**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 2 (#4 and #66) of 25 residents reviewed in the initial screening for advanced directives. Review of the facility’s undated policy titled, “LaPOST”, revealed the following, in part:Procedure6. Place the original LaPOST form in a prominent and appropriate place in the medical record. Do not document code status in the electronic record. Resident #4Review of Resident #4’s clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's current Physician Orders revealed the following, in part:Order date: [DATE]-Full Code Status. Review of Resident #4's hard, physical chart revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) dated [DATE]. The LaPOST revealed Resident #4’s Health Care Representative checked DNR/Do Not Attempt Resuscitation. Resident #66 Review of Resident #66’s clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #66’s electronic medical record revealed a LaPOST dated [DATE]. The LaPOST revealed Resident #66’s Health Care Representative checked CPR/Attempt Resuscitation. Further review of Resident #66’s electronic medical record revealed no other LaPOST documents. Review of Resident #66’s hard, physical chart revealed a LaPOST dated [DATE]. The LaPOST revealed Resident #66 checked DNR/Do Not Attempt Resuscitation. On [DATE] at 12:58 p.m., an interview was conducted with S6LPN. She stated she was assigned to Resident’s #66 and #4. She stated Resident #66 was a full code but recently changed to a DNR. She stated the facility’s process was to look directly in the resident's hard, physical chart for code status and not in the resident’s electronic medical record. On [DATE] at 1:05 p.m., an interview was conducted with S2DON. She stated the facility’s process for checking a resident’s code status was to look directly in the resident’s hard, physical chart. She stated she went through all residents’ charts and deleted the code status orders to eliminate confusion. She was made aware of the findings above. She stated she did not realize LaPOST forms were scanned into some of the resident’s residents’ charts. She confirmed if a resident’s code status was found in two different places, the code statuses should match.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, video observation, and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 (#4) of 24 sampled residents reviewed for abuse. The facility failed to ensure Resident #4 was free from physical abuse by Resident #50.Review of the facility's policy dated 2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Each resident has the right to be free from abuse.Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities.Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired.Review of Resident #4's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S9RN wrote, Resident #4 wheeled himself into nurse's station and stated to S9RN, Resident #50 just punched me in my face. S9RN asked Resident #4 why the other Resident #50 would have punched him in the face, and he stated, I don't know. I was just down there sitting next to her and she told me to go away and I didn't, and she punched me. Once S9RN completed assessment of Resident #4, S9RN, entered day room, where incident occurred, to ask Resident #50 if she had in fact hit resident. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified.Review of Resident #4's current Care Plan revealed in part, the following:On 07/13/2025, Resident #4 reported Resident #50 hit him in the face because he sat next to her and did not move when she asked him to.Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression and Anxiety.Review of Resident #50's Annual MDS with an ARD of 06/20/2025 revealed a BIMS of 10, which indicated she was moderately cognitively impaired.Review of Resident #50's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S13LPN wrote, Resident #4 stated Resident #50 punched him in the face. S13LPN completed assessment of Resident #4, entered day room, where incident occurred, and asked Resident #50 if she hit Resident #4. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified. On 07/29/2025 at 8:05 a.m., review of the facility's incident log dated July 2025 revealed in part, the following:Physical Aggression Received Incidents:07/13/2025 at 2:00 p.m.-Resident #4Physical Aggression Initiated Incidents:07/13/2025 at 2:00 p.m. - Resident #50On 07/29/2025 at 8:05 a.m., review of the facility's incident report dated 07/13/2025 revealed in part, the following:Incident Location: Activity RoomPerson Preparing Report: S9RNIncident Description:Resident #4 wheeled himself into the nurse's station and stated to S9RN, Resident #50 just punched me in my face. S9RN asked Resident #4 why Resident #50 punched him in the face, and he stated he didn't know. Resident #4 stated he was sitting down next to Resident #50, she told him to go away and he didn't, and then she punched him.Immediate Action Taken:S9RN immediately assessed Resident #4. After assessing Resident #4 S9RN entered the day room, where the incident occurred. S9RN asked Resident #50 if she hit Resident #4 and she responded, Yeah, I sure did. But I didn't hit him hard. S9RN notified S10WS of the incident. S1ADM was then notified by S10WS. Review of Resident #50's current Care Plan revealed on 07/13/2025, Resident #50 became angry and hit another resident when he did not do what she asked him to do and said something inappropriate to her. Resident #50 has the potential to be physically aggressive, related to poor impulse control.An interview was conducted on 07/29/2025 at 9:20 a.m. with Resident #50. She was alert and oriented to person, place, time, and situation. Resident #50 stated around 2 weeks ago, she punched Resident #4 in the face with a closed fist in the activity room. She stated Resident #4 came to her table and began speaking to her in a sexually inappropriate manner. Resident #50 stated she told Resident #4 multiple times to leave her alone and he did not. She stated she then punched Resident #4 in the face with a closed fist. Resident #50 stated she meant to punch him and would do it again if he bothers me. She stated after the incident, S1ADM asked her what happened. Resident #50 stated she told S1ADM that she punched Resident #4 in the face when he spoke to her in a sexually inappropriate manner in the activity room.An interview was conducted on 07/29/2025 at 9:30 a.m. with Resident #4. He was alert and oriented to person, place, time, and situation. He stated around 2 weeks ago, Resident #50 punched him in the face with a closed fist in the activity room. He stated it hurt a little. He stated after the incident, S1ADM asked him what happened. He stated he told S1ADM Resident #50 punched him in the face when he was trying to talk to her in the activity room.An interview and video camera footage observation was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. Review of the video camera footage with S1ADM dated 07/13/2025 at 1:49 p.m. revealed Resident #4 and Resident #50 can be seen at a table together in the activity room. Resident #50 hit Resident #4 in the head with her hand. Resident #50 then placed her head in her hands while looking down at the table.An interview was conducted on 07/29/2025 at 2:15 p.m. with S2DON. She stated she was aware of the incident on 07/13/2025 between Resident #4 and Resident #50 and stated it was not willful abuse.An interview was conducted on 07/29/2025 at 3:03 p.m. with S9RN. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, Resident #4 told her Resident #50 punched me in the face. She stated Resident #50 told her Yes I sure did hit him, but I didn't hit him hard. I'll do it again if I have to. She stated Resident #50 told her she was not sorry for hitting Resident #4. She stated she immediately notified S10WS, who then notified S1ADM. She stated Resident #50 punching Resident #4 was physical abuse.An interview was conducted on 07/30/2025 at 11:57 a.m. with S10WS. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, S9RN notified her Resident #50 punched Resident #4 in the face. She stated this was not abuse because Resident #50 is a b***h. She stated she immediately notified S1ADM of the incident.An interview was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. He stated he was notified on 07/13/2025 by S10WS that Resident #4 was punched in the face by Resident #50 in the activity room. He stated he did not believe this incident was abuse because it was not willful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure allegations of physical abuse were reported to the State Agency in the required timeframe for 1 (#4) of 24 sampled residents reviewed for abuse.Review of the facility's policy dated 02/2025 and titled, Policy for Prohibition of Abuse revealed in part, the following:Reporting:1. Report incidents to the state agency as required.Internal Reporting Timelines:Abuse: Immediately.Resident #4Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Depression, and Mild Intellectual Disabilities.Review of Resident #4's Quarterly MDS with an ARD of 06/05/2025 revealed a BIMS of 11, which indicated he was moderately cognitively impaired.Review of Resident #4's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S9RN wrote, Resident #4 wheeled himself into nurse's station and stated to S9RN, Resident #50 just punched me in my face. Once S9RN completed assessment of Resident #4, S9RN, entered day room, where incident occurred, to ask Resident #50 if she had in fact hit resident. Resident #50 responded Yeah, I sure did. But I didn't hit him hard. Notified S10WS of incident. S1ADM was then notified.Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Depression and Anxiety.Review of Resident #50's Annual MDS with an ARD of 06/20/2025 revealed a BIMS of 10, which indicated she was moderately cognitively impaired.Review of Resident #50's July 2025 Progress Notes revealed in part, the following:On 07/13/2025 S13LPN wrote, Resident #4 stated Resident #50 punched him in the face. Notified S10WS of incident. S1ADM was then notified. On 07/29/2025 at 8:05 a.m., review of the facility's incident log dated July 2025 revealed in part, the following:Physical Aggression Received Incidents:07/13/2025 at 2:00 p.m.-Resident #4Physical Aggression Initiated Incidents:07/13/2025 at 2:00 p.m. - Resident #50On 07/29/2025 at 8:05 a.m., review of the facility's incident report dated 07/13/2025 revealed in part, the following:Incident Location: Activity RoomPerson Preparing Report: S9RNIncident Description:Resident #4 stated he was sitting down next to Resident #50, she told him to go away and he didn't, and then she punched him.Immediate Action Taken:S9RN notified S10WS of the incident. S1ADM was then notified by S10WS. An interview was conducted on 07/29/2025 at 9:20 a.m. with Resident #50. She was alert and oriented to person, place, time, and situation. Resident #50 stated around 2 weeks ago, she punched Resident #4 in the face with a closed fist in the activity room. She stated after the incident, S1ADM asked her what happened. Resident #50 stated she told S1ADM that she punched Resident #4 in the face when he spoke to her in a sexually inappropriate manner in the activity room.An interview was conducted on 07/29/2025 at 9:30 a.m. with Resident #4. He was alert and oriented to person, place, time, and situation. He stated around 2 weeks ago, Resident #50 punched him in the face with a closed fist in the activity room. He stated after the incident, S1ADM asked him what happened. He stated he told S1ADM Resident #50 punched him in the face when he was trying to talk to her in the activity room.An interview was conducted on 07/29/2025 at 3:03 p.m. with S9RN. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, Resident #4 told her Resident #50 punched me in the face. She stated she immediately notified S10WS, who then notified S1ADM. She stated Resident #50 punching Resident #4 was physical abuse.An interview was conducted on 07/30/2025 at 11:57 a.m. with S10WS. She stated Resident #4 and Resident #50 are alert, oriented, and able to make their needs known. She stated on 07/13/2025, S9RN notified her Resident #50 punched Resident #4 in the face. She stated she immediately notified S1ADM of the incident.An interview was conducted on 07/29/2025 at 11:00 a.m. with S1ADM. He stated he was notified on 07/13/2025 by S10WS that Resident #4 was punched in the face by Resident #50 in the activity room. He stated he did not believe this incident was abuse because it was not willful therefore it was not reported to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#2) of 3 (#2, #9, and #47) residents reviewed for PASRR.Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder. Further review revealed he was diagnosed with Adjustment Disorder on 10/26/2019 and Schizophrenia on 12/23/2019. Review of Resident #2's Level 1 PASRR dated 09/24/2019 revealed Section III: Mental Illness, did not have Adjustment Disorder or Schizophrenia selected as a diagnosis. On 07/30/2025 at 9:30 a.m., an interview was conducted with S7SSD. She stated she was responsible for resubmitting resident review forms to the Office of Behavioral Health (OBH) if a new mental health diagnosis was acquired. She reviewed Resident #2's Level 1 PASSR dated 09/24/2019 and confirmed a mental diagnosis of Major Depressive Disorder was checked. She reviewed Resident #2's current diagnoses list and confirmed he received a diagnosis of Adjustment Disorder on 10/26/2019 and Schizophrenia on 12/23/2019. She confirmed a resident review form should have been resubmitted to OBH for Level II evaluation after the new mental health diagnoses and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure a resident's oxygen was administered at the physician ordered rate for 1 of 1 (#10) residents reviewed for respiratory care.Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Senile Degeneration of the Brain.Review of Resident #10's current Physician Orders revealed the following, in part:Start date 05/12/2025 - Oxygen at 3L per nasal cannula continuous every shift.An observation was made on 07/28/2025 at 12:02 p.m. of Resident #10 in her room wearing oxygen per nasal cannula at 2.5L.An observation was made on 07/29/2025 at 9:00 a.m. of Resident #10 in her wearing oxygen per nasal cannula at 2.5L.An interview was conducted on 07/29/2025 at 9:02 a.m. with S8LPN. S8LPN confirmed Resident #10 had an order for oxygen per nasal cannula continuous at 3L. S8LPN confirmed Resident #10's oxygen was set at 2.5L and should have been at 3L.An interview was conducted on 07/29/2025 at 9:13 a.m. with S3ADON. She confirmed all residents' oxygen should be administered at the ordered rate.An interview was conducted on 07/30/2025 at 10:10 a.m. with S2DON. She confirmed all residents' oxygen should be administered at the ordered rate.

Based on observations and interviews, the facility failed to store and prepare food under sanitary conditions by failing to ensure the food was properly stored and labeled in the facility's kitchen. This deficient practice had the potential to affect all of the 69 facility residents who were served from the facility's kitchen. Review of facility's undated policy titled, How to Store Under Sanitary Conditions revealed in part:1. For dry storage-All items must be in a container with a lid or in a labeled zip lock bag. All items must be labeled with what it is, the date it was opened and the initial of the person who placed it in there. On 07/28/2025 at 8:27 a.m., an observation was made of the kitchen food preparation area with S5CK. The observation revealed and S5CK confirmed the following items were found to be open and undated.1 - 20 ounce package of whole wheat sliced bread; and1 - 24 ounce package of dinner rolls.On 07/28/2025 at 8:32 a.m., an observation was made of the dry storage area with S5CK. The observation revealed and S5CK confirmed the following items were found to be open and undated.1 - 26 ounce package of instant mashed potatoes;1 - 5 pound package of macaroni noodles; and1 - 5 pound package of instant sliced potatoes. On 07/28/2025 at 8:45 a.m., an observation was made of the walk in cooler with S5CK. The observation revealed and S5CK confirmed the following items were open and undated. 1 - 2 quart pitcher of red punch and 1 - 5 pound container of chicken salad. On 07/28/2025 at 10:10 a.m., an interview was conducted with S4FSD. S4SFD stated she was responsible for the staff and the meals prepared in the facility's kitchen/dietary department. S4SFD observed the above observations. S4SFD confirmed all items should be labelled with the open date once opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 4 (#3, #6, #19, and #32) of 19 sampled residents reviewed for accurate documentation. The facility failed to ensure the following: 1. Resident #3's medication administration and wound care treatment administration were accurately documented; 2. Resident #6's Percutaneous Endoscopic Gastrostomy (PEG) site care was accurately documented; 3. Resident #19's medication administration and wound care treatment administration was accurately documented; and4. Resident #32's suprapubic catheter care was accurately documented. 1.Resident #3Review of Resident #3’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Diabetes Mellitus II (DM), Acquired Absence of Left Great Toe, Non-Pressure Chronic Ulcer of Right Ankle, Acquired Absence of Other Left Toe, Cerebral Infarction Due to Embolism of Cerebral Artery, Acquired Absence of Limb, and Chronic Osteomyelitis with Draining Sinus. