Every finding on record at Valley View Health Care Facility

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect the 77 residents who resided in the facility. The facility failed to ensure appropriate environmental cleaning and disinfecting solutions were used to disinfect surfaces throughout the facility. Findings: Review of a facility policy on 01/29/2026 at 3:20 p.m. titled, Standard Precautions with an effective date of 11/28/2016 revealed the following in part .Purpose: To prevent the spread of infections. 7. Disinfect or sterilize reusable equipment before use on another resident. Equipment: Disinfectant. Review of a facility policy on 01/29/2026 at 12:38 p.m. titled, Housekeeper Aide Description with an effective 04/15/2015 revealed the following in part . Must have knowledge of Infection Control; and knowledge of Material Safety Data Sheets. Clean floors, to include sweeping, dusting, damp, damp/wet mopping, stripping, waxing, buffing, disinfecting. Etc. Clean walls and ceiling by washing, wiping, dusting spot cleaning, disinfecting, deodorizing, etc. Remove dirt, dust, grease, film etc. form surfaces using proper cleaning/disinfecting solutions. Review of the facility's Safety Data Sheet on 01/29/2026 at 11:47 a.m. titled, Fabuloso All Purpose Cleaner Liquid Ocean Cool with a revision date 05/30/2019 revealed no evidence of disinfecting or sanitizing properties of the solution. Review of the facility's Fabuloso bottle labels on 01/29/2026 at 11:47 a.m. revealed the following information on the labels .Fabuloso All Purpose Cleaner; Kill Time: N/A; No EPA (Environmental Protection Agency) listing: Does not kill COVID.Observation on 01/29/2026 at 9:40 a.m. of a housekeeping cart, accompanied with S3 HSK Sup, revealed a labeled Fabuloso spray bottle. S3 HSK Sup revealed that Fabuloso was used daily for cleaning in the resident's rooms and throughout the facility. In an interview on 01/29/2026 at 10:23 a.m., S4 HSK revealed she had been working as a housekeeper for two months and was trained to use Fabuloso daily. S4 HSK revealed she used Fabuloso to wipe down bedside tables, bedrails, window seals, sinks, and countertops in resident rooms and throughout the facility. S4 HSK stated she did not wipe down these areas with any other chemical solution after wiping with Fabuloso. Observed a bottle of Fabuloso in S4 HSK's cart with a label that stated the following: NO EPA listing; Does not kill COVID; Kill Time N/A. S4 HSK stated she did not know if Fabuloso killed germs or disinfected anything and it made it smell good.In an interview on 01/29/2026 at 10:33 a.m., S1 Admin revealed that Fabuloso was used in the facility for odor control and the housekeepers would wipe down areas in the resident rooms with Fabuloso. S1 Admin stated that Fabuloso did kill germs. In an interview on 01/29/2026 at 10:55 a.m., S1 Admin provided the original bottle of the Fabuloso solution. Observed the original packaging label which read in part .Fabuloso Professional All-Purpose Cleaner and Degreaser. No evidence on the label that stated the solution killed germs or disinfected surfaces. In an interview on 01/29/2026 at 11:00 a.m., S1 Admin revealed he purchased the Fabuloso that did not have the anti-bacterial component within the solution. S1 Admin confirmed the facility had been using the wrong solutions to disinfect surfaces such as the bedside tables, dressers, counters, bed rails, and multi-touch surfaces in the resident rooms and throughout the facility for about 1 year. S1 Admin confirmed the housekeeping staff should had used the approved Micro-Kill Q3 concentrated disinfectant, Clorox Disinfecting wipes, and/or Germicidal wipes for disinfecting in the facility, not the Fabuloso he purchased.

Based on record reviews and interviews, the facility failed to transmit a completed MDS (Minimum Data Set) assessments within 14 days after completion for 1 (#8) of 1 residents reviewed. Findings: A review of a facility policy on [DATE] at 9:50 a.m., titled MDS Policy and Procedure revealed in part.Policy: All Minimum Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Review of Resident #8's medical record revealed an admission date of [DATE], Resident #8 expired in the facility on [DATE]. A review of Resident #8's Death in a Facility MDS, with an ARD (Assessment Reference Date) of [DATE], revealed it was completed on [DATE]. Further review revealed it was not transmitted and was 88 days overdue. In an interview on [DATE] at 2:23 p.m., S8 MDS LPN reviewed Resident #8's MDS and stated she was responsible for transmitting the MDS after completion. S8 MDS LPN confirmed she hadn't transmitted Resident #8's Death in Facility MDS within the required timeframe after completion but should have and confirmed it was 88 days overdue.

Based on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon discharge for 1 (Resident #23) of 5 sampled residents investigated for Resident Assessment.Findings: Review of facility policy on [DATE] at 2:25 p.m. titled, MDS Policy and Procedure with an effective date of [DATE] revealed the following part .All Minimum Data Sets (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. The Interdisciplinary Team will assess the resident and document during the 7 day look back and accurately complete the MDS according to the RAI manual. Review of Resident #23's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Further review of Resident #23's medical record revealed the last MDS conducted was a Quarterly MDS on [DATE] and there was no evidence that the Discharge MDS was completed. Review of Resident #23's nursing progress notes revealed that on [DATE] Resident #23 was sent to the emergency room and expired at the hospital that same day. In an interview on [DATE] at 2:09 p.m., S8 MDS LPN revealed she was assigned to complete Resident #23's Discharge MDS. In a record review with S8 MDS LPN, she revealed the last MDS completed for Resident #23 was a Quarterly on [DATE]. S8 MDS LPN confirmed the Discharge MDS for Resident #23 was not completed within the required 14-day timeframe but should have been.

Based on observation, record review and interview, the facility failed to ensure ADLs (activities of daily living) were performed for 1 (#57) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #40 received nail care. Findings: Review of the medical record for Resident #57 revealed an admit date of 05/21/2025 with diagnoses that included in part.Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Peripheral Vascular Disease, and Tobacco Use. Review of Resident #57's Quarterly MDS with an ARD of 11/18/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of the MDS revealed Resident #57 required supervision or touching assistance with personal hygiene. Review of Resident #57's current care plan revealed Resident #57 required staff assistance for ADL care related to needing assistance with ADLs and mobility. Interventions included in part, assist the resident with bathing, hygiene, and grooming tasks. Resident #57 was also at risk for skin impairment related to bladder and bowel incontinence at times. Interventions included in part, keep fingernails short. An observation on 01/27/2026 at 9:47 a.m. revealed Resident #57 was noted to have long fingernails to both hands with a brown unknown substance underneath them. Interview with Resident #57 revealed he wanted his nails cut and had asked staff to cut them previously. Resident #57 stated he was not a Diabetic. An observation on 01/28/2026 at 9:40 a.m. revealed Resident #57 was noted to have long fingernails to both hands. Interview with Resident #57 stated he had a bath yesterday but no one looked at his nails. Resident #57 stated that he had asked staff to cut his nails and would like his nails cut. In an interview on 01/28/2026 at 10:00 a.m. S10 CNA stated Resident #57 requires assistance with personal hygiene such as nail care. S10 CNA stated Resident #57's nail care is done on his shower days and that she doesn't cut his nails but can clean them. S10 CNA stated the treatment nurse is who cuts the residents nails. During interview with S10 CNA, Resident #57 walked and S10 CNA confirmed that Resident #57's nails were long and should have been cut. In an interview on 01/28/2026 at 10:08 a.m., S9 Treatment Nurse stated all residents in the facility have a standing order to receive nail care that includes cutting and trimming. S9 Treatment Nurse stated Resident #57 is not a Diabetic therefore all staff are responsible for cutting and trimming his nails. S9 Treatment Nurse confirmed Resident #57's nails should've been cut but was not. In an interview on 01/28/2026 at 10:28 a.m., S2 DON stated that CNAs can cut, trim, and file any resident that doesn't have a diagnosis of Diabetes. S2 DON stated the CNAs will usually ask S Treatment Nurse to go around and cut residents nails. S2 DON acknowledged that Resident #57's nails were long and should have been cut but was not.

