reported they were unable to print another history of transaction on this card due to it now being deactivated. An interview with S1Administrator on 07/30/2025 at 8:30 a.m. revealed he was notified on 07/08/2025 by S8SSD of the allegation of misappropriation of funds/exploitation reported by Resident #11 by a CNA on his hall. S1Administrator reported he interviewed Resident #11, they were able to identify that the accused was S7CNA, and she had obtained information from Resident #11's EBT card to purchase items for this resident from a grocery store.Review of Resident #11's Transaction History for his EBT card transactions from 06/28/2025 through 07/10/2025 revealed a purchase was made to a grocery store in the amount of $225.32. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to ensure a thorough investigation was completed for the allegation of misappropriation of funds/exploitation reported by Resident #11. S1Administrator confirmed the facility did not attempt to interview S7CNA after the allegation was reported, did not retrain staff on misappropriation of funds/property after the allegation was reported and failed to ensure residents were interviewed promptly with relevant questions related to misappropriation of funds/property.

Based on record reviews and interviews, the facility failed to notify the state-designated mental health disability authority promptly for a review when a resident with Mental Disorders or Intellectual Disorders experienced a change in mental or physical status for 1 (#7) of 2 (#7 and #8) residents reviewed for Pre-admission Screening and Resident Review (PASARR).Findings: Review of Resident #7's record revealed an admission date of 06/24/2025 with diagnoses including unspecified dementia mild with mood disturbance, bipolar disorder current episode depressed mild or moderate severity unspecified, panic disorder, insomnia due to other mental disorder, post-traumatic stress disorder acute, hypertension, tachycardia, hypothyroidism, personal history of other mental and behavioral disorders. Further review of the record revealed Resident #7 was admitted to the facility from an inpatient psych facility.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of Resident #7's Form 142 (Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification) dated 06/18/2025 revealed resident was approved for Medicaid medical eligibility services for a temporary period effective 06/18/2025-09/26/2025 for skilled therapies. Review of Resident #7's record revealed he had combative and aggressive behaviors after he was admitted to the facility and he was transferred back to the inpatient psych facility on 06/27/2025 through 07/10/2025. An interview on 07/30/2025 at 8:00 a.m. with S8Social Service Director (SSD) revealed Resident #7 was admitted on [DATE] from an inpatient psych facility and the PASARR was done by the inpatient psych facility prior to the resident being admitted to the facility. S8SSD confirmed Resident #7 was transferred to an inpatient psych facility on 06/27/2025 due to aggressive and combative behaviors and did not return to the nursing home until 07/10/2025. S8SSD revealed he was not aware he was required to send in a PASARR review to the designated state authority following an inpatient psych stay for Resident #7. S8SSD confirmed he did not send in a PASARR review for Resident #7 after his inpatient psych stay from 06/27/2025 through 07/10/2025. Interview on 07/30/2025 at 8:30 a.m. with S1Administrator confirmed he was not aware that a PASARR review should have been submitted to the designated state authority after an inpatient psych stay for a resident.Review of the consult note from the psych admission dated 06/28/2025 for Resident #7 revealed the reason for admission was aggressive behavior, agitation and mood lability, and discharge diagnoses included aggressive behavior, bipolar, depression, antidepressive discontinuation syndrome and insomnia. Review of the record revealed no documentation of a PASARR review for Resident #7 after an inpatient psych stay from 06/27/2025 through 07/10/2025. Review of Resident #7's PASARR Level I Screen Outcome dated 06/17/2025 revealed PASARR Level I Determination: no level II required. Level I screen indicates - no evidence of a PASARR condition of intellectual/developmental disability or a serious behavioral health condition, if changes occur or new information refutes these findings, a new screen must be submitted. No medications listed and no diagnoses listed on PASARR form. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to send in a PASARR review on Resident #7 to the designated state authority after he had an inpatient psych stay from 06/27/2025 through 07/10/2025 due to aggressive and combative behaviors.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (#89) of 2 (#63 & #89) sampled residents reviewed for mood/behavior. Findings: Review of the medical record for Resident #89 revealed an admission date of 10/21/2018 with diagnosis of Parkinson's disease, breast cancer, edema, transient ischemic attack, dementia, Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and atrial fibrillation. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed Resident #89 needed maximal assistance with all activities of daily living. Review of section I revealed the resident had a Psychiatric/Mood disorder of Post-Traumatic Stress Disorder (PTSD). Review of Resident #89's current care plan dated 09/10/2024 revealed no documentation that included person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward his/her goals for the diagnosis of Post-Traumatic Stress Disorder. Interview on 07/30/2025 at 3:30 p.m. with S2Director of Nursing (DON) confirmed the diagnosis of PTSD was not care planned for Resident #89. S2DON further confirmed there should be a person centered care plan with interventions for PTSD in place for Resident #89.

Based on record review and interview, the facility failed to ensure a resident was as free of accident hazards as is possible by failing to ensure an appropriate intervention was attempted for 1 (#71) of 8 (#2, #4, #9, #10, #18, #36, #71, #89) residents reviewed for accidents.Findings:Review of the medical record for Resident #71 revealed an admission date of 01/14/2025 with diagnoses that included vascular dementia, displaced fracture of middle phalanx of left middle finger, repeated falls, history of transient ischemic attack, and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment with daily decision making. Resident #71 required substantial/maximal assistance with sit to lying, lying to sitting, and chair/bed-to-chair transfer. Additionally, the April MDS assessment documented the resident as always continent of bowel and bladder. Review of the in-service training report dated January 2025 revealed Certified Nursing Assistants (CNA) were to round on residents every 2 hours and as needed.Review of the incident report dated 04/27/2025 at 11:40 a.m. revealed that Resident #71 suffered an unwitnessed fall in her room. Resident #71 was found on the floor lying on her left side beside the bed. Resident #71 reported to staff that she rolled out of the bed to go to the bathroom. Resident #71 was assessed and no apparent injuries were found. Review of the active plan of care revealed that Resident #71 was at risk for falls. Further review of the care plan revealed the resident suffered a fall on 04/27/2025. The intervention added on 04/27/2025 for the fall was for the Certified Nursing Assistant (CNA) staff to offer toileting assist when rounding. On 07/30/2025 at 2:00 p.m., S2Director of Nursing (DON) was informed that the intervention to offer toileting assist when rounding was inappropriate because CNA staff had already received in-service training to round on residents and every 2 hours and as needed.