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Resident 3’s current Physician Orders revealed the following wound care orders, in part: DM wound right lateral ankle, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic bandage dressing and secured with tape until resolved;DM wound to right 4th toe lateral, clean with wound cleanser, pat dry with 4x4, apply betadine, alginate between 4th and 5th toe, cover with pad, gauze wrap, elastic dressing and secure with tape until resolved;DM wound to right foot lateral, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic dressing and secured with tape until resolved; andDM wound to right heel, clean with wound cleanser, pat dry with 4x4, apply betadine, pad, gauze wrap, elastic dressing and secured with tape. Review of Resident #3’s Treatment Administration Records (TAR) dated July 2025 revealed the aforementioned wound care treatment orders were not initialed as completed from 07/04/2025 through 07/11/2025 at 16:00, 07/15/2025 through 07/25/2025 at 16:00, and 07/28/2025 at 16:00. Review of Resident #3’s Medication Administration Records (MAR) dated July 2025 revealed the following medications were not initialed as completed on the following dates/times, in part:Novolog flex pen subcutaneous solution pen injector 100 unit/milliliters (ML) inject as per sliding scale on 07/26/2025 at 16:00 and 20:00, 07/27/2025 at 16:00 and 20:00;Observe for signs and symptoms of abnormal bleeding/bruising on the 07/26/2025 and 07/27/2025 evening shift;Pain monitoring on 07/27/2025 evening shift;Protein oral liquid 30 ML by mouth (PO) Twice a Day (BID) on 07/27/2025 at 16:30;Sotalol hydrochloride oral tablet 80 milligram (MG) give 1 tablet PO BID on 07/26/2025 and 07/27/2025 at 20:00;Vitamin C oral tablet 500 mg PO BID on 07/27/2025 at 20:00;Novolog flex pen subcutaneous (SC) solution pen injector 100 unit/ml inject 4 unit SC BID on 07/27/2025 at 16:00.Pregabalin oral capsule 150 mg give 1 capsule PO every 12 hours on 07/27/2025 at 20:00;Apixaban oral tab 5 mg PO BID on 07/27/2025 at 20:00;Atorvastatin calcium oral tablet give 1 tablet PO at bedtime on 07/27/2025 at 20:00;Fenofibrate Oral Tablet 145 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00; andMiralax oral powder 17 gram/scoop give 1 scoop PO one time a day on 07/27/2025 at 20:00. On 07/28/2025 at 1:43 p.m., an interview was conducted with Resident #3. She stated the nurses had not missed any wound care treatments since her admission to the facility. On 07/30/2025 at 1:09 p.m., an interview was conducted via telephone with S12LPN. She confirmed she worked the evening shift from 3:00 p.m. to 11:00 p.m. on 07/26/2025 and 07/27/2025 and completed medication administration for all of Resident #3’s medications. She further confirmed if the box was blank on the MAR next a medication, then medication administration was not accurately documented and should have been. On 07/30/2025 at 2:20 p.m., an interview was conducted with S2DON. She stated she expected the wound care nurse to accurately document each resident’s wound care treatment administration on the TAR and medication administration on the MAR. After review of Resident #3’s TAR and MAR dated July 2025, and S2DON confirmed the aforementioned wound care treatments and medication administration dates/ times were not accurately documented and should have been. 2.Resident #6Review of Resident #6’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status and Mild Protein-calorie Malnutrition. Review of Resident #6’s current Physician Orders revealed the following, in part: PEG site: Clean with wound cleanser, pat dry, and cover with a drain sponge every day shift. Review of Resident #6’s TAR dated July 2025 revealed PEG site care was not documented as complete on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She stated she worked and performed Resident #6’s PEG site care on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. She confirmed if there was a blank box on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 2:17 p.m., an interview was conducted with S2DON. She stated S11LPN was responsible for Resident #6’s PEG site care and documentation on the aforementioned dates/times. S2DON reviewed Resident #6’s TAR dated July 2025 and confirmed incomplete documentation of PEG site care. S2DON further confirmed all PEG site care should be accurately documented upon completion. 3.Resident #19Review of Resident #19’s clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pain in Right Knee, Hypertensive Emergency, End Stage Renal Disease and DM. Review of Resident #19’s TAR dated July 2025 revealed the following wound care treatment orders were not initialed as completed, in part:Monitor surgical areas/sutures on right knee, cleanse and keep open to air every day shift for skin healing on 07/19/2025 and 07/20/2025. Review of Resident #19’s MAR dated July 2025 revealed the following medications were not initialed as completed on the following dates/ times, in part:Novolog flexpen subcutaneous solution pen injector 100 unit/ml inject as per sliding scale on 07/27/2025 at 1600 and 2000;Right upper arm midline to be checked every shift for increased redness, heat, signs of infiltration, or drainage on 07/27/2025 evening shift;Vitamin C oral tablet 500 mg give 1 tablet PO BID on 07/27/2025 at 20:00;Haloperidol oral tablet 1 mg give 1 tablet PO BID on 07/27/2025 at 20:00;Protein oral liquid give 30 ml PO BID on 07/27/2025 at 20:00;Carvedilol oral tablet 6.25mg give 1 tablet PO BID on 07/27/2025 at 20:00;Zinc sulfate oral capsule 220 mg give 1 capsule PO at bedtime on 07/27/2025 at 20:00;Normal Saline flush intravenous solution use 1 syringe intravenously in the evening to maintain midline patency on 07/27/2025 at 20:00;Ceftriaxone sodium injection solution reconstituted 1 gram use 1 gram intravenously at bedtime for anti-infective on 07/27/2025 at 20:00;Atorvastatin Calcium Oral Tablet 20 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00; andTizanidine hcl oral tablet 2 mg give 1 tablet PO at bedtime on 07/27/2025 at 20:00. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She confirmed she worked and performed Resident #19’s wound care on 07/19/2025 and 07/20/2025. S11LPN confirmed if the box was a blank on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 1:09 p.m., an interview was conducted with S12LPN. She confirmed she worked the evening shift from 3:00 p.m. to 11:00 p.m. on 07/26/2025 and 07/27/2025 and completed medication administration for all of Resident #19’s medications. She further confirmed if the box is blank on the MAR next to the medications, then medication administration was not accurately documented and should have been. On 07/30/2025 at 2:20 p.m., an interview was conducted with S2DON. She stated she expected the wound care nurse to accurately document each residents’ wound care treatment administration on the TAR and medication administration on the MAR. After review of Resident #19’s TAR and MAR dated July 2025, S2DON confirmed the aforementioned wound care treatments and medication administration dates/ times were not accurately documented and should have been. 4. Resident #32 Review of Resident #32's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute Kidney Failure and Neuromuscular Dysfunction of Bladder. Review of Resident #32’s current Physician Orders revealed the following, in part: Suprapubic Catheter: Clean with wound cleanser, pat dry, paint with betadine and cover with a drain sponge every day shift. Review of Resident #32’s TAR dated July 2025 revealed Suprapubic Catheter care treatment was not documented as complete on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. On 07/30/2025 at 12:40 p.m., an interview was conducted with S11LPN. She stated she worked and performed Resident #32’s suprapubic catheter care on 07/05/2025, 07/06/2025, 07/19/2025, and 07/20/2025. She confirmed if there was a blank box on the TAR for those dates, then treatment administration was not accurately documented. On 07/30/2025 at 2:17 p.m., an interview was conducted with S2DON. She stated S11LPN was responsible for Resident #32’s suprapubic catheter care and documentation on the aforementioned dates/times. S2DON reviewed Resident #6’s TAR dated July 2025 and confirmed incomplete documentation of suprapubic catheter care. S2DON further confirmed all suprapubic catheter care should be accurately documented upon completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #3 was coded correctly for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Age Related Osteoporosis and Unspecified Disorder of Adult Personality and Behavior. Further review revealed Resident #3 had a diagnosis of Displaced Intertrochanteric Fracture of Right Femur on 12/16/2024. Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed Section J1700: Fall History was blank. An interview was conducted on 01/29/2025 at 1:10 p.m. with S3RN. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #3's Incident Report dated 12/11/2024. She stated Resident #3 was admitted to the hospital and returned on 12/16/2024 with a diagnosis of Displaced Intertrochanteric Fracture of Right Femur. She reviewed Resident #3's Quarterly MDS with an ARD of 12/23/2024 and stated Section J1700 was not coded for falls. An interview was conducted on 01/29/2025 at 1:47 p.m. with S2DON. She reviewed the aforementioned findings and confirmed Resident #3's MDS assessment was not coded for falls and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of the facility's policy titled, Fall Policy and Procedure, and dated 01/10/2017, revealed in part, the following: 6. The fall care plan shall be updated after a fall and is to include any interventions. Treatment/Management: 1. Based on the assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to mitigate risks of serious injuries associated with falls. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Age Related Osteoporosis. Review of the facility's Incident Report dated 12/08/2024 revealed, in part the following: Resident #3 had an unwitnessed fall in the day room. Review of Resident #3's Nurse's Note dated 12/08/2024 revealed, in part, the following: Nurse was flagged down by another resident to the dayroom. She notified staff that resident had fallen. Resident was seen lying on her left side with her head on the floor. Resident unable to explain what happened and how she fell. Review of Resident #3's Care Plan revealed it was not revised to include interventions to address Resident #3's fall on 12/08/2024. An interview was conducted on 01/28/2025 at 1:10 p.m. with S3RN. S3RN stated she was responsible for updating Resident #3's Care Plan. S3RN reviewed Resident #3's Care Plan. S3RN stated after Resident #3's fall on 12/08/2024, the only intervention added to the care plan was to send Resident #3 to the local hospital for evaluation. An interview was conducted on 01/28/2025 at 1:47 p.m. with S2DON. S2DON stated S3RN was responsible for updating Resident #3's Care Plan. S2DON reviewed Resident #3's Care Plan. S2DON stated after Resident #3's fall on 12/08/2024, bright signs were placed throughout the resident's room to remind the resident to ask for assistance. S2DON stated the Care Plan should have been revised to reflect the intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure device site care orders were obtained for 1 (#56) of 3 (#25, #39, and #56) residents reviewed for indwelling devices. Findings: Review of the facility's policy dated 12/03/2009 titled Peripherally Inserted Central Catheter and Midline revealed the following, in part: Purpose: The purpose of this guideline is to provide information on the best practices related to preventing complications with peripherally inserted central catheter lines: routine care and dressing changes, medication infusion, maintaining patency. Routine care & dressing: 4. If peripherally inserted central catheter line dressing is not found to be torn, loose, damp, soiled, or raised, the insertion site dressing should be routinely changed every 7 days to decrease incidence of infection. This is a sterile dressing change task and should be done by a registered nurse. Review of Resident #56's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia, Severe Sepsis without Septic Shock, Bacteremia and Urinary Tract Infection. Review of Resident #56's Nurses Notes dated August 2024 revealed the resident had a midline catheter placed on 08/09/2024. Further review revealed no documentation of site monitoring or dressing changes to the midline catheter site. Review of Resident #56's Physician's Orders dated August 2024 revealed no orders for midline catheter dressing changes or site monitoring. Review of Resident #56's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August 2024 revealed no documentation site monitoring or dressing changes had been performed to the resident's Midline catheter. On 08/20/2024 at 12:55 p.m., an observation was made of Resident #56 midline catheter. The date on the dressing was illegible. On 08/20/2024 at 2:49 p.m., an observation was made with S2DON of Resident #56's midline catheter dressing. She stated the date labeled on the dressing was illegible. She confirmed facility policy was to perform site dressing change every seven days and the dressing was overdue to be changed. On 08/21/2024 at 10:10 a.m., an interview was conducted with S7LPN. She stated she worked on 08/09/2024 when Resident #56's midline catheter was placed. S7LPN confirmed she did not obtain an order to initiate the ongoing site monitoring or care of the midline catheter and should have. On 08/20/2024 at 2:49 p.m., an interview was conducted with S2DON. She reviewed Resident #56's Physician's Orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and Nurses' Notes and confirmed there was no documentation in the clinical record to show midline catheter care had been initiated to ensure ongoing site monitoring and site care. She stated it was the floor nurses responsibility to obtain and initiate orders to monitor the midline catheter site. She confirmed midline catheter care orders should have been obtained and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a resident's code status matched and was maintained throughout the clinical record for 1 (Resident #63) of 25 residents reviewed for code status in the initial screening. Findings: Review of Resident #63's medical record revealed he was admitted to the facility on [DATE]. Review of Resident #63's active physician orders revealed in part, an order dated [DATE] which read CPR (Cardiopulmonary Resuscitation) LaPOST. Review of Resident #63's hard chart revealed a DNR LaPOST dated [DATE]. On [DATE] at 2:38 p.m., an interview was conducted with S5LPN. He stated the protocol if a resident codes was for the nurse to use the call light and call the front desk to verify the resident's code status on the hard chart. S5LPN stated Resident #63's code status was DNR. On [DATE] at 2:48 p.m., an interview was conducted with S4SW. She stated she was responsible for updating code statuses in the electronic health record. S4SW reviewed Resident #63's code status in the electronic health record and confirmed it read CPR LaPOST. S4SW then reviewed Resident #63's LaPOST dated [DATE]. S4SW confirmed Resident #63's code status should have been updated to DNR and it was not. On [DATE] at 2:42 p.m., an interview was conducted with S2DON. She stated the protocol if a resident codes was for the nurse to use the call light and call the front desk to verify the resident's code status on the hard chart. She stated if the resident was in another location in the facility, the nurse could verify code status in the electronic health record. S2DON reviewed Resident #63's code status in the electronic health record and stated Resident #63's code status read CPR LaPOST. S2DON stated she would expect staff to do CPR. S2DON then reviewed Resident #63's LaPOST dated [DATE] and confirmed Resident #63's electronic health record code status did not match with DNR LaPOST and should have. S2DON confirmed Resident #63 should have been a DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#25) of 3 (#25, #56, and #270) resident's reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the Enhanced Barrier Precautions sign posted on Resident #25's door revealed the following: Gown required for direct, hands on care for this resident. Review of Resident #25's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Functional Quadriplegia and Gastrostomy Status. An observation was made on 08/19/2024 at 9:25 a.m. of S3LPN administering a bolus tube feeding to Resident #25. S3LPN did not have a gown on. An interview was conducted on 08/19/2024 at 9:26 a.m. with S3LPN. S3LPN stated she did not wear her gown when administering the bolus tube feeding to Resident #25 and should have. An interview was conducted on 08/21/2024 at 10:41 a.m. with S2DON. S2DON confirmed Resident #25 required EBP while providing bolus tube feedings, which consisted of gown and gloves. S2DON stated she expected all staff to wear the appropriate PPE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were properly labeled for 4 (#11, #43, #62, and #64) of 4 (#11, #43, #62, and #64) residents reviewed for oxygen therapy. Findings: Review of the facility's policy dated 12/09/2026 and titled, Changing of Oxygen Tubing, Humidifiers, and Nebulizer Tubing and Mask/Pipes revealed the following, in part: Nurses working the 11:00 p.m.-7:00 a.m. shift shall change the tubing, humidifier, and nebulizer sets every Sunday night for those residents who use the equipment continually. These items should be dated on day of exchange. Resident #11 Review of the clinical record for Resident #11 revealed she was admitted to the facility on [DATE] and had a diagnosis of Heart Failure. Review of the current Physicians Orders for Resident #11 revealed the following, in part: Start date: 06/03/2024 May use 2-4 liters via nasal cannula PRN for SOB. On 08/19/2024 at 8:55 a.m., an observation was made of Resident #11wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing indicating when changed. On 08/19/2024 at 9:25 a.m., an observation was made of Resident #11's oxygen tubing with S6RN. She confirmed the oxygen tubing was not labeled with the date last changed. She stated per facility policy, oxygen tubing was to be changed every Sunday by night shift nursing staff and dated when changed. Resident #43 Review of the clinical record for Resident #43 revealed he was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Review of the current Physicians Orders for Resident #43 revealed the following, in part: Start date: 06/03/2024 Oxygen at 2 liters per nasal cannula or mask PRN every shift for COPD. On 08/19/2024 at 8:55 a.m., an observation was made of Resident #43wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing or humidifier bottle indicating when changed. Resident #62 Review of the clinical record for Resident #62 revealed he was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the current Physicians Orders for Resident #62 revealed the following, in part: Start date: 06/03/2024 Oxygen at 4-5 L per minute as needed for SOB. On 08/19/2024 at 8:48 a.m., an observation was made of Resident #62 wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing or humidifier bottle indicating when changed. Resident #64 Review of the clinical record for Resident #64 revealed she was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Review of the current Physicians Orders for Resident #64 revealed the following, in part: Start date: 06/07/2024 Oxygen at 3 LPM continuous. Start date: 06/09/2024 Oxygen: NC/Mask and Humidifier change every Sunday night shift. On 08/19/2024 at 9:00 a.m., an observation was made of Resident #64 wearing oxygen via nasal cannula. There was no date observed on the oxygen tubing indicating when changed. On 08/19/2024 at 9:20 a.m., an observation was made of Resident #43, #62, and #64's oxygen tubing with S3LPN. She observed the above resident's oxygen tubing and humidifiers and confirmed they were not labeled with the date last changed. She stated all resident's oxygen tubing and humidifiers should be changed every Sunday on night shift and should be labeled with the date changed. On 08/20/2024 at 1:00 p.m., an interview was conducted with S2DON. She was made aware of the observations regarding the aforementioned resident's oxygen tubing and humidifiers. She stated the facility's policy was for the nurse working Sunday night to change and date oxygen tubing or humidifiers. She confirmed all oxygen tubing or humidifier bottles should be labeled with the date it was changed.

