Based on observations and interviews, the facility failed to: 1. Contain a used resident wash basin (Resident #31); and, 2. Maintain the smoking area in a clean manner (Resident #20). This deficient practice was identified for 2 (Resident #31 and Resident #20) of 31 (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #11, Resident #22, Resident #28, Resident #31, Resident #32, Resident #35, Resident #38, Resident #42, Resident #49, Resident #52, Resident #57, Resident #60, Resident #66, Resident #67, Resident #72, Resident #75, Resident #81, Resident #101, Resident #105, Resident #106, Resident #109, Resident #111, Resident #112, Resident #163, Resident #165, Resident #363) sampled residents observed during the initial pool process. Findings: 1. Observation on 03/10/2025 at 9:05AM revealed Resident #31's name was written on a wash basin which was under the sink on the floor of Resident #31's shared bathroom and not contained. Observation on 03/10/2025 at 3:45PM revealed Resident #31's name was written on a wash basin which was under the sink on the floor of Resident #31's shared bathroom and not contained. In an interview on 03/10/2025 at 3:52PM, S7Certified Nursing Assistant (CNA) indicated the wash basin was for Resident #31. S7CNA further indicated Resident #31's wash basin should not have been on the bathroom floor and should be contained in a plastic bag. In an interview on 03/10/2025 at 4:14PM, S2Director of Nursing indicated Resident #31's wash basin should not have been on the bathroom floor and should have been contained in a plastic bag. 2. In an interview on 03/10/2025 at 9:56AM, Resident #20 complained to the surveyor that the smoking area was dirty. Resident #20 then pointed to a cigarette that was on a window ledge and cigarette ashes all over the window ledge. Observation on 03/10/2025 at 9:58AM revealed a cigarette and cigarette ashes were present on the window ledge. Observation further revealed the smoking patio wall had an unknown black substance. Observation on 03/11/2025 at 10:25AM revealed a cigarette and cigarette ashes were present on the window ledge. Observation further revealed the smoking patio wall had an unknown black substance on the surface. In an interview on 03/12/2025 at 9:45AM, S1Administrator confirmed the smoking patio areas needed to be cleaned.

Based on interviews and record reviews, the facility failed to implement an appropriate fall intervention for a resident to prevent future falls for 1 (Resident #4) of 3 (Resident #4, Resident #32, Resident #49) sampled residents reviewed for falls. Findings: Review of Resident #4's Minimum Data Set with an Assessment Reference Date of 01/14/2025 revealed, in part, Resident #4 had a Brief Interview for Mental Status score of 3, which indicated Resident #3 had severe cognitive impairment, a diagnosis of dementia (memory loss), used a manual wheelchair for mobility, was dependent on staff for transfers, and had 2 or more falls since her prior assessment. Review of Resident #4's incident report dated 02/14/2025 revealed Resident #4 had an unwitnessed fall in her room and was found on the floor in front of her unlocked wheelchair. Review of Resident #4's care plan dated 02/17/2025 and revised on 03/11/2025 revealed, in part, Resident #4 had a history of falls with an intervention implemented on 02/14/2025 for staff to ensure brightly colored tape was applied to Resident #4's wheelchair brakes. In an interview on 03/11/2025 at 2:21PM, Resident #4 was unable to appropriately respond when questioned about the use of the brightly colored tape on her wheelchair brakes. In an interview on 03/12/2025 at 12:12PM, S10Licensed Practical Nurse (LPN) indicated Resident #4 had severe dementia and would not be able to remember to use her wheelchair brakes and/or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes. In an interview on 03/12/2025 at 12:15PM, S3Assistant Director of Nursing (ADON) indicated Resident #4's had poor safety awareness and severe cognitive impairment. S3ADON further indicated Resident #4 would not know how to use her wheelchair brakes and/or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes. In an interview on 03/12/2025 at 2:04PM, S9LPN indicated Resident #4 was definitely not cognitive enough to understand how to use her wheelchair brakes or identify the brightly colored tape on the brake handles as a reminder to use her wheelchair brakes.

