Does Cypress at Lake Providence have any serious inspection findings?

Yes, Cypress at Lake Providence has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 68 total deficiencies from recent inspections.

What are the staffing levels at Cypress at Lake Providence?

Cypress at Lake Providence has a one-star staffing rating from CMS with 0.14 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Cypress at Lake Providence located?

Cypress at Lake Providence is located in LAKE PROVIDENCE, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Cypress at Lake Providence have?

Cypress at Lake Providence has 108 certified beds.

Who owns Cypress at Lake Providence?

Cypress at Lake Providence is a for profit - corporation facility and is part of the VOLARE HEALTH chain.

What questions should families ask when visiting Cypress at Lake Providence?

Families visiting Cypress at Lake Providence should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Cypress at Lake Providence compare to other nursing homes?

Cypress at Lake Providence has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Cypress at Lake Providence

Name: Cypress at Lake Providence
Address: 5976 US-65 NORTH, LAKE PROVIDENCE, LA, 71254, US
Telephone: (318) 559-2248
Rating: 1.0

5976 US-65 NORTH, LAKE PROVIDENCE, LA 71254 · (318) 559-2248

For profit - Corporation 108 Beds VOLARE HEALTH Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#194 of 264 in LA

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Cypress at Lake Providence nursing home in LAKE PROVIDENCE, LA - Photo 1 of 2

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Cypress at Lake Providence has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. Ranking #194 out of 264 facilities in Louisiana places them in the bottom half, and they are the only nursing home option in East Carroll County. Unfortunately, the facility is worsening, with issues increasing from 23 in 2024 to 28 in 2025, and a concerning 58% staff turnover rate, which is higher than the state average. Additionally, they have been fined $81,880, which is more than 79% of Louisiana facilities, suggesting ongoing compliance problems. While the facility maintains average RN coverage, there have been critical incidents, including a failure to protect residents from sexual abuse and physical abuse by staff, raising serious red flags about resident safety and care quality.

Trust Score: F
In Louisiana: #194/264
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $81,880 in fines. Higher than 83% of Louisiana facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 68 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 28 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Louisiana average (2.4)

Significant quality concerns identified by CMS

Staff Turnover: 58%

12pts above Louisiana avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $81,880

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: VOLARE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (58%)

10 points above Louisiana average of 48%

The Ugly 68 deficiencies on record

2 life-threatening 1 actual harm

May 2025 23 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the rights of Residents to receive written notice, including the reason for the change, before the Resident's room in the facility is changed for 1 (#41) of 1 Residents reviewed for rights. Findings: Review of the facility's Resident Rights - Right to Share a Room with Person of Choice Policy dated 02/2023 revealed in part: Purpose: Clarify the Resident's rights regarding sharing a room with a roommate of choice. 4. When a Resident is being moved at the request of the facility, the Resident, or family and/or Resident representative receives an explanation in writing as to why the room change is required. Review of the medical record for Resident #41 revealed an admission date of 08/20/2020. Resident #41 had diagnoses including diabetes mellitus, chronic venous hypertension, pain, cognitive communication deficit, reduced mobility, lack of coordination, hypertension, lymphedema, depression and obesity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition for daily decision making. On 05/19/2025 at 11:05 a.m. interview with Resident #41 revealed she was moved to her current room from another room and she was not happy. Review of the nurses notes dated 12/26/2024 at 11:10 a.m. revealed Resident #41 was being moved to a different room. Review of the nurses notes dated 12/25/2024 at 9:00 a.m. revealed Resident #41 was observed to curse and holler at her roommate. Further review of the nurses notes revealed Resident #41 was informed that since she was causing the problem then she will have to be moved to another room. On 05/20/2025 at 5:00 p.m. interview with S2Director of Nursing (DON) revealed she told Resident #41 she had to move to another room due to she was being rude to her previous roommate. S2DON revealed she verbally informed Resident #41 of the room change. S2DON confirmed she did not give Resident #41 or her Responsible Party a written notice of the room change as stated in the facility's policy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure a Resident with a facility initiated discharge with Medicare Part A skilled service with days remaining was provided with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage from Centers for Medicare and Medicaid Services CMS-10055 and Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for 1 (#16) of 3 (#8, #16, #322) Residents reviewed for termination of Medicare Part A services. Findings: Record review revealed Resident #16's Medicare Part A skilled services episode start date was 01/05/2025. The last covered day of Part A services was 02/03/2025. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Resident #16 remained in the facility. Further review revealed no documented evidence Resident #16 was provided CMS-10055 and CMS-10123 prior to being discharged from Medicare Part A Services. On 05/20/2025 at 11:02 a.m. an interview with S14Clinical Reimbursement Specialist confirmed she was not able to locate the completed forms CMS-10055 and CMS-10123 for Resident #16.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#35, #41 and #63) of 8 (#15, #20, #35, #41, #52, #61, #63, #321) Residents reviewed for environment. Findings: Resident #41 On 05/19/2025 at 9:47 a.m., and 05/21/2025 at 8:30 a.m., observations of Resident #41's room revealed the air/heating unit had grime and debris on the air vents. Resident #63 On 05/19/2025 at 8:45 a.m., and 05/20/2025 at 11:00 a.m., observations of Resident #63's room revealed the air/heating unit had grime and dust on the air vents. On 05/21/2025 at 8:40 a.m. an interview with S2Director of Nursing (DON) confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned. On 05/21/2025 at 8:30 a.m. an interview with S16Maintenance Director confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned. Resident #35 Observations of Resident #35's room on 05/19/2025 at 7:43 a.m. and 05/21/2025 at 8:40 a.m. revealed numerous dead flying insects noted stuck to the bathroom walls, heavy lint buildup to the ceiling vent in the Resident's bathroom, the lid on top of the toilet was ajar with the inside part of the toilet visible, and black buildup noted to the inside of the air conditioner unit in the resident's room. Observation/interview on 05/21/2025 at 12:45 p.m. of Resident #35's room with S2DON and S1Administrator confirmed that Resident #35's air conditioner unit, ceiling vent in bathroom, and bathroom walls needed to be cleaned and lid to commode needed to be adjusted.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's drug regimen was free from unnecessary medications by failing to monitor for side effects and behaviors of psychotropic medications for 1 (#61) of 5 (#3, #32, #36, #61, and #63) residents reviewed for unnecessary medications. Findings: Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, and chronic kidney disease. Review of Resident #61's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed Resident #61 required assistance with activities of daily living. Medication section of the MDS revealed Resident #61 received antiaxiety medications and antipsychotic medications. Review of the Resident #61's current care plan revealed the resident had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, psychotropic drug use. Further review of the care plan revealed the following interventions: 1) Administer medications as ordered, monitor/document for side effects and effectiveness. 2) Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. Review of the May 2025 Physician's Orders revealed the following active orders for Resident #61: 04/18/2025- Seroquel (antipsychotic) oral tablet 50 milligrams (mg) give 1 tab by mouth (po) in afternoon and Seroquel oral Tablet 50 mg give 1 tablet by mouth one time a day ; and 04/17/2025- Seroquel Oral Tablet 200 mg give 1 tablet by mouth at bed time, and Clonazepam (antianxiety) oral Tablet 0.5 mg give 1 tablet by mouth three times a day. Review of the April and May 2025 Medication Administration Record (MAR) revealed no documented evidence of monitoring for side effects and behaviors every shift of antipsychotics and antianxiety medications for Resident #61. An interview on 05/21/2025 at 12:10 p.m. with S7Regional Director of Clinical confirmed no documented evidence of monitoring for side effects and behaviors every shift associated with the use of antipsychotics and antianxiety medications for Resident #61 from 04/17/2025 through 04/30/2025, and from 05/04/2025 through 05/20/2025.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to implement the plan of care for 2 (#13, #62) of 37 total sampled residents. The facility failed to: 1. place a smoking apron on Resident #13 while smoking as stated in the care plan and 2. place a fall mat by Resident #62's bedside as stated in the care plan. Findings: Review of the Physical Environment Facility with Independent and Supervised Smokers revised date 03/2019 revealed in part: Purpose: To provide a safe environment for residents. 2. The Facility will furnish the designated smoking area with a fire extinguisher and proper receptacle for extinguishing smoking materials. Smoking blankets or aprons will be furnished for Residents who are assessed to require a smoking blanket or apron. Resident #13 Review of the medical record for Resident #13 revealed diagnoses including heart disease, chronic obstructive pulmonary disease (COPD), depressive disorder, diabetes mellitus, paranoid schizophrenia, muscle wasting, wasting, cognitive communication deficit, and moderate intellectual disabilities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition for daily decision making. Review of Resident #13's current care plan revealed he was a smoker, was to wear a smoking apron while smoking and required supervision while smoking. Review of the smoking assessment dated [DATE] revealed Resident #13 required a smoke apron while smoking and required supervision while smoking. On 05/20/2025 at 10:15 a.m. Resident #13 was observed sitting outside in the smoking area with a staff member present. Resident #13 was sitting in a wheelchair holding a lit cigarette and he was not wearing a smoking apron. On 05/20/25 at 2:20 p.m. Resident #13 was observed sitting outside in the smoking area. Resident #13 was sitting in a wheelchair holding a lit cigarette and he was not wearing a smoking apron. On 05/20/2025 at 3:35 p.m. interview with S18Activity Director revealed Resident #13 should wear a smoke apron when smoking. On 05/20/2025 at 5:20 p.m. S1Administrator and S2Director of Nursing (DON) were notified of Resident #13 smoking and not wearing a smoke apron as stated in the care plan. Resident #62 Review of Resident #62's medical record revealed an admission date of 01/14/2025 and diagnoses which include in part: osteomyelitis, diffuse traumatic brain injury, unspecified intracranial brain injury with loss of consciousness, depression, nontraumatic subarachnoid hemorrhage, other reduced mobility, and encephalopathy. Review of quarterly MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 10 which indicates moderate cognitive impairment. On 05/19/2025 at 12:44 p.m., a fall mat was observed in Resident #62's room propped against wall away from the Resident's bed. Resident #62 did not have a fall mat on floor next to his bed. On 05/20/2025 at 10:12 a.m., observation of Resident #62's room revealed that the fall mat was still propped up against the wall away from the Resident's bed. There was no fall mat on the floor next to Resident #62's bed. On 05/20/2025 at 3:50 p.m., review of Resident #62's medical records revealed that Resident #62 fell from his bed on 02/26/2025 and on 05/08/2025. Further review of Resident #62's fall risk care plan revealed that a fall mat should be utilized. On 05/21/2025 at 8:15 a.m., observation of Resident #62's room revealed that there was no floor mat next to the Resident's bed and that the floor mat was still propped against the wall in the corner of the room. On 05/21/2025 at 8:15 a.m., an interview with S4Licensed Practical Nurse (LPN) confirmed that Resident #62 did not have a fall mat next to his bed. On 05/21/2025 at 8:25 a.m., Interview conducted with S2DON at Resident #62's bedside. S2DON confirmed that Resident #62's fall mat was propped against the wall and not at his bedside as care planned. Further review of Resident #62's care plan with S2DON confirmed that Resident #62's plan of care had not been individualized to the Resident's needs.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure Residents who required respiratory care received the care and services consistent with professional standards by failing to properly store nebulizer mouth pieces and post oxygen use signage for 3 (#27, #15, #171) of 3 Residents reviewed for respiratory care. Findings: Resident #15 Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included diabetes and shortness of breath. Review of the current physician orders revealed Resident #15 was to receive Ipratropium/Albuterol, 1 application, inhaled orally four times a day for shortness of breath. On 05/19/2025 at 9:25 a.m., observation of the nebulizer mouth piece for Resident #15 was on a bedside dresser open to the air and not contained in a bag. Observation on 05/20/2025 at 7:45 a.m., the nebulizer mouth piece for Resident #15 was on his bed and not contained in a bag. On 05/20/2025 at 10:45 a.m., interview with S2Director of Nursing (DON) confirmed the nebulizer mouth piece should be stored in a plastic bag when not in use. Resident #171 Review of the medical record for Resident #171 revealed an admission date of 05/09/2025. Resident #171 had diagnoses including chronic obstructive pulmonary (COPD) disease, hypertension, heart disease, anxiety, shortness of breath, poly-osteoarthritis and atrial fibrillation. Review of the May 2025 physician orders revealed an order dated 05/09/2025 for Ipratropium-Albuterol solution 0.5-2.5 - 3 milligrams (mg)/3 milliliters (ml) inhale four times a day related to COPD with acute exacerbation at 6:00 a.m., 10:00 a.m. 4:00 p.m. and 8:00 p.m. On 05/19/2025 at 7:45 a.m., 05/20/2025 at 8:05 a.m. and 12:10 p.m. observations of Resident #171's room revealed a nebulizer mouth piece on the bedside table and not stored in a bag. On 05/20/2025 at 12:10 p.m. observation of Resident #171's room with S2DON confirmed the nebulizer mouth piece should be stored in a bag when not in use. Resident #27 Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses that included morbid (severe) obesity, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, primary pulmonary hypertension, atrial fibrillation, and shortness of breath. Review of active May 2025 Physician orders revealed Oxygen at 2 Liters Per Minute (LPM) via Nasal Cannula (NC) continuous to maintain saturation greater than or equal to 93%. Review of the May 2025 Electronic Medication Administration Record (EMAR) revealed documentation Resident #27 received Oxygen at 2 LPM via NC as ordered. On 05/19/2025 at 08:30 a.m. and 05/20/2025 at 10:10 a.m., observations of Resident #27 revealed she was receiving oxygen at 2 LPM via NC. Further observation revealed there was no signage posted outside Resident #27's room indicating no smoking oxygen in use. On 05/20/2025 at 12:10 p.m., an observation and interview conducted with S2Director of Nursing (DON) in Resident #27's room revealed Resident #27 was receiving Oxygen at 2 LPM via NC. Further observation revealed there was no signage posted outside Resident #27's door indicating no smoking oxygen in use. S2DON confirmed there should have been signage posted outside of Resident #27's door indicating no smoking/oxygen in use.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, record reviews and interviews, the facility failed to ensure it provided pharmaceutical services to meet the needs of the Residents by failing to have medications available for administration for 2 (#33, #8) of 3 (#33, #8, #30) Residents observed for a medication pass. Findings: Resident #33 On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart. Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. On 05/19/2025 at 12:50 p.m. observation of the medication room revealed Resident #33's Vitamin D-2 was not in the medication room. On 05/19/2025 at 1:00 p.m., interview with S2Director of Nursing (DON) confirmed Resident #33's Vitamin D-2 was not available in the facility for administration. Resident #8 On 05/19/2025 at 7:40 a.m., a medication pass was observed for Resident #8 with S3LPN. During the medication pass, S3LPN reported Farxiga 10 milligrams (mg) was not on the cart. Review of the physician's orders revealed Resident #8 was to receive Farxiga 10 mg daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. On 05/19/2025 at 12:50 p.m. observation of the medication room revealed #8's Farxiga was not in the medication room. On 05/19/2025 at 1:00 p.m., interview with S2DON confirmed Resident #8's Farxiga was not available in the facility for administration.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for edema while resident was on a diuretic for 1 (#61) of 5 (#3, #32, #36, #61, and #63) residents reviewed for unnecessary medications. Findings: Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living. Review of the May 2025 Physician's Orders revealed an order dated 04/18/2025 for Hydrochlorothiazide (diuretic) Oral Tablet 25 milligrams (mg) give 1 tablet by mouth one time a day. Review of the April 2025 Medication Administration Record (MAR) revealed no documented evidence of monitoring for edema for 13 times in April 2025. Review of the May 2025 MAR revealed no documented evidence of monitoring for edema for 16 times in May 2025. An interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) and S7Regional Director of Clinical confirmed the facility should have been monitoring Resident #61 for edema while she was taking a diuretic. S2DON and S7Regional Director of Clinical confirmed there was no documented evidence of monitoring for edema on Resident #61 while on a diuretic for 13 times in April 2025 and 16 times in May 2025.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations, interview, and record reviews, the facility failed to ensure it did not have a medication error rate of 5 percent or greater by having 2 errors in 27 opportunities resulting in a medication error rate of 7%. Findings: Resident #33 On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart. Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. This resulted in an error by omission. Resident #8 On 05/19/2025 at 7:40 a.m., a medication pass was observed for Resident #8 with S3LPN. During the medication pass, S3LPN reported Farxiga 10 milligrams (mg) was not on the cart. Review of the physician's orders revealed Resident #8 was to receive Farxiga 10 mg daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. This resulted in an error by omission.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored properly in a locked compartment by leaving medication at resident's bedside for 2 (#55, #64) of 2 (#55, #64) residents reviewed for medication storage. Findings: Review of the facility Pharmacy Services Medication Administration policy dated (03/2023) revealed the following: 2. Medications will be prepared and administered in accordance with: a. Prescriber's order 15. Medications will be administered within (1) hour before or after the scheduled administration time. Resident #64 Review of Resident #64's medical record revealed an admit date of 01/14/2025 and diagnoses which include in part: depression, bipolar disorder, non-traumatic subarachnoid hemorrhage, cerebral infarction, hypertension, and hypothyroidism. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the Resident was cognitively intact. On 05/19/2025 at 7:00 a.m., a bottle of Flonase nasal spray was observed on Resident #64's bedside table. Resident # 64 stated that she kept the medication there and administers it to herself when she feels she needs it. On 05/20/2025 at 10:07 a.m., a Flonase bottle was observed sitting on resident #64's bedside table. On 05/20/2025 at 11:20 a.m., a review of Resident #64's current active orders revealed no order for Flonase nasal spray. On 05/20/2025 at 12:55 p.m., an interview was conducted with S2Director of Nursing (DON) at Resident #64's bedside. S2DON confirmed that Resident #64 had a bottle of Flonase at her bedside and was self-administering the medication. Resident #55 Review of Resident #55's medical record revealed an admit date of 12/23/2023 and diagnoses which include in part: monoplegia of lower limb affecting unspecified side, unspecified psychosis not due to substance or known physiological condition, human immunodeficiency virus (HIV) disease, other seizures, and constipation. Review of quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score 11 which indicated moderate cognitive impairment. On 05/19/2025 at 7:55 a.m., Resident #55 was observed lying in bed with his bedside table positioned next to his bed within his reach. Observed on the bedside table was a medication administration cup that contained two tablets. On 05/19/2025 a.m., interview with S4Licensed Practical Nurse (LPN) confirmed that there were medications on Resident #55's bedside table. S4LPN identified the medications as Levetiracetam and a stool softener. S4LPN also confirmed that the two medications were Resident #55's night medications and should have been administered the prior night. On 05/20/2025 at 11:20 a.m., review of Resident #55's Medication Administration Record (MAR) revealed there were no documented refusals of medication by Resident #55 on 05/18/2025. On 05/20/2025 at 12:55 p.m., S2DON was notified that on 05/19/2025 Resident #55 had medications left on his bedside table from the prior night and that S4LPN confirmed the medications were left on his bedside table.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to have quarterly Quality Assessment and Assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of QAA meetings being held since the previous annual survey. Findings: On 05/22/2025 at 2:40 p.m., an interview with S1Administrator revealed the facility was unable to locate documentation of any quarterly QAA meetings held since the prior annual survey.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it maintained an infection control program designed to provide a sanitary environment by having staff store used tube feeding syringes improperly for 1 (#44) of 1 (#44) residents reviewed for tube feeding. Findings: Resident #44 Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction and dysphasia. Review of the physician orders revealed an order to crush crushable medications and to flush with 30 cubic centimeters (cc) of water before and after medications. On 05/20/2025 at 10:11 a.m., observation revealed the tip of the syringe used to administer medications was filled with an orange colored liquid and the plunger of the syringe was in the plunger. On 05/20/2025 at 10:45 a.m., interview with S2Director of Nursing (DON) revealed the syringe should have been rinsed and disassembled before being stored for later use.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Review of the medical record for Resident #3 revealed an admission date of 01/14/2009 with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, psychosis, schizophrenia, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #3 was cognitively intact. The MDS also indicated that Resident #3 was prescribed a/an: antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the May 2025 Medication Administration Record (MAR) revealed that Resident #3 received Divalproex for the treatment of schizophrenia, Clozapine for the treatment of psychosis, Mirtazapine for the treatment of depression, and Lorazepam for the treatment of restlessness/agitation. Review of the medical record revealed that there was no consent by Resident #3 for the psychotropic medications. On 05/21/2025 at 12:06 p.m., S7Regional Director of Clinical confirmed that there was no consent for the psychotropic medications: Divalproex, Clozapine, Mirtazapine, and Lorazepam. Resident #36 Review of the medical record for Resident #36 revealed an admission date of 02/07/2025 with diagnoses that included Parkinson's disease, dysphagia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, and seizures. Review of the Medicare 5 day MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #36 was cognitively intact. The MDS also indicated that Resident #3 was prescribed a/an: antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the May 2025 MAR revealed that Resident #36 received Seroquel for the treatment of schizoaffective disorder, Sertraline for the treatment of bipolar disorder, Depakote for the treatment of schizoaffective disorder, Clonazepam for the treatment of generalized anxiety disorder, and Geodon for the treatment of mood. Review of the medical record revealed that there was no consent by Resident #36 for the psychotropic medications. On 05/21/2025 at 12:06 p.m., S7Regional Director of Clinical confirmed that there was no consent for the psychotropic medications: Seroquel, Sertraline, Depakote, Clonazepam, and Geodon. Resident #61 Review of the record for Resident #61 revealed an admission date of 08/28/2024 with diagnoses which included dementia with other behavioral disturbances. Review of the May 2025 Physician Orders revealed the following orders for psychotropic medications for Resident #61: 04/18/2025- Seroquel (antipsychotic) oral tablet 50 milligrams (mg) give 1 tab by mouth (po) in afternoon and Seroquel oral Tablet 50 mg give 1 tablet by mouth one time a day ; and 04/17/2025- Seroquel Oral Tablet 200 mg give 1 tablet by mouth at bed time, and Clonazepam (antianxiety) oral Tablet 0.5 mg give 1 tablet by mouth three times a day. Review of the record revealed no documented evidence of a pyschotropic medication consent for Resident #61 to receive Seroquel and Clonazepam. On 05/21/2025 at 1:40 p.m., interview with S7Regional Director of Clinical confirmed there were no consents for the use of psychotropic medications Seroquel and Clonazepam on Resident #61. Resident #63 Review of the medical record for Resident #63 revealed an admission date of 01/01/2025 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, depression, psychoactive substance induced psychotic disorder, hyperlipidemia, and hypertension. Review of the May 2025 physician orders revealed an order dated 01/03/2025 for Zyprexa (antipsychotic) 2.5 mg to be given at bedtime Review of the medical record for Resident #63 revealed no documented evidence of a psychoactive medication consent for the resident to receive Zyprexa. On 05/21/2025 at 12:00 p.m. interview with S7Regional Director of Clinical confirmed Resident #63 did not have a medication consent for Zyprexa. Based on record reviews, and interviews the facility failed to ensure Residents were informed of the risks, benefits and side effects of an antipsychotic medication for 5 (#3, #32, #36, #61 and #63) of 5 (#3, #32, #36, #61 and #63) Residents reviewed for unnecessary medications. Findings: Resident #32 Review of the medical record for Resident #32 revealed he was admitted on [DATE] with diagnoses which included bipolar disorder and depression. Review of the physician orders revealed the Resident received the psychotropic medications Haldol and Seroquel for the treatment of bipolar disorder and Escitalopram for the treatment of depression. Review of the medical revealed there was no consent by the Resident for the psychotropic medications. On 05/20/2025 at 3:15 p.m., interview with S2Director of Nurses (DON) confirmed there were no consents for the psychotropic medications Haldol, Seroquel and Escitalopram.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure it posted the results of the most recent surveys of the facility by failing to post the results of 3 surveys that occurred after the facility's last annual survey on 05/08/2024. Findings: On 05/21/2025 at 11:35 a.m., observation of the facility posted surveys revealed the results of the annual survey dated 05/08/2024 were accessible to residents in a survey results binder. The facility was also surveyed on 09/26/2024 resulting in 2 deficiencies, on 04/01/2025 resulting in 2 deficiencies and on 04/23/2025 resulting in 3 deficiencies. The results of the 3 surveys were not posted. On 05/21/2025 at 1:45p.m., interview with S1Administrator confirmed the results of the 3 surveys conducted after the annual survey of 05/08/2025 were not posted.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 Review of the medical record for Resident #19 revealed an admission date of 09/01/2020. Resident #19 had diagnoses including hypertensive heart disease, pain, dysphagia, anxiety, depressive disorder, moderate intellectual disabilities and psychosis. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 which indicated Resident #19 had severe cognitive impairment for daily decision making and required assistance with activities of daily living (ADL). Further review of the MDS revealed the number of falls since admission or prior assessment with no injury - 2 or more and the number of falls since admission or prior assessment with injury (except major) - none Review of the Incident/Accident report dated 04/19/2025 at 9:05 a.m. revealed a Certified Nursing Assistant (CNA) reported to the nurse that the Resident was lying on the floor near his wheelchair face down. Nurse noted blood near resident. Laceration to right brow was cleansed with wound cleanser and bandaged. Review of the nurses notes dated 04/19/2025 revealed the Resident returned to the facility at approximately 1:20 p.m. via ambulance from the hospital. The Resident had 5 stitches to middle of his forehead. Review of the current care plan for Resident #19 revealed the Resident had an actual fall on 04/19/2025. On 05/21/2025 at 10:06 a.m. interview with S15LPN/MDS revealed the MDS should have had the number one on the MDS for injury (not major) when Resident #19 received stitches to his forehead on 04/19/2025. On 05/21/2025 at 11:15 a.m. S2DON was notified of the inaccurate assessment for falls on the MDS. Based on interviews and record reviews, the facility failed to ensure the assessments accurately reflected the Residents' status by failing: 1. to ensure Minimum Data Set (MDS) assessments documented falls for Resident #61 and a pressure ulcer for Resident #35 and #62; 2. to ensure MDS assssment was accurate regarding falls for Resident #19; 3. to ensure risk assessments for skin were completed for Resident #35 quarterly; and 4. to ensure risk assessment for falls were completed for Resident #61 quarterly. Findings: Review of the facility's undated Skin and Wound Management Guidelines Policy and Procedure revealed the following, in part: Purpose: To provide guidance to prevent alteration in skin integrity, when possible; To identify and address risk factors for avoidable skin breakdown; To provide a process for managing pressure related and non-pressure related skin issues. Admission/Readmission 2. Wound Care Nurse b. Within 72 hours of admission, verify the Braden that was completed upon admission. Complete a Braden Scale Assessment quarterly. Resident #35 Review of the record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including other sequelae following unspecified cerebrovascular disease, other idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, major depressive disorder, aphasia, hypothyroidism, dementia in other disease classified elsewhere moderate with mood disturbance, anxiety disorder, unspecified psychosis, flaccid neuropathic bladder, mild cognitive impairment, hypertension, transient ischemic attack, and hyperlipidemia. Review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #35 required assistance with activities of daily living (ADLs). Review of the skin condition section of the MDS revealed Resident #35 had no risk of pressure ulcers and had no current pressure ulcers. Review of the record revealed Resident #35 had a stage 3 pressure ulcer to her rear left malleolus that was facility acquired on 07/25/2024. An interview on 05/20/2025 at 10:00 a.m. with S13Licensed Practical Nurse (LPN)/Treatment Nurse revealed Resident #35 had a stage 3 pressure ulcer to her rear left malleolus that was facility acquired on 07/25/2024. S13LPN/Treatment Nurse reported that Resident #35's pressure ulcer to left malleolus was healed on 05/19/2025. Review of Resident #35's last Braden scale for predicting Pressure Sore Risk for resident dated 09/04/2024 revealed a score of 18 indicating Resident #35 was at risk for pressure ulcers. No documented evidence of pressure sore risks assessments completed for Resident #35 since 09/04/2024. An interview on 05/21/2025 at 10:00 a.m. with S15LPN/Minimum Data Set (MDS) confirmed she did not mark Resident #35 as having a stage 3 pressure ulcer on the 04/28/2025 quarterly MDS. S15LPN/MDS reported she does not do the Braden scale risk assessments for the Residents but the hall nurse/treatment nurse does the Braden scale risk assessments quarterly. An interview on 05/21/2025 at 10:30 a.m. with S14Clinical Reimbursement Specialist confirmed Resident #35's last Braden Scale for predicting pressure sore risk was completed on 09/04/2024. S14Clinical Reimbursement Specialist confirmed the Braden scale for predicting pressure sore risk assessment should be done quarterly by the hall nurse or the treatment nurse. S14Clinical Reimbursement Specialist confirmed Resident #35's MDS from 04/28/2025 did not identify that Resident #35 had a stage 3 pressure ulcer resulting in inaccuracy of the MDS assessment completed by S15LPN/MDS. Interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) confirmed that Resident #35's quarterly MDS was inaccurate and failed to identify Resident's stage 3 pressure ulcer. S2DON confirmed the Braden scale for predicting pressure sore risk assessment was last completed on Resident #35 on 09/04/2024, and should be completed quarterly by the hall nurse or treatment nurse. Resident #61 Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living. Section J of the MDS revealed no falls documented for Resident #61. Review of the facility's incident/accident log revealed Resident #61 had falls on 04/22/2025 and 04/23/2025, which were prior to her quarterly MDS on 05/01/2025. An interview on 05/21/2025 at 10:00 a.m. with S15LPN/MDS confirmed Resident #61 had falls on 04/22/2025 and 04/23/2025. S15LPN/MDS confirmed she did not document falls on Resident #61's 05/01/2025 quarterly MDS. Review of Resident #61's last fall risk assessment was completed on 12/30/2024. An interview on 05/21/2025 at 10:30 a.m. with S14Clinical Reimbursement Specialist confirmed Resident #61 had falls on 04/22/2025 and 04/23/2025. S14Clinical Reimbursement Specialist confirmed that S15LPN/MDS failed to identify Resident 61's falls on the quarterly MDS on 05/01/2025, and confirmed the inaccuracy of the MDS. S14Clinical Reimbursement Specialist confirmed fall risk assessments should be completed quarterly, and confirmed Resident #61's last fall risk assessment was completed on 12/30/2024. An interview on 05/21/2025 at 11:45 a.m. with S2DON confirmed S15LPN/MDS failed to identify falls on Resident #61 on the quarterly MDS dated [DATE]. S2DON confirmed the last fall risk assessment on Resident #61 was on 12/30/2024. S2DON confirmed the facility failed to complete the fall risk assessment quarterly for Resident #61. Resident #62 Review of Resident #62's medical record revealed an admission date of 01/14/2025 and diagnoses which include in part: osteomyelitis, diffuse traumatic brain injury, unspecified intracranial brain injury with loss of consciousness, depression, nontraumatic subarachnoid hemorrhage, other reduced mobility, and encephalopathy. Review of quarterly MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 10 which indicated moderate cognitive impairment. Further review of section M of the MDS assessment reveals that Resident #62 did not have a pressure ulcer/injury over a bony prominence and no unhealed pressure ulcers/injuries. On 05/19/2025 at 7:45 a.m., interview with Resident #62 revealed that he had a wound on his right hip. On 05/20/2025 at 10:12 a.m., Resident #62 observed laying in his bed on his left side watching television. A dressing dated 05/19/2025 was noted to his right hip. On 05/20/2025 at 3:24 p.m., interview with S13 LPN/Treatment Nurse revealed that an outpatient wound consultant currently comes to facility to treat Resident #62's right hip and sacral wounds every Monday and Thursday. On 05/20/2025 at 3:24 p.m., record review revealed Resident #62 had the pressure ulcers to his right hip and sacrum on admission. On 05/21/2025 at 10:00 a.m., an interview conducted with S15LPN/MDS confirmed that Resident #62 did not have an accurate MDS skin assessment on quarterly MDS assessment dated [DATE]. On 05/21/2025 at 10:21 a.m., interview with S2DON confirmed that Resident #62 did not have any wounds documented on the quarterly MDS assessment dated [DATE].

