Every finding on record at Landmark of Plaquemine

Based on interviews and record reviews, the facility failed to ensure hospice services met professional standards and principles by failing to maintain a system to ensure a hospice resident's clinical binder contained up to date documentation of Hospice Nurse Visit notes for 1 (Resident #2) of 2 residents reviewed for hospice care. Findings: Review of Resident #2's clinical record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #2 was a patient of a local hospice agency with a current certification period of 06/04/2026 through 09/01/2026.Review of Resident #2's hospice binder revealed the resident was admitted to the hospice agency on 06/04/2026. Further review revealed no Hospice Nurse Visit notes for nursing visits conducted on 07/02/2026, 07/06/2026, 07/07/2026, and 07/09/2026.In an interview on 07/14/2026 at 1:00 p.m., S3Hospice Liaison confirmed she was the staff member responsible to coordinate with the hospice agency. S3Hospice Liaison indicated she spoke with Resident #2's hospice company, and skilled nursing visits were made on 07/02/2026, 07/06/32026, 07/07/2026, and 07/09/2026. S3Hospice Liaison reviewed Resident #2's hospice binder and confirmed there were no hospice progress notes in the binder for nursing visits conducted on 07/02/2026, 07/06/2026, 07/07/2026, and 07/09/2026.In an interview on 07/14/2026 at 2:20 p.m., Medical Records employee for Resident #2's hospice provider confirmed she had not placed documentation of Resident #2's weekly nursing visit notes in the facility's hospice binder for nursing visits made on 07/02/2026, 07/06/2026, 07/07/2026, and 07/09/2026.In an interview on 07/14/2026 at 2:55 p.m., S2Director of Nursing confirmed as per the facilities agreement hospice progress notes should be updated and kept in the resident's hospice binder, and were not.In an interview 07/15/2026 at 2:46 p.m., S1Administrator confirmed hospice binders should be up to date, and were not.

Based on interviews and record review, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days and indicated the duration for 1 (Resident #2) of 5 residents reviewed for unnecessary meds.Findings:Review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with unspecified psychotic disturbance, unspecified mental disorder due to known physiological condition, disorientation, and delirium. Review of Resident #2's July 2024 physician's orders revealed an order written on 04/30/2026 for Hydroxyzine HCL 50 mg - one tablet as needed for anxiety related to disorientation. Review of Resident #2's Medication Administration Record (MAR) for June 2026 revealed administration of Hydroxyzine 50 mg on 6/16/2026 at 1:48 a.m. and 6/17/2026 at 3:15 a.m. Review of the MAR for July 2026 revealed administration of Hydroxyzine 50 mg on 07/04/2026 at 7:59 p.m. An interview was conducted on 07/14/2026 at 2:55 p.m. with S2DON. S2DON confirmed Hydroxyzine was prescribed as a psychotropic medication. She confirmed Resident #2 had an order on 04/30/2026 for PRN Hydroxyzine with no reorder after 14 days as required.

Based on observation, interview, and record review, the facility failed to ensure meals were prepared in a sanitary manner as required. This deficient practice had to potential to affect any of the 71 residents who received meals from the facility. Findings: 1. Observation on [DATE] at 9:20AM revealed S18Cook in the facility's kitchen with a beard and mustache hair approximately 1/4 inch long and had no beard cover. Observation on [DATE] 11:36AM revealed S18Cook with a beard and mustache hair approximately 1/4 inch long cooking potatoes on the grill and had no beard cover. In an interview [DATE] at 11:45AM, S18Cook indicated he did not wear a face/beard cover because the facility doesn't have them available. In an interview on [DATE] at 11:48AM, S10Dietary Manager confirmed S11Cook should have had a face/beard cover on. 2. Observation on [DATE] at 9:12AM of the facility's kitchen's dry storage room revealed 33 packets of blue cheese salad dressing with an expiration date of [DATE]. In an interview on [DATE] at 9:13AM, S10Dietary Manager indicated the blue cheese dressing was expired and was available for resident use and should have been discarded and not be available for resident use. In an interview on [DATE] at 12:45PM, S4Regional Administrator confirmed the blue cheese dressing was expired and was available for resident use and should have been discarded and not be available for resident use.

Based on observation and interview, the facility failed to ensure food was served at a palatable temperature as required. This deficient practice had the potential to affect any of the 71 residents who consumed meals from the facility's kitchen. Findings: In an interview on 07/07/25 at 10:45AM, Resident #48 indicated the food served, on the meal tray, in her room was cold and didn't taste good. In an interview on 07/08/2025 at 10:13 AM, Resident #46 indicated the food served, on the meal tray, in his room was cold. In an interview on 07/08/2025 at 10:14AM, Resident #58 indicated the food served, on the meal tray, in her room was cold. Observation on 07/08/2025 at 12:15PM revealed staff members passing meal trays on the hall, from the meal cart that contained Resident #48's meal tray. On 07/08/2025 at 12:15PM, the surveyor selected Resident #48's meal tray from the cart. On 07/08/2025 at 12:17PM the surveyor team tasted the food on Resident #48's meal tray and the beef, potatoes, and carrots were noted to be lukewarm. Observation on 07/08/2025 at 12:19PM, revealed S11Cook tested the temperatures of the food on Resident #48's meal tray. Further observation revealed Resident #48's carrots were 102 degrees Fahrenheit, the potatoes were 110 degrees Fahrenheit, and the beef was 108 degrees Fahrenheit. In an interview on 07/08/2025 at 12:23PM, S11Cook confirmed the above mention food on the meal trays, was not at an appropriate temperature for consumption. In an interview on 07/08/2025 at 12:45PM, S4Regional Administrator confirmed the food served to the residents on the meal trays should have been at an appropriate temperature for consumption, as required.

Based on interviews and record reviews, the facility failed to ensure: 1. A Certified Nursing Assistant (CNA) notified a nurse of a resident's change in gastrointestinal (parts of the digestive trach) conditions (Resident #56); and, 2. A nurse reported a resident's refusal of supplemental nutrition to the resident's medical provider (Resident #56). This deficient practice was identified for 1 (Resident #56) of 2 (Resident #56, Resident #61) sampled residents reviewed for nutrition. Findings: Review of Resident #56's Care Plan with an effective start date of 08/28/2024 and a next review date of 07/22/2025 revealed, in part, an intervention to administer Resident #56's supplements as ordered. Review of Resident #56's July 2025 physician's orders revealed, in part, an order to administer Resident #56 four (4) ounces (oz) of house supplement (a liquid nutritional supplement) three times a day and 30 milliliters (ml) of liquid protein daily. Review of Resident #56's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #56 refused the 4 oz of house supplement: -at 8:00AM on 06/02/2025, 06/05/2025, 06/06/2025, 06/07/2025, 06/08/2025, 06/12/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/20/2025, 06/21/2025, 06/22/2025, 06/24/2025, 06/25/2025, 06/26/2025, 06/27/2025, 06/28/2025, and 06/29/2025; -at 12:00PM on 06/08/2025, 06/13/2025, 06/16/2025, 06/21/2025, 6/23/2025, 06/27/2025, 06/28/2025, and 06/29/2025; and, -at 4:00PM on 06/02/2025, 06/04/2025, 06/07/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/17/2025, 06/18/2025, 06/19/2025, 06/20/2025, 06/22/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/28/2025, and 06/29/2025. Further review revealed Resident #56 refused the 30 ml of liquid protein on 06/12/2025, 06/19/2025, 06/20/2025, 06/24/2025, and 06/25/2025. Review of Resident #56's July 2025 eMAR revealed, in part, documentation Resident #56 refused the 4 oz of house supplement: -at 8:00AM on 07/02/2025, 07/03/2025, 07/04/2025, 07/05/2025, 07/06/2025, 07/07/2025, and 07/08/2025; and -at 12:00PM on 07/02/2025, 07/03/2025, 07/04/2025, 07/05/2025, 07/06/2025, 07/07/2025, and 07/08/2025; and, -at 4:00PM on 07/01/2025, 07/02/2025, 07/03/2025, 07/04/2025, 07/05/2025, 07/07/2025, and 07/08/2025. Further review revealed Resident #56 refused the 30 ml of liquid protein on 07/03/2025, 07/04/2025, 07/06/2025, 07/07/2025, and 07/08/2025. Review of the task log of Resident #56's bowel movements revealed, in part, documentation Resident #56 had a loose watery bowel movement on: -06/11/2025 at 11:33PM; -06/17/2025 at 2:08AM; -06/23/2025 at 12:29PM; -06/23/2025 at 7:59PM; -06/29/2025 at 1:59PM; -06/30/2025 at 1:59PM; -06/30/2025 at 3:59PM; -07/02/2025 at 1:40PM; -07/03/2025 at 2:25PM; -07/08/2025 at 9:59PM; and, -07/09/2025 at 5:54AM. In an interview on 07/07/2025 at 9:44AM, Resident #56 indicated she has had diarrhea for the last month. In an interview on 07/08/2025 at 12:32PM, S12Licensed Practical Nurse (LPN) indicated Resident #56 often refused her house supplement and the liquid protein. In an interview on 07/08/2025 at 12:55PM, Resident #56's Nurse Practitioner (NP) indicated she was not made aware by the facility's staff Resident #56 had repeatedly refused her house supplement and/or liquid protein in June and July 2025. In an interview on 07/09/2025 10:36AM, S12LPN indicated indicated a resident's physician should have been notified when a resident refused interventions. In an interview on 07/09/2025 at 11:19AM, S14Certified Nursing Assistant indicated (CNA) indicated Resident #56 had diarrhea all of the time. S14CNA further indicated Resident #56 barely ate because Resident #56 was afraid she would have more diarrhea. In an interview on 07/09/2025 at 11:27AM, S15CNA Supervisor indicated the facility's CNAs should notify the facility's nurses if a resident was having diarrhea. In an interview on 07/09/2025 at 11:29AM, S16CNA indicated Resident #56 had diarrhea a few days, to every day of the week. S16CNA further indicated Resident #56 indicated to her that she could not eat because she would have more diarrhea. In an interview on 07/09/2025 at 11:31AM, S12LPN indicated she was not notified Resident #56 was having loose watery bowel movements on 07/09/2025 at 5:54AM. S12LPN further indicated the facility's CNAs should have reported loose watery bowel movements to the facility's nurses. In an interview on 07/09/2025 at 11:47AM, S13LPN (who was Resident #56's assigned nurse on 07/09/2025 at 5:54AM) indicated the CNA had not reported to her Resident #56 had a large watery bowel movement this morning, but should have. S13LPN further indicated if a resident was refusing an intervention, she would have notified the resident's medical provider. In an interview on 07/09/2025 at 1:18PM, S3Assistant Director of Nursing (ADON) indicated the facility's staff should have notified Resident #56's medical provider of Resident #56's refusal of the liquid protein and the house supplemental. S3ADON further indicated the facility's CNAs should have notified the facility's nurses when residents were having large watery bowel movements so nurses could implement interventions. In an interview on 07/09/2025 at 1:55PM, Resident #56's NP indicated she was not notified of Resident #56's multiple loose watery bowel movements in June and July 2025 by the facility's staff. Resident #56's NP further indicated had she been notified of Resident #56's loose watery bowel movements, and Resident #56's refusal of the liquid protein and the house supplement she probably would have started Resident #56 on an appetite stimulant sooner. Review of Resident #56's medical record revealed, no documented evidence, and the provider did not present any documented evidence Resident #56's medical provider was notified of Resident #56's refusal of the 30 ml of liquid protein, the 4 oz of house supplement, and/or Resident #56's watery bowel movements on the above mentioned dates. In an interview on 07/09/2025 at 2:06PM, S2Director of Nursing (DON) indicated the facility's CNAs should have reported Resident #56's loose water bowel movements to the facility's nurses. S2DON Further indicated the facility's nurses should have informed Resident #56's medical provider of Resident #56 refusal of the house supplement and the liquid protein.

Based on interviews and record reviews, the facility failed to ensure the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine was administered for 2 (Resident #70, Resident #173 ) of 5 (Resident #22, Resident #68, Resident #70, Resident #173, Resident #372) sampled residents investigated for COVID-19 vaccines. Findings: Review of the facility's Coronavirus (Covid-19) policy, latest revision date 07/2024, revealed in part, all residents would be offered the Covid-19 vaccine upon admission and at least annually thereafter if previously declined. Resident #70 Review of Resident #70's vaccine consent form revealed Resident #70's responsible party signed a consent form for Resident #70 to receive the COVID-19 vaccine on 06/02/2025. Review of Resident #70's physician's orders revealed in part, an order with a revision date of 06/15/2025, stated the Covid-19 vaccine may be administered as recommended with consent. Review of Resident #70 immunization documentation revealed there was no documentation Resident #70 received the Covid-19 vaccine. There was no documented evidence, and the facility did not present documented evidence the COVID-19 vaccine was not recommended for Resident #70, or that the COVID-19 vaccine was administered as per the consent form signed on 06/02/2025. Resident #173 Review of Resident #173's vaccine consent form revealed Resident #173 signed a consent form to receive the COVID-19 vaccine on 06/18/2025. Review of Resident #173's physician's orders revealed, in part, an order with a revision date of 06/20/2025, stated the Covid-19 vaccine may be administered as recommended with consent. Review of Resident #173's immunization documentation revealed there was no documentation Resident #70 received the Covid-19 vaccine. There was no documented evidence, and the facility did not present documented evidence the COVID-19 vaccine was not recommended for Resident #173, or that the COVID-19 vaccine was administered as per the consent form signed on 06/18/2025. In an interview on 07/09/2025 at 11:35AM, S5Infection Preventionist (IP) confirmed Resident #70 and Resident #173 consented to receive the Covid-19 vaccine and did not recieve the vaccine. In an interview on 07/09/2025 at 11:45AM, S2Director of Nursing (DON) indicated a Covid-19 clinic would be arranged to be administered to residents who consented to receive the Covid-19 vaccine. S2DON confirmed the facility did not make arrangements to ensure Resident #70 or Resident #173 received the Covid-19 vaccine after Resident #70 and Resident #173 had signed consents forms to receive the vaccine. In an interview on 07/09/2025 at 11:53AM, S6QI Nurse indicated Resident #70 and Resident #173 should have received the Covid-19 vaccine with a signed consent form as recommended.

