Every finding on record at Many Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews the facility failed to maintain a safe, functional, and comfortable environment for 4 (Resident #1, Resident #3, R1, and R2) residents of 6 sampled residents reviewed for physical environment. The facility failed to provide transportation for residents to their appointments with a fully functional air conditioning system during the warm/hot weather climates.Findings: Review of a facility policy on 05/26/2026 at 3:10 p.m. titled, State of Resident Rights with an revision date of 12/13/2023 revealed the following in part .The resident does not give up any right when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. The resident has a right to: 1. all care necessary for you to have the highest possible level of health; 2. Safe, decent and clean conditions. Review of a facility vehicle maintenance inspection report on 05/27/2026 at 1:54 p.m. with a date of 11/2025-05/2026 revealed in part .Inspect air conditioning front and rear units, if equipped. Review of a facility vehicle maintenance inspection report on 05/27/2026 at 2:18 p.m. with a date of 04/29/2026 revealed in part .Grey Van: Heating and air conditioning with a result of Poor.Review of the weather forecast of the city Resident #1's appointment was located, on 04/29/2026, revealed in part . the weather had a prediction of a high temperature of 87 degrees. Resident #1Review of Resident #1's medical record revealed an admission date of 12/04/2025 with diagnosis which included in part .End Stage Renal Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Essential Primary Hypertension. Review of Resident #1's current physician orders revealed the following orders in part .- Ophthalmology follow up appointment at _____ on 04/29/2026 at 1:45 p.m. one time only.- Resident to receive dialysis 3 days a week on Tues, Thurs, and Sat at _____ dialysis center under the care of Nephrology; Chair Time 6:30 a.m.Review of Resident #1's Quarterly MDS with an ARD of 03/12/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #1 used a wheelchair for mobility and required dialysis services. Review of Resident #1's care plan with an initial date of 12/04/2025 revealed in part .Focus: The resident has acute renal failure elated to End Stage Renal Disease and requires dialysis x3 weekly. In an interview on 05/26/2026 at 10:32 a.m., S4 Maintenance revealed he worked as the facility maintenance man for 2 years and the facility had 2 transportation vans (1 grey van and 1 white van). S4 Maintenance confirmed the grey van's air conditioning was not working in the back/rear of the van. S4 Maintenance stated, himself, and Administration/Corporate were made aware of the air conditioning was not working for at least 2 years. S4 Maintenance revealed that Corporate obtained quotes for repairs and the quote was more than what the van was worth, so Corporate decided not to fix the broken air conditioning in the grey van. S4 Maintenance was instructed (along with the drivers) to still utilize the grey van. The facility was to use the grey van for short/local trips such as: dialysis trips, during the winter months, or in emergency situations. S4 Maintenance stated the grey van was often used for dialysis trips weekly.In a telephone interview on 05/26/2026 at 11:14 a.m., Resident #1 revealed she resided at the facility from 12/2025-05/11/2026 and received dialysis three times weekly, (Tuesday, Thursday, and Saturday). Resident #1 stated on 04/29/2026 she had an eye appointment scheduled. Resident #1 revealed that S6 Driver drove her to her eye appointment (about 1.5-2 hours away from the facility) in the grey van. They left for the appointment at 11:45 a.m. and returned to the facility about 7:00 p.m. that evening. Resident #1 stated she used a wheelchair and sat in the back/rear of the van where the air conditioning was not working. Resident #1 stated the outside weather on her appointment day was sunny and hot, at least 80 degrees. Resident #1 stated she was hot and very uncomfortable in the van, however she did not say anything to S6 Driver because the air conditioning was broken for so long and staff always said there was nothing they could do. Resident #1 stated Corporate was not fixing the air condition, so there was no point in reporting it. Resident #1 stated she always rode in the grey van for her dialysis appointments three times weekly and it was hot and uncomfortable riding in the grey van since she admitted to the facility. Resident #1 revealed that the grey van interior ceiling drapes would always fall onto her head while sitting in the back seat, which was ridiculous. Resident #1 stated the van was old, outdated and needed some maintenance. Observation of the facility grey van on 05/26/2026 at 11:48 a.m., accompanied with S4 Maintenance and S8 Driver revealed in part .the grey van had 2 front seats (driver and passenger), a middle row, and a rear area to fit 2 wheelchair residents. While the van was running and air condition ON, the rear 4 air condition vents did not blow any air. S4 Maintenance confirmed the findings stated above. S4 Maintenance and S8 Driver confirmed the grey van was currently used for dialysis appointments, during the winter months, for an emergency situation, and used on 04/2026 for an appointment to _______ (1.5- 2 hours from the facility). S8 Driver revealed S6 Driver drove Resident #1 to ______ in 04/2026 to her appointment. S8 Driver revealed she did not know why S6 Driver drove the grey van out of town on a long trip with no air conditioning. In an interview on 05/26/2026 at 12:01 p.m., S3 Transportation Scheduler revealed she was the medical records/transportation scheduler for 2.5 years and the facility had 2 vans (the white van and the grey van). S3 Transportation Scheduler stated the appointment scheduling was very difficult due to only having 1 functional van and the grey van not having proper air conditioning for the state's climate. S3 Transportation Scheduler revealed the grey van's air conditioning does not work in the back/rear of the van where the wheelchair residents were seated. S3 Transportation Scheduler stated she and everyone (Administration and Corporate) were all aware for at least 2 years of the air conditioning was not working. S3 Transportation Scheduler was instructed by Administration/Corporate to still utilize the grey van during the winter months, for emergency situations, and local trips such as: to/from dialysis .which S3 Transportation Scheduler did routinely use the grey van to bring different residents to/from dialysis three times weekly. S3 Transportation Scheduler voiced the grey van was not intended to be used for trips out of town, due to the hot weather, at this time. S3 Transportation Scheduler revealed the last time the grey van was used was on 05/18/2026, 05/20/2026 and 05/22/2026 for dialysis transports of multiple residents. S3 Transportation Scheduler revealed the last time the grey van was used to go out of town was on 04/29/2026 for Resident #1's eye appointment in _______and S6 Driver drove her. S3 Transportation Scheduler revealed she had difficulty scheduling transportation at this time, so she spoke to S2 DON to work on how Resident #1 was going to go to the appointment in ______, on 04/29/2026. S3 Transportation Scheduler stated they agreed to send Resident #1 on the grey van due to Resident #1 kept her room hot and the weather was supposed to be in the 70s-80s. S3 Transportation Scheduler revealed the driver and the resident left the facility in the grey van on 04/29/2026 at 11:45 a.m. to ______and returned in the evening (not sure of return time, due to after business hours). S3 Transportation Scheduler confirmed the drive to the appointment was about 1.5-2 hours and the drive back to the facility was 1.5-2 hours. S3 Transportation Scheduler confirmed when she used the grey van to pick up dialysis in the afternoon it was hot and uncomfortable and that the dialysis residents were acute residents and should not be in the hot van with no air conditioning. S3 Transportation Scheduler stated the days when it was hot outside it was even hotter in the grey van. S3 Transportation Scheduler revealed she was instructed to still use the grey van; however, she would rather not use to the grey van due to the poor conditions and felt the facility needed a new functional van for the residents. In an interview on 05/26/2026 at 3:20 p.m., S6 Driver revealed she was the driver for Resident #1's appointment on 04/29/2026. S6 Driver stated she left with the resident on 04/29/2026, at about 12:00 p.m. and returned about 7:00 p.m. to the facility. S6 Driver revealed since 10/2025 as the van driver, she was aware the grey van did not have proper air conditioning but this van was still used for local appointments and going to/from dialysis. S6 Driver claimed she, nor the resident were not hot in the van on 04/29/2026.In an interview on 05/26/2026 at 4:08 p.m., S4 Maintenance revealed the grey van was a 2006 model van with over 242,000 miles on it. S4 Maintenance confirmed the grey van was old and unreliable. S4 Maintenance revealed he would rather to just park the van and not use it. S4 Maintenance revealed that the Corporate Maintenance Director was aware of the issues with the grey van and the facility was supposed to get new vans, but that was 2 years ago.Observation on 05/27/2026 at 10:31 a.m., accompanied by S4 Maintenance, revealed it was very hot in the back/rear of the van. Observed the interior ceiling of the back/rear of the van with over 50% of the interior ceiling drapes torn open, exposing the cushions, with the drapes hanging downward into the back sitting area. Observation of the ceiling drapes revealed they were hanging in a manner where, when a wheel-chaired resident was seated in the back, the drapes would fall over their head area. S4 Maintenance confirmed all the above findings during the observation. S4 Maintenance stated the interior ceiling drapes were hanging due to being so worn down, old age, and being dry rotten.In an interview on 05/27/2026 at 11:22 a.m., S2 DON revealed Resident #1 had an appointment on 04/29/2026, and S3 Transportation Scheduler voiced she needed help with transportation due to the white van being used for other appointments. S2 DON stated Resident #1 liked to have her room hot, so S2 DON reviewed the weather forecast on 04/29/2026 (she did not know which city weather she reviewed or if she reviewed the morning or afternoon weather) and it was expected to be in the 70s. S2 DON instructed S3 Transportation Scheduler to schedule the grey van for transport. S2 DON acknowledged the grey van was old, unreliable, had a non-functioning air condition but still used the van for an appointment to _____ (1.5-2 hour drive away from the facility). S2 DON confirmed the appointment was in the afternoon and the resident and driver were gone all afternoon, stating the temperatures probably did change from city to city and from morning to afternoon. S2 DON acknowledged it was hotter in a vehicle with non-working air conditioning than it was in outside weather. S2 DON stated she would have rather had the grey van parked and not in use. S2 DON confirmed that the dialysis residents were acute residents with possible blood pressure issues and sitting in a hot van without air conditioning for any amount of time was not acceptable. In reference to the ceiling interior of the grey van, S2 DON stated, The grey van is actually embarrassing and should not be used anytime. S2 DON was unaware the grey van interior ceiling was in such poor conditions.In an interview on 05/27/2026 at 12:29 p.m., S1 Administrator revealed she was notified by S2 DON that Resident #1 had an appointment in _____ on 04/29/2026 and the nursing team decided to use the grey van. S1 Administrator stated she was told S2 DON that Resident #1's son called on that day and reported that his mother was hot on the van. S1 Administrator stated she, and Corporate, were aware the grey van's air conditioning has not worked properly for about 1.5-2 years. Corporate had chosen not fix the grey van due to the repairs costing more than what the van was worth. S1 Administrator revealed the van was to be utilized for short trips, and in the winter time. S1 Administrator confirmed that Resident #1's appointment on 04/29/2026 was from 11:45 a.m. - 6:30 p.m. and the weather probably did change and the temperature did get warmer throughout the day- that it probably was hot and uncomfortable in the van. S1 Administrator acknowledged that the state's weather changes from morning to afternoon and from city to city. S1 Administrator agreed that the inside of a vehicle, without proper air conditioning, would be hotter than the outside temperatures and uncomfortable. Resident #3Review of Resident #3's medical record revealed an admission date of 12/06/2024 with diagnoses which included in part .Fusion of the Spine, Cervical Region, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder.Review of Resident #3's Annual MDS with ARD of 03/16/2026 revealed a BIMS score of 14, which indicated intact cognition and the resident used a rolling walker for mobility. In an interview on 05/26/2026 at 2:36 p.m., Resident #3 revealed she resided at the facility for 2 years and the facility vans transported her to all her appointments. Resident #3 revealed she used a rolling walker for mobility and sat in the front seat or the middle seat when she rode in the vans. Resident #3 revealed it was common knowledge to all the staff and Administration that the air conditioning in the grey van did not work in the back/rear area. Resident #3 stated many residents also know this information and Corporate don't want to fix the air conditioning because it will cost more than what the van is worth and I don't understand why they drive residents in a hot van with no air conditioning. Resident #3 revealed residents voiced that they stopped complaining about the hot van because Corporate was already aware and did not do anything. Resident #3 had rode in the grey van in the past and it was very hot and uncomfortable for her in the front seat .so she knew the residents in the back/rear seat were very hot. Resident #3 told transportation she refused to ride in the grey van again and they knew better than to book her in the grey van. R1Review of R1's medical record revealed an admission date of 08/04/2021 with diagnoses which included in part .End Stage Renal Disease, Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney Disease, and/or Unspecified Chronic Kidney Disease. Review of R1's Significant Change MDS with an ARD of 04/10/2026 revealed the resident used a wheelchair and required dialysis services. In an interview on 05/26/2026 at 2:24 p.m., R1 revealed he went to dialysis Monday, Wednesday, and Friday and the facility van took him to his dialysis appointments. R1 revealed he ambulated and sat in the middle seat of the van .when he was weak he would use his wheelchair and sat in the back/rear of the van. R1 stated that one van had broken air conditioning and he has ridden on this van to/from dialysis. R1 stated he was hot, uncomfortable and tired from dialysis on these trips in this van. R1 has told the drivers in the past, but the driver's tell him, I know it's hot, there is nothing we can do. R1 stated he rode on the van with the broken air conditioning last week and it was hot and uncomfortable .he stated he was tired of complaining so he just does not complain anymore. R1 stated 2 other residents rode with him to dialysis and he knew they were hot too, especially because they sat in the back/rear seat with no air conditioning. R1 stated the facility needed to do something with the broken air conditioning on the van. R2Review of R2's medical record revealed an admission date of 10/10/2023 with diagnoses which included in part .Asperger's Syndrome, Type 2 Diabetes Mellitus without Complications, and Generalized Anxiety Disorder. Review of R2's Quarterly MDS with an ARD of 03/13/2026 revealed a BIMS score of 15, which indicated intact cognition. In an interview on 05/26/2026 at 2:48 p.m., R2 revealed he was the facility Resident Council President and the residents and staff were aware for a long time that the grey van had broken air conditioning. R2 revealed the Resident Council stopped complaining a long time ago about the air conditioning, due to corporate being aware and said they were not going to fix it. R2 stated he ambulated with no issues and sat in the middle seat when he rode in the van. R2 stated he rode in the grey van in the past, on the middle seat, and it was hot and uncomfortable. R2 stated he asked for future appointments, to not put him on the grey van because it was so hot. R2 revealed S1 Administrator was aware and thought S1 Administrator would make sure other residents did not use this van during the hot weather.

