Every finding on record at Onyx Care of Ruston

Based on observation and interview, the facility failed to treat each resident with respect and dignity in an environment that promotes or enhances his or her quality of life for 1 (#1) of 3 residents reviewed for resident rights. Findings: Review of the facility's Smoking policy and procedure, revised 06/2025, revealed the following, in part:Policy: No smoking or use of smoking materials will be allowed inside the building or in facility vehicles. This includes e-cigarette devices.Procedure:5 Smoking is only permitted in designated smoking areas with smoking times to be designated by the facility 05/02/2026 8:09 p.m.- 8:10 p.m. A review of the video footage from Resident #1's room dated 05/02/2026 was conducted. The following was observed: At 8:09 p.m., Resident #1 was lying in his bed in his room when S8CNA entered the resident's room and removed the resident's nebulizer mask from his trach. Then S8CNA was standing beside the resident's bed and used the remote control to turn on the resident's television. S8CNA brought a vaping device up to her lips, put the device in her mouth, and a light indicator came on the vaping device. Then S8CNA placed the vaping device behind her back until she left Resident #1's room.On 08/25/2026 at 3:58 p.m., an observation of the video footage from Resident #1's room dated 05/02/2026 at 8:09 p.m. to 8:10 p.m. was completed with S2DON and S1Administrator. S2DON and S1Administrator confirmed that S8CNA had used a vaping device while she was providing care to Resident #1 on 05/02/2026 and should not have been vaped in a resident's room.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 6 (#72, #75, #76, #91, #120, #124) of 6 residents reviewed for respiratory care. The facility failed to ensure:1). emergency tracheostomy supplies were available in resident rooms (#72, #124), 2). Oxygen concentrator filters were cleaned timely (#120), and 3). signage regarding oxygen in use was placed on resident doors (#75, #76, #91). Findings: Resident #72Review of the record for Resident #72 revealed an admission date of 04/13/2026 with diagnoses that included sequelae of cerebral infarction, COPD, chronic respiratory failure with hypoxia, and encounter for attention to tracheostomy. Review of the comprehensive MDS dated [DATE] revealed Resident #72 had severe impairment of cognition skills for daily decision making, and required tracheostomy care. Review of the physician orders revealed an order dated 06/22/2026 for size 6 uncuffed Shiley tracheostomy tube.Review of the current plan of care revealed tracheostomy present due to respiratory failure with interventions that included suction as ordered and tracheostomy tube care. On 07/07/2026 at 11:08 a.m., an observation with S4LPN at Resident #72's bedside revealed the oxygen tank was empty. On 07/07/2026 at 11:15 a.m., an observation with S2DON at Resident #72's bedside confirmed the oxygen tank was empty. S2DON confirmed the oxygen tank should be full. On 07/08/2026 at 9:15 a.m., an observation with S2DON at Resident #72's bedside revealed a size smaller tracheostomy tube was not present. S2DON confirmed a size smaller tracheostomy tube should be at the bedside. Resident #124 Review of the record for Resident #124 revealed diagnoses that included encounter for attention to tracheostomy, respiratory failure, and diffuse traumatic brain injury. Review of the Admit MDS assessment dated [DATE] revealed Resident #124 had a BIMS score of 15 which indicated no cognitive impairment. Further review revealed she was dependent on staff for all ADLs. Resident #124 also required tracheostomy care and suctioning. Review of Resident #124's July 2026 physician's orders revealed an order to evaluate the resident's Shiley tracheostomy every shift. Review of Resident #124's care plan dated 04/22/2026 revealed the resident had altered respiratory status related to a tracheostomy. Further review revealed interventions to provide tracheostomy care and suction as ordered. On 07/06/2026 at 9:55 a.m., an observation of Resident #124 revealed she was in bed with tracheostomy tube intact. On 07/08/2026 at 8:30 a.m. during an observation of Resident #124's emergency tracheostomy supplies, S7LPN confirmed the following supplies were not available in her room: 1 smaller size Shiley Tracheostomy tube, manual resuscitator, and portable oxygen tank. On 07/08/2026 at 9:00 a.m. during an observation of Resident #124's emergency tracheostomy supplies, S2DON confirmed the above emergency supplies should have been available at the resident's bedside. Resident #120 Review of Resident #120's revealed diagnoses that included COPD, history of pneumonia, shortness of breath, and hypertensive heart disease without heart failure. Review of the Resident #120's July 2026 physician's orders revealed an order dated 06/04/2026 for continuous oxygen at 2 liters per nasal cannula every shift for shortness of breath. Review of Resident #22's active care plan revealed she had chronic obstructive pulmonary disease and required continuous oxygen. On 07/07/2026 at 11:30 a.m. and 07/08/2026 at 8:20 a.m. observations revealed Resident #120 was in bed with oxygen at 2 liters per nasal cannula. Further observation revealed there was dust and grime build up on the filters located on each side of the oxygen concentrator. On 07/09/2026 at 11:40 a.m., an observation of Resident #120's oxygen concentrator with S7LPN confirmed there was a buildup of dust on the oxygen concentrator's filters and they were in need of cleaning. On 07/09/2026 at 11:45 a.m., S2DON was informed of the dust and grime buildup on both filters on Resident #120's oxygen concentrator filter and that filters were in need of cleaning. Resident #75 Review of the facility's Oxygen Therapy policy dated 08/2014 revealed the following in part: Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Equipment: 5. No smoking/oxygen in use sign Procedure: 7. Place sign on door Review of the medical record for Resident #75 revealed an admission date of 08/27/2025. Resident #75 had diagnoses that included COPD, chronic respiratory failure with hypoxia, heart failure and dementia. Review of the July 2026 physician orders revealed an order dated 04/08/2026 for oxygen at 2 LPM via nasal cannula continuously for shortness of breath related to COPD. On 07/06/2026 at 9:00 a.m. and 1:10 p.m. and on 07/07/2026 at 10:35 a.m., observations of Resident #75 revealed he received oxygen at 2 LPM per nasal cannula. Further observation revealed no signage was noted on the outside of the door to indicate no smoking oxygen in use. On 07/07/2026 at 10:50 a.m., observation of Resident #75 with S2DON revealed the resident received oxygen at 2 LPM per nasal cannula. At this time, S2DON confirmed signage to indicate no smoking oxygen in use was not on the outside of the door. Resident #76 Review of the medical record for Resident #76 revealed an admission date of 02/17/2023. Resident #76 had diagnoses that included hypertension, heart failure and atrial fibrillation. Review of the July 2026 physician orders revealed an order dated 04/08/2026 for oxygen at 3 LPM via nasal cannula continuously. On 07/06/2026 at 9:21 a.m. and 07/07/2026 at 10:55 a.m., observations of Resident #76 revealed he received oxygen at 3 LPM per nasal cannula. Further observation revealed no signage was noted on the outside of the door to indicate no smoking oxygen in use. On 07/07/2026 at 10:58 a.m., an observation of Resident #76 with S2DON revealed the resident received oxygen at 2 LPM per nasal cannula. At this time S2DON confirmed signage to indicate no smoking oxygen in use was not on the outside of the door. Resident #91 Review of the record for Resident #91 revealed diagnoses in part of aphasia, diffuse traumatic brain injury with loss of consciousness, traumatic hemorrhage of cerebrum, persistent vegetative state, and abnormalities of breathing. Review of the current physician orders in part revealed: oxygen at 2 LPM continuous. On 07/06/2026 at 2:18 p.m., observation of Resident #91 revealed oxygen at 2 LPM was running per nasal cannula. Observation of outside of Resident #91's door revealed there was no sign posted indicating oxygen was in use. On 07/07/2026 at 2:22 p.m., interview with S2DON confirmed there was no oxygen sign posted outside Resident #91's door.

Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nursing staff implemented the physician's order for oxygen and nursing staff failed to perform a respiratory assessment before and after suctioning per competency for 1 (#72) of 6 residents reviewed for respiratory care. Findings:Review of the record for Resident #72 revealed an admission date of 04/13/2026 with diagnoses that included sequelae of cerebral infarction, COPD, chronic respiratory failure with hypoxia, and encounter for attention to tracheostomy.Review of the comprehensive MDS dated [DATE] revealed Resident #72 had severe impairment of cognition skills for daily decision making. Further review revealed she required oxygen therapy and tracheostomy care.Review of the physician orders revealed orders dated 06/22/2026 for size 6 uncuffed Shiley tracheostomy tube, tracheostomy care daily, tracheostomy suctioning to be performed as needed and oxygen at 2 LPM per tracheostomy with 28% PSI.Review of the current plan of care revealed tracheostomy present due to respiratory failure with interventions that included suction as ordered, tracheostomy tube care, and oxygen as ordered.On 07/06/2026 at 9:02 a.m., an observation of Resident #72 revealed oxygen tubing was not connected to the tracheostomy.On 07/06/2026 at 9:13 a.m., an observation with S3RN confirmed oxygen tubing was not connected to the tracheostomy and Resident #72 had orders for oxygen therapy.On 07/06/2026 at 9:37 a.m., S3RN was observed performing tracheostomy care and suctioning without performing a respiratory assessment before and after suctioning.On 07/08/2026 at 9:00 a.m., S2DON confirmed a respiratory assessment should have been performed before and after suctioning and she independently confirmed with S3RN that it was not done.

Based on observations, interviews and record reviews, the facility failed to maintain infection control principles by staff not appropriately sanitizing hands during medication administration for 3 (#25, #63, #67) of 8 residents observed during medication administration and staff failed to use EBP during tracheostomy care and suctioning for 1 (#72) of 2 residents with tracheostomies.Findings: On 07/08/2026 at 7:50 a.m. observation of medication administration with S4LPN to Resident #63 revealed she used gloves for the entire medication administration and did not sanitize her hands when the gloves were removed. On 07/08/2026 at 8:00 a.m., observation of medication administration with S4LPN to Resident #25 revealed that after cleaning the blood pressure cuff and removing her gloves she sanitized her hands. S4LPN then put gloves back on and dispensed the medications, administered the medications, took the gloves off and did not sanitize her hands. She then walked down the hallway to obtain a new bottle of eye drops for Resident #25. S4LPN put on gloves again, administered the eye drops, and failed to sanitize her hands after administering the eye drops. On 07/08/2026 at 8:45 a.m., interview with S4LPN regarding not sanitizing her hands revealed she was adamant that she did sanitize her hands. On 07/08/2026 at 8:50 a.m., observation of medication administration with S5LPN to Resident #67 revealed she took the resident's blood pressure and upon exiting the room she failed to sanitize the blood pressure machine. Further observation of the medication administration revealed she did not sanitize her hands at all during the medication administration. On 07/08/2026 at 8:55 a.m., S5LPN was notified of not sanitizing her hands during the medication administration. On 07/08/2026 at 1:30 p.m., S2DON was notified that S4LPN and S5LPN did not properly sanitize their hands during medication administration. S2DON stated that S4LPN told her that she sanitized her hands, so they watched the video recording in S1Administrator's office. On 07/08/2026 at 3:00 p.m. observation of the video footage starting at 7:53 a.m. revealed S4LPN was seen administering medications to Resident #63 which revealed S4LPN did not sanitize her hands. Further observation of S4LPN administering medications to Resident #25 confirmed S4LPN did not appropriately sanitize her hands. Interview with S1Administrator revealed he agreed after watching video surveillance S4LPN did not appropriately sanitize her hands during medication administration. Resident #72 Review of the record for Resident #72 revealed an admission date of 04/13/2026 with diagnoses that included sequelae of cerebral infarction, COPD, chronic respiratory failure with hypoxia, and encounter for attention to tracheostomy. Review of the comprehensive MDS dated [DATE] revealed Resident #72 had severe impairment of cognition skills for daily decision making, and required tracheostomy care. Review of the physician's orders revealed orders dated 06/22/2026 for size 6 uncuffed Shiley tracheostomy tube, tracheostomy care daily, tracheostomy suctioning to be performed as needed, and EBP when performing high contact activities related to tracheostomy. Review of the current plan of care revealed tracheostomy present due to respiratory failure with interventions that included suction as ordered and tracheostomy tube care. On 07/06/2026 at 9:37 a.m., S3RN was observed performing tracheostomy care and suctioning without donning a gown per EBP precautions. After this, S3RN confirmed EBP precautions were not implemented as ordered. On 07/07/2026 at 12:22 p.m., S2DON was informed EBP precautions were not implemented as ordered for Resident #72.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principals. Findings:Review of the facility's Medication Labels Policy dated April 2014 revealed:1. Each prescription medication label includes:a. Resident's name5. Nonprescription medications, other than floor stock, that are administered to a resident by nursing personnel are kept in the manufacturer's original container which is identified with the resident's name or is dispensed as a prescription by the pharmacy. On 07/09/2026 at 9:32 a.m., observation of Hall-B medication cart revealed an opened bottle of artificial tears in the medication cart with an opened date of 07/08/2026 written on the packaging. Further observation of the medication revealed no resident name on the bottle or the packaging.On 07/09/2026 at 9:33 a.m., an interview with S4LPN revealed she opened the bottle of eye drops on 07/08/2026 for Resident #25. S4LPN stated she wrote the date on the eye drop packaging but forgot to write the resident's name on the bottle or packaging.On 07/09/2026 at 9:43 a.m., S2DON was informed of the observation of improperly labeled eye drops on the medication cart.

