Every finding on record at Legacy Nursing and Rehabilitation of Morgan City

Based on interviews and record reviews, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of discharges and/or transfers from the facility for 1 (Resident #16) of 1 sampled resident investigated for discharge and 3 (Resident #53, Resident #85, Resident #98) of 4 sampled residents investigated for Resident Assessment. Findings:Review of Resident #16's Nurse Progress Note dated [DATE] at 8:15AM revealed Resident #16 died in the facility on [DATE]. Review of Resident #53's electronic medical record revealed, in part, Resident #53 was transferred to another facility on [DATE]. Review of Resident #85's Nurse Progress Note dated [DATE] at 11:48AM revealed Resident #85 was discharged from the facility on [DATE]. Review of Resident #98's Discharge Minimum Data Set with an Assessment Reference Date of [DATE] revealed, in part, Resident #98 was discharged from the facility on [DATE]. Review of the facility's presented documentation revealed no evidence the Long-Term Care Ombudsman was sent a copy of the discharge and/or transfer notice for Resident #53's transfer to another facility or Resident #16's, Resident #85's and Resident #98's discharge from the facility. In an interview on [DATE] at 4:05PM, S5Director of Social Services indicated she did not report facility discharges and transfers to the Long-Term Care Ombudsman. In an interview on [DATE] at 8:18AM, S1Administrator indicated the facility was not aware facility discharges and transfers had to be reported to a representative of the Long-Term Care Ombudsman. In a telephone interview on [DATE] at 12:01PM, a representative of the Long-Term Care Ombudsman's office indicated the Long-Term Care Ombudsman was not notified of the above mentioned facility transfer and discharges.

Based on observations, interviews, record reviews the facility failed to:Ensure the facility's ice machine was maintained in a sanitary manner;Ensure a kitchen garbage receptacle was not near the clean dinnerware; and,Ensure a log, including the sanitization level testing and water temperature monitoring, was maintained for the facility's three compartment sink. Findings:1.Observation on 07/29/2026 at 9:23AM revealed the facility's ice machine in the dining area had an, unknown brown substance about 6 inches long, on the interior flap above the ice, and water was dripping from the interior flap down onto the ice. In an interview on 07/29/2026 at 9:25AM, S8Maintenance Director indicated he did not recall nor did he have documentation of the last scheduled cleaning of the facility's ice machine. Observation on 07/29/2026 at 9:30AM revealed S8Maintenance Director used a white paper towel and wiped the plastic interior flap of the facility's ice machine. Further observation revealed the unknown brown substance inside the ice machine was removable and was transferred onto the white paper towel. In an interview on 07/29/2026 at 9:27AM, S8Maintenance Director indicated the unknown brown removable substance on the interior flap of the facility's ice machine could cause cross contamination, and the facility's ice machine should have been clean. 2.Observation of the facility's kitchen on 07/28/2026 at 8:25AM revealed a gray rolling garbage receptacle, with a lid next to an uncovered rolling cart which contained trays of clean dinnerware. Observation of the facility's kitchen on 07/29/2026 at 9:00AM revealed a gray rolling garbage receptacle without a lid was present next to an uncovered rolling cart which contained trays of clean dinnerware. In an interview on 07/29/2026 at 9:24AM, S14Dietary Manager indicated the gray rolling garbage receptacle that was in the facility's kitchen should not have been kept next to the facility's uncovered clean dinnerware. S14Dietary Manager further indicated this practice could cause cross contamination. 3.Review of the facility's three compartment sink's sanitization testing and water temperature monitoring or audit log revealed no documentation sanitization testing or water temperature monitoring was completed prior to July 2026. In an interview on 07/29/2026 at 9:20AM, S14Dietary Manager indicated she did not have recorded documentation the three compartment sink's sanitization and water temperatures were monitored prior to July 2026. In an interview on 07/29/2026 at 10:19AM, S2Director of Nursing (DON) indicated the unknown brown substance on the inside of the facility's ice machine could cause cross contamination, and the ice machine should have been free from the unknown brown substance on the inside of the ice machine. S2DON further indicated the garbage receptacle in the kitchen should not have been kept near the clean dishes on the uncovered rolling cart. In an interview on 07/29/2026 at 10:07AM, S4Infection Preventionist indicated the rolling plastic gray garbage can that was open should not have been near the uncovered rolling cart with clean dishes. S4Infection Preventionist further indicated this practice could cause cross contamination.

Based on interviews and record reviews, the facility failed to conduct a Quarterly Review Assessment at least every 92 days following the previous assessment for 1 (Resident #26) of 4 sampled residents reviewed for Resident Assessment. Findings:Review of Resident #26's completed Minimum Data Set (MDS) assessments revealed, in part, Resident #26 had a quarterly MDS assessment completed on 02/11/2026. Further review revealed Resident #26 had no other documented MDS assessments since the 02/11/2026 quarterly MDS assessment. Review of the facility's Validation Report dated 03/02/2026 and printed on 07/29/2026 revealed, in part, Resident #26's last resident assessment, a quarterly MDS with an ARD of 02/11/2026, was accepted on 03/02/2026. Further review revealed no further assessment was completed by the facility for Resident #26 since the 02/11/2026 quarterly MDS assessment. In an interview on 07/27/2026 at 2:06PM, S10Minimum Data Set Nurse indicated Resident #26 should have had an additional quarterly MDS assessment completed by 05/14/2026. S10Minimum Data Set Nurse further indicated she could not produce any documentation Resident #26 had a MDS assessment completed since 02/11/2026. In an interview on 07/27/2026 at 2:53PM, S2Director of Nursing confirmed Resident #26 did not have a quarterly MDS completed since 02/11/2026 as required, and should have.

Based on interviews and record reviews, the facility failed to electronically transmit encoded and completed Minimum Data Set (MDS) assessments to the Center for Medicare and Medicaid Services (CMS) for 3 (Resident #16, Resident #53, Resident #85) of 4 sampled residents reviewed for Resident Assessment. Findings: Resident #16Review of Resident #16's Nurse Progress Note dated [DATE] at 8:15AM revealed Resident #16 died in the facility on [DATE]. Review of Resident #16's completed MDS assessments revealed, in part, Resident #16 had no other encoded, completed, and transmitted MDS assessment since Resident #16's entry MDS with an Assessment Reference Date (ARD) of [DATE]. Further review revealed Resident #16 did not have a discharge MDS assessment completed after Resident #16 expired in the facility on [DATE]. Resident #53Review of Resident #53's electronic medical record revealed, in part, Resident #53 was transferred to another facility on [DATE]. Review of Resident #53's completed MDS assessments revealed, in part, Resident #53 had no other encoded, completed, and transmitted MDS assessment since Resident #53's admission MDS with an ARD of [DATE]. Further review revealed Resident #53 did not have a discharge MDS assessment completed after Resident #53 was transferred to another facility on [DATE]. Resident #85Review of Resident #85's Nurse Progress Note dated [DATE] at 11:48AM revealed Resident #85 was discharged from the facility on [DATE]. Review of Resident #85's completed MDS assessments revealed, in part, Resident #85 had no other encoded, completed, and transmitted MDS assessment since Resident #85's admission MDS with an ARD of [DATE]. Further review revealed Resident #85 did not have a discharge MDS assessment completed after Resident #85 was discharged from the facility on [DATE]. Review of the facility's Validation Reports dated [DATE], [DATE], and [DATE] revealed, in part, Resident #16, Resident #53, and Resident #85 did not have any other encoded, completed, and transmitted MDS since their respective admission MDS assessments. In an interview on [DATE] at 2:03PM, S10Minimum Data Set Nurse indicated Resident #16's, Resident #53's, and Resident #85's MDS assessments were not completed once the residents were discharged from the facility; therefore, the MDS assessments were not electronically transmitted to CMS, but should have been. In an interview on [DATE] at 2:53PM, S2Director of Nursing indicated Resident #16's, Resident #53's, and Resident #85's MDS assessments were not completed; therefore, the MDS assessments were not electronically transmitted to CMS, but should have been.

Based on interviews and record reviews, the facility failed to ensure a Minimum Data Set assessment accurately reflected a resident's oxygen therapy status for 1 (Resident #92) of 24 sampled residents reviewed for accuracy of assessments. Findings:Review of Resident #92's electronic medical record revealed, in part, Resident #92 was admitted to the facility on [DATE] and had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (lung disease that blocks airflow) with a start date of 11/26/2025. Review of Resident #92's July 2026 Physician's Orders revealed, in part, an order for Resident #92 to receive oxygen therapy at 2 liters per minute via nasal cannula through a concentrator every shift related to Resident #92's diagnosis of COPD, with an order start date of 11/28/2025. Review of Resident #92's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2026 revealed, in part, Resident #92 did not receive oxygen therapy. Review of Resident #92's Quarterly MDS with an ARD of 05/06/2026 revealed, in part, Resident #92 did not receive oxygen therapy. Observation on 07/27/2026 at 3:02PM revealed Resident #92 was lying in bed appropriately wearing a nasal cannula connected to an oxygen concentrator, which was set at 2 liters per minute. Observation on 07/28/2026 at 9:45AM revealed Resident #92 was lying in bed appropriately wearing a nasal cannula connected to an oxygen concentrator, which was set at 2 liters per minute.In an interview on 07/28/2026 at 10:54AM, S10Minimum Data Set Nurse indicated Resident #92's Quarterly MDS dated [DATE] and Resident #92's Quarterly MDS dated [DATE] did not accurately reflect Resident #92's oxygen therapy, and should have. In an interview on 07/28/2026 at 2:30PM, S2Director of Nursing confirmed Resident #92 received oxygen therapy. S2Director of Nursing confirmed Resident #92's Quarterly MDS dated [DATE] and Resident #92's Quarterly MDS dated [DATE] did not accurately reflect Resident #92's oxygen therapy, and should have.

Based on interviews and record reviews, the facility failed to ensure a referral was made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASARR) program for a resident with a diagnoses of post-traumatic stress disorder (PTSD) for 1 (Resident #23) of 1 sampled resident investigated for PASARR. Findings: Review of Resident #23's Electronic Medical Record (EMR) revealed, in part, Resident #23 was admitted to the facility on [DATE]. Further review revealed Resident #23 had a diagnosis of PTSD upon admission. Review of Resident #23's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/12/2026 revealed, in part, Resident #23 had a diagnosis of PTSD. Review of the Louisiana Office of Behavioral Health PASARR Evaluation Summary and Determination Notice dated 06/03/2026 revealed, in part, Resident #23's diagnosis of PTSD was not documented on the form. Review of Resident #23's medical record revealed there was no documented evidence a PASARR Level II evaluation was completed for Resident #23 and/or a referral was made to the Louisiana Office of Behavioral Health's PASARR program for Resident #23 due to the diagnosis of PTSD. In an interview on 07/29/2026 at 9:35AM, S5Director of Social Services indicated Resident #23 had a diagnosis of PTSD. S5Director of Social Services indicated Resident #23 did not have a referral to the Louisiana Office of Behavioral Health for a Level II screening for Resident #23's diagnosis of PTSD. In an interview on 07/29/2026 at 9:47AM, S1Administrator indicated Resident #23's referral to the Louisiana Office of Behavioral Health for a Level II screening due to a diagnosis of PTSD was not submitted and it should have been.

