Based on interviews and record reviews, the facility failed to implement facility policy to ensure all witness statements received verbally were titled, and signed by both the person making the statement and the witness. Findings: Review of the facility's Abuse, Neglect, and Misappropriation of Funds Policy and Procedure, with revised date of March 2025, if only oral information can be obtained about an allegation of abuse, the following is required, in part: A statement must be documented signed and date; and, The recorder and the witness to the statement must sign, date, and title statement. Review of the facility's investigation related to an allegation of sexual abuse dated 12/04/2024, revealed S1Administrator had documented S13Housekeeper's statement regarding alleged sexual abuse; however, S13Housekeeper had not signed and dated the statement, and S1Administrator had not titled the statement. Review of S5LPN's Sexual Abuse Allegation Statement dated 03/15/2025 revealed the statement was not signed by S5LPN, nor any witness. Review of S12CNA's Sexual Abuse Allegation Statement dated 03/19/2025 revealed the statement was not signed S12CNA, nor any witness. In an interview on 03/26/2025 at 5:10PM, S3Corporate Administrator indicated he took the verbal statements from S5LPN and S12CNA with S1Administrator and S2DON present, but did not get the witnesses to write a statement, nor sign the verbal documentation of the investigation.

Based on interview and record review, the facility failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors for 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) of 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) sampled staff reviewed for behavior training. Findings: Review of the facility's Facility Assessment Tool updated on 10/16/2024 revealed, in part, the facility was able to accept residents with psychiatric/mood disorders and psychiatric symptoms and behaviors would be identified and interventions implemented to help support the residents. Review of Resident #2's Minimum Data Set Assessment Reference Date 12/24/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 8 (score of 08-12 indicated moderate cognitive impairment). Review of Resident #2's care plan revealed, in part, Resident #2 had the potential to touch female peers inappropriately (touching a resident's arm without permission) initiated on 03/16/2025 Review of Resident #2's S13Housekeeper Verbal Witness Statement dated 12/04/2024 revealed, in part, Resident #2 exposed his penis to staff. Review of Resident #2's Progress Note dated 12/04/2024 revealed, in part, Resident #2 was transferred to a psychiatric facility for inappropriate sexual behavior. Review of Resident #2's Physician's Emergency Certificate (PEC) (a document used to admit a resident into a psychiatric facility) dated 12/04/2024 revealed, in part, Resident #2 had behaviors of exposing self to staff and peers and hypersexual behavior. Review of Resident #2's PEC dated 02/05/2025 revealed, in part, Resident #2 was assessed as having hypersexual behaviors and touching others inappropriately. Review of Resident #2's PEC dated 03/03/2025 revealed, in part, Resident #2 was hypersexual with staff and peers, with unwanted sexual advances to other residents. In an interview on 03/20/2025 at 10:19AM, S8Porter indicated he was assigned to provide 1:1 supervision to Resident #2. S8Porter indicated no one had explained to him the reason Resident #2 was placed on 1:1 supervision, but he was instructed he was to be with Resident #2 at all times. S8Porter further indicated he had a binder with a list of questions to fill out regarding Resident #2's behaviors for every shift. In an interview on 03/20/2025 at 3:12PM, S10Housekeeping Supervisor indicated she was assigned to 1:1 supervision of Resident #2. S10Housekeeping Supervisor further indicated she was not sure what behaviors Resident #2 displayed or how to intervene if the behavior occurred. In an interview on 03/25/2025 at 2:40PM, S9Porter indicated last night (03/24/2025) was about the third time he was assigned to 1:1 supervision of Resident #2. S9Porter further indicated he did not receive any education on Resident #2's specific behaviors or how to intervene if the behaviors occurred. Record review revealed no documented evidence and the facility was unable to present any evidence the above mentioned staff members received specific training Resident #2's behaviors or training on how to care for residents with psychosocial disorders. In an interview on 03/25/2025 at 2:58PM, S2Director of Nursing (DON) indicated the facility had no documented evidence the above mentioned staff had been trained in Resident #2's behaviors prior to being assigned one on one supervision with Resident #2. In an interview on 03/26/2025 at 2:49PM, S1Administrator confirmed the above mentioned staff provided one on one supervision for Resident #2. S1Administrator further indicated the above mentioned staff members did not receive trainings on caring for residents with mental or psychosocial disorders.

Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (Resident #R1) of 7 (Resident #2, Resident #3, Resident #4, Resident #R1, Resident #R2, Resident #R3, Resident #R4) sampled residents observed during medication administration. Findings: Review of Resident #R1's record revealed, in part, Resident #R1 had diagnoses which included chronic diastolic congestive heart failure (condition in which the heart was unable to pump blood proficiently) and sinusitis. Review of Resident #R1's March 2025 Physician Orders revealed, in part, Lasix (medication used to remove excess fluid from the body) 20 milligrams (mg) administer three tablets by mouth daily. Further review revealed an order for Flonase (medication used to treat allergies) 50 micrograms (mcg) per actuation one spray in both nostrils one time a day. Observation on 03/21/2025 at 8:15AM revealed S4Licensed Practical Nurse (LPN) was unable to locate Resident #R1's Flonase and Lasix to administer. In an interview on 03/21/2025 at 8:15AM, S4LPN indicated the facility recently had to order multiple medications from the pharmacy and was waiting for the medications to be delivered. Review of Resident #R1's March 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #R1's Flonase and Lasix were not administered as ordered on 03/21/2025. In an interview on 03/21/2025 at 11:51AM, S2Director of Nursing (DON) indicated the facility did not obtain the Lasix and Flonase medications in a timely manner.

Based on observation, record reviews, and interviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #21) of 2 (Resident #21 and Resident #27) sampled residents observed during incontinence care. Findings: Review of the facility's undated Resident [NAME] of Rights revealed, in part, staff shall protect the right to privacy of the resident's body during toileting, bathing, and other activities of personal hygiene. Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated Resident #21 had severe cognitive impairment. Further review revealed Resident #21 was dependent on staff assistance for toileting hygiene. Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care while Resident #21's roommate, Resident #46, remained in the room. Further observation revealed S11CNA and S12CNA did not close Resident #21's bedside privacy curtain and proceeded to remove Resident #21's pants, remove Resident #21's incontinence diaper and start Resident #21's incontinence care. Further observation revealed Resident #21's genitalia remained uncovered during the entire incontinence care process. In an interview on 01/15/2025 at 9:05 a.m., S11CNA confirmed she did not close Resident #21's bedside curtain to ensure Resident #21's privacy during incontinence care and should have. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated the CNAs should have ensured a resident's privacy was maintained during incontinence care. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed a resident's privacy should have been maintained during incontinence care by closing the resident's privacy curtain since another resident was in the room.

Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #84) of 3 (Resident #26, Resident #64, and Resident #84) residents investigated for abuse. Findings: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Funds Program dated October 2024 revealed, in part, the facility should ensure the safety and well-being of residents was maintained at all times and was committed to zero tolerance of any form of abuse. Further review revealed, abuse was the willful infliction of injury with resulting physical harm or pain, and this applied to all residents regardless of their medical condition or mental capacity. Further review revealed, physical abuse included hitting and slapping. Review of facility's Statewide Incident Management System (SIMS) Report investigation entered on 10/01/2024 for an incident that occurred on 10/01/2024 at 2:17 p.m. revealed, in part, Resident #64 hit Resident #84 in the face with an open hand while sitting outside in the courtyard. Further review revealed, S1Administrator determined Resident #84 was the victim of resident to resident physical abuse by Resident #64. Further review also revealed S1Administrator determined physical abuse was substantiated based on Resident #64's confession and video surveillance footage of the above mentioned incident. Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #84 went to the nurse's station and reported she had been hit in the face by another resident while outside on the patio. Further review revealed, Resident #84 had a red mark/scratch noted to the left side of her eye. Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #64 had a documented incident of physical aggression. Further review revealed Resident #64 initiated a physical altercation by striking another resident in the face. Review of #84's nurse's note dated 10/01/2024 revealed, in part, Resident #84 was sent out to the hospital to be evaluated for complaints of pain to Resident #84's left side of her face and her left eye. Review of Resident #64's progress note dated 10/01/2024 revealed, in part, Resident #64 was sent out by the physician to behavioral health for an evaluation due to aggressive behavior toward another resident. In an interview on 01/15/2025 at 9:05 a.m., Resident #64 confirmed the physical altercation with Resident #84 and indicated she hit Resident #64 in the face. In an interview with 01/16/2025 at 8:55 a.m., S16Social Services confirmed the above mentioned incident between Resident #64 and Resident #84 that occurred on 10/01/2024. In an interview on 01/16/2025 at 9:00 a.m., S1Administrator acknowledged the above mentioned incident had occurred on 10/01/2024 between Resident #64 and Resident #84. S1Administrator confirmed the above mentioned incident of resident to resident physical abuse was substantiated after being investigated by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident, with a new diagnosis of Schizoaffective Disorder, was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 3 (Resident #12, Resident #63, and Resident #84) sampled residents reviewed for PASARR. Findings: Review of Resident #63's medical record revealed, in part, Resident #63 was readmitted to the facility on [DATE]. Further review revealed Resident #63 was diagnosed on [DATE] with Schizoaffective Disorder. Further review revealed no documented evidence a PASARR Level II evaluation was completed for Resident #63. Review of Resident #63's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed, in part, Resident #63's active diagnoses included Schizoaffective Disorder-Bipolar Type. In an interview on 01/15/2025 at 11:20 a.m., S3Admissions Coordinator indicated a PASARR Level II evaluation was not completed for Resident #63 after Resident #63's new diagnosis of Schizoaffective Disorder on 02/27/2023. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed Resident #63 did not have a PASARR Level II submitted after a new diagnosis of Schizoaffective Disorder was determined on 02/27/2023 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations the facility failed to: 1. Develop a person-centered care plan for a resident with dialysis and, 2. Implement interventions per the resident's plan of care. This deficient practice was identified for 1 (Resident #27) of 1 (Resident #27) residents investigated for dialysis. Findings: Review of Resident #27's electronic medical record (EMR) revealed, in part, Resident #27 was admitted to the facility on [DATE] and had diagnoses, which included, in part, Diabetes Mellitus, Sacral pressure ulcer, and renal insufficiency. Review of Resident #27's January 2025 Physician's orders revealed, in part, an order for Resident #27 to receive dialysis. Review of Resident #27's care plan dated 07/21/2024, revealed, in part, Resident #27 received dialysis three times per week, and the facility would monitor Resident #27's intake and output. 1. In an interview on 01/14/2025 at 9:50 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated Resident #27's care plan was generated from the dialysis care plan template and the intervention to monitor intake and output should not have been on it. 2. In an interview on 01/14/2025 at 8:50 a.m., S2DON/Infection Preventionist indicated the facility's staff should document a resident's intake and output in the care task section of the resident's EMR. Review of Resident #27's completed tasks revealed, in part, no documented evidence Resident #27's intake and output were monitored. There was no documented evidence, and the facility did not present any documented evidence the facility monitored Resident #27's intake and output. In an interview on 01/14/2025 at 9:42 a.m., S17Medical Director indicated the intervention on the care plan should have been followed as documented in the specific approaches as noted on the dialysis plan of care, he expected the facility to follow Resident #27's care plan. In an interview on 01/14/2025 at 9:50 a.m., S2DON/Infection Preventionist confirmed the facility did not have documentation Resident #27's intake and output was required.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's blister was evaluated and treated for 1 (Resident #79) of 2 (Resident #12 and Resident #79) residents investigated for skin conditions. Findings: Observation on 01/13/2025 at 9:22 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/14/2025 at 9:05 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/15/2025 at 9:09 a.m., had a blister to his right lower leg that measured approximately 3 centimeters. Observation on 01/15/2025 at 12:20 p.m., revealed the blister to Resident #79's right lower leg blister had opened, Resident #79's skin was no longer intact, and a clear liquid drainage was observed. Review of Resident #79's medical record revealed no documented evidence, and the provider did not present any documented evidence, an evaluation/assessment of Resident #79's right lower leg blister had been completed. In an interview on 01/15/2025 at 12:30 p.m., S19Certified Nursing Assistant (CNA) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S19CNA further indicated she had not noticed the blister to Resident #79's lower right leg. In an interview on 01/15/2025 at 2:30 p.m., S15Licensed Practical Nurse (LPN) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S15LPN further indicated she was unaware and was not made aware by any of the CNAs caring for Resident #79 that there were any blisters to Resident #79's 70 right lower leg. S15LPN further indicated the facility's CNA were supposed to notify the nurse of any changes in a resident's skin condition. In an interview on 01/15/2025 at 2:45 p.m., S20LPN/Charge Nurse indicated if the above mentioned blister was present on Resident #79's right lower leg since 01/13/2025, the facility's CNAs and/or nurses should have noted and reported Resident #79's blister. S20LPN/Charge Nurse further indicated the CNAs should have noted Resident #79's right lower leg blister during his bath/shower on 01/15/2025 and reported the blister to the nurse for evaluation/assessment. In an interview on 01/16/2025 at 11:15 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated the blister on Resident #79's right lower leg was not reported to the nurse or wound care nurse until 01/15/2025 after it had opened. S2DON/Infection Preventionist further acknowledged Resident #79's blister should have been noticed and reported to her so an evaluation/assessment could be completed but it was not.