Based on interview and record view, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R3) resident of 6 sampled residents reviewed for quality of care. The facility failed to transport R3 to a nephrologist appointment in a timely manner as ordered. Findings:Review of R3's medical record revealed an admission date of 02/07/2025 with diagnoses which included in part . Chronic Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Peripheral Vascular Disease, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of R3's current physician orders revealed in part . - Nephrology follow up appointment with Nurse Practitioner ______ at _______ on 06/11/2026 @ 9:00 a.m. one time only. (This is the rescheduled appointment- for reference.)Review of R3's 05/2026 monthly physician appointment calendar revealed in part .On 05/22/2026, R3 had an appointment at 8:20 a.m. with the Nephrologist. Further review of this date, revealed the appointment was marked through and a note written, No Gas.Review of R3's Quarterly MDS with ARD of 04/15/2026 revealed a BIMS score of 14, which indicated intact cognition and the resident used a wheelchair for mobility. In an interview on 05/26/2026 at 2:56 p.m., R3 revealed he had an appointment scheduled on 05/22/2026 to go to a Nephrologist out of town. R3 stated he was scheduled to leave early about 6:00 a.m. on this day. R3 waited to leave for his appointment by the facility front door; but time passed by and it was after his leave time. R3 revealed he went to the nurse's station and asked when he was leaving for his appointment. R3 revealed the 2 nurses at the front desk stated his appointment was rescheduled due to the facility van having no gas. R3 stated he was very upset and this was unacceptable and not my fault .that was not right. R3 stated he told his daughter and she was upset too . now he had to wait another 3-4 weeks until he had his appointment rescheduled. R3 stated this was not the first time the van did not have gas for appointments, that another resident missed an appointment for the same reasons. In an interview on 05/26/2026 at 3:20 p.m., S6 Driver revealed she was the driver scheduled to bring R3 to his appointment on 05/22/2026 and planned to leave the facility 6:00 a.m. S6 Driver stated when she got to the facility, the van did not have enough gas to bring R3 to the appointment. S6 Driver stated the gas card was locked in S1 Administrator's office and it was too late to get gas. S6 Driver stated she did not know why the last driver did not put gas in the van. S6 Driver revealed all drivers have the ability to put gas in the vans and should do so when needed. In an interview on 05/26/2026 at 4:08 p.m., S4 Maintenance revealed last week (didn't know what day) a resident's appointment was rescheduled due to not having gas in the van. S4 Maintenance stated that all the drivers had the ability to put gas in the vans . they just needed to use the facility gas card before the day ended and fill up on gas. S4 Maintenance confirmed this should not have happened and the driver should have put gas in the van for the next day.In an interview on 05/27/2026 at 10:49 a.m., S5 LPN revealed she worked on 05/22/2026 when R3's appointment was rescheduled. S5 LPN revealed R3 had a scheduled appointment to go to the Nephrologist early, about 6:00 a.m. S5 LPN stated the resident came to the nurses' station and asked what time he was leaving for his appointment. S5 LPN received report from the night nurse that the van had no gas in it and R3's appointment had to be rescheduled. S5 LPN stated the driver called S1 Administrator and to notify her; but the gas card was locked in the office. When S1 Administrator arrived to work, it was too late and the appointment still needed to be rescheduled. S5 LPN confirmed that, running out of gas was an unacceptable excuse for a resident to miss an appointment and it should have never happened. S5 LPN revealed the residents need their appointments and it is already hard enough to get a specialist appointment scheduled. S5 LPN confirmed R3's rescheduled appointment will be another 4 weeks wait for the resident. S5 LPN revealed that this was not the first time a resident had missed an appointment due to not having gas in the van. S5 LPN knew of this happening at least 2 other times for other residents.In an interview on 05/27/2026 at 11:22 a.m., S2 DON revealed that in regard to R3's missed appointment on 05/22/2026, That should have never happened. S2 DON stated that no resident should miss an appointment due to there being not enough gas in the van. S2 DON confirmed these were unacceptable practices and delayed R3's treatment. S2 DON confirmed that R3's Nephrologist appointment was an acute appointment, should not have been missed, and acknowledged how difficult it was to obtain these appointments, and now reschedule them. In an interview on 05/27/2026 at 12:29 p.m., S1 Administrator revealed on 05/22/2026 R3's appointment was canceled due to not having gas in the van. S1 Administrator confirmed that this was inexcusable and should have not happened .that all the drivers were capable of and responsible for putting gas in the van. S1 Administrator stated the gas card was kept locked in her office, but the drivers should have filled up the van with gas the day prior. The driver could have also asked to leave the gas card locked in the nurse's cart for the morning shift or they could have paid for the gas and gotten reimbursed. S1 Administrator stated all drivers were aware of the gas procedures. S1 Administrator agreed that R3's appointment was an important specialist appointment and was now delayed 4 more weeks due to poor transportation planning on the facility's part, but should have never happened.

Based on interview and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (Resident #1) resident of 6 sampled residents. The facility failed to ensure nursing staff accurately documented Resident #1's medication/treatment administrations.Findings: Review of facility policy on 05/27/2026 at 1:54 p.m., titled, Medication Administration with a revision date of 03/05/2026 revealed the following in part .Purpose: To ensure medications were prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. Review of Resident #1's medical record revealed an admission date of 12/04/2025 with diagnosis which included in part .End Stage Renal Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Essential Primary Hypertension.Review of Resident #1's 03/2026 EMAR/ETAR (electronic medication administration record/electronic treatment administration record) revealed the following dates with no documented evidence of order administration for the following orders: -03/15/2026 at 4:30 p.m., 03/18/2026 at 6:30 a.m., 03/21/2026 at 6:30 a.m., 03/22/2026 at 6:30 a.m. 03/27/2026 at 6:30 a.m.: Sevelamer Hydrochloride oral tablet 800 milligram give 3 tablets by mouth before meals related to End Stage Renal Disease;-03/27/2026: Artificial Tears Ophthalmic Solution 1 % Instill 2 drops in both eyes one time a day related to Dry Eye Syndrome of Bilateral Lacrimal Glands;-03/27/2026: Cinacalcet Hydrochloride oral tablet 60 milligrams give 1 tablet by mouth one time a day related to End Stage Renal Disease;-03/27/2026: Cranberry oral tablet 450 milligrams give 1 tablet by mouth one time a day for Frequent Dysuria;-03/27/2026: Lantus Solo-Star Subcutaneous Solution pen injector 100 unit/milliliter (Insulin Glargine) Inject 20 units subcutaneously one time a day related to Type 2 Diabetes Mellitus with Hyperglycemia;-03/27/2026: Polyethylene Glycol 3350 oral powder 17 grams/scoop give 1 scoop by mouth one time a day every Monday, Wednesday, Friday, and Sunday related to Constipation.-03/27/2026: Spironolactone oral tablet 25 milligrams give 1 tablet by mouth one time a day related to Generalized Edema;-03/27/2026: Torsemide oral tablet 100 milligrams give 1 tablet by mouth one time a day related to Generalized Edema. If edema 3+ or greater for 3 consecutive days, notify Medical Doctor; and-03/27/2026: Novolog Injection Solution 100 unit/milliliter (Insulin Aspart) Inject as per sliding scale: if 0-150 = 0 units; if blood sugar is 400, give 12 units & recheck in 1 hour. If still >400, notify Medical Doctor subcutaneously three times a day related to Type 2 Diabetes Mellitus with Hyperglycemia.In an interview on 05/27/2026 at 10:31 a.m., S7 LPN revealed all nurses were aware to chart on the EMAR/ETAR in real-time during medication administration . that this was standard practice. S7 LPN stated if a nurse accidently did not chart on the EMAR/ETAR the order will show up as red/alert until the nurse addressed the order in the medical record. S7 LPN stated that if a nurse does not chart in the EMAR/ETAR or medical record then the procedure did not happen. S7 LPN confirmed that a resident's medical record should be considered inaccurate if a nurse omitted documenting in the EMAR/ETAR properly. In an interview on 05/27/2026 at 11:22 a.m., S2 DON revealed she had been the DON of the facility for about 20 years, and she expected the nurses to document on the EMAR/ETAR in real time when administering medications/treatments. S2 DON revealed all nurses were aware to do so. S2 DON stated if a medication/treatment was missed it would have flagged in red on the EMAR/ETAR, thus prompting the nurse to address the order. S2 DON stated all orders should be documented and never left blank. In a record review, at the time of interview, S2 DON confirmed the above information for Resident #1's 03/2026 EMAR/ETAR and that all mentioned orders were not documented on properly and left blank, but should not have been. S2 DON confirmed Resident #1's medical record was inaccurate due to omission of documentation on the 03/2026 EMAR/ETAR.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the pureed meals for 13 Residents who receive pureed meals prepared by the facility kitchen.Findings: Review of the facility's policy titled: Food and Nutrition Services read in part . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Review of the facility's Pureed lunch Menu revealed.Turkey Breast Thigh- 1/4 cup, Cornbread Dressing f/Mix- 1/2 cup, [NAME] Bean Casserole w/Cut Freeze & Soup- 1/3 cup, Unfrosted Red Velvet f/Choc Mix-1/4 cup. Review of the Pureed Recipe menu revealed preparation steps and resident serving sizes to prepare each individual food item for residents' pureed meals according to the number of residents on pureed diets. Observation on 03/10/2026 at 2:40 p.m. revealed S5 [NAME] prepared pureed turkey by scooping an unmeasured amount into a smaller pan, then into blender, and added turkey juice using a 6oz ladle with it totaling to 5 ladles of turkey juice added during blending. Next, S5 [NAME] was observed preparing corn bread dressing by scooping an unmeasured amount into smaller pan, then into blender, and adding turkey juice using a 6 oz ladle with it totaling to 3 ladles of turkey juice added during blending. Finally, S5 [NAME] prepared pureed green bean casserole by pouring half of the container of green bean casserole including the juice into the blender, adding thickener, and blended. S5 [NAME] was observed not using the pureed recipe menu. Observation of the pureed recipe binder which contained pureed recipe menus was closed sitting on the shelf. In an observation and interview on 03/10/2026 at 11:43 a.m., S5 [NAME] confirmed she does not measure any of the food in regard to portion sizes that she prepares for residents who are on pureed meals. S5 [NAME] shrugged her shoulders and stated, I just know how much food to prepare. In an interview on 03/10/2026 at 12:01 p.m., S11 RD confirmed the dietary staff are supposed to use the recipe menu to prepare pureed meals for residents on pureed diets. In an interview on 03/10/2026 at 12:45 p.m., S1 Admin acknowledged dietary cooks did not use the recipe menus to prepare the pureed meals at lunch, but should have.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions by: Failing to ensure safe food was served on the food line; and Failing to store clean dishes appropriately This failed practice had the potential to affect all 73 residents who receive food prepared from the facility's kitchen. Findings:Review of the facility's policy dated 03/05/2026 titled Food Preparation and Service revealed in part.Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Service/Distribution. 2. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. Observation of temperature logs for steam tables for 03/2026 on 03/09/2026 at 9:15 a.m. revealed temperatures of prepared steam table foods were not completed for the following days and meals:March 3-breakfast and lunchMarch 5-breakfast, lunch, and dinnerMarch 6-breakfast, lunch, and dinnerMarch 7-breakfast, lunch, and dinnerMarch 8-breakfast, lunch, and dinnerMarch 9-breakfast In an interview on 03/09/2026 at 9:15 a.m., S4 DM confirmed temperatures of the prepared foods on the steam table were not completed for the dates and meals listed above but should have been. Observation and interview with S4 DM on 03/09/2026 at 8:52 a.m. revealed a dirty, dusty electric fan blowing on clean dishes placed in a drying rack next to drying station. S4 DM stated the fan is used to dry the dishes. S4 DM confirmed the fan was dirty and dusty but should not have been.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 2 (Resident #2 and Resident #81) of 2 residents reviewed for transfer/discharge. The total sample size was 33. Review of a facility policy on 03/11/2026 at 2:51 p.m. titled, Transfer or Discharge Notices with a revision date of 03/2025 revealed in part .Residents (or Resident Representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Notice of Transfer or Discharge (Anticipated) 2. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge: b. The resident's health improves sufficiently to allow a more immediate transfer or discharge, c. An immediate transfer or discharge is required by the resident's urgent medical needs. Review of Resident #2's medical record revealed an admission date of 02/12/2026 and a discharge date of 03/04/2026. Resident #2 had diagnoses which included in part . Displaced Fracture of Shaft of Fourth Metacarpal Bone, Right Hand, Subsequent Encounter for Fracture with Routine Healing, Multiple Fractures of Ribs, Right Side, Subsequent Encounter for Fracture with Routine Healing and Displaced Fracture of Distal Phalanx of Right Thumb, Subsequent Encounter for Fracture with Routine Healing. Review of Resident #2's 03/2026 Physician orders revealed in part .Order Date 03/02/2026: Discharge home with LA Homecare Home Health skilled nursing therapy services on Wednesday, 03/04/2026. Review of Resident #2's Discharge Summary revealed in part .Effective date: 03/04/2026- admission Date 02/12/2026 and discharge date [DATE]. Reason for discharge: Resident discharged home with LA Home Care with skilled PT/OT. Review of the facility's transfer logs titled, Louisiana Ombudsman Program/Emergency Transfer Log from dates 01/01/2026-03/11/2026 revealed Resident #2's planned discharged home on [DATE] was not logged or reported. In an interview on 03/11/2026 at 2:13 p.m., S10 BOM revealed she was responsible for reporting the transfer logs to the LA Ombudsman Program. S10 BOM stated she was unaware to report planned discharges or any discharges to the LA Ombudsman Program. S10 BOM confirmed she did not report Resident #2's planned discharge home to the LA Ombudsman Program. Resident #81 Review of Resident #81's Electronic Health Record (EHR) revealed an admission date of 01/30/2026 and a discharge date of 02/07/2026. Resident #81 had diagnoses that included in part.Displaced Mid-cervical Fracture of Left Femur, 2-Part Displaced Fracture of Surgical Neck of Left Humerus, and Disorientation, Unspecified. Review of Resident #81's 02/2026 Physician Orders revealed in part, send to emergency room for evaluation/treatment due to complaining of chest pain (initiated 02/07/2026). Review of Resident #81's departmental progress notes revealed in part. 02/07/2026 6:16 p.m. General Nurses Note Narrative: Resident #81 pulling nasal cannula off and yelling, I can't breathe! Nasal Cannula placed back on and she removed again. Resident #81 yelled, My chest hurts, I want to go to the hospital! Physician notified, new order received to send to emergency room for chest pain. Ambulance notified. 02/07/2026 6:48 p.m. General Nurses Note Narrative: Resident #81 transferred out to emergency room at 6:45 p.m. Review of Resident #81's Facility Discharge summary dated [DATE] revealed in part, sent to hospital related to chest pains. Was transferred from emergency room to another hospital due to NSTEMI. Resident #81 was discharged from the hospital to home on hospice care. Interview on 03/11/2026 at 1:35 p.m. with S7 Unit Manager revealed Resident #81 was sent out to the hospital with chest pains and difficulty breathing. S7 Unit Manager stated Resident #81 did not return to the facility and was discharged from the hospital to home with hospice. Requested the Office of the State Long Term Care Ombudsman Emergency Transfer Log. S7 Unit Manager stated she would go get it. Interview on 03/11/2026 at 1:54 p.m., S7 Unit Manager confirmed that Resident #81 was not on the Office of the State Long Term Care Ombudsman Emergency Transfer Log and that S10 BOM was responsible for notifying the Ombudsman of transfers and discharges. Interview on 03/11/2026 at 2:16 p.m., S10 BOM revealed that she is responsible for notifying the Ombudsman of resident transfers and discharges. S10 BOM stated she only includes hospitalizations, not discharges, in the emergency transfer log. S10 BOM revealed she was cited for this last year so she reviewed the requirements and even had a discussion with the Ombudsman about the Emergency Transfer Log. S10 BOM confirmed she did not submit in writing to the Ombudsmen a notification of Resident #81's hospitalization or discharge from the facility.