Based on interviews and record reviews, the facility failed to:1. Develop a person-centered care plan to address a resident's dialysis care and treatment (Resident #2); and,2. Develop a person-centered care plan to address a resident's specific care needs (Resident #49).This deficient practice was identified for 2 (Resident #2, Resident #49) of 2 sampled residents investigated for care plans. Findings: 1. Review of Resident #2's record revealed, in part, Resident #2 was admitted to the facility on [DATE] and had a diagnosis of End-Stage Renal Disease (ESRD). Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2026 revealed, in part, Resident #2 had diagnosis of ESRD and received dialysis as a resident. Review of Resident #2's current physician orders revealed, in part, Resident #2 had the following physician's orders: -Dialysis treatment every Monday, Wednesday and Friday at the local dialysis center; -Check Resident #2's dialysis shunt site (the site where the dialysis access occurs) to the left arm for a bruit and thrill each shift; and, -Do not take blood pressures in Resident #2's left arm. Review of Resident #2's care plan revealed, in part, a plan of care was not developed regarding dialysis care for Resident #2. Further review revealed Resident #2's plan of care did not include Resident #2 receiving dialysis or shunt site monitoring or care. In an interview on 07/28/2026 at 2:40PM, S11MDS Nurse indicated Resident #2 did not have a plan of care developed for dialysis or dialysis care, and should have. In an interview on 07/28/2026 at 2:45PM, S2Director of Nursing (DON) indicated Resident #2 should have had a dialysis plan of care for dialysis care. 2. Review of Resident #49's Quarterly MDS with an ARD of 06/03/2026 revealed, in part, Resident #49 required partial/moderate assistance with transfers and used a wheelchair for mobility. Further review revealed, Resident #49 was dependent with walking. Review of Resident #49's care plan initiated on 02/14/2025 with a new review date of 09/22/2026 revealed, in part, Resident #49 required staff assistance with all activities of daily living. Further review revealed the following interventions: - Resident #49 preferred a bed bath; - Resident #49 preferred bathing in the tub/whirlpool in the evening; - Resident #49 preferred bathing in the tub/whirlpool in the morning; - Resident #49 preferred evening showers; - Resident #49 preferred morning showers; - Resident #49 required a mechanical lift for transfers; - Resident #49 required assistance for transfers to the toilet; - Resident #49 used a quad cane for ambulation support; - Resident #49 used a walker for ambulation; - Resident #49 used a wheelchair for mobility; and, - Resident #49 used a wheeled walker for ambulation. In an interview on 07/28/2026 at 3:15PM, S2DON reviewed Resident #49's care plan with the surveyor and indicated it looked like they just checked all the boxes. S2DON further indicated Resident #49 did not have a care plan that was person-centered and specific to Resident #49's care, and should have.

Based on observations, interviews, and record reviews, the facility failed to:1. Complete neurological checks for a resident with an incident involving a head injury (Resident #21); and,2. Ensure a resident's anti-slip grip strips were not an accident hazard (Resident #94).This deficient practice was identified for 2 (Resident #21, Resident #94) of 3 sampled residents investigated for accidents.Findings: 1. Review of the facility's undated Incident and Accident Policy and Procedure revealed, in part, neurological signs should be monitored and documented for 72 hours following an incident with a head injury. Observation on 07/27/2026 at 9:30AM revealed Resident #21 had a bruise to the left eye with a laceration above the left eye. Review of the Resident #21's Incident Report dated 07/25/2026 at 6:00AM revealed, in part, Resident #21 hit the left side of his head on a tube feeding pump which resulted in a laceration. Review of Resident #21's electronic medical records revealed, in part, there was no documentation neurological signs were monitored and documented for 72 hours following an incident involving a head injury as required. In an interview on 07/27/2026 at 3:32PM, S2Director of Nursing indicated assessments and documentation of Resident #21's neurological signs should have be completed for Resident #21 due to the incident involving Resident #21's head on 07/25/2026. In an interview on 07/29/2026 at 9:10AM, S12Licensed Practical Nurse (LPN) indicated neurological assessment and documentation was not started on Resident #21 after the incident involving a head injury on 07/25/2026. S12LPN further indicated the neurological assessments should have been done. 2. Review of Resident #94's quarterly Minimum Data Set with an Assessment Reference Date of 05/12/2026 revealed, in part, a brief interview mental status score of 11, which indicated Resident #94 had moderate cognitive impairment. Further review revealed Resident #94 either had a fall since admission, reentry, or prior assessment. Observation off Resident #94's bathroom on 07/27/2026 at 9:19AM revealed there were two anti-slip grip strips attached to the floor in front of the bathroom mirror with the edges peeling and curling. Further observation revealed parts of Resident #94's anti-slip grip strips were missing. Observation of Resident #94's bathroom on 07/27/2026 at 3:17PM revealed there were two anti-slip grip strips attached to the floor in front of the bathroom mirror with the edges peeling and curling. Further observation revealed parts of Resident #94's anti-slip grip strips were missing. In an interview on 07/27/2026 at 3:20PM, S8Maintenance Director indicated he was aware Resident #94's anti-slip grip strips needed to be replaced, as this was reported to him about a month ago by a nurse. S8Maintenance Director further indicated he had initially placed the anti-slip grip strips as a safety intervention for Resident #94, and in the present condition, Resident #94's anti-slip grip strips would posed itself as a safety hazard. In an interview on 07/27/2026 at 3:32PM, Resident #94 indicated she utilized the bathroom where the above mentioned tattered anti-slip grip strips were located. In an interview on 07/28/2026 at 8:00AM, S2Director of Nursing (DON) indicated the anti-slip grip strips should have been replaced for Resident #94. In an interview on 07/28/2026 at 2:43PM, S1Administrator indicated the anti-slip grip strips should have been replaced for Resident #94.

Based on observations, interviews, and record review, the facility failed to:1. ensure clean linens were stored separately from soiled linens; and,2. handled and/or transported properly.Findings: 1. Observation on 07/27/2026 at 10:15AM revealed an uncovered metal rack present on the soiled side of the laundry room which contained 32 clean mop pads, 6 clean mop heads, 29 clean cleaning cloths and 7 clean dusting pads. In an interview on 07/27/2026 at 10:18AM, S13Laundry Aide (LA) indicated the 32 mop pads, 6 mop heads, 29 cleaning cloths and 7 dusting pads were clean. S13LA further indicated the clean housekeeping supplies were stored on the soiled side of the laundry room. In an interview on 07/27/2026 at 10:45AM, S6Environmental Supervisor (ES) indicated the above documented housekeeping supplies were clean. S6ES indicated the clean housekeeping supplies had been stored on the soiled side of the laundry room for the last 1-2 months because there was more storage space available on the soiled side of the laundry room. S6ES further indicated clean housekeeping supplies should not have been stored on the soiled side of the laundry room. In an interview on 07/27/2026 at 2:36 PM, S3Regional Nurse indicated the clean housekeeping supplies should not have been stored on the soiled side of the laundry room. 2. Review of the facility's undated Infection Prevention and Control Environmental Services policy and procedure revealed soiled linen shall be bagged, in or near the resident room, and securely closed prior to transport. Observation on 07/27/2026 at 2:35PM revealed S6ES carried uncontained soiled linen, which was in direct contact with S6ES's clothing, through the facility's hallway. In an interview on 07/27/2026 at 2:36PM, S6ES indicated she carried the uncontained soiled linen to the laundry room. In an interview on 07/28/2026 at 8:00PM, S2DON indicated staff should keep uncontained soiled linen away from their clothing while transporting the soiled linen through the facility. In an interview on 07/29/2026 at 2:00PM, S4Infection Preventionist (IP) indicated staff should not carry soiled linen and the soiled linen should never touch their clothing. S4IP further indicated soiled linen should be placed in a barrel for transport through the facility.

Based on interviews and record reviews, the facility failed to ensure the resident's medical record was complete for 1 (Resident #1) of 3 sampled residents reviewed for activities of daily living documentation. Findings:Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 10/22/2025 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15 (a score of 13-15 indicated Resident #1 was cognitively intact). Further review revealed Resident #1 was dependent on staff for toileting, showering, and bathing. Review of Resident #1's care plan revealed Resident #1 required staff assistance for all activities of daily living with a goal date of 02/06/2026 with approaches that included, in part, certified nursing assistant (CNA) staff were to assist Resident #1 with hygiene and grooming tasks as needed. Further review of Resident #1's care plan revealed Resident #1 refused showers at times with a goal date of 02/06/2026 with approaches that included, in part, allow Resident #1 opportunities to make choices and participate in care. Review of Resident #1's October 2025 Documentation Survey Report for Activities of Daily Living revealed no evidence Resident #1 had received and/or refused morning care on: 10/07/2025, 10/12/2025, 10/13/2025, 10/14/2025, 10/16/2025, 10/17/2025, 10/18/2025, 10/19/2025, 10/22/2025, 10/23/2025, 10/27/2025, 10/28/2025, and 10/31/2025. Further review revealed, in part, Resident #1 was documented as having refused a bath or shower on the following dates: 10/04/2025, 10/07/2025, 10/11/2025, 10/14/2025, 10/16/2025, 10/23/2025, 10/25/2025, and 10/30/2025. Review of Resident #1's November 2025 Documentation Survey Report for Activities of Daily Living revealed no evidence Resident #1 had received and/or refused evening care on 11/08/2025. Further review revealed, in part, Resident #1 was documented as having refused a bath or shower on the following dates: 11/01/2025, 11/04/2025, 11/11/2025, and 11/13/2025. In an interview on 12/29/2025 at 2:20PM, S5CNA indicated Resident #1 often refused baths and care. S5CNA further indicated once Resident #1 was comfortable with her, she often gave Resident #1 a bath every day since he was a larger man; however, S5CNA indicated she was only able to document in the computer system on Resident #1's assigned bath days, which were Tuesdays, Thursdays, and Saturdays. S5CNA further indicated if Resident #1 refused care with other CNA staff, the other CNA staff would get S5CNA to bathe Resident #1, but S5CNA could not chart Resident #1's bath was completed. In an interview on 12/30/2025 at 10:15AM, S6CNA Supervisor indicated she had complaints from staff about Resident #1 refusing care; therefore, the facility tried to change the CNA staff responsible for Resident #1's care to ensure Resident #1 received his activities of daily living care. In an interview on 12/30/2025 12:38PM, S6CNA Supervisor indicated all care and/or refusal would be documented in the electronic medical record, and the facility did not document care in any other form. S6CNA Supervisor confirmed the blanks on Resident #1's October and November 2025 Documentation Survey Report Activities of Daily Living and indicated the documentation should not be left blank. In an interview on 12/30/2025 at 12:43PM, S7CNA indicated the above mentioned care was provided to Resident #1 but was not documented. S7CNA indicated on multiple shifts in October 2025 and November 2025, S8CNA was assigned to Resident #1, but Resident #1 refused care. S7CNA indicated S8CNA would ask S7CNA to provide Resident #1's care. S7CNA indicated she provided Resident #1's bath/shower but did not document the care, since Resident #1 was not assigned to her. S7CNA further indicated Resident #1 would also refuse a bath/shower if the night shift provided the care; however, since the system only had ability to document on Resident #1's assigned bath/shower days and for the day shift, the baths/showers given at night were not documented. In an interview on 12/30/2025 at 12:44PM, S8CNA indicated due to Resident #1 knowing her prior to being admitted to the facility he refused to allow her to provide his care. S8CNA further indicated she often worked with S7CNA who he would allow to provide care. S8CNA further indicated she did not document the bath/shower given by S7CNA, as she did not provide the care. In an interview on 12/30/2025 at 12:49PM, S9CNA indicated Resident #1 refused baths/showers and other care. S9CNA indicated it was common practice to have CNAs swap during showers to find a CNA Resident #1 would allow to provide his care. S9CNA further indicated if Resident #1 was not assigned to her, she did not have availability to document the care provided to Resident #1 in the facility's computer system. In an interview on 12/30/2025 at 12:51PM, S2Director of Nursing indicated the staff should have documented Resident #1's care provided and/or refusals of care. S2Director of Nursing reviewed the above mentioned documentation and confirmed missing documentation for care. S2Director of Nursing indicated the only activity of daily living documentation was the electronic medical record, and the facility had no further information to present to the surveyor. In an interview on 12/30/2025 at 12:52PM, S4Assistant Director of Nursing reviewed the above mentioned documentation and confirmed missing documentation for Resident #1's care. S4Assistant Director of Nursing indicated the only activity of daily living documentation was the electronic medical record, and the facility had no further information to present to the surveyor. In an interview on 12/30/2025 at 1:01PM, S1Administrator was informed of the above findings and S1Administrator indicated there should have been documentation of all care provided or documentation of any refusals. S1Administrator confirmed the above findings and indicated there should be documentation of Resident #1's care. S1Adminsitrator further indicated the facility did not have any further documentation to present to the surveyor at this time. In an interview on 12/30/2025 at 1:03PM, S3Previous Director of Nursing indicated the facility did have a change in the computer software in October and November 2025; however, the facility had no documentation these issues were identified and corrected. S3Previous Director of Nursing further indicated the facility had no further documentation to present for the above mentioned deficient practice.