Based on observations, interviews, and record reviews, the facility failed to follow the physician's order for oxygen administration for 1 (Resident #165) of 2 (Resident #164, Resident #165) sampled residents investigated for oxygen administration. Findings: Review of the facility's Oxygen-Administration, Concentration, Storage, Assemblage policy revised January 2024 revealed, in part, the procedure was to check the resident's oxygen flowmeter for the correct liter flow. Review of Resident #165's March 2025 Physician's Orders revealed, in part, an order for oxygen at two liters per minute (LPM) per nasal cannula continuously every shift related to chronic obstructive pulmonary disease. Observation on 03/10/2025 at 9:44AM revealed Resident #165's oxygen per nasal cannula was set between 1 and 1.5 LPM on the oxygen concentrator. Observation on 03/11/2025 at 2:09PM revealed Resident #165's oxygen per nasal cannula was set at 1.5 LPM on the oxygen concentrator. In an interview on 03/11/2025 at 2:10PM, S8Licensed Practical Nurse indicated Resident #165's oxygen was set at 1.5 LPM on the oxygen concentrator and should have been at 2 LPM per Resident #165's physician's orders. In an interview on 03/11/2025 at 3:25PM, S2Director of Nursing (DON) indicated the nurses should follow the physician's orders for oxygen administration. In an interview on 03/11/2025 at 4:05PM, S2DON confirmed Resident #165's oxygen order was for 2 LPM.

Based on interviews and record reviews, the facility failed to ensure a resident's hospice plan of care and certification of terminal illness was obtained from the contracted hospice agency for 1 (Resident #4) of 1 (Resident #4) sampled resident reviewed for hospice services. Findings: Review of Resident #4's Significant Change Minimum Data Set with an Assessment Reference Date of 01/14/2025 revealed, in part, Resident #4 had a life expectancy of less than 6 months and received hospice services. Review of Resident #4's March 2025 Physician's Orders revealed, in part, an order to admit Resident #4 to the contracted hospice agency on 01/03/2025. Review of the facility's Hospice Service Agreement dated 01/03/2025 revealed, in part, the facility was responsible for obtaining the most recent contracted hospice agency's plan of care and physician certification of terminal illness. Review of Resident #4's contracted hospice agency's binder revealed, in part, Resident #4 was admitted to hospice services on 01/03/2025. Further review revealed there was no documented evidence, and the facility was unable to present any documented evidence of Resident #4's physician certification of terminal illness or contracted hospice agency's plan of care. In an interview on 03/12/2025 at 1:43PM, S2Director of Nursing (DON) indicated it was the responsibility of S11Medical Records to ensure all hospice documents were maintained in Resident #4's clinical records. S2DON confirmed Resident #4's contracted hospice agency binder and electronic chart did not contain Resident #4's certification of terminal illness or Resident #4's contracted hospice agency's plan of care as required. In an interview on 03/12/2025 at 1:55PM, S11Medical Records indicated she was responsible to ensure all hospice documents were maintained in Resident #4's clinical record. S11Medical Records further indicated she did not know the specific hospice documents that should have been maintained in Resident #4's clinical record. S11Medical Records confirmed Resident #4's physician certification of terminal illness and contracted hospice agency's plan of care were not in Resident #4's clinical records as required.

Based on record reviews and interviews, the facility failed to document and address complaints voiced by the Resident Council during the facility's Resident Council meetings for 3 of 3 Resident Council meeting minutes reviewed. Findings: Review of the facility's Grievances-Residents policy, dated 03/1993 and revised on 05/2024 revealed, in part, the minutes of each Resident Council meeting should be recorded and future meetings should indicate progress made on each suggestion/recommendation, and/or the reason(s) for rejection if changes suggested could not be implemented. Further review of the policy revealed the grievance official was responsible for overseeing the grievance process, which included receiving, investigating and tracking grievances. Review revealed concerns which could not be promptly resolved should be treated as a grievance. Further review revealed the administrator or grievance official would conduct an impartial investigation of the allegations and would discuss the findings and recommendations within five working days of receiving the complaint. Review revealed the resident had the right to review the grievance and obtain a written decision regarding the grievance. In interview during a meeting held by the surveyor with members of the Resident Council on 03/11/2025 at 10:00AM, Resident #72 indicated the facility did not respond to the resident council's concerns discussed during the meetings regarding the taste and quality of food served from the kitchen. Resident #72 further indicated food concerns were discussed for the last three months and the food had not improved. Resident #15, Resident #59, and Resident #75 all agreed the taste and quality of the food served from the kitchen was discussed monthly for the last three months. Resident #72, Resident #15, Resident #59, and Resident #75 indicated there had been no follow-up from administration regarding the concerns of the taste and quality of food, and there had been no improvements in the taste and quality of food served from the kitchen. In an interview on 03/11/2025 at 10:15AM, Resident #72 indicated the food was over cooked, was under cooked, not seasoned, or was of poor quality overall. Resident #72 further indicated S4Dietary Manager was present at the Resident Council meetings and told the resident