Every finding on record at St. Agnes Healthcare and Rehab Center

Based on interviews and record reviews, the facility failed to identify and correct situations that could possibly result in actual or suspected abuse by failing to immediately report a complaint made by a resident to the Administrator or designee for 1 (#92) resident out of 30 sampled residents. Findings: Review of the facility's policy titled, Grievance, with a last revised date of 11/24/2025, read in part: Grievance or complaint is filed, if staff has received the complaint, he/she is to notify administrator or his designed as soon as possible.Prevention- identify and correct situations that could possibly result in abuse. Encourage staff to report actual or suspected abuse without fear of retribution.Identification- C) any staff person receiving a complaint of abuse, neglect, or an injury of unknown origin whether it is from the resident, a family member of staff, should listen to the complaint, writing down the date, and time complaint is being received time, and any details given. Review of Resident #92's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] and had diagnosis of incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic. Review of Resident #92's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that his cognition was intact.On 05/05/2026 at 12:56 p.m., an interview was conducted with Resident #92. He stated he began having right shoulder pain after S10CNA pulled his wrist and arm. He was unable to remember the exact date. He stated he was sitting on the edge of bed, facing the window, and asked S10CNA to assist him with getting out of bed. S10CNA grabbed his wrist area and arm and in the process of helping him to stand, she pulled his whole arm out of socket. He reported the incident to the S9LPN the following week. Review of an x-ray report dated 10/09/2025 revealed in part: - Impression: Moderate osteoarthritis glenohumeral joint.Chronic rotator cuff tear. Review of facility's grievance log from October 2025 to May 2026 did not reveal a grievance was filed for Resident #92. On 05/05/2026 at 1:50 p.m., an interview was conducted with S9LPN. She stated Resident #92 complained to her that his right shoulder and arm started hurting after S10CNA pulled his arm when helping to get him out of bed. She stated she was unsure of when it exactly happened because when he reported it to her, S10CNA was not employed at the facility. She stated that when Resident #92 reported this to her, she reported it to either S4AsstADM/MDS/IP or S6DON, but she was not completely sure. However, she was sure she reported this complaint to a superior. An x-ray was ordered for the resident, because on 10/09/2025, he complained of right shoulder pain while in therapy. On 05/05/2026 at 2:45 p.m., an interview was conducted with S7QA who was responsible for quality assurance. S7QA stated that sometime in December, the resident told her that his shoulder was injured when a CNA pulled his arm while moving him. S7QA stated that she did not further investigate to determine which CNA pulled his arm or when the incident actually occurred. On 05/06/2026 at 9:55a.m., a joint interview was conducted with S6DON, S4AsstADM/MDS/IP, S7QA, and S9LPN. S6DON confirmed that on 10/09/2025, the resident had an x-ray that revealed a chronic rotator cuff tear. S6DON and S4AsstADM/MDS/IP stated they were not aware of Resident #92's complaint that S10CNA pulled his arm out of the socket and caused the injury to his arm until the surveyor brought it to their attention. S7QA stated that a couple of months after the resident was confirmed to have a chronic rotator cuff tear, he began to complain of right shoulder pain again, and told her She's the reason my shoulder is hurt in an accusatory manner. S7QA was unable to recall the exact date the resident told this to her and was unable to recall which CNA the resident was referring to. S7QA confirmed she did not report this complaint to S6DON or the Administrator and she should have so that the CNA could have been identified and they could have investigated the concern. S9LPN confirmed the resident complained that his arm was manipulated in some manner by S10CNA while helping him to sit up and remembered that she reported this to S11ADON who no longer works at the facility. S6DON confirmed that S11ADON should have notified her of the resident's complaint and also confirmed there was no documentation of the resident's complaint to S9LPN, S11ADON, or S7QA. S10CNA and S11ADON were unavailable for interview at the time of the survey. On 05/06/2026 at 11:37 a.m., an interview was conducted with S8ADM. He stated that on 10/09/2025, Resident #92 informed him that a CNA moved him improperly and he conducted an investigation, but he was not aware of any other claims of possible mistreatment by staff members resulting in injury to his shoulder after 10/09/2025. He also did not follow up with the resident to confirm which CNA moved him improperly. He confirmed that he was not informed that the resident complained to two different staff members that a CNA injured his arm and if he would have known, he would have investigated the complaint. He also confirmed that S11ADON and S7QA nurse, should have reported the resident's claims to S6DON or himself.

Based on interview and record review, the facility failed to ensure a resident received an assistive device to maintain and/or improve hearing for 1 (Resident #6) out of 1 resident investigated for communication-sensory.Findings:Review of Resident #6's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included, in part, major depressive disorder, cognitive communication deficit, and anxiety disorder.Review of Resident #6's Quarterly MDS (Minimum Data Set) with an ARD of 02/26/2026, under Section C, revealed she had a BIMS score of 15 which indicated her cognition was intact. Further review of the MDS revealed, under Section B, that Resident #6 had minimal difficulty hearing and no hearing aid or other appliance was used.Review of Resident #6's Progress notes revealed a note dated 02/26/2026 written by S5SSD which stated the following: No hearing aids noted for assist device. Is slightly HOH however was able to hear when spoken to in a louder tone. Is on wait list for free hearing aids with (Social Services Organization). Further review of the progress notes revealed a note dated 12/04/2025 written by S5SSD which stated: No hearing aids noted for assist device. Is slightly HOH however was able to hear when spoken to in a louder tone. Is on wait list (Social Services Organization) for free hearing aids.On 05/04/2026 at 10:44 a.m., an interview was conducted with Resident #6 and she stated she had trouble hearing. Resident #6 stated the facility was aware that she had trouble hearing and she was on a waiting list for hearing aids. She stated she was told the list was long and she had not heard anything else regarding her hearing aids.On 05/05/2026 at 3:30 p.m., an interview was conducted with S5SSD. S5SSD confirmed that Resident #6 was on the (Social Services Organization) waiting list for hearing aids. S5SSD stated the waiting list was long and it usually takes about 6-9 months for a resident to receive hearing aids.On 05/05/2026 at 3:35 p.m., a record review and interview was conducted with S5SSD. A review of a progress note in Resident #6's chart revealed an entry written by S5SSD dated 09/30/2024 at 8:30 a.m. which revealed the following: No hearing aid noted for assist device. Offered assist device.phoned (Social Services Organization).Resident #6 placed on wait list for free hearing aids. S5SSD confirmed that Resident #6 had been on the (Social Services Organization) waiting list for hearing aids since 09/30/2024.On 05/05/2026 at 3:55 p.m., an interview was conducted with S5SSD. S5SSD stated that if it was taking long for a resident to receive their hearing aids, and a resident has not received their hearing aids, she would call the (Social Services Organization) to follow up. S5SSD stated she did not realize that Resident #6 was on the (Social Services Organization) waiting list for hearing aids since 09/30/2024 until present. S5SSD stated she supposed it was her responsibility to follow up with the (Social Services Organization) regarding Resident #6's hearing aids, since the resident had been on the waiting list for hearing aids longer than 6-9 months.

Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to:Appropriately store, label and date frozen food items, and Ensure kitchen staff used good hygienic practices while preparing and serving food to residents.This had the potential to affect 93 residents who consumed foods from the facility's kitchen.Findings:1.On 05/05/2026, a review of the facility's policy titled, Food Storage with a last reviewed date of 11/24/2025, read in part . 14. Frozen Foods .c. All foods should be covered, labeled and dated .All foods will be checked to assure that foods will be consumed by their use by dates or discarded . On 05/04/2026 at 8:53 a.m., an observation of the facility's freezer with S2DMT revealed the following:- 1/2 a plastic bag of frozen meat patties which was tied at the opening. The bag had a small hole in the plastic bag, was not labeled with the contents, and did not have a used by dated.- 4 mid-sized plastic bags with frozen brown substance. The bags were not labeled with the contents and used by date.-2 large frozen plastic bags with a brown substance. The bags were not labeled with the contents and/or used by date. S2DMT confirmed the above findings. She stated each of the items were supposed to be labeled with the contents and used by date when they were removed from their original container. She also stated the bag with the meat patties should not have had a hole. 2.On 05/05/2026, a review of the facility's policy titled, Bare Hand Contact with Food and Use of Plastic Gloves with a last reviewed date of 11/24/2025, read in part .Procedure: 1. Staff will use good hygienic practices and techniques .2. Staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. 3. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready-to-eat food ., used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation .5. Clean gloves are to be used when: a. Handling ready-to-eat foods . On 05/04/2026 at 10:50 a.m., an observation was made of S3Cook preparing pureed vegetables to serve the resident's for lunch. S3Cook wore the same pair of single use plastic gloves during the process. S3Cook was observed wearing single use plastic gloves to retrieve a food processer and a scooper, scooped vegetables from a pot on the stove, placed the vegetables in the food processer, then touched the food processer wearing the same pair of single use plastic gloves to turn on the food processor. S3Cook was then observed using her gloved right hand to scoop the pureed vegetables from the food processer into a pan. She did not change her gloves or use a food utensil. S3Cook stated she should have used a spoon and not her contaminated glove to remove the pureed vegetables from the food processer. S3DM, who was also observing the process, stated S3Cook should have used a food utensil to remove the vegetables from the food processer. On 05/04/2026 at 11:45 a.m., an observation was made of S3Cook serving resident's lunch from the steam table. S3Cook was wearing a pair of single use plastic gloves. She picked up a thermometer to check food temperatures, touched the steam table several times, picked up plates to serve the food and touched the scoopers for each food item each time she placed food on a plate. S3Cook was observed cutting meat with a knife that she held in her gloved right hand as she held the meat with her gloved left hand. S3Cook did not change her gloves or used a utensil to hold the meat. She confirmed the above findings and stated she should have used a fork. On 05/04/2026 at 2:48 p.m., an interview was conducted with S4AsstADM/MDS/IP. She stated S3Cook should not have touched the residents' food with her gloved hands after touching another surface, because she could transfer contaminants from that surface to the residents' food. On 05/05/2026 at 10:38 a.m., an interview was conducted with S1DM. S1DM stated S3Cook should not have touched all those non-food items with her gloved hand and then go back and touch the residents' food with the same contaminated glove. She stated S3Cook should have gotten a spoon and used it to scoop the vegetables out of the food processer and used a fork to hold the meat while cutting it.

Based on record review and interview, the facility failed to ensure that a resident's care plan was accurately updated to reflect the resident's current code status for 1 (Resident #3) out of 30 sampled residents. This deficient practice had the potential to affect a total census of 95 residents.Findings: Review of Resident #3's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage renal disease, atherosclerotic heart disease, and diabetes mellitus.Review of Resident #3's electronic medical record revealed she was a DNR (Do Not Resuscitate).Review of Resident #3's electronic medical record revealed a Louisiana Physician Orders For Scope of Treatment (LaPOST) that read in part:.A. Do Not Attempt Resuscitation (DNR).F. Summary of Goals: Discussed with: Personal Health Care Representative. The basis for these orders is: Patient's Personal Health Care Representative (Qualified Patient without capacity), signed by physician and signed by Personal Health Care Representative on [DATE]. Review of Resident #3's [DATE] physician's orders revealed the following order dated [DATE]: Do Not Resuscitate-No CPR (cardiopulmonary resuscitation). Review of Resident #3's care plan read in part.I am a Full Code and want CPR done on me. On [DATE] at 11:42 a.m., an interview and record review was conducted with S4AsstADM/MDS/IP who stated that she was responsible for completing and updating care plans for residents in the facility. S4AsstADM/MDS/IP confirmed Resident #3's record revealed the LaPOST form that indicated the resident had a DNR status and was signed on [DATE]. A review of resident's care plan was conducted with S4AsstADM/MDS/IP, who confirmed that the resident's care plan had not been updated and/or revised to reflect the code status to DNR status and was not.