Based on interviews and record reviews, the facility failed to ensure pneumococcal (a bacterial infection caused by Streptococcus pneumonia bacterial) vaccines were administered for 2 (Resident #70, Resident #173) of 5 (Resident #22, Resident #68, Resident #70, Resident #173, Resident #372) sampled residents investigated for pneumococcal vaccines. Findings: Review of the facility's policy titled Pneumococcal Vaccination of Residents, with a revision date of 01/2024 revealed, in part, residents or their resident representative, will be asked upon admission for the resident's pneumococcal vaccination history and the resident's age at the time of the vaccination. The resident's records will also be used to determine the resident's vaccination status. If there is no evidence the resident has received the vaccination, the vaccine will be offered. The administration of the pneumococcal vaccine will be documented in the resident's medical record. Resident #70 Review of Resident #70's vaccine consent form revealed, in part, Resident #70's responsible party signed a consent form for Resident #70 to receive the pneumococcal vaccine on 06/02/2025. Review of Resident #70's physician's orders revealed, in part, an order dated 06/15/2025, indicated the pneumonia vaccine series may be administered as directed, if not contraindicated. There was no documented evidence and the facility did not present documented evidence the pneumococcal vaccine was medically contraindicated for Resident #70, or that the pneumococcal vaccine was administered to Resident #70 as per the consent form signed on 06/02/2025. Resident #173 Review of Resident #173's vaccine consents form revealed, in part, Resident #173 signed a consent form to receive the pneumococcal vaccine on 06/18/2025. Review of Resident #173's physician's orders revealed, in part, an order dated 06/20/2025, indicated the pneumonia vaccine series may be administered as directed, if not contraindicated. There was no documented evidence and the facility did not present documented evidence the pneumococcal vaccine was medically contraindicated for Resident #173, or that the pneumococcal vaccine was administered to Resident #173 as per the consent form signed on 06/18/2025. In an interview on 07/09/2025 at 11:35AM, S5Infection Preventionist (IP) confirmed Resident #70 and Resident #173's consent forms were signed to receive the pneumococcal vaccine, and they were not administered. In an interview on 07/09/2025 at 11:45AM, S2Director of Nursing (DON) confirmed Resident #70 and Resident #173's consent forms were signed to receive the pneumococcal vaccine, and they were not administered. In an interview on 07/09/2025 at 11:53AM, S6Quality Improvement (QI) Nurse indicated if the consent form for pneumococcal vaccine were signed for Resident #70 and Resident #173, the pneumococcal vaccination should have been administered, if there were no documented medical contraindications.

Based on observation, interviews, and record reviews, the facility failed to implement a system to consistently and accurately reconcile controlled medications for 1 (Medication Cart a) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for the reconciliation of controlled substances. Findings: Review of the facility's Drug-Controlled Substances policy and procedure, dated 04/2006 and revised on 11/2017, revealed, in part, controlled medications were to be signed out on Form NS-618 Individual Resident Narcotics Record at the time they were administered. Review of Resident #23's Electronic Medication Administration Record (EMAR) for July 2025 revealed, in part, Resident #23 had an order for Modafinil 200 milligram (mg) (a controlled medication used to promote wakefulness) give 1 tablet once daily. Further review revealed S7Licenesed Practical Nurse (LPN) administered Modafinil 200 mg 1 tablet to Resident #23 at 9:00AM. Record review on 07/09/2025 at 1:21PM of Medication Cart a's narcotic binder with S7LPN revealed, in part, Resident #23 had an Individual Resident Narcotic Record which indicated 12 tablets of Modafinil 200 mg tablets were available for use. Observation on 07/09/2025 at 1:21PM of Resident #23's Modafinil 200 mg medication card revealed, in part, a total of 11 Modafinil 200 mg tablets remained on the medication card and were available for use. Review of Resident #28's EMAR for July 2025 revealed, in part, Resident #28 had an order for Lorazepam 0.5 milligram (mg) (a controlled drug used to treat anxiety) give 1 tablet three times a day. Further Review revealed S7LPN administered Lorazepam 0.5mg 1 tablet to Resident #28 on 07/09/2025 at 9:00AM and 1:00PM. Record review on 07/09/2025 at 1:21PM of Medication Cart a's narcotic binder with S7LPN revealed, in part, Resident #28 had an Individual Resident Narcotic Record which indicated 12 tablets of Modafinil 200 mg tablets were available for use. Observation on 07/09/2025 at 1:21PM of Resident #28's Lorazepam 0.5 mg medication card revealed, in part, a total of 14 mg tablets remained on the medication card and were available for use. In an interview on 07/09/2025 at 1:21PM, S7LPN indicated Resident #23's and Resident #28's above mentioned Individual Resident Narcotic Records were not consistent with the medication card tablet count. S7LPN indicated she did not reconcile the above mentioned controlled medications at the time they were administered, as required. In an interview on 07/09/2025 at 1:55PM, S2Director of Nursing confirmed S7LPN did not reconcile the above mentioned controlled medications at the time they were administered, as required.

Based on observation and interviews the facility failed to ensure expired medications were not available for use for 1 (Medication Room a) of 1 (Medication Room a) medication rooms observed during medication storage observations. Findings: Observation on 07/09/2024 at 2:17 p.m. of Medication Room a revealed the following, in part, a bottle of Aspirin 325 milligrams (mg) with an expiration date of 04/2024. Further observation revealed four boxes of Influenza Fluad Quadrivalent (injectable medication use to prevent the flu) with an expiration date of 06/30/2024. In an interview on 07/09/2024 at 2:20 p.m., S3Licensed Practical Nurse (LPN) indicated the above mentioned medications should not have been available for resident use. In an interview on 07/09/2024 at 2:55 p.m., S2Director of Nursing (DON) indicated the above mentioned medications should not have been available for use.

Based on observation, and interviews, the facility failed to ensure staff removed gloves and perform hand hygiene prior to exiting a resident's room for 1 (S6Housekeeper) of 1 (S6Housekeeper) housekeepers observed for infection control. Findings: Observation on 07/10/2024 at 1:05 p.m. revealed S6Housekeeper exited the elevator on the first floor by the dining room with her gloves on. Observation further revealed she was the only person on the elevator. In an interview on 07/10/2024 at 1:10 p.m., S6Housekeeper indicated she forgot to take her gloves off after cleaning a resident's room on the second floor. In an interview on 07/10/2024 at 1:15 p.m., S5Housekeeping Supervisor indicated staff should take off gloves and perform hand hygiene when exiting resident rooms. In an interview on 07/10/2024 at 2:27 p.m., S4Assistant Director of Nursing/Infection Preventionist indicated gloves should be removed and hand hygiene performed when exiting resident rooms. In an interview on 07/10/2024 at 3:50 p.m., S2Director of Nursing confirmed gloves should be removed prior to leaving a resident room.

Based upon observations, record reviews, and interviews, the facility failed to assess a resident's respiratory status and provide oxygen (O2) accordingly for 1 (Resident #12) of 1 (Resident #12) sampled residents reviewed for respiratory care. Findings: Observation on 07/08/2024 at 12:03 p.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Observation on 07/09/2024 at 10:10 a.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Observation on 07/10/2024 at 11:31 a.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Review of Resident #12's electronic medical record (EMR) revealed an order dated 04/23/2024 for oxygen at 2 lpm via NC as needed (PRN) for saturations less than 93 Further review revealed instructions to check and record oxygen saturation levels. Review of Resident #12's electronic medication administration record (EMAR) for May, June, and July 2024 revealed the oxygen saturation was only documented for the PRN O2 order once; on 05/24/2024 at 7:07 p.m., the measurement was 93%. In an interview on 07/10/2024 at 12:19 p.m., S3Licensed Practical Nurse (LPN) indicated Resident #12 was always on O2 when she entered the room. S3LPN indicated she believed Resident #12 was supposed to be on continuous O2. In an interview on 07/10/2024 at 12:25 p.m., S8LPN indicated Resident #12 had an order for PRN oxygen at this time. In order to administer O2 as PRN in computer, the special requirement for oxygen saturation measurement must be met and recorded; but Resident #12 was wearing O2 continuously, so the last recorded saturation was on 05/24/2024. S8LPN indicated the Resident #12's oxygen saturation should have been taken and recorded before administering oxygen. In an interview on 7/11/2024 at 10:55 a.m., S2DON indicated Resident #12's oxygen order was unclear, and the nurses should have been measuring the O2 saturations and documenting them. S2DON further indicated the O2 should have only been given to the resident if saturations were less than 93%, and Resident #12 had been wearing the O2 continuously and should not have been.

Based on record reviews, observation, and interviews, the facility failed to ensure a resident's continuous enteral feeding (intake of food through a tube placed into the stomach) was not stopped and restarted by a certified nursing assistant (CNA) for 1 (Resident #228) of 2 (Resident #10 and Resident #228) sampled residents investigated for enteral feeding. Findings: Review of Resident #228's record revealed, in part, an admitted [DATE] and diagnoses including mild protein-calorie malnutrition and failure to thrive. Review of Resident #228's Minimum Data Set with an Assessment Reference Date of 07/02/2024 revealed, in part, Resident #228 required enteral feeding through a gastrostomy tube (an artificial hole in the stomach to deliver enteral feedings). Review of Resident #228's July 2024 Physician's Orders revealed, in part, an order for Isosource 1.5 calories (a type of enteral feeding formula) at 40 milliliters an hour continuously via a feeding pump. Further review revealed an order to check the placement of Resident #228's gastrostomy tube prior to the administration of feedings. Review of Resident #228's care plan revealed, in part, Resident #228 was care planned to be at risk for malnutrition related to poor appetite and enteral feedings with an intervention to administer enteral feedings as ordered by the physician. Observation on 07/08/2024 at 10:35 a.m. revealed Resident #228 was being assisted with care by S7CNA. Further observation revealed Resident #228's enteral feeding pump was on hold and alarming. Observation then revealed S7CNA restarted Resident #228's enteral feeding pump. In an interview on 07/10/2024 at 10:39 a.m., S8Licensed Practical Nurse (LPN) indicated CNAs were not supposed to manipulate a resident's enteral feeding pump at all during care of the resident. S8LPN indicated the CNAs were supposed to have the nurse stop, pause, or restart the enteral feeding pump. In an interview on 07/11/2024 at 1:02 p.m., S7CNA indicated during care of a resident who was being administered enteral feedings, S7CNA paused the enteral feeding pump in order to lower the head of the bed. S7CNA stated once the resident's care was completed, S7CNA would elevate the HOB and restart the enteral feeding pump. In an interview on 07/11/2024 at 1:40 p.m., S7CNA confirmed she paused and restarted Resident #228's tube feeding pump while providing care on 07/08/2024. S7CNA stated she should have asked the nurse to turn off the enteral feeding pump and then restart it. In an interview 07/11/2024 1:55 p.m., S9Corporate Registered Nurse confirmed a CNA should not manipulate a resident's enteral feeding pump. In an interview on 07/11/2024 at 1:59 p.m., S2Director of Nursing (DON) indicated only a nurse should pause and restart a resident's enteral feeding pump. S2DON confirmed a CNA should not operate a resident's tube feeding pump.

Based on record reviews and interviews, the facility failed to ensure a resident's nurse documented and communicated a resident's fall for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accidents. Findings: Review of the facility's Accident/Incident Reports policy and procedure revealed, in part, all accidents and/or incidents including residents will be reported to the Charge Nurse and to the appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Further review revealed an accident and/or injury was defined as an unexpected happening which may or may not have caused loss or injury. Review also revealed following an incident, an incident report will be completed on any accident and/or incident that occurred within the facility and information regarding accidents and/or incidents that involve a resident will be recorded in the resident's medical record in the nurses' notes. Review of the facility's Fall policy and procedure revealed, in part, when a resident sustained a fall or was found on the ground without a witness to the fall, the following should be completed: note position of resident; record vital signs; evaluate the resident for injuries, perform range of motion on all extremities; and, observe for the cause of the fall. Further review revealed if the fall involved head injury or was unwitnessed, neurological checks should be initiated. Review also revealed documentation of fall information should be completed in the resident's medical record. Review of Resident #3's record revealed, in part, Resident #3 was admitted on [DATE] following surgical intervention of a left femur fracture sustained from a fall at home. Further review revealed Resident #3 was discharged from the facility on 10/21/2023. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/2023 revealed, in part, Resident #3 had one fall with no injury and one fall with injury that was not major since admission to the facility. Review of Resident #3's Nurse Data Collection and Screening completed on 10/04/2023 revealed Resident #3 was assessed as a high risk for falls. In an interview on 12/20/2023 at 10:56 a.m., S3Licensed Practical Nurse (LPN) stated that Resident #3 was moved to a room closer to the nurse's station, because Resident #3 had two falls back to back shortly after he was admitted . In an interview on 12/20/2023 at 2:28 p.m., Resident #3's wife stated the facility had informed her that Resident #3 had 2 falls while Resident #3 was admitted to the facility. Resident #3's wife further stated Resident #3's falls were on two separate days around 11:00 p.m. Review of Resident #3's Nurse's Note from 10/07/2023 at 6:34 p.m. revealed, in part, S4LPN documented Resident #3 denied pain or discomfort from his fall. Review of Resident #3's Nurse's Notes from admission to discharge did not reveal any documentation Resident #3 had a fall prior to S4LPN's nurse's note on 10/07/2023 at 6:34 p.m. Review of Resident #3's Neurological Observations Head Injury flowsheet revealed neurological assessments were initiated on 10/06/2023 at 11:00 p.m. In an interview on 12/21/2023 at 11:17 a.m., S4LPN stated when she arrived to work on the morning of 10/07/2023, S4LPN received in report that Resident #3 had fallen on the night of 10/06/2023. S4LPN further stated Resident #3 had fallen again the following night on 10/07/2023. Review of Resident #3's Nurse's Notes from 10/08/2023 at 12:43 a.m. revealed, in part, S6LPN documented Resident #3 had an unwitnessed fall on 10/07/2023 at 11:15 p.m. Review of Resident #3's Nurse Practitioner's Progress Note from 10/09/2023 revealed, in part, Resident #3 had two unwitnessed falls over the weekend while attempting to ambulate. In an interview on 12/21/2023 at 12:11 p.m., S5MDS Nurse confirmed Resident #3's 10/11/2023 MDS revealed Resident #3 had a fall with no injury and a fall with an injury that was not major since admission. S5MDS Nurse stated she used S4LPN's nurse's note from 10/07/2023 at 6:34 p.m. and S6LPN's nurse's note from 10/08/2023 at 12:43 a.m. to obtain Resident #3's fall data. In an interview on 12/21/2023 at 12:23 p.m., S2Assistant Director of Nursing (ADON) stated the only documented evidence she had of Resident #3's 10/06/2023 fall was the neurological checks initiated on 10/06/2023 at 11:00 p.m. by S7LPN. S2ADON stated the facility's nursing administration was not made aware of Resident #3's fall on 10/06/2023. In an interview on 12/21/2023 at 2:38 p.m., S1Director of Nursing (DON) stated when a nurse noted a resident's fall, an incident report and communication to the facility's administration should be completed. S1DON confirmed that discussion of the details of a resident's fall could prevent future falls from occurring. In an interview on 12/21/2023 at 2:41 p.m., S2ADON stated Resident #3's nurse should have communicated Resident #3's fall on 10/06/2023 at 11:00 p.m. in order for interventions to be placed to prevent future falls. S2ADON confirmed there was no documented evidence that the nurse documented the details of Resident #3's fall on 10/06/2023. In an interview on 12/21/2023 at 2:45 p.m., S8Quality Improvement Nurse confirmed there was no documented evidence Resident #3's nurse communicated Resident #3's 10/06/2023 fall to administrator or documented any specifics regarding Resident #3's 10/06/2023 fall. S8Quality Improvement Nurse further confirmed Resident #3's 10/06/2023 fall details were important to discuss with the facility administration in order to place appropriate interventions to prevent future falls.