council members that the kitchen was short of staff at the time. In an interview on 03/12/2025 at 9:45AM, Resident #20 stated she attended the Resident Council meeting the last three months, and residents expressed concerns regarding the taste and quality of the food served. Resident #20 further indicated there were times when the beans were still hard and not cooked, the salads offered only had lettuce, and/or the food was just not cooked properly. Review of the Resident Council's meeting minutes for the months of January, February, and March 2025 revealed, in part, there were no documentation of the Resident Council's concerns regarding the taste and quality of food served from the kitchen as discussed in the resident council meetings. Review of the facility grievance logs from 12/2024 to 03/2025 revealed, in part, there were no documented grievances regarding the taste and/or quality of food served from the kitchen. In an interview on 03/11/2025 at 10:20AM, S5Activity Director indicated she was responsible for documenting the residents' concerns discussed during the resident council meetings. S5Activity Director further indicated residents discussed food displeasures during the meetings, but she did not document the concerns because she considered the concerns personal dislikes and not a generalized issue. In an interview on 03/11/2025 at 11:40AM, S6SocialWorker indicated she did not have any documented grievances regarding the taste and quality of food served from the kitchen. In an interview on 03/11/2025 at 5:45PM, S2Director of Nursing (DON) indicated she had recently received several complaints from residents regarding food served from the kitchen. S2DON further indicated she reported the concerns to S1Administrator. In an interview on 03/11/2025 at 5:52PM, S1Administrator indicated the resident council concerns regarding the taste and quality of food served from the kitchen should have been documented in the Resident Council meeting minutes. S1Administrator further indicated the residents' concerns should have been treated as a grievance with an investigation and response given to the residents.

Based on interview and record review, the facility failed to ensure a grievance was addressed and acted upon promptly per the facility's Grievance procedure for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for grievances. Findings: Review of the facility's policy titled, Resident's Right, last revised in 12/2023, revealed, in part, a resident should be encouraged to exercise their rights as a resident and present grievances. Review of the facility's policy/procedure titled ,Grievances-Residents, last revised in 10/2023, revealed, in part, the facility shall make prompt efforts to resolve grievances. Further review revealed the Administrator or Designee appointed as the Grievance Official, was responsible for overseeing the grievance process, receiving and tracking the grievances through their conclusion, leading any necessary investigations by the facility, and issuing written grievance decisions to the residents. Further review revealed the Social Worker or Social Services Designee had been appointed by the Administrator to receive concerns, grievances and recommendations by the residents. Further review revealed concerns that cannot be resolved within a shift shall be treated as a grievance. Further review revealed, these grievances shall be directed to the appropriate Department Head and/or Administrator for investigation and follow-up according to the following procedure: -Upon the receipt of a grievance/complaint the staff receiving the complaint would initiate the Grievance/Complaint Form NS-795, and an investigation led by the Administrator based on the allegations would be set forth. Further review revealed the Grievance/Complaint Form NS-795 would be completed electronically in the Quality Assurance module. In an interview on 04/23/2024 at 1:25 p.m., Resident #2 stated her personal underwear, a white undershirt, and an outfit were missing from her room. Resident #2 further stated she asked staff for the missing underwear, and they were unable to produce the missing items. In an interview on 04/23/2024 at 1:30 p.m., S4Certified Nursing Assistant (CNA) indicated she knew of Resident #2 missing personal items, and further indicated Resident #2's missing personal items were unable to be located. In an interview on 04/23/2024 at 2:05 p.m., S3LPN indicated she was not aware of Resident #2's missing personal items. In an interview on 04/23/2024 at 2:15 p.m., S5Houskeeping/Laundry Supervisor indicated staff had not reported Resident #2's missing personal items to him. In an interview on 04/23/2024 at 2:51p.m., S2Social Services Director indicated a resident's missing personal items should be reported to her immediately. In an interview on 04/24/2024 at 9:05 a.m., Resident #2 indicated her missing personal items had not been found. In an interview on 04/24/2024 at 9:14 a.m., S2Social Services Director indicated she was unaware of any grievance for Resident #2's missing personal items reported yesterday. In an interview on 04/24/2024 at 9:14 a.m., S1Administrator indicated she was unaware of any grievance for Resident #2's missing personal items reported yesterday. In an interview on 04/24/2024 at 9:15 a.m., S2Social Services Director indicated the facility had no documented evidence that a Grievance/Complaint Form NS-795 had been started regarding Resident #2's missing personal items from yesterday. There was no documented evidence, and the facility did not present any documented evidence, the facility's grievance procedure was started regarding Resident #2's grievance of missing personal items. In a phone interview on 04/24/2023 at 9:17 a.m., S5Houskeeping/Laundry Supervisor confirmed he was made aware of Resident #2 missing personal items yesterday, and did not report Resident #2's missing personal items to S2Social Services Director.

