Based on observation, interviews and record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Treatment Cart A) of 2 (Treatment Cart A, Medication Cart B) medication carts observed for expired medications. Findings: Review of the facility's policy titled, Storage of Medication dated 2001 and revised in April 2019, revealed, in part, expired drugs or biologicals should be returned to the dispensing pharmacy or destroyed. Observation of Treatment Cart A on 02/12/2025 at 11:50AM revealed one bottle of New Skin liquid bandage (a liquid that creates a thin transparent barrier on a wound) with an expiration date of 06/2024. Further observation revealed two tubes of Thera Honey gel (a gel used for wound treatment) both with an expiration date of 08/11/2024. In an interview on 02/12/2025 at 11:53AM, S7Treatment Nurse confirmed the bottle of New Skin liquid bandage and the tubes of Thera Honey gel found stored on Treatment Cart A was expired and available for resident use, and should not have been. In an interview on 02/12/2025 at 1:50PM, S2Director of Nursing confirmed the expired bottle of New Skin liquid bandage and two tubes of expired Thera Honey gel should not have been stored in Treatment Cart A and available for resident use.

Based on observation, interview, and record review, the facility failed to: 1. Promptly repair the loose toilet fixture (Resident #62); and, 2. Prevent discarded waste and personal protective equipment (PPE) from accumulating in the facility's parking lot. This deficient practice was identified for 1(Resident #62) of 25 (Resident #1, Resident #3, Resident #10, Resident #12, Resident #13, Resident #16, Resident #17, Resident #20, Resident #21, Resident #22, Resident #26, Resident #27, Resident #28, Resident #33, Resident #34, Resident #45, Resident #47, Resident #54, Resident #60, Resident #62, Resident #62, Resident #63, Resident #78, Resident #236, Resident #386) sampled residents observed for environment. Findings: 1. In an interview on 02/10/2025 at 10:10AM, Resident #62 indicated the bathroom toilet had been loose for some time and she had reported it to S4Maintenance Director. Observation on 02/10/2025 at 10:11AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. Observation on 02/11/2025 at 8:40AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. Observation on 02/12/2025 at 7:55AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. In an interview on 02/12/2025 at 7:57AM, S4Maintenance Director indicated Resident #62's bathroom toilet base was loose and needed to be fixed. In an interview on 02/12/2025 at 8:00AM, S5Regional Administrator indicated Resident #62's bathroom toilet needed to be repaired. 2. Observation on 02/10/2024 at 9:21AM revealed the facility's back parking lot was littered with multiple discarded PPE gloves. Observation on 02/11/2025 at 8:15AM revealed the facility's back parking lot was littered with multiple discarded PPE gloves. In an interview on 02/11/2025 at 8:15AM, S1Administrator confirmed the above findings and indicated the facility's parking lot should be free of discard PPE gloves and general trash or debris.

Based on observations and interviews, the facility failed to: 1. Ensure staff performed hand hygiene while passing ice for 1 (S6Certified Nursing Assistant[CNA]) of 1 (S6CNA) CNAs observed passing ice; and, 2. Ensure hallway linen carts were kept covered for 2 Linen Carts (g, linen cart h) of 3 (linen cart b, linen cart h, linen cart i) linen carts observed. Findings: 1 Review of the facility's Handwashing-Hand Hygiene policy and procedures dated 01/22/2023 and reviewed on 1/28/2025 revealed, in part, personnel shall use alcohol-based hand rub or soap and water after contact with objects near the resident. Observation on 02/10/2025 at 10:20AM revealed S6CNA went into Room a, grabbed Resident #33's pitcher with ungloved hand, filled the pitcher with ice, returned the pitcher to Resident #33'a room, and exited Room a without performing hand hygiene. Observation on 02/10/2025 at 10:21AM revealed S6CNA went into Room b, grabbed Resident #32's pitcher with ungloved hand, filled the pitcher with ice, returned the pitcher to Resident 32's room, and exited Room b without performing hand hygiene. Observation on 02/10/2025 at 10:22AM revealed S6CNA went into Room c, grabbed Resident #16 and Resident #60's pitchers with ungloved hand, filled the pitchers with ice, returned the pitchers to Resident #16 and Resident #60's room, and exited Room c without performing hand hygiene. Observation on 02/10/2025 at 10:23AM revealed S6CNA went into Room d, grabbed Resident #78's pitcher with ungloved hand, filled the pitcher with ice, returned Resident 78's pitcher, and exited Room d without performing hand hygiene. Observation on 02/10/2025 at 10:24AM revealed S6CNA went into Room e, grabbed Resident #27's pitcher with ungloved hand, filled the pitcher with ice, returned Resident #27's pitcher, and exited Room e without performing hand hygiene. Observation on 02/10/2025 at 10:25AM revealed S6CNA went into Room f, grabbed Resident #38's pitcher with an ungloved hand, filled the pitcher with ice, returned Resident #38's pitcher, and exited the Room f without performing hand hygiene. In an interview on 02/10/2025 at 10:26AM, S6CNA confirmed she did not perform hand hygiene between residents' rooms while passing ice and should have. In an interview on 02/11/2025 at 12:21PM, S2Director of Nursing (DON) confirmed staff should perform hand hygiene between rooms when passing ice. 2. Observation on 02/10/2025 at 1:05PM revealed Linen Cart g was left uncovered, and clean linens were exposed to the surrounding environment. Observation on 02/10/2025 at 1:08PM revealed Linen Cart h was left uncovered, and clean linens were exposed to the surrounding environment. In an interview on 02/11/2025 at 12:21PM, S2DON indicated the linen carts should have been covered.