Based on interviews, observations, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 (#1) of 3 sampled residents reviewed for care plans. Findings: Review of the record revealed an admission date of 05/23/2025 with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere mild with mood disturbance, repeated falls, hypothyroidism, and hyperlipidemia.Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Further review of the MDS revealed resident required substantial/maximal assistance with shower/bathing and personal hygiene.Review of the Resident #1's current care plan revealed the resident had an actual fall with minor injury related to poor balance with an intervention updated on 11/05/2025 for meals to be eaten in dining room for lunch and supper.Review of Resident #1's current ADL care plan revealed resident required total care with all ADLs including bathing and interventions included a bed bath on Monday, Wednesday, and Friday and as needed and shave resident on bath days.Observations of Resident #1 on 12/30/2025 at 12:30 p.m., 01/05/2026 at 12:50 p.m. and 01/06/2026 at 12:25 p.m. revealed the resident was in bed eating his lunch meal and long facial hair was noted. An interview on 01/06/2026 at 12:30 p.m. with S8LPN revealed Resident #1 had a whirlpool bath on 01/05/2026. Observation of Resident #1 with S8LPN confirmed the resident had long facial hair and it needed to be trimmed. An interview on 01/06/2026 at 3:00 p.m. with S2DON confirmed during an observation of Resident #1 with the surveyor that the resident had long facial hair that needed to be trimmed. S2DON confirmed during review of resident's current care plans that Resident #1 received a whirlpool bath three times per week, shaved by staff on bath days, and should be eating his lunch meal in the dining room. S2DON confirmed that the facility failed to implement interventions listed in Resident #1's current care plan.

Based on record review and interviews, the facility failed to maintain the door locking mechanism on an exterior door in the secured unit to prevent elopement from the secured unit for 1 (#1) of 3 (#1, #2, #3) residents reviewed. The deficient practice resulted in an immediate jeopardy for Resident #1 on 05/23/2025 at 11:07 a.m. when Resident #1 who was an elopement risk was able to exit the secured unit to the outside of the building through a door with a malfunctioning locking mechanism. Resident #1 was picked up on the two lane highway with a speed limit of 55 miles per hour approximately 0.2 miles from the facility by S8Housekeeper. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 05/29/2025, thus it was determined to be a past noncompliance citation. Findings: Review of the record revealed Resident #1 was admitted to the facility on [DATE] from an inpatient psychiatric facility to the secured unit with diagnoses of unspecified dementia unspecified severity with other behavioral disturbances, depression, anxiety, auditory hallucinations, visual hallucinations, and unspecified psychosis. Review of the progress note from the inpatient psychiatric facility dated 02/11/2025 revealed in part: hyperreligious, trying to get everyone to exit the building thinking God was going to put the building on fire. Patient was labile and potentially aggressive. Patient was agitated, anxious and irritable. Patient was experiencing confusion, cognitive deficit, hallucinations, and delusional thinking. Criteria for continued stay: titrating medications, psychosis, danger to self/others, and gravely disabled: unable to support functional life skills. Review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 12 indicating Resident #1 had moderate cognitive impairment. Resident #1 was independent with mobility. Review of the plan of care in part revealed: ADLs (Activities of Daily Living) - Ambulates independently, continent of bowel and bladder, supervised bathing, supervision for wandering. Updated 03/06/2025 elopement risk wander guard to left ankle, 03/18/2025 resides on secure unit. The resident is an elopement risk/wanderer related to diagnosis of dementia. Interventions- census checks every hour, elopement assessment per policy and as needed, 03/06/2025 - wander guard bracelet to left ankle. Review of the elopement assessment completed 02/25/2025 revealed Resident #1 was scored not at high risk for elopement. Review of the elopement assessment completed 03/06/2025 revealed Resident #1 scored at high risk for elopement. Review of the nurses' notes dated 03/06/2025 and 03/07/2025 revealed Resident #1 followed a staff member out of the secured unit and was brought back to the secured unit by another staff member. Further review of the nurses' notes revealed Resident #1 had exit seeking behaviors on 03/11/2025, 03/23/2025, 03/25/2025, 03/27/2025, 04/14/2025, 04/28/2025, 04/30/2025, 05/02/2025, 05/19/2025, and 05/20/2025. Review of the nurses' notes dated 03/06/2025 revealed the resident said police have his family outside and says he can hear it through the wire. Further review of the nurses' notes revealed on 03/07/2025 the resident was self-talking and resident stated, If the police came in here, I'm going to knock them out. I don't swing to hit, I swing to hurt something. Resident continues to self-talk throughout the shift. Review of the nurses' notes dated 03/23/2025 revealed the resident had visual and auditory hallucinations, hearing voices and talking back to them. The resident was sent to the emergency room per ambulance. Review of the nurses' noted dated 03/26/2025 revealed the resident had increased confusion and agitation and talking to self. Review of the nurses' notes dated 04/30/2025 revealed the resident had increase agitation, talking and arguing with self. Review of the nurses' notes dated 05/23/2025 at 11:07 a.m. - Resident reported per staff to have exited facility via door on the secured unit and was walking fast. Staff member stated she attempted to call resident's name while gardening and he kept walking. She stated that other members of staff were running across yard and he was insistent on leaving. Housekeeper was able to get resident in her car, picked resident up, and returned to facility. Resident stated Oh, she brought me back here. Resident was placed on 1:1 for the remainder of the day shift and every 30 minutes from 2:30 p.m. -10:30 p.m. and every 1 hour to continue from 10:30 p.m. - 6:30 a.m. On 05/29/2025 at 10:30 a.m., an interview with S8Housekeeper confirmed she was working on 05/23/2025 when Resident #1 was able to get out of the facility. S8Housekeeper said she was going to her car for something and a CNA (Certified Nursing Assistant) told her a resident got out of the facility. S8Housekeeper said she got in her car to go and find the resident. S8Housekeepr confirmed she located Resident #1 on the two lane highway, up the road to the right of the facility at the dirt road. S8Housekeeper confirmed no staff would have been able to see Resident #1 from the facility from where she picked him up. Further interview with S8Housekeeper revealed she said she was able to get Resident #1 in the car and he asked her to take him to another town. S8Housekeeper said she drove up the highway, turned around and came back to the facility. On 05/29/2025 at 10:45 a.m., an interview with S9Maintenance Director revealed he was not at the facility when Resident #1 exited the building. He arrived and checked the door Resident #1 exited through and it was not broken. S9Maintenance Director further said he called the company that installed the doors with the secure locking features to come and inspect the door. Further interview with S9Maintenance Director revealed he said that if you push on any of these doors hard enough you can get them to open. On 05/29/2025 at 10:50 a.m. while inspecting the door that Resident #1 exited through with S9Maintenance Director, S10Housekeeping Director was also present. Interview at that time with S10Housekeeping Director revealed he was working on 05/23/2025 when Resident #1 exited the facility. S10Housekeeping Director said Resident #1 just pushed on the handle of the door, it opened and he walked out. S9Maintenance Director used the code pad to unlock the door and S10Housekeeping Director demonstrated how the metal bar at the top of the door which created a magnet and secured the door shut was loose and hanging down at an angle when Resident #1 opened the door. Further interview with S9Maintenance Director revealed the door did not have a wander guard locking mechanism. On 05/29/2025 at 1:25 p.m., an interview with S5Rehab Director revealed she was outside at the therapy garden and all of a sudden she saw a man running down the tree line. She said she did not know he was a resident and thought he was maintenance personnel. S5Rehab Director said she was not able to catch Resident #1 because he was running so fast and he was very tall and big. S5Rehab Director confirmed Resident #1 did get out to the 2 lane highway and down the road out of sight of the facility. On 06/02/2025 at 8:15 a.m., an interview with Resident #1 revealed he pushed the door and it opened. Resident #1 further revealed when he opened the door, no alarm sounded and the door shut right behind him. Resident #1 said he was going to an apartment in town. He said he made it to the highway and up the road about a quarter of a mile. On 06/02/2025 at 3:00 p.m., an interview with S7LPN (Licensed Practical Nurse) revealed she was working on 05/23/2025 when Resident #1 eloped from the secured unit. S7LPN revealed S6CNA came running into the secured unit and said she thought she saw Resident #1 running outside. S7LPN said she and S6CNA went out the facility's front door and ran through the grassy field in front of the facility all the way to the two lane highway and only at that point where they able to visually see Resident #1 being picked up by S8Housekeeper. S7LPN confirmed Resident #1 was not at the end of the driveway or even at the facility's tree line and was not visible from the facility. On 06/02/2025 at 3:40 p.m., an interview with S6CNA revealed on 05/23/2025 she was returning to the facility on an ambulance with another resident from a medical appointment. S6CNA said she saw someone walking very fast over by the tree line of the facility. She further said she tried to call into the facility to alert them of the resident being out but her phone would not work. S6CNA said she ran in the facility and alerted the staff in the front of the building that there was a resident out of the facility. She continued to run back to the secured unit and asked S7LPN if Resident #1 was still in the facility. S6CNA said they determined Resident #1 was not in the secured unit and ran back out to the front of the building. S6CNA said she and S7LPN ran all the way through the grass to the highway and only then were they able to see Resident #1 being picked up by S8Housekeeper. S6CNA confirmed Resident #1 made it to the two lane highway and up the highway to the dirt road. S6CNA said you could not see the resident from the front of the facility or even while in the grassy area. S6CNA said she was only able to visually see Resident #1 once they got to the end of the property and on the two lane highway. On 06/03/2025 at 10:50 a.m., an interview with S1Administrator and S2DON (Director of Nursing) confirmed the facility immediately closed off the doors to the area that Resident #1 eloped from and further corrective actions were put into place on 05/23/2025. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility on 05/29/2025. On 05/23/2025 the facility implemented the following actions to correct the deficient practice: 1. On 05/23/2025, the door allowing access to the outside from the secured unit was immediately closed off from any resident access. 3. On 05/23/2025, Resident #1 was assessed for any injuries or ill effects. 2. Resident #1 was placed 1 on 1 supervision for the remainder of the day shift on 05/23/2025, then placed on every 30 minute observation from 2:30 p.m.-10:30 p.m. and then every 1 hour observation thereafter. 2. On 05/23/2025 after Resident #1 was returned to the facility, 100 % of building was checked for resident census. 3. On 05/23/2025 after Resident #1 was returned to facility the company that installed the doors with security code locking mechanism was contacted to have them come and inspect the door. 4. On 05/23/2025 after Resident #1 was returned to the facility 100% inspection of all doors within the facility were checked to ensure working properly. 5. In-service initiated on 05/23/2025 for all staff: Title: Wander guards/monitoring residents/checking alarms. Subject: Please monitor all residents especially those with wander guards. They are in place for safety and to prevent the resident from exiting the facility. When an alarm is going off, please check the alarm no matter where it is. Door by ice room will be left unlocked and doors by nurses' station will be locked. Do not leave door until verifying it is locked. 6. Monitoring of 5 doors 5 days per week for 4 weeks was initiated on 05/26/2025 to ensure it is locked and wander guard was working adequately. Date facility asserts the likelihood for serious harm to any recipient no longer exists: 05/26/2025.