Based on record review and interview, the facility failed to ensure the resident's plan of care was implemented as ordered for 2 (Resident #3, Resident #7) out of a total sample of 30 residents by failing to:follow physician's order for assessing Resident #3's dialysis site; andfollow physician's order for monitoring of right hand splint; administering enteral feed; and administering enteral flush for Resident #7.Findings:1.Review of Resident #3's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage renal disease, atherosclerotic heart disease, and diabetes mellitus.Review of Resident #3's February 2026 physician's order and Hall TAR (Treatment Administration Record) revealed the following order dated 09/27/2022: Dialysis Access Site-observe daily for bleeding or signs of infection. Notify dialysis center/MD (medical doctor) if noted every shift. The resident's Hall TAR failed to include nurses' initials or evidence that the resident's dialysis access was observed for bleeding or signs of infection on 02/27/2026, day and evening shift. Review of Resident #3's April 2026 physician's order and Hall TAR revealed the following order dated 09/27/2022: Dialysis Access Site-observe daily for bleeding or signs of infection. Notify dialysis center/MD (medical doctor) if noted every shift. The resident's Hall TAR failed to include nurses' initials or evidence that the resident's dialysis access was observed for bleeding or signs of infection on 04/07/2026 evening, 04/13/2026-evening, 04/16/2026-evening, 04/18/2026-day, 04/22/2026-evening, and 04/29/2026-night.On 05/06/2026 at 11:48 a.m., an interview and record review was conducted with S4AsstADM/MDS/IP. She reviewed Resident #3's February 2026 and April 2026 Hall TARs and confirmed there was no evidence the nurses were monitoring the resident's dialysis access site for the above dates. S4AsstADM/MDS/IP confirmed the resident's monitoring was not done as ordered in February 2026 and April 2026.2.Review of Resident #7's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis, muscle wasting and atrophy, encounter for attention to gastrostomy, dysphagia, and aphasia.Review of Resident #7's January 2026 physician's order and Hall TAR revealed the following order dated 01/30/2025: Check right hand splint-color of limb, movement ability, sensation when touched, and temperature of skin on feel every shift for monitoring. Document plus or minus. Minus must be reported to the physician. The Hall TAR failed to include nurses' initials or evidence that the resident's dialysis access was observed for bleeding or signs of infection on the date of 01/21/2026-evening, 01/26/2026-day, and 01/29/2026-day.Review of Resident #7's February 2026 physician's order and Hall TAR revealed the following order dated 01/30/2025: Check right hand splint-color of limb, movement ability, sensation when touched, and temperature of skin on feel every shift for monitoring. Document plus or minus. Minus must be reported to the physician. The Hall TAR failed to include nurses' initials or evidence that the resident's right hand splint was checked for the above on the date of 02/04/2026-evening, 02/14/2026-night, and 02/18/2026- night, and 02/27/2026-day.Review of Resident #7's March 2026 physician's order and MAR (Medication Administration Record) revealed the following in part:Order dated 12/30/2024: Enteral Feed Order, every shift enteral formula feedings of Diabetasource 60 cc/hr (cubic centimeters per hour) continuously. The MAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 03/20/2026--evening.Order dated 01/02/2025: Enteral Flush-Check placement and residual prior to administering water flush. Hold if residual is > (greater than) or = (equal to) 100 ml (milliliters). Recheck in 1 hour and/or notify MD if unresolved. The MAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 03/20/2026 at 1030.Review of Resident #7's April 2026 physician's order and MAR (Medication Administration Record) revealed the following in part:Order dated 12/30/2024: Enteral Feed Order, every shift enteral formula feedings of Diabetasource 60 cc/hr (cubic centimeters per hour) continuously. The MAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 04/02/2026-evening.Order dated 01/02/2025: Enteral Flush-Check placement and residual prior to administering water flush. Hold if residual is > (greater than) or = (equal to) 100 ml (milliliters). Recheck in 1 hour and/or notify MD if unresolved. The MAR failed to include nurses' initials or evidence that the treatment was administered for the resident on the date of 04/02/2026 at 1030.Review of Resident #7's April 2026 physician's order and Hall TAR revealed the following order dated 01/30/2025: Check right hand splint-color of limb, movement ability, sensation when touched, and temperature of skin on feel every shift for monitoring. Document plus or minus. Minus must be reported to the physician. The Hall TAR failed to include nurses' initials or evidence that the resident's right hand splint was checked for the above on the date of 04/07/2026-evening, 04/13/2026-night, and 04/16/2026-night, and 04/18/2026-day, 04/22/2026-evening, and 04/29/2026-night.On 05/06/2026 at 11:56 a.m., an interview and review of Resident #3 and Resident #7's physician orders and Hall TAR was conducted with S4AsstADM/MDS/IP. She reviewed Resident #7's January 2026, February 2026, and April 2026 Hall TAR and confirmed that the TARs failed to include nurses' initials or evidence that the nurses the resident's right hand splint was checked for the above dates. S4AsstADM/MDS/IP also reviewed Resident #7's March 2026 and April 2026 MAR, and confirmed that the MARs failed to include nurses' initials or evidence that the treatments of enteral feed or enteral flush were administered for the above dates. S4AsstADM/MDS/IP confirmed the resident's right hand splint was not checked and enteral feed and enteral flush were not done as ordered in January 2026, February 2026, March 2026 and April 2026.

Based on observation, interview, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; and 2. food was properly sealed and stored. The facility had a census of 95 residents. Findings: On 03/24/2025, a review of the facility's policy titled, Correct Food Storage with a revised date of 12/30/2024, read in part, all foods shall be stored in a manner to ensure First-in - ''First- Out use and all items shall be labeled, dated and sealed. On 03/24/2025 at 9:01 AM, an observation was made of the dry storage area with S1DM (Dietary Manager). S1DM confirmed the following observations: -1 partially used bottle of imitation vanilla with no opened date; -1 partially used bottle of imitation banana with no opened date; -1 opened unsealed bag of corn flakes with no opened date; -1 opened and unsealed box of quick oats opened with no opened date; -1 opened and unsealed bag of grits with no opened date. On 03/24/2025 at 9:07 AM, an interview was conducted with S1DM. S1DM confirmed all opened items should be sealed and labeled with an opened date.

Based on observations, interviews and infection policy review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to: 1. Appropriately handle and transfer soiled laundry; 2. perform proper hand hygiene; 3. appropriately remove PPE (Personal protective equipment); and 4. sanitize dirty scissors before re-using. Findings: 1. On 03/24/2025, a review of the facility's policy titled Laundry, with a last reviewed date of 12/30/2024, read in part: Policy: The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens .Policy Explanation and Compliance Guidelines: 1. Aligning with principles of standard precautions, staff shall consider all previously worn clothing and used linen as potentially contaminated .4. Soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. a. Linens shall be bagged separately from resident's clothing at the point of use. On 03/24/2025 at 09:25 AM, S5CNA (Certified Nursing Assistant) was observed walking out of Room D into Hall A with bed linen held in front her. The linen was not in a bag and S5CNA was not wearing any PPE. During an interview with S5CNA on 03/24/2025 at 9:30 AM, she confirmed that the linen was dirty and not in a bag. She further stated that she should not to wear gloves in the hallway, and was not sure if she should have bagged the linen. During an interview and review of infection control policies with S8ADONIP (Assistant Director of Nursing, Infection Preventionist) on 03/24/2025 at 12:01 PM, she stated that S5CNA should have bagged the laundry at the bedside before removing it from the resident's room. She also stated the CNA should have treated the laundry as contaminated, which meant handling the dirty laundry with gloves. 2. On 03/24/2025, a review of the facility's policy titled Handwashing, with a last reviewed date of 12/30/2024, read in part: Handwashing: Wash your hands even though you were wearing gloves, and washing your hands between residents is an absolute necessity to prevent from spreading germs/virus. During an observation on HALL A on 03/24/2025 at 09:25 AM, S5CNA walked into Room D with clean bed linen, made the bed closest to the door then immediately moved to Room C without performing hand hygiene. During an interview with S5CNA on 03/24/2025 at 9:30 AM she confirmed not performing hand hygiene after making the bed in Room D and before touching the beds in Room C and stated that she should have. On 03/24/2025 at 10:03 AM an observation was made of S6HSKP (Housekeeper) walking out of Room E bathroom with gloved hands. He walked into the hallway and disposed of the gloves in the trash bag on the housekeeping cart. Further observation revealed S6HSKP changed into a clean pair of gloves without performing hand hygiene then walked back into Room E. During an interview with S7HSKPSup (Housekeeping Supervisor) on 03/24/2025 at 10:05 AM, she stated S6HSKP should have washed his hands before using gloves and after removing the gloves. During an interview and review of the facility's hand hygiene policy with S8ADONIP on 03/24/2025 at 12:01 PM, she confirmed that hand hygiene should be performed according to the facility's policy above. 3. On 03/26/2025, a review of the facility's policy titled Donning and Doffing, with a revised date of 11/2024 read in part, Policy: Donning and Doffing. Purpose: Preventing the spread of infectious diseases and protecting healthcare workers and patients .Removing the gown as well as all other PPE (personal protective equipment). Remove your gloves first by pinching the glove in the palm of your hand and pulling the glove slowly downward .Then remove your gown . On 03/25/2025 at 10:34 AM, an observation was made of S9RNTX (Treatment Nurse/Treatment Nurse) performing a dressing change on Resident #25. After completing the dressing change S9RNTX was observed reaching behind her neck with her dirty gloved hands and removed her gown, then she removed her dirty gloves. During an interview with S9RNTX on 03/25/2025 at 10:34 AM, she confirmed removing her gown before her dirty gloves and stated she should have removed her dirty gloves first. During an interview with S8ADONIP on 03/26/2025 at 3:30 PM, she stated S9RNTX should have removed her dirty gloves before her gown according to the facility's policy. 4. On 03/25/2025 at 10:34 AM, an observation was made of S9RNTX performing a dressing change on Resident #25. S9RNTX removed the resident's old dressings by cutting the gauze wraps with a pair of reusable metal scissors. She placed the scissors on the far side of her treatment table without sanitizing them. Further observation revealed S9RNTX used the dirty scissors to cut the clean gauze that she used to wrap the resident's wound on her right leg. During an interview with S9RNTX on 03/25/2025 at 10:34 AM, she confirmed using the dirty scissors to cut Resident #25's clean dressing and stated she should have sanitized the scissors before using them. During an interview with S8ADONIP on 03/26/2025 at 3:30 PM, she stated that S9RNTX should have sanitized the scissors after using it to cut the resident's old dressing and before cutting the new dressing.