Based on observation and interviews, the facility failed to ensure residents were treated with respect and dignity during dining for 2 (Resident #47 and Resident #74) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) residents observed for dining. Findings: Resident #47 Observation on 02/26/2024 at 11:55 a.m., revealed lunch trays were being served to the residents in Dining Room B. Observation on 02/26/2024 at 12:14 p.m., revealed all residents, except for Resident #47, were served their lunch trays in Dining Room B. Further observation revealed, some of the residents in Dining Room B had finished their meals, and staff were no longer passing lunch trays and were feeding residents. Resident #47 was observed looking around the dining room at other residents eating. In an interview on 02/16/2024 at 12:15 p.m., Resident #47 stated he had not yet received a lunch tray and wanted to eat. In an interview on 02/26/2024 at 12:15 p.m., S3Assistant Director of Nursing (ADON) stated Resident #47 should have been served a lunch tray. In an interview on 02/27/2024 at 12:57 p.m., S1Director of Nursing (DON) stated Resident #47 should have been served a lunch tray when the rest of the residents were served. Resident #74 Observation on 02/26/2024 at 12:00 p.m., revealed a peppershaker was being passed around by the residents in Dining Room B. Observation on 02/26/2024 at 12:05 p.m., revealed Resident #74, who was eating in Dining Room B, requested pepper for his meal from S8Certified Nurse Aide (CNA).Further observation revealed S8CNA responded to Resident #74 that he could not have pepper because the facility was out of pepper, and she could not get him any. In an interview on 02/26/2024 at 12:15 p.m., S3ADON stated if Resident #74 had requested pepper from S8CNA, S8CNA should have provided Resident #74 with pepper, unless it was contraindicated by his diet order. There was no evidence, and the facility did not present any evidence, Resident #74 could not have pepper with his diet. In an interview on 02/27/2024 at 12:57 p.m., S2DON stated if Resident #74 had requested pepper, S8CNA should have provided him with pepper.

Based on interview and record review, the facility failed to ensure a resident with a new diagnosis of Major Depressive Disorder was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #55) of 5 (Resident #3, Resident #15, Resident #40, Resident #55, and Resident #78) sampled residents reviewed for PASARR. Findings: Review of Resident #55's Electronic Medical Record (EMR) revealed, in part, Resident #55 had a diagnosis of Major Depressive Disorder on 01/25/2022. Review of Resident #55's Level I determination dated 05/27/2019 revealed, in part, only Resident #55's diagnosis of Schizophrenia was listed under his mental illnesses. There was no documented evidence and the facility did not present any documented evidence of completing a Level II PASARR evaluation as required for Resident #55. In an interview on 02/29/2024 at 1:48 p.m., S6Social Services stated Resident #55's mental illness of Major Depressive Disorder was not addressed on his Level I screening. S6Social Services further stated Resident #55's record should have been submitted to the appropriate state agency for review when he had a new diagnosis of Major Depressive Disorder.

Based on observations and interviews, the facility: 1. failed to handle a resident's catheter bag in a manner to prevent urinary tract infections (Resident #78); and 2. failed to ensure staff provided catheter care in a manner to prevent urinary tract infections (Resident #78). This deficient practice was identified for 1 (Resident #78) of 1 sampled residents observed for catheter care. Findings: Observation of Resident #78 during personal care on 02/29/2024 at 11:01 a.m. revealed, while S18Certified Nurse Aide (CNA) was attempting to get a dried brown substance off Resident #78's Foley catheter, S18CNA used a towel to wipe the dried brown substance up Resident #78's Foley catheter towards his catheter insertion site three times. After personal care was completed S18CNA was observed lifting Resident #78 with a lift to put him in a wheelchair. Further observation revealed, S18CNA hung Resident #78's catheter bag on the arm of the lift. Further observation revealed, the urine and sediment in Resident #78's catheter bag flowed down the tubing of the catheter bag and back towards Resident #78's bladder after it was hung on the lift's arm. Further observation revealed, after Resident #78 was placed in wheelchair, S18CNA placed Resident #78's catheter bag on the floor. In an interview on 02/29/2024 at 11:16 a.m., S18CNA confirmed she had wiped from the end of Resident #78's Foley catheter towards Resident #78's catheter insertion site and should not have. S18CNA further stated she should not have hung Resident #78's Foley catheter bag, above his bladder, on the lift's arm. S18CNA further stated she should not have placed Resident #78's catheter bag on the floor. In an interview on 02/29/2024 at 11:20 a.m., S2Director of Nursing (DON) stated S18CNA should not have been wiping Resident #78's Foley catheter towards the catheter insertion site. S2DON further stated the resident's catheter bag should not have been hung above his bladder or placed on the floor.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received the appropriate interventions to decrease the risk of falls for 2 (Resident #46 and Resident #79) of the 3 sampled residents (Resident #46, Resident #61, and Resident #79) residents reviewed for falls. Findings: Resident #46 Review of Resident #46's Electronic Medical Record (EMR) revealed, in part Resident #46 had a diagnosis of hemiplegia and abnormal posture. Review of Resident# 46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/2023 revealed, in part, Resident #46 had a Brief Interview Mental Status (BIMS) score of 11, which indicated Resident #46 moderately cognitive impaired. Further review revealed, Resident #46 was dependent and needed substantial to maximum assistance with transfers. Review of Resident #46's Physician Orders dated 10/13/2023 revealed, in part, the following: Resident #46 was at risk for falls. Review of the facility's incident documentation for November 2023, December 2023, and January 2024 revealed, in part, Resident #46 had unwitnessed falls on 08/23/2024, 11/11/2023, 01/26/2024, 01/28/2024, and 01/30/2024. Review of Resident #46's Fall Risk Screening dated 01/30/2024 revealed, in part, Resident #46 was assessed as being at moderate risk for falls and impaired mobility and gait. Review of Resident #46's Comprehensive Care Plan with a start date of 11/14/2023 revealed, in part, Resident #46 was at high risk for falls related to left sided hemiplegia. Further review revealed an intervention included to place frequently used items within Resident #46's reach. Observation on 02/27/2024 at 9:38 a.m., revealed Resident #46 was siting in wheelchair in his room. Further observation revealed, Resident #46's call bell and frequently used items out of Resident #46's reach. Observation on 02/29/2024 at 1:30 p.m. revealed, Resident #46 was lying in bed. Further observation revealed, Resident 46's frequently used items out of Resident #46's reach. In an interview on 02/29/2024 at 1:42 p.m. S2Director of Nursing stated Resident 46's frequently used items should be within Resident #46's reach. Resident #79 Review of Resident #79's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2024 revealed, in part, Resident #79's Brief Interview for Mental Status (BIMS) score was 15, which indicated Resident #79 was cognitively intact. Review of the facility's incident documentation for January 2024 and February 2024 revealed, in part, Resident #79 had unwitnessed falls on 01/31/2024, 02/05/2024, 02/06/2024 at 7:30 p.m., 02/06/2024 at 11:00 p.m., 02/09/2024, 02/12/2024, and 02/17/2024. Review of Resident #79's fall risk screening dated 01/23/2024 revealed, in part, Resident #79 had a fall risk score of 13, which indicated Resident #79 was at high risk for falls. Review of Resident #79's Comprehensive Care Plan with a start date of 02/12/2024 revealed, in part, a