**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a Physical Therapy, Occupational Therapy, and Speech Therapy evaluation as ordered for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents review for falls, who were at risk for falls and had a history of falls. Findings: Review of the facility's incident/accident log from 01/17/2025 to 03/15/2025 revealed, in part, Resident #1 had falls on 01/17/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/24/2025, 02/28/2025, 03/02/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/11/2025, and 03/15/2025. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, impulse disorder, psychosis, schizoaffective disorder, schizoaffective disorder/bipolar type, major depressive disorder, pseudobulbar affect and extrapyramidal movement disorder. Review of Resident #1's most recent Minimum Data Set with an Assessment Reference Date of 01/08/2025 revealed, in part, Resident #1 had short and long term memory loss, had some difficulty in making decisions in new situations, was inattentive, had disorganized thinking at times, had two or more falls since the previous assessment, and did not receive therapy services during the observation period. Review of Resident #1's medical records revealed a request for therapy services form, with a physician approval date and signature date of 01/07/2025. Review of Resident #1 physician's orders revealed, in part, an order dated 01/07/2025 for physical therapy, occupational therapy, and speech therapy to evaluate and treat. Review of Resident #1's therapy records revealed, in part, Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were not completed until 01/27/2025. There was no documented evidence, and the facility did not present any documented evidence Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were completed prior to 01/27/2025. In an interview on 03/20/2025 at 9:16AM, S4Therapy Director indicated staffing issues were one of the reasons therapy evaluations were delayed. S4Therapy Director confirmed Resident #1 physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were not completed until 01/27/2025. In an interview on 03/20/2025 at 10:46AM, S2Director of Nursing (DON) confirmed Resident #1's therapy evaluations ordered on 01/07/2025 were completed on 01/27/2025. S2DON indicated Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations should have been completed as per physician orders. In an interview on 03/20/2025, S1Administrator indicated the facility did not have any documented evidence Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were completed before 01/27/2025.

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) registry verification was obtained prior to hire for 1 (S7Certified Nursing Assistant [CNA]) of 5 (S4CNA, S5CNA, S6CNA, S7CNA, 8CNA) personnel records reviewed for registry verification. Findings: Review of S7CNA's personnel record revealed, in part, S7CNA had a hire date of 07/10/2024. Further review revealed a CNA registry verification with a date of 03/20/2025. There was no documented evidence, and the facility did not present any documented evidence, a CNA registry verification was obtained prior to hire for S7CNA. In an interview on 03/20/2025 at 2:06PM, S3Human Resource designee indicated a CNA registry check was not obtained prior to hire for S7CNA as required. In an interview on 03/20/2025 at 2:26PM, S1Adminitrataor indicated the facility did not have documented evidence a CNA registry verification was obtained prior to hire for S7CNA as required.

Based on observations, interviews, and record reviews, the facility failed to provide assistance with showering/bathing, shampooing, and shaving for dependent residents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for activities of daily living (ADLs). Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed, in part, Resident #1 required moderate assistance with showering/bathing, and personal hygiene. Review of Resident #1's Care Plan revealed, in part, Resident #1 require assistance with all ADLs. Further review revealed Resident #1 needed to be assisted with bathing/showering, and personal hygiene. Review of Resident #1's tasks list for bathing revealed, in part, in the last 30 days Resident #1 received a bed bath on 01/24/2025, 02/14/2025 and 02/17/2024. Further review revealed he received a shower on 01/20/2025, 01/31/2025, and 02/07/2025. Further review revealed there was no documented evidence, and the facility did not present any documented evidence Resident #1's hair had been washed. Review of Resident #1's tasks list for AM/PM care revealed, in part, in the last 30 days, Resident #1 was shaved on 01/29/2025 and 02/16/2025. Observation on 02/17/2025 at 10:55AM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. In an interview on 02/17/2025 at 10:56AM, Resident #1 indicated the staff gave him bed baths and he preferred bed baths. Resident #1 further indicated he would like to have his hair washed and his facial hair shaved, but staff had not completed it for him. Observation on 02/17/2025 at 2:10PM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. Observation on 02/18/2025 at 9:30AM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. In an interview on 02/18/2025 at 9:30AM, Resident #1 indicated S3Certified Nursing Assistant (CNA) gave him a bed bath this morning. Resident #1 further indicated he did not get shaved nor his hair washed. Observation on 02/19/2025 at 9:28AM revealed Resident #1 sitting in his wheelchair in the common area. Observation further revealed Resident #1 had white flakes in his hair and on his shirt. In an interview on 02/19/2025 at 10:52 AM, S3CNA indicated Resident #1 received bed baths. S3CNA further indicated she had not attempted to wash Resident #1's hair while he was in bed and she also had not shaved Resident #1. In an interview on 02/19/2025 at 11:05 AM, S2Infection Preventionist confirmed Resident #1 had flakes in his hair and on his shirt and he should not. In an interview on 02/19/2025 at 11:06 AM, S1Director of Nursing confirmed Resident #1 had white flakes in his hair and on his shirt and he should not. S1DON further indicated Resident #1 should also have dandruff shampoo. S1DON further indicated Resident #1 should have been given assistance with shaving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's physician was immediately notified of a resident's ear pain and drainage for 1 (Resident #43) of 3 (Resident #29, Resident #43, and Resident #79) residents investigated for pain. Findings: Review of Resident #43's record revealed, in part, Resident #43 was admitted to the facility on [DATE] with a diagnosis of otitis media (ear infection) of the right ear. Review of Resident #43's Minimum Data Set with an Assessment Reference Date of 10/07/2024 revealed Resident #43 had a Brief Interview Mental Status Score of 15 which indicated he was cognitively intact. In an interview on 01/06/2025 at 2:46 p.m., Resident #43 indicated he reported right ear pain and drainage to the nurse last week, but nothing has been done. In an interview on 01/07/2025 at 10:05 a.m., Resident #43 indicated he had not been seen by a physician, and had not received any information about his right ear complaints. In a telephone interview 01/07/2025 at 2:02 p.m., S16Licensed Practical Nurse (LPN) indicated Resident #43 complained to her of right ear pain and drainage over the weekend. S16LPN further confirmed that she did note minimal drainage to Resident #43's right ear. S16LPN further indicated she should have notified the doctor about Resident #43's ear, and should have. In an interview on 01/07/2025 at 2:05 p.m., S2Director of Nursing indicated if S16LPN felt like she should have notified the doctor, then she should have notified the doctor.

Based on record reviews, and interviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 1 (Resident #112) of 1 (Resident #112) sampled residents investigated for abuse. Findings: Review of the facility's undated policy titled Abuse Prevention and Prohibition revealed, in part, each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse is defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Resident abuse may include resident to resident abuse. Physical abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. Examples include hitting, slapping, pinching, biting, shoving, and kicking. Review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 revealed, in part, a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. Review of Resident #112's nurse's notes dated 11/28/2024 at 8:33 a.m. revealed, in part, Resident #112 walked to the dining room doorway. Resident #24 was standing at the dining room doorway and hit Resident #112 in the back of the head. Staff asked Resident #24 why he hit Resident #112 in the head, and he stated he could hit whoever he wanted. Review of Resident #112's nurse's notes dated 01/04/2025 at 8:45 a.m. revealed, in part, Resident #112 was involved in a physical altercation with Resident #174. Resident #112 was in the hallway when Resident #174 started the physical altercation. Resident #112 was in the corner and screamed for help. S7Certified Nursing Assistant (CNA) separated Resident #112 and Resident #174. Resident #112's lip was swollen and bleeding. In a telephone interview on 01/06/2025 at 11:32 a.m., S7CNA indicated she heard Resident #112 scream for help. S7CNA further indicated she observed Resident #112 and Resident #174 in the hallway and Resident #174 had pushed Resident #112 against the wall. S7CNA indicated Resident #112 was observed with blood on her lips. In a telephone interview on 01/06/2025 at 11:53 a.m., S6LPN indicated on 01/04/2025 she heard Resident #112 scream for help. S6LPN indicated Resident #112 and Resident #174 had to be separated. S6LPN further indicated Resident #112 had blood on her lips. In an interview on 01/06/2025 at 12:15 p.m., S2Director of Nursing (DON) confirmed she was aware of the above documented incidents. In an interview on 01/06/2025 at 12:25 p.m., S1Administrator indicated the above documented incidents were resident to resident abuse.

Based on interviews and record reviews, the facility failed to ensure allegations of physical abuse were reported to the Statewide Incident Management System (SIMS) for resident to resident physical abuse for 1 (Resident #112) of 1 (Resident #112) sampled residents investigated for abuse. Findings: Review of the facility's undated policy titled Abuse Prevention and Prohibition revealed, in part, an alleged violation of abuse will be reported immediately, but not later then, 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility administrator or designee shall report or cause a report to be made to the mandated stated agency per reporting criteria within guidelines of notification of an alleged abuse. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS reporting according to DHH guidelines. Review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 revealed, in part, a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. Review of Resident #112's nurse's notes dated 11/28/2024 at 8:33 a.m. revealed, in part, Resident #112 walked to the dining room doorway. Resident #24 was standing at the dining room doorway and hit Resident #112 in the back of the head. Staff asked Resident #24 why he hit Resident #112 in the head, and he stated he could hit whoever he wanted. Review of Resident #112's nurse's notes dated 01/04/2025 at 8:45 a.m. revealed, in part, Resident #112 was involved in a physical altercation with Resident #174. Resident #112 was in the hallway when Resident #174 started the physical altercation. Resident #112 was in the corner and screamed for help. S7Certified Nursing Assistant (CNA) separated Resident #112 and Resident #174. Resident #112's lip was swollen and bleeding. In a telephone interview on 01/06/2025 at 11:32 a.m., S7CNA indicated she heard Resident #112 scream for help. S7CNA further indicated she observed Resident #112 and Resident #174 in the hallway and Resident #174 had pushed Resident #112 against the wall. S7CNA indicated Resident #112 was observed with blood on her lips. In a telephone interview on 01/06/2025 at 11:53 a.m., S6LPN indicated on 01/04/2025 she heard Resident #112 scream for help. S6LPN indicated Resident #112 and Resident #174 had to be separated. S6LPN further indicated Resident #112 had blood on her lips. In an interview on 01/06/2025 at 12:25 p.m., S1Administrator indicated the above documented incidents were resident to resident abuse. S1Administrator further indicated the incidents were not reported to the SIMS system, and should have been.

