Every finding on record at River Oaks Nursing & Rehabilitation Center LLC

Based on interviews and record reviews, the facility failed to ensure there was an effective process in place to ensure residents were offered the updated COVID-19 vaccination for 4 (#28, #103, #105, and #113) of 5 residents reviewed for immunizations.Findings: Review of the facility's policy titled, COVID-19 Vaccine Policy and Procedures for Residents revised 07/01/2023 revealed the following, in part:Purpose:To establish the COVID-19 vaccination process in order to educate residents, offer the vaccine, and administer the vaccine to any resident who will agree to be vaccinated. By receiving the COVID-19 vaccination, the resident will potentially help reduce the risk of contracting and spreading COVID-19 to residents and facility staff.The CDC recommends everyone, including people who live and work in long-term care settings, stay up to date with COVID-19 vaccines for their age group.According to the CDC, COVID-19 vaccines are safe and effective - especially against becoming seriously ill, being hospitalized and dying -and very important for older adults. COVID-19 vaccines can help keep a person from getting seriously ill if the person does get COVID-19.Currently, vaccinated (up to date) is defined as anyone 6 years and older having received one updated (bivalent) Pfizer or Moderna Covid-19 vaccine, regardless of whether the person has received any original COVID-19 vaccines.Responsibility:Nursing facility leadership is responsible for developing, implementing and maintaining these policies and procedures related to resident vaccination.Educating and Offering Residents on the Covid-19 Vaccine:COVID-19 vaccinations will be offered to residents upon admission to the facility unless such immunization is medically contraindicated, per CDC guidance, or the individual has already been immunized.If a resident chooses not to be vaccinated at all or declines a subsequent Covid-19 vaccination, education will still be provided to the resident regarding the vaccine. Additionally, once education has been provided, the resident will sign a declination corresponding to the vaccine that is being decliner and kept on file.Currently, vaccinated (up to date) is defined as anyone 6 years and older having received one updated (bivalent) Pfizer or Moderna Covid-19 vaccine, regardless of whether the person has received any original Covid-19 vaccines.Other Considerations and Facts:The updated vaccines are called updated because they protect against both the original virus that causes COVID-19 and new strains of COVID. Resident #28Review of Resident #28's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed no documentation of consent, declination, and/or offering of the 2025-2026 COVID-19 vaccination. Resident #103Review of Resident #103's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed no documentation of consent, declination, and/or offering of the 2025-2026 COVID-19 vaccination. Resident #105Review of Resident #105's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed no documentation of consent, declination, and/or offering of the 2025-2026 COVID-19 vaccination. Resident #113Review of Resident #113's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed no documentation of consent, declination, and/or offering of the 2025-2026 COVID-19 vaccination. An interview was conducted with S4IP on 07/07/2026 at 11:04 a.m. She confirmed the facility had not offered the 2025-2026 COVID-19 vaccinations. She stated the facility's process for offering COVID-19 vaccinations was to complete an informed consent/declination for each resident when the vaccinations became available. An interview was conducted with the Pharmacist in Charge at the facility's contracted Pharmacy on 07/07/2026 at 11:07 a.m. He stated the COVID-19 vaccination season for 2025-2026 started in September 2025. He stated the COVID-19 vaccinations should have been offered to the facility's residents beginning in September 2025. He stated the facility had not requested any 2025-2026 COVID-19 vaccinations. An interview was conducted with S2DON on 07/07/2026 at 3:30 p.m. She reviewed Residents' #28, #103, #105, and #113's Clinical Records and confirmed there was no 2025-2026 COVID-19 informed consent, declination, and/or documentation of offering of the vaccination. She confirmed there was no documentation the facility offered COVID-19 vaccinations to the residents for 2025-2026. An interview was conducted with S2DON and S3CN on 07/07/2026 at 4:20 p.m. S2DON and S3CN both confirmed the 2025-2026 COVID-19 vaccinations should have been offered to the facility's residents and had not been. S2DON and S3CN stated the facility did not have an effective process in place to ensure the residents were offered the up to date COVID-19 vaccinations.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) Assessments were completed timely and accurately for 2 (#10 and #106) of 30 sampled residents. The facility failed to ensure: 1.)Resident #10 Death MDS Assessment was completed in the required timeframe; and2.)Resident #106 was coded correctly for weight loss. Findings: Review of the facility's undated policy, titled Resident Assessment Instrument (RAI) Policy revealed the following, in part: Policy: It is the policy of the facility to conduct and document, initially and periodically, a comprehensive, accurate assessment on all residents. Comprehensive assessments will accurately describe each resident's functional capacity using a standardized, reproducible, state approved form, referred to as the Minimum Data Set (MDS) or (RAI) Resident Assessment Instrument. The assessment will be completed by following the specific directions found in the RAI manual. Assessment Accuracy: Other individuals who complete a portion of the assessment will sign and certify the accuracy of that portion of the assessment. All participating health professionals will review the assessment data after encoding for electronic submission to ensure accuracy. Review of the RAI Manual Chapter 2, Section 2.6, dated [DATE] and titled Required OBRA Assessments for the MDS revealed the following, in part: Death in Facility Tracking Record: Must be completed when the resident dies in the facility. Must be completed within 7 days after the resident's death. 1. Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] and expired in the facility on [DATE]. Review of Resident #10's MDS assessments as of [DATE] revealed his Death MDS with Assessment Reference Date (ARD) of [DATE] was incomplete. The Death MDS had a complete by date of [DATE], and was 6 days overdue. An interview was conducted with S6MDS on [DATE] at 11:35 a.m. S6MDS confirmed Resident #10 expired in the facility on [DATE]. She reviewed Resident #10's assessments and confirmed his Death MDS with an ARD of [DATE] was not completed within 7 days after his death and should have been. 2. Review of Resident #106's Clinical Record revealed he was admitted to the facility on [DATE]. Resident #106 had a diagnosis of Abnormal Weight Loss. Review of Resident #106's documented weights revealed the following: [DATE] 173.2lbs [DATE] 141.2lbs Review of Resident #106's Quarterly MDS with ARD of [DATE] revealed Section K0300- weight loss of 5% or more in the last month or 10% or more in the last 6 months, was coded no or unknown. An interview was conducted with S5RD on [DATE] at 11:05 a.m. She confirmed on [DATE] Resident #106 triggered for a 10% or more weight loss in the last 6 months. An interview was conducted with S6MDS on [DATE] at 12:02 p.m. She confirmed Resident #106 had a diagnosis of Abnormal Weight Loss. She reviewed Resident #106's weights for the last 6 months and confirmed he had a 10% or more weight loss in the last 6 months. She reviewed Resident#106's Quarterly MDS with ARD of [DATE] and confirmed Section K0300 – weight loss of10% or more within the last 6 months was coded no. She stated it was coded incorrectly and should have been coded yes. An interview was conducted with S2DON on [DATE] at 12:32 p.m. S2DON confirmed she expected staff to accurately code all MDS assessments and complete them within the required timeframes.

Based on observations, interviews and record review the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff followed proper hand hygiene protocols for 2 (#13 and #69) of 3 residents observed during incontinence and perineal care.Findings: A review of the facilities undated policy titled Incontinent Care: Bladder revealed: Procedure: 8. Put on disposable gloves.10a-10e. [steps to perform incontinence care] 11. Remove and discard gloves.12. Perform handwashing or use alcohol gel. Resident #69A review of Resident #69's clinical record revealed he was admitted to the facility on [DATE]. On 07/08/2026 at 10:57 a.m., an observation was made of S8CNA performing perineal care on Resident #69. S8CNA performed hand hygiene and donned clean gloves. S8CNA removed the dirty brief and put it in the trash. She removed soiled gloves and put on clean gloves without performing hand hygiene. She used wipes to clean his perineal area and disposed of them in the trash can. She removed soiled gloves and donned clean gloves without performing hand hygiene. She dried his perineal area with a towel, wiped his buttocks with cleaning wipes and disposed of the dirty wipes in the trash can. She removed her dirty gloves and donned clean gloves without performing hand hygiene. She dried Resident #69's buttocks with a towel, applied a clean brief and secured it to the resident. She removed dirty gloves and performed hand hygiene. On 07/08/2026 at 11:20 a.m., an interview was conducted with S8CNA. She confirmed she did not perform hand hygiene between glove changes and when going from clean to dirty surfaces while performing perineal care and should have. Resident #13A review of Resident #13's Clinical Record revealed he was admitted to the facility on [DATE]. On 07/08/2026 at 11:03 a.m., an observation was made of S7CNA performing perineal care on Resident#13. She performed hand hygiene and donned clean gloves. Resident #13 stood up and removed his brief. S7CNA wiped the resident's perineal area with wipes and disposed of the wipes in the trash can. Without removing soiled gloves or performing hand hygiene, S7CNA grabbed Resident #13's clean clothes and dressed him. She disposed of her dirty gloves and performed hand hygiene prior to exiting the room. On 07/08/2026 at 11:28 a.m., an interview was conducted with S7CNA. She confirmed she did not change gloves when going from dirty to clean areas of the body or perform hand hygiene while performing perineal care for Resident #13 and should have. On 07/08/2026 at 11:35 a.m., an interview was conducted with S2DON. She stated she expected CNAs to change gloves and apply hand sanitizer when going from a contaminated body site to a clean body site while performing perineal care.

Based on observations, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 2 (#1 and #2) of 3 residents observed for incontinence care. The facility failed to ensure staff performed proper hand hygiene and glove changes during incontinence care.Findings: Review of the facility's policy titled, Incontinent Care: Bladder revealed the following, in part:Policy: Perineal management is the cleansing of the perineal area that includes the genitalia and rectal areas.Perform handwashing or use alcohol gel.8. Put on disposable gloves.10. For male perineal care: e. Turn to sidelying position and wash, rinse, and dry the anal area.11. Remove and discard gloves.12. Perform handwashing or use alcohol gel. 13. Change the gown and bed linens if needed. Resident #1Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE]. Resident #2Review of the Resident #2's clinical record revealed he was admitted to the facility on [DATE]. On 03/25/2026 at 8:41 a.m., an observation was made of S2CNA providing incontinence care for Resident #1. S2CNA donned clean gloves and used clean perineal wipes to remove bowel movement off of Resident #1's buttocks. S2CNA then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under Resident #1's buttocks. S2CNA proceeded to place the soiled brief and urine soaked bed pad at the foot of Resident #1's mattress on top of Resident #1's clean comforter. S2CNA then disposed of the soiled brief into Resident #1's trash can. S2CNA spread the clean incontinence pad on Resident #1's bed, and secured the clean brief to Resident #1. S2CNA undressed Resident #1, touched the closet door and Resident #1's clean clothes, back, back of his head, both of his hands, both of his arms and both of his legs. S2CNA touched Resident #1's wheelchair arm rests, transferred Resident #1 into the wheelchair, opened the resident's door, and wheeled Resident #1 into the hallway. S2CNA then returned to Resident #1's room, retrieved the soiled incontinence pad, and carried it down the hall to dispose of it in the soiled linen barrel. S2CNA then disposed of his gloves. S2CNA was not observed to change soiled gloves or complete hand hygiene during Resident #1's incontinent care. On 03/25/2026 at 8:58 a.m., an observation was made of S2CNA and S3CNA performing incontinence care of Resident #2. Without performing hand hygiene, S2CNA and S3CNA donned clean gloves and turned Resident #2 to his right side. S2CNA used clean perineal wipes to remove bowel movement off of Resident #2's buttocks. S2CNA disposed of the soiled brief into the trash. S2CNA then removed the soiled gloves, and without performing hand hygiene, applied clean gloves. S2CNA then touched Resident #2's bedside table, left leg, right leg, left arm, and bed sheets. S2CNA applied a clean brief to Resident #2 and a clean incontinence pad to Resident #2's bed. S2CNA proceeded to remove soiled gloves, applied clean gloves, and placed a clean gown on Resident #2. At that time, S2CNA touched Resident #2's neck, bilateral arms, and back. S2CNA was not observed to perform hand hygiene during the above observation. S3CNA unfastened Resident #2's brief and confirmed Resident #2 was still soiled with bowel movement. S3CNA wiped Resident #2's buttocks with clean perineal wipes to remove the remaining stool. S3CNA and S2CNA secured the clean brief back on Resident #2. S3CNA exited Resident #2's room to obtain the soiled linen barrel. S2CNA discarded the soiled linens and his dirty gloves, and exited Resident #2's room. S3CNA was not observed to change soiled gloves and neither CNA was observed to perform hand hygiene during Resident #2's incontinence care. On 03/25/2026 at 9:12 a.m., an interview was conducted with S2CNA. S2CNA confirmed the observations above. S2CNA confirmed he should have removed his soiled gloves, performed hand hygiene, and applied clean gloves after removing bowel movement from Resident #1 and #2 and prior to moving to a clean area. S2CNA confirmed he should not have placed the soiled brief and incontinence pad on Resident #1's clean linen. S2CNA confirmed he did not perform hand hygiene between glove changes, after removing soiled gloves, and between resident care, and should have. On 03/25/2026 at 9:15 a.m., an interview was conducted with S3CNA. S3CNA confirmed she should have performed hand hygiene and changed gloves after she wiped Resident #2 and before she put the clean diaper back on. S3CNA confirmed she did not perform hand hygiene upon removing soiled gloves and exiting Resident #2's room and should have. On 03/25/2026 at 12:35 p.m., an interview was conducted with S1DON. She confirmed staff should change their gloves when soiled and when moving from a contaminated to a clean area during resident care. She confirmed staff should sanitize their hands between glove changes and between residents. She confirmed soiled linen should not have been placed onto clean linen.

Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#2) of 6 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by Resident #1. This deficient practice resulted in actual physical harm on 10/28/2025 for Resident #2 when Resident #1 hit Resident #2 in the face with a chair. Resident #2 obtained an Acute right orbital floor and anterior orbital rim fractures with no signs of entrapment, acute fracture of the anterior and posterolateral wall of the right maxillary sinus, and a comminuted fracture of the nasal bone with recommended surgical repair. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Findings: Review of the facility's policy titled Abuse/Neglect Policy with a revised date of 04/03/2025, revealed the following, in part:Policy: It is the policy of the facility that each resident will be free from abuse.DefinitionsA. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.iii. Physical Abuse - includes hitting, slapping, pinching, and kicking. Review of the facility census revealed Resident #1 and Resident #2 shared a room beginning in April 2025. Review of Resident #1 and #2's incident reports dated 07/18/2025 through 10/27/2025 revealed no physical altercations. Resident #2Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia, Bipolar Disorder, Cognitive Communication Deficit, and Primary Bilateral Open Angle Glaucoma. Review of Resident #2's Quarterly MDS with an ARD of 02/19/2025 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #2's current Care Plan revealed the resident had a potential for verbal aggression related to Depression, Bipolar Disorder, and Schizophrenia. On 10/28/2025, Resident #2 was verbally aggressive with Resident #1 which resulted in a physical altercation. Resident #2 sustained bruising and a skin tear to right eye. Staff immediately separated the 2 residents, implemented 1:1 supervision for both residents, began neurological assessments and skin treatments for Resident #2, and placed Resident #2 in a new room. Resident #2 refused to go to the Emergency Room. An x-ray of the right facial bone was completed in the facility and revealed a sinus fracture. Resident #2 agreed to go to emergency room with much encouragement. Review of Resident #2's Hospital records with a date of service of 10/28/2025 revealed a CT of the Head without Contrast was completed with results of an Acute right orbital floor and anterior orbital rim fractures with no signs of entrapment, acute fracture of the anterior and posterolateral wall of the right maxillary sinus, and comminuted fractures of the nasal bone. Review of the Emergency Department Provider Notes dated 10/28/2025 revealed Resident #2 complained of pain to face, reported blurry vision at baseline, and no vision changes following incident. Review of the Hospital Ophthalmology Consult Note dated 10/29/2025 revealed the following in part:Assessment/Plan:1. Primary Open Angle Glaucoma-Denies pain currently; exam within normal limits in terms of trauma. No evidence of traumatic injury to anterior or posterior eye structures.2. Orbital Fracture Right Eye- no evidence of entrapment on imaging; extraocular muscles intact; Follow up with ENT/OMFS/Plastics for repair outpatient. Review of Resident #2's care plan, updated upon return from the hospital on [DATE] revealed the resident was discharged from the hospital due to refusing interventions. Resident #2 refused to cease smoking upon return to the facility when taken off droplet isolation. On 11/03/2025 an intervention was added for the resident to be seen by the Psychiatric MD on the next physician's round. Review of Resident #2's current Physician's Orders dated 10/31/2025 revealed the following, in part:Tylenol 325 mg by mouth every 4 hours as needed for pain per standing order for 7 days. Review of Resident #2's MAR revealed Tylenol 325 mg for pain had not been administered by the facility since the incident on 10/28/2025 or since his discharge from the hospital on [DATE]. Review of Resident #2's Nurses' Notes dated 10/31/2025-11/06/2025 revealed documentation Resident #2 was assessed by a nurse at least daily for pain and denied pain. Further review of Resident #2's Nurses' Notes revealed the following, in part:10/30/2025 at 1:46 p.m., a call was received from the hospital social worker who said Resident #2 refused to have scheduled surgery. S3DON and family were notified. Will continue to follow-up. 10/31/2025 at 9:09 p.m. Resident #2 returned to facility at 8:50 p.m. Resident #2 was alert x3, PERRL, with facial bruising was noted to right side eyes, cheeks and forehead. Resident #2 had 2 butterfly bandages to upper eyebrow. Resident #2 denied pain or shortness of breath. Resident #2 denied SOB. Follow up with OMFS scheduled for 11/12/2025 with tentative surgery plans for 11/13/2025. 11/01/2025 at 5:40 a.m., Resident #2 was in bed appearing to be resting with respirations even and unlabored, Vital Signs: Blood Pressure 140/91, Pulse 87, Respirations 17, Oxygen saturation was 97% with 2L nasal cannula in place, Temperature 98.2. Resident #2 was alert to verbal stimuli, Resident #2 complained of no pain or discomfort. Resident #2 was able to make needs known. 11/01/2025 at 11:08 a.m., Resident #2 observed lying in bed awake and alert. He was verbally responsive with clear, coherent speech. Resident #2 is oriented to name, place, and date. Dark bruising and hematoma noted around the right eye, related to a previous physical altercation. Discoloration appears deep purple to dark brown, consistent with healing. No new swelling, drainage, or open areas observed. Resident #2 denies pain or tenderness to the site at this time. Resident #2 has a documented diagnosis of legal blindness, which was present prior to the incident. He remains calm, cooperative, and able to communicate needs effectively during assessment. 11/04/2025 at 10:30 a.m. Resident #2 denies feelings of sadness, hopelessness, loss of appetite, agitation. Reassured Resident #2 that he is safe, and denied needing anything. Resident #2 remains on isolation at this time. Will continue to monitor. 11/04/2025 at 7:25 p.m. Resident #2 in bed listening to the television. Resident #2 remains on isolation precautions. Resident #2 in pleasant mood. Resident #2 ate 2 sandwiches for dinner along with snack and fruit from dinner tray. Resident very talkative and denies pain or discomfort. No complaints of shortness of breath. 11/05/2025 at 1:39 p.m. Resident #2 in room up in wheelchair listening to music. Remains on isolation precautions. Resident #2 denies pain at this time. Appetite has increased, Resident #2 ate all of breakfast and snacks and 75% of lunch. Medication administered as prescribed and taken without difficulty. Resident #2 in good spirits. O2 98% on room air.11/05/2025 at 8:31 p.m. Resident #2 in bed resting at this time. No complaints of pain or discomfort. Resident #2 ate all of his dinner and said he has been having a sweet tooth, eating lots of snacks. Resident #2 pleasant this shift and smiled and talked to this nurse during rounding. 11/06/2025 at 9:00 a.m. Resident #2 sitting outside on the back patio and appears to be in a good mood. Resident #2 stated, I am doing fine, and thank you for checking on me! Resident #2 denies pain/discomfort. Voices no concerns. Denies unsafe feelings at this time. Reassured resident that he is safe and discussed measures put in place by facility to maintain his and all residents' safety. Resident #2 verbalized understanding and expressed gratitude. Will continue to monitor. 11/06/2025 at 1:46 p.m. Resident #2 has no open skin noted to his face. He continues with bruising to the right side of his face. There is no swelling noted at this time or complaints of pain. Will continue to monitor. Resident #1Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Cognitive Communication Deficit, Paranoid Schizophrenia, and Vascular Dementia Review of Resident #1's MDS with an ARD of 08/19/2025 revealed Resident #1 had a BIMS of 8, which indicated moderate cognitive impairment. Review of Resident #1's current Care Plan revealed the resident had impaired cognitive function/dementia or impaired thought processes related to Dementia and Schizophrenia. On 10/28/2025, Resident #1 was in an altercation with roommate. Following the incident Resident #1 was placed on 1:1 supervision with staff until discharged to the behavioral hospital for evaluation. On 11/06/2025 at 4:18 p.m., an observation and interview was conducted with Resident #2 sitting on his bed in his room. An area of dark discoloration was noted under his right eye. No swelling or obvious deformity was observed to the facial area. No signs of distressed breathing or any other outward signs of pain noted. Resident #2 stated Resident #1 hit him in the face with a chair about a week ago after he asked Resident #1 if he had moved his shirt. He explained Resident #1 became angry and yelled, I don't have your shirt; I can't wear your clothes, and then hit him with a chair. He stated Resident #1 had never hit him before. He said staff immediately intervened, separated him from Resident #1, and examined his injury. He said he had a facial fracture and was sent to the emergency room. He denied having pain when the incident occurred. He said the only pain he currently had was occasional headaches, but that he had those prior to the fracture. He said he and Resident #1 had argued before at times, but it had never became physical. He stated he always felt safe in the facility and prior to Resident #1 hitting him the administrator had offered to move him to a new room, but he declined. He stated after the incident the facility sent Resident #1 out of here and he had not returned. Resident #2 stated he did not have any change in vision, or problems with eating and drinking following the incident. On 11/07/2025 at 10:30 a.m., an observation was made of Resident #2 in the dining room seated in his wheelchair at a table interacting with other residents. No distress noted. On 11/07/2025 at 10:40 a.m., an interview was conducted with Resident #2 in his room. He denied having any pain and confirmed staff always asked if he had pain and offered medicine, but he didn't need it. He denied feelings of depression, anxiety or emotional distress. He confirmed he had been talking to the Social Worker day to day since he got back from the hospital. He stated he was going to have surgery to fix the area around his eye and nose soon, and was glad to be off isolation and enjoying smoking his cigarettes.On 11/07/2025 at 12:22 p.m., an interview as conducted with S4LPN. She confirmed she witnessed the incident on 10/28/2025 at 1:00 p.m. between Resident #1 and Resident #2. She stated both residents were verbally arguing about a shirt when she first intervened and de-escalated the situation. She stated Resident #2 returned to his room, and Resident #1 sat in a chair outside of the room calmly. S4LPN stated about 5 minutes later, she was still in the hallway two doors away when she heard loud arguing. She saw Resident #2 in the hallway standing over Resident #1 in his personal space. S4LPN stated as she intervened, Resident #1 stood, picked up his chair and swung it once at Resident #2, hitting S4LPN in the arm, and hitting Resident #2's face. She stated she immediately called for help and the residents were separated, put on 1:1 observation, and assessed. She said there was a skin tear to the right side of Resident #2's face, and redness to his chin, but no obvious deformity or swelling. She stated Resident #2 denied any pain, and refused having his vital signs checked. S4LPN stated Resident #2's nose bled intermittently, and an x-ray was ordered after notifying the medical provider. She stated when the results showed a fracture, the provider was notified, and Resident #2 was sent to the Emergency Room. S4LPN confirmed Resident #2 has not complained of pain since his return from the hospital, continued to eat well, and had resumed smoking. S4LPN confirmed she received training on abuse and handling aggressive resident behaviors after the incident. She stated she notified S3DON immediately of the incident. On 11/07/2025 at 11:00 a.m., an interview was conducted with S7NP. She confirmed the Medical Doctor had been notified of the incident on 10/28/2025, and an x-ray was ordered after Resident #2's nose bled off and on afterward. She confirmed the x-ray revealed a sinus fracture, and Resident #2 was sent to the emergency room for further assessment. She said there had been no changes in Resident #1 or Resident #2's behaviors prior to the incident on 10/28/2025. S7NP stated Resident #2 denied pain or emotional distress since the incident. S7NP stated Resident #2 initially refused the surgery but later agreed. She stated the facility could not have anticipated or prevented this incident from occurring. On 11/07/2025 at 11:46 a.m., an interview was conducted with S12CNA. S12CNA confirmed she worked with Resident #2 regularly, but did not work on his hall the day of the incident. S12CNA stated Resident #2's behavior had been the same as before the incident and he had not verbalized any pain or fear to her since returning from the hospital. S12CNA confirmed she received training on abuse and dealing with difficult or aggressive behaviors after the incident. On 11/07/2025 at 2:07 p.m., an interview as conducted with S5CNA. S5CNA confirmed she worked on 10/28/2025 but did not witness the incident between Residents #1 and #2. She stated after the incident both residents were placed on 1:1 observation and had no further issues. She stated she had not witnessed any changes in either resident's behavior leading up to the incident and had never seen either be physically or verbally aggressive toward each other. S5CNA stated she had been trained on abuse and neglect previously and received training again a few days after the incident, and correctly verbalized types of abuse, and to report it immediately if witnessed. S5CNA stated she had not noticed any changes in Resident #2's behavior after the incident, and he had not complained of any pain to her. On 11/07/2025 at 3:01 p.m., an interview as conducted with S11CNA. He confirmed he worked on 10/28/2025 but did not witness the incident between Residents #1 and #2. He stated he heard loud talking, but staff had already responded and the residents were being separated and put on 1:1 observation, which meant in arms' length of staff at all times. He denied being aware of any changes in Residents #1 or #2's behaviors leading up to the incident. He said he did not know of any other incidents between the 2 residents. He confirmed he received abuse and neglect training annually and again after the incident on 10/28/2025. He was able to correctly identify types of abuse and vernalized he would report it immediately if he witnessed it happen. On 11/07/2025 at 3:08 p.m., an interview was conducted with S13PNP. S13PNP stated she assessed Resident #2 on 11/04/2025. She confirmed he was pleasant, expressed no concerns related to the incident, and exhibited appropriate behavior. She stated he denied pain, fear, depression, or anxiety.On 11/10/2025 at 11:45 a.m., an interview was conducted with S3DON. S3DON confirmed on 10/28/2028 Resident #1 hit Resident #2 with a chair. S3DON stated staff were present and able to immediately intervene when the incident began. S3DON said after the incident, both residents were immediately separated, assessed by nursing staff and placed on 1:1 observation until Resident #1 was discharged to the behavioral hospital, and staff implemented neuro checks for Resident #2. Resident #2 received an x-ray where results showed a nasal fracture and the resident was sent to the Emergency room. She stated staff responded timely and appropriately to the incident, and it could not have been predicted. S3DON stated Resident #2 had not complained of pain to his face since the incident or requested pain medication related to the incident. She further stated he had not displayed sadness, hopelessness, loss of appetite, or agitation. She confirmed after fracture precautions had been explained to Resident #2, he still resumed smoking on 11/07/2025, and had not complained of difficulty breathing. She confirmed after the incident she began the process of implementing a Plan of Correction which included training all staff on abuse, neglect, and dealing with aggressive resident behaviors. She stated a QAPI plan related to abuse was also implemented on abuse, and there was ongoing monitoring tools in which random cognitively impaired and cognitively intact residents had been identified by BIMS and were being monitored for abuse 3 times a week for 6 weeks and monthly thereafter. She stated cognitively impaired resident monitoring was accomplished by assessing for any indication of abuse by direct observation of resident change in behavior such as crying, withdrawn, decrease in activity participation, acting out at others; and skin audits when indicated. S3DON stated cognitive residents were also interviewed regarding any concerns of abuse, and this would be monitored 3 times a week for 6 weeks and monthly thereafter. On 11/10/2025 at 12:38 p.m., an interview was conducted with S1ADM. S1ADM said after being notified by S3DON of the incident, and viewing the incident of the facility's video footage, he could confirm Resident #1 physically abused Resident #2 on 10/28/2025 when he hit Resident #1 with a chair. S1ADM explained the video revealed Resident #2 standing in front of and over Resident #1 speaking in a loud voice, before Resident #2 hit him with the chair. He stated staff could be seen responding immediately and appropriately. He stated after the incident both residents were separated and put on 1:1 observation for safety, later sent to the appropriate outside facilities, and the appropriate agencies had been notified timely. He confirmed Resident #1 was being discharged from the facility and would not be returning. S1ADM confirmed to prevent future resident to resident physical abuse, S3DON implemented a Plan of Correction in which all staff were trained on abuse and handling aggressive resident behaviors after the incident. He stated S3DON had also implemented ongoing monitoring tools in which random cognitively impaired and cognitively intact residents had been identified and were being monitored for abuse. S1ADM stated since Resident #2 returned from the hospital, he complained of being unable to smoke while on isolation for the flu, but had resumed smoking since his room isolation had ended. S1ADM stated Resident #2 denied pain on every occasion he asked, and was only concerned about smoking. S1ADM further stated Resident #2 has not displayed or voiced fear, emotional distress, or depression since returning to the facility. On 11/06/2025 at 10:20 a.m., S3DON provided documentation the facility initiated an effective Plan of Correction on 10/28/2025, which included: On 10/28/2025 at 1:00 p.m., an altercation occurred between Resident #2 (BIMS 15) and Resident #1(BIMS 8).S4LPN was on the hall when she heard both residents arguing with each other and immediately de-escalated the situation. S4LPN witnessed Resident #1 holding the chair he had been sitting in over his head and attempting to swing it at [Resident #2], his roommate. S4LPN immediately intervened by reaching over to grab the chair from the Resident #1's hand, but Resident #1 continued to swing the chair, which resulted in the leg of the chair hitting S4LPN's arm and Resident #2's face. Both residents were immediately separated and put on 1:1 supervision. S3DON/S9ADON notified S10WCN, and S4LPN assessed Resident #2 with facial injuries noted. Treatment to skin tear underneath right eye provided by S10WCN. Order for facial x-ray received. Resident #1 refused to be assessed. Resident #2 remained a 1:1 and moved to a different room. Resident #1 remained on 1:1 supervision until transportation arrived to transport to a local behavioral hospital at approximately 7:50 p.m. 1:1 Supervision consists of one staff member assigned to supervise a single resident indicating a staff member to remain within close proximity of the resident being supervised. 1:1 supervision is indicated for a resident who poses a specific threat to another resident. On 10/28/2025 S3DON and S9ADON initiated an in service with all staff and reviewed the following areas:1. Abuse/Neglect, Reporting Abuse/Neglect to Immediate Supervisor, Administrator, Director of Nursing, Charge Nurse, Weekend RN, Floor Nurse.2. How to respond to an aggressive resident per policy/procedure.A resident list as completed for resident's BIMS scores for identification of other residents at risk. Resident with a BIMS of 10 or less were identified as Cognitive Impairment/Communication Impairment. A QAPI monitor was developed to assess random residents who reside on the [Memory Care] unit and are Cognitively Impaired, for any indication of abuse by direct observation of resident change in behavior (crying, withdrawn, decrease in activity participation, acting out at others). The QA Monitor will be completed for 3 random residents that are cognitively impaired 3 times a week for 6 weeks and monthly thereafter. A resident list for residents that are cognitively intact with a BIMS of 13 or greater as completed by S3DON. An additional QA Monitor as developed for reporting of alleged violations. The QA Monitor will be completed 3 times a week for 6 weeks and monthly thereafter. We need to add a review of the training log (you can put it down here) to say we looked at the logs and the monitoring. On 10/28/2025 S10WCN and S9ADON in-serviced nursing staff regarding CNA assignments in designated locations for both secure unites. The assignment of designated locations is to ensure staff are visible and ensure any resident care concerns are identified. The in-services were on-going. The PRN staff and new hires will be in-serviced prior to working. The likelihood for resident to resident altercation with injury to any resident no longer existed as of 10/28/2025. Monitors ongoing. Throughout the survey from 11/06/2025 to 11/12/2025, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure and were given questionnaires testing their knowledge. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#7 and #9) of 4 (#5, #7, #9, and #19) sampled residents reviewed for PASRR Level II.Resident #7 Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Undifferentiated Schizophrenia on 01/09/2023. Review of Resident #7’s Form 142 dated 09/22/2014 revealed he did not meet the criteria for PASRR Level II services. On 07/16/2025 at 10:58 a.m., an interview was conducted with S3SSD. She stated she was responsible for submitting Resident Review Forms to OBH. She reviewed Resident #7’s Form 142 dated 09/22/2014 and confirmed it was the most recent on file. She then reviewed Resident #7’s diagnoses, which included Undifferentiated Schizophrenia with an onset date of 01/09/2023. S3SSD confirmed a Resident Review Form should have been resubmitted and was not. Resident #9Review of the Clinical Record revealed Resident #9 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Post-Traumatic Stress Disorder (PTSD) and Delusional Disorder upon admission. On 07/17/2025 at 10:10 a.m., an interview was conducted with S3SSD. She stated Resident #9 admitted to the facility on [DATE] with diagnoses of PTSD and Delusional Disorder with a Level I dated 4/8/2025. She stated upon review of the OBH PASSR Level II Request for Resident Review indicated Delusional Disorder was a Tier 2 diagnosis. She confirmed Resident #9 diagnosis of Delusional Disorder should have been captured on the Level I screening form and was not.

