Based on record reviews and interviews, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, the following: Purpose: Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. No one shall abuse a resident. The policy applies to covered individuals (the owner, operator, employees, managers, vendors, agency staff, agents or contractors) Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal, . abuse of a resident, . mistreatment of a resident . I. Types of Abuse: Abuse: is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or anguish. Our policy presumes that abuse of any resident, ., causes physical harm, pain or mental anguish. 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: Name-calling, cursing or yelling at a resident in anger. Threats of harm. II. Procedures 2. Training. Guidelines for Employees: If a resident starts to show signs of aggressive or catastrophic behavior verbally or physically, remain calm. Do not engage in an argument with the resident. Exit the area to prevent an incident. Resident #98 Review of Resident #98's Clinical Record revealed an admission date of 06/20/2023 with diagnoses which included, in part, the following; Anxiety Disorder; Dementia; Cognitive Communication Deficit; Unspecified Psychosis. Review of Resident #98's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 5, which indicated resident had severe cognitive impairment. Review of the facility's Incident Report, dated 05/29/2024, revealed, in part, the following: Date/Time of Incident: 05/29/2024 at 7:27 a.m. Incident Type: Verbal Contact-Staff Resident Involved: Resident #98 Staff Involved: S23LPN Description of Incident: Verbal altercation between Resident #98 and S23LPN. S23LPN and Resident #98 were on the elevator alone when Resident #98 touched S23LPN's hair. As elevator opened, S23LPN was observed to be very upset with Resident #98 and they began arguing loudly using inappropriate language and curse words towards each other. Both S23LPN and Resident #98 continued to become increasingly agitated as they cursed at each other louder and louder. Staff members present on the 3rd floor intervened to pull S23LPN into a supply room away from Resident #98 in attempt to deescalate the situation. Resident #98 calmed down until S23LPN exited the supply room and began cursing at him again, which in turn re-escalated the situation. Staff from the 2nd floor heard the commotion and came up to assist with de-escalation and removed S23LPN from the floor. Witnesses: S13ADON, S19ADON, S20CNA, S21UC, S22LPN, S23LPN, and S24LPN. Review of the facility's Incident Report submitted to the State Survey Agency revealed, in part, the following: Date Occurred: 05/29/2024, 7:50 a.m. Accused Allegations: Verbal Abuse Resident Victim: Resident #98 Accused: S23LPN Allegation Findings: Substantiated. Review of a signed Witness Statement written by S19ADON, dated 05/29/2024, revealed, in part, the following: At approximately 7:28 a.m., S19ADONwas sitting at her desk when she overheard S23LPN and Resident #98 involved in a verbal altercation. S19ADON recalled hearing S23LPN telling Resident #98 that he should not have touched her hair. S23LPN stated that if she let him slide, he would try to touch other things. Other words were exchanged between the two that S19ADON could not hear. S23LPN walked to the supply room as Resident #98 yelled 'F**k You' and threw a book at S23LPN from the nurses station. S23LPN turned around and they both were yelling offensive words, such as, N***a, Black B***h, F***k you. S13ADON, S22LPN and other staff members came up to 3rd floor because they heard the commotion from the 2nd floor. S13ADON took S23LPN into the supply room while others were trying to get Resident #98 into his room. However, Resident #98 would not leave from the nurses' station. S23LPN then came out still talking to Resident #98 and S13ADON took her back into the supply room. Resident #98 hit the supply room door causing myself and another nurse to run out of the office to assist. Resident #98 stated he was going to get his people to kill S23LPN and anyone who gets in his way. Resident #98 then stated he was going to stab her with a pen that he had in his hand. S13ADON and others finally got S23LPN in the elevator. Review of a signed Witness Statement written by S22LPN, dated 05/29/2024, revealed, in part, the following: Loud voices were heard coming from the third floor. S13ADON and S22LPN immediately ran up the stairs to the third floor and witnessed Resident #98 and S23LPN having a verbal altercation. S22LPN did not know how the incident started but she did witness S23LPN shouting don't put your f***king hands on me. As S22LPN walked up to Resident #98 to calm him down he stated I was just moving her hair. It was in her face. Resident #98 then continued to go back and forth with S23LPN arguing. S22LPN heard Resident #98 say F**k you black b***h and S23LPN said no, you are the black b***h. F**k you. Resident #98 then stated I'll get my people from the park to come f**k you up. S23LPN shouted I got people to f**k you. S22LPN was able to calm Resident #98 down as S13ADON brought S23LPN in the supply room. When S23LPN came out the supply room she overheard Resident #98 saying I was moving her hair so S23LPN stated I don't care, don't f**king touch me. Resident #98 and S23LPN continued the verbal argument until Resident #98 charged at S23LPN without hitting her and the verbal argument continued with cursing from both parties before S23LPN entered the elevator to go to the 4th floor. Review of a signed Witness Statement written byS20CNA, dated 05/29/2024, revealed, in part, the following: S20CNA stated she was on the second floor and heard the shouting commotion getting louder on the third floor so she rushed upstairs. She stated as she exited the elevators she heard S23LPN shouting F**k you to Resident #98. Review of a signed Witness Statement written by S21UC, dated 05/29/2024, revealed, in part, the following: While on the 3rd floor, she saw Resident #98 get off the elevator. S23LPN was by the nurses' station when Resident #98 touched her. She stated S23LPN told him not to touch her. She said I have asked you before not to touch me. She stated the exchange went back and forth and eventually escalated to both Resident #98 and S23LPN cursing and shouting at each other. An interview was conducted on 07/31/2024 at 3:00 p.m. with S13ADON. She stated she was working on the 2nd floor on the morning of 05/29/2024 when the incident between S23LPN and Resident #98 occurred. She stated she heard shouting from the 3rd floor that continued to get louder so she went up to determine what was occurring. She stated when she arrived to the 3rd floor, S23LPN and Resident #98 were shouting and cursing at each other but still had space between them. She confirmed S23LPN was shouting profanities at Resident #98 causing the situation to escalate rather than attempting to deescalate as she had been trained to do. She stated she immediately grabbed S23LPN and pulled her into the supply room to separate the two in attempt to deescalate the situation. She stated a few minutes later when S23LPN exited the supply room, she immediately began fussing and cursing at Resident #98 which got him agitated all over again. S13ADON stated she and the other staff then pulled S23LPN onto the elevator to get her out of there. She confirmed she would consider a staff member shouting and/or cursing at a resident to be abuse. An interview was conducted on 07/31/2024 at 3:22 p.m. with S24LPN. She stated she was working as a nurse on the 3rd floor on the morning of 05/29/2024 when the incident between S23LPN and Resident #98 occurred. She stated she saw the elevator open on the 3rd floor with S23LPN and Resident #98 inside and both exited. She stated S23LPN approached the nurses' station and she could tell she was not happy. S24LPN stated S23LPN informed her Resident #98 put his hand in her hair and she didn't appreciate it. She stated S23LPN was visibly upset and becoming agitated, as was Resident #98. She stated Resident #98 told S23LPN I didn't mean anything by it. She stated S23LPN began telling Resident #98 to keep his hands to himself. Resident #98 called S23LPN names and cursed at her. S23LPN began shouting curse words at Resident #98. She confirmed she would consider it abuse if a staff member shouted or cursed at a resident for any reason. An interview was conducted on 07/31/2024 at 3:40 p.m. with S2AADM. She confirmed S13ADON made her aware of the verbal altercation between S23LPN and Resident #98 immediately after it occurred. She confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. An interview was conducted on 07/31/2024 at 3:33 p.m. with S1ADM. He confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. He confirmed S13ADON notified him, S2AADM and S12DON of the altercation between S23LPN and Resident #98 immediately after the event occurred.