Based on interview and record review the facility failed to ensure that a person-centered plan of care was developed for 1 (Resident #6) of 33 sampled residents to reflect a diagnosis of Dementia. The facility had a total census of 73. Findings: Review of Resident #6's medical record revealed an admit date [DATE] with diagnoses which included: Unspecified Dementia, Major Depressive Disorder, Psychotic Disorder with Delusions due to known physiological condition and Age-Related Cognitive Decline. Review of Resident #6's Quarterly MDS with an ARD of 12/29/2025 revealed a BIMS score of 99 (indicating severe impaired cognition), and required partial/moderate assistance with oral hygiene, bathing and toilet use. Resident #6's MDS revealed he was coded for a diagnosis of Non-Alzheimer's Dementia. Review of Resident #6's most recent care plan revealed no documented evidence of a care plan related to his diagnosis of Dementia. Interview on 03/11/2026 at 11:43 a.m. with S3 LPN/MDS confirmed Resident #6 did not have a care plan related to his diagnosis of Dementia, but should have.

Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to asses a Central Venous Catheter for 1 (Resident #59) of 33 sampled residents. Findings:Review of a facility policy titled, Dialysis Management and AV Access Policy with a review date of 02/26/2026 read in part.Purpose: To establish standardized procedures for safe management of residents receiving hemodialysis, ensuring preservation of vascular access integrity, continuity of care, regulatory compliance, and effective interdisciplinary coordination.Policy Statement: The facility shall ensure all residents receiving dialysis services are monitored, assessed, and managed in accordance with physician orders, accepted standards of nursing practice, and regulatory requirements. Review of Resident #59's medical record revealed an admit date of 08/04/2021 with diagnoses that included in part.End Stage Renal Disease, Hypertensive Chronic Kidney Disease, Protein-Calorie Malnutrition, Human Immunodeficiency Disease, and Acute on Chronic Diastolic Heart Failure. Review of Resident #59's Quarterly MDS with an ARD of 12/15/2025 revealed a BIMS sore of 7, which indicated severe cognitive impairment. Resident #59 required partial/moderate assistance with eating and upper body dressing; substantial/maximal assistance with lower body dressing; and dependent for hygiene, toileting, and bathing. Review of Resident #59's Care Plan revealed in part.Monitor dialysis catheter to left chest wall as ordered. Monitor/document/report as needed any signs or symptoms of infection to access site: Redness, swelling, warmth or drainage. Review of Resident #59's 03/2026 Physician Orders read in part .Resident to receive dialysis 3 days a week on Monday, Wednesday, and Friday at the Dialysis Center related to End Stage Renal Disease. Observation on 03/10/2026 at 11:00 a.m. revealed Resident #59 sitting in a wheelchair outside on the patio with a dressing noted to the left chest wall. Resident #59 was unable to state if staff were monitoring the dialysis catheter. Interview on 03/10/2026 at 11:10 a.m. S8 LPN revealed Resident #59 had a port to his left chest wall in which he received Hemodialysis through. S8 LPN revealed this information was documented on the resident's MAR (Medication Administration Record). Review of Resident #59's 03/2026 medical record revealed no documentation of Resident #59's Central Venous Catheter to the left chest being monitored or assessed.Interview on 03/11/2026 at 12:50 a.m. with S1 DON revealed Resident #59 previously had an Internal Jugular Catheter that was discontinued on 01/27/2026. S1 DON confirmed a Central Venous Catheter was placed in Resident #59's left chest wall, and was not put on to the MAR to monitor or assess, but should have been.

Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #4) of 33 sampled residents.Findings: Review of the facility's policy titled Oxygen Administration and Oxygen Safety, with a review date of 03/03/2026, revealed the following in part, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. Preparation: 1. Review the physician's orders or facility protocol for oxygen administration. Review of Resident #4's medical record revealed an admission date of 02/13/2025 with diagnoses that included in part, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Chronic Respiratory Failure, Type 2 Diabetes Mellitus with Hyperglycemia, and Functional Quadriplegia. Review of Resident #4's 03/2026 Physician Orders for revealed O2 (oxygen) at 2 liters per minute via nasal cannula continuously, every shift related to Chronic Respiratory Failure with an order date of 02/16/2025. Review of Resident #4's Annual Minimum Data Set (MDS) with an ARD (Assessment Reference Date) date of 01/16/2026 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognition impairment. Further review revealed Resident #4 required oxygen therapy. Observation on 03/09/2026 at 8:55 a.m., revealed Resident #4 lying in bed alert to self only. Resident #4 observed with oxygen in progress at 1 liter/minute via nasal cannula per oxygen concentrator. Observation on 03/09/2026 at 3:00 p.m., revealed Resident #4 lying in bed asleep with oxygen in infusing at 1 liter/minute via nasal cannula. Observation on 03/10/2026 at 8:50 a.m., revealed Resident #4 lying in bed alert to self only with oxygen infusing at 1 liter/minute via nasal cannula. Interview on 03/10/2026 at 8:55 a.m., S8 LPN stated Resident #4 is ordered continuous oxygen at 2 liters/minute via nasal cannula. S8 LPN revealed that she hadn't been in Resident #4's room yet to check the oxygen concentrator and that Resident #4 shouldn't have been on 1 liter of oxygen. Interview on 03/10/2026 at 8:58 a.m., S7 Unit Manager accompanied this surveyor to Resident #4's bedroom and confirmed that Resident #4 was ordered continuous oxygen at 2 liters/minute via nasal cannula and was currently on 1 liter/minute of oxygen, and shouldn't have been.

Based on observation and interview, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure medical equipment was cleaned in between uses with multiple residents. This had to potential to affect 73 residents. Findings: Review of the facility's policy dated 03/03/2026 on Infection Prevention and Control Program revealed in part Policy Statement-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent and development and transmission of communicable diseases and infections. Observation of medication administration on 03/10/2026 at 9:20 a.m., revealed S9 LPN used an unclean, wrist blood pressure medical equipment in between uses with multiple residents. In an interview on 03/10/2026 at 10:05 a.m., S9 LPN revealed she did not clean wrist blood pressure medical equipment in between uses with multiple residents, but should have. In an interview on 03/11/2026 at 3:11 p.m., S2 DON acknowledged S9 LPN did not clean wrist blood pressure medical equipment in between uses with multiple residents, but should have.