Based on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide assistance with bathing for 1 (Resident #55) of 4 residents reviewed for ADLs. Findings:Review of Resident #55's medical record revealed an admit date of 08/06/2024 with diagnoses which included: Cellulitis of the Chest Wall, Unsteadiness on Feet, Depression, Tachycardia, Cardiac Arrest, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, End Stage Renal Disease, Ventricular Tachycardia, Implants and Grafts, and Blindness in the Right and Left eye Category 5. Review of Resident #55's Quarterly MDS with an ARD of 10/28/2025 revealed Resident #55 had a BIMs score of 15, indicating intact cognition. Resident #55 required partial/moderate assistance with bathing. Review of Resident #55's Care Plan, dated 11/12/2025, revealed that the resident required staff assistance with ADL care, including bathing. Review of the document titled POC Task Response History-Daily Bed Bath revealed in part. Resident #55 did not receive a bed bath on the following dates:12/29/2025- documented as not applicable01/19/2026- documented as resident not available01/23/2026- documented as resident not available On 01/27/2026 at 9:37 a.m., an interview with Resident #55 revealed that she was not consistently receiving her bed baths as scheduled. On 01/28/2026 at 2:58 p.m., an interview with S6 CNA Sup, confirmed that Resident #55 was scheduled to receive a bed bath daily and specifically prior to dialysis on Monday, Wednesdays, and Fridays. S6 CNA Sup confirmed that Resident #55 did not receive her scheduled bed bath on 12/29/2025, 01/19/2026, and 01/23/2026, but should have.

Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #78) of 25 sampled residents. Findings:Review of Resident #78's electronic health record revealed an admission date of 05/24/2024 with diagnoses which included: Osteoarthritis, Critical illness Myopathy, Age-Related Osteoporosis, Muscle Weakness, Repeated Falls, and Spinal Stenosis. Review of Resident #78's Quarterly MDS with an ARD of 10/14/2025 revealed a BIMS score of 8, indicating moderate cognitive impairment. Resident #78 required partial to moderate assistance with ADLs. Review of Resident #78's Physician Order dated 10/21/2025 read in part.fall mat to be placed on the right side of Resident #78's bed every shift for fall precautions. Review of Resident #78's comprehensive care plan with a review date of 01/12/2026 read in part.Resident #78 is at risk for falls. Interventions dated 10/21/2025 included an order to place a fall mat on the right side of Resident #78's bed. Review of Resident #78's Fall assessment dated [DATE] revealed a score of 11, indicating Resident #78 was at high risk for falls. On 01/28/2026 at 9:00 a.m., observation revealed no fall mat present on the right side of Resident #78's bed. On 01/29/2026 at 9:36 a.m., observation revealed no fall mat present on the right side of Resident #78's bed. On 01/29/2026 at 9:49 a.m., an interview with S5LPN confirmed that resident #78 had a physician order and had a care planned intervention that required a fall mat on the right side of the bed as a fall prevention measure. S5LPN confirmed through observation that the fall mat was not in place, but should have been.