Based on record review and interviews, the facility failed to ensure an allegation of abuse was reported immediately, but no later than 2 hours, after the allegation was made to the state survey agency for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, the following: 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. If you suspect verbal, . abuse of a resident, . mistreatment of a resident, Contact the Administrator immediately. Employees should immediately report their knowledge related to abuse allegations to the Administrator. The Administrator shall immediately initiate a report to the state survey agency and the facility's local law enforcement agency; but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse ( . verbal abuse .). Review of Resident #98's Clinical Record revealed an admission date of 06/20/2023 with diagnoses which included, in part, the following; Anxiety Disorder; Dementia; Cognitive Communication Deficit; Unspecified Psychosis. Review of the facility's Incident Report, dated 05/29/2024, revealed, in part, the following: Date/Time of Incident: 05/29/2024 at 7:27 a.m. Incident Type: Verbal Contact-Staff Resident Involved: Resident #98 Staff Involved: S23LPN Description of Incident: Verbal altercation between Resident #98 and S23LPN. S23LPN and Resident #98 were on the elevator alone when Resident #98 touched S23LPN's hair. As elevator opened, S23LPN was observed to be very upset with Resident #98 and they began arguing loudly using inappropriate language and curse words towards each other. Both S23LPN and Resident #98 continued to become increasingly agitated as they cursed each other louder and louder. Staff members present on the 3rd floor intervened to pull S23LPN into a supply room away from Resident #98 in attempt to deescalate the situation. Resident #98 calmed down until S23LPN exited the supply room and began cursing at him again, which in turn re-escalated the situation. Staff from the 2nd floor heard the commotion and came up to assist with de-escalation and removed S23LPN from the floor. Witnesses: S13ADON, S19ADON, S20CNA, S21UC, S22LPN, S23LPN, S24LPN Review of the facility's Incident Report submitted to the State Survey Agency revealed, in part, the following: Date Occurred: 05/29/2024, 7:50 a.m. Date Reported: 05/29/2024, 1:11 p.m. Accused Allegations: Verbal Abuse Resident Victim: Resident #98 Accused: S23LPN Review of a signed Witness Statement written by S22LPN, dated 05/29/2024, revealed, in part, the following: Loud voices were heard coming from the third floor. S13ADON and S22LPN immediately ran up the stairs to the third floor and witnessed Resident #98 and S23LPN having a verbal altercation. S22LPN did not know how the incident started but she did witness S23LPN shouting don't put your f***king hands on me. As S22LPN walked up to Resident #98 to calm him down he stated I was just moving her hair. It was in her face. Resident #98 then continued to go back and forth with S23LPN arguing. S22LPN heard Resident #98 say F**k you black b***h and S23LPN said no, you are the black b***h. F**k you. Resident #98 then stated I'll get my people from the park to come f**k you up. S23LPN shouted I got people to f**k you. S22LPN was able to calm Resident #98 down as S13ADON brought S23LPN in the supply room. When S23LPN came out the supply room she overheard Resident #98 saying I was moving her hair so S23LPN stated I don't care, don't f**king touch me. Resident #98 and S23LPN continued the verbal argument until Resident #98 charged at S23LPN without hitting her and the verbal argument continued with cursing from both parties before S23LPN entered the elevator to go to the 4th floor. An interview was conducted on 07/31/2024 at 3:00 p.m. with S13ADON. She confirmed she was present for the altercation on 05/29/2024 that occurred shortly after 7:30 a.m. between S23LPN and Resident #98. She stated she was on the 2nd floor and heard shouting from the 3rd floor that continued to get louder. She stated when she arrived to the 3rd floor, S23LPN and Resident #98 were shouting and cursing at each other but still had space between them. She confirmed S23LPN was shouting profanities at Resident #98 causing the situation to escalate rather than attempting to deescalate as she had been trained to do. She stated she immediately grabbed S23LPN and pulled her into the supply room to separate the two in attempt to deescalate the situation. She stated a few minutes later when S23LPN exited the supply room, she immediately began fussing and cursing at Resident #98 which got him agitated all over again. She stated she and the other staff then pulled S23LPN onto the elevator to get her out of there. She confirmed as soon as she was able to remove S23LPN from the 3rd floor and deescalate the situation, she immediately notified S1ADM, S2AADM and S12DON of what occurred. An interview was conducted on 07/31/2024 at 3:33 p.m. with S1ADM. He confirmed he was responsible for submitting the facility's incident reports to the state agency. He confirmed any allegation or suspicion of resident abuse should be reported within 2 hours, including allegations of verbal abuse from a staff member. He confirmed a staff member shouting and cursing at a resident would be considered verbal abuse. He confirmed S13ADON notified him, S2AADM and S12DON of the altercation between S23LPN and Resident #98 immediately after the event occurred. He confirmed he did not submit an incident report to the state agency within 2 hours of being notified of the altercation from S13ADON.

Based on interviews and record reviews, the facility failed to ensure resident MDS assessments accurately reflected the resident's status for 4 (#11, #68, #100, and #119) of 8 (#10, #11, #23, #68, #100, #109, and #119) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations. Findings: #11 Review of Resident #11's Clinical Record revealed an admission date of 06/20/2023 with diagnoses which included Dementia, Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder. Further review revealed an approved Level II PASRR. Review of Resident #11's Annual MDS with ARD of 06/19/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #68 Review of Resident #68's Clinical Record revealed an admission date of on 06/20/2023 with diagnoses which included Generalized Anxiety Disorder, Depression, and Bipolar Disorder. Further review revealed an approved Level II PASRR. Review of Resident #68's Annual MDS with ARD of 06/19/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #100 Review of Resident #100's Clinical Record revealed an admission date of 06/20/2023 with diagnoses, which included, in part, the following; Schizoaffective Disorder; Schizophrenia; Major Depressive Disorder. Further review revealed an approved Level II PASRR. Review of Resident #68's Annual MDS with ARD of 06/26/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. #119 Review of Resident #119's Clinical Record revealed an admission date of 11/28/2023 with diagnoses which included Schizophrenia. Further review revealed an approved Level II PASRR. Review of Resident #119's Annual MDS with ARD of 11/28/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. On 07/31/2024 at 11:03 a.m., an interview was conducted with with S5MDS. He confirmed he was responsible for Resident #100's annual MDS assessments. He stated comprehensive MDS assessments should include if the resident has a state level II PASRR. He confirmed Resident #100 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have. On 07/31/2024 at 11:04 a.m., an interview was conducted with S4MDS. She stated she was responsible for Residents #11, #68 and #119 annual MDS assessments. She stated comprehensive MDS assessments should include if the resident has a state level II PASRR. She confirmed Residents #11, #68 and #119 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have. On 07/31/2024 at 4:44 p.m., an interview was conducted with S2DON. She confirmed the MDS assessments should be accurate for all residents.

Based on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning, and transitions of care for 3 (#14, #100, and #109) of 8 (#10, #11, #14, #23, #68, #100, #109, and #119) residents reviewed for PASRR. Findings: Review of facility's Policy and Procedure, dated 10/31/2014, revealed the following, in part: Policy: The Facility is required to ensure that the Specialized Service Recommendations indicated on the PASRR/ Level 2 are implemented and documentation of the recommended services is recorded in the resident's clinical record. If the recommended services are refused, the facility should ensure the refusal of such services is documented in the residents' clinical record. Resident #14 Review of Resident #14's Clinical Record revealed an admission date of 12/21/2023 with diagnoses, which included, in part, the following: Generalized Epilepsy, Anxiety Disorder, Schizophrenia, Depression, Slurred Speech, and Schizoaffective Disorder. Review of Resident#14's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/2024, indicated resident #14 had a Brief Interview of Mental Status (BIMS) of 5, which indicated resident was severely cognitively impaired. Review of Resident #14's BHSF Form 142, dated 03/12/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 03/12/2024 through 03/11/2025. Review of Resident #14's OBH-PASRR Level II Summary and Determination Notice, dated 03/11/2024, effective 03/12/2024 through 03/11/2025, revealed, in part, the following: Recommended Lesser Services: Medication Education; Training in ADLs; Training in independent living skills; Structured leisure activities; and Evaluation for a diagnosis of dementia. Review of Resident #14's Care Plan revealed no documented care plan