Based on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (Resident #46) of 29 sampled residents. The facility failed to ensure medications were administered safely and timely by leaving Resident #46's medications at her bedside. Findings: Review of the facility's policy titled Medication Administration dated 07/08/2024 revealed in part .Medications are administered in a safe and timely manner, and as prescribed. Review of Resident #46's medical record revealed an admitted [DATE] with diagnoses that included in part .Bilateral Primary Osteoarthritis, Morbid (severe) Obesity, Bipolar Disorder, Obstructive Sleep Apnea, Unspecified Myalgia, Repeated Falls, Chest Pain and Edema. Review of Resident #46's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #46 required supervision for: Bed mobility, Transfer, Eating and Toilet use. Review of Resident #46's care plan with a target date of 04/09/2025 revealed the resident has frequent health complaints with interventions that included administer medications as ordered. Observation and interview on 01/12/2025 at 9:41 a.m. revealed Resident #46 lying in bed. Resident #46 noted to have a cup of medicine sitting on her bed side table. Resident #46 revealed the medications in the cup were her morning medications that the nurse had left for her to take. Resident #46 revealed she had fallen back asleep before she could take her medications. Observation and interview on 01/12/2025 at 9:48 a.m. with S8 LPN in Resident #46's room confirmed the medications left on Resident #46's bed side table in a medicine cup were her morning medications. S8 LPN confirmed she did not ensure Resident #46 had swallowed her medications before she left Resident #4's room, but she should have. Review of Resident #46's January 2025 Medication Administration Record with S8 LPN revealed the following medications were left at Resident #46's bedside: 1. Cranberry Oral Tablet 450 MG PO-8:00 a.m. 2. Effexor XR 75 MG (antidepressant) PO-8:00 a.m. 3. Ezetimibe 10 MG (cholesterol lowering) PO-8:00 a.m. 4. Loratadine 10 MG (antihistamine) PO-8:00 a.m. 5. Eliquis 2.5 MG (anticoagulant) PO-8:00 a.m. 6. Lasix 40 MG (diuretic) PO-8:00 a.m. 7. Lyrica 100 MG (anticonvulsant) PO-8:00 a.m. 8. Preservision AREDS 2 Capsules (vitamin and mineral) PO-8:00 a.m. Interview on 01/13/2025 at 10:25 a.m. with S2 DON confirmed it was the expectation of nurses and nursing standards, that nurses ensure residents swallow their medications and not leave them at the resident's bedside.

Based on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 4 (S11 CNA, S12 CNA, S13 CNA, and S14 CNA) of 5 (S11 CNA, S12 CNA, S13 CNA, S14 CNA, and S15 CNA) CNA personnel records reviewed. Findings: Review of CNA personnel records revealed the following: S11 CNA- date of hire was on 09/15/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S12 CNA-date of hire was on 11/21/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S13 CNA-date of hire was on 02/01/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S14 CNA-date of hire was on 04/26/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. Interview on 01/14/2025 at 12:00 p.m. with S1 Administrator revealed all employees should have yearly performance evaluations completed. Telephone interview on 01/14/2025 at 12:06 p.m. with S4 Corporate HR confirmed all employees should have performance evaluations completed yearly. Interview on 01/14/2025 at 2:12 p.m. with S1 Administrator confirmed the performance evaluations were not completed for S11 CNA, S12 CNA, S13 CNA, and S14 CNA as required, but should have been.

Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 70. Findings: Observation on 01/12/2025 at 8:40 a.m. revealed a form for daily staffing dated 01/10/2025 was posted on a bulletin board near the nurse's station. Complete daily staffing information including census, and total number and actual hours worked by nursing staff were not posted for 01/10/2025, 01/11/2025, and 01/12/2025. Observation on 01/12/2025 at 9:06 a.m. revealed the posted daily staffing forms remained not updated for 01/10/2025, 01/11/2025, and 01/12/2025. Interview with S16 RN and S17 LPN at time of observation revealed they were unsure who was responsible for completing and posting the daily staffing hours over the weekend. S16 RN and S17 LPN confirmed the facility had not posted daily nurse staffing information on a daily basis, but should have. Interview on 01/12/2025 at 9:33 a.m. with S1 Administrator confirmed nurse staff information including daily required and provided hours should have been posted daily over the weekend, but had not.

Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The facility failed to follow the menu in regards to recipe and portion size to ensure nutritional adequacy of the meal for 6 (#57, #41, #4, #1, #36 and #23) of 6 residents (#57, #41, #4, #1, #36 and #23), who received pureed diets. Review of the facility's recipe book located in the kitchen for pureed diets revealed in part . P/PU4 (coded for pureed foods-no lumps, require no chewing). Beef Meatballs f/Frz (fresh/frozen) w/mushroom gravy. [NAME] Method: Puree; Serving Utensil: #8 scoop; Serving Size: 1/2 Cup. Preparation Step: IDDSI (International Dysphagia Diet Standardization Initiative) Pureed foods: The number of portions served should equal the same number of portions pureed. Use Fork-Drip and Spoon-tilt test to ensure proper PU4 consistency is reached. Potato Mashed f (fresh)/ Inst (instant) Mix (Mashed Potatoes). Serving Utensil: #8 scoop; serving size: 1/2 cup. Ingredients: Water, Tap (Boiled) and Potato, Mashed Flake Dry. Preparation Step: Prepare mashed potatoes according to package instructions. 1.Observation of preparation of the pureed lunch meal, and interview of S18 [NAME] on 01/12/2025 at 10:35 a.m., revealed the following: The pureed meal preparation consisted of Meatballs, Mashed Potatoes and [NAME] Gravy. S18 [NAME] stated that she was told to just make it look like baby food. S18 [NAME] was observed to add an unmeasured amount of cold tap water from the sink, and an unmeasured amount of the meatballs, in the food processor. S18 [NAME] paused the food processor to check the consistency of the meatballs, and then added more meatballs. S18 [NAME] stated that she was unaware of the amount of meatballs that had been added. S18 [NAME] did not follow a recipe to prepare the food items, and stated that she was unaware of a recipe binder for pureed food preparation. S18 [NAME] stated that she was told to just make it look like baby food. S18 [NAME] stated that there were 6 residents who received a pureed diet. Observation of S18 [NAME] prepare the mashed potatoes revealed there were preparation instructions on the bag; however, S18 [NAME] added an unmeasured amount of instant mashed potatoes to boiling water until the potatoes reached the consistency she preferred and S18 [NAME] used the same process for preparing the brown gravy mix. Interview on 01/12/2025 at 10:50 a.m. with S7 Dietary Manager, confirmed that S18 [NAME] did not refer to the recipe for the P/PU4 diet prior to preparing the food, and confirmed that S18 [NAME] did not prepare the pureed items correctly. 2. Observation of the lunch meal service on 01/12/2025 at 12:10 p.m., revealed the P/PU4 diet of beef meatballs were not served with a #8 scoop (1/2 cup or 4 ounces). S18 [NAME] used a yellow scoop that measured 1 and 5/8 oz., served one meal tray that was to have 2oz of meat per the resident's meal card and changed to a green scoop that measured 2 and 2/3 oz. after S7 Dietary manager informed her of the incorrect utensil size. Interview on 01/12/2025 at 12:26 p.m. with S7 Dietary Manager confirmed that the pureed meal item was served using the incorrect serving size utensil, and that they should have used the utensil designated on the posted print out titled NSF Certified Dishers, that contained color coded utensil serving measurements.

Based on observation and interview the facility failed to store and prepare food under sanitary conditions in accordance with professional standards of food service safety, as evidenced by failing to: 1. Properly store food items located in the facility's refrigerator, freezer, resident dining area, and kitchen area. 2.Store clean dishes in an area that would remain free of food debris. 3. Monitor and record the temperatures of a refrigerator that was used to store prepared meal items for residents, from [DATE] to current ([DATE]). 4.Test and document the dishwasher's sanitizing solution concentration for dinner dishes on [DATE] and [DATE], and breakfast dishes on [DATE]. 5.Ensure dietary staff wore proper hair covering. Findings: Review of the facility's policy dated ,d+[DATE], and titled Refrigerators and Freezers, read in part . Policy Statement: This facility will ensure safe refrigerator temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 4. Food Service Supervisors, or designated employees will check and record refrigerator and freezer temperatures daily with first opening, and at closing in the evening. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired, or past perish dates. Review of the facility's policy dated ,d+[DATE], and titled Food Receiving and Storage read in part . Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee, and documented according to state - specific requirements. c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Review of the facility's policy dated ,d+[DATE], and titled Food Preparation and Service read in part . Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Food Preparation Area 6. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Review of the facility's policy dated ,d+[DATE], and titled Dry Storage read in part . 4. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated. 11. Bags of bread products should be closed and dated with the date that it was opened. 12. All bins for storage must be emptied and cleaned before new food can be added. After the bin has been cleaned and dried, it should be dated with the date that it is filled. Review of the facility's policy dated ,d+[DATE], and titled Sanitization read in part . Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary . Review of the facility's policy dated ,d+[DATE], and titled Dishwashing Machine Use read in part . Policy Statement: Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: 5. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine, and once a week thereafter. Concentrations will be recorded in a facility approved log. Observation of refrigerated items, and interview with S18 [NAME] during the initial tour of the kitchen that began on [DATE] at 8:58 a.m., revealed 3 sticks of butter that had been removed from the packaging, and was not dated; 1 stick of butter opened, and undated; sausage links unsealed; a gallon size jar of Italian dressing open and undated; 1 pack of turkey sandwich meat, undated; a clear liquid substance in the bottom a silver container that contained the opened turkey sandwich meat and other unopened sandwich meats; and a bottle of liquid garlic opened and undated. Observation of the Freezer during the initial tour of the kitchen that began on [DATE] at 8:58 a.m., revealed 4 bags of frozen spinach that had been removed from the box and was undated; 6 bags of frozen red potatoes that had been removed from the box, and was undated; 7 packages of whipped topping that had been removed from the box and was undated; 1 bag of frozen chicken wings opened and undated; 1 package of Shrimp opened and undated; 1 box of frozen pie dough unsealed and undated with a Best By date of [DATE]; 1 box of frozen pie dough undated with a Best By date of [DATE]; 1 box of cookie dough unsealed and undated; 5 bags of frozen cauliflower that had been removed from the box and was undated; 6 bags of frozen vegetable blend that had been removed from the box and was undated. Observation in the kitchen area on [DATE] at 9:30 a.m. with S7 Dietary Manager revealed hamburger buns on the prep area table, opened and undated; pan lids located under the steam table, dirtied with food particles; a box of bananas stored under the kitchen mixer right next to a trash can; and an apple juice dispensing carton opened and uncovered. Observation of the resident dining area on [DATE] at 9:45 a.m., revealed a black refrigerator with no thermometer in the freezer area that held ice cream used for resident consumption, and prepared meal items in the refrigerated area to include puddings, and a red juice for today's lunch meal, with no temperature log observed at that time. Observation revealed 4 loaves of sandwich bread and 2 bags of rolls that were located on the shelving unit, and had been removed from the original container and was undated; a box of Kellogg's cereal that was opened, unsealed and undated. Interview with S7 Dietary Manager on [DATE] at 10:00 a.m. confirmed that in the refrigerator there were 3 sticks of butter that had been removed from the packaging, and were undated; 1 stick of butter that had been opened, and was undated; 1 package of sausage links were unsealed; a big jar of Italian dressing was opened and undated; 1 pack of turkey sandwich meat, was undated; and that there was a clear liquid substance in the bottom of the silver container that contained the undated turkey sandwich meat and other unopened sandwich meats; and that a bottle of liquid garlic was opened and undated. S7 Dietary Manager confirmed that in the freezer, there were 4 bags of frozen spinach that had been removed from the box and was undated; 6 bags of frozen red potatoes that had been removed from the box, and was undated; 7 packages of whipped topping that had been removed from the box and was undated; 1 bag of frozen chicken wings opened and undated; 1 package of Shrimp opened and undated; 1 box of frozen pie dough unsealed and undated with a Best By date of [DATE]; 1 box of frozen pie dough undated with a Best By date of [DATE]; 1 box of cookie dough unsealed and undated; 5 bags of frozen cauliflower that had been removed from the box and was undated; 6 bags of frozen vegetable blend that had been removed from the box and was undated. S7 Dietary Manager stated that the frozen pie dough should have been thrown out. S7 Dietary Manager confirmed that in the Dining area, there was no thermometer in the black refrigerator's freezer area, and that there were 4 loaves of sandwich bread and 2 bags of rolls that were located on the shelving unit, that had been removed from the original container and was undated; a box of Kellogg's cereal that was opened, unsealed and undated. Interview with S20 Kitchen Aide on [DATE] at 10:13 a.m., revealed that she was unaware of how or where to document the dishwasher's sanitizer solution concentration results, and had already used the dishwasher for the breakfast dishes without the sanitizer concentration being checked. Review of the ,d+[DATE] dishwasher's sanitizing solution concentration log, revealed that the dinner log had not been completed for [DATE] and [DATE], and the breakfast log had not been completed for [DATE]. Interview and review of the Kitchen's freezer/refrigerator logs with S7 Dietary Manager on [DATE] at 10:29 a.m., confirmed that the temperature log for the black refrigerator located in the dining area, had not been completed the entire month of ,d+[DATE], and from [DATE] to current ([DATE]), and it should have been. Observation of the lunch meal service on [DATE] at 12:10 p.m., which consisted of Corndogs, French fries and creamed corn, revealed hair was observed in the corndogs. S18 [NAME] who served the corn dogs wore a green bandana as a hair covering. S7 Dietary Manager observed the corn dogs at that time, and confirmed that hair was in the corn dogs.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (#71) out of 1 resident reviewed for discharge. The total sample size was 29. Findings: Review of the facility's policy titled Transfer or Discharge Notice with a review date of 01/2023 read in part . Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. 6. A copy of the notice is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Record Review of Resident #71's Electronic Health Record (EHR) revealed an admitted [DATE] and a discharge date of [DATE]. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee; Cognitive Communication Deficit; Age-Related Osteoporosis without current pathological fracture; Anxiety Disorder. Record Review of Resident #71's Discharge MDS with an ARD of 12/10/2024 revealed a discharge date of [DATE]. Record Review of Resident #71's EHR revealed no documentation that the Ombudsman had been notified of Resident #71's discharge to another facility on 12/10/2024. Interview on 01/14/2025 at 2:26 p.m. with S5 Social Services Director (SSD) revealed Resident #71 was discharged to a behavioral hospital due to an increase in behaviors. S5 SSD stated S6 Business Office Manager was responsible for sending notification of transfers and discharges to the Ombudsman. Interview on 01/14/2025 at 2:29 p.m. with S6 Business Office Manager confirmed she did not submit in writing to the Ombudsmen a notification of Resident #71's discharge. Interview on 01/14/2025 at 2:49 p.m. with S3 Corporate RN confirmed the facility should submit a notification in writing to the Ombudsmen of resident transfers and discharges, but did not.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#5) of 1 residents investigated for PASARR in a final sample of 29 residents. Findings: Record Review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part .Major Depressive Disorder, Anxiety Disorder, Cerebral Infarction without residual deficits, Vascular Dementia Unspecified Severity without Behavioral Disturbance. Further review revealed he was diagnosed with Schizoaffective Disorder on 10/10/2023. Record Review of Resident #5's Quarterly MDS with an ARD of 01/30/2025 revealed a BIMS summary score of 99, indicating BIMS was unable to be completed. Record Review of the Resident #5's Care Plan with a Target Date of 01/22/2025 revealed in part .The resident had the potential to be verbally aggressive, yelling at staff, cursing at staff (initiated 10/09/2023). Interventions: Psychiatric/Psychogeriatric consult as indicated. Administer medications as ordered. Monitor/document for side effects and effectiveness. The resident uses psychotropic medications (initiated 10/09/2023). Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness. Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Further review of Resident #5's record revealed there was no evidence that a new review or a Level II PASARR had been submitted to the appropriate state-designated authority after the new diagnosis of Schizoaffective Disorder on 10/10/2023. Interview on 01/13/2025 at 12:40 p.m. with S5 Social Services Director revealed she was responsible for sending referrals to the appropriate state-agencies for Level II PASARR evaluations. After review of Office of Behavioral Health (OBH) PASRR Level II Resident Review Form, S5 Social Services Director stated Resident #5 didn't meet criteria for a Level II PASARR evaluation. Interview on 01/13/2025 at 2:37 p.m. with S5 Social Services Director reviewed Resident #5's diagnoses list and confirmed Resident #5 had a diagnosis of Schizoaffective Disorder on 10/10/2023. S5 Social Services Director confirmed the OBH PASRR Level II Resident Review Form that was submitted for Resident #5 was incorrect, and a Level II PASARR evaluation should have been submitted, but was not.