Based on observations, record review and interview, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (#61) of 1 (#61) residents reviewed for respiratory care. The facility failed to ensure there was signage indicating oxygen in use was posted outside the entrance of Resident #61's room. Findings:Review of the facilities Oxygen Administration policy, revised date of October 2010, revealed in-part: Place an Oxygen in Use sign on the outside of the room entrance door.On 07/29/2025 at 07:52 a.m. an observation of Resident #61 revealed she was receiving oxygen at 4 liters per minute (LPM) via nasal cannula (NC). Further observation revealed there was no signage posted outside Resident #61's room indicating no smoking oxygen in use. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounters for orthopedic aftercare, chronic respiratory failure with hypoxia, other specified interstitial pulmonary diseases, chronic kidney disease stage 4, type 2 diabetes mellitus with hyperglycemia, and paroxysmal atrial fibrillation.Review of the July 2025 Physician orders revealed Oxygen 4 LPM/nasal cannula via concentrator continuously dated 07/02/2025 and bi-level positive airway pressure (BIPAP) to be worn every (q) hour of sleep (HS) with following settings: inspiratory pressure - 12; expiratory pressure - 5; fraction of inspired oxygen (FiO2) - 45.Review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident was cognitively intact and able to make daily decisions. Further review revealed the resident has shortness of breath and wears oxygen.Review of the July 2025 electronic medication administration record revealed documentation Resident #61 received Oxygen at 4 LPM per nasal cannula and the BIPAP q HS as ordered by the physician. On 07/29/2025 at 09:45 a.m. an observation and interview conducted with S2Director of Nursing (DON) outside of Resident #61's room revealed there was no signage indicating no smoking oxygen in use posted outside Resident #61's room. S2DON confirmed Resident #61 receives continuous oxygen at 4 LPM via NC. S2DON further confirmed there should be signage posted outside Resident #61's room indicating no smoking oxygen in use.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#1) 3 (#1, #61, #71) reviewed for general concerns.Findings:Review of the medical record for Resident #1 revealed an admission date of 06/25/2025 with diagnoses that included acute on chronic congestive heart failure, chronic pulmonary edema, atrial fibrillation and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Resident #1 was cognitively intact with daily decision making. The MDS indicated that the resident received an anticoagulant which is a high risk medication.Review of the current plan of care documented the resident's risk for abnormal bleeding related to anticoagulant therapy. The plan of care also indicated that Resident #71 should be monitored for signs and symptoms of bleeding: bleeding gums, bruises, petechiae, nosebleeds, tarry stools, and hematuria. Review of the July 2025 Physician's Orders documented that the resident had an active order for Eliquis 2.5 milligrams (mg) by mouth twice daily. There was not a physician's order in place to monitor for signs and symptoms of bleeding. Review of the July 2025 Medication Administration Record (MAR) documented that Resident #1 received the Eliquis. Additionally, there was no documentation in present to monitor for signs and symptoms of bleeding. On 07/30/2025 at 2:00 p.m., S2Director of Nursing was informed of the findings related to the absence of monitoring for signs and symptoms of bleeding as indicated per the plan of care.

Based on observation, review of the policy, and interviews, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an unlocked, open medication room that was not being monitored by licensed nursing staff. Findings: Review of facility's policy and procedure for Administering Medications (no date) revealed the following: Medications and biological are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Observation on 03/18/2025 at 5:02 a.m. revealed the medication room (medication room a) door was unlocked and propped open by a wooden board. No nursing staff were present in the nurse's station or medication room at this time. Interview on 03/18/2025 at 5:05 a.m. with S4 Certified Nursing Assistant (CNA) confirmed that the medication room door was unlocked and propped open and that no nurses were in the room or in view of the medication room. Interview on 03/18/2025 at 5:10 a.m. with S3 Licensed Practical Nurse (LPN) confirmed that the door was unlocked and propped open and that it should have been locked. S3LPN confirmed that no nurses were in medication room and that only authorized nurses are to have access to the medication room. Interview on 03/18/2025 at 8:30 a.m. with S2 Director of Nursing confirmed that medication rooms are to be locked at all times if staff are not present and that the door is never to be propped open.

Based on record reviews and interviews, the facility failed to ensure that before allowing an individual to serve as a nurse aide, a facility must receive receive registry verification that the individual has met competency evaluation requirements for 1 Certified Nursing Assistant (S5CNA) of 3 (S5CNA, S6CNA, and S7CNA) personnel files reviewed. The facility allowed an employee to work as a CNA with an expired and out of State certification. Findings: Review of S5CNA's personnel file revealed his date of hire was on [DATE]. Further review revealed that S5CNA received his nurse aide certification in a different state from which he was currently empoyed. Review further revealed the certification had expired on [DATE]. On [DATE] at 8:15 a.m., an interview with S1Administrator confirmed that S5CNA did not have a current nurse aide certification in the state he was currently employed. On [DATE] at 9:53 a.m., an interview with S8CNA Supervisor confirmed that S5CNA had provided services to residents after his nurse aide certification had expired on [DATE].

Based on observations, record reviews, and interviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (#1) of 2 (#1 and #2) resident records reviewed, by assessing that bed rails were not indicated for a resident who was identified as having bed rails in use. Findings: Review of the medical record revealed a recent admitted [DATE]. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observation on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident #1 had 1/4 bed rails, one intact to each side of the resident's bed frame. Both rails were upright and in a locked position. Review of the Bed Rail assessment dated [DATE] at 6:54 a.m. revealed a check mark next to Side Rails/Assist Bar not indicated at this time. The assessment was signed by S3Registered Nurse (RN). On 12/26/2024 at 12:03 p.m., during a telephone interview, S3RN was notified of the findings regarding a check mark being documented next to side rails/assist bar are not indicated at this time. S3RN confirmed that she had completed the Bed Rail assessment dated [DATE] at 6:54 a.m. for resident #1. She revealed that she had been informed by the facility's previous Director of Nursing (DON) that by marking the use of bed rails, the facility had shown a high indicator use for restraints. She revealed that she had done what she had been told to do by her DON, at that time. S3RN confirmed the assessment was inaccurate. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #1.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 2 (#1 and #2) of 2 (#1 and #2) residents reviewed for accident hazards. The facility failed to have documented evidence of an assessment for the risk of entrapment from bed rails for residents identified as having 1/4 bed rails in use. Findings: Resident #1 Review of the medical record for resident #1 revealed a recent admitted [DATE]. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observations on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident 1/4 bed rails, one intact to each side of the resident #1's bedframe. Both rails were upright and in a locked position. Review of the medical record revealed there was no documented evidence of resident #1 being assessed for risk of entrapment for bed rails of any kind. Review of the Bed Rail assessment dated [DATE] at 6:54 a.m. revealed a check mark next to Side Rails/Assist Bar not indicated at this time. The assessment was signed by S3Registered Nurse (RN). On 12/26/2024 at 12:03 p.m., during a telephone interview, S3RN was notified of the findings regarding a check mark being documented next to side rails/assist bar are not indicated at this time. S3RN confirmed that she had completed the Bed Rail assessment dated [DATE] at 6:54 a.m. for resident #1. She revealed that she had been informed by the previous Director of Nursing (DON) that by marking the use of bed rails, the facility had shown a high indicator use for restraints. S3RN further confirmed that she could not recall if resident #1 actually required the use of the bed rails at the time she had completed the assessment on 12/18/2024 nor if resident #1 required the use of bed rails at the present time. On 12/26/2024 at approximately 2:00 p.m., an interview with S4Maintenance Supervisor was notified of the findings regarding resident #1 having 1/4 bed rails, one intact to each side of the bedframe. S4Maintenance Supervisor confirmed that he did not have any documentation to indicate that resident #1 was assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #1. Resident #2 Review of the medical record revealed that resident #2 was admitted to the facility on [DATE] with diagnoses including, left femur fracture with joint replacement, major depressive disorder, and insomnia. Review of the Admission MDS assessment dated [DATE] revealed resident #2 had a BIMS score of 08 indicating that resident #2 had moderate cognitive impairment with daily decision making skills. On 12/26/2024 at 8:25 a.m. and 12/30/2024 at 9:39 a.m., observations revealed resident #2 had 1/4 bed rails, one intact to each side of the bedframe. Both bed rails were observed in an upright and locked position. Review of the medical record revealed there was no documented evidence of resident #2 being assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 2:00 p.m., an interview with S4Maintenance Supervisor was notified of the findings regarding resident #2 having 1/4 bed rails, one intact to each side of the bedframe. S4Maintenance Supervisor confirmed that he did not have any documentation to indicate that resident #2 was assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #2.