Based on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by failing to:1. Ensure opened foods were sealed properly; and2. Ensured expired food items were disposed.This deficient practice had the potential to affect all 130 residents served from the kitchen. Findings: Review of the undated facility policy titled Food Safety and Sanitation Policy and Procedure revealed the following, in part:Food Storage1. Food that is stored is protected from contamination and growth of any pathogenic organisms.10. Foods with expiration dates are used prior to the use by date on the package Review of the provider's policy dated 2021 and titled Food Storage Safety revealed the following, in part:Food storage from top to bottom when items are stored in the same refrigerator or freezer - Cooked foods are stored over Raw Poultry. On 07/14/2025 at 10:30 a.m., an initial tour of the kitchen was conducted with S4DM. The following observations were made and confirmed: Freezer a 1 case of uncooked fritter style chicken breasts and 1 plastic bag of raw chicken tenderloins were stored over 1 case of Boston cream pies and 1 case of Philadelphia cheese cakes Refrigerator a 1 1/2 gallon of 100% lactulose free 2% reduced fat milk with an expiration date of 07/08/2025. Refrigerator b1 open and unsealed plastic bag of cheese slices1 open and unsealed plastic bag of ham1 open and unsealed plastic bag of bacon On 07/14/2025 at 10:30 a.m., an interview was conducted with S4DM. S4DM confirmed Boston cream pies and Philadelphia cheese cakes should not be stored under raw chicken. S4DM confirmed expired milk should be discarded. S4DM confirmed items stored in the refrigerator should be sealed. On 07/17/2025 at 10:31 a.m., an interview was conducted with S1ADM. S1ADM confirmed items in the kitchen should be stored in a clean, safe way.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse by another resident for 2 (#22 and #101) of 3 (#9, #22, and #101) residents reviewed for abuse. Findings: Review of the facility's manual with a revision date of 04/03/2025 and titled Abuse-Neglect Prevention Manual, revealed the following, in part:iii. Physical abuse includes hitting, slapping. Resident #22Review of Resident #22's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. On 07/14/2025 at 1:26 p.m., an interview was conducted with Resident #22. Resident #22 stated he got into an altercation with Resident #101 about two weeks ago. He stated he was unable to recall the exact date. Resident #22 stated he was going to his seat in the dining room, and Resident #101 cut him off. Resident #22 stated he grabbed the back of Resident #101's wheelchair, and Resident #101 backhanded him to the side of the face. Resident #22 stated he then hit Resident #101 in the face. Resident #22 stated S7CNA separated them. Resident #22 stated Resident #101 then got up from his wheelchair, walked to him, and tried to hit him while his back was turned. Resident #22 stated he hit Resident #101 in the lower jaw, and Resident #101 went and sat back down in his chair. Review of Resident #22's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. Resident #101Review of Resident #101's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #101's Quarterly MDS with an ARD of 05/02/2025 revealed a BIMS score of 11, which indicated moderately impaired cognition. On 07/16/2025 at 8:42 a.m., an interview was conducted with Resident #101. Resident #101 stated he got into a fight with Resident #22. Resident #101 stated Resident #22 hit him first behind the head on the right side so Resident #101 stated he retaliated. Resident #101 stated the incident happened in the dining room at dinnertime and staff were around. Review of Resident #101's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. On 07/15/2025 at 1:51 p.m., an interview was conducted with S7CNA. S7CNA confirmed she witnessed a physical altercation between Residents #22 and #101 about a month ago in the dining room. S7CNA stated the trays were delivered, she turned around, and Residents #22 and #101 were punching each other. S7CNA stated she told the residents to stop and broke them up. S7CNA stated she placed Resident #101 into his wheelchair and went to get the nurse. S7CNA stated she was unable to recall the exact day the altercation occurred nor the nurse she reported to. S7CNA confirmed the residents hitting each other was physical abuse. On 07/16/2025 at 11:25 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #101 reported he had hit Resident #22 on the evening shift. S5LPN stated she was unable to recall the exact date, but it was around 06/19/2025. S5LPN confirmed Resident #101 hitting Resident #22 was an allegation of resident to resident physical abuse. On 07/16/2025 at 1:22 p.m., an interview was conducted with S2DON. S2DON denied staff reporting a physical altercation between Residents #22 and #101. S2DON confirmed residents hitting each other was physical abuse. S2DON confirmed she would expect staff to report if two residents were involved in a physical altercation. On 07/16/2025 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated staff did not report an incident between Residents #22 and #101. S1ADM confirmed residents punching or hitting each other was physical abuse. He confirmed the incident should have been reported to him immediately.