Based on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident verbal abuse, for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #3, a cognitive resident, experienced mental anguish and psychosocial harm as a result of the verbal abuse by staff. This deficient practice resulted in an actual harm for Resident #3 on 02/27/2025 at 12:54 p.m., when Resident #3 reported to the Administrator that while in the activity room, S3 LPN confronted her (Resident #3), engaged in a verbal altercation with her, and shouted at her to shut her mouth. Resident #3, who had a BIMS score of 15 (cognitively intact), stated she was tearful, scared, and nervous during and after the verbal altercation with S3 LPN. As a result of the verbal abuse, Resident #3 was referred for, and received individual psychotherapy to address incident and improve anxiety. Findings: Review of the facility policy on 03/10/2025 at 1:00 p.m., and titled, Abuse-Prevention and Prohibition Policy and Procedure, with an effective date of 03/25/2023, revealed in part .Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. Policy: To provide a safe, abuse-free environment for all residents .I. Types of Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse, sexual abuse, physical abuse, and mental abuse includes abuse facilitated or enabled through the use of technology . Our policy presumes that abuse of any resident, even in a coma, causes physical harm, pain, or mental anguish. 1. Verbal Abuse is 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 or sight, regardless of the resident's age, ability to comprehend, or disability .Examples: a. Name calling, cursing, or yelling at a resident in anger. b. Threats of harm; saying things to frighten a resident . Review of Resident #3's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Type II Diabetes Mellitus with Diabetic Polyneuropathy, Major Depressive Disorder recurrent moderate, Obsessive Compulsive Behavior, Generalized Anxiety Disorder, and Insomnia. Review of Resident #3's Quarterly MDS with an ARD of 12/10/2024, revealed Resident #3 had a BIMS score of 15, which indicated cognition was intact. The MDS revealed Resident #3 required set up supervision for bed mobility, transfers, and eating, and one person physical assistance with toileting. The MDS revealed Resident #3 used a walker for ambulation and exhibited no behaviors. Review of Resident #3's Care Plan with a review date of 03/25/2025, read in part . The resident has Anxiety related to Anxiety Disorder, with interventions that included: approach the resident in a calm manner. Review of a Psychiatric Progress note dated 03/07/2025 at 1:00 p.m., read in part .Psych services were due to an incident with an employee. The patient had a verbal altercation with a particular nurse multiple times. The most recent incident the patient was verbally abused by this particular nurse. During today's assessment, the patient is sitting with peers in dining room, and getting ready to play bingo. She is cooperative, with an anxious mood and affect. She was able to recall events and states she felt this particular nurse was out to get her, and made comments towards her in front of other residents, and a hospice employee. She stated this made her scared and anxious. She feels that the symptoms are better today, but began to become tearful and anxious again when talking about it. Treatment plan: Referred for individual psychotherapy to address incident and improve Anxiety. Patient having difficulty processing this event. Review of a facility report dated 02/28/2025 at 12:40 p.m., revealed in part . on 02/27/2025 at 12:54 p.m., Resident #3 reported to S4 ADON that she wanted to file a complaint against S3 LPN. Resident #3 indicated that while she was in the activity room, S3 LPN came into the room and confronted her in front of other residents. Resident #3 reported that S3 LPN told her she was being sarcastic for making a comment to other residents. Interview with S1 Administrator on 03/11/2025 at 9:04 a.m., revealed Resident #3 was involved in two verbal altercations with S3 LPN. S1 Administrator revealed the first incident occurred on 02/23/2025, and was not reported by Resident #3 until 02/27/2025. S1 Administrator revealed on 02/23/2025 Resident #3 reported there were residents sitting at the entry of the activity room, so Resident #3 went around them. S3 LPN confronted Resident #3 and told Resident #3 she had been rude to the other residents. S1 Administrator revealed Resident #3 indicated that during the confrontation, S3 LPN told Resident #3 to shut her mouth in front of everyone. S1 Administrator revealed he asked Resident #3 why hadn't she reported the incident, and Resident #3 replied if it happened again she was going to report S3 LPN. S1 Administrator stated on 02/27/2025 at 1:10 p.m., Resident #3 reported to S4 ADON that she was ambulating to the activity room and a resident was sitting close to the entrance of the door, so Resident #3 stated I better go around the other way, I don't want to get into trouble again. S1 Administrator revealed Resident #3 entered the activity room and sat at the table. S1 Administrator revealed S3 LPN entered the activity room, and approached Resident #3 and called her sarcastic in front of the other residents. S1 Administrator revealed a hospice employee was in the activity room and witnessed the incident. S1 Administrator revealed he watched the video surveillance (no audio), for both incidents and witnessed interactions between Resident #3 and S3 LPN. S1 Administrator revealed Resident #3 was crying and upset during interview. S1 Administrator revealed S3 LPN was terminated on 02/28/2025. Interview on 03/11/2025 at 11:15 a.m. with Resident #3, revealed that on 02/23/2025 (no time), she went to the activity room to play bingo. Resident #3 revealed there were several other residents seated near the entrance, and she said Oh my goodness, I better go around the other way. Resident #3 revealed S3 LPN entered the activity room, and confronted her, and told her she had been rude to the other residents. Resident #3 stated she attempted to explain what happened, and S3 LPN told her to shut her mouth. Resident #3 revealed she did not report this incident to anyone. Resident #3 revealed the second incident was on 02/27/2025, when she went to play bingo in the activity room. Resident #3 revealed there were several residents at the entrance door to the activity room, and she said I better go around before I get into trouble again. Resident #3 revealed S3 LPN confronted her at this time and yelled at her you're sarcastic. Resident #3 stated that she became tearful and afraid, and asked S3 LPN Why are you treating me like this? What have I done to you? Resident #3 stated S3 LPN replied everyone else might be scared to stand up to you, but I'm not. Resident #3 stated she repeatedly asked S3 LPN to go away and leave her alone; however, S3 LPN continued badgering her. Resident #3 revealed S3 LPN looked at her as if she (S3 LPN) could have killed her, and she (Resident #3) was very scared. Resident #3 revealed R1 and a Hospice Volunteer Coordinator witnessed the verbal altercation. Resident #3 stated she told S3 LPN that she was going to report her to S1 Administrator. S3 LPN then laughed in her face and replied No, you're not because he (S1 Administrator) is not here. Resident #3 stated she was fearful. Resident #3 was observed visibly upset, nervous, and shaking throughout the interview. Resident #3 stated that she was afraid that S3 LPN might come through her window at night and kill her. Interview on 03/11/2025 at 12:05 p.m. with S4 ADON revealed that on 02/27/2025 at approximately 1:00 p.m., Resident #3 reported to her that she walked to the activity room to play bingo, and a resident's foot blocked the entrance way. Resident #3 stated she went around the other resident so she wouldn't get into trouble. Resident #3 stated S3 LPN, who was sitting at the nurses' station, walked into the activity room, and yelled at Resident #3 that she was being sarcastic. S4 ADON stated that Resident #3 said she's (S3 LPN) after me and was tearful and anxious. S4 ADON stated that Resident #3 then reported an incident that occurred o02/23/2025, when S3 LPN told her to shut her mouth. S4 ADON stated Resident #3 informed her that she had not reported the 02/23/2025 incident to anyone. Interview with S5 CNA/Unit Coordinator on 03/11/2025 at 12:12 p.m., revealed she was in the day room attending to a resident after lunch on 02/27/2025. S5 CNA/Unit Coordinator revealed she observed Resident #3 walk through the TV room to enter the activity room. Resident #3 stated, I don't want to get into trouble again. S5 CNA/Unit Coordinator revealed S3 LPN was at the nurse's station and overheard Resident #3's comment. S5 CNA/Unit Coordinator revealed S3 LPN entered the activity room, then Resident #3 and S3 LPN passed words. S5 CNA/Unit Coordinator stated that she didn't remember the words that were spoken, and Resident #3 was very upset at that time. Telephone interview on 03/11/2025 at 1:37 p.m. with the Hospice Volunteer Coordinator revealed the following: She was at the facility after lunch on 02/27/2025 to call bingo for the residents. Resident#3 came into the activity room and sat down. S3 LPN entered the activity room, approached Resident #3, and said, I heard the smart comment you made when you passed the nurse's station. Resident #3 said I didn't say that, and S3 LPN replied to Resident #3, I heard you, you're mad because you've met someone that's going to stand up to you. Resident #3 then asked S3 LPN to go away and leave her alone; but, S3 LPN continued to make comments to Resident #3. Resident #3 asked S3 LPN, Why are you so mean to me?, and repeatedly pleaded with S3 LPN to leave her alone. Resident #3 was tearful and very upset. S3 LPN's voice became loud and aggressive as S3 LPN continued talking to Resident #3. Hospice Volunteer Coordinator revealed Resident #3 became too upset to play bingo. Interview on 03/11/2025 at 3:12 p.m. with R1 who had a BIMS score of 13, (which indicated intact cognition), revealed Resident #3 was seated in the activity room when S3 LPN entered, and yelled at Resident #3 that she was sarcastic. R1 revealed another incident happened the previous weekend when S3 LPN told Resident #3 to shut her mouth. R1 stated Resident #3 was shaking, crying, and asked R1 for help. R1 revealed she accompanied Resident #3 when she reported the incident to S4 ADON. R1 revealed on 02/27/2025, as they were waiting to speak with S4 ADON, S3 LPN exited S4 ADON's office and told Resident #3, I guess you're happy now. R1 stated that Resident #3 was still nervous and upset after the incident occurred. Interview on 03/11/2025 at 3:51 p.m. with S1 Administrator, confirmed that S3 LPN did verbally abuse Resident #3 on 02/23/2025 and 02/27/2025. Telephone Interview on 03/12/2025 at 11:41 a.m. with S3 LPN, revealed on 02/23/2025 there were residents waiting to play bingo, and she heard a commotion. S3 LPN revealed she left the nurse's station to see what was going on. S3 LPN revealed two other residents said that Resident #3 had said something to them, and they were upset. S3 LPN revealed she approached Resident #3 in the activity room, and asked her if she said anything ugly to the two residents, and if she had said something ugly, not to do it again. S3 LPN revealed Resident #3 became upset, and wouldn't stop talking. S3 LPN confirmed she told Resident #3 to shut it. S3 LPN revealed Resident #3 said, So you want me to shut my mouth? and she replied to Resident #3, Yes. S3 LPN revealed that on 02/27/2027, she overheard from the nurse's station Resident #3 say, I'll go around the other way, I don't want to get accused again. S3 LPN revealed she went into the activity room and told Resident #3 she shouldn't have made that remark, and that it was unnecessary. S3 LPN stated, I shouldn't have said anything to Resident #3, and I should have just let it go. S3 LPN confirmed that Resident #3 was still upset and witnessed Resident #3 cry after the verbal altercation that occurred on 02/27/2025.

Based on interview and record review the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident verbal abuse was discovered, for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Interview on 03/11/2025 at 3:51 p.m. with S1 ADM revealed on 02/27/2025 at 12:45 p.m., Resident #3 was verbally abused by S3 LPN. S1 ADM revealed this incident of staff to resident verbal abuse was witnessed by a Hospice Volunteer Coordinator and R1. Review of the SIMS (Statewide Incident Management System) report dated 03/06/2025 revealed the discovery date and time of verbal abuse for Resident #3 was on 02/27/2025 at 12:54 p.m. The SIMS entry time was documented as 02/28/2025 at 12:40 p.m. Interview on 03/11/2025 at 3:51 p.m. with S1 ADM confirmed a SIMS report was not entered immediately or within 2 hours after discovery of abuse.