Based on interviews and record reviews, the facility failed to ensure residents were free from resident-to-resident abuse for 2 (Resident #8 and Resident #25) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only), most recently reviewed and/or revised on 10/2022 revealed, in part, abuse was the willful infliction of injury or punishment with resulting 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, willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #8 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and on the face when asked to wait her turn at the door to the activity room. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. Resident #25 Review of Resident #25's nurse's progress note dated 12/04/2023 revealed, in part, staff heard Resident #25 and Resident #80 yelling and cursing at each other regarding the air conditioner. Further review revealed Resident #80 hit Resident #25 on the right arm. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #25 revealed, in part, the incident was witnessed by a Certified Nursing Assistant that Resident #80 hit Resident #25 on the right arm. In a phone interview on 03/07/2024 at 1:38 p.m., S7CNA stated she saw Resident #80 hit Resident #25 on the arm. In a phone interview on 03/07/2023 at 2:42 p.m., S8CNA stated she witnessed resident #80 hit Resident #25. S8CNA stated the incident was started due to Resident #25 touching Resident #80's personal items and the air conditioner in their room.

Based on observations, record reviews, and interviews, the facility failed to maintain accurate count of the disposition of controlled medications for 2 (Resident #17 and Resident #27) of 2 (Resident #17 and Resident #27) who received controlled medications from Medication Cart a. Findings: Resident #17 On 03/07/2024 at 11:25 a.m. a reconciliation was completed of the controlled substances on Medication Cart a and the controlled substance binder for Medication Cart a and revealed the following: Observation of Resident #17's medication card for Phenobarbital 32.4milligrams (mg) (a medication used for seizures) revealed 56 pills remained on the medication card. Review of Resident #17's individual resident narcotics record for Phenobarbital 32.4mg tablet revealed 57 pills remained on the card. In an interview on 03/07/2024 at 11:26 a.m., S9Licensed Practical Nurse (LPN) stated she failed to document the administration of Resident #17's Phenobarbital 32.4mg on the individual resident narcotics record after she administered the controlled medication. Resident #27 On 03/07/2024 at 12:00 p.m. a reconciliation was completed of the controlled substances on Medication Cart b and the controlled substance binder for Medication Cart b and revealed, in part, the following: Observation of Resident #27's medication card for Lorazepam 0.5mg (medication used for anxiety) revealed the card had 5 pills. Review of Resident #27's individual resident narcotics record for Lorazepam 0.5mg tablet revealed 6 pills remained on the card. In an interview on 03/07/2024 at 12:02 p.m., S11Registered Nurse (RN) stated she failed to document the administration of Resident #27's Lorazepam 0.5mg on the individual resident narcotics record after she administered the medication. In an interview on 03/07/2024 at 1:27 p.m., S2Director of Nursing (DON) stated nurses were expected to update the individual resident narcotics record when a medication was administered. S2DON confirmed Resident #17 and Resident #27's individual resident narcotic records were not correct.