Based on record reviews and interviews, the facility failed to ensure an incident involving abuse was reported to the facility administrator and State Agency in accordance with the mandated reporting guidelines for 2 (#22 and #101) of 3 (#9, #22, and #101) residents sampled for abuse. Findings: Review of the facility's manual with a revision date of 04/03/2025 and titled Abuse-Neglect Prevention Manual revealed the following, in part:iii. Physical abuse includes hitting, slapping, pinching.5. Investigation and Protection: in the event that any evidence involving.abuse.the issue will be reported immediately to the administrator or his designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines.1. Any person who has knowledge of any act or suspected act of abuse. will notify his/her supervisor immediately.Internal Reporting a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or his designee of the facility. Findings: Review of Facility Reported Incidents from 06/14/2025 to 07/14/2025 revealed no incidents had been reported to the state agency for Residents #22 and #101. Resident #22Review of Resident #22's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. On 07/14/2025 at 1:26 p.m., an interview was conducted with Resident #22. Resident #22 stated he got into an altercation with Resident #101 about two weeks ago. He stated he was unable to recall the exact date. Resident #22 stated he was going to his seat in the dining room, and Resident #101 cut him off. Resident #22 stated he grabbed the back of Resident #101's wheelchair, and Resident #101 backhanded him to the side of the face. Resident #22 stated he then hit Resident #101 in the face. Resident #22 stated S7CNA separated them. Resident #22 stated Resident #101 then got up from his wheelchair, walked to him, and tried to hit him while his back was turned. Resident #22 stated he hit Resident #101 in the lower jaw, and Resident #101 went and sat back down in his chair. Review of Resident #22's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. Resident #101Review of Resident #101's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #101's Quarterly MDS with an ARD of 05/02/2025 revealed a BIMS score of 11, which indicated moderately impaired cognition. On 07/16/2025 at 8:42 a.m., an interview was conducted with Resident #101. Resident #101 stated he got into a fight with Resident #22. Resident #101 stated Resident #22 hit him first behind the head on the right side. Resident #101 stated he retaliated. Resident #101 stated the incident happened in the dining room at dinnertime and staff were around. Resident #101 stated he reported the incident but could not recall who he reported it to. Review of Resident #101's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. On 07/15/2025 at 1:51 p.m., an interview was conducted with S7CNA. S7CNA confirmed she witnessed a physical altercation between Residents #22 and #101 about a month ago in the dining room. S7CNA stated the trays were delivered, she turned around, and Residents #22 and #101 were punching each other. S7CNA stated she told the residents to stop and broke them up. S7CNA stated she placed Resident #101 into his wheelchair and went to get the nurse. S7CNA stated she was unable to recall the exact day the altercation occurred nor the nurse she reported to. S7CNA confirmed the residents hitting each other was physical abuse. On 07/16/2025 at 11:25 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #101 reported he had hit Resident #22 on the evening shift. S5LPN stated she was unable to recall the exact date, but it was around 06/19/2025. S5LPN stated Resident #101 told her he had reported the incident to a nurse already, but did not tell her which nurse. S5LPN confirmed Resident #101 hitting Resident #22 was an allegation of resident to resident physical abuse. On 07/16/2025 at 1:22 p.m., an interview was conducted with S2DON. S2DON denied staff reporting a physical altercation between Residents #22 and #101. S2DON confirmed residents hitting each other was physical abuse. S2DON confirmed she would expect staff to report if two residents were involved in a physical altercation. On 07/16/2025 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated staff did not report an incident between Residents #22 and #101. S1ADM confirmed residents punching or hitting each other was physical abuse. He confirmed the incident should have been reported to him immediately.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) resident out of a total of 28 sampled residents by failing to ensure Resident #3 was accurately coded for PASRR (Pre-admission Screening and Resident Review). Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Recurrent Depressive Disorders, Bipolar Disorder, and Post-Traumatic Stress Disorder. Review of Resident #3's Form 142 titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 05/22/2024, revealed an approval for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. Review of Resident #3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2025 revealed Section A1500: Preadmission Screening and Resident Review (PASRR) was coded 0-No. Section A1510: Serious Mental Illness was blank. On 07/17/2025 at 12:25 p.m., an interview was conducted with S8MDS. S8MDS verified Resident #3's Form 142 indicated Resident #3 was approved for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. She reviewed Resident #3's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 07/17/2025 at 12:50 p.m., an interview was conducted with S2DON. S2DON reviewed and confirmed Resident #3's Form 142 indicated Resident #3 was approved for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. She reviewed Resident #3's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 (#3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 was free from physical abuse by Resident #4; and 2. Resident #6 was free from physical abuse by Resident #5. This deficient practice resulted in an actual physical harm on 02/23/2025 when Resident #4, a severely cognitively impaired resident, pushed Resident #3, a severely cognitively impaired resident, onto the floor in the hallway causing Resident #3 to sustain a left eyebrow laceration. Resident #3 was sent to the local emergency room (ER) where he received 9 sutures to his left eyebrow. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled Abuse/Neglect Policy Statement dated 09/2024 revealed the following, in part: Each resident residing in this facility has the right to be free from physical abuse. Residents must not be subjected to abuse by anyone, including but not limited to, other residents. Abuse and Neglect Reporting Definitions 1. Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 5. Physical Abuse - includes hitting, slapping, pinching, and kicking. 1. Resident #3 Review of Resident #3's clinical record revealed an admitted to the facility of 06/24/2024 with diagnoses, which included Vascular Dementia, Sequelae of Cerebral Infarction, and Bipolar Disorder. Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Review of Resident #3's current Care Plan revealed the following, in part: Risk for altered skin integrity/pressure ulcers 02/23/2025 - in altercation with another resident after wandering into that resident's room, end result laceration above left brow, new order send to ER for Evaluation; 02/23/2025 - return from ER 9 sutures to left brow, no complaint of pain noted; 02/26/2025 -redness bruising swelling noted to left eyebrow Interventions: 02/23/2025 immediate separation from other resident; Neuro checks as ordered; Send to ER as ordered; Unit change to keep both residents separated; Monitor sutures to left brow, report any changes to Medical Doctor (MD) Review of Resident #3's current Physician's Orders revealed the following, in part: 02/24/2025 Left forehead: Monitor dissolvable sutures and area for signs and sysmptoms of infection until resolved. every day shift 08/01/2024 Visual check for resident's location every 1 hour every shift Review of Resident #3's Incident Report dated 02/23/2025 revealed the following, in part: Around 10:45 a.m. S5LPN was called to the unit. Resident #3 was observed on floor with blood coming from area above his eyebrow. Resident #3 was crying and frightened. Certified Nursing Assistant (CNA) stated Resident #4 hit Resident #3 because Resident #3 wandered into Resident #4's room. Immediate Action Taken Charge nurse attempted to stop bleeding. Resident #3 was sent out to a local hospital via ambulance for evaluation and treatment. Injury Type: Laceration Injury Location: Face Review of Resident #3's Hospital records with a date of service 02/23/2025 revealed the following, in part: Laceration Repair: 02/23/2025 at 7:15 p.m. Location: Left Eyebrow Length: 3 centimeter (cm) Depth: 1 millimeter Number of Sutures: 9 Review of Resident #3's Psychiatric Nurse Practitioner noted dated 02/24/2025 revealed the following, in part: Chief complaint/nature of presenting problem: Assault from another resident. Pushed, unwitnessed fall with laceration .evaluation this morning in bed sleeping, then resident noted ambulating up and down hallways, zero distress is noted. Plan: Bipolar Affective disorder, current episode severity unspecified: No medication other than Paxil at present- Recent altercation - no behaviors now other than pulling at dressings over left eye. Resident #4 Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paranoid Schizophrenia. Review of Resident #4's Optional State Assessment (OSA) MDS with an ARD of 02/19/2025 revealed a BIMS of 1, which indicated severe cognitive impairment. Review of Resident #4's Incident Report dated 02/23/2025 revealed the following, in part: Around 10:45 a.m., S5LPN was called to the unit. Resident #4 was observed to be standing over Resident #3 with fist balled up, cursing, and telling resident, I told you, I will kill you. It appeared Resident #4 had made physical contact with Resident #3. CNA stated Resident #4 had hit Resident #3 because he wandered into his room. Review of Resident #4's current Care Plan revealed the following: Focus: The resident is physically aggressive with others. 02/23/2025-Noted with physical aggression toward another resident. New orders to send to a local emergency room (ER) for Psychiatric evaluation. 02/24/2025-admitted to a Behavioral Health Unit. Interventions: 02/23/2025- 1:1 supervision with resident until transported to behavior for Physician's Emergency Certificate (PEC); PEC to a local hospital's behavioral unit; Send to a local hospital for psychiatric evaluation; Psychiatric/Psychogeriatric consult as needed. On 03/03/2025 at 2:08 p.m., 03/03/2025 at 2:42 p.m., and 03/05/2025 at 11:05 a.m., unsuccessful attempts were made to interview Resident #3's responsible party. On 03/03/2025 at 11:01 a.m., an interview was conducted with Resident #3. Resident #3 had a scabbed laceration in his left eyebrow. Resident #3 stated he did not know what happened to his eyebrow. On 03/05/2025 at 10:20 a.m., an observation and interview was conducted with Resident #4 about the incident with Resident #3. Resident #4 became agitated, his body became tense and he was speaking in a loud voice. With exaggerated hand movements, Resident #4 began shouting, It was a little accident. I don't want to talk about it. Leave. Getting on my nerves. On 03/03/2025 at 3:00 p.m., an interview was conducted with S5LPN. S5LPN confirmed she worked on 02/23/2025 when Resident #3 and Resident #4 had the incident but did not witness it. S5LPN stated she observed Resident #3 visibly shaken, crying, and bleeding from his left eyebrow in the hallway after the incident. S5LPN stated she observed Resident #4 was standing with his fists balled up, stated he would punch or hit him, and stated, I swear to God I will kill him. S5LPN stated Resident #3 and Resident #4 were separated. S5LPN stated the charge nurse stayed with Resident #3 until he was sent to the hospital for the treatment of his behaviors. S5LPN stated Resident #4 was sent to the hospital for behaviors. S5LPN stated Resident #3 has been moved to a different hall. On 03/05/2025 at 9:34 a.m., an interview was conducted with S13CNA. S13CNA stated Resident #3 would wander the halls after his meals and staff would redirect him to his room or the dining room. S13CNA stated once Resident #3 was brought to his room, he usually stayed there. S13CNA stated she received abuse training a week ago. S13CNA was knowledgeable on the types of abuse. S13CNA defined physical abuse as fighting and touching. S13CNA stated she would report abuse to the nurse or the supervisor immediately. On 03/05/2025 at 10:17 a.m., an interview was conducted with S11CNA. S11CNA stated she did not witness the 02/23/2025 incident between Resident # and Resident #4. S11CNA stated she was in another resident's room and heard yelling and commotion down the hall. S11CNA stated she saw Resident #3 side-lying on the floor in the hall and bleeding from his eyebrow. S11CNA stated Resident #4 was standing over Resident #3 with his fist clenched, yelling for him to get out of his room. S11CNA stated Resident #3 was brought into another room and was provided nursing care until Emergency Medical Services (EMS) arrived. S11CNA stated Resident #3 required stitches. S11CNA denied any changes in Resident #3's behavior after the incident. S11CNA stated an in-service on abuse and neglect was provided after the incident. S11CNA confirmed that the incident between Resident #3 and Resident #4 was physical abuse. On 03/03/2025 at 3:17 p.m., an interview was conducted with S1ADM. S1ADM stated he reviewed the video footage of the incident between Resident #3 and Resident #4 on 02/23/2025. S1ADM stated Resident #3 went into Resident #4's room and Resident #4 pushed Resident #3 out of the room and Resident #3 fell face forward into the hallway. S1ADM stated Resident #3 fell to his knees and hit his left forehead on the floor. S1ADM stated Resident #3 and #4 were placed on 1:1 supervision until they were sent to the hospital. S1ADM stated Resident #3 was sent to the hospital for stitches and returned the same day. S1ADM stated Resident #4 was sent to a psych hospital in excess of a week. S1ADM stated Resident #3 was moved to a different locked unit due to his wandering and to prevent further problems. On 03/05/2025 at 10:32 a.m., an interview was conducted with S3ADON. S3ADON confirmed she responded to the incident with Resident #3 and Resident #4 on 02/23/2025. S3ADON stated staff were assisting Resident #3 when she arrived. S3ADON stated Resident #3's left forehead was bleeding. S3ADON confirmed Resident #3 was sent out to the hospital and received 9 sutures to the laceration. S3ADON stated Resident #4 stated Resident #3 came into his room and he wanted him out and he pushed him out. On 03/05/2025 at 12:33 p.m., an interview was conducted with S2DON. S2DON confirmed on the video footage they saw Resident #4 physically push Resident #3 out of the room on 02/23/2025. S2DON confirmed the incident between Resident #3 and Resident #4 was an incident of resident to resident physical abuse. S2DON stated after the 02/23/2025 incident with Resident #3 and #4, staff ensured both residents were safe and separated until they were sent out of the facility. S2DON stated Resident #3 was moved to a different unit. S2DON stated the facility reported the 02/23/2025 incident between Resident #3 and #4 to the State Agency, notified the police, and opened a Quality Assurance and Performance Improvement (QAPI) on resident to resident altercations. S2DON stated staff were educated on abuse and received an abuse quiz. S2DON stated cognitive residents were also interviewed regarding abuse - abuse by staff and other residents, and were encouraged to report. S2DON stated Residents with BIMS less than 10 were assessed for any concerns related to abuse and behavioral changes - depression or being withdrawn. S2DON stated she has completed monitoring randomly on 3 cognitively impaired residents 3 three times a week. S2DON stated monitoring will continue until compliance is met. 2. Resident #6 Review of Resident #6's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Dementia. Review of Resident #6's Quarterly MDS with ARD of 11/05/2024 revealed the provider assessed the resident has having a BIMS of 7, which indicated cognitive impairment. On 03/05/2025 multiple attempts were made to contact Resident #6's Responsible Party with no answer. On 03/05/2025 at 10:00 a.m., an attempt to interview Resident #6 revealed he was unable to answer any historical questions regarding the incident on 02/14/2025. Resident #5 Review of Resident # 5's Clinical Record revealed he was admitted to the facility on [DATE] with Diagnoses which included Chronic Kidney Disease and Chronic Schizoaffective Disorders. Review of Resident #5's Annual MDS with ARD of 12/04/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #5's Care Plan, updated 02/14/2025 revealed, in part: Mood State: Mood disorder related to diagnosis of Schizoaffective Disorder. 02/14/2025 - Resident's roommate reported that he was hit by this resident, aggressive with staff, PEC for behavioral hospital in house evaluation. Interventions: assess for changes in mood status, assess for effectiveness of medication therapy, monitor for side effects of psychoactive therapy, (02/14/2025) remove from room immediately, send to behavioral hospital per PEC, 02/28/2025) room change upon return to facility. Review of Resident #5's incident report, dated 2/14/2025 revealed the following, in part: at approximately 7:00 a.m. S12CNA heard a noise coming from Resident #5 and Resident #6's room. S12CNA went to the room and witnessed Resident #5 hitting Resident # 6. On 03/05/2025 three attempts were made to contact S12CNA, she was unavailable. On 03/05/2025 at 9:00 a.m., an interview was conducted with Resident #5. He stated he was sent out to the hospital on 02/14/2025 for hitting his roommate, Resident #6. On 03/05/2025 at 9:10 a.m., an interview was conducted with S4LPN. She stated on 02/14/2025 S12CNA summoned her to Resident #6's room. S4LPN stated S12CNA told her Resident #5 was hitting Resident #6. S4LPN stated they were separated and Resident #6 was brought to the nurse's station for 1:1 observation. S4LPN stated Resident #6 was examined and did not have any injury. S4LPN stated Resident #5 was placed on 1:1 observation until he was transferred to the behavioral hospital for evaluation. S4LPN stated Resident #5 hitting Resident #6 was resident to resident abuse. On 03/05/2025 at 10:15 a.m., an interview was conducted with S2DON. S2DON stated on 02/14/2025 Resident #5 and Resident #6 were involved in an altercation. She stated S12CNA witnessed Resident #5 hitting Resident #6. S2DON stated Resident #6 did not have any injuries and was placed on 1:1 observation. S2DON stated Resident #5 was placed on 1:1 observation until admitted to the psychiatric hospital for evaluation and treatment. She confirmed Resident #5 was moved to another room upon return to the facility. S2DON confirmed on 02/14/2025 In-Service Training was conducted with all staff by S1ADM on Abuse and Neglect and Redirection of Residents with Aggressive Behaviors. S2DON confirmed Resident #5 hitting Resident #6 was abuse. On 03/05/2025 at 3:10 p.m., an interview was conducted with S1ADM. He confirmed the incident on 02/23/2025 between Residents #3 and #4 was an incident of resident to resident abuse. He confirmed the incident on 02/14/2025 between Residents #5 and #6 were incidents of resident to resident abuse. The facility had implemented the following corrective actions to correct the deficient practice: Plan of Correction: Resident to Resident Altercation/Abuse Allegation On 02/14/2025 at 9:28 a.m. an altercation occurred between 2 residents. Resident #5 and Resident #6. S12CNA was making rounds on the hall when she heard Resident #5 yelling out. When she entered Resident #5's room she witnessed Resident #5 hitting Resident #6. She immediately intervened and separated the 2 residents and notified the nurse. Resident #5 was placed on 1:1 supervision. The NP (Nurse Practitioner) assessed Resident #6 and no injuries were found. Resident #5 remained on 1:1 supervision until the ambulance arrived at approximately 4:00 p.m. On 02/14/2025, the Administrator and Director of Nursing held an in-service with the nursing staff and reviewed the following areas: 1-Abuse/Neglect, Reporting Abuse/Neglect to Immediate Supervisor, Administrator Director of Nursing, Assistant Director of Nursing, Charge Nurse, Weekend Registered Nurse, Floor Nurse. 2-Fall Incident/Accident Reporting, per facility Policy/Procedure. A resident list was completed by the Clinical Care Coordinator for residents BIMS scores. Residents with a BIMS of 10 or less were identified as Cognitive Impairment/Communication Impairment. A Quality Assurance Performance Improvement (QAPI) monitor was developed to assess random residents who are Cognitively Impaired for any indication of Abuse by direct observation of resident change in behavior (crying, withdrawn, decrease in activity participation, acting out at others). A QAPI monitor was developed by the Director of Nursing. The Quality Assurance (QA) Monitor will be completed tor 3 random residents that are cognitively impaired 3 times a week for 6 weeks and monthly thereafter. A resident list for residents that are cognitively intact with a BIMS of 13 or greater was completed by the Director of Nursing. An additional QA Monitor was developed for Reporting of Alleged Violations. The QA monitor will be completed 5 times per week for 3 weeks and randomly thereafter. The in-services were completed 02/25/2025. The PRN (As needed) staff will be in-serviced prior to working. 47732