Based on record reviews and interviews, the facility failed to ensure nursing staff was competent in providing nursing and related services to assure resident safety and maintain resident's highest practicable physical, mental, and psychological well-being for each resident. The facility failed to ensure: 1) the Certified Nursing Assistants (CNAs) conducted a walk through round and provided a report on residents during shift change and 2) CNAs rounded on residents every 2 hours for 2 (#1, #2) of 3 (#1, #2, #3) sampled residents. Findings: Resident #1 Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple myeloma not having achieved remission, personal history of Non-Hodgkin's lymphoma, adult failure to thrive, unspecified dementia unspecified severity without behavioral disturbance, depression, history of falling, and acute kidney failure unspecified. Review of Assessment Reference Date (ARD) Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident #1 was cognitively intact. Resident #1 had no range of motion impairment to upper or lower extremities and ambulated independently without any assisted devices. Resident #1 was independent with eating and oral hygiene. Resident #1 required setup or clean up assistance with personal hygiene and dressing upper body and required supervision or touching assistance with toileting hygiene and putting on/off footwear. Resident #1 required partial/moderate assistance with shower/bathe and dressing lower body. On 08/08/2024 at 9:40 a.m., an interview with S4CNA revealed she worked the day shift (7a.m to 3p.m.) on 08/03/2024 on hall A. S4CNA reported when she arrived to work S3CNA who worked the night shift, told her hi, but did not do a walk through or give her a report on the residents before she left. S4CNA reported she and S5CNA were both assigned to work hall A. S4CNA reported S5CNA was assigned to provide care for resident #1. S4CNA reported after she had finished making rounds on her residents, she started passing out ice water to residents. S4CNA reported around 7:40 a.m. she took ice water to resident #1's room. On 08/08/2024 at 10:42 a.m., a telephone interview with S3CNA reported she work the night shift (11p.m. to 7:00 a.m.) on hall A on 08/02/2024 and provided care for resident #1. S3CNA reported she checked on resident #1 at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. S3CNA reported resident #1 was awake most of the night watching television. S3CNA reported resident #1 did not voice any needs or report any discomfort when she checked on him throughout the night. S3CNA reported she last checked on resident #1 around 5:00 a.m. and he was in his bed watching television. S3CNA revealed resident #1 reported he did not needing anything when she asked him. S3CNA reported she did not do a walk through or give report to the oncoming CNAs before she got off. On 08/08/2024 at 12:13 p.m., a telephone interview with S5CNA revealed he worked the day shift (7 a.m. to 3 p.m.) on 08/03/2024. S5CNA reported he did not receive a report from S3CNA who worked the night shift and they did not do a walk through at shift change. S5CNA reported he and S4CNA were assigned to work the day shift on hall A. S5CNA reported he started his rounds around 7:05 a.m. assisting residents. S5CNA reported he generally assist the residents who are not able to walk and require extensive assistance with their Activities of Daily Living (ADL) first. S5CNA reported he had not made it to resident #1's room until around 8:15 a.m. Resident #2 Record review revealed resident #2 was admitted to the facility on [DATE] with diagnoses that include bradycardia, presence of pacemaker, primary osteoarthritis right hand, idiopathic gout multiple sites, essential hypertension, atherosclerotic heart disease, unspecified atrial fibrillation, mixed hyperlipidemia, obstructive sleep apnea, solitary plasmacytoma not having achieved remission, anemia, type 2 diabetes mellitus without complications, morbid obesity, and multiple myeloma not having achieved remission. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated resident #2 was cognitively intact. Resident #2 required extensive one person assistance with bed mobility, transfers, and toilet use. Resident #2 required supervision one person assistance with eating. Resident #2 was always incontinent of bowel and bladder. Resident #2 was unable to walk and used a wheel chair for ambulation. On 08/08/2024 at 9:40 a.m., an interview with S4CNA revealed she worked the day shift (7a.m to 3p.m.) on 08/03/2024 on hall A. S4CNA reported when she arrived to work S3CNA who worked the night shift, told her hi, but did not do a walk through or give her a report on the residents before she left. S4CNA reported she and S5CNA were both assigned to work hall A. S4CNA reported S5CNA was assigned to provide care for resident #2. S4CNA reported after she had finished making rounds on her residents, she started passing out ice water to residents. S4CNA reported around 7:40 a.m. she took ice water to resident #2's room. On 08/08/2024 at 10:42 a.m., a telephone interview with S3CNA reported she worked the night shift (11p.m. to 7:00 a.m.) on hall A on 08/02/2024 and provided care for resident #2. S3CNA reported she checked on resident #2 at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. S3CNA reported she provided incontinent care and brief change for resident #2 when she rounded on him throughout the night. S3CNA reported she last checked on resident #2 around 5:00 a.m. and she brought him 2 cups of coffee per his request. S3CNA reported she did not do a walk through or give report to the oncoming CNAs before she got off. On 08/08/2024 at 12:13 p.m., a telephone interview with S5CNA revealed he work the day shift (7 a.m. to 3 p.m.) on 08/03/2024. S5CNA reported he did not receive a report from S3CNA who worked the night shift and they did not do a walk through at shift change. S5CNA reported he and S4CNA were assigned to work the day shift on hall A. S5CNA reported he started his rounds around 7:05 a.m. assisting residents. S5CNA reported he generally assist the residents who are not able to walk and require extensive assistance with their Activities of Daily Living (ADL) first. S5CNA reported he had not made it to resident #2's room until around 8:15 a.m. On 08/12/2024 at 8:50 a.m., an interview with S2Director of Nursing (DON) revealed it is expected that the CNAs and nurses make rounds every 2 hours on residents they are assigned to provide care for. S2DON further revealed it is expected that the CNAs and LPNs give report and do a walk through round at the beginning and end of their shifts. On 08/08/2024 at 2:15 p.m., interview with S6CNA Supervisor confirmed she conducted a CNA in-service on 06/19/2024 about transferring, turning, rounding every 2 hours. S6CNA Supervisor revealed CNAs were also informed they were required to do a walk through and give a report with the oncoming CNAs before they get off. The off going CNA and the oncoming CNA are to physically go into the residents' rooms together for the walk through report at the beginning and ending of each shift. Review of the in-service sign in sheet with S6CNA Supervisor revealed S3CNA, S4CNA, and S5CNA's signatures were noted.