Based on record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart c, and Medication Cart d) medication carts observed for expired medications. Findings: Review of the facility's policy titled, Storage of Medication Policy and Procedure, dated 10/2024, revealed, in part, expired drugs or biologicals should be returned to the dispensing pharmacy or destroyed. Observation of Medication Cart c on 01/15/2025 at 8:39 a.m. revealed a bottle of Meclizine Hydrochloride (HCl) 12.5 milligram (mg) caplets with an expiration date of 12/2024 was available for resident use. In an interview on 01/15/2025 at 8:41 a.m., S22Licensed Practical Nurse (LPN) confirmed the bottle of Meclizine HCl 12.5 mg caplets found stored in Medication Cart c was expired, and available for resident use, and should not have been. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist confirmed an expired medication should not have been stored in the Medication Cart c and available for resident use. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator indicated an expired medication should not have been stored in the Medication Cart c and available for resident use.

Based on record review and interviews, the facility failed to ensure the dietary manager had completed an approved food safety program and passed the accompanying test for 1 (S13Dietary Manager) of 1 (S13Dietary Manager) sampled dietary managers employed by the facility. Findings: In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated she had been the facility's dietary manager for 2 years. S13Dietary Manager further indicated she had not taken the exam for the ServSafe course. In an interview on 01/14/2025 at 3:50 p.m., S1Administrator indicated the facility was not aware S13Dietary Manager had not completed the examination for her ServSafe course, and therefore did not have ServSafe certification. At time of exit the facility had not presented any evidence S13Dietary Manager had passed the ServSafe examination.

Based on observations, record review, and interviews, the facility failed to ensure: 1. Food items were not placed in areas in which water had accumulated on food packaging; 2. Food items were covered in the refrigerator; 3. Expired food items were discarded and not available for use; 4. Damaged food items were not stored amongst other food items; 5. Staff had all hair restrained when in the food preparation areas; 6. Chemicals were not stored in food preparation areas; 7. Food items were labeled with an opened date and labeled with the contents of the container/bag; and, 8. Staff did not store their food items with residents' food items; Findings: Review of the facility's policy titled, Food Receiving and Storage Policy and Procedure, last reviewed in 01/2025 revealed, in part: -staff were to ensure refrigerated foods were labeled, dated, and monitored so they are used by their use by date, frozen, or discarded; and, -food may not be stored under leaking water lines, or under lines on which water has condensed. Observation on 01/13/2025 at 9:46 a.m. with S13Dietary Manager revealed, in part: - ice had accumulated on the left and right side of the freezer's fan and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the box; - the facility's refrigerator had a cart with 83 uncovered containers of fruit cocktail; - the facility's refrigerator contained three one-quart containers of heavy whipping cream with an expiration date of 01/12/2025; -the facility's dry storage area contained a dented container of mandarin oranges on the shelf between other canned goods; and - S13Dietary Manager's hair was not fully contained by her hairnet. Observation on 01/14/2025 at 11:15 a.m. with S13Dietary Manager revealed, in part: -S13Dietary Manager's hair was not fully contained by her hairnet; -ice had accumulated on the left and right side of the freezer's fan, and a box of cut okra, a box of ground beef, a box of chocolate pudding, and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the boxes; -two small buckets of sanitizer were stored under the facility's food preparation table; -the facility's refrigerator had two undated plastic containers that were not labeled with the contents of the containers and an undated bottle that was not labeled with the contents of the bottle; and, -the facility's refrigerator had the following: an undated half-empty one gallon container of mayo; an undated half-empty five pound container of sour cream; an undated half-empty one gallon container of yellow mustard; an undated one gallon container of sweet pickles with approximately one-fourth of the container used; and an undated half-empty one gallon container of Italian dressing. In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated the facility had to defrost the freezer approximately every two weeks due to the accumulated ice of the freezer's fans. S13Dietary Manager confirmed the bottle and two plastic containers of prepared food observed in the facility's refrigerator on 01/14/2025 belonged to the staff and should have not been in the facility's refrigerator with residents' food items. S13Dietary Manager further confirmed the above findings and indicated the above findings were deficient. In an interview on 01/14/2025 at 3:50 p.m., S1Administrator confirmed the above findings were deficient.