Based on interviews and record reviews, the facility failed to ensure resident privacy and confidentiality was maintained for 1 (#1) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #R10) sampled residents. The facility failed to ensure S5A did not take and keep an unauthorized photograph of Resident #1. This deficient practice had the potential to affect all 130 residents on the current census. Findings: Review of the facility's policy titled, Resident's Rights dated 12/01/1991, revealed the following, in part: A facility must protect and promote the rights of each resident, including each of the following rights: (e) Privacy and Confidentiality Review of Resident #1's Clinical Record revealed the resident was admitted on [DATE] with diagnoses, in part: Alzheimer's Disease, Dementia, Moderate with Other Behavioral Disturbances, Aphasia, Cognitive Communication Deficit, Attention and Concentration Deficit Following Other Cerebrovascular Disease, and Recurrent Depressive Disorder. Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/03/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) of 99, which indicated the interview was incomplete, related to nonsensical responses, or no verbal or written responses to questions were provided by Resident #1. Review of Resident #1's Consent to Photograph and Activities Consent Form, dated 06/07/2024 and signed by Resident #1's Responsible Party, revealed consent was not authorized for the attending physician or other designated person (s) to take: 2. Photographs of appropriate parts of the body of the resident in order to provide supporting documentation of my medical condition. (I understand any photographs taken will be placed in and remain part of the resident's medical record.) 3. Photographs of the resident for publicity, the facility newsletter or the birthday board. 4. Photographs of the resident for the purpose of (specify): blank On 12/27/2024 at 11:59 a.m., an interview was conducted with S5A. S5A confirmed she had saved text messages on her phone and would provide them to the State Agency. On 12/27/2024 at 1:56 p.m., review of screenshots of text messages provided by S5A revealed a photograph of Resident #1 in his room. On 01/02/2025 at 2:59 p.m., an interview was conducted with S3DON and S4ADON. S3ADON and S4DON reviewed the text message/photograph and confirmed the photograph was of Resident #1 in his room. S3DON and S4DON confirmed staff should maintain resident's confidentiality and privacy at all times. S3DON and S4ADON confirmed when staff took and kept an unauthorized photograph of Resident #1, it was a violation of Resident #1's right to privacy and confidentiality. On 01/02/2025 at 3:30 p.m., an interview was conducted with S1ADM and S2RD. S1ADM and S2RD reviewed the text message/photograph and S1ADM confirmed the photograph was of Resident #1 in his room. S1ADM and S2RD confirmed staff should maintain resident's confidentiality and privacy at all times. S1ADM and S2RD confirmed staff should not take and keep unauthorized photographs of residents, as it is a violation of their right to privacy and confidentiality.

48333 Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles by failing to: 1. Ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents observed during the initial pool; and 2. Ensure Schedule III-IV medications were stored in a permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 Medication Storage Room reviewed. Findings: Review of the facility's undated Policy titled, Medication Storage in the Facility revealed the following: Policy Statement: Medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Procedure: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications . 1. Resident #33 Review of Resident #33's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Glaucoma. Review of Quarterly MDS with ARD of 6/11/2024 that resident had a BIMS of 15 which revealed resident was cognitively intact. Review of Resident #33's August 2024 Physician Orders revealed the following, in part: Start date: 01/01/2022- Brimonidine Tartratetimolol Maleate 0.2%-0.5% eye drops. Instill 1 drop in right eye two times a day. Start date: 01/01/2022 - Latanoprost 0.005% Eye drops. Instill 1 drop in both eyes at bedtime. Review of Resident #33's August 2024 MAR revealed the following, in part: Brimonidine Tartratetimolol 0.2-0.5% was administered on 08/19/2024 at 8:00 p.m. Latanoprost 0.005% was administered on 08/19/2024 at 8:00 p.m. On 08/20/2024 at 8:52 a.m., an observation was made of two bottles of eye drops, Latanaprost 0.005% and Brimonidine 0.2-0.5%, at Resident #33's bedside. Resident #33 stated the eye drops were his and were left last night by the nurse. On 08/20/2024 at 8:59 a.m., an observation and interview was conducted with S12LPN. She confirmed eye drops, Latanaprost 0.005% and Brimonidine 0.2-0.5%, had been left at Resident #33's bedside. She stated medications, including eye drops, should not have been left at Resident #33's bedside. On 08/20/2024 at 10:35 a.m., an interview was conducted with S3ADON. She confirmed nurses should never leave medications at a resident's bedside, including eye drops. 2. On 08/19/2024 at 9:40 a.m., an observation was made of Room A with S4LPN. There was a small tan colored box, Controlled Substance Emergency Kit, present in Room A on a corner shelf. The Controlled Substance Emergency Kit was not permanently affixed. S4LPN picked the entire Controlled Substance Emergency Kit up and held it in her hands. An interview was conducted with S4LPN at that time. S4LPN confirmed the Controlled Substance Emergency Kit contained Schedule III-IV medications and was not permanently affixed. Review of the list of medications present in the Controlled Substance Emergency Kit revealed the following Schedule III - IV medications were present in the kit: 1. Alprazolam 0.25mg tablet - Quantity 8 tablets 2. Clonazepam 0.5mg tablet - Quantity 8 tablets 3. Lorazepam 0.5mg - Quantity 8 tablets 4. Tramadol HCL 50mg - Quantity 8 tablets 5. Tramadol/APAP 37.5mg/325mg tablet - Quantity 8 tablets 6. APAP/Codeine 300/30mg tablet - Quantity 8 tablets 7. APAP/Codeine 300/60mg tablet - Quantity 8 tablets On 08/19/2024 at 2:44 p.m., an interview was conducted with S2DON and S3ADON in Room A. S2DON and S3ADON both reported every floor nurse and administrative nurse had keys to Room A and had access to the Controlled Substance Emergency Kit. S2DON picked up the Controlled Substance Emergency Kit containing Schedule III-IV medications and held it in her hands. Both S2DON and S3ADON confirmed the Controlled Substance Emergency Kit box was not permanently affixed and could easily be removed from Room A. S2DON and S3ADON both confirmed the Controlled Substance Emergency Kit was not a single unit dose distribution system and contained Scheduled III-IV medications. S2DON stated she was unaware the Controlled Substance Emergency Kit should have been stored in a permanently affixed compartment. On 08/20/2024 at 10:00 a.m., an interview was conducted with S1ADM who confirmed he was unaware controlled medications should have been in a permanently affixed compartment or a single unit dose distribution system.

Based on record review and interviews, the facility failed to develop and implement an effective discharge planning process which focused on the resident's discharge goals for 1 (#71) of 1 residents reviewed for choices. The facility failed to update the discharge plan to accurately reflect the discharge wishes of the resident. Findings: Review of the facility's undated policy titled Discharge Planning revealed the following: Policy: It is the policy of this facility that discharge planning and evaluating services be provided by the Department of Social Services for each resident. Discharge planning involves the resident, the family and/or representative, interdisciplinary staff, and other resources as needed. Review of Resident #71's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #71's quarterly MDS with an ARD of 07/03/2024 revealed he had a BIMS of 12, which indicated he had moderate cognitive impairment. Review of Resident #71's facility facesheet revealed he was his own responsible party. Review of Resident #71's care plan revealed the following: Onset: 04/30/2024 Problem: Discharge plans - Resident and RP plans are for the resident to remain in the facility Intervention: Assess residents and responsible party's feelings and desires toward discharge; Support and assist resident in making own choices Review of Resident #71's care team notes dated April 2024 to August 2024 revealed the following: 04/04/2024 at 3:16 p.m. - He is understood when making request and needs known . Resident scored 12 on BIMS scale which indicates that he is moderately impaired. Resident does not care for this facility and desires to transfer to a facility closer to his home. Signed by: S7SSD 04/04/2024 at 5:03 p.m.-Resident is new to facility and lives out in general population .No plans for discharge at this time. Signed by: S12AD 05/10/2024 at 10:52 a.m. - He is understood when making request and needs known . Resident expects to transfer to other facility . Signed by: S7SSD 05/15/2024 at 12:13 p.m. - Resident is new admit to facility .No plans for discharge at this time. Signed by: S12SSD On 08/19/2024 at 9:48 a.m., an interview was conducted with Resident #71. He stated he requested to be transferred to a facility closer to his family. He stated he talked with S7SSD about this, but nothing had been done about it. On 08/20/2024 at 9:58 a.m., an interview was conducted with S4LPN. She stated Resident #71 was able to communicate and make his needs known. She stated he had voiced to her he wanted to leave the facility, but never stated or specified he wanted to be moved to another facility closer to home. On 08/20/2024 at 10:18 a.m., an interview was conducted with S13CNA. She stated Resident #71 had mentioned to her his desire to be transferred to another facility closer to his family. On 08/20/2024 at 11:10 a.m., an interview was conducted with S7SSD. She stated Resident #71 was a new resident at the facility and was admitted in March. She stated he told her he wanted to be transferred to a facility closer to where his family was located. She confirmed she had not sent any documents for approval of transfer to another facility closer to his home because he was newly admitted to this facility.