Based on observation, record review and interview the facility failed to ensure the implementation of a comprehensive person centered care plan for 1 (Resident #44) of 29 sampled residents. The facility failed to ensure Resident #44's NPO status was implemented. Findings: Review of Resident #44's clinical record revealed an admitted [DATE], with diagnoses which included dysphagia-oropharyngeal phase; hemiplegia and hemiparesis following cerebral infarction protein-calorie malnutrition; dysphasia following other cerebrovascular disease; dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; adult failure to thrive and age-related physical debility. Review of Resident #44's Quarterly MDS with an ARD of 11/12/2024, revealed a BIMS score of 4. Resident had severe cognitive impairment. Resident had impairment on both sides for upper and lower extremities. Resident was dependent for eating, oral hygiene, toileting, showering/bathing; lower/upper body dressing and personal hygiene. Review of Resident #44's physician's order with a start date of 11/06/2024, read in part NPO diet, NPO texture, NPO consistency. Review of Resident #44's Care Plan revealed in part The resident requires tube feeding, NPO. Interventions to include: *****NPO**. Review of Resident #44's Tasks revealed a Kardex that read in part . Level of Staff assistance during care: Resident is nothing by mouth for swallowing. Eating/Nutrition: *****NPO**. Observation of Resident #44 on 01/13/2025 at 10:28 a.m. revealed Resident #44 in bed; Grey water pitcher with a straw noted on Resident #44's bedside table. Interview with S10 LPN on 01/13/2025 at 10:36 a.m. revealed that if Resident #44 requested anything by mouth; she would explain to Resident #44 that she was NPO. Interview with S9 CNA on 01/13/2025 at 10:41 a.m. revealed S9 CNA provided Resident #44 with small swallows of water when she goes in to check on Resident #44. S9 CNA stated that the water pitcher in Resident 44's room is used for sips of water. S9 CNA stated that she would ask the nurse if a resident was not able to have anything by mouth. Observation and Interview with S10 LPN on 01/13/2025 at 2:29 p.m. revealed that S9 CNA was aware that she should not have been giving Resident #44 anything by mouth to include water. S10 LPN stated that she was unsure of why the grey pitcher with a straw was in Resident #44's room. Interview with S2 DON on 01/13/2025 at 2:50 p.m. confirmed that Resident #44 should not have been given sips of water since she was NPO and that there should not have been a water pitcher with a straw on her bedside table. S2 DON also stated that CNA's are aware of resident status by checking the Kiosk.

Based on interview and record review the facility failed to document a Discharge Summary when a resident was discharged from the facility for 1 (#71) out of 1 residents reviewed for discharge. The total sample size was 29. Findings: Review of the facility's policy titled Transfer or Discharge Documentation and Notice with a review date of 01/2023 read in part . When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Record Review of Resident #71's Electronic Health Record (EHR) revealed an admitted [DATE] and a discharge date of [DATE]. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee; Cognitive Communication Deficit; Age-Related Osteoporosis without current pathological fracture; Anxiety Disorder. Record Review of Resident #71's Discharge MDS with an ARD of 12/10/2024 revealed a discharge date of [DATE]. Record Review of Resident #71's departmental progress notes read in part . 12/10/2024 4:50 pm General Nurses Note: Resident accepted by facility . S2 DON notified, notified Resident #71's responsible party (RP), and Physician . awaiting pick up from ambulance service. 12/10/2024 6:25 p.m. General Nurses Note: Resident #71 left out of facility via ambulance, Resident #71 left in stable condition via stretcher. Gave report to LPN, and notified Resident #71's RP and S2 DON of resident departure from facility. 12/10/2024 8:23 p.m. Social Services Note: Resident #71 discharged . Record Review of Resident #71's EHR and paper medical record revealed no documentation of a discharge summary completed. Interview on 01/14/2025 at 2:42 p.m. with S2 DON accompanied with S3 Corporate RN confirmed a discharge summary should have been completed for Resident #71, but was not.

Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#44) of 29 sampled residents by failing to use enhanced barrier precautions, when needed. Findings: Review on 01/14/2025 of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Resident Activity/Assistance for Residents on EBP [NAME] Gloves and Gown Administer medications enterally: Yes Device care or use: central line, urinary catheter, feeding tube . Yes Any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device Yes Review of Resident #44's clinical record revealed an admitted [DATE], with diagnoses which included dysphagia-oropharyngeal phase; hemiplegia and hemiparesis following cerebral infarction protein-calorie malnutrition; dysphasia following other cerebrovascular disease; dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; adult failure to thrive and age-related physical debility. Review of Resident #44's Quarterly MDS with an ARD of 11/12/2024, revealed a BIMS score of 4. Resident had severe cognitive impairment. Resident had impairment on both sides for upper and lower extremities. Resident was dependent for eating, oral hygiene, toileting, showering/bathing; lower/upper body dressing and personal hygiene. Review of Resident #44's Care Plan revealed in part The resident requires tube feeding; NPO. Interventions to include . Promote enhanced barrier precaution when providing care or having physical contact with resident. Observation of Resident #44 in room on 01/12/2025 at 2:57 p.m. revealed an Enhanced Barrier Precaution (EBP) sign on the outside of the room but no PPE noted on door or in room. Observation of Resident #44 in bed on 01/13/2025 at 10:28 a.m. revealed an Enhanced Barrier Precaution sign by Resident #44's door but no PPE hanging on door or in Resident #44's room. Observation of Resident #44's Medication administration via PEG tube on 01/13/2025 at 1:59 p.m. revealed S10 LPN did not wear a gown while in contact with Resident #44's PEG tube. S10 LPN confirmed that she should have worn a gown while flushing and administering medications via Resident #44's PEG tube. Interview with S2 DON on 01/13/2025 at 2:50 p.m. confirmed that a gown and gloves should have been worn by S10 LPN while administering Resident #44's medication and flush via PEG tube.