Based on observations, interviews, and policy review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure food and dietary supplements used for resident consumption was not expired. There were 35 facility residents who were provided dietary supplements from the facility's kitchen and nursing stations. Findings: Review of Facility's Policy dated October 2017 titled Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 14. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept at or below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurse's station and labeled with a use by date. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. An observation was made of Med Storage Room B and the nursing station's refrigerator on 08/19/2024 at 1:00 p.m. with S2DON, who confirmed the following: 4- 32 oz. No Sugar Added Vanilla supplements opened, with expiration dates 06/03/2024; 3- 32 oz. No Sugar Added Vanilla supplements, with expiration date 05/07/2024; and, 1- 8 oz. 1% milk with expiration date 08/14/2024. An interview was conducted with S2DON on 08/19/2024 at 1:15 p.m. S2DON confirmed the facility failed to store food and dietary supplements properly. S2DON confirmed she would expect all food products and supplements to be used by the expiration date and any opened supplements should have been discarded after 24 hours and were not. An observation was made of Med Cart C on 08/19/2024 at 1:20 p.m. with S3LPN, which revealed the following: 1-32 oz. No Sugar Added Vanilla supplement opened, with expiration date of 05/07/2024. An interview was conducted with S3LPN on 08/19/2024 at 1:22 p.m. S3LPN confirmed the above observation, and stated the expired supplement available for residents' consumption should have been discarded and was not. An interview was conducted with S1ADM on 08/20/2024 at 2:10 p.m. Observations conducted on 08/19/2024 of Med Cart C and Med Storage Room B and the nurse's station refrigerator were discussed. S1ADM confirmed food and dietary supplements available for resident consumption should be discarded prior to the expiration date or within 24 hours after the open date and were not.

Based on observations, interviews, and record reviews, the facility failed to ensure residents with hand contractures had an appropriate call light to notify staff for assistance for 1 (#2) of 2 (#2 and R2) residents reviewed with contractures. FINDINGS: A review of Resident #2's record revealed a re-admit date of 02/28/2023 and diagnoses which included Hemiplegia following Cerebral Infarct affecting the Right Dominant Side and Mild Bilateral Hand Contractures. A review of the Quarterly MDS with an ARD of 04/10/2024 revealed Resident #2 had a BIMS of 12 which indicated the Resident was moderately cognitively impaired. A review of Resident #2's Care Plan revealed Resident #2 had mild contractures to bilateral hands. A review of Resident #2's call light log revealed no call light usage from April 1, 2024 to May 1, 2024. On 05/01/2024 at 3:55 p.m., an interview and observation was conducted with Resident #2. The resident's hands were observed to be contracted bilaterally. The resident attempted to open and close his hands and was noted to have very little use of his right hand and no use of his left hand. A grey oval shaped squeeze bulb call light was observed on the bed by his side. He used his right hand and attempted to squeeze and press the call bulb. His fingers on the right hand were curled inwards towards his palm preventing him from fully wrapping his hand around the bulb to squeeze or press the call light. The resident was unable to activate the call light. He stated he can't use the call light because of his hands. On 05/01/2024 at 3:45 p.m., an interview was conducted with S7CNA. She said Resident #2 told her he couldn't squeeze or press the bulb call light because his hands were contracted. She said she notified the nurse, but couldn't remember who she notified because it was a while back. On 05/01/2024 at 4:10 p.m., an interview was conducted with S6LPN. She said it was hard for Resident #2 to squeeze or press his bulb call light because of his hands. She said she did not report this to anyone. On 05/02/2023 at 10:30 a.m., an observation was conducted of Resident #2 with S8CNA present. Resident #2 attempted to squeeze and press the bulb call light for staff assistance, but was unable to. Immediately following the observation, S8CNA was interviewed. She said Resident #2 could not squeeze or push the bulb call light with enough force to activate it because of his hands. She stated the resident had not been able to use the bulb call light for call light for a while. She said she did not report this to anyone. On 05/02/2024 at 10:00 a.m., an observation was conducted of Resident #2 with S4RN present. She observed Resident #2 attempt to squeeze and press the bulb call light for staff assistance, but he was unable to because his hands were contracted and shaky. Immediately following the observation, S4RN was interviewed. S4RN confirmed Resident #2 was unable to push or squeeze his bulb call light with enough force to activate it because his hands were contracted and shaky. On 05/02/2024 at 10:35 a.m., an observation was conducted of Resident #2 with S2ADON. Resident #2 attempted to squeeze and press his call light for staff assistance, but was unable to. Immediately following the observation, S2ADON was interviewed. She confirmed he was unable to push or squeeze his call light with enough force to activate it because of his hands. On 05/06/2024 at 11:30 a.m., an interview was conducted with S1DON. She said she expected staff to report when a resident was unable to activate their call light for staff assistance. She confirmed there were other call lights available to accommodate resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment. Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Repeated Falls. Review of Resident #1's admission MDS with an ARD of 03/11/2024 revealed the following: Section J-Health Conditions: Falls since admit/reentry/prior assessment: any falls: 1. Yes Falls since admit/reentry/prior assessment: no injury: 1. One Falls since admit/reentry/prior assessment: injury: 0. None Review of the Facility's Incident Log revealed Resident #1 had two falls on 03/10/2024. Review of the Nurses Note dated 03/10/2024 revealed the following, in part: Resident #1 was found on the floor during meal pass around 5:45 p.m. The resident was found lying on his right side in between the bed and the nightstand .After further assessment, skin tears were noted. Signed, S5LPN. On 05/02/2024 at 8:55 a.m., an interview was conducted with S5LPN. She verified she was working when Resident #1 fell on [DATE]. She stated as a result of the fall he had that afternoon, he acquired skin tears on his arms and legs. On 05/02/2024 at 1:15 p.m., an interview was conducted with S3MDS. She stated she completed Resident #1's admission MDS assessment. She stated she reviewed incident reports and nurses' notes each morning to determine if a resident had a fall and if an injury occurred with the fall. She reviewed the nurse's notes for Resident #1 and confirmed he had two separate falls on 03/10/2024. After reviewing the nurse's notes, she verified Resident #1 acquired skin tears after the second fall. She reviewed Resident #1's admission MDS assessment and confirmed he was not coded for a fall with injury and should have been. She stated a skin tear was considered an injury, and it should have been coded on the MDS assessment. On 05/06/2024 at 11:34 a.m., an interview was conducted with S1DON. She stated Resident #1 had two falls on 03/10/2024, one in the morning and one in the afternoon. She reviewed the nurse's note for the second fall and verified Resident #1 acquired skin tears from the fall. She reviewed Resident #1's admission MDS assessment and confirmed a fall with injury was not coded, and should have been.