Based on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#130) of 28 residents reviewed in the final sample. Findings: Review of Resident #130's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #130's Discharge MDS, with an ARD of 07/09/2024, indicated, in part, the following; Section A: Planned/Unplanned Discharge: 1. Planned. discharge date : 07/09/2024. Discharge Status: 4. Short Term General Hospital. Assessment Reference Date: 07/09/2024. Review of Resident #130's Physician Orders revealed, in part, an order written on 07/09/2024 to discharge to a private facility. Review of Resident #130's Nurses Notes revealed, in part, a note written on 07/09/2024 at 5:50 p.m. by S8LPN indicating Resident #130's son has arrived to transport this resident to a group home . On 08/20/2024 at 4:00 p.m., an interview was conducted with S7SSD. She stated Resident #130 discharged from the facility to a group home. On 08/20/2024 at 4:20 p.m., an interview was conducted with S6RN. She confirmed she was responsible for entering MDS Assessments for the facility. She reviewed Resident #130's Discharge MDS and Nurses Notes dated 07/09/2024. She confirmed the resident was discharged to a group home, not a short term hospital and the MDS was coded incorrectly.

Based on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported immediately but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents interviewed during the initial pool and reviewed for abuse. Findings: Review of the facility's document titled Abuse/Neglect Policy Statement dated March 2016 revealed in part, the following: Definitions: Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Alleged Violation - the terminology used when a verbal allegation of resident abuse has been made either by a resident, family member, visitor, or employee . Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability . Physical Abuse - includes hitting, slapping, pinching, and kicking . Review of the facility's Policy titled Abuse/Neglect Investigation, Protection, and Reporting dated March 2016 revealed in part, the following: In the event of any evidence involving abuse .an occurrence will be immediately reported to the Administrator or designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines . Review of Resident #33's clinical record revealed the resident was admitted to the facility on [DATE]. Review of the incident reports for Resident #3 revealed no report regarding alleged verbal abuse by S17CNA. Review of Resident #33's Quarterly MDS with an ARD of 06/11/2024 revealed Resident #33 had a BIMS of 15, which indicated the resident was cognitively intact. On 08/19/2024 at 10:00 a.m., an interview was conducted with Resident #33. Resident stated S17CNA yelled and cursed at him on Saturday. Resident #33 stated he reported what S17CNA had done to S16LPN and S1ADM on the morning of 08/19/2024. On 08/19/2024 at 10:00 a.m., an interview was conducted with Resident's roommate. He stated he saw and heard S17CNA yelling and cursing at Resident #33. Resident #33. On 08/19/2024 at 10:48 a.m., an interview was conducted with S16LPN. She stated Resident #33 told her this morning S17CNA had yelled and cursed at him. She stated she immediately notified S2DON and S1ADM. On 08/20/2024 at 2:00 p.m., an interview was conducted with S2DON. She stated S16LPN notified her on the morning of 08/19/2024 Resident #33 reported S17CNA had yelled and cursed at him. She stated any allegations of staff yelling or cursing at residents would be considered abuse. On 08/20/2024 at 2:30 p.m., an interview was conducted with S1ADM. S1ADM confirmed he was informed of S17CNA yelling and cursing at Resident #33 on 08/19/2024 by S16LPN and confirmed he had not reported it to the state survey agency. S1ADM stated staff yelling or cursing at a resident was considered abuse.

Based on observations, interviews, and record review, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#43 and #120) of 28 residents reviewed in the final sample. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over and sitting on Residents #43 and #120's beds while assisting them to eat. Findings: Review of the facility's undated policy titled, Feeding A Resident revealed the following, in part: Procedure: 5. Sit in a chair to feed the resident. Resident #43 Review of Resident #43's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Senile Degeneration of Brain and Dementia. On 08/20/2024 at 7:35 a.m., an observation was made of Resident #43 in bed. S11CNA was observed feeding Resident #43 while standing next to his bed. S11CNA then sat on Resident #43's bed and continued feeding him the rest of the meal. On 08/20/2024 at 1:30 p.m., an interview was conducted with S11CNA. She confirmed the aforementioned observations. She confirmed she should sit in a chair to feed a resident. Resident #120 Review of Resident #120's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Dementia. On 08/20/2024 at 7:43 a.m., an observation was made of Resident #120 in bed. S10CNA was observed standing next to the bed and then sat on Resident #120's bed to feed the resident. On 08/20/2024 at 1:25 p.m., an interview was conducted with S9LPN. She confirmed CNA's should not stand while feeding residents or sit on the resident's bed, they should sit in a chair. On 08/20/2024 at 2:05 p.m., an interview was conducted with S10CNA. She confirmed the aforementioned observations. She confirmed she should sit in a chair to feed a resident. On 08/20/2024 at 4:50 p.m., an interview was conducted with S2DON. She confirmed CNA's should not be standing or sitting in the resident's beds while feeding a resident, they should be seated in a chair next to the resident.

Based on record review, observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff passed ice and water to 2 (#10 and #112) of 33 residents reviewed in the initial pool. Findings: Review of the facility's undated policy titled, Hydration Management revealed the following, in part: Procedure: 1. A pitcher of ice water will be available to all residents in their rooms . Efforts will be made to keep water pitchers within the resident's reach . 2. Water pitchers will be filled with ice not less than three times per 24 hours. Resident #10 Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #10's Admission MDS with ARD of 06/26/2024 revealed Resident #10 had a BIMS of 14, which indicated he was cognitively intact. Review of Resident #10's current Physician Orders revealed the following, in part: Start date: 08/01/2024- Low Concentrated Sweets/Controlled Carbohydrate Diet, Regular texture. On 08/19/2024 at 9:11 a.m., an interview was conducted with Resident #10. Two plastic pink cups were observed sitting on the air conditioning unit by his bed. Resident #10 removed the lids off both cups and they were observed empty. He stated he had no ice or water and was lucky to get his cup filled once a day. On 08/19/2024 at 2:15 p.m., an interview was conducted with Resident #10. Two plastic pink cups were observed sitting on the air conditioning unit by his bed. Resident #10 removed the lids off both cups and they were observed empty. He stated staff had not filled his cup with water and ice for 2 weeks and he would like some. On 08/20/2024 at 8:30 a.m., an observation was made of Resident #10 room. Two plastic pink cups were observed empty sitting on the air conditioning unit by Resident #10's bed. Resident #112 Review of Resident #112's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #112's Quarterly MDS with an ARD of 05/24/2024 revealed Resident #112 had a BIMS of 3, which indicated he was severely cognitively impaired. Review of Resident #112's current Physician Orders revealed the following, in part: Start date: 08/01/2024- Regular diet, Regular texture, Regular/thin consistency. On 08/19/2024 at 2:18 p.m., an interview was conducted Resident #112. No ice or water was observed on his bedside table. A pink cup was observed empty on the cabinet shelf out of the resident's reach. Resident #112 stated no ice or water were passed or offered by the CNA's. He stated he used to ask the CNA's for ice and water, but they never bring any, so he quite asking them because it was a waste of time. On 08/20/2024 at 8:30 a.m., an observation was made of Resident #112's room. A pink cup was observed empty on the cabinet shelf out of Resident #112's reach. No ice or water was observed on Resident #112's bedside table. On 08/20/2024 at 12:48 p.m., an interview was conducted S9LPN. She stated the plastic pink cups in the resident rooms should have ice and water in them. She stated the CNA's should pass ice and water to the residents every shift and as requested. On 08/20/2024 at 1:30 p.m., an interview was conducted with S11CNA. She stated the plastic pink cups in the resident rooms should be filled up with ice and water. She stated the CNA's had not passed ice and water to Resident #10 and Resident #112's room this week and should have. On 08/20/2024 at 1:50 p.m., an interview was conducted with S10CNA. She stated she was assigned to Resident #10 and Resident #112 today, 08/20/2024. She confirmed she did not pass ice or water to Resident #10 or Resident #112 during her shift and should have. She stated ice and water should be offered to residents each shift and as requested. On 08/20/2024 at 4:50 p.m., an interview was conducted with S2DON. She stated the CNA's should pass ice and water once to twice a shift and as requested by residents.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices. The facility failed to ensure Physician Orders for monitoring of behaviors and side effects for a psychotropic medication were obtained and documented for 1 (#124) of 28 residents reviewed in the final sample. Findings: Review of Resident #124's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Other Specified Depressive Episodes and Severe Vascular Dementia with Other Behavioral Disturbance. Review of Resident #124's current Physician Orders revealed the following, in part: Revision Date: 08/01/2024 Sertraline HCl Tab 100 mg give 1 tablet by mouth one time a day. Further review revealed no orders pertaining to monitoring for behaviors or side effects of psychotropic medications. Review of Resident #124's MAR dated June 2024-August 2024 revealed the following, in part: Start date: 04/24/2024 Sertraline 100 mg tablet administer 1 tablet by mouth one time a day. Further review revealed no documentation pertaining to monitoring for behaviors and side effects of psychotropic medications. On 08/20/2024 at 12:38 p.m., an interview was conducted with S9LPN. She stated she was assigned to Resident #124. She reviewed Resident #124's physician orders and MAR and verified he received the antidepressant medication Sertraline daily. She confirmed there was no physicians order or task assigned to the nurses to monitor Resident #124 for behaviors or side effects related to the antidepressant and there should have been. On 08/20/2024 at 4:30 p.m., an interview was conducted with S14LPN. She reviewed Resident #124's clinical record and confirmed he received psychotropic medications. She confirmed Resident #124 did not have orders for monitoring behaviors and side effects for psychotropic medication and should have. On 08/20/2024 at 4:40 p.m., an interview was conducted with S2DON. She reviewed Resident #124's physician orders and MAR and confirmed he was prescribed Sertraline for depression. She confirmed a physician's order was not entered or a task assigned to the nurses for the monitoring of the psychotropic medication.