Based on observations, interviews and record review the facility failed to assess 1(#12) out of 1 sampled residents for self-administration of medication in a final sample of 35 residents. Findings: On 03/24/2025, a review of the facility's policy titled, Resident Self-Administration of Medications with a las review date of 12/30/2024 revealed in part, Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administer safely. Policy Explanation and Compliance Guidelines: .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record . Resident #12 was admitted to the facility on [DATE] with diagnoses that included essential hypertension and dermatitis. Review of Resident #12's quarterly MDS (Minimum Data Set) dated 02/24/2025 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, which indicated he was cognitively intact. Review of Resident #12's Medication Administration Record (MAR) revealed an order with a start date 06/07/2024 for Miconazole Nitrate 2% (percent) powder (antifungal medication)-apply to affected area every 8 hours as needed. On 03/24/25 at 1:28 PM, Resident #12 was observed sitting in his wheelchair in his room. A clear medication cup with a white powdery substance was observed on the resident's bedside dresser. Resident #12 stated that it was a powder that he had to apply to his abdominal folds for itching. A review of Resident #12's electronic and paper medical record revealed no documented evidence that a medication self-administration assessment was conducted. On 03/25/2025 at 9:25 AM, an interview and review of Resident #12's electronic medication administration record was conducted with S12LPN (Licensed Practical Nurse). She confirmed that Resident #12 had an order for Miconazole Nitrate 2% powder to apply to affected every 8 hours as needed to his groin or abdominal folds when he develop a yeast-like rash in those areas. On 03/25/2025 at 9:30 AM, an observation of the resident's room was conducted with S12LPN. A clear medication cup with a white powdery substance was noted on Resident #12's bedside dresser. Resident #12 stated that someone had put the medication cup in one of the drawers of the table. S12LPN confirmed that there was a clear medication cup with a white powdery substance on the resident's bedside dresser. On 03/25/2025 at 9:40 AM, an interview was conducted with S13TN (Treatment Nurse) She stated that she was responsible for applying the Miconazole Nitrate powder to Resident #12's abdominal and/or groin area when needed if the resident develops a rash. She confirmed that Resident #12 was not assessed for self-administration of his medications. She also confirmed that she may have left the medication cup in the resident's room and that she should not have left it in the resident's room. On 03/25/2025 at 10:10AM, record review and interview was conducted with S11DON (Director of Nursing). S11DON reviewed the resident's paper chart. She confirmed that Resident #12 had not been assessed for self-administering his own medications. She also confirmed that the medication cup with the Miconazole Nitrate 2% powder should not have been left at the resident's room because he was not assessed for self-administering his own medications.

Based on record review, policy review and interviews, the facility failed to report to the administrator of the facility a resident report of sexual abuse for 1(#85) of 1 resident sampled for abuse. This had the potential to affect the 95 residents that reside in the facility. Findings: A review of the facility's policy titled Abuse and Neglect with a last reviewed date of 12/30/2024 read in part, Identification- A) Any staff member receiving a complaint of abuse, neglect, or an injury of unknown origin whether it is from the resident, a family member or staff, should listen to the complaint, writing down the date, and time complaint is being received, and any details given D) Administrator or his designee should be notified as soon as possible. Resident #85 was admitted to the facility on [DATE] with a diagnoses which included, but were not limited to cerebral infarction, unspecified psychosis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #85's Quarterly MDS (Minimum Data Set) dated 12/17/2024, revealed the resident had a BIMS (Basic Interview for Mental Status) of 15, indicating his cognition was intact. On 03/24/25 at 10:00 AM, an interview was conducted with Resident #85. He stated about four weeks ago, a young, black CNA (Certified Nursing Assistant) Punched him in the nuts while changing his diaper. He stated that he had informed multiple staff including S14SSD (Social Service Director) and S11DON (Director of Nursing) of the incident. Resident #85 stated that S14SSD and S11DON had continued to report to him that they had been looking into it. On 03/25/25 at 02:41 PM, an interview was conducted with S16CNA (Certified Nursing Assistant). S16CNA stated about 1 and 1/2 months ago, Resident #85 reported to her that he had been sexually assaulted by a CNA. S16CNA stated that Resident #85 reported to her that S17CNA had pushed on his scrotum too hard while changing him. S16CNA stated that she reported the resident's claim to S18LPN (Licensed Practical Nurse). S16CNA stated that the day after Resident #85's claim of abuse, S16CNA had a discussion with S11DON about the resident's claim of sexual assault. On 03/25/25 at 04:41 PM, a phone interview was conducted with S17CNA. S17CNA stated that within the last few months, she was performing perineal care for Resident #85 in his room when he began to yell out Sexual Battery and refused to let her proceed with care. She stated she was only wiping him like she usually done. S17CNA requested that S16CNA come in the resident's room with her to complete care, because of Resident #85's accusations. She stated that S16CNA had informed her that she had reported the resident's allegation to the nurse. S17CNA stated the next day, she completed a written statement of the resident's accusations at the request of S11DON. S17CNA stated that the facility no longer allowed her to care for Resident #85 due to the resident's accusation. On 03/26/25 at 01:28 PM, an interview was conducted with S19ADM (Administrator) and S20AADM (Assistant Administrator). Both S19ADM and S20AADM stated that they had not been informed of Resident #85's claim of sexual abuse and should have been. Both stated that they would have reported this claim to the appropriate state agency if they had been made aware of the claim.