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure Residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene by failing for provide adequate bathing and nail care for 4 (#27, #3, #40, #52) of 4 (#27, #3, #40, #52) Residents reviewed for activities of daily living. Findings: Resident #52 Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease and major depression. Review of the 02/24/2025 Minimum Data Set (MDS) assessment revealed Resident #52 had a Brief Interview for Mental Status Score (BIMS) of 14 indicating he was cognitively intact. The MDS assessment also indicated Resident #52 needed assistance with personal hygiene. On 05/19/2025 at 10:17 a.m., observation and interview of Resident #52 revealed he had long dirty fingernails that were in need of care. Resident #52 reported he had asked staff to trim his fingernails recently. On 05/20/2025 at 1:10 p.m., interview with S4Licensed Practical Nurse (LPN) revealed resident #52 was a good historian and would tell the truth when recollecting. At that time S4LPN observed the fingernails of resident #52 and confirmed the fingernails were long and dirty and needed to be trimmed and cleaned. Resident #27 Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses that included morbid (severe) obesity, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, primary pulmonary hypertension, and shortness of breath, atrial fibrillation, generalized muscle weakness, muscle wasting and atrophy multiple sites, and abnormalities of gait and mobility. On 05/19/2025 at 8:30 a.m., an interview with Resident #27 revealed she did not receive a bed bath on Friday (05/16/2025). Resident #27 reported she was to receive bed baths on Monday, Wednesday, and Friday. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #27 was cognitively intact. Further review revealed Resident #27 required substantial/maximal assistance with toileting, shower/bathe, dressing, bed mobility, and personal hygiene. Review of care plan revealed Resident #27 had an Activities of Daily Living (ADL) self-care deficit. An intervention listed was to provide bed bath on scheduled bath days with maximal assist x 2. Review of the April 2025 Documentation Survey Report v2 revealed Resident #27 was to receive a shower/bath on Monday, Wednesday, and Friday. Further review revealed documentation Resident #27 only received shower/bathe on 04/07/2025. Review of the May 2025 Documentation Survey Report v2 revealed Resident #27 was to receive Shower/bathe on Monday, Wednesday, and Friday. Further review revealed documentation Resident #27 only received shower/bathe on 05/05/2025, 05/12/2025, and 05/19/2025. On 05/20/2025 at 3:22 p.m., an interview with S17LPN revealed she was never notified by any of the aides that Resident #27 had refused a bed bath. On 05/21/2025 at 12:15 p.m., surveyor informed S2Director of Nursing (DON) that Resident #27 reported she did not receive a bed bath on Friday (05/16/2025). S2DON confirmed there was no documentation that Resident #27 received a bed bath on Friday (05/16/2025). Resident #40 Record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #40 diagnoses included unspecified dementia, generalized anxiety disorder, schizoaffective disorder, muscle wasting and atrophy multiple sites, generalized muscle weakness, lack of coordination, and abnormalities of gait and mobility. Review of quarterly MDS assessment dated [DATE] revealed BIMS score of 8 which indicated Resident #40 was moderately cognitively impaired. Further review revealed Resident #40 required substantial/maximal assistance with personal hygiene, dressing upper and lower body, shower/bathe, and toileting. Review of the care plan revealed Resident #40 had an ADL self-care deficit. An intervention listed was maximal assistance x1 with personal hygiene. On 05/19/2025 at 10:28 a.m. and 05/20/2025 at 10:10 a.m., observations of Resident #40 revealed fingernails on both hands were very long. On 05/21/2025 at 9:15 a.m., an observation conducted with S2DON in Resident #40's room revealed Resident #40's fingernails on both hands were very long. S2DON confirmed Resident #40's fingernails were long and needed to be trimmed. Resident #3 Review of the medical record for Resident #3 revealed an admission date of 01/14/2009 with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, psychosis, schizophrenia, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that Resident #3 was cognitively intact. The MDS also indicated that Resident #3 required substantial/maximal assistance with personal hygiene. On 05/19/2025 at 1:35 p.m. it was noted that Resident #3 had lengthy facial hair below the nose and on the chin. On 05/20/2025 at 11:30 a.m., Resident #3 was observed in her room with lengthy facial hair below the nose and on the chin. On 05/20/2025 at 11:52 a.m. an interview with S5Certified Nursing Assistant (CNA) revealed that Resident #3 should receive baths on Monday, Wednesday, and Friday. Review of the April and May 2025 Documentation Survey Report v2 revealed Resident #3's bath days were scheduled for Tuesday, Thursday, and Saturday. Further review of the report revealed the only documentation of bathing was completed on 04/07/2025, 05/05/2025, and 05/19/2025 for the months of April and May 2025. On 05/21/2025 at 12:06 p.m., S2DON confirmed that Resident #3 did not have baths documented.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #13 Review of the medical record for Resident #13 revealed an admission date of 09/01/2020. Resident #13 had diagnoses including heart disease, chronic obstructive pulmonary disease (COPD), depressive disorder, diabetes mellitus, paranoid schizophrenia, muscle wasting, cognitive communication deficit, and moderate intellectual disabilities. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 14 which indicated the resident had intact cognition for daily decision making and required partial to moderate assistance with toileting and bathing. Review of the Fall Risk assessment dated [DATE] revealed Resident #13 was at risk for falls. Review of the Incident/Accident report dated 04/22/2025 at 9:10 a.m. revealed Resident #13 was found sitting on the floor in front of his wheelchair alert and oriented. Review of the current care plan revealed the Resident had limited physical mobility. Further review of the care plan revealed the fall on 04/22/2025 was not addressed on the care plan. Review of the medical record revealed no documented evidence of an intervention attempted after Resident #13 was found on the floor on 04/22/2025. On 05/21/2025 at 11:55 a.m. S2DON confirmed no new interventions were attempted after Resident #13 had a fall on 04/22/2025 and also confirmed the fall on 04/22/2025 was not addressed on the care plan. Based on interviews, observations, and record reviews, the facility failed to ensure Residents remained as free of accident hazards as possible for 2 (#13 and #61) of 4 (#13, #19, #61 and #62) Residents reviewed for accidents. The facility failed to ensure: 1) an appropriate intervention was attempted after each fall for Resident #61, and 2) new interventions were attempted after each fall for Resident #13 and #61. Findings: Review of the facility's Accident Hazards/Supervision/Devices policy dated 03/2023 revealed in part: Purpose: To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents. Policy: The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to Residents to avoid preventable accidents. 5. Facility data will be used to aid in identification of potential hazards, risks and solutions. 10. Interventions will be based on the results of the evaluation and analysis of information related to hazards and risks. Interventions will be consistent with professional standards. 13. Monitoring and modification process may include: a. Verifying that interventions are implemented as planned; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed, and; d. Evaluating the effectiveness of new interventions. Resident #61 Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Further review of the MDS revealed the Resident required assistance with activities of daily living. Section J of the MDS revealed no falls documented for Resident #61. Review of the facility's incident/accident log revealed falls for Resident #61 on 04/22/2025, 04/23/2025, 05/13/2025, and 05/18/2025. Review of Resident #61's Incident and Accident reports revealed the following: 04/22/2025- staff were walking by Resident's room and heard something hit the floor and saw Resident #61 fall on her bottom with no injuries; 04/23/2025- nurse received report from certified nursing aide (CNA) that the resident lost her balance and hit her head on the door frame, and the CNA caught the resident before she fell, was going to bathroom and lost her balance, no injuries; 05/13/2025- nurse was notified by CNA that Resident #61 had slid out of her wheelchair onto the floor, no injuries; and 05/18/2025- Resident was found on the floor, resident had rolled out of the bed, no injuries. Review of Resident #61's current care plan revealed Resident #61 had actual falls with unsteady gait. Further review of the care plan revealed Resident #61 had a fall on 04/22/2025, 04/23/2025, 05/13/2025, and 05/18/2025. Review of the interventions for the fall on 04/22/2025 revealed staff education to ensure Resident's wheelchair is within reach. Review of the interventions for the fall on 04/23/2025 revealed to remind Resident to call for assistance with any transfers or getting from one place to the other. Falls on 05/13/2025 and 05/18/2025 were not added to the fall care plan. An interview on 05/21/2025 at 11:45 a.m. with S2Director of Nursing (DON) confirmed the intervention (reminding the Resident to call for assist with transfers or getting from one place to another) for Resident #61's fall on 04/23/2025 was not appropriate due to resident's cognition. S2DON confirmed that the facility failed to identify and implement interventions for Resident #61's falls on 05/13/2025 and 05/18/2025.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to: 1) assess Residents for risk of entrapment from bed rails prior to installation of bed rails, 2) obtain informed consent from the Resident or Resident's responsible party for bed rail use, 3) ensure a physician's order for bed rail use, and 4) ensure care plan reflected the use of bed rails for 3 (#8, #18, #321) of 3 (#8, #18, #321) Residents reviewed for bedrails. Findings: Review of the facility's Quality of Care Bedrails policy dated 03/20203 revealed: Purpose: To provide for resident safety if bed rails are used. Policy: The facility will attempt to use alternatives prior to installing a bed rail, including side rails, grab bars, and other assist rails. Prior to implementing a bed rail, the facility will assess the resident for entrapment, inform the resident and or representative of the risk and benefits of bed rails and obtain consent and verify that the bed is suited to the resident's size and weight. Manufacturer's recommendations will be followed when installing bed rails. Guidelines: 1. Prior to utilizing a bed rail, alternative measures will be attempted to meet the resident's needs and provide for his/her safety. 2. The resident will be assessed for risk of entrapment and possible benefits of bed rails, if it is determined that alternative measures are not effective. 3. The resident and/or representative will be informed of the risk and benefits of bed rails and informed consent will be obtained prior to instillation of bed rail. 4. Bed rails will be maintained and installed according to manufacturer recommendations. 5. Bed rails will be compatible with the bed frame and mattress in use by the resident. 6. Bed rails that are in use will be checked routinely to verify condition and installation security. 7. If a bed rail is implemented, the resident will re-assessed at routine intervals to verify the on-going need for the bed rail. 8. A bed rail will be used for the shortest time necessary to meet the needs of the resident. 9. Use of a bed rail will be reflected in the resident care plan. Resident #8 Record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #8's diagnoses included type 2 diabetes mellitus, generalized muscle weakness, hypertension, heart failure, chronic kidney disease, pain unspecified, and repeated falls. Review of active May 2025 Physician orders revealed there was no order for Resident #8 to have bilateral quarter bed rails. On 05/19/2025 at 9:40 a.m., 05/20/2025 at 9:00 a.m., and 05/21/2025 at 8:00 a.m., observations of Resident #8 revealed he was lying in bed with head of bed elevated up 15 degrees, quarter bed rails times 2 at the head of bed were in the upright position. Review of the care plan revealed Resident #8's plan of care did not include the use of bilateral quarter bed rails. Further record review revealed no documentation Resident #8 was assessed for the risk of entrapment from bed rails prior to the installation of bed rails or an informed consent was obtained for bed rails. On 05/21/2025 at 9:45 a.m. an interview with S7Regional Director of Clinical confirmed Resident #8 had not been assessed for bed rails, assessed for entrapment prior to the installation of bed rails, obtained an informed consent for bed rails, obtained an order for bed rails, or added bed rails to the care plan. Resident #18 Record review revealed Resident #18 was initially admitted to the facility 12/20/2023 and readmitted to the facility on [DATE]. Resident #18's diagnoses included acute necrotizing hemorrhagic encephalopathy, unspecified pain, paranoid schizophrenia, generalized anxiety disorder, generalized muscle weakness, seizures, and lack of coordination. Review of active May 2025 Physician orders revealed there was no order for Resident #18 to have quarter bed rail. Review of the care plan revealed Resident #18's plan of care did not include the use of a quarter bed rail. Further record review revealed no documentation Resident #18 was assessed for the risk of entrapment from bed rails prior to installation of bed rails or an informed consent obtained for bed rails. On 05/19/2025 at 10:45 a.m., an observation of Resident #18 revealed he was lying on his right side with right quarter bed rail in the upright position at the head of the bed, and left side of the bed was positioned next to the wall. On 05/21/2025 at 9:45 a.m. an interview with S7Regional Director of Clinical confirmed Resident #18 had not been assessed for bed rails, assessed for entrapment prior to the installation of bed rail, obtained an informed consent for bed rails, obtained an order for bed rails, or added bed rail to the care plan. Resident #321 Review of Resident #321's medical record revealed an admission date of 05/13/2025 with diagnosis which included in part: anemia, syncope and collapse, adult failure to thrive, and subluxation of cervical vertebrae. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #321 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #321 was cognitively intact. Further review of MDS revealed that Resident #321 was able to transfer self with standby assist. Observations on 05/19/2025 at 7:30 a.m., 05/20/2025 at 10:10 a.m., and 05/21/2025 at 8:12 a.m. of Resident #321's right upper quarter bedrail was observed on bed in the up position while the Resident was laying in it. On 05/20/2025 at 11:08 a.m., record review reveals that Resident #321's record did not have a physician's order for bed rail use, care plan, or bed rail assessment. On 05/21/2025 at 9:45 a.m., interview with S7Regional Director of Clinical confirmed that the facility did not assess Resident #321 for bed rails or risks of entrapment prior to the installation of bed rail. S7Regional Director of Clinical also confirmed that Resident #321 did not have a physician's order, consent, or care plans for bed rails.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each Resident by having staff fail to follow physician orders for 1 (#32) of 5 (#32, #3, #36, #63, #61) reviewed for unnecessary medications. Findings: Review of the medical records revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of the physician orders revealed Resident #32 was to receive accu-checks four times daily. If the results were 401 or greater, staff were to administer 10 units of insulin and call the physician. Review of the accu-check results revealed the following: On 05/02/2025 at 10:00 a.m., Resident #32 had an accu-check of 434. There was no documentation that the physician was notified. On 05/03/2025 at 10:00 a.m., Resident #32 had an accu-check of 407. There was no documentation that the physician was notified. On 05/11/2025 at 10:00 a.m., Resident #32 had an accu-check of 455. There was no documentation that the physician was notified. On 05/16/2025 at 10:00 a.m., Resident #32 had an accu-check of 410. There was no documentation that the physician was notified. On 05/17/2025 at 10:00 a.m., Resident #32 had an accu-check of 423. There was no documentation that the physician was notified. On 05/20/2025 at 3:15 p.m., interview with S2Director of Nursing (DON) confirmed there was no documentation that the staff notified the physician when Resident #32 had an accu-check of 401 or greater.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the physician documented a rationale for denying a gradual dose reduction for 1 (#32) of 5 (#32, #3, #36, #63, #61) Residents reviewed for unnecessary medications, and 2) The pharmacist failed to identify irregularities related to adequate monitoring of prescribed medications for 2 (#3 and #36) of 5 (#3, #36, #32, #63, #61). Findings: Review of the facility's Pharmacy Services: Medication Regimen Review Policy number 756 dated 03/2023 revealed the following, in part: Policy: The medication regimen will be reviewed at least monthly by a licensed pharmacist. The facility develops a system which supports irregularities acted upon in order to minimize adverse consequences which may be associated with medications. Guidelines: 4. The pharmacist reports any irregularities in a separate written report to the attending physician, medical director and the director of nursing. The recommendations are reviewed, and a response provided, in a timely manner, dependent upon the nature of the concern. 5. If recommendation is declined, the response includes a valid clinical rationale for rejection of the pharmacist's recommendation unless warranted by a change in the resident's condition or other circumstances. Resident #32 Review of the medical record for Resident #32 revealed he was admitted on [DATE] with diagnoses which included bipolar disorder and depression. Review of the physician orders revealed Resident #32 received the medications Haldol and Seroquel for the treatment of bipolar disorder and Escitalopram for the treatment of depression. Review of the consultant Pharmacist reports revealed a dose reduction letter recommending a gradual dose reduction for Seroquel and Escitalopram. The physician chose not to attempt a gradual dose reduction, but the physician failed to give a clinical rationale denying the gradual dose reduction and simply responded with the one word response severity. On 05/20/2025 at 11:45 a.m., interview with S2Director of Nursing (DON), confirmed the physician did not respond with an adequate rationale for declining a dose reduction for Resident #32. Resident #3 Review of the medical record for Resident #3 revealed an admission date of 01/14/2009 with diagnoses that included cerebral infarction, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, malignant neoplasm of pancreas, psychosis, schizophrenia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Resident #3 was cognitively intact. Review of the May 2025 Medication Administration Record (MAR) revealed that Resident #3 was prescribed Levothyroxine daily. Review of the monthly drug regimen review revealed that the pharmacist failed to report irregularities related to the need for Resident #3's thyroid level to be monitored. On 05/21/2025 at 1:40 p.m., S7Regional Director of Clinical confirmed that the pharmacist did not identify the irregularity related to monitoring lab work. Resident #36 Review of the medical record for Resident #36 revealed an admission date of 02/07/2025 with diagnoses that included Parkinson's disease, dysphagia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, and seizures. Review of the Medicare 5 day MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated that resident #36 was cognitively intact. Review of the May 2025 MAR revealed that Resident #36 was prescribed Atorvastatin Calcium nightly. Review of the monthly drug regimen review revealed that the pharmacist failed to report irregularities related to the need for Resident #36's lipid panel to be monitored. On 05/21/2025 at 1:40 p.m., S7Regional Director of Clinical confirmed that the pharmacist did not identify the irregularity related to monitoring lab work.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure it maintained an effective pest control so that the facility was free of pests by having flies throughout the facility on all days of the survey, and by observing flies in Resident #52, #15 and #20's room. Findings: On all days of the survey flies were observed throughout the facility. Resident #52 On 05/19/2025 at 10:16 a.m., Resident #52 reported he had to constantly shoo flies away from his food when he ate. Several flies were observed in the resident's room at that time. On 05/20/2025 at 7:50 a.m., Resident #52 was in his room eating breakfast. Resident #52 was observed swatting flies away as he ate. Resident #52 also reported flies remained a problem in his room. Resident #15 On 05/19/2025 at 9:25 a.m., Resident #15 voiced concerns that flies are bad in his room and throughout the facility. Several flies observed in his room at that time. On 05/20/2025 at 7:45 a.m., Resident #15 was in his room. Resident #15 reported flies remained a problem in his room and several flies were observed in his room. Resident #20 On 05/19/2025 at 11:30 a.m., observation of Resident #20's room revealed numerous flies. On 05/19/2025 at 11:32 a.m., an interview with Resident #20 revealed the flies were bad in his room and in the hallways. On 05/20/2025 at 10:03 a.m., observation of Resident #20's room revealed there were multiple flies. On 05/21/2025 at 01:07 p.m., S1Administrator was informed of the numerous amount of flies in resident rooms and throughout the facility observed during each day the survey. S1Administrator confirmed he had also observed flies within throughout the building.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure that required dementia management and abuse prevention training was completed for 2 (S11Certified Nursing Assistant [CNA], S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed. Additionally, the facility failed to ensure that competencies and skills training was provided for 4 (S8CNA, S9CNA, S10CNA, S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed. Findings: Review of S11CNA's personnel record revealed no documented evidence of required dementia management, abuse prevention training, or competencies and skills training. Review of S12CNA's personnel record revealed no documented evidence of required dementia management and abuse prevention training. Review of S8CNA's personnel record revealed no documented evidence of competencies and skills training. Review of S9CNA's personnel record revealed no documented evidence of competencies and skills training. Review of S10CNA's personnel record revealed no documented evidence of competencies and skills training. On 05/21/2025 at 2:07 p.m., S2Director of Nursing confirmed that there was no documented evidence of dementia management, abuse prevention, and competencies/skills training.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to ensure nurse staffing data requirements were posted daily in a prominent location and readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 68 residents who resided in the facility. Findings: On 05/19/2025 at 8:00 a.m., the daily staffing for 05/19/2025 was unable to be located. On 05/20/2025 at 10:05 a.m., the daily staffing for 05/20/2025 was unable to be located. On 05/20/2025 at 10:10 a.m., an interview and observation were conducted with S2Director of Nursing (DON). S2DON confirmed that the daily staffing had not been posted.