plan of care was developed for Resident #79 for being at high risk for falls with interventions to include the use of a chair alarm when in the wheelchair and bed alarm when in bed. Review of Resident #79's February 2024 Physician Order Summary Report revealed an order to ensure a bed alarm is in place while Resident #79 was in bed and ensure a chair alarm was in place while Resident #79 was in the wheelchair. Observation on 02/28/2024 at 9:20 a.m. revealed Resident #79 was sitting in her wheelchair with no chair alarm. Observation on 02/29/2024 at 9:50 a.m. revealed Resident #79 was sitting in her wheelchair with no chair alarm. In an interview on 02/29/2024 at 9:50 a.m. Resident #79 stated she did not have a chair alarm on her chair, and further stated she did not have a bed alarm or chair alarm yesterday or last night. In an interview on 02/29/2024 at 10:00 a.m. S17Licensed Practical Nurse (LPN) stated Resident #79 had a history of falling and required a bed alarm. S17LPN stated Resident #79 did not require a chair alarm. In an interview on 02/29/2024 at 10:10 a.m. S16Certified Nurse Aide (CNA) stated Resident #79 had a history of falls and required a bed alarm and a chair alarm. S16CNA stated she did not put Resident #79's chair alarm on this morning. In an interview on 02/29/2024 at 10:15 a.m. S12Minimum Data Set (MDS) Nurse stated Resident #79 had a history of falls. S12MDS Nurse further stated Resident #79 required a bed alarm while in the bed and a chair alarm while in the wheelchair to decrease Resident #79's risk of falls and injury. Observation with S12MDS Nurse on 02/29/2024 at 10:18 a.m., revealed Resident #79 did not have on a chair alarm. In an interview on 02/29/2024 at 10:18 a.m., S12MDS Nurse confirmed Resident #79 did not currently have on a chair alarm and stated a chair alarm should have been placed on Resident #79's chair when Resident #79 was put in her chair. In an interview on 02/29/2024 at 11:59 a.m., S1Director of Nursing confirmed Resident #79 should have had a chair alarm on her wheelchair and a bed alarm per interventions on Resident #79's care plan.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program by: 1.) failed to perform hand hygiene while feeding residents for 4 (Resident #8, Resident #16, Resident #52, and Resident #57) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) sampled residents observed for dining; 2.) administering crushed medication from an open medication pill crusher pouch that fell on the floor. This practice was observed for 1 (S20Licensed Practical Nurse [LPN]) of 6 (S15LPN, S17LPN, S20LPN, S21LPN, S22LPN, and S23LPN) Licensed Practical Nurses observed during medication administration; 3.) failed to perform proper hand hygiene during urinary catheter care for 1 (Resident #78) of 1 (Resident #78) sampled resident observed for catheter care; and 4.) failed to perform proper hand hygiene during wound care for 1 (Resident #54) of 2 (Resident #54 and Resident #78) sampled residents observed for wound care. Findings: 1. Observation on 02/26/2024 at 12:08 p.m. revealed S7Cerified Nurse Aide (CNA) fed Resident #8, wiped his mouth with a napkin, and then fed Resident #16 without performing hand hygiene. Further observation revealed, S7CNA finished feeding Resident #16 and then fed Resident #8 without performing hand hygiene. S7CNA was then observed feeding Resident #16 two bites of food then fed Resident #8 three bites of food, then fed Resident #16 two bites of food without performing hand hygiene. Further observation revealed, after feeding Resident #8 a bite of food, S7CNA fed Resident #16 two more bites of food without performing hand hygiene. In an interview on 02/26/2024 at 12:11 p.m., S7CNA confirmed she did not perform hand hygiene between feeding residents and she should have. In an interview on 02/26/2024 at 12:15 p.m., S3Assistant Director of Nursing (ADON) stated S7CNA should have performed hand hygiene between feeding residents bites of food. Observation on 02/27/2024 at 11:48 a.m., revealed S9CNA fed Resident #57 a bite of food, and then picked up Resident #52's spoon from his tray to feed him. Further observation revealed Resident #52 was not ready for a bite of food and S9CNA placed Resident #52's spoon back onto his plate and began to feed Resident #57 without performing hand hygiene. In an interview on 02/26/2024 at 12:11 p.m., S9CNA confirmed she did not perform hand when she started to feed Resident #52 and Resident #57. S9CNA further stated she should have performed hand hygiene between touching resident's spoons. In an interview on 02/27/2024 at 12:57 p.m., S2Director of Nursing (DON) stated S7CNA and S9CNA should have performed hand hygiene between feeding residents. 2. Observation on 02/28/2024 at 1:37 p.m. revealed S20LPN crushed Gabapentin 600 milligrams (a medication use for nerve pain) in a clear open medication pill crusher pouch. Further observation revealed S20LPN dropped the clear open medication pill crusher pouch with the crushed medication in it on the floor. Further observation revealed S20LPN pick up the clear open medication pill crusher pouch with her hands and proceeded to Resident #33's room. Further observation revealed S20LPN put on gloves without washing her hands with soap and water or without hand sanitizer. Further review revealed S20LPN poured the medication from the clear open medication pill crusher pouch into a one ounce medication cup and diluted with water. Further observation revealed S20LPN administered the diluted medication into Resident #33's peg tube. In an interview on 02/28/2024 at 2:05 p.m,. S20LPN stated she did not think the clear open medication pill crusher pouch with medication was contaminated. S20LPN further stated she did not wash her hands after picking the clear open medication pill crusher pouch up off of the floor and she should have. In an interview on 02/29/2024 at 4:10 p.m., S2Director of Nursing (DON) stated S20LPN should have disposed of the dropped clear open medication pill crusher pouch and should have performed hand hygiene before performing peg tube medication administration. 3. Observation on 02/29/2024 at 11:01 p.m. revealed S18CNA put on gloves without first performing hand hygiene and performed Resident #78's catheter care. Further observation revealed S18CNA opened Resident #78's drawer and pulled out a pack of wipes without removing her gloves or performing hand hygiene. Further observation revealed, after wiping stool off of Resident #78's buttocks with a wipe and wet towel, S18CNA removed her gloves, did not perform hand hygiene, and reached into another assisting CNA's pocket to grab another pair of gloves. In an interview on 02/29/2024 at 11:16 a.m., S18CNA confirmed she did not perform hand hygiene before starting Resident #78's catheter care and should have. S18CNA stated she had not removed her gloves or performed hand hygiene before opening Resident #78's drawer and pulling out Resident #78's wipes and should have. S18CNA further confirmed she did not perform hand hygiene after cleaning stool from Resident #78's buttocks and removing her gloves, before reaching into the other CNA's pocket and should have. In an interview on 02/29/2024 at 11:20 a.m., S2DON stated S18CNA should have performed hand hygiene before starting catheter care, when removing her gloves, before putting new gloves on, and before reaching into another staff member's pocket. 4. Review of the policy and procedure titled, Wound Care and most recently revised in November 2017 revealed, in part, after removing a dressing staff should remove their gloves and wash and dry their hands before proceeding with wound care. Observation of wound care performed on 02/28/2024 at 10:45 a.m. revealed S14Treatment Nurse removed the dressing from Resident #54's sacral wound. Further observation revealed S14Treatment Nurse cleaned, packed, and redressed Resident #54's sacral wound without changing gloves or performing hand hygiene. In an interview on 02/28/2024 at 11:00 a.m., S14Treatment Nurse stated she should have performed hand hygiene and changed gloves while performing wound care to Resident #54's sacral wound.

