Every finding on record at Metairie Health Care Center

Based on interviews and record reviews, the facility failed to ensure staff administered a resident's scheduled pain medication as ordered for 1 (Resident #2) of 1 sampled residents investigated for pain. Findings: Review of the facility's Administering Medications policy, revised April 2019, revealed in part, medications should be administered in accordance with the prescriber's orders, including any required time frame and needs and benefits of the resident. Further review of the policy revealed if the dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences the nurse should contact the prescriber. Review of Resident #2's record revealed, in part, Resident #2 was admitted to hospice services on 07/26/2023. Review of Resident #2's December 2025 physician's orders revealed, in part, Resident #2 had an order for Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) by mouth four times daily for unspecified pain with a start date of 07/01/2024. Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 09/30/2025 revealed, in part, Resident #2 was on a scheduled pain management regimen. Review of Resident #2's Plan of Care revealed, in part, Resident #2 received hospice services and interventions which included, to provide comfort measures and administer pain medications as ordered. Observation on 12/16/2025 at 9:17AM revealed Resident #2 was yelling out for the nurse. Resident #2 indicated to surveyor his legs and his back were hurting. Review of Resident #2's December 2025 electronic Medication Administration Record (eMAR) revealed, in part, on 12/09/2025 and 12/15/2025, S12Licensed Practical Nurse (LPN) documented she did not administer Hydrocodone-Acetaminophen tablet 5-325 mg to Resident #2 at 8:00PM, because Resident #2 was asleep; and on 12/16/2025 S12LPN documented she did not administer Hydrocodone-Acetaminophen tablet 5-325 mg to Resident #2 at 6:00AM, because Resident #2 was asleep. In an interview on 12/17/2025 at 9:00AM, S15LPN nurse indicated scheduled pain medications ordered four times daily should be administered as ordered. S15LPN confirmed Resident #2's pain medication was scheduled and ordered to be administered four times daily. S15LPN further indicated if Resident #2 was asleep at the time his scheduled medication were due, she would wake up Resident #2 and administer the pain medication as ordered, unless there was another reason not to administer the medication. Review of Resident #2's nursing progress notes revealed, in part, there was no documentation of any other reason Resident #2's scheduled pain medication was not administered by S12LPN as ordered on 12/09/2025 and 12/15/2025 at 8:00PM, and on 12/16/2025 at 6:00AM. In an interview on 12/17/2025 at 9:17AM, S2Director of Nursing (DON) confirmed Resident #2's pain medication was scheduled to be administered four times daily at 6:00AM, 11:00AM, 5:00PM, and 8:00PM. S2DON indicated Resident #2's scheduled pain medication should have been administered as ordered four times daily regardless if he was asleep at the time the medication was scheduled. S2DON further indicated if Resident #2's medications were held due to over sedation or side effects the nurse should have documented the changes observed and contacted the physician.

Based on observation, interviews and record reviews, the facility failed to ensure:1. Narcotic logs were accurately reconciled for a resident (Resident #2); and, 2. Medications were available to be administered as ordered for a resident (Resident #2). This deficient practice was identified for 1 (Resident #2) of 1 sampled residents reviewed for pharmacy services. Findings: 1.Review of the facility's undated Controlled Drug policy and procedure revealed, in part, the inventory of the controlled drugs must be recorded on narcotic records and signed for correctness of count. If a discrepancy is found, residents' orders are to be checked and chart should be reviewed to see if a narcotic has been administered and not recorded. If the cause of the discrepancy cannot be located, report the matter to the supervisor. Review of Resident #2's Narcotics and Controlled Drug records from 11/29/2025 at 9:30AM through 12/07/2025 at 9:00PM revealed, in part, S14Licensed Practical Nurse (LPN) documented she administered Hydrocodone-Acetaminophen 5-325 milligrams (mg) 1 tablet on 12/07/2025 at 9:00PM and there were 0 tablets remaining. Review of Resident #2's Narcotics and Controlled Drug records from 12/07/2025 at 6:00AM through 12/16/2025 at 9:00PM revealed, in part, S14LPN documented she administered Hydrocodone-Acetaminophen 5-325 mg 1 tablet on 12/07/2025 at 9:00PM and there were 26 tablets remaining. Review of the Narcotics and Controlled Drug records mentioned above could not be reconciled accurately due to the discrepancies in the documentation when S14LPN documented she administered the scheduled pain medication two times on 12/07/2025 at 9:00PM. In an interview on 12/17/2025 at 9:17AM, S2Director of Nursing (DON) indicated she could not explain the discrepancy with the narcotic sheet, and further indicated the narcotic sheet should have been reconciled accurately. 2. Observation on 12/16/2025 at 2:50PM of Resident #2's Hydrocodone-Acetaminophen tablet 5-325 mg medication card revealed 1 tablet remaining in the bubble pack on the card. Review of Resident #2's electronic Medication Administration Record (eMAR) revealed, in a part Resident #2 was scheduled to receive Hydrocodone-Acetaminophen tablet 5-325 mg on 12/16/2025 at 5:00PM and 8:00PM, and 12/17/2025 at 6:00AM. Review of Resident #2's Hydrocodone-Acetaminophen tablet 5-325 mg Narcotics and Controlled Drug record from 12/07/2025 at 6:00AM through 12/16/2025 at 9:00PM revealed, in part, Resident #2 had 0 remaining tablets. Review of Resident #2's nursing progress note dated 12/17/2025 at 5:46AM revealed, in part, S18LPN documented Resident #2's Hydrocodone-Acetaminophen tablet 5-325 mg was not available for administration, waiting on hospice pharmacy. In an interview on 12/17/2025 at 9:07AM, S15LPN confirmed Resident #2 had 1 tablet of Hydrocodone-Acetaminophen 5-325 mg available on 12/16/2025 at 3:00PM. S15LPN indicated Resident #2's Hydrocodone-Acetaminophen 5-325 mg was documented as not available for administration on 12/17/2025 at 6:00AM, and further indicated the medication was not available on 12/17/2025 at 9:07AM. Review of Resident #2's nursing progress notes dated 12/17/2025 at 10:35AM revealed, in part, S15LPN documented Resident #2 was out of Hydrocodone-Acetaminophen tablet 5-325 mg, the hospice nurse was notified to send over the medication at approximately 9:00AM, and S2DON was notified. In an interview on 12/17/2025 at 10:00AM, S2DON confirmed Resident #2's Hydrocodone-Acetaminophen tablet 5-325 mg was not available for administration, and it should have been. S2DON indicated it was the nurses' responsibility to notify hospice when the medications needed to be refilled.