Based on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents and accidents. The facility failed ensure a resident received supervision during a bed bath for 1 (#1) of 3 (#1, #2, #3) residents reviewed for falls. The deficient practice resulted in an immediate jeopardy for Resident #1 on 04/15/2025 at 10:00 a.m. when Resident #1 fell out of the left side of the bed during a bed bath when S3CNA (Certified Nursing Assistant) failed to ensure the resident was secured and safe in the bed to prevent him from falling before she turned away to retrieve Resident #1's clothing from the closet. S3CNA had removed Resident #1's fall mat from the left side of the bed to provide ADL (Activities of Daily Living) care and Resident #1 landed on the floor on his right side. Resident #1 was transferred to a local emergency room (ER) related to a laceration to Resident #1's forehead. Resident #1's laceration was sutured closed and Resident #1 returned to the facility on [DATE]. Resident #1 was sent to a local hospital on [DATE] after Resident #1's RP (Responsible Party) noted swelling to Resident #1's right leg. Review of Resident #1's hospital record dated 04/21/2025 revealed, Resident #1 was diagnosed to have a right humerus fracture and a right hip fracture. Resident #1 was discharged back to the facility on [DATE] as a non-operative patient, unable to undergo physical therapy or any other intervention other than pain control. 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: Resident #1 was admitted to the facility on [DATE] with diagnoses, which included in part, other sequelae of other non-traumatic intracranial hemorrhage, aphasia following cerebral infarction, functional quadriplegia, anxiety disorder and joint derangement. Review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 99. Further review indicated Resident #1 was rarely or never understood. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL care. Review of Resident #1's comprehensive care plan revealed in part, Resident #1 was at risk for falls related to impaired mobility, uncontrolled movements and impaired communication with approaches in place for 1 person assist with bath, bed bolsters to bed, and fall mats to bilateral sides of the bed. Resident #1 was care planned for impaired cognition and communication deficits related to diagnosis of aphasia and rarely-never able to make himself understood. Review of Resident #1's physician orders revealed in part: 03/17/2025 Fall mats x 2 every shift for falls. 03/17/2025 Bed bolster to bed x 2, every shift for falls. Review of the facility's Incident Log for the past 3 months revealed Resident #1 had a witnessed fall on 04/15/2025 with no other incidents or accidents related to a fall after 04/15/2025. Review of the Incident Report dated 04/15/2025 at 10:00 a.m., revealed in part, S3CNA stated during Resident #1's bed bath, she (S3CNA) turned to get something out of Resident #1's closet right behind her and Resident #1 slid out of bed . Resident #1 had an abrasion on the right of his head. Resident #1 was not removed from floor until the arrival of EMS (Emergency Medical Services). Review of S3CNA's signed witness statement dated 04/15/2025 revealed, at approximately 9:30 a.m. to 10:00 a.m., I (S3CNA) had just finished giving Resident #1 a bed bath. I (S3CNA) proceeded to turn around to get his clothes out of the closet and he (Resident #1) rolled out of the bed onto the floor which caused Resident #1 to hit his head on the floor. Review of Resident #1's interdisciplinary notes revealed a nursing note dated 04/14/2025 at 10:55 a.m. by S4LPN (Licensed Practical Nurse), which read in part: 10:00 a.m., summoned to Resident #1's room; Resident #1 on floor on his right side; an abrasion noted . Resident #1 was never moved from the floor; EMS transferred Resident #1 from the floor to stretcher then to ER to evaluate and treat . Further review of Resident #1's interdisciplinary notes revealed Resident #1 returned to the facility on [DATE] with staples in place to Resident #1's head. Resident #1 was sent to the hospital on [DATE] at the request of Resident #1's RP (Responsible Party) who had concerns of Resident #1's right great toe and facial swelling from his past fall and decline. Resident #1 returned to the facility on [DATE] at 8:00 p.m. with a diagnosed right humerus fracture and right hip fracture. Review of Resident #1's hospital records with a visit date of 04/21/2025 revealed in part, a chief complaint of a fall that occurred 1 week ago and Resident #1's feet having become discolored since the fall. An x-ray of Resident #1's right hip dated 04/21/2025 revealed an acute right femoral neck trans-cervical fracture. An x-ray of Resident #1's right humerus dated 04/21/2025 revealed an acute comminuted humeral head and greater tuberosity fracture. Resident #1 was discharged back to the facility on [DATE] as a non-operative patient, unable to undergo physical therapy or any other intervention other than pain control. An observation on 05/05/2025 at 11:30 a.m. revealed Resident #1 was asleep in bed with a sling to his right arm. Further observation revealed bed bolsters in place bilaterally and fall mats to both sides of bed with a safety mat on top of each fall mat. Further observation revealed Resident #1's left side of the bed sat parallel to his closet and was approximately 4 feet away in distance. During an interview on 05/05/2025 at 4:00 p.m., S4LPN reported she was the nurse who entered Resident #1's room immediately after his fall out of the bed on 04/15/2025. S4LPN reported Resident #1 was lying on his right side on the floor at the left side of his bed. S4LPN reported Resident #1's fall mat had been removed from the left side of the bed. S4LPN further reported S3CNA told her she had just finished Resident #1's bed bath and when she turned to get something out of the closet, Resident #1 slipped off of the bed. During an interview on 05/06/2025 at 9:15 a.m., S2DON (Director of Nursing) reported S3CNA had removed the safety mat to provide ADL care on 04/15/2025 and when Resident #1 fell out of the bed he landed on the floor. S2DON acknowledged S3CNA had turned away during Resident #1's bed bath and should not have. During an interview on 05/06/2025 at 10:00 a.m., S3CNA reported on 04/15/2025 she gave Resident #1 a bed bath and when she entered the room, she removed the fall mat that was positioned at the left side of his bed and raised the bed. S3CNA reported after she had completed the bath, she removed the wet sheets and moisturized Resident #1 with a mixture of baby oil and baby lotion. S3CNA further reported she then turned away in a right direction to get Resident #1's clothes from his closet and Resident #1 turned over the bolster and fell to the floor. S3 CNA confirmed Resident #1 fell out of the left side of the bed and landed on the floor on his right side. S3CNA stated, Resident #1 was too slick; I put too much baby oil and lotion on him. S3CNA acknowledged she should have had Resident #1's clothes within reach prior to the bed bath and should not have turned away during care. During an interview on 05/06/2025 at 12:00 p.m. Resident #1's RP reported on 04/21/2025, Resident #1's toes on his right foot looked bruised and Resident #1 had swelling to his right leg. Resident #1's RP further reported, she requested the facility to send Resident #1 to his primary hospital. During an interview on 05/07/2025 at 2:00 p.m., S1Administrator reported S3CNA turned her back during the bath to grab Resident #1's clothes. S1Administrator acknowledged Resident #1 was not supervised in a safe manner during the bed bath and S3CNA should not have turned away. During an interview on 05/08/2025 at 2:25 p.m., S1Administrator confirmed the corrective actions put into place were completed on 04/28/2025. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice beginning on 04/15/2025 with a completion date of 04/28/2025: 1. On 04/15/2025, Resident #1 was made a 2 person assist with bathing. 2. Bed bath competency completed with S3CNA on 04/15/2025. 3. Upon notification of fractures, on 04/21/2025 all residents with BIMS score 10 or lower had skin assessments initiated and completed to rule out any signs or symptoms of abuse. 4. On 04/21/2025 all residents with BIMS score higher than 10 were interviewed regarding seeing any abuse, being abused and if they felt safe in the facility. 5. On 04/22/2025, auditing of 5 residents to ensure proper assistance is being used for bathing and tools are at bedside initiated, 5 days per week x 4 weeks and ongoing as deemed necessary by the QA committee. 6. On 04/22/2025, in-servicing of nursing staff initiated regarding provided care to keep needed items at beside; in-servicing completed on 04/28/2025. 7. On 04/22/2025 in-servicing of staff initiated regarding abuse prevention, bed bolsters and ensuring the thin landing mat stays in place at all time; in-servicing completed on 04/28/2025.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#104) of 5 (#20, #33, #60, #96, and #104) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #104 revealed an admitted [DATE] with diagnoses including chronic kidney disease, chronic diastolic congestive heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #104's Brief Interview for Mental Status (BIMS) score was 14 which indicated intact cognition for daily decision making. Resident #104 was independent or required set up help only with activities of daily living. Review of the current care plan revealed resident #104 was at risk for abnormal bleeding and/or bruising related to the use of an anticoagulant. The interventions were to monitor for active bleeding/bruising or for symptoms of internal bleeding and if noted to notify the resident's physician. Review of the April 2025 physician's orders revealed an order dated 08/29/2025 for Apixaban (Eliquis, anticoagulant) 5 milligrams, give 1 tablet orally twice daily related to atrial fibrillation. Further review revealed an order dated 08/29/2025 to monitor for active bleeding or for symptoms of internal bleeding such as: abnormal bruising, black tarry stools, or bright red vomit and to notify the resident's physician if any of the above is noted. Review of the record for resident #104 revealed no documented evidence of monitoring for active bleeding/bruising or for any sign or symptoms of internal bleeding. On 04/16/2025 at 1:25 p.m., an interview with S5Clinical Operations/Regional Support confirmed there was no documentation regarding monitoring for active bleeding or for any symptoms of internal bleeding for resident #104.