Based on record reviews and interviews, the facility failed to immediately notify a resident's physician following incidents of resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of the facility's Change in a Resident's Condition or Status policy and procedure revealed, in part, the nurse will notify the resident's Attending Physician, Nurse Practitioner or physician on call when there has been a(n): accident or incident involving the resident and a significant change in the resident's physical/emotional/mental condition. Resident #1 Review of Resident #1's admission Record revealed, in part, Resident #1's primary physician was S10Medical Director. Review of Resident #1's nurse's note completed by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported Resident #2 hit her in her left breast. Further review revealed documentation Resident #1's physician's office was notified of the incident via fax. There was no documented evidence and the facility was unable to present any documented evidence S10Medical Director was notified of Resident #1's above mentioned incident of resident to resident physical abuse immediately upon discovery. Resident #2 Review of Resident #2's admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S6Licensed Practical Nurse (LPN) on 10/28/2023 at 3:20 p.m. revealed, in part, Resident #2 and Resident #3 were observed swinging and cursing at one another. Review of the facility's Fax Form for Non-Emergency Communication document sent to S10Medical Director's office on 10/29/2023 (Sunday) at 11:27 a.m. revealed, in part, Resident #2 was documented to have been in 2 physical altercations with 2 different residents. Further review revealed S10Medical Director signed and dated his response on 10/30/2023 along with a written note that in the future the on call physician was to be notified of incidents. In an interview on 11/15/2023 at 11:39 a.m., S2Director of Nursing (DON) confirmed a fax was sent to S10Medical Director's closed office on 10/29/2023 (Sunday) which documented Resident #2 was involved in 2 physical altercations that occurred on 10/28/2023. S2DON confirmed Resident #2's physician or the on call physician should have been notified of the incident on 10/28/2023. In a telephone interview 11/15/2023 at 2:49 p.m., S6LPN stated she sent a fax to S10Medical Director's closed office regarding Resident #2's 2 physical altercations with residents, but the facility did not receive a fax or any form of communication back from S10Medical Director. In an interview on 11/15/2023 at 2:25 p.m., S2DON stated S10Medical Director did not want to be notified of incidents involving his residents via fax. S2DON additionally stated S10Medical Director was upset that he was not called immediately after the incident. S2DON confirmed sending a fax to a physician's office on a weekend without an immediate confirmation of the fax did not ensure the physician was made aware of an incident and/or change in condition. Resident #3 Review of Resident #3's verbal statement obtained and written by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated he swung his arm with a closed fist and hit Resident #2. Resident #3 further stated following the incident he informed S5Weekend Supervisor, he hit Resident #2. Review of Resident #3's nurse's note completed by S7Charge Nurse on 10/30/2023 at 9:25 a.m. revealed, in part, Resident #3's primary care physician was made aware of the above stated incident. In an interview on 11/15/2023 at 12:56 p.m., Resident #3's physician stated she was notified on 10/30/2023 of the incident that occurred between Resident #2 and Resident #3 by S7Charge Nurse when Resident #3 requested to discharge from the facility. In an interview on 11/15/2023 at 2:27 p.m., S5Weekend Supervisor stated she did not contact Resident #3's physician regarding the incident that occurred on 10/28/2023 between Resident #2 and Resident #3. In an interview on 11/15/2023 at 2:40 p.m., S7Charge Nurse stated S4Social Services informed her on 10/30/2023 that Resident #3 hit Resident #2 and Resident #3's physician needed to be notified. S7Charge Nurse stated she notified Resident #3's physician of the incident on 10/30/2023. S7Charge Nurse further stated prior to this date Resident #3's physician had not been notified of the above stated incident. In an interview on 11/15/2023 at 3:20 p.m., S2DON stated Resident #3's physician should have been notified immediately after Resident #3 hit Resident #2.