Based on observations, interviews, and record reviews, the facility failed to protect a resident's right to be free from verbal and mental abuse by another resident for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. This deficient practice resulted in an actual harm on 07/06/2025 at approximately 9:30PM, when Resident #15, a resident with known aggressive behaviors towards staff and other residents, was overheard by her roommate, Resident #30, during a telephone conversation where Resident #15 used racial slurs so loudly that Resident #30 overheard the conversation. On 07/07/2025 at approximately 2:30PM, Resident #30 was observed by staff crying. Resident #30 informed S9Certified Nursing Assistant (CNA) of the conversation that was overheard on 07/06/2025 when Resident #15 used racial slurs. Resident #15 who was in the room during the conversation reacted to S9CNA and Resident #30 by using racial slurs, cursing, and kicking the trash can. Resident #30 indicated this aggressive behavior caused her to be anxious, nervous, and unable to avoid Resident #15 because she was bed bound. Resident #30 further indicated she kept her grabber within reach and planned to use it to defend herself against any physical attacks from Resident #15. Resident #30 indicated she notified S3Social Services, S4Infection Preventionist, S5CNA, S6CNA, S7CNA, S8CNA, S9CNA, and S11Licensed Practical Nurse (LPN) that she was upset, felt anxious and depressed having to room with Resident #15. The facility failed to intervene on behalf of Resident #30. Findings:Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents; abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Further review revealed the safety of other residents and employees of the facility was the primary concern. Resident #30Review of Resident #30's MDS with an ARD of 05/07/2025 revealed, in part, Resident #30 was admitted to the facility on [DATE] and was African American. Further review revealed Resident #30 had a BIMS score of 13, which indicated Resident #30 was cognitively intact. Review revealed Resident #30 was dependent on staff for all activities of daily living. Resident #15Review of Resident #15's electronic medical record (EMR) revealed, in part, Resident #15 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and depression. Review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, Resident #15 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #15 had moderate cognitive impairment. Further review revealed Resident #15 was capable of propelling herself in her manual wheelchair.Review of Resident #15's admission packet from Resident #15's previous facility revealed, in part, a nurse's note dated 09/27/2024 which indicated Resident #15 became upset at another resident and stated that black mother f*cker. Review of Resident #15's Follow-Up Question Report documentation by Certified Nursing Assistants (CNA) dated 05/15/2025 through 07/07/2025 revealed, in part, Resident #15 had documented behaviors including screaming at others, agitation, cursing at others, expressing frustration and anger at others, spitting, and physical aggression towards others. Review of Resident #15's Social Service Progress Note dated 07/07/2025 at 5:41PM revealed, in part, S3Social Services documented the CNA reported that on 07/06/2025, Resident #15 was talking on the phone and stated her roommate was the devil. Further review revealed Resident #15 made derogatory comments about African Americans due to the way she was raised. Further review revealed Resident #15 would have a psychiatric evaluation. Review of Resident #15's Psychiatric Evaluation dated 07/08/2025 revealed, in part, Resident #15 was seen due to displaying verbal aggression. Further review revealed Resident #15 was started on buspirone hydrochloride (a medication used to treat anxiety) 5 milligrams by mouth every 12 hours. Further review revealed the Psychiatric Evaluation did not address the incidents from 07/06/2025 and 07/07/2025. Review of Resident #15's Follow-Up Question Report documentation by CNAs dated 07/08/2025 through 08/06/2025 revealed, in part, Resident #15 continued to have behaviors following Resident #15's psychiatric evaluation and medication initiation. Further review revealed Resident #15's documented behaviors included cursing at others, expressing frustration and anger at others, disruptive sounds, agitation, screaming at others, threatening others, pushing others, and entering other residents' personal space. Review of Resident #15's record revealed, in part, Resident #15 did not have any additional documented incidents of verbally or mentally abusing Resident #30 following the 07/06/2025 and 07/07/2025 incidents. There was no documented evidence, and the facility failed to present any documented evidence, additional interventions were implemented to protect Resident #30 from additional mental and verbal abuse and ensure Resident #30 was assessed and provided services following the verbal and mental abuse by Resident #15. In an tearful interview on 08/05/2025 at 8:57AM, Resident #30 indicated on 07/06/2025 at approximately 9:30PM, she overheard her roommate, Resident #15, informing someone on the phone that Resident #15's niece brought home a n*gger. Resident #30 further indicated Resident #15 then stated if Resident #15's mother was aware, Resident #15's mother would beat the sh*t out of her because we do not like n*ggers. Resident #30 further indicated that on the same phone conversation, Resident #15 called Resident #30 evil and the devil. Resident #30 reported that on 07/07/2025 at approximately 2:30PM, S9CNA found Resident #30 crying and asked Resident #30 what was wrong. Resident #30 indicated she reported to S9CNA that Resident #30 overheard Resident #15's telephone conversation the night before. Resident #30 further indicated Resident #15 overheard Resident #30 and S9CNA speaking about the incident, and Resident #15 became violent and screamed racial slurs towards both Resident #30 and S9CNA. Resident #30 indicated this aggressive behavior caused her to be anxious, nervous, and unable to avoid Resident #15 because she was bed bound. Resident #30 further indicated she kept her grabber within reach and planned to use it to defend herself against any physical attacks from Resident #15. Resident #30 indicated she reported the incident to S3Social Services and several staff, but Resident #30 felt like the facility did not care because nothing was done. Resident #30 was not asked by the surveyor if S1Administrator offered her a room change. In an interview at 08/05/2025 at 10:35AM, S11LPN indicated Resident #15 stated she did not like black people because that was the way she was raised. S11LPN further indicated Resident #15 would often say racial slurs to Resident #30. S11LPN further indicated this would be considered bulling or verbal abuse due to Resident #30's reaction to the behavior by being tearful and visibly upset. In an interview on 08/05/2025 at 12:06PM, S11LPN indicated S3Social Services and S1Administrator were aware of the behavior from Resident #15 towards Resident #30. In an interview on 08/05/2025 at 1:21PM, S9CNA indicated on 07/07/2025 at about 2:30PM she was going into Resident #15 and Resident #30's room for rounds and upon entering she observed Resident #30 crying. Resident #30 explained to S9CNA that she overheard a phone conversation by Resident #15 in which Resident #15 used racial slurs of the n word and called Resident #30 the devil. S9CNA indicated during the conversation, Resident #15 overheard Resident #30 speaking to S9CNA and propelled her wheelchair over to Resident #30's side of the room and exclaimed, I was raised that way, I don't give a f*ck. S9CNA indicated Resident #15 continued to curse and yell at her and Resident #30. S9CNA further indicated she reported the above mentioned incident to S10CNA Supervisor. In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA reported that Resident #30 was upset because Resident #15 was used racial slurs and profanity towards S9CNA and Resident #30. S10CNA Supervisor further indicated she informed the S2DON, S3Social Worker, and S1Administer, and they came up with a plan to document all of Resident #15's aggressive behaviors. S10CNA Supervisor further indicated she was not made aware of any interventions implemented for Resident #30. In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware Resident #15 was vulgar, aggressive and used racial slurs. S3Social Services further indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 and was aware Resident #30 was upset as a result. S3Social Services further indicated the facility did not have another room available to separate the residents. In an interview on 08/05/2025 at 3:59PM, S8CNA confirmed worked with Resident #15 and 30 on 07/06/2025 from 6:00PM to 6:00AM. S8CNA indicated she was told by Resident #30 that Resident #15 was on a phone call with a friend when Resident #15 called Resident #30 derogatory names and stated that Resident #15 hated black people. S8CNA further indicated that Resident #15 often had behaviors and was very aggressive towards anyone around her. S8CNA confirmed that Resident #15 often cursed and said derogatory comments to Resident #30. S8CNA further indicated she did feel like Resident #15 was verbally abusive to Resident #30. In an interview on 08/05/2025 at 4:22PM, S5CNA, indicated she had witnessed Resident #15 use racial slurs to staff and Resident #30. S5CNA further indicated Resident #30 was negatively affected by Resident #15's derogatory racial slurs because she became upset and had nonverbal indicators of being upset. S5CNA further indicated Resident #15's racial slurs were considered verbal abuse to staff and Resident #30. S5CNA confirmed she was never made aware of any changes to Resident #30's care due to Resident #15's behaviors. In an interview on 08/05/2025 at 4:30PM, S7CNA indicated Resident #30 had informed her about the incident between Resident #15 and Resident #30 after the incident happened. S7CNA indicated Resident #30 was very upset about it. S7CNA further indicated that Resident #15 acted out and cursed everyone around her when Resident #15 was upset. S7CNA further indicated she could see how Resident #30 would take this behavior from Resident #15 as verbal abuse. In an interview on 08/05/2025 at 4:32PM, S6CNA confirmed she worked with Resident #15 and Resident #30. S6CNA confirmed Resident #15 cursed out staff and was very hostile and impatient. S6CNA confirmed on 07/07/2025, Resident #30 was crying and informed her that Resident #15 made racially inappropriate remarks on the telephone. S6CNA indicated Resident #30 was very upset and offended by what Resident #15 said on 07/06/2025. S6CNA further indicated the administration was aware of Resident #15's behaviors and never implemented anything new to divert Resident #15's behaviors. S6CNA confirmed Resident #15 verbally abused Resident #30 and staff. In an interview on 08/06/2025 at 10:33AM, S15CNO indicated she was not aware of Resident #15's aggressive behaviors or the incidents between Resident #15 and Resident #30 prior to the surveyor bringing the information to her attention. S15CNO further indicated that Resident #15 should have been removed from Resident #30's room immediately and interventions should have been in place for both residents following the discovery of the incidents on 07/06/2025 and 07/07/2025. S15CNO further indicated, per the Abuse and Neglect policy, Resident #30 was verbally and mentally abused by Resident #15. In an interview on 08/06/2025 at 10:48AM, S1Administrator indicated he was aware of the incidents between Resident #15 and Resident #30 prior to the survey because Resident #30 informed him of the telephone conversation where Resident #15 directed racial slurs towards Resident #30. S1Administrator further indicated he was aware that Resident #30 was upset, but was not aware that Resident #30 was crying or tearful. S1Administrator further indicated that Resident #15 was verbally aggressive, cursed, used racial slurs and based on the interviews and documentation the staff presented, S1Administrator would consider that Resident #15 verbally and emotionally abused Resident #30. S1Administrator indicated he offered Resident #30 a room change, but Resident #30 declined.