Based on observation, interviews, and record review, the facility failed to ensure all opened food items contained an opened and/or discard date for 1 (Cooler #1) of 1 sampled coolers observed during kitchen observations.Findings:Review of the 2022 United States Food and Drug Administration's Food Code revealed, in part, commercially processed food which was prepared and packaged by a food processing plant shall be clearly marked, at the time the original container was opened and if the held food was held for more than 24 hours, indicate the date or day by which the food shall be consumed, sold, or discarded.Observation on 12/15/2025 at 9:05AM of Cooler #1 revealed the following items were opened without an opened and/or discard date documented, in part:-one large package of shredded lettuce which was greenish brown in color;-one large bag of white shredded substance; and,-a 2.5 pound bag of sliced ham.In an interview on 12/15/2025 at 8:50AM, S10Dietary Manager stated the above food packages should have had an opened and/or discard date written on the outside of the packages. In an interview on 12/16/2025 at 12:15PM, S1Administrator stated previously opened food packages or containers in Cooler #1 should be labeled with an opened and/or use by or discard date.

Based on interviews and record reviews, the facility failed to maintain accurate documentation of the electronic medication administration record (eMAR) and the narcotic and controlled drug records for 1 (Resident #2) of 1 sampled residents reviewed for accurate documentation. Findings:Review of Resident #2's December 2025 eMAR revealed, in part, S13Licensed Practical Nurse (LPN) documented she administered Resident #2 Hydrocodone-Acetaminophen 5-325 milligrams (mg) 1 tablet on 12/10/2025 at 8:00PM, 12/13/2025 at 8:00PM, 12/14/2025 at 8:00PM, and 12/16/2025 at 5:00PM. Review of Resident #2's Hydrocodone-Acetaminophen 5-325 mg narcotic and controlled drugs record revealed, in part, no evidence of the 12/10/2025 at 8:00PM, 12/13/2025 at 8:00PM, 12/14/2025 at 8:00PM, and 12/16/2025 at 5:00PM doses had been documented on the narcotic and controlled drug record. In an interview on 12/17/2025 at 10:00AM, S2Director of Nursing (DON) indicated Resident #2's eMAR and Narcotic and Controlled Drug record did not match and the documentation was not accurate. In a telephone interview on 12/17/2025 at 11:10AM, S13LPN indicated on 12/16/2025 at 5:00PM she did not administer Resident #2 Hydrocodone-Acetaminophen 5-325 mg to Resident #2 and the documentation for 12/16/2025 on the eMAR was incorrect.

Based on interviews and record reviews, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or his/her responsible party prior to the discontinuation of Medicare Part A services for 1 (Resident #46) of 3 residents reviewed for Beneficiary Notification. Findings:Review of Resident #46's NOMNC revealed, in part, the effective date of coverage for current skilled nursing facility services would end on 10/30/2025 and was signed by Resident #46 on 10/30/2025. Review of Resident #46's Physical Therapy Discharge Summary revealed, in part, a start date of 08/26/2026, a discharge date of 09/30/2025. Further review revealed the reason for Resident #46's therapy discharge was Resident #46's highest practical level was achieved. In an interview on 12/17/2025 at 1:25PM, S17Social Services indicated the NOMNC for Resident #46 should have a service end date of 09/30/2025, and should have been signed by Resident #36 no later than 09/28/2025, and was not. In an interview on 12/17/2025 at 1:50PM, S2Director of Nursing indicated the NOMNC for Resident #46 should have been signed prior to the end of services, and was not.

Based on observations and interviews, the facility failed to ensure a resident's tube feeding pump (a pump that delivers liquid nutrients directly into a person's stomach or small intestine) and the tube-feeding pump's pole were maintained in a sanitary manner for 1 (Resident #1) of 3 residents sampled for tube feedings. Findings: Observation on 12/15/2025 at 11:21AM revealed Resident #1's tube feeding pole and pump was observed to have a dried beige substance covering the tube-feeding pump and the bottom of the tube-feeding pole.Observation on 12/16/2025 at 12:00PM revealed Resident #1's tube feeding pole and pump was observed to have a dried beige substance covering the tube-feeding pump and the bottom of the tube-feeding pole.Observation on 12/17/2025 at 11:20AM revealed Resident #1's tube feeding pole and pump was observed to have a dried beige substance covering the tube-feeding pump and the bottom of the tube-feeding pole.In an interview on 12/17/2025 at 12:05PM, S3Licensed Practical Nurse indicated Resident #1's tube feeding pump and pole should have been cleaned and should not have a dried beige substance on it.In an interview on 12/17/2025 at 12:06PM, S2Director of Nursing confirmed Resident #1's tube feeding pump and pole should have been cleaned daily and should not have a dried beige substance on it.In an interview on 12/17/2025 at 12:15PM, S1Administrator indicated Resident #1's tube feeding pump and pole should not have a dried beige color substance on it, and should have been cleaned.

Based on record reviews and interviews, the facility failed to ensure direct care staff were provided Quality Assurance and Performance Improvement (QAPI) training for 5 (S10Certified Nursing Assistant [CNA], S12CNA, S14CNA, S15CNA, S16CNA) of 5 (S10CNA, S12CNA, S14CNA, S15CNA, S16CNA) sampled direct care staff investigated for training requirements. Findings:Review of S10CNA's personnel record revealed, in part, S10CNA had a date of hire of 10/18/2021. Further review revealed S10CNA did not receive QAPI training since hire. Review of S12CNA's personnel record revealed, in part, S12CNA had a date of hire of 06/25/2024. Further review revealed S12CNA did not receive QAPI training since hire. Review of S14CNA's personnel record revealed, in part, S14CNA had a date of hire of 04/15/2025. Further review revealed S14CNA did not receive QAPI training since hire. Review of S15CNA's personnel record revealed, in part, S15CNA had a date of hire of 12/12/2022. Further review revealed S15CNA did not receive QAPI training since hire. Review of S16CNA's personnel record revealed, in part, S16CNA had a date of hire of 09/22/2011. Further review revealed S16CNA did not receive QAPI training since hire. In an interview on 09/03/2025 at 10:37AM, S3CNA Supervisor indicated she was responsible for providing training for a CNA's new hire orientation. S3CNA Supervisor further indicated QAPI training was not included in orientation training or in-services. In an interview on 09/03/2025 at 1:45PM, S2Director of Nursing confirmed S10CNA, S12CNA, S14CNA, S15CNA, and S16CNA had not received QAPI training.