Apr 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by S6Certified Nursing Aide (CNA) for 1 (#5) of 3 (#1, #3, and #5) sampled residents reviewed for abuse. Findings: Review of the facility's Freedom from Abuse, Neglect, and Exploitation, revised 03/2023, revealed the following, in part: Purpose: To keep residents free from abuse, neglect, and corporal punishment of any kind by any person. Policy: The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. This protection extends to abuse by staff, consultants, contractors, volunteers, students, and visitors (collectively staff). Guidelines: 4. Staff to resident abuse: a. Staff are expected to be in control of their behavior, are to behave professionally, and understand how to work with the facility population. For example, striking a combative resident is not considered appropriate. b. A knee-jerk or reflexive reaction is not acceptable. c. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm. d. Retaliation by staff is abuse, regardless of whether harm was intended. Types of Abuse: 3. Mental and Verbal Abuse a. Verbal and nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. b. Verbal abuse may be considered to be a type of mental abuse. c. Verbal abuse may be oral, written, or gestured communication or sounds to residents within hearing distance regardless of the residents' ability to comprehend. Review of the record for resident #5 revealed an admission date of 07/02/2013 with diagnoses including anoxic brain damage, other intracranial injury without loss of consciousness, cervical root disorders, mild protein calorie malnutrition, major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, delusional disorders, psychotic disorder with delusions due to known physiological condition, pain, and impulse disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 indicating unable to determine cognitive function. Further review of the MDS revealed the resident required moderate to maximal assistance with activities of daily living. Review of the resident's current care plan revealed the resident had aggressive behaviors and had one on one care 24 hours per day. Review of the facility's investigation dated 04/18/2025 revealed S2Director of Nursing (DON) notified S1Admininstrator at 5:00 p.m. that S5Agency Licensed Practical Nurse (LPN) overheard S6CNA raise his voice and use inappropriate language to resident #5. S6CNA notified S5Agency LPN that resident #5 had grabbed him with her nails and it was painful. Interview on 04/22/2025 at 9:10 a.m. with S5Agency LPN revealed on 04/18/2025 about 10:00 a.m. she overheard someone raise their voice and say b let me go. She turned around and it was S6CNA that had said this to resident #5. S6CNA told S5Agency LPN that resident #5 had grabbed his wrist and it was painful. S5Agency LPN reported that S6CNA immediately apologized. Interview on 04/22/2025 at 10:08 a.m. with S6CNA reported he was working one on one with resident #5 on 04/18/2025. S6CNA reported that around 9:00 a.m. to 10:00 a.m. resident #5 grabbed his wrist and her nails dug into him and he pulled his arm back. S6CNA reported he did not remember cussing at resident #5, but he was in pain. S6CNA reported that resident #5 had a history of hitting, pinching, and grabbing staff. S6CNA acknowledged he reported this to the nurse that was on the hall. S6CNA reported he has worked with resident #5 for 2 years. Interview on 04/22/2025 at 11:05 a.m. with S2DON revealed she was notified on 04/18/2025 about 2:30 p.m. by S5Agency LPN that S5Agency LPN overheard S6CNA say b let me go to resident #5. S2DON revealed she removed S6CNA from caring for resident #5 on 04/18/2025 at approximately 1:00 p.m., however S2DON revealed she was not aware of the allegation of verbal abuse by S6CNA to resident #5 until approximately 2:30 p.m. An interview on 04/22/2025 at 1:20 p.m. with S1Administrator confirmed that he was notified on 04/18/2025 by S2DON at 5:00 p.m. that S5Agency LPN overheard S6CNA cuss at resident #5. S1Administrator confirmed that S6CNA was suspended while the incident was under investigation.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents recieved the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management for 1 (#4) of 2 (#3, #4) sampled residents reviewed for pain management. Findings: Review of the record revealed an admission date of 05/03/2024 with diagnoses including paresthesia of skin, morbid obesity, bipolar disorder, hypertension, cellulitis of groin, lumbar radiculopathy, sleep apnea, aggressive behavior, open fracture of first lumbar vertebra, stenosis of lateral recess of lumbar spine, prolapsed lumbar intervertebral disc, and secondary kyphosis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of the April 2025 Physician's Orders revealed an order dated 02/27/2025 for Oxycodone-Acetaminophen oral tablet 10-325 milligrams (mg) give 1 tablet by mouth (po) every 8 hours (hrs) as needed (prn) pain. Review of the March 2025 Medication Administration Record (MAR) revealed the following: March 2025- Oxycodone-Acetaminophen 10-325 mg 1 tablet po every 8 hrs prn pain was administered 45 times. Review of the April 2025 MAR revealed Oxycodone-Acetaminophen 10-325 mg was not administered from 04/01/2025 through 04/03/2025. Review of the Controlled Drug Record for resident #4 revealed resident's Oxycodone-Acetaminophen 10-325 mg was not available for resident #4 from 03/31/2025 through 04/03/2025. Review of the resident's current care plan revealed the following: resident has pain- interventions included administer analgesia as per orders, give 1/2 hour before treatments or care, and anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the nurse's note dated 04/03/2025 at 9:59 a.m. revealed resident was agitated and upset about his pain medicine and proceeded to fuss at the nurse about the pain medicine. Nurse offered resident #4 Tylenol and ibuprofen and he refused. Nurse assured him that he will have to wait until pharmacy deliver his meds. Nurse tried to use non-pharmacological method of distraction but resident was still upset. Nurse stated I told him he's fussing at me over something I have no control of and have to continue to pass meds he then states yeah you always say that I then turned to leave out the room and he yelled out and f . you I then left out the room An interview on 04/21/2025 at 2:40 p.m. with S7Licensed Practical Nurse (LPN) revealed that she has been working at the facility for a little over a month and she provided care to resident #4. S7LPN confirmed resident #4 did run out of his pain medication since she had been working at the facility but was unsure of the dates. On 04/20/2025 at 4:20 p.m., an interview with resident#4 was conducted in the privacy of his room. Resident#4 reported he was without his as needed (prn) pain medication from 03/31/2025 through 04/03/2025. On 04/22/2025 at 10:35 a.m. S2Director of Nursing (DON) and S4Corporate Registered Nurse (RN) confirmed resident #4 did not have his prn Oxycodone-Acetaminophen 10-325 mg available from 03/31/2025 through 04/03/2025.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to the State Survey Agency in accordance with State law for 2 (#1, #5) of 4 (#1, #3, #5, #6) residents investigated for possible abuse or neglect. The failed practice was evidenced by the facility failing to report: 1.) an injury of unknown source to the State Survey Agency within 2 hours of the incident which involved resident #1 and 2.) abuse to the administrator and State Survey Agency within 2 hours of an incident involving resident #5. Findings: Policy/Procedure Review of abuse policy with a revision date of 05/15/2023 revealed the following in part: Response to Allegations and Suspicions 1. Allegations may be verbal or in writing and will be reported to the administrator of the facility and other officials as required. 2. Report any reasonable suspicion of a crime against a resident that involves serious bodily injury immediately, but not later than (2) hours after forming the suspicion. 3. In the absence of abuse or serious bodily injury, reporting is required not later than 24-hours after forming the suspicion. Investigation: 1. The facility Administrator/designee will conduct thorough investigations of alleged violations and report the findings to the State agency within 5 working days of the allegation. 2. The facility will immediately protect the resident from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. This includes: a. Removing employee/s from duty when an allegation has been made until the investigation has been completed and a determination has been made. b. Separating involved residents to protect the alleged victim. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, conversion disorder with seizures or convulsions, acute kidney failure, adjustment disorder with anxiety, pain, abnormal posture, muscle spasm, and lack of coordination. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 00 indicating unable to determine cognitive functioning. Review of accident/incident reports revealed a report involving resident #1 dated 03/21/2025. The report acknowledged resident #1 was found in his bed with a small laceration to the back of his head on 03/21/2025 at 7:05 p.m. Resident #1 was sent to a hospital and received two sutures to the back of his head. The incident category was reported as an injury of unknown origin. The report recorded the incident was reported to the State Survey Agency on 03/22/2025 at 4:39 p.m. On 04/22/2025 at 1:02 p.m., an observation and attempted interview with resident #1 was conducted in his room. Resident #1 could not answer simple yes or no questions verbally or with body gestures. Resident #1 could not report any information related to the laceration to the back of his head that occurred on 03/21/2025. On 04/23/2025 at 1:10 p.m., a telephone interview was conducted with S8Certified Nursing Aide (CNA). S8CNA reported she was in the hallway outside of resident #1`s room on 03/21/2025 around 7:00 p.m., when she heard a loud noise in the room. S8CNA reported the room door was closed and resident #1 and resident #7 (roommate) were the only people in the room. S8CNA reported she discovered resident #1 in his bed with a laceration to the back of the head. She reported resident #1 was lying on his side facing the wall and resident #7 was standing beside resident #1`s bed. S8CNA reported resident #7 responded he didn`t know when S8CNA asked resident #7 what happened. On 04/23/2025 at 1:15 p.m., an interview with S2Director of Nursing (DON) revealed their investigation could not determine how resident #1 obtained the laceration to the back of his head. S2DON reported resident #7 consistently reported he did not know what happened and denied injuring resident #1. On 04/23/2025 at 1:52 p.m., an interview with S9Licensed Practical Nurse (LPN) confirmed she was working the evening of 03/21/2025. She reported there was no blood observed anywhere in in resident #1`s room other than to the back of his head and on the cover where his head was laying. S9LPN reported resident #7 was in close proximity to resident #1`s bed. S9LPN reported resident #7 did not have any blood on him. S9LPN reported resident #7 reported he did not know what happened to resident #1 and denied making physical contact with him. S9LPN reported there was no physical evidence or admission that could prove resident #7 injured resident #1. S9LPN reported resident #7 had short term memory loss that seemed to have worsened in the past few months. On 04/23/2025 at 4:05p.m., an interview with S4Corporate Registered Nurse confirmed the facility failed to ensure allegations involving an injury of unknown source was reported to the State Survey Agency within 2 hours of the incident on 03/21/2025 involving resident #1. Resident #5 Review of the record revealed an admission date of 07/02/2013 with diagnoses including anoxic brain damage, other intracranial injury without loss of consciousness, cervical root disorders, mild protein calorie malnutrition, major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, delusional disorders, psychotic disorder with delusions due to known physiological condition, pain, and impulse disorder. Review of the Annual MDS assessment dated [DATE] revealed a BIMS score of 99 which indicated unable to determine cognitive function. Further review of the MDS revealed the resident required moderate to maximal assistance with activities of daily living. Review of the resident's current care plan revealed the resident had aggressive behaviors and had one on one care 24 hours per day. Review of the facility's investigation dated 04/18/2025 revealed S2DON notified S1Admininstrator at 5:00 p.m. that S5Agency LPN overheard S6CNA raise his voice and use inappropriate language to resident #5. S6CNA notified S5Agency LPN that resident #5 had grabbed him with her nails and it was painful. Interview on 04/22/2025 at 9:10 a.m. with S5Agency LPN revealed on 04/18/2025 about 10:00 a.m. she overheard someone raise their voice and say b let me go. She turned around and it was S6CNA that had said this to resident #5. S6CNA told S5Agency LPN that resident #5 had grabbed his wrist and it was painful. S5Agency LPN reported that S6CNA immediately apologized. S5Agency LPN reported she failed to notify S2DON immediately but no later than 2 hours when she overheard S6CNA cuss at resident #5. Interview on 04/22/2025 at 10:08 a.m. with S6CNA reported he was working one on one with the resident #5 on 04/18/2025. S6CNA reported that around 9:00 a.m. to 10:00 a.m. resident #5 grabbed his wrist and her nails dug into him and he pulled his arm back. S6CNA reported he did not remember cussing at resident #5, but he was in pain. S6CNA reported that resident #5 had a history of hitting, pinching, and grabbing staff. S6CNA acknowledged he reported this to the agency nurse that was on the hall. Interview on 04/22/2025 at 11:05 a.m. with S2DON revealed she was notified by S5Agency LPN on 04/18/2025 about 2:30 p.m. that S5Agency LPN overheard S6CNA say b let me go to resident #5. S2DON reported that she notified S1Administrator of this on 04/18/2025 around 5:00 p.m. S2DON confirmed that S5Agency LPN failed to notify her immediately when she overheard S6CNA cuss at resident #5. S2DON further acknowledged she failed to report this to S1Administrator until 04/18/2025 at 5:00 p.m. An interview on 04/22/2025 at 1:20 p.m. with S1Administrator confirmed that he was notified by S2DON on 04/18/2025 at 5:00 p.m. that S5Agency LPN overheard S6CNA cuss at resident #5. S1Administrator confirmed that S5Agency LPN failed to report immediately or within 2 hours of her overhearing S6CNA cussing at resident #5. S1Administrator confirmed S2DON failed to report immediately or within 2 hours of an allegation of verbal abuse to S1Administrator. S1Administrator confirmed he failed to submit a report to the State Survey Agency immediately or within 2 hours of an allegation of verbal abuse by S6CNA.