Based on record review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 3 (#43,#48, and #94) of 3 (#43,#48, and #94) residents reviewed for the completion of a fourteen day discharge assessment. Findings: Record review revealed resident #43 was admitted to the facility on [DATE] and discharged on [DATE]. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/19/2024. Record review revealed resident #48 was admitted to the facility on [DATE] and discharged on [DATE]. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/05/2024. Record review revealed resident # 94 was admitted to the facility on [DATE] and discharged on [DATE]. The last transmitted MDS assessment in the electronic health record was a quarterly assessment completed on 03/06/2024. On 07/24/2024 at 04:20 p.m., an interview with S2Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) nurse confirmed a minimum data set assessment was not submitted within fourteen days of discharge for resident #43, resident #48, and resident #94.

Based on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#66) of 1 (#66) residents identified with a skin rash. Findings: On 07/22/2024 at 10:48 a.m., observation of resident #66 revealed a dark patchy red rash to the face, back and arms. Interview at that time with resident #66 revealed she did not know the cause of the rash. On 07/24/2024 review of the record for resident #66 revealed diagnoses in part of dermatitis, arthritis, stage 3 chronic kidney disease, mild cognitive impairment and atrial fibrillation. Further review of the record revealed resident #66 had allergies to sulfonamide antibiotics. Review of the record also revealed the initial treatment for the rash began on 06/07/2024 with an order for hydrocortisone 1% ointment apply to areas on the face twice a day (BID) for 10 days- avoid the eyes and for Claritin 10 milligrams (mg) by mouth (po) one time a day for 10 days. Further review of the record revealed the following orders for resident #66's rash: 07/01/2024 Benadryl 25mg every 24 hours as needed for itching. 07/08/2024 Claritin 10mg 1 tab po every day for 30 days. Prednisone 10mg 1 tab po every day for 5 days in the morning. Consult dermatology for dermatitis to face/arms. 07/09/2024 Stop prednisone, start Diflucan 100mg po every other day for 4 doses (Fungal Rash). 07/09/2024 Claritin 10mg every day related to Dermatitis give until 08/09/2024. 07/20/2024 Hydralazine hydrochloric acid (HCL) 25mg every day and on 07/26/2024 give 1 po every day for 1 week then stop. On 07/24/2024 review of the current plan of care revealed there were no problems/needs related to the skin condition or rash for resident #66 implemented. On 07/24/2024 at 3:01 p.m., an interview with S1Director of Nursing (DON) confirmed the current plan of care did not address the problems/needs related to the skin condition/rash for resident #66.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#25, #71) of 2 (#25, #71) sampled residents reviewed for respiratory care. The facility failed to ensure: 1) a resident's oxygen (O2) was administered as ordered, the O2 tubing was dated, and the nebulizer was dated/stored properly (#25); and 2) a resident's O2 concentrator was clean (#71). Findings: Review of the facility Oxygen Administration (Concentrator or Tank) Policy (no date noted) revealed in part: Humidifier bottles, cannulas and O2 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. Resident #25 On 07/23/2024 at 2:11 p.m., review of the record for resident #25 revealed diagnoses in part of hypothyroidism, vascular dementia, atrial fibrillation, major depressive disorder, chronic obstructive pulmonary disease, chronic viral hepatitis C, and sleep apnea. Review of the quarterly Minimum Data Set (MDS) assessment revealed resident #25 was unable to be scored for the Brief Interview Mental Status (BIMS) review due to cognitive impairment. On 07/23/2024 at 9:34 a.m. review of the record revealed physician orders in part with start date noted: 06/29/2024 admit to hospice due to dementia. 07/01/2024 oxygen at 3 liters per minute continuous per nasal cannula for shortness of breath or wheezing and to keep the pulse oximeter greater than or equal to 92% and for albuterol sulfate nebulization solution (2.5milligrams/3milliliters) every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease (COPD). On 07/22/2024 at 3:35 p.m., an observation of resident #25 revealed oxygen was being administered at 5 liters per minute (lpm) per nasal cannula with no humidification noted and there was no date on the oxygen tubing. Further observation revealed the nebulizer mask was not covered or dated. On 07/23/2024 at 9:45 a.m., an observation again of resident #25 revealed the oxygen continued again at 5 lpm per nasal cannula with no humidification noted and there was no date on the oxygen tubing. Further observation revealed the nebulizer mask was not covered or dated. On 07/24/2024 review of the July 2024 medication administration record (MAR) revealed resident #25 received albuterol sulfate nebulizer on 07/09/2024, 07/10/2024 and 07/11/2024. Further review of the July 2024 MAR revealed record of resident #25 receiving oxygen at 3 liters per minute and keep pulse oximeter greater than or equal to 92%. Review of the documentation on 07/22/2024, 07/23/2024, and 07/24/2024 revealed the nurse documented the oxygen as being delivered at 3 lpm. On 07/23/2024 at 2:50 p.m., observation again of resident #25 oxygen revealed it was being administered again at 5 lpm with no humidification per nasal cannula and no date on the oxygen tubing. Further observation of the room revealed the nebulizer mask was not covered and not dated. 07/23/24 at 3:17 p.m., an observation and interview with S1Director of Nursing (DON) confirmed the oxygen was flowing at 5 lpm per nasal cannula and should not have been flowing at 5 lpm per nasal cannula. S1DON further confirmed the oxygen tubing was not dated and the nebulizer tubing was not covered or dated and should have been. Resident #71 Review of the medical record for resident #71 revealed the resident was admitted on [DATE] with diagnoses including: chronic systolic congestive heart failure, hypertension, and atherosclerotic heart disease. Review of the Admission MDS assessment dated [DATE] revealed resident #71 scored a 10 on the BIMS which indicated he had moderately impaired cognition for daily decision making skills. Observations on 07/22/2024 at 9:10 a.m., 07/23/2024 at 10:30 a.m., and 07/24/2024 at 8:25 a.m., revealed resident #71 was receiving O2 via nasal cannula. Further observation revealed his O2 concentrator had a dirty buildup on both the front panel and the filter on the back of the concentrator. Review of resident #71's July 2024 physician orders revealed an order dated 07/12/2024 for O2 3 lpm continuous via nasal cannula. Review of the record revealed the following care plan for resident #71: administer oxygen therapy as ordered by the physician and to monitor for signs and symptoms of respiratory distress. During an observation of resident #71's O2 concentrator on 07/24/2024 at 2:10 p.m. with the surveyor, S3Licensed Practical Nurse (LPN) confirmed the resident's O2 concentrator had a dirty buildup on both the front panel and the filter on the back of the concentrator. On 07/24/2024 at 4:40 p.m., during an interview with S1DON, she was informed of resident #71's concentrator having a dirty buildup on both the front panel and the filter on the back of the concentrator. S1DON was informed the concentrator was in need of cleaning. 22575