Based on interview and record review, the facility failed to ensure the facility assessment included active involvement from direct care staff, residents, and residents' representatives in its development. Findings:Review of the facility assessment dated [DATE] revealed, in part, a resident and resident representative and direct care staff, including a Registered Nurse (RN), Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were not included in the development of the facility's assessment. In an interview on 09/03/2025 at 12:52PM, S1Administrator confirmed he had no documentation the facility assessment dated [DATE] was developed with any of the above mentioned staff, residents, and/or residents' representatives.

Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) and ensure staff performed hand hygiene during a percutaneous endoscopic gastrostomy (PEG) tube (a medical device that provides nutrition, fluids, and medications directly into the stomach) dressing change for 1 (Resident #2) of 2 (Resident #2, Resident #3) sampled residents observed for indwelling device care. Findings: Review of the facility's undated EBP policy and procedure revealed, in part, gloves were to be used during high-contact resident care activities for residents with indwelling medical devices such as feeding tubes (a general term for PEG tube). Review of facility's Handwashing/Hand Hygiene policy and procedure, revised on 12/2009 revealed, in part, employees must wash their hands before and after direct resident contact, before and after handing invasive devices, after handling soiled or used dressings, and after removing gloves. Review of Resident #2's August 2025 physician's orders revealed, in part, an order to cleanse Resident #2's PEG tube site with normal saline or wound cleanser, pat dry, apply a drain sponge, and secure with tape as needed. Review of Resident #2's care plan with a start date of 08/13/2024 and a next review date of 09/09/2025 revealed, in part, Resident #2 was on EBP with an intervention for staff to wear gloves. Observation on 09/02/2025 at 11:55AM revealed S17Licensed Practical Nurse (LPN) entered Resident #2's room without putting on gloves. S17LPN then removed Resident #2's PEG tube dressing with her ungloved hand, disposed of the dressing, and applied gloves without performing hand hygiene. S17LPN then cleaned Resident #2's PEG tube site, removed her gloves, did not perform hand hygiene, and redressed Resident #2's PEG tube site with ungloved hands. Observation on 09/02/2025 at 12:00PM revealed an EBP sign on Resident #2's door that indicated providers and staff must wear gloves for high-contact resident care activities such as feeding tube care. In an interview on 09/02/2025 at 12:05PM, S17LPN indicated she did not wear gloves when she removed and replaced Resident #2's PEG tube dressing and did not perform hand hygiene after removing her gloves and should have. In an interview on 09/03/2025 at 12:45PM, S2Director of Nursing (DON) confirmed S17LPN did not wear gloves and perform hand hygiene appropriately during PEG tube site care and should have.

Based on observation and interviews, the facility failed to post the required nurse staffing information at the beginning of each shift daily for 1 (09/02/2025) of 2 (09/02/2025, 09/03/2025) days observed for nurse staffing information. Findings:Observation on 09/02/2025 at 10:10AM revealed the facility's posted nurse staffing information dated 09/02/2025 did not include the facility's daily census. In an interview on 09/03/2025 at 12:45PM, S3CNA Supervisor indicated the posted daily nurse staffing information dated 09/02/2025 should have included the daily census. In an interview on 09/03/2025 at 12:52PM, S1Administrator indicated he was unaware the daily posted nurse staffing information should include the daily census.

Based on observation, interviews, and record review the facility failed to maintain privacy and confidentiality of medical records observed during a medication pass for 1 (Resident R4) of 1 (Resident R4) random resident observed. Findings: Review of the facility's policy titled Resident Rights, dated 02/2017, revealed, in part, federal and state laws guarantee the right to privacy and confidentiality to all resident of the facility.Observation on 07/21/2025 at 9:25AM revealed S6Licensed Practical Nurse (LPN) stepped away from her computer in the hallway to administer Resident R4's medication in Resident R4's room. Further observation revealed the unattended computer screen visibly displayed and allowed access to Resident R4's private medical information.In an interview on 07/22/2025 at 9:28AM, S6LPN confirmed she should not have allowed Resident R4's private medical information to be visible and accessible when she left her computer unattended in the hallway. S6LPN indicated her action was a Health Insurance Portability and Accountability Act (HIPAA) violation.In an interview on 07/22/2025 at 1:33PM, S2Director of Nursing (DON) confirmed that the staff computer screen should have been locked to prevent the resident's private information is being accessed. S2DON further indicated that S6LPN's action of leaving her computer screen unattended with resident's information available for access was a violation of HIPAA.

Based on interviews and record reviews, the facility failed to ensure residents' comprehensive care plan was prepared by an interdisciplinary team (IDT) with all required members for 2 (Resident #1, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for care plans.Findings:Resident #1Review of Resident #1's medical records revealed, in part, an admit date of 05/21/2025. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, Resident #1 Brief Interview of Mental Status (BIMS) score of 7, which indicated Resident #1 had severe cognitive impairment.Review of Resident #1's progress note dated 05/29/2025 revealed, in part, a comprehensive care plan meeting was held to discuss Resident #1's progress in therapy. Further review revealed the only members of the IDT in attendance were S3Social Worker, S4MDS Coordinator, and S7Rehab Director. Further review revealed no documented evidence, and the facility was unable to present any documented evidence, Resident #1 and/or Resident #1's representative and the additional required IDT members were included in the preparation of Resident #1's comprehensive care plan.There was no documented evidence, and the facility did not present any documented evidence, Resident #1 and/or Resident #1's representative were invited by the facility to prepare Resident #1's comprehensive care plan.In a telephone interview on 07/16/2025 at 4:55PM, Resident #1's representative indicated the facility had not given him the opportunity to attend and participate in the preparation of Resident #1's comprehensive care plan. Resident #3Review of Resident #3's medical records revealed, in part, an admit date of 05/30/2025. Review of Resident #3's admission MDS with an ARD of 05/28/2025 revealed, in part, Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact.Review of Resident #3's Care Plan Signature Sheet dated 06/10/2025 revealed, in part, a comprehensive care plan meeting was held to discuss Resident #3's care. Further review revealed the only members of the IDT in attendance were S3Social Worker, S4MDS Coordinator, and Resident #3's representative. Further review revealed no documented evidence, and the facility was unable to present any documented evidence, Resident #3 and the additional required IDT members were included in the preparation of Resident #3's comprehensive care plan.There was no documented evidence, and the facility did not present any documented evidence, Resident #3 was invited by the facility to prepare Resident #3's comprehensive care plan.In an interview on 07/22/2025 at 7:52AM, Resident #3 indicated she had not been given the opportunity by the facility to participate in in the preparation of a resident's comprehensive care plan.In an interview on 07/22/2025 at 11:25AM, S3Social Worker indicated a resident's comprehensive care plan was prepared by only the social worker and the MDS coordinator nurse. S3Social Worker further indicated a resident's attending physician did not participate in the preparation of a resident's comprehensive care plan.In an interview on 07/22/2025 at 12:25PM, S2Director of Nursing (DON) indicated none of the attending physicians or other designated providers participated in the preparation of the resident's individual comprehensive care plans. In an interview on 07/22/2025 at 3:15PM, S4MDS Coordinator indicated none of the attending physicians or other designated providers participated in the preparation of the resident's individual comprehensive care plans.In an interview on 07/22/2025 at 12:40PM, S1Administrator indicated the attending physicians did not participate in the preparation of the resident's comprehensive care plans. S1Administrator also indicated there was no documented evidence and he could not provide documented evidence, the above mentioned residents, the above mentioned resident representative, physicians or designated provider's participated in the preparation of the residents' individual comprehensive care plan.