Based on record reviews, observations, and interviews, the facility failed to administer a resident's oxygen per physician's orders for 1 (Resident #69) of 1 (Resident #69) sampled residents investigated for respiratory care. Findings: Review of the facility's undated policy titled oxygen administration policy and procedure revealed, in part, check physician's order for liter flow and method of administration. Review of Resident #69's January 2025 Physician's Orders revealed, in part, an order for oxygen 2 liters per minute (lpm) per nasal cannula (nc). Review of Resident #69's care plan revealed, in part, oxygen to be administered per physician orders. Observation on 01/05/2025 at 11:05 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. Observation on 01/06/2025 at 10:00 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. Observation on 01/07/2025 at 9:10 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. In an interview on 01/07/2025 at 10:38 a.m., S4Licensed Practical Nurse (LPN) confirmed Resident #69's physician order was for oxygen to be administered at 2lpm per nc via an oxygen concentrator, but it was delivered at 3lpm per nc via an oxygen concentrator. In an interview on 01/07/2025 at 10:43 a.m., S2Director of Nursing (DON) indicated Resident #69's oxygen should have been administered at 2lpm per nc via an oxygen concentrator as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to fully assess a resident's pain for 1 (Resident #43) of 3 (Resident #29, Resident #42, and Resident #79) sampled residents investigated for pain. Findings: Review of the facility's undated Pain Management Policy and Procedure revealed in part, the nurse was to document in the clinical record the reason for pain, characteristics of pain, and pain management effectiveness. Review of Resident #43's record revealed he was admitted to the facility on [DATE] with a diagnosis of otitis media (ear infection) of the right ear. Review of Resident #43's Minimum Data Set with an Assessment Reference Date of 10/07/2024 revealed Resident #43 had a Brief Interview Mental Status Score of 15 which indicated he was cognitively intact. Review of Resident #43's Comprehensive Care Plan revealed he had a history of pain with a goal to verbalize decrease frequency/intensity of pain. Further review revealed an intervention to watch Resident #43 for worsening of pain and report symptoms to the physician. Review of Resident #43's January 2025, Physician's orders revealed, in part, an order for Tylenol (a medication used for pain) Oral Tablet 325 milligrams (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for sinus headache or general discomfort. Review of Resident #43's Electronic Medical Record revealed, in part, Tylenol was given at the following times: 01/01/2025 at 9:19 a.m. for a pain rating of 6 with no documented evidence and the facility did not present any documented evidence for the reason for pain or characteristic of pain; 01/02/2025 at 8:13 a.m. for a pain rating of 8 with no documented evidence and the facility did not present any documented evidence of the reason for pain or characteristic of pain; 01/05/2025 at 7:35 p.m. for a pain rating of 8 for right side pain/earache; and, 01/06/2025 at 7:58 a.m. for a pain rating of 8 with no documented evidence and the facility did not present any documented evidence of the reason for pain or characteristic of pain. In an interview on 01/06/2025 at 2:46 p.m., Resident #43 indicated he reported right ear pain and drainage to the nurse last week but nothing had been done. In an interview on 01/07/2025 at 10:05 a.m., Resident #43 indicated he still has not had a doctor come assess him or hear about any treatments for his complaints of right ear pain with drainage. In a telephone interview 01/07/2025 at 02:02 p.m., S16Licensed Practical Nurse (LPN) indicated Resident #43 complained of right ear pain and drainage to her over the weekend. S16LPN further confirmed that she did note minimal drainage to Resident #43's right ear. In an interview on 01/07/2025 at 2:05 p.m., S2Director of Nursing could offer no explanation as to why staff had not assessed resident's ear pain and ear drainage, and why staff had not followed the facility's pain management policy and procedures as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure residents identified as safe smokers maintained their rights to keep their smoking supplies and smoke at their leisure for 4 (Resident #40, Resident #51, Resident #90, and Resident #105) of 4 (Resident #40, Resident #51, Resident #90, and Resident #105) sampled residents reviewed for resident rights. Findings: Review of the facility's undated, Resident Smoking policy revealed, in part, residents who had independent smoking privileges are were permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Review of the facility's smoking policy revealed, in part, that the purpose was to establish guidelines for the facility's residents' safe smoking. Further review revealed residents who were identified as safe smokers were permitted to keep cigarettes and other smoking articles in their possession. Review of the facility's smoking hours revealed, in part, smoking times were at 8:30 a.m., 10:30 a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. Review of the facility's resident council meeting minutes dated 10/04/2024 at 2:00 p.m. revealed, in part, residents requested a meeting with S1Administrator regarding the change in the facility's smoking procedure. There was no documented evidence, and the facility was unable to present any documented evidence the facility responded to the residents' request. Review of the facility's safe smokers list revealed, in part, Resident #40, Resident #51, Resident #90, and Resident #105, were listed as a safe smokers. Observation on 01/6/2025 at 3:15 p.m., revealed a group of residents, which included Resident #40, Resident #51, Resident #90, and Resident #105, waiting for a staff member to give them their smoking material, and go outside with them to smoke at 3:30 p.m. Resident #40 Review of Resident #40's Smoking Safety Screen dated 10/04/2024 revealed, in part, Resident #40 was assessed as being a safe smoker. In an interview on 01/6/2025 at 10:07 a.m., Resident #40 indicated the facility does not allow him to keep his cigarette and lighter, and does not allow him to smoke when he would like to smoke. Resident #40 further indicated he was not a child and the facility should allow him to keep his own smoking materials and should be allowed to smoke when he desires. Resident #51 Review of Resident #51's Smoking Safety Screen dated 12/05/2024 revealed, in part, Resident #51 was assessed as being a safe smoker. In an interview on 01/06/2025 at 3:10 p.m., Resident #51 indicated he was a [AGE] year old veteran and was responsible enough to keep his own smoking materials. Resident #51 further indicated he did not appreciate being treated like a child. Resident #90 Review of Resident #90's Smoking Safety Screen dated 01/03/2025 revealed, in part, Resident #90 was assessed as being a safe smoker. In an interview on 01/06/2025 at 10:10 a.m., Resident #90 indicated she was not happy about not being allowed to keep her smoking materials. Resident #90 further indicated she was grown and should be allowed to smoke when she wishes. Resident #105 Review of Resident #105's Smoking Safety Screening dated 11/18/2024, revealed, in part, Resident #105 was assessed as being a safe smoker. Review of Resident #105's current Care Plan revealed, in part, Resident #105 was identified as a safe smoker with no restrictions. Further review revealed Resident #105 had a diagnosis of Major Depressive Disorder and Generalized Anxiety with an intervention which included to allow Resident #105 to make choices regarding her schedule. In an interview on 01/06/2025 at 10:05 a.m., Resident #105 indicated the smoking times were implemented a couple of months ago, and staff removed the resident's smoking supplies from their possession, locked them in a tackle box behind the nurse's station, and only passed them out to the residents at certain times. Resident #105 further indicated the smoking residents did not have a choice or proper notification of the new procedure. Resident #105 indicated this made her more anxious and was afraid to miss the smoking session so she came out early to ensure she did not miss the smoking session. Resident #105 indicated staff only allowed the smoking residents about 20 minutes to smoke. Resident #105 further indicated that she would prefer to have her smoking supplies in her possession. Resident #105 indicated staff issued two cigarettes per resident during the smoking session, and residents were not allowed to smoke more than two during this time. Resident #105 indicated she should be allowed to have as many of her cigarettes as she wanted to smoke because it was her personal property. Resident #105 indicated she should be able to smoke in the smoking area at her leisure. Observation on 01/06/2025 at 10:25 a.m. revealed staff and 12 residents were in the smoking area when the staff brought a rolling, locked tackle box and started to pass out the resident's smoking supplies. Resident #105 was provided two of her cigarettes and demonstrated safe smoking practices. Resident #105 finished her second cigarette at 10:40 a.m. and then entered the facility with staff and the other smoking residents. In an interview on 01/06/2025 at 12:45 p.m., S3Liscense Practical Nurse (LPN), indicated Resident #105 enjoyed smoking and would wake up ready to go outside to smoke and would spend most of her time outside by the smoking area. In an interview on 01/06/2025 at 3:35 p.m. S1Administrator verified the facility removed the residents smoking material, and the safe smokers were not allowed to keep their smoking material and smoke at their leisure.

Based on record review and interviews, the facility failed to respond and maintain documented responses to the complaints voiced during the facility's resident council meetings for 3 of 3 resident council meeting minutes reviewed. Findings: Review of the facility's undated Grievance Policy and Procedure revealed, in part, the purpose of the policy was to ensure a resident's grievance would be followed up by prompt efforts to resolve the grievance of the resident. Further review of the policy revealed the resident council minute meetings were to be given to administration after completion of the meeting and the findings were to be documented and given to the administrator or designee for review. In interviews on 01/06/2025 at 10:00 a.m., during a meeting conducted with members of the resident council, Resident #40 indicated the facility does not respond to the resident council's concerns discussed in the monthly meetings. Resident # 71, Resident #90, and Resident #101 all agreed the facility did not follow-up with a responds to the concerns discussed during the resident council meetings. Review of the resident council's meeting minutes for the months of October, November, and December 2024 revealed, in part, there were no documented responses to the concerns discussed in the resident council meetings. Review of the facility's October 2024 resident council meeting minutes revealed, in part, the facility's residents requested to meet with S1Administrator regarding the smoking times. Review of the facility's November and December 2024 resident council meeting minutes revealed there was no documented response to the resident council above mentioned October 2024 request. In an interview on 01/6/2025 at 11:00 a.m., S10Assistant Activity Director indicated there was no documented responses to the residents' concerns discussed in the resident council meetings. In an interview on 01/6/2025 at 11:40 a.m., S9SocialWorker indicated she did not have any documented responses to the residents' concerns discussed in the resident council meetings. In an interview on 01/06/2025 at 3:35 p.m., S1Administrator indicated the facility did not have any documented evidence of the facility's response to the resident council concerns as required. S1Adminsitrator further indicated he was not notified the resident council requested to meet with him in October 2024, and he had not met with the resident council regarding their concerns.