Based on record review and interviews the facility failed to ensure that the pharmacist reported any irregularities to the physician and director of nursing for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The pharmacist failed to identify that resident #15 was receiving as needed (prn) doses of the psychotropic medication clonazepam beyond 14 days without a documented rationale and duration date for administration. Findings: Record review revealed resident #15 was admitted to the facility 02/09/2019 with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram (mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no evidence of a stop date. Review of the quarterly minimum data set assessment dated [DATE] revealed a brief interview mental status score of 3 which indicated severe cognitive impairment. Review of the narcotic log revealed resident #15 received prn clonazepam 0.5 mg on multiple days in May, June, and July 2024. Review of the resident's medical record revealed no recorded reasoning by the physician for the continuation of clonazepam 0.5 mg by mouth every day prn for agitation order. Review of the monthly drug regimen by the consultant pharmacist dated 06/19/2024 revealed no documentation by the consultant pharmacist to address the prn medication clonazepam. On 07/24/2024 at 8:35 a.m., an interview with S4Licensed Practical Nurse (LPN) revealed resident #15 occasionally needed the prn dose of clonazepam 0.5 mg due to behaviors such as hollering out for her momma, crying, and making repetitive noises. On 07/24/2024 at 11:35 a.m., an interview with S1Director of Nursing (DON) confirmed resident #15 had an order for clonazepam 0.5 mg by mouth every day prn for agitation that was ordered on 05/23/2024 with no stop date. S1DON confirmed there was no documented evidence from the physician regarding a documented rationale for extended use of the prn medication clonazepam. S1DON further confirmed there was no documented evidence of the consultant pharmacist identifying and notifying the physician or the director of nursing of the ongoing need for the prn medication clonazepam.

Based on record review and interviews, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The facility failed to have a documented rationale in the resident's medical record to indicate the duration of an as needed (prn) psychotropic medication to be extended beyond 14 days of use for resident #15 who received the prn medication clonazepam. Findings: Record review revealed resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram(mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no evidence of a stop date. Review of the quarterly minimum data set assessment dated [DATE] revealed a brief interview mental status score of 3 which indicated severe cognitive impairment. Review of the narcotic log revealed resident #15 received prn clonazepam 0.5 mg on multiple days in May, June, and July 2024. Review of the resident #15 medical record revealed no recorded reasoning by the physician for the continuation of clonazepam 0.5 mg by mouth every day prn for agitation order. On 07/24/2024 at 8:35 a.m., an interview with S4Licensed Practical Nurse (LPN) revealed resident #15 occasionally needed the prn dose of clonazepam 0.5 mg due to behaviors such as hollering out for her momma, crying, and making repetitive noises. On 07/24/2024 at 11:35 a.m., an interview with S1Director of Nursing (DON) confirmed resident #15 had an order for clonazepam 0.5 mg by mouth every day prn for agitation that was ordered on 05/23/2024 with no stop date. S1DON confirmed there was no documented evidence from the physician regarding a documented rationale for extended use of the prn medication clonazepam.

Based on record review, observation and interview, the facility failed to ensure a resident's right to be free from mental, physical, verbal and sexual abuse for 1 (Resident #1) of 5 (Residents #1-#5) sampled residents reviewed. The facility failed to: 1. Increase monitoring and supervision of CNAs (certified nursing assistants)/direct care staff providing care and services to residents after the incident, 2. Provide additional in-service education/training to CNAs/direct care staff on abuse, and 3. Interview all residents throughout the facility regarding concerns of mental, physical, verbal and/or sexual abuse. An Immediate Jeopardy occurred for Resident #1 on 07/21/19 at 8:20PM when S6CNA was observed to hit the resident in the head, fondle the resident's genitalia, cover the resident's head with a towel and use derogatory and threatening language toward the resident. This abuse was observed by S5CNA, but S5CNA did not report the abuse until 10:20PM when S4LPN mentioned there had been a change in the resident's behavior. S1Administrator and S2DON (director of nursing) were notified of the Immediate Jeopardy on 08/08/19 at 11:30AM. The Immediate Jeopardy was removed on 08/08/19 at 5:15PM when the facility submitted and initiated the following Plan of Removal that included the following: 1. Provide increased monitoring and supervision of other CNAs/staff providing care and services to the residents by developing and implementing Abuse/Neglect Monitoring and Supervision Tool. Leadership team will be in-serviced immediately by supervisory staff to observe care being provided to all residents in the facility. Nurses will be in-serviced on use of this monitoring tool as they supervise CNAs. DON/designee will track responses. Monitoring tool will be initiated on 08/08/19 for days and evening staff. Night staff will be monitored on 08/09/19. By 08/16/19, all remaining staff will have been monitored. Agency and any staff not available will be monitored upon their return. Monitoring tool will be used twice weekly for one month, weekly for three months, then monthly thereafter. To ensure all staff have been monitored at least monthly, DON/designee will use active staff roster and compare to completed monitoring tools. Any negative findings will result in disciplinary action to be provided by S1Administrator or S2DON. Additional training will be required and successfully completed before staff member allowed to return to assignment. Staff member will receive increased monitoring weekly for four weeks and then monthly monitoring thereafter. All findings will be brought to QA (quality assurance) committee for tracking and trending. 2. Provide additional in-service education/training on abuse to CNAs/staff providing care and services to the residents in the facility by: a. Telephone call to Assistant Attorney General (AG) and requested educational visit from AG office regarding abuse and neglect for all staff. Awaiting response from AG office. b. Telephone call to Northeast Louisiana Ombudsman Office to request in-service regarding abuse and neglect. c. Contacted Chief Detective with police department for in-service on consequences of committing crime to elderly. Detective will return call to S1Administrator to set up date for in-service. d. Staff in-service on 08/08/19. Agenda including items regarding abuse and neglect discussed. In-service will continue until all staff are trained. 3. Assess 3 residents not interviewed in the area in which the accused CNA worked and interview other residents throughout the facility regarding concerns of sexual and/or physical abuse by: a. Treatment nurse completed body audit/assessment on two of the three residents who were not interviewed in the area in which the accused provided care. One of the residents is currently in the hospital and will be assessed on return. b. Body audits for residents residing in rooms 100-409 have been completed. Body audits for the remainder of the facility are ongoing. 