Based on record reviews and interviews, the facility failed to implement their written policies and procedures for abuse by failing to ensure residents were protected after an allegation of physical abuse for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention Program policy revealed, in part the facility was to protect residents during abuse investigations. Review of the facility's Abuse Investigation and Reporting policy revealed, in part in the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. Review of the facility's Abuse and Neglect- Clinical Protocol policy revealed, in part, if the facility staff did not provide immediate interventions to assure the safety of residents, the facility did not provide sufficient protection to prevent resident to resident abuse. Review of Resident #3's statement obtained and written by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of the facility's monitoring tool for Resident #3 revealed no documentation for 10/29/2023 from 6:00 p.m.- 12:00 a.m. and 10/30/2023 from 12:00 a.m.- 10:00 a.m. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated he swung his arm with a closed fist and hit Resident #2. Resident #3 further stated following the incident he informed S5Weekend Supervisor, he hit Resident #2. In an interview on 11/13/2023 at 2:33 p.m., S6Licensed Practical Nurse (LPN) confirmed she was the nurse assigned to Resident #3 on 10/28/2023. S6LPN further stated no action such as an in increase in supervision and/or one on one monitoring of Resident #3 was taken on 10/28/2023 or 10/29/2023. In an interview on 11/14/2023 at 12:45 p.m., S5Weekend Supervisor stated the facility's process following resident to resident physical altercations, was to place the residents involved on one on one monitoring until the resident could be removed from the facility to ensure all the residents in the facility were safe. S5Weekend Supervisor confirmed she did not place Resident #3 on one on one monitoring because Resident #3 did not have any psychiatric diagnosis. S5Weekend Supervisor further stated Resident #3 stated he was calm; therefore, she did not feel he was a danger to other residents in the facility. In an interview on 11/14/2023 at 1:03 p.m., S2Director of Nursing (DON) confirmed the facility's process following resident to resident physical altercations, was to place the residents involved in the physical altercation on one on one monitoring, regardless of the residents diagnosis, until the resident could be removed from the facility to ensure all the residents in the facility were safe. S2DON further stated Resident #3 should have been placed on one on one monitoring immediately following Resident #3 hitting Resident #2 to ensure the protection of all of the residents in the facility.

Based on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Investigation and Reporting policy revealed, in part an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two house if the alleged violations involves abuse. Resident #1 and Resident #2: Review of the facility's incident report entered on 10/28/2023 at 7:06 p.m. revealed, in part, S5Weekend Supervisor was notified by Resident #1 of an allegation of resident to resident physical abuse involving Resident #2 on 10/28/2023 at approximately 3:15 p.m. Review of Resident #1's nurse's note written by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported that Resident #2 hit her in her left breast. In an interview on 11/15/2023 at 3:01 p.m., S5Weekend Supervisor confirmed 3:15 p.m. was the time she discovered Resident #1 and Resident #2's alleged resident to resident physical abuse incident. S5Weekend Supervisor stated she did not immediately notify S2Director of Nursing (DON) following the discovery of the alleged resident to resident abuse incident. In an interview on 11/15/2023 at 3:04 p.m., S2DON confirmed S5Weekend Supervisor did not immediately notify S2DON upon the discovery of Resident #1's allegations of resident to resident physical abuse. S2DON confirmed the SIMS report was entered on 10/28/2023 at 7:06 p.m., which was greater than 2 hours after the discovery of the above mentioned alleged resident to resident physical abuse. Resident #2 and Resident #3: Review of a incident report entered on 10/30/2023 at 1:55 p.m. revealed, in part an incident of verbal and physical abuse had occurred between Resident #2 and Resident #3. Further review revealed an allegation of verbal abuse with a discovered date of 10/30/2023 at 12:30 p.m. Further review revealed, during the incident investigation Resident #3 was interviewed on 10/30/2023 at 9:00 a.m. and stated his interaction with Resident #2 became physical. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of Resident #3's progress note written by S6Licensed Practical Nurse (LPN) on 10/28/2023 at 9:30 p.m. revealed, in part Resident #3 denied discomfort related to the incident involving Resident #2. Review of Resident #3's progress note written by S7Charge Nurse with an effective date of 10/30/2023 at 9:25 a.m. revealed, in part Resident #3's Primary care physician was made aware of the incident. Review of Resident #3's progress note written by S4Social Services on 10/30/2023 at 10:35 a.m. revealed, in part upon review of a previous incident that occurred over the weekend, it was revealed that Resident #3 taunted and hit another resident. In an interview on 11/15/2023 at 2:45 p.m., S5Social Services stated she was notified by S1Adminsitrator on 10/30/2023 around 9:30 a.m. that Resident #2 and Resident #3 had been in a physical altercation. In an interview on 11/15/2023 at 3:10 p.m., S1Administrator stated despite S5Weekend Supervisor being made aware of the physical abuse incident between Resident #2 and Resident #3 on 10/28/2023 and Resident #3 confirmed on 10/30/2023 with S4Social Worker that he hit Resident #2 on 10/28/2023, S1Administrator still felt the discovered time of the incident on 10/30/2023 at 12:30 p.m. was the time the facility had concluded their investigation and could initiate a SIMS report. In an interview on 11/15/2023 at 3:20 p.m., S2DON stated she was made aware Resident #2 and Resident #3 verbally and physically abusing each other on 10/30/2023 at approximately 9:00 a.m. when she arrived to the facility. S2DON further stated Resident #2 and Resident #3's incident was discovered prior to the listed discovered date and time of 10/30/2023 at 12:30 p.m. S2DON further stated the SIMS report should have been entered within 2 hours after the initial discovery of the incident and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain a physician's order prior to transferring a resident to an inpatient psychiatric hospital for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents investigated for abuse. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standards, Part XLVII Nurses: Practical Nurses and Registered Nurses, Subpart 2 Registered Nurses, Chapter 37 Nursing Practice revealed, in part, a standard of nursing practice included executing health care regimes as prescribed by a licensed physician, or authorized prescriber. Review of Resident #2's admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S2Director of Nursing (DON) on 10/28/2023 at 9:31 p.m. revealed, in part, an inpatient behavioral hospital was contacted to complete evaluation and treatment for Resident #2. Review of Resident #2's nurse's note completed by S6LPN on 10/29/2023 at 1:10 p.m. revealed, in part, Resident #2 was transported and admitted to an inpatient psychiatric hospital. On 11/15/2023 at 12:10 p.m. Resident #2's electronic medical record revealed no documented evidence of a physician's order from S10Medical Director to transfer and admit Resident #2 to an inpatient psychiatric hospital. Review of Resident #2's physical chart revealed no documented telephone orders from S10Medical Director to send Resident #2 to the inpatient psychiatric hospital on [DATE]. There was no documented evidence and the facility did not present any documented evidence