Based on observations, interviews, record reviews, the facility failed to ensure: 1. A facility-wide surveillance of resident's infections were maintained (Resident #7, Resident #12, Resident #27, and Resident #84); and, 2. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care (Resident #21). This deficient practice was identified for 4 (Resident #7, Resident #12, Resident #27, and Resident #84) of 13 (Resident #1, Resident #7, Resident #12, Resident #27, Resident #39, Resident #55, Resident #56, Resident #63, Resident #73, Resident #76, Resident #79, Resident #84, and Resident #88) sampled residents reviewed for infection surveillance; and, for 1 (Resident #21) of 2 (Resident #21 and Resident #27) residents observed during incontinence care. Findings: 1. Review of the facility's Antibiotic Stewardship- Review of and Surveillance of Antibiotic Use and Outcomes, with revised date of February 2024, revealed, in part: -as part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. -all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form, and the information gathered will include, in part: resident name, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. Review of Resident #7's July 2024's Physician Orders revealed, in part, Resident #7 was prescribed and received Levofloxacin (antibiotic medication used to treat infections) 500 milligrams (mg) one tablet by mouth daily for 10 days for a right knee infection with a start date of 07/05/2024; and Doxycycline (antibiotic medication use to treat infections) 100mg one tablet by mouth every 12 hours for right knee wound with a start date of 07/06/2024. Review of Resident #12's July 2024's Physician Orders revealed, in part, Resident #12 was prescribed Cefepime Hydrochloride (HCl) (antibiotic mediation used to treat infections) intravenous (IV) solution reconstituted (amount of medication dissolved in a solution) (medication administered directly into the vein) 2 grams (gm) IV one time a day related to acute osteomyelitis (infection of the bone) of the left ankle, with a start date of 07/04/2024. Review of the facility's Infection Surveillance Map and Infection Reports for July 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #7 and Resident #12's above mentioned antibiotics and infections as part of the facility's July 2024 infection surveillance. Review of Resident #27's August 2024's Physician Orders revealed, in part, Resident #27 was prescribed, in part, Tobradex (antibiotic medication used to treat infections) Opthalmic (medication administered into the eye) 0.3-0.1 percent ointment. Instill into left eye four times a day for 10 days with a start date of 08/01/2024 for blepharitis (inflammation and infection) of the left upper eyelid. Review of the facility's Infection Surveillance Map and Infection Reports for August 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #27's above mentioned antibiotic and infection as part of the facility's August 2024 infection surveillance. Review of Resident #84's November 2024 Physician Orders revealed, in part, Resident #84 was prescribed Augmentin (antibiotic, medication used to treat infections) 500/125mg one tablet by mouth twice a day for cellulitis (infection of the skin) with a start date of 11/18/2024. Review of the facility's Infection Surveillance Map and Infection Reports for November 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #84's above mentioned antibiotic and infection as part of the facility's November 2024 infection surveillance. In an interview on 01/16/2025 at 2:08 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) indicated the documents presented to the surveyor was all of the facility's infection surveillance for all of the facility's infections for July 2024 through January 2025. S2DON/IP further indicated after reviewing the above mentioned documents the facility was not capturing all residents' infections, and therefore the facility did not have a comprehensive facility Antibiotic Stewardship and Surveillance of Infections. 2. Review of the facility's Handwashing and Hand Hygiene policy and procedure dated October 2024 revealed, in part, hand hygiene should be performed before moving from a contaminated body site to a clean body site during resident care. Review of Resident #21's Minimum Data Set with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 was always incontinent of bowel and bladder. Further review revealed Resident #21 was dependent on staff for toileting hygiene. Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care. S11CNA and S12CNA then removed Resident #21's urine and feces soiled brief, cleaned Resident #21's buttock area of feces, and placed a clean brief on Resident #21 without changing gloves or performing hand hygiene. S11CNA then disposed of Resident #21's soiled brief into the trash. S11CNA and S12CNA then manually transferred Resident #21 from the bed to a wheelchair with the same gloves used to perform incontinence care. In an interview on 01/14/2025 at 2:25 p.m., S12CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have. In an interview on 01/14/2025 at 2:30 p.m., S11CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have. In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on a resident during incontinence care. In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on resident during incontinence care.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error was not greater than 5% for 2 (Resident #R3 and Resident #R4) of 10 (Resident #1, Resident #3, Resident #R1, Resident #R2, Resident #R3, Resident #R4, Resident #R5, Resident #R6, Resident #R7, and Resident #R8) sampled residents observed during medication administration. Findings: Review of the facility's undated Medication Pass Administration policy and procedure revealed, in part, medications were to be administered within 60 minutes before or after scheduled time. Review of Resident #R3's December 2024 Physician's Orders and electronic Medication Administration Record (eMAR) revealed Resident #R3 had an order for Sodium Bicarbonate (medication used to treat low sodium levels) 650 milligrams (mg), administer one tablet by mouth three times a day at 5:00 AM, 11:00 AM, and 8:00 PM. Observation on 12/26/2024 at 1:17 PM revealed S3Licensed Practical Nurse (LPN) administered Sodium Bicarbonate 650 mg one tablet by mouth to Resident #R3. Review of Resident #R4's December 2024 Physician's Orders and eMAR revealed Resident #R4 had the following orders, in part: Furosemide (medication used to remove excess fluid from the body) 20 mg, administer one tablet by mouth daily at 8:00 AM; Potassium Chloride (CL) Extended Release (ER) 20 milliequivalents (meq) (medication used to replace low potassium levels), administer one tablet by mouth daily at 8:00 AM; Oxycodone-Acetaminophen (APAP) (medication used to treat pain) 7.5/325 mg, administer one tablet by mouth three times a day at 8:00 AM, 2:00 PM, and 8:00 PM; Albuterol Sulfate (medication used to open the airway) 90 micrograms (mcg) per actuation (pump of inhaler), administer two actuations every six hours as needed for wheezing; and, Budesonide-Fumoterol Fumarate Aerosol (medication used to treat constricted airways) 106-4.5 mg/actuation, administer one puff two times a day at 8:00 AM and 4:00 PM. Observation on 12/27/2024 at 9:29 AM revealed S4LPN administered Resident #R4 the following medication, in part: Furosemide 20mg one tablet by mouth; Potassium CL ER 20 meq one tablet by mouth; Oxycodone-APAP 7.5/325 mg one tablet by mouth; Albuterol Sulfate 90 mcg two inhalations. Further observation revealed S4LPN did not administer Resident #R4's Budesonide-Fumoterol Fumarate. There were 27 medication administration opportunities for error, with 6 observed errors for a medication administration error rate of 22%. In an interview on 12/27/2024 at 11:27 AM, S4LPN indicated she administered Resident #R4 an Albuterol inhaler today and had not administered the Budesonide-Formoterol inhaler today as ordered. S4LPN further indicated she had not assessed Resident #R4 for wheezing nor had Resident #R4 requested the as needed Albuterol inhaler prior to administration. In an interview on 12/30/2024 at 11:46 AM, S2Director of Nursing (DON) indicated medications should be administered within one hour prior to or one hour after the physician ordered medication time, and it was not for neither Resident #R3 nor Resident #R4. In an interview on 12/30/2024 at 11:47 AM, S1Administrator confirmed Resident #R3 and Resident #R4's medications were not administered as per the physician's orders. In an interview on 12/30/2024 at 12:43 AM, S4LPN indicated she had residents on two halls and was not sure which medication were scheduled for 8:00 AM and which medications were scheduled for 9:00 AM. S4LPN further indicated she was late with medication administration for Resident #R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's abuse policy to protect residents from potential neglect (S3LPN and S4LPN). Findings: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Funds Program, last revised in 01/2024, revealed, in part, all incidents or suspected incidents of neglect or mistreatment will be investigated immediately as directed by the Administration and/or the Director of Nursing. Further review revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further review revealed the facility's staff would immediately correct and intervene in reported or identified situations in which neglect is at risk for occurring. Further review revealed all allegations involving staff will necessitate immediate suspension without pay, pending completion of the investigation. Further reviewed revealed the administrator will take actions necessary to ensure that abuse, neglect or mistreatment does not continue. Review of the facility's Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards and the facility's policies and procedures. Review also revealed the nurse's responsibility was to routinely make rounds to observe and evaluate residents' physical and emotional status. Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to elopement risk, and census checks to be conducted on Resident #1 every two hours. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, S4LPN was assigned to the care of the residents in Room Assignment u from the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's time sheet report dated 08/28/2024 revealed, in part, S4LPN clocked in at 8:41 a.m., clocked out at 4:26 p.m., clocked in at 4:56 p.m., and clocked out at 9:55 p.m. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 time sheet reports, revealed, in part, S3LPN clocked in at 11:30 p.m. on 08/28/2024 and clocked out at 7:15 a.m. on 08/29/2024. Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m. Further review revealed S4LPN went into Resident #1's room on 8/29/2024 at 5:29 p.m. Further review revealed S3LPN went into Resident #1's room on 08/29/2024 at approximately 12:03-12:04 a.m. Further review revealed S3LPN went into Resident #1's room [ROOM NUMBER] times on 08/29/2024 between 6:04 a.m. and 6:34 a.m. Further review revealed no other evidence that S3LPN and or S4LPN went into Resident #1's room at any other part of their assigned shifts. Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4LPN was seen entering Resident #1's room on 08/28/2024 at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed S3LPN looked into Resident #1's room on 08/29/2024 at 12:04 a.m. and 6:15 a.m. Further review revealed S3LPN only entered Resident #1's room at 6:04 a.m., 6:14 a.m., and 6:35 a.m. on 08/29/2024. The facility was unable to provide any evidence S3LPN and/or S4LPN rounded (performed a visual inspection of Resident #1) on Resident #1 every 2 hours as per the physician's orders on 08/28/2024 and 08/29/2024. Observation on 08/30/3034 at 9:50 a.m., revealed S4LPN was working in the facility. In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift on 08/28/2024 through 08/29/2024. S3LPN further indicated had she looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), the oncoming nurse, and/ or Certified Nursing Assistant (CNA) she was working with. In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him all night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notifying administration she was not able to locate him. In an interview on 08/30/2024 at 2:43 p.m., S1Administrator indicated that S3LPN worked last night on 8/29/2024 and was scheduled to work tonight on 08/30/2024. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours per the physician's orders. S1Administrator further indicated when she watched the facility's surveillance footage, she was preoccupied with seeing what time Resident #1 eloped, and had not noticed how often the staff monitored him. In an interview on 09/05/2024 at 3:18 p.m., S1Administrator indicated during the investigation, the facility's focus was on finding Resident #1. S1Administrator further indicated as soon as she would have identified the issues of the nurses not rounding on and/or locating Resident #1 during their shifts, she would have immediately suspended them, but because the focus was so much on finding Resident #1, their suspension was an oversite.