Based on observation, interviews, and record reviews, the facility failed to:1. Ensure expired medications were not available for resident use (Medication Cart A);2. Ensure the facility's shift verification of controlled substances count sheet was completed every shift (Medication Cart A); and,3. Ensure medications were documented as administered on the electronic Medication Administration Record (eMAR) when administered (Resident #83).This deficient practice was identified for 1 (Medication Cart A) of 2 (Medication Cart A, Medication Cart B) sampled medication carts observed during medication storage observations and 1 (Resident #83) of 1 (Resident #83) sampled residents investigated for hospice. Findings:1. Review of the facility's undated Storage of Medications policy and procedure revealed, in part, no discontinued, outdated, or deteriorated medications were available for use in the facility. Further review revealed all discontinued, outdated, or deteriorated medications were to be destroyed. Observation of Medication Cart A on 08/06/2025 at 3:30PM revealed, in part: -Advair diskus (medication used to treat inflammatory lung issues) with an expiration date of 10/11/2024 prescribed to Resident #36; - Famotidine (medication used to treat excessive stomach acid) 10 milligram tablets for general resident use with an expiration date of 07/2025; and, - Four Hydrocortisone Acetate (medication used to treat inflammation) 25 mg suppositories (medication inserted into the rectum) for general resident use with an expiration date of 07/2025. In an interview on 08/06/2025 at 3:35PM, S16Licensed Practical Nurse (LPN) confirmed the above mentioned medications' expiration dates and confirmed the above mentioned medications were expired and should not have been on the medication cart available for resident use. In an interview on 08/07/2025 at 9:55AM, S2Director of Nursing (DON) confirmed the above mentioned expired medications should not have been available for resident use. 2. Review of facility's undated Narcotics policy and procedure revealed one licensed nurse from the off-going shift and one licensed nurse from the oncoming shift must count and sign the narcotic count sheet in front of the narcotic box. Review of Medication Cart A's Shift Verification of Controlled Substances Count document revealed, in part: -no documented evidence of the nurse from the off-going 6:00PM-6:00AM shift having verified the narcotic count on: 06/04/2025 and 07/04/2025; -no documented evidence of the off-going 10:00PM-6:00AM shift having verified the narcotic count on: 6/12/2025; -no documented evidence of the nurse from the off-going 6:00AM-10:00PM shift having verified the narcotic count on: 6/28/2025; -no documented evidence of the nurse from the off-going 6:00AM-6:00PM shift having verified the narcotic count on: 07/08/2025; -no documented evidence of the nurse from the on-coming 6:00AM-6:00PM shift having verified the narcotic count on: 07/04/2025 and 7/21/2025; and, -no documented evidence of the nurse from the on-coming unidentified shift having verified the narcotic count on: 06/27/2025 In an interview on 08/06/2025 at 3:35PM, S16LPN confirmed the above mentioned shifts did not have documentation of the off-going and on-coming shift verified the narcotic count, as required. In an interview on 08/07/2025 at 1:38PM, S2DON indicated the facility had no further documentation to present and had no further explanation for the omission of signatures on the above mentioned dates. 3. Review of the facility's undated Medication Administration policy and procedure revealed, in part, each dose of medication administered shall be properly recorded in the resident's medical record. In an interview on 08/04/2025 at 4:05PM, S13LPN indicated Resident #83 was administered Ativan 0.5milligrams/mg (a medication used to treat anxiety) earlier during the shift. The surveyor asked S13LPN what time she administered Resident #83's Ativan. S13LPN indicated Resident #83's Ativan 0.5mg was administered at approximately 12:30PM; however, S13LPN failed to document the administration of Ativan 0.5mg on Resident #83's eMAR. There was no documented evidence, and the facility was unable to present any documented evidence, Resident #83's Ativan 0.5mg was documented as administered on 08/04/2025. In an interview on 08/06/2025 at 1:26PM, S2DON indicated when a medication was administered the nurse should document the administration on the eMAR. S2DON confirmed S13LPN did not document the administration of Resident #83's on 08/04/2025 on Resident #83's eMAR, and should have.

Based on observations, interviews, and record reviews, the facility failed to:1. Ensure the scoop used to serve ice did not have the handle submerged in the residents' ice (Ice Chest A); 2. Ensure staff properly handled soiled linen (S12Certified Nursing Assistant); and, 3. Ensure staff implemented Enhanced Barrier Precautions (EBP) for a resident (Resident #76). This deficient practice was identified for 1 (Ice Chest A) of 2 (Ice Chest A, Ice Chest B) ice chests used to provide ice to residents; 1 (S12CNA) of 1 (S12CNA) CNAs observed during random linen handling observations; and, 1 (Resident #76) of 12 (Resident #5, Resident #9, Resident #10, Resident #17, Resident #32, Resident #70, Resident #76, Resident #77, Resident #81, Resident #85, Resident #90, Resident #91) sampled residents observed on EBP. Findings: 1.Observation on 08/04/2025 at 8:46AM revealed a blue and white ice chest located in the dining room with the ice scoop handle submerged in water and ice. In an interview on 08/04/2025 at 8:55AM, S2Director of Nursing (DON) confirmed the ice scoop handle was inside the ice chest submerged in the residents' water and ice. S2DON indicated the ice scoop should be stored in the ice scoop holder on outside of ice chest and should have not been in the ice chest submerged in residents' water and ice. 2. Review of the facility's undated Linen Handling policy revealed, in part, soiled linen should be bagged, in or near the resident's room, and securely closed prior to transport. Observation on 08/04/2025 at 8:40AM revealed S12Certified Nursing Assistant (CNA) walked in the hallway with unbagged soiled linen.In an interview on 08/04/2025 at 8:42AM, S10Certified Nursing Assistant Supervisor indicated S12CNA should not have walked in the hall with unbagged soiled linen.In an interview on 08/04/2025 at 8:55AM, S2DON indicated S12CNA should not have walked in the hallway with unbagged soiled linen. In an interview on 08/04/2025 at 10:11AM, S12CNA indicated she should not have walked in the hallway with unbagged soiled linen. 3. Review of the facility's undated (EBP) policy and procedure revealed, in part, EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms, where employees wear gowns and gloves during high contact resident care activities. Further review of the policy revealed EBP was to be used for residents with indwelling medical devices which included central lines. Review of the policy also revealed EBP should be used when performing care of or accessing a central line. Review of Resident #76's record revealed, in part, Resident #76 had a peripherally inserted central catheter (PICC) for the administration of intravenous (administered directly into the vein) medication due to a diagnosis of osteomyelitis (infection of the bone). Observation on 08/05/2025 at 7:40AM revealed an EBP signage was present on Resident #76's door indicating personal protective equipment of gloves and gowns were required. Observation on 08/05/2025 at 8:00AM revealed S11Licensed Practical Nurse (LPN) prepared an IV medication for administration and entered Resident #76's room without wearing a surgical gown. In an interview on 08/05/2025 at 8:05AM, S11LPN indicated Resident #76 required EBP and she administered an IV antibiotic via Resident #76's PICC line. S11LPN further indicated she did not wear a gown when accessing Resident #76's PICC line for medication administration. In an interview on 08/05/2025 at 8:15AM, S4Infection Preventionist (IP) indicated EBP required staff to wear gloves and gowns when administering medications via a PICC line. S4IP further indicated S11LPN should have worn a gown when she accessed Resident #76's PICC line for medication administration. In an interview on 08/05/2025 at 9:59AM, S2DON confirmed S11LPN should have worn a gown when she accessed Resident #76's PICC line for medication administration.

Based on interviews and record reviews, the facility failed to report an allegation of verbal and mental abuse to the state agency for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents reviewed for abuse.Findings:Cross Reference F600Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Further review revealed staff should immediately report their knowledge related to abuse allegations to the Administrator or DON without fear of reprisal. Further review revealed an alleged violation of abuse will be reported immediately, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury. Review revealed the facility administrator, or designee shall report or ensure a report was submitted to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Review revealed the administrator would have 5 working days from the initial report of abuse to complete the Statewide Incident Management System (SIMS) report according to the Department of Health and Hospitals (DHH) guidelines.Review of Resident #15's social services progress note dated 07/07/2025 revealed, in part, staff reported Resident #15 was talking on the phone on 07/06/2025 and stated Resident #30 was the devil. Further review revealed Resident #15 and Resident #30 began to argue, and then Resident #15 made derogatory comments about African Americans. Review further revealed Resident #15 was asked to refrain from derogatory remarks.In an interview on 08/05/2025 at 8:57AM, Resident #30 indicated Resident #15 called one of her friends on speaker phone on 07/06/2025 at approximately 9:30PM and Resident #15 told her friend very loudly that Resident #15 did not like n****rs. Resident #30 further stated in Resident #15's same phone conversation, Resident #15 called Resident #30 evil and the devil. Resident #30 further indicated on 07/07/2025 at approximately 2:30PM she informed S9Certified Nursing Assistant (CNA) of the Resident #15's phone conversation from 07/06/2025. Resident #30 indicated during her conversation with S9CNA Resident #15 became violent and screamed profanities and racial slurs toward Resident #30 and S9CNA. Resident #30 further indicated Resident #30 spoke to the social worker and several staff about the incidents which occurred on 07/06/2025 and 07/07/2025.In an interview on 08/05/2025 at 9:04AM, S1Administrator reported the facility did not report any Statewide Incident Management Systems (SIMS) to the state agency for Resident #15 and Resident #30.In an interview on 08/05/2025 at 12:06PM, S11Licensed Practical Nurse indicated she was aware of the continued conflict between Resident #15 and Resident #30. S11LPN further indicated S3Social Services and S1Administrator were aware of the behavior from Resident #15 towards Resident #30.In an interview on 08/05/2025 at 1:21PM, S9CNA indicated on 07/07/2025 at approximately 2:30PM, Resident #30 was crying and informed her of the above mentioned incident from 07/06/2025. S9CNA further indicated while Resident #30 explained the incident to S9CNA, Resident #15 propelled herself over to Resident #30's side of the room and started to curse and yell at S9CNA and Resident #30. S9CNA further indicated she reported this incident to S10CNA Supervisor.In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA reported the above mentioned incidents to her immediately after it happened. S10CNA Supervisor further indicated she notified S1Administrator, S2Director of Nursing (DON), and S3Social Services of the above mentioned incidents on 07/07/2025.In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025.In an interview on 08/06/2025 at 10:48AM, S1Administrator, indicated he was aware of the incidents on 07/06/2025 and 07/07/2025 between Resident #15 and Resident #30 prior to the survey. There was no documented evidence, and the facility did not present any documented evidence, the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 had been reported to the state agency.