FACILITY Infection Control Based on observations, staff interviews and facility policy record reviews, the facility failed to maintain an 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. These deficiencies had the potential to effect 73 residents that resided in the facility. The facility failed to: 1. Ensure the lint drawers on the clothes dryers and the washing machine filters were regularly cleaned; 2. Ensure proper PPE use and infection control measures were used when performing wound care for Resident #32; and 3. Have a water management program in place that specified testing protocols and acceptable ranges for control measure, and the results of testing and corrective actions taken when control limits were not maintained. Findings: Observation during tour of the facility's laundry department on 10/30/2024 at 11:00 a.m. revealed lint drawers of both dryers were dirty, lint traps completely full of lent with an excessive amount of lint that fell out onto the floor when the lint drawers were opened. S7 Laundry/ Housekeeping revealed the night shift must not have emptied it out after using the dryer. S7 Laundry/ Housekeeping revealed the washing machine filters were dirty and are supposed to be cleaned by maintenance but was not done. Interview in the facility's laundry department on 10/30/2024 at 11:20 a.m. with S5 Maintenance Supervisor revealed he had cleaned the washer filters and the lint drawers with a shop vacuum last week. Interview on 10/30/2024 at 11:45 a.m. in the facility's laundry room with S6 Housekeeping Supervisor revealed the laundry housekeeping staff are responsible for cleaning the lint drawer traps after every 3-4 loads that are dried. S6 Housekeeping Supervisor opened both dryer lint drawers with lint fell out onto the floor and confirmed that both of lent drawer traps were dirty with the lint traps completely full of lint. S6 Housekeeping Supervisor confirmed the washing machine filters were dirty and the dryer lint drawer traps should have been cleaned after 3-4 loads and was not done. 46773 Review of the Facility's Wound care policy titled Dressing Change (Wound Care), Clean Policy and Procedure on 10/30/2024 with a revision date of 10/30/2024 read in part . Purpose: 1. To Protect wound 2. To prevent irritation 3. To prevent infection and spread of infection 4. To promote healing Procedure: 12. Perform hand hygiene 13. Apply disposable gloves 14. Pour prescribed solution onto gauze to be used for cleaning 15. Cleanse wound with prescribed solution 16. Remove disposable gloves and discard them into biohazard 17. Perform hand hygiene Resident #32 Review of Resident #32's 10/2024 Physician Orders read in part . 10/15/2024-Cleanse Stage III Pressure area to right heel with Dakin's (pat dry), apply Santyl, then calcium alginate, then Gentian [NAME] to periwound area, and pad with abdominal pad then wrap with gauze roll daily Monday-Friday until resolved. An observation of wound care for Resident #32 on 10/30/2024 at 9:25 a.m. revealed S3 RN providing wound care to right foot pressure ulcer. S3 RN was observed cleaning the right heel wound with a 4x4, discarded soiled 4x4, obtained a new 4x4 from the clean field and cleansed the wound with soiled gloves two more times without discarding gloves and cleansing hands. An interview on 10/30/2024 at 2:55 p.m., S2 RN was notified by this surveyor that she failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and cleansing the wound. S2 RN confirmed that she should have removed the soiled gloves and sanitized her hands after discarding the soiled 4x4 and obtaining the new 4x4 to continue to cleanse wound, but did not. 51096 Review of the facility's Water Management Program Facility assessment dated [DATE] revealed the hot water temperatures at plumbing fixtures used by residents are automatically regulated by control valves to assure a temperature between 110 and 120 degrees Fahrenheit at the faucet outlet . Review revealed the person responsible for ensuring/monitoring this was the Administrator. Review of the facility's Water Management Program not dated revealed the water management team will consist of the following staff members . Administrator and Assistant Director of Nursing/ Infection Preventionist. Review revealed Control measures have been put into place such as . taking water temperature throughout facility in resident room and shower rooms; Should control limits meet criteria for not meeting standards the equipment in question will be shut down and troubleshooting will commence; testing of water for bacteria, flushing system, notifying the Municipal Supplier will take place. Review of the water temperature log for August 2024 revealed 66 out of 68 temps in resident's room out of range; review of water temperature logs for September 2024 revealed 68 out of 68 temps in resident's rooms out of range and review of water temperature logs for October 2024 revealed 63 out of 68 temps out of range specified in the water management program with no interventions listed. Interview on 10/30/2024 at 2:15 p.m. with S11 ADON who has been the Infection Preventionist for one year revealed that S1 Administrator was in charge of the Water Management Program. Interview on 10/30/2024 at 03:50 p.m. with S1 Administrator revealed that housekeeping collects the temperature checks on all rooms in the facility monthly. S1 Administrator revealed that he then reviews the logs and must have overlooked the temperatures that were out of range and did not take any corrective actions. Interview on 10/30/2024 at 4:11 p.m. with S8 Regional Administrator revealed the facility has a water management program but does not have a policy in place that specifies testing protocols and acceptable ranges for control measures or documenting the results of testing and corrective actions taken when control limits are not maintained.

FACILITY Based on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 3 2024 (April 1- June 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 3 2024 (April 1- June30) revealed the facility triggered for Excessively Low Weekend Staffing and No RN Hours on 04/13/2024, 04/27/2024, 06/29/2024, and 06/30/2024. Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/30/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report revealed the facility provided more hours than required of nursing coverage and the required RN hours on 04/13/2024, 04/27/2024, 06/29/2024, and 06/30/2024. During an interview on 10/30/2024 at 9:34 a.m., S4 HR (Human Resources) reported she gives the PBJ information to the facility's corporate office who then submits the PBJ information to CMS. S4 HR indicated the discrepancy may have been due to agency staffing hours not being counted. During an interview on 10/30/2024 at 12:40 p.m. S1 Administrator reported the facility's corporate office submits the PBJ to CMS based on the information S4 HR submits to the corporate office. S1 Administrator reported he did not know why the incorrect information was submitted to CMS.

Based on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#48) of 22 sampled residents by failing to connect the clip alarm and monitor the alarm sounding sensor pad while Resident #48 was up in the wheelchair. Findings: Review of Resident #48's clinical record revealed an admitted [DATE]. Resident #48's diagnoses included Edema, unspecified, Disorientation, unspecified, Localized edema, Unilateral primary osteoarthritis, left hip, Polyosteoarthritis, unspecified, Other lack of coordination, Muscle wasting and atrophy, not elsewhere classified, multiple sites, Muscle weakness (generalized), Difficulty in walking, not elsewhere classified, Rheumatoid arthritis, unspecified, Age-related osteoporosis without current pathological fracture. Review of Resident #48's Significant change MDS with an ARD of 10/08/2024 revealed a BIMS of 7, indicating severe cognitive impairment. Resident #48 was dependent for Toileting hygiene, Lower body dressing and putting on/ taking off footwear. Resident #48 required substantial/ maximal assist with showering/bathing. Resident #48 required partial/moderate assist with upper body dressing and personal hygiene. Resident #48 was dependent for chair to bed transfer and tub/shower transfer. Sit to stand transfer, toilet transfer and walking 10 feet once standing was not attempted for Resident #48 d/t medical concern/safety. Resident #48 used a Bed and Chair alarm daily. Review of Resident #48's physician's orders dated 05/13/2024 and 05/06/2024, read in part Clip alarm while up in wheelchair and Sensor pad to wheelchair. Review of Resident #48's Care Plan revealed in part . The resident is at risk for falls r/t impaired mobility, weakness, Type II DM, RA, OP, Difficulty walking, Unsteadiness on feet, Diuretic medication use, hx of falls. Fall interventions in place. Interventions included: Alarm sounding clip alarm to w/c as fall intervention; staff to monitor safety alarm sounding sensor pad and grip liner maintained to w/c as fall intervention; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and follow facility fall protocol. Observation of Resident #48 on 10/29/2024 at 09:05 AM revealed Resident #48 sitting in wheelchair in front of the television. Clip alarm noted hanging from left handle of wheelchair, not connected to alarm sensor pad. Interview with S10 CNA on 10/29/24 at 09:43 AM revealed that she was responsible for checking the resident's chair alarm. Interview and observation on 10/29/24 at 09:36 AM, S3 RN stated S10 CNA was responsible for Resident #48's care that day. S3 RN revealed that the clip alarm was not connected and it should have been.