4. Resident #1 and all residents who are not able to be interviewed have the potential for increased refusal for peri-care, ADLs (activities of daily living), toileting and wound care leading to a decline of physical condition. These residents also have the potential for psychosocial problems such as increased depression, anxiety, and withdrawal. If behaviors are exhibited by any resident, nurse will perform head to toe assessments for physical change in condition, request medical evaluation from consultant pharmacist, and notify the physician of any changes to obtain additional interventions. If no physical changes are noted, DON/designee will use staffing schedule to interview staff and track behaviors. If any negative patterns are noted, then resident-staff interaction will be observed using abuse/neglect supervision tool. 5. Facility will add addendum to staff job descriptions to emphasize recognizing burnout, preventing stress, identifying and reporting abuse. 6. Three additional Relias educational learning courses have been added for staff to complete entitled; Take a Deep Breath and Manage Your Stress, Employee Wellness- Stress Management, and Taking Care of YOU- Avoiding Burnout to enhance staff ability to identify burnout and stress in themselves and coworkers. Courses to be completed by 10/31/19 and are mandatory for all facility employees. S10HR will be responsible for monitoring and ensuring that courses are completed. 7. Developed and implemented Abuse/Neglect Monitoring and Supervision Tool. Leadership team consisting of S1Administrator, S2DON, Assistant Director of Nursing, Medicare nurses, Dietary manager, CNA supervisor, Bookkeeper, Infection Control Preventionist, Admissions coordinator, and S10HR in-serviced on the use of the monitoring tool that will be used immediately by supervisory staff to observe care being provided to all residents in facility. Nurses will be in-serviced on use of this monitoring tool as they supervise CNAs. DON/designee will track responses. Monitoring tool will be used twice weekly for one month, weekly for three months, then monthly thereafter. To ensure all staff have been monitored at least monthly, DON/designee will use active staff roster to compare to completed monitoring tools. Any negative findings will result in disciplinary action to be provided by S1Administrator or S2DON. Additional training will be required and successfully completed before staff member allowed to return to assignment. Staff member will receive increased monitoring weekly for four weeks and then monthly monitoring thereafter. All findings will be brought to QA (quality assurance) committee for tracking and trending. 8. Provide additional in-service education/training on abuse to CNAs/staff providing care and services to the residents in the facility by: a. Telephone call to the Assistant AG and requested educational visit regarding abuse and neglect for all staff. Awaiting response. b. Telephone call to Ombudsman to request in-service regarding abuse and neglect. In-service is schedule for 08/13/19 at 2PM. c. Contacted Chief Detective with police department for in-service on consequences of committing crimes related to elderly. Detective will return call to set up date for in-service. d. Staff in-serviced on 08/08/19 with agenda including items regarding abuse and neglect addressed. The deficient practice continued at a potential for more than minimal harm for the remaining 120 residents in the facility. Findings: Review of the facility's Abuse and Neglect Prohibition Policy revealed, in part, the following: Training- 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. Prevention- 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. Identification- 1. The facility Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns, and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. 2. The facility supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, which are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. Investigation- 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. Protection- 1. The facility will protect residents from harm during the investigation. Record review revealed Resident #1 was admitted in 2014 and had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] indicated Resident #1 had severe cognitive impairment. The resident was totally dependent on staff for all activities of daily living except eating. Staff reported that sometimes he could feed himself finger foods. On 08/05/19 at 8:33PM, an observation of Resident #1 revealed the resident was confused and not interviewable. Observation of S7CNA providing care to the resident revealed the resident was cooperative and calm during linen change and pericare. Resident #1 talked to S7CNA about various things including letting his dog outside to play tomorrow. Resident #1 tolerated care provided with no behaviors noted. S7CNA was asked if he had in-service education related to abuse since the incident on 07/21/19 and he confirmed that he had not. On 08/06/19 at 11AM, Resident #1 was in the lobby in a geri-chair appropriately dressed and kempt. On 08/08/19 at 9:40AM, an observation was made of S11CNA and S7CNA assisting Resident #1 on to the stand lift for transfer to the shower chair. CNAs provided cues for the resident during the transfer. The resident exhibited no signs of resistance or behaviors during the transfer. Review of an investigative report dated 07/21/19 at 8:20PM for Resident #1 revealed S5CNA reported to S4LPN that she had observed S6CNA slap the resident in the face, about the head, and touch the resident inappropriately while performing care. S5CNA did not report the incident until 10:20PM. S4LPN notified S1Administrator and performed a body audit on Resident #1. Review of handwritten statements dated 07/21/19 and provided by S1Administrator revealed the following: S5CNA reported, in part, that after dinner she and S6CNA were putting Resident #1 down for bed and the resident began to resist care. S6CNA told the resident to shut up and pushed resident to the side so the lift straps could be placed around him. Resident #1 stated 'get away from me' and started to hit in the air. S6CNA stated 'watch this' and placed his finger between the resident's legs, while the resident had clothes on, and started moving his finger back and forth. S6CNA then stated, 'look, he always gets aroused when I do that, his nasty self.' At that time, Resident #1 hit S6CNA and S6CNA slapped him back and the resident and S6CNA started hitting back and forth. Resident #1 was in the stand lift near the door and S6CNA started to race toward the bed with the resident and stated, 'throw that cr**ker in the lake' to scare the resident. S6CNA was being rough with the resident while putting the resident in bed. S6CNA then called the resident a 'bi**h' and pushed him in the chest and told him 'good night'. Signed by S5CNA, 07/21/19, 8:20. S4LPN noted at 10:20PM on 07/21/19 that she remarked to S5CNA that Resident #1 was more combative while trying to perform wound care. S5CNA stated that she knew why and proceeded to report that while she was assisting S6CNA put Resident #1 to bed S6CNA hit the resident. S5CNA went on to say that the resident and S6CNA started slapping each other. S5CNA reported S6CNA then touched between Resident #1's legs moving his finger back and forth and stated, 'he always gets aroused when I do this with his nasty self'. S5CNA stated that after they stood Resident #1 in the lift, S6CNA placed a towel over the resident's head and stated 'throw that cr**ker in the lake' as he pushed the lift toward the resident's bed. S5CNA reported that she believed it was to startle the resident. S5CNA reported S6CNA told the resident 'you are the b**ch while pushing the resident in the chest. S5CNA reported that she did not tell immediately because she was afraid S6CNA would retaliate. Review of the facility's Abuse Prevention Program revealed, in part, the following: 8. Protect residents during investigations, 9. Establish and implement a QAPI (quality assurance performance improvement) review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. On 08/07/19 at 8:50AM, an interview with S10Human Resources confirmed that she makes sure employees are completing their abuse and neglect training on the computer on time for