Based on interviews and record reviews, the facility failed to provide a Baseline Care Plan summary to a resident and the resident representative for 2 (Resident #1, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for care plans.Findings: Resident #1Review of Resident #1's medical record revealed, in part, an admit date of 05/21/2025. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 7, which indicated Resident #1 had severe cognitive impairment. Review of Resident #1's Baseline Care Plan revealed, in part, the Baseline Care Plan was completed on 05/21/2025. Further review revealed the resident and resident's representative signature and date box was not signed or dated.There was no documented evidence, and the facility could not present any documented evidence, the facility had provided Resident #1 and Resident #1's representative a summary of Resident #1's Baseline Care Plan.In a telephone interview on 07/16/2025 at 4:55PM, Resident #1's representative indicated the facility had not provided them with a summary of Resident #1's Baseline Care Plan. Resident #3Review of Resident #3's medical record revealed, in part, an admit date of 05/30/2025. Review of Resident #3's admission MDS with an ARD of 05/28/2025 revealed, in part, Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's Baseline Care Plan revealed, in part, the Baseline Care Plan was completed on 05/30/2025. Further review revealed the resident and resident's representative signature and date box was not signed or dated.There was no documented evidence, and the facility could not present any documented evidence, the facility had provided Resident #3 and Resident #3's representative a summary of Resident #3's Baseline Care Plan.In an interview on 07/22/2025 at 7:51AM, Resident #3 indicated the facility had not provided her with a summary of her Baseline Care Plan since she had been admitted into the facility. In an interview on 07/22/2025 at 12:25PM, S2Director of Nursing (DON) indicated she could not provide any documentation that revealed Resident #1, Resident #1's representative, Resident #3, or Resident #3's representative were provided a summary of their Baseline Care Plan.

Based on interviews, observations, and policy review the administrative staff failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents by overseeing the effective implementation of the facility's smoking policy and procedure for monitoring and supervision for 3 (Resident #15, Resident #31, and Resident #53) of 3 (Resident #15, Resident #31, and Resident #53) residents identified as unsafe smokers. This lack of administrative oversight resulted in Immediate Jeopardy situation on 12/16/2024 at 9:50 a.m., when facility staff failed to ensure implementation of their smoking policy when an unsafe smoker (Resident #31) was observed smoking on the smoking patio, in possession of a cigarette and a lighter, alone, and without supervision. S1Administrator was notified of the Immediate Jeopardy on 12/17/2024 at 3:58 p.m. This deficient practice had the likelihood to cause more than minimal harm to the 3 residents (Resident #15, Resident #31, and Resident #53) identified as unsafe smokers. Findings: Cross-Reference Findings at F-689 Review of the facility's policy titled Smoking Policy, last updated 07/04/2024 revealed, in part, residents who continue to smoke will be assessed for the safety of smoking unattended. Further review revealed the administrator is responsible for seeing that the smoking designated areas are enforced. The nursing staff are responsible for keeping and distributing smoking paraphernalia for residents, and the ward clerk was responsible to monitor the active smoker list. In an interview on 12/16/2024 at 12:29 p.m., S1Administrator confirmed Resident #31 was on the unsafe smoker list. S1Administrator further indicated he observed Resident #31 smoking on the smoking patio, without a smoker's apron on, in possession of a cigarette and a lighter, alone, and without supervision. In an interview on 12/16/2024 at 3:58 p.m., S1Administrator indicated he is ultimately responsible to ensure the facility's smokers are safe and that the facility's policy and procedures for smoking is adhered to. In an interview on 12/17/2024 at 9:03 a.m., S2Director of Nursing (DON) indicated prior to the observation of Resident #31 smoking on the facility's smoking patio unsupervised, without a smoker's apron on, and in possession of smoking paraphernalia on 12/16/2024 at 12:24 p.m., the facility's staff was not educated on the facility's smoking policy. In an interview on 12/17/2024 at 3:30 p.m., S22Regional Administrator (RA) indicated he would provide in person oversight to S1Administrator and the administrative staff weekly beginning 12/17/2024. Further, S22RA would monitor the safe smoking areas of the facility on a weekly basis. In an interview on 12/17/2024 at 4:15 p.m., S22RA indicated in his absence, daily monitoring of the safe smoking areas of the facility will be done by S1Admininstrator. Further, S22RA indicated in the absence of S1Admininistrator, the daily monitoring of the safe smoking areas of the facility will be done by S2DON. In the absence of S2DON, the daily monitoring of safe smoking areas of the facility will be done by S6ADON. In the absence of S6ADON, the daily monitoring of the safe smoking areas of the facility will be done by the charge nurse on duty for that shift. The Immediate Jeopardy was removed on 12/18/2024 at 3:36 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit. A Plan of Removal was accepted on 12/18/2024 at 3:36 p.m., which included the following actions to correct the deficient practice: S22Regional Administrator will provider oversight as follows: in part; 1.) On 12/17/2024, S22Regional Administrator (RA) provided in-person oversight to S1Admininistrator and administrative staff in the monitoring of unsafe smokers and the smoking areas on a weekly basis. 2.) On 12/17/2024, S22RA reviewed the Smoking Policy to ensure compliance with safe smoking 3.) On 12/17/2024, S22RA monitored unsafe smoking to ensure residents do not have smoking material on their person, are wearing smoker's aprons and are supervised. 4.) On 12/17/2024, S22RA quizzed direct care staff about the smoking policy and their role within. 5.) On 12/17/2024, S22RA reviewed the current smoking list to ensure it was updated. 6.) On 12/17/2024, S22RA reviewed all unsafe resident assessments and care plans to ensure all assessments and care plans were updated. The likelihood of serious harm no longer existed for residents related to unsafe smoking on 12/18/2024 at 3:36 p.m.