a physician's order obtained for Resident #2 to be transferred and admitted to a psychiatric hospital on [DATE]. In an interview on 11/15/2023 at 1:39 p.m., S2DON confirmed she reviewed Resident #2's physical chart and there was no documentation that S10Medical Director was contacted on 10/28/2023 or 10/29/2023 to obtain an order to send Resident #2 to an inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:19 p.m., S5Weekend Supervisor stated following Resident #2's alleged physical altercations with two residents, she called an inpatient psychiatric hospital to set up placement for Resident #2. S5Weekend Supervisor denied speaking with S10Medical Director to obtain an order prior to sending Resident #2 to the inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:25 p.m., S2DON confirmed it was out of a nurse's scope of practice to transfer a resident and have the resident admitted to an inpatient psychiatric hospital without a physician's order. In a telephone interview 11/15/2023 at 2:49 p.m., S6LPN stated she did not get a telephone order or verbal order on 10/28/2023 or on 10/29/2023 from S10Medical Director to send Resident #2 to an inpatient psychiatric hospital. S6LPN stated she sent a fax to S10Medical Director's office on 10/29/2023 (Sunday), which indicated Resident #2 was being transferred to an inpatient psychiatric hospital. S6LPN further indicated she had not received a fax or any form of communication back from S10Medical Director with an order to send Resident #2 to the psychiatric hospital prior to doing so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure staff did not transcribe an order that was not obtained from a physician for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of Resident #2's admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S6Licensed Practical Nurse(LPN) on 10/29/2023 at 1:10 p.m. revealed, in part, Resident #2 was transported and admitted to an inpatient psychiatric hospital. Review of Resident #2's physical chart revealed no documented telephone orders from S10Medical Director to send Resident #2 to the inpatient psychiatric hospital on [DATE]. On 11/15/2023 at 12:10 p.m., Resident #2's electronic medical record revealed no documented evidence of a physician's order from S10Medical Director to transfer and admit Resident #2 to an inpatient psychiatric hospital. On 11/15/2023 at 1:24 p.m., Resident #2's electronic medical record revealed, in part, a telephone order was given by S10Medical Director to S5Weekend Supervisor on 10/29/2023 at 11:00 a.m. to send to Resident #2 to an inpatient psychiatric hospital. Further review of the order details revealed the order was created by S5Weekend Supervisor on 11/15/2023 at 1:14 p.m. and signed by S10Medical Director on 11/15/2023 at 1:20 p.m. In an interview on 11/15/2023 at 1:39 p.m., S2DON confirmed the physician's order to send Resident #2 to the inpatient psychiatric hospital was created on 11/15/2023 at 1:14 p.m. S2DON confirmed S5Weekend Supervisor should not have back dated the above mentioned physician's order. In an interview on 11/15/2023 at 2:19 p.m., S5Weekend Supervisor denied obtaining a telephone order from S10Medical Director on 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital. S5Weekend Supervisor stated she was instructed by her team on 11/15/2023 to enter the above mentioned telephone order from S10Medical Director dated 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:25 p.m., S2DON confirmed she, S3Assistant Director of Nursing, and S1Administrator instructed S5Weekend Supervisor to enter an order from S10Medical Director on 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital today (11/15/2023). S2DON stated when the surveyor asked to see Resident #2's physician's orders, S2DON noticed Resident #2 did not have an physician's order to be sent to the inpatient psychiatric hospital on [DATE]. S2DON stated she then directed S5Weekend Supervisor to enter a physician's order S5Weekend Supervisor did not obtain. In an interview on 11/15/2023 at 2:45 p.m., S5Weekend Supervisor confirmed she did not speak with S10Medical Director on 10/29/2023 to obtain a physician's order to send Resident #2 to an inpatient psychiatric hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prevention Program policy revealed, in part, the facility's residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Physical abuse included, but was not limited to hitting, slapping, pinching, and kicking. Resident #1 and Resident #4: Review of Resident #1's admission Record revealed, in part, Resident #1 had diagnoses of anxiety disorder and schizoaffective disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had no behaviors directed towards others documented. Review of Resident #4's admission Record revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, anxiety disorder, and schizoaffective disorder. Review of Resident #4's MDS with an ARD of 08/28/2023 revealed, in part, Resident #4 had a BIMS score of 99, which indicated Resident #4 was unable to complete the interview. Further review revealed Resident #4 was documented to be moderately impaired in daily decision making. Review of the facility's Incident and Accident log revealed, in part, Resident #1 and Resident #4 had an incident on 09/18/2023 at 3:30 p.m. Review of Resident #1's Physician Progress Notes, signed by the physician on 09/19/2023, revealed, in part, Resident #1's physician, S10Medical Director, documented patient was struck by her roommate yesterday. Further review revealed S10Medical Director included the diagnosis of assault in unarmed fight in Resident #1's progress note. In an interview on 11/13/2023 at 3:01 p.m., Resident #1 stated Resident #4 deliberately hit her behind her head with an open hand on 09/18/2023 as they were passing one other in the hallway. Resident #1 stated Resident #R5 and Resident #R6 witnessed the incident between Resident #1 and Resident #4. Review of Resident #R5's MDS with an ARD of 08/23/2023 revealed, in part, Resident #R5 was diagnosed with aphasia (an inability to formulate language because of damage to specific area of the brain). Observation on 11/13/2023 at 3:11 p.m. revealed Resident #R5 demonstrated the above mentioned incident by taking his hand and hitting himself behind his head. Resident #R5 nodded yes when asked if that was how Resident #4 hit Resident #1 on 09/18/2023. In an interview on 11/14/2023 at 9:40 a.m., S9Maintenance stated he heard Resident #1 say, don't f*cking hit me, as Resident #4 was passing by Resident #1 in the hallway. S9Maintenance stated he did not witness Resident #4 hit Resident #1, but S9Maintenance did witness a vulgar verbal altercation between Resident #1 and Resident #4. S9Maintenance stated he informed S1Administrator regarding the incident between Resident #1 and Resident #4. In an interview on 11/14/2023 at 12:07 p.m., Resident #R6 stated he witnessed Resident #4 hit Resident #1 behind the head for no reason. Resident #R6 stated he was ambulating down the hall with Resident #4 walking on side of him. Resident #R6 further indicated Resident #4 hit Resident #1, and then Resident #1 cussed out Resident #4. In an interview on 11/14/2023 at 12:43 p.m., S2DON confirmed Resident #R6 was cognitive and reliable. In an interview on 11/14/2023 at 10:15 a.m., S4Social Services confirmed Resident #R5 was a reliable source of information, but Resident #R5 was nonverbal due to a previous stroke. S4Social Services additionally stated Resident #R5 was capable of acting out what happened during the 09/18/2023 incident between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:05 a.m., S1Administrator stated physical abuse between Resident #1 and Resident #4 could not be substantiated despite witness statements. S1Adminisrtator was unable to provide any explanation as to why he was unable to substantiate physical abuse between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:06 a.m., S2Director of Nursing (DON) stated physical abuse between Resident #1 