Based on record reviews and interviews, the facility failed to: 1. Maintain a system to periodically reconcile controlled drugs for 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances; and 2. Administer a resident's medication per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: 1. Review of the facility's undated Storage of Medications Policy and Procedure revealed, in part, controlled medications must be counted at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty determine the count together. Review of the facility's 2024 Floor Nurse Job Description/Responsibility revealed, in part, a narcotic (controlled substance) count must be performed at ongoing and off going of the shift, and the nurse must sign in the appropriate spot on the Controlled Drugs-Count Record. Review of the facility's August 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: -08/09/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/09/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/12/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/30/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/31/2024 on the 7:00 a.m. to 3:00 p.m. shift; and -08/31/2024 on the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's August 2024 Medication Cart b Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: -08/09/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/09/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/14/2024 on the 7:00 a.m. to 3:00 p.m. shift; -08/14/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/15/2024 on the 7:00 a.m. to 3:00 p.m. shift; -08/15/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/16/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/17/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/18/2024 on the 7:00 a.m. to 3:00 p.m. shift; -08/30/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/31/2024 on the 7:00 a.m. to 3:00 p.m. shift; and, -08/31/2024 on the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's August 2024 Medication Cart c Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: -08/01/2024 on the 7:00 a.m. to 3:00 p.m. shift; -08/10/2024 on the 7:00 a.m. to 3:00 p.m. shift; -08/14/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/16/2024 on the 11:00 p .m. to 7:00 a.m. shift; and, -08/17/2024 on the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's August 2024 Medication Cart d Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: -08/05/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/05/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/12/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/12/2024 on the 11:00 p.m. to 7:00 a.m. shift; -08/19/2024 on the 3:00 p.m. to 11:00 p.m. shift; -08/19/2024 on the 11:00 p.m. to 7:00 a.m. shift; and, -08/26/2024 on the 11:00 p.m. to 7:00 a.m. shift. In an interview on 09/04/2024 at 1:51 p.m., S9Licensed Practical Nurse (LPN) indicated nurses were required to reconcile controlled substances with the off-going nurse at the beginning of their shift and reconcile control substances with the on-coming nurse at the end of their shift. S9LPN confirmed she has had occurrences where the assigned nurse she was relieving left the facility without reconciling controlled substances with her as required. In an interview on 09/05/2024 at 9:55 a.m., S2Director of Nursing (DON) indicated whenever there was a change in nurses from shift to shift, the off-going nurse was supposed to verify the controlled substance count with the oncoming nurse. S2DON indicated the narcotic count sheet should be filled out in its entirety to ensure the reconciliation of controlled drugs was completed as required. 2. Review of the facility's undated Floor Nurse Job Description revealed, in part, the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards, and the facility's policies and procedures. Review of Resident #1's August 2024 physician's orders revealed, in part, orders to administer Resident #1 Atorvastatin Calcium (a medication used to manage cholesterol) 10 mg tablet daily at bedtime, Quetiapine Fumarate (a medication used to treat depression) 25 mg tablet daily at bedtime, Mirtazapine Tartrate (a medication used to treat depression) 15 mg tablet daily. Review of Resident #1's August 2024 electronic Medication Administration Record revealed, in part, S4LPN documented she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:00 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:00 p.m. on 08/28/2024, and one Quetiapine Fumarate 25 mg tablet at 8:00 p.m. on 08/28/2024. Review of the facility's Medication Administration Audit Report from 08/27/2024 to 08/28/2024 for Resident #1 revealed, in part, S4LPN documented that she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:23 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:23 p.m. on 08/28/2024, one Quetiapine Fumarate 25 mg tablet at 8:23 p.m. on 08/28/2024. Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed S4LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed no other evidence S4LPN entered Resident #1's room at any other time during her shift. The facility was unable to produce any evidence that S4LPN administered Resident #1's medications as documented above. In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time.

Based on record reviews and interview, the facility failed to ensure a certified nurse aide's (CNA) criminal background check was completed for 1 (S6CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs' personnel files reviewed. Findings: Review of Louisiana Revised Statue 40:1203.2 revealed prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual, the employer shall request that a criminal history and security check be conducted on the non-licensed person. Review of S6CNA's personnel file revealed S6CNA had a date of hire of 12/30/2021. Further review revealed no documented evidence, and the facility presented no documented evidence, S6CNA had a criminal background check completed prior to hire or thereafter. Review of the facility's time sheets and room assignments revealed S6CNA provided care to the following rooms on the following dates and times: -11:53 p.m. on 08/22/2024 through 7:00 a.m. on 08/23/2024 for Room Assignment aa; -11:37 p.m. on 08/23/2024 through 7:02 a.m. on 08/24/2024 for Room Assignment bb; -11:46 p.m. on 08/24/2024 through 7:00 a.m. on 08/25/2024 for Room Assignment bb; -11:49 p.m. on 08/25/2024 through 6:59 a.m. on 08/26/2024 for Room Assignment bb; -on 08/28/2024 S6CNA had a clock-out time of 7:00 a.m. with no documented clock-in time record with Room Assignment cc; -11:41 p.m. on 08/28/2024 through 7:11 a.m. on 08/29/2024 for Room Assignment dd; and, -11:01 p.m. on 08/29/2024 through 7:02 a.m. on 08/30/2024 for Room Assignment dd. In an interview on 09/04/2024 at 12:24 p.m., S34Human Resources Director indicated the facility did not have any documented evidence S6CNA had a criminal background check completed as required. In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated the facility had no further information to present, and did not have a criminal background check completed as required for S6CNA.

Based on record reviews and interview the facility failed to ensure certified nursing assistants (CNAs) were provided Quality Assurance and Performance Improvement (QAPI) training for 4 (S6CNA, S31CNA, S32CNA, and S33CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs reviewed for training requirements as required. Findings: Review of S6CNA's Personnel File revealed S6CNA had a date of hire of 12/30/2021. Further review of S6CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S6CNA had received QAPI training as required. Review of S31CNA's Personnel File revealed S31CNA had a date of hire of 04/11/2024. Further review of S31CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S31CNA had received QAPI training as required. Review of S32CNA's Personnel File revealed S32CNA had a date of hire of 06/20/2024. Further review of S32CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S32CNA had received QAPI training as required. Review of S33CNA's Personnel File revealed S33CNA had a date of hire of 08/15/2024. Further review of S33CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S33CNA had received QAPI training as required. In an interview on 09/04/2024 at 12:24 p.m., S34Human Resources Director indicated the facility did not have documented evidence of QAPI training for the above mentioned employees. In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated she had no additional documentation to present regarding the above mentioned deficient practice. In an interview on 09/05/2024 at 4:39 p.m., S2Director of Nursing (DON) indicated the facility did not have evidence of the above mentioned employees had QAPI training as required.

Based on record review and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) received ethics training for 1 (S6CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs' personnel files reviewed for training requirements. Findings: Review of S6CNA's personnel file revealed S6CNA had a date of hire of 12/30/2021. Further review revealed no documented evidence, and the facility presented no documented evidence S6CNA had received ethics training. In an interview on 09/04/2024 at 12:24 p.m., S34Human Resources Director indicated the facility did not have any documented evidence S6CNA had received ethics training as required. In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated the facility had no additional documentation to present regarding the above mentioned deficient practice.