present for any of the following services: Medication Education, Training in ADLs, Training in independent living skills, or evaluation for a diagnosis of dementia. An interview was conducted on 07/31/2024 at 9:00 a.m. with Resident #14. He stated he would be willing to participate in the following: medication education, training in ADLs, training in independent living skills, and structured leisure activities, but these services were never offered to him. An interview was conducted on 07/31/2024 at 9:43 a.m. with S16SSD. She confirmed she was responsible for ensuring Level II PASRR recommended services were offered and carried out for each resident. She stated she offered the above services to Resident #14 but he refused. She confirmed she could not provide documented evidence to indicate Resident #14 refused the services. An interview was conducted on 07/31/2023 at 11:03 a.m. with S3MDS. She reviewed Resident #14's care plan and confirmed it did not include the recommended services from his Level II PASRR and should. She confirmed if services were refused, the care plan should reflect that and it did not. Resident #100 Review of Resident #100's Clinical Record revealed an admission date of 06/20/2023 with diagnoses, which included, in part, the following; Schizoaffective Disorder; Schizophrenia; and Major Depressive Disorder. Review of Resident #100's most recent MDS, with an ARD of 06/26/2024, indicated resident had a BIMS of 12, which indicated resident was cognitively intact. Review of Resident #100's BHSF Form 142, dated 04/22/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 04/22/2024 through 04/21/2025. Review of Resident #100's OBH-PASRR Level II Summary and Determination Notice, dated 04/22/2024, effective 04/22/2024 through 04/21/2025, revealed, in part, the following: Recommended Lesser Services: Training in independent living skills; and Structured leisure activities. Specialized Services Recommendations: Community Psychiatric Support and Treatment (CPST); and Psychosocial Rehabilitation (PSR) - Group. Review of Resident #100's Clinical Record revealed no documented evidence to indicate the facility offered or implemented any of the following: Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group. Review of Resident #100's Care Plan revealed no documented care plan present for any of the following services: Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group. An interview was conducted on 07/30/2024 at 1:32 p.m. with Resident #100. She confirmed she would enjoy participating in Training in Independent Living Skills, Structured Leisure Activities, CPST; or PSR-Group because she enjoyed doing new things and being around other people. She confirmed she did not recall being offered any of those services in the past and if she had, she would not have refused them. An interview was conducted on 07/31/2024 at 9:50 a.m. with S16SSD. She stated she offered the above services to Resident #100 but she refused. She confirmed she could not provide documented evidence to indicate Resident #100 refused the services. An interview was conducted on 07/30/2024 at 11:03 with S5MDS. He reviewed Resident #100's careplan and confirmed it did not include the recommended services from her Level II PSARR and should. He confirmed if services were refused, the care plan should reflect that and it did not. Resident #109 Review of Resident #109's Clinical Record revealed an admission date of 03/25/2024 with diagnoses which included, in part, the following; Anxiety Disorder. Review of Resident #109's most recent MDS, with an ARD of 12/28/2023, indicated resident had a BIMS of 11, which indicated resident was moderately cognitively intact. Review of Resident #109's BHSF Form 142, dated 04/30/2024, revealed, in part, the following: Form 142 - Section II: Approved for admission by Level II Authority, effective 05/01/2024 through 04/30/2025. Review of Resident #109's OBH-PASRR Level II Summary and Determination Notice, dated 04/30/2024, effective 05/01/2024 through 04/30/2025, revealed, in part, the following: Recommended Lesser Services: Structured leisure activities. Specialized Services Recommendations: CPST. Review of Resident #109's Care Plan revealed no documented care plan present for any of the following services: Structured leisure activities and CPST. An interview was conducted on 07/30/2024 at 1:30 p.m. with Resident #109. She confirmed she did not recall being offered any of the services identified in her Level II PASRR in the past and if she had, she would not have refused them. An interview was conducted on 07/31/2024 at 9:50 a.m. with S16SSD. She stated she offered the above services to Resident #109 but she refused. She confirmed she could not provide documented evidence to indicate Resident #109 refused the services. An interview was conducted on 07/30/2024 at 11:03 with S5MDS. He reviewed Resident #109's careplan and confirmed it did not include the recommended services from her Level II PSARR and should. He confirmed if services were refused, the care plan should reflect that and it did not. An interview was conducted on 07/31/2024 at 9:57 a.m. with S1ADM. He confirmed he would expect residents to be offered and careplanned for all services recommended by their Level II PASRRs. He confirmed he would expect staff to document when those services were offered, especially if the services were refused by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#40 and #119) of 2 (#40 and #119) residents reviewed for ADL's. The facility failed to clean and trim fingernails for Residents #40 and #119. Findings: #40 Review of Resident #40's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia following Cerebral Vascular Accident Affecting Left Non-Dominant Side, Lack of Coordination, and Type 2 Diabetes Mellitus. Review of Resident #40's Annual MDS with an ARD of 06/19/2024 revealed Resident #40 had a BIMS of 8, which indicated moderate cognitive impairment. Further review revealed Resident #40 was dependent on staff for ADL's. Review of Resident #40's July Physician Orders revealed the following: 11/17/2023 Assess and trim fingernails and toenails monthly and as needed. On 07/29/2024 at 8:39 a.m., an observation was conducted of Resident #40. Her fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. She stated she would like her nails trimmed and cleaned. On 07/30/2024 at 8:52 a.m., an observation was conducted of Resident #40 eating breakfast in her bed. Her fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. On 07/30/2024 at 9:54 a.m., an interview was conducted with S8CNA. She stated she was assigned to Resident #40 and provided her morning ADL care on 07/29/2024. She stated the wound care nurse was responsible for cleaning and trimming fingernails and she did not clean the nails during her morning ADL care on 07/29/2024. On 07/30/2024 at 1:08 p.m., an interview was conducted with S17LPN. She stated the floor nurse would assess fingernails weekly during the scheduled skin assessment. She confirmed she never assessed, cleaned, or trimmed Resident #40's fingernails. She further confirmed she worked on 07/28/2024 and was assigned to complete the scheduled skin assessment and did not provide nail care. #119 Review of Resident #119's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, Weakness, and Generalized Arthritis. Review of Resident #119's Quarterly MDS with an ARD of 07/17/2024 revealed Resident #119 had a BIMS of 3, which indicated severe cognitive impairment. Further review revealed Resident #119 required supervision assistance for ADLs. Review of Resident #119's July Physician Orders revealed the following: 11/28/2023 Assess and trim fingernails and toenails monthly and as needed. On 07/29/2024 at 8:33 a.m., an observation was conducted of Resident #119 laying in his bed. His fingernails are noted to be 1/2 cm long with black stuff under multiple fingernails. He stated he would like his nails trimmed and cleaned. On 07/30/2024 at 8:31 a.m., an observation was conducted of Resident #119 laying in his bed. His fingernails are noted to be 1/2 cm long with black stuff under multiple fingernails. He stated he would like his nails trimmed and cleaned. On 07/30/2024 at 9:54 a.m., an interview was conducted with S7CNA. She stated she was assigned to Resident #119 and provided his morning ADL care today. She stated the wound care nurse was responsible for cleaning and trimming fingernails and she did not clean the nails during her morning ADL care this morning. On 07/30/2024 at 10:17 a.m., an interview was conducted with S6WC. She stated she assessed and trimmed fingernails for all residents monthly. She stated the assigned floor nurse was responsible for weekly fingernail assessment and care if needed. She further stated CNAs should be cleaning under the nails during baths. On 07/30/2024 at 10:19 a.m., an observation of Resident #40 and #119 was conducted with S6WC. She confirmed Resident #40's fingernails were dirty and should have been trimmed. She stated the staff nurse should assess fingernails weekly and trim them or inform her if they are not comfortable. She stated she was not made aware Resident #40's fingernails needed trimming. She further confirmed Resident #119's fingernails were dirty and should have been cleaned during morning ADL care. She stated it was a normal length for him because sometimes he did not like them cut short. On 07/31/2024 at 4:44 p.m., an interview was conducted with S12DON. She stated CNA's were responsible for cleaning under the fingernails during morning ADL care and nurses assessed fingernail care weekly with the scheduled skin assessment. She confirmed fingernails should not have black under them and should be trimmed as needed.