Based on record review, observation, and interview, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to properly secure Resident #3's wheelchair prior to transporting the resident in 1 of the facility's 2 vans. This deficient practice resulted in an immediate jeopardy situation on 03/20/2024 at 9:50 a.m., when Resident #3 was placed in the facility's van, and her wheelchair was anchored/secured in the facility's van with only three of the four anchors required. While the van was in motion, Resident #3's wheelchair fell backwards, and Resident #3 hit the back of her head on the lift. Resident #3 sustained an abrasion with bleeding noted to the back of her head. The Administrator stated the weekly safety inspections on the transportation van had not been completed by the van driver prior to the accident, as directed by the facility's policy. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review on 04/11/2024 of the facility policy revised on 03/2023 titled Facility Vehicle Log, A Part of the Driver and Vehicle Safety Policy revealed in part . Driver's Weekly Vehicle Safety Inspection- To be completed by the company vehicle driver once each week, and prior to driving a vehicle that has been returned to service after repairs. If there are safety concerns noted during the inspection, they are to be noted on the Driver's Weekly Vehicle Safety Inspection form, and reported immediately to Maintenance or the Administrator. The vehicle should immediately be taken out of service if the driver or others determine that the vehicle cannot be driven safely. Maintenance and Repair Invoices- In addition to the form maintained above, all invoices for maintenance and repairs must be maintained either in the Facility Vehicle Log, or in another secure location so that a complete record of the vehicle's history is available. Securing Residents in Van - Competency Determination- Secure two front tie-downs to a solid, structural frame member of the wheelchair. Secure two back tie-downs to a solid, structural frame member of the wheelchair. Secure the passenger with shoulder and lap belts. Review of the Q'straint Installation Instructions - Vehicle Anchorages & Accessories for 4-Point Wheelchair Securement Systems dated September 2009, and reviewed on 04/09/2024 at 4:36 p.m. revealed in part . WARNINGS Do not alter or modify the system or components in any way without first consulting Q'Straint. The system is a complete, integrated system. Do not interchange or substitute any components. Q'Straint systems and components have been tested in a configuration similar to that recommended in these instructions. Any deviation from these recommendations is the responsibility of the installer. Systems and components should only be installed by an experienced technician. Review of Resident #3's medical record revealed an admitted [DATE], with diagnoses that included in part .Cerebral Infarction, Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Contracture of Left Hand, Bipolar Disorder, and Pain. Review of Resident #3's Quarterly MDS with an ARD of 02/07/2024, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #3 used a manual wheelchair, and required substantial/maximal assistance with sit to stand and chair/bed to chair transferring. Review of Resident #3's Comprehensive Plan of Care, with a target date of 05/14/2024, revealed Resident #3 was care planned for the following problems: 1. Resident has an ADL self-care performance deficit due to left sided weakness. Interventions included: extensive assistance by two person assist with bed mobility, transfers, and toileting; and set up assist with eating. 2. Resident #3 is at risk for falls. Interventions included: anticipate and meet resident's needs. On 03/20/2024 - fall in van-wheelchair tipped backward/abrasion to back of head. Review of the facility's Incident/Accident report completed by S5 RN on 03/20/2024 at 10:07 a.m., revealed in part .This nurse was called by S4 CNA, who stated Resident #3 fell back and hit her head while on van. Resident was brought in wheelchair by S3 CNA/Transportation, who stated her chair flipped over backwards in van, and she hit her head. Blood noted to back of head. Resident brought to nurses' station and area to head cleaned and assessed by S5 RN, and small abrasion noted, no active bleeding. Abrasion also noted to base of neck between shoulders, no bleeding noted to area. Neuro checks started. Resident complained of headache, Tylenol offered. Resident Description: We hit a bump, and I tipped over in my wheelchair. Pain rated at 4, on a pain scale of 1 - 10. During an interview on 04/08/2024 at 2:30 p.m., Resident #3 stated she was coming back from a doctor's appointment with S3 Transportation and another employee the day the accident occurred on the van. Resident #3 stated they hit a bump, her wheelchair flipped backwards, and she hit her head on the back door. Resident #3 stated she felt the back of her head with her hand, and there was blood. Resident #3 stated she was sitting in her wheelchair which was buckled to the floor, and didn't know how she tipped over backwards. Resident #3 stated it did hurt, and she kept a headache for some days. During an interview on 04/09/2024 at 8:00 a.m., with S3 Transportation, she stated on the day of the accident, S4 CNA anchored Resident #3's wheelchair down in the van using 3 of the 4 required anchors. S3 Transportation stated the front right anchor was already broken prior to the accident, and had been replaced with a type of ratchet strap. She stated she didn't know how long the anchor had been broken. S3 Transportation stated while driving on 03/20/2024, she heard a click, looked back, and saw Resident #3 falling backwards, so she pulled the van over. S3 Transportation stated the wheelchair was tilted back, and once stopped, they repositioned the resident back into the wheelchair and secured the wheelchair again. S3 Transportation stated she saw a small amount of blood, and a small gash to the back of Resident #3's head. S3 Transportation stated she called the nursing home to report it, and S5 RN came out to check on the resident when they arrived. S3 Transportation stated the anchor was fixed now. Observation of the van at that time, 04/09/2024 at 8:00 a.m., revealed 4 silver anchors secured to the floor of the van. During an interview on 04/09/2024 at 8:12 a.m., S2 Maintenance stated about a month ago he replaced the right front anchor with a manual ratchet strap when one of the drivers told him the front right anchor was not working. S2 Maintenance said the manual ratchet strap was working at the time of the accident with Resident #3 on 03/20/2024, but it was harder to use. S2 Maintenance stated he didn't know if S3 Transportation and S4 CNA knew how to use the ratchet strap. S2 Maintenance stated since Resident #3's accident, he replaced the manual ratchet strap with the silver automatic one that was observed in place now. During an interview on 04/09/2024 at 8:20 a.m., S4 CNA stated on the day of Resident #3's accident, she strapped down Resident #3 into the van in her wheelchair. S4 CNA stated while they were traveling, the brakes were hit hard, she heard the wheelchair locks make a sound, and Resident #3 screamed. S4 CNA stated she looked and saw Resident #3 falling backwards in her wheelchair, and they pulled over. S4 CNA stated the wheelchair was tilted back, and they unstrapped Resident #3, fixed the wheelchair, put Resident #3 back in the wheelchair, and secured it down again. S4 CNA stated Resident #3 reached for the back of her head with her hand, and said it was bleeding. S4 CNA stated Resident #3 said My head hurts. S4 CNA stated she had strapped Resident #3's wheelchair down using the two back anchors and the front left one. S4 CNA stated the front right one was different, it was a tow strap that didn't work. S4 CNA described the tow strap as the kind that was used to tow cars. S4 CNA stated she didn't know how long the front right anchor had been broken. S4 CNA stated she had never been trained on how to secure residents' wheelchairs in the van, and didn't know she wasn't supposed to do it, or she wouldn't have. S4 CNA stated she secured Resident #3's wheelchair because S3 Transportation just got in the driver's seat, and it had to be done. S4 CNA stated she went on transports often, but had never used the tow strap before, and didn't know how long it had been in use. During a telephone interview on 04/09/2024 at 2:10 p.m., S2 Maintenance stated a driver reported the front right anchor wasn't working around the first week of 03/2024 (could not remember the exact date). S2 Maintenance stated he fixed it immediately by replacing the silver automatic anchor with the manual ratchet strap, and the van was not taken out of service. S2 Maintenance stated he did not report to the Administrator when he made the repairs and switched out the anchor to the ratchet strap. S2 Maintenance stated he switched the ratchet strap back to a silver automatic anchor on 03/20/2024 while inspecting the van after the incident. S2 Maintenance stated he did not document any of the repairs on the inspection form, or an invoice of any type, but should have. S2 Maintenance stated he had not received any special training or certification on how to repair the van. S2 Maintenance stated he swapped out the anchors when needed, but took the van to a business who repaired wheelchair accessible vehicles for all other repairs. During a telephone interview on 04/11/2024 at 8:38 a.m., S4 CNA stated on the day of the accident with Resident #3, she told S3 Transportation the tow strap wasn't working. S4 CNA stated S3 Transportation stated she had informed S2 Maintenance that the tow strap was not working; however, he said it was. During a telephone interview at 8:41 a.m. on 04/11/2024, S3 Transportation stated S4 CNA secured Resident #3's wheelchair into the van the day of the incident because We do team work. S3 Transportation stated she knew there were only 3 anchors working, and they had reported it to S2 Maintenance in the past, but maybe he forgot. S3 Transportation stated they had been using the van with only 3 working anchors for a while, (unable to remember how long), and this was not the first time a resident had been transported with only three anchors in use. S3 Transportation stated she wasn't aware that the CNA riding along shouldn't be securing residents' wheelchairs into the van. During an interview on 04/09/2024 at 10:11 a.m., S1 Administrator confirmed S4 CNA was not trained to secure residents' wheelchairs in the van. S1 Administrator stated S4 CNA was riding along on the transport because the resident required 2 person assistance. S1 Administrator stated S3 Transportation had been trained on securing residents' wheelchairs prior to the accident on 03/20/2024, and should have been the one to secure Resident #3's wheelchair into the van. S1 Administrator stated they only train the drivers to secure residents' wheelchairs. S1 Administrator was unable to provide the Driver's Weekly Safety Inspections for 02/2024 and 03/2024, as requested. S1 Administrator confirmed the drivers were not completing the Driver's Weekly Safety inspection of the van each week prior to the accident on 03/20/2024, and should have been. During an interview on 04/11/2024 at 12:00 p.m., S1 Administrator confirmed Resident #3's wheelchair had not been properly secured in the van on the day of the accident, because the wheelchair was secured with three anchors instead of the four that were required. S1 Administrator stated S2 Maintenance said the ratchet strap was working when checked immediately after Resident #3's accident. S1 Administrator acknowledged the CNAs and Drivers may not have known how to use the ratchet strap. S1 Administrator stated when S2 Maintenance replaced the silver automatic anchor with the ratchet strap, it was not reported to her. S1 Administrator stated it was her understanding that the manual ratchet straps were okay to use in place of the silver automatic anchor. S1 Administrator stated she did not have any manuals on the van, because the van was there when she was hired. S1 Administrator stated she obtained the Q'straint Installation Instructions from Corporate after the surveyor inquired about it. The facility has implemented the following actions to correct the deficient practice: Plan of Correction Date 03/23/2024 The monthly Healthstream topic for April is Driver and Vehicle Safety. This course, which includes videos and Driver and Vehicle Safety Policy, will be completed by all Nexion staff by April 30, 2024. Inservice on Driver and Vehicle Safety Policy was initiated by the Maintenance Director to all current company authorized drivers on March 20, 2024. Securing Resident in Van - Competency Demonstration for all drivers according to Driver and Vehicle Safety Policy initiated March 21, 2024 through present. Monitor each driver that is scheduled for transport once daily by Maintenance Director, Administrator, or DON. Monitored by Securing Residents in Van - Competency Demonstration. Began March 22, 2024 through present. All van Q'Straints are working properly. Inspected by Maintenance Director March 20, 2024 and monthly. Weekly van inspection log being completed by driver per policy and procedure. The Maintenance Director continues to complete the monthly van inspection log. The Maintenance Director was trained by Regional Maintenance Director. The facility was in compliance on March 23, 2024. Ongoing training will continue to be provided as determined by the QA team.