Based on record reviews, observation, and interviews, the facility failed to: 1. ensure medications were available for use for 1 (Resident #16) of 3 (Resident #16, Resident #51, and Resident #80) sampled residents reviewed for pharmacy services; and, 2. maintain an accurate count of the disposition of controlled medications for 5 (Resident #51, Resident #54, Resident #72, Resident #73, and Resident #115) of 5 (Resident #51, Resident #54, Resident #72, Resident #73, and Resident #115) sampled residents who received controlled medications from Medication Cart a. Findings: 1. Resident #16 Review of Resident #16's January 2025 physician's orders revealed, in part, Resident #16 had an order for Systane Balance Ophthalmic Solution (a medication used for dry eye) 1 drop in both eyes 4 times a day. Observation on 01/07/2025 at 9:05 a.m. revealed S8Agency Licensed Practical Nurse (LPN) did not administer Resident #16 her Systane Balance Ophthalmic Solution. In an interview on 01/06/2025 at 11:54 a.m., S8Agency LPN confirmed she did not administer Resident #16 her Systane Balance Ophthalmic solution. S8Agency LPN, further indicated Resident #16's Systane Balance Ophthalmic Solution was unavailable because it was on back order. In an interview on 01/06/2025 at 12:30 p.m., S3Assistant Director of Nursing indicated Resident #16's doctor should have been notified about her eye drops being on backorder so that a similar eye drop could have been ordered. 2. Review of the facility's undated policy titled Narcotics Policy and Procedure revealed, in part, the total of each drug found in the controlled substance drawer shall be listed on the narcotic count sheet. On 01/07/2025 at 1:40 p.m. a reconciliation was completed of the controlled substances on Medication Cart a and the controlled substance binder for Medication Cart a and revealed, in part, the following: Resident#51 Review of Resident #51's medication card for Alprazolam (a medication used to treat anxiety) 0.5 milligram (mg) revealed 36 pills remained on the medication card. Review of Resident #51's controlled medication administration record for Alprazolam 0.5mg revealed 37 pills remained on the medication card. Resident #54 Review of Resident #54's medication card for Tramadol (a medication used to treat pain) 50mg revealed 46 pills remained on the medication card. Review of Resident #54's controlled medication administration record for Tramadol 50mg revealed 47 pills remained on the medication card. Resident #72 Review of Resident #72's medication card for Clonazepam (a medication used to treat anxiety) 0.5mg revealed 17 pills remained on the medication card. Review of Resident #72's controlled medication administration record for Clonazepam 0.5mg revealed 18 pills remained on the medication card. Further review revealed Resident #72's medication card for Oxycodone/APAP Tablet (a medication used for pain) 7.5-325 revealed 30 pills remained on the medication card. Review of Resident #72's controlled medication administration record for Oxycodone/APAP Tablet 7.5-325 revealed 31 pills remained on the medication card. Resident #73 Review of Resident #73's medication card for Tramadol (a medication used to treat pain) 50mg revealed 54 pills remained on the medication card. Review of Resident #73's controlled medication administration record for Tramadol 50mg revealed 53 pills remained on the medication card. Resident #115 Review of Resident #115's medication card for Lorazepam (a medication used to treat anxiety) 0.5mg revealed 36 pills remained on the medication card. Review of Resident #115's controlled medication administration record for Lorazepam 0.5mg revealed 37 pills remained on the medication card. In an interview on 01/07/2025 at 1:40 p.m., S8Agency Licensed Practical Nurse (LPN) confirmed the above documented medications available on the medication cards did not match the count documented on the controlled medication administration record. In an interview on 01/07/2025 at 1:45 p.m., S1Director of Nursing (DON) indicated the number of pills available on the medication card and the number of pills documented on the controlled medication administration record should be the same.

Based on record reviews, observations, and interviews, the facility failed to ensure the medication error rate was not greater than 5% by having a medication 12.9% for 1 (Resident #16) of 3 (Resident #16, Resident #51, and Resident #80) sampled residents observed during medication administration. Findings: Review of the facility's undated Medication Pass Administration Policy and Procedure revealed, in part, medications shall be administered as ordered by the physician. Review of Resident #16's January 2025 physician's orders revealed, in part, Resident #16 had the following orders: Tolterodine Tartrate ER (a medication used for blood pressure) 2 milligrams (mg) give 1 capsule by mouth daily; Fetzima Capsule Extended Release 24 hour (a medication used for depression) 20 mg give 1 capsule by mouth with 40 mg capsule to equal 60 mg daily; Fetzima Capsule Extended Release 24 hour 40 mg give 1 capsule by mouth with 20 mg capsule to equal 60 mg daily; Systane Balance Ophthalmic Solution (a medication used for dry eye) 1 drop in both eyes 4 times a day; and, May crush medications except for enteric coated/time released medications Observation on 01/07/2025 at 8:59 a.m. revealed S8Agency Licensed Practical Nurse (LPN) opened 2 Fetzima Capsules and 1 Tolterodine Capsule and placed the medication inside of the capsules on top of pudding. S8Agency LPN then administered the medication with the pudding to Resident #16. Observation on 01/07/2025 at 9:05 a.m. revealed Resident #16 did not have her Systane Balance Ophthalmic Solution administered to her. In an interview on 01/06/2025 at 11:54 a.m., S8Agency LPN confirmed she opened Resident #16's Tolterodine Capsules and Fetzima Capsules and placed the medication that was inside the capsules on top of the pudding, and administered it to Resident #16. S8Agency LPN further indicated she did not know if the medications Tolterodine Capsule and Fetzima Capsule could be opened or not. S8Agency LPN, further indicated Resident #16's Systane Balance Opthalmic Solution was on back order; therefore, she unable to administer the eye drops to Resident #16. In an interview on 01/06/2025 at 12:14 p.m., a Pharmacist, working at the pharmacy that fills Resident #16's medications, indicated Tolterodine and Fetzima capsules should not be opened, and should be taken whole. There were 31 medication administration opportunities for error, with 4 observed errors for a medication administration error rate of 12.9%. In an interview on 01/07/2025 at 11:03 a.m., S2Director of Nursing confirmed the medication error rate should not have been over 5%. In an interview on 01/06/2025 at 12:30 p.m., S3Assistant Director of Nursing indicated Resident #16's doctor should have been notified about her eye drops being on backorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement an effective discharge planning process for a resident who left the facility against medical advice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for discharge planning. Findings: Review of the facility's form entitled, Leaving Skilled Nursing Facility Against Medical Advice dated 09/13/2024 revealed, in part, the following: I (Resident #1) am voluntarily leaving the nursing home against the advice of S5physican and a representative of the nursing home administration. I have been told by the physician of the risks and consequences involved with leaving the nursing home at this time, the benefits of continued treatment and care, and the alternatives, if any, to continued treatment and care, and the alternatives, if any, to continued treatment and nursing home placement. Resident #1 was his own responsible party. Further review revealed Resident #1 was discharged from the facility on 09/13/2024. Review of Resident #1's diagnoses revealed, in part, Resident #1 had chronic kidney disease, paralysis, had weakness on one side of his body following a stroke, and was receiving dialysis. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed, in part, revealed his cognition was moderately impaired, had renal insufficiency, renal failure, or end-stage renal disease, and had limited range of motion with an impairment to both sides of his upper extremities and impairment to one side of his lower extremity. Further review revealed Resident #1used a manual wheel chair, required partial to moderate staff assistance with toileting, showering, bathing, upper body dressing, and personal hygiene. Resident #1 also required substantial to maximal staff assistance with lower body dressing, putting on and taking off footwear. Review of Resident #1's progress notes, revealed in part, the following: - On 09/13/2024 at 5:04 p.m. Resident #1 was discharged from the facility today on 09/13/2024 at 3:42 p.m. per S3SocialServices; and, - On 09/13/2024 at 3:42 p.m. Resident #1 signed out AMA (Against Medical Advice) with medication in stable condition. There was no documented evidence and the faciity did not present any documented evidence Resident #1 was informed of the implications and/or risks of being discharged to a location that was not equipped to meet Resident #1's needs, attempted to ascertain why Resident #1 was chose that location, documented that other, more suitable, options of locations were equipped to meet the needs of Resident #1 were presented and/or discussed, and that despite being offered other options that could meet Resident #1's needs, Resident #1 refused those other more appropriate settings. In an interview on 10/14/2024 at 12:10 p.m. S3Social Services (SS) indicated Resident #1 was discharged to an apartment on 09/13/2024 since he went AMA. S3SS indicated S1Administrator, S6Assistant Director, and herself were involved in the discharge of Resident #1. S3SS indicated Resident #1 had urgent medical needs due to being on dialysis, and needed assistance with walking and activities of daily living such as using the bathroom. S3SS further indicated she could not set up outside transportation services for Resident #1 to be picked up at his apartment to be transported to dialysis because of it being too early in the morning for the transportation company. In an interview on 10/14/2024 at 2:45 p.m., S7Licensed Practical Nurse (LPN) indicated Resident #1 had weakness on one side of his body, needed help to transfer from a wheelchair to bedside commode, was unable to walk, and required assistance with all activities of daily living and could not walk. S7LPN further indicated the place that he was discharged to was not equipped to tend to his needs In an interview on 10/16/2024 at 10:35 a.m., S6Assistant Director of Nursing indicated she had no documentation to present to dispute the above findings. There was no documented evidence, and the facility did not present any documented evidence, that the facility documented Resident #1 was being discharged to a location that was not equipped to meet his needs, and attempts were being made to ascertain why Resident #1 chose that location. There was no documented evidence, and the facility did not present any documented evidence, that other, more suitable, options of locations equipped to meet Resident #1's needs were presented and discussed, and that despite being offered other options that could meet the resident's needs, Resident #1 refused those other more appropriate settings. In an interview on 10/16/2024 at 10:39 a.m., S2Director of Nursing (DON) indicated she had nothing to present to dispute the above findings other than the documentation to show that Resident #1 left the facility against medical advice (AMA) and had signed the AMA form. In an interview on 10/16/2024 at 12:30pm, S1Administrator indicated the facility did not implement and/or complete the required documentation related to Resident #1 leaving the facility AMA.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored in a secure manner for 1 (Nursing Station x) of 2 (Nursing Station x and Nursing Station y) nursing stations observed. Findings: Review of the facility's undated Medication Storage policy and procedure revealed, in part, the purpose of the policy was to ensure medications were stored safely, securely, and properly. Further review revealed medications are stored in a medication cart or other designated area and only those lawfully authorized to administer medications were allowed access to medications. Observation on 08/05/2024 at 2:05 p.m. of Nursing Station x revealed a medication card and a medication bottle left unattended by staff on the counter. Further observation revealed both medications were for Resident #3 and filled by the pharmacy on 08/05/2024. Observation of the medication card revealed 15 Ropinrole (a medication used to treat restless leg syndrome) 0.5 milligram (mg) tablets were on the card. Observation of the medication bottle revealed 240 milliliters (ml) of Guaifenesin (a liquid used to treat cough and chest congestion) 100mg/5ml liquid was observed in the medication bottle. In an interview on 08/05/2024 at 3:00 p.m., S6Mininmum Data Set Nurse indicated she reviewed the camera footage of Nursing Station x and observed S7Licensed Practical Nurse (LPN) place Resident #3's above mentioned medications on the counter at Nursing Station x and then left the above medications unattended, and should not have. In an interview on 08/06/2024 at 10:50 a.m., S7LPN indicated she received the above mentioned medications for Resident #3 from the pharmacy and placed them on the counter at Nursing Station x. S7LPN further indicated the nurse responsible for the medications was not available so she placed the above mentioned medications on the counter at Nursing Station x under the supervision of a certified nursing assistant (CNA). S7LPN stated she should have secured Resident #3's above mentioned medications inside the locked medication room instead of leaving them with an unauthorized CNA.