47500 Based on observations, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene during wound care for 2 (Resident #46 and Resident #71) of 2 (Resident #46, Resident #71) sampled residents observed for wound care and; 2. Staff performed hand hygiene during incontinence care for 2 (Resident #36 and Resident #46) of 2 (Resident #36 and Resident #46) sampled residents observed for incontinence care, Findings: Review of the facility's Dressing Change Policy and Procedure revealed, in part, steps in the procedure include: wash hands thoroughly before beginning the procedure, put on disposable gloves, remove dressing and pull gloves over dressing and discard, perform hand hygiene, cleanse the area as ordered, dry the skin, perform hand hygiene, apply disposable gloves, dress the area as prescribed, remove gloves and discard, and wash hands. Review of the facility's Hand Hygiene policy revealed, in part, indications for hand hygiene include: hand hygiene should be performed when entering or exiting a resident's room, before and after procedures, before and after applying gloves, and when hands are visibly soiled. Resident #36 Observation on 09/13/2023 at 9:37 a.m. revealed S17Certified Nursing Assistant (CNA) entered Resident #36's room to provide incontinence care. Observation further revealed S17CNA put on clean gloves, opened Resident #36's soiled brief, and cleaned the top of Resident #36's genital area and down Resident #36's left and right groin area. Observation further revealed S17CNA placed an adult brief on Resident #36, and covered Resident #36 with her gown without changing gloves and performing hand hygiene. In an interview on 09/13/2023 at 10:45 a.m., S17CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident #36 and before she touched Resident #36's adult brief and gown. In an interview on 09/13/2023 at 2:22 p.m., S2Director of Nursing (DON) stated S17CNA should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident #36 and before she touched Resident #36's adult brief and gown. Resident #46 Observation on 09/12/2023 at 12:50 p.m., revealed S3Treatment Nurse (TN) cleaned Resident #46's left ischial (forms the lower and back region of the hip bone) wound with wound cleanser and applied calcium alginate (a dressing used to absorb wound drainage) and Medihoney (antibacterial honey used for wound healing) to Resident #46's left ischial wound bed without changing her gloves or performing hand hygiene between steps. Observation on 09/12/2023 at 12:55 p.m., revealed S16CNA performed incontinence care of a loose bowel movement for Resident #46. Further observation revealed that once S16CNA completed Resident #46 incontinence care, S16CNA removed her soiled gloves, did not perform hand hygiene, and reached into her pocket and pulled out new gloves to put on. Further observation revealed S16CNA then placed on new gloves and touched both Resident #46 and Resident #46's bedrail while assisting S3TN with wound care. Observation on 09/12/2023 at 12:57 p.m., revealed S3TN cleaned Resident #46's right buttocks wound with wound cleanser and applied calcium alginate and Medihoney to Resident #46's right buttocks wound bed without changing her gloves or performing hand hygiene between steps. Observation on 09/13/2023 at 9:36 a.m., revealed S6CNA removed gloves from her pocket and applied gloves without performing hand hygiene and performed incontinence care of a loose bowel movement for Resident #46. S6CNA removed dirty gloves, obtained gloves from her pocket, and applied gloves without performing hand hygiene. Observation on 09/13/2023 at 9:42 a.m., revealed S3TN cleansed Resident #46's right buttock with wound cleanser and gauze, applied Medihoney on the calcium alginate dressing, applied it to the wound bed then secured with bordered gauze without changing her gloves or performing hand hygiene between steps. Further observation revealed S3TN cleaned Resident #46's left ischial wound with wound cleanser, applied applied Medihoney on the calcium alginate dressing, applied it to the wound bed then secured with bordered gauze without changing her gloves or performing hand hygiene between steps. Further observation revealed S3TN cleaned Resident #46's sacral wound with dakin's solution without performing hand hygiene and applying clean gloves. In an interview on 09/13/2023 at 10:00 a.m., S3Treatment Nurse stated she should have removed gloves after cleaning Resident #46's right ischium wound, performed hand hygiene, applied clean gloves, and then applied dressing to Resident #46's right buttock wound. S3Treatment Nurse also stated she should have followed the same process with Resident #46's left ischial wound and sacral wound. S3TN further stated she did not remove her gloves, perform hand hygiene after cleansing the right ischial, and applying the dressing to Resident #46's right ischium wound. S3TN further stated she cleaned Resident #46's left ischium wound, applied the dressing to Resident #46's left ischial wound, and then cleaned Resident #46's sacral wound with dakin's solution with the same gloves. S3Treatment Nurse also stated she should have performed hand hygiene after returning to Resident #46's room prior to applying clean gloves. In an interview on 09/13/2023 at 11:47 a.m., S3TN stated that gloves are supposed to be changed and hand hygiene performed between cleansing wounds and placing a clean wound dressing on, and she should have changed her gloves between those steps when performing wound care to Resident #46's right buttocks and left ischial wounds on 09/12/2023. In an interview on 09/13/2023 at 10:27 a.m., S7Quality Improvement (QI) Nurse stated hand hygiene should be performed prior to starting wound care, gloves should be applied, dressing should be removed and disposed of per standards, gloves should be removed, and hygiene should be performed prior to moving to cleansing the wound. S7QI Nurse further stated clean gloves should be applied after performing hand hygiene, the wound should be cleansed, and then gloves should be removed, hand hygiene should be performed and clean gloves should be applied to apply the clean dressing to the wound. S7QI Nurse confirmed S3TN should have removed gloves and performed hand hygiene after cleansing a wound, prior to applying a dressing. S7QI Nurse further stated S3TN should have performed hand hygiene after returning to Resident #46's room with additional supplies. S7QI Nurse stated hand hygiene should be performed before applying gloves and after removing gloves. S7QI Nurse confirmed S6CNA should have performed hand hygiene after removing gloves. In an interview on 09/13/2023 at 11:00 a.m., S6CNA stated she should have performed hand hygiene before applying gloves to perform personal care and after removing gloves. S6CNA also stated she stored gloves in her pocket and should not store gloves in her pocket. S6CNA confirmed she did not perform hand hygiene after removing gloves before she obtained gloves from her pocket during Resident #46's incontinence care. In an interview on 09/13/2023 at 4:23 p.m., S16CNA stated she should not have had gloves in her pocket. S16CNA further stated, after performing incontinence care on Resident #46, she should have performed hand hygiene after removing her gloves before placing new gloves on. Resident #71 Observation on 09/12/2023 at 10:40 a.m. revealed S3TN was observed disposing items in the red biohazard bag, and with the same soiled gloves, removed the red biohazard bag from the garbage can and exited Resident #71's room wearing soiled gloves. In an interview on 09/13/2023 at 10:27 a.m., S2DON stated gloves should be removed and hand hygiene should be performed prior to exiting a resident's room. S2DON confirmed S3Treatment Nurse should have removed gloves and performed hand hygiene prior to exiting Resident #71's room on 09/12/2023. In an interview on 09/13/2023 at 1:30 p.m., S3Treatment Nurse acknowledged she did not remove her gloves and perform hand hygiene prior to exiting Resident #71's room on 09/12/2023 after completing wound care.

Based on observation, interview, and record review the facility failed to ensure a functional call light was available for 2 (Resident #46 and Resident # 48) of 2 (Resident #46 and Resident # 48) sampled residents investigated for call lights. 26 initial pool residents were observed for call bell use. Findings: Resident #46 Review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed, in part, resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact, and that Resident #46 required extensive assistance with bed mobility and transfers. Review of Resident #46's care plan revealed, in part, an intervention to place the call light within Resident #46's reach and to educate Resident #46 on calling for assistance. A test of Resident #46's call light was conducted on 09/11/2023 at 10:06 a.m., which revealed the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. Observation on 09/13/2023 at 10:00 a.m., revealed Resident #46's lying in bed. Further observation revealed, Resident #46's call light was tested again for functioning, which revealed, the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. Observation on 09/14/2023 at 9:30 a.m., revealed Resident #46's lying in bed. Further observation revealed, Resident #46's call light was tested again for functioning, which revealed, the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. In an interview on 09/14/2023 at 9:35 a.m., S16Certified Nursing Assistant (CNA) stated Resident #46's call light should be placed within her reach to call if assistance is needed. S16CNA further stated Resident #46 can use the call light, but sometimes hollers for assistance instead of using call light. In an interview on 09/14/2023 at 9:40 a.m., S12Licensed Practical Nursing (LPN) stated to prevent falls, Resident #46's call light should be placed within her reach to call for assistance. S12LPN further stated Resident #46 can use the call light, but often screamed for assistance instead of using the call light. A test of Resident #46's call light was performed by S12LPN on 09/14/2023 at 9:45 a.m., and S12LPN confirmed that Resident #46's call light was not working. In an interview on 08/14/2023 at 9:50 a.m., S19Maintenance Supervisor confirmed Resident #46's call light was not working. S19Maintenance Supervisor further stated Resident #46's call light should be working. In an interview on 09/14/2023 at 10:00 a.m., S1Administrator stated Resident #46's call light should have been functioning and was not. Resident #48 Review of Resident #48's MDS with an ARD of 08/02/2023 revealed, in part, Resident #48 received hospice services and required staff assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene Review of Resident #48's care plan revealed, in part, staff should assist Resident #48 with activities of daily living (ADL) and place the call light within reach. Observation on 09/12/2023 at 9:15 a.m. revealed Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Resident #48 was asked if he could locate his call light. Further observation revealed Resident #48 was unable to reach the call light. Observation on 09/12/2023 at 1:01 p.m. revealed Resident #48 was sitting up in his bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Further observation revealed Resident #48 was unable to reach the call light. Observation on 09/13/2023 at 10:18 a.m. Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Resident #48 was asked if he could find his call light. Resident #48 felt on the right side of his bed and was unable to locate the call light. In an interview on 09/13/2023 at 10:18 a.m., Resident #48 was asked how he gets assistance from staff if he cannot find the call light. Resident #48 stated he has to wait for staff to come into his room and he gets tired of waiting. In an interview on 09/14/2023 at 10:09 a.m., S16CNA stated Resident #48 required total assistance with ADL's and was able to use the call light when he needed staff assistance. Observation on 09/14/2023 at 10:10 a.m. Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Further observation revealed Resident #48 was unable to reach the call light. In an interview on 09/14/2023 at 10:10 a.m., Resident #48 stated he did not know where his call light was. In an interview on 09/14/2023 at 10:18 a.m., S2Director of Nursing confirmed Resident #48's call light should have been in reach to allow him to call staff for assistance. 47487