Based on interview, observation and record review, the facility failed to implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 resident (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure a positioning device was provided as ordered for Resident #1 with hand contractures. Findings: Review of Resident #1's Medical Record revealed an admitted [DATE] with diagnoses that included in part: Cardiovascular Disease, Transient Cerebral Ischemic Attack, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Primary Generalized Osteoarthritis, Generalized Muscle Weakness, Contracture, Right Hand and Contracture, Left Hand. Review of Resident 1's 03/2024 Physician's Orders revealed orders in part: 08/25/2023 - Carrot roll to right hand daily. 07/06/2023 - Carrot roll to left hand daily. Review of Resident #1's Quarterly MDS with an ARD of 11/16/2023 revealed a BIMS score of 99. Resident was severely cognitively impaired, rarely made decisions and unable to complete BIMS. Review of Resident #1's Care Plan with a Target date of 06/26/2024 revealed in part: Resident #1 with limited ROM and at risk for skin breakdown related to Diagnoses of Contractures Right and Left hand, bilateral. Interventions included in part . Carrot roll bilateral hands daily. Observation on 03/25/2024 at 9:30 a.m. revealed Resident #1 lying in bed with a carrot roll to her left hand contracture. Resident #1's right hand contracture observed without a carrot roll or positioning device in place. Observation on 03/25/2024 at 1:30 p.m. revealed Resident #1 lying on her left side in bed with a carrot roll noted to her left hand contracture. Resident #1's right hand contracture observed without a carrot roll or positioning device in place. Interview at the time of observation with S5 CNA revealed she did not know where Resident #1's carrot roll for her right hand was. Observation on 03/26/2024 at 7:50 a.m. revealed Resident #1 did not have a hand carrot roll to her right hand contracture. Observation on 03/26/2024 at 8:30 a.m. revealed Resident #1's right hand contracture without a carrot roll in place. Interview on 03/26/2024 at 8:30 a.m. in Resident #1's room with S5 ADON confirmed Resident #1 did not have her carrot roll in place to her right hand contracture and should have.

Based on record review and interview the facility failed to ensure a reportable unwitnessed and/or incident of unknown origin was thoroughly investigated for 1 Resident (Resident #2) of 3 sampled Residents (Resident #1, Resident #2, and Resident #3). The facility failed to investigate an incidence of Resident #2's injury of unknown origin. Findings: Review of the facility's policy and procedure titled Abuse Prevention and Prohibition with an effective date of 03/25/2023 revealed in part: II. Procedures 5. Investigation: Administrator completes a thorough investigation, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. The investigator interviews the resident if the resident is cognitively able to answer questions. If the residents is not able to be interviewed, the investigator interviews any roommate. The investigator maintains a private and confidential file in the administrator's office. Review of the EHR (Electronic Health Record) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included in part: Major Depressive Disorder, recurrent severe with psychotic symptoms, Delusional Disorders, Bipolar disorder, current episode manic severe with Psychotic features, acute on chronic systolic Congestive Heart Failure, Anxiety Disorders, Type 2 Diabetes Mellitus and Alzheimer's Disease. Review of the facility's incident reports revealed on 02/18/2024 at 11:46 a.m., Resident #2 had an unwitnessed fall in her room with no head injury. Resident #2 was noted to bruising to her left elbow and hip with no complaint of pain and/or discomfort. Resident #2's Physician and RP (responsible party) were notified. On 02/19/2024 at approximately 2:40 p.m., an unobserved fall with no apparent injury was reported. Resident #2 was noted lying on the fall mat, assessed by the nurse with no injuries and denied any pain and/or discomfort. Nurse Practitioner notified with no new orders and RP was notified. Review of the Physician's Telephone orders revealed on 02/20/2024 a 12:00 p.m., the Nurse Practitioner ordered an X-ray of left femur, tibular/fibular X-ray due to left hip pain. Review of Resident #2's Radiology Interpretation report dated 2/20/2024 revealed significant findings: Left Femur 2 Views - There is an acute-appearing fracture of the inter-trochanteric left femur. There is mild displacement of the distal fragment. There are no gross lytic or blastic lesions in the bones. There is no abnormal radiopaque foreign body. Interview on 03/27/2024 at 5:05 p.m. with S2 DON revealed the facility was not able to determine the root cause nor when and how the fracture occurred. S2 DON confirmed a thorough investigation was not conducted by the facility and should have been.

Based on record review and interview the facility failed to ensure a reportable unwitnessed and/or incident of unknown origin was reported to the State Agency for 1 Resident (Resident #2) of 3 sampled Residents (Resident #1, Resident #2, and Resident #3). The facility failed to report an incidence of Resident #2's injury of unknown origin. Findings: Review of the facility's policy and procedure titled Abuse Prevention and Prohibition with an effective date of 03/25/2023 revealed in part: II. Procedures 7. Reporting/Response: The Administrator shall immediately initiate a SIMS (Statewide Incident Management System) report to the Louisiana Department of Health and the facility local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse or results in serious bodily injury; or no later than 24 hours after forming the suspicion if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury. Review of the EHR (Electronic Health Record) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included in part: Major Depressive Disorder, recurrent severe with psychotic symptoms, Delusional Disorders, Bipolar disorder, current episode manic severe with Psychotic features, acute on chronic systolic Congestive Heart Failure, Anxiety Disorders, Type 2 Diabetes Mellitus and Alzheimer's Disease. Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/01/2024 revealed she was coded as being severely impaired for cognitive decision making, and required 2+ persons physical assistance for transfers. Review of Resident #2s Comprehensive Plan of Care revealed a problem of at risk for falls. Interventions included fall mat on right side of the bed, bed in low position, gripper socks while in bed, sensor pad to bed/recliner, bed alarm with perimeter mattress, and staff education on fall/safety monitoring. Review of the facility's incident reports revealed on 02/18/2024 at 11:46 a.m., Resident #2 had an unwitnessed fall in her room with no head injury. Resident #2 was noted to bruising to her left elbow and hip with no complaint of pain and/or discomfort. Resident #2's Physician and RP (responsible party) were notified. On 02/19/2024 at approximately 2:40 p.m., an unobserved fall with no apparent injury was reported. Resident #2 was noted lying on the fall mat, assessed by the nurse with no injuries and denied any pain and/or discomfort. Nurse Practitioner notified with no new orders and RP was notified. Interview on 03/27/2024 at 5:05 p.m. with S2 DON revealed S1 ADM was responsible for opening SIMS reports. S2 DON stated as far as she could recall, No SIMS Report was opened for Resident #2 who sustained a left femur fracture after being found on the floor in her room on 02/18/2024 and 02/19/2024. S2 DON stated it was not until 02/20/2024 that Resident #2 complained of pain of the left hip, that an X-ray was ordered. The X-ray revealed a fracture left femur. Interview on 03/27/2024 at 5:13 p.m. with S1 ADM confirmed there was no SIMS Report opened for Resident #2. S1 ADM revealed he didn't feel like it was an injury of unknown origin. S1 ADM confirmed because Resident #2 had 2 consecutive falls on 02/18/2024 and 02/19/2024 prior to confirmation of a left femur fracture on 02/202/2024. S1 Adm. stated it was not until 02/20/2024 did Resident #2 complain of left hip pain. S1 ADM revealed it was not known when and how Resident #2 sustained a fracture to her left hip.