Apr 2025 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to protect resident #1 from being sexually abused by resident #2. The facility failed to provide 1:1 (one to one) supervision to resident #2 after an allegation of sexual abuse. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2025 at 12:33 a.m. when resident #2 returned to the facility and was not monitored 1:1. Resident #1 alleged resident #2 entered her room and touched her breast on 03/14/2025 at 10:44 p.m. Resident #2 was removed from the facility by law enforcement and returned on 03/15/2025 at 12:33 a.m. Resident #2 was placed on 1:1 observation at that time. The facility failed to implement the 1:1 observation; therefore resident #2 entered resident #1's room a second time on 03/15/2025 at 4:47 a.m. and resident #1 alleged resident #2 touched her genitals over her underwear. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/26/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy on Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed the following: When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect resident from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. Review of the facility's One to One Resident Care Guidelines (undated) revealed the following: A resident that requires one to one care means that this resident must be visually monitored every minute of every day until it is identified by the management team that one to one is no longer necessary. This means you may not leave the resident unobserved for any length of time. Review of the medical record of resident #1 revealed she had an admit date of 03/13/2025. Resident #1 had diagnoses which included hemiplegia to one side upper extremity, hemiparesis, aphasia, acute hepatitis C, history of a traumatic brain injury and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the medical record of resident #2 revealed he had an admission date of 12/03/2024. Resident #2 had diagnoses which included Parkinson's, schizoaffective bipolar type, vascular dementia and insomnia. Review of the MDS dated [DATE] revealed he had BIMS score of 9 indicating moderate cognitive impairment. Review of the facility's investigation dated 03/14/2025 revealed on the night of 03/14/2025 at 10:50 p.m., resident #1 reported resident #2 entered her room and grabbed her breast. In the early morning hours of 03/15/2025, resident #1 reported resident #2 entered her room a second time and touched her genitals over her underwear. Review of the progress notes dated 03/14/2025 at 10:50 p.m. revealed S5Licensed Practical Nurse (LPN) documented that a staff member came to the desk and reported that resident #1 alleged resident #2 entered her room. When she sat up her breast fell out of her shirt. Resident #2 grabbed her breast and said he would like to suck on it. Resident #2 then left the room. Resident #1 activated the call light and when staff arrived she reported it to them. Review of the progress notes dated 03/14/2025 at 11:20 p.m. revealed resident #2 was escorted from the building by law enforcement. Review of the progress notes dated 03/15/2025 at 12:33 a.m. revealed resident #2 was returned to the facility by law enforcement. Review of the progress notes dated 03/15/2025 at 5:10 a.m. revealed S5LPN wrote a Certified Nurse Aid (CNA) told her that resident #1 alleged resident #2 entered her room a second time, but that she may have dreamt it. S5LPN spoke with S3CNA who had been assigned to monitor resident #2 one to one. S3CNA reported that resident #2 did not enter the room of resident #1 a second time. Review of the progress notes dated 03/16/2025 at 11:58 a.m. revealed S2Director of Nursing (DON) documented she was speaking with resident #1. Resident #1 reported to her that she initially thought she may have dreamt resident #2 entered her room a second time early in the morning of 03/15/2025, but it wasn't a dream. Resident #1 alleged resident #2 touched her panties at her groin. On 03/27/2025 at 2:50 p.m., interview with S3CNA revealed on 03/15/2025 after resident #2 was returned to the facility by the police, she was instructed to monitor resident #2 one to one by S2DON. S3CNA reported that while she was monitoring resident #2, she also responded to call lights on hall A. On 03/27/2025 at 3:30 p.m., interview with S5LPN revealed on 03/14/2025 shortly before 11:00 p.m., S6CNA approached the nurse's station and reported resident #1 alleged that resident #2 entered her room and grabbed her breast. She went to the resident's room, assessed resident #1, found no injury and resident #1 was not upset. S2DON and the police arrived shortly afterwards. The police escorted resident #2 from the facility. About 1-2 hours later the police returned resident #2 to the facility. After resident #2 returned, S3CNA was assigned to monitor the resident one to one. On the morning of 03/15/2025 around 5:00 a.m., S6CNA approached the nurse's station and reported that resident #1 alleged resident #2 entered her room a second time. The resident was assessed and no injuries were found. Resident #1 said she may have dreamed the incident. After leaving the resident's room, S5LPN asked S3CNA if resident #2 entered the room of resident #1 a second time. S3CNA told her resident #1 did not enter the room of resident #2 a second time. On 03/31/2025 at 12:00 p.m., interview with S1Administrator and S2DON revealed after resident #1 alleged resident #2 entered her room on 03/14/2025 and grabbed her breast, the police were called. When they arrived at the facility, resident #2 was arrested and escorted from the building. The police did not say that they would be returning the resident after processing. S2DON reported she was still in the building when resident #2 was returned by law enforcement. S2DON assigned S3CNA to monitor resident one to one for the remainder of the shift. S1Administrator and S2DON reported the investigation of the allegations indicated resident #2 did enter the room of resident #1 twice, once late in the night of 03/14/2025 and again early in the morning of 03/15/2025. They confirmed S3CNA did not monitor resident #2 one to one and failed to protect resident #1 from potential abuse. A review of the video footage was conducted. The following was observed: On 03/14/2025 at 10:44 p.m., resident #2 entered the room of resident #1. At 10:48 p.m., resident #2 exited the room. At 10:52 p.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. On 03/15/2025 at 4:47 a.m., resident #2 entered the room of resident #1. At 4:50 a.m., resident #2 exited the room of resident #1. At 4:54 a.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. Resident #2 was alone and there was no staff monitoring the resident one to one. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/18/2025: Corrective Action: 1) Full body assessment completed on the resident #1 on 03/14/2025. 2) Resident # 1 was offered to be evaluated at the emergency room and declined on 03/14/2025 3) Police notified and the accused resident #2 was taken into custody on 03/14/2025. 4) Accused resident #2 was placed on 1:1 upon return to facility on 03/15/2025. 5) DON/Designee has put daily monitors in place on 03/15/2025 for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited. 6) DON/Designee has in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, noting sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbally returned demonstrations of types of abuse, signs and proper reporting procedures. 7) A Statewide Incident Management System (SIMS) report was initiated on 03/14/2025 Identification of others at risk: 1) All residents had the potential to be affected. 2) DON/Designee has interviewed all residents with a BIMs of 8 or greater -03/15/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 3) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings 03/15/2025. Systemic Change: 1) DON/Designee in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on the care expectations of a resident in 1:1 care, abuse, noting sexual and verbal abuse, the proper reporting procedure, and how to identify abuse and signs of abuse. Employees gave verbal return demonstrations of types of abuse, signs, and proper reporting procedures. Monitoring 1) The DON or designee will complete interviews with residents with a BIM score of 8 or greater weekly until they are compliant by 03/18/2025. 2) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings weekly until compliant-compliant 03/18/2025. 3) A regional team or corporate office nurse has been onsite since 03/17/2025 and will contact the facility daily for 2 weeks by phone or onsite to review audits and any new allegations of abuse. Then weekly for 1 month. The nurse(s) from the regional team or home office assist with investigations, observe the treatment of residents, perform chart audits, and provide oversight and consultation. 4) On 03/18/2025, the DON/Designee will perform walking rounds in which 10 residents (5 with BIMs >8 and 5 with BIMs <8) will be visited by the department head. Five residents will be interviewed regarding abuse for those who can be interviewed. At the same time, a skin check will be completed by a nurse for those residents unable to be interviewed to identify any abuse concerns for 2 weeks. This will then continue with 6 residents (3 with BIMs >8 and 3 with BIMs <8) daily for 4 weeks. Results from the resident interviews, assessments, and staff questionnaires will be reported to the QA committee weekly to assess the ongoing need for continued education or revisions to the plan. At that time, based on evaluations, the QA committee will determine the frequency at which resident interviews, assessments, and staff questionnaires should continue. Any concerns identified will be corrected immediately and reported to the administrator. 5) The Director of Nursing or a regional staff member will review all resident interviews and assessments daily for grievances/concerns. Starting on 03/15/2025, investigations will be initiated upon receipt. 6) The Director of Nursing and Administrator will review and discuss all resident-to-resident altercations daily, starting on 03/15/2025, to ensure that the resident is protected, the perpetrator is removed from the resident care area, reports to the Regulatory entities are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Regional [NAME] President, Director of Clinical Operations, Regional Controller and or Regional Nurse Consultant will review the investigation to ensure protection of the resident, that the perpetrator is removed from the resident care area that reports are filed timely, and a thorough investigation has been completed. This will occur daily for 2 weeks. After 2 weeks, it will be discussed in the Quality Assurance Performance Improvement committee meeting, at which time it will be determined at what frequency the audits need to continue. 7) The Regional Nurse Consultant, Regional Controller, or corporate staff member will complete administrative oversight of the facility daily for two weeks beginning 03/15/2025, then weekly for four weeks, then monthly. 8) A Quality Assurance meeting will be held weekly until immediacy is removed beginning on 03/18/2025, then for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A Quality Assurance meeting was held on 03/19/2025, and an action plan was formulated and implemented. On 03/26/2025, a second Quality Assurance meeting was held to review the current plan for any needed revisions, compliance, and/or further education. At that time, based upon evaluation, the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being, identify facility concerns, and implement a correction plan to involve all facility staff. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Regional Nurse of Clinical or a member of the regional staff daily until the removal of immediacy beginning 03/15/2025, then weekly for 4 weeks, then monthly.

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Abuse Prevention Policies (Tag F0607)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure it implemented written policies and procedures that prohibited the abuse of residents for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to implement their Abuse and One to One Monitoring policies. The facility failed to provide one to one (1:1) supervision to resident #2 after an allegation of sexual abuse. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2025 at 12:33 a.m. when resident #2 returned to the facility and was not monitored 1:1. Resident #1 alleged resident #2 entered her room and touched her breast on 03/14/2025 at 10:44 p.m. Resident #2 was removed from the facility by law enforcement and returned on 03/15/2025 at 12:33 a.m. Resident #2 was placed on 1:1 observation at that time. The facility failed to implement the one to one observation; therefore resident #2 entered resident #1's room a second time on 03/15/2025 at 4:47 a.m. and resident #1 alleged resident #2 touched her genitals over her underwear. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/26/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy on Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed the following: When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect resident from additional abuse immediately. This includes but is not limited to: a. Take steps to prevent further potential abuse. Review of the facility's One to One Resident Care Guidelines (undated) revealed the following: A resident that requires one to one care means that this resident must be visually monitored every minute of every day until it is identified by the management team that one to one is no longer necessary. This means you may not leave the resident unobserved for any length of time. Review of the medical record of resident #1 revealed she had an admit date of 03/13/2025. Resident #1 had diagnoses which included hemiplegia to one side upper extremity, hemiparesis, aphasia, acute hepatitis C, history of a traumatic brain injury and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of the medical record of resident #2 revealed he had an admission date of 12/03/2024. Resident #2 had diagnoses which included Parkinson's, schizoaffective bipolar type, vascular dementia and insomnia. Review of the MDS dated [DATE] revealed he had BIMS score of 9 indicating moderate cognitive impairment. Review of the facility's investigation dated 03/14/2025 revealed on the night of 03/14/2025 at 10:50 p.m., resident #1 reported resident #2 entered her room and grabbed her breast. In the early morning hours of 03/15/2025 resident #1 reported resident #2 entered her room a second time and touched her genitals over her underwear. Review of the progress notes dated 03/14/2025 at 10:50 p.m. revealed S5Licensed Practical Nurse (LPN) documented that a staff member came to the desk and reported that resident #1 alleged resident #2 entered her room. When she sat up her breast fell out of her shirt. Resident #2 grabbed her breast and said he would like to suck on it. Resident #2 then left the room. Resident #1 activated the call light and when staff arrived she reported it to them. Review of the progress notes dated 03/14/2025 at 11:20 p.m revealed resident #2 was escorted from the building by law enforcement. Review of the progress notes dated 03/15/2025 at 12:33 a.m. revealed resident #2 was returned to the facility by law enforcement. Review of the progress notes dated 03/15/2025 at 5:10 a.m. revealed S5LPN wrote a Certified Nurse Aid (CNA) told her that resident #1 alleged resident #2 entered her room a second time, but that she may have dreamt it. S5LPN spoke with S3CNA who had been assigned to monitor resident #2 one to one. S3CNA reported that resident #2 did not enter the room of resident #1 a second time. Review of the progress notes dated 03/16/2025 at 11:58 a.m. revealed S2Director of Nursing (DON) documented she was speaking with resident #1. Resident #1 reported to her that she initially thought she may have dreamt resident #2 entered her room a second time early in the morning of 03/15/2025, but it wasn't a dream. Resident #1 alleged resident #2 touched her panties at her groin. On 03/27/2025 at 2:50 p.m., interview with S3CNA revealed on 03/15/2025 after resident #2 was returned to the facility by the police, she was instructed to monitor resident #2 one to one by S2DON. S3CNA reported that while she was monitoring resident #2 she also responded to call lights on hall A. On 03/27/2025 at 3:30 p.m., interview with S5LPN revealed that on 03/14/2025 shortly before 11:00 p.m., S6CNA approached the nurse's station and reported resident #1 alleged that resident #2 entered her room and grabbed her breast. She went to the resident's room, assessed resident #1, found no injury and resident #1 was not upset. S2DON and the police arrived shortly afterwards. The police escorted resident #2 from the facility. About 1-2 hours later the police returned resident #2 to the facility. After resident #2 returned, S3CNA was assigned to monitor the resident one to one. On the morning of 03/15/2025 around 5:00 a.m., S6CNA approached the nurse's station and reported that resident #1 alleged resident #2 entered her room a second time. The resident was assessed and no injuries were found. Resident #1 said she may have dreamed the incident. After leaving the resident's room, S5LPN asked S3CNA if resident #2 entered the room of resident #1 a second time. S3CNA told her resident #1 did not enter the room of resident #2 a second time. On 03/31/2025 at 12:00 p.m., interview with S1Administrator and S2DON revealed after resident #1 alleged the resident #2 entered her room on 03/14/2025 and grabbed her breast, the police were called. When they arrived at the facility, resident #2 was arrested and escorted from the building. The police did not say that they would be returning the resident after processing. S2DON reported she was still in the building when resident #2 was returned by law enforcement. S2DON assigned S3CNA to monitor resident one to one for the remainder of the shift. S1Administrator and S2DON reported the investigation of the allegations indicated resident #2 did enter the room of resident #1 twice, once late in the night of 03/14/2025 and again early in the morning of 03/15/2025. They confirmed S3CNA did not monitor resident #2 one to one and failed to protect resident #1 from potential abuse. A review of the video footage was conducted. The following was observed: On 03/14/2025 at 10:44 p.m., resident #2 entered the room of resident #1. At 10:48 p.m., resident #2 exited the room. At 10:52 p.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. On 03/15/2025 at 4:47 a.m., resident #2 entered the room of resident #1. At 4:50 a.m., resident #2 exited the room of resident #1. At 4:54 a.m., the call light was activated, a CNA entered the room then exited the room in the direction of the nurse's station. Resident #2 was alone and there was no staff monitoring the resident one to one. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/18/2025: Corrective Action 1) Resident #2 remained on 1:1 care and was sent to in-patient psych on 03/15/2025. 2) Resident #1 was offered to be evaluated at ER and declined on 03/15/2025 3) Police notified of the second occurrence on 3/15/2025. 4) Full body skin assessment of Resident #1 completed on 03/15/2025. 5) DON/Designee has put daily monitors in place on 03/15/2025 for each shift for resident #1 that staff will ask resident does she feel safe in the facility with no psycho-social harm exhibited 6) DON/Designee has in-serviced all employees and agency personnel starting on 03/15/2025 and will educate all employees and agency staff prior to the beginning of their shift on care expectations of a resident on 1:1 care, abuse, sexual and verbal, and the proper reporting procedure and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs and proper reporting procedures. 7) Staff involved received disciplinary action 03/15/2025 and resigned from her position at the facility. Identification of others at risk 1) All residents had the potential to be affected 03/15/2025. 2) DON/Designee has interviewed all residents with a BIMs of 8 or greater 03/15/2025 to determine if they have experienced sexual/verbal abuse, and if they feel safe in the facility with no findings. 3) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings 03/15/2025. Systemic Changes 1) DON/Designee in-serviced all employees and agency personnel starting on 03/14/2025 and will educate all employees and agency staff prior to the beginning of their shift on the care expectations of a resident in 1:1 care, abuse, noting sexual and verbal abuse, the proper reporting procedure, and how to identify abuse and signs of abuse. Employees gave verbal returned demonstrations of types of abuse, signs, and proper reporting procedures. 2) The Regional Director of Clinical (RDC) educated the DON and Administrator on the policies and procedures for Abuse, including immediate provisions to protect residents in abuse situations. This was completed on 03/16/2025. Monitoring: 1.) DON/designee to complete interviews with residents of a BIMs of 8 or greater and weekly until compliant 03/15/2025. 2) DON/Designee has completed full body assessments and observed psycho-social signs of sexual/verbal abuse with no findings on residents with a BIMs score of 8 or less with no findings weekly until compliant. 3) A regional team or corporate office nurse has been onsite since 03/17/2025 and will contact the facility daily for 2 weeks by phone or onsite to review audits and any new allegations of abuse. Then weekly for 1 month. The nurse(s) from the regional team or home office assist with investigations, observe the treatment of residents, perform chart audits, and provide oversight and consultation. 4) On 03/18/2025, the DON/Designee will perform walking rounds in which 10 residents (5 with BIMs >8 and 5 with BIMs <8) will be visited by the department head. Five residents will be interviewed regarding abuse for those who can be interviewed. At the same time, a skin check will be completed by a nurse for those residents unable to be interviewed to identify any abuse concerns for 2 weeks. This will then continue with 6 residents (3 with BIMs >8 and 3 with BIMs <8) daily for 4 weeks. Results from the resident interviews, assessments, and staff questionnaires will be reported to the QA committee weekly to assess the ongoing need for continued education or revisions to the plan. At that time, based on evaluations, the QA committee will determine the frequency at which resident interviews, assessments, and staff questionnaires should continue. Any concerns identified will be corrected immediately and reported to the administrator. 5) The Director of Nursing or a regional staff member will review all resident interviews and assessments daily for grievances/concerns. Starting on 03/15/2025, investigations will be initiated upon receipt. 6) The Director of Nursing and Administrator will review and discuss all resident-to-resident altercations daily, starting on 03/15/2025, to ensure that the resident is protected, the perpetrator is removed from the resident care area, reports to the Regulatory entities are filed timely, and a thorough investigation is completed. The Administrator and one of the following: Regional [NAME] President, Director of Clinical Operations, Regional Controller and or Regional Nurse Consultant will review the investigation to ensure protection of the resident, that the perpetrator is removed from the resident care area that reports are filed timely, and a thorough investigation has been completed. This will occur daily for 2 weeks. After 2 weeks, it will be discussed in the Quality Assurance Performance Improvement committee meeting, at which time it will be determined at what frequency the audits need to continue. 7) The Regional Nurse Consultant, Regional Controller, or corporate staff member will complete administrative oversight of the facility daily for two weeks beginning 03/15/2025, then weekly for four weeks, then monthly. 8) A Quality Assurance meeting will be held weekly until immediacy is removed beginning on 03/18/2025, then for 4 weeks, then monthly for recommendations and further follow-up regarding the above-stated plan. A Quality Assurance meeting was held on 03/19/2025, and an action plan was formulated and implemented. On 03/26/2025, a second quality assurance meeting was held to review the current plan for any needed revisions, compliance, and/or further education. At that time, based upon evaluation, the QA Committee will determine at what frequency any ongoing audits will need to continue. The Administrator has the oversight to ensure an effective plan is in place to meet resident well-being, identify facility concerns, and implement a correction plan to involve all facility staff. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Regional Nurse of Clinical or a member of the regional staff daily until the removal of immediacy beginning 03/15/2025, then weekly for 4 weeks, then monthly.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficient practice was identified for 1 (#7) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents reviewed for allegations of abuse. Findings: Review of the facility`s abuse policy with a revision date of 05/15/2023 revealed in part: Responsibilities of Facilities and covered individuals 2. Reporting responsibilities for reasonable suspicion of a crime in accordance with state law: d. assault and battery Response to Allegations and Suspicions 2. Report any reasonable suspicion of a crime to a resident that involves serious bodily injury immediately, but not later than (2) hours after forming the suspicion. Record review revealed resident #6 was admitted to the facility on [DATE] with diagnoses that included central cord syndrome at C5, diabetes and psychoactive substance dependence. Review of the most recent minimum data set (MDS) assessment dated [DATE] revealed resident #6 had a brief interview of mental status (BIMS) score of 15 which indicated he was cognitively intact. On 09/25/2024 at 8:31 a.m., an interview with resident #6 revealed he and resident #7 had been having words all day on 08/31/2024. He confirmed they were having a disagreement. He reported resident #7 attempted to push him out of his wheelchair and when he could not do that, resident #7 picked up his walker and hit him in the back of the head. Resident #6 reported he refused to go to the ER for evaluation because he wasn`t hurt and was not hit that hard. Resident #6 reported resident #7 hit him one time and they were immediately separated by the staff present with them. Record review revealed resident #7 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, unsteadiness on feet, syphilis, schizophrenia, alcohol dependence, and lack of coordination. Review of the most recent minimum data set (MDS) assessment dated [DATE] revealed resident #7 had a brief interview of mental status (BIMS) score of 9 which indicated he had moderate cognitive impairment. On 09/26/2024 at 08:45a.m, an interview with resident #7 revealed the resident was alert, oriented and calm. Resident #7 confirmed he hit resident #6 in the head with his walker. Resident #7 reported he and resident #6 had been arguing all day and resident #6 would not shut up. Resident #7 reported he got angry and hit resident #6 in the head with his walker. Resident #7 reported that this was the only negative incident he had at the facility and he regretted it. Review of the nurse`s notes dated 08/31/2024 revealed resident #7 hit resident #6 in the head with his walker while outside at the gazebo during their smoke break. The note also revealed S3Licensed Practical Nurse (LPN) assessed both residents and found no injuries. S3LPN recorded there was no redness or swelling to the back of resident #6`s head where he was struck by resident #7 with his walker. On 09/25/2024 at 9:45 a.m., an interview with S3LPN confirmed she assessed resident #6 and resident#7 after the incident on 08/31/2024 and found no injuries to either person. S3LPN reported the responsible parties of both residents were notified as well as the Director of Nursing (DON) and the medical director. Review of the Accident/Incident Reports from 07/01/2024 - 09/23/2024 revealed resident #7 hit resident #6 in the head with his walker on 08/31/2024 at approximately 7:35 p.m. Further review of the incident report revealed S2DON was informed of the incident on the evening of 08/31/2024 (no exact time of the notification). Review of the facility`s state reported incidents revealed the incident, involving resident #6 and resident #7, was reported to the state survey agency on 09/01/2024 at 09:06 a.m. On 09/25/2024 at 1:15 p.m., an interview with S1Administrator confirmed the incident between resident #6 and resident #7 that occurred on 08/31/2024 was not reported to the state agency within 2 hours of the occurrence.