F689 Based on observations, interviews and record review, the facility failed to implement appropriate interventions, to monitor effectiveness of interventions, and to modify interventions following a fall for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for falls. The facility failed to: 1. Ensure the bed remained in the low position for Resident #2; and 2. Implement new or appropriate safety interventions after each fall for Resident #2. Findings: A review of the facility's policy dated 01/10/2017 and titled, Fall Policy and Procedure revealed in part: Treatment/Management 1. Based on the assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to mitigate risks of serious injuries associated with falls. Monitoring and Follow Up 1. The staff will monitor the individual's response to interventions intended to reduce falling and/or mitigate the risk of serious injury as a result of a fall. 2. If the resident continues to fall, the staff will continue to re-evaluate and consider other possible sources for the resident's falling and will re-evaluate interventions. A review of Resident #2's clinical record revealed a re-admission date of 02/28/2023 and diagnoses which included Hemiplegia following Cerebral Infarct affecting the Right Dominant Side. Further review revealed he had mild contractures to bilateral hands. A review of the Quarterly MDS with an ARD of 04/10/2024 revealed Resident #2 had a BIMS of 12, indicating he was moderately impaired cognitively. A review of Resident #2's Care Plan revealed: Problem: Resident #2 is at risk for falls r/t: Syncope, Left Sided Hemiplegia, and poor judgement Interventions: 10/10/2019: Keep personal items in reach and in sight, Resident is non-compliant with safety, place personal items within reach and sight, keep bed in low, locked position, monitor/report any changes or decline in cognitive status or physical function, Resident #2 instructed again to call for assistance, Resident had discussion with the nurse and NP about safety, not falling and getting assistance. 03/15/2024: Resident is non-compliant with safety. Place personal objects in reach and insight. 03/19/2024: Resident again instructed to call and wait for assistance. 04/26/2024: Resident had discussion with nurse about safety, not falling and getting assistance. Problem: Resident #2 requires total assist to complete ADL's. Interventions: 10/10/2019: Be sure call button is in reach, Mild contractures to bilateral hands. Review of the Incident Investigation Reports revealed the following, in part: On 03/15/2024 at 5:50 p.m., S9LPN standing in the hallway near cafeteria when she heard yelling and a loud noise. S9LPN entered room and noted Resident #2 lying face down beside his bed. Resident #2 said he was reaching for his CDs. Resident #2 had fallen from his bed to the floor. On 03/19/2024 at 1:10 p.m., S4RN entered Resident #2's room, to find resident laying on floor on left side with feet facing towards bed. Resident #2 stated that he was reaching for something in his drawer, causing him for fall out of bed. Resident #2's call light within reach of resident and was instructed by CNA to call for assistance. Immediate Action: Resident educated on importance of calling for assistance. On 04/26/2024 at 6:15 a.m., S9LPN notified by Laundry attendant that Resident #2 was on floor in his room. S9LPN entered room and found resident on the floor Resident #2 fell from wheelchair to floor. Immediate Action: Items requested placed within reach. On 05/01/2024 at 8:40 a.m., an observation and interview was conducted with Resident #2. His hands were contracted bilaterally. He was lying in his bed. His bed was in a high position. He had a gray call light bulb on the bed by his side. He said he was unable to use the call light to call for assistance. He attempted to press his call light and was unable to. He said he needs the staff's assistance for all ADL needs. He said he yells for staff to assist him and if they don't come, he tries to get what he needs and sometimes he falls. On 05/01/2024 at 3:45 p.m., an interview was conducted with S7CNA. She said Resident #2 needs total assistance from the staff for all of his needs. She said she is aware he had fallen several times. She said she constantly tells him to use the call light but he told her he couldn't use the call light. On 05/02/2024 at 6:40 a.m., an interview was conducted with S10CNA. She said Resident #2 needs total care from the staff. She said to prevent Resident #2 from falling, they put his bed low position. She said there are no other interventions in place to keep him from injuring himself when he falls. On 05/02/2024 at 3:30 p.m., an interview was conducted with S9LPN. She said interventions they have in place are keeping his call light within reach and keeping his bed low position. She said there are no other safety measures in his room to prevent him from being injured. On 05/02/2024 at 10:00 a.m., an interview and observation was conducted with S4RN. She said to prevent Resident #2 from falls, they educate him on using his call light and keeping his bed in the low position. She observed Resident's bed in high position and him trying to use his call light unsuccessfully. She confirmed his bed was in a high position and he was unable to properly use his call light. On 05/02/2024 at 10:35 a.m., an interview and observation was conducted with S2ADON. She said she was responsible for implementing fall interventions. She said Resident #2's bed should not have been in a high position. She observed Resident #2 attempting to press and squeeze the call light bulb. She confirmed Resident #2 was unable to press or squeeze the call light bulb. She said she expected staff to notify her if a resident is unable to use the call light. She said she was not notified Resident #2 could not use his call light. On 05/06/2024 at 12:35 a.m., an interview was conducted with S1DON. She stated staff should have notified her of Resident #2 not being able to properly use his call light. She confirmed Resident #2 had a potential for injury with his bed in the high position. She confirmed Resident #2's current fall prevention interventions listed on his care plan were ineffective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's physician/ physician's representative and responsible party were notified after a resident fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Policy: Review of the facility's Policy titled, Fall