Based on record reviews and interviews, the facility failed to: 1. Ensure the facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024, 08/14/2024, and 08/21/2024); and, 2. Ensure a nurse assigned to a group of residents did not leave the facility before the scheduled oncoming nurse arrived at the facility to assume the responsibility of the group of residents (08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024). This deficient practice was identified for 13 (08/08/2024, 08/13/2024, 08/14/2024, 08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024) of 30 (08/01/2024, 08/02/2024, 08/03/2024, 08/04/2024, 08/05/2024, 08/06/2024, 08/07/2024, 08/08/2024, 08/09/2024, 08/10/2024, 08/11/2024, 08/12/2024, 08/13/2024, 08/14/2024, 08/15/2024, 08/16/2024, 08/17/2024, 08/18/2024, 08/19/2024, 08/20/2024, 08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024) days reviewed for sufficient staffing. Findings: Review of the facility's Facility Assessment Tool completed on 07/24/2023 revealed, in part, the facility's average daily census was 90-120. Review of the facility's Major RUG-IV Categories (a Centers for Medicare and Medicaid classification system used to determine payment based on the average resources needed to care for someone with similar needs) revealed a number/average of 10 residents for Rehabilitation services, a number/average of 2 residents for Extensive Services, a number/average of 2 residents for Special Care High services, a number/average of 3 residents for Special Care Low services, a number/average of 17 residents for Clinically Complex services, a number/average of 5 residents for Behavioral Symptoms and Cognitive Performance services, and a number/average of 23 residents for Reduced Physical Function services. Further review revealed the facility's staffing plan was to have 2 to 4 licensed nurses providing direct care during the day shift (7:00 a.m. to 3:00 p.m.), 2 to 4 licensed nurses providing direct care during the evening shift (3:00 p.m. to 11:00 p.m.) and 2 to 3 licensed nurses providing direct care during the night shift (11:00 p.m. to 7:00 a.m.). Review of the facility's Census and Conditions of Residents dated 09/05/2024 revealed, in part, the facility had a total of 98 residents. Further review revealed 2 residents had an indwelling or external catheter, 90 residents were occasionally or frequently incontinent of bladder, and 77 residents were occasionally or frequently incontinent of bowel. Review revealed 71 residents were in a chair all or most of the time and 5 residents ambulated with assistance or assistive devices. Review revealed 31 residents had a psychiatric diagnosis, 19 residents had dementia, and 11 residents had behavioral healthcare needs. Further review revealed 2 residents had pressure ulcers, 5 residents received hospice care, 4 residents received dialysis treatments, 1 resident required the administration of intravenous (into the vein) medication, 10 residents required respiratory treatments, and 2 residents required ostomy (a surgical opening in the abdomen that changed the way waste exited the body) care. Further review revealed 21 residents required medication injections, 3 residents required tube feedings, and 33 residents required rehabilitative services. Review of the facility's 2024 Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed it was unacceptable to clock out of the facility and leave their assigned residents without changeover of care. Review also revealed a proper shift report must be given to the nurse that would hold responsibility for the assigned residents until the next oncoming nurse arrived. 1. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/08/2024 the facility's census was documented as 108 residents. Review of the facility's 08/08/2024 time sheet reports revealed, in part, from 7:00 a.m. until 7:05 a.m., S3Licensed Practical Nurse (LPN) was the only documented nurse assigned to direct resident care present in the facility. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/13/2024 the facility's census was documented as 112 residents. Review of the facility's 08/13/2024 time sheet reports revealed, in part, from 7:00 a.m. until 7:07 a.m., S3LPN was the only documented nurse assigned to direct resident care present in the facility. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/14/2024 the facility's census was documented as 113 residents. Review of the facility's 08/14/2024 time sheet reports revealed, in part, from 7:03 a.m. until 7:10 a.m., S3LPN was the only documented nurse assigned to direct resident care present in the facility. Further review revealed from 7:10 a.m. until 7:18 a.m., there was no documented nurse assigned to direct resident care present in the facility. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/21/2024 the facility's census was 109 residents. Review of the facility's 08/21/2024 time sheet reports revealed, in part, from 11:31 p.m. until 12:00 a.m. on 08/22/2024, S14LPN was the only documented nurse assigned to direct resident care present in the facility. There was no documented evidence, and the facility did not present any documented evidence that sufficient direct care nursing staff was provided to residents during the above mentioned time periods. In a telephone interview on 09/01/2024 at 3:11 p.m., S14LPN indicated it was not safe for her to have 50 to 60 or more residents assigned to her. In an interview on 09/04/2024 at 11:52 a.m., S20Assistant Director of Nursing (ADON) indicated that when she arrived to the facility on the morning shifts, she did not accept the responsibility of residents' direct care. S20ADON further indicated that more than 1 direct care nurse was needed for 109 to 110 residents. S20ADON confirmed she assigned 3 direct care nurses for a night shift with 109 to 110 residents. In an interview on 09/04/2024 at 12:04 p.m., S29Agency LPN indicated that the facility had a problem with nurses arriving to their assigned shift late or leaving their assigned shift early. 2. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment w for the 7:00 a.m. to 3:00 p.m. shift and S10LPN was the nurse assigned to the residents in Room Assignment w for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:17 p.m. and S10LPN did not clock in at the facility until 3:30 p.m., leaving the residents in Room Assignment w without an assigned nurse for 13 minutes. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S11LPN and S12LPN were the nurses assigned to the residents in Room Assignment z for the 3:00 p.m. to 11:00 p.m. shift and S13LPN was the nurse assigned to the residents in Room Assignment z for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 10:47 p.m. and S12LPN clocked out of the facility at 11:03 p.m. Further review revealed S13LPN did not clock into the facility until 12:00 a.m. on 08/22/2024, leaving the residents in Room Assignment z without an assigned nurse for 57 minutes. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment s for the 3:00 p.m. to 11:00 p.m. shift and S13LPN was the nurse assigned to the residents in Room Assignment s for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:30 p.m., and S13LPN did not clock into the facility until 12:00 a.m. on 08/22/2024, leaving the residents in Room Assignment s without an assigned nurse for 30 minutes. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment t on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment t on the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:30 p.m. Further review revealed no documented evidence S3LPN worked at the facility on 08/21/2024 from 11:00 p.m. to 7:00 a.m. on 08/22/2024. There was no documented evidence, and the facility was unable to present any documented evidence a nurse was assigned to the residents in Room Assignment t on 08/21/2024 from 11:30 p.m. until 7:00 a.m. on 08/22/2024. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment u for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:13 p.m. Further review revealed no documented evidence S3LPN worked at the facility on 08/21/2024 from 11:00 p.m. to 7:00 a.m. on 08/22/2024. There was no documented evidence, and the facility was unable to present any documented evidence a nurse was assigned to the residents in Room Assignment u on 08/21/2024 from 11:30 p.m. until 7:00 a.m. on 08/22/2024. In an interview on 09/04/2024 at 12:00 p.m., S20ADON confirmed there was no documented evidence S3LPN worked on 08/21/2024 as scheduled. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S13LPN was the nurse assigned to residents in Room Assignment i for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment i on the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S13LPN clocked out of the facility at 5:50 a.m. on 08/22/2024. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:16 a.m., leaving residents in Room Assignment i without an assigned nurse for 1 hour and 26 minutes. Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S13LPN was the nurse assigned to residents in Room Assignment ee for the 11:00 p.m. until 7:00 a.m. shift. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment ee on the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/21/2024 time sheet reports revealed, in part, S13LPN clocked out of the facility at 5:50 a.m. on 08/22/2024. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:03 a.m., leaving the residents in Room Assignment ee without an assigned nurse for 1 hour and 13 minutes. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to residents in Room Assignment o for the 7:00 a.m. to 3:00 p.m. shift and S10LPN was the nurse assigned to residents in Room Assignment o for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:04 p.m. and S10LPN did not clock into the facility until 3:09 p.m., leaving the residents in Room Assignment o without a nurse for 5 minutes. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment l on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the assigned nurse to the residents in Room Assignment l on the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 10:58 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/23/2024, leaving the residents in Room Assignment l without an assigned nurse for 1 hour and 2 minutes. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the assigned nurse to the residents in Room Assignment m on the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:21 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/23/2024, leaving the residents in Room Assignment m without an assigned nurse for 2 hours and 39 minutes. Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment ff for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment ff for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/22/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:12 a.m. on 08/23/2024. Review of the facility's 08/23/2024 time sheet reports revealed, in part, S11LPN did not clock into the facility until 7:49 a.m., leaving the residents in Room Assignment ff without an assigned nurse for 37 minutes. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift, and S16LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/23/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 3:03 p.m. and S16LPN did not clock into the facility until 3:42 p.m., leaving the residents in Room Assignment g without an assigned nurse for 39 minutes. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment l for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/23/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:00 p.m. and S3LPN did not clock into the facility until 12:15 a.m. on 08/24/2024, leaving the residents in Room Assignment l without an assigned nurse for 1 hour and 15 minutes. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/23/2024 time sheets revealed, in part, S4LPN clocked out of the facility at 9:11 p.m. and S3LPN did not clock into the facility until 12:15 a.m. on 08/24/2024, leaving the residents in Room Assignment m without an assigned nurse for 3 hour and 4 minutes. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/23/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:55 a.m. on 08/24/2024. Review of the facility's 08/24/2024 time sheet reports revealed, in part, S11LPN clocked into the facility at 7:05 a.m., leaving the residents in Room Assignment f without an assigned nurse for 10 minutes. Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S17LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/23/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:55 a.m. on 08/24/2024. Review of the facility's 08/24/2024 time sheet reports revealed, in part, S17LPN clocked into the facility at 7:15 a.m., leaving the residents in Room Assignment g without an assigned nurse for 20 minutes. Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment n for the 7:00 a.m. to 3:00 p.m. shift and S22LPN was the nurse assigned to the residents in rooms Room Assignment n for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/24/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 2:56 p.m. and S22LPN did not clock into the facility until 3:43 p.m., leaving the residents in Room Assignment n without an assigned nurse for 47 minutes. Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S17LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift and S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/25/2024 time sheet reports revealed, in part, S17LPN clocked out of the facility at 10:09 p.m. and S14LPN did not clock into the facility until 10:45 p.m., leaving the residents in Room Assignment g without an assigned nurse for 36 minutes. Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S15LPN was nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/25/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:45 a.m. on 08/26/2024. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:11 a.m., leaving the residents in rooms Assignment f without an assigned nurse for 26 minutes. Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/25/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:45 a.m. on 08/26/2024. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:30 a.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 45 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. and S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:09 p.m. and S14LPN did not clock into the facility until 10:46 p.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 37 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S26Minimum Data Set Licensed Practical Nurse (MDSLPN) was the nurse assigned to the residents in Room Assignment l for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S26MDSLPN clocked out of the facility at 11:15 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/27/2024, leaving the residents in Room Assignment l without an assigned nurse for 45 minutes. Review of the facility's Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S15LPN clocked out of the facility at 11:23 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/27/2024, leaving the residents in Room Assignment m without an assigned nurse for 37 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:48 a.m. on 08/27/2024. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:03 a.m., leaving the residents in Room Assignment f without an assigned nurse for 15 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:48 a.m. on 08/27/2024. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:19 a.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 31 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility 08/27/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment l for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:11 a.m. on 08/27/2024. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:15 a.m., leaving the residents in Room Assignment l without an assigned nurse for 4 minutes. Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S24LPN was the nurse assigned to the residents in Room Assignment m for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/26/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:11 a.m. on 08/27/2024. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S24LPN did not clock into the facility until 7:18 a.m., leaving the residents in Room Assignment m without an assigned nurse for 7 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift and S16LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S25LPN clocked out of the facility at 3:18 p.m. and S16LPN did not clock into the facility until 3:52 p.m., leaving the residents in Room Assignment g without an assigned nurse for 34 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment o for the 7:00 a.m. to 3:00 p.m. shift and S27LPN was the nurse assigned to the residents in Room Assignment o for the 3:00 p.m. to 11:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:47 p.m. and S27LPN did not clock into the facility until 5:01 p.m., leaving the residents in Room Assignment o without an assigned nurse for 1 hour and 14 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 8:07 p.m. and S3LPN did not clock into the facility until 11:30 p.m., leaving the residents in Room Assignment m without an assigned nurse for 3 hours and 23 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment p for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment p for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:09 a.m., leaving the residents in Room Assignment p without an assigned nurse for 3 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment q for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment q for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:25 a.m., leaving the residents in Room Assignment q without an assigned nurse for 1 hour and 19 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment p for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment p for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:09 a.m., leaving the residents in Room Assignment p without an assigned nurse for 3 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment q for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment q for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:25 a.m., leaving the residents in Room Assignment q without an assigned nurse for 1 hour and 19 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment t for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment t for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:15 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:20 a.m., leaving the residents in Room Assignment t without an assigned nurse for 5 minutes. Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift. Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S24LPN was the nurse assigned to the residents in Room Assignment u for the 7:00 a.m. to 3:00 p.m. shift. Review of the facility's 08/27/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:15 a.m. on 08/28/2024. Review of the facility's 08/28/2024 time sheet reports revealed, in part, S24LPN did not clock into the facility until 7:21 a.m., leaving the residents in Room Assignment u without an assigned

Based on record review and interview, the facility failed to ensure the Facility Assessment Tool: 1. Was reviewed and updated as necessary annually; 2. Addressed contracts; 3. Had involvement from the certified nursing assistants (CNAs); and 4. Used input from residents and residents' representatives. Findings: 1. Review of the Facility Assessment Tool revealed the facility assessment date or update date was documented as 07/24/2023. In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not reviewed or updated the Facility Assessment since 07/24/2023. 2. Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, of facility contracts required for resident care. In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not included information about contract services as part of the facility assessment. 3. Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, the facility had involvement from the certified nursing assistants for the development of the facility assessment. In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not involved the certified nursing assistants in the development of the Facility Assessment. 4. Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, the facility had used input from residents and residents' representatives for the development of the facility assessment. In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not included input from the residents and/or residents' representatives for the development of the facility assessment.