May 2024 18 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to protect a residents' right to be free from physical and psychosocial abuse by a Certified Nursing Assistant (CNA) for 1 (#16) of 4 (#10, #16, #63, and #73) residents reviewed for abuse. The deficient practice resulted in an actual harm for resident #16 (who was cognitively impaired) on 04/28/2024 during the day shift between 6:00 a.m. - 2:00 p.m. when S4CNA was observed by S5CNA and S6CNA punching resident #16 in the face, chest and side several times with a closed fist. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be treated in this manner in her own home or health care facility. Findings: Review of the facility's policy and procedure for Freedom from Abuse, Neglect and Exploitation dated 03/2023 revealed: Purpose: To keep residents free from abuse, neglect, and corporal punishment of any kind by any person. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root disorder, insomnia, anoxic brain damage, delusional disorder, psychotic disorder with delusions due to known physiological condition, dementia with behavioral disturbance, impulse disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #16 had severe cognitive impairment for daily decision making and required extensive assistance with activities of daily living. Review of the physician orders dated 11/01/2023 revealed an order for resident #16 to have one on one care at all times. This physician order continued each month up to the present date of the survey. Review of the current plan of care revealed resident #16 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Resident #16 has a self-care performance deficit and required assistance with activities of daily living. Resident #16 required 1:1 care 24 hours a day. Review of the facility's Investigation Report dated 04/28/2024 at approximately 2:30 p.m. revealed S7CNA was the oncoming CNA assigned to resident #16's hall. Another aide, S8CNA asked for assistance in getting resident #16 to her room. S9CNA, S8CNA and S7CNA noticed a bruise on resident #16's face. The incident was immediately reported to S3Licensed Practical Nurse (LPN). Review of the nurses' notes dated 04/28/2024 at 4:40 p.m. revealed the staff reported that resident #16 had bruising and scratches on her body. The CNA brought the resident to the nurse to assess. The resident was sitting upright in a wheelchair, awake and alert. Upon assessment, the resident was noted to have bruising to the right eye, scratches to the left breast and one scratch to left posterior shoulder. Review of the Incident Report dated 04/28/2024 at 3:31 p.m. revealed resident #16 was noted to have bruising of the right eye, a scratch to the left breast and one scratch to the posterior shoulder. The resident was unable to give any description of incident. Further review of the Incident Report revealed everyone involved in the care of the resident was immediately suspended pending further investigation. On 05/06/2024 at 11:00 a.m., observation of resident #16 revealed she was in the hall sitting in a wheelchair with the 1:1 staff member next to her. Resident #16 was noted to have a bruise under her right eye. On 05/07/2024 at 4:30 p.m., an interview with S9CNA revealed she worked on 04/28/2024 from 2:00 p.m. - 10:00 p.m. and she noticed a bruise to resident #16's right eye and she informed S13ADON (Assistant Director of Nursing). On 05/06/2024 at 3:30 p.m., an interview with S13ADON revealed she was working on 04/28/2024 when the CNAs for the 2:00 p.m. - 10:00 p.m. shift came into work, they noticed that resident #16 had a bruise to her right eye. S13ADON further revealed that she assessed resident #16 and saw a bruise to her right eye and a scratch to her left chest and left shoulder. On 05/07/2024 at 10:30 a.m., an interview with S13ADON revealed on 04/28/2024 S4CNA had already completed her shift and had left the nursing home. S4CNA was called to come back to the nursing home to provide a statement of events when she worked with resident #16 on 04/28/2024. S4CNA returned to the nursing home, provided a statement and denied any issues regarding resident #16 during her shift on 04/28/2024. Further interview with S13ADON revealed she attempted to contact S5CNA and S6CNA on 04/28/2024 without success. S5CNA and S6CNA were the other two aides that assisted in the care of resident #16 on 04/28/2024. S13ADON revealed S5CNA and S6CNA came to the nursing home on [DATE] and provided a statement. S5CNA and S6CNA revealed they saw S4CNA hit resident #16 in the face, chest and side multiple times on 04/28/2024. The facility notified the local Sheriff's department and the Sherriff's department started an investigation on 04/29/2024. Review of the statement provided by S5CNA revealed on 04/28/2024, S4CNA asked if S5CNA could help change resident #16. Resident #16 grabbed S4CNA's necklace and S4CNA got mad and began punching resident #16 repeatedly everywhere. Review of the statement provided by S6CNA revealed on 04/28/2024, S4CNA asked if S6CNA could help change resident #16. During the care resident #16 began to grab S4CNA and once she grabbed her S4CNA punched her in the face several times. Resident #16 broke S4CNA's necklace and S4CNA got mad and punched resident #16 in the face, chest and side multiple times. Review of the Sheriff's Department Investigation Report revealed on 04/29/2024 at approximately 4:48 p.m. S4CNA confirmed she did hit resident #16 with a closed fist on the shoulder and back. S4CNA was arrested on 04/29/2024. On 05/07/2024 at 11:00 a.m., an interview with S3LPN revealed on 04/28/2024 at 2:10 p.m., S7CNA came and informed her that resident #16 had a bruise on her left eye. S3LPN revealed S13ADON and she assessed the resident and she was observed to have a bruise to her right eye and a scratch to her left breast and left shoulder. On 05/08/2024 at 6:15 p.m., an interview with S1Administrator confirmed resident #16 was physically abused by S4CNA and it was everyone's responsibility at the nursing facility to ensure residents are free from abuse.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to inform each resident as soon as possible of changes in Medicare covered services as evidenced by the facility's failure to provide: 1.) the Form Centers for Medicare and Medicaid Services (CMS) 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and Form CMS 10123 Notice of Medicare Non-Coverage as required for 1 resident (#84) and 2.) the Form CMS 10123 Notice of Medicare Non-Coverage as required for 1 resident (#236) of 3 (#57, #84, and #236) residents reviewed for Beneficiary Notification who required the notification. Findings: Resident #84 Review of the list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months completed by the facility revealed resident #84 was discharged from Medicare Part A Services on 04/04/2024 with benefit days remaining. Further review of the records revealed Form CMS-10055 and Form CMS-10123 had not been provided to resident #84. Resident #236 Review of the list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months completed by the facility revealed resident #236 was discharged from Medicare Part A Services on 03/28/2024 with benefit days remaining. An interview with S10Minimum Data Set (MDS) nurse on 05/07/2024 at 2:00 p.m. revealed the resident had benefit days remaining and he had a planned discharge on [DATE]. Further review of the records revealed Form CMS-10123 had not been provided to resident #236. An interview with S1Administrator on 05/07/2024 at 3:25 p.m. revealed the Director of Social Services was responsible for completing the Form CMS 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and Form CMS 10123 Notice of Medicare Non-Coverage for residents and she started her employment with facility last week. S1Administrator confirmed there was no documentation that resident #84 was provided Form CMS 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and Form CMS 10123 Notice of Medicare Non-Coverage and there was no documentation that resident #236 was provided Form CMS 10123 Notice of Medicare Non-Coverage.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately to the facility administration for 1 (#16) of 4 (#10, #16, #63 and #73) residents reviewed for abuse. Findings: Review of the facility's policy and procedure for Abuse with a revised date of 05/15/2023 revealed: Intent: To promote a safe environment for residents, visitors, and employees through prompt and appropriate response and follow up to abuse allegations and events. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root disorder, insomnia, anoxic brain damage, delusional disorder, psychotic disorder with delusions due to known physiological condition, dementia with behavioral disturbance, impulse disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #16 had severe cognitive impairment for daily decision making and required extensive assistance with activities of daily living. Review of the current plan of care revealed resident #16 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Resident #16 has a self-care performance deficit and required assistance with activities of daily living. Resident #16 required 1:1 care 24 hours a day. Review of the facility's Investigation Report dated 04/28/2024 at approximately 2:30 p.m. revealed S7CNA was the oncoming CNA assigned to resident #16's hall. Another aide, S8CNA asked for assistance in getting resident #16 to her room. S9CNA, S8CNA and S7CNA noticed a bruise on resident #16's face. The incident was immediately reported to S3Licensed Practical Nurse (LPN). Review of the nurses' notes dated 04/28/2024 at 4:40 p.m. revealed the staff reported that resident #16 had bruising and scratches on her body. The CNA brought the resident to the nurse to assess. The resident was sitting upright in a wheelchair, awake and alert. Upon assessment, the resident was noted to have bruising to the right eye, scratches to the left breast and one scratch to left posterior shoulder. Review of the Incident Report dated 04/28/2024 at 3:31 p.m. revealed resident #16 was noted to have bruising of the right eye, a scratch to the left breast and one scratch to the posterior shoulder. The resident was unable to give any description of incident. Further review of the Incident Report revealed everyone involved in the care of the resident was immediately suspended pending further investigation. On 05/06/2024 at 3:30 p.m., an interview with S13Assistant Director of Nursing (ADON) revealed she was working on 04/28/2024 when the CNAs for the 2:00 p.m. - 10:00 p.m. shift came into work, they noticed that resident #16 had a bruise to her right eye. S13ADON further revealed that she assessed resident #16 and saw a bruise to her right eye and a scratch to her left chest and left shoulder. On 05/07/2024 at 10:30 a.m., S13ADON revealed on 04/28/24 S4CNA had already completed her shift and had left the nursing home. S4CNA was called to come back to the nursing home to provide a statement of events when she worked with resident #16 on 04/28/2024. S4CNA returned to the nursing home, provided a statement and denied any issues during her shift on 04/28/2024. Further interview with S13ADON revealed she attempted to contact S5CNA and S6CNA on 04/28/2024 without success. S13ADON revealed S5CNA and S6CNA came to the nursing home on [DATE] and provided a statement. S5CNA and S6CNA revealed they saw S4CNA hit resident #16 in the face, chest and side multiple times. The facility notified the local Sheriff's department and the Sherriff's department started an investigation on 04/29/2024. Review of the statement provided by S5CNA revealed on 04/28/2024 S4CNA asked if S5CNA could help change resident #16. Resident #16 grabbed S4CNA's necklace and S4CNA got mad and began punching resident #16 repeatedly everywhere. Further review of S4CNA's statement revealed she really didn't know what to do and was scared to say something. Review of the statement provided by S6CNA revealed on 04/28/2024 S4CNA asked if S6CNA could help change resident #16. During care resident #16 began to grab S4CNA and once she grabbed her S4CNA punched her in the face several times. Resident #16 broke S4CNA's necklace and S4CNA got mad and punched resident #16 in the face, chest and side multiple times. Further review of S4CNA's statement revealed documentation that she was shaken up about the situation and afraid to tell. So we proceeded to go back to the hall and do our last rounds. On 05/07/2024 at 10:45 a.m., an interview with S1Administrator revealed staff should report any type of abuse immediately. Further interview with S1Administrator confirmed S5CNA and S6CNA did not report the abuse to resident #16 by S4CNA immediately.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to conduct a comprehensive assessment which included the resident's safe smoking assessment for 1 (#18) of 1 (#18) residents reviewed for smoking. Findings: Review of the facility policy and procedures for Physical Environment: Smoking - Supervised Smokers dated March 2023 revealed in part: Guidelines: Smoking assessments will be completed on admission, quarterly, with significant change of condition and as needed for residents who wish to smoke. Smoking assessment will include a return demonstration of ability to safely manage smoking paraphernalia. Review of resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. Review of resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Review of resident #18's active care plan revealed she required extensive to total dependence for all activities of daily living. On 05/06/2024 at 4:02 p.m. an observation of resident #18 revealed she was outside in the designated smoking area smoking a cigarette. Review of resident #18's Nursing Smoking Screen dated 11/26/2023 revealed she was assessed as an unsafe smoker. Further review revealed there was no documented evidence that the facility had conducted a quarterly smoking assessment for resident #18 per the facility policy. The resident's quarterly smoking assessment should have been conducted in 02/2024. On 05/08/2024 at 6:00 p.m. an interview with S2Director of Nursing and S18Regional Director of Clinical confirmed resident #18's smoking assessment should have been conducted quarterly per the facility policy. S18Regional Director of Clinical confirmed that resident #18's quarterly smoking assessment was not conducted quarterly in 02/2024.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0729 (Tag F0729)