Based on observations, interviews, and record reviews the facility failed to ensure residents, who had a history of unsafe smoking used a safety smoking device and was supervised while smoking for 3 (Resident #31, Resident #15 and Resident #53) of 3 (Resident #15, Resident #31, and Resident #53) sampled residents reviewed for unsafe smoking. This deficient practice resulted in an Immediate Jeopardy situation on 12/16/2024 at 9:50 a.m. when Resident #31, a resident identified by the facility as an unsafe smoker with moderate cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #31's care plan, initiated on 10/02/2024, included Resident #31 was an unsafe smoker, was required to wear a smoking apron, and required staff supervision while smoking. S1Administrator was notified of the Immediate Jeopardy situation on 12/16/2024 at 5:52 p.m. This deficient practice had the likelihood to cause more than minimum harm to all 3 residents (Resident #15, Resident #31, and Resident #53) identified by the facility as unsafe smokers who required safety smoking devices and/or supervision while smoking. Findings: Review of the facility's policy titled Smoking Policy, updated 07/04/2024, revealed in part, residents that smoke would be assessed for the safety of smoking unattended and if determined unsafe, would not be allowed to have smoking paraphernalia in their possession, and would be care planned for the amount of supervision needed while smoking. Further review revealed the administrator was responsible for enforcing the designated smoking area, the nursing staff was responsible for keeping and distributing smoking paraphernalia for residents who were identified as unsafe smokers, and the ward clerk was responsible to monitor an active unsafe smoker list. Resident #31 Review of the facility's smoking list revealed, in part, Resident #31 was identified by the facility as unsafe smoker. Review of Resident #31's medical record revealed, in part, Resident #31 was admitted to the facility on [DATE] with diagnoses of, in part, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting his right dominant side. Review of Resident #31's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/10/2024 revealed, in part, Resident #31 had a Brief Interview of Mental Status (BIMS) score of 9, which indicated Resident #31 had moderate impaired cognition. Further review revealed Resident #31 was identified as a tobacco user. Review of Resident #31's quarterly MDS with ARD of 05/10/2024 revealed, in part, Resident #31 had a BIMS score of 10 which indicated Resident #31 had moderate impaired cognition. Further review revealed Resident #31 was identified as a tobacco user. Review of Resident #31's Comprehensive Care Plan, with an initiation date of 10/02/2024 revealed, in part, Resident #31 was actively an unsafe smoker who was required to wear a smoker's apron, and required staff supervision while smoking. Review of Resident #31's physician orders with a start date of 07/01/2024 revealed, in part, Resident #31 was an unsafe smoker and was required to wear a smoker's apron at all times while smoking. Observation on 12/16/2024 at 9:00 a.m., revealed Resident #31 was sitting in his wheelchair in his room with two burn holes in his shirt, one unlit cigarette under his left leg, and a lighter attached to a retractable device on his jacket. Observation on 12/16/2024 at 11:07 a.m., revealed Resident #31 was rolling in his wheelchair down hall c, with two burn holes in his shirt and a lighter attached to a retractable device on his jacket. In an interview on 12/16/2024 at 11:08 a.m., Resident #31 indicated he does not need anyone to go outside with him to smoke. Observation on 12/16/2024 at 12:18 p.m., revealed Resident #31 wheeled himself down hall c, with two burn holes in his shirt, and a lighter attached to a retractable device on his jacket. In an interview on 12/16/2024 at 12:19 p.m., Resident #31 indicated he was going to smoke. Observation on 12/16/2024 at 12:24 p.m., revealed Resident #31was outside on the facility's smoking patio, unsupervised and without a smoker's apron on. Further observation revealed Resident #31 removed a pack of cigarettes out of his jacket, removed the cigarette lighter attached to a retractable device on his jacket, and lit a cigarette using the lighter. Observation on 12/16/2024 at 12:39 p.m., S1Administrator witnessed and confirmed Resident #31 was identified as an unsafe smoker, was on the facility's smoking patio unsupervised, without a smoker's apron on, and was in possession of a cigarette and a lighter. There was no documented evidence and the facility could not provide any documented evidence there was a list of identified unsafe smokers located at the nurses' station. In an interview on 12/17/2024 at 9:03 a.m., S2Director of Nursing (DON) indicated Resident #31, an unsafe smoker, was observed smoking unsupervised, without a smoker's apron on, and in possession of smoking paraphernalia. S2DON further indicated administrative staff was aware of unsafe smokers smoking unsupervised, without a smoker's apron on and in possession of smoking paraphernalia. In an interview on 12/17/2024 at 10:35 a.m., S5CNA indicated she was not aware Resident #31 was an unsafe smoker who required a smoker's apron with supervision while smoking. S5CNA further indicated she had not been aware that Resident #31 had smoking paraphernalia in his possession. Resident #15 Review of Resident #15's annual MDS with ARD of 06/11/2024 revealed, in part, Resident #15 was identified as a tobacco user. A review of the facility's smoking list revealed, in part, Resident #15 was identified by the facility as an unsafe smoker. Observation on 12/16/2024 at 3:30 p.m., revealed Resident #15 sitting in his wheelchair in hall c with an opened full pack of cigarettes between his legs. Review of Resident #15's care plan revealed Resident #15 was care planned for unsafe smoking. Further, safe smoking interventions revealed in part; Resident#15 is an unsafe smoker, must wear a smoker's apron while smoking, cigarettes and lighter must be locked in the nurse's cart and Resident #15 must be supervised while smoking in the designated smoking location. In an interview on 12/17/2024 at 9:56 a.m., S4CNA indicated she was unaware Resident #15 was an unsafe smoker and should not have smoking material in his possession. Resident #53 Review of Resident #53's smoking assessment dated [DATE], revealed, in part, Resident #53 was an unsafe smoker. Review of Resident #53's annual MDS with an ARD date of 05/28/2024, revealed, in part, Resident #53 had a BIMS of 15 which indicated Resident #53 was cognitively intact and was identified as a tobacco user. Review of Resident #53's care plan, dated 10/24/2024, revealed, in part, Resident #53 should be supervised while smoking and should use a smoker's apron. In an interview on 12/16/2024 at 12:45 p.m., Resident #53 indicated he kept his cigarettes in his personal locked box and a lighter in his shirt pocket and he does not have to be supervised while smoking. Observation on 12/16/2024 at 12:45 p.m., revealed Resident #53 took a lighter out of his shirt pocket. In an interview on 12/16/2024 at 12:46 p.m., S8CNA indicated Resident #53 should not have smoking material in his room. In an interview on 12/16/2024 at 12:47 p.m., S4CNA indicated Resident #53 should not have smoking material in his room. In an interview on 12/16/2024 at 12:48 p.m., S11LPN, indicated Resident #53 should not have any smoking paraphernalia in his room. In an interview on 12/16/2024 at 12:50 p.m., S2Director of Nursing (DON) indicated she was aware Resident #53 was identified as an unsafe smoker, Resident #53 had to be supervised while smoking, and Resident #53 had smoking material in his possession. In an interview on 12/17/2024 at 8:55 a.m., S1Administrator confirmed the administrative personnel is responsible for ensuring the facility's designated smoking areas are enforced, Residents who are identified as unsafe smokers do not have smoking paraphernalia available in their rooms or on their person, and there was a current list of identified unsafe smokers at the nursing station In an interview on 12/17/2024 at 9:45 a.m., S1Administrator indicated Resident #15 was an unsafe smoker and should not have had smoking material in his possession. The Immediate Jeopardy was removed on 12/17/2024 at 6:50 p.m., after it was verified through observations, interviews, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit. A Plan of Removal was accepted on 12/17/2024 at 6:50 p.m., which included the following actions to correct the deficient practice: 1.) On 12/16/2024, S2DON and S1Administrator inspected other identified unsafe smokers from a review of an updated smokers list in order to collect and store items on the nursing cart and to prevent other potential harm that could occur. 2.) On 12/16/2024, a review of the current smoker's policy was conducted by S1Admnistrator and S2DON immediately with no immediate changes made. 3.) On 12/16/2024, S2DON and S1Administerator inspected personal belongings of all unsafe smokers and any smoking material found in possession of residents and was confiscated to given to the assigned nurse on the medication cart. All materials collected by S1Administrator and S2DON were placed in a zip locked bag and labeled with the resident's name. 4.) On 12/16/2024, direct care staff were immediately in-serviced on the facility smoker's policy by S2DON, and made aware of who was currently deemed as an unsafe smoker and each resident's level of safety to smoke. 5.) Beginning on 12/16/2024, all direct care staff, CNAs and nurses, were notified and in-serviced by S2DON. All staff would assist with supervising smoking for unsafe smokers as well as ensuring smoker's aprons were worn. This was initiated with the staff who were present and would continue with each shift, prior to the provision of care. 6.) On 12/16/2024, nurses were told by S2DON that they would secure smoking items and would locate a smoking attendant that could assist with smoking activity each time a resident requested to go out and smoke. In-services would be ongoing. 7.) On 12/16/2024, an updated smoking list was provided by S2DON to the Minimum Data Set (MDS) nurses and placed at the desk for all staff to reference. 8.) On 12/16/2024, MDS nurses reviewed care plans to ensure all unsafe smokers' care plans were up to date with appropriate interventions as well as verifying a smoking assessment was on file to correlate to the person centered care plan. 9.) On 12/16/2024, the S2DON and S1Administrator ensured all unsafe smokers did not have any smoking materials on their person and made a final round prior to exit. There were no smoking materials identified on any resident. The likelihood of serious harm no longer existed for residents related to unsafe smoker supervision on 12/17/2024 at 6:50 p.m. 45877 48855