and Resident #4 could not be substantiated despite witness statements. S2DON was unable to provide any explanation as to why she was unable to substantiate physical abuse between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:07 a.m., S4Social Services denied physical abuse between Resident #1 and Resident #4 could be substantiated despite witness statements. S4Social Services was unable to provide any explanation as to why she was unable to substantiate physical abuse between Resident #1 and Resident #4. Resident #1 and Resident #2: Review of Resident #1's admission Record revealed, in part, Resident #1 had diagnoses of anxiety disorder and schizoaffective disorder. Review of Resident #1's MDS with an ARD of 10/24/2023 revealed, in part, Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had no documented behaviors directed towards others. Review of Resident #2's admission Record revealed, in part, Resident #2 had diagnoses of schizoaffective disorder, anxiety disorder, and impulse disorder. Review of Resident #2's MDS with an ARD of 08/22/2023 revealed, in part, Resident #2 had a BIMS score of 3, which indicated Resident #2 had severe cognitive impairment. Further review revealed Resident #2 had physical behavior symptoms directed toward others, which occurred 1 to 3 days within the 7-day look back period. Review of Resident #1's nurse's note written by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported that Resident #2 hit her in her left breast. Review of Resident #1's Incident Note on 10/28/2023 3:33 p.m. revealed, in part, S5Weekend Supervisor observed Resident #1 who appeared tearful or saddened. Further review revealed Resident #1 reported to S5Weekend Supervisor that Resident #2 hit her. Review of Resident #2's Behavioral Note on 10/28/2023 at 3:00 p.m. revealed, in part, Resident #2 was accused of hitting Resident #1 in her chest. Review of S8Certified Nursing Assistant's (CNA) written statement signed and dated on 10/28/2023 revealed, in part, S8CNA witnessed Resident #1 and Resident #2 passing punches and fussing and cussing. Review of Resident #3's MDS with an ARD of 09/12/2023 revealed, in part, Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor revealed, in part, on 10/28/2023, Resident #3 witnessed Resident #2 punch Resident #1 in her chest. Review of Resident #1's Physician Progress Notes signed by the physician on 10/31/2023 revealed, in part, over the weekend there was an altercation with another resident. Further review revealed another resident hit her in the chest and it does appear that she struck the resident also. Review also revealed a diagnosis of injury due to altercation. In an interview on 11/13/2023 at 3:01pm, Resident #1 stated as she was coming back from the dining room on 10/28/2023, and Resident #2 punched her in her left breast with a closed fist. She stated at that time, she lifted her arms to stop Resident #2 from hitting her again, and Resident #2 attempted to bite her arm. Resident #1 stated Resident #R5 witnessed the incident. Observation on 11/13/2023 at 3:11 p.m. revealed when Resident #R5 was asked if Resident #2 hit Resident #1 in the chest, Resident #R5 nodded his head yes. Observation further revealed Resident #R5 demonstrated how Resident #2 hit Resident #1 by punching the left side of his own chest with a closed fist. In an interview on 11/14/2023 at 8:56 a.m., S8CNA, stated she witnessed Resident #1 and Resident #2 cursing at each other and hitting each other in the hallway coming from the dining room on 10/28/2023. S8CNA confirmed the incident between Resident #1 and Resident #2 was an incident of resident to resident verbal and physical abuse. In an interview on 11/14/2023 at 11:05 a.m., S1Administrator stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 11:06 a.m., S2DON stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 11:07 a.m., S4Social Services stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated as residents were leaving the dining room on 10/28/2023, Resident #2 was harassing Resident #1. Resident #3 then stated he witnessed Resident #2 punch Resident #1 in her breast. In an interview on 11/14/2023 at 12:45 p.m., S2DON stated she came up with the scenario that was included in the SIMS report where Resident #1 was accidentally hit by Resident #2's arms after he threw them in the air due to his impulse control diagnosis. S2DON confirmed no witness statements aligned with her scenario. S2DON stated Resident #2 was sweet and had a diagnosis of intellectual disability, so S2DON felt Resident #2 was not capable to willfully hit Resident #1. S2DON further stated Resident #1 had a history of fabricating stories and prior abuse allegations. S2DON stated, I know how [Resident #2] is. S2DON also stated Resident #2 had psychiatric diagnoses which made it impossible for Resident #2 to have willful intent to physically abuse another resident. S2DON proceeded to state Resident #1 also had psychiatric diagnoses, but Resident #1 was capable to willfully hit Resident #1. In an interview on 11/14/2023 at 1:00 p.m., S1Administrator confirmed that despite a resident's diagnosis, all residents had a right to be free from abuse. In an interview on 11/14/2023 at 1:01 p.m., S2DON confirmed that despite a resident's diagnosis, all residents had a right to be free from abuse. Resident #2 & Resident #3: Review of the facility's incident report entered on 10/30/2023 at 1:55 p.m. revealed, in part a physical altercation had occurred between Resident #2 and Resident #3. Further review revealed, during the incident investigation that Resident #3 was interviewed on 10/30/2023 at 9:00 a.m. and stated his interaction with Resident #2 became physical. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with a diagnoses of Impulse Disorder, Schizophrenia, and Cognitive Communication Deficit. Review of Resident #2's MDS with an ARD of 08/22/2023 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 3, which indicated Resident #2 was severely cognitively impaired. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE] with a diagnoses of Anxiety and Major Depressive Disorder. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 09/12/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status score of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of Resident #3's progress note written by S4Social Services on 10/30/2023 at 10:35 a.m. revealed, in part, upon review of a previous incident that occurred over the weekend, it was revealed that Resident #3 taunted and hit another resident. Further review revealed, S4Social Services interviewed Resident #3 on what caused the altercation with Resident #3 and Resident #3 stated Resident #2 said something about his mother. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated Resident #2 made derogatory remarks about Resident #3's family member. Resident #3 stated Resident #2 swung his arm with a closed fist and hit Resident #3. Resident #3 further stated, he swung his arm with a closed fist and hit Resident #2 back. Resident #3 further stated following the incident he informed S5Weekend Supervisor, Resident #2 and himself got into a verbal and physical altercation. In an interview on 11/15/2023 at 2:45 p.m., S5Social Services stated she was notified by S1Adminsitrator on 10/30/2023 around 9:30 a.m. that Resident #2 and Resident #3 had been in a physical altercation and Resident #3 hit Resident #2. S5Social Services further stated Resident #3 stated Resident #2 hit him and made derogatory remarks about Resident #3's mother. In an interview on 11/15/2023 at 3:00 p.m., S2Director of Nursing (DON) stated it is the facility and staff's responsibility to keep the residents safe and free from abuse. S2DON confirmed the above mentioned incident between Resident #2 and Resident #3 was considered verbal and physical abuse. In an interview on 05/31/2023 at 9:21 a.m., S1Administrator confirmed the above mentioned incident between Resident #2 and Resident #3 was considered verbal and physical abuse.