Based on observations, interviews, and record review, the facility failed to: 1. Ensure food that was cooled improperly was not served to facility residents; 2. Implement a system where a refrigerator and freezer temperature was monitored and documented; 3. Ensure food held at an improper temperature on the facility's steam table was not served to the facility's residents; and 4. Ensure the concentration level of the sanitizing solution in the facility's 3 compartment sink was correct. This deficient practice was identified for 74 residents who consume food from the facility as documented on the facility's Census and Conditions of Resident CMS Form-672. Findings: 1. Review of the facility's Storage of Cooked Foods policy revealed, in part, cooked foods must be cooled to 70 degrees Fahrenheit within two hours and then to 41 degrees Fahrenheit or lower in an additional four hours for a total cooling time of six hours. If food is not cooled to 70 degrees F in two hours, then it must be cooled to 41 degrees F within four hours. Observation on 09/12/2023 at 9:15 a.m. revealed S28Dietary Staff placed a metal container of oatmeal into the facility's walk- in refrigerator that was hot to the touch. A temperature check of the above mentioned oatmeal with S27Dietary Manager on 09/12/2023 at 11:25 a.m. revealed the temperature of the oatmeal was 75 degrees Fahrenheit. A temperature check of the above mentioned oatmeal with S27Dietary Manager on 09/12/2023 at 3:35 p.m. revealed the temperature of the oatmeal was 42 degree Fahrenheit. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated the oatmeal in the facility's walk in refrigerator was not cooled down properly and was not safe to serve. In an interview on 09/13/2023 at 9:08 a.m., S28Dietary Staff confirmed the above mentioned oatmeal was served to the facility's resident's for breakfast on 09/13/2023. In an interview on 09/13/2023 at 9:08 a.m., S27Dietary Manager stated that the above mentioned oatmeal should not have been served to the residents, as it had been improperly cooled the day before. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated if S27Dietary Manager knew the above mentioned oatmeal was cooled improperly, then it should not have been served to the facility's residents. 2. Review of the facility's Storage of Refrigerated Food policy revealed, in part, temperatures were to be monitored regularly and was to be documented on the approved temperature monitoring log. Review of the facility's Storage of Frozen Food policy revealed, in part, temperatures were to be monitored regularly and was to be documented on the approved temperature monitoring log. Review of the United States Drug and Food Administration (FDA) Food Code 2022 revealed, in part, cold holding equipment used for temperature control for food safety shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the devices temperature display. Observation on 09/12/2023 at 9:25 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one closed bag of assorted two stick freezer pops, and two closed packages of assorted popsicles. Further observation revealed no thermometer was present in freezer. Observation on 09/12/2023 at 9:25 a.m. of the facility's activity room refrigerator revealed, two closed bottles of orange juice, a closed bottle of sparkling apple cider, and two cartoons of eggs. Further observation revealed, no log of the facility's activity room refrigerator temperature present. Observation on 09/13/2023 at 9:10 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one closed bag of assorted two stick freezer pops, and two closed packages of assorted popsicles. Further observation revealed no thermometer was present in freezer. Observation on 09/13/2023 at 12:00 p.m. of the facility's activity room refrigerator revealed, two closed bottles of orange juice, a closed bottle of sparkling apple cider, and a tray of assorted cheeses. Further observation revealed, no log of the facility's activity room refrigerator temperature present. Observation on 09/14/2023 at 9:00 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one open bag of assorted two stick freezer pops, two packages of assorted popsicles (one open and one sealed). Further observation revealed no thermometer was present in the freezer. Observation 0on 09/14/2023 at 9:55 a.m. of the facility's activity room refrigerator revealed, two bottles of orange juice (one opened and one closed), and a closed bottle of sparkling cider, and a tray of assorted cheeses. Further observation revealed, no log of the facility's activity room refrigerator temperature present. In an interview on 09/14/2023 at 9:55 a.m., S29Activities stated food was kept for resident use in the facility's activity room refrigerator and freezer. S29Activites also stated that there was not a thermometer present in the facility's activity room freezer. S29Activites further stated she was not aware that a log had to be kept of the facility's activity room refrigerator and freezer. In an interview on 09/14/2023 at 10:00 a.m., S1Administrator stated the facility's activity room freezer should have had a thermometer in place, if the freezer contained food available for a resident's consumption. S1Administrator further stated a temperature log should have been kept of the facility's activity room refrigerator and freezer. The facility was unable to produce a temperature log for the facility's activity room refrigerator and freezer. 3. Review of the facility's Monitoring Temperatures of Cooked Food policy revealed, in part, potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher. Further review revealed, when food is placed in the hot holding equipment, if the temperature is below 135 degrees Fahrenheit, the food should be reheated to 165 degrees Fahrenheit for fifteen seconds. A temperature check of the foods on the facility's steam table on 09/12/2023 at 11:01 a.m., revealed the pureed carrots' temperature was 121 degrees Fahrenheit. The pureed carrots on the facility's steam table were observed on 09/12/2023 between 11:01 a.m. to 11:29 a.m. Observation revealed the pureed carrots being held of the facility's steam table were not reheated, and the temperature of the pureed carrots was not rechecked. Observation on 09/12/2023 at 11:29 a.m. until the end of lunch service revealed, S28Dietary Staff served 3 plates of food for different residents containing the above mentioned pureed carrots without reheating them as required. A temperature check of the foods on the facility's steam table on 09/12/2023 at 4:02 p.m., revealed, the chopped meatballs' temperature was 100 degrees Fahrenheit, the baked chicken's temperature was 120 degrees Fahrenheit, the mechanical soft ground chicken patties' temperature was 110 degrees Fahrenheit, the pureed jambalaya's temperature was 125 degrees Fahrenheit, the pureed green beans' temperature was 125 degrees Fahrenheit, and the gravy's temperature was 120 degrees Fahrenheit. Observation on 09/12/2023 of the above mentioned foods was conducted from 4:02 p.m. until it was served on the second floor at 4:51 p.m. which revealed, at no point were any of the above mentioned foods reheated or had their temperatures checked. Observation on 09/12/2023 starting at 4:51 p.m. revealed Resident #45 was served a plate with chopped meatballs and gravy, Resident #40 was served a plate with chopped meatballs and gravy, Resident #5 was served a plate with chopped meatballs and gravy, Resident #4 was served a plate with chopped mechanical soft chicken patties and gravy, and Resident #19 was served a plate with chopped meatballs and gravy from the above mentioned steam table Review of steam table temperature logs for June, July, August, and September 2023 revealed no record that temperatures of the food held of the steam table temperatures were checked before each meal. There was no documented evidence and the facility did not present any documented evidence of steam table food temperature were monitored for the months of June, July, August, and September 2023. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated that the temperature of food held for service on the facility's steam table should be 145 degrees Fahrenheit or higher. S27Dietary Manger further stated that the pureed carrots, the chopped meat balls, the baked chicken, the mechanical soft ground chicken patties, the pureed jambalaya, the pureed green beans, and the gravy were not at a safe temperature to serve, and should not have been served to the facility's residents without being reheated. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated that the above mentioned foods that were held at a subpar temperature on the steam table should not have been served to the facility's residents. S24Regional Supervisor further stated logs of the temperatures of food held on the steam table should have been kept. 4. Review of the facility's Manual Warewashing policy revealed, in part, items should be immersed in the third sink in hot water or chemical sanitizing solution. Further review revealed, if chemical sanitizing is used, the sanitizer must be mixed to the proper concentration and the concentration of the sanitizing solution should be checked with a test kit. A test of the facility's 3 compartment sink was conducted on 09/12/2023 at 11:10 a.m. with S27Dietary Manager and revealed, the test strip placed in the sanitizing sink was bright blue, which was not one of the colors that indicated a part per million (ppm) measurement of the sanitization solution labeled on the side of the test strip bottle. In an interview on 09/12/2023 at 11:10 a.m., S27Dietary Manager stated she was unsure of the ppm measurement of the sanitization solution in the sanitizing sink, because the color of the test strip was not one indicated on the side of the test strip bottle for a ppm range. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated because she could not tell what the ppm of the sanitization solution was in the sanitizing sink, she did not know if the kitchen ware was properly sanitized or not. In an interview on 09/13/2023 at 9:08 a.m., S27Dietary Manager stated that she still could not get the test strips used to check the ppm of the sanitization solution in the sanitizing sink to indicate a color that would indicate the ppm on the sanitization solution in the sanitizing sink. S27Dietary Manger confirmed that the dietary staff continued to sanitize the kitchen ware in the sanitizing sink and used this kitchen ware to cook the resident's breakfast despite not knowing the ppm level of the sanitization solution in the sanitizing sink. S27Dietary Manger again stated that did not know if the facility's kitchen ware was properly sanitized because she could not tell what the ppm of the sanitization solution was in the sanitizing sink. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated S27Dietary Manger should have found a way to sanitize the facility's kitchen ware differently, or had someone come to inspect the sanitizing sink and did not.

Based on observation, interview and record review, the facility failed to: 1.) Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) was secure to prevent pulling for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for catheter care; and, 2.) Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) drainage bag was positioned below the level of the bladder for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for catheter care. Findings: Review of the facility's urinary catheter policy revealed, in part, the drainage bag should be positioned lower than the bladder by attaching to a fixed part of the bed frame. Further review revealed the drainage bag should not be attached to the side rails. Review of Resident #36's medical record revealed, in part, Resident #36 had the following diagnosis: Functional Quadriplegia, Neuromuscular Dysfunction of the Bladder, Presence of Urogenital Implants, and Retention of Urine. Review of Resident #36's Minimum Data Set with an Assessment Reference Date of 07/19/2023 revealed, in part, Resident #36 required extensive assistance from staff for toileting. Review of Resident #36's Comprehensive Care Plan revealed, in part, Resident #36 had a suprapubic catheter and required assistance with toileting. Further review revealed, Resident #36's urine catheter bag should be positioned below the bladder and Resident #36's catheter should be secured to prevent pulling. Observation on 09/11/2023 at 11:06 a.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation on 09/12/2023 at 8:55 a.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation on 09/13/2023 at 9:37 a.m. revealed, S17Certified Nursing Assistant (CNA) entered Resident #36's room to provide incontinence care. Observation revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation further revealed, S17CNA proceeded to perform incontinence care on Resident #36, turned Resident #36 on her right side, which caused Resident #36's catheter to be pulled tight. Observation also revealed no secure device in place. In an interview on 09/13/2023 at 10:45 a.m., S17CNA stated she did not have a secure device in place and she did not secure Resident #36's catheter during incontinence care. S17CNA further stated she should have ensured Resident #36's catheter was secured. Observation on 09/13/2023 at 2:20 p.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. In an interview on 09/13/2023 at 2:22 p.m., S2Director of Nursing (DON) confirmed Resident #36's suprapubic catheter bag was placed at the head of her bed and it should not have been. S2DON further stated Resident #36 did not have a securement device in place to ensure her catheter tubing was not pulling and she should have. In an interview 09/13/2023 at 2:30 p.m., S7Quality Improvement Nurse stated Resident #36's catheter bag should have been secured and placed lower than the level of Resident #36's bladder.

Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #48) of 1 (Resident #48) sampled residents reviewed for PASARR. Findings: Review of Resident #48's clinical record revealed, in part, an admitted [DATE]. Review of Resident #48's Level 1 PASARR screening dated 01/31/2019 revealed, in part, Resident #48 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review. Review of Resident #48's diagnosis list revealed, in part, an active diagnosis of schizophrenia (a serious mental illness that can cause distorted reality, delusions, and paranoia) with an onset date of 01/27/2021. Review of Resident #48's last documented comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/20/2023 revealed, in part, Resident #48 was assessed to have active diagnoses of schizophrenia and did not have a diagnosis of dementia. Further review revealed Resident #48 was not evaluated for a Level II PASARR. Review of Resident #48's Quarterly MDS with an ARD of 08/02/2023 revealed, in part, Resident #48 was assessed to have active diagnoses of schizophrenia and did not have a diagnosis of dementia. Additional record review revealed Resident #48 received antipsychotic medications daily. Review of Resident #48's September 2023 physician orders revealed, in part, Resident #48 received Risperdal 0.5 milligrams twice daily (a medication used to treat schizophrenia) with a target behavior of paranoia. Review of Resident #48's care plan revealed, in part, Resident #48 had potential for behaviors secondary to a diagnosis of schizophrenia with interventions to monitor for behaviors and to approach resident in a calm manner. Review of Residents #48's clinical record revealed no documented evidence and the facility did not present any documented evidence a Level II PASARR was completed on Resident #48. In an interview on 09/14/2023 at 10:25 a.m. S18Social Worker stated she was responsible to submit a Level II PASARR when a resident was newly diagnosed with a mental illness. S18Social Worker further stated Resident #48 was diagnosed with schizophrenia after his admission and she did not ensure Resident #48 received the required Level II PASARR screening.

Based on observation, interview, and record review the facility failed develop a care plan for dental issues for 1 (Resident #33) of 21 residents (Resident #48, Resident #7, Resident #79, Resident #40, Resident #21, Resident #24, Resident #3, Resident #38, Resident #34, Resident #36, Resident #29, Resident #33, Resident #11, Resident #46, Resident #16, Resident #60, Resident #49, Resident #43, Resident #2, Resident #51, and Resident #68) reviewed. Findings: Review of Resident #33's Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2023 revealed, in part, Section L - Oral/Dental Status no issues indicated. Review of Resident #33's dental evaluation forms dated 12/06/2022 and 06/06/2023 revealed, in part, obvious or likely cavity, broken natural teeth, and loose natural teeth. Review of Resident #33's care plan revealed, in part, Resident #33 was not care planned for dental issues. An observation on 09/12/2023 at 09:18 a.m. of Resident #33's mouth revealed one tooth noted to left lower side, gray in color, not positioned correctly and multiple areas on upper and lower gums of black to dark brown areas where teeth should have been. In an interview on 09/12/2023 at 9:18 a.m., Resident #33 stated he would like to see a dentist and have a set of dentures. In an interview on 09/13/2023 at 10:17 a.m., S18MDS/Licensed Practical Nurse (LPN) stated Resident #33 had no documentation, and she could not present documentation, of a plan of care being developed for Resident #33's dental issues. S18MDS/LPN stated Resident #33 should have had a care plan developed for Resident #33's dental issues. In an interview on 09/14/2023 at 1:35 p.m., S1Administrator stated there was no documentation, and he could not present documentation, Resident #33 had a care plan developed for oral/dental issues. S1Administrator further stated Resident #33 should have had a care plan developed for oral/dental issues.

Based on record review and interview, the facility failed to ensure a thorough investigation was conducted when an injury of unknown origin was discovered for 2 (Resident # 7 and Resident #34) of 2 (Resident # 7 and Resident #34) sampled residents reviewed for injuries of unknown origin. Findings: Review of the facility's Incident Investigation and Reporting Policy revealed the facility's investigation should include signed statements from all staff involved. Further review revealed, if only oral information can be obtained for a statement, the facility must have at least two persons present to receive information and the reporter must have the statement read back to him or her. The reporter, the recorder, and the witness must also sign. Resident #7 Review of Resident #7's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 06/23/2023 revealed, in part, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 1 indicating severe cognitive impairment and Alzheimer's disease. Review of Resident #7's departmental note dated 08/28/2023 revealed, in part, Resident #7's was screaming in pain. Resident #7's left ankle and foot was assessed and found to be turned inward. Further review revealed Resident #7 was sent to the hospital for evaluation. Review of the facility's Health Standard Incident Report dated 08/28/2023 revealed, in part, Resident #7 had an injury of unknown origin discovered by the nurse on 08/28/2023. Further review revealed, in part, the facility's administrative staff was alerted to a possible fracture to Resident #7's left lower leg and Resident #1 was sent to the hospital for evaluation. Further review of the incident report revealed an investigation was conducted and statements were obtained from 5 staff members (S8Certified Nursing Assistant (CNA), S11CNA, S22MDS Nurse, S25Licensed Practical Nurse (LPN), and S26LPN). Further review revealed 5 residents were interviewed for abuse, and camera footage was reviewed. Additional review of the incident report revealed the facility did not find the injury suspicious of abuse. Review of the facility's camera footage on 08/28/2023 from 5:00 a.m. until 9:15 a.m. revealed, in part, various staff members from multiple departments completing tasks on the hallway with Resident #7 present. Further review revealed, S11CNA and S20CNA entered and then exited Resident #7's room twice between 8:28 a.m. and 8:35 a.m. Additional review revealed S9Human Resources entered and then exited Resident #7's room at approximately 8:51 a.m. In an interview on 09/13/2023 at 1:15 p.m., S20CNA stated she was present in Resident #7's room on the morning of 08/28/2023 to assist S11CNA with Resident #7's a.m. care. S20CNA stated she observed S11CNA complete a manual transfer on Resident #7 and then they both left the room to get supplies to change Resident #7. S20CNA further stated she and S11CNA entered Resident #7's room again a few minutes later to provide incontinence care and that was when they noticed her left foot looked strange and twisted and they then notified the S25LPN. In an interview on 09/14/2023 at 10:18 a.m., S2Director of Nursing (DON) stated she had no documented evidence S20CNA was questioned or a written statement was obtained from S20CNA regarding care provided and/or what she observed on the morning of 08/28/2023 related to Resident #7's injury of unknown origin. S2DON confirmed statements were obtained from only 5 staff members (S8CNA, S11CNA, S22MDS Nurse, S25LPN, and S26LPN) the morning of 08/28/2023. S2DON confirmed there were multiple staff members present the morning of 08/28/2023 before the injury was discovered that were not questioned or asked to provide a statement. In an interview on 09/14/2023 at 1:31 p.m., S20CNA stated the facility staff never questioned her or asked her to provide a statement regarding what she observed while providing care to Resident #7 or when she became aware of Resident #7's injury on the morning of 08/28/2023. In an interview on 09/14/2023 at 1:45 p.m., S1Administrator stated not all staff observed on the hallway and observed entering Resident #7s room during the camera footage on 08/28/2023 were interviewed and/or asked to provide a statement regarding any knowledge of Resident #7's injury of unknown origin. S1Administrator stated S20CNA was not asked to provide a statement of care provided and/or observed on 08/28/2023. Record review revealed no documented evidence and the facility did not present any documented evidence S20CNA was questioned about care provided and/or observed for Resident #7 on 08/28/2023. Resident #34 Review of Resident #34's record revealed, in part, Resident #34 had a diagnosis of unspecified dementia. Review of the facility's Statewide Incident Management System (SIMS) report revealed an incident was discovered at 1:15 p.m. on July 27, 2023 for Resident #34. Further review revealed, S23Licensed Practical Nurse noticed a bruise and small laceration located on the lower left forearm of Resident #34 and Resident #34 could not state what happened due to severe cognitive impairment. Review revealed Resident #34 was in a private room and did not have a roommate. Further review revealed, five staff members were interviewed in regards to the incident with Resident #34. Review of the facility's investigation revealed no documented evidence of statement completed by the above stated staff members. In an interview on 09/14/2023 at 12:30 p.m., S1Administrator stated he had no documented evidence that written statements were gathered from staff in regards to Resident #34. In an interview on 09/14/2023 at 12:40 p.m., S24RegionalSupervisor stated the facility had no documented evidence of written staff's statements. There was no documented evidence and the facility did not present any documented evidence that staff interviews were completed and a thorough investigation was completed upon the discovery of a bruise and laceration to Resident #34's lower left forearm. 46683