Based on observations, record reviews and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by having wheelchairs in need of repair for 5 (#6, #7, #22, #32, #33) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment. Findings: Resident 32 Review of the medical record for resident #32 revealed an admitted [DATE]. Resident #32 had diagnoses of Parkinson's disease, diabetes mellitus, heart disease, Alzheimer's disease, vascular dementia, anxiety and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact for daily decision making. Resident #32 required extensive assistance with bed mobility, transfers and toilet use. On 04/14/2025 at 8:30 a.m. an observation of resident #32 revealed she was in a wheelchair and the armrest on the right side was missing. On 04/16/2025 at 9:15 a.m. an interview with S6Licensed Practical Nurse (LPN) confirmed the armrest on the right side of the wheelchair was missing on resident #32's wheelchair. On 04/16/2025 at 1:00 p.m. S3Director of Nursing Services (DNS) observed resident #32's wheelchair and confirmed the armrest on the right side of the wheelchair was missing on the wheelchair. Resident 22 Review of the medical record revealed resident #22 was admitted on [DATE] with diagnoses of Alzheimer's disease, respiratory failure, muscle weakness, cognitive communication deficit, atrial fibrillation, and dementia. Review of the quarterly MDS dated [DATE] revealed resident #22 was cognitively impaired for daily decision making and required extensive assistance with bed mobility, transfers and toileting. On 04/14/2025 at 8:10 a.m., 04/15/2025 at 9:33 a.m., and on 04/16/2025 at 9:00 a.m. observations of resident #22 revealed the bilateral armrests were missing on the wheelchair. On 04/16/2025 at 9:15 a.m. an interview with S6LPN confirmed bilateral armrests were missing on the wheelchair. On 04/16/2025 at 1:00 p.m. S3DNS observed resident #22's wheelchair and confirmed bilateral armrests were missing from the wheelchair. 22575 Resident 6: Review of the medical record for resident #6 revealed an admitted [DATE] with diagnoses including end stage renal disease, chronic kidney disease, and unspecified dementia. Review of the annual MDS assessment dated [DATE] revealed resident #6 was cognitively intact for daily decision making. Further review revealed resident #6 was independent and/or required supervision for activities of daily living (ADL). On 04/14/2025 at 8:25 a.m. an observation of resident # 6 revealed she was in her room in her wheelchair. The resident's right wheelchair armrest pad was missing and her arm was directly on top of the metal portion of the armrest. Resident #6 reported that her wheelchair brakes do not work very well. On 04/15/2025 at 2:45 p.m. an observation of resident # 6's right wheelchair armrest revealed the padding was missing. Also at this time, resident #6 demonstrated that her brakes were in the locked position but she was still able to roll backwards. On 04/16/2025 at 3:00 p.m. the surveyor informed S2Project Manager/Regional Support that resident #6's right wheelchair armrest was missing and her wheelchair brakes were not working properly. Resident 7: Review of the medical record for resident #7 revealed an admitted [DATE] with diagnoses including quadriplegia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, seizures and Type 2 diabetes. Review of the quarterly MDS assessment dated [DATE] revealed resident #7 was cognitively intact for daily decision making. Further review revealed resident #7 was totally dependently on staff for ADLs. On 04/14/2025 9:42 a.m. and 04/15/2025 at 9:00 a.m. observations of resident #7's wheelchair revealed his right wheelchair armrest was cracked and was in need of repair. On 04/16/2025 at 3:00 p.m. the surveyor and S2Project Manager/Regional Support observed resident #7's right wheelchair armrest and she confirmed his right wheelchair armrest was cracked and needed to be repaired. 52271 Resident 33: Review of the medical record for resident #33 revealed an admitted [DATE] with diagnoses that included spinal stenosis, type 2 diabetes mellitus, acquired absence of right leg below knee, acquired absence of other left toe, bipolar disorder, and depression. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated that resident #33 was cognitively intact. Resident #33 required partial/moderate assistance with bed mobility and transfers. On 04/14/2025 at 1:41 p.m., and 04/15/2025 at 3:53 p.m. observations of resident #33's scooter revealed the seat cushion was torn. On 04/16/2025 at 3:00 p.m., the surveyor and S2Project Manager/Regional Support observed resident #33's electric scooter cushion was torn and she confirmed that the cushion needed to be repaired.

Based on observations, record reviews, and interviews, the facility failed to ensure residents received services for reasonable accommodation of needs by failing to provide set-up assistance with meals for 1 (#26) of 1 residents reviewed for positioning and mobility. Findings: Review of the record for resident #26 revealed an admitted [DATE]. Resident #26 had diagnoses that included flaccid hemiplegia affecting right dominant side, right hand contracture, sequelae of cerebrovascular disease, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 which indicated that resident #26 had moderate cognitive impairment. Additionally, the MDS documented that resident #26 had a one sided functional limitation in range of motion and required set-up or clean-up assistance with meals. Review of resident #26's current plan of care revealed an intervention dated 12/20/2024, per occupational therapy, staff is to assist with meal tray set-up. On 04/14/2025 at 12:15 p.m., resident #26's lunch tray was observed being delivered to his bedside table. It was observed that S9Certified Nursing Assistant (CNA) did not provide set-up assistance for resident #26 which included not opening seasoning packets or beverages. S9CNA then exited the room. Resident #26 turned his bedside table to reposition his tray in front of him. Interview at that time with resident #26 revealed staff do not assist him with opening items such as milk cartons or pepper packets. Resident #26 was observed opening a pepper packet with his teeth. Resident #26 confirmed that he does have difficulty chopping his meat and revealed that it would be helpful if staff would chop his meat. On 04/16/2025 at 8:07 a.m., resident #26 was observed in his room with his breakfast tray delivered and he had consumed approximately 50% of his meal. Further observation revealed that resident #26's milk carton had not been opened and additional fluids on the tray were still covered. S7LicensedPracticalNurse (LPN) was notified that resident #26's milk carton and fluids were not opened. On 04/16/2025 at 7:55 a.m., an interview was conducted with S7LPN regarding resident #26's requirement for assistance with meals. S7LPN confirmed that resident #26 was independent with feeding himself but staff open his drinks. On 04/16/2025 at 2:15 p.m., S1ExecutiveDirector was notified of the findings related to the facility's failure to provide reasonable accommodation of needs for resident #26 who required set-up assistance with meals.

Based on observation and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (#29) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment. The failed practice was evidenced by resident #29 not having bed linen on the bed. Findings: Review of the record for resident #29 revealed an admission of 01/16/2024 with diagnoses of type 2 diabetes, cerebral vascular disease and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 was cognitively intact for daily decision making. Resident #29 required two person physical assistance with bed mobility, transfers, and toilet use. On 04/14/2025 at 3:19 p.m., observation of resident #29's bed revealed there was no linen on the bed and the resident was observed lying on a draw sheet. Interview with resident #29 at that time revealed this was a frequent problem with staff failing to put linen on the bed. Resident #29 stated she had reported not having linen to the nurses and nothing had changed. Interview with S9Certified Nursing Assistant on 04/14/2025 at 4:40 p.m. confirmed that no bed linen was currently on the bed for resident #29. She revealed that this frequently occurs with residents who have a bariatric bed. On 04/16/2025 at 2:15 p.m. S1Executive Director was notified resident #29 did not have linens on her bed and she was in the bed lying on a draw sheet.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints. The facility failed to ensure that resident #31 was able to self-release his wheelchair seatbelt upon request which resulted in the failure to identify the seatbelt as a restraint. Findings: Review of the facility's Restraint Evaluation and Restraint Reduction Policy dated 08/2013 revealed: Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. The policy states that individuals responsible for restraints include all members of the interdisciplinary team (as appropriate to individual resident needs) and the Director of Nursing (DON) monitors restraints. Seatbelts that are front-fastened and can be easily unfastened by the alert and somewhat oriented resident are not included if the resident can demonstrate self-release upon request. Review of the medical record for resident #31 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, history of falling, age related osteoporosis, and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate impaired cognition. Review of the Physician's Orders dated 01/04/2025 specified resident #31's seatbelt as: self-releasing alarming seatbelt (non-restraint) due to unawareness of physical limitations with a diagnosis of schizoaffective disorder. Review of resident #31's current plan of care revealed the self-releasing alarming seatbelt to wheelchair was a fall intervention. On 04/14/2025 at 3:47 p.m., resident #31 was observed in his wheelchair and it was noted that the wheelchair seatbelt was secured. On 04/16/2025 at 10:57 a.m., an observation of resident #31 with S3Director of Nursing Services (DNS) was conducted. Resident #31 was seated in his wheelchair with his seatbelt in place. S3DNS asked resident #31 to unbuckle his seatbelt. Resident #31 did attempt to release the seatbelt but was unable to complete the act. Resident #31 stated to S3DNS that he could not complete the task. On 04/16/2025 at 11:15 a.m., an interview with S3DNS revealed there was no supporting documentation regarding restraint reduction attempts or reassessments for resident #31. On 04/16/2025 at 2:15 p.m., S1ExecutiveDirector was notified of the findings related to the facility's failure to identify that resident #31's wheelchair seatbelt was a restraint.

Based on observations, record reviews, and interviews, the facility failed to ensure a care plan had been revised for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints. Findings: Review of the facility's Restraint Evaluation and Restraint Reduction Policy dated 08/2013 revealed: Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. The policy states that individuals responsible for restraints include all members of the interdisciplinary team (as appropriate to individual resident needs) and the Director of Nursing (DON) monitors restraints. The policy procedure states that all residents using a restraint are to be evaluated and re-evaluated approximately every quarter. The policy procedure states that care plan updates are to occur approximately every quarter and/or as a goal or approach direction changes. Review of the medical record for resident #31 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, history of falling, age related osteoporosis, and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate impaired cognition. The MDS indicated a chair alarm in use daily, however, there was no documentation that indicated a wheelchair seatbelt was in place. Review of the Physician's Orders dated 01/04/2025 specified resident #31's seatbelt as: self-releasing alarming seatbelt (non-restraint) due to unawareness of physical limitations with a diagnosis of schizoaffective disorder. Review of resident #31's current plan of care revealed the self-releasing alarming seatbelt to wheelchair was a fall intervention. The current plan of care did not address the use of a restraint. On 04/16/2025 at 11:15 a.m., S3Director of Nursing Services confirmed that there was no supporting documentation available regarding reassessing resident #31 for restraints.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 1 (#20) of 2 (#20, #104) residents reviewed for ADL care. The facility failed to ensure that resident #20 had neatly groomed and shaved facial hair. Findings: Review of resident #20's record revealed an admitted [DATE] with diagnoses that included unspecified psychosis, end stage renal disease, right hand contracture, type 2 diabetes mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 which indicated that resident #20 had severe cognitive impairment. Resident #20 required substantial/maximal assistance with bathing and grooming. On 04/14/2025 at 4:10 p.m., resident #20 was observed seated in a wheelchair at the nurses station and it was noted that his facial hair was poorly groomed and unshaven. On 04/15/2025 at 1:10 pm, resident #20 was observed lying in bed with his head of bed elevated. His facial hair was poorly groomed and unshaven. On 04/16/2025 at 7:44 a.m., resident #20 was observed lying in bed with his head of bed elevated. His facial hair was poorly groomed and unshaven. On 04/16/2025 at 8:01 a.m., an interview was conducted with S7LicensedPracticalNurse (LPN) who confirmed that resident #20 received a bed bath daily. S7LPN confirmed that the bed bath included a shave. On 04/16/2025 at 10:36 a.m., an interview was conducted with S8CertifiedNursingAssistant (CNA) who confirmed that resident #20 received a bath on the night shift. S8CNA confirmed that resident #20 should have been shaved. On 04/16/2025 at 2:15 p.m. S1ExecutiveDirector were notified of the findings related to the facility's failure to provide ADL care to resident #20 who was dependent for ADL care.

Based on observation, record review, and interviews the facility failed to ensure that nursing staff had the appropriate competencies and skills necessary to care for resident needs. The facility failed to obtain orders and document treatment performed to a tracheostomy stoma for 1 (#34) of 2 (#34 and #60) residents reviewed for wound care. Findings: Review of the medical record revealed resident #34 was admitted to the facility on [DATE] with diagnoses that included in part, depression, schizoaffective disorder, depressive type, type 2 diabetes mellitus without complications, chronic cough, artificial opening status, and personal history of non-Hodgkin lymphoma. Review of Resident #34's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7 which indicated resident #34 had severe cognitive impairment for daily decision making. Review of Resident #34's care plan revealed the resident had a neck stoma related to an old tracheostomy and dressing to stoma was to be changed per treatment order. Review of resident #34's April 2025 physician's orders revealed the resident did not have an active wound care order for the tracheostomy stoma. On 04/15/2025 at 2:20 p.m. resident #34 was observed sitting in the day area with a dressing over his anterior throat, and the dressing was dated 04/15/2025. On 04/16/2025 at 8:10 a.m. interview with resident #34 stated the facility staff change his stoma dressing daily. On 04/16/2025 at 9:00 a.m. a review of resident #34's electronic medical records revealed no documentation of the trach stoma care being performed. On 04/16/2025 at 10:10 a.m. an interview with S1Exective Director and S2Project Manager/Regional Support confirmed the order for the tracheostomy stoma wound care was removed from the active orders and electronic treatment administration record (ETAR) on 02/27/2025 and the wound care had not been documented. On 04/16/2025 at 10:20 a.m. an interview with S4Respiratory Therapist revealed she provided tracheostomy stoma care to resident #34; however, S4 Respiratory Therapist confirmed she failed to document the treatments.