Deficiency Text Not Available

Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for nail care received assistance to ensure their fingernails were kept clean and trimmed for 1 (Resident #1) of 2 (Resident #1 and Resident #68) residents reviewed for activities of daily livings (ADLs) in a total sample of 21. Findings: Review of Resident #1's Care Plan revealed, in part, resident's fingernails will be checked and cleaned daily. Review of Resident #1's Minimum Data Set with an Assessment Review Date of 02/02/2023 revealed, in part, a BIMS of 99 (severely cognitively impaired). Further review indicated resident was dependent on staff for assistance with all activities of daily living (ADLs). Observation on 02/26/2023 at 11:04 a.m., revealed Resident #1's fingernails on his right hand extended past his fingertips, and his fingernails on his contracted left hand extended past his fingertips and touched the palm of his hand. Observation on 02/27/2023 at 1:16 p.m., revealed Resident #1's fingernails on his right hand extended past his fingertips, and his fingernails on his contracted left hand extended past his fingertips and touched the palm of his hand. Further observation revealed, a grain of rice under the nail of his thumb on his right hand. Observation on 02/28/2023 at 9:40 a.m., revealed Resident #1's fingernails on his right hand extended past his fingertips, and his fingernails on his contracted left hand extended past his fingertips and touched the palm of his hand. In an interview on 02/28/2023 at 10:35 a.m., S3CNA (Certified Nursing Assistant) confirmed Resident #1 relied on staff for all Activities of Daily Living. S3CNA further stated Resident #1 was supposed to get his nails cleaned when he went to the shower room. In an interview on 02/28/2023 at 12:05 p.m., S4CNA Supervisor confirmed the CNAs or the Shower Aides were supposed to trim and clean the fingernails of the residents. S4CNA Supervisor confirmed Resident #1 had fingernails that extended past the tips of his fingers on his right hand and contracted left hand.

Based on observation and interview the facility failed to ensure garbage was properly contained in 2 of 2 dumpsters observed. Findings: Observation on 02/26/2023 at 9:25 a.m., revealed, in part, two dumpsters with open lids located in the back of the facility with multiple large closed plastic bags inside the dumpsters. Further observation revealed, in part, two rolling garbage cans without lids near the dumpsters contained large filled closed black plastic garbage bags. Further observation revealed, in part, two large closed black plastic garbage bags on the ground near the dumpsters. Further observation revealed, in part, a moist dark unknown substance on the ground around the black plastic garbage bags with flies around the garbage bags. Observation on 02/27/2023 at 11:25 a.m., revealed, in part, both dumpsters were empty. Further observation revealed, in part, two large filled black plastic garbage bags on the ground near the dumpsters. Further observation revealed, in part, two rolling garbage cans without lids near the dumpsters contained large filled closed black plastic garbage bags. Observation on 2/28/2023 at 3:00 p.m., revealed, in part, two large filled closed black plastic garbage bags were on the ground near the dumpsters. Further observation revealed, in part, two rolling garbage cans without lids near the dumpsters contained large filled plastic garbage bags. In an interview on 02/28/2023 at 3:00 p.m., S1Administrator stated dietary and housekeeping staff were responsible for disposal of garbage into the dumpsters. S1Administrator further indicated the dumpsters should be kept closed, the large filled plastic garbage bags should not have been left on the ground around the dumpsters, and the large filled plastic garbage bags inside the open rolling garbage cans should have been disposed of inside the dumpster.

Deficiency Text Not Available

Based on observation and interview the facility failed to ensure: 1) proper storage of dry food to prevent physical cross contamination; 2) the outside of food storage containers were clean and sanitary; and, 3) dishware used for meal service was stored on clean sanitary surface. This had the potential to affect any of the 76 residents who are served meals from the kitchen as documented on the dietary manager's meal service list. Findings: Observation on 02/26/2023 at 9:25 a.m., of the kitchen revealed, in part, a large plastic rolling storage container labeled cake mix which contained four closed plastic bags labeled cake mix and one closed plastic bag labeled grits. Further observation of the storage container revealed, in part, the plastic bags of grits and cake mix were laying directly on a half inch thick brown coarse substance with unidentified black particles mixed throughout. Observation of the kitchen revealed, in part, 4 of 6 white plastic containers labeled peanut butter had a thick brown substance smeared on the lids and around the outside of the containers. Observation of the storage rack which contained insulated plate servers revealed the insulated plate servers were resting on the surface which was moist and contained unknown particles. In an interview on 02/26/2023 at 9:50 a.m., S7Dietary Manager stated the substance in the bottom of the container labeled cake mix was grits which had spilled, however she was unable to identify the scattered black pieces in the grits. S7Dietary Manager stated the facility should not have multiple food items in the same container and the food should not be laying on another uncontained food item. S7Dietary Manager further stated the 4 plastic containers labeled peanut butter should not have been stored on the shelf with peanut butter smeared on the outside of the containers. S7Dietary Manager stated the rack which stored the insulated plate servers was dirty. Observation on 02/27/2023 at 12:12 p.m. and 02/28/2023 at 11:35 a.m., during meal service revealed Dietary Staff was using plates and bowls which were being removed from a rolling cart which the shelves contained scattered unknown particles. In an interview on 02/28/2023 at 2:45 p.m., S1Administrator confirmed bags of multiple food items should not be stored in the same container directly on a layer of dry grits. He further confirmed the storage containers of peanut butter should not be stored with peanut butter smeared on the outside of the container. S1Administrator also confirmed the black rolling carts used to store clean dishware were not clean or sanitary.