Based on record review and interview, the facility failed to follow the care plan for Resident #80 as evidenced by failing to offer the resident a visit with the in house dental consultant for 1 (#80) out of 35 sampled residents. Findings: Resident #80. On 03/24/2025 at 10:11 AM, an interview was conducted with the resident. The resident stated that he had some broken and missing teeth and he wanted to see a dentist. The resident stated that no one discussed dental services with him. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. Review of the resident's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was coded to have obvious or likely cavity or broken natural teeth and inflamed or bleeding gums or loose natural teeth. Review of the resident's care plan revealed that it addressed the resident having carious teeth and gum inflammation. An intervention included to offer the resident a visit with the in house dental consultant if needed or asked. Review of the resident's clinical record and social service notes revealed no evidence the resident was offered a visit with the in house dental consultant. On 03/25/2025 at 1:35 PM, an interview was conducted with S14SSD (Social Service Director). S14SSD stated that the residents who did not purchase dental insurance would be seen by S15RDH (Registered Dental Hygienist). S14SSD stated the process was that S15RDH would receive the census list of all the residents in the facility without dental insurance and from that list he would select the residents he would visit on the day he was in the facility. S14SSD stated S15RDH would visit the facility once a month and see the residents at least once a year. S14SSD stated the resident did not have dental insurance and confirmed that she did not have evidence S15RDH saw the resident and evaluated his oral care. On 03/26/2025 at 11:58 AM, a telephone interview was conducted with S15RDH. He confirmed that he did not evaluate the resident's oral care until 03/25/2025 when it was brought to his attention. S15RDH stated that he thought the resident had dental insurance to see the dentist.

Based on record review and interview, the facility failed to ensure that services were provided to meet professional standards of quality as evidenced by S13TN (Treatment Nurse) leaving medication at the bedside for 1 (#12) out of 1 resident, who was not assessed for self-administration of his medication, out of a total sample of 35 residents. This deficient practice had the potential to affect the 95 residents in the nursing home. Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses that included essential hypertension and dermatitis. Review of Resident #12's quarterly MDS (Minimum Data Set) dated 02/24/2025 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, which means cognitively intact. On 03/24/25 at 1:28 PM, Resident #12 was observed sitting in his wheelchair in his room. A clear medication cup with a white powdery substance was observed on the resident's bedside dresser. Resident #12 stated that it was a powder that he used to apply to his abdominal folds for itching. On 03/25/2025 at 9:40 AM, an interview was conducted with S13TN (Treatment Nurse) She stated that she was responsible for applying the Miconazole Nitrate powder (antifungal medication) to Resident #12's abdominal and/or groin area when needed if the resident develops a rash. She confirmed that she may have left the medication cup in the resident's room and confirmed that she should not have left it in the resident's room. On 03/25/2025 at 10:10AM, record review and interview was conducted with S11DON (Director of Nursing). S11DON confirmed that S13TN should not have left the medication cup with the Miconazole Nitrate 2% powder in Resident #12's room.

Based on record review and interview, the facility failed to ensure that staffing data posted daily included resident census and total number of hours worked. Findings: On 03/25/2025 at 12:35 PM, an observation of staffing data posted revealed the following: Staffing for: 03/25/2025 6-2 (6:00 AM to 2:00 PM): 2 RN (Registered Nurse) @ 16 HRS (hours), 5 LPN (Licensed Practical Nurse) @ 40 HRS, 23 CNA (Certified Nursing Assistant) @ 184 HRS. Further review revealed the census and total number of hours worked were missing. During an interview with S2WC (Ward Clerk) on 03/25/2025 at 1:30 PM, she stated she was responsible for completing and posting the staffing sheet. S2WC confirmed that the census number and total number of hours worked were left blank, and stated she had never included that information when she posted the staffing. On 03/26/2025 at 8:00 AM an observation of staffing data posted revealed the following: Staffing for: 03/26/2025 6-2: 2 RN @ 16 HRS, 5 LPN @ 40 HRS, and 24 CNA @ 192 HRS. Further review revealed the census and total number of hours worked were missing. During an interview with S3WC (Ward Clerk) on 03/26/2025 at 8:15 AM, she stated that she was responsible for completing and posting the staffing sheet. S3WC confirmed that the census and total number of hours worked were left blank, and stated she had never included that information when she posted the staffing. During an interview with S4PR (Payroll Clerk) on 03/26/2025 at 8:20 AM, she stated that the ward clerks were responsible for completing the staffing sheet with the census and hours and posting it on the board daily. She stated that she pulled the staff clock-ins at the end of the day and completed the actual hours provided and the difference. She stated that on 03/24/2025 and 03/25/2025, she had to fill in the census and total number of working hours because the ward clerks had not included it on the staffing sheets posted for either days and should have.

Based on observation, record review and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments as evidenced by the nurse leaving the medication cart unlocked and unattended during the medication pass on Hall B. Findings: Review of the facility's policy and procedure titled, Medication Administration last reviewed on 12/30/2024 read in part, .Medication cart locked if left unattended in resident care area . On 03/25/2025 at 7:55 AM during the medication pass, S10LPN (Licensed Practical Nurse) was observed locking the medication cart on Hall B. During this observation, a nurse walked up to the medication cart and pulled on the bottom compartment of the cart and it opened. The bottom compartment had medications stored in it. S10LPN stated that she was not aware that the bottom compartment did not lock. S10LPN confirmed the bottom compartment had medications stored in it and that the compartment should have been locked when she left the medication cart unattended.

Based on observations, interviews and record reviews, the facility failed to ensure that certified nursing aides (CNAs) who transported residents in the facility's van were trained and competent on the proper and safe procedure for securing the resident's wheelchair in the van according to the manufacturer's instructions. This deficient practice was evidenced by 1 (S2TransportationCNA) of 2 transportation CNAs observed improperly securing Resident R1 in the facility's transportation van. Findings: On 07/16/2024 at 10:00 a.m., S1ADM (Administrator) was asked to provide the manufacturer's instruction manual for securing a resident in the facility's transportation van. He stated the facility's van was purchased in 2016, and a conversion was put into the van by a third party company. That company demonstrated to staff how to properly secure residents in the van once, when the conversion was put into the van in 2016. He stated the previous transportation drivers trained the new transportation drivers how to secure residents' wheelchairs in the van, and he was not sure if the new drivers were trained on the manufacturer's instructions. S1ADM stated he would look for the manufacturer's instruction manual as he did not know if the facility still had it. On 07/16/2024 at 11:00 a.m., an observation was made with S1ADM of S2TransportationCNA as she secured Resident R1 in the facility's van for transportation. S2TransportationCNA wheeled Resident R1 into the back of the van via the van's ramp, locked the wheelchair, then secured the resident with the rear tie down straps. She then entered through the front of the van, secured the resident with the seatbelt, then proceeded to use the J- hooks at the front of the van to secure the front of the resident's wheelchair. S2TransportationCNA secured the J- hooks to the left and right front wheels of the wheelchair, and not to the frame or welded junction of the frame of the wheelchair. On 07/16/2024 at 1:30 p.m., S1ADM provided the manufacturer's instruction manual for securing a resident in the facility's van. He stated that the L- track system was installed in the van, and confirmed that the instructions provided were how residents should be properly and safely secured in the van. Review of the manufacturer's instructions for the facility's transportation van wheelchair strapping system provided by S1ADM revealed the following in part: With either the manual or retractable straps, it is important to make sure that you securely attach the pin to the floor anchor or L- track , and the J- hooks are placed properly and tightened so that the chair does not move. W19 wheelchairs feature securement points to attach the straps to. On a non- W19 wheelchair, attach the straps to welded junctions of the frame, or to places where the frame is bolted. Never attach straps to moving or adjustable parts of the wheelchair. Review of the facility's training and in-service records revealed an attestation signed by S2TransportationCNA stating that she participated in an in-service training for van drivers on 12/14/2023, 04/28/2024, and 05/16/2024. There were no training materials attached to show what procedures she was trained on or that she was trained to properly restrain residents in wheelchairs according to the manufacturer's instructions for the van's strapping system. On 07/16/2024 at 3:50 p.m., S1ADM did not confirm or deny that during the observation, S2TransportationCNA secured the J- hooks to the wheels of the resident's wheelchair instead of the frame of the wheelchair as the instructions indicated.