Based on interviews and record reviews the facility failed to ensure a resident's right to request, refuse and/or discontinue treatment, and to formulate an advanced directive was properly reflected in the resident's record as evidenced by: 1. Failure to ensure all records regarding code status consistently reflected the residents wishes for 1 (#8) of 3 (#8, #71 and #78) residents reviewed for advanced directives in the final sample; and 2. Failure to ensure a completed advanced directive was placed on the chart for 2 (#71 and #78) of 3 (#8, #71 and #78) residents reviewed for advanced directives in the final sample. This deficient practice had the potential to affect 121 residents currently residing in the facility. Findings: A review of the facility's Advanced Directive Policy revealed, in part, the following: Purpose: To outline the mechanism whereby requests not to administer cardiac resuscitation can be brought to the attention of those who might be required to respond. Authority: Each patient/resident shall be given the opportunity to refuse treatment. If a terminally ill patient/resident is comatose, incompetent, or is physically/mentally incapable of communication, certain other individuals may make the request on his/her behalf. The following procedure shall be complied with in handling the request not to administer cardiac resuscitation. Procedure: 2. The physician shall have prescribed a plan regimen of total care for the patient/resident which shall include special exceptions to the treatment regimen. 3. If the patient/ resident has elected to appoint or designate an individual to make the request to refuse treatment, then that request must be evidenced by a witnessed document, statement or expressions, voluntarily made by the patient/ resident authorizing the withholding or withdrawal of life sustaining procedures in accordance with the requirements of Louisiana law. This declaration may be in writing, orally, or by other means of non-verbal communication. 4. The facility attorney shall have certified in a written statement that the patient/ residents declaration is valid and that the patient/resident is a qualified patient as documented by the two physicians as set forth hereinabove. 1. Resident #8 Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE]. A review of Resident #8's current Medication Administration Record (MAR) revealed DNR code status with a start date of [DATE]. A review of Resident #8's current Physician's Orders revealed an order written on [DATE] for DNR. Review of Resident #8's Louisiana Physician Orders for Scope of Treatment (LAPOST) advanced directive in the paper chart revealed, in part, the following: A. CPR/Attempt Resuscitation: Selected. Print Physician's Name: Blank. Physician Signature (Mandatory): Blank. Physician Phone Number: Blank. Date (Mandatory): Blank. PHCR Signature (Mandatory): Signature by Resident #8's responsible party. Date (Mandatory): [DATE]. An interview was conducted on [DATE] at 10:13 a.m. with Resident #8's responsible party. She stated she discussed making Resident #8 a DNR with his physician roughly a year prior but did not recall signing any paperwork to make it happen. An interview was conducted on [DATE] at 8:56 a.m. with S3LPN. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor. An interview was conducted on [DATE] at 9:14 a.m. with S12LPN. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor. An interview was conducted on [DATE] at 9:22 a.m. with S14CNA. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor. An interview was conducted on [DATE] at 9:15 a.m. with S9MR. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and confirmed it indicated full code. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status. She confirmed there was a discrepancy for Resident #8's advanced directive. She confirmed Resident #8's most up to date, completed advanced directive was not on his chart and should have been. An interview was conducted on [DATE] at 11:38 a.m. with S20LPN. She confirmed she was responsible for ensuring the accuracy and completeness of advanced directives for the residents of the facility. She confirmed Resident #8's LAPOST advanced directive did not match his electronic orders in the computer but should. An interview was conducted on [DATE] at 2:20 p.m. with S3DON. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and confirmed it indicated full code. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status. She confirmed there was a discrepancy for Resident #8's advanced directive. She confirmed all resident charts should contain the most up to date, accurate and complete advanced directive at all times and Resident #8's did not. 2. Resident #71 Review of Resident #71's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #71's LAPOST advanced directive in the paper chart revealed, in part, the following: A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected. Print Physician's Name: Blank. Physician Signature (Mandatory): Blank. Date (Mandatory): Blank. PHCR Signature (Mandatory): Signature by Resident #71's responsible party. Date (Mandatory): [DATE]. Resident #78 Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #78's LAPOST advanced directive in the paper chart revealed, in part, the following: A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected. Print Physician's Name: Blank. Physician Signature (Mandatory): Illegible loops present, not on the signature line, in purple ink. Physician Phone Number: Blank. Date (Mandatory): Blank. PHCR Signature (Mandatory): Signature by Resident #78's responsible party. Date (Mandatory): [DATE]. An interview was conducted on [DATE] at 12:55 p.m. with S18LPN. She reviewed Resident #71 and #78's LAPOST advanced directive present on their paper chart and stated she would not perform CPR in the event of an emergency. She confirmed she did not verify Resident #71 and Resident #78's LAPOST advanced directives contained all of the information required to make the forms valid. An interview was conducted on [DATE] at 3:46 p.m. with S21LPN. She reviewed Resident #71 and #78's LAPOST advanced directive present on their paper chart and stated she would not perform CPR in the event of an emergency. She confirmed she did not verify Resident #71 and Resident #78's LAPOST advanced directives contained all of the information required to make the forms valid. An interview was conducted on [DATE] at 2:20 p.m. with S3DON. She confirmed Resident #71 and Resident #78's LAPOST Advanced Directives did not contain the required information for them to be complete and valid and should have. She confirmed all resident charts should contain the most accurate, complete advanced directive at all times. An interview was conducted on [DATE] at 9:15 a.m. with S9MR. She confirmed Resident #71 and Resident #78's most up to date, accurate and complete advanced directives were not on their paper chart and should have been. An interview was conducted on [DATE] at 11:38 a.m. with S20LPN. She confirmed Resident #71's LAPOST advanced directive did not have the required physician's signature to make the form valid but should. She confirmed Resident #78's LAPOST advanced directive did not have the required date to accompany the physician's signature to make the form valid but should. She confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times. An interview was conducted on [DATE] at 12:04 p.m. with S5NP. She confirmed an LAPOST advanced directive required a physician's signature and date to be considered valid. She confirmed a resident's LAPOST advanced directive should match the electronic orders present in a resident's chart. She confirmed she was never made aware by the facility of any issues or concerns regarding incomplete or inaccurate Advanced Directives. An interview was conducted on [DATE] at 1:55 p.m. with S4MD. He confirmed he was the Medical Director for the facility. He confirmed an LAPOST advanced directive required a physician's signature and date to be considered valid. He confirmed a resident's LAPOST advanced directive should match the electronic orders present in the resident's chart. He confirmed he was never made aware by the facility of any issues or concerns regarding incomplete or inaccurate Advanced Directives. An interview was conducted on [DATE] at 2:14 p.m. with S1ADM. He confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times. An interview was conducted on [DATE] at 2:14 p.m. with S17CRN. She confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times. 46981 48872

Based on interviews and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the safety of each resident for 1 (#4) of 4 (#1, #2, #4, and #5) sampled residents reviewed for falls. Review of the Census dated 02/23/2019 revealed a facility total census of 91 residents. The facility failed to: 1. implement their policy and procedure to ensure appropriate action was taken after an accident/incidence involving Resident #4, 2. ensure the transportation driver did not move Resident #4 after a fall in the facility's transportation van prior to the resident being assessed by a nurse, 3. develop and implement a policy and procedure that addressed actions to take in an emergency while transporting residents in the facility's van and, 4. train transportation drivers on actions to take in the event a resident experienced a fall while being transported in the facility van. An Immediate Jeopardy occurred for Resident #4 on 2/15/2019 at 3:30 p.m. while being transported via wheelchair in the facility's van when the resident's wheelchair fell over backwards to the floor. The resident, who hit the back of his head on the floor resulting in a hematoma, was assisted up from the floor and walked to the front passenger seat of the van by the transportation driver. The transportation driver did not immediately notify her supervisor or any other facility staff prior to assisting the resident off of the floor. The Administrator was notified of the Immediate Jeopardy on 02/27/2019 at 2:54 p.m. The Immediate Jeopardy was removed on 02/27/2019 at 5:30 p.m. when the facility presented an acceptable plan of removal. Through interview and record review, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. 1. Plan of correction has been executed. The resident affected (#4) was examined by the nurse on 02/15/2019. Appropriate treatment was given. MD and family notified. All residents have the potential to be affected by the deficient practice. Policy and procedure addendum was added to Incident/Accident policy specific to incidents and accidents occurring offsite to include van transports. Van drivers were educated by the Administrator on the procedure for falls/incidents on the van during transport. 02/27/2019 QA monitoring will be done three times per week for two weeks, weekly for six weeks and randomly thereafter by the Transportation Supervisor or designee. Noncompliance will result in corrective or disciplinary actions up to and including termination. -02/27/2019 Root cause is staff lack of understanding of what to do in the case of an emergency on the van. 2. Policy and Procedure addendum was added to the policy and procedure specific to incidents and accidents occurring offsite to include van transports. 3. Both van drivers and Supervisor were re-educated by the administrator on 02/27/2019 on the addendum to the Incident and Accident policy and procedure. The addendum is: Should the incident occur offsite the van driver will 1-ensure you and resident are in a safe place, 2-call emergency services and 3-notify facility supervisor on duty. Objectives are to properly execute incidents and accidents that occur offsite and during van transports. Content is attached policy with addendum and acknowledgement statements signed by the van drivers and Supervisor. Oral posttests were given by the Administrator on 02/27/2019 to van drivers and the Supervisor with return understanding verbalized. 4. Administrator or designee will supervise the van drivers. Supervision will occur three times per week for two weeks, weekly for six weeks and randomly thereafter. Expected behaviors are competency in lifting, checking equipment integrity, strapping and stability of residents in wheelchairs, safe operation on roadway and an oral affirmation of incident and accident policy offsite and during van transport. Administrator or designee will evaluate the van drivers. The van drivers will be able to perform a return demonstration and verbalize understanding of the Incident and Accident policy. Evaluations will occur three times per week for two weeks, weekly for six weeks and randomly thereafter. The new process is effective and efficient and demonstrated by the QA executed on 02/27/2019. Annual training will be conducted with current employees. Newly hired transportation drivers will be oriented to the Incident and Accident Policy to include the addendum for offsite incidents. The deficit practice remains at a potential for more than minimal harm for 40 residents who used wheelchairs and could potentially be transported by the facility van. Findings: Cross reference findings at F689 Review of the facility's policy titled Accident and Incidents revealed the following in part: PURPOSE: The purpose of this policy is to ensure appropriate follow through on all accidents and incidents, as well as determine the cause of the event and to give guidance for corrective/preventative action. POLICY: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. All staff is required to report any incident to the Charge Nurse and/or Nurse Supervisor who shall promptly initiate and document investigation of the accident or incident. All accidents or incidents involving residents shall be investigated and reported to the Administrator. PR[NAME]EDURE: These procedures are offered as a resource for use by staff as they attempt to determine how best to achieve the goal of providing each resident with appropriate health care. Do not move resident until a licensed nurse evaluates their condition. Notify the Charge Nurse Review of the nurse's notes revealed the following: 02/15/2019 3:30 p.m. Fall - Initial Observation. Summoned by van driver of nursing facility that when she was bringing resident back to facility resident wheelchair fell backwards in van while she was driving and resident fall on the floor in van. Wheelchair fall backwards as the van was turning. Asked resident did he want to go to hospital resident stated no he didn't want to go to the hospital at this time that he feels fine. Resident has small hematoma noted to center of top of head. Applied cold compress to head and monitor resident vital signs, contact doctor and family and also informed of incident as well. 02/15/2019 3:46 p.m.- Nursing- This nurse was called to hallway with transportation staff, floor nurse and social services direction to assess resident. This nurse was informed that resident fell while in transport to facility. Resident stated that he bumped his head but denied any pain or discomfort. This nurse noted a hematoma to back head. Nurse Practitioner notified and verbal orders given to implement neurochecks and ice pack to hematoma. An interview conducted on 02/26/2019 at 1:36 p.m. with S1ADM. He confirmed S8TRN should have called the facility prior to moving Resident #4. He said he did not have a policy on how to handle an emergency while transporting residents in the facility's van. An interview was conducted on 02/27/2019 at 10:52 a.m. with S2DON. She said if a resident had a fall in the facility, the staff had been instructed not to move a resident until they had been assessed by a nurse. She said the resident could have a fracture and moving them would make the injury worse.