Could have caused harm · This affected 1 resident

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Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 3 (S23CNA, S24CNA, and S25CNA) of 5 (S23CNA, S24CNA, S25CNA, S26CNA, and S27CNA) personnel files reviewed. Findings: Review of S23CNA's personnel file revealed a hire date of 12/08/2023. Further review of S23CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. Review of S24CNA's personnel file revealed a hire date of 08/28/2023. Further review of S24CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. Review of S25CNA's personnel file revealed a hire date of 02/05/2024. Further review of S25CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. An interview with S1Administrator on 05/07/2024 at 10:45 a.m. revealed the Human Resource Coordinator was responsible for the State Adverse Actions checks and she was not available this week. S1Administrator confirmed there was no documentation of State Adverse Action checks prior to 05/03/2024.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to maintain all resident care equipment in safe operating condition for 2 (#26, #48) of 2 (#26, #48) residents observed with resident care equipment concerns. This failure had the potential to affect the 82 residents in the facility. Findings: Resident #48 Review of the record for resident #48 revealed in part the following diagnoses: traumatic subarachnoid hemorrhage, primary generalized osteoarthritis, generalized muscle weakness, unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, and unspecified dementia. Further review of the record revealed resident #48 had a Brief Interview for Mental Status (BIMS) of 3 indicating he was severely cognitively impaired and required the use of a wheelchair for locomotion. On 05/07/2024 at 03:40 p.m. observation of resident #48's wheelchair revealed the rubber protective cover on the resident's right wheelchair handle was missing. On 05/08/2024 at 3:30 p.m. S22Licensed Practical Nurse (LPN) confirmed resident # 48's right wheelchair handle's rubber cover was missing and was in need of repair. She revealed she was unsure how long the wheelchair handle had been missing. On 05/08/2024 at 6:00 p.m. S2Director of Nursing and S18Regional Director of Clinical was informed of resident #48's above concern with his wheelchair. They confirmed that resident #48's wheelchair should have been repaired in a timely manner. Resident #26 On 05/07/2024 at 4:02 p.m. review of the record for resident #26 revealed in part the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease (ESRD), congestive heart failure (CHF), and left great toe amputation. Further review of the record revealed resident #26 had a BIMS of 14 indicating cognition was intact and required the use of a wheelchair for locomotion. On 05/06/2024 at 9:49 a.m. observation of resident #26's wheelchair revealed the right armrest was torn all the way to wood portion of armrest. On 05/07/2024 8:51 a.m. observation of resident #26's wheelchair revealed the right armrest was torn all the way to wood portion of arm rest. On 05/08/24 11:20 p.m. observation of resident #26 wheelchair revealed the right armrest was torn all the way to wood portion of arm rest. On 05/08/2024 at 01:17 p.m. interview with S15Certified Nursing Assistant CNA confirmed she transfers resident #26 into the wheelchair with the torn right arm rest. S16CNA further confirmed the area is torn all the way through the padding down to the wood part of arm and that she has never reported the torn area on the right armrest of the wheelchair.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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Resident #186: On 05/07/2024 at 10:53 a.m. review of the record for resident #186 revealed an admit date of 04/22/2024. Further review of the record revealed no documentation of an advance directive indicating the resident's code status. On 05/08/2024 at 9:57 a.m. S2DON (Director of Nursing) was informed there was no documented evidence of resident #186's advance directive. S2DON revealed that social services usually obtains the residents' advance directive upon admit. On 05/08/2024 at 2:56 p.m. an interview with S19SSD revealed resident #186's advance directive was in the social folder in her office and was not available to staff. S19SSD said she is new and just started and is in the process of going through each resident's record and social folder. On 05/08/2024 at 6:00 p.m. interview with S2DON and S18Regional Director of Clinical confirmed resident # 186's advanced directive should have been obtained upon admit and entered into the resident's electronic record available for staff to review. Based on record reviews and interviews, the facility failed to ensure the residents' code status was obtained and available for staff to review for 2 (#188, #186) of 2 (#188, #186) residents who did not have a code status available for staff review. Findings: Review of the facility Resident Rights Advance Directives Policy and Procedure dated March 2023 revealed in part: Purpose: To support the resident's right to have an Advance Directive. Guidelines: Upon admission, if the resident has not formulated an advance directive, the facility will determine if the resident wishes to formulate an advance directive. Information about whether or not the resident has an advance directive in place is featured in the medical record. Resident #188: On 05/07/2024 at 10:43 a.m. review of the record for resident #188 revealed an admit date of 04/10/2024. Further review of the record revealed no documentation of an advance directive indicating the resident's code status. On 05/08/2024 at 1:51 p.m. a request to review the resident's advance directive was made. On 05/08/2024 at 2:56 p.m. an interview with S19Social Service Director (SSD) revealed the advance directive was in the social folder in her office and was not available to staff. S19SSD said she is new and just started and is in the process of going through each resident's record and social folder.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Resident #83 Observations of resident #83's room on 05/06/2024 at 11:50 a.m. and on 05/07/2024 at 11:30 a.m. revealed the following: 2 vertical holes (approximately 15 inches x 2.5 inches and approximately 24 inches x 2.5 inches) in the gypsum board wall behind the head of the bed, 2 areas (approximately 15 inches x 3 inches and 4 inches x 3 inches) where the paint was missing and gypsum board was gouged on the wall next to the bed, the door of closet was not secure to the closet and was leaning against the wall next to the closet. Observations of resident # 83's bathroom revealed the plastic dual roll toilet paper holder was lying on the floor next to the toilet, there was small holes in the wall of the bathroom where the toilet paper holder was previously attached. On 05/08/2024 at 4:39 p.m. an observation of resident #83's room with S1Administrator and S20Maintenance Supervisor revealed the following: 2 vertical holes (approximately 15 inches x 2.5 inches and approximately 24 inches x 2.5 inches) in the gypsum board wall behind the head of the bed, 2 areas (approximately 15 inches x 3 inches and 4 inches x 3 inches) where the paint was missing and gypsum board was gouged on the wall next to the bed, the door of closet was not secure to the closet and was leaning against the wall next to the closet. Observations of resident # 83's bathroom revealed the plastic dual roll toilet paper holder was lying on the floor next to the toilet, there was small holes in the wall of the bathroom where the toilet paper holder was previously attached. Interview with S1Administrator and S20Maintenance Supervisor confirmed that the closet door needed to be properly secured to the closet, the holes in the gypsum wall behind the bed and the gouges in the gypsum wall beside his bed needed to be repaired, and the toilet paper roll dispenser needed to be properly secured to the restroom wall. Resident #64: On 05/06/2024 at 2:03 p.m. an observation of resident #64's room revealed there was a large hole in the wall next to resident #64's bed exposing the water pipes to the bathroom. The hole was approximately 1.5 foot (ft) wide and 2.5 feet long with another open piece to the right side of the large hole that was approximately 2 feet wide and unknown how long due to resident #62 items in front of a portion of the hole. Further observation of resident #64's bathroom revealed there was a blanket that was folded and placed on floor behind the toilet next to the wall. On 05/08/2024 at 1:15 p.m. an observation of resident #64's room revealed the hole remained in the wall adjoining to the bathroom exposing the water pipes to the room. On 05/08/2024 at 4:44 p.m. an observation of resident # 64's room with S20Maintenance Director and S1Administrator confirmed there was a hole in the wall with exposed water pipes next to resident #64's bed. On 05/08/2024 at 4:44 p.m. further observation of resident #64's bathroom with S20Maintenance Director and S1Administrator confirmed the folded blanket remained on the floor between the toilet and the wall. Interview at that time with S20MaintenanceDirector and S1Administrator agreed the blanket that was folded on the floor between the toilet and the wall should not have been placed there Resident #74: On 05/08/2024 at 5:14 p.m. an observation of resident #74's bathroom revealed there was a large hole with exposed water pipes in the wall to the left of the toilet. The hole was a square opening approximately 3 ft x 3 ft. On 05/08/2024 at 4:40 p.m. an observation of resident # 64's bathroom with S20Maintenance Director and S1Administrator confirmed there was a hole in the wall with exposed water pipes next to resident #74's toilet. Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#64, #74, #44, #83) of 4 ( #64, #74, #44, #83) residents' rooms observed with environmental concerns. Findings: Review of the facility's policy for Physical Environment dated March 2023 revealed in part: Purpose: To provide a safe, functional, sanitary and comforable environment for resident. Resident #44 Observations of resident #44's room on 05/06/2024 at 2:25 p.m. and on 05/07/2024 at 11:13 a.m. revealed a metal fluorescent light fixture, approximately 3.5 feet long by 5 inches wide by 5 inches deep, was only secured to the wall on the very left side of the light fixture and the light fixture was leaning down to the right. On 05/08/2024 at 4:35 p.m. an observation of resident #44's room with S1Administrator and S20Maintenance Supervisor revealed the metal fluorescent light fixture was only secured to the wall on the left side and was leaning down to the right. Interview with S1Administrator and S20Maintenance Supervisor confirmed the light fixture in resident #44's room needed to be properly secured to the wall.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44 Record review revealed resident #44 was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes mellitus without complications, non-ST elevation myocardial infarction, heart failure, generalized weakness, lack of coordination, cognitive communication deficit, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 which indicated resident #44 had severe cognitive impairment. Further review revealed resident #44 required partial/moderate assistance with bathing, showering, and personal hygiene. Review of the active care plan revealed resident #44 had an Activities of Daily Living (ADL) self-care performance deficit. Personal hygiene/oral care: the resident is totally dependent on (1) staff for personal hygiene and oral care. On 05/06/2024 at 02:26 p.m. an observation of resident #44 revealed there was a brown, grime substance under fingernails on both hands. On 05/07/2024 at 11:11 a.m. an observation of resident #44 revealed there was a brown, grime substance under finger nails on both hands. On 05/07/2024 at 04:40 p.m. an interview with S2DON (Director of Nursing) confirmed resident #44's fingernails needed to be trimmed and cleaned. Resident #71 Record review revealed resident #71 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, essential hypertension, personal history of venous thrombosis and embolism, major depressive disorder, retention of urine, and fatigue. Review of the quarterly MDS assessment dated [DATE] revealed it was in progress. Review of the 5 day admission MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated resident #71 was cognitively intact. Further review revealed resident #71 was dependent on staff for toileting, transfers, hygiene, bathing/showering, and dressing. Review of active care plan revealed resident #71 had an ADL self-care performance deficit. Personal hygiene/oral care: the resident is totally dependent on (2) staff for personal hygiene and oral care. On 05/06/2024 at 11:15 a.m. an observation and interview with resident #71 revealed he was sitting in a manual wheel chair in the therapy department. Resident #71's fingernails on both hands were long and jagged with a brown, grime substance under fingernails on both hands. Resident #71 had a long full beard and mustache. Resident #71 reported he would like to have his fingernails cleaned and trimmed and his beard cut and mustache trimmed but no one has offered to assist him. Resident #71 reported he always had a mustache, but never had a beard before being admitted to the facility. On 05/07/2024 at 11:08 a.m. an observation of resident #71 revealed fingernails on both hands were long and jagged with a brown, grime substance under fingernails on both hands. Resident #71's beard and mustache was long. On 05/07/2024 at 03:45 p.m. an interview with S2DON was conducted in resident #71's room. S2DON confirmed resident #71's fingernails needed to be trimmed and cleaned. S2DON further confirmed resident #71's beard needed to be cut and his mustache need to be trimmed. Resident #60: Review of the medical record for resident #60 revealed diagnoses of cerebral infarction, hemiplegia affecting his right dominant side, and cognitive communication deficit. Review of resident #60's quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 99 which indicated the facility was unable to conduct the test. Review of resident #60's active care plan revealed he required extensive to total assistance for all activities of daily living, which included personal hygiene. On 05/06/2024 at 9:15 a.m. observation of resident #60's fingernails and toenails revealed a brown substance was observed under his fingernails and toenails and all nails needed trimming. On 05/07/2024 at 03:45 p.m., an observation of resident #60's fingernails and toenails with S21Certified Nursing Assistant (CNA) present revealed S21CNA confirmed the resident's fingernails and toenails needed to be cleaned and trimmed. On 05/07/2024 at 03:50 p.m. an interview with S22Licensed Practical Nurse (LPN) confirmed that resident #60's fingernails and toenails needed to be cleaned and trimmed. On 05/08/2024 at 06:00 p.m. an interview with S2DON and S18Regional Director of Clinical confirmed resident # 60's fingernails and toenails should have been cleaned and trimmed. Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for 5 (#26, #44, #60, #64 and #71) of 5 (#26, #44, #60, #64 and #71) residents sampled for Activities of Daily Living. Findings: Resident #26 On 05/07/2024 at 4:02 p.m. record review for resident #26 revealed diagnoses in part of: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease (COPD), type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease, and congestive heart failure. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #26 had a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the functional assessments revealed resident required substantial/maximum assistance with toileting, bathing, dressing, and hygiene. On 05/06/2024 at 9:43 a.m. an observation of resident #26 revealed his fingernails were long with debris under nails, resident's beard was long, and in need of shaving. Interview with resident #26 on 05/06/2024 at 9:43 a.m. revealed he agreed he was in need of having his beard shaved and his fingernails needed to be trimmed and cleaned. On 05/07/2024 at 3:56 p.m., an observation of resident #26 while S2Director of Nursing (DON) was present revealed resident #26's fingernails continued to be long and dirty and the resident's beard remained unshaven. S2DON confirmed resident #26's fingernails were long and dirty, and his beard needed to be shaved. Resident #64 On 05/08/2024 at 4:58 p.m. record review for resident #64 revealed diagnoses in part of COPD, muscle weakness, lack of coordination, respiratory failure, hypertension, gait and mobility problems, psychoactive substance abuse, cellulitis right and left lower limb, cardiomyopathy, idiopathic aseptic necrosis of left femur, cirrhosis of liver, osteonecrosis of the femur, and chronic viral hepatitis C. Review of the annual MDS dated [DATE] revealed resident #64 had a BIMS score of 15 indicating the resident was cognitively intact. Review of the functional assessments revealed resident required partial/moderate assistance with bathing, dressing, and hygiene. On 05/06/2024 at 1:56 p.m. an observation of resident #64 revealed a very strong urine odor and body odor, toenails were long with black material under the nails, fingernails were dirty with dark material under the nails, and multiple stains and odor noted to the resident's shirt. On 05/07/2024 at 3:59 p.m. observation of resident #64 while S2DON was present revealed resident #64 remained unkempt by wearing the same stained and odorous shirt as on 05/06/2024, fingernails were in need of cleaning and trimming, toenails were long and dirty with dark material under the nails. On 05/07/2024 at 3:59 p.m. an interview with S2DON confirmed resident #64 was in need of grooming, bathing, clean clothing, fingernails needed to be cleaned, and toenails needed to be cleaned and trimmed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #39 Record review revealed resident #39 was admitted to the facility on [DATE] with diagnoses that included stage 4 pressure ulcer of right hip, stage 3 pressure ulcer of sacral region, dementia, anemia, reduced mobility, peripheral vascular disease, hereditary idiopathic neuropathy, edema, mild protein-calorie malnutrition, major depressive disorder, gastrostomy status, and bilateral above the knee amputation. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed BIMS (Brief Interview Mental Status) score of 15 which indicated resident #39 was cognitively intact. Resident #39 was dependent on staff assistance for all ADLs (Activities of Daily Living). Resident #39 required extensive one person assistance with eating, bed mobility, toileting, hygiene, and bathing. Resident #39 required extensive two person assistance with transfers. Resident #39 was incontinent of bowel and bladder. Resident #29 was at risk for pressure ulcers/skin injuries. Resident #39 had 2 stage 4 pressure ulcers. Review of active May 2024 physician orders revealed an order for moisture associated dermatitis to scrotum apply moisture barrier cream to scrotum area TID (three times daily and prn (as needed) after incontinent care (ordered 05/07/2024 at 17:45). Weekly skin checks - document results on weekly skin observation assessments. Review of progress note dated 05/03/2024 at 22:57 revealed the following in-part: Complaint of pain in perineal area. Treatment applied to area and pain medication administered by S17LPN. On 05/07/2024 09:05 a.m. an observation of resident #39 revealed he was sitting in geri chair with head elevated up 60 degrees, resting quietly, and watching TV in his room. On 05/07/2024 at 3:55 p.m. an interview with S9CNA (Certified Nursing Aide) revealed she works the 2 pm-10 pm shift. S9CNA reported she checks on resident #39 every 2 hours to make sure he is clean and dry and provides incontinent care and change his brief when need. S9CNA reported that she uses the wedge cushions to help position him. Surveyor observed S9CNA check resident #39 to see if he needed to be changed. Resident #39 was noted to have an incontinent episode and S9CNA provided incontinent care. Surveyor observed an irregular shaped ulceration approximately 4.5 cm (centimeter) x 1.5 cm to resident #39's right scrotum. There was no drainage or odor noted. There was no signs of infection noted. On 05/07/2024 at 4:10 p.m. an interview with S12Treatment Nurse revealed she was not aware of resident #39 having a wound on his scrotum. On 05/07/2024 at 4:30 p.m. the surveyor informed S2DON (Director of Nursing) of the wound observed on resident #39's right scrotum. The surveyor informed S2DON there was no documentation of the wound or an order for wound care noted. On 05/08/2024 at 08:30 a.m. an interview with S15CNA revealed one day last week, either Wednesday or Thursday, she noticed resident #39 had redness to his right scrotum and a small crack in the skin and she notified S16LPN (Licensed Practical Nurse). S15CNA reported she had been putting the pink cream on his scrotum every brief change. S15CNA reported that sore on his scrotum has gotten bigger since last week. On 05/08/2024 at 08:35 a.m. an interview with S3LPN revealed she was not notified of resident #39 having any issues with the skin on his scrotum until today. On 05/08/2024 at 08:39 a.m. an interview with S13ADON (Assistant Director of Nursing) revealed she was not aware of resident #39 having a wound on his scrotum until yesterday evening when S2DON asked her to assess resident #39's scrotum. S13ADON reported she and S12Treatment Nurse assessed resident #39's scrotum yesterday evening around 5:00 p.m. and identified a new moisture associated dermatitis to his right scrotum. S13ADON reported they obtained measurements and took a picture of the wound. S13ADON notified the physician and obtained an order for moisture barrier cream to scrotum area three times a day and prn after incontinent care. Review of wound assessment revealed the following: #4 MASD (Moisture Associated Skin Damage) - IAD (Incontinence Associated Dermatitis) Right scrotum. New wound identified 05/07/2024 acquired in house. Wound measurements: length 4.44 cm, width 1.59 cm, deepest point 0. No tunneling. No undermining. Wound bed 80% epithelial and 20% granulation. No evidence of infection. No exudate. Physician made aware. Order noted to apply moisture barrier cream TID and prn incontinent care. On 05/08/2024 at 08:50 a.m. an interview with S16LPN revealed she was notified by S15CNA last week on 05/02/2024, that resident #39 had a red area on the right side of his scrotum. S16LPN reported she assessed resident #39's scrotum and found the skin to the right side of his scrotum to be red but did not see any breaks in the skin. S16LPN reported the CNA's were applying zinc and a pink cream to the area every brief change. S16LPN reported she did not make a nurses note to document her assessment of resident #39's scrotum. S16LPN reported she did not notify S12Treatment Nurse of the redness to resident #39's scrotum because she thought S12Treatment Nurse already knew about it. Resident #60 Review of the medical record for resident #60 revealed diagnoses of cerebral infarction, hemiplegia affecting his right dominant side, and cognitive communication deficit. Review of resident #60's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a BIMS score of 99 which indicated the facility was unable to conduct the test. Review of resident #18's active care plan revealed he required extensive to total assistance for all activities of daily living. Review of resident #60's May 2024 physician orders revealed a 10/23/2023 order for a hand roll to be placed in his right hand to prevent contractures. On 05/07/2024 at 3:45 p.m. and 05/08/2024 at 8:40 a.m., observations revealed resident #60 was in his gerichair in his room. Further observation revealed the resident did not have a hand roll in his right hand. On 05/07/2024 at 3:23 p.m., an interview with S22LPN revealed she had worked with resident for approximately 2 months. S22LPN confirmed she had not observed a hand roll in resident #60's right hand this week. She also confirmed she had not observed a hand roll in resident #60's right hand for the past 2 months that she had worked with him. On 05/08/24 at 06:00 p.m,. an interview with S2DON and S18Regional Director of Clinical confirmed staff failed to ensure that resident # 60's right hand roll was in place as ordered. Based on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 (#60) of 2 (#10 & #60) residents reviewed for positioning/mobility and 2 (#26 & #39) of 3 (#26, #39, & #83) residents reviewed for skin conditions. The facility failed to: 1) identify non-pressure related wounds to resident #26, 2) provide a right hand roll to resident #60 and 3) provide treatment to resident #83's scrotal wound. Findings: Resident #26 Record review for resident #26 revealed the resident was admitted on [DATE] with diagnoses in part of: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, type 2 diabetes, vascular dementia with behavioral disturbance, hypertension, end stage renal disease, and calciphylaxis wounds (known as calcific uremic arteriolopathy, it is characterized by painful skin lesions caused by cutaneous arteriolar calcification leading to restricted blood flow to tissue (ischemia) and injury or death of tissue or organs (infarction)). Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #26 had a Brief Interview of Mental Status (BIMS) of 14 which indicated the resident was cognitively intact. Review of the functional assessments revealed the resident required substantial/maximum assistance for toileting, bathing, dressing, and hygiene and partial/moderate assistance for turning. Review of current May 2024 physician orders for resident #26's wound care revealed: Coccyx - (calciphylaxis) clean site with wound cleanser, pat dry with gauze, paint with betadine, cover with foam dressing daily, and prn (as needed) soilage. Left Hip - (calciphylaxis) clean site with wound cleanser, pat dry with gauze, paint with betadine, apply foam dressing daily, prn soilage. Scrotum - (calciphylaxis) clean with wound cleanser , pat dry with gauze, paint with betadine and cover with dressing of choice daily and prn soiled or non-intact. On 05/07/2024 at 9:32 a.m., review of the current wound assessments revealed resident #26 had the identified wounds: Left trochanter (hip) - Ulcer/calciphylaxis- acquired in house 04/16/2024- measuring 3.79 centimeters (cm) x 2.94 cm with an area of 7.8 cm2 when identified. Coccyx- calciphylaxis- acquired in house 04/29/2024 measuring 6.1 cm x 5.6 cm x 10.0 cm2 when identified. Scrotum-Calciphylaxis- acquired in house 05/01/2024 measuring 2.5 cm x 0.7 cm with an area of 1.5 cm2 when identified. Review of the weekly skin assessments dated 05/04/2024, 04/27/2024, and 04/20/2024 revealed no new wounds. Observation of wound treatment with S12Treatment Nurse and S13Assistant Director of Nursing (ADON) on 05/08/2024 at 10:19 a.m. revealed wound treatment was provided to the left trochanter, coccyx and scrotum as ordered. During the wound treatment for resident #26 with S12Treatment Nurse and S13ADON, the following new wounds were identified: Left gluteal fold, the right heel was black and hard, left heel had a black hard area, and a dark blister area to left inner knee. On 05/08/2024 at 3:30 p.m., review of the wound documentation for the unidentified wounds found on 05/08/2024 revealed the following: Left gluteal fold- Length 8.11 cm x 0.94 cm - total area 0.8 cm2, Front left knee- 1.59 cm x 1.36 cm - total area 1.47 cm2, Right heel- 4.28 cm x 2.3 cm - total area 7.49 cm2, and Left heel- 3.93 cm x 1.31 cm - total area 3.86 cm2. S13ADON confirmed during the wound treatment that the new areas had not previously been identified or reported to the treatment nurse. S13ADON further said the CNAs are supposed to report any areas to the nurse when providing care and the floor nurses are to complete the weekly skin assessment. S13ADON further said the areas looked to be calciphylaxis like the rest of the wounds and not pressure related, but the resident's physician will determine the classification of the wounds.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses had documentation of medications administered for 1 (#16) of 5 (#16, #26, #53, #61, and #64) residents reviewed for unnecessary medications. Findings: Review of the facility's Pharmacy Services Medication Administration Policy dated 03/2023 revealed: Purpose: To provide residents with safe, accurate medication administration. 2. Medications will be prepared and administered in accordance with: a. Prescriber's order; b. Manufacturer's specifications (not recommendations); c. Accepted professional standards and principles. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root disorder, insomnia, anoxic brain damage, delusional disorder, psychotic disorder with delusions due to known physiological condition, dementia with behavioral disturbance, impulse disorder, and anxiety. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed resident #16 had severe cognitive impairment for daily decision making and required extensive assistance with activities of daily living. Review of the May 2024 physician orders revealed an order for the following with a start date of 11/01/2023: Clonazepam 1 mg (milligrams) to be given orally three times a day (tid), Divalproex Sodium delayed release 500 mg to be given orally tid, Gemfibrozil 600 mg to be given orally two times a day (bid), Benzotropine Mesylate 1 mg to be given orally bid, Melatonin 3 mg to be given orally every day (qd), Loratadine 10 mg to be given orally qd, Nudexta 20 -10 mg to be given orally bid, Ziprasidone Hydrochloride 20 mg to be given orally bid, Mirtazapine 15 mg to be given orally at bedtime, Gabapentin 300 mg to be given orally bid, and Docusate Sodium 200 mg to be given orally qd. Review of the May 2024 Medication Administration Record (MAR) revealed there was no documented evidence of the above medications administered on 05/04/2024 and 05/06/2024 at 6:00 p.m. On 05/08/2024 at 11:45 a.m., an interview with S2Director of Nursing (DON) revealed she was not sure why the resident did not receive the medications. On 05/08/2024 at 4:40 p.m., an interview with S16Licesnsed Practical Nurse (LPN) revealed she worked with the resident on 05/04/2024 and 05/06/2024 and she forgot to sign out the medications when she administered them.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services of 8 consecutive hours a day on 12/23/2023, 12/25/2023, 12/26/2023 and 12/30/2023. Findings: Review of the facility's Payroll Based Journal (PBJ) Data time sheets for the dates of 12/23/2023, 12/25/2023, 12/26/2023 and 12/30/2023 revealed that there was no staffing hours for the RN. There was no evidence the RN worked 8 consecutive hours on those dates. Review of the time sheets revealed no documented evidence a RN worked for 8 hours on the dates listed above. On 05/08/2024 at 8:20 a.m., an interview with S1Administrator revealed she was unable to find the documentation or time sheet to prove a RN worked for 8 hours on the dates listed above.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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Based on record reviews and interviews, the pharmacist failed to report any irregularities to the attending physician and the facility's medical director and director of nursing for 3 (#26, #53, and #62) of 5 ( #16, #26, #53, #61, and #64) records reviewed for unnecessary medication review. Resident #26 On 05/07/2024 at 4:02 p.m. review of the record for resident #26 revealed, in part, the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease (ESRD), congestive heart failure (CHF), and left great toe amputation. Review of May 2024 physician orders revealed current orders for the following laboratory tests:: Chemistry 14, Glycated Hemoglobin (A1C) every 3 months due in July, October, January and April. Further lab orders revealed to have liver function test (LFT) every 6 months in July and January and for complete blood count (CBC), prostatic-specific antigen (PSA), and lipids in July. On 05/08/24 at 5:03 p.m., an interview with S13Assistant Director of Nurisng (ADON) revealed she was only able to locate the laboratory results of a complete blood count and complete metabolic panel dated 04/19/2024. S13ADON said that dialysis draws labs every month on resident #26 and she has called to get those labs for January 2024 and April 2024. Review of the monthly Drug Regiment Review (DRR) for February 2024 and March 2024 and April 2024 revealed the pharmacist did not address the missing labs that were ordered for resident #26. On 05/08/2024 at 5:19 p.m., an interview with S13ADON confirmed she has been handling the DRR. She confirmed the pharmacist did not report the missing labs. Resident #64 On 05/08/2024 at 4:58 p.m. record review for resident #64 revealed diagnoses in part of: chronic obstructive pulmonary disease (COPD), muscle weakness, lack of coordination, respiratory failure, hypertension, psychoactive substance abuse, cellulitis right and left lower limb, cardiomyopathy, idiopathic aseptic necrosis of left femur, cirrhosis of liver, osteonecrosis femur, and chronic viral hepatitis C. Review of the May 2024 Physician Orders in part revealed a current order for Furosemide (Lasix) 40 milligrams (mg) by mouth every day (QD) for edema. Review of the April 2024 and May 2024 medication administration record (MAR) revealed no documentation of the nurse checking for edema prior to administering the Lasix. Further review of the February 2024 and March 2024 and April 2024 DRR revealed the pharmacist did not address the monitoring for edema while resident #64 was receiving Lasix. On 05/08/2024 at 5:19 p.m., interview with S13ADON confirmed she has been handling the DRR. She confirmed the pharmacist did not report there was no monitoring for edema for resident #64. Resident #53 Review of the medical record for resident #53 revealed diagnoses of myocardial infarction, obesity, muscle weakness, pulmonary embolism, leiomyoma of uterus, edema, psychotic disorder, depression, and anxiety. Review of the physician orders dated 10/18/2023 revealed an order for Furosemide 40 mg to be administered orally one time a day for edema, and Spironolactone 25 mg to be given one time a day orally for edema. Review of the medical record for April 2024 and May 2024 revealed no documented evidence of edema checks performed for resident #53. On 05/08/2024 at 1:30 p.m., an interview with S2DON revealed no documented evidence of edema checks noted for resident #53. Review of the Consultant Pharmacist's March 2024 and April 2024 monthly DRR revealed the pharmacist failed to address no documented evidence of edema checks performed. On 05/08/2024 at 5:30 p.m., an interview with S13ADON confirmed the pharmacist did not address the edema checks not being performed for resident #53.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

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Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 3 ( #26, #53 and #64) of 5 (#16, #26, #53, #61 and #64) sampled residents reviewed for unnecessary medications. The facility failed to 1) perform edema checks for residents #53 and #64 while taking a diuretic, and 2) obtain labs as ordered for resident #26. Findings: Resident #26 On 05/07/2024 at 4:02 p.m. review of the record for resident #26 revealed in part the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease (ESRD), congestive heart failure (CHF), and left great toe amputation. Review of May 2024 physician orders revealed current orders for the following laboratory tests:: Chemistry 14, Glycated Hemoglobin (A1C) every 3 months due in July, October, January and April. Further lab orders revealed to have liver function test (LFT) every 6 months in July and January and for complete blood count (CBC), prostatic-specific antigen (PSA), and lipids in July. On 05/08/24 at 5:03 p.m. an interview with S13Assistant Director of Nursing (ADON) revealed she was not able to locate the laboratory results for the Glycated Hemoglobin (A1C) for January 2024 and April 2024, the LFT for January 2024, or the CBC, PSA and lipids for July 2023. On 05/08/2024 at 5:19 p.m., an interview with S13ADON confirmed they did not obtain the Glycated Hemoglobin (A1C) for January 2024 and April 2024, the LFT for January 2024, or the CBC, PSA and lipids for July 2023 for resident #26. Resuident #64 On 05/08/2024 at 04:58 p.m. record review for resident #64 revealed diagnoses in part of: chronic obstructive pulmonary disease (COPD), muscle weakness, lack of coordination, respiratory failure, hypertension, psychoactive substance abuse, cellulitis right and left lower limb, cardiomyopathy, idiopathic aseptic necrosis of left femur, cirrhosis of liver, osteonecrosis femur, and chronic viral hepatitis C. Review of the April 2024 and May 2024 Physician Orders revealed a current order for Furosemide (Lasix) 40 mg by mouth every day (QD) for edema. Review of the April 2024 and May 2024 Medication Administration Record (MAR) revealed no documentation of the nurse checking for edema prior to administering the Lasix. On 05/08/2024 at 5:19 p.m., an interview with S13ADON confirmed there was no monitoring of edema with the administration of the Lasix order for resident #64. Resident #53 Review of the medical record for resident #53 revealed diagnoses of myocardial infarction, obesity, muscle weakness, pulmonary embolism, leiomyoma of uterus, edema, psychotic disorder, depression, and anxiety. Review of the physician orders dated 10/18/2023 revealed an order for Furosemide 40 milligrams (mg) to be administered orally one time a day for edema, and Spironolactone 25 mg to be given orally one time a day for edema. Review of the medical record revealed no documented evidence of edema checks performed for resident #53. On 05/08/2024 at 1:30 p.m., an interview with S2DON revealed no documented evidence of edema checks noted for resident #53.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety. This failed practice had the potential to affect all residents who receive meals from the kitchen. Findings: On 05/06/2024 at 8:28 a.m. observation of the kitchen environment with S11DM (Dietary Manager) revealed the front of ice machine was open exposing inside of machine and electrical components. Observation of the stand-up refrigerator revealed the temperature reading was 48 degrees Fahrenheit. Observation of the temperature logs hanging on the 3 refrigerators and the 2 freezers in the kitchen revealed there were no temperature logs maintained. Interview at that time with S11DM confirmed the temperature logs had not been maintained. Observation of the walk-in refrigerator revealed a temperature reading of 61 degrees Fahrenheit. Further observation revealed there were vegetables and multiple food items stored in the refrigerator. S11DM said they would have to take everything out of the refrigerator. Observation again revealed there was no temperature log maintained for this refrigerator. Observation of the inside of the stand-up refrigerator in the kitchen revealed a pan of red beans, sausage and rice with no date and 1 bowl of unidentified food with unreadable date and S11DM said she was not sure what it was. A request for a chemical test strip for the 3 compartment sink revealed the S11DM attempted to check the sanitizer by running the test strip under the running stream and not filling the sink with the sanitizer and checking the levels. S11DM revealed no one showed her how to check the sanitizer in 3 compartment sink. While at the 3 compartment sink S14Dietary Worker picked up large pans out of 3 compartment sink from sanitizer bin. The compartment had no water in it. S14Dietary Worker said he washed the pans, and then just hoses them off with the sanitizer and leaves them in the sink to dry. Requested to review the log for the sanitizer checks on the 3 compartment sink and S11DM confirmed there was no log for the sanitizer checks for the dish machine or 3 compartment sink. Observation of the dishwashing area revealed the clean dishes were stacked facing in the up-right position. On 05/06/2024 at 11:00 a.m. observation of the steam table temperatures for the noon meal revealed an electric thermometer was used. S14Dietary Worker placed the thermometer in the food items without ever cleaning the thermometer prior to placing it in food items or between food items. Review of the food temperature log revealed no documentation of checking food temperatures on the steam table since 03/24/2024. On 05/06/2024 1:30 p.m., interview with S11DM revealed she had been employed at facility since 04/01/2024 and only has restaurant management experience. She further confirmed she did not receive training on the correct way to be the dietary manager of a kitchen in a nursing facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #39 On 05/06/2024 at 10:10 a.m., an interview with resident # 39's family member revealed they are short staffed on the night shift on the resident's hall. Resident #39's family member further reported they usually only have one aide for this resident's hall and have to pull aides from other halls. On 05/08/2024 at 1:16 p.m., an interview with S2Director of Nursing (DON) revealed they staff 2 CNAs on each hall for the day shift (6 a.m. - 2 p.m.) and 2 CNAs on each hall for the evening shift (2 p.m. -10 p.m.). S2DON reported they staff 1 CNA for each hall with 1 floater on the night shift (10 p.m. - 6 a.m.). S2DON further reported on the day shift the following CNAs are not included in that number: CNA Supervisor, bath aide, restorative CNA, and the CNA who provides 1:1 sitting with resident #16. Surveyor requested a copy of the evening and night shift staffing assignment for last 2 weeks. During review of the evening and night shift CNA staffing assignment for last 2 weeks with S2DON on 05/08/2024 at 2:43 p.m., S2DON confirmed they were short 1 CNA on each of the following shifts: 04/24/2024 night shift (10 p.m. - 6 a.m.), 04/25/2024 night shift (10 p.m. - 6 a.m.), 04/27/2024 evening shift (2 p.m. -10 p.m.), and 04/28/2024 night shift (10 p.m. - 6 a.m.). Resident #38 Review of the medical record for resident #38 revealed diagnoses of paraplegia, congestive heart failure, and generalized osteoarthritis. Review of resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated he was moderately cognitively impaired. Review of resident #38's active care plan revealed he was totally dependent on staff for most of his activities of daily living. On 05/08/2024 at 8:50 a.m., an interview with resident #38 revealed the Certified Nursing Assistants (CNA) on his hall take a long time to answer his call light especially on the night shift. On 05/08/2024 at 2:43 p.m., an interview with S2Director of Nursing (DON) confirmed there was insufficient CNA staffing on the evening and night shifts for multiple days in the last 2 weeks. Based on record reviews and interviews, the facility failed to ensure it operated and provided services in compliance with Federal, State, and local laws by 1) not providing a sufficient number of nursing service personnel to provide nursing care to all residents, and 2) not ensuring residents received nursing care in accordance with resident care plans 24 hours per day for 2 (#38 & #39) of 2 (#38 & #39) sampled residents. Findings: The current Long Term Care Minimum Licesning Standards, statute 9823, A. states the nursing facility shall provide 2.35 hours of care per patient per day. Review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 03/01/2024 through 05/04/2024 revealed the facility did not meet the required hours according to the State statue noted above. The staffing form showed the facility was short on the hours provided to the resdient census on 11 out of 65 days. On 05/08/2024 at 2:50 p.m., an interview with S1Administrator confirmed the facility did not meet the required hours for 11 days listed on the Personnel Staffing Patterns that were provided.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observations and interviews and record review, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 4 (#48, #60, #18, #38) of 4 (#48, #60, #18, #38) sampled residents and had the potential to affect all 82 residents that resided in the facility. Findings: Review of the facility's policy titled, Physical Environment Safe, Functional, Sanitary Environment dated March 2023 read in part . Purpose: To provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Guidelines: The facility will maintain an effective pest control program to control pests and rodents. Observations on all days of the survey (05/06/2024 - 05/08/2024) revealed there were multiple flies flying around throughout the facility, including the dining room, all resident hallways, and in common areas of the facility. On 05/07/2024 at 3:40 p.m. an observation revealed resident #48 was in his room in bed and there was a fly noted on the resident's sheet near his head. On 05/07/2024 at 3:45 p.m. an observation revealed resident #60 was in his room in bed with his eyes closed. There were 3 flies noted near his bed. On 05/07/2024 at 3:55 p.m. an observation revealed resident #18 in was in her wheelchair in the hallway. The resident had a dressing on her right lower leg with a fly noted on top of the dressing. On 05/08/2024 at 8:50 a.m. an observation revealed resident #38 was in his room in bed. A fly was flying around his head and landed on his face. Resident #38 waved his hand to get the fly off his face. On 05/08/2024 at 6:00 p.m. S18Regional Director of Clinical confirmed the facility failed to ensure the residents' environment was free from pest.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected multiple residents