Based on record reviews and interviews the facility failed to ensure its Quality Assessment and Assurance Committee met at least quarterly to evaluate the activities under the Quality Assurance and Performance Improvement (QAPI) program. Findings: Review of the facility's Quality Assurance Committee sign in sheets revealed the only Quality Assurance Committee meetings documented were on 11/14/2023 and 06/28/2024. Further review revealed no documented evidence, and the facility presented no documented evidence, a Quality Assurance Committee meeting was held between 11/14/2023 and 06/28/2024 to meet the requirement of quarterly meetings. In an interview on 09/05/2024 at 10:25 a.m., S1Administrator indicated the facility had no documented evidence a Quality Assurance Committee meeting had been held between 11/14/2023 and 06/28/2024. In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated she had no additional documentation to present regarding the above mentioned deficient practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a resident did not sustain an injury when staff placed a rolling bedside table in front of a resident to prevent a fall. This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accidents. Findings: Reviewed Facility's Incident/Accident Log revealed, in part, Resident #1 experienced an unwitnessed fall with head injury on 07/14/2024. Record review revealed, in part, Resident #1's was admitted to the facility on [DATE] with a history of falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2024 revealed, in part, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 04 which indicated her cognition was severely impaired. Further review revealed she was not ambulatory, sustained previous falls with injury, used a wheelchair, and required moderate assistance by staff with transfers. Review of facility's Incident/Accident Log dated 07/14/2024 revealed, in part, Resident #1 experienced a fall. Review of the facility's Fall Risk assessment dated [DATE] revealed, in part, Resident #1 had one and up to two falls in the past three months, was chair bound, and was identified as being at high risk for falls. In a telephone interview on 07/30/2024 at 10:19 a.m., S3Certified Nursing Assistant (CNA) indicated on 07/14/2024, she placed Resident #1 in her wheelchair and then positioned her rolling bedside table in front of her to prevent her from falling forward and injuring herself. S3CNA further indicated she discovered Resident #1 slumped over the rolling bedside table, did not see any injury to Resident #1, and Resident #1 did not complain of any pain. Review of the facility's CNA Communication Log dated 07/14/2024 revealed, in part, S3CNA discovered Resident #1 was face down on the bedside table. In an interview on 07/29/2024 at 2:42 p.m., S9CNA indicated shortly after 7:20 a.m. on 07/14/2024, she entered Resident #1's room and wheeled Resident #1 to the dining area for breakfast. S9CNA further indicated Resident #1's hand covered her face and did not see any bruising or injury to Resident #1's face. In a telephone interview on 07/30/2024 at 9:37 a.m., S7Licensed Practical Nurse (LPN) indicated she was working Monday on 07/14/2024, and S2CNA, S4CNA, and S8Woundcare Treatment Nurse wheeled Resident #1 from the dining room to be assessed for bruising. S9LPN further indicated Resident #1 had bruising noted to the left side of the mouth and left shoulder with blood noted to the upper oral cavity (space). Review of Resident #1's Hospital Emergency Department Report dated 07/14/2024 revealed, in part, Resident #1 was examined and diagnosed with bruising to left side of lip and jaw and an abrasion of the upper oral cavity. In an interview on 07/30/2024 at 8:30 a.m., S1Administrator indicated Resident #1's facial bruising was a linear bruise with a curved edge that resembled the curve of a bedside table. S1Administrator further indicated a bedside table should not be used as a fall precaution intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to obtain a final disposition for a fugitive charge that appeared on a Certified Nursing Assistant's (CNA) criminal background check. This deficient practice was identified for 1 (S2CNA) of 5 (S2CNA, S3CNA, S4CNA, S5CNA, and S6CNA) personnel records reviewed for personnel requirements. Findings: Review of S2CNA's Personnel Record revealed a hire date of 07/07/2023. Review of S2CNA's criminal background check dated 06/30/2023 revealed, in part, the following: 10/17/2016 CCRP 575 Fugitive (Louisiana Code of Criminal Procedure Article 575); 1 charge and 1 count. Review of Louisiana State Government Legislature Law website revealed, in part, CCRP 575 Art. 575. Interruption of time limitations. The periods of limitation established by this Chapter shall be interrupted when the defendant: (1) For the purpose of avoiding detection, apprehension or prosecution, [NAME] from the state, is outside the state, or is absent from his usual place of abode within the state; or (2) Lacks mental capacity to proceed at trial and is committed in accordance with Article 648 of this Code. Further review revealed no final disposition for the above mentioned charge. There was no documented evidence and the facility did not present any documented evidence that a final disposition was obtained upon hire to determine if S2CNA's fugitive status involved a conviction which barred employment. In an interview on 07/30/2024 at 3:02 p.m., S1Administrator indicated she did not have documented evidence of a final disposition for S2CNA's charge of CCRP 575 Fugitive and did not know if the charge barred employment.

Based on record review and interview, the facility failed to ensure an injury of unknown origin was reported to the state survey agency no later than 2 hours after it was discovered for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's incident documentation dated 04/11/2024 at 3:01 p.m., revealed, in part, sustained a fracture of unknown origin. Further review revealed, the type of incident was bruising/swelling. Review of Resident #2's MDS(Minimum Data Sheet) with an ARD (Assessment Reference Date) of 04/03/2024, revealed in part, Resident #2 had a BIMS (brief interview mental status) score of 03 indicating she had severe cognitive impairment. Review of Resident #2's care plan revealed Resident #2 had a history of falls and was identified as being at high risk for falls related to poor safety awareness Review of the facility's report to the state agency revealed, in part, Resident #2 had a major injury of unknown origin that was discovered on 04/11/2024 at 3:00 p.m. Further review revealed the incident was not reported to the state until 04/13/2024 at 10:02 a.m. In an interview on 04/15/2024 at 12:02 p.m., S1Administrator indicated she did not report Resident #2's fracture to the state within two hours of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with identified mental health diagnosis were referred for a preadmission screening and resident review (PASARR) Level II evaluation as required for 2 (Resident #47 and Resident #54) of 4 (Resident #42, Resident #47, Resident #54, and Resident #58) sampled residents reviewed for PASARR. Findings: Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 was readmitted to the facility on [DATE] with a diagnosis of Bipolar (a mental disorder). Review of Resident #47's Level I PASARR evaluation prior to admission revealed, in part, Resident #47 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review. Review of Resident #47's pre-admission Level II PASARR revealed documentation of no mental illness, a categorical determination of Primary Dementia, and level II is not required. Resident #54 Review of Resident #54's medical record revealed, in part, Resident #54 was readmitted to the facility on [DATE] with a diagnosis of Unspecified Mood (affective disorder). Review of Resident #54's Level 1 PASARR evaluation prior to admission revealed, in part, Resident #54 was not diagnosed with a mental illness, therefore, no psychiatric disability diagnoses were selected to review. Review of Resident #54's active diagnoses list revealed, in part, a diagnosis of Bipolar with onset date of 04/03/2023. Further review revealed no documented evidence and the facility did not present any documented evidence that a Level II PASARR was completed for Resident #54. In an interview on 02/01/2024 at 12:20 p.m., S12Admissions Coordinator stated she was responsible for obtaining PASARRs. S12Admissions Coordinator further stated she reviews the PASARRs for accuracy and to obtain corrections as applicable. S12Admissions Coordinator further stated when a resident is diagnosed with a new mental disorder, the nurse is responsible for notifying the physician to obtain a new PASSAR. In an interview on 02/01/2024 at 2:38 p.m., S1Administrator stated the facility did not have a policy for PASARRs. S1Administrator acknowledged the Level I and Level II PASARRs for Resident #47 were inaccurate, and needed to be resubmitted. When asked what is done if a resident develops a mental disorder or an intellectual disability during their stay after admit, S1Administrator stated she did not know what needed to be done. S1Administrator further stated she did not realize a Level II PASARR needed to be resubmitted for Resident #54 with a new diagnosis of Bipolar Disorder.

Based on record reviews and interviews, the facility failed to: Maintain ongoing communication regarding a resident's condition prior to leaving the facility for dialysis treatments for 1 (Resident #21) of 1 (Resident #21) sampled residents investigated for dialysis services. Findings: Review of the facility's Care of a Resident with End-Stage Renal Disease Policy and Procedure revealed, in part, agreements between the facility and the dialysis facility must include all aspects of how the resident's care will be managed, including how information will be exchanged between the facility and the dialysis facility. Review of Resident #21's Dialysis Care Plan revealed, in part, an intervention for Resident #21 to attend dialysis on Monday, Wednesday and Friday's as per the physician's order. Review of Resident #21's January 2024 Physician's Order's revealed, in part, an order for Resident #21 to attend dialysis on Mondays, Wednesdays and Fridays. Review of Resident #21 dialysis communication binder revealed the communication forms were not completed prior to Resident #21 leaving for the dialysis on Monday, Wednesday and Friday for the months of October 2023, November, 2023, December 2023 and January 2024. In an interview on 02/01/2024 at 2:45p.m., S13Licensed Practical Nurse stated the facility used a dialysis communication form to communicate back and forth with dialysis regarding a dialysis resident's condition. S13LPN acknowledged she did not complete the dialysis communication. Review of the dialysis communication binder revealed no documented evidence and the facility was unable to provide any documented evidence of communication between the facility and the dialysis facility regarding Resident #21's condition before leaving the facility for dialysis on Monday, Wednesdays and Fridays. In an interview on 02/01/2024 at 4:00 p.m., S1Administrator and S2Director of Nursing (DON) stated communication with dialysis centers should have been completed by use of the dialysis communication forms. S2DON further stated the dialysis communication form should have been completed and signed by the nurse before Resident #21 exited the facility for dialysis.

Based on interviews and observations, the facility failed to ensure food was palatable to residents in temperature. This deficient practice had the potential to affect any of the 101 residents who receive food from the facility's kitchen. Findings: Review of Resident #1's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. In an interview on 01/30/2024 at 1:28 p.m., Resident #1 stated the food was often cold and that she would like to have a hot meal. On 01/31/2024 at 12:13 p.m., the last resident food tray on Food Cart F was tasted by 6 surveyors. The food tray contained meatloaf, gravy, loaded mashed potatoes, and mixed vegetables. All six surveyors agreed the food was lukewarm to room temperature. In an interview on 01/31/2024 at 12:23 p.m., S5Dietary Manager stated she had a couple complaints about breakfast being cold and she gave those residents another tray. In an interview on 02/01/2024 at 12:45 p.m., Resident #1 stated her lunch today was lukewarm at best and she would have preferred her food to be hotter. Resident #1 further stated her breakfast was cold and she would have preferred to have a hot breakfast. On 02/01/2024 at 12:14 p.m., the last resident food tray on Food Cart F was tasted by 4 surveyors and all 4 surveyors agreed the food was lukewarm to room temperature. The food tray contained pulled pork, a hamburger bun, and pork and beans. In an interview on 02/01/2024 at 12:18 p.m., S5Dietary Manager stated the resident food trays were placed correctly on Food Cart F today and she did not know why the food was not warm.