Based on observation and interviews, the facility failed to ensure a Certified Nursing Assistant performed hand hygiene after providing incontinence care for 1 (Resident #26) of 1 (Resident #26) sampled resident observed for incontinence care. Findings: Observation on 03/06/2024 at 12:28 p.m., revealed S12Certified Nursing Assistant (CNA) performed incontinence care for Resident #26 by wiping her vaginal area and then cleaning stool from her buttocks with gloved hands. Further observation revealed, after S12CNA completed Resident #26's incontinence care, S12CNA did not remove her gloves or perform hand hygiene. S12CNA then proceeded to assist Resident #26 back in her wheelchair and rolled Resident #26's wheelchair back to her bed. S12CNA pulled back the bed covers, and assisted with transferring Resident #26 to bed with same pair of gloves and without performing hand hygiene. S12CNA proceeded to adjust Resident #26's bed remote, fluff the bed pillows, pull up the bed covers, and hand Resident #26 her television remote with the same pair of gloves used to perform incontinence care and without performing hand hygiene. In an interview on 03/06/2024 at 12:40 p.m., S12CNA stated she did not usually remove her gloves after performing incontinence care and prior to putting the residents in bed. S12CNA agreed she should have changed her gloves and/or performed hand hygiene before she touched Resident #26's wheelchair, bed remote, pillows, blankets, and television remote after she performed Resident #26's incontinence care. In an interview on 03/07/2024 at 9:04 a.m., S2Director of Nursing indicated the CNA should have removed her gloves and/or performed hand hygiene after performing Resident #26's incontinence care, and before going to a clean area, and touching Resident #26's pillows, blankets, bed remote, and television remote.

Based on interviews and record reviews, the facility failed to report an allegation of abuse and the results of the investigation as required for 6 (Resident #8, Resident #10, Resident #25, Resident #53, Resident #56, and Resident #80) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only) , most recently reviewed and/or revised on10/2022 revealed, the administrator shall report to the State Survey Agency, no later than two hours after forming the suspicion, if the event that cause the suspicion involve abuse. Resident #8 and Resident #10 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and the face when asked to wait her turn at the door to the activity room. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. In an interview on 03/07/2024 at 3:08 p.m., S1Administrator stated she would have reported the incident between Resident #8 and Resident #10 on 12/17/2023 to the state agency. In an interview on 03/07/2024 at 3:09 p.m., S4Administrator stated he did not report the incident of Resident #10 hitting Resident #8 to the state agency. Resident #25 and Resident #80 Review of Resident #25's nurse's note dated 12/04/2023 revealed, in part, staff heard Resident #25 and Resident #80 yelling and cursing at each other regarding the air conditioner. Further review revealed Resident #80 hit Resident #25 on the right arm. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #25 revealed, in part, incident was witnessed by a Certified Nursing Assistant that Resident #80 hit Resident #25 on the right arm. In a phone interview on 03/07/2024 at 1:38 p.m., S7CNA stated she saw Resident #80 hit Resident #25 in the arm. In a phone interview on 03/07/2023 at 2:42 p.m., S8CNA stated she witnessed resident #80 hit Resident #25. S8CNA stated the incident was started due to Resident #25 touching Resident #80's personal items and the air conditioner in their room. In an interview on 03/07/2024 at 3:04 p.m., S4Administrator stated he did not report the incident of Resident #80 hitting Resident #25 to the state agency. Resident #53 and Resident #56 Review of Resident #53's nurse's note dated 02/03/2024 revealed, in part, Resident #53 approached S5Medical Records in the hall and was very upset. Further review revealed Resident #53 stated another resident hit the top of his hand. Review of Resident #56's nurse's note dated 02/03/2024 revealed, in part, Resident #56 struck another resident who was seated at the table with her and continued to be upset and combative. In an interview on 03/07/2024 at 11:16 a.m., S5Medical Records stated Resident #53 reported to her Resident #56 had slapped his hand and he was upset. S5Medical Records further stated she has seen Resident #56 trying to aggravate Resident #53 after the incident. In a phone interview on 03/07/2024 at 12:05 p.m., S13LPN stated she was in the facility's dining area when she saw Resident #56 picking on Resident #53. S13LPN further stated that she separated Resident #56 from Resident #53, and then went to speak to another resident that needed assistance. S13LPN further stated she heard Resident #53 yell out, she hit me, and when she turned around, she saw Resident #56 was back by Resident #53 and was swinging her arms. In an interview on 03/07/2024 at 3:36 p.m., S4Administrator stated he did not report the incident of Resident #56 allegedly hitting Resident #53 to the state agency.

Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of abuse for 4 (Resident #8, Resident #10, Resident #53, and Resident #56) of 8 (Resident #8, Resident #10, Resident #18, Resident #25, Resident #53, Resident #56, Resident #80, and Resident #84) sampled residents investigated for abuse. Findings: Review of a policy and procedure titled, Incident Investigation and Reporting (LA Only), most recently reviewed and/or revised on 10/2022 revealed, in part, the facility would thoroughly investigate all alleged violations under the direct supervision of the Administrator. Further review revealed, the investigation would include a signed statement from all witnesses including the accused, if applicable, stating the date and time with a detailed account of the incident. Resident #8 and Resident #10 Review of Resident #8's nurse's progress note dated 12/17/2023 revealed, in part, Resident #8 was slapped by Resident #10 on the right upper arm and on the side of his face. Review of Resident #10's nurse's progress note dated 12/17/2023 revealed, in part, at 10:10 a.m., it was reported by staff Resident #10 had slapped Resident #8 on the right upper extremity and face, when Resident #10 was asked by the staff to wait her turn at the door to facility's activity room. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #8 revealed, in part, Resident #8 was slapped on the upper right arm and on the right side of his face by another resident. Further review revealed documentation the above mentioned incident was not witnessed. Review of the facility's documentation dated 12/17/2023 related to the above mentioned incident for Resident #10 revealed, in part, Resident #10 had slapped Resident #8 on the right upper extremity and the face when asked to wait her turn at the door to the activity room. Further review revealed documentation the above mentioned incident was not witnessed. In an interview on 03/07/2024 at 11:45 a.m., S6Activities Staff stated Resident #10 was upset Resident #8 was in her way. S6Activities Staff further stated she witnessed Resident #10 hit Resident #8 on the arm. There was no documented evidence, and the facility was unable to present any documented evidence, a thorough investigation, including validating if the allegation occurred through witness statements was completed following Resident #8's physical abuse of Resident #10. In an interview on 03/07/2024 at 3:36 p.m., S4Adminstrator indicated the documents he presented to the survey team was the only documentation the facility had regarding the above mentioned incident. S4Administrator further indicated the facility did not have any further documentation of written statements or interviews with staff. Resident #53 and Resident #56 Review of Resident #53's nurse's note dated 02/03/2024 revealed, in part, Resident #53 approached S5Medical Records in the hall and was very upset. Further review revealed Resident #53 stated another resident hit the top of his hand. Review of Resident #56's nurse's note dated 02/03/2024 revealed, in part, Resident #56 struck another resident who was seated at the table with her and continued to be upset and combative. In an interview on 03/07/2024 at 11:16 a.m., S5Medical Records stated Resident #53 reported to her Resident #56 had slapped his hand and he was upset. S5Medical Records further stated she has seen Resident #56 trying to aggravate Resident #53 after the incident. In a phone interview on 03/07/2024 at 12:05 p.m., S13LPN stated she was in the facility's dining area when she saw Resident #56 picking on Resident #53. S13LPN further stated that she separated Resident #56 from Resident #53, and then went to speak to another resident that needed assistance. S13LPN further stated she heard Resident #53 yell out, she hit me, and when she turned around, she saw Resident #56 was back by Resident #53 and was swinging her arms. There was no documented evidence and the facility was unable to present any documented evidence a thorough investigation, including validating if the allegation occurred through witness statements and/or video surveillance, was completed following Resident #56's alleged physical abuse of Resident #53. In an interview on 03/07/2024 at 3:36 p.m., S4Adminstrator indicated the documents he presented to the survey team was the only documentation the facility had regarding the above mentioned incident. S4Administrator further indicated the facility did not have any further documentation of written statements or interviews with staff.