Based on observation, record review, and interview, the facility failed to ensure food was palatable, and served at an appetizing temperature. Findings: Review of the record for resident #29 revealed an admitted [DATE] with diagnoses of type 2 diabetes, cerebral vascular disease and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 was cognitively intact for daily decision making. Interview on 04/14/2025 at 10:00 a.m. with resident #29 revealed the food was terrible. Resident #29 stated that the taste, texture, and choices of food was poor and that no substitutions were offered. A lunch test tray was requested from S10 Dietary Manager (DM) on 04/14/2025. The test tray was placed on the hall meal cart and was observed to leave the kitchen at 12:02 p.m. Further observation revealed that the test tray was given to the surveyor by S9 Certified Nursing Assistant at 12:23 p.m. The test tray meal consisted of BBQ pork loin, beans, vegetable medley, corn bread and cake. The pork loin was tough and the vegetable medley consisted of broccoli, cauliflower and carrots. The vegetable medley was overcooked, had a mushy consistency, had no flavor or seasoning, and the food was cool to taste. On 04/15/2025 at 2:15 p.m., S10 DM was notified of the results of the test tray. On 04/16/2025 at 1:50 p.m., the Executive Director was notified of the results of the test tray.

Based on record reviews and interviews, the facility failed to ensure residents were free from misappropriation of resident property for 32 (#1-#32) of 32 representative sampled residents of 132 total residents identified with an active trust fund account since [DATE]. Findings: Review of the facility's policy and procedure on Resident Trust Fund, with a revision date of ,d+[DATE], revealed the following, in part: Disbursements: All disbursements must be authorized by the resident and/or designated representative on any one of the following: 1) Petty Cash Disbursement slip, 2) Disbursement Voucher, 3) Trust Fund Disbursement Log, or 4) Monthly Disbursement Authorization Form. Small dollar disbursement amounts can be requested from the Resident Trust Fund petty cash fund maintained by the business office. Cash Withdrawals- Petty Cash Fund: Cash withdraws made by the resident and/or designated representative or power of attorney from available individual funds (resident account balance on deposit). They are limited to fifty dollar ($50.00) increments, or $49.00 in Louisiana. Should additional funds over the fifty dollars ($50.00) or $49.00 in Louisiana limit be requested, the resident will be required to accept a check. 1) A petty cash box designated exclusively for Resident Trust Fund shall be maintained by the facility Business Office in the amount of between three hundred dollars ($300.00) and six hundred dollars ($600.00). 2) Each transaction is recorded on a Petty Cash Disbursement slip or Disbursement Log for withdrawals. The Petty Cash Disbursement or Disbursement Log should be signed by the resident and/or designated representative receiving the cash withdrawal. The signed original is retained in the petty cash box to substantiate weekly replenishments to the cash box from the Resident Trust Fund bank account, and provide support for posting to the individual resident trust account. 3) The Petty Cash box balance is maintained and replenished via a withdrawal from the Resident Trust Fund checking account as required. Trust Fund Disbursement Log revealed the following, in part: H) Have the person authorizing the disbursement sign, if resident marks with X, have this mark witnessed by 2 witnesses. Resident #1 Review of record revealed resident #1 was admitted to the facility on [DATE]. Review of resident #1's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating he was cognitively intact. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #1`s trust fund account for petty cash-vending totaling $490.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #1: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 2:30pm an interview with resident #1 confirmed he went to S3 Business Office Manager (BOM) on [DATE] and was told he did not have enough money in his account to honor his withdrawal request. Resident #1 reviewed his records and discovered there was a discrepancy in his money so he reported it to the administrator on [DATE]. Resident #1 reported his account was $490.00 short and he knew someone took his money. On [DATE] at 1:26 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #1. Resident #2 Review of record revealed resident #2 was admitted to the facility on [DATE]. Review of resident #2's admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #2's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of the resident #2's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $49.00. On [DATE] at 9:07 a.m., an interview with resident #2 revealed she was not aware of missing funds until S1Administrator came to her with the news. Resident #2 reported she could get a balance any time at her request but never really worried about it because there was not very much money in the account. On [DATE] at 1:28 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #2. Resident #3 Review of record revealed resident #3 was admitted to the facility on [DATE]. Review of resident #3's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #3 trust account for petty cash-vending totaling $972.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $26.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $15.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #3: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $26.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $15.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 1:29 p.m., an interview with S2Regional Financial Consultant confirmed resident #3's discrepancies were identified by review of the trust fund receipt book showing alleged forged witness's signatures because the witnesses claimed they did not sign the receipts. Resident #3 signed with an X thus requiring 2 witnesses to sign the trust fund receipt book. Resident #4 Review of record revealed resident #4 was admitted to the facility on [DATE]. Review of resident #4's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #4 trust account for petty cash-vending totaling $5.00 on [DATE]. Review of resident #4's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $5.00. On [DATE] at 1:37 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #4. Resident #5 Review of record revealed resident #5 was admitted to the facility on [DATE]. Review of resident #5's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #5's trust account for petty cash-vending totaling $98.00 as follows: [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #5: [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 1:38 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #5. Resident #6 Review of record revealed resident #6 was admitted to the facility on [DATE]. Review of resident #6's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #6's trust account for petty cash-vending totaling $234.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $38.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #6: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $38.00 On [DATE] at 1:39 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #6. Resident #7 Review of record revealed resident #7 was admitted to the facility on [DATE]. Review of resident #7's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #7's trust account for petty cash-vending totaling $8.00 on [DATE]. Review of resident #7's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $8.00. On [DATE] at 1:40 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt books showing suspected forged signatures of Resident #7. Resident #8 Review of record revealed resident #8 was admitted to the facility on [DATE]. Review of resident #8's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #8's trust account for petty cash-vending totaling $236.00 as follows: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $34.00 [DATE] - $49.00 [DATE] - $15.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #8: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $34.00 [DATE] - $49.00 [DATE] - $15.00 On [DATE] at 1:42 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #8. Resident #9 Review of the record revealed resident #9 was admitted to the facility on [DATE]. Review of resident #9's most recent significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #9's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of resident #9's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $49.00. On [DATE] at 1:42 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #9. Resident #10 Review of record revealed resident #10 was admitted to the facility on [DATE]. Review of resident #10's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #10's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of resident #10's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $49.00. On [DATE] at 1:43 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book showing a forged witness signature with misspelled resident name. Resident #11 Review of record revealed resident #11 was admitted to the facility on [DATE]. Review of resident #11's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 99 indicating the assessment could not be completed. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #11's trust account for petty cash-vending totaling $114.00 as follows: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $14.00 [DATE] - $20.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #11 totaling $114.00: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $14.00 [DATE] - $20.00 On [DATE] at 1:43p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #11. Resident #12 Review of record revealed resident #12 was admitted to the facility on [DATE]. Review of resident #12's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #12's trust account dated [DATE] for petty cash-vending in the amount of $10.00. Review of resident #12's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $10.00. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing an inconsistent (forged) resident signature and was confirmed by the family member for resident #12. Resident #13 Review of record revealed resident #13 was admitted to the facility on [DATE]. Review of resident #13's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #13's trust account for petty cash-vending totaling $78.00 as follows: [DATE]- $15.00 [DATE]- $9.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]-$9.00 [DATE]- $10.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #13: [DATE]- $15.00 [DATE]- $9.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]-$9.00 [DATE]- $10.00 An interview on [DATE] at 9:18 a.m. with resident #13 revealed she got a statement from the business office when she wanted it. Resident #13 reported when she needed money she would go to the business office and sign for the money. Resident #13 reported the facility notified her of money missing from her trust fund account. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book as follows: 1 receipt with no signature, 2 receipts with unauthorized signature by the resident's daughter, and several inconsistent (forged) resident signatures for resident #13. Resident #14 Review of record revealed resident #14 was admitted to the facility on [DATE]. Review of resident #14's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #14's trust account dated [DATE] for petty cash-vending in the amount of $20.00. Review of the resident's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $20.00 for resident #14. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing forged resident signature with the name misspelled for resident #14. Resident #15 Review of record revealed resident #15 was admitted to the facility on [DATE]. Review of resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #15's trust account for petty cash-vending totaling $58.00 as follows: [DATE]- $20.00 [DATE]- $38.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #15: [DATE]- $20.00 [DATE]- $38.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 inconsistent (forged) resident signatures compared to her prior signatures for resident #15. Resident #16 Review of record revealed resident #16 was admitted to the facility on [DATE]. Review of resident #16's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #16's trust account dated [DATE] for petty cash-vending in the amount of $14.00. Review of the resident's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $14.00 for resident #16. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing S5Business Manager Assistant signed as a witness to her own signature with no other witness signature. S2Regional Financial Consultant confirmed resident #16 was unable to sign receipt physically, and required 2 witness signatures to obtain money from petty cash. Resident #17 Review of record revealed resident #17 was admitted to the facility on [DATE]. Review of resident #17's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #17's trust account for petty cash-vending totaling $368.00 as follows: [DATE]- $49.00 [DATE]- $44.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $30.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #17: [DATE]- $49.00 [DATE]- $44.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $30.00 An interview on [DATE] at 9:10 a.m. with resident #17 revealed he received his account balance monthly, and he signed when he got his money from the business office. Resident #17 reported the facility notified him that over $300 had been taken out of his account. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing the date was changed on the [DATE] receipt, 1 receipt with an odd amount for this resident, and multiple misspelled resident signatures on the receipts for resident #17. Resident #18 Review of record revealed resident #18 was admitted to the facility on [DATE]. Review of resident #18's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #18's trust account for petty cash-vending totaling $37.00 as follows: [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $2.00 [DATE]- $5.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #18: [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $2.00 [DATE]- $5.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing inconsistent (forged) resident signatures on all receipts, and a change was made to the amount on 1 of the boxes on the receipt for resident #18. Resident #19 Review of record revealed resident #19 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Review of resident #19's significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #19's trust account for petty cash-vending totaling $83.00 as follows: [DATE]- $49.00 [DATE]- $34.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #19: [DATE]- $49.00 [DATE]- $34.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 receipts had forged resident signatures for resident #19. Resident #20 Review of record revealed resident #20 was admitted to the facility on [DATE]. Review of resident #20's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #20's trust account for petty cash-vending totaling $35.00 as follows: [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #20: [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing inconsistent (forged) resident signatures for the above receipts for resident #20. Resident #21 Review of record revealed resident #21 was admitted to the facility on [DATE]. Review of resident #21's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #21's trust account for petty cash-vending totaling $25.00 as follows: [DATE]- $6.00 [DATE]- $2.00 [DATE]- $17.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #21: [DATE]- $6.00 [DATE]- $2.00 [DATE]- $17.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 receipts with no signatures and 1 receipt with a forged resident signature for resident #21. Resident #22 Review of record revealed resident #22 was admitted to the facility on [DATE]. Review of resident #22's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status assessment score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #22's trust account dated [DATE] for petty cash-vending in the amount of $20.00. Review of resident #22's statement register from [DATE] to [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $20.00. On [DATE] at 1:58 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book which showed the receipt amount had been changed in the top box, and it was an irregular amount from what he would normally receive out of his account. S2Regional Financial Consultant revealed resident #22 signed for himself. Resident #23 Review of record revealed resident #23 was admitted to the facility on [DATE]. Review of resident #23's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #23's trust account dated [DATE] for petty cash-vending in the amount of $38.00. Review of resident #23's statement register from [DATE] to [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $38.00. On [DATE] at 2:03 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book showing the amount was changed on the receipt and the amount not consistent with the amount resident #23 normally received from her trust account. S2Regional Financial Consultant reported the receipt was not to be modified. If an error was made on the receipt it was voided and the correct information put on a new receipt. S2Regional Financial Consultant reported resident #23 signed for herself. Resident #24 Review of record revealed resident #24 was admitted to the facility on [DATE]. Review of resident #24's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #24's trust account for petty cash-vending totaling $977.00 as follows: [DATE]- $49.00 [DATE]- $46.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 Review of resident #24's statement register from [DATE] to [DATE] revealed the following transactions for petty cash-vending withdraws: [DATE]- $49.00 [DATE]- $46.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 On [DATE] at 9:00 a.m. an interview with resident #24 revealed a lady in the office (unknown to resident) had informed her that $977.00 was stolen out of her trust fund account and S5Business Office Assistant had been fired. Resident #24 reported she was not aware of any money missing from her trust fund account until it was brought to her attention by the lady in the office. Resident #24 reported she was told they would be refunding her $977.00 but she had not received it yet. On [DATE] at 2:03 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing forged resident signatures and an irregular amount was taken out. S2Regional Financial Consultant revealed resident #24 signed for herself. Resident #25 Review of record revealed resident #25 was admitted to the facility on [DATE]. Review of resident #25's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #25's trust account for petty cash-vending totaling $147.00 as follows: [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 Review of resident #25's statement register from [DATE] to [DATE] revealed the following transactions for petty cash-vending withdraws: [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 On [DATE] at 9:16 a.m. an interview with resident #25 revealed he was made aware there was $147 missing from his account. Resident #25 revealed he received a receipt whenever he got money out