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Based on observation and interviews, the facility failed: 1.) to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility and 2.) to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Findings: During the Resident Council Meeting on 05/06/2024 at 1:40 p.m., resident #6, resident #9, resident #31, resident #32, resident #34, and resident #53 were unaware of where the state inspection results were located. Observation with S1Administrator on 05/06/2024 at 2:54 p.m. revealed the state inspection results were not labeled and were held in a clear plastic bin on the wall out of the reach of the residents in wheelchairs. S1Administrator confirmed at this time that the state inspection results were not labeled and were not within reach of the residents in wheelchairs.

Feb 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to have documented evidence that allegations of physical abuse were thoroughly investigated for 4 (#5, #6, #8, #9) of 10 (#1 - #10) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Policy with a revision date of 05/15/2023 revealed in part: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Investigation: 1. The facility Administrator/designee will conduct thorough investigations of alleged violations and report the findings to the State agency within 5 working days of the allegation. 2. The facility will immediately protect the resident from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. This includes: d. Conducting interviews with other residents and other staff. 3. Documentation related to investigations will be maintained by the facility. Resident #8 Review of the medical record for resident #8 revealed the resident was admitted on [DATE] with diagnoses including osteoarthritis, anxiety, dementia with behavior disturbances, delusional disorders, bipolar disorder, diabetes, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had independent cognitive skills for daily decision making. The resident had no range of motion impairment and required a wheelchair for mobility. Review of the care plan revealed resident #8 had the potential to be verbally aggressive. Resident #9 Review of the medical record for resident #9 revealed the resident was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, congestive heart failure, anxiety disorder, alcohol dependence, arthritis, cognitive communication deficit, dementia with behavioral disturbances, depression, and depression with psychotic features. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had independent cognitive skills for daily decision making. The resident had no range of motion impairment and required a wheelchair for mobility. Review of the care plan revealed resident #9 had physical aggression toward another resident. Review of the Resident Incident Report for resident #8 dated 12/29/2023 revealed the Certified Nursing Assistant (CNA) reported that resident #8 was in the dining room when resident #9 hit her. CNA stated that she did not see resident #9 hit resident #8, but it was reported to her by a few residents. Resident #8 stated resident #9 hit her on her shoulder. No bruising noted to left arm. No complaints of pain voiced at this time. Resident #8 able to move extremity well. Review of the facility's Investigation Report dated 12/29/2023 revealed there were no witnesses. Further review of the investigation revealed there was no documented evidence of statements from resident #8, resident #9, staff or residents. An interview with S1Administrator on 02/05/2024 at 11:15 a.m. confirmed there was no documented evidence of statements from resident #8, resident #9, staff or residents. S1Administrator reported she was unaware of which residents witnessed the incident in the dining room. During an interview on 02/07/2024 at 2:20 p.m., S1Administrator was notified that the allegation of physical abuse involving resident #8 and resident #9 was not thoroughly investigated due to no documented evidence of interviews with the involved residents or staff per the facility's abuse policy guidance. Resident #5 Review of the medical record for resident #5 revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, depression, anxiety, dysphagia, altered mental status, and dysphonia. Review of the annual MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #5 required assistance with transfers, had no range of motion impairment and used a wheelchair for mobility. Review of the care plan revealed resident #5 had the potential to be verbally aggressive. Resident #6 Review of the medical record for resident #6 revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, dementia with behavior disturbances, and schizophrenia. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Resident #6 required assistance with transfer and used a wheelchair for mobility. Review of the care plan revealed resident #6 had the potential to be physically aggressive. Review of the Resident Incident Report dated 12/13/2023 revealed resident #6 was in the dining room and hit resident #5 in the face. The residents were separated. The residents were assessed with no injuries noted. Review of the facility's incident investigation report dated 12/13/2023 revealed at approximately 3:30 p.m. S18Activity Director (AD) reported that she was preparing to start an activity in the dining room where both residents, as well as other residents were present. S18AD stated when she looked up resident #6 was standing up from his chair and hit resident #5 in the face. An interview with S1Administrator on 02/05/2024 at 11:15 a.m. confirmed there was no documented evidence of statements from the other residents that were present in the dining room at the time of the altercation. S1Administrator reported she was unaware of which residents witnessed the incident in the dining room. During an interview on 02/07/2024 at 2:20 p.m., S1Administrator was notified that the allegation of physical abuse involving resident #5 and resident #6 was not thoroughly investigated due to no documented evidence of interviews with the involved residents or staff per the facility's abuse policy guidance.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect residents' right to be free from physical abuse by another resident for 7 (#1, #2, #3, #5, #6, #7, #10) of 10 (#1 - #10) sampled residents reviewed for abuse. The facility failed to protect residents #1, #2, #3, #5, #6, #7, and #10 from being physically abused. Findings: Review of the current facility's Abuse Prevention Policy revealed: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Resident #1 Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with diagnoses including complete intestinal obstruction, colostomy, hypertension, reflux, and convulsions. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with cognitive skills for daily decision making. Resident #1 was independent with transfers and ambulation. Review of the care plan revealed resident #1 had the potential to be physically aggressive. Review of the record revealed the resident #1 was discharged on 01/18/2024. Resident #2 Review of the medical record for resident #2 revealed the resident was admitted on [DATE] with diagnoses including diabetes, heart failure, myocardial infarction, cognitive communication deficit, dementia with behavioral disturbances, alcohol dependence, hypertension and disorientation. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #2 was independent with transfers and ambulation. Review of the current plan of care revealed resident #2 had shown physical aggression towards another resident. Review of the facility's incident investigation revealed on 01/04/2024 resident #1 and #2 had an altercation. Review of the Resident Incident Report for resident #1 dated 01/04/2024 at 11:30 a.m. revealed the incident location was in the dining room. Further review revealed the nurse was called to the dining room by the Certified Nursing Assistant (CNA) to report that resident #2 had hit resident #1 in the back of his head. Both residents were separated with no apparent injuries. No injuries were noted and no complaints of pain. Further review of the Incident Report revealed resident #1 stated he was sitting at the table, resident #2 was standing at the door and resident #1 heard resident #2 say something about the door. Resident #1 then stated resident #2 hit him in the back of the head and I hit him back. An interview with resident #2 on 02/01/2024 at 11:00 a.m. revealed resident #2 was uninterviewable. An interview on 02/01/2024 at 12:53 p.m. with S5Certified Nursing Assistant (CNA) revealed she witnessed the altercation between resident #1 and resident #2 on 01/04/2024. S5CNA reported resident #2 was walking around like normal. Resident #2 had walked to the door in the dining room and looked out the window. Resident #1 was sitting at a dining room table facing away from the door. Resident #2 mumbled, Not letting me out the door. Resident #2 then punched resident #1 on the back left side of his head with a closed fist. Then resident #1 hit resident #2 back with a closed fist. S5CNA revealed the residents were separated and the nurse was notified. An interview on 02/07/2024 at 3:30 p.m. with S1Administrator confirmed the physical altercation on 01/04/2024 between resident #1 and resident #2. S1Administrator confirmed physical abuse did occur between resident #1 and resident #2. Resident #7 Review of the medical record for resident #7 revealed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbances, alcohol dependence with alcohol induced persisting dementia, psychosis, depression, anxiety, insomnia, unspecified intellectual disabilities, hypertension, osteoarthritis, cervicalgia, neuropathy, low back and left knee pain, tobacco use, and chronic obstructive pulmonary disease. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #7 required extensive assistance with transfers and had no range of motion impairment. Resident #7 required a wheelchair for mobility. Review of the current plan of care revealed resident #7 had verbal and possible physical aggressive behavior toward staff and other residents related to anger. Review of the record revealed resident #7 was discharged on 01/29/2024. Review of the facility's incident investigation revealed on 12/22/2023 resident #2 and #7 had an altercation. Review of the Resident Incident Report dated 12/22/2023 revealed resident #7 was in his wheelchair by the nursing station when resident #2 walked behind resident #7 and placed his hands around resident #7's neck. The nurse and social worker separated the two residents. A body audit was done. No apparent bruising at this time. No complaints of pain voiced. Resident #7 stated that resident #2 placed his hands around his neck. An interview with S3Licensed Practical Nurse (LPN) on 02/01/2024 at 3:10 p.m. revealed she witnessed the altercation between resident #7 and resident #2. S3LPN reported resident #7 was talking with other residents by the nursing station, resident #2 walked behind resident #7 and grabbed him with both hands around the neck. S3LPN reported she intervened immediately and staff separated the residents. S3LPN reported there were no injuries noted. An interview on 02/07/2024 at 3:30 p.m. with S1Administrator confirmed the physical altercation on 12/22/2023 between resident #7 and resident #2. S1Administrator was informed of the abuse deficiency related to resident #7 and resident #2's physical altercation. Resident #4 Review of the medical record for resident #4 revealed the resident was admitted on [DATE] with diagnoses including anxiety, depression, bipolar, psychosis, and moderate intellectual disability. Review of the annual MDS assessment dated [DATE] revealed the resident had moderate impaired cognitive skills for daily decision making. Resident #4 required assistance with transfers and had impairment of range of motion on one side. Resident #4 required a wheelchair for mobility. Review of the care plan revealed resident #4 had physical aggression towards other residents. Resident #10 Review of the medical record for resident #10 revealed the resident was admitted on [DATE] with diagnoses including aphasia, depression, cerebral infarction, dysphagia, muscle weakness, and cognitive communication deficit. Review of the quarterly MDS assessment dated [DATE] revealed the resident had independent cognitive skills for daily decision making. Resident #10 required assistance with transfers and had impairment of range of motion on one side. Resident #10 required a wheelchair for mobility. Review of the care plan revealed the resident had the potential to be physically aggressive related to anger. Review of the facility's incident investigation revealed on 01/26/2024 resident #4 and #10 had an altercation. Review of the Resident Incident Report dated 01/26/2024 revealed resident #10 was hit in the face by resident #4. Resident #4 was arguing with resident #10 for reasons unknown. Resident #10 had swelling noted to the top of the eyelid on the left side of the face. On 02/06/2024 at 1:40 p.m., an interview with resident #10 revealed he did remember when the he was hit in the face by another resident. Resident #10 stated he didn't hit him hard. He revealed the staff said he had a little swelling to his left eye but it did not bother him and it did not last long. On 02/05/2024 at 10:50 a.m., an interview with S16Social Services Department (SSD) revealed on 01/26/2023 she came out of her office and saw resident #4 and resident #10 kicking at each other in their wheelchairs. S16SSD revealed the residents were separated and the nurse was notified. On 02/07/2024 the surveyors viewed the video footage of the altercation on 01/26/2024. The surveyors verified physical contact between resident #4 and resident #10 had occurred. An interview on 02/07/2024 at 3:30 p.m. with S1Administrator confirmed the physical altercation on 01/26/2024 between resident #4 and resident #10. S1Administrator was informed of the abuse deficiency related to resident #4 and resident #10's physical altercation. Resident #3 Review of the medical record for resident #3 revealed the resident was admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage, muscle weakness, dementia, schizoaffective disorder, and anxiety, Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #3 was independent with transfers, had no range of motion impairment and used a wheelchair for mobility. Review of the care plan revealed resident #3 had verbal behavioral issues. Review of the facility's incident investigation revealed on 12/08/2023 resident #3 and #4 had an altercation. Review of the Resident Incident Report dated 12/08/2023 revealed resident #3 was walking up the hall pushing a wheelchair. It was reported that resident #4 hit resident #3 in the face twice, no injuries were noted. On 02/01/2024 at 10:15 a.m. interview with resident #3 stated he did not remember getting hit in the face or having any altercation at the facility. On 02/06/2024 at 9:15 a.m., an interview with S7PhysicalTherapyAssisant (PTA) revealed on 12/07/2023 when she came to work she started walking down the hall in which resident #4 resided and saw him in the hall in his wheelchair and resident #3 was pushing a wheelchair in close proximity. S7PTA revealed when resident #3 was by resident #4, resident #4 stood up out of the wheelchair and hit resident #3 in the face with a closed fist two times. S7PTA revealed she yelled for help and the two residents were separated. On 02/06/2024 at 9:30 a.m., an interview with S17LPN revealed she did not witness resident #4 hit resident #3 but was informed by S7PTA of the altercation. S17LPN revealed she assessed resident #3 and resident #4 and no injuries were observed. An interview on 02/07/2024 at 3:30 p.m. with S1Administrator confirmed the physical altercation on 12/08/2023 between resident #3 and resident #4. S1Administrator was informed of the abuse deficiency related to resident #3 and resident #4's physical altercation. Resident #5 Review of the medical record for resident #5 revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, depression, anxiety, dysphagia, altered mental status, and dysphonia. Review of the annual MDS assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #5 required assistance with transfers, had no range of motion impairment and used a wheelchair for mobility. Review of the care plan revealed resident #5 had the potential to be verbally aggressive. Resident #6 Review of the medical record for resident #6 revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, dementia with behavior disturbances, and schizophrenia. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Resident #6 required assistance with transfer and used a wheelchair for mobility. Review of the care plan revealed resident #6 had the potential to be physically aggressive. Review of the facility's incident investigation revealed on 12/13/2023 revealed resident #5 and #6 had an altercation. Review of the Resident Incident Report dated 12/13/2023 revealed resident #6 was in the dining room and hit resident #5 in the face. The residents were separated. The residents were assessed with no injuries noted. On 02/01/2024 at 2:04 p.m., an interview with S18Activity Director (AD) confirmed she witnessed the above altercation that occurred in the dining room. S18AD reported resident #6 hit resident #5 in the head with a closed fist and resident #5 retaliated and started hitting resident #6. S18AD revealed she yelled for help and they separated the two residents. On 02/07/2024 at 10:00 a.m., an interview with S17LPN revealed she assessed both resident #5 and resident #6 and no injuries were noted. An interview on 02/07/2024 at 3:30 p.m. with S1Administrator confirmed the physical altercation on 12/22/2023 between resident #5 and resident #6. S1Administrator was informed of the abuse deficiency related to resident #5 and resident #6's physical altercation.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident receiving a psychotropic medication was monitored for effectiveness and side effects for 1 (#2) of 10 (#1 - #10) sampled residents. Findings: Review of the medical record for resident #2 revealed the resident was admitted on [DATE] with diagnoses including diabetes, heart failure, myocardial infarction, cognitive communication deficit, dementia with behavioral disturbances, alcohol dependence, hypertension and disorientation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #2 was independent with transfers and ambulation. Review of the physician orders revealed orders dated 01/27/2024 for Rexulti 1 milligrams (mg) one tablet one time a day and Zoloft 50 mg one time a day. Review of the care plan revealed the resident used psychotropic medications. Further review revealed an approach to monitor for side effects and effectiveness every shift. Review of the record revealed there was no documented evidence that the staff were monitoring the effectiveness or side effects of the psychotropic medications. An interview with S2Director of Nursing (DON) on 02/06/2024 at 12:25 p.m. confirmed there was no documented evidence that the staff were monitoring the effectiveness or side effects of the psychotropic medications. S2DON further confirmed resident #2's psychotropic medications should have been monitored for effectiveness and side effects.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0949 (Tag F0949)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services that is appropriate and effective as determined by the facility assessment. The facility failed to ensure all staff (direct, indirect, and contract) were trained on the behavioral health care needs and services for all 80 residents residing in the facility. The facility failed to ensure the following staff received behavioral management health care training: 1) 1 staff providing direct care to the residents (S4Licensed Practical Nurse (LPN), 2) 4 (S6OccupationalTherapist (OT), S7PhysicalTherapistAssistant (PTA), S8CertifiedOccupationalTherapistAssistant (COTA), S9SpeechTherapist (ST)) and 3) 6 (S10LPN, S11Certified Nursing Assistant (CNA), S12LPN, S13CNA, S14LPN, S15CNA) contract staff. Findings: Review of the current facility assessment dated [DATE] revealed the facility had residents that have Psychiatric/Mood Disorders such as Psychosis (Hallucinations, Delusion, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, and Behavior that Needs Interventions. Further review of the facility assessment revealed the following statement. We have more behavioral residents admitting, so more trainings are needed. On 02/07/2024 at 11:50 a.m., an interview with S2Director of Nursing (DON) revealed the facility has 40 residents that have a diagnoses of Psychiatric/Mood Disorders and 41 residents that receive psychotropic medications. On 02/06/2024 at 9:15 a.m., an interview with S7PhyscialTherapistAssistant (PTA) revealed she had not received training on how to handle residents that have behaviors. Review of the training material and training sign in sheets revealed no documented evidence that S4LPN, S6OT, S7PT, S8COTA, S9ST, S10LPN, S11CNA, S12LPN, S13CNA, S14LPN, S15CNA received behavioral management health care training prior to working with the residents. On 02/07/2024 at 2:50 p.m., an interview with S1Administrator and S2DON confirmed the therapy department, the LPN, and agency (contracted) staff did not receive training in behavior management prior to working with the residents.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review and interviews the facility failed to inform the resident's responsible party of a resident's change in condition for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure responsible party was notified of Resident1's fall and emergency room visit. Resident1 was admitted to the facility 01/23/2020 with diagnoses that include but not limited to the following: Cerebral Palsy, anxiety disorder, anemia, major depressive disorder, epilepsy unspecified, Crohn's disease, and pain unspecified. Review of Resident #1's incident report dated 09/12/2023 at 9:10 p.m. revealed Resident #1 was found on floor beside bed by a CNA (Certified Nursing Assistant). Resident was assessed by S3LPN (Licensed Practical Nurse) and no apparent injury was noted. Resident denied hitting head. Resident complained of hurting all over. Resident reported she did not remember falling. Resident's vital signs were the following: tempurature 98.6, pulse 80, respirations 20, blood pressure 133/87, and pain scale 7. Physician was notified on 09/12/2023 at 9:23 p.m. and instructed to transfer resident to the emergency room for evaluation and treatment. Further review of the incident report revealed no documentation of Resident #1's responsible party being notified. Review of Resident #1's nurses note dated 09/12/2023 failed to reveal notification of the responsible party. An interview on 10/02/2023 at 9:40 a.m. with S3LPN revealed she attempted to call Resident #1's responsible party on 09/12/2023 at 9:30 p.m. without success. S3LPN revealed she did not notify Resident #1's Responsible party and informed the oncoming nurse at the end of her shift. During an interview on 10/03/2023 at 11:30 a.m. S2DON(Director of Nursing) reviewed Residen#1's incident report dated 09/12/2023 and Resident #1's nurses notes and agreed there was no documentation of Resident #1's responsible party being notified of the fall and emergency room visit on 09/12/2023. S2DON confirmed Resident1's responsible party should have been notified.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to protect the resident's right to be free from physical and verbal abuse by S3 CNA (Certified Nursing Assistant), when she used profanity and cursed at the resident and overturned a tray full of his belongings into his lap. The incident involved 1 (#1) of 5 (#1-5) sampled residents reviewed for abuse. Findings: Review of the facility`s policy on abuse revealed the facility would provide protections for the health, welfare and rights of each resident to prevent resident abuse. The policy also called for the facility to establish coordination with the quality assurance and performance improvement (QAPI) program. Review of facility incident report revealed an incident on 08/03/2023 occurred between resident #1 and S3 CNA. The completed facility incident report substantiated that Resident #1 sustained physical and verbal abuse by S3 CNA. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, major depressive disorder, congestive heart failure, morbid obesity and neuropathy. Review of the most recent minimum data set assessment revealed resident #1 required 2 person assistance for most activities of daily living and he had a Brief Interview of Mental Status (BIMS) score of 13, which indicated he was cognitively intact. On 08/28/2023 at 10:30 a.m., an interview with resident #1 was conducted in his room. Resident #1 confirmed he had an altercation with S3 CNA a few weeks back that resulted in her termination. Resident #1 reported on the night of the incident, S3 CNA went into his room to fill his water pitcher. Resident #1 reported S3 CNA went in the bathroom to fill the pitcher and he requested that she go to the front of the facility to get the filtered water. Resident #1 reported S3 CNA left the room while cursing under her breath and came back in the room and placed the water on his bedside table while cursing under her breath. Resident #1 reported he informed S3 CNA she needed to check her attitude as she was leaving the room and she began walking toward him in an aggressive stance. Resident #1 reported he threatened her by telling her she better backup up before something bad happened. Resident #1 reported they exchanged some curse words then she turned to walk away and he had the water pitcher. Resident #1 acknowledged he had the water pitcher in his hand and he wanted to hit her in the face with it but he reported he did not want to deal with the consequences so he decided to throw it against the wall beside her. He reported S3 CNA picked the pitcher up and threw it back at him but did not hit him. Resident #1 reported S3 CNA then walked up and attempted to push the over the bed table into his chest as he was sitting upright in the bed so he stopped the table with his hands. Resident #1 reported she was unable to push the table into him so she turned the table over and spilled the contents of the table in his lap. He reported there were books, mouthwash, drinks, hairbrush and other miscellaneous personal care items that fell in his lap. Resident #1 reported another lady came in and removed S3 CNA from his room. On 08/28/2023 at 01:18 p.m. an interview with S4 housekeeping supervisor revealed she was at the end of the hall when she overheard cursing from resident #1`s room. She went to the room and saw S3 CNA push the bedside table toward resident #1 and the table`s contents dumped on the foot of the bed. She reported Resident #1 then threw a water pitcher at S3 CNA but did not hit her. S4 housekeeping supervisor reported the water pitcher hit the wall and went out into the hallway. S4 housekeeper confirmed both S3 CNA and resident #1 were both using profanity cursing toward one another. S4 housekeeping supervisor reported she was able to get S3 CNA out of the room before things got worse. On 08/29/2023 at 09:00 a.m. an interview with S2 Director of Nursing (DON) was conducted in her office. S2 DON confirmed she was working on 08/03/2023 when the incident between resident #1 and S3 CNA occurred on 08/03/2023 at 3:00 p.m. S2 DON revealed S3 CNA was taken to her office and interviewed immediately following the incident. S3 CNA admitted pushing the table toward resident #1 so she was immediately suspended then later terminated after the investigation confirmed physical and verbal abuse was substantiated. The investigation found S3 CNA had dumped the table contents onto resident #1's lap and had used profanity and cursed at the resident during this incident. On 08/29/2023 at 12:10 p.m. an interview with S1 Administrator confirmed the allegations of physical and verbal abuse was substantiated by their internal investigation involving resident #1 and S3 CNA on 08/03/2023. S1 administrator confirmed there was no record of implementation of a quality assurance plan with a staff member assigned to monitoring the facility for abuse after substantiating the allegation of abuse. S1 administrator confirmed the facility failed to establish coordination with the quality assurance and performance improvement (QAPI) program as directed by their policy on abuse.