Based on record review and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately to the administrative staff for 2 (#1 and #2) out of 3 (#1, #2, and #3) sampled residents. Findings: Review of the facility's Abuse and Neglect policy and procedure that was updated 01/2024 per S2AsstAdm (Assistant Administrator) read in part: Policy: It is the policy of this facility to provide an environment for our residents that is free of abuse, neglect, extortion, self-neglect or misappropriation of funds . 4. Identification-Any staff person receiving a complaint of abuse, neglect, or an injury of unknown origin whether it is from the resident, a family member or staff, should listen to the complaint, writing down the date, and time complaint was received, time, and any details given .The charge nurse then notifies the administrator or his designee immediately even if this is a weekend or at midnight . 1. Resident #1. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Muscle Spasm, Age-Related Osteoporosis, and Other Specified Disorders of Bone Density. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating her cognition was severely impaired. Review of the facility's incident report that was entered on 03/31/2024 at 8:28 p.m. revealed that on 03/30/2024 S7CNA (Certified Nursing Assistant) explains to Resident #1's RP (Responsible Party) that Resident #1 told her that she hurt her hands when helping her stand up . Review of the facility's incident report investigation revealed, On 04/05/2024 at 10:45 a.m., S2AsstAdm (Assistant Administrator) wrote: Resident #1 03/31/2024 S7CNA approached Resident #1's RP son of Resident #1) telling him that she was assisting Resident #1 the day before (03/30/2024) to stand and Resident #1 said she hurt her hands and bruised them . Interview with S8LPN, S7CNA never reported any incident on 03/30/2024 regarding Resident #1 to the nurse in charge or the supervisor. She reported to S8LPN at 5:45 p.m. on 03/31/2024 the conversation she had with Resident #1's RP was the first notification of this incident . Review of S8LPN's handwritten statement that was not dated revealed, 03/31/2024 at 5:45 p.m. On the above date and approximately time S7CNA called facility and stated that Resident #1 had informed her son that she had been abusive towards her. S7CNA stated that Resident #1's RP questioned her about this and she told him that she was helping the Resident #1 stand up with her hands clasping Resident #1 hard. Resident #1 alleged that she was hurt in the process . Three attempts were made to contact S7CNA via phone on 05/01/2024 at 2:00 p.m., at 2:20 p.m., and at 2:40 p.m. S7CNA failed to return any phone calls and was unable to be interviewed. On 05/01/2024 at 2:50 p.m., a telephone interview was conducted with S8LPN. S8LPN stated she was the nurse and S7CNA was the CNA for Resident #1 on 03/30/2024 and 03/31/2024. S8LPN stated that she received a telephone call on 03/31/2024 at around 5:45 p.m. from S7CNA who stated on 03/30/2024 that Resident #1 complained that S7CNA clasped her hands too tight while transferring her and hurt her hands. S8LPN confirmed that all alleged cases of any type of abuse has to be reported immediately to the charge nurse or supervisor and S7CNA did not report the case of alleged abuse to S8LPN until the next day. On 05/02/2024 at 8:51 a.m., a joint interview was conducted with S4Adm (Administrator) and S2AsstAdm. S2AsstAdm stated she initiated the facility incident report and completed the investigation regarding Resident #1's complaint. S4Adm and S2AsstAdm stated that they were notified of the allegation of abuse from S8LPN on 03/31/2024 in the evening around 6:30 p.m. They were told by S8LPN that S7CNA called the facility and told S8LPN that Resident #1 told her on 03/30/2024 that S7CNA clasped her hands to tight while transferring her and her hands were hurt and bruised. S4Adm and S2AsstAdm confirmed that S7CNA did not report the alleged abuse until the next day on 03/31/2024 and S7CNA should have immediately reported the alleged abuse to the charge nurse or administration staff. 17364 2. Resident #2. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Anxiety Disorder, and Dysphagia. Review of the resident's significant change MDS (Minimum Data Set) dated 03/27/2024 revealed the resident was assessed as being severely impaired for cognition. Review of the facility's incident report that was entered on 03/11/2024 at 4:41 p.m. revealed that on 03/11/2024 at 4:15 p.m. the resident's daughter entered the administration office. The resident's daughter stated that she was at the facility on Friday evening after supper and an aide came to take her mother, Resident #2, to bed. The resident's daughter stated that the CNA handled her mother really rough and did not want that CNA to provide care to her mother again. An investigation was assigned and started by the S2AsstAdm. Review of the facility's incident report investigation revealed, Incident Investigation: On 03/12/2024 at 4:23 p.m., S2AsstAdm wrote: 03/08/2024 S4CNA stated that S5CNA was assigned to care for Resident #2. After supper, the resident's daughter asked to have Resident #2 put to bed. S5CNA approached the resident and grabbed her hands and pulled her to stand, then S4CNA intervened and said she needs to go slow when helping her as she can't stand well. The resident's daughter then said that she doesn't want that aide taking care of her mother . Review of S4CNA's handwritten statement that was not dated revealed, I S4CNA worked 03/08/2024 . with another agency CNA (S5CNA). After supper, the resident's daughter wanted her to be put in bed for the night. The CNA that had assigned to her went to yank on her in process of getting her up out chair to stand. I, myself, and the daughter got up and told the CNA she can't do that and she has to go slow with her in order to get her to stand and catch her balance . the daughter called me to the room and told me the other aide was very ruff (rough) handling her mother for me to get the nurse. I went to nurse S3LPN. She went talk with the daughter and I was told to care for resident. After that, the daughter didn't want the other aide in her mother's room or touching her . On 05/01/2024 at 3:50 p.m., a telephone interview was conducted with S4CNA. The CNA stated that she was working with S5CNA when the CNA attempted to get the resident out of the chair. S4CNA stated after supper one evening, the resident's daughter requested that the resident be put back to bed. S4CNA stated that S5CNA was observed handling the resident very rough. Surveyor asked, what do you mean the CNA was rough? S4CNA stated that S5CNA was pulling and yanking the resident's hands hard and fast to pull her up out of the chair. S4CNA stated that she and the resident's daughter told S5CNA no, you can't do that and that you have to go slow with her in order to get her up and out of the chair to stand up. S4CNA stated that the resident's daughter told her that she did not want S5CNA to take care of her mother because she did not like the way she was handling her mother. S4CNA stated that S3LPN was there and was informed about the incident. On 05/01/2024 at 4:01 p.m., an interview was conducted with S3LPN. She stated that Resident #2's daughter reported to her that she did not like the way the assigned CNA (S5CNA) was handling her mother during a transfer. S3LPN stated that she asked the resident's daughter if the CNA hurt her mother and the daughter replied that she did not want the CNA caring for her mother. The surveyor asked S3LPN if she reported the incident to the administrative staff. S3LPN stated that she did not report the incident to the administrative staff. On 05/01/2024 at 4:34 p.m., an interview was conducted with S2AsstAdm. She stated that she initiated the facility incident report concerning the resident's daughter's complaint that S5CNA was rough with her mother. S2AsstAdm stated that staff did not report the incident to her on 03/08/2024. S2AsstAdm stated that the resident's daughter reported the incident to her on 03/11/2024, which was 3 days after the incident occurred. On 05/02/2024 at 7:40 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated S2AsstAdm was responsible for completing the facility incident reports and investigations. S1DON stated that she was not involved with the facility incident report or investigation concerning the incident involving the CNA handling the resident in a rough manner. S1DON stated that she would have expected S4CNA, S5CNA or S3LPN to report the incident to the administrative staff when the incident occurred on 03/08/2024. S1DON confirmed that the resident's daughter and not the staff members reported the incident to the S2Asst Adm on 03/11/2024, which was 3 days after the incident occurred.