Policy and Procedure revealed the following, in part: Reporting: 1. Notify the following individuals when a resident falls: a. The resident's family or resident representative; b. The attending physician/Nurse Practitioner. Review of Resident #3's Clinical Record revealed she was admitted on [DATE] with diagnoses including Huntington's Disease, Dementia, Dysarthria, Anarthria, Cognitive Communication Deficit and Syncope and Collapse. Review of Resident #3's nurse's notes dated December 2023 revealed no documented evidence the physician/ physician's representative or responsible party were notified of Resident #3's falls on 12/30/2023 and 12/31/2023. An interview was conducted on 01/30/2024 at 11:48 a.m. with S9HSK. She stated on 12/30/2023 Resident #3 was sitting on the floor in an empty room and she notified S4CNA. After, she stated she held the wheelchair in place while S4CNA placed Resident #3 in the wheelchair and S4CNA wheeled her down the hall. An interview was conducted on 01/30/2024 at 8:38 a.m. with S4CNA. She stated on 12/30/2023 Resident #3 was sitting on the floor in an empty room, which would be considered an unwitnessed fall. She stated, without notifying the nurse, she pulled Resident #3 up off of the floor and placed her into the wheelchair. After, she stated she wheeled Resident #3 back into her assigned room. She stated she should have followed the fall reporting process, which was to immediately notify S3LPN of the fall before she moved Resident #3 for S3LPN to assess and treat Resident #3 and did not. An interview was conducted on 01/30/2024 at 12:12 p.m. with S5CNA. She stated on 12/31/2023 Resident #3 was sitting on the floor in the day room with no staff present, which would be considered a fall. She stated she pulled Resident #3 off of the floor and back into the wheelchair. She stated she wheeled Resident #3 into her assigned room without notifying nursing staff. She stated she should have followed the fall reporting process, which was to immediately notify S3LPN of the fall before she moved Resident #3 for S3LPN to assess and treat Resident #3 and did not. An interview was conducted on 01/30/2024 at 4:29 p.m. with S3LPN. She verified she provided care to Resident #3 on 12/30/2023 and 12/31/2023. She confirmed she was not made aware of Resident #3's falls on 12/30/2023 and 12/31/2023. She stated if she would have been made aware of the falls on 12/30/2023 and 12/31/2023, she would have assessed and treated Resident #3, and notified the physician/ physician's representative and the responsible party. An interview was conducted on 01/30/2024 at 4:05 p.m. with S2DON. She confirmed she expected all nursing staff to notify a resident's physician/ physician's representative and responsible party when falls occurred. She confirmed the falls that occurred for Resident #3 were not reported to the physician/ physician's representative and the responsible party on 12/30/2023 and 12/31/2023. An interview was conducted on 01/30/2024 at 4:39 p.m. with S6NP. He stated he expected to be immediately notified when a resident had an unwitnessed fall with a suspected visible injury, change in mental status, resident on anticoagulation, or head trauma. He stated the resident would be sent out for immediate evaluation to the hospital. An interview was conducted on 1/30/2024 at 4:45 p.m. with S1ADM. He confirmed he expected all CNAs to notify nursing staff of any residents' falls. He further confirmed he expected all nursing staff to notify a resident's physician/ physician's representative and responsible party when falls occurred. He confirmed the falls that occurred for Resident #3 were not reported to nursing staff, physician/ physician's representative, or the responsible party on 12/30/2023 and 12/31/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#5 and #33) of 3 (#5, #19, and #33) sampled residents reviewed for PASRR Level II. Findings: Resident #5 Review of the Clinical Record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder and Bipolar Disorder. Further review revealed an additional medical diagnosis of Schizoaffective Disorder Bipolar Type diagnosed on [DATE]. On 09/27/2023 at 3:28 p.m., an interview was conducted with S7SSD. She stated she was responsible for submitting a PASRR Level II Resident Review Form when a resident received a new mental illness diagnosis. She stated she was unaware Resident #5 was diagnosed with Schizoaffective Disorder Bipolar Type after admit. S7SSD confirmed Resident #5 did not have a PASRR Level II Resident Review Form submitted to the Office of Behavioral Health when Resident #5 received the new diagnosis of Schizoaffective Disorder Bipolar Type, and should have. On 09/27/2023 at 3:28 p.m., an interview was conducted with S1ADM. He stated S7SSD was responsible for submitting a PASRR Level II Resident Review Form when a resident received a new mental illness diagnosis. S1ADM confirmed Resident #5 did not have a Resident Review submitted to the Office of Behavioral Health when Resident #5 received the new diagnosis of Schizoaffective Disorder Bipolar Type, and should have. Resident #33 Review of the Clinical Record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included: Depression and Anxiety. Further review revealed an additional medical diagnosis of Post-Traumatic Stress Disorder on 07/28/2023. On 09/27/2023 at 1:39 p.m., an interview was conducted with S4MDS. She stated S7SSD was new at the time Resident #33 was diagnosed with Post-Traumatic Stress Disorder. S4MDS stated she should have notified S7SSD the new diagnosis of Post-Traumatic Stress Disorder required an update to evaluate for a Level II PASSR. S4MDS stated Resident #33 should have had a PASRR Level II Resident Review Form submitted to the OBH and did not. On 09/27/2023 at 2:32 p.m., an interview was conducted with S7SSD. She reviewed Resident #33's diagnosis of Post-Traumatic Stress Disorder and her Level I PASRR. S7SSD confirmed she should have submitted a Resident Review Form for a Level II PASSR for Resident #33 to the Office of Behavioral Health and did not. On 09/27/2023 at 1:59 p.m., an interview was conducted with S2DON. She stated S7SSD was responsible for submitting PASSR's to the OBH. She reviewed Resident #33's diagnosis of Post-Traumatic Stress Disorder with a diagnosis date of 07/28/2023, and confirmed a Resident Review Form for a Level II PASSR should have been submitted to the Office of Behavioral Health and was not.