Based on interview, record review, and the resident's comprehensive assessments the facility failed to ensure medications were administered in accordance with professional standards of practice and their person centered care plan for 11 randomly sampled residents reviewed (Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8, Resident R9, Resident R10, Resident R11, and Resident #8). The deficient practice resulted in an Immediate Jeopardy situation by residents being not assigned a nurse when the LPN clocked out to go home and reported off to another LPN leaving unit H and unit I without an assigned nurse on 06/24/19. The facility had no system in place for nurse staff coverage when assigned nurse does not report for scheduled duty. The other nurses on duty did not care for or administer the scheduled medication when the nurse assigned did not report to duty. There was no nurse available to administer scheduled medications as ordered to residents on 6/24/19, 6/25/19, 6/26/19 and 6/27/19 resulting in a resident;s missed scheduled doses of insulin, antihypertensive medication, pain medications, medication prescribed to prevent [MEDICAL CONDITION], blood clots and [MEDICAL CONDITION]. The facility representative was notified of the Immediate Jeopardy situation on 7/26/19 at 10:15 AM. This deficient practice was identified for 11 random residents (Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8, Resident R9, Resident R10, Resident R11 and for 1 of 10 sampled residents (Resident #8), but had the potential to affect any of the 102 residents who reside at the facility as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. The Immediate Jeopardy situation was removed on 07/01/19 at 3:22pm, when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included: * Residents with medication omissions were assessed by RN for any negative outcomes (none noted) and MD notified of omissions on 07/01/2019. * SIMS #2770 was initiated and completed * In-service will be completed with nursing staff on notifying Administrator/DON when scheduled nursing relief is not available, documentation of medication administration, abuse/neglect and professional standards of practice. * System put in place for nurse staff coverage when assigned nurse does not report for scheduled duty is nurse on duty will notify DON/Administrator and continue to provide care until relief nurse assumes care of assigned residents. * New Administrator and New DON are currently managing daily staffing and monitoring for compliance daily. * Date by which serious harm to any resident no longer exists 07/01/2019. The deficiency practice remained at a potential for more than minimal harm for the 102 residents in the facility. Findings: On 06/19/19, the facility's Ombudsman identified a list of concerns brought up by residents at the resident council meeting which included in part, staffing and medication concerns which was forwarded to S1Administrator and S2Corporate Nurse per resident request. There was no documented evidence and the facility did not present any documented evidence that staffing and medication concerns were addressed prior to 06/26/19. Review of the following resident's Electronic Medication Administration Record [REDACTED] June 24, 2019 Resident R1: Juven packet (supplement used for wound healing) was not administered at 6:00am; [MEDICATION NAME] 500mg (medication used for mild to moderate pain) was not administered at 6:00am; [MEDICATION NAME] 12.5mg (medication used to treat high blood pressure) was not administered at 6:00am; Imdur (medication used to prevent chest pain) was not administered at 6:00am; Vitamin C 500mg (medication used to aid in wound healing) was not administered at 6:00am; Two doses of [MEDICATION NAME] 10mg (medication used to treat heartburn) was not administered at 12:00am; [MEDICATION NAME] 600mg (medication used to treat nerve pain and prevent [MEDICAL CONDITION]) was not administered at 6:00am; Valporic Acid 250mg (medication used treat mental/mood disorders) was not administered at 6:00am; [MEDICATION NAME] 20mg (medication used to treat depression) was not administered at 6:00am; Levimir Insulin 15units (medication used to treat high blood sugar) was not administered at 6:00am; and No accucheck was performed at 6:00am to determine if sliding scale Humalog insulin needed to be administered. Resident R2: [MEDICATION NAME] EC 325mg (medication used to treat low iron levels in the blood) was not administered at 6:00am; Aspirin 81mg (medication used to prevent [MEDICAL CONDITION]) was not administered at 6:00am; [MEDICATION NAME] 40mg (medication used to prevent acid reflux) was not administered at 6:00am; [MEDICATION NAME] 75mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am; and [MEDICATION NAME]-[MEDICATION NAME] 10-325mg (medication used for chronic pain) was not administered at 3:00am. Resident R3: [MEDICATION NAME] 25mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am. Resident R4: [MEDICATION NAME] 75mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am. Resident R5: [MEDICATION NAME] 100mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am; and [MEDICATION NAME] 15mg (medication used to treat pain) was not administered at 6:00am. Resident R6: Two applications of hemorrhoid ointment (medication used to treat hemorrhoids) were not applied at 6:00am and 6:00pm. Resident R7: [MEDICATION NAME] 3.125mg (medication used to treat high blood pressure) was not administered at 6:00am. Resident R8: [MEDICATION NAME] 20mg (medication used to treat reflux) was not administered at 6:00am. Resident R9: [MEDICATION NAME] 40mg (medication used to treat reflux) was not administered at 6:00am; [MEDICATION NAME] 100mg (medication used to treat constipation) was not administered at 5:00pm; and [MEDICATION NAME] 80mg (medication used to treat high cholesterol) was not administered at 6:00am. Resident R10: [MEDICATION NAME] 88mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am; and [MEDICATION NAME] 100mg (medication used to treat nerve pain and prevent [MEDICAL CONDITION]) was not administered at 4:00pm. Resident R11: [MEDICATION NAME] Sodium 20mg (medication used to treat high cholesterol) was not administered at 6:00pm. Resident #8: [MEDICATION NAME] 20mg (medication used to treat Reflux) was not administered at 6:00am. June 25, 2019 Resident R1: Levimir Insulin 15units (medication used to treat high blood sugar) was not administered at 6:00am; and No accucheck was performed at 6:00am, to determine if sliding scale Humalog insulin (medication used to treat high blood sugar) needed to be administered. June 26, 2019 Resident R1: Levimir Insulin 15units (medication used to treat high blood sugar) was not administered at 6:00am; and No accucheck was performed at 6:00am, to determine if sliding scale Humalog insulin (medication used to treat high blood sugar) needed to be administered. Resident R2: [MEDICATION NAME] EC 325mg (medication used to treat low iron levels in the blood) was not administered at 6:00am; Aspirin 81mg (medication used to prevent [MEDICAL CONDITION]) was not administered at 6:00am; [MEDICATION NAME] 40mg (medication used to prevent acid reflux) was not administered at 6:00am; [MEDICATION NAME] 75mcg (medication used to treat an underactive [MEDICAL CONDITION]) was not administered at 6:00am; and [MEDICATION NAME]-[MEDICATION NAME] 10-325mg (medication used for chronic pain) was not administered at 3:00am. Resident R8: [MEDICATION NAME] 20mg (medication used to treat reflux) was not administered at 6:00am. June 27, 2019 Resident R1: Levimir Insulin 15units (medication used to treat high blood sugar) was not administered at 6:00am; and No accucheck was performed at 6:00am to determine if sliding scale Humalog insulin (medication used to treat high blood sugar) needed to be administered. Resident R2: [MEDICATION NAME] EC 325mg (medication used to treat low iron levels in the blood) was not administered at 6:00am. Resident R6: One application of hemorrhoid ointment (medication used to treat hemorrhoids) was not applied at 6:00am. In interview on 06/26/19 at 11:16am, S1Administrator stated she and S2Corporate Nurse had just met with the residents to follow-up on the concerns that were brought to their attention on 06/19/19 In interview on 06/28/19 at 6:42am S14Licensed Practical Nurse (LPN) stated in part, that on (MONTH) 23rd and (MONTH) 24th, 2019 she was the night nurse for unit G, that there was no nurse for unit H and unit I for the night shift, and that nobody got their medicine on those units on that shift. In interview on 06/28/19 at 9:32am, S17LPN verified that she worked at a sister facility, but came work the night shift on 06/24/19 and 06/25/19 at this facility from 10:20pm to 8:30am on unit H upstairs and gave medications. Surveyor asked S17LPN if she also was the unit I, and S17LPN stated that she did not know what unit I was. In an interview on 6/28/19 at 10:12am Resident #7 stated she did not receive several of her prescribed medications last week for about 7 days. In interview on 06/28/19 at 11:02am, S16Licensed Practical Nurse (LPN) stated she gave her resignation effective on (MONTH) 24, 2019 at 5:17pm when she left the facility. S16LPN stated on (MONTH) 24, 2019 well before 3pm, S3Director of Nurses (DON) informed me (S16LPN) that they did not have a nurse to take her place at the end of her shift at 3:00pm. S16LPN further indicated S3DON also told her that she would get with S2Corporate Nurse and would do what they can to have someone come in, and I (S16LPN) reminded S3DON that I couldn't stay past 3:45pm because of child obligations. S16LPN further stated at 3:30pm, she informed S3DON that she was feeling weak and her blood pressure was high, and was told that she (S3DON) will tell S2Corporate Nurse and she shut her office door. S16LPN further stated at 5:00pm, her blood pressure was 219/117, her pulse was 122, and she was having chest pain. S16LPN went to S1Administrator's office and was told not to put the keys down because that would be abandonment, and that S2Corporate Nurse had left the building because she had to leave before traffic got bad. S16LPN indicated she made one more attempt to pass the keys to other nurses, but they refused so she ended up calling 9-1-1 for herself. In interview on 06/28/19 at 11:56am, S2Corporate Nurse stated when S3DON and I (S2Corporate Nurse) came to work on Monday, (MONTH) 24th, is when I (S2Corporate Nurse) found out that there was no night nurse on (MONTH) 23rd. S3DON and I (S2Corporate Nurse) immediately went give residents their medications. S2Corporate Nurse was asked if she assessed residents after she realized they had not received their medications and S2Corporate Nurse stated she did not document it, but she spoke with the residents or assessed them after she gave them their medications and asked some residents how they were doing. S2Corporate Nurse stated they were busy dealing with a lot of issues, some developing from outside of the facility and then dealing with the state being on-site, and hasn't had time to look into everything yet. In interview on 06/28/19 at 2:03pm, S3DON stated she did not know that they did not have a night nurse on the (MONTH) 23rd until (MONTH) 25th, and that nobody ever called her to report there wasn't a nurse for those units. S3DON further stated S2Corporate Nurse and I (S3DON) pretty much did the medication pass together on (MONTH) 24, 2019, and I notified S2Corporate Nurse and S1Administrator about unit H and I not having a nurse, and then I (S3DON) gave my resignation. In interview on 06/29/19 at 7:50am, S8LPN stated she worked the evening shift on (MONTH) 23rd, 2019 and when her relief did not show up she called S1Administrator, S3DON, and S15ADON to report it. S8LPN stated she left messages, because nobody answered their phone, and the only one that called back was S15ADON who stated she was going to send someone. S8LPN further stated she had a sick husband at home, and had already worked overtime, so she reported off to S14/LPN who was there on unit G and went home.