Based on record review, observations, and interviews, the facility failed to provide appropriate urinary catheter care according to professional standards for 2 (Resident #26 and Resident #89) residents investigated for urinary catheters in a total investigative sample of 25. This failed practice had the potential to effect any of the 11 residents with urinary catheters as documented on the facility's Resident Census and Conditions of Residents form (CMS-672). Findings: Review of the facility's Urinary Catheter Policy revealed, in part, perform hand hygiene and apply clean gloves. Using a clean washcloth or wash wipe, start at the meatus and wash the tubing in a circular motion away from the body about 4-5 inches. Rinse using same method. RESIDENT #89 Review of Resident #89's record revealed, in part, an admit date of 04/25/2022 with diagnoses of Hydronephrosis (a condition of an excess accumulation of urine in the kidneys which causes swelling) with renal and ureteral calculous obstruction, and retention of urine. Review of Resident #89's yearly Minimum Data Set with an Assessment Reference Date of 03/07/2023 revealed, in part, Resident #89 had an in-dwelling catheter. Review of Resident #89's Care Plan revealed, in part, catheter care every shift. An observation on 03/15/2023 at 11:30 a.m., of catheter care on Resident #89 revealed S3Certified Nursing Assistant (CNA) placed her soiled gloved hand into the multipack of wipes three times. Observation also revealed CNA wiped the catheter tubing both away from the resident and towards the resident. Additionally, the CNA left the contaminated multipack of wipes at Resident #89's bedside for future usage. In an interview on 03/15/2023 at 12:30 p.m., S3CNA stated if there were no body wipes in a resident room for use and none in the storage room she would look in another resident's room for a pack. S3CNA further stated that she considered Resident #89's multipack of wipes to be contaminated with stool, and the pack of wipes should have been thrown away. In an interview on 03/15/2023 at 4:30 p.m., S1Director of Nursing (DON) stated once gloves touched a soiled area the gloves are considered contaminated. S1DON further stated if body wipes are retrieved from a body wipe multipack with contaminated gloves, the pack should be thrown away and not available for future use. RESIDENT 26 Review of Resident #26's record revealed, in part, an admit date of 07/22/2020 with a diagnosis of Urinary Tract Infection. Review of Resident #26's Care Plan revealed, in part, Catheter Care every shift. An observation on 03/15/2023 at 11:10 a.m., revealed S4CNA provided catheter care to Resident #26 without changing gloves and sanitizing hands after cleaning stool from Resident #26. Observation also revealed S4CNA wiped the catheter tubing both away from the resident and towards the resident. S4CNA was observed obtaining body wipes from a multi pack two times while cleaning stool from Resident #26 with the same gloves on. S4CNA placed the contaminated body wipe pack on the shelf in the storage room. In an interview on 03/15/2023 at 4:30 p.m. S1DON stated once gloves touch a soiled area they are considered contaminated. S1DON further stated S4CNA should have changed her gloves and sanitized her hands after cleaning Resident #26's stool and before proceeding with Resident #26's catheter care. S1DON further stated if body wipes are retrieved from a body wipe multipack with contaminated gloves, the pack should be thrown away and not available for future use.

Based on record reviews and interviews, the facility failed to ensure a resident's care plan was implemented by failing to document meal intakes. This deficient practice was identified for 2 (Resident #92 and Resident #105) of 6 residents investigated for nutrition in a total investigative sample of 25. Findings: Review of the facility's Food Intake Records policy and procedure revealed, in part, the intake of each resident must be documented at each meal. Resident #92 Review of Resident #92's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2022 revealed, in part, Resident #92 had diagnoses including cancer, anorexia nervosa, and abnormal weight loss. Further review revealed Resident #92 weighed 102 pounds and had nutrition and hydration as a treatment intervention for skin issues. Review of Resident #92's weights revealed, in part, on 02/09/2023 Resident #92 weighed 106.6 pounds, and on 03/09/2023 Resident #92 weighed 96.8 pounds. Further review revealed Resident #92 had a significant weight loss of 5.3% in one month. Review of Resident #92's care plan revealed, in part, Resident #92 was at risk for skin breakdown as a result of skin cancer with an intervention for staff to record meal intake. Further review revealed Resident #92 was care planned for skin cancer lesions to the face with interventions for staff to record the percentage of meals