Based on observations and interviews, the facility failed to maintain a safe, functional, sanitary and comfortable environment for 5 of 5 (a, b, c, d, e) rooms observed for environmental concerns. The facility failed to ensure maintenance of: 1. The walls, door frame and facing, and ceiling tiles in Room a; 2. Water entering the interior of Room a; 3. Water entering from windows and from ceiling above electrical outlet in Room b; 4. Ceiling tiles and prevention of sagging, black discolorations for Room c; 5. The walls and flooring of Room d; 6. Sanitary conditions for cleaning station, eye wash station, and ceiling tiles of Room e Findings: Room a On 07/29/2024 at 8:45 a.m., an observation was made of Room a. One ceiling tile was hanging and not in place above the television. There was black, spotty staining noted at the top of all walls where the ceiling is joined in the room and around the door frame. The door facing had a green, fuzzy staining on it. There was one corner ceiling tile in the bathroom with stains/discoloration. On 07/30/2024 at 10:08 a.m., an observation was made of Room a. One ceiling tile was hanging and not in place above the television. There was black, spotty staining noted at the top of all walls where the ceiling is joined in the room and around the door frame. The door facing had a green, fuzzy staining on it. There was one corner ceiling tile in the bathroom with stains/discoloration. On 07/30/2024 at 11:00 a.m., an observation was made of Room a with S12DON present. An interview was conducted with S12DON at that time. S12DON confirmed the above observations and stated Room a looked like water had dripped around the door and top of the walls. S12DON confirmed she was unaware of the findings. On 07/30/2024 at 3:35 p.m., an interview was conducted with S1ADM. He confirmed S12DON informed him of the above findings. S1ADM confirmed black staining on the walls was not comfortable and homelike. Room b On 07/29/2024 at 9:25 a.m., an observation was made of Room b. On the interior wall to the left of the window and air conditioning unit, water lines were noted 15 inches wide from the ceiling halfway down the wall. On the interior wall to the right of the window and air conditioning unit with Resident #66's bed against it, the bead board on the bottom half of the wall was warped with water lines present. Two half dollar sized holes were on the exterior wall with a black substance surrounding them and extending outward to the rest of the wall. The sheet rocked upper half of the wall contained signs of water damage with water mark stains of varying colors throughout with peeling and bubbling. The bead boarded bottom half of the wall contained two electrical outlets, one outlet was in use running the room's air conditioner and one outlet was not in use. 100% of the bead board, including the areas immediately surrounding the electrical outlets, were warped and had water mark stains of varying colors. The baseboards on the exterior wall were laying on the floor, not attached to the wall. The metal trim surrounding the window contained rust throughout. The window glass contained dried water lines coming from the top of the window downward toward the room's air conditioner located directly beneath the window. On 07/29/2024 at 9:25 a.m., an interview was conducted with Resident #66. She confirmed Room a had been in rough shape since she moved in this past January. She confirmed she made numerous complaints in attempt to get it fixed since she moved in. She stated every time it rained, water came in from around the window and from the ceiling tiles along the exterior wall. She stated any time she spoke with anyone at the facility, they told her the repairs would have to wait until her floor was remodeled because they weren't doing anything until then. On 07/30/2024 at 1:40 p.m., an observation was conducted of Room b. On the interior wall to the left of the window and air conditioning unit, water lines were noted 15 inches wide from the ceiling halfway down the wall. On the interior wall to the right of the window and air conditioning unit with Resident #66's bed against it, the bead board on the bottom half of the wall was warped with water lines present. Two half dollar sized holes were on the exterior wall with a black substance surrounding them and extending outward to the rest of the wall. The sheet rocked upper half of the wall contained signs of water damage with water mark stains of varying colors throughout with peeling and bubbling. The bead boarded bottom half of the wall contained two electrical outlets, one outlet was in use running the room's air conditioner and one outlet was not in use. 100% of the bead board, including the areas immediately surrounding the electrical outlets, were warped and had water mark stains of varying colors. The baseboards on the exterior wall were laying on the floor, not attached to the wall. The metal trim surrounding the window contained rust throughout. The window glass contained dried water lines coming from the top of the window downward toward the room's air conditioner located directly beneath the window. On 07/30/2024 at 3:20 p.m., an interview was conducted with S18CNA. She confirmed she was regularly assigned to Resident #66. She confirmed during periods of heavy rain or high wind and rain, she had seen water come in from around the window in Room a and run down the walls and around the air conditioner. She confirmed staff had mopped water up from the floor along the exterior wall. She confirmed she reported the issue to maintenance in the past but was told it wouldn't be fixed until the remodel of the third floor took place so she quit reporting it. On 07/30/2024 at 3:40 p.m., an observation was made of Room b with S15M. An interview was conducted with S15M at that time. He stated he was not aware of the damage to Room a. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. On 07/30/2024 at 4:00 p.m., an observation was made of Room b with S14MS. An interview was conducted with S14MS at that time. He stated he was not aware of the damage to Room b. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. On 07/30/2024 at 4:00 p.m., an observation was made of Room b with S1ADM. An interview was conducted with S1ADM at that time. He stated he was not aware of the damage to Room b. He confirmed the presence of damage to the exterior and two interior walls and the lack of baseboards being in place. He stated the damage appeared to be water damage, including surrounding two electrical outlets. He confirmed the facility was aware of some on-going issues with exterior windows leaking but it was a big process to get them resealed and was going to cost a bunch of money so it had not been done yet. He confirmed resident rooms should be maintained for safety and in good repair at all times and Room b was not. Room c On 07/29/24 at 10:10 a.m., an observation was made of Room c. There were five water stained ceiling tiles in the hallway between the kitchen and dry storage room. One ceiling tile had green/black discolorations, softball size, and the entire tile was sagging downward toward the floor. S14MS was walking through the hallway during the observation, and an interview was conducted with S14MS. S14MS verified the ceiling tiles were an ongoing challenge. He confirmed the ceiling tiles should have been changed. Room d On 07/29/2024 at 8:45 a.m., an observation was made of Room d with a 4x10 inch piece of vinyl wood floor plank missing. The wall on the right side of the room had black and greenish widespread circles and was fuzzy in spots. On 07/30/2024 at 10:55 a.m. an observation was made of vinyl floor plank still missing 4x10 piece and wall on right side of room black and greenish widespread circles fuzzy in spots had been freshly painted over. Room e On 07/31/2024 at 10:15 a.m., an observation was made of Room e with S25HK and S9HKS. There was a large amount of debris/dirt in the sink with an eye wash station. The floor was covered with dirt and debris, and in the right back corner of Room e, there was a drain with raised edges. The drain area had blackish colored, sludge, water with a foul smell. S9HKS said Room e had been a long time issue. S9HKS pointed to the floor drain area and said that is where housekeeping staff dump all dirty water mop buckets. There were three large opened ceiling areas with missing tiles and visible ceiling wiring. S25HK stated the ceilings had been open for the past three days. S9HKS stated the above issues had been reported to S1ADM and requested for improvements to the area, but they had not been done. On 07/31/2024 at 5:45 p.m., an interview was conducted with S1ADM. He stated S9HKS notified him earlier today of observations made in Room e. He stated he was aware of the cleanliness/sanitation issue, foul odor, and flooring dirty with sludge around the drain. He stated he was aware of the eye wash station location in this room. S1ADM stated the condition of Room e was not acceptable.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 128 residents who currently reside in the facility. Findings: An observation was made on 07/29/2024 at 8:45 a.m. of a small roach crawling across floor in main kitchen food preparation area. An observation was made on 07/29/2024 at 8:48 a.m. of a dead roach, close to clean pans. Further observations revealed small, black, grains of rice size particles on the main kitchen floor. An interview was conducted with S10AM on 07/29/2024 at 8:50 a.m. She stated that kitchen staff were responsible for making Management aware of pest observations. S10AM verified insect sightings in kitchen areas had been reported to Administration. An observation was made on 07/29/2024 at 8:55 a.m. of dead insects and small, black particles on the floor in food storage room. An observation was made on 07/29/2029 at 8:49 a.m. of a small spider crawling inside main kitchen area. S10AM verified recent insect and pest control issues. An observation was made on 07/29/2024 at 9:10 a.m. midway down the short side of Hall 3 of a cockroach, 3 inches in length, crawling on the lid of the yellow rolling bin utilized for dirty linens. The dirty linen bin was located in the hallway 3 feet from the clean linen cart. An interview was conducted on 07/29/2024 at 9:12 a.m. with S25CNA. She confirmed a roach was crawling on the lid of the yellow rolling bin utilized for dirty linens and roughly 3 feet from the clean linen cart. An observation was made on 07/29/2024 at 12:00 p.m. of a large cockroach crawling on the ceiling approximately 1ft. from door entry into dry food storage room. An observation was made on 07/30/2024 at 11:10 a.m. of a fly hovering over steam table during food temperature checks. S26C was observed waving her arms rapidly over the prepared food service table to shoo the fly away. An interview was conducted on 07/31/2024 at 5:45 p.m. with S1ADM. He stated he was aware there was a pest problem and increased pest control services were needed.

Based on observations, interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to affect 126 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Storage Of Refrigerated Food revealed the following: Policy: The facility will ensure the quality and safety of refrigerated food through acceptable storage practices. Procedure: 4. All non-hazardous, opened foods are labeled with name of food and date stored 5. Foods are labeled with date to be discarded or the date stored. An observation was made on 07/29/2024 at 8:45 a.m. of the facility's walk-in refrigerator with S10AM. The following was observed: - 6 8 oz plastic containers of whole milk with expiration date of July 27, 2024 An observation was made on 07/29/2024 at 8:50 a.m. of the facility's refrigerator #2 with S10AM. The following was observed: - 1 plastic package of opened turkey with no discard date An observation was made on 07/29/2024 at 8:55 a.m. of the facility's dry food storage room with S10AM. The following was observed: - 1 open plastic bag of yellow cake mix, with no discard date - 1 open bag of powdered sugar box, unsealed, with no discard date - 1 16 oz plastic container of chili powder, unable to read open date, no discard date An interview was conducted on 07/29/2024 at 9:00 a.m. with S10AM. She confirmed the above observations. She confirmed the above food items were available for resident use. She confirmed all expired food items should have been discarded. She confirmed all opened food items should have a label including both opened and expiration dates. An interview was conducted on 07/31/2024 at 5:45 p.m. with S1ADM. S1ADM confirmed all food storage items should be labeled and checked for both opened and expiration dates.

Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment in 12 of 12 (a, b, c, d, e, f, g, h, i, j, k, and l) rooms observed for environmental concerns. Findings: On 06/07/2024 at 12:10 p.m., an environmental tour was conducted with S2MAIN. S2MAIN confirmed the following findings: Room a -There was an approximate 1 gap in the right hand top corner between the air conditioner unit and the wall mount harness; Room b -Wires were hanging from the bottom of the telephone jack face plate cover; Room l -A hole was in the ceiling tile above the toilet; Room c -The edge of the bead board/paneling above the air conditioner unit was peeling away from the wall; Room d -An approximate ½ gap was between the air conditioner unit and the wall mount harness with outside light visible; -The edge of the bead board/paneling above the air conditioner unit was peeling away from the wall; Room e -The bathroom vanity's laminate covering had peeled away from the right side. The bottom edge of the vanity's laminate covering was broken and rough; Room f -Stained ceiling tiles were near the window along the wall; -The cover of the air conditioner's power button was missing and the button covers for the temperature controls, mode, and speed were damaged; Room g -A rectangular hole was in the wall above the resident's bed on the right side wall; -A wall socket face plate cover was peeling from the wall near the resident's bed on the right side wall; -A wall socket face plate cover was broken on the wall near the bathroom; Room h -Ceiling tiles x2 were drooping above the resident's bed; -A ceiling tile was drooping over the toilet; Room k -A wall socket near the air conditioner unit was missing a face plate cover; Room i -The slats on the air conditioner unit were broken; Room j -An approximate ¼ gap was between the air conditioner unit and the wall mount harness with outside light visible; and, -A wooden block was on the floor supporting the left hand side of the air conditioner unit. On 06/11/2024 at 12:10 p.m., an interview was conducted with S1ADM. S1ADM stated he was made aware of the aforementioned findings by S2MAIN and confirmed the findings should not be that way. On 06/11/2024 at 1:57 p.m., an observation was made of a bed in Room l with S1ADM. The head board of the bed was sitting on the bed frame leaning at an angle. The head board was missing one of the two metal brackets which allowed the headboard to be attached to the bed. S1ADM confirmed the head board was missing the bolts which held the brackets in place to support the head board to the bed frame. S1ADM confirmed the head board should not be like that.

Based on observations of video footage, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse by S5CNA for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Abuse - Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each resident has the right to be free from abuse . No one shall abuse a resident. This policy applies to covered individuals ( .employees .) Policy: To provide a safe abuse fee 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. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or mental anguish. 3. Physical abuse may include hitting, shoving. Physical abuse also includes controlling behavior through corporal (physical) punishment. Review of Resident #1's Clinical Record revealed an admission date of 06/20/2023 and diagnoses which included Cognitive Communication Deficit, Other Abnormalities of Gait and Mobility, Unspecified Dementia, and Unspecified Mood Disorder. Review of Resident #1's Quarterly MDS with an ARD of 09/20/2023 revealed, in part, a BIMS of 5, which indicated severe cognitive impairment. Review of Resident #1's Nurses' Note dated 10/18/2023 at 4:23 p.m. revealed the following, in part: S3LPN: Nurse entered the secure unit. Upon entrance, observed S5CNA charging towards Resident #1 and used shoulder to shove resident down. Resident #1 fell down. Review of Resident #1's Incident Report dated 10/18/2023 at 2:45 p.m. revealed the following, in part: Report prepared by: S3LPN Associate involved: S5CNA Narrative of Incident: Nurse entered the secure unit. Upon entrance, S3LPN observed S5CNA charging towards Resident #1 and her used shoulder to shove resident down. Resident #1 fell down. Narrative of Investigation: After investigation it was determined that S5CNA thrust her right anterior shoulder into the back of resident left shoulder area causing resident to fall to the floor. Incident was witnessed by S3LPN completing incident report and S4CNA, and statement obtained from S4CNA. S5CNA was terminated and escorted from the facility. Police were notified and responded. Review of Resident #1's Physician Progress Note dated 10/19/2023 revealed the following in part: Assessment and Plan: 1. Physical Assault (Primary) Overview: Patient reportedly pushed to the ground by a staff member. Review of S4CNA's statement revealed the following: I was talking to S5CNA on the hallway in the women's unit. Resident #1 was walking down the hall towards S5CNA and Resident #1 touched her bottled drink. S5CNA mumbled, don't put your hands in my food. S5CNA got up, followed Resident #1, and said I'm about to beat this B. S5CNA bumped Resident #1 with her right shoulder. Resident #1 fell to the floor. Signed: S4CNA An interview was conducted with S4CNA on 10/24/2023 at 9:17 a.m. She stated on the afternoon of 10/18/2023, she was talking with S5CNA in the hallway of the women's secure unit. She stated S5CNA had food and a drink on a bedside table, and Resident #1 knocked over the drink. She explained S5CNA stated, I am about to go whoop this B****. She stated S5CNA got up and walked very fast behind Resident #1. She stated S5CNA then used her right shoulder and pushed Resident #1's posterior shoulder, causing Resident #1 to fall. She stated after Resident #1 fell, Resident #1 was saying, She pushed me. She pushed me. S4CNA stated during the incident, S3LPN was coming through the unit's door and saw what occurred. S4CNA confirmed S5CNA physically abused Resident #1. An interview was conducted with S3LPN on 10/25/2023 at 11:40 a.m. She stated on the afternoon of 10/18/2023, she entered the women's secure unit and saw S5CNA charging toward Resident #1. She stated S5CNA used her right shoulder to push Resident #1 from behind, and Resident #1 fell down. She explained S5CNA used a tackle motion to push Resident #1 down. She stated after Resident #1 fell she yelled, help, help, elder abuse. She confirmed the incident was physical abuse. A telephone interview was conducted with S5CNA on 10/25/2023 at 10:45 a.m. She stated on the afternoon of 10/18/2023, Resident #1 was having behaviors. She stated her and S4CNA were in the hallway when Resident #1 passed by them and knocked her drink over. She stated she then went behind Resident #1 and used her shoulder to nudge Resident #1. She confirmed Resident #1 fell. She stated she should have ignored Resident #1's behaviors and not reacted. She stated, I knew better. She confirmed making intentional physical contact with a resident was physical abuse and she should not have made contact with Resident #1. An observation was made of the facility's video footage of the incident on 10/25/2023 at 11:49 a.m. with S1ADM. The following was observed on 10/18/2023 at 2:42 p.m.: S5CNA was sitting on the hallway of the women's secure unit at a bedside table with a styrafoam food container in a plastic bag and a bottled drink. Resident #1 walked by S5CNA and tapped the bottled drink, causing it to tilt. S5CNA then positioned her head toward Resident #1 and the back of her head was visible with a nodding motion. S5CNA then got up and walked toward Resident #1. S5CNA positioned her right shoulder out in front of her and made contact with Resident #1's back. Resident #1 immediately fell to the floor. S5CNA then immediately turned around and walked away from Resident #1 and raised her arms out to her side. S3LPN and S4CNA observed the incident. An interview was conducted with S2DON on 10/25/2023 at 10:14 a.m. She stated on the afternoon of 10/18/2023, she received a call from S3LPN who reported S5CNA pushed Resident #1 onto the floor. She stated the facility's video footage showed S5CNA sitting in the hallway of the women's secure unit by a bedside table with a drink on it. She stated Resident #1 touched the bottled drink, and continued walking down the hall. She stated S5CNA got up from the chair and walked behind Resident #1 and used her right shoulder to nudge Resident #1's left shoulder, causing the resident to fall to the floor. She stated S5CNA was escorted off the facility's premises and terminated immediately. She confirmed the incident was physical abuse. An interview was conducted with S1ADM on 10/25/2023 at 11:34 a.m. He stated he was made aware of the incident on 10/18/2023 involving Resident #1 and S5CNA immediately after it occurred. He confirmed S5CNA physically abused Resident #1. The facility had implemented the following actions to correct the deficient practice: 1. Corrective actions of the alleged deficient practice were accomplished by: a. Employee removed from area and terminated b. Law enforcement called and report made c. Abuse reported to CNA registry d. SIMS opened and investigation started e. In-service started immediately by DON for abuse, self-assessment, professionalism, and burnout 2. All residents have the potential to be affected by this alleged deficient practice. 3. Measures put in place to ensure the alleged practice will not occur: a. In-service started immediately for abuse, self-assessment, professionalism, and burnout b. Elder abuse questionnaire implemented to assess employee understanding of teaching. Also DON/ADON help Q&A with employees. 4. Facility will monitor the corrective actions of the alleged deficient practice by: a. DON/Designee will monitor by direct observation the secure unit 2-3 times per week to continue through 11/15/2023. b. Additional in-servicing and or progressive disciplinary action will occur if non-compliance is noted. Started 10/18/2023; Completed and all staff in-serviced by 10/20/2023. Throughout the survey from 10/24/2023 to 10/25/2023, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure and questionnaires testing their knowledge. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment for 3 (#3, #4, #5) of 5 (#1, #2, #3, #4, and #5) sampled residents. The facility failed to ensure: 1. Walls were free of holes 2. Baseboards were secured to the wall 3. Sheetrock was intact 4. Ceiling tiles were free of damage and secured Findings: Review of the Maintenance Log dated 06/25/2023 - 08/15/2023 revealed no documentation of Room a, Room b, or Room c requiring maintenance. On 08/15/2023 at 10:42 a.m., an interview was conducted with Resident #3's family member. She stated Room c had a large area on the wall near the head of the bed where paint was missing from the wall. She stated the wall had been missing paint for over a month. On 08/15/2023 at 10:53 a.m., an interview was conducted with Resident #5's family member. She stated Room a had missing ceiling tiles, missing baseboards, a very large area of missing sheetrock, and dark brown substance on the ceiling in his bathroom for over a month. On 08/15/2023 at 1:35 p.m., an environmental tour was conducted with S9MS. He confirmed the below observations: Room a bedroom: Baseboard missing from wall to the right of the air conditioner and two ceiling tiles above the foot of the resident's bed sagging down. Room a bathroom: 6 foot long by 3 foot tall section of the left wall missing sheetrock and paint, one ceiling tile missing above toilet with pipe covered with dark brown substance visible in the ceiling, and baseboard missing from 2 walls. Room b bedroom: Baseboard missing from wall directly under the hand sanitizer machine to the left of the entrance door to room. Room b bathroom: One ceiling tile missing above the toilet and a large amount of dark brown substance on 2 ceiling tiles above the toilet. Room c bedroom: 2 inch long by 2 inch tall hole in the wall behind the entrance door to the room and 6 inch long by 6 inch tall section of the wall beside the head of the resident's bed missing paint. On 08/15/2023 at 1:40 p.m., an interview was conducted with S9MS. He confirmed the environmental issues listed above needed to be repaired, and these issues did not provide a homelike environment for the 3 residents who resided in those rooms. On 08/16/2023 at 11:05 a.m., an interview was conducted with S1ADM. He stated he was aware of the environmental issues in need of repair. He stated the issues in the residents' rooms were not up to his standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to protect the resident's right to be free from physical abuse by an employee for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for abuse. 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: A review of the facility's policy titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each resident has the right to be free from abuse .No one shall abuse a resident .This policy applies to facility staff Policy: 3. Physical Abuse includes hitting, slapping . A review of the facility's Self-Reported Incident Report, dated 07/19/2023, revealed the following, in part: Victim: Resident #1 Accused: S6CNA Allegations: Physical abuse A review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE]. The resident had diagnoses which included Schizophreniform Disorder, Alzheimer's Disease, and Unspecified Dementia. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 3, which indicated he was severely cognitively impaired. A review of the Nurse's Notes dated July 2023 for Resident #1 revealed the following, in part: 07/19/2023 at 11:06 p.m.-5:45 p.m. This nurse was doing a med pass and witnessed S6CNA ask resident do you have my charger? This nurse observed resident holding a black colored charger in his hand. This nurse witnessed S6CNA take black colored charger from resident. Then this nurse witnessed resident punch S6CNA in the face. S6CNA started punching resident in the face and resident was punching S6CNA in the face. Physical altercation was de-escalated by this nurse and S7CNA. Head to toe assessment done. No apparent injury or bruising noted. Denies being in pain. Resident states, I'm not hurt. I'm ok. In-service done on resident abuse prevention and reporting 5:50 p.m.-S2DON made aware. A review of the written statement by S7CNA revealed the following: S6CNA saw her charger she was looking for in Resident #1's pocket. She asked him to give it to her as she proceeded to take it out his pocket. Resident #1 hit S6CNA on the side of her face. They started fighting. I proceeded to break up the fight, pulling them away from each other and S6CNA continued fighting with Resident #1. A review of the written statement by S4LPN dated 07/19/2023 revealed the following: This nurse was doing a med pass and witnessed S6CNA ask resident do you have my charger? This nurse observed resident holding a black colored charger in his hand. This nurse witnessed S6CNA take black colored charger from resident, then this nurse witnessed resident punch S6CNA in the face. S6CNA started punching resident in the face and resident was punching S6CNA in the face. Physical altercation was de-escalated by this nurse and S7CNA. No apparent injury or bruising noted. A review of the facility's video camera footage revealed on 07/19/023 at 5:44 p.m., Resident #1 was standing in the activity room of the locked memory care unit. Resident #1 stepped out of the video camera footage, then at 5:45 p.m., Resident #1 was seen being placed into a wheelchair by S7CNA and S4LPN. Upon being placed into wheelchair, S6CNA was seen slapping Resident #1 with her right hand against Resident #1's left side of his face. End of video camera footage. On 08/15/2023 at 10:53 a.m., an interview was conducted with S4LPN. She stated she was the nurse working on 07/19/2023, and she witnessed the physical altercation between Resident #1 and S6CNA. She stated S6CNA was looking for her phone charger. She stated Resident #1 was standing up in the activity room, and S6CNA confronted him, because she saw her phone charger in his hand. S4LPN stated S6CNA reached for her charger and Resident #1 hit her. She stated S6CNA hit him back. She stated, they started fighting. She stated S7CNA and herself separated Resident #1 and S6CNA. She stated S6CNA hitting Resident #1 was abuse. On 08/15/2023 at 3:12 p.m., an interview was conducted with S7CNA. She stated she was working on 07/19/2023 and witnessed the physical altercation between Resident #1 and S6CNA. She stated Resident #1 had S6CNA's phone charger in his pocket and S6CNA saw it. She stated S6CNA told Resident #1 to give her back the phone charger. She stated Resident #1 would not give it back to her. She stated S6CNA grabbed the phone charger out of Resident #1's pocket, and he hit her. She stated S6CNA hit him back, then both Resident #1 and S6CNA started hitting each other back and forth. She stated she and S4LPN separated them. She stated after they were separated, S6CNA hit Resident #1 again. She stated hitting a resident was abuse. She stated when S6CNA hit Resident #1 back, it was abuse. On 08/16/2023 at 8:37 a.m., an interview was conducted with S2DON. She stated on 07/19/2023, S4LPN called her and notified her S6CNA hit Resident #1, after Resident #1 hit S6CNA. She stated if a staff member hit a resident, it was abuse, and that employee had to immediately leave the facility. She stated S6CNA left the facility right after the altercation and was terminated. She stated S4LPN assessed Resident #1, and no injuries were noted. On 08/16/2023 at 9:30 a.m., an interview was conducted with S1ADM. He stated he was notified of the altercation between Resident #1 and S6CNA, and went to the facility to review the camera footage. He stated he could not see much in the camera footage, but he could see S4LPN and a CNA separate Resident #1 and S6CNA, and put Resident #1 back in his wheelchair. He stated per camera footage, he saw S6CNA come back and hit Resident #1 in his face. He stated S6CNA was sent home as soon as the incident occurred and was terminated. He stated it was never appropriate for a staff member to hit a resident. Throughout the survey from 08/15/2023 to 08/16/2023, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, the effect of staff approach in relation to resident's behaviors, were knowledgeable of the types of abuse, and were aware abuse should be reported to administration immediately. The facility has implemented the following actions to correct the deficient practice: 1. Corrective actions were accomplished for residents found to be affected by the alleged deficient practice include: a) S6CNA was told to leave the facility immediately following the incident and was terminated. b) On 07/19/2023, S2DON immediately began in-services with nursing staff on shift immediately after incident and staff moving forward related to: abuse policy training; personal belongings not being in resident care areas or easily accessible by residents; Alzheimer's-impaired reasoning and judgement, may exhibit aggressive behaviors; de-escalating aggressive behaviors'; and the effect of staff approach in relation to residents behavior. c) Police Department notified per S1ADM and responded. d) Staff on male unit provided a locked closet to keep personal items should they need them. e) S2DON performed a walk-through of the unit to evaluate and analyze for any other potential risk hazards and none found. f) Interviewed staff to assess if S6CNA had any past behaviors towards residents. g) On 08/09/2023 the Ombudsman performed in house in-service on abuse. f) On 08/11/2023 the Risk Management consultant performed round on unit and provided feedback. 2. Other residents who have the potential to be affected by the alleged deficient practice include all residents in the facility. Corrective actions for those residents include: a) On 07/19/2023, S2DON immediately began in-services with nursing staff on shift after incident and staff moving forward related to: abuse policy training; personal belongings not being in resident care areas or easily accessible by residents; Alzheimer's-impaired reasoning and judgement, may exhibit aggressive behaviors; de-escalating aggressive behaviors'; and, the effect of staff approach in relation to resident's behavior. All staff in-serviced by 07/26/2023. 3. The measures that will be put in place to ensure the alleged deficient practice does not recur: a) S6CNA was terminated. 4. The facility plans to monitor its performance to ensure the results are sustained by: a) S2DON or designee will monitor for personal belongings being accessible to residents on the unit and the way staff responds to residents with behaviors 2-3 times a week for 4 weeks through 08/17/2023. Monitoring will be done via direct observation. 5. Compliance date: 07/27/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 4 (#2, #3, #4, #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for MDS. Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Dementia and Alzheimer's. Review of Resident #2's admission MDS with an ARD of 07/01/2023 revealed Dementia and Alzheimer's were not coded as active diagnoses in Section I. Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder. Review of Resident #3's admission MDS with an ARD of 06/22/2023 revealed Anxiety Disorder was not coded as an active diagnosis in Section I. Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dementia. Review of Resident #4's admission MDS with an ARD of 06/26/2023 revealed Dementia was not coded as an active diagnosis in Section I. Review of Resident #5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Hypothyroidism. Review of Resident #5's admission MDS with an ARD of 06/26/2023 revealed Thyroid Disorder was not coded as an active diagnosis in Section I. On 08/16/2023 at 10:45 a.m., an interview was conducted with S3MDS. She stated she was responsible for resident's MDS assessments. She stated when a MDS assessment is performed, all diagnoses should be coded accurately for every resident. She reviewed the admission MDS for Residents #2, #3, #4, and #5 and confirmed their MDS' were not coded accurately for active diagnoses in Section I. On 08/16/2023 at 10:55 a.m., an interview was conducted with S2DON. She confirmed if a resident had an active diagnosis, the MDS should be coded correctly with those diagnoses. On 08/16/2023 at 11:05 a.m., and interview was conducted with S1ADM. He confirmed if a resident had an active diagnosis, the MDS should be coded correctly with those diagnoses.