Based on observation, interview, and record review the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless unavoidable and failed to ensure a resident with pressure ulcers received the necessary care and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing by: 1.) Failing to ensure a resident had a pressure relieving device placed between skin on skin contact between a resident's fingers and a resident's legs (Resident #1); 2.) Failing to ensure a resident had a pressure relieving device placed on a resident's Geri-chair (Resident #1); 3.) Failing to ensure a Dietician's recommendation was implemented in a timely manner (Resident #1); 4.) Failing to ensure a resident was turned more frequently per facility policy and procedure to prevent further pressure ulcers from developing (Resident #1) and 5.) Failing to ensure a Physician Assistant's recommendations were implemented in a timely manner (Resident # 1). This deficient practice resulted in actual harm when Resident #1 developed an Unstageable pressure ulcer located on his outer right ankle, an Unstageable pressure ulcer located on his left heel, a Stage II blister located on his left outer shin, a Stage II blister located on his right outer shin, a Stage II blister located on his left inner thigh, and a Stage II blister located on his first left inner finger. The facility staff didn't implement Resident #1's Plan of Care regarding use of pressure relieving devices. Further, the facility staff didn't initiate increased turning of Resident #1 per policy and didn't implement dietician and Physician Assistant recommendations in a timely manner that would facilitate wound healing and prevent further pressure ulcer development. The deficient practice was identified for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for pressure ulcers, of a total of 6 residents residing in the facility with pressure ulcers, but had the potential to affect any of the 104 residents who resided within the facility as documented on the Facility's current Resident Census List. Findings: Review of the Facility's Policy and Procedure entitled Prevention of Pressure Ulcers, last revised 09/2013, revealed in part: Interventions and Preventive Measures: General 2. For a person in a bed: b. Determine if resident needs a special mattress per bed selection algorithm 3. For a person in a chair: b. Use foam, gel or air cushion as indicated to relieve pressure. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. Interventions and Preventive Measures: Residents with Risk Factors 3. Risk Factor- Bed Fast a. Change position at least every two hours and more frequently as needed. b. Determine if the resident needs a special mattress (refer to bed selection algorithm as a reference source) d. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees (e.g., for residents with tube feeding) 5. Risk Factor - Immobility b. Use pillows, wedges, or other off-loading devices to keep bony prominences such as knees or ankles from touching each other. Review of the Facility's Policy and Procedure entitled Pressure Ulcer Treatment, last revised 09/2013, revealed in part an Unstageable Pressure Ulcer was defined as full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Review of Resident #1's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review revealed he was admitted to the facility without any pressure ulcers. Review of Resident #1's Minimum Data Sheet with Assessment Reference Date of 05/04/17 revealed in part, Resident #1 was cognitively impaired, as needing extensive assistance from staff with transfers, was incontinent, and as having no pressure ulcers upon admit. Review of Braden Risk Assessments dated 05/04/17, 05/11/17, 05/18/17, 06/14/17, and 06/19/17 revealed Resident #1 was assessed as being at high risk for development of a pressure ulcer. Review of Resident #1's Care Plan with problem onset dated 05/04/17 revealed in part, Resident #1 was identified as having the potential for skin breakdown due to decreased mobility and incontinence. Further review revealed Resident #1 developed a Deep Tissue Injury to the Right Ankle on 05/08/17; a Stage II Blister Pressure Ulcer to the Left Outer Shin on 05/11/17; an Unstageable Pressure Ulcer to the Left Heel and a Stage II Pressure Ulcer to the Right Outer Shin on 05/15/17; a Stage II Pressure Ulcer to the Back Left Forearm on 05/25/17; a Stage II Pressure Ulcer to the Left Inner Thigh on 05/29/17; a Stage II Blister Pressure Ulcer to the Left First Finger on 06/02/17; and Stage II Pressure Ulcer to the Left Upper Elbow, a Stage III Pressure Ulcer to the Right Inner Buttock, and an Unstageable Pressure Ulcer to the Right Outer Ankle assessed upon return from the hospital on [DATE]. Further review revealed the following measures were to provide heel/elbow protectors, to minimize pressure over bony prominences, to avoid skin to skin contact, and to turn every two hours. Review of Wound Assessment Report dated 05/08/17 revealed in part an Unstageable Pressure Ulcer was identified on Resident #1's right outer ankle. Review of Wound Assessment Report dated 05/11/17 revealed in part a Stage II Fluid Filled Blister Pressure Ulcer was identified on Resident #1's Left outer shin Review of Wound Assessment Report dated 05/15/17 revealed in part a Stage II Fluid Filled Blister Pressure Ulcer was identified on Resident #1's Right Outer Shin and an Unstageable Pressure Ulcer was identified on Resident #1's Left heel. Review of Wound Assessment Report dated 05/29/17 revealed in part a Stage II Pressure Ulcer was identified on Resident #1's Left Inner Thigh. Review of Wound Assessment Report dated 06/02/17 revealed in part a Stage II Pressure Ulcer was identified on Resident #1's left first inner finger. Review of Wound Assessment Report dated 06/14/17 revealed in part a Stage II Pressure Ulcer was identified on Resident #1's Left Upper Chest. Review of Wound Assessment Report dated 06/14/17 revealed in part a Stage II Pressure Ulcer was identified to Resident #1's Left Elbow. Review of Completed Care and CNA (Certified Nursing Assistant) Flow sheet Roster dated 05/01/17 to 06/23/17 revealed Resident #1 was being turned every two hours by CNA staff. Review of Registered Dietitian's Nutrition assessment dated [DATE] revealed in part, the Dietician recommended Zinc 220mg (used for wound healing) and a daily Multivitamin (medication used for vitamin deficiency and to aid in wound healing). Review of Resident #1's Medication Administration Record [REDACTED]. Review of Nurse to MD Communication dated 05/25/17 revealed in part, order request for Promod, Vitamin C, Zinc, and Multivitamin for Resident #1. Further review revealed Physician gave order dated 05/26/17 for initiation of Promod, Vitamin C, Zinc, and Multivitamin. Review of Resident #1's wound care agency notes dated 06/16/17 revealed in part, Resident #1's Physician Assistant (PA) assessed Resident #1 as having wounds to the left ankle, left heel, left distal lateral lower leg, right ankle, left upper chest, left elbow, and right calf. Further review revealed all wounds were documented as pressure being the cause of the above mentioned wounds. Further review revealed the PA's plan to heel the pressure ulcers included in part, to separate the touching of skin on calf, buttock, and joint areas, to cushion all areas that touch other body areas. Resident #1's Physician Assistant's wound care notes further revealed that a low air loss mattress was recommended. Observation on 06/22/17 at 11:30am revealed Resident #1was lying on his back, with head of the bed elevated 45 degrees, and no pillows floating his heels, and no heel or elbow protectors on. No air loss bed. Further review revealed a Geri chair present at Resident #1's bedside with no pressure reducing device on his Geri chair. Observation of wound care by S3/LPN/Wound Care on 06/22/17 at 1:47pm revealed in part, Resident #1 was turned to his left side by staff. Further observation revealed Resident #1 did not have any pressure relieving devices between his legs and his skin on his left leg was touching the skin to his right leg. Resident #1's fingers on his left hand were tightly pressed together with skin on skin contact and no pressure relieving devices were seen between his fingers. Observation on 06/23/17 at 10:20am revealed Resident #1 was lying on his back with his fingers touching each other, skin to skin with no pressure relieving device between fingers, and no elbow protectors on. Observation on 06/23/17 at 11:40am revealed Resident #1 lying with the head of the bed elevated at 45 degrees and Resident #1 in a left lateral tilt position. Further observation revealed Resident #1 was lying in bed with no pillow under his heels to float his heels above the mattress, and no pillow or positioning device between his legs to prevent skin on skin contact. Further observation revealed Resident #1's right leg was lying over his left leg, mid-calf, with no pressure relieving devices between the two legs, had no padding under his left elbow which was against the mattress, and no elbow protector or padding to Resident #1's right elbow. Observation on 06/23/17 at 01:20pm revealed Resident #1 lying in bed with the head of the bed elevated at 45 degrees and Resident #1 was in a right lateral tilt position. Further observation revealed Resident #1 was lying in bed with no pillow under his heels to float his heels above the mattress, and no pillow or positioning device between his legs to prevent skin on skin contact. Further observation revealed Resident #1's left leg was lying over his right leg, mid-calf, with no pressure reducing devices between the two legs, had no padding under his right elbow which was against the mattress, and no elbow protector or padding to Resident #1's left elbow. In interview on 06/22/17 at 11:37am S5/LPN stated Resident #1's wounds were a result of pressure. In Interview on 06/22/17 at 1:33pm S3/LPN/Treatment Nurse stated she had been doing wound care at the facility since 04/2017 and received minimal training prior to becoming the wound care nurse. S3/LPN/Treatment Nurse further stated Resident #1 was admitted to the facility on [DATE] with no pressure ulcers or other wounds present. Further stated a wound care specialist was consulted and made an initial assessment of Resident #1 on 06/16/17. S3/LPN further stated Resident #1 was being turned every two hours, he had a pressure reduction mattress, and gets up to the Geri chair daily. In interview on 06/22/17 at 2:11pm S4/CNA stated Resident #1 gets up in the Geri chair with a pillow placed in the bottom of the chair under Resident #1's bottom, but Resident #1 had not been in the Geri chair since 06/20/17. S4/CNA further stated Resident #1 is turned every two hours on no set turning schedule. In phone interview on 06/23/17 at 10:30am Resident #1's PA stated he first saw Resident #1 on 06/16/17 and had seen him only once. Further stated Resident #1's wounds were due to pressure from contact with bed surfaces or due to prolonged skin to skin contact. Further stated Resident #1's co-morbidities complicated Resident #1's wounds, but Resident #1's wounds were a result of prolonged pressure to the areas where Resident #1's wounds were present and if pressure was relieved, the wounds would be easy to heal. In interview on 06/23/17 at 12pm, S6/Corporate Nurse stated, when asked if the facility had a specific policy on use of or criteria for special air flow mattresses, all special mattresses are different and it depends on the individualized resident and the status of the wound in deciding to use one. Further stated if the wounds were a result of increased and prolonged pressure, the facility would probably put the resident on a special mattress other than a routine pressure reduction mattress used for all residents. In interview on 06/23/17 at 12:35pm S3/LPN/Treatment Nurse stated Resident #1 cannot move anything but his head, can feel pressure on his body, but not on his wounds. Further stated Resident #1 was assessed as being at risk for skin breakdown but had no wounds or skin breakdowns upon his admission to the facility on [DATE]. Further stated one week after his admission to the facility, Resident #1 developed an Unstageable pressure wound to his right ankle on 05/08/17 and developed multiple wounds after that within a few days. Further stated Resident #1's wounds were a result of prolonged pressure. When asked why the wound care specialist wasn't consulted prior to 06/016/17, S3/LPN stated Resident #1's wounds hadn't been open prior to his 06/05/17 hospitalization so the wound care specialist wasn't contacted. When asked why Zinc Sulfate and Multivitamins recommended by the facility's Registered Dietician on 05/11/17 were not initiated prior to 05/29/17, S3/LPN stated she wasn't aware of that recommendation. When asked if Resident #1 should be turned more frequently than every two hours, S3/LPN stated yes. When asked if an air loss mattress or some type of specialty mattress had been considered for Resident #1, S3/LPN stated she had not recommended an air loss mattress because Resident #1 didn't have a Stage 4 Pressure Ulcer. When asked if an Unstageable Pressure Ulcer could be considered, S3/LPN stated an Unstageable Pressure Ulcer could be a Stage 3 or Stage 4. When informed of the above observations to Resident #1, S3/LPN/Treatment Nurse stated she never thought to implement elbow protector use for Resident #1 and Resident #1 should have some type of pressure reducing device in between his legs and his heels were to be floated. In interview on 06/23/17 at 2:15pm, S2/DON stated Resident #1 couldn't reposition himself or turn himself and was dependent on staff for all of his Acts of Daily Living care. Further stated S3/LPN started in wound care 04/2017, received basic wound care training for all staff, but did not receive in-depth training regarding wound care. When asked how she felt Resident #1's wounds occurred, S2/DON stated she wasn't sure. When informed Resident #1 did not have elbow protectors in place while having a current Stage 2 elbow pressure ulcer, did not have pressure relieving devices between his legs, fingers, or under his legs to float his heels according to Resident #1's Plan of Care, S2/DON stated the Plan of Care should be implemented. When asked if she felt Resident #1 would benefit from more frequent turning and repositioning, S2/DON stated Resident #1 should be turned more frequently than every two hours. When asked who was responsible to make sure dietary recommendations were carried out while reviewing the Registered Dietician Recommendation dated 05/11/17 with the surveyor, S2/DON stated she gets the recommendations but they were generally on a different sheet and she had not received the 05/11/17 recommendation. When asked if she or S3/LPN had considered contacting the wound care specialist prior to 06/16/17, S2/DON stated they had attempted earlier contact but were unsuccessful and didn't contact him again until after Resident #1's hospital discharge of 06/13/17.

Based on interview and record review the facility failed to ensure that each resident is provided sufficient fluid intake to maintain proper hydration and health for 1(#3) of 3 (#1, #3, #4) residents with tube feeding from a total sample of 5 residents (#1, #2, #3, #4, #5) with a medical condition which required that they received and maintain adequate hydration. The facility failed to ensure: 1. Staff followed physician orders [REDACTED].#3) resident receiving a diuretic and in a universe of 3 (#1, #3, #4) residents with peg tube feedings; 2. That once recommendations from the Registered Dietitian were made and the order was written by the physician to increase fluid intake for Resident #3, staff transcribed the order to the MAR; 3. Staff assess for signs of possible dehydration for 1 (#3) resident receiving a diuretic in a universe of 3 (#1, #3, #4) residents with peg tubes; 4. Staff failed to have an interim plan of care to address the hydration status of Resident #3 who was totally dependence on staff for activities of daily living and who received PEG tube feedings and received no fluids by mouth. This deficient practiced resulted in actual harm to Resident #3 when Resident #3 was hospitalized and diagnosed with [REDACTED]. The staff also failed to insert a foley catheter on 4/7/16 as ordered by the physician. The resident became difficult to awake and was transferred to the hospital on [DATE]. Findings: Resident #3 was admitted to the facility on [DATE] with diagnosis, in part, of [MEDICAL CONDITION], Drug Induced Tremors, Dysphagia, status [REDACTED]. Review of Resident #3's admit orders dated 4/5/16, revealed, in part, the following: -Isosorce 1.5cal (Nutritional Supplement) at 45ml hour per pump continuous feeding, -Water flush per pump 50cc every 4 hours. -[MEDICATION NAME] 40mg twice a day. Review of Resident #3 Physician ' s admit orders dated April 2016 revealed, in part, to record intake. Review of Resident #3's telephone order dated 4/7/16 revealed, in part, Place Foley catheter and change every month. Review of Resident #3's Enteral Nutrition assessment dated [DATE] by the dietician revealed, in part, Dementia, gastric mass, and was on the medications [MEDICATION NAME] and [MEDICATION NAME] and took nothing by mouth. The resident was on a water flush order for 50 milliliters (ml) every four hours which equaled 300 ml. The current Tube feedings were not adequate to meet the resident needs. Recommendations were the following: (1) increase tube feeding to [MEDICATION NAME] 1.5 at 50 ml hour(2) increase flush order to 200 ml of water four times a day. Review of Resident #3's Telephone order signed by the physician dated 4/14/16 at 12:00pm revealed, in part, (1) increase the [MEDICATION NAME] 1.5 to 50ml/hour, (2) increase flush order to 200ml of water four times a day. Review of Resident #3 ' s Medication Administration Record (MAR) for April 2016 revealed, in part, the following: -[MEDICATION NAME] 1.5 calorie 45ml/hour per pump continuous was mostly documented as being given, -water flush per pump every 4 hours, had no documentation of being given. -[MEDICATION NAME] 40mg twice a day was documented as mostly being given. Review of Resident #3's MAR dated April 14, 2016 to April 26, 2016 revealed no documentation of the above physicaian's order dated 4/14/16 to increase the tube feeding rate and the tube feeding flushes with water. Review of the Physician's Progress Notes dated 4/7/16, in part, revealed the resident does not follow commands well at all, had urine retention, Dysphagia had a PEG, found with gastric mass. Review of the only nurse's note found per the facility staff documented on Resident #3 revealed, in part, on 4/18/16 at 9:41pm, the nurse and C.N.A. was unable to alert resident and ambulance was called. Review of Resident #3's Hospital Notes dated on 4/19/16 revealed, in part, the resident had evidence of severe dehydration, due to decreased intake, sodium is high at 158, ( 135-145 normal milliequivalents per liter), hypotensive (low blood pressure) with evidence of pyuria ( white blood cells or pus in urine), likely [DIAGNOSES REDACTED]. In an interview on 4/25/16 at 11:50am, S5/Minimum Data Set Coordinator stated that Resident #3 did not have a care plan yet but may have a temporary care plan done but none was noted under the section she identified for the surveyor to look at in Resident #3's clinical record. In an interview on 4/25/16 at 12:00pm, S6/Care Plan Nurse stated that she did not have an interim care plan for Resident #3 and the only thing known about the resident to her was that the resident was transferred to the hospital. In an interview on 4/25/16 at 12:05pm, S4/C.N.A. (Certified Nursing Assistant) stated that she had worked with the resident the day she went to the hospital but had left at 3:00pm when her shift ended and heard that the resident left later that day. She stated that the resident was bed ridden and had a PEG tube. S4/C.N.A stated the resident would moan and yell but that day the resident was much quieter than her usual self and she had informed a nurse but she cannot remember her name. S4/C.N.A stated that the resident did not have a catheter. She stated that the resident was taking nothing by mouth only through a feeding tube. In an interview on 4/25/15 at 12:34pm, S9/C.N.A stated that she had worked with resident #3 a few times and was not here when the resident left, She stated that the resident would not talk, had a feeding tube and no catheter. In an interview on 4/26/16 at 10:55am, S7/Clinical Consultant stated that resident's that are receiving tube feedings should be monitored on intake and output per policy. In an interview on 4/26/16 at 10:55am S2/DON stated that the order for 4/14/16 to increase feedings and water flushes was not followed and was not transferred to the MAR. The nurses were not documenting the water flush every 4 hours for the 50ml hour. S2/DON stated that the above order dated 4/14/16 if it was followed the nurse would checked it off and put their initials and there was no documentation that this was being done and the order was not written on the MAR. S2/DON further stated that there was no system to prioritize the Registered Dietician (RD) recommendations for residents needs to be acted on, and she (DON) tries to get the RD recommendations acted on within 48 hours from the doctor to address the resident's needs. In an interview on 4/26/16 at 12:08pm, S2/DON stated that the resident should have been on intake and output to monitor her fluids. She further stated there was no documentation to reflect this. She stated that with the Iitake and output done one could use the information to report to the MD to adjust her intake therapy. Review of the facility's policy for Intake, Measuring and Recording revealed, in part, review the resident's care plan to assess for any special needs of the resident, fluids taken intravenously are recorded by the licensed nurse, at the end of the shift, total the amounts of all liquids the resident consumed, record all fluid intake on the intake and output record in cubic centimeters. Review of the facility's policy on Enteral (Feeding by gastrointestinal tract) Tube feeding via Continuous pump revealed, in part, verify there is an order for [REDACTED]. Under documentation section revealed the person performing this procedure should record the following information in the resident's medical record: -the date and time the procedure was performed, -The average fluid intake per day, -the name of individuals that performed the procedure. Review of Resident #3's April 2016 MAR revealed record daily intake. Review revealed this documentation was started on 4/7/16 (Admit 4/5/16) on evening shift (3:00pm to 11:00pm), was not documented as done on the day shift (7:00am-3:00pm) at all, so the total intake only reflected the evening and night shift worked. Further review revealed there was no documentation of urine output recorded. In an interview on 4/26/15 at 12:15pm, the S2/DON stated that she did not see that the orders written on 4/7/16 to follow up with the neurologist, urologist, and orthopedic, and the family about hospice were carried out by staff. In an interview on 4/26/16 at 12:23pm, S7/Clinical Consultant stated that some intake and outputs were recorded on the MAR and they (staff) were not consistent with documenting and totaling the amounts to reflect the resident's intake. She also said the day shift did not record anything and there were a few days with nothing documented to reflect what intake the resident received. In an interview on 4/26/16 at 12:35pm, the DON was asked if the order on 4/7/15 was followed to place and change Foley catheter every month was acted on and she stated that it was not and agreed that a urinary catheter would have made it easier to monitor the residents intake and output. In a telephone interview on 4/26/16 at 12:55pm, S8/Nephrologist, that saw the Resident at the hospital, stated that the resident ' s fluid intake and output needed to be balanced. He stated the resident needed more water like 400cc every 4 to 6 hours. S8/Nephrologist finally stated the resident was extremely dehydrated, she was not getting enough fluids and needed at least 200cc every 4 hours.