Based on record review and interview, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated. Findings: Review of Resident #3's record revealed, in part, an admit date of 04/09/2024. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 06/04/2024 revealed, in part, Resident #3 was admitted to the facility with a Stage IV pressure ulcer (a wound caused by pressure that extends below the subcutaneous fat into deep tissues, including muscle, tendons, ligaments and/or bone). Review of Resident #3's July 2024 Physician's Orders revealed, in part, an order with a start date of 04/09/2024 to obtain a Complete Metabolic Panel (CMP) (a blood test that measures several body functions and processes, such as kidney and liver functioning), a Complete Blood Count (CBC) (a blood test that measures the amount of white blood cells, red blood cells, and platelets), and a Prealbumin level (a blood test that measures the amount of protein in the dietary intake) every month until Resident #3's Stage IV sacral pressure ulcer was healed. Review of Resident #3's record revealed no documented evidence, and the facility was unable to present any documented evidence Resident #3's Prealbumin laboratory test was completed as ordered by the physician in May 2024. Review of Resident #3's record revealed no documented evidence, and the facility was unable to present any documented evidence Resident #3's CMP, CBC and Prealbumin laboratory tests were competed as ordered by the physician in June 2024. In an interview on 07/03/2024 at 10:54 a.m., S1Director of Nursing confirmed Resident #3 did not have laboratory tests completed as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Ensure a registered nurse assessed a resident's left heel diabetic ulcer (a wound caused by complications of high blood sugar) initially to deem the diabetic ulcer stable and predictable prior to the delegation of care to a licensed practical nurse (Resident #1); and, 2. Ensure a weekly assessment was completed for a resident's left heel diabetic ulcer (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated. Findings: 1. Review of the Louisiana State Board of Nursing's Declaratory Statement Scope of Practice for Registered Nurses for Wound Care Management adopted 02/10/1999 revealed, in part, the registered nurse may delegate to a licensed practical nurse wound care interventions in any situation when the registered nurse has deemed the patient's status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Review of Resident #1's record revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed, in part, Resident #1 had a diabetic foot ulcer. Review of Resident #1's nurse's note dated 05/14/2024 at 3:27 p.m. revealed, in part, Resident #1's left foot diabetic ulcer was assessed and measured by S3Former Wound Care Licensed Practical Nurse (WCLPN). Review of Resident #1's Skin and Wound Evaluation dated 05/14/2024 at 4:27 p.m. revealed, in part, Resident #1's left heel diabetic ulcer was assessed and measured by S3Former WCLPN. There was no documented evidence and the facility was unable to present any documented evidence Resident #1's left heel diabetic ulcer was initially assessed by a registered nurse to deem Resident #1's left heel diabetic ulcer stable and predictable prior to delegating care to a licensed practical nurse. Review of Resident #1's record revealed, in part, Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 06/13/2024 revealed, in part, Resident #1 had a diabetic foot ulcer. Review of Resident #1's Skin and Wound Evaluation dated 06/11/2024 at 4:37 p.m. revealed, in part, Resident #1's left heel diabetic ulcer was assessed and measured by S2WCLPN. There was no documented evidence and the facility was unable to present any documented evidence Resident #1's left heel diabetic ulcer was initially assessed by a registered nurse to deem Resident #1's left heel diabetic ulcer stable and predictable prior to delegating care to a licensed practical nurse. In an interview on 07/03/2024 at 2:24 p.m., S1Director of Nursing (DON) confirmed there was no documented evidence that a registered nurse assessed Resident #1's left heel diabetic ulcer wound upon admit or readmission to deemed the wound stable and predictable in order the care to be delegated to a licensed practical nurse. 2. Review of the facility's undated Skin/Wound Documentation Policy and Procedure revealed, in part, skin and wounds will be documented upon admission, readmission, weekly and as needed. Review of Resident #1's record revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed, in part, Resident #1 had a diabetic foot ulcer. Review of Resident #1's Skin and Wound Evaluation dated 05/15/2024 at 8:50 a.m. revealed, in part, Resident #1 had a left heel diabetic ulcer present on admission to the facility. Review of Resident #1's record revealed no documented evidence, and the facility presented no documented evidence wound assessments had been completed for the weeks of 05/19/2024 through 05/25/202 and 05/26/2024 through 06/01/2024. Review of Resident #1's record revealed, in part, Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 06/13/2024 revealed, in part, Resident #1 had a diabetic foot ulcer. Review of Resident #1's Skin and Wound Evaluation dated 06/11/2024 at 4:38 p.m. revealed, in part, Resident #1 had a left heel diabetic ulcer present on readmission to the facility. Review of Resident #1's record revealed no documented evidence, and the facility presented to documented evidence wound assessments had been completed for the week of 06/16/2024 through 06/22/2024 and 06/23/2024 through 06/29/2024. In an interview on 07/01/2024 at 2:50 p.m., S1DON confirmed wound assessments should be completed for all wounds at least weekly. S1DON further confirmed there was no documented evidence Resident #1's left heel diabetic ulcer was assessed weekly during the above mentioned time frames. S1DON confirmed Resident #1's left heel diabetic ulcer should have had weekly assessments. In an interview on 07/01/2024 at 3:18 p.m., S3Former WCLPN confirmed wound assessments should be completed weekly for all wounds. In an interview on 07/02/2024 at 10:02 a.m., S2WCLPN confirmed wound assessments should be completed weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Ensure a registered nurse assessed a resident's Stage III (wound caused by pressure that extends into the fat tissue) sacral pressure ulcer initially to deem the pressure ulcer stable and predictable prior to the delegation of care to a licensed practical nurse (Resident #1); and, 2. Ensure weekly assessment was completed for a resident's Stage III sacral pressure ulcer (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated. Findings: 1. Review of the Louisiana State Board of Nursing's Declaratory Statement Scope of Practice for Registered Nurses for Wound Care Management adopted 02/10/1999 revealed, in part, the registered nurse may delegate to a licensed practical nurse wound care interventions in any situation when the registered nurse has deemed the patient's status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Review of Resident #1's record revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed, in part, Resident #1 was admitted with a Stage III pressure ulcer. Review of Resident #1's nurse's note dated 05/15/2024 at 7:50 a.m. revealed, in part, Resident #1's Stage III sacral pressure ulcer was present on admission to the facility and was assessed and measured by S3Former Wound Care Licensed Practical Nurse (WCLPN). Review of Resident #1's Skin and Wound Evaluation dated 05/15/2024 at 8:50 a.m. revealed, in part, Resident #1's Stage III sacral pressure ulcer was assessed and measured by S3Former WCLPN. There was no documented evidence and the facility was unable to present any documented evidence Resident #1's Stage III sacral pressure ulcer was initially assessed by a registered nurse to deem Resident #1's Stage III sacral pressure ulcer stable and predictable prior to delegating care to a licensed practical nurse. Review of Resident #1's record revealed, in part, Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 06/13/2024 revealed, in part, Resident #1 was readmitted to the facility with a Stage III pressure ulcer. Review of Resident #1's Skin and Wound Evaluation dated 06/11/2024 at 4:38 p.m. revealed, in part, Resident #1's Stage III sacral pressure ulcer was assessed and measured by S2Wound Care Licensed Practical Nurse (WCLPN). There was no documented evidence and the facility was unable to present any documented evidence Resident #1's Stage III sacral pressure ulcer was initially assessed by a registered nurse to deem Resident #1's Stage III sacral pressure ulcer was stable and predictable prior to delegating care to a licensed practical nurse. In an interview on 07/03/2024 at 2:24 p.m., S1Director of Nursing (DON) confirmed there was no documented evidence that a registered nurse assessed Resident #1's Stage III sacral pressure ulcer wound upon admission or readmission to deem the wound stable and predictable in order for the care to be delegated to a licensed practical nurse. 2. Review of the facility's undated Skin/Wound Documentation Policy and Procedure revealed, in part, skin and wounds will be documented upon admission, readmission, weekly and as needed. Review of Resident #1's record revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed, in part, Resident #1 was admitted with a Stage III pressure ulcer. Review of Resident #1's Skin and Wound Evaluation dated 05/15/2024 at 8:50 a.m. revealed, in part, Resident #1 had a Stage III sacral pressure ulcer present upon admission to the facility. Review of Resident #1's record revealed no documented evidence, and the facility was unable to present any documented evidence assessments had been completed for Resident #1's Stage III sacral pressure ulcer for the weeks of 05/19/2024 through 05/25/2024, and 05/26/2024 and 06/01/2024. Review of Resident #1's record revealed, in part, Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 06/13/2024 revealed, in part, Resident #1 was readmitted to the facility with a Stage III pressure ulcer. Review of Resident #1's Skin and Wound Evaluation dated 06/11/2024 at 4:38 p.m. revealed, in part, Resident #1 had a Stage III sacral pressure ulcer present on readmission to the facility. Review of Resident #1's record revealed no documented evidence and the facility was unable to present any documented evidence assessments had been completed for Resident #1's Stage III sacral pressure ulcer for the weeks of 06/16/2024 through 06/22/2024 and 06/23/2024 and 06/29/2024. In an interview on 07/01/2024 at 2:50 p.m., S1DON confirmed wound assessments should be completed for all wounds at least weekly. S1DON further confirmed there was no documented evidence Resident #1's Stage III sacral pressure ulcer was assessed weekly on the above mentioned time frames. S1DON stated Resident #1's Stage III sacral pressure ulcer should have had weekly assessments. In an interview on 07/01/2024 at 3:18 p.m., S3Former WCLPN confirmed wound assessments should be completed weekly for all wounds. In an interview on 07/02/2024 at 10:02 a.m., S2WCLPN stated wound assessments should be completed weekly.