Based on observations, interviews, and record review, the facility failed to ensure expired enteral nutritional feedings were not available for resident use. This deficient practice had the potential to affect 1 of 1 (#209) resident that received Isosource 1.5 calorie enteral nutritional feeding. Findings: Review of facility's policy entitled Medical Room Guidelines revealed in part, the following: 11. Discontinued and expired drugs are removed from med cart, med room, and refrigerator in a timely manner. Review of the current Physician Orders for Resident #209 revealed in part, the following: Order start date: 06/20/2023 Order: Isosource 1.5 cal at 50mL/hr An observation was made on 06/26/2023 at 9:30 a.m. of Med Room a with S4LPN. An observation was made of 1 bag of Isosource 1.5 calorie tube feeding solution available on the shelf with an expiration date of 10/2022. An interview was conducted on 06/26/2023 at 9:30 a.m. with S4LPN. She confirmed the bag of Isosource feeding solution was expired and should have been discarded. She stated Med Room a was the only location where enteral nutritional tube feeding solutions were stored. An interview was conducted on 06/28/2023 at 10:47 a.m. with S8LPN. She stated all enteral nutritional tube feeding solutions were stored in Med Room a. She stated all facility staff obtained resident's feeding solutions from Med Room a. An interview was conducted on 06/27/2023 at 1:30 p.m. with S2DON. She stated no expired feeding solution should be available for use in a storage room. She confirmed the bag of expired Isosource feeding solution should not have been available for use and should have been properly discarded.

Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. Walls and doors were free of holes 2. Wallpaper remained intact 3. Baseboards were secured to the wall 4. Sheetrock was intact 5. Ceiling tiles were free of damage and secured 6. Toilet paper holders were properly functioning 7. Towel rack was secured to bathroom wall 8. In-room air conditioner unit was free of leaks 9. Privacy curtains were secured to ceiling and in working condition This deficient practice had the potential to affect 125 residents that resided in the facility. Findings: On 06/27/2023 at 12:24 p.m., an environmental tour was conducted with S3MS. He confirmed the below observations: Room a: Two brown sagging ceiling tiles. Room b: Three brown ceiling tiles above air conditioner soft and mushy to touch. Hall a: One ceiling tile covered with black and brown substance. Room c: Baseboard missing off the wall behind bed, and one hanging ceiling tile above toilet which was covered in dark brown substance. Room d: Privacy curtain unable to open, and baseboard below the air conditioner was peeling off the wall on both ends. Room e: One baseball-sized hole and one ping pong ball-sized hole in wall to the left of the foot of the bed. Room f: Towel rack hanging off the wall in the shower. Room g: Hockey puck-sized hole in closet door. Room h: One ceiling tile separated from the ceiling on its left side directly above the head of the bed. Room i: One baseball-sized hole in the bathroom door. Room j: Baseboard missing off the wall on the right side of the room with a 43 inch long by 7.5 inch tall by 4 inch deep hole in the wall. A bed cover with brown substance was rolled up and placed underneath the air conditioner. Room k: Baseboard loose on the left side of the wall, and toilet paper holder broken in restroom. Room l: Baseboard on left wall was lying on floor, and toilet paper holder broken in restroom. Room m: Baseboard missing off wall underneath the bathroom sink, and toilet paper holder broken in restroom. On 06/27/2023 at 1:00 p.m., an interview was conducted with S3MS. He stated the environmental issues listed above needed to be repaired. On 06/28/2023 at 9:36 a.m., an interview was conducted with S1ADM. He stated he had been at the facility for six days and was aware of the environmental issues in need of repair.

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Med Room a) of 2 (Med Room a and Med Room b) Medication Storage Rooms observed for medication storage. Findings: Review of the facility's policy titled Medical Room Guidelines revealed in part, the following: 11. Discontinued and expired drugs are removed from med cart, med room, and refrigerator in a timely manner. An observation was conducted on 06/28/2023 at 9:25 a.m. of Med Room a. Nine boxes containing ten vials per box of FluAd vaccines was observed with an expiration date of 05/31/2023 in the locked Medication refrigerator. An interview was conducted on 06/28/23 at 10:35 a.m. with S7AL. She stated all new admissions were offered the flu vaccine upon admission. She stated if a resident wished to receive the vaccine, the DON or the ADON would administer the vaccine out of the Medication Storage Room refrigerator where the vaccines are stored. An interview was conducted on 06/28/2023 at 9:26 a.m. with S6ADON. She confirmed the vaccines were expired and should have been discarded. An interview was conducted on 06/28/2023 at 10:00 a.m. with S2DON. She confirmed the vaccines were expired and should have been discarded.

Based on observations, interviews and record review, the facility failed to store and prepare food under sanitary conditions by failing to ensure food was properly stored in the refrigerators of the facility's kitchen. This had the potential to effect 122 residents served out of the kitchen. Findings: Review of the facility's policy entitled Storage of Cooked Foods revealed, in part, the following: 4. After product has been cooled to 41 degrees, seal tightly and label. Date the food with a use by date or discard date. An observation was made on 06/26/2023 at 8:20 a.m. of the facility's walk-in cooler and nourishment cooler with S5DM. The following was observed: 2 undated, unsealed packages of sliced ham were located on the 3rd shelf of the nourishment cooler with packages of cheese and a gallon of whole milk stored beneath it; and 1 unlabeled, undated pan of brown gravy covered with clear plastic was located on the 2nd shelf of the walk-in cooler. An interview was conducted on 06/26/2023 at 8:25 a.m. with S5DM. She confirmed the 2 packages of sliced ham were open, unsealed and stored in an inappropriate location within the cooler. She confirmed the packages of ham should have been stored in a sealed container and not located above any other food items. She confirmed the pan of brown gravy was not dated or labeled and should have been. An interview was conducted on 06/27/2023 at 2:43 p.m. with S1ADM. He confirmed all food items should be labeled and dated. He confirmed opened and unsealed meat products should not be located above any other food items when stored.

Based on observations and interview, the facility failed to label food in accordance with professional standards for food service safety as evidenced by the presence of improperly sealed and undated packages of food in the storage closet, walk-in refrigerator, and walk-in freezer in the facility's kitchen; The facility census was 113 and 105 residents ate meals from the facility kitchen. Findings: Review of facility policy titled Food Storage Labeling revealed the following, in part: Policy: The facility will store and label all foods to ensure safety and quality Procedures, in part: 1. All temperature controlled foods and ready-to-eat foods that are prepared in the facility shall be labeled with the food name, date and time of storage and use by or discard date. 3. The First In, First Out (FIFO) method of food storage is used to rotate all food in all storage areas. 4. Food is routinely monitored in storage to identify and discard foods that have passed the expiration or use by date. 7. Food is stored in containers that are sealable, leak proof, durable and undamaged. Dry Storage Area: -Opened 160 ounces, (10 pound) bag of pasta noodles wrapped in clear plastic wrapping laying on top of a box of rice with no open date identified -One 16 ounce container of [NAME] chocolate sauce, half-full, opened and not dated -One 16 ounce container of caramel sauce, opened and not dated -One 16 ounce container of blackberry sauce, opened and not dated -One 3 pound bag of powdered sugar open, in a zip-closure bag with no open date identified Walk-In Refrigerator: -Zip-closure bag with pickle spear slices with no open date identified Walk-In freezer: -Opened bag of frozen biscuits, approximately 10-12 in the bag with no open date identified -One opened bag of frozen French fries with no open date identified -One opened zip-closure bag of chicken tenders with no open date identified 06/19/2022 at 8:20 a.m., during the initial tour of the kitchen S12DM confirmed the food items should have been labeled and dated correctly after opening or should have been discarded.