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to complete maintenance rounds to identify and repair the following: 1. Resident # 21's Chest of Drawer was broken 2. Resident # 63's bathroom toilet paper dispenser was broken 3. Resident # 19's bathroom toilet was loose 4. Resident # 250's headboard was loose and not working properly 5. Residents # 9, # 57, and # 93's hot water faucet produced only cold water Findings: Review of the facility's policy and procedure titled, Safe and Homelike Environment, read in part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximized resident independence and does not pose a safety risk .3 Maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .9 .e. Report any furniture in disrepair to Maintenance promptly . Resident #21 1. Review of the facility's maintenance log for 03/04/2024 for Resident #21's hall revealed no notes under [NAME] drawers section. On 03/04/2024 at 9:00 a.m., an observation was made of Resident # 21's room. The observation revealed the facing of the bottom drawer of Resident #21's chest of drawers, was falling off. On 03/05/2024 at 9:28 a.m., a follow up observation was made of Resident #21's chest of drawers. The bottom drawer facing remained falling off. On 03/05/2024 at 11:26 a.m., an interview and observation was conducted with S3MaintSup (Maintenance Supervisor). S3MaintSup verified that the front facing of the bottom drawer of chest of drawers for Resident #21 was broken. S3MainSup stated that is was his responsibility to complete a daily round through each resident room to inspect for anything in need of repair, and arrange for repair. 44269 Resident #63 Review of Resident #63's electronic health record revealed she was admitted to the facility on [DATE]. Review of Resident #63's quarterly MDS assessment dated [DATE], revealed a BIMS (Basic Interview for Mental Status) score of 13 that indicated the resident was cognitively intact. Review of the facility's maintenance logs for the week of 03/04/2024 revealed no documented evidence that the resident's toilet paper holder was checked or reported to be broken. On 03/04/2024 at 9:18 a.m., an interview was conducted with Resident # 63. Resident # 63 stated that the toilet paper dispenser's plastic covering sometimes fell off in the middle of the night, awakening her from her sleep. An observation of the resident's bathroom revealed a large toilet paper dispenser mounted on the bathroom wall. Closer observation revealed the plastic covering of the dispenser was secured with duct tape. On 03/05/2024 at 12:46 p.m., a follow up observation was made of Resident # 63's bathroom. The plastic covering of the large toilet paper dispenser was still secured with duct tape. On 03/06/2024 at 9:47 a.m., a third observation was made of Resident # 63's bathroom, which revealed the large toilet paper dispenser had not been repaired. On 03/06/2024 at 10:35 a.m., an interview and observation of Resident #63's bathroom was conducted with S3MaintSup. S3MaintSup confirmed the large wall mounted toilet paper dispenser's plastic covering was broken and required replacement. 47251 Resident #19 Review of Resident #19's medical records revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unsteadiness on Feet, Unspecified Lack of Coordination and Other Abnormalities of Gait and Mobility. On 03/04/2024 at 1:19 p.m., an observation was conducted of Resident #19's bathroom. The resident's toilet bowl was very loose. On 03/05/2024 at 10:05 a.m., an interview, review of maintenance logs, and observation of Resident #19's toilet was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that the resident's toilet was checked the week of 03/04/2024. S3MaintSup confirmed that Resident #19's toilet bowl was loose and needed repair. Resident #250 Review of Resident #250's clinical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Weakness, Hypertension and Other, Retention of Urine. On 03/04/2024 at 11:47 a.m., an interview was conducted with Resident #250. The resident stated that the headboard on his bed was broken. An observation revealed the headboard was loose and leaned toward the head of the mattress. On 03/05/2024, at 8:45 a.m., a follow-up interview and observation was conducted with Resident #250. The resident stated that his headboard was not repaired, and had been broken since his admission about three weeks ago. He also stated that the head of his bed did not go up. On 03/05/2024 at 10:10 a.m., an interview, review of daily maintenance log and observation of Resident # 250's bed was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #250's headboard was identified. S3MaintSup confirmed that the headboard was broken and needed to be repaired. Resident #9 A review of Resident #9's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Traumatic Intracerebral Hemorrhage, Major Depressive Disorder and Diabetes Mellitus. On 03/04/2024 at 2:11 p.m., an observation of Resident #9's bathroom revealed that there was no hot water in the bathroom sink. On 03/05/2024 at 10:01 a.m., an interview, review of daily maintenance log and observation of Resident #9's bathroom was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #9's issue with hot water was identified for the week of 03/04/2024. S3MaintSup confirmed that Resident #9's water was not hot and should have been. Resident #57 A review of Resident #57's clinical record revealed he was admitted on [DATE] with diagnoses that included, but were not limited to, Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung, Type 2 diabetes Mellitus with Diabetic Polyneuropathy, Hypertension, COPD and Centrilobular Emphysema. A review of Resident #57's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/05/2023, revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. On 03/04/24 at 10:09 a.m., an interview was conducted with Resident #57. The resident stated that the water in his bathroom was not hot enough, and that he had reported it to maintenance. An observation of Resident #57's hot water revealed it was cold. 03/05/2024 at 10:00 a.m., an interview and observation of Resident #57's water in his bathroom was conducted with S3MaintSup (Maintenance Supervisor). S3MaintSup confirmed that the water in Resident #57's bathroom was cold and stated that it should have been hot. Resident #93 Review of Resident #93's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but was not limited to, Orthostatic Hypotension, Hypertension, Pre Diabetes and Cognitive Communication Deficit. On 03/04/2024 at 9:44 a.m., an observation of Resident #93's bathroom revealed there was no hot water in the bathroom sink. On 03/05/2024 at 10:01 a.m., an interview, review of daily maintenance log, and observation of Resident #93's bathroom sink was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #93's hot water issue had been identified for the week of 03/04/2024. S3MaintSup confirmed that Resident #93's water was cold and should have been hot.