Based on record review and interview, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 1 sampled residents reviewed for misappropriation of resident funds. Findings: Review of the facility`s abuse prevention policy revealed the latest revision was made in August 2017. Review of the Reporting section of the policy contained the following requirement: Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. Review of record revealed resident #1 was admitted to the facility on [DATE]. Review of resident #1's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating he was cognitively intact. On 06/17/2024 at 2:30 p.m., an interview with resident #1 confirmed he went to S3Business Office Manager (BOM) on 05/30/2024 and was told he did not have enough money in his account to honor his withdrawal request. Resident #1 reviewed his records and discovered there was a discrepancy in his money so he reported it to the administrator on 05/31/2024. Resident #1 reported his account was $490.00 short and he knew someone took his money. On 06/18/2024 at 9:55 a.m., an interview with S3BOM revealed on 05/30/2024 resident #1 came to her office to check his resident trust fund account balance. Resident #1 informed S3BOM that he should have more money in his account than the balance he was given. Resident#1 and S3BOM reviewed the petty cash receipt book and resident #1 informed S3BOM some of the signatures in the petty cash receipt book were not signed by him. S3BOM informed resident #1 that S1Aministrator was out of the facility that day and they would review the questionable withdrawals. On 06/18/2024 at 11:45 a.m., an interview with S1Administrator revealed resident #1 met with her on 05/31/2024 with copies of resident trust fund receipts. Resident #1 claimed his signature was forged on several receipts on days he did not receive money according to his receipts. S1Administrator reported allegations of misappropriation of resident property to the state survey agency, but did not report the allegations to a law enforcement entity within 24 hours of becoming aware of the misappropriation of funds allegation. S1Administrator reported the facility notified the Attorney General's office on 06/13/2024 and the local sheriff`s department on 06/14/2024 after they completed their internal investigation.

Based on record review and interview the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 1 (#120) of 4 (#21, #63, #87 and #120) records reviewed for competent staff. The facility failed to ensure resident #120 received medications as ordered by the physician. Findings: Medication Administration General Guidelines (undated) revealed Responsibility: All Licensed Nursing Personnel/Certified Medication Technician (CMT) Procedure: 1. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. Review of the medical record for resident #120 revealed diagnoses of dementia, pain, seizures, Alzheimer's disease, schizophrenia, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was unable to be determined. Resident #120 required assistance with activities of daily living. Review of the physician's orders dated 02/09/2024 revealed an order for Trileptal 300 milligrams (mg)/5milliliters (ml) oral suspension give 5 ml via percutaneous endoscopic gastrostomy (PEG) tube three times daily. Review of the February 2024 Medication Administration Record (MAR) revealed the Trileptal 300 mg/5ml oral suspension, give 5 ml via PEG tube three times a day was not administered at 4:00 a.m. on 02/21/2024, 02/22/2024, 02/23/2024, 02/24/2024, and 02/29/2024. Review of the March 2024 MAR revealed Trileptal 300 mg/5ml oral suspension, give 5 ml via PEG tube three times a day was not administered at 4:00 a.m. on 03/01/2024, 03/02/2024 and 03/05/2024. Review of the medical record revealed no documented evidence of the reason the medication was not administered to resident #120. On 03/06/2024 at 2:50 p.m., an interview S2Director of Nursing (DON) and S1Administrator revealed the medication was not administered to resident #120 according to the physician's order. On 03/06/2024 at 3:00 p.m., an interview with S3Licensed Practical Nurse (LPN) revealed the facility had plenty of resident #120's medication and she was not sure of the reason why the medication was not given.

Based on observations, record reviews and interviews the facility failed to provide an environment free of accident hazards for 1 (#2) of 5 (#2, #4, #5, #6 and #7) residents identified at high risk for elopement. The facility failed to ensure all exit doors were secured to prevent residents at high risk for elopement from exiting the facility unsupervised. This deficient practice resulted in an Immediate Jeopardy situation on 10/22/2023 at approximately 1:15 a.m. when resident #2 (a severely cognitively impaired resident identified as an elopement risk) was found across the street in a neighbor's yard by a staff member. Resident #2 was located 50 minutes after she eloped on 10/22/2023 through an unsecured door and was returned to the facility at approximately 2:00 a.m. S1Administrator was notified of the Immediate Jeopardy on 10/30/2023 at 5:30 p.m. The Immediate Jeopardy was removed on 10/31/2023 at 2:35 p.m., as confirmed by onsite verification through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for resident #2. Findings: Review of the facility's Missing Resident/Elopements Policy dated 05/2022 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the medical record for resident #2 revealed an admitted [DATE] with diagnoses including diabetes mellitus, atrioventricular block, and cognitive communication deficit, abnormality of gait, delirium, major depressive disorder, pain, cardiac pacemaker, dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #2 had severe cognition for daily decision making and required extensive assistance with one person assist for bed mobility and supervision with one person assist for transfers. The resident used a wander/elopement alarm daily. During all days of the survey on 10/30/2023 to 11/02/2023 resident #2 was observed ambulating independently in the hallways. Review of the care plan dated 10/14/2020 revealed resident #2 was at risk for elopement related to wandering. The approaches for resident #2 included: having a Wanderguard in place (on her left ankle) and the staff will check placement of the Wanderguard every shift, monitoring the whereabouts of the resident every hour, and checking the Wanderguard batteries every Wednesday. On 10/30/2203 at 1:00 p.m. interview with S3Licensed Practical Nurse (LPN) revealed on 10/22/2023 at 12:45 a.m. resident #2 came to the nurses' station and informed S3LPN that she had to get out of here. Further interview with S3LPN revealed she redirected resident #2 to her room, gave her a snack and walked with her to the nurse assigned to care for her and the resident sat on the sofa in the lobby. Review of the Risk of Elopement Evaluation dated 08/14/2023 revealed resident #2 had confusion, ambulated independently and wore a monitoring bracelet. Further review of the Risk of Elopement Evaluation revealed resident #2 was identified at high risk for elopement. Review of the facility's investigation report dated 10/22/2023 revealed it was discovered at approximately 1:15 a.m. that resident #2 was not in the facility. Staff immediately began to look for the resident. It was identified that resident #2 exited the facility through an unlocked door leading to the outside in room (d). She was located at approximately 2:00 a.m. in the yard of the house across the street from the facility. She was placed on 1:1 supervision until an alarm could be placed on all exit doors in the facility. On 10/30/2023 at 10:30 a.m. interview with S1Administrator revealed the resident that resided in room d sometimes kept the chain on the door unlatched because he would sit outside on pretty days. Review of the Incident/Accident Report dated 10/22/2023 at 1:20 a.m. revealed resident #2 wandered from the grounds. Resident #2 left the facility via another resident's room (room d) that had a door leading to the outside. Further review of the Incident/Accident Report revealed the immediate action taken revealed all rooms that have a door leading to the outside (not the courtyard area) have alarms installed to indicate any potential for wandering from facility. During the survey review of the medical record revealed the 1:1 monitoring was discontinued on 10/25/2023 and the facility started monitoring the resident every hour as ordered before the elopement on 10/22/2023. On 10/30/2023 at 10:00 a.m. observations of resident rooms' e, f, g, and h revealed the rooms had a door that led to an enclosed outside courtyard. Further observations of the door revealed the doors had a safety chain at the top of the door and a doorknob that could be locked; however, the door could be opened by the residents by unfastening the safety chair and turning the doorknob with easy access to the outside of the facility, and into an internal courtyard; that had a concrete sidewalk and a bird feeder on a metal hook. On 10/30/2023 at 10:30 a.m. an interview with S1Administrator revealed prior to the resident eloping the doorknobs in rooms a, b, c, and d were like the doorknobs in rooms' e, f, g and h in which someone could open them and exit if the chain was unlatched. On 10/30/2023 at 10:10 a.m., observation of room g (room resident #2 was moved to after the 10/22/2023 elopement incident). There was a door in Resident #2's room located on the back wall, and the surveyor was able to open the door which lead to the enclosed, internal courtyard. On 10/30/2023 at 9:20 a.m. interview with S5LPN revealed resident #2 ambulated independently and wandered in the halls. On 10/30/2023 at 9:40 a.m. interview with S6Ceritified Nursing Assistant (CNA) revealed resident #2 can walk by herself and she would walk in the halls. On 10/30/2023 at 10:30 a.m. interview with S1Administrator revealed resident #2 ambulated independently and would walk in the halls. On 10/30/2023 at 12:20 p.m. interview with S7Receptionist revealed resident #2 ambulated by herself and wandered in the hallways. On 10/31/2023 at 8:50 a.m. interview with S8CNA revealed resident #2 can walk by herself and would walk in the hallways. On 10/31/2023 at 9:30 a.m. interviews with S9CNA and S10CNA revealed resident #2 was able to walk by herself and would walk in the halls. On 10/30/2023 at 1:35 p.m. interview with S4LPN revealed she was taking care of resident #2 on 10/22/2023 (the night of the incident). S4LPN revealed resident #2 was able to walk independently and walked in the hallways. S4LPN revealed resident #2 stated earlier that she had to go check on the children. S4LPN revealed she had just seen resident #2 sitting on the sofa at 1:00 a.m., after the S3LPN brought resident #2 back to the hall in which she resided. The resident fell asleep and S4LPN and a Certified Nursing Assistant went into a room to assist another resident. S4LPN revealed when she returned at approximately 1:15 a.m., to the area in which resident #2 was previously on the sofa asleep, she revealed the resident was no longer there. On 10/30/2023 at 11:00 a.m. S1Administrator revealed they did not change out the doorknobs in rooms' e, f, g, and h due to they led to an enclosed courtyard. S1Administrator confirmed she did not identify the enclosed courtyard as a potential accident hazard for residents. Further interview with S1Administrator revealed the facility did not attempt anything new for monitoring to prevent resident #2 from eloping, such as replacing the locks on the doorknobs on rooms' e, f, g, and h. S1Administrator further stated after the 1:1 monitoring was stopped on 10/25/2023 they did not increase any type of monitoring after resident #2's elopement.