Based on interviews and record reviews, the facility failed to ensure compliance with COVID-19 routine testing requirements according to the parish community transmission rate for 12 (S2LPN, S4MS, S8LPN, S9UC, S13MDS, S14BOS, S15DA, S16UC, S18LS, S19CNA, S20CNA, S21UC) of 12 unvaccinated staff members reviewed for the COVID-19 Infection Control requirements. Findings: Review of facility's policy titled Coronavirus 2019: Employee & Resident Testing Plan revealed the following: Purpose: to minimize exposure and infection of COIVD-19 within out facility. It is the policy of the facility to follow the State Department of Health and Centers for Disease Control (CDC) guidelines related to COVID-19 and strategies to mitigate the risk of transmission of COVID-19 within the nursing home population. Review of the CMS memo regarding COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements effective 09/10/2021 revealed the following: Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their community transmission level as the trigger for staff testing frequency. Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission Level of COVID-19 Community Transmission Minimum Testing Frequency of Unvaccinated Staff: Low (blue) Not recommended Moderate (yellow) Once a week Substantial (orange) Twice a week High (red) Twice a week A review of the facility's Community Transmission Level Log dated 05/01/2022-06/20/2022 revealed on 05/16/2022-05/23/2022 the facility was in the substantial level (orange) and on 05/23/2022-06/20/2022 the facility was in the high level (red). This indicated unvaccinated staff should have been tested for COVID-19 twice week. A review of the facility's Parish Positivity Rate Log revealed for the weeks of 05/16/2022 - 05/23/2022, the facility's parish positivity rate was substantial (orange) which required unvaccinated staff members to be tested twice a week and for the weeks of 05/23/2022 - 06/20/2022, the facility's parish positivity rate was high (red) which required unvaccinated staff members to be tested twice a week. A review of COVID-19 testing results for 11 unvaccinated staff revealed from 05/16/2022-06/20/22 the facility only tested staff for COVID-19 weekly. On 06/20/2022 at 10:15 a.m., an interview was conducted with S8LPN. She stated she had an accepted exemption and has not been vaccinated. S8LPN stated she was tested weekly for COVID-19. On 06/21/2022 at 11:21 a.m., an interview was conducted with S7ADON. S7ADON stated the parish transmission level was currently high (red). S7ADON verified the facility was not testing unvaccinated staff twice a week from 05/16/2022-06/20/2021 during which time the Community Transmission level was substantial (orange) or high (red). On 06/22/2022 at 10:07 a.m., an interview was conducted with S2LPN. S2LPN stated she had an approved religious exemption from the COVID-19 vaccination. S2LPN stated she was tested weekly for COVID-19. On 06/22/2022 at 9:48 a.m., an interview was conducted with S9UC. S9UC stated she had an approved religious exemption from the COVID-19 vaccination. S9UC stated she was tested weekly for COVID-19. On 06/22/2022 at 9:50 a.m., an interview was conducted with S4MS. S4MS stated he had an approved religious exemption from the COVID-19 vaccination. S4MS stated he was tested weekly for COVID-19. On 06/22/2022 at 10:10 a.m., an interview was conducted with S1ADM. S1ADM stated the facility was testing facility wide weekly due to the outbreak. S1ADM stated the community transmission level was currently high (red). S1ADM stated he was unaware when the Level of Community Transmission for COVID-19 was substantial (orange) or high (red) level, the facility should be testing twice a week.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 113 residents who currently reside in the facility. Findings: Review of the Pest Control Policy and Procedure revealed the following, in part: Policy: Each facility will have an effective pest control plan in place with resident safety as the top priority. Contingency plans will also be in place should active pest activity be identified. Procedure: No Active Pest Activity 1. A contract will in place with a professional pest control provider. a. This provider will inspect and treat monthly as well as be available for additional treatments should pest activity be identified. 2. Facility maintenance staff will perform daily weekday exterior rounds assessing for pest activity. c. All rounds should be documented in a log and turned in to the administrator at the end of each month. 3. Department head staff will perform 2 times weekly ambassador rounds to identify any signs of active pest activity in resident rooms. Active Pest Activity - Indoor Staff member will notify the administrator immediately upon identifying indoor pest activity. 4. Department head staff will inspect all resident rooms searching for active pest activity. 10. All activity should be tracked and trended using a copy of the facility map. 12. All of the above items should be documented as part of a QA. An observation was made on 06/19/2022 at 8:30 a.m. of a dead roach in the facility lobby. An observation was made on 06/19/2022 at 8:35 a.m. of a roach crawling at the nurses' station. An observation was made on 06/19/2022 at 8:45 a.m. of Room B. There were 15 gnats surrounding the bed and bedside table. An interview was conducted on 06/19/2022 at 9:00 a.m. with S2LPN. She stated she had seen roaches dead and alive consistently when she worked. An observation was made on 06/19/2022 at 9:59 a.m. of a fly, 5 gnats, and 3 dead roaches in Room G. An interview was conducted on 06/19/2022 at 10:50 a.m. with Resident #52. She stated she had seen bugs and roaches in her bathroom at nighttime just about every night. An interview was conducted on 06/19/2022 at 10:55 a.m. with Resident #88. She stated she saw roaches at night in the bathroom almost every night, including last night. An interview was conducted on 06/19/2022 at 11:04 a.m. with Resident #112. He stated he frequently saw roaches. Resident #112 opened his closet door, and there was a dead roach in the doorframe. An observation was made at 06/19/2022 at 11:05 a.m. of a roach as it crawled on the baseboard behind Room H's door. An observation was made on 06/19/2022 at 11:40 a.m. of Resident #79 while he ate his lunch tray. There was a gnat and a fly, which flew around his tray. An observation was made on 06/19/2022 at 12:48 p.m. of a roach as it crawled on Hall E. An interview was conducted on 06/19/2022 at 12:49 p.m. with S10CNA. She identified the bug as a roach and stepped on it. She stated she saw roaches weekly. An interview was conducted on 06/20/2022 at 10:17 a.m. with Resident #88. She stated she saw a roach this morning crawling out of her bathroom. An interview was conducted on 06/20/2022 at 10:35 a.m. with Resident #55. He stated he saw roaches in his room twice a month. An interview was conducted on 06/20/2022 at 2:05 p.m. with S1ADMIN. While interviewing S1ADMIN, Resident #110's family member approached S1ADMIN to inform him there was a roach infestation in the resident's room. An observation was made on 06/20/2022 at 2:40 p.m. of a small roach as it crawled on the floor in the day area on Hall E. An interview was conducted on 06/20/2022 at 2:41 p.m. with S11CNA. She identified the bug as a roach. She stated she saw a roach at least once a week. An observation was made on 06/20/2022 at 2:45 p.m. of a dead roach in the hallway on Hall E. An interview was conducted on 06/20/2022 at 2:46 p.m. with S11CNA. She identified the dead bug as a roach. An observation was made on 06/21/2022 at 12:30 p.m. of a roach as it crawled on the floor in the facility's conference room. On 06/21/2022 at 12:33 p.m. a food tray was received in the conference area. At 1:50 p.m., 4 gnats were noted on the tray while in the conference room. An observation was made on 06/22/2022 at 10:00 a.m. of a fly on Hall A. An interview was conducted on 06/22/2022 at 10:15 a.m. with Resident #63. She stated she saw roaches at night in her room. She stated there was an abundance of gnats in her room. An observation was made on 06/22/2022 at 10:15 a.m. of 6 gnats by the sink in Room C. An interview was conducted on 06/22/2022 at 10:20 a.m. with Resident #59. He stated he always had gnats in his room. He stated roaches crawl on him at night. An interview was conducted on 06/22/2022 at 10:30 a.m. with S3LPN. She stated the roaches were bad at night in the halls, resident rooms, and nurses' station. She stated gnats gravitated towards any food because of how many there was in the facility. An observation was made on 06/22/2022 at 10:45 a.m. of a gnat on Hall A. An interview was conducted on 06/22/2022 at 11:14 a.m. with S1ADMIN. He stated he was aware there was a roach problem. An interview was conducted on 06/22/2022 at 12:00 p.m. with S4MS. He stated he did not keep a log of when he treated resident rooms or halls for gnats or flies. He stated he was unaware he was supposed to keep a log. He stated when the baseboards were removed from the walls; roaches crawled out and have been bad since. An interview was conducted on 06/22/2022 at 12:20 p.m. with S1ADMIN. He stated the only maintenance log the facility kept was for ant treatment.