Based on record reviews, interviews, and observations, the facility failed to ensure staff were able to demonstrate competency in skills necessary to assess for safe smoking for 3 (Resident #31, Resident #15 and Resident # 53) of 3 (Resident #31, Resident #15 and Resident #53) residents reviewed for unsafe smoking. Findings: Review of the facility's policy titled Smoking Policy, updated 07/04/2024, revealed in part, residents that smoke would be assessed for the safety of smoking unattended and if determined unsafe, would not be allowed to have smoking paraphernalia in their possession, and would be care planned for the amount of supervision needed while smoking. Further review revealed the administrator was responsible for enforcing the designated smoking area, the nursing staff was responsible for keeping and distributing smoking paraphernalia for residents who were identified as unsafe smokers, and the ward clerk was responsible for monitoring an active unsafe smoker list. Resident #31 Review of the facility's smoking list revealed, in part, Resident #31 was identified by the facility as unsafe smoker. Review of Resident #31's medical record revealed, in part, Resident #31 was admitted to the facility on [DATE] with diagnoses, in part, of hemiplegia and hemiparesis following an unspecified cerebrovascular accident (stroke) affecting his right dominant side. Review of Resident #31's quarterly MDS with an ARD of 05/10/2024 revealed, in part, Resident #31 had a BIMS score of 10 which indicated Resident #31 had moderately impaired cognition. Further review revealed Resident #31 was identified as a tobacco user. Review of Resident #31's Comprehensive Care Plan, with an initiation date of 10/02/2024 revealed, in part, Resident #31 was an unsafe smoker who was required supervision and a smoker's apron while smoking. Review of Resident #31's physician orders with a start date of 07/01/2024 revealed, in part, Resident #31 was an unsafe smoker and was required to wear a smoker's apron at all times while smoking. Observation on 12/16/2024 at 9:00 a.m., revealed Resident #31 was sitting in his wheelchair in his room with two burn holes in his shirt, one unlit cigarette under his left leg, and a lighter attached to a retractable device on his jacket. Observation on 12/16/2024 at 11:07 a.m., revealed Resident #31 was rolling in his wheelchair down hall c, with two burn holes in his shirt and a lighter attached to a retractable device on his jacket. Observation on 12/16/2024 at 12:18 p.m., revealed Resident #31 wheeled himself down hall c, with two burn holes in his shirt, and a lighter attached to a retractable device on his jacket. Observation on 12/16/2024 at 12:24 p.m., revealed Resident #31 was outside on the facility's smoking patio, unsupervised and without a smoker's apron on. Further observation revealed Resident #31 removed a pack of cigarettes out of his jacket, removed the cigarette lighter attached to a retractable device on his jacket, and lit a cigarette using the lighter that was attached to his jacket. Observation on 12/16/2024 at 12:39 p.m., S1Administrator confirmed Resident #31 was identified as an unsafe smoker, was on the facility's smoking patio unsupervised, without a smoker's apron on, and was in possession of a cigarette and a lighter. In an interview on 12/16/2024 at 12:40 p.m., S1 Administrator confirmed Resident #31 was identified as an unsafe smoker, was on the facility's smoking patio unsupervised, without a smoker's apron on, and was in possession of a cigarette and a lighter. There was no documented evidence and the facility could not provide any documented evidence there was a list of identified unsafe smokers located at the nurses' station. In an interview on 12/17/2024 at 8:40 a.m., S7Agency Certified Nursing Assistant (ACNA) indicated he had not received any training on safe and/or unsafe smoking policies. In an interview on 12/17/2024 at 9:03 a.m., S2Director of Nursing (DON) indicated prior to Resident #31's above mentioned observation on 12/16/2024 at 12:24 p.m., staff had not received education on the facility's smoking policy and there was no evidence presented that staff were educated on residents who were identified as unsafe smokers. In an interview on 12/17/2024 at 9:56 a.m., S4CNA indicated she did not know Resident #15 was an unsafe smoker and should not have had smoking material in his possession. S4CNA further indicated prior to 12/16/2024 she was not educated on residents considered to be unsafe smokers and interventions required for unsafe smokers. In an interview on 12/17/2024 at 10:35 a.m., S5CNA indicated she was not aware Resident #31 was an unsafe smoker, who required a smoker's apron with supervision while smoking. Resident #15 Review of Resident #15's annual MDS with ARD of 06/11/2024 revealed, in part, Resident #15 was identified as a tobacco user. A review of the facility's smoking list revealed, in part, Resident #15 was identified by the facility as an unsafe smoker. Observation on 12/16/2024 at 3:30 p.m., revealed Resident #15 sitting in his wheelchair in hall c with an opened full pack of cigarettes between his legs. Review of Resident #15's Comprehensive Care Plan revealed, in part, Resident #15 was an unsafe smoker. Further review revealed, interventions for Resident #15 included he must wear a smoker's apron while smoking, cigarettes and lighter must be locked in the nurse's cart and Resident #15 required supervision while smoking. In an interview on 12/17/2024 at 9:56 a.m., S4CNA indicated she was unaware Resident #15 was an unsafe smoker and should not have had smoking material in his possession. Resident #53 Review of Resident #53's smoking assessment dated [DATE], revealed, in part, Resident #53 was an unsafe smoker. Review of Resident #53's annual MDS with an ARD date of 05/28/2024, revealed, in part, Resident #53 had a BIMS of 15 which indicated Resident #53 was cognitively intact and was identified as a tobacco user. Review of Resident #53's Comprehensive Care Plan, dated 10/24/2024, revealed, in part, Resident #53 required supervision and a smoker's apron while smoking. Observation on 12/16/2024 at 12:45 p.m., revealed Resident #53 received a lighter from his shirt pocket. In an interview on 12/17/2024 at 8:55 a.m., S1Administrator confirmed the administrative personnel was responsible for ensuring staff are educated and trained on unsafe smoking policy and procedures. Further, S1Administrator indicated staff training/education was not implemented and the policy was not enforced as required for unsafe smokers.