Based on interviews and record reviews, the facility failed to have documented evidence a thorough investigation was completed following allegations of verbal and mental abuse for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. Findings:Cross Reference F600 Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Review revealed an abuse investigation included interviewing employees who worked in the resident's room and signed statements should be obtained from the employees. Further review revealed the investigation included interviewing the resident if they were cognitive. Review revealed the facility employee or agent, who became, aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. Further review revealed the administrator or designee would notify the regional director and corporate nurse. Review of Resident #15's social services progress note dated 07/07/2025 revealed, in part, staff reported that on 07/06/2025, Resident #30 had overheard Resident #15's phone conversation in which Resident #15 stated Resident #30 was the devil, and the residents argued. Further review revealed Resident #15 then made derogatory remarks about African Americans. In an interview on 08/05/2025 at 12:06PM, S11Licensed Practical Nurse (LPN) indicated she was aware of the continued conflict between Resident #15 and Resident #30. S11LPN further indicated S3Social Services and the S1Administrator were aware of Resident #15's behaviors toward Resident #30. In an interview on 08/05/2025 at 1:21PM, S9Certified Nursing Assistant (CNA) indicated on 07/07/2025 at approximately 2:30PM, S9CNA observed Resident #30 crying. S9CNA further indicated Resident #30 informed her about Resident #15's phone conversation Resident #30 overheard on 07/06/2025 where Resident #15 called Resident #30 the devil and used racial slurs. S9CNA further indicated while Resident #30 explained the incident to S9CNA, Resident #15 propelled herself over to Resident #30's side of the room and started to curse and yell at S9CNA and Resident #30. S9CNA indicated she reported this incident to S10CNA Supervisor on 07/07/2025. In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA made her aware of the above mentioned incidents from 7/06/2025 and 07/07/2025. S10CNA Supervisor indicated she reported the incidents to S1Administrator, S2DON, and S3Social Services on 07/07/2025. In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 and she was aware Resident #30 was upset. In an interview on 08/06/2025 at 10:33AM, S15Chief Nursing Officer (CNO) indicated she was not aware of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025 prior to the survey; therefore, S15CNO did not have any documented evidence of an investigation was completed following the incidents. In an interview on 08/06/2025 at 10:48AM, S1Administrator indicated he was aware of the incident on 07/06/2025 and 07/07/2025 between Resident #15 and Resident #30 prior to the survey. S1Administrator further indicated based on the surveyor's presented findings, Resident #30 was verbally and mentally abused by Resident #15. In an interview on 08/06/2025 at 1:49PM, S2Director of Nursing (DON) was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S2DON indicated she would try to find the facility's investigation to provide to the surveyor.In an interview on 08/06/2025 at 11:25AM, S1Administrator was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S1Administrator indicated he would not present any further investigation regarding the incident between Resident #15 and Resident #30.In an interview on 08/06/2025 at 1:36PM, S3Social Services was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S3Social Services indicated the only investigation she completed regarding incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025 was the Social Services note she documented on 07/07/2025. In an interview on 08/06/2025 at 1:54PM, S1Administrator was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S1Administrator indicated the facility was refusing to present any documentation of an investigation following the 07/06/2025 and 07/07/2025 incidents between Resident #15 and Resident #30. There was no documented evidence, and the facility failed and/or refused to present any documented evidence, the facility had completed a thorough investigation following the 07/06/2025 and 07/07/2025 incidents between Resident #15 and Resident #30.

Based on observations, interviews, and record reviews, the facility failed to implement interventions for residents who were identified at risk for falls for 2 (Resident #3, Resident #7) of 8 (Resident #3, Resident #7, Resident #8, Resident #12, Resident #16, Resident #17, Resident #30, Resident #73) sampled residents investigated for accidents.Findings:Resident #3: Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2025 revealed, in part, a Brief Interview for Mental Status score of 4. A score of 4 which indicated Resident #3 had severe cognitive impairment. Review of Resident #3's electronic medical record (EMR) chart revealed, in part, a special instruction for Resident #3 to have an auto lock brakes feature. (An auto lock brake feature engages the wheelchair's brakes when the user's weight is removed from the seat, preventing the chair from rolling away unintentionally). Review of Resident #3's Fall Risk assessment dated [DATE] revealed, in part, a score of 55 (A score of 45 or higher indicated high risk of falls). Review of Resident #3's care plan revealed, in part, Resident #3 was identified at risk for falls related to an unsteady gait. Further review revealed Resident #3's Care Plan included a documented intervention, dated 12/13/2024, for the auto lock brake feature. Review of Resident #3's social service progress note dated 07/24/2025 revealed, in part, Resident #3 was up daily in his wheelchair with confusion, impulsivity, and attempted to transfer without assistance. Further review revealed redirection was unsuccessful. Observation on 08/06/2025 at 1:45PM revealed Resident #3 was in his wheelchair and the wheelchair did not have the auto lock brake feature. In an interview on 08/06/2025 at 2:25PM, S2Director of Nursing (DON) confirmed Resident #3 was in a wheelchair which did not have the auto lock brake feature. Resident #7 Review of Resident #7's EMR revealed Resident #7 was admitted to the facility on [DATE] with a diagnosis of, in part, dementia (a loss of brain function that occurs with certain diseases) and a history of falls. Review of Resident #7's MDS with an ARD of 07/16/2025 revealed, in part, Resident #7 had a history of falls with two or more falls since admit. Review of Resident #7's care plan with the latest revision revealed, in part, Resident #7 was at risk for falls and injury related to a history of falls prior to admission, psychoactive medication use, impaired safety awareness, unsteady gait (how a person walks), dementia, and left sided weakness with a revised date of 07/28/2025. Further review revealed an intervention to provide Resident #7 with a wheelchair pocket attachment to facilitate the storage of snacks to be easily accessible to avoid dropping items on the floor. Observation on 08/05/2025 at 8:35AM revealed Resident # 7 was in her wheelchair at the nursing station. Further observation revealed no evidence Resident #7's wheelchair had a pocket attachment. Observation on 08/06/2025 at 8:40AM revealed Resident #7 was in her wheelchair at the nursing station. Further observation revealed no evidence Resident #7's wheelchair had a pocket attachment. In an interview on 08/05/2025 at 12:35PM, S13Licensed Practical Nurse (LPN) indicated the staff put Resident #7's snacks close to Resident #7 to prevent Resident #7 from falls. S13LPN further indicated Resident #7 often forget she could not walk and attempted to get snacks which resulted in falls. In an interview on 08/06/2025 at 8:45AM, S16LPN indicated Resident #7 had a history of attempting to retrieve items that were out of her reach; therefore, staff placed everything within her reach to prevent falls. In an interview on 08/06/2025 at 9:00AM, S2DON indicated Resident #7's care plan implementation for the wheelchair pocket attachment was to facilitate storage of snacks. In an interview on 08/06/2025 at 9:10AM, S17MDS Coordinator indicated all interventions on the current care plan should have implemented. In an interview on 08/06/2025 at 9:30AM, S2DON indicated Resident #7 did not have a wheelchair pocket attachment as per Resident #7's care plan and should have.

Based on observations, interviews, and record reviews, the facility failed to:1. Follow a physician's order for oxygen administration (Resident #33, Resident #63); and, 2. Ensure oxygen tubing was changed and dated weekly (Resident #33, Resident #63). This deficient practice was identified for 2 (Resident #33, Resident #63) of 2 (Resident #33, Resident #63) sampled residents investigated for respiratory care. Findings:1.Review of the facility's undated Oxygen Administration policy and procedure revealed, in part, staff should check the physician's order for liter flow rate of oxygen and method of administration. Further review revealed staff should adjust the liter flow rate of oxygen to the rate ordered by the physician. Resident #33Review of Resident #33's August 2025 Physician Orders revealed, in part, an order dated 09/29/2023 for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula continuously related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident #33's care plan dated 09/14/2023 revealed, in part, staff were to administer Resident #33's oxygen as ordered by the physician. Observation on 08/04/2025 at 4:57PM with S2Director of Nursing (DON) present, revealed Resident #33 received oxygen at 3.5LPM per nasal cannula. In an interview on 08/04/2025 at 4:57PM, S2DON confirmed Resident #33 received oxygen at 3.5LPM per nasal cannula. In an interview on 08/04/2025 at 4:59PM, S13Licensed Practical Nurse (LPN) indicated Resident #33 had an order for oxygen to be administered continuously at 2LPM via nasal cannula, and should not have received oxygen at 3.5LPM. Resident #63Review of Resident #63's August 2025 Physician Orders revealed, in part, an order for oxygen to be administered at 2LPM via nasal cannula as needed. Observation on 08/04/2025 at 9:23AM revealed Resident #63 received oxygen via nasal cannula between 2.5LPM and 3LPM. Observation on 08/04/2025 at 4:50PM with S13LPN present, Resident #63 received oxygen between 2.5LPM and 3LPM via nasal cannula. In an interview on 08/04/2025 at 4:50PM, S13LPN indicated Resident #63 had an order for oxygen to be administered at 2LPM as needed, and should not have received oxygen between 2.5LPM and 3LPM. In an interview on 08/06/2025 at 2:37PM, S2DON indicated Resident #33 and Resident #63 should have received oxygen according to their physician orders, as mentioned above. 2.Review of the facility's undated Oxygen Concentration Cleaning policy and procedure revealed, in part, oxygen tubing/cannula should be changed weekly and as needed. Resident #33Review of Resident #33's August 2025 Physician Orders revealed, in part, an order dated 09/29/2023 for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula. Observation on 08/04/2025 at 4:57PM with S2DON present, revealed Resident #33 received oxygen via nasal cannula and Resident #33's oxygen tubing was not dated. In an interview on 08/04/2025 at 4:57PM, S2DON indicated Resident #33's oxygen tubing should have been dated on the day it was changed, and was not. Observation on 08/05/2025 at 12:22PM with S4Infection Preventionist present, revealed Resident #33's oxygen tubing was not dated. In an interview on 08/05/2025 at 12:22PM, S4Infection Preventionist indicated Resident #33's oxygen tubing was not dated, and should have been. Resident #63Review of Resident #63's Quarterly Minimum Data Set with an Assessment Reference Date of 06/18/2025 revealed, in part, Resident #63 had a BIMS score of 13, which indicated Resident #63's cognition was intact. Review of Resident #63's August 2025 Physician Orders revealed, in part, an order dated 12/26/2023 for oxygen to be administered at 2LPM via nasal cannula as needed. Observation on 08/04/2025 at 9:23AM revealed Resident #63 received oxygen via nasal cannula and Resident #63's oxygen tubing was not dated. In an interview on 08/04/2025 at 9:23AM, Resident #63 indicated her oxygen tubing had not been changed for approximately 2 weeks. Observation on 08/04/2025 at 4:45PM revealed Resident #63 received oxygen via nasal cannula and Resident #63's oxygen tubing was not dated. In an interview on 08/04/2025 at 4:50PM, S13LPN confirmed Resident #63 received oxygen via nasal cannula, and Resident #63's oxygen tubing was not dated. S13LP confirmed Resident #63's oxygen tubing should have been dated to indicate when it was last changed and was not. There was no documented evidence, and the facility was unable to provide any documented evidence, Resident #33's and Resident #63's oxygen tubing was changed weekly, as required. In an interview on 08/06/2025 at 2:37PM, S2DON indicated Resident #33's and Resident #63's oxygen tubing should have been dated to indicate the date it had been changed.