Based on record review and interview, the facility failed to ensure a resident's right to be free from physical and sexual abuse, and psychosocial harm by another resident, for (#1) of 3 (#1, #2, and #3) residents investigated for abuse. This failed practice resulted in an actual harm situation on 12/27/2023 at 3:40 p.m., when Resident #2 put his hands under Resident #1's shirt, and on her breast. On 11/19/2023, Resident #2 tried to throw a coffee cup at Resident #1; however, staff intervened. On 12/26/2023, Resident #2 lurched towards Resident #1 when staff tried to take Resident #1 to provide care, and a CNA had to step between the residents. On 12/27/2023, Resident #2 put his hand under Resident #1's shirt and on her breast, became angry when he was redirected, and grabbed and pinched Resident #1 on her back, and through her clothes, leaving a reddened area on her back. On 12/29/2023, Resident #2 grabbed Resident #1's hand squeezing it, and she yelled out Ouch! with a facial grimace. A reasonable person in Resident #1's situation would have experienced severe psychosocial harm and humiliation, as a result of this inappropriate, unwanted sexual contact/abuse. Findings: Review of the facility's Abuse Prohibition Policy revealed in part . Physical abuse includes hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment. Sexual abuse includes, but is not limited to, rape, sexual harassment, sexual coercion, or sexual assault. 13. If the incident involves sexual behavior, the following will occur: -Determine if both victim and perpetrator are able to make decisions. A resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if consent was obtained through intimidation, fear or coercion. Sexual abuse is non-consensual sexual contact of any type with a resident as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses that included in part .Alzheimer's disease with early onset; Sjogren's syndrome; Anxiety disorder; and Muscle wasting. Review of Resident #1's Quarterly MDS with an ARD of 11/21/2023 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required partial/moderate assistance with toilet hygiene and was always incontinent of bowel and bladder. Review of Resident #1's care plan revealed a problem of impaired cognitive function with dementia related to Alzheimer's. Interventions included administer medications as ordered, ask yes or no questions in order to determine resident's needs and cue, reorient, and supervise as needed. Review of the interventions revealed the resident needs extensive assistance with all decision making. Review of Resident #1's nurses' notes documented by S10 LPN revealed the following: 12/27/2023 at 3:39 p.m. - Resident (Resident #1) in day room observed with male friend (Resident #2), and his hand was inside resident's shirt. When this nurse approached the male resident to remove his hand from under her shirt, he got angry and started grabbing the resident on the back, telling her not to get up. Treatment nurse (S9 LPN) redirected male resident to dining room, and this nurse redirected resident (#1) to Wing X lobby to separate the two residents. Will continue to monitor. 12/29/2023 at 1:09 p.m. - CNA attempting to assist Resident #1 to the dining room when Resident #2 grabbed her hand squeezing it. She yelled out Ouch! with facial grimace. CNA asked him to let go of her hand. He started yelling, placed hands on chest pushing CNA into Christmas tree. Redirected Resident #2 to another room, and CNA assisted Resident #1 to dining room. No injuries noted. Notified Administrator and DON, MD, S11 NP, and RP. New order to send to behavioral health and collect CBC/CMP/UA per S11 NP. Referral sent and awaiting response. Documented by S7 LPN. In an interview on 01/23/2024 at 12:30 p.m., Resident #1 stated she had been residing at the facility for two days, and her parents lived there too. Resident #1 denied ever being abused physically or sexually by a staff member, or another resident. Resident #1 denied ever being touched inappropriately by another resident. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included in part .Unspecified Dementia, moderate with agitation; Hypertension; Major Depressive Disorder; Schizoaffective Disorder, Depressive type; Emphysema; and Cognitive Communication Deficit. Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating. Resident #2's Care Plan revealed a problem of The resident is at risk for impaired cognitive function/dementia. Interventions included: Aricept as ordered; cue, reorient and supervise as needed; monitor/document/report prn any changes in cognitive function, changes in decision making ability, memory, recall and general awareness, difficulty expressing self or understanding others, level of consciousness, or mental status. Review of an 11/09/2023 progress note documented by S12 NP, revealed Resident #2 was seen for ongoing behaviors including agitation and combativeness. Patient is agitated and combative when staff attempts to redirect him and perform tasks separate from his female friend (Resident #1), who also resides in facility. Review of S15 Psychiatric NP's progress note dated 12/04/2023 revealed the following in part . Psych Impression: Pt has hypersexual thoughts . Review of Resident #2's nurses' notes revealed the following in part . 11/05/2023 at 6:59 p.m. - CNA assisting another resident (Resident #1) to her room so that she could be changed. This resident (Resident #2) became agitated and yelled at staff, You let her be, I'll take care of her. Writer explained to resident that staff had to care of this resident. Administered prn Vistaril for agitation. Documented by S5 LPN. 11/05/2023 at 8:29 p.m. - A female resident (Resident #1) was falling asleep on the couch and writer asked if she were ready to lie down and she stated yes. When writer went to assist resident (Resident #1) to her room, this resident (Resident #2) stated to female, No you come with me! Writer explained to Resident #2 that the resident was wanting to go lie down and he bowed his shoulders to writer and yelled, No! She can go with me over there pointing to the other day room. CNA then escorted female to her room to assist with her getting ready for bed and Resident #2 stormed off cursing. MD notified of resident's behaviors this shift. Documented by S5 LPN. 11/09/2023 at 2:19 p.m. - Attempting to provide care to another resident (Resident #1), when Resident #2 became verbally aggressive with staff. Redirection unsuccessful. PRN Vistaril given. S12 NP made rounds, new orders to increase Paxil from 10mg to 20mg daily. Continue to monitor. Documented by S7 LPN. 11/12/2023 at 4:04 p.m.: Resident became disrespectful and aggressive towards staff when staff attempted to remove Resident #1 from day room. Staff explained to Resident #2 that Resident #1 needed to go to her room for some female care, and Resident #2 said, That's a damn lie, I know when I have to go to the bathroom, and y'all just trying to control me standing between staff and Resident #1. I explained to Resident #2 that Resident #1 does not always know when she needs to go to the restroom, and that we are here to help her stay clean and safe. Resident #2 continued being rude and did not want us to take Resident #1 to her room. While nurse was explaining again to Resident #2 that Resident #1 needed help, CNAs were able to sneak Resident #1 to her room to assist her. Documented by S7 LPN. 11/19/2023 at 11:21 a.m. - Resident refused to let staff care for another resident (Resident #1). When the resident (Resident #1) went with staff he (Resident #2) told her (Resident #1), I said come on here. She continued to walk with staff, and he tried to throw a coffee cup at her (Resident #1). I got the cup out of resident's hand and redirected him to the lobby area in front of nursing home. He walked off telling the resident (Resident #1), You better be ready when I get back and I mean it. Documented by S10 LPN. 12/10/2023 at 1:55 p.m. - Resident #2 observed by this nurse pulling another resident (Resident #1) away from staff while (staff) were trying to take the resident for care. When staff directed the lady resident away from this resident, he got mad and said, Y'all full of shit over here. He walked away and threw his coffee all over the floor. Documented by S10 LPN. 12/14/2023 at 3:40 p.m. - Resident in lobby with female resident (Resident #1). When staff went to direct female resident to room to do routine care, he got angry and started yelling at CNA. He states, That is my wife and you going to let her go. Redirected successful. Will monitor. Documented by S10 LPN. 12/15/2023 at 12:20 p.m. - CNA was assisting Resident #1 up from couch in dayroom A, to take her to the bathroom. CNA stated , I asked Resident #1 to get up and let's go to the restroom, and Resident #2 stated, no she doesn't need to go. I said yes she does, and he kicked me in my leg. Documented by S8 LPN. 12/15/2023 at 4:19 p.m. - Resident #2 transferred to inpatient psychiatric facility. 12/21/2023 at 2:46 p.m. - Resident #2 returned to facility by transporter from Behavioral Hospital. Documented by S10 LPN. 12/26/2023 at 4:26 p.m. - Patient agitated when attempting to provide care to another resident (his girlfriend) (Resident #1), multiple times throughout the day. S12 NP made rounds, new order to start Vistaril 25mg po q 6 hours prn agitated/behaviors/combativeness/anxiety. Documented by S7 LPN. 12/26/2023 at 7:45 p.m. - When staff attempted to provide care to a female resident (Resident #1), who this resident identifies as his girlfriend, he became aggressive with staff. When CNAs went to assist female resident to her room he then lurched towards female resident, and CNA stepped in between them. Writer got between resident and CNA, and he grabbed writer by the shoulders from behind attempting to move writer. He then shoved writer. Female resident taken to her room for care. Documented by S5 LPN. 12/27/2023 at 3:40 p.m. - Resident in dayroom observed with his hand inside a female resident (Resident #1) shirt. When this nurse approached resident to remove his hand from under her shirt, he got angry and started grabbing the female on her back telling her not to get up. S9 LPN redirected resident to dining room. MD and RP notified. Documented by S10 LPN. 12/29/2023 at 1:09 p.m. - CNA attempting to assist Resident #1 to dining room when Resident #2 grabbed Resident #1's hand squeezing it. She yelled out Ouch! with facial grimace. CNA asked him to let go of her hand. He started yelling, placed his hands on (CNA's) chest, pushing CNA into Christmas tree. Redirected him to another room, and CNA assisted Resident #1 to the dining room. No injuries noted. Notified S1 Administrator, S2 DON, S11 NP and RP. New order to send to behavioral health Referral sent and awaiting response. Documented by S7 LPN. 12/29/2023 at 3:44 p.m. - Resident transferred to Behavioral hospital. During a telephone interview on 01/23/2024 at 11:35 a.m., S13 CNA stated she observed Resident #2's hand under Resident #1's shirt and on her breast, while they were in the day room. S13 CNA stated she reported it to S9 LPN and S10 LPN, who went immediately to the day room. S13 CNA stated they separated the residents and took Resident #1 to her room. S13 CNA stated Resident #2 once grabbed Resident #1 by the hands when they were trying to change her, and Resident #1 said it hurt her hand. In a telephone interview on 01/23/2024 at 11:51 a.m., S10 LPN revealed on 12/27/2023, S13 CNA told her Residents #1 and #2 were sitting in the dayroom, and Resident #2 had his hand under her shirt, rubbing her breast. She said she and S9 LPN went in and tried to separate them. She said she told Resident #1 to come with her to go change her clothes. S10 LPN said when Resident #1 tried to get up off the couch, Resident #2 grabbed her and pinched her on the back to try to keep her from getting up. S10 LPN stated she told Resident #2 to let go of her and Resident #2 said she, Resident #1, couldn't go with us. S10 LPN said she told him yes she can, but she can come right back. S10 LPN said they then separated the two residents, and took Resident #1 into her room. S10 LPN said Resident #1 had a spot on her back that was red for a little while where Resident #2 had pinched her. S10 LPN stated Resident #2 pinched her skin through her clothes and her clothes were twisted. S10 LPN said Resident #1 said Ouch when he pinched her. S10 LPN stated we told Resident #2 to let her go and he did, so it just lasted for a second. S10 LPN stated the next day they (Resident #1 and Resident #2) were back walking together and eating lunch together like nothing ever happened. During a telephone interview on 01/23/2024 at 12:20 p.m., S9 LPN stated on 12/27/2023, Resident #2 put his hand under Resident #1's shirt and pinched her skin on her back, and told her not to get up. S9 LPN stated they separated the residents, and she examined Resident #1, who had a red pinch mark on her back. S9 LPN stated the redness was gone within an hour, and didn't bruise. In an interview on 01/23/2024 at approximately 3:30 p.m., S2 DON said Resident #2 started obsessing over Resident #1 not too long after he was admitted to the facility. S2 DON said it was sweet at first, they would just sit together and hold hands. S2 DON said around the end of November 2023, Resident #2 started getting more aggressive with staff, possessive over Resident #1, and didn't want staff to change her. S2 DON said when he continued to get more aggressive with staff, he was sent to a behavioral hospital. S2 DON said when he returned to the facility, it was the same thing all over again, with the possessiveness of Resident #1. S2 DON stated they were trying to adjust his medications. S2 DON confirmed on 12/27/2023, Resident #2 put his hand up Resident #1's shirt on her breast, and pinched her back. S2 DON stated she thought staff were trying to keep the residents separated. S2 DON said she hated to send Resident #2 back out to a behavioral hospital, and was hoping his medications would start working. S2 DON stated from 12/26/2023 through 12/29/2023, staff were trying to redirect Resident #2, and giving him Vistaril as needed. In an interview on 01/24/2024 at 9:00 a.m., S2 DON stated she had to send Resident #2 out to a psychiatric hospital after it happened again on 12/29/2023, when he squeezed Resident #1's hand, and pushed a CNA into the Christmas tree. S2 DON acknowledged that Resident #2 and Resident #1 were not kept separated and allowed to spend time together after the incident on 12/27/2023, when Resident #2 touched Resident #1's breast, and pinched her back. In a telephone interview on 01/24/2024 at 10:00 a.m., S12 NP stated the NF called her often about Resident #2's behaviors, but was unsure of exact dates. S12 NP stated she understood the incident on 12/27/2023 to be that Resident #2 had his hand under Resident #1's shirt, but didn't know it was on her breast. S12 NP stated that was not told to her, and said she was told it was under her shirt, so it could've been on her back or anywhere. S12 NP said Resident #2 was possessive of Resident #1 like a jealous boyfriend. When asked if Resident #2 should have been sent out after the sexual abuse, S12 NP said she didn't consider it to be sexual abuse, and she would have to investigate that further. S12 NP confirmed if Resident #2's hand was on Resident #1's breast, the residents should have been kept separate after that had occurred. S12 NP stated that would be hard to do unless they put Resident #2 on 1:1 supervision. S12 NP stated she didn't have the authority to PEC him, but the Psychiatric NP did. S12 NP stated she considered Resident #2's behaviors as combativeness, and she wouldn't label it sexual abuse. In an interview on 01/24/2024 at 10:25 a.m., S10 LPN confirmed S13 CNA informed that Resident #2 had his hand on Resident #1's breast. S10 LPN stated she walked over to the dayroom couch where the residents were sitting, and observed Resident #2's hand under the front of Resident #1's shirt, which Resident #2 removed as she was walking in. S10 LPN stated she called S12 NP and told her Resident #2's hands were on Resident #1's breast. S10 LPN stated S12 NP instructed to get a mental health consult because they were the only ones who could do a PEC. S10 LPN stated she did pass on the need for the mental health consult, but couldn't remember who she told. During a telephone interview on 01/24/2024 at 12:00 p.m., Resident #1's responsible party stated this would have never happened to her mother before she had dementia. Resident #1's RP explained her mother would never have held hands in public. Resident #1's daughter stated Resident #1 was a very [NAME] and proper lady, and the incident with his hand under her shirt would have absolutely upset her. Resident #1's daughter stated her mother would have been devastated and horrified.

Based on record review and interview, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Resident #2 fell to the ground, and sustained an Acute Left Femur Fracture. This failed practice resulted in an actual harm situation for Resident #2 on 09/06/2023 at 9:00 a.m., when S4 CNA transferred the resident from the bed to a wheelchair without assistance of another staff, as indicated on Resident #2's plan of care. During the transfer, Resident #2 fell to the ground. Resident #2 complained of left knee pain with swelling noted, and an x-ray was obtained which revealed an Acute Left Femur Fracture. Resident #2 was sent to the emergency roiagnom on [DATE], and had a Retrograde Nailing of the Left Distal Femur performed. Findings: Review of the facility's Fall Prevention Program revealed in part . All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall and upon significant change in condition. Residents identified as being at risk will have interventions identified in their plan of care to minimize falls. Review of the facility's Safe Patient Handling and Moving Protocol revealed in part . It is important to remember that each resident is different; transfer techniques and bed mobility/positioning may need to be modified for the particular resident to meet their individual needs. Please verify level of assistance required prior to initiating transfer or bed mobility/positioning. Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included Cerebral Infarction, Type 2 Diabetes Mellitus, and Repeated Falls. Review of Resident #2's Quarterly Fall Scale Evaluation dated 08/15/2023 revealed Resident #2 had a score of 55, which was deemed high risk for falling. Review of Resident #2's Quarterly MDS with an ARD of 08/15/2023 revealed a BIMS score of 15, indicating the resident was cognitively intact. Review of the MDS revealed Resident #2 required extensive two person physical assistance with transferring, bed mobility, and toilet use. Review of Resident #2's care plan with a target date of 11/07/2023 revealed in part . Resident #2 needs assist with activities of daily living. Interventions included in part .Transfers-extensive assist with assist of two. Bed mobility and toileting-extensive assist with assist of two. Walk in room-did not occur. Review of an incident report dated 09/06/2023 at 9:00 a.m. read in part . Nursing Description: CNA was assisting resident with transfer from bed to wheelchair, and when going to pivot and turn, resident states she was about to fall and CNA eased resident to the floor slowly .Wheelchair was placed beside bed and locked for easy transfer. Resident was sitting on her bottom with her legs straight out in upright position. Resident did not hit her head or any extremities on anything. Resident Description: I just got weak. Review of a left knee x-ray dated 09/06/2023, revealed an Impression of Acute Fracture of the Distal Femur. Review of the Operative Procedure Note documented on 09/08/2023, revealed Resident #2's preoperative diagnoses was Displaced Left Distal Third Femur Fracture. The procedure performed was Retrograde Nailing of Left Distal Third Femur Fracture. In an interview on 09/20/2023 at 8:15 a.m., S3 LPN stated on the morning of the incident, S4 CNA told her she went to get Resident #2 ready to shower. S3 LPN stated S4 CNA told her she was transferring Resident #2 from the bed to the wheelchair when the resident got weak and said she could not do it. S3 LPN stated S4 CNA reported to her that she eased her down to the floor from a standing position. S3 LPN said she assessed Resident #2 and said she complained of left knee pain, which was normal for the resident. S3 LPN said Resident #2's knee was swollen, which was also usual for the resident. S3 LPN stated a portable x-ray was done, and they were notified her leg was fractured. S3 LPN said she notified the physician who came and assessed her later that day, and ordered an orthopedic consult. S3 LPN said there was no orthopedic doctor available for a few days, so Resident #2 was sent to the emergency room the following day. In a telephone interview on 09/20/2023 at 9:40 a.m., S4 CNA stated on 09/06/2023, she was working as a Shower Aide. S4 CNA stated she went to Resident #2's room, gathered her clothes, and then asked Resident #2 if she was ready to go shower. S4 CNA said Resident #2 sat up on the side of the bed. S4 CNA stated Resident #2 was sitting on the edge of the bed so she counted to 3 and Resident #2 stood up fine. S4 CNA stated she was ready to turn her, and Resident #2 said she was falling. S4 CNA stated she held Resident #2 under her arms and breasts, and eased her to the floor. S4 CNA said Resident #2 said Ouch and complained of back or knee pain. S4 CNA stated she reported it to S3 LPN. S4 CNA stated she only works at the facility prn, and Resident #2 had been more mobile the last time she worked with her. S4 CNA stated after the fall, she was then told Resident #2 only gets bed baths. S4 CNA stated she didn't know Resident #2 didn't get out of bed anymore. S4 CNA confirmed she didn't know Resident #2 required two person assistance to transfer. S4 CNA stated she should have asked someone. S4 CNA confirmed she did know how to look up how much assistance was required by each resident, but did not look it up, and should have. In an interview on 09/20/2023 at 10:00 a.m., S2 DON stated CNAs should check residents' tasks on their Ipads (portable tablets) to determine how much assistance residents require with ADLs. S2 DON stated at the time of the fall on 09/06/2023, Resident #2 was care planned for 2 person assistance with transfers. S2 DON confirmed S4 CNA should have checked the tasks before the transfer to determine how much assistance Resident #2 required, and found someone to assist her with transferring Resident #2.