Based on record review and interview the facility failed to ensure all residents are free from sexual abuse for 1 of 6 sampled residents (Resident #3). The facility failed to: 1) care plan interventions regarding Resident #3 ' s history of sexual inappropriate behaviors with staff and other residents; 2) follow the 2/3/12 discharge instructions for resident #3 to be seen by a psychiatrist and social worker within 7 days of discharge from a Behavioral hospital; 3) update resident #3's care plan after the 2/3/12 discharge from a behavioral hospital; 4) after an incident of staff to resident #3 sexual abuse, revise resident #3's care plan regarding resident #3 approaching other residents and staff for sexual inappropriate behavior and what an employee was to do if approached by resident #3; 5) obtain a criminal background check for an employee; 6) train new employees on abuse/neglect. Resident #3, a [AGE] year old female resident with moderate cognitive impairment, that is easily understood and independent with all activities of daily living. The resident has a history of inappropriate sexual behaviors toward staff and other residents. Resident #3 was in Immediate Jeopardy on 1/6/12 after the resident was admitted to the facility and the facility failed to: put a monitoring system in place with specified times and staff responsible for monitoring, conduct background checks on new employees, and train employees regarding what do if resident #3 was sexually inappropriate towards them. The facility failed to review and revise Resident #3's care plan when evidence of inappropriate sexual behaviors toward staff and residents began and continued. The Immediate Jeopardy ended for the resident on 1/30/12 when she was transferred to a behavior unit for inappropriate sexual behaviors toward a resident. The resident was in Immediate Jeopardy on 2/3/12 when she returned to the facility and the facility failed to plan care regarding the resident ' s sexually inappropriate behaviors. Resident #3 reported to the nurses that on 3/17/12 she, Resident #3, asked a male employee (S15 housekeeping staff) to give her $5.00 and a pack of cigarettes to perform a sex act on him. The resident said that the employee agreed. On 03/17/2012 the male housekeeping staff person (S15) sexually abused Resident #3. The Immediate Jeopardy ended for Resident #3 on 03/20/2012 when Resident #3 was discharged from the facility. The Resident Census and Conditions of Residents Report dated 03/30/12 revealed the facility total census was 74 and 54 of the 74 residents had a psychiatric [DIAGNOSES REDACTED]. This deficient practice of the facility failing to put protective measures in place in order to ensure residents are free from sexual, verbal and mental abuse has the potential of affecting all 74 residents residing in the facility. Findings: Review of the Abuse and Neglect Prevention Program Policy and Procedure Statement revised April 2, 2010 revealed that the residents had a right to be free from verbal, sexual, physical and mental abuse. The facility's Policy and Procedure for Abuse and Neglect Prevention revealed that the facility will commit to protecting residents from abuse by anyone, including but not limited to the facility, staff, other residents, consultants, volunteers, and staff of other agencies, family members, friends, visitors and legal guardians. In addition, the Policy and Procedure for Abuse and Neglect Prevention revealed the charge nurse and/or nurse supervisor must conduct an immediate investigation of incidents and accidents of alleged abuse. The facility must ensure that the residents are protected, monitored and separated. The Policy and Procedure revealed Residents will be protected from harm during the investigation by reassigning or suspending the implicated employee pending the completion of the investigation. The implicated employee will be monitored and depending on the outcome of the investigation, separated accordingly. The Abuse and Neglect Prevention Policy and Procedure revealed the facility has zero tolerance for abuse and neglect in the health care profession. Abuse and neglect should be reported at all times, the minute it happens, it should be reported to the immediate supervisor right away. If you are a health care employee and suspect or a witness to abuse, it is your duty and responsibility to respond accordingly. When the problem is reported or discovered and the person who witnessed the abuse failed to come forward, they too will be subject to suspension and termination if the implicated employee is found guilty. Review of the Accumulative [DIAGNOSES REDACTED]. Record review of Nurses Notes revealed: 01/08/2012: Resident #3 standing next to floor nurse and Resident #3 told floor nurse that she would like to kiss her. 01/15/2012: Resident #3 was exhibiting inappropriate sexual behavior toward staff and patient. Resident #3 was redirected, 01/25/2012: Resident #3 continued to make sexual advances toward employees and residents. Record review of the Social Progress notes revealed: 01/09/2012: Resident #3 was sexually inappropriate with staff and was trying to grab staff breast, kiss staff and attempting to put her hands between staff legs. The Social Service Director noted in the progress notes that she informed corporate of Resident #3's inappropriate behaviors. 01/17/2012: staff reported that resident continues to be sexually inappropriate with staff and that Resident #3 keeps propositioning them for sex. 01/24/2012: Resident made inappropriate sexual comments toward the social service director and the resident was redirected. 01/30/12: Resident #3 was sent to a Behavioral Health Center due to inappropriate behaviors and the Social Progress notes revealed that it was reported by staff that Resident #3 had been touching her roommate inappropriately and that Resident #3 was reporting that bugs were crawling out of her body and that her skin was falling off. In interview on 04/02/2012 at 11:00am the Licensed Practical Nurse/S11 indicated Resident #3 was sexually inappropriate toward staff and residents. The LPN/S11 indicated that the employees were trained to redirect Resident #3. In interview on 04/02/2012 at 1:00am the Licensed Practical Nurse/S6 indicated Resident #3 was admitted on [DATE] and had a history of [REDACTED].#3's inappropriate sexual behaviors. In addition the LPN/S6 indicated that Resident #3 and Resident #6 shared a room and a night nurse reported that Resident #3 was found touching Resident #6 inappropriately. LPN/S6 said she could not recall the specific nurse who reported the allegation of inappropriate sexual behavior but she can remember that it was a night nurse. LPN/S6 said that Resident #6 was moved out of the room and Resident #6 was sent to the hospital after the incident was reported. Record review failed to reveal documentation from a night nurse regarding this incident or an incident report. In interview on 04/03/2012 at 10:00am the CNA/S8 indicated that staff (Corporate /Trainer) informed her that when Resident #3 was admitted , the resident was hypersexual and needed to be redirected. The CNA/S8 indicated that she was informed that Resident #3 had touched Resident #6 inappropriately. The CNA/S8 further indicated that Resident #3 was afraid of her roommate (Resident #3) and the CNA/S8 noticed that Resident #6 was not acting the same and, appeared withdrawn and would cry easily. The CNA/S8 indicated that Resident #6 was moved to another room. The CNA/S8 did not know the exact date of the move. Review of Resident #3 ' s Care Plan dated 01/19/2012 revealed Potential for social isolation, unacceptable social behavior sexually inappropriate with female staff, begs for money from staff, visitors, and other residents. Resident #3 frequent use of profanity, yelling, and screaming at staff. The Approaches noted on Resident #3's Care Plan revealed the facility would assist Resident #3 with selecting appropriate activities, provide verbal reminders of upcoming activities, offer verbal praise, provide one- to one visits for activity program, participate in group activities and document resident response to interventions and redirection. Review of the Care Plan dated 01/19/12 failed to reveal interventions regarding monitoring to prevent inappropriate sexual behaviors toward cognitive and non-cognitive residents. Record review revealed the facility failed to develop a care plan (aftercare) after Resident #3 was discharged on [DATE] from the behavioral unit for the treatment of [REDACTED].#3. In interview on 03/30/2012 at 10:40am the LPN/S4 indicated that when a resident was discharged from the hospital the care plan coordinator is to be notified and the resident ' s name is placed on the care plan list. LPN/S4 indicated that Resident #3's name was not placed on the list and the care plan had not been updated. In interview on 03/30/2012 the DON/S2 indicated that she did not see where the facility had obtained the discharge instructions. The DON/S2 contacted the Behavioral Unit on 03/30/2012 and requested Resident #3's discharge instructions. Review of the Discharge Instructions revealed Resident #3's discharge instructions were faxed to the facility on [DATE]. The DON/S2 indicated that the primary physician does all of his patient's medication adjustments and the residents were not seeing the psychiatrist as recommended by the behavioral hospital. In addition the DON/S2 indicated that the nurse who was working with Resident #3 should have requested the discharge summary from the hospital on [DATE] when the resident was discharged from the hospital and should have notified the primary physician of the appointments. Review of Resident #3 ' s Discharge Home Instruction report obtained from the Behavioral Unit by the facility on 03/30/2012 at 3:51pm revealed, Resident #3 was admitted to the hospital on [DATE] and was discharged on [DATE]. The follow-up recommendation/treatment /referrals revealed that Resident #3 was to be seen by a psychiatrist and a counselor within 7 days of discharge. Review of Resident #3 ' s Behavioral Health Unit Crisis /Safety Plan obtained from the Behavioral Health Unit on 03/30/2012 and dated 02/01/2012 revealed [MEDICAL CONDITION], sexually Inappropriate History, Paranoia and that Internal coping strategies should include: exercise, prayer/meditation, and listening to music. The Crisis /Safety Plan dated 02/01/2012 revealed Nursing Home to monitor agitation, psychotic symptoms, behaviors and the facility should remove all items that could be used as a weapon. The facility had no documented evidence indicating that Resident #3 was seen by the Psychiatrist and the social worker (a counselor) as indicated by the Behavioral Unit discharging team. The facility had no documented evidence that the Crisis /Safety measures were incorporated in Resident #3 ' s Care Plan. Record review of the Nurses Notes dated 03/17/2012 at 2:40pm revealed Resident #3 was overheard talking about an incident where Resident #3 had performed a sex act on an employee for $5.00 and a pack of cigarettes. Review of a Facility Incident Report initiated on 03/17/2012 and completed on 03/19/2012 revealed: Resident #3, a [AGE] year old female resident with moderate cognitive impairment, that is easily understood and independent with all activities of daily living. The resident has a history of being overtly sexually inappropriate toward staff, including soliciting them for money in exchange for sexual favors and [MEDICATION NAME] grabbing at staff. On 3/17/12, Resident #3 reported to the nurses that on 3/17/12 she, Resident #3, asked a male employee (S15 housekeeping staff) to give her $5.00 and a pack of cigarettes to perform a sex act on him. The resident said that the employee agreed. The resident said that on 3/17/12, the employee (S15) gave Resident #3 the $5.00 and they went to the bathroom where a chair was placed behind the door and Resident #3 proceeded with the sex act. Resident #3 described the size of the employee's penis and the type of underwear the housekeeping staff (S15) was wearing. The report revealed that on 3/19/12, Resident #5 reported that on 3/17/12 he went to use the bathroom, knocked on the bathroom door and no one answered. Resident # 5 indicated per report that he tried to open the door and it was blocked. He said that once the door was opened, he observed Resident #3 and the employee (S15) in the bathroom together. The report indicated that law enforcement was called and that Resident #3 reported to law enforcement that the housekeeping staff (S15) approached her and told her to "come with him and she did " . The Facility Resident/Client Incident Report completed by the facility on 03/19/2012 revealed the allegation of sexual abuse was verified with Resident #3 being the victim and the allegation of sexual abuse was substantiated for sexual abuse conducted by employee S15. Record review revealed S15/housekeeping staff was previously hired at the facility in 2004. Record review of S15's personnel record revealed a criminal background check from the hire date in 2004. The criminal background revealed criminal charges filed on 06/23/1997 for the illegal use of a weapon and the disposition on 01/10/2000 revealed S15/housekeeping staff pleaded guilty and was sentenced to 2 years of hard labor. Review of S15/Housekeeping personnel record revealed the housekeeper/S15 was re-hired on 12/22/2012. Record Review of the criminal background check for non -licensed employees revealed the facility had not obtained a criminal background check for the 12/22/11 employment of S15, Housekeeping staff. On 3/22/12, the facility obtained the criminal background check for S15 from the investigational agency via Fax. Review of S15's criminal background check revealed S15/Housekeeper had the following charges and arrests : 1989 shoplifting and contributing to the delinquency of [MEDICATION NAME], theft by shoplifting, resisting an officer,1990 aggravated assault, 1993 disturbing the peace, simple assault, 1994 discharge of a firearm,1995 La -DOC P&P adult services, illegal use of weapons, 1997 intoxication , disturbing the peace, 1997 possession of a firearm by a convicted felon, resisting arrest, 1999 child desertion, 2003 La-DOC P&P Adult Services, monetary instrument abuse, 2004 LA-DOC P&P . In interview on 04/03/2012 at 1:00 pm S1/ADM indicated that S15 was hired on 12/22/12, prior to theS1/ADM being hired. S1/ADM indicated that S15 was dismissed from the facility on 03/17/12 after allegations of sexual abuse with a resident was reported. S1/ADM indicated after reviewing S15/Housekeeping's personnel record, S1/ADM discovered that the criminal background check was not in S15/Housekeeper's personnel record. In addition, S1/ADM indicated that a copy of S15's criminal background check was requested and faxed to the facility from the investigational agency on 03/20/12 (3 days after S15 was dismissed from the facility). S1/ADM. indicated that she was not aware of the charges and that S15 was employed at the facility in 2004 and was re-hired again on 12/22/2012. Review of Personnel Records revealed: S10/Dietary Staff was employed on 02/24/12, S12/Activity Director was hired on 02/13/2012, S13/CNA was hired on 02/24/2012, S14 CNA was hired on 03/16/2012 and S15 Housekeeping Staff was hired on 12/22/2011. Review of the Orientation and Check List for Abuse/Neglect included " after all modules have been presented have the new employees sign and date the orientation form and indicate that the information has been explained by checking the line preceding the item. The person responsible for orienting the employees will also sign and date the orientation checklist " . Review of 5 of 5 Employees ' Personnel Records (Employees S10Housekeeping, S12Activity Director, S13CNA, S14CNA, and S15Housekeeping) revealed the orientation check list was signed and dated by the employee and Human Resource staff. The Abuse/Neglect section on the orientation check list was not checked as being provided to the employee. In interview on 04/03/2012 at 1:00pm S1/ADM indicated that the department supervisors are responsible for providing the orientation on abuse and neglect. In addition S1/ADM acknowledges that she did not see where the abuse and neglect orientation was signed or checked off as being done. S1/ADM indicated that the facility was in the process of addressing orientation because the QA department identified areas of concern with training. In interview on 04/03/2012 at 12:51pm, S9/Dietary Supervisor indicated that she was responsible for providing the training in abuse and neglect prevention. In addition S9/ Dietary Supervisor indicated that she obtained the personnel folder from human resources. S9/Dietary staff indicated that she went over the forms with staff and had the employee sign the orientation form and the personnel folder was given back to human resource department staff. The Dietary Supervisor/S9 stated, "I do not sign anything" referring to the orientation /training for employees. Record review failed to reveal who was to provide the orientation and abuse /neglect training.