newly hired employees and for annual competency training. She further indicated there were no other quality assurance measures being tracked and monitored after substantiated allegations of physical and sexual abuse on 07/21/19. On 08/07/19 at 11:15AM, an interview with S12Social Services confirmed that she had interviewed residents that lived on Resident #1's hall on 07/22/19 after a report of physical and sexual abuse. When asked, S12Social Services confirmed that not all of the residents on the hall were interviewed. S12Social Services confirmed that she only interviewed residents that lived on the same hall as Resident #1. Review of the CNA Satisfaction Survey provided by S1 Administrator revealed 11 residents had been interviewed on Resident #1's hall on 07/22/19. According to documentation provided by the Administrator, there were 15 residents residing on Resident #1's hall on 07/21/19. On 08/07/19 at 11:30, S1Administrator confirmed 3 residents, excluding Resident #1, who resided on the resident's hall were not interviewed. Additionally, S1Administrator confirmed the 3 residents that did not complete the interview had not been assessed for signs of abuse by body audit. On 08/07/19 at 2:15PM, an interview with S3CNA Supervisor revealed, in part, S6CNA worked a double shift on 07/21/19. Supervisor reported S6CNA was assigned to Resident #1 during the morning shift and S5CNA was assigned to the resident during the afternoon shift. S3CNA Supervisor reported that S1Administrator called her at home on 07/21/19 at around 10:25 PM and informed her that an abuse investigation regarding S6CNA had been initiated. S1Administrator told S3CNA Supervisor that S6CNA was not to come back to work until the investigation was completed. S3CNA Supervisor reported that she immediately called S6CNA and told him that he was being investigated for abuse. CNA Supervisor reported that S6CNA's shift had ended and he had already left the facility when she called him. She stated that S6CNA called her back later and said he may know what it's about because he had been play fighting with Resident #1. Supervisor asked S6CNA if he had hit the resident and S6CNA reported that he had tapped the resident. S3CNA Supervisor stated that she asked 'what do you mean that you tapped him?' S6CNA repeated 'tapped him'. Supervisor stated that she told S6CNA 'you can't do that, he has dementia'. S3CNA Supervisor further reported that S6CNA had only been assigned to the 800 hall while he was working at the nursing home. When asked if it was possible that S6CNA had been pulled to another hall or area to help out, she stated that it was possible. S3CNA Supervisor added that S6CNA may have also gone out with a resident to a doctor appointment, but it was not likely that it was documented anywhere. As the interview with S3CNA Supervisor continued on 8/07/2019 at 2:15 PM, she confirmed there had been no increase in supervision and monitoring of CNAs since the incident on 07/21/19. On 08/07/19 at 3:15PM, a telephone interview with S4LPN revealed, in part, that she is very familiar with Resident #1 and she provided care for the resident every weekend. S4LPN reported that on 07/21/19 she attempted to provide wound care for Resident #1 and he would not let her touch him. She stated that he has behaviors at times but it was heightened aggressiveness and very different from what she had witnessed before. S4LPN stated that she could normally provide care for him but this time he was adamant that she was not going to touch him. S4LPN reported that she left the resident's room around 10:20PM and mentioned his behavior to S5CN[NAME] She stated that S5CNA responded that she might know why the resident was responding in that manner. S4LPN told S5CNA to tell her everything so she could inform the Administrator immediately. S4LPN reported that S5CNA informed her what happened on 07/21/19 at about 8:20PM and she called the Administrator at home to tell her. She stated that S1Administrator told her to have S6CNA leave the building and for S4LPN and S5CNA to each write a statement of what happened. S4LPN reported that S6CNA had already completed his shift and left the building. S4LPN was asked if she had any in-service education related to abuse since the incident on 07/21/19 and she confirmed that she had not. She further confirmed that she was not aware if there had been any increased supervision and monitoring of direct care staff. On 08/07/19 at 3:37PM, an interview with S5CNA reported that she was working a double on 07/21/19 and was assigned to Resident #1 on the 2P-10P shift. She stated that after dinner, they were putting everyone down and she asked S6CNA for assistance because Resident #1 is a 2-person assist for transfers. S5CNA reported that she and S6CNA were trying to get the lift straps around the resident but he wouldn't comply and S6CNA stated 'I'm tired of this' and shoved the resident over hard to get the strap on him and called the resident 'b**ch'. She stated the resident got rowdy at that point and started slapping in the air at S6CN[NAME] S6CNA slapped the resident in the head. S6CNA then stated 'watch this, he always gets aroused when I do this with his nasty self' and put his hand over the resident's genital area and moved his hand back and forth. S6CNA stood the resident up using the lift and then wrapped a towel around his head and began to push the lift quickly toward the resident's bed and said 'we are going to throw you in the lake, cr**ker'. After the resident was in bed, S6CNA pushed down on the resident's chest and said 'good night'. S5CNA reported that S6CNA approached her a little while later and said 'you are not going to tell what happened, you know I was playing'. As the interview with S5CNA continued, when asked about Resident #1's behavior during the incident, S5CNA reported that she had never seen the resident act as agitated and upset as he was during the incident. S5CNA added that S6CNA was provoking the resident. S5CNA confirmed that she had not had any abuse training since the incident on 07/21/19. On 08/07/19 at 4:35PM, an interview with S13CNA, who was working on Resident #1's hall, reported that he had heard about the incident of abuse in passing by people talking about it. CNA confirmed that he had not had any in-service training on abuse since the incident. On 08/07/19 at 4:39PM, an interview with S7CNA reported that he had heard about the incident of abuse by people talking about it. CNA reported that he had not had any abuse training since the incident. On 08/07/19 at 4:45PM, an interview with S14CNA reported that she first found out about the incident of abuse on social media. CNA reported that there had been no in-service training on abuse since the incident. On 08/07/19 at 5:03PM, an interview with S15CNA reported that she was not informed about the incident of abuse by the facility for a while after it happened. CNA reported that she had no in-service training on abuse since the incident. On 08/07/19 at 5:13PM, an interview with S16CNA confirmed that she had not had in-service training on abuse since the incident on 07/21/19. On 08/08/19, an interview with S1Administrator and S2DON confirmed there had been no in-service training for CNAs on abuse since 07/21/19. S1Administrator confirmed there been no increase in supervision and monitoring of CNAs/direct care staff after substantiating allegations of physical and sexual abuse by S6CN[NAME] S1Administrator and S2DON confirmed that only residents that were residing on Resident #1's hall had been interviewed and that no other residents in the facility had been interviewed in regards to abuse. Lastly, S1Administrator and S2DON confirmed that 3 residents residing in the area where S6CNA had been assigned were not interviewed and no head-to-toe body audit had been performed to assess for evidence of abuse.