Based on interviews and record reviews, the facility failed to administer pain medication and diuretic medications in accordance with the resident's Person Centered Plan of Care and professional standards of practice, for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sampled residents. This deficient practice resulted in an Actual Harm for Resident #1 that began on 04/08/2022, when Resident #1, who was ordered [MEDICATION(S)]/Acetaminophen (a narcotic analgesic) 10-325mg 1 tab orally every 6 hours as needed for pain, was administered [MEDICATION(S)]/Acetaminophen more frequently than ordered by the physician. Resident #1 also received [MEDICATION(S)] (a diuretic) 50 mg po twice daily, for 5 days (04/07/2022, 04/08/2022, 04/09/2022, 04/10/2022, and 04/11/2022), despite a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EMS was called on 04/11/2022 at approximately 10:15 a.m. in response to Resident #1's complaint of lethargy. According to the EMS report, Resident #1 was found to be lethargic, hypoxic, with an oxygen saturation of 84%, and hypotensive with a blood pressure of 99/74. EMS administered Supplemental oxygen to Resident #1 at 10:31 a.m., and [MEDICATION(S)] 2mg/2ml was administered IV at 10:36 a.m. with a result status documented as improved. The EMS report documented suspected overdose. Resident #1 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility's policy titled: Administering Medications, revealed in part . 1. Medications are administered in accordance with prescribers orders, including any required time frame. Review of Resident #1's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's 5 day MDS Assessment with an ARD of 04/08/2022 revealed the resident had a BIMS of 11 (moderate cognitive impairment), and required extensive assistance of 2 or more persons for bed mobility, transfers, toileting, and personal hygiene. Further review revealed the resident received opioids 7 days during the last 7 days of MDS assessment. Review of Resident #1's Comprehensive Person Center Plan of Care revealed a problem of Pain (Wong Baker Scale) R/T general pain, restless leg, chronic back pain, cancer. Interventions included: [MEDICATION(S)] Acetaminophen as ordered. Further review of the Comprehensive Person Center Plan of Care revealed a problem of Potential Fluid Deficit. Interventions included: administer medications as ordered, HCTZ as ordered, [MEDICATION(S)] as ordered, Obtain and monitor lab/diagnostic work as ordered, Report results to MD and follow up as indicated. Review of Resident #1's hospital discharge and nursing home admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)]-Acetaminophen tablet 10-325mg give 1 tablet by mouth every 6 hours as needed for pain. 2. [MEDICATION(S)] 20mg (a durietic) po daily. Hold medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50mg oral 1 time a day. Hold instructions: Resume on 04/12/2022. Hold while taking [MEDICATION(S)]. Review of Resident #1's 04/2022 MAR and Narcotic Log Sheets, revealed Resident #1 received [MEDICATION(S)]-Acetaminophen 10-325 mg 1 tab as follows: 04/08/2022 at 6:28 a.m., 7:00 a.m., 10:00 a.m., 1:00 p.m. and 7:00 p.m. 04/09/2022 at 4:00 a.m., 7:00 a.m., and 7:00 p.m. 04/10/2022 at 4:00 a.m., 7:00 a.m., 11:00 a.m., and 4:00 p.m. 04/11/2022 at 4:00 a.m. and 8:00 a.m. Further review of the 04/2022 MAR revealed Resident #1 received [MEDICATION(S)] 50mg po twice daily at 8:00 a.m. and 4:00 p.m. on 04/07/2022, 04/08/2022, 04/09/2022, 0/10/2022 and 04/11/2022; however, [MEDICATION(S)] was ordered held by the physician until 04/12/2022, while Resident #1 received [MEDICATION(S)] 20 mg daily. Review of an EMS Report dated 04/11/2022 revealed that at approximately 10:15 a.m., EMS was called to respond to Resident #1 for a complaint of lethargy. Upon arrival the resident was found to be lethargic, hypoxic, with an oxygen saturation of 84%, and hypotensive with a blood pressure of 99/74. Further review revealed supplemental oxygen was applied to the resident per EMS at 10:31 a.m., and [MEDICATION(S)] 2mg/2ml was administered IV to the resident at 10:36 a.m. with a result status noted as improved. EMS impressions noted as: Primary Impression-Toxicological-Suspected drug overdose/poisoning (prescription drugs), Secondary Impression- Other-Generalized weakness, Is this a suspected overdose-Yes. Review of the hospital's Discharge Summary revealed in part . admitted [DATE]. discharged [DATE]. Patient was admitted from rehabilitation facility for altered mental status. It was surmised that patient was on too much pain medication. Pain medication was decreased and patient eventually woke up and became quite active and alert. Interview on 04/27/2022 at 1:40 p.m. with S2 LPN revealed that on 04/08/2022 she was told by S4 LPN that Resident #1 could have something every 3 hours for pain. S2 LPN stated she looked in the computer at that time and saw Resident #1's pain medication was ordered every 6 hours as needed. S2 LPN stated she did not call the doctor and confirm the order change, nor did she change the order herself in the computer. S2 LPN stated she proceeded to administer [MEDICATION(S)]-Acetaminophen 10-325mg 1 tab to the resident at 7:00 a.m., 10:00 a.m., and 1:00 p.m. without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S2 LPN stated S3 LPN agreed to write the order for her. S2 LPN stated she later found out she had misunderstood what S4 LPN told her on 04/08/2022, and had not clarified the order for pain medications and she should have. Telephone interview on 04/28/2022 at 6:45 a.m. with S3 LPN revealed she was the nurse assigned to Resident #1 on the night shifts. S3 LPN stated she relieved S2 LPN on 04/08/2022, and during report S2 LPN told her that Resident #1 could have pain medication every 3 hours, and that she had put the order in the computer. S3 LPN stated that after S2 LPN left the facility, she checked Resident #1's orders and saw a new order for [MEDICATION(S)] q3hrs prn. S3 LPN stated she called S2 LPN at home to clarify the resident's pain medication order, and S2 LPN told her she had mistakenly ordered [MEDICATION(S)], and the order should have been for [MEDICATION(S)]-Acetaminophen. S3 LPN stated S2 LPN asked her to change the pain medication order to [MEDICATION(S)]-Acetaminophen 10-325 mg 1 tab orally every 3 hours as needed for pain, and she did. S3 LPN confirmed she entered pain medication orders for [MEDICATION(S)]-Acetaminophen 10-325mg every 3 hours as need for pain without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S3 LPN stated resident #1 received physical therapy services, voided per urinal, and slept in a glider rocker-recliner in his room. Interview on 04/27/2022 at 2:00 p.m. with S5 CNA revealed she worked the 6:00 a.m. to 2:00 p.m. shift on 04/11/2022. S5 CNA stated around 8:30 a.m. Resident #1's granddaughter was visiting and asked her to clean the resident up. Resident #1 was sitting in a chair next to his bed with his eyes closed. S5 CNA stated the resident's eyes remain closed, but he was able to answer questions. S5 CNA stated Resident #1's daughter arrived a short while later and stated Resident #1 was going to the hospital. S5 CNA stated when EMS arrived, an EMT had to physically pick Resident #1 up from the chair and place him on a stretcher. S5 CNA stated Resident #1 did not open his eyes during the transfer. After being positioned on the stretcher, Resident #1's daughter hollered at him to open his eyes, but he did not. Interview on 04/27/2022 at 12:30 p.m. with S1 DON revealed Resident #1 was having pain control issues. S1 DON stated S4 LPN received and entered an order on 04/07/2022 for Resident #1 to have [MEDICATION(S)] for breakthrough pain every 6 hours as needed on 04/07/2022. S1 DON stated S2 LPN misunderstood S4 LPN, and began administering [MEDICATION(S)]-Acetaminophen 10-325mg every 3 hours to Resident #1 on 04/08/2022 without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . S1 DON stated S3 LPN changed the frequency of [MEDICATION(S)]-Acetaminophen without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the NP's progress note dated 04/07/2022 revealed in part .patient reports lethargy and malaise but reports no fever. Reports sob when walking, sob when lying down, and ankle swelling; extensive cardiac hx, recently hospitalized with Afib RVR and CHF; voids to urinal. Physical Exam: Mental status: lethargic, Skin: fluid filled blisters to bilateral feet. Lesion to bunion of right foot. Assessment/Plan 1. Peripheral [CONDITION(S)]-increased [MEDICATION(S)] to 20mg po BID 2. Dyspnea on exertion CXR pending During an interview on 04/27/2022 at 12:50 p.m., S1 DON revealed that on 04/06/2022, S6 LPN received an order to increase Resident #1's [MEDICATION(S)] to 20mg twice a day. S1 DON stated that during order entry, S6 LPN accidentally chose the order to start [MEDICATION(S)] 50mg twice a day instead of [MEDICATION(S)] 20mg twice a day. S1 DON stated the medication error was not caught until Resident #1 was transferred to the hospital on 04/11/2011. During a telephone interview on 04/28/2022 at 3:20 p.m., S6 LPN revealed she received an order on 04/07/2022 to increase the frequency of the resident's [MEDICATION(S)] to twice a day. S6 LPN stated she accidentally clicked on the [MEDICATION(S)] because she had too many things going on, and was moving too fast. S6 LPN confirmed she increased the frequency of [MEDICATION(S)] instead of [MEDICATION(S)]. Telephone interview on 04/28/2022 at 12:47 p.m. with S7 NP revealed she provided care for Resident #1 while he was a resident at the nursing facility. S7 NP stated S1 DON notified her of the medication errors involving Resident #1 on 04/12/2022. S7 NP stated no verbal or written orders had been given to change the frequency of the resident's [MEDICATION(S)]-Acetaminophen to every 3 hours as needed, or to add [MEDICATION(S)] 50mg twice a day to the resident's medication regimen. S7 NP revealed the dose of [MEDICATION(S)] given to Resident #1 was much too large, and could be detrimental to kidneys and make lab values much worse. S7 NP also stated no person should receive [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen) every three hours or sooner. S7 NP was questioned by the Surveyor as to whether she thought the increased frequency of [MEDICATION(S)]-Acetaminophen and administration of [MEDICATION(S)] 50mg twice a day could have contributed to Resident #1's lethargy and need to be transferred to the hospital to which S7 NP replied absolutely.