Based on record review and interview, the facility failed to refer residents who had a qualifying diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #70) of 1 resident sampled for PASARR. The deficient practice had the potential to affect a total census of 99. Findings: Review of Resident #70's record revealed an admitted [DATE] with diagnoses that included; in part, Unspecified Psychosis. Review of Resident #70's records revealed no evidence that a Level II PASARR had been re-submitted to the appropriate state-designated authority that indicated he had the qualifying diagnosis of Unspecified Psychosis. On 03/05/24 at 10:26 a.m., an interview was conducted with S4SSD (Social Services Director). S4SSD confirmed the residents admitted as well as the date of the qualifying diagnosis. S4SSD confirmed the PASARR should have been resubmitted for re-review and had not been.

Based on observations, interviews, and records reviewed, the facility failed to identify and provide resident centered care and services in order to attain the highest practicable well-being for 1 (# 200) resident out of a finalized sample of 44 residents. This deficient practice was evidenced when the facility's staff failed to accommodate Resident # 200's smoking preference while he was on Contact isolation precautions. Findings: Review of Resident # 200's electronic health record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses: Major Depressive Disorder, Anxiety Disorder, and Tobacco Use. Review of Resident # 200's Safe Smoking assessment completed on 02/16/2024 by S11MDS (Minimum Data Set Coordinator) revealed the resident was able to make decisions regarding tasks of daily life. Further review revealed he had adequate eyesight and was determined to be a safe smoker. Review of Resident # 200's Activity Admit assessment completed on 02/19/2024 by S12RAD (Resident Activity Director) revealed the resident was his own responsible party. Further review revealed he used tobacco, was able to read and write, was alert and had a great attention span. The resident was also assessed as being able to verbally express self. Review of Resident # 200's Preferences for Customary Routine and Activities interview completed on 02/28/2024 by S12RAD revealed the resident was able to complete the interview. The resident gave a response of 1. Very important to the following, in part: While you are in this facility .F. how important is it to you to do your favorite activities? G. how important is it to you to go outside to get fresh air when the weather is good? Review of Activities progress note completed on 02/28/2024 by S12RAD revealed, in part .admitted to facility on 02/16/2024 .Resident enjoys .sitting outside when the weather is nice to smoke .sitting in the dining area with other residents . Review of Resident # 200's March 2024 physician's orders revealed an order entry dated 03/02/2024 to place in isolation Dx (Diagnosis): ESBL (Extended Spectrum Beta-Lactamase) in urine. Further review of Resident # 200's health record failed to include interventions and/or alternatives to accommodate the resident's smoking preferences while on isolation. On 03/04/2024 at 1:35 p.m., an interview was conducted with Resident # 200. The resident stated he was an every day smoker and had not been able to go outside to smoke a cigarette because he was on isolation for ESBL- an infection in his urine. The resident denied the facility staff offered him any alternatives to satisfy his smoking preferences. On 03/05/2024 at 12:53 p.m., an interview was conducted with S9CNA (Certified Nursing Assistant). S9CNA stated she was caring for Resident # 200 and that the resident was on contact precautions due to bacteria in his urine. She confirmed the resident did not have a foley catheter and used a urinal. S9CNA further confirmed the resident was a smoker and had not been able to go outside to smoke because he was on isolation. On 03/05/2024 at 12:56 p.m., a second interview was conducted with Resident # 200. The resident stated he had not been offered any alternative to smoke while on isolation. The resident stated he would really like to go outside because all he had was his television and that he feels as if he was in jail. On 03/06/2024 at 10:45 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN stated she was familiar with Resident # 200 and that the resident was able to verbalize his needs and wants. S8LPN confirmed the resident was an every day smoker and had not been able to smoke because he was on isolation due to bacteria in his urine. S8LPN stated she was not sure why an alternative was not considered. On 03/06/2024 at 12:34 p.m., an interview was conducted with S12RAD who confirmed Resident # 200 was an every day smoker. S12RAD further confirmed she completed the admission activity assessment for the resident and identified that he enjoyed being outside to smoke a cigarette and visit with other residents. S12RAD denied any alternative being offered to the resident while he (the resident) was on isolation. On 03/06/2024 at 12:45 p.m., an interview was conducted with S5ADON. S5ADON stated she was also the facility's Infection Preventionist and confirmed Resident # 200 was on contact isolation precautions due to bacteria in his urine. S5ADON confirmed the resident had not been outside to smoke since being placed on isolation precautions. S5ADON further confirmed there were no alternatives to accommodate the resident's smoking preferences while on isolation precautions.

Based on record review and interviews, the facility failed to ensure an alleged violation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#21) out of 2 (#21 and #94) residents investigated for abuse. Findings: Review of the facility's policy, Abuse and Neglect, revealed in part, the following, Policy: It is the policy of this facility to provide an environment for our residents that is free of abuse, neglect, exportation, self neglect or misappropriation of funds . Physical abuse is the hitting, slapping, pinching, burning, jerking, or shoving of a resident. Physical contact is abusive whenever touching a resident is not helpful . H) Reporting all alleged violations and all substantiated incidents to the states agency as per state policy. Report will be made to all applicable agencies in the time manner as applicable. Resident #21: Review of Resident #21's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Lack of Coordination, Parkinson's Disease, and Low Back Pain. Review of Resident #21's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 14, indicating her cognition was intact. Review of the facility's form titled, Complaint Form, completed by S2ADMAsst (Assistant Administrator) dated 02/07/2024, revealed in part, the following, Complaint: Complained that S10CNA (Certified Nursing Assistant) hit her in the face with some pants . Review of SIMS (Statewide Incident Management System) log for the last 6 months provided by the facility did not reveal Resident #21 on the log for the date of the incident on 02/07/2024. On 03/05/2024 at 3:27 p.m., a joint interview was conducted with S1ADM (Administrator) and S2ADMAsst. S2ADMAsst stated she conducted an investigation of alleged abuse for Resident # 21 on 02/07/2024. S1ADM and S2ADMAsst stated they did not report this alleged abuse to their state agency. After review of regulations with S1ADM and S2ADMAsst they confirmed they should have reported the allegation of abuse immediately, but not later than 2 hours to their state agency.

Based on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#57) out of 3 residents (#91, #10, and #57) investigated for respiratory care. Findings: Review of the facility's policy titled Policy: Nebulizer Mask, O2 (Oxygen) Tubings read in part, Policy: Equipment will be changed a minimum of monthly and prn (as needed), placed in a plastic bag with date changed. A. Respiratory Equipment: Place in plastic bag, (a zip lock bag is acceptable) with date changed . Resident #57 A review of Resident #57's clinical record revealed he was admitted on [DATE] with diagnoses that included Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertension, COPD (Chronic Obstructive Pulmonary Disease) and Centrilobular Emphysema. A review of Resident #57's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/05/2023 revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. Further Review of Resident #57's MDS Section O, Special Treatments, Procedures and Programs revealed he was coded for using oxygen during the 7 day lookback period. Review of Resident #57 revealed a physician's order dated 02/29/2024 that read in part, Oxygen at 2 liters per minute via mask at hs (hour of sleep) every evening shift for Hypoxemia and Dyspnea. On 03/04/24 at 10:05 a.m., an observation and interview was conducted with Resident #57. Resident #57's oxygen mask was uncovered on his oxygen tank and not place in a dated bag. He stated the mask was never placed in a bag when not being used. There was no bag observed in resident's room. On 03/05/2024 at 10:26 a.m., an interview was conducted with S5ADON (Assistant Director of Nursing) and she confirmed that Resident #57's oxygen mask was not in a bag on the morning of 03/04/2024 and that it should have been in a bag and dated with the date changed.