Based on record reviews and interviews, the facility failed to ensure a resident was free from physical abuse for 2 (Resident #87 and Resident #94) residents of 6 (Resident #25, Resident #35, Resident #80, Resident #87, Resident #94, and Resident #461) residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition Policy revealed, in part, abuse is defined as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Further review revealed, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Further review revealed, resident abuse may include resident to resident abuse and physical abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. Resident #87 Review of Resident #416's progress note dated 09/19/2023 revealed, in part, Resident #416 grabbed another resident by a choke hold. Further review revealed, staff had stated earlier in the day, Resident #416 had pointed at the resident he had choked and commented that he was afraid of him. In an interview on 01/22/2024 at 3:44 p.m., S15CNA stated she saw Resident #416 choking Resident #87 in the hallway on 09/29/2023. Resident #94 Review of Resident #416's progress note dated 09/29/2023, revealed, in part, it was reported to S10Licensed Practical Nurse (LPN), Resident #416 had struck another resident in the face with his shoe. Review of Resident #94's progress note dated 09/29/2023 revealed, in part, it was reported to S10LPN Resident #416 had struck another resident in the face with his shoe and Resident #94 was noted with a laceration below his left eye. Review of Resident #94's progress note dated 09/29/2023 revealed, in part, Resident #94 returned from the emergency room, and the left side of Resident #94's face had 3 staples and 4 sutures to the laceration. In an interview on 01/22/2024 at 3:12 p.m., S10LPN stated she saw Resident #416 with a shoe in his hand and possible lacerations from the shoe strings on his hand. S10LPN further stated Resident #94 had a laceration under his eye. In an interview on 01/24/2023 at 1:57 p.m., S1Administrator stated he watched the facility's surveillance video, and Resident #416 did hit Resident #94 on 09/29/2023. Review of a written statement dated 09/29/2023 by S1Administrator revealed, in part, an incident occurred on 09/29/2023 regarding Resident #416 and Resident #94. Further review revealed, Resident #416 raised a shoe towards Resident #94 hitting him in the face. Further review revealed, a video of this incident was viewed, and it showed as above.

Based on record reviews and interviews, the facility failed to implement it's abuse prevention and prohibition policy by failing to report an allegation of abuse to the Administrator or Director of Nurses for 1 (Resident #35) of 6 (Resident #25, Resident #35, Resident #80, Resident #87, Resident #94, and Resident #416) residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy revealed, in part, each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Review of the Abuse Prevention and Prohibition policy revealed resident abuse may include: resident to resident abuse, staff to resident abuse; or family/visitor to resident abuse. Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Further review of the Abuse Prevention and Prohibition policy revealed seven components to be implemented included screening, training, prevention, identification, coordination with quality assurance and performance improvement, investigation, protection, and reporting. Review of the reporting component of the Abuse Prevention and Prohibition policy revealed, in part, the facility employee or agent, who becomes aware of abuse or neglect shall immediately report the matter to the facility administrator or director of nurses. The administrator or designee will notify the regional director and corporate nurse. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility administrator or designee shall report or cause a report to be made to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Such reports may also be made to the local law enforcement agency after receiving corporate approval or immediately if the abuse constitutes an emergency situation. Review of the investigation component of the Abuse Prevention and Prohibition policy revealed, in part, the administrator or designee will complete a thorough investigation. Interview employees who were working in resident's room during the time in question. Signed statements should be obtained from these employees. Interview the resident if they are cognitively able to answer questions. If the resident is not interview able, interview the roommate. Resident family and friends may be questioned. A licensed professional nurse will examine the resident for signs of injury and notify the resident's physician of any injuries noted. If sexual assault has been alleged, the physician will be contacted for an order to transfer to the emergency room for examination. Police notification may be done after discussion with corporate staff. Maintain a file in the administrator or designee office. This file must be kept private and confidential. Review of the facility's incident log dated 01/01/2024 to 01/19/2024 revealed no documented incidents for Resident #35. Review of Resident #35's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed, in part, a brief interview for mental status (BIMS) of 3. A BIMS score of 0 to 7 suggests severe cognitive impairment. Review of Resident #35's Nurse's Note dated 01/01/2024 at 12:20 p.m. revealed, in part, S3Weekend Supervisor documented she was called to Resident #35's room by S10Licensed Practical Nurse(LPN). It was reported by the Certified Nursing Assistant Resident #35 hollered no, no, no and Resident #35's husband was on top of her without his clothes on trying to kiss her. Further review of Resident #35's Nurse's Notes revealed S3Weekend Supervisor opened Resident #35's door and observed Resident #35 laying supine in her bed. Resident #35's husband was standing on the side of Resident #35's bed wearing only a shirt and socks. Resident #35's husband's pants, underwear, and shoes were on the floor beside the bed. Review of the notes revealed he smelled of alcohol. He stated he was not trying to do anything. S3Weekend Supervisor told Resident #35's husband he had to put his clothes back on and he was not allowed to do anything like that here and he could not stay here at this time. S3Weekend Supervisor escorted Resident #35's husband out the front door of the building and he waited for someone to pick him up. Review of Resident #35's clinical record revealed no additional documentation in regards to the above documented nurses note. In an interview on 01/22/2024 at 11:42 a.m., S10LPN stated on 01/01/2024 she was the nurse assigned to care for Resident #35. S10LPN stated she was at the nursing station and she heard Resident #35 repeatedly holler no. S10LPN stated she opened the door of the nurse's station and S8Certified Nursing Assistant (CNA) was in the hallway and told her to go to Resident #35's room because Resident #35's husband was trying to get in the bed with her. S10LPN stated when she entered Resident #35's room the privacy curtain was pulled around the bed and when she pulled the curtain, Resident #35's husband was on the side of bed and his pants and underwear were on the floor. S10LPN stated no one in Administration interviewed her or requested a written statement. In an interview on 01/22/2024 at 11:54 a.m., S8CNA stated on 01/01/2024 S9CNA asked her to go to Resident #35's room. S8CNA stated when she entered Resident #35's room her husband was standing next to her bed without pants and underwear. S8CNA stated she asked Resident #35 if she was okay and she stated 'no. S8CNA stated Resident #35's husband's hands were on Resident #35. S8CNA was unable to say where his hands were on her. S8CNA stated no one in administration interviewed her about the incident and she was no asked to provide a written statement. In an interview on 01/22/2024 at 12:08 p.m., S9CNA stated on 01/01/2024 she was assigned to pass meal trays on Resident #35's hall and noticed Resident #35's door was closed. S9CNA stated she knocked and there was no answer and when she opened the door the privacy curtain was pulled back and she saw clothes on the floor. S9CNA stated that she announced I got your lunch and a man's voice said hey. S9CNA stated the man was Resident #35's husband and he was only wearing a shirt and his pants and underwear were on the floor. S9CNA stated Resident #35 was hollering no and her husband was hovered over the bed and his hand was near her vagina and the fasteners for her adult disposable brief were undone on one side. S9CNA stated she was not interviewed by administration in regards to the incident with Resident #35 and her husband. In an interview on 01/22/2024 at 3:38 p.m., S7CNA stated on 01/01/2024 at around lunch time she was taking Resident #35's roommate to the bathroom and the room door was closed. S7CNA stated when she opened the door to bring the resident to the bathroom she noticed Resident #35's privacy curtain was pulled around her bed and she heard Resident #35 holler no. She stated she called out and asked Resident #35 if she was ok and she said no. S7CNA stated she saw jogging pants and underwear on the floor and shoes under the bed and a cell phone on the floor. S7CNA stated she saw Resident #35's husband leaning over Resident #35. S7CNA stated she was not interviewed by administration in regards to the incident on 01/01/2024 with Resident #35's husband. In an interview on 01/22/2024 at 12:24 p.m., S3Weekend Supervisor confirmed she was the facility supervisor on 01/01/2024 and she was notified by S10LPN that Resident #35's husband was in her room without pants and underwear. S3Weekend Supervisor stated when she entered Resident #35's room her husband did not have pants and underwear and he was next to the bed. S3Weekend Supervisor stated she told Resident #35's husband if he did not leave the facility she would call the police. S3Weekend Supervisor stated she did not complete an incident report and she did not report the incident to S1Administrator or S2Director of Nursing. In an interview on 01/22/2024 at 2:43 p.m., S1Administrator stated S3Weekend Supervisor should have notified him or S2DON of the incident with Resident #35 and her husband on 01/01/2024. S1Administrator stated the facility's Abuse Prevention and Prohibition policy was not implemented because the alleged sexual abuse incident with Resident #35 and her husband was not reported to him or S2DON as required by the Abuse Prevention and Prohibition policy. S1Administrator stated he was unable to report the alleged incident the state as required due to the failure of the staff to report the incident.