Based on interviews, record review and facility policy review, the facility failed to ensure an allegation of physical abuse was reported on the Statewide Incident Management System no later than 2 hours after an allegation for resident to resident physical abuse for 1 (Resident #62) of 2 residents (Resident #5 and Resident #62) sampled residents investigated for abuse. Findings: Review of the facility's undated Abuse, Neglect, and Misappropriation of Funds Program policy revealed, in part, if a determination of abuse occurred the incident would be reported by the Administrator to the Department of Health and Hospitals via the Statewide Incident Management System (SIMS). Review of Resident #5's progress note dated 11/28/2024 at 2:17 p.m., revealed, in part, Resident #5 stated another resident (Resident #62) came into her room and punched her (Resident #5) in the face while she was asleep. Review of Resident #62's progress note dated 11/28/2024 at 2:09 p.m., revealed, in part, Resident #62 went into another resident's (Resident #5) room, punched her in her face, waking her up out of her sleep. Further review revealed, Resident #62 told Resident #5, Bitch get your yellow ass out my bed. Review of an undated Resident Incident Report revealed, in part, an incident between Resident #5 and Resident #62 was reported on 11/28/2024 at 2:25 p.m. Further review revealed Resident #62 propelled his wheelchair into Resident #5's room, hit Resident #5 in the face, and told Resident #5 to get out of his bed. In an interview on 12/18/2024 at 2:06 p.m., S2Director of Nursing (DON) indicated on 11/28/2024 at 2:25 p.m., she received a text message from S6Assistant Director of Nursing (ADON) that Resident #62 hit Resident #5. S2DON further indicated she texted S1Administrator with this information immediately after receiving the information from S6ADON. S2DON further indicated S1Administraotr was the only staff who could input incidents into the SIMS system. In an interview on 12/19/2024 at 11:32 a.m., S1Administrator indicated on 11/28/2024 at approximately 1:30 p.m. he received a text from S2DON that Resident #62 hit Resident #5. S1Administrator further indicated there was no documented evidence and he could not produce documented evidence that a Statewide Incident Management System incident report or investigation was reported and it should have been.

Based on record reviews and interviews, the facility failed to ensure: 1. a thorough investigation was completed following an allegation of abuse for 2 (Resident #5 and Resident #62) of 2 (Resident #5 and Resident #62) sampled residents was investigated for abuse; and 2. increased supervision was provided after an allegation of resident to resident abuse for (Resident #62) of 2 sampled residents (Resident #5 and Resident #62) investigated for abuse. Findings: Review of the facility's undated Abuse, Neglect, and Misappropriation of Funds Program policy revealed, in part, all incidents or suspected incidents of resident abuse would be investigated immediately. Further review of the facility's undated Abuse, Neglect, and Misappropriation of Funds Program policy revealed a thorough investigation of facts regarding the incident would be recorded and maintained by the administrator. Further review revealed in the instance of resident to resident abuse, the involved resident would be separated, monitored, and protected. Further review revealed the Description of Investigation shall include: 1. Date/time of incident; 2. Statement that allegation was found to be valid or invalid; 3. Signature of Director of Nursing or Administrator; and 4. Identify of Resident. Review of Resident #5's progress note dated 11/28/2024 at 2:17 p.m. revealed, in part, Resident #5 stated another resident (Resident #62) went into her room and punched her (Resident #5) in the face while Resident #5 was asleep. Review of Resident #62's progress note dated 11/28/2024 at 2:09 p.m., revealed, in part, Resident #62 went into another resident's (Resident #5) room, punched her in her face waking her up out of her sleep. Further review revealed, Resident #62 told Resident #5, Bitch get your yellow ass out my bed. Review of the facility's Resident Incident Report revealed, in part, no indication the allegation of resident to resident abuse was valid or invalid. Further review revealed no indication the Administrator or Director of Nursing investigated the incident on the date it occurred. Further review revealed no documentation of a 24 hour follow-up. Review of Resident #62's December 2024 Electronic Medication Administration Record revealed visual checks every 2 hours starting on 12/06/2024 at 4:00 p.m. In an interview on 12/18/2024 at 2:06 p.m., S2DON indicated on 11/28/2024 at 2:25 P.M., S6Assistant Director of Nursing (ADON) texted her Resident #62 hit Resident #5. She further indicated the was no documented evidence and she could produce documented evidence a thorough investigation on the incident of resident to resident abuse between Resident #5 and Resident #62 was completed. She further indicated there was no documented evidence and she could not produce documented evidence of increased supervision for Resident #62 immediately after the 11/28/2024 incident. She further indicted a more complete investigation should have been completed and increased supervision of Resident #62 should have been done. In an interview on 12/19/2024 at 11:32 a.m., S1Administrator indicated on 11/28/2024 at approximately 1:30 p.m. he received a text from S2DON that Resident #62 hit Resident #5. S1Administrator further indicated there was no documented evidence and he could not produce documented evidence that a thorough investigation of resident to resident abuse. S1Administrator further indicated there was no documented evidence and he could not produce documented evidence increased supervision for Resident #62 was provided after the incident occurred on 11/28/2024.