Based on observations, record reviews and interviews the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#2) of 5 (#2, #4, #5, #6 and #7) residents reviewed for elopement. The facility failed to: Have an effective system in place to ensure resident #2 (whom was at high risk for elopement, and wore a wander alert bracelet) was adequately supervised to prevent resident #2 from exiting the building through an unsecured door. The Administrator failed to ensure the facility's environment was free of accident hazards and resident #2 had increased monitoring after she eloped from the facility on 10/22/2023. This deficient practice resulted in an Immediate Jeopardy situation on 10/22/2023 at approximately 1:15 a.m. when resident #2, a severely cognitively impaired resident identified as an elopement risk was found across the street in a neighbor's yard by a staff member. Resident #2 was located 50 minutes after she eloped on 10/22/2023 and was returned to the facility at approximately 2:00 a.m. The failure to provide an environment free of accident hazards and adequate supervision for resident #2 resulted in an immediate jeopardy. S1Administrator was notified of the Immediate Jeopardy on 10/30/2023 at 5:30 p.m. The Immediate Jeopardy was removed on 10/31/2023 at 2:35 p.m., as confirmed by onsite verification through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for resident #2. Findings: Cross Reference F689 Review of the facility's Missing Resident/Elopements Policy dated 05/2022 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the facility's investigation report dated 10/22/2023 that resident #2 exited the facility through an unlocked door leading to the outside in room d. Review of the Incident/Accident Report dated 10/22/2023 revealed the immediate action taken would be all rooms that have a door leading to the outside (not the courtyard area) have alarms to indicate any potential for wandering from facility. Review of the medical record for resident #2 revealed the 10/22/2023 increased monitoring was discontinued after three days. The resident was then placed back on the monitoring she was on when she eloped. On 10/30/2023 at 10:00 a.m. observations of resident rooms' e, f, g, and h revealed the rooms had a door that led to an enclosed outside courtyard. Further observations of the door revealed the doors had a safety chain at the top of the door and a doorknob that could be locked; however, the door could be opened by the residents by unfastening the safety chair and turning the doorknob with easy access to the outside of the facility. On 10/30/2023 at 11:00 a.m. S1Administrator revealed they did not change out the doorknobs in rooms' e, f, g, and h due to they led to an enclosed courtyard. S1Administrator confirmed she did not identify the enclosed courtyard as a potential accident hazard for residents. Further interview with S1Administrator revealed the facility did not attempt anything new for monitoring to prevent resident #2 from eloping, such as replacing the locks on the doorknobs on rooms' e, f, g, and h. S1Administrator further stated after the 1:1 monitoring was stopped on 10/25/2023 they did not increase any type of monitoring after resident #2's elopement.

Based on record review and interview, the facility 1) failed to assess a resident's need for increased fluids to prevent dehydration for 1 of 1 resident returning from the ER with diarrhea after ingestion of a harmful substance and 2) failed to conduct ongoing assessments for 1 of 1 resident who had a decline in condition in a total sample of 5 (Sample #1). As a result, sampled resident #1 was sent to the hospital, diagnosed with [REDACTED]. Findings: Review of the medical record for sampled resident #1 revealed a readmitted [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately impaired and dependent on staff for all ADLs. The RAPs dated [DATE] triggered the resident to be at risk for dehydration. Review of the dietary assessment dated [DATE] revealed the resident required at least 2400cc of fluids per day as his baseline fluid needs. Review of the nurses notes dated [DATE] at 9:15AM revealed the resident was constantly into things. The nurses notes dated [DATE] at 10:42AM revealed the resident wanders in and out of rooms. The nurses notes dated [DATE] at 9:21AM revealed the resident asks everyone who passes by for water. The nurses notes dated [DATE] at 5:44PM revealed the resident wanders in and out of resident rooms. The nurses notes dated [DATE] at 9:14AM revealed the resident is always asking for something to drink. Review of the nurses notes dated [DATE] at 10:40AM revealed the S1CNA brought the resident to the nurses station, stating that the resident drank some liquid soap. The notes stated that the resident was given several glasses of water and obtained a physician order [REDACTED]. Review of the Resident Incident Report dated [DATE] at 9:53AM revealed S1CNA observed that sampled resident #1 had wandered into another resident's room and was drinking liquid soap that was to be used for a bedbath. On [DATE] at 10:50AM, an interview with S1CNA confirmed she saw resident #1 sitting in the doorway of another resident's room drinking whirlpool soap ([MEDICATION NAME]) from a 4 ounce clear plastic cup. S1CNA stated she had seen the cup earlier and it was full of soap. On [DATE] at 2PM, interview with S4DON revealed that the facility sent the Material Safety Data Sheet (MSDS) for the [MEDICATION NAME] to the ER with the resident on [DATE]. Review of the MSDS revealed that ingestion of [MEDICATION NAME] may result in cramps and diarrhea. Further review revealed that if ingested, one should drink large amounts of water and contact a physician. Review of the nurses notes dated [DATE] at 11:02AM revealed the resident returned to the facility from the ER with no new orders or paperwork. There was no documented assessment of the resident at this time. There was no evidence that measures were put into place to increase fluids or monitor for dehydration at this time. Review of the CNAs documentation sheets for bowel movements revealed the resident had large loose bowel movements on [DATE], [DATE] and [DATE]. On [DATE] at 11AM, interview with S5LPN revealed that the resident had several episodes of watery diarrhea stools all day on [DATE]. Review of the CNAs meal/fluid intake documentation sheets revealed the resident consumed 960cc on [DATE], 480cc on [DATE], 1457cc on [DATE] and 957cc on [DATE]. There was no breakfast meal or fluid intake documented for [DATE]. There was no lunch meal or fluid intake documented for [DATE], [DATE] or [DATE]. Fluid intake documentation record revealed that the resident did not meet his minimum fluid needs from [DATE] to [DATE]. There was no evidence of any documentation of nurses notes or assessment of the resident's condition for three days after drinking the soap, from [DATE] at 11:02AM until [DATE] at 3:03AM, when a late entry was made for [DATE]. Review of the nurses notes for [DATE] revealed the following: - 8:15AM, blood pressure ,[DATE] - 10:50AM, blood pressure was ,[DATE]. The resident's physician was notified to send him to the ER if his blood pressure did not increase. - 11:10AM, blood pressure ,[DATE] - 11:45AM, blood pressure ,[DATE] - 4:30PM, blood pressure ,[DATE], pulse 56. Spoke with resident's son related to status of resident having diarrhea and fluids increased for hydration. - 5:00PM, in bed with CNA assisting with feeding. Resident began to have audible wheezing and gurgling in throat area. Resident coughing non productive. - 5:30PM, pulse oximetry was ,[DATE]% on room air. Oxygen applied at 2 liters per nasal cannula. Blood pressure ,[DATE] palpated, pulse 103, temperature 100.1 axillary. - 5:45PM, son at bedside requesting to transfer resident to the ER On [DATE] at 11AM, interview with S5LPN (day shift nurse) revealed that on [DATE] at 10:50AM, the resident's son came to the nurses station and reported that his father was not looking well. S5LPN stated she checked his blood pressure and called the physician because it was low. There was no documented evidence that any further assessment was performed at this time. On [DATE] at 3PM, interview with S6LPN (evening shift nurse) revealed that on [DATE] at 4:30PM, the resident's son came to the nurses station and reported to her that his father was feeling sick and weak. S6LPN stated that she obtained his vital signs and thought that he was okay at that point. There was no documented evidence that any further assessment was performed at this time. Further interview with S6LPN revealed that on [DATE] at 5PM, the CNA was feeding the resident and reported that he was having trouble swallowing. She stated that she removed some food from his mouth and got him to drink some water. She further stated that then the resident began to start having audible wheezing and gurgling. S6LPN confirmed that no further assessment was performed and the resident's physician was not notified of the decline in condition. Further interview with S6LPN on [DATE] at 3PM revealed that on [DATE] at 5:30PM, she placed the resident on oxygen. She further stated that the automatic blood pressure machine would not register the resident's blood pressure, so she palpated the resident's blood pressure to be ,[DATE]. There was no documented assessment of lung sounds, level of consciousness or communication with the physician regarding the resident's further decline in condition. Further interview with S6LPN revealed that on [DATE] at 5:45PM, the resident's son requested for him to be sent to the ER. There was no documented assessment of the resident's condition at this time. Review of the nurses notes dated [DATE] revealed that the resident was transferred to the ER per ambulance at 6:15PM. Review of the notes from the ambulance service dated [DATE] revealed the resident was found in bed with his head leaned forward and to the right side. The resident was responsive to sternal rub only. Review of the ER notes dated [DATE] at 6:17PM revealed the resident had a temperature of 102.2, was unresponsive with only a grunt to sternal rub. The resident had diminished breath sounds throughout and would quit breathing at times. The resident's lab work revealed BUN, 39 (Normal ,[DATE]), Creatinine, 1.9 (Normal 0XXX,[DATE].7), Potassium 3.3 (Normal 3XXX,[DATE].1), all indicating dehydration. The ER physician diagnosed the resident with intravascular volume depletion and fever and admitted him to the hospital. Review of the resident's hospital records revealed the resident expired on [DATE] at 5:55AM. On [DATE] at 2PM, interview with S4DON confirmed that there was no documented evidence that measures were put into place to prevent dehydration after the resident returned from theER on [DATE] with diarrhea. S4DON further confirmed that there was no documented evidence that the facility conducted ongoing assessments of the resident's decline in condition on [DATE].