Based on observations, interviews, and record review, the facility failed to: 1. ensure food stored in the facility's refrigerator was labeled with an opened date and/or discarded prior to the item's expiration date; and,2. ensure scoops were not stored inside the dry goods storage bins. Findings:1.Review of the facility's undated Food Safety and Sanitation policy and procedure revealed, in part, leftovers were to be dated when stored, and foods with expiration dates were to be used prior to the use by date on the package. Observation on 08/04/2025 at 8:30AM of the facility's kitchen with S14Dietary Manager revealed an opened gallon size container of ranch dressing stored in the facility's refrigerator. Further review revealed the container of ranch dressing had not been labeled with an opened date and had an expiration date of 07/24/2025. In an interview on 08/04/2025 at 8:39AM, S14Dietary Manager confirmed the container of ranch dressing, as mentioned above, was not labeled with an opened date and had an expiration date of 07/24/2025. S14Dietary Manager indicated the opened container of ranch dressing should have been discarded and should not have been available for resident consumption. 2. Observation on 08/04/2025 at 8:30AM of the facility's kitchen with S14Dietary Manager revealed the sugar and flour dry storage bins had scoops stored inside of the bins, with the handle of the scoop in direct contact with the flour and sugar. In an interview on 08/04/2025 at 8:30AM, S14Dietary Manager confirmed scoops were stored inside of the sugar and flour dry storage bins, and should not have been. In an interview on 08/06/2025 at 2:37PM, S2Director of Nursing (DON) confirmed the opened gallon sized container of ranch dressing, with an expiration date of 07/24/2025, should have been discarded and should not have been available for resident consumption. S2DON confirmed scoops should not have been stored inside the flour and sugar storage bins.

Based on observation, interview, and record review, the facility failed to post the most recent survey results in a place readily accessible to residents.Findings: Review of the facility's survey history revealed the last survey conducted was a complaint survey with an exit date of 04/03/2025. Observation on 08/05/2025 at 2:27PM of the facility's past survey results binder posted in the hallway next to the dining room revealed the last survey results available for review were dated 08/22/2024 for the recertification survey. There was no documented evidence, and the facility was unable to provide any documented evidence, the last survey results were posted in a place readily accessible to residents as required. In an interview on 08/05/2025 at 3:59PM, S1Administrator confirmed the complaint survey with an exit date of 04/03/2025 was not in the survey results binder.

Based on interviews and record reviews, the facility failed to ensure the required number of nursing staff members were present and working in the facility for 22 (10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/10/2024, 11/16/2024, 02/16/2025, 02/18/2025, 02/22/2025, 02/23/2025, 02/24/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/13/2025) of 53 (10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/15/2025) days reviewed for sufficient staff. Findings: Review of the facility's Facility Assessment, last updated on 02/18/2025 revealed, in part, the average daily census from 01/01/2024 to 12/31/2024 was 83 residents. Further review revealed on a weekday, the facility required 72 hours of Licensed Practical Nurses (LPNs) providing direct care a day, 144 hours of Certified Nursing Assistants (CNAs) care a day, 40 hours of other nursing/administrative nursing personnel per day, and 8 hours of other staff to provide behavioral healthcare and services (for a total of 264 hours.) Further review revealed, on a weekend, the facility required 72 hours of LPNs providing direct care per day, 144 hours of CNAs care per day, 8 hours of a RN per day, and 8 hours of other staff to provide behavioral healthcare and services (for a total of 232 hours.) Review of the facility's Resident Council Meeting minutes dated 01/08/2025 revealed, in part, residents had issues with not getting changed on time and issues with CNAs not checking on them at night. Further review revealed a resident indicated the facility needed more CNAs. Review of the facility's Resident Council Meeting minutes dated 02/12/2025 revealed, in part, residents had issues with not getting changed in a timely manner. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 10/05/2024 through 10/27/2024 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following weekend days did not meet or exceed the number of required hours: On 10/19/2024 the facility had a census of 83. Further review revealed the facility provided 202.10 nursing staff hours, which was 29.90 hours less than the required 232 hours. On 10/20/2024 the facility had a census of 82. Further review revealed the facility provided 198.34 nursing staff hours, which was 33.66 hours less than the required 232 hours. On 10/26/2024 the facility had a census of 85. Further review revealed the facility provided 201.97 nursing staff hours, which was 30.03 hours less than the required 232 hours. On 10/27/2024 the facility had a census of 85. Further review revealed the facility provided 223.97 nursing staff hours, which was 8.03 hours less than the required 232 hours. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 11/02/2024 through 11/30/2024 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following weekend days did not meet or exceed the number of required hours: On 11/02/2024 the facility had a census of 82. Further review revealed the facility provided 212.89 nursing staff hours, which was 19.11 hours less than the required 232 hours. On 11/03/2024 the facility had a census of 82. Further review revealed the facility provided 220.22 nursing staff hours, which was 11.27 hours less than the required 232 hours. On 11/10/2024 the facility had a census of 82. Further review revealed the facility provided 224.76 nursing staff hours, which was 7.24 hours less than the required 232 hours. On 11/16/2024 the facility had a census of 84. Further review revealed the facility provided 201.40 nursing staff hours, which was 30.60 hours less than the required 232 hours. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 02/16/2025 through 03/01/2025 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following days did not meet or exceed the number of required hours: On 02/16/2025 the facility had a census of 87. Further review revealed the facility provided 206.55 nursing staff hours, which was 25.45 hours less than the required 232 hours. On 02/18/2025 the facility had a census of 86. Further review revealed the facility provided 255.06 nursing staff hours, which was 8.94 hours less than the required 264 hours. On 02/22/2025 the facility had a census of 86. Further review revealed the facility provided 222.23 nursing staff hours, which was 9.77 hours less than the required 232 hours. On 02/23/2025 the facility had a census of 85. Further review revealed the facility provided 201.72 nursing staff hours, which was 30.28 hours less than the required 232 hours. On 02/24/2025 the facility had a census of 85. Further review revealed the facility provided 254.94 nursing staff hours, which was 9.06 hours less than the required 264 hours. On 03/01/2025 the facility had a census of 87. Further review revealed the facility provided 204.80 nursing staff hours, which was 27.2 hours less than the required 232 hours. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 03/02/2025 through 03/15/2025 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following days did not meet or exceed the number of required hours: On 03/02/2025 the facility had a census of 86. Further review revealed the facility provided 203.08 nursing staff hours, which was 28.92 hours less than the required 232 hours. On 03/03/2025 the facility had a census of 86. Further review revealed the facility provided 242.52 nursing staff nursing staff hours, which was 21.48 hours less than the required 264 hours. On 03/04/2025 the facility had a census of 87. Further review revealed the facility provided 254.15 nursing staff hours, which was 9.85 hours less than the required 264 hours. On 03/05/2025 the facility had a census of 87. Further review revealed the facility provided 261.81 nursing staff hours, which was 2.19 hours less than the required 264 hours. On 03/07/2025 the facility had a census of 86. Further review revealed the facility provided 253.38 nursing staff hours, which was 10.62 hours less than the required 264 hours. On 03/08/2025 the facility had a census of 86. Further review revealed the facility provided 209.08 nursing staff hours, which was 22.92 hours less than the required 232 hours. On 03/09/2025 the facility had a census of 86. Further review revealed the facility provided 202.97 nursing staff hours, which was 29.03 hours less than the required 232 hours. On 03/13/2025 the facility had a census of 86. Further review revealed the facility provided 252.71 nursing staff hours, which was 11.29 hours less than the required 264 hours. In an interview on 03/26/2025at 12:32PM, Resident #1's family member indicated she felt the facility was understaffed on the skilled nursing unit of the facility. In an interview on 03/31/2025 at 10:00AM, Resident #2's spouse indicated she thought there was an issue with staffing in the facility that was causing a delay in care. In an interview on 03/31/2025 at 10:45AM, S8CNA indicated there was a 50/50 chance there would not be enough staff working in the facility when she comes into work. In an interview on 03/31/2025 at 10:56AM, S9CNA indicated she does not feel like there was enough staff on the skilled nursing unit of the facility because the residents that resided on the skilled unit required more care from CNAs due to their care needs. In a telephone interview on 04/01/2025 at 12:27PM, S6LPN indicated the facility does not have enough CNA staff, especially on the skilled nursing unit of the facility, because the residents there need more care. S6LPN indicated residents are going without care due to the lack of CNA staff. S6LPN further indicated, with an adequate number of staff, residents could better meet their care goals. In an interview on 04/02/2025 at 11:50AM, S4LPN indicated the facility definitely needed to staff more CNAs. S4LPN further indicated the facility's CNAs are getting burnt out and rarely get breaks because they work constantly. S4LPN further indicated she felt the facility does not schedule the needed number of CNAs. In an interview on 04/02/2025 at 11:54AM, S10CNA indicated the facility does not have enough CNAs working in the facility. S10CNA further indicated the staff were getting burned out because they are having to overwork to take care of the resident's care needs. In an interview on 04/02/2025 at 12:00PM, S5LPN indicated there was an issue with CNA staffing. S5LPN further indicated the facility's CNAs are getting burnt out by the amount of work they are having to do to meet the needs of the residents. In an interview on 04/02/2025 at 12:05PM, S7LPN indicated the facility needed another nurse on the skilled nursing unit of the facility and more CNAs. S7LPN further indicated the facility definitely needed more CNAs to work on the skilled nursing unit of the facility because of the acuity of the residents. In an interview on 04/02/2025 at 12:10PM, S11CNA indicated the facility's staffing was not good. S11CNA further indicated the facility's residents sometimes had to wait longer than usual to receive care because the CNAs were busy caring for other residents. In an interview on 04/03/2025 at 9:39AM, Resident #R7 indicated there were very few CNAs on the weekends and other residents were having to wait 30 minutes to get care when they called for assistance. In an interview on 04/03/2025 at 11:30AM, S1Administrator offered no evidence that disputed the above deficient practice.