Based on record reviews and interviews, the facility failed to report an allegation of abuse timely to the State Survey Agency and Certification Agency as required for 6 (Resident #25, Resident #35, Resident #80, Resident #87, and Resident #94, Resident #416) of 6 residents (Resident #25, Resident #35, Resident #80, Resident #87, and Resident #94, Resident #416) residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy revealed, in part, each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Further review of the Abuse Prevention and Prohibition policy revealed seven components to be implemented included screening, training, prevention, identification, coordination with quality assurance and performance improvement, investigation, protection, and reporting. Review of the reporting component of the facility's Abuse Prevention and Prohibition policy revealed, in part, alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two hours if the alleged violation involves abuse or has resulted in serious bodily injury. The facility administrator or designee shall report or cause a report to be made to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Resident #25 Review of Resident #25's progress note dated 09/14/2023 revealed, in part, Resident #25 was noted with bruises to his face, left outer eye, and bilateral inner eyes. Further review revealed, Resident #25 stated He Hit me! In an interview on 01/22/2024 at 2:58 p.m., S16Licensed Practical Nurse (LPN) stated she spoke to Resident #25, and he had told her that he had been hit. S16LPN further stated she also spoke with Resident #416, and he had stated Resident #25 had hit him, and he hit Resident #25. In an interview on 01/23/2023 at 2:00 p.m. S2Director of Nursing (DON) stated she spoke to Resident #25 and Resident #416 and their stories did not coincide. S2DON further stated the incident was unwitnessed and the facility did not report this incident to the state agency. In an interview ono 01/23/2023 at 3:45 p.m. S1Administrator stated he did not notify the state agency of the incident where Resident #25 and Resident #416 claimed they were hit by each other. S1Administrator further stated he did not feel there was any need to report this incident to the state agency. Resident #35 Review of Resident #35's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed, in part, a brief interview for mental status (BIMS) of 3. A BIMS score of 0 to 7 suggests severe cognitive impairment. Review of Resident #35's Nurse's Note dated 01/01/2024 at 12:20 p.m. revealed, in part, S3Weekend Supervisor documented she was called to Resident #35's room by S10Licensed Practical Nurse. It was reported by the Certified Nursing Assistant Resident #35 hollered no, no, no and Resident #35's husband was on top of her without his clothes on trying to kiss her. Further review of Resident #35's Nurse's Notes revealed S3Weekend Supervisor opened Resident #35's door and observed Resident #35 laying supine in her bed. Resident #35's husband was standing on the side of Resident #35's bed wearing only a shirt and socks. Resident #35's husband's pants, underwear, and shoes were on the floor beside the bed. Review of the notes revealed he smelled of alcohol. He stated he was not trying to do anything. S3Weekend Supervisor told Resident #35's husband he had to put his clothes back on and he was not allowed to do anything like that here and he could not stay here at this time. S3Weekend Supervisor escorted Resident #35's husband out the front door of the building and he waited for someone to pick him up. Review of Resident #35's clinical record revealed no additional documentation in regards to the above documented nurses note. In an interview on 01/22/2024 at 11:42 a.m., S10LPN stated on 01/01/2024 she was the nurse assigned to care for Resident #35. S10LPN stated she was at the nursing station and she heard Resident #35 repeatedly holler no. S10LPN stated she opened the door of the nurse's station and S8Certified Nursing Assistant (CNA) was in the hallway and told her told her to go to Resident #35's room because Resident #35's husband was trying to get in the bed with her. S10LPN stated when she entered Resident #35's room the privacy curtain was pulled around the bed and when she pulled the curtain, Resident #35's husband was on the side of bed and his pants and underwear were on the floor. In an interview on 01/22/2024 at 11:54 a.m., S8CNA stated on 01/01/2024 S9CNA asked her to go to Resident #35's room. S8CNA stated when she entered Resident #35's room her husband was standing next to her bed without pants and underwear. S8CNA stated she asked Resident #35 if she was okay and she stated no. S8CNA stated Resident #35's husband's hands were on Resident #35. In an interview on 01/22/2024 at 12:08 p.m., S9CNA stated on 01/01/2024 she was assigned to pass meal trays on Resident #35's hall and noticed Resident #35's door was closed. S9CNA stated she knocked and there was no answer and when she opened the door the privacy curtain was pulled back and she saw clothes on the floor. S9CNA stated that she announced I got your lunch and a man's voice said hey. S9CNA stated the man was Resident #35's husband and he was only wearing a shirt and his pants and underwear were on the floor. S9CNA stated Resident #35 was hollering No and her husband was hovered over the bed and his hand was near her vagina and the fasteners for her adult disposable brief were undone on one side. In an interview on 01/22/2024 at 3:38 p.m., S7CNA stated on 01/01/2024 at around lunch time she was taking Resident #35's roommate to the bathroom and the room door was closed. S7CNA stated when she opened the door to bring the resident to the bathroom she noticed Resident #35's privacy curtain was pulled around her bed and she heard Resident #35 holler no. She stated she called out and asked Resident #35 if she was ok and she said no. S7CNA stated she saw jogging pants and underwear on the floor and shoes under the bed and a cell phone on the floor. S7CNA stated she saw Resident #35's husband leaning over Resident #35. In an interview on 01/22/2024 at 12:24 p.m., S3Weekend Supervisor confirmed she was the facility supervisor on 01/01/2024 and she was notified by S10LPN that Resident #35's husband was in her room without pants and underwear. S3Weekend Supervisor stated when entered Resident #35's room her husband did not have pants and underwear and he next to the bed. S3Weekend Supervisor stated she told Resident #35's husband if he did not leave the facility she would call the police. S3Weekend Supervisor stated she did not complete an incident report and she did not report the incident to S1Administrator or S2Director of Nursing. In an interview on 01/22/2024 at 2:43 p.m., S1Administrator stated S3Weekend Supervisor should have notified him or S2DON of the incident with Resident #35 and her husband on 01/01/2024. S1Administrator stated the facility's Abuse Prevention and Prohibition policy was not implemented because the alleged sexual abuse incident with Resident #35 and her husband was not reported to him or S2DON as required by the Abuse Prevention and Prohibition policy. S1Administrator stated he was unable to report the alleged incident to the state agency as required. Resident #80 Review of Resident #80's progress note dated 09/10/2023 revealed, in part, Resident #80's responsible party was notified Resident #80 was hit on the left side of his face by another resident, and Resident #80's face was red in color and slightly swollen. In an interview on 01/23/2024 at 12:16 p.m., S2DON stated Resident #416 hit Resident #80 in the face on 09/10/2023. In an interview on 01/23/2024 at 2:00 p.m., S2DON stated that on 09/10/2023, Resident #80 had been hit by Resident #416, because Resident #416 was going after the nurse. S2DON further stated this incident was not reported to the state agency. In an interview on 01/23/2024 at 3:45 p.m., S1Administrator stated he did not report the incident of Resident #416 hitting Resident #80 to the state agency. Resident #87 Review of Resident #416's progress note dated 09/19/2023 revealed, in part, Resident #416 grabbed another resident by a choke hold. Further review revealed, staff had stated earlier in the day, Resident #416 had pointed at the resident he had choked and commented that he was afraid of him. In an interview on 01/22/2024 at 3:44 p.m., S15CNA stated she saw Resident #416 choking Resident #87 in the hallway on 09/29/2023. In an interview on 01/23/2024 at 3:45 p.m., S1Administrator stated he did not report the incident of Resident #416 choking Resident #87 to the state agency. Resident #94 Review of Resident #416's progress note dated 09/29/2023, revealed, in part, it was reported to S10Licensed Practical Nurse (LPN), Resident #416 had struck another resident in the face with his shoe. Review of Resident #94's progress note dated 09/29/2023 revealed, in part, it was reported to S10LPN Resident #416 had struck another resident in the face with his shoe and Resident #94 was noted with a laceration below his left eye. In an interview on 01/23/2024 at 3:45 p.m., S1Administrator stated the incident that occurred between Resident #416 and Resident #94 on 09/29/2023 was not resident to resident abuse because he did not feel Resident #416 had willful intent when he hit Resident #94 due to his dementia diagnosis. S1 Administrator further stated that he did not report this incident to the state agency. In an interview on 01/24/2023 at 1:57 p.m., S1Administrator stated he watched the facility's surveillance video, and Resident #416 did hit Resident #94 on 09/29/2023. Review of a written statement dated 09/29/2023 by S1Administrator revealed, in part, an incident occurred on 09/29/2023 regarding Resident #416 and Resident #94. Further review revealed, Resident #416 raised a shoe towards Resident #94 hitting him in the face. Further review revealed, a video of this incident was viewed, and it showed as above. Resident #416 Review of Resident #416's progress note dated 09/14/2023, revealed, in part, Resident #416 approach S15LPN with noted bruising to his face and nose. Further review revealed Resident #416 stated he hit me first. I'm sure I hit him back. In an interview on 01/22/2024 at 2:58 p.m., S16Licensed Practical Nurse (LPN) stated she spoke to Resident #25, and he had told her that he had been hit. S16LPN further stated that she also spoke to Resident #416 and he had stated Resident #25 had hit him, and he also hit Resident #25 back. In an interview on 01/23/2024 at 2:00 p.m., S2Director or Nursing stated that she had spoken to both Resident #25 and Resident #216 and their stories did not coincide as both have dementia. S2DON further stated the incident was unwitnessed and the facility did not report this incident to the state agency. In an interview ono 01/23/2024 at 3:45 p.m., S1Administrator stated he did not notify the state agency of the incident where Resident #25 and Resident #416 claimed they were hit by each other. S1Administrator further stated he did not feel there was any need to report this incident to the state agency.

Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of abuse for 6 (Resident #25, Resident #35, Resident #80, Resident #87, and Resident #94, Resident #416) of 6 residents (Resident #25, Resident #35, Resident #80, Resident #87, and Resident #94, Resident #416) residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy revealed, in part, each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Further review of the Abuse Prevention and Prohibition policy revealed seven components to be implemented included screening, training, prevention, identification, coordination with quality assurance and performance improvement, investigation, protection, and reporting. Review of the investigation component of the Abuse Prevention and Prohibition policy revealed, in part, administrator or designee will complete a thorough investigation. Interview employees who were working in resident's room during the time in question. Signed statements should be obtained from these employees. Interview the resident if they are cognitively able to answer questions. If the resident is not interview able, interview the roommate. Resident family and friends may be questioned. A licensed professional nurse will examine the resident for signs of injury and notify the resident's physician of any injuries noted. If sexual assault has been alleged, the physician will be contacted for an order to transfer to the emergency room for examination. Police notification may be done after discussion with corporate staff. Maintain a file in the administrator or designee office. This file must be kept private and confidential. Resident #25 Review of Resident #25's progress note dated 09/14/2023 revealed, in part, Resident #25 was noted with bruises to his face, left outer eye, and bilateral inner eyes. Further review revealed, Resident #25 stated He Hit me! In an interview on 01/22/2024 at 2:58 p.m., S16Licensed Practical Nurse (LPN) stated she spoke to Resident #25, and he had told her that he had been hit. S16LPN further stated she also spoke with Resident #416, and he had stated Resident #25 had hit him, and he hit Resident #25. In an interview on 01/23/2023 at 2:00 p.m. S2Director of Nursing (DON) stated she spoke to Resident #25 and Resident #416 and their stories did not coincide. S2DON further stated the incident was unwitnessed. In an interview on 01/24/2024 at 9:45 a.m., S1Administrator stated he did not have any documentation of a complete investigation regarding the incident between Resident #25 and Resident #416 hitting each other. The facility did not present any documentation regarding a complete investigation of the alleged incident of Resident #25 and Resident #416 hitting each other. Resident #35 Review of the facility's incident log dated 01/01/2024 to 01/19/2024 revealed no documented incidents for Resident #35. Review of Resident #35's Nurse's Note dated 01/01/2024 at 12:20 p.m. revealed, in part, S3Weekend Supervisor documented she was called to Resident #35's room by S10Licensed Practical Nurse. It was reported by the Certified Nursing Assistant Resident #35 hollered no, no, no and Resident #35's husband was on top of her without his clothes on trying to kiss her. Further review of Resident #35's Nurse's Notes revealed S3Weekend Supervisor opened Resident #35's door and observed Resident #35 laying supine in her bed. Resident #35's husband was standing on the side of Resident #35's bed wearing only a shirt and socks. Resident #35's husband's pants, underwear, and shoes were on the floor beside the bed. Review of the notes revealed he smelled of alcohol. He stated he was not trying to do anything. S3Weekend Supervisor told Resident #35's husband he had to put his clothes back on and he was not allowed to do anything like that here and he could not stay here at this time. S3Weekend Supervisor escorted Resident #35's husband out the front door of the building and he waited for someone to pick him up. Review of Resident #35's clinical record revealed no additional documentation in regards to the above documented nurses note. In an interview on 01/22/2024 at 11:42 a.m., S10LPN stated on 01/01/2024 she was the nurse assigned to care for Resident #35. S10LPN stated she was at the nursing station and she heard Resident #35 repeatedly holler no. S10LPN stated she opened the door of the nurse's station and S8Certified Nursing Assistant (CNA) was in the hallway and told her told her to go to Resident #35's room because Resident #35's husband was trying to get in the bed with her. S10LPN stated when she entered Resident #35's room the privacy curtain was pulled around the bed and when she pulled the curtain, Resident #35's husband was on the side of bed and his pants and underwear were on the floor. S10LPN stated no one in administration interviewed her about the incident and she was no asked to provide a written statement. In an interview on 01/22/2024 at 11:54 a.m., S8CNA stated on 01/01/2024 S9CNA asked her to go to Resident #35's room. S8CNA stated when she entered Resident #35's room her husband was standing next to her bed without pants and underwear. S8CNA stated she asked Resident #35 if she was okay and she stated no. S8CNA stated Resident #35's husband's hands were on Resident #35. S8CNA stated no one in administration interviewed her about the incident and she was no asked to provide a written statement. In an interview on 01/22/2024 at 12:08 p.m., S9CNA stated on 01/01/2024 she was assigned to pass meal trays on Resident #35's hall and noticed Resident #35's door was closed. S9CNA stated she knocked and there was no answer and when she opened the door the privacy curtain was pulled back and she saw clothes on the floor. S9CNA stated that she announced I got your lunch and a man's voice said hey. S9CNA stated the man was Resident #35's husband and he was only wearing a shirt and his pants and underwear were on the floor. S9CNA stated Resident #35 was hollering No and her husband was hovered over the bed and his hand was near her vagina and the fasteners for her adult disposable brief were undone on one side. S9CNA stated no one in administration interviewed her about the incident and she was no asked to provide a written statement. In an interview on 01/22/2024 at 3:38 p.m., S7CNA stated on 01/01/2024 at around lunch time she was taking Resident #35's roommate to the bathroom and the room door was closed. S7CNA stated when she opened the door to bring the resident to the bathroom she noticed Resident #35's privacy curtain was pulled around her bed and she heard Resident #35 holler no. She stated she called out and asked Resident #35 if she was ok and she said no. S7CNA stated she saw jogging pants and underwear on the floor and shoes under the bed and a cell phone on the floor. S7CNA stated she saw Resident #35's husband leaning over Resident #35. S7CNA stated she was not interviewed by administration in regards to the incident on 01/01/2024 with Resident #35's husband. In an interview on 01/22/2024 at 12:24 p.m., S3Weekend Supervisor confirmed she was the facility supervisor on 01/01/2024 and she was notified by S10LPN that Resident #35's husband was in her room without pants and underwear. S3Weekend Supervisor stated when entered Resident #35's room her husband did not have pants and underwear and he next to the bed. S3Weekend Supervisor stated she told Resident #35's husband if he did not leave the facility she would call the police. S3Weekend Supervisor stated she did not complete an incident report and she did not report the incident to S1Administrator or S2Director of Nursing. In an interview on 01/22/2024 at 2:27 p.m., the surveyor presented S1Administrator with Resident #35's Nurses Notes dated 01/01/2024. S1Administrator reviewed the notes and stated he had not been informed of the incident on 01/01/2024 involving Resident #35 and her husband. S1Administrator further stated an investigation was not conducted on the incident from 01/01/2024. Resident #80 Review of Resident #80's progress note dated 09/10/2023 revealed, in part, Resident #80's responsible party was notified Resident #80 was hit on the left side of his face by another resident, and Resident #80's face was red in color and slightly swollen. In an interview on 01/23/2024 at 12:16 p.m., S2DON stated Resident #416 hit Resident #80 in the face on 09/10/2023. In an interview on 01/23/2024 at 2:00 p.m., S2DON stated that on 09/10/2023, Resident #80 had been hit by Resident #416, because Resident #416 was going after the nurse. In an interview on 01/24/2024 at 9:45 a.m., S1Administrator stated that he did not have any documentation of a complete investigation regarding the incident of Resident #80 being hit by Resident #416. The facility did not present any documentation regarding a complete investigation of the alleged incident of Resident #80 being hit by Resident #416. Resident #87 Review of Resident #416's progress note dated 09/19/2023 revealed, in part, Resident #416 grabbed another resident by a choke hold. Further review revealed, staff had stated earlier in the day, Resident #416 had pointed at the resident he had choked and commented that he was afraid of him. In an interview on 01/22/2024 at 3:44 p.m., S15CNA stated she saw Resident #416 choking Resident #87 in the hallway on 09/29/2023. In an interview on 01/23/2024 at 3:45 p.m., S1Administrator stated he did not consider the incident of Resident #416 choking Resident #87 as resident to resident abuse because Resident #416 did not have any intent behind his actions. S1Admiinistrator further stated he did not report the incident of Resident #416 choking Resident #87 to the state agency. In an interview on 01/24/2024 at 9:45 a.m., S1Administrator stated that he did not have any documentation of a complete investigation regarding the incident of Resident #87 being choked by Resident #416. The facility did not present any documentation regarding a complete investigation of the alleged incident of Resident #87 being choked by Resident #416. Resident #94 Review of Resident #416's progress note dated 09/29/2023, revealed, in part, it was reported to S10Licensed Practical Nurse (LPN), Resident #416 had struck another resident in the face with his shoe. Review of Resident #94's progress note dated 09/29/2023 revealed, in part, it was reported to S10LPN Resident #416 had struck another resident in the face with his shoe and Resident #94 was noted with a laceration below his left eye. In an interview on 01/23/2024 at 3:45 p.m., S1Administrator stated some kind of intervention or increased monitoring should had been put in place after Resident #416 choked Resident #94 on 09/19/2023 to prevent Resident #416 from having more aggressive episodes. In an interview on 01/24/2023 at 1:57 p.m., S1Administrator stated he watched the facility's surveillance video, and Resident #416 did hit Resident #94 on 09/29/2023. Review of a written statement dated 09/29/2023 by S1Administrator revealed, in part, an incident occurred on 09/29/2023 regarding Resident #416 and Resident #94. Further review revealed, Resident #416 raised a shoe towards Resident #94 hitting him in the face, in what appeared to be a startled reaction by Resident #416. Further review revealed, a video of this incident was viewed, and it showed as above. In an interview on 01/24/2024 at 9:45 a.m., S1Administrator stated that he did not have any documentation of a complete investigation regarding the incident of Resident #416 hitting Resident #94 in the face with a shoe. The facility did not present any documentation regarding a complete investigation of the alleged incident of Resident #25 and Resident #416 hitting each other. Resident #416 Review of Resident #416's progress note dated 09/14/2023, revealed, in part, Resident #416 approach S15LPN with noted bruising to his face and nose. Further review revealed Resident #416 stated he hit me first. I'm sure I hit him back. In an interview on 01/22/2024 at 2:58 p.m., S16Licensed Practical Nurse (LPN) stated she spoke to Resident #25, and he had told her that he had been hit. S16LPN further stated she also spoke with Resident #416, and he had stated Resident #25 had hit him, and he hit Resident #25. In an interview on 01/23/2023 at 2:00 p.m. S2Director of Nursing (DON) stated she spoke to Resident #25 and Resident #416 and their stories did not coincide. S2DON further stated the incident was unwitnessed. In an interview on 01/24/2024 at 9:45 a.m., S1Administrator stated that he did not have any documentation of a complete investigation regarding the incident between Resident #25 and Resident #416 hitting each other. The facility did not present any documentation regarding a complete investigation of the alleged incident of Resident #25 and Resident #416 hitting each other.

Based on observation, record review, and interview, the facility failed to ensure: 1. A bucket which contained sanitizing solution and a soiled towel was not stored near food seasonings and food preparation area; and 2. Kitchen staff kept all hair contained. Findings: Review of the facility's Food Safety and Sanitation Policy and Procedure revealed, in part: - Poisonous and toxic materials, including cleaning agents are store (and secured) outside the area for food and paper products; - Hair restraints are required and should cover all hair on the head. Observation on 01/21/2024 at 9:17 a.m. revealed S12Dietary Worker had approximately three inches of hair exposed below the hair net. Observation on 01/21/2024 at 9:19 a.m. revealed a red bucket with a cloudy white liquid and towel next to the seasonings on the bottom shelf of the table next to the stove. Observation on 01/22/2024 at 10:47 a.m. revealed a red bucket with a cloudy white liquid and towel next to the seasonings on the bottom shelf of the table next to the stove. In an interview on 01/22/2024 11:26 a.m., S13Dietary Manager stated the red bucket near the seasoning was sanitizer to clean the prep areas; however the kitchen staff should not store cleaning products and/or the bucket with sanitizer near the seasonings/food items. Observation on 01/23/2024 at 1:09 p.m. revealed S12Dietary Worker had approximately three inches of hair exposed below the hair net. In interview on 01/23/2024 at 1:09 p.m., S13Dietary Manager stated all dietary staff should ensure the hair net and/or any hair covering covered all hair on the head. In an interview on 01/23/2024 at 2:30 p.m., S1Administrator was informed of the above mentioned findings. S1Administrator stated the dietary staff should have all hair covered while in the kitchen, and sanitizer should not have been stored next to the seasonings and food preparation areas.