Dining Observation Based on observation and interview 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 by failing to provide meals to 2 of 4 Residents at a table, who were seated at the same time. Observation on 11/07/2023 at 11:25 a.m. revealed dining tables in Dining Room B were not served together. Two of the Residents in the dining room had been served a meal while two other Resident's seated at the same dining table without a meal tray. Observation on 11/07/2023 at 11:35 a.m. revealed two Residents being fed by CNAs in Dining Room B together and the other two Residents sitting at the same dining table waiting on their meal tray. Interview at this time with S8 CNA stated the kitchen had finished serving the feeders trays and started serving the trays for the Residents in the main Dining room A. Residents were in Dining Room B when meal service started. Observation on 11/07/2023 at 11:40 a.m. revealed S9 CNA arrived to Dining Room B with the meal cart. S8 CNA and S9 CNA removed the lunch trays from the meal cart and served to the remaining two Residents sitting at the dining table. Fifteen minutes elapsed before the two Residents were served a lunch tray. Interview on 11/07/2023 at 11:40 a.m. with S7 CNA SUP stated the kitchen had finished serving the feeders trays before staff noticed that two Residents did not have a lunch meal tray. Interview on 11/07/2023 at 11:45 a.m. with S6 LPN stated the residents sitting at the same table are usually served together and did not know why they were not served together today. S6 LPN confirmed the Residents sitting at the same dining table should have their meals served and fed together but was not.

Based on observation, interview, and record review the facility failed to ensure a residents' rights to be free from physical abuse for 1 (#31) of 3 (#31, #73 and #284) residents sampled for abuse, in a total sample of 28 residents. The facility failed to protect Resident #31 from physical abuse by Resident #284. 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 policy titled: Abuse - Prevention and Prohibition read in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Resident to Resident altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's mental status and notify the physician for a determination regarding treatment and/or discharge options. The safety of other residents and employees of the facility is of primary concern. Resident #31 Review of Resident #31's EHR revealed an admitted [DATE]. Diagnoses included in part . Parkinson's Disease, Cognitive Communication Deficit, Muscle Weakness, Dementia, Aphasia, Major Depressive Disorder, and Generalized Anxiety. Review of Resident #31's Quarterly MDS with an ARD of 09/12/2023 revealed Resident #31 had a BIMS score of 99 (unable to complete interview). The MDS revealed Resident #31 required 2 person physical assist for bed mobility, dressing, transfers, and toileting; and 1 person physical assist for eating, and locomotion on and off the unit. The MDS revealed Resident #31 had no behaviors. Review of Resident #31's Comprehensive Person Centered Care Plan with a target date of 12/19/2023 revealed in part . Resident #31 required secure unit placement related to requiring a small structured environment. Interventions included: placing Resident #31 in an area where observation was possible. Resident #31 had altered mood state related to his diagnoses. Interventions included observe for changes in mood status. Review of Resident #31's plan of care revealed there were no problems identified regarding abuse or abusive behaviors. Observation on 11/07/2023 at 8:35 a.m. of Resident #31 in the dining area of Unit X revealed Resident #31 was unable to answer surveyor questions. Resident #284 Review of Resident #284's EHR revealed an admitted [DATE]. Resident #284 had diagnoses that included in part . Parkinson's Disease, Acute Kidney Failure, Neurocognitive disorder with Lewy Bodies, Depression, Anxiety, and Unspecified Mood Disorder. Review of Resident #284's Quarterly MDS with an ARD of 03/07/2023, revealed Resident #284 had a BIMS of 99 (unable to complete interview). The MDS revealed Resident #284 required 2 person physical assist with bed mobility, transfers, and toileting; and 1 person physical assist for locomotion on and off unit, dressing, eating, and personal hygiene. The MDS revealed Resident #284 had no behaviors including physical behavior symptoms directed towards others, and utilized a wheelchair for locomotion. Review of Resident #284's Comprehensive Person Centered Care Plan with a target date of 06/07/2023, revealed a problem of exhibited behaviors of restlessness, and agitation. A Care Plan update on 11/19/2022 read in part .Had an altercation with another resident on 11/19/2022. Physician ordered inpatient psych evaluation. admitted to behavioral health hospital on 11/22/2022 and returned 12/05/2022 with noted med changes. Care Plan update on 03/07/2023 read . No behaviors noted during lookback period. Review of an Incident Report dated 11/19/2022, revealed the following in part . a Resident to Resident altercation occurred on 11/19/2022 when Resident #284 slapped Resident #31. On 11/19/2022 at approximately 7:20 p.m., S3 CNA and S4 CNA were observing residents on Unit X, when Resident #284 got up out of his wheelchair, walked over to Resident #31, and began slapping at Resident #31 in the facial area. S3 CNA and S4 CNA immediately redirected Resident #284 and separated the two residents. Resident #284 was assessed by the nurse with no injuries noted. Resident #31 was assessed by the nurse and noted to have redness to his right upper neck area. The physician was notified of the incident. Resident #284 was ordered to be transferred to a local ED for psych evaluation, and Resident #31 was placed on observation for monitoring. The surveyor was unable to obtain interviews with S3 CNA and S4 CNA, as they are no longer employed at the facility. Interview on 11/07/2023 at 8:25 a.m. with S5 LPN, who is a nurse on Unit X, revealed she began working at the facility in September 2023, so she was not aware of Resident #31's altercation on 11/19/2022. S5 LPN stated that Resident #31 currently resides on Unit X, and receives Hospice services. S5 LPN stated Resident #31 did not communicate verbally, and that the current residents on Unit X did not display aggressive behaviors. Interview on 11/07/2023 at 2:20 p.m. with S2 DON revealed she recalled the incident that occurred on 11/19/2022 between Resident #31 and Resident #284. S2 DON stated the facility substantiated findings of physical abuse as staff witnessed Resident #284 slap Resident # 31. S2 DON stated Resident #284 passed away in March of 2023. S2 DON stated Resident #31 had no injuries from the incident, and did not exhibit any emotional changes or changes in his mood following the incident on 11/19/2022. Interview on 11/07/2023 at 3:40 p.m. with S2 DON revealed the facility had implemented corrective actions following the 11/19/2022 altercations between Resident #284 and Resident #31. S2 DON stated Resident # 284 was sent to a local ED for psych evaluation on 11/19/2022. S2 DON stated Resident #284 was admitted to an inpatient behavioral health hospital on 11/22/2022, and returned to the facility on [DATE]. S2 DON stated Resident #284 was not ambulatory and was admitted to hospice upon his return to facility on 12/05/2022. S2 DON stated the facility continued to monitor Resident #284 for behaviors, and Resident #284 had no behaviors following his re-admission to facility on 12/05/2022. The facility implemented the following actions to correct the deficient practice: 1. Resident #31 and Resident #284 were separated and placed on 1:1 monitoring immediately on 11/19/2022. 2. Resident #31 and #284 were counseled by the facility's charge nurse regarding the incident to prevent further altercation. 3. Each resident's physician and responsible party were notified regarding the incident. 4. Resident #31 had redness to his upper neck area after the incident, and has had no further injuries. 5. Resident #284's physician was notified, and orders were received to send the resident to a local ED for psych evaluation on 11/19/2022. Resident #284 returned back to the facility on [DATE] following evaluation, with no signs/symptoms of aggressive behavior, no new orders were given. Upon his return to the facility, Resident #284 was kept separated from Resident #31, and monitored on a 1:1 basis until he was sent to a Behavioral Health Hospital on 11/22/2023. 6. On 11/22/2022, due to his behavior on 11/19/2022, Resident #284's physician referred him to a Behavioral Health Hospital for in-patient evaluation. Resident #284 was admitted on the same day, and returned to the facility on [DATE]. No further behavioral issues has been noted from Resident #284 since his return from the behavioral hospital. 7. The facility's Abuse policy was reviewed with no changes required to the facility's Abuse policy. 8. On 11/20/2023, Facility administration initiated Departmental In-services/training on Abuse Prevention and Prohibition Policy, Resident Rights, Memory Care Neighborhood Residents, and 1:1 supervision of Resident #284 on Unit X. All inservices/training completed for all facility staff as of 11/21/2022. 9. The Facility's Ombudsman will be notified of incident upon their next facility visit. 10. QA committed met on 11/20/2022 to discuss the resident to resident altercation that occurred on 11/19/2022 between Resident #31 and Resident #284. Resident to Resident altercations on Unit X was monitored by the DON as part of the facility's QAPI. Monitoring began on 11/19/2022 and occurred daily for the first week, and continued weekly for 4 weeks. There were no further incidences on the unit. There have been no other incidences of abuse at the facility. Facility correction date of 11/21/2022.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions 2) ensure food stored was dated and expired food was disposed of and 3) preparation equipment was clean. This deficient practice had the potential to affect the 64 Residents that received meals prepared in the kitchen. Findings: Review of the Facility's Policy & Procedure titled Cleaning and Sanitation of dining and food service areas read in part: Policy: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Procedure: Staff will be trained on the frequency of cleaning as necessary. A cleaning schedule will be posted for all cleaning task, and staff will initial the tasks as completed. Staff will be held accountable for cleaning assignments Sample cleaning schedule- After each use: mixers, dishes, pots/pans Twice per month: ice machine. Review of the Facility's Policy titled Cleaning Instructions: Ice machine and Equipment read in part: Policy: Ice machine and equipment . be cleaned and sanitized on a regular basis. Clean the exterior of the machine with a detergent solution daily. Rinse and allow to air dry. Clean the area underneath and around the machine. Observation on kitchen on [DATE] at 8:40 a.m. accompanied by S7 Dietary Manager revealed: 1. (48) serving tray stacked on top of each other on the serving line were note to be wet. 2. (4) large cooking pots and stored under food the prep table were noted to be wet and ,d+[DATE] pots were noted to have dried greenish and yellow substance on the sides and bottoms of the pots. 3. (12) 14 inch pans were stored under the food prep table wet. 4. (number of plastic salad bowls) stacked inside one another were stored in a large plastic container wet. 5. Food Processor stored on a stationary stainless steel cart was stored wet with dried pale yellow color substance around the outside top and inside the plastic container. 6. Mixer was stored on a stationary stainless steel cart was stored with dried pale yellow substance on the flat wire whip beaters with food remnants to inside and outside of machine 7. 2 large cooking pots hanging on hooks from a bracket were stored with dried dark brown substances. 8. 5 metal serving spoons stored in a drawer under the food prep table was noted to have old dried yellowish, white, and/or dark brown substances on them. 9. (2) cereal bowls were noted in a plastic container were stored with dried yellowish substance inside each and the storage container was noted to have dark grayish and black trash particles. 10. (5) 8 packs of hot dog buns with an expiration date of [DATE] were stored in the freeze. 11. (1) 24 pack of Hamburger buns were on a tray on the food prep table with an expiration date of [DATE] was being thawed out for use. 12. (1) Upstate yogurt with an expiration date of [DATE] was located in the refrigerator. 13. (2) 4 ounce containers of prune juice were located in the outside storage with an expiration date of [DATE]. 14. (9) bowls of cereal stored in a plastic container on corner of food prep table were filled with cereal covered with saran wrap undated. The following food items were opened, undated, and expired were stored in the dry storage area: (1) loaf of wheat bread with an expiration date of [DATE]. (3) large bags of cereal: crispy rice, fruit whirls, cornflakes were opened and not dated. Interview on [DATE] at the time of the observations accompanied by S7 Dietary Manager, confirmed the above findings.

Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 2 of 3 medication carts. Findings: Observation of the Wing A medication cart on 10/11/2022 at 2:50 p.m. accompanied by S5 LPN revealed it contained the following items: 1 tube of [MEDICATION(S)] Sodium 100g gel with an expiration date of 10/01/2022 and 1 opened tube of [MEDICATION(S)] Sodium 100g gel with no cap. Further observation revealed the presence of 4 loose pills in the second medication drawer. At the time of observation, S5 LPN confirmed there should not be expired, open, or loose medications on the medication cart. Observation of the Wing B medication cart on 10/11/2022 at 3:00 p.m. accompanied by S2 LPN/MDS Coordinator revealed it contained the following items: 1 opened 90 count bottle of [MEDICATION(S)] vitamins with an expiration date of 08/2022 and 1 opened 16g bottle of [MEDICATION(S)] Nasal spray with an expiration date of 09/2022. At the time of observation, S2 LPN/MDS Coordinator acknowledged expired medications should not be on the medication cart.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#36 and #268) of 2 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was stored properly. Findings: Review of the facility policy titled: Nebulizer Machine Cleaning Policy and Procedure, revealed in part 1. Store tubing, mouthpiece, and mask in plastic bag when not in use. #36 Observation on 10/10/22 at 10:28 a.m. revealed an Aerosol mask attached to a Nebulizer machine on Resident #36's over bed table, open to air. Observation on 10/11/2022 at 12:51 p.m. revealed an Aerosol mask attached to a Nebulizer machine on Resident #36's over bed table, open to air. Interview at 10/11/2022 at 1:00 p.m. with S3 RN/Treatment nurse confirmed the above findings. S3 RN/Treatment nurse stated the Aerosol mask should be stored in a bag when not in use and his was not. #268 Observation on 10/10/2022 at 11:00 a.m. revealed an Aerosol mask attached to a Nebulizer machine on Resident #268's over bed table open to air. Observation on 10/11/2022 at 1:03 p.m. revealed an Aerosol mask attached to a Nebulizer machine on Resident #268's over bed table open to air. Interview on 10/11/2022 at 1:08p.m. with S4 LPN confirmed the above findings. S4 LPN stated all respiratory equipment was supposed to be stored in blue bags at the resident's bedside. She confirmed Resident #268 did not have a storage bag and should.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 3 Residents (#2, #3, & #4) of 3 sampled Residents with MDS record over 120 days old. The total sample size was 48. Findings: #2 Review of the clinical record for Resident #2 revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS with an ARD (Assessment Reference Date) of 05/31/2022 revealed the assessement was completed and transmitted on 07/20/2022. #3 Review of the clinical record for Resident #3 revealed the Resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #3's Annual MDS Assessment with an ARD of 06/07/2022 revealed the assessment was completed and transmitted on 07/20/2022. #4 Review of the clinical record for Resident #4 revealed the Resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #4's Quarterly MDS with an ARD (Assessment Reference Date) of 06/07/2022 revealed the assessent was completed on 06/20/2022 and transmitted on 07/22/2022. An interview conducted on 10/12/2022 at 11:26 a.m. with S2 LPN/ MDS Coordinator revealed that she was the Nurse in charge of completing Resident #2, Resident #3, and Resident #4's MDS. She confirmed that Resident #2 and Resident #3's MDS were not transmitted until 07/20/2022, and Resident #4's MDS was not transmitted until 07/22/2022. S2 LPN/ MDS Coordinator further confirmed that the MDS assessments were transmitted late and should have been transmitted within 14 days of the completion of the assessment and wasn't. S2 LPN/ MDS Coordinator stated that the reason for the late transmission of the MDS was due to an outbreak of COVID-19 which created a shortage of nurses and she was scheduled to work as a floor nurse from time to time. An interview conducted on 10/12/2022 at 12:15 p.m. with S1 DON revealed she was aware of Resident #2, Resident #3, and Resident #4's MDS being transmitted late. S1 DON stated the facility had an outbreak of COVID-19 during that time and the other Assessment nurse was out sick. S1 DON further stated she and the ADON were trained to do MDS Assessments.