Based on interview and record review, it was determined that the facility failed ensure a pneumonia vaccine was administered for 1 (Resident #23) of 5 ( Resident #10, Resident #23, Resident #41, Resident #42 and Resident #46) reviewed for vaccines. Findings: Review of Resident #23's medical record revealed the Responsible Party (RP) signed a consent on 01/10/2024 for Resident #23 to receive a pneumonia vaccine. There was no documented evidence that the pneumonia vaccine was administered as per the consent, and the facility could not provide documentation the pneumonia vaccine had been administered. In an interview on 12/17/2024 at 5:35 PM, S2Director of Nursing (DON) confirmed the pneumonia vaccine had not been administered to Resident #23 after the RP signed the consent on 01/10/2024. 49753

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 1 (Resident #5) of 2 (Resident #5 and Resident #62) sampled residents investigated for abuse. Findings: Review of the facility's undated Abuse, Neglect, and Misappropriation of Funds Program revealed, in part, the facility was to ensure the safety and well-being of residents at all times, and the facility was committed to a zero tolerance of any form of abuse in our facility. Review of Resident #5's record revealed, in part, a Brief Interview for Mental Status score of 14, which indicated a cognitive mental status. Review of Resident #62's record revealed, in part, a Brief Interview for Mental Status score of 4, which indicated severe cognitive impairment. Review of Resident #5's progress note dated 11/28/2024 at 2:17 p.m. revealed, in part, Resident #5 stated another resident (Resident #62) went into her room and punched her (Resident #5) in the face while she was asleep. Review of Resident #62's progress note dated 11/28/2024 at 2:09 p.m. revealed, in part, Resident #62 went into another resident's (Resident #5) room, punched her in her face and, waking her up out of her sleep. Further review revealed, Resident #62 told Resident #5, Bitch get your yellow ass out my bed. Review of an undated Resident Incident Report revealed, in part, an incident between Resident #5 and Resident #62 was reported on 11/28/2024 at 2:25 p.m. Further review revealed Resident #62 propelled his wheelchair into Resident #5's room, and hit her in the face, and told Resident #5 to get out of his bed. In an interview on 12/18/2024 at 1:56 p.m., S6Assistant Director or Nursing (ADON) indicated on 11/28/2024 at 2:14 p.m., S18Licensed Practical Nurses (LPN) sent her a text message to inform her Resident #62 hit Resident #5 in the face. In an interview on 12/18/2024 at 2:06 p.m., S2Director of Nursing (DON) indicated on 11/28/2024 at 2:25 p.m., S6ADON texted her that Resident #62 hit Resident #5. S2DON further indicated resident to resident abuse should not have occurred between Resident #5 and Resident #62. In an interview on 12/19/2024 at 11:32 a.m., S1Administrator indicated on 11/28/2024 about 1:30 p.m. S1Administrator received a text from S2DON that Resident #62 hit Resident #5. S1Administratorr indicated resident to resident abuse should not have occurred between Resident #5 and Resident #62.

40405 Based on record reviews and interviews, the facility failed to ensure two Certified Nursing Assistants (CNAs) used a mechanical lift to transfer a resident who was dependent on staff for transfers from the bed to the wheelchair as indicated on their plan of care. This deficient practice resulted in an actual harm when a CNA transferred Resident #10 alone via the mechanical lift from the bed to the wheelchair when the strap on the lift pad broke causing Resident #10 to fall to the floor which resulted in a closed fracture of the left hip and laceration of right lower leg. The left hip fracture required surgery for an Open Reduction and Internal Fixation (ORIF) and the laceration to the right leg required sutures. This deficient practice was identified for 1 (Resident #10) of 14 sampled residents who required mechanical lift transfer. Findings: Record review revealed, in part, Resident #10 was admitted to the facility on [DATE] with a diagnosis, in part, of Morbid Obesity. Review of Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, in part, Resident #10 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #10 was cognitively intact, required extensive assistance of two persons with transfers between surfaces which included to or from the bed, chair, wheelchair, and standing position. Review of Resident 10's Nurses Notes dated 12/21/2023 at 2:43 p.m. revealed, in part, S16Certified Nursing Assistant (CNA) was transferring Resident #10 from the bed to the wheelchair via a mechanical lift when the strap on the lift pad broke and Resident #10 fell to floor landing on her left side. Review of Resident #10's hospital progress notes dated 12/23/2023 revealed, in part, a diagnosis of a closed fracture of the left hip and laceration of right lower leg. Further review revealed the left hip fracture required surgery for an Open Reduction and Internal Fixation (ORIF) and sutures for a laceration to the right leg. Further review of Resident #10's progress notes revealed, in part, Resident #10 was admitted to the hospital for a left femur fracture after falling to the ground from the strap breaking on the mechanical lift. In an interview on 01/22/2024 at 11:38 a.m., Resident #10 stated she sustained a fall from a mechanical lift last month because an employee attempted to transfer her from the bed to the wheelchair without asking for help. Resident #10 further stated this action caused her to break her left hip and get stitches in her right leg. In an interview on 01/23/2024 at 10:35 a.m., S2Director of Nursing (DON) stated on 12/21/2023, S16CNA transferred Resident #10 without a 2 person assist and as a result of the fall, Resident #10 sustained a fracture to her left hip and a laceration to her right shin which required sutures. S2DON also acknowledged that S16CNA should have asked for help and should have not transferred Resident #10 without a second person to assist as indicated by Resident #10's care plan. In an interview on 01/25/2024 at 12:10 p.m. S16CNA stated on 12/21/2023 she did not ask for a second person to assist her before transferring Resident #10 from the wheelchair to the bed and again from the bed to the wheelchair using the mechanical lift. S16CNA further stated she should have asked for a second person to assist her in transferring Resident #10 from the bed to the chair using the mechanical lift. 46683