eaten daily. Review of Resident #92's Meal Intake documentation from 01/15/2023 through 03/15/2023 revealed, in part, no documented evidence and the facility was unable to present any documented evidence of meal intake documentation for the following meals on the following dates: - 01/15/2023 - breakfast, lunch, and dinner; - 01/17/2023 - lunch and dinner; - 01/19/2023 - breakfast and lunch; - 01/20/2023 - lunch; - 01/21/2023 - lunch; - 01/22/2023 - lunch; - 01/23/2023 - lunch and dinner; - 01/24/2023 - lunch; - 01/25/2023 - breakfast, lunch, and dinner; - 01/26/2023 - breakfast, lunch, and dinner; - 01/27/2023 - breakfast, lunch, and dinner; - 01/28/2023 - breakfast, lunch, and dinner; - 01/29/2023 - dinner; - 01/30/2023 - dinner; - 01/31/2023 - breakfast, lunch, dinner; - 02/01/2023 - breakfast and lunch; - 02/02/2023 - breakfast, lunch, and dinner; - 02/04/2023 - breakfast, lunch, and dinner; - 02/06/2023 - breakfast and lunch; - 02/07/2023 - breakfast, lunch, and dinner; - 02/08/2023 - breakfast and lunch; - 02/09/2023 - breakfast, lunch, and dinner; - 02/10/2023 - lunch; - 02/11/2023 - lunch and dinner; - 02/12/2023 - lunch; - 02/13/2023 - breakfast and lunch; - 02/14/2023 - breakfast, lunch, and dinner; - 02/15/2023 - lunch; - 02/16/2023 - dinner; - 02/17/2023 - dinner; - 02/18/2023 - breakfast and lunch; - 02/19/2023 - breakfast and lunch; - 02/20/2023 - lunch and dinner; - 02/21/2023 - breakfast and lunch; - 02/23/2023 - breakfast and lunch; - 02/24/2023 - dinner; - 02/25/2023 - breakfast and lunch; - 02/26/2023 - breakfast, lunch, and dinner; - 02/27/2023 - breakfast and lunch; - 02/28/2023 - dinner; - 03/02/2023 - dinner; - 03/04/2023 - breakfast, lunch, and dinner; - 03/05/2023 - lunch; - 03/08/2023 - dinner; - 03/10/2023 - lunch; - 03/11/2023 - dinner; - 03/13/2023 - breakfast and dinner; and, - 03/14/2023 - dinner. Resident #105 Review of Resident #105's MDS with an ARD of 02/09/2023 revealed, in part, Resident #105 had a diagnosis of malnutrition. Further review revealed Resident #105 had a feeding tube and a therapeutic diet. Review of Resident #105's March 2023 Physician's Order revealed, in part, an order with a start date of 02/17/2023 for a pureed diet with no added salt and low concentrated sweets. Further review revealed an order for Diabetisource tube feeding formula at 60 milliliters per hour via pump continuously from 6:00 p.m. to 6:00 a.m. infused though Resident #105's feeding tube. Review of Resident #105's Care Plan revealed, in part, Resident #105 was care planned for the potential for aspiration related to being prescribed mechanically altered therapeutic pleasure feedings with interventions for staff to record meal intake. Review of Resident #105's Meal Intake documentation from 02/17/2023 through 03/15/2023 revealed, in part, no documented evidence and the facility was unable to present any documented evidence of meal intake documentation for the following meals on the following dates: - 02/17/2023 - breakfast, lunch, and dinner; - 02/18/2023 - breakfast, lunch, and dinner; - 02/19/2023 - breakfast, lunch, and dinner; - 02/20/2023 - breakfast, lunch, and dinner; - 02/21/2023 - dinner; - 02/22/2023 - dinner; - 02/23/2023 - lunch and dinner; - 02/24/2023 - lunch; - 02/25/2023 - lunch and dinner; - 02/27/2023 - dinner; - 02/28/2023 - breakfast, lunch, and dinner; - 03/04/2023 - breakfast and lunch; - 03/06/2023 - lunch and dinner; - 03/08/2023 - dinner; - 03/09/2023 - lunch; - 03/11/2023 - breakfast and lunch; - 03/12/2023 - breakfast and lunch; and, - 03/14/2023 - lunch. In an interview on 03/16/2023 at 1:54 p.m., S5Certified Nursing Assistant (CNA) stated the CNA feeding a resident would be responsible for documenting the meal intake percentage on the meal ticket, then the resident's assigned CNA would document the meal intake in the computer. S5CNA further stated every resident's meal intake should be documented for every meal. In an interview on 03/16/2023 at 2:12 p.m., S6Assessment Nurse stated breakfast, lunch, and dinner should be recorded every day to reflect a resident's nutritional status. In an interview on 03/16/2023 at 2:16 p.m., S7Dietary Manager stated CNAs should document meal intakes for every meal every day on all residents. In an interview on 03/16/2023 at 2:33 p.m., S8Assistant Director of Nursing (ADON) stated meal intakes should be documented for every meal for every resident. S8ADON stated meal intake would be utilized to complete a resident's weight evaluation. In an interview on 03/16/2023 at 3:06 p.m., S1Director of Nursing (DON) confirmed meal intake documentation was lacking for Resident #92 and Resident #105. S1DON stated meal intakes should be documented for every meal every day on every resident. S1DON further stated meal intake documentation is especially important for the nutritional evaluation of residents with known weight loss, feeding tubes, and wounds.