Based on observation, interview, and record review the facility failed to ensure that a resident's environment remained as free of accident hazards as possible. The facility failed to ensure a resident received adequate supervision and the assistance of two persons to prevent an accident for 1 (#3) of 5 (#1, #2, #3, #4, #5) sampled residents. An actual harm occurred on 1/10/19 for Resident #1 when the resident started sliding out of bed and S9 CNA, who was alone without any other staff present, said she caught the resident's left leg by pressing her legs against them to prevent the fall. The resident was assessed and care planned for two person physical assist with dressing and transfers. S9 CNA then transferred the resident per Hoyer lift from the bed to the Geri chair without assistance. The family during a visit that afternoon notified nursing staff that the resident's leg was swollen and she was in pain. The resident was later transferred to the hospital at the request of the family and an x-ray revealed an Acute Comminuted Impacted [MEDICAL CONDITION] Distal Femur. Findings: Review of the facility's Lifting Machine Using a Portable policy and procedure revealed under the General Guidelines - 2 nursing assistants are required to perform this procedure. Review of the resident's record revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's Annual MDS dated [DATE] revealed the resident was coded to have a BIMS summary score of 99 (unable to complete interview), and determined by the facility to be totally dependent with two or more persons physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was assessed to be unsteady and only able to stabilize with staff assistance for surface to surface transfers (transfer between bed and chair or wheelchair). Review of the resident's Comprehensive Plan of Care with a goal date of 3/8/19 included the following problems: 1. Resident had mobility deficits related to weakness, CV disease, and end stage [MEDICAL CONDITION] (on hospice) and approaches included: Dressing - required total assist X 2, Bed Mobility - required total assist X 2 CNAs, Transfers - required total assist X 2 or more CNAs, use of mechanical lift for any transfer. Further review of the CP[NAME] revealed an update on 1/10/19 for 2 person assist for all transfers, turning/repositioning, dressing, bed mobility and nurse to supervise transfers. Review of the Progress Notes dated 1/10/19 at 4:22 p.m., revealed in part, S10 LPN was called to resident #3's room by S9 CNA. The resident was lying in bed and stated her leg was sore and pointed to her left thigh. S9 CNA stated when she pulled the resident's pants up in the back with the resident in bed, she turned the resident over on her left side; that was when the resident's legs began to slide out of the bed. S9 CNA caught the resident's left leg with her legs. The resident's top half of her body remained on the bed. S9 CNA revealed the resident did not fall out of the bed onto the floor nor had the resident hit her head on anything. At 4:27 p.m. the physician was notified of the incident and that the resident had no apparent injuries but complained of pain to the thigh. There were no new orders, just monitor the resident. At 5:24 p.m. the resident was administered [MEDICATION NAME] tablet 7.5-325 mg one by mouth for complaints of left leg pain. At 7:51 p.m. the resident was followed-up on for her pain medication effectiveness, the resident complained of pain of 5 on a scale of 0-10. Review of the Client Incident Report Summary revealed in part, Resident #3 required assistance with ADLs including dressing - 2 person assist, transfers - total assist of 2 person with the use of mechanical lift for any transfers and Geri-chair for mobility. Review of a Mobile Radiology Report for resident #3 dated 1/10/19 at 9:35 p.m. revealed the reason for the study was pain. The Impression was as follows: Acute comminuted impacted [MEDICAL CONDITION] femur involving the metaphysis and femoral condyles. Review of the nurses' notes dated 1/10/19 at 10:00 p.m. revealed the x-ray results were received. At 10:05 p.m. the resident's Physician was notified and ordered for the resident to be transferred to the hospital. Observation of resident #3 on 1/22/19 at 11:00 a.m. revealed the resident was lying in bed with O2 per nasal cannula on, she was turned on her left side with a wedge behind her back, her right stump was positioned on a pillow, she had a heel protector on her left foot, her call light was within reach and she was asleep. During that time S12 CNA and S13 CNA came in with S14 LPN and the CNA's provided incontinent care and the LPN assisted when asked for positioning of the left leg. The resident when turned stated oh, oh, oh and grimaced. But after she was repositioned she stated she was okay when asked. Interview with S1 Administrator on 1/22/19 at 11:45 a.m. revealed that he began the investigation immediately. He said that he felt that it was either during the time S9 CNA provided ADL care or during the one person transfer use of the mechanical lift that the resident sustained [REDACTED]. He revealed that S9 CNA had not followed the resident's plan of care or the facility's policy for the use of a mechanical lift. He also stated that her care plan had been updated to include all ADL care other than feeding and giving fluids were to be supervised by a nurse in the room. Interview with S10 LPN on 1/22/19 at 12:16 p.m. confirmed she was working the floor on 1/10/19 when the incident occurred. She stated S9 CNA called her to the resident's room and stated when she pulled up the resident's pants in the bed, the resident's legs slid out of the bed and she stopped them from sliding by pressing her leg up against the resident's left leg and the bed. She stated, when she arrived at the resident's room, the resident stated to S10 LPN her leg was sore. She stated, she and S9 CNA pulled the resident's pants down and she assessed the resident's legs. She stated the incident occurred around 4:30 p.m. and she stated after she had assessed the resident she told the CNA she could go ahead and get her up into the Geri-chair for supper. Further interview with S10 LPN revealed at around 5:00 - 5:30 p.m. the resident's daughter came to visit. She stated she was giving report to the agency nurse when the daughter came to the nurses' station and requested pain medication for her mother. She stated she checked the orders and she had [MEDICATION NAME] 7.5-325 mg one by mouth ordered every 4 hours for pain and she knew the resident had stated her leg was sore earlier, so the pain medication was administered. She stated before she left the resident's daughter had come back up to the nurses' station and stated her mother's left leg looked swollen. She stated she went back down to the room and re-assessed the resident's leg. She stated there was still very little change from when she had assessed it earlier, maybe a little swelling was noted. S10 LPN stated during that time someone called the hospice nurse and requested an x-ray. She stated the hospice nurse called the physician and notified him the family had requested an x-ray, therefore an x-ray was obtained. Interview with Agency nurse on 1/22/19 at 12:00 noon revealed she didn't know how the resident's leg normally looked being she was an agency nurse. She revealed the resident complained of some pain and the family was very concerned about her having pain. The Agency nurse revealed she called the hospice nurse per family request. She stated the hospice nurse came to the facility and put ice on the area, while they waited on the mobile x-ray to come. Interview with S4 LPN/CNA Coordinator on 1/22/19 at 1:45 p.m. revealed she worked on 1/10/19 when the incident with resident #3 occurred, but she was not the resident's nurse that day. She stated, as she was leaving around 4:00 p.m., when S9 CNA came up to her and stated she felt like the resident needed to go to the hospital, because the resident's leg was hurting (Do we know what time this was?). She stated she instructed S9 CNA to go tell the resident's nurse S10 LPN. She stated she saw the resident up in her Geri-chair, she was not crying but did complain that her left leg hurt. She stated she told S10 LPN what S9 CNA had told her and that the resident had pointed to her left leg when she asked where it hurt.