Based on record reviews and interviews, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified on hire and/or every 6 months for 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) of 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) personnel records reviewed. Findings: Review of S3CNA Supervisor's personnel record revealed a hire date of 05/23/2013. Further review revealed the last CNA Registry verification was completed on 01/25/2014. Review of S6CNA's personnel record revealed a hire date of 11/01/2021. Further revealed the last CNA Registry verification was last completed on 01/22/2019. Review of S7CNA's personnel record revealed a hire date of 12/09/2019. Further review revealed the last CNA Registry verification was last completed on 12/05/2019. Review of S8CNA's personnel record revealed a hire date of 08/10/2021. Further review revealed no documented evidence the CNA Registry was verified on hire or until 01/30/2024. Review of S9CNA's personnel record revealed a hire date of 04/06/2023. Further review revealed the last CNA Registry verification was completed on 04/03/2023. In an interview on 01/31/2024 at 11:44 a.m., S11Human Resources stated she was unaware the CNA Registry was supposed to be verified every 6 months. S11Human Resources confirmed the facility did not have proof the above mentioned CNAs had a current CNA certification. In an interview on 01/31/2024 at 2:25 p.m., S1Administrator confirmed the CNA Registry verifications should have been conducted to ensure CNA certifications were valid and current.

Based on observations, interviews and record reviews the facility failed to ensure dishwasher temperature gauges were maintained in proper working order and maintain the ice machine and water dispenser in a sanitary manner. Findings: Review of the manufacturer's dishwasher operational sign revealed, in part, the dishwasher temperatures should be at a minimum of 120 degrees Fahrenheit. Observation on 01/31/2024 at 9:30 a.m., during kitchen tour, revealed the facility's dishwasher temperature gauge did not go above 115 degrees Fahrenheit after 4 attempts of restarting the dish cycle by S5Dietary Manager. In an interview on 01/31/2024 at 9:32 a.m., S5Dietary Manager acknowledged the dishwasher temperature should be at a minimum 120 degrees Fahrenheit or above to properly clean dishes. S5Dietary Manager acknowledged after 4 attempts at temperature checks, the dishwasher temperature gauge did not get above the minimum 120 degrees Fahrenheit. In an interview on 01/31/2024 at 10:41 a.m., S4Maintenance Supervisor acknowledged the temperature gauge on the facility's dishwasher was not working properly. In an interview on 01/31/2024 at 1:57 p.m., Contracted Dishwasher Company Service Representative stated the temperature valve on the facility's dishwasher was not functioning properly. Observation on 01/30/2024 at 12:06 p.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser. Observation on 01/31/2024 at 11:33 a.m. revealed S10Certified Nursing Assistant (CNA) filled an ice pitcher with ice from Ice Machine A and water from the water dispenser on Hall X. In an interview on 01/31/2024 at 11:34 a.m. S10CNA confirmed Ice Machine A and the water dispenser on Hall X was utilized to fill residents' ice pitchers. Observation on 01/31/2024 at 11:35 a.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser. Observation on 02/01/2024 at 10:12 a.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had dried a brown substance and a dried white substance on the front of the dispenser. Observation on 02/01/2024 at 1:19 p.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser. In an interview on 02/01/2024 at 1:20 p.m., S2Director of Nursing confirmed Ice Machine A and the water dispenser on Hall X were unsanitary and needed to be cleaned.

Based on record reviews and interviews, the facility failed to ensure a resident had a comprehensive care plan that addressed her sexual health care needs for 1 (Resident #1) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) residents reviewed in the sample for care planning. Findings: Review of Resident #1's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 11/07/2023 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) of 14, which indicated her cognition was intact. Review of Resident #1's care plan with a target date of 02/16/2024 revealed, in part, Resident #1 did not have a care plan to address her sexual activity and sexual healthcare needs. In an interview on 12/07/2023 at 1:45 p.m., S3Certified Nursing Assistant (CNA) stated she was aware of Resident #1's sexual activity with a male resident who lived across the hall from her. S3CNA stated she reported the sexual activity to the nurse. In an interview on 12/07/2023 at 2:50 p.m., S2Licensed Practical Nurse (LPN) stated she was aware of Resident #1's sexual activity on two separate occasions with two different male residents (Resident #3 and Resident #5). S2LPN stated she confirmed with Resident #1 she had sexual intercourse with him. S2LPN stated she reported the sexual activity to the nurse supervisor. S2LPN confirmed the administrative staff was aware of Resident #1's sexual activity. In an interview on 12/07/2023 at 3:20 p.m., Resident #1 stated she was sexually active with other male residents in the facility. Resident #1 stated the administrative nurses and staff were aware of her sexual activity and she had many conversations with the staff about maintaining privacy. In an interview on 12/07/2023 at 4:30 p.m., S4Corporate MDS (Minimum Data Set) Nurse stated she did not implement a care plan to address sexual health for Resident #1 because she was not aware Resident #1 was sexually active. S4Corporate MDS nurse stated Resident #1's care plan should have addressed her sexual health care needs. In an interview on 12/07/2023 at 4:46 p.m., S1Administrator stated the facility had not confirmed Resident #1 was having sex with other male residents in the facility because no sexual acts were observed by the staff. S1Administrator stated she was not aware nursing employees were knowledgeable about Resident #1's sexual activity. S1Administrator confirmed Resident #1 did not have a care plan to address her sexual health needs and should have.

Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA's) had completed annual competencies as required for 3 (S11CNA, S12CNA, S10CNA)of 3 CNAs reviewed for annual competencies Findings: Review of S11CNA's personnel file revealed, in part, no documented annual competency since hired 7/7/2017. Review of S12CNA's personnel file revealed, in part, no documented annual competency since hired 07/29/2014. Review of S10CNA's personnel file revealed, in part, no documented annual competency since hired 04/01/1996. In an interview on 01/13/2023 at 10:30 a.m., S1Administrator confirmed the Certified Nursing Assistants did not have annual competencies completed since hired and all direct care staff should have had up to date annual competencies completed prior to performing direct care to residents. In an interview on 01/13/2023 at 10:36 a.m., S13CNA Supervisor stated she has not completed annual competencies for the certified nursing assistants because she did not know competencies had to be completed annually. The facility was unable to provide any documented evidence of annual competencies completed annually since the above mentioned dates.

Based on observation and interview, the facility failed to have the nurse staffing information posted on a daily basis. Findings: Observation on 01/10/2023 at 09:46 a.m. revealed no daily nursing staffing hours were posted in the facility. Observation on 01/11/2023 at 10:02 a.m. revealed no daily nursing staffing hours were posted in the facility. Observation on 01/12/2023 at 10:16 a.m. revealed no daily nursing staffing hours were posted in the facility. In an interview on 01/12/2023 at 6:40 p.m., S1Administrator confirmed daily nursing staffing hours were not posted and they should have been posted. In an interview on 01/13/2023 at 8:40 a.m. S18Unit Clerk confirmed she had not posted daily staffing hours on 01/10/2023, 01/11/2023, and 01/12/2023 and she should have posted daily nursing staffing hours.

Based on interviews and record review, the facility failed to ensure that physician orders were entered correctly into facility's records for 1 (Resident #373) of 26 sampled residents. Findings: Review of Resident #373's Physician's orders dated December 2022 and January 2023 revealed, in part, Osmolite 1.5 at 75 milliliters (mls)/hour (hr) with 40ml/hr free water flush 6 p.m. -6 a.m. as tolerated. Review of Resident #373's December 2022 and January 2023 Medication Administration Record (MAR) revealed, in part, no documentation of Osmolite 1.5 at 75mls/hr with 40ml/hr free water flush 6 p.m. - 6 a.m. Review of Resident #373's dietary note dated 01/12/2023 revealed, in part, meal intake had been poor and recommendation was to continue present tube feeding as tolerated. In an interview on 1/11/2023 at 9:20 a.m., S6 Licensed Practical Nurse (LPN) stated Resident #373 received continuous feedings at night. Observation on 01/12/2023 at 6:02 p.m., revealed Resident #373 lying in bed with no tube feeding in progress. Observation on 01/12/2023 at 7:00 p.m., revealed Resident #373 lying in bed asleep, alone in room, and no tube feeding in progress. In an interview on 01/13/2023 at 10:45 a.m., S2Director of Nursing (DON) stated tube feedings should be documented on the MAR when administered per physician order. S2DON further stated the 6 p.m. - 6 a.m. feeding was not on the MAR. In an interview on 01/13/2023 at 11:30 a.m., S1Administrator confirmed all tube feedings should be documented in the MAR when administered.