Based on record review and interview the facility failed to ensure the physician received notification of a change in condition for falls timely for 2 (Resident #3 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for timely physician notification. Findings: Resident #3 Review of Resident #3's Nursing Progress Note dated Friday, 05/19/2023 revealed Resident #3 was observed sliding out his wheelchair and was assisted to the floor per the nurse. A faxed communication was sent to a fax machine at Resident #3's Physician's office with no documentation confirming the physician was aware of and/or read the communication. Review of Resident #3's Nursing Progress Note dated 05/22/2023 revealed the facility received communication back from Resident #3's physician on Monday, 05/22/2023 regarding Resident #3's fall on 05/19/2023. Review of Resident #3's Nursing Progress Note dated 06/03/2023 revealed Resident #3 was noted on the floor with an abrasion to the forehead. Further review revealed Resident #3 was sent to the hospital and a communication sheet was sent to Resident #3's physician with no documentation confirming the physician was aware of and/or read the communication. Review of Resident #3's Nursing Progress Note dated 06/05/2023 revealed the nurse was called to a general area due to Resident #3 had an unwitnessed fall and was found on the floor on his side. Resident #3 had a skin tear to his forehead and abrasion to his left elbow. Further review revealed no documented evidence on how Resident #3's physician was notified of the fall. Review of Resident #3's Nursing Progress Note dated 06/06/2023 revealed Resident #3's physician was responding on 06/06/2023 to the communication sheet sent on 06/03/2023 via fax with no documented evidence the of physician read the communication regarding Resident #3's fall. Review of Resident #3's Nursing Progress Note dated 06/07/2023 revealed Resident #3 was found lying on the floor next to his bed. Further review revealed a communication sheet was sent via fax to a fax machine at Resident #3's physician office with no documented evidence confirming the physician was aware of and/or read the communication. Review of Resident #3's Nursing Progress Note dated 06/10/2023 revealed Resident #3's physician was responding on 06/10/2023 to the communication sheet sent on 06/07/2023 via fax with no documented evidence the physician read the communication regarding Resident #3's fall. Resident #4 Review of Resident #4's Nursing Progress Note dated 04/20/2023 revealed Resident #4 was found on the floor of his room lying on his right side. Review revealed when Resident #4 was asked if he hit his head he stated yes. Further review revealed the nursing progress note was sent to the physician office to a fax machine at Resident #4's physician office with no documented evidence confirming the physician was aware of and/or read the communication. Review of Resident #4's record revealed no documented evidence and the facility presented no documented evidence confirming Resident #4's physician was aware of and/or read the communication regarding the fall on 04/20/2023. In an interview on 06/14/2023 at 2:20 p.m., S9Licensed Practical Nurse (LPN) stated the physician was to be made aware of any change of condition and fall. S9LPN stated if no immediate injuries noted after a fall we may fax the progress note instead of calling the physician. S9LPN further stated after reviewing the record she had no documented evidence that Resident #4's physician had received or responded to the fax regarding Resident #4's fall. In an interview on 06/14/2023 at 2:33 p.m., S1Director of Nursing (DON) stated when a resident has a fall or change in condition the nurse will use her nursing judgement to decide if the nurse needed to call the physician or if the nurse could just fax a note. S1DON stated the facility nurses are to put the faxed or sent communications in a binder and the nurses were to follow-up on any communications which the physician had not responded to within 24 hours. S1DON stated herself and the Assistant Director of Nursing (ADON) were to review those binders daily to ensure the nurses are following up with the physicians on all notifications sent for a response. S1DON further stated after reviewing the above mentioned residents' records with the surveyor, the facility did have an issue with ensuring the physician immediately notified and responding to notifications of changes in a resident's condition in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Resident #1 had a follow-up appointment with an oncologist (a medical practitioner qualified to diagnose and treat tumors/mass) as ordered after a new diagnosis of a pancreatic mass. This deficient practice was identified for 1 (Resident #1) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed. Findings: Review of the Resident #1's medical record revealed, Resident #1 was re-admitted to the facility on [DATE] after an acute care hospital stay with a new diagnosis of a pancreatic mass. Review of Resident #1's admission orders dated 02/24/2023 revealed, in part, orders to admit to the nursing home and follow-up with an oncologist due to new diagnosis of pancreatic mass. Review of Resident #1's discharge orders from a local hospital dated 02/24/2023 at 11:35a.m., revealed in part, discharge to nursing home with orders to follow-up with an oncologist. Review of Resident #1's 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/2023 revealed in part, Section A - Resident #1 was a new admit from an acute care hospital, and Section I - Resident #1 diagnosis included, but was not limited to, a diagnosis of disease of the pancreas. Review of Resident #1's Comprehensive Care Plan dated 02/24/2023 revealed, a plan of care was developed for Resident #1 being a new admit to the facility including an intervention to schedule follow-up appointments. Further review of the care plan revealed, there was no plan of care developed for Resident #1's new diagnosis of pancreatic mass or disease of pancreas. In an interview on 06/12/2023 at 1:26p.m., Resident #1's Responsible Party (RP) stated Resident #1 was diagnosed with a pancreatic mass while in the hospital in February 2023. The RP stated her was discharged from the hospital to the nursing home on [DATE] and was never seen by a cancer doctor or treated for the pancreatic mass. There was no documented evidence and the facility did not present any documented evidence of progress notes and/or that Resident #1 had a follow-up appointment with an oncologist as ordered. In an interview on 06/13/2023 at 9:30a.m., S10LPN stated she was the nurse when Resident #1 was admitted on [DATE] and stated she did not make a follow-up appointment with an oncologist for Resident #1. S10LPN further stated it was the responsibility the ward clerk to make the appointments and schedule transportation. In an interview on 06/13/2023 at 1:50p.m., S11Ward Clerk stated she did not remember making an appointment with an oncologist for Resident #1. Review of the appointment schedule log from February 2023 to April 2023 did not reveal any scheduled appointments for Resident #1 to see an oncologist. In an interview on 06/13/2023 at 2:15p.m., S1DON stated Resident #1 was admitted to the facility on [DATE] with orders to follow-up with an oncologist due to a new diagnosis of pancreatic mass. S1DON stated the appointment was not scheduled as ordered. S1DON confirmed the facility did not schedule Resident #1's follow-up appointment with an oncologist as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to serve food menu based on Resident #96's preferences and per his plan of care. This deficient practice was identified for 1 resident (Resident # 96) of 3 sampled residents who were reviewed for food in a total sample of 40 residents. Findings: Review of Resident #96's record revealed Resident #96 was admitted to the facility on [DATE] and had a diagnosis of Gastroesophageal reflux disease (GERD) and was on a regular diet. Review of Resident #96's Care Plan revealed, in part, to avoid foods or beverages that tend to irritate esophageal lining such as alcohol, chocolate, caffeine, acidic, or spicy foods, fried or fatty foods. In an interview on 01/10/2023 10:50 a.m., Resident #96 complained he did not like the grits that he was served on his table for breakfast, and the facility had served him acidic food and drinks that he did not like because he had GERD and this food makes him feel bad. Observation on 01/10/2023 at 10:52 a.m. revealed the meal ticket of Resident #96 had no dislikes noted on it. Observation further revealed Resident #96 was served grits on his breakfast tray, but Resident #96 had not eaten them. Observation on 01/12/2023 at 8:44 a.m. revealed Resident #96 was served grits on his breakfast tray, but Resident #96 had not eaten them. Observation on 01/12/2023 at 11:33 a.m. revealed Resident #96 had his breakfast tray still on the table in his room with grits not eaten. In an interview on 01/12/2023 at 11:34 a.m., Resident #96 stated he could not eat the grits because it made him sick to his stomach, and he had been telling the facility staff. In an interview on 01/12/2023 at 11:47 a.m., S3Certified Nursing Assistant (C.N.A) stated that Resident #96's likes or dislikes were not written on his meal ticket and that would be up to the kitchen department staff to document on it. Observation on 01/12/2023 at 11:50 a.m. revealed Resident #96 was eating lunch but was not eating the cabbage that was surrounding the meat on his plate. In an interview on 01/12/2023 at 11:52 a.m., Resident #96 stated that the cabbage that was wrapped around his meat was acidic, which is why he did not eat it. Observation on 01/13/2023 at 11:00 a.m. revealed Resident #96 was served grits on his breakfast tray, but Resident #96 had not eaten them. In an interview on 01/13/2023 at 11:01 a.m., Resident #96 stated that he did not like grits because it made his GERD worse. In an interview on 01/12/20223 at 12:05 p.m., S4Dietary Manager stated the cabbage would be acidic since it was tomato based. In an interview on 01/12/2023 at 12:08 p.m., S4Dietary Manager stated that it would be up to the nurses to assess for Resident #96 dietary preferences and then to let her know, and so far this had not been done. In an interview on 01/12/2022 at 2:42 p.m., S5Minimum Data Set/Licensed Practical Nurse stated that she would be the one to do an assessment of Resident #96's food preferences or even a C.N.A could complete an assessment of his preferences, but a dietary preference assessment was not done for Resident #96. In an interview on 01/12/2023 at 2:45 p.m., S2Director of Nursing confirmed Resident #96 did not have his dietary preferences assessed, and Resident #96 should not be served acidic foods per his plan of care.

Based on observation and interview the facility failed to have an effective pest control program by having ants in a resident's bathroom. This deficient practice was identified for 1 Resident (Resident #63) out of 4 residents sampled for environment in a total sample list of 40 residents. Findings: Observation on 01/10/2023 at 12:03 p.m. revealed in bathroom a what appeared to be multiple small dead ants in the bathroom on top of a cup lid, a shelf, the sink, and around the bathroom light fixture. Observation on 01/12/2023 at 8:47 a.m. revealed in bathroom a what appeared to be multiple small dead ants in the bathroom on top of a cup lid, a shelf, the sink, and around the bathroom light fixture. In an interview on 01/12/2023 at 9:14 a.m. S7Licensed Practical Nurse stated that there were dead ants in the bathroom a. In an interview on 01/12/2023 at 9:18 a.m., S8Houskeeping stated that there were dead ants in bathroom a. S8 Housekeeping further stated she cleaned bathroom a yesterday. Observation on 01/12/2023 at 3:01 p.m. revealed with S1Adminstrator present in bathroom a the ants were alive and moving around on the sink and the shelf. In an interview on 01/12/2023 at 3:02 p.m., S1Administrator stated that there should not be ants in bathroom a. In an interview on 01/12/2022 at 3:05 p.m., S1Administrator stated that the pest control company came to the facility from 06/2022 to 11/2022 and had recently came in 12/2022. S1Administrator stated there was no comment about ants in bathroom a. S1Adminstrator stated he was not aware about the ants in bathroom a, and S1Adminstrator stated that he called maintenance, and it was just reported to him about ants in bathroom a In an interview on 01/13/2023 at 11:50 a.m., S6Maintenance stated that he had been spraying for the ants in bathroom a for weeks and the last time he sprayed was yesterday. S6Maintneance stated he called the pest control company yesterday for the first time. S6Mainteance further stated that he had no license to spray pesticides and had no training on spraying pesticides. In an interview on 01/13/2023 at 12:38 p.m., S1Adminstrator stated that S6Maintenance should have called the pest control company the first time there were ants found in bathroom a. In an interview on 01/13/2022 at 12:40p Resident #63 stated that he uses bathroom a.