Based on policy review, observations, and interviews, the facility failed to ensure: 1.Medications were properly stored and labeled in for 1 of 1 (Med Room A) med rooms observed, 2.Medications were properly stored and labeled for 2 of 2 ( Med Cart 1 and Med Cart 2) med carts observed. Findings: 1. Review of the facility's policy titled Expired, Discontinued, and Unwanted Medications revealed, in part, the following: Policy: Expired, discontinued, and unwanted medications or medications left in the facility after a resident is discharged or expired will be destroyed. Procedures: For non- controlled substance needing destruction, due to death of a resident, medication expiration, discontinue orders, or discharge of a resident, the non- scheduled drugs will be destroyed. Resident #15: A review of the Physician Orders dated September 2023 revealed the following: Drug: Morphine Sulfate 100mg/5ml (20mg/ml) give 0.25 ml by mouth sublingual every 4 hours as needed for pain/dyspnea. Start Date: 10/11/2022 Drug: Ondansetron ODT 8mg tablet give 1 tablet by mouth sublingual every 8 hours as needed for nausea/vomiting. Start date: 12/12/2018 Drug: Lorazepam 2mg/ml five give 0.25ml by mouth sublingual every 4 hours as needed for anxiety/ agitation Start date: 10/11/2022 Resident #29: Drug: Morphine sulf 20mg/ml Concentrated Give 0.25 ml by mouth every 4 hours as needed for pain/shortness of breath. Start date: 06/03/2022 On 09/25/2023 at 9:55 a.m., an observation of Med Room A was conducted with S6LPN he confirmed the following observations: The locked narcotic box in the fridge had two vials of Morphine for Resident #29 with expiration date of 08/2023 and 07/2023. There was one vial of Morphine with expiration date of 04/2023 and one vial Lorazepam with an expiration date 08/2023 for Resident #15. On 09/25/2023 at 10:23 a.m., an interview was conducted with S6LPN. He stated he was the nurse for Hall a. He stated hospice medications were kept locked in the fridge in the Medication Room. He stated if a Hospice Resident would need Morphine or Lorazepam he would use the Morphine or Lorazepam locked in the Narcotic Fridge. S6LPN confirmed the two vials of Morphine for Resident #29 had an expiration date of 08/2023 and 07/2023 and should not have been available for use. S6LPN confirmed Resident #15's Morphine had an expiration date of 04/2023 and Lorazepam had an expiration date 08/2023. He stated these were both expired and should not have been in the medication box available to be given. Resident #21: Drug: Hydromorphone HCL/PF 0.2 mg/ml syringe give 0.5ml every 2 hours sublingual for pain/shortness of breath as needed. Start date: 03/22/2023 On 9/25/2023 at 10:15 a.m., an observation of the controlled medication locked drawer in the refrigerator of the Medication Room revealed Hydromorphone 1mg/ml solution for Resident #21 with an expiration date of 06/01/2023. S8LPN confirmed date of expiration of the Hydromorphone and stated if the resident needed this medication this was in fact was the only vial available for this resident and this was the one she would administer to the resident. On 09/25/2023 at 9:55 a.m., an observation of Medication Room was conducted with S6LPN and revealed two bottles of Glucosamine KCL 500 mg tablets with an expiration date of January 2022. S6LPN verified that the Glucosamine was expired and should not have been available for use. 2. Review of the facility's policy titled Insulin Policy revealed, in part, the following: Policy: Insulin bottles or pens will be dated and initialed when first punctured. Insulin will be used for thirty days, and then discarded. Resident #19: Drug: Lantus Solostar 100 unit/ml give 30 units subcutaneously into the skin every morning Start date: 08/18/2023 Drug: Humulin R 100 unit/ml vial per sliding scale subcutaneously into the skin before meals and at bedtime Start date: 03/01/2023 On 09/25/2023 at 10:55 a.m., an observation was made of Med Cart 2 with S8LPN. She confirmed Resident #19's Lantus and Humulin R Insulin were not labeled. Further observation revealed Resident #19's Humulin R Insulin had an open date of 08/22/2023, and should have been discarded on 09/22/2023, and was not. On 09/25/2023 at 11:00 a.m., an interview was conducted with S8LPN. She stated she was responsible for Hall b. She verified the open date for Resident #19's Lantus was not on the label of the medication and should have been. She also verified Resident #19 Humulin R Insulin had an open date of 08/22/2023 and should have been discarded one month later on 09/22/2023. She stated whoever opens insulin should write the open date on the medication label. She confirmed the Humulin R Insulin and the Lantus should not have been in the Medication Cart 2 readily available to be given to Resident#19. On 09/25/2023 at 11:05 a.m., an observation of Medication Cart 1 was observed with S6LPN. He confirmed there was one box of Mucinex DM with an expiration date of 04/2023. S6LPN confirmed this was expired, and should not have been on the medication cart available for use. On 09/25/2023 at 11:10 a.m. an interview was conducted with S2DON. S2DON was made aware of expired medications. S2DON verified the procedure for labeling insulin when opened. She stated the day the insulin was opened the nurse would date the insulin with the date opened. S2DON confirmed the expired medications were available to be given and should not have been. On 9/27/23 at 2:40 p.m. an interview was conducted with S1ADM. He verified medications that were expired should have been discarded on expiration date and not be available for administration to residents past expiration date.

Based on record review and interviews, the facility failed to maintain temperature logs in the kitchen for all meals to ensure food served was at a proper temperature range to prevent food borne illnesses. This deficient practice had the potential to affect 72 of the residents in the facility who received food from the kitchen. Findings: Review of facility's food temperature logs revealed the facility failed to record food temperatures on 09/20/2023 for breakfast, 09/22/2023 for lunch and supper, 09/23/2023 and 09/24/2023 for breakfast, lunch, and supper. Further review of the facility's food temperature logs revealed the facility failed to record milk temperatures on the following dates: 08/10/2023, 08/11/2023, 08/14/2023, 08/29/2023, 08/31/2023, and 09/01/2023 through 09/25/2023. On 09/25/2023 at 09:15 a.m., an observation was made of S9Cook performing temperature checks for milk. The milk was in an ice bin waiting to be served. S9Cook placed the thermometer in the ice water itself in which the milk was stored and told surveyor the temperature. Surveyor informed her the milk needed to be checked not the ice water in which the milk was stored in. S9Cook agreed she did not properly temperature check the milk and should have placed the thermometer in the milk and not the ice water. On 09/25/2023 at 2:06 p.m., an interview was conducted with S9Cook. S9Cook confirmed the above food and milk temperature omissions. She stated foods and milk temperatures should have been obtained and documented at each meal and they were not. On 09/27/2023 at 1:41 p.m., an interview was conducted with S1ADM. He confirmed food and milk temperature checks should have been performed and documented daily on the food temperature logs.

Based on observations, interviews, and policy review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety by failing to ensure: 1. food was properly labelled and stored in the walk-in fridge and dry storage room, and 2. Proper food handling practices to prevent the outbreak of foodborne illness were followed. This deficient practice had the potential to affect all 72 residents who received food from the kitchen. Findings: Review of the facility's policy titled, Food Receiving and storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in- first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the facility's policy titled, Food Preparation and Service revealed the following in part: Policy Statement: Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Thawing Frozen Food 1) Foods will not be thawed at room temperature. Thawing procedures include: a) Thawing in the refrigerator in a drip-proof container: b) Submerging the item in cold running water (70 degrees F or below); c) Thawing in a microwave oven and then cooking and serving immediately; or d) Thawing as part of a continuous cooking process. 1. On 09/25/2023 at 8:24 a.m., an initial tour of the facility's kitchen was made with S9Cook. The following expired items in the refrigerator were identified and verified with S9Cook: one and a half 32oz containers of chopped garlic with an expiration date of 9/9/2023 and 16 cups of 4 fluid oz. thick and easy clear hydrolyte water thickener with an expiration date of 04/04/2023. S9Cook stated she did not know thickener expired. Two metal containers full of diced ham with no open date or expiration date were also identified in the fridge. There was a bag of dry fruit in the refrigerator which was watery and had no open date on the container. S9Cook stated someone brought the fruit in last week for a party, and it should not have been in the refrigerator. S9Cook stated it should have been thrown away. On 09/25/2023 at 8:24 a.m., an observation was made of the facility's dry storage area with S9Cook. S9Cook identified and verified the following: one plastic container of flour and one plastic container of sugar with no open or expiration date labeled. Above the container of flour was a half opened bag of flour with a date on 09/20/2023 was not sealed. S9Cook stated the containers should have been labeled and dated but were not. There was an opened bag of fish fry in the pantry; S9Cook stated there should have been a twist tie to keep it sealed and confirmed the bag did not have one. There was half of a 10 pound bag of pasta unsealed with no opened date labeled on the bag. There was a loaf of raisin bread expired since 09/17/2023. There was a bag of opened rice that had not been sealed after opening. S9Cook verified all opened dried goods should be sealed once opened, and all containers should be labeled with opened and expiration date. 2. On 09/25/2023 at 8:24 a.m., an observation was made of two packs of frozen ground beef, along with a box of frozen sliced deli meat, being thawed out on a baking sheet at room temperature in the kitchen. S9Cook stated the meat was going to be used for dinner tonight and she had been thawing them out since this morning. She stated she was unaware frozen meat had to be thawed out under cold water or in the refrigerator. On 09/27/2023 at 1:41 p.m., an interview was conducted with S1ADM. He confirmed opened dry foods should have been sealed and dated once opened. He confirmed the expired foods should have been discarded and not available for use after the date of expiration. He also confirmed frozen deli meat and ground meat should not have been left out to defrost at room temperature, and that was not the correct thawing process for frozen foods.