Based on record review, observation, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 (Residents #1-5) residents reviewed. The facility failed to have an effective system that ensured a resident's safety from abuse after substantiating allegations of sexual and physical abuse for Resident #1 on 07/21/19. The facility failed to: 1. Increase monitoring and supervision of CNAs (certified nursing assistants)/direct care staff providing care and services to residents after the incident, 2. Provide additional in-service education/training to CNAs/direct care staff on abuse, and 3. Interview all residents throughout the facility regarding concerns of mental, physical, verbal and/or sexual abuse. An Immediate Jeopardy occurred for Resident #1 on 07/21/19 at 8:20PM when S6CNA was observed to hit the resident in the head, fondle the resident's genitalia, cover the resident's head with a towel and use derogatory and threatening language toward the resident. This abuse was observed by S5CNA, but S5CNA did not report the abuse until 10:20PM when S4LPN mentioned there had been a change in the resident's behavior. S1Administrator and S2DON (director of nursing) were notified of the Immediate Jeopardy on 08/08/19 at 11:30AM. The Immediate Jeopardy was removed on 08/08/19 at 5:15PM when the facility submitted and initiated the following Plan of Removal that included the following: 1. Provide increased monitoring and supervision of other CNAs/staff providing care and services to the residents by developing and implementing Abuse/Neglect Monitoring and Supervision Tool. Leadership team will be in-serviced immediately by supervisory staff to observe care being provided to all residents in the facility. Nurses will be in-serviced on use of this monitoring tool as they supervise CNAs. DON/designee will track responses. Monitoring tool will be initiated on 08/08/19 for days and evening staff. Night staff will be monitored on 08/09/19. By 08/16/19, all remaining staff will have been monitored. Agency and any staff not available will be monitored upon their return. Monitoring tool will be used twice weekly for one month, weekly for three months, then monthly thereafter. To ensure all staff have been monitored at least monthly, DON/designee will use active staff roster and compare to completed monitoring tools. Any negative findings will result in disciplinary action to be provided by S1Administrator or S2DON. Additional training will be required and successfully completed before staff member allowed to return to assignment. Staff member will receive increased monitoring weekly for four weeks and then monthly monitoring thereafter. All findings will be brought to QA (quality assurance) committee for tracking and trending. 2. Provide additional in-service education/training on abuse to CNAs/staff providing care and services to the residents in the facility by: a. Telephone call to Assistant Attorney General (AG) and requested educational visit from AG office regarding abuse and neglect for all staff. Awaiting response from AG office. b. Telephone call to Northeast Louisiana Ombudsman Office to request in-service regarding abuse and neglect. c. Contacted Chief Detective with police department for in-service on consequences of committing crime to elderly. Detective will return call to S1Administrator to set up date for in-service. d. Staff in-service on 08/08/19. Agenda including items regarding abuse and neglect discussed. In-service will continue until all staff are trained. 3. Assess 3 residents not interviewed in the area in which the accused CNA worked and interview other residents throughout the facility regarding concerns of sexual and/or physical abuse by: a. Treatment nurse completed body audit/assessment on two of the three residents who were not interviewed in the area in which the accused provided care. One of the residents is currently in the hospital and will be assessed on return. b. Body audits for residents residing in rooms 100-409 have been completed. Body audits for the remainder of the facility are ongoing. 4. Resident #1 and all residents who are not able to be interviewed have the potential for increased refusal for peri-care, ADLs (activities of daily living), toileting and wound care leading to a decline of physical condition. These residents also have the potential for psychosocial problems such as increased depression, anxiety, and withdrawal. If behaviors are exhibited by any resident, nurse will perform head to toe assessments for physical change in condition, request medical evaluation from consultant pharmacist, and notify the physician of any changes to obtain additional interventions. If no physical changes are noted, DON/designee will use staffing schedule to interview staff and track behaviors. If any negative patterns are noted, then resident-staff interaction will be observed using abuse/neglect supervision tool. 5. Facility will add addendum to staff job descriptions to emphasize recognizing burnout, preventing stress, identifying and reporting abuse. 6. Three additional Relias educational learning courses have been added for staff to complete entitled; Take a Deep Breath and Manage Your Stress, Employee Wellness- Stress Management, and Taking Care of YOU- Avoiding Burnout to enhance staff ability to identify burnout and stress in themselves and coworkers. Courses to be completed by 10/31/19 and are mandatory for all facility employees. S10HR will be responsible for monitoring and ensuring that courses are completed. 7. Developed and implemented Abuse/Neglect Monitoring and Supervision Tool. Leadership team consisting of S1Administrator, S2DON, Assistant Director of Nursing, Medicare nurses, Dietary manager, CNA supervisor, Bookkeeper, Infection Control Preventionist, Admissions coordinator, and S10HR in-serviced on the use of the monitoring tool that will be used immediately by supervisory staff to observe care being provided to all residents in facility. Nurses will be in-serviced on use of this monitoring tool as they supervise CNAs. DON/designee will track responses. Monitoring tool will be used twice weekly for one month, weekly for three months, then monthly thereafter. To ensure all staff have been monitored at least monthly, DON/designee will use active staff roster to compare to completed monitoring tools. Any negative findings will result in disciplinary action to be provided by S1Administrator or S2DON. Additional training will be required and successfully completed before staff member allowed to return to assignment. Staff member will receive increased monitoring weekly for four weeks and then monthly monitoring thereafter. All findings will be brought to QA (quality assurance) committee for tracking and trending. 8. Provide additional in-service education/training on abuse to CNAs/staff providing care and services to the residents in the facility by: a. Telephone call to the Assistant AG and requested educational visit regarding abuse and neglect for all staff. Awaiting response. b. Telephone call to Ombudsman to request in-service regarding abuse and neglect. In-service is schedule for 08/13/19 at 2PM. c. Contacted Chief Detective with police department for in-service on consequences of committing crimes related to elderly. Detective will return call to set up date for in-service. d. Staff in-serviced on 08/08/19 with agenda including items regarding abuse and neglect addressed. The deficient practice continued at a potential for more than minimal harm for the remaining 120 residents in the facility. Findings: Cross refer to findings at F600. Review of the facility's Abuse Prevention Program Policy revealed, in part, the following: 8. Protect residents during investigations, 9. Establish and implement a QAPI (quality assurance performance improvement) review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Review of the facility's Abuse and Neglect Prohibition Policy revealed, in part, the following: Training- 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. Prevention- 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. Identification- 1. The facility Quality Assessment & Assurance (QA&A) Committee will investigate occurrences, patterns, and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits, and reports. 2. The facility supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, which are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. Investigation- 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. Protection- 1. The facility will protect residents from harm during the investigation. On 08/08/19, an interview with S1Administrator and S2DON confirmed there had been no in-service training for CNAs on abuse since 07/21/19. S1Administrator confirmed there been no increase in supervision and monitoring of CNAs/direct care staff after substantiated allegations of physical and sexual abuse by S6CN[NAME] S1Administrator and S2DON confirmed that only residents that were residing on Resident #1's hall had been interviewed and that no other residents in the facility had been interviewed in regards to abuse. Lastly, S1Administrator and S2DON confirmed that 3 residents residing in the area where S6CNA had been assigned were not interviewed and no head-to-toe body audit had been performed to assess for evidence of abuse.