Based on record reviews and interview, the facility failed to ensure the residents remained as free of accident hazards as possible for each resident who was transported in the facility's van via wheelchair for 1 (#4) of 4 (#1, #2, #4, #5) residents reviewed for accident/falls. The facility failed to: 1. implement their policy and procedure to ensure appropriate action was taken after an accident/incidence involving Resident #4, 2. ensure the transportation driver did not move Resident #4 after a fall in the facility's transportation van prior to the resident being assessed by a nurse, 3. ensure the transportation van drivers were competent on actions to take in the event a resident experienced a fall/injury while being transported, and 4. ensure the transportation van driver immediately notified her supervisor for directions/instructions on how to proceed when Resident #4 fell over backwards in his wheelchair while riding in the transportation van. An Immediate Jeopardy occurred for Resident #4 on [DATE] at 3:30 p.m. while being transported via wheelchair in the facility's van when the resident's wheelchair fell over backwards to the floor. The resident, who hit the back of his head on the floor resulting in a hematoma, was assisted up from the floor and walked to the front passenger seat of the van by the transportation driver. The transportation driver did not immediately notify her supervisor or any other facility staff prior to assisting the resident off of the floor. The Administrator was informed of the Immediate Jeopardy on [DATE] at 2:54 p.m. The Immediate Jeopardy was removed on [DATE] at 5:30 p.m. when the facility presented an acceptable plan of removal. Through interview and record review, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. 1. Plan of correction has been executed. The resident affected (#4) was examined by the nurse on [DATE]. Appropriate treatment was given. MD and family notified. All residents have the potential to be affected by the deficient practice. Policy and procedure addendum was added to Incident/Accident policy specific to incidents and accidents occurring offsite to include van transports. Van drivers were educated by the Administrator on the procedure for falls/incidents on the van during transport. [DATE] QA monitoring will be done three times per week for two weeks, weekly for six weeks and randomly thereafter by the Transportation Supervisor or designee. Noncompliance will result in corrective or disciplinary actions up to and including termination. -[DATE] 2. Root cause is staff lack of understanding of what to do in the case of an emergency on the van. 3. Policy and Procedure addendum was added to the policy and procedure specific to incidents and accidents occurring offsite to include van transports. 4. Both van drivers and Supervisor were re-educated by the administrator on [DATE] on the addendum to the Incident and Accident policy and procedure. The addendum is: Should the incident occur offsite the van driver will 1-ensure you and resident are in a safe place, 2-call emergency services and 3-notify facility supervisor on duty. Objectives are to properly execute incidents and accidents that occur offsite and during van transports. Content is attached policy with addendum and acknowledgement statements signed by the van drivers and Supervisor. Oral posttests were given by the Administrator on [DATE] to van drivers and the Supervisor with return understanding verbalized. 5. Administrator or designee will supervise the van drivers. Supervision will occur three times per week for two weeks, weekly for six weeks and randomly thereafter. Expected behaviors are competency in lifting, checking equipment integrity, strapping and stability of residents in wheelchairs, safe operation on roadway and an oral affirmation of incident and accident policy offsite and during van transport. Administrator or designee will evaluate the van drivers. The van drivers will be able to perform a return demonstration and verbalize understanding of the Incident and Accident policy. Evaluations will occur three times per week for two weeks, weekly for six weeks and randomly thereafter. The new process is effective and efficient and demonstrated by the QA executed on [DATE]. Annual training will be conducted with current employees. Newly hired transportation drivers will be oriented to the Incident and Accident Policy to include the addendum for offsite incidents. This deficient practice continued at a potential for more than minimal harm for the 40 residents who used wheelchairs and who were transported in the facility's vans. Finding: Review of the facility's policy titled Accident and Incidents revealed the following: PURPOSE: The purpose of this policy is to ensure appropriate follow through on all accidents and incidents, as well as determine the cause of the event and to give guidance for corrective/preventative action. POLICY: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. All staff is required to report any incident to the Charge Nurse and/or Nurse Supervisor who shall promptly initiate and document investigation of the accident or incident. All accidents or incidents involving residents shall be investigated and reported to the Administrator. PR[NAME]EDURE: These procedures are offered as a resource for use by staff as they attempt to determine how best to achieve the goal of providing each resident with appropriate health care. Do not move resident until a licensed nurse evaluates their condition. Notify the Charge Nurse Review of the nurse's notes revealed the following: [DATE] 3:30 p.m. Fall - Initial Observation. Summoned by van driver of nursing facility that when she was bringing resident back to facility resident wheelchair fell backwards in van while she was driving and resident fall on the floor in van. Wheelchair fall backwards as the van was turning. Asked resident did he want to go to hospital resident stated no he didn't want to go to the hospital at this time that he feels fine. Resident has small hematoma noted to center of top of head. Applied cold compress to head and monitor resident vital signs, contact doctor and family and also informed of incident as well. [DATE] 3:46 p.m.- Nursing- This nurse was called to hallway with transportation staff, floor nurse and social services direction to assess resident. This nurse was informed that resident fell while in transport to facility. Resident stated that he bumped his head but denied any pain or discomfort. This nurse noted a hematoma to back head. Nurse Practitioner notified and verbal orders given to implement neurochecks and ice pack to hematoma. An interview was conducted on [DATE] at 2:00 p.m. with Resident #4. He said he was returning back to the facility from a local hospital in the facility's transportation van when he heard a loud jerking sound, and he fell straight back in his wheelchair hitting his head on the floor of the van. He said the transportation driver assisted him up from the floor and walked him to the passenger front seat. An interview was conducted on [DATE] at 2:46 p.m. with S7TS. She said an incident occurred on [DATE] involving Resident #4 in the facility van. She said S8TRN was transporting Resident #4 from a local hospital to the facility when Resident #4's wheelchair fell backwards hitting his head on the floor. She said S8TRN reported she picked Resident #4 off the floor of the van and assisted him to the front passenger seat. She confirmed S8TRN did not call for instructions at the time of the fall, and S8TRN notified her of the incident when she returned to the facility. S7TS said she could not confirm the wheelchair restraints were correctly secured. An interview was conducted on [DATE] at 3:00 p.m. with S8TRN. She said when transporting Resident #4 back to the facility on [DATE], the restraint loosened, and he fell backwards in his wheelchair hitting his head on the floor. She said she assisted Resident #4 off the floor of the van and assisted him to the front passenger seat. She reported she did not call the facility or notify her supervisor when the incident occurred. She said it was her fault Resident #4 fell out of his wheelchair. She said she did not properly twist and tighten the restraint on the front left side of the wheelchair. An interview was conducted on [DATE] at 12:40 p.m. with S9TRN. When asked what would he do if a resident fell out of a wheelchair to the floor during transport, he said he would stop the van, assist the resident up, and make sure the resident was ok. He said after assisting the resident off of the floor, he said he would then call the facility for further instructions. An interview conducted on [DATE] at 1:36 p.m. with S1ADM. He confirmed S8TRN should have called the facility prior to moving Resident #4. He said he did not have a policy on how to handle an emergency while transporting residents in the facility's van. An interview was conducted on [DATE] at 9:15 a.m. with S7TS. She reported S8TRN and S9TRN were not Certified Nursing Assistants or First Aid/CPR trained. An interview was conducted on [DATE] at 10:52 a.m. with S2DON. She said if a resident had a fall in the facility, the staff had been instructed not to move a resident until they had been assessed by a nurse. She said the resident could have a fracture and moving them would make the injury worse. Review of the facility's in-service dated [DATE] revealed the following: Attached instructions for use of the restraint for van straps. Each van driver will receive a copy of the instructions and will be trained on the proper procedure to use restraints. An interview was conducted on [DATE] at 11:34 a.m. with S7TS. She confirmed there was no documented evidence transportation drivers had been trained not to move a resident after a fall and to call the facility if there was an emergency. She confirmed she had not provided any further training related to falls in the transportation van since the incident on [DATE]. She also verified she was the person responsible for conducting trainings to the transportation drivers.

Based on observation, interviews and record review, the facility failed to provide necessary services to prevent a resident from developing multiple pressure ulcers in the same location for 1 (#53) of 3 (#19, #22, #53) residents reviewed for Pressure Ulcers in Stage 2 out of a total sample of 35. The facility failed to: 1) Accurately and consistently assess the resident's hands for pressure wounds daily; 2) Attempt alternative approaches to prevent the development of reoccurring Stage 2 and Stage 3 pressure ulcers to the resident's left index finger; 3) Address the resident's pain during hand movement and cleaning of the hands. This resulted in an actual harm when the resident had developed a pressure wound to the left index finger for a 3rd time and the facility failed to show documentation of different attempts made to prevent the wound from recurring. The resident exhibited nonverbal expressions of pain when the resident's hand was opened to provide wound care and PRN (as needed) pain medication was never documented as given to the resident prior to receiving any wound care treatments. Findings: Review of the clinical record for Resident #53 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/29/17 for Resident #53 revealed the resident was coded as 3 which indicated the resident was severely impaired for decision making skills. Review of the Wound Assessment documentation for Resident #53 revealed the following: -3/7/17- Onset- 3/7/17- Stage 2 Pressure Wound to first left finger- Acquired in the facility- Measurements: 2.5 x 2.3 x 0.3- No drainage, 100% granulation- Support Devices- Repositioning and positioning devices, seat cushion -3/13/17- Onset 3/7/17- Stage 2 Pressure Wound located on the first left finger- Acquired in the facility- -Measurements: 2.5 x 2.3 x 0.3-No drainage, 100% granulation- Support Devices- Repositioning and positioning devices, seat cushion -3/20/17- Onset 3/7/17- Stage 2 Pressure Wound located on the first left finger- Acquired in the facility- Measurements: 2.0 x 2.0 x 0.0 -No drainage, 100% granulation- Support Devices- Repositioning and positioning devices, seat cushion Wound resolved on 3/24/17 -5/15/17- Onset- 5/15/17- Stage 2 Pressure Wound located on the left index finger- Acquired in the facility. Measurements: 2.0 x 1.5 x 0.2- No drainage, 100% granulation- Support Devices- Repositioning and positioning devices, seat cushion, hand rolls -5/22/17- Onset- 5/15/17- Stage 2 Pressure Wound located on the left index finger- Acquired in the facility. Measurements: 2.0 x 1.5 x 0.2- No drainage, 100% granulation- Support Devices- Repositioning and positioning devices, seat cushion, hand rolls Wound resolved on 5/30/17 -6/26/17- Onset- 6/24/17- Stage 3 located on the left index finger- Acquired in the facility- Measurements: 1.5 x 1.0 x 0.4- Sanguineous drainage, 100% granulation- Support devices- hand rolls, repositioning, positioning devices Review of the current care plan for Resident #53 revealed the following: Potential for skin breakdown related to occasionally incontinent of bowel and bladder, potential for friction/shearing, slightly limited decreased mobility/activity; contractures of bilateral hands, removes hand rolls/hand splints after frequently reapplied. Interventions included 2/9/16- Ensure hand rolls off loading device were in resident's hand at all times, keep resident clean and dry, check every 2 hours, notify MD of any problems. There were no new interventions documented on the care plan for each time the wound to resident #53's left index finger re-occurred on 5/15/17 and 6/24/17. Actual skin impairment related to Stage 3 Ulcer to right palm. 12/19/16-Discontinue treatment to right palm, area resolved. 3/7/17- Stage 2 to left index finger. 3/24/17- Stage 2 left index finger resolved. 5/15/17- Stage 2 Pressure Ulcer to left index finger, cleanse both hands with soap and water everyday. 5/30/17- Stage 2 to left index finger resolved. Interventions included 6/26/17- Discontinue previous treatment order to left index finger, Stage 3 to left index finger, treatment as ordered, Report signs and symptoms of infection to doctor, treatment as ordered. Review of the TAR (Treatment Administration Record) for Resident #53 for March, May and June 2017 revealed staff was to ensure the residents hand roll/offloading device was in the left hand at all times for every shift. Further review of the TAR revealed the night shift only monitored it for one shift for all 3 months. There was also no documentation an alternate intervention had been put in place each time the wound on the residents left index finger had re-occurred. An interview was held with S3Treat on 06/27/2017 at 2:56 p.m. She stated the resident removing the hand rolls was an ongoing issue. She stated he would frequently take them out after staff would put them in place. She stated she would treat the wound to his left hand and it would come back again. An observation was made of Resident #53 on 6/28/17 at 9:45 a.m. with S3Treat and S2ADON present. Resident #53 was observed lying in bed looking around. An attempt was made to interview the resident at that time. Resident non-verbal and did not follow commands. Resident appeared comfortable. When S2ADON opened Resident #53's left hand so S3Treat could provide wound care, he began to holler and moan loudly. Once S3Treat was finished providing wound care, the resident no longer moaned and hollered. Review of the MAR (Medication Administration Record) for Resident #53 for March, April, May and June 2017 revealed no documentation Tylenol 650 mg (milligrams) ordered as needed for pain was given prior to providing wound care. An interview was held with S5CNA on 06/28/2017 at 12:42 p.m. She stated she was caring for Resident #53 today. She stated the nurse would put the hand rolls in the resident's hand. She stated he would wear them to both hand but he would often pull one of them out. She stated last week she was cleaning his hand and she noticed that he had a sore where his fingernail was digging into his hand. She stated she went to look at it and he hollered. She stated it seemed like he was in pain so she went and told the nurse. An interview was conducted with S4LPN on 06/28/2017 at 12:46 p.m. She stated the CNAs were responsible for washing the resident's hand daily and they were also responsible for making sure the hand rolls were in place. She stated she was not aware the resident currently had a wound on his index finger. She stated she was not aware of the resident refusing care. An interview was held with S3Treat on 06/28/2017 at 1:50 p.m. She stated she had been providing wound care to residents since December 2016. She stated the resident had been removing hand rolls from his hands for a long time. She stated after they had discovered the wound in March, there was no new intervention put in place to ensure the resident would not develop another wound, she stated with the second wound, they continued to try to put a hand roll in place and put the netting on it. She stated she was responsible for washing the resident's hand every day, she stated the shower aide would wash the hands on his bath days. She stated the resident would pull out the hand rolls several times a day. She stated she told staff they needed to make sure the rolls were in the resident's hands. An interview was held with S19OT on 6/29/17 at 8:50 a.m. He stated the last time he was consulted regarding Resident #53 when having a wound to his hand was when the resident developed a wound 5/15/17. He stated since the resident had a wound, he recommended a soft hand roll until the wound was resolved and then to use the come with finger straps once wound was resolved. He stated they were consulted again on 3/8/17 and he just recommended to continue to use the hand rolls. He stated he was not aware the resident currently had another wound to his hand. He stated they would usually discuss in the morning meeting when the resident had a wound. He stated he was not aware the resident developed a wound again on 6/24/17. An interview was held with S2ADON on 06/29/2017 9:57 a.m. She stated she was responsible for monitoring the wound care program. She stated the staff were to check hand roll placement for Resident #53 during each shift. She stated the resident had a wound that was discovered on 3/7/17, Stage 2. When asked what the intervention was to put in place to prevent future wounds, she stated to continue to monitor hand roll placement. She stated they discovered a wound on his left index finger again on 5/15/17. She stated they consulted with therapy and ordered a different hand splint but the resident was still frequently removing the hand splints. She explained they also added washing the hands once a shift by the wound care nurse. When S2ADON reviewed the MAR for Resident #53 she verified the night shift was not documenting they were monitoring the hand roll placement. She verified that prior to the resident developing a new wound in March, Staff was already supposed to be monitoring the hand roll placement every shift. She verified a new intervention had not been put in place for the resident's wound in March 2017 and the monitoring for hand roll placement had not been increased. When she reviewed the TAR and care plan for the resident's wounds, she verified a new intervention had not been put in place after a Stage 3 wound have be discovered again to the resident's left index finger on 6/24/17. She verified that if staff were monitoring the resident's hand rolls and skin integrity, they should not have found the resident's wound at a Stage 3.