Based on observation and interview, the facility failed to ensure residents were supervised and kept free from thermal burns for 2 (Resident #19 and Resident #49) of 2 (Resident #19 and Resident #49) sampled residents investigated for an accident/hazard related to burns. This deficient practice resulted in actual harm when on 02/04/2024 for Resident #49 and on 02/21/2024 for Resident #19, when Resident #19 and Residnet #49 were left unsupervised and sustained first degree superficial burns from spilled coffee. Findings: Review of Appendix PP of the State Operations Manual, last revised on 08/08/2024, revealed, in part, third degree burns can occur within 1 to 2 seconds with hot water temperatures between 140 degrees Fahrenheit (F) and 155 degrees F. Review of the National Library of Medicine's Burn Evaluation and Management article, last revised on 08/08/2023, revealed, in part, burns may be caused by hot liquids. Further review revealed superficial burns (first degree) are red on the skin. Resident #19 Review of Resident #19's Electronic Medical Record (EMR) revealed, in part, Resident #19 had diagnoses which included epilepsy (a seizure disorder) and Hemiplegia (muscle weakness or partial paralysis on one side of the body)/Hemiparesis (a condition that causes partial or total paralysis of one side of the body) following a cerebral infarction (a type of stroke) that affected Resident #19's Left Non-Dominant side. Review of Resident #19's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed, in part, Resident #19 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #19 cognition was severely impaired. Further review revealed Resident #19 required supervision and/or touching assistance (occasionally assisting to steady food) with eating. Review of Resident #19's progress note dated 02/21/2024 at 6:00 a.m., revealed, in part, Resident #19 received a thermal superficial burn from hot coffee with redness noted to the top of her fingers and the palm of her hand. Review of Resident #19's Skin and Wound Evaluation dated 02/21/2024 revealed, in part, Resident #19 had a reddened area on her left 3rd finger that measured 1.5 centimeters (cms) by 1 cm. In an interview on 08/22/2024 at 9:55 a.m., S7Licensed Practical Nurse (LPN) indicated the coffee pot in the main dining area was not supervised. Resident #49 Review of Resident #49's EMR revealed, in part, Resident #49 had diagnoses which included anoxic brain damage, type 2 diabetes, and altered mental status. Review of Resident #49's MDS with an ARD of 11/22/2023 revealed, in part, Resident #49 had a BIMS score of 12 which indicated Resident #49's cognition was moderately impaired. Further review revealed Resident #49 required supervision and/or touching assistance with eating. Review of Resident #49's progress note dated 02/04/2024 at 10:46 p.m. revealed, in part, at 7:35 a.m., Resident #49 was yelling hospital hospital. Further review revealed, upon inspection, it was noted that Resident #49 spilled hot coffee on herself. Further review revealed Resident #49 had a red areas to lower left abdomen that measured 12 cm by 4 cm, right upper leg that measured 7cm by 2 cm, and right upper leg that measured 12 cm by 15 cm. Observation on 08/21/2024 at 10:08 a.m., revealed Resident #49 went up to the coffee pot in Dining Room a, placed a coffee cup under coffee dispenser spigot, and pressed the dispenser button to make herself a cup of coffee. Further observation revealed Resident #49 continuously repositioned the coffee cup under the spigot while attempting to fill the cup with coffee. Further observation revealed a staff member was present in the dining area, but had her back turned to the coffee dispenser. Further observation revealed staff did not intervene when Resident #49 attempted to pour coffee in her coffee cup. A check of the coffee temperature on 08/21/2024 at 10:09 a.m. with S15Dietary Supervisor revealed the coffee in the coffee dispenser in Dining Room a was 150.8 degrees Fahrenheit. In an interview on 08/21/2024 at 10:45 a.m., S14Certified Nursing Assistant (CNA) indicated Resident #49 needed assistance and supervision with filling her coffee cup due to her cognition. S14CNA further indicate staff had to redirect and assist Resident #49 with the coffee pot. In an interview on 08/22/2024 at 10:56 a.m., S15Dietary Supervisor indicated the coffee dispenser in Dining Room a was not always supervised. S15Dietary Supervisor further indicated attempts were initially made to address the hot coffee issue, but nothing was put in place and supervision was not increased. In an interview on 08/22/2024 at 12:05 p.m., S1Administrator acknowledged a resident in the facility should not be burned.

Based on interview and record review, the facility failed to provide or arrange services for the resident by qualified persons in accordance with each resident ' s written plan of care by failing to transfer a resident that required the use of a mechanical lift with the assistance of two staff members for transfers. The resident (Resident #2) was lowered to the floor during a transfer by one staff member without the use of a mechanical lift and the assistance of another staff member. As a result of this deficient practice the resident (Resident #2) suffered pain, which required pain relief by use of a narcotic pain medication every 4 hours, and sustained a right ankle fracture. This deficient practice affected 1 resident (#2) of 5 (#1, #2, #3, #4, #5) sampled residents who required the use of a mechanical lift with the assistance of two staff members out of 19 residents that required the use of a mechanical lift with the assistance of two staff members. FINDINGS: Resident #2 was a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 ' s [DIAGNOSES REDACTED]. Record review of the MDS (Minimum Data Set) dated 3/19/14 revealed the resident ' s BIMS (Brief Interview of Mental Status) score was an 8, which indicated that the resident ' s cognition was severely impaired. The MDS revealed that Resident #2 required two or more person physical assistance with bed mobility. The MDS also revealed Resident #2 required total dependence-full staff performance with two or more person physical assistance. Record review of Resident #2 ' s care plan revealed the following: 1. Care Planned for " Problem Onset: 11/21/12: Resident requires assistance with her ADL ' s due to her physical limitations ...Transfers 4:3 (Total Dependence with two or more person assistance) ... Is at risk for falls ...Goal: Resident will be assisted with her ADL ' s as needed, will have no injury due to falls, and will improve/maintain her present level of function by: 12/5/13 (last date noted) ... Approaches: Assist Resident with her ADL ' s---2 assistants for transferring/toileting ... " Care plan updated last on 3/19/14. 2. Care Planned for " Problem Onset: 11/21/12: At risk for falls ...Goal: Resident will have no significant injury R/T (related to) falls thru (through) next assessment R/T use of hoyer lift ...Approaches: Assist resident with transfer X (times) 2 staff c (with) hoyer lift ...(Handwritten note): Transfer with assist of hoyer lift X 2 assist ... " Record review of Resident #2 ' s nurses ' notes revealed the following: 5/20/14 at 11:21 AM " 615-Called to resident room per CNA (Certified Nursing Assistant,) due to pain to right ankle when moving, resident upper right ankle noted with swelling and not proportionate, noted slightly bent back ...MD (Medical Doctor) notified ...Order for X-ray ...Signed S3LPN " 5/20/14 at 2:53 PM " X-ray results received. fx (Fracture) of the distal shaft of the tibia and fibula ...S7MD (Resident #2 ' s Primary Physician) here making rounds informed of results, order to notify fam (family) and refer to S8MD (Orthopaedic Surgeon) if needs tx (treatment) ...Daughter informed of results ...MD to assess resident ...Request for new order for pain aid ...Informed MD resident currently has pain med BID (two times a day) and possible increase regimen ...Signed by: S3LPN " 5/20/14 at 9:49 PM " LATE ENTRY: 5/19/14 @ 1830 Called to resident ' s room by CNA. Resident noted on floor in front of wheelchair. CNA states that she was attempting to transfer resident from her wheelchair to her bed without the use of the hoyer lift and states that she lowered resident to the floor in a sitting position ...Signed by: S4LPN " Record review of a radiology report of Resident #2 ' s right ankle dated 5/20/14 revealed the resident had fractures of the distal shaft of the tibia and fibula. During an interview with S2DON and S1ADM on 6/2/14 at 1:45 PM, S2DON and S1ADM verified that on the morning of 5/20/14, Resident #2 complained of pain to her right ankle, an X-ray was done that day, and the resident was diagnosed with [REDACTED].#2 without using the lift and assistance from another staff member and had to lower the resident to the floor. S2DON and S1ADM verified that S4LPN informed them that she was supposed to have reported the incident at the time it happened and should not have waited until the following day to report the incident. During an interview with S4LPN on 6/3/14 at 2:20 PM, S4LPN stated that S5CNA told her that she tried to transfer Resident #2 from her wheelchair to her bed by herself without using the lift and assistance from another staff member. S4LPN stated that S5CNA informed her that she had to lower Resident #2 to the floor because she could not hold her up and complete the transfer by herself. S4LPN stated that S5CNA knew that the resident required two person staff assistance with a lift when transferred because this was how S5CNA and another CNA transferred the resident from her bed to her chair earlier that evening. S4LPN stated that S5CNA did not give any explanation as to why she transferred the resident by herself. S4LPN stated that she worked the 2:00 PM to 10:00 PM shift and that she forgot to write the incident report and notify Resident #2 ' s physician and responsible party at the time of the incident.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care by failing to transfer a resident that required the use of a mechanical lift with the assistance of two staff members for transfers and by failing to notify a change in the resident ' s status to the physician in a timely manner causing delayed treatment. The resident (Resident #2) was lowered to the floor during a transfer by one staff member without the use of a mechanical lift and the assistance of another staff member. As a result of this deficient practice the resident (Resident #2) suffered pain, which required pain relief by use of a narcotic pain medication every 4 hours, and sustained a right ankle fracture. This deficient practice affected 1 resident (#2) of 5 (#1, #2, #3, #4, #5) sampled residents who required the use of a mechanical lift with the assistance of two staff members out of 19 residents that required the use of a mechanical lift with the assistance of two staff members. FINDINGS: Resident #2 was a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 ' s [DIAGNOSES REDACTED]. Record review of the MDS (Minimum Data Set) dated 3/19/14 revealed the resident ' s BIMS (Brief Interview of Mental Status) score was an 8, which indicated that the resident ' s cognition was severely impaired. The MDS revealed that Resident #2 required two or more person physical assistance with bed mobility. The MDS also revealed Resident #2 required total dependence-full staff performance with two or more person physical assistance. Record review of Resident #2 ' s care plan revealed the following: 1. Care Planned for " Problem Onset: 11/21/12: Resident requires assistance with her ADL ' s due to her physical limitations ...Transfers 4:3 (Total Dependence with two or more person assistance) ... Is at risk for falls ...Goal: Resident will be assisted with her ADL ' s as needed, will have no injury due to falls, and will improve/maintain her present level of function by: 12/5/13 (last date noted) ... Approaches: Assist Resident with her ADL ' s---2 assistants for transferring/toileting ... " Care plan updated last on 3/19/14. 2. Care Planned for " Problem Onset: 11/21/12: At risk for falls ...Goal: Resident will have no significant injury R/T (related to) falls thru (through) next assessment R/T use of hoyer lift ...Approaches: Assist resident with transfer X (times) 2 staff c (with) hoyer lift ...(Handwritten note): Transfer with assist of hoyer lift X 2 assist ... " Record review of Resident #2 ' s nurses ' notes revealed the following: 5/20/14 at 11:21 AM " 615-Called to resident room per CNA (Certified Nursing Assistant,) due to pain to right ankle when moving, resident upper right ankle noted with swelling and not proportionate, noted slightly bent back ...MD (Medical Doctor) notified ...Order for X-ray ...Signed S3LPN " 5/20/14 at 2:53 PM " X-ray results received. fx (Fracture) of the distal shaft of the tibia and fibula ...S7MD (Resident #2 ' s Primary Physician) here making rounds informed of results, order to notify fam (family) and refer to S8MD (Orthopaedic Surgeon) if needs tx (treatment) ...Daughter informed of results ...MD to assess resident ...Request for new order for pain aid ...Informed MD resident currently has pain med BID (two times a day) and possible increase regimen ...Signed by: S3LPN " 5/20/14 at 9:49 PM " LATE ENTRY: 5/19/14 @ 1830 Called to resident ' s room by CNA. Resident noted on floor in front of wheelchair. CNA states that she was attempting to transfer resident from her wheelchair to her bed without the use of the hoyer lift and states that she lowered resident to the floor in a sitting position ...Signed by: S4LPN " Record review of a Physcian ' s Telephone Order dated 5/20/14 read, " X-ray R (right) ankle ... " Record review of a Physician ' s Telephone Order dated 5/20/14 read, " ... Notify Fam (family) and refer to S8MD (Orthopaedic Surgeon) ... " Record review of a Physician ' s Telephone Order dated 5/21/14 read, " Remain nonweightbearing R (right) leg, F/U (follow-up) in 2 weeks ... " Record review of a radiology report of Resident #2 ' s right ankle dated 5/20/14 revealed the resident had fractures of the distal shaft of the tibia and fibula. Record review of Resident #2 ' s May 2014 MAR (Medication Administration Record) revealed the following: On 5/19/14 at 2300, Resident #2 received a prn (as needed) dose of Tylenol 325mg (milligrams) PO (by mouth) for pain to her feet for a pain intensity of 10 on a numerical scale of 0 to 10. On 5/21/14 at 1300, Resident #2 received a prn dose of Tylenol 325mg PO for pain to her right lower leg for a pain intensity of 10 on a numerical scale of 0 to 10. On 5/21/14 at 1700, Resident #2 received a prn dose of Tylenol 325mg PO for pain to her right lower leg for a pain intensity of 10 on a numerical scale of 0 to10. During an interview with S2DON and S1ADM on 6/2/14 at 1:45 PM, S2DON and S1ADM verified that on the morning of 5/20/14, Resident #2 complained of pain to her right ankle, an X-ray was done that day, and the resident was diagnosed with [REDACTED].#2 without using the lift and assistance from another staff member and had to lower the resident to the floor. S2DON and S1ADM verified that S4LPN informed them that she was supposed to have reported the incident at the time it happened and should not have waited until the following day to report the incident. During an interview with S3LPN on 6/3/14 at 10:00 AM, S3LPN stated that on the morning of 5/20/14 S6CNA asked her to go examine the resident ' s right ankle because she noted something was wrong with her ankle by the way it looked. S3LPN stated that she assessed the resident ' s right ankle and knew that her ankle was broken because it was " bent and deformed. " S3LPN stated that S6CNA said the resident was in pain and kept saying " oh it ' s hurting " when she tried to get her up. S3LPN stated that she called Resident #2 ' s daughter and explained to her what happened, and she asked if she would want to send her mother out or have a mobile X-ray done at the facility. S3LPN stated that the resident ' s daughter chose to have a mobile X-ray done at the facility, so she called the doctor and was given an order for [REDACTED]. During an interview with S4LPN on 6/3/14 at 2:20 PM, S4LPN stated that S5CNA told her that she tried to transfer Resident #2 from her wheelchair to her bed by herself without using the lift and assistance from another staff member. S4LPN stated that S5CNA informed her that she had to lower Resident #2 to the floor because she could not hold her up and complete the transfer by herself. S4LPN stated that S5CNA knew that the resident required two person staff assistance with a lift when transferred because this was how S5CNA and another CNA transferred the resident from her bed to her chair earlier that evening. S4LPN stated that S5CNA did not give any explanation as to why she transferred the resident by herself. S4LPN stated that she worked the 2:00 PM to 10:00 PM shift and that she forgot to write the incident report and notify Resident #2 ' s physician and responsible party at the time of the incident.