Based on record review, observations, and interviews, the facility failed to maintain accurate reconciliation records of controlled medication for 2 (D1Medication Cart and D2Medication Cart) of 3 medication carts observed. This deficient practice had the potential to affect any of the 70 residents who resided in the facility as documented on the facility's Resident Census and Condition of Residents Form CMS-672. Findings: Review of the facility's Controlled Substances Policy revealed, in part, controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. In an interview on 1/12/2023 at 10:35 a.m., S7Licensed Practical Nurse (LPN) stated she administered controlled medication for 2 residents and did not sign the controlled medication log. In an interview on 1/12/2023 at 11:30 a.m., S6LPN stated there was no documentation of a controlled count signature record for D2Medication Cart. In an interview on 1/12/2023 at 11:50 a.m., S2Director of Nursing (DON) stated the policy for controlled substance count was the oncoming and off going shift count the controlled substances together then sign the controlled count record in the front of the narcotic binder. In an interview on 01/12/2023 at 3:35 p.m., S2DON confirmed the controlled drug count record for November 2022, December 2022, and January 2023 was not signed by both nurses at shift change. In an interview on 01/13/2023 at 11:30 a.m., S1Administrator stated on coming and off going nurses should both sign the controlled drug count record once count was completed at shift change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure: 1.) Medication and treatment carts were locked when unattended for 2 (D1Medication Cart and D2Medication Cart) of 3 medication carts and 1 (D3Treatment Cart) of 2 treatment carts observed 2.) Medications were labeled properly for 2 (D1Medication Cart and D2Medication Cart) of 3 medication carts, 1 (D3Treatment Cart) of 2 treatment carts observed, 3.) Expired medications were not available for administration to residents for 1 (Medication Room A) of 1 medication storage rooms observed; and 4.) Expired medications were not available for administration to residents for 2 (D1Medication Cart and D2Medication Cart) of 2 medication carts and 1 (D3Treatment Cart) of 1 treatment cart observed. This deficient practice had the potential to affect any of the 70 residents who resided in the facility as documented on the facility's Resident Census and Condition of Residents Form CMS-672. Findings: Review of the facility's Storage of Medication policy revealed, in part, compartments containing drugs and biologicals are locked when not in use. Further review of the Storage of Medication policy revealed, in part, controlled medications are stored in separately locked, permanently affixed compartments, and access to controlled medication was separate from access to non-controlled medications. Review of the facility's Storage of Medication policy revealed, in part, outdated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's Labeling of Medication Containers revealed, in part, labels for individual resident medications included all necessary information, such as: the resident's name; name, strength, and quantity of the drug; and directions for use. Observation on 01/11/2023 at 12:15 p.m., revealed D2Medication Cart sitting near room [ROOM NUMBER], S6Licensed Practical Nurse (LPN) left out of room [ROOM NUMBER] then went down the hall, returned to medication cart at 12:20 p.m. and locked the medication cart. Observation on 01/11/2023 at 12:25 p.m. revealed the D3Treatment Cart sitting near room [ROOM NUMBER] unlocked and unattended with two small silver keys hanging from the cart lock. Observation on 01/12/2023 at 8:43 a.m., revealed the D2Medication Cart sitting near room [ROOM NUMBER] unlocked and unattended. Observation on 01/12/2023 at 9:45 a.m., revealed D3Treatment Cart contained the following expired items: 1. Optifoam heel non adhesive wound dressings 2 expired on 10/2021 and 3 expired on 11/2021, 2. Povidone-iodine (antiseptic) swab sticks 1 pack expired on 03/2020, and 3. Aquaphor ointment (moisturizer) 1 container expired on 11/2022. Observation on 01/12/2023 at 9:45 a.m., revealed D3Treatment Cart contained the following items with no open date: 1. Dakin's solution (a liquid medication that contains to bleach used to clean a wound) 16 ounce bottle, 2. Hydrogel amorphous (wound dressing) 3 ounce tube, 3. Isodosorb gel (antimicrobial gel), 4. Therahoney gel (wound gel), 5. Venelex wound dressing ointment, and 6. Santyl (a medication used to remove dead tissue from a wound) ointment. In an interview on 01/12/2023 at 09:50 a.m., S3ADON stated she is responsible for checking for expired items on the treatment cart. Observation on 01/12/2023 at 10:00 a.m., revealed the Medication Room A contained the following expired medication: 1. 1 Gvoke PFS (medication used for low blood sugar) 1mg per 0.2ml pre-filled syringe expired on 11/2022, and 2. Latanoprost (used for glaucoma) ophthalmic solution 0.005% expired on 11/2022. In an interview on 01/12/2023 at 10:00 a.m., S3ADON stated the charge nurse checks the medication storage room to complete temperature logs and checks expiration dates. Observation on 01/12/2023 at 10: 20 a.m., revealed the D1Medication Cart contained the following medications with no open date: 1. Vitamin D3 (vitamin) 50 microgram bottle, 2. Simethicone (used for gas relief) 180 milligram bottle, 3. Clear Moisture Barrier Antifungal ointment (skin protectant), 4. Zinc Oxide ointment (skin protectant), 5. Calcium with Vitamin D (vitamin supplement) 500 mg, 6. Reguloid (fiber supplement), and 8. Albuterol Sulfate Inhalation Aerosol Inhaler (medication used for bronchospasms) has no label. Observation on 01/12/2023 at 10:28 a.m., revealed S7LPN Nurse left cart unlocked and unattended with keys on the cart. Observation on 01/12/2023 at 10:49 a.m., revealed the DON's office unlocked and unattended. Observation on 01/12/2023 at 11:20 a.m., revealed the D2Medication Cart contained the following medications with no open date on the bottle: 1. Aspirin (medication used for pain and fever) 81mg bottle, 2. Zinc (vitamin) 50mg bottle, 3. Magnesium oxide (vitamin) 400mg bottle, 4. Polyethylene glycol 3350 powder for oral solution (laxative), 5. Robafen Congestion relief (medication used for congestion) 200mg bottle, 6. Acetaminophen (pain reliever) 500mg tablet bottle, and 7. Magnesium Oxide (vitamin) 400mg tablet bottle. Observation on 1/12/2023 at 11:20 a.m., revealed the D2Medication Cart contained the following expired medications: Acetaminophen (pain reliever) 160mg/5ml oral suspension expired 09/2022. Observation on 1/12/2023 at 11:48 a.m., revealed S2DON's office door was unlocked and unattended. Observation on 01/12/2023 at 11:57 a.m., revealed S2DON's office unlocked and unattended. Observation on 01/12/2023 at 6:52 p.m., revealed S2DON's office door unlocked. In an interview on 01/13/2023 at 11:30 a.m., revealed S2DON confirmed her office door is not locked when she leaves the office, and controlled medications are stored in the filing cabinet. In an interview on 01/13/2023 at 11:30 a.m., S1Administrator verified all controlled drugs stored in medication carts and the DON's office should be double locked when unattended and all medication carts should be locked when unattended. S1Administrator also stated expired medications should be removed from medication carts, treatment carts, and medication storage areas.

Based on record review, observation, and interview the facility failed to ensure staff: 1) performed hand hygiene prior to providing meal assistance for 8 (Resident #4, Resident #15, Resident #18, Resident #45, Random Resident #1, Random Resident #2, Random Resident #3, Random Resident #4) of 70 residents who required meal assistance; 2) performed hand hygiene and/or wore personal protective equipment prior to administration of medications for one (Resident #3) of 14 residents who received medications on the 200 hall. Findings: Review of the facility's policy on Handwashing/Hand Hygiene revised on August 2019 revealed, in part, the facility considers hand hygiene the primary means to prevent the spread of infections: 7.) Use of alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: b.) before and after direct contact with residents; c.) before preparing or handling medications; p.) before and after assisting a resident with meals. Observation on 01/11/2023 at 09:15 a.m., S5LPN (Licensed Practical Nurse) prepared Resident #3's medications and placed a total of 10 tablets in Resident #3's medication cup. S5LPN acknowledged Resident #3's blood pressure was low and Resident #3's antihypertensive medications should not be administered. Further observation revealed S5LPN did not perform hand hygiene after contact with the medication cart and used her ungloved finger to remove the Lisinopril tablet and Norvasc tablet from the medication cup which contained 8 other tablets. S5LPN administered the 8 remaining tablets in the medication cup to Resident #3. Observation on 01/11/2023 at 12:25 p.m., revealed, in part, S11CNA was in the dining room sitting between Resident #45 and Resident #4 assisting both residents with their meal. S11CNA touched Resident #45's tray, utensil, and cup and then touched Resident #4's tray, cup, and straw without performing hand hygiene. Further observation revealed, in part, S11CNA touched Resident #45's wheelchair and then touched Resident #4's meal tray and cup. S11CNA was observed touching her own chair to reposition closer to Resident #4 and then touched Resident #4's straw while assisting Resident #4 to drink from her cup. Further observation revealed, in part, Resident #4 grabbed both of S11CNA's hands and S11CNA then touched Resident #45's tray and spoon without performing hand hygiene. Observation on 01/12/2023 at 8:43 a.m., revealed, in part, S12CNA did not perform hand hygiene between meal assistance for Random Resident #1 and Random Resident #2. Further observation revealed, in part, S12CNA touched Random Resident #2's skin while applying a protective garment and then proceeded to feed both Random Resident #1 and Random Resident #2 without performing hand hygiene. Observation on 01/12/2023 at 12:18 p.m., revealed, in part, S11CNA touched Resident #18's straw and then touched Resident #15's spoon and tray without performing hand hygiene. Observation on 01/13/2023 at 12:31 p.m., revealed, in part, S15CNA touched Random Resident #3's wheelchair, stood up from the table and pulled up her own pants, touched her own mask, and then fed Random Resident #3 without performing hand hygiene. Observation on 01/13/2023 at 12:33 p.m., revealed, in part, S16CNA fed Resident #18 and Random Resident #4 and touched both residents' trays and utensils without performing hand hygiene between tasks. In an interview on 01/13/2023 at 1:50 p.m., S11CNA was asked why she did not perform hand hygiene between residents when providing meal assistance. S11CNA explained she did not know she should get up from the table to wash her hands between each resident. S11CNA acknowledged the facility provided hand sanitizer in the past to keep in her pocket but she was not given any sanitizer recently and she did not ask for more. In an interview on 01/13/2023 at 10:00 a.m., S1Administrator acknowledged hand hygiene should be performed before and after providing meal assistance to each residents. In an interview on 01/13/2023 at 10:00 a.m., S5LPN acknowledged during medication administration on 01/11/2023 she did not perform hand hygiene after touching the medication cart and then used her ungloved finger to remove the Lisinopril and Norvasc tablets from Resident #3's medication cup. S5LPN acknowledged she should not have removed the two tablets with her ungloved finger prior to administering Resident #3 her medications. In an interview on 01/13/2023 at 11:29 a.m., S2DON (Director of Nursing) acknowledged S5LPN should have performed hand hygiene and not used her unwashed and ungloved finger to remove two tablets from the medication cup prior to administering Resident #3 her medications.