Based on observation, record review and interview, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 of 5 sampled residents who were cognitively impaired and mobile throughout the facility. The facility allowed a cognitively impaired resident to have access to a harmful substance. As a result, resident #1 experienced actual harm when he developed diarrhea, dehydration and subsequent death. After this incident, the facility continued to have chemicals accessible to residents who were cognitively impaired. Findings: Review of the medical record for sampled resident #1 revealed a readmitted [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately impaired and dependent on staff for all ADLs. The RAPs dated [DATE] triggered the resident to be at risk for dehydration. Review of the nurses notes dated [DATE] at 9:15AM revealed the resident was constantly into things. The nurses notes dated [DATE] at 10:42AM revealed the resident wanders in and out of rooms. The nurses notes dated [DATE] at 9:21AM revealed the resident asks everyone who passes by for water. The nurses notes dated [DATE] at 5:44PM revealed the resident wanders in and out of resident rooms. The nurses notes dated [DATE] at 9:14AM revealed the resident is always asking for something to drink. Review of the nurses notes dated [DATE] at 10:40AM revealed the S1CNA brought the resident to the nurses station, stating that the resident drank some liquid soap. The notes stated that the resident was given several glasses of water and obtained a physician order [REDACTED]. Review of the Resident Incident Report dated [DATE] at 9:53AM revealed S1CNA observed that sampled resident #1 had wandered into another resident's room and was drinking liquid soap that was to be used for a bedbath. On [DATE] at 10:50AM, an interview with S1CNA confirmed she saw resident #1 sitting in the doorway of another resident's room drinking whirlpool soap (Aloe Vesta) from a 4 ounce clear plastic cup. S1CNA stated she had seen the cup earlier and it was full of soap. On [DATE] at 2PM, interview with S4DON revealed that the facility sent the Material Safety Data Sheet (MSDS) for the Aloe Vesta to the ER with the resident on [DATE]. Review of the MSDS revealed that ingestion of Aloe Vesta may result in cramps and diarrhea. Further review revealed that if ingested, one should drink large amounts of water and contact a physician. Review of the nurses notes dated [DATE] at 11:02AM revealed the resident returned to the facility from the ER with no new orders or paperwork. There was no documented evidence that measures were put into place to increase fluids or monitor for dehydration at this time. Review of the CNAs documentation sheets for bowel movements revealed the resident had large loose bowel movements on [DATE], [DATE] and [DATE]. On [DATE] at 11AM, interview with S5LPN revealed that the resident had several episodes of watery diarrhea stools all day on [DATE]. Review of the CNAs meal/fluid intake documentation sheets revealed the resident consumed 960cc on [DATE], 480cc on [DATE], 1457cc on [DATE] and 957cc on [DATE]. There was no breakfast meal or fluid intake documented for [DATE]. There was no lunch meal or fluid intake documented for [DATE], [DATE] or [DATE]. Fluid intake documentation records revealed that the resident did not meet his minimum fluid needs from [DATE] to [DATE]. On [DATE] at 5:00PM, the resident began to have audible wheezing and gurgling in his throat area. On [DATE] at 5:30PM, the resident was placed on oxygen and had a blood pressure of ,[DATE], with a temperature of 100.1 degrees axillary. At 5:45PM, the resident's son requested that the resident be sent to the ER. Review of the nurses notes dated [DATE] revealed that the resident was transferred to the ER per ambulance at 6:15PM. Review of the notes from the ambulance service dated [DATE] revealed the resident was found in bed with his head leaned forward and to the right side. The resident was responsive to sternal rub only. Review of the ER notes dated [DATE] at 6:17PM revealed the resident had a temperature of 102.2, was unresponsive with only a grunt to sternal rub. The resident had diminished breath sounds throughout and would quit breathing at times. The resident's lab work revealed BUN, 39 (Normal ,[DATE]), Creatinine, 1.9 (Normal 0XXX,[DATE].7), Potassium 3.3 (Normal 3XXX,[DATE].1), all indicating dehydration. The ER physician diagnosed the resident with intravascular volume depletion and fever and admitted him to the hospital. Review of the resident's hospital records revealed the resident expired on [DATE] at 5:55AM. On [DATE], an educational in-service was conducted with staff following the ingestion of soap by resident #1. Review of the in-service record revealed the subject was noted as: No chemicals should be left unattended, this includes soap, shampoo, hygiene items. Because soap in a cup was left at bedside a resident had access to it and actually drank it. The resident had to go to the ER. This incident could cause harm to a resident, harm that could have been prevented. On [DATE] at 9:00AM, a tour of the facility revealed the activity storage room was unlocked and accessible to residents. Observation of the storage area revealed nail polish remover and AJAX soap. On [DATE] at 9:15AM, observation of the central supply room revealed S2RN walked into the room through an unlocked door. At that time the surveyor followed S2RN into the room. Observation of the room revealed multiple bottles of Tylenol, geri-tussin cough syrup, Docusate liquid, Pepto bismol, aspirin 81mg, aspirin 325mg, enteric coated aspirin 81mg, ibuprofen 200mg, magnesium oxide 400mg, Aloe Vista Body Wash 7 gallons, alcohol gel, Betadine 5 bottles, wound cleanser, razors and shaving cream. At this time, an interview with S2RN confirmed the room was not supposed to be unlocked. On [DATE] at 9:20AM, an interview with S3LPN, who is over the central supply room, revealed she thought the door only had to be closed and that it was not locked. On [DATE] at 9:30AM, observation of the soiled utility room on the 200 hall revealed it was unlocked with a mop bucket with old mop water in it and a spray bottle of comet cleaner with bleach hanging on the bucket. On [DATE] at 9:40AM, observation of the whirlpool room on the 200 hall revealed the door was unlocked with a gallon of Aloe Vesta body wash and shampoo open and accessible to residents. On [DATE] at 9:10AM, observation of the medication cart on the 200 hall revealed liquid medication in a medicine cup was sitting unattended on the top of the cart. On [DATE] at 10:45AM, another observation of the 200 hall whirlpool revealed Aloe Vesta body wash and shampoo sitting open on the side of the tub with the door open. On [DATE] at 10:45AM, observation of the 200 hall housekeeping room revealed a comet bleach spray bottle hanging on the sink. On [DATE] at 10:55AM, observation of the 100 hall whirlpool room revealed the door was open and there was a bottle of mineral oil and a bottle of whirlpool disinfectant cleaner on the table close to the door. On [DATE] at 2:00PM, another observation of the 100 hall whirlpool room revealed disinfectant, mineral oil, alcohol gel and deodorant were in an unlocked cabinet. On [DATE] at 2:00PM, an observation of the 200 hall whirlpool room revealed an open 4 liter bottle of Aloe Vesta body was/shampoo was sitting on top of the whirlpool tub, and an opened, ,[DATE] full 4 liter bottle of Aloe Vesta conditioner was sitting on a low shelf beside the whirlpool. All the above areas were unlocked and unattended, available and accessible to all residents who were independently mobile by ambulation or wheelchair. On [DATE] at 2:00PM, an interview with S4DON confirmed that staff was instructed during the [DATE] inservice that all chemicals should be locked and unaccessible to residents to prevent possible harm to other residents.

Based on record review and interview, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health. The facility 1) failed to assess a resident's need for increased fluids to prevent dehydration for 1 of 1 resident returning from the ER with diarrhea after ingestion of a harmful substance and 2) failed to implement measures to increase fluid intake after 1 of 1 resident developed diarrhea in a total sample of 5 (Sample #1). As a result, sampled resident #1 was sent to the hospital, diagnosed with [REDACTED]. Findings: Review of the medical record for sampled resident #1 revealed a readmitted [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately impaired and dependent on staff for all ADLs. The RAPs dated [DATE] triggered the resident to be at risk for dehydration. Review of the resident's care plan revealed dehydration was not addressed. Review of the dietary assessment dated [DATE] revealed the resident required at least 2400cc of fluids per day as his baseline fluid needs. Review of the nurses notes dated [DATE] at 9:15AM revealed the resident was constantly into things. The nurses notes dated [DATE] at 10:42AM revealed the resident wanders in and out of rooms. The nurses notes dated [DATE] at 9:21AM revealed the resident asks everyone who passes by for water. The nurses notes dated [DATE] at 5:44PM revealed the resident wanders in and out of resident rooms. The nurses notes dated [DATE] at 9:14AM revealed the resident is always asking for something to drink. Review of the nurses notes dated [DATE] at 10:40AM revealed the S1CNA brought the resident to the nurses station, stating that the resident drank some liquid soap. The notes stated that the resident was given several glasses of water and obtained a physician order [REDACTED]. On [DATE] at 2PM, interview with S4DON revealed that the facility sent the Material Safety Data Sheet (MSDS) for the [MEDICATION NAME] to the ER with the resident on [DATE]. Review of the MSDS revealed that ingestion of [MEDICATION NAME] may result in cramps and diarrhea. Further review revealed that if ingested, one should drink large amounts of water and contact a physician. Review of the nurses notes dated [DATE] at 11:02AM revealed the resident returned to the facility from the ER with no new orders or paperwork. There was no documented assessment of the resident at this time. There was no evidence that measures were put into place to increase fluids or monitor for dehydration at this time. Review of the CNAs documentation sheets for bowel movements revealed the resident had large loose bowel movements on [DATE], [DATE] and [DATE]. On [DATE] at 11AM, interview with S5LPN revealed that the resident had several episodes of watery diarrhea stools all day on [DATE]. Review of the CNAs meal/fluid intake documentation sheets revealed the resident consumed 960cc on [DATE], 480cc on [DATE], 1457cc on [DATE] and 957cc on [DATE]. There was no breakfast meal or fluid intake documented for [DATE]. There was no lunch meal or fluid intake documented for [DATE], [DATE] or [DATE]. Fluid intake documentation records revealed that the resident did not meet his minimum fluid needs from [DATE] to [DATE]. There was no evidence of any documentation of nurses notes or assessment of the resident's hydration status for three days after drinking the soap, from [DATE] at 11:02AM until [DATE] at 3:03AM, when a late entry was made for [DATE]. There was no documented evidence in the resident's medical record that his fluid intake was meeting his baseline fluid needs, or that measures were put into place to increase fluid intake after the resident began to have diarrhea. Review of the nurses notes for [DATE] revealed the following: - 8:15AM, blood pressure ,[DATE] - 10:50AM, blood pressure was ,[DATE]. The resident's physician was notified to send him to the ER if his blood pressure did not increase. - 11:10AM, blood pressure ,[DATE] - 11:45AM, blood pressure ,[DATE] - 4:30PM, blood pressure ,[DATE], pulse 56. Spoke with resident's son related to status of resident having diarrhea and fluids increased for hydration. - 5:00PM, in bed with CNA assisting with feeding. Resident began to have audible wheezing and gurgling in throat area. Resident coughing non productive. - 5:30PM, pulse oximetry was ,[DATE]% on room air. Oxygen applied at 2 liters per nasal cannula. Blood pressure ,[DATE] palpated, pulse 103, temperature 100.1 axillary. - 5:45PM, son at bedside requesting to transfer resident to the ER On [DATE] at 11AM, interview with S5LPN (day shift nurse) revealed that on [DATE] at 10:50AM, the resident's son came to the nurses station and reported that his father was not looking well. S5LPN stated she checked his blood pressure and called the physician because it was low. On [DATE] at 3PM, interview with S6LPN (evening shift nurse) revealed that on [DATE] at 4:30PM, the resident's son came to the nurses station and reported to her that his father was feeling sick and weak. S6LPN stated that she obtained his vital signs and thought that he was okay at that point. Further interview with S6LPN revealed that on [DATE] at 5PM, the CNA was feeding the resident and reported that he was having trouble swallowing. She stated that she removed some food from his mouth and got him to drink some water. She further stated that then the resident began to start having audible wheezing and gurgling. Further interview with S6LPN on [DATE] at 3PM revealed that on [DATE] at 5:30PM, she placed the resident on oxygen. She further stated that the automatic blood pressure machine would not register the resident's blood pressure, so she palpated the resident's blood pressure to be ,[DATE]. Further interview with S6LPN revealed that on [DATE] at 5:45PM, the resident's son requested for him to be sent to the ER. Review of the nurses notes dated [DATE] revealed that the resident was transferred to the ER per ambulance at 6:15PM. Review of the notes from the ambulance service dated [DATE] revealed the resident was found in bed with his head leaned forward and to the right side. The resident was responsive to sternal rub only. Review of the ER notes dated [DATE] at 6:17PM revealed the resident had a temperature of 102.2, was unresponsive with only a grunt to sternal rub. The resident had diminished breath sounds throughout and would quit breathing at times. The resident's lab work revealed BUN, 39 (Normal ,[DATE]), Creatinine, 1.9 (Normal 0XXX,[DATE].7), Potassium 3.3 (Normal 3XXX,[DATE].1), all indicating dehydration. The ER physician diagnosed the resident with intravascular volume depletion and fever and admitted him to the hospital. Review of the resident's hospital records revealed the resident expired on [DATE] at 5:55AM. On [DATE] at 2PM, interview with S4DON confirmed that there was no documented evidence that measures were put into place to prevent dehydration or monitor the resident's hydration status after the resident returned from theER on [DATE] with diarrhea.