Based on interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents by failing to transfer a resident that required the use of a mechanical lift with the assistance of two staff members for transfers and by failing to notify a change in the resident ' s status to the physician in a timely manner causing delayed treatment. The resident (Resident #2) was lowered to the floor during a transfer by one staff member without the use of a mechanical lift and the assistance of another staff member. As a result of this deficient practice the resident (Resident #2) suffered pain, which required pain relief by use of a narcotic pain medication every 4 hours, and sustained a right ankle fracture. This deficient practice affected 1 resident (#2) of 5 (#1, #2, #3, #4, #5) sampled residents who required the use of a mechanical lift with the assistance of two staff members out of a total of 19 residents that required the use of a mechanical lift with the assistance of two staff members. FINDINGS: Resident #2 was a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 ' s [DIAGNOSES REDACTED]. Record review of the MDS (Minimum Data Set) dated 3/19/14 revealed the resident ' s BIMS (Brief Interview of Mental Status) score was an 8, which indicated that the resident ' s cognition was severely impaired. The MDS revealed that Resident #2 required two or more person physical assistance with bed mobility. The MDS also revealed Resident #2 required total dependence-full staff performance with two or more person physical assistance. Record review of Resident #2 ' s care plan revealed the following: 1. Care Planned for " Problem Onset: 11/21/12: Resident requires assistance with her ADL ' s due to her physical limitations ...Transfers 4:3 (Total Dependence with two or more person assistance) ... Is at risk for falls ...Goal: Resident will be assisted with her ADL ' s as needed, will have no injury due to falls, and will improve/maintain her present level of function by: 12/5/13 (last date noted) ... Approaches: Assist Resident with her ADL ' s---2 assistants for transferring/toileting ... " Care plan updated last on 3/19/14. 2. Care Planned for " Problem Onset: 11/21/12: At risk for falls ...Goal: Resident will have no significant injury R/T (related to) falls thru (through) next assessment R/T use of hoyer lift (mechanical lift,) ...Approaches: Assist resident with transfer X (times) 2 staff c (with) hoyer lift ...(Handwritten note): Transfer with assist of hoyer lift X 2 assist ...(Handwritten note dated 5/20/14): fall with fx (fracture) ... " Record review of Resident #2 ' s nurses ' notes revealed the following: 5/20/14 at 11:21 AM " 615-Called to resident room per CNA (Certified Nursing Assistant,) due to pain to right ankle when moving, resident upper right ankle noted with swelling and not proportionate, noted slightly bent back ...MD (Medical Doctor) notified ...Order for X-ray ...Signed S3LPN " 5/20/14 at 2:53 PM " X-ray results received. fx (Fracture) of the distal shaft of the tibia and fibula ...S7MD (Resident #2 ' s Primary Physician) here making rounds informed of results, order to notify fam (family) and refer to S8MD (Orthopaedic Surgeon) if needs tx (treatment) ...Daughter informed of results ...MD to assess resident ...Request for new order for pain aid ...Informed MD resident currently have pain med BID (two times a day) and possible increase regimen ...Signed by: S3LPN " 5/20/14 at 9:49 PM " LATE ENTRY: 5/19/14 @ 1830 Called to resident ' s room by CNA. Resident noted on floor in front of wheelchair. CNA states that she was attempting to transfer resident from her wheelchair to her bed without the use of the hoyer lift and states that she lowered resident to the floor in a sitting position ...Signed by: S4LPN " 5/21/14 at 12:41 PM " Returned from appt (appointment) with S8MD (Orthopaedic Surgeon,) Resident to be tx (treatment) non-operatively, placed with CAM (Controlled Ankle Movement) boot at MD (Medical Doctor) ofc (office,) to remain non weight bearing on the right leg, Norco (pain medication) 10mg (milligrams) PO (by mouth) q (every) 4 hours for pain...Signed by: S3LPN " 5/21/13 at 2:50 PM " ...Verbal order to d/c (discontinue) scheduled Hydrocodone (pain medication) 7.5mg and continue the Norco ...Signed by: S3LPN " Record review of a Physcian ' s Telephone Order dated 5/20/14 read, " X-ray R (right) ankle ... " Record review of a Physician ' s Telephone Order dated 5/20/14 read, " ... Notify Fam (family) and refer to S8MD (Orthopaedic Surgeon) ... " Record review of a Physician ' s Telephone Order dated 5/21/14 read, " Remain nonweightbearing R (right) leg, F/U (follow-up) in 2 weeks ... " Record review of a radiology report of Resident #2 ' s right ankle dated 5/20/14 revealed the resident had fractures of the distal shaft of the tibia and fibula. Record review of Resident #2 ' s May 2014 MAR (Medication Administration Record) revealed the following: On 5/19/14 at 2300, Resident #2 received a prn (as needed) dose of Tylenol 325mg (milligrams) PO (by mouth) for pain to her feet for a pain intensity of 10 on a numerical scale of 0 to 10. On 5/21/14 at 1300, Resident #2 received a prn dose of Tylenol 325mg PO for pain to her right lower leg for a pain intensity of 10 on a numerical scale of 0 to 10. On 5/21/14 at 1700, Resident #2 received a prn dose of Tylenol 325mg PO for pain to her right lower leg for a pain intensity of 10 on a numerical scale of 0 to10. Record review of the facility ' s Resident Incident Report dated 5/20/14 at 9:39 PM for Resident #2 revealed the following: Incident Type: Fall/no head injury, Reported to Supervisor: No, Date/Time: 5/19/14 at 6:30 PM, Location: Resident Room, Activity at Time: From chair w (with) assist, Incident Reported by S5CNA, Report Prepared by: S4LPN, Narrative of incident and description of injuries: " Called to room by CNA. Resident noted to be seated on the floor in front of her wheelchair. CNA states that she was attempting to transfer resident from the chair into the bed and had to sit resident on the floor. " Immediate Actions Taken: Inserviced CNA, Taken to hospital: No, Disposition: Observation. Record review of facility form titled " No Lifting Policy " in S5CNA ' s personnel file stated in part " From this point forward, any employee found to be manually lifting any patient who is to be transferred with a lift except with the permission of their supervisor, will be in violation of this policy. Any employee in violation of this policy will be subject to disciplinary action, which could include immediate termination. I have been properly inserviced on the use of these transfer devices. I will comply with this policy to the fullest extent. I understand this policy as witnessed below. " The form was signed by S5CNA on 5/8/14 and the witness signature line was not signed. During an interview with S2DON and S1ADM on 6/2/14 at 1:45 PM, S2DON and S1ADM verified that on the morning of 5/20/14, Resident #2 complained of pain to her right ankle, an X-ray was done that day, and the resident was diagnosed with [REDACTED].#2 without using the lift and assistance from another staff member and had to lower the resident to the floor. S2DON and S1ADM verified that S4LPN informed them that she was supposed to have reported the incident at the time it happened and should not have waited until the following day to report the incident. During an interview with S3LPN on 6/3/14 at 10:00 AM, S3LPN stated that on the morning of 5/20/14 S6CNA asked her to go examine the resident ' s right ankle because she noted something was wrong with her ankle by the way it looked. S3LPN stated that she assessed the resident ' s right ankle and knew that her ankle was broken because it was " bent and deformed. " S3LPN stated that S6CNA said the resident was in pain and kept saying " oh it ' s hurting " when she tried to get her up. S3LPN stated that she called Resident #2 ' s daughter and explained to her what happened, and she asked if she would want to send her mother out or have a mobile X-ray done at the facility. S3LPN stated that the resident ' s daughter chose to have a mobile X-ray done at the facility, so she called the doctor and was given an order for [REDACTED]. During an interview with S4LPN on 6/3/14 at 2:20 PM, S4LPN stated that S5CNA told her that she tried to transfer Resident #2 from her wheelchair to her bed by herself without using the lift and assistance from another staff member. S4LPN stated that S5CNA informed her that she had to lower Resident #2 to the floor because she could not hold her up and complete the transfer by herself. S4LPN stated that S5CNA knew that the resident required two person staff assistance with a lift when transferred because this was how S5CNA and another CNA transferred the resident from her bed to her chair earlier that evening. S4LPN stated that S5CNA did not give any explanation as to why she transferred the resident by herself. S4LPN stated that she worked the 2:00 PM to 10:00 PM shift and that she forgot to write the incident report and notify Resident #2 ' s physician and responsible party at the time of the incident.