Based on record reviews and interviews, the facility failed to have an effective administration that would enable the facility to effectively maintain the highest practical wellbeing for all residents, by: 1. Failing to ensure that all residents were free from sexual, physical and mental abuse 2. Failing to implement the policy and procedures that prohibit the mistreatment and abuse of residents 3. Failing to put monitoring and protective mechanisms in place for 2 of 6 sampled residents (Resident #3 & Resident #6). Resident #3 had a history of [REDACTED]. Record review revealed that Resident #3 was witnessed by Resident #5 (a cognitive resident) in the bathroom with a male employee. It was reported by Resident #3 that a sex act occurred between Resident #3 and the employee (for a pack of cigarettes and $5.00). The facility had no documented evidence indicating that administration ensured that monitoring systems were put in place, that adjustments were made to a plan of care and that measures for protection were put in place to prevent negative outcomes from occurring for Resident #3. Resident #3 has a history of being overtly sexually inappropriate toward staff and residents. The facility failed to ensure that their written policy and procedure that prohibits neglect and abuse was implemented for a cognitively impaired resident (Resident #6). The facility failed to ensure Resident #6 was free from sexual, verbal and mental abuse by failing to put protective measures in place in order to protect Resident #6, who was placed in the same bedroom with Resident #3. Resident #3 was identified as having a history of inappropriate sexual behaviors toward employees and residents. Documentation revealed Resident #3 was witnessed by staff, cursing and inappropriately touching Resident #6. Documentation and interview revealed Resident #6's was afraid of Resident #3 and was observed crying and covering her head during one incident. Resident #3 was hospitalized at a behavioral unit after staff observed Resident #3 inappropriately touching the roommate (Resident #6). Resident #3 was discharged from the behavioral unit and was readmitted back into the facility on [DATE]. The facility failed to: 1. have a system in place to develop interventions to prevent the occurrence of resident to resident and employee to resident abuse once the potential risk was identified; 2. have a system in place to ensure adequate supervision of Resident #3 to reduce other resident ' s risk of unwanted sexual advances; 3. have a system in place to ensure the effectiveness of abuse training to immediately remove Resident #6 from inappropriate sexual behavior occurrences. Record review of the Resident Census and Conditions of Residents Report dated 03/30/12 revealed the facility total census was 74 and 54 of the 74 residents has a psychiatric [DIAGNOSES REDACTED]. This deficient practice of the facility failing to put protective measures in place in order to ensure that residents were free from sexual, verbal and mental abuse has the potential of affecting all 74 residents residing in the facility. Findings: Record review of the facility ' s policy and procedure for addressing Abuse and Neglect Prevention Program revised on April 2, 2010 revealed that residents had the right to be free from verbal, sexual, physical, mental abuse and neglect. The Policy and Procedure for Abuse and Neglect revealed residents will be protected and employees will be suspended pending completion of the investigation. The residents will be monitored and separated according to the outcome of the investigation. The policy revealed that the facility was committed to protecting the residents from abuse by any person, including but not limited to facility staff and other residents. Record review of the Accumulative [DIAGNOSES REDACTED]. Record review of Resident #3's Incident Report dated 03/17/2012 revealed Resident #3 was a [AGE] year old female resident at the facility who reported to the nurses that she ( Resident #3) asked a male employee ( S15 housekeeping staff) to give her $5.00 and a pack of cigarettes to perform a sex act on him and the employee agreed. The Incident Report dated 03/17/2012 revealed that the employee (S15) gave Resident #3 the $5.00 and they went to the bathroom where a chair was placed behind the door and Resident #3 proceeded with the sex act. In addition Resident #3's incident report dated 03/17/2012 revealed Resident #3 had a history of [REDACTED]. The incident report revealed Resident #3 was moderately impaired cognitively and the resident was easily understood and independent with all activities of daily living. Resident #3's Incident Report revealed on 03/19/2012 that a resident went to use the bathroom and after knocking on the bathroom door no one answered. The Incident Report dated 03/19/2012 revealed a witness. Resident # 5 indicated per report that he tried to open the door it but it was blocked. After Resident #5 opened the bathroom door, Resident #3 and the employee (S15/Housekeeper) were observed in the bathroom together. Review of the Incident Report dated 03/20/2012 revealed Resident #3 reported to law enforcement that the housekeeping staff (S15) approached her and told her (Resident #3) to" come with him and she did. Resident/Client Incident Report completed by the facility on 03/19/2012 revealed the investigation of sexual abuse was verified with Resident #3 being the victim and the allegation of sexual abuse was substantiated for sexual abuse (employee S15). The Nurse ' s Note dated 01/08/2012 revealed the following: Resident #3 standing next to floor nurse and Resident #3 told floor nurse that she would like to kiss her. 01/06/2012 Nurse ' s Note revealed Resident #3 yelling at nurses and other staff. 01/15/2012 Resident #3 was exhibiting inappropriate sexual behavior toward staff and patient. Further review of the Nurses Note dated 01/15/12 revealed resident re-directed. 01/25/12 Resident #3 continues to make sexual advances toward employees and residents. Record review of the Social Progress Notes revealed the following: On 01/09/12 Resident #3 was sexually inappropriate with staff and was trying to grab staff breast, kiss staff and attempting to put her hands between staff legs. The Social Service Director noted in the progress notes that she informed the facility ' s corporate staff of Resident #3's inappropriate behaviors. Record review of the Social Progress Notes dated 01/17/2012 revealed staff reported that resident continues to be sexually inappropriate with staff. Employees were reporting that Resident #3 kept propositioning them for sex. On 01/24/2012 Resident #3 made inappropriate sexual comments toward the social service director and the resident was redirected. Record review of the Nurses Notes dated 03/17/2012 at 2:40pm revealed Resident #3 was overheard talking about an incident where Resident #3 had performed a sex act on an employee for $5.00 and a pack of cigarettes. Review of the Nurses Notes dated 01/28/2012 at 9:30am revealed Resident #3 was harassing her roommate (Resident #6) and the House Supervisor was notified and instructed staff to pay closer attention to Resident #3. Resident #3 was placed at the nurses ' station and the resident walked away. The Nurses Note dated 01/29/2012 revealed that Resident #3 was in her bedroom cursing her roommate (Resident #6) and the roommate (Resident #6) was crying in bed with her head covered. Record review of the Social Progress Notes dated 01/30/12 revealed Resident #3 was sent to a Behavioral Health Center due to inappropriate behaviors and the Social Progress notes revealed that it was reported by staff that Resident #3 had been touching her roommate inappropriately and was reporting that bugs were crawling out of her body and that her skin was falling off. Record Review of Resident #3's Status History Report revealed Resident #6 & #3 shared a bedroom from 01/06/2012 through 01/30/2012. The Status History Report revealed Resident #6 was moved to another room in the facility on 01/30/2012. Record review of the History and Physical (H&P) dated 02/03/2012 and obtained from the Behavioral Unit revealed that Resident #3 was admitted to the Behavioral unit on 01/30/12. Resident #3 had a history of [REDACTED].#3 was sexually inappropriate with another resident. In addition, the H&P revealed that Resident #3 was found doing sexually inappropriate things to other residents in the nursing home. On 3/30/2012 at 1:00am the Administrator/ S1 indicated that Resident #3 was admitted to the facility with a history of eloping and inappropriate sexual behaviors. The S1/Administrator indicated that the nurse on duty on March 17, 2012 notified her by telephone that Resident #3 had informed her that she did a sexual act on an employee and that the resident identified the employee. In interview on 03/30/2012 at 2:50pm the Maintenance/S5 indicated that he was aware of the sexual incident which occurred between Resident #3 and the Housekeeper/S15. Maintenance/S5 indicated that Resident #3 was very sexual and he indicated that Resident #3 would go up and attempt to hug or kiss staff and residents. The Maintenance /S5 further indicated that Resident #3 was easily redirected and staff knew not to "entertain her comments." S5/ Maintenance indicated that Resident #3 was transferred to another facility after she (Resident #3) reported that she had a sexual encounter with an employee ( S15). In interview on 04/02/2012 at 1:00am the Licensed Practical Nurse/S6 indicated Resident #3 was admitted on [DATE] and had a history of [REDACTED].#3's inappropriate sexual behaviors. In addition, the LPN/S6 indicated that Resident #3 and #6 shared a room and that the night nurse reported that Resident #3 was found touching Resident #6 inappropriately. The LPN /S6 further indicated that Resident #6 was moved to another room and she could not remember the exact day Resident #3 was moved. Record review of the criminal background check (from a previous hire of 2004) located in S15/Housekeeper's personnel record revealed the following charges were filed in the courts on 06/23/1997. Further review of S15/Housekeeper background check dated 06/23/97 revealed S15 was charged for illegal use of a weapon and the disposition on 01/10/2000 revealed S15 pleaded guilty and was sentenced to 2 years of hard labor. Record review of S15/Housekeeping personnel record revealed the housekeeper/S15 was employed on 12/22/2012. The criminal background check in S15's personnel record revealed the facility obtained the criminal background check from the investigational agency on 03/22/2012 via Fax. Further review of S15's criminal background check revealed S15/Housekeeper had the following charges and arrests : 1989 shoplifting and contributing to the delinquency of [MEDICATION NAME], theft by shoplifting, resisting an officer,1990 aggravated assault, 1993 disturbing the peace, simple assault, 1994 discharge of a firearm,1995 La -DOC p&p adult services, illegal use of weapons, 1997 intoxication , disturbing the peace, 1997 possession of a firearm by a convicted felon, resisting arrest, 1999 child desertion, 2003 La-DOC P&P Adult Services, monetary instrument abuse, 2004 LA-DOC P&P . In interview on 04/03/2012 at 1:00 pm S1/ADM indicated that S15 was hired on 12/22/12, prior to the administrator being hired. S1/ADM indicated that S15 was dismissed from the facility on 03/17/12 after allegations of sexual abuse with a resident was reported. S1/ADM. indicated after reviewing S12/Housekeeping ' personnel record S1/ADM. discovered that the criminal background check was not in S12/Housekeepers personnel record. In addition S1/ADM indicated that a copy of S15's criminal background check was requested and faxed to the facility from the investigational agency on 03/20/12 (5 days after S15 was dismissed from the facility). S1/ADM. indicated that she was not aware of the charges and that S15 was employed at the facility in 2004 and was re-hired again on 12/22/2012. Review of personnel files revealed that S10/ Dietary staff was hired on 02/24/12, S12/ Activity Director was hired on 02/13/2012, S13/CNA was hired on 02/24/2012, S14 CNA was hired on 03/16/2012 and S15 Housekeeping staff was hired on 12/22/2011. In addition, review of the orientation and check list for Abuse/Neglect revealed that after all modules have been presented, the new employee signs and dates the orientation form. That indicates that the information has been explained by checking the line preceding the item. The person responsible for orienting the employees will also sign and date the orientation checklist. Review of 5 of 5 employee ' s personnel records (S10HK, S12AD, S13CNA, S14CNA, and S15HK) revealed the orientation check list was signed and dated by the employee and Human Resource staff. The Abuse/Neglect section on the orientation check list was not checked as being provided to the employee. In interview on 04/03/2012 at 1:00pm S1/ADM indicated that the department supervisors are responsible for providing the orientation on abuse and neglect. In addition S1/ADM acknowledges that she did not see where the abuse and neglect orientation was signed or checked off as being done. S1/ADM indicated that the facility was in the process of addressing orientation training because the QA department identified areas of concern with training. In interview on 04/03/2012 at 12:51pm S9/Dietary Supervisor indicated that she was responsible for providing the training in abuse and neglect prevention. In addition S9/ dietary Supervisor indicated that she obtains the personnel form from human resources and she goes over the forms with the employee and has the employee sign the orientation form. The file is then given back to human resource staff. The Dietary Supervisor/S9 stated, "I do not sign anything" referring to the orientation/training for employees.