May 2023 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to notify the resident representative when a resident had a fall for 2 (#13, #63) of 3 (#13, #63, #65) residents with falls. Findings: Resident #13 Review of the medical record revealed resident #13 had falls on 01/26/2023, 02/16/2023, 03/26/2023, and 04/07/2023. Review of incident and accident report for resident #13 dated 03/26/2023 revealed the resident was reaching for items and fell onto the floor mat at the bedside. Further review of the incident and accident report and the nurses' notes revealed there was no documentation of notification to the resident representative after the fall. On 05/23/2023 at 9:31 a.m., an interview with S2 RN (Registered Nurse) Manager revealed there was no documentation of notification to the resident representative after the fall. Resident #63 Review of the incident and accident report for resident #63 dated 04/20/2023 at 12:46 p.m. revealed resident #63 was noted on the floor in front of his wheelchair in the dining room. Resident #63 stated he didn't know what he was doing, he was just on the floor. Review of the nurses' notes revealed there was no documentation of any incidents for 04/20/2023. On 05/23/2023 at 8:49 a.m. review of the incident and accident report and nurses notes with S17 LPN (Licensed Practical Nurse) agreed there was no documentation in the nurses' notes regarding the resident's fall on 04/20/2023. S17 LPN further confirmed there was no documentation of notifying the resident's representative after the fall.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #79 Record review revealed resident #79 was admitted to the facility on [DATE] with diagnosis that included encounter for orthopedic aftercare following surgical amputation of toe, diabetes, pain, depression and hyperlipidemia. Record review revealed resident # 79 was transferred to a rehabilitation hospital on [DATE]. Record review revealed no documentation of notification to the family or the ombudsman of the transfer to the rehabilitation hospital. On 05/23/2023 at 5:21 p.m. interview with S7 Assistant Administrator confirmed the facility did not notify the family or the Ombudsman when resident #70 was transferred to the rehabilitation hospital. S7 Assistant Administrator further said he was in charge of the notifications and had not done it. Based on record review and interview the facility failed to provide written notice of transfer or hospitalization to the Ombudsman and resident`s representative for 2 (#20, and #79) of 2 (#20, and #79) residents reviewed for hospitalizations. Findings: Resident #20 Review of the record for resident #20 revealed admit date [DATE] with diagnosis of left knee osteoarthritis, hypertension, schizophrenia, depression, shortness of breath, abnormality of gait, cardiomegaly, aftercare following joint replacement surgery, cognitive communication deficit, insomnia, discitis lumbar region, spondylodiscitis in addition to moderate malnutrition, metabolic acidosis, epidural abscess, acute kidney injury, bipolar disorder, Alzheimer's disease, dementia, schizophrenia, and paraspinal abscess. Resident #20 had a BIMS (Brief Interview Mental Status) of 9 indicating Resident #20 had moderate mental impairment. Record review revealed resident #20 was sent to the emergency room on [DATE] due to an abdominal hernia and returned to the facility on [DATE]. Further review of the record revealed resident #20 was sent to the emergency room on [DATE] for evaluation of a mass to the left abdomen and returned to the facility on [DATE]. Review of the nurses' notes revealed no documentation of notification of the family when resident #20 was sent to the hospital on [DATE] and 02/13/2023. Further review of the record revealed there was no documentation the Ombudsman was notified of the transfer to the hospital on [DATE] and 02/13/2023. On 05/23/2023 at 5:21 p.m. interview with S7 Assistant Administrator confirmed the facility did not notify the family or the Ombudsman when resident #20 was transferred to the hospital. S7 Assistant Administrator further said he was in charge of the notifications and had not done it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to update the plan of care with appropriate approaches after a resident fall for 1 (#63) of 3 (#13, #63, #65) residents investigated for falls. Resident #63 On 05/21/2023 observation of resident #63's bed revealed there was a mattress on the floor. Interview with S2 RN (Registered Nurse) Manager revealed they put his mattress on the floor a long time ago because he was having behaviors such as pulling things off the tables, hitting the walls, and falling out of a regular bed onto the floor. Review of the incident and accident report for resident #63 dated 04/20/2023 revealed resident #63 had a fall in the dining room from his wheelchair. Review of the plan of care update approaches for the fall on 04/20/2023 revealed: 1/2 side rails put on bed, bed mattress placed on side of bed. During observations on 05/21/2023 and 05/22/2023 the resident's mattress was on the floor and not on a frame. On 05/22/2023 at 3:46 p.m., an interview with S8 MDS (Minimum Data Set) Coordinator revealed she gets the updated interventions for the care plan from the DON (Director of Nurses). S8 MDS further revealed she doesn't read the incident reports and agreed the intervention was not appropriate. At that same time, S6 Corporate MDS Coordinator agreed the intervention was not an appropriate updated approach to the plan of care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to provide the necessary services for a resident who was unable to carry out activities of daily living to maintain good personal hygiene for 1 (#36) of 1 (#36) residents reviewed for activities of daily living out of a sample of 18. The failed practice was made evident by the facility failing to provide clean bed linen for Resident #36. Findings On 05/21/2023 at 10:49 a.m., resident #36 reported she needed help making her bed and she needed clean linens. Resident #36 reported her bed sheets had not been changed in a week. The bed sheets were dingy and dirty and the draw sheet had a brown smear on the left hand side. Resident # 36 reported she did not have a left femur so she needed help changing her bed sheets. On 05/22/2023 at 1:33 p.m., resident #36 reported the bed sheets had not been changed. The bed sheets remained dingy and dirty. The draw sheet had a brown smear on the left hand side. On 05/23/2023 at 8:43 a.m., an observation and interview with S1 Administrator was conducted in resident #36's room. The bed sheets remained dingy and dirty. The draw sheet had a brown smear on the left hand side. S1 Administrator agreed the draw sheet and linens needed to be changed. S1 Administrator was informed the draw sheet had the same brown smear on the left hand side since 05/21/2023.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0729 (Tag F0729)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews the facility failed to ensure State Registry verifications were obtained prior to hire of 2 (S13 CNA (Certified Nursing Assistant) and S16 CNA) of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA and S16 CNA) personnel files reviewed. Findings: Review of the facility's policy for Abuse, Neglect and Exploitation revealed in part: The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 3. The facility will maintain documentation of proof that the screening occurred. Review of the personnel file for S13 CNA revealed a hire date of 04/19/2023. Further review of the personnel file revealed no documented evidence of a CNA state registry verification obtained. Review of the personnel file for S16 CNA revealed a hire date of 11/11/2022. Further review of the personnel file revealed no documented evidence of a CNA state registry verification obtained. On 05/22/2023 at 2:10 p.m., an interview with S9 Business Office Manager revealed there was no documented evidence of CNA state registry checks for S13 CNA and S16 CNA obtained prior to the CNAs being hired. On 05/23/2023 at 4:45 p.m., S1 Administrator was notified of no CNA registry checks for S13 CNA and S16 CNA obtained prior to hire.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#38) of 5 (#13, 32, 38, 68, 72) residents reviewed for unnecessary medications. The facility failed to obtain a lipid panel and a liver function test for resident #38. Findings: Review of the medical record for resident #38 revealed diagnoses of diabetes mellitus, pain, mood disorder, heart disease, hyperlipidemia, hypertension, anxiety, insomnia, and depressive disorder. Review of the careplan revealed at risk for medication side effects and for the pharmacist consultant to review the medications every month, obtain lab work as ordered and report results. Review of the quarterly MDS (Minimum Data Set) dated 04/17/2023 revealed the resident had independent cognition for daily decision making and required supervision with set up help for activities of daily living. Review of the physician's orders revealed an order dated 01/09/2023 for Gemfibrozil 600 milligrams (cholesterol lowering medication) to be given every day. Further review of the physician's orders revealed an order dated 01/09/2023 for a lipid panel to be obtained yearly in January, and a liver function test to be obtained every 6 months in January and July. Review of the lab results revealed no documented evidence of the lipid panel and a liver function test obtained in January 2023 as ordered. Further review of the lab results revealed the most recent lab results for a lipid panel was dated 01/05/2022, and a liver function test dated 07/05/2022. On 05/23/2023 at 4:15 p.m., an interview with S5 Corporate Compliance LPN (Licensed Practical Nurse) confirmed there was no documented evidence of the lipid panel or the liver function test obtained in January 2023 as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure all drugs and biologicals are stored in locked compartments. The facility failed to ensure medications were not left unattended at the bedside for 1 (#12) of 1 (#12) residents. Findings: Review of the facility's Medication Storage policy revealed in part: Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering mediations or locked in the medication storage area/cart. Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, peripheral vascular disease, bipolar, diabetes mellitus, hyperlipidemia, and overactive bladder. Review of resident #12's MDS (Minimum Data Set) dated 04/04/2023 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating independent cognition for daily decision making. Further review revealed the resident required assistance with activities of daily living. Observation on 05/21/2023 at 8:20 a.m. revealed resident #12 was in the bed and a medication cup with 8 unidentifiable pills in the cup was located on the resident's over bed table which was positioned over the bed in front of the resident. Further observation revealed the nurse was not in view of the resident and/or the medications. On 05/21/2023 at 8:30 a.m., S2 RN (Registered Nirse) Nurse Manager was notified of the medications that were located on resident #12's over bed table in the resident's room. At this time S2 RN/Nurse Manager went into resident #12's room and witnessed the 8 medications left on the table. S2 RN/Nurse Manager confirmed the medications should not have been left at the bedside unattended. S2 RN/Nurse Manager confirmed the nurse should have observed the resident consuming the medications. On 05/23/2023 at 4:30 p.m., S5 Corporate Compliance Licensed Practical Nurse was notified of the medications left unattended at resident #12's bedside. On 05/23/2023 at 4:45 p.m., S1 Administrator was notified of the medications left unattended at resident #12's bedside.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 Resident #28 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation, major depressive disorder, acquired absence of kidney, gastrostomy status, mild protein calorie malnutrition, hypokalemia, anxiety disorder, conversion disorder with seizures or convulsions, cerebral infarction, hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, contracture right knee and left knee. Review of resident #28's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Further review of the MDS revealed resident does not have an Advanced Directive. Review of resident #28's paper chart revealed no documentation of Advanced Directive. On 05/23/2023 at 4:15 p.m., an interview with S5 Corporate Compliance LPN (Licensed Practical Nurse) confirmed that resident #28 did not have documentation of an Advance Directive on the chart. Resident #68 Resident #68 was admitted on [DATE] with diagnoses including unspecified psychosis, dementia, anxiety, anemia, hypertension, chronic pain, metabolic encephalopathy, unspecified convulsions, Alzheimer's disease, other nontraumatic intracerebral hemorrhage, and depression. Review of resident #68's quarterly MDS assessment dated [DATE] with a BIMS score of 9 indicating moderate cognitive impairment. Further review of MDS revealed resident did not have an Advanced Directive. Review of resident #68's paper chart revealed no documentation of an Advanced Directive. An interview on 05/23/2023 at 4:15 p.m. with S5 Corporate Compliance LPN confirmed that resident #68 did not have an Advance Directive. Based on record reviews and interviews the facility failed to ensure that residents or the resident's responsible representative were provided written Advance Directive information for 3 (#12, #28, and #68) of 3 (#12, #28, and #68) residents reviewed for advance directives. Findings: Resident #12 Review of the Facility's Resident' Rights Regarding Treatment and Advance Directives revealed in part: Policy Explanation and Compliance Guidelines: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate and advance directive. Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, sleep apnea, peripheral vascular disease, bipolar, diabetes mellitus, reflux, hyperlipidemia, and overactive bladder. Review of resident #12's MDS (Minimum Data Set) dated 04/04/2023 revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident had independent cognition for daily decision making. Review of resident #12's paper chart revealed there was no documented evidence of an Advance Directive. On 05/23/2023 at 4:20 p.m., an interview with S6 Corporate MDS Coordinator confirmed there was no documented evidence of an Advance Directive located in the chart.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment by having a dirty whirlpool room, dirty resident bathrooms, not having paper towels or soap available in resident bathrooms, and by having large holes in resident bathroom wall. Findings: On 05/21/2023 at 08:45 a.m. observation of room (a) revealed: Shower stall had a dirty brief lying on the floor, dirty towel and dirty washcloth lying on the floor. On the floor next to the whirlpool tub was a dirty towel. Observation of the bathroom area in the whirlpool room revealed the tank cover was missing to the toilet and there was mold in the toilet. Further observation of the bathroom revealed there was a broken toilet seat in the trash can. Observation of the floor by the entrance and exit door to the 100 hall whirlpool room revealed there was a used glove on the floor by the door, and a used cigarette butt on floor by door. Interview at the same time with S3 WC (Wound Care Nurse) revealed they don't do showers on Sundays, she further confirmed all of the observations and said she would take care of it personally. On 05/21/2023 at 9:00 a.m. during initial tour observations revealed: Bathroom to room (s) revealed there was a strong urine odor, brown substance smeared on the toilet seat and a thick layer of brown substance covering the inside of the toilet. Resident #45 said at that time that if you put paper in the toilet it will not flush. On 05/22/2023 at 10:00 a.m. an observation of room (e) revealed there was a strong urine odor in the bathroom, there was liquid on the floor, and mold in the toilet bowl. Resident #38 said at that time that they only clean the bathroom one time a day and one of the other residents that share the bathroom always urinates on the floor. On 05/22/2023 at 10:02 a.m. observation of the following bathrooms revealed: Room f- dried feces on the rim inside of toilet, Room g- dried feces on the inside of the toilet bowl, Room e- very strong urine odor, and urine in toilet. S10 Housekeeper said she was getting ready to clean the bathroom. S10 Housekeeper reported residents urinate on the floor. On 05/22/2023 at 1:30 p.m. observation of the resident bathrooms revealed the following: Room b- no soap and no paper towels, Room f- no soap and no paper towels, Room g- no soap and no paper towels, Room i- no soap and no paper towels, Room j- no soap and no paper towels, Room h- no soap and no paper towels, Room e- no soap and no paper towels, Room d- no soap and no paper towels, Room c- no soap, Room r- no paper towels, Room k- no soap, Room l- no soap, Room m- no soap and no paper towels, Room q- toilet stained, dried feces on side of inner bowl, Room p- large hole under sink exposing pipes, sheet rock pieces were on the floor, another hole in sheet rock behind toilet, Room o- no soap and no paper towels, Room n- mold growing on shower head, in the bottom and sides of the shower and on the shower curtain. On 05/22/2023 at 3:05 p.m. all observations and findings were discussed with S1 Administrator and S7 Assistant Administrator. S1 Administrator and S7 Assistant Administrator agreed the issues discussed needed to be corrected.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #59 Record review revealed resident #59 was admitted to the facility 04/18/2022 with diagnosis that included cerebral infarction, aphasia, shortness of breath, reduced mobility, encephalopathy, dementia, malnutrition, dysphagia, type 2 diabetes, and abnormal posture. Review of the MDS dated [DATE] revealed resident # 59 had total dependence on staff for ADL (Activities of Daily Living) care which included bed mobility and transferring from bed to geri chair (reclining chair with foot rest for people with mobility issues). Review of the current physician's order revealed an order dated 02/15/2023 as follows: Diabetic ulcer left heel: clean with w/c (wound cleanser), pat dry with gauze, cover with dry dressing of choice daily and prn (as needed) soiled or non intact. Review of the ETAR revealed wound care to left heel had not been recorded as completed on Saturdays or Sundays for the months of April and May 2023. Review of wound assessments revealed weekly wound assessments had not been completed for the months of April, and May 2023 by a RN. On 05/23/23 at 03:05 p.m., an interview with S1 Administrator confirmed weekly wound assessments should have been completed by a registered nurse for resident #59. S1 Administrator also agreed wound care should have been provided and recorded on the ETAR every day including weekends as directed by physician orders. Based on observations, interviews and record reviews the facility failed to provide care and treatment in accordance with professional standards for 2 (#12, 32) of 3 (#12, 32, 59) residents reviewed for pressure ulcers. The failed practice was evidenced by the facility having: 1) no record of weekly RN (Registered Nurse) wound assessments for Residents #12 and #32 and, 2) no record of weekend wound care provided on Saturdays and Sundays in April and May 2023 for Resident #12 and #32. Resident #12 Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, peripheral vascular disease, bipolar, diabetes mellitus, hyperlipidemia, and overactive bladder. Review of resident #12's MDS (Minimum Data Set) dated 04/04/2023 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating independent cognition for daily decision making. Further review revealed the resident required assistance with activities of daily living. Review of the care plan revealed the resident was at moderate risk for pressure ulcer development and the approaches were to do a full skin evaluation with bath/shower, encourage good nutritional intake and to use supportive devices to assist with positioning. Review of the physician orders dated 04/10/2023 revealed an order to clean stage 3 right lateral malleolus with wound cleanser, pat dry with gauze, apply calcium alginate, cover with dressing of choice, change every day and as needed. Review of the Braden scale dated 04/10/2023 revealed the resident was scored at moderate risk for pressure ulcer development. Review of ETAR (electronic treatment administration record) revealed wound care had not been recorded as completed on Saturday or Sundays for the months of April and May 2023. Review of wound assessments revealed weekly wound assessments had been not been completed for the months of April, and May 2023 by a RN. On 05/23/2023 at 11:30 a.m., an interview with S2 RN Manager confirmed there was not weekly wound assessment performed by a RN. On 05/23/2023 at 4:30 p.m. an interview with S5 Corporate Compliance Licensed Practical Nurse revealed resident #12 should have received wound care daily including the weekends. S5 Corporate Compliance Licensed Practical Nurse confirmed weekly wound assessments were not performed by a RN for April 2023 and May 2023.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #68 Resident #68 was admitted on [DATE] with diagnoses including unspecified psychosis, dementia, anxiety, anemia, hypertension, chronic pain, metabolic encephalopathy, unspecified convulsions, Alzheimer's disease, other nontraumatic intracerebral hemorrhage, and depression. Review of resident #68's May 2023 Physician's Orders revealed an order dated 02/27/2023 for Klonopin 0.25 mg (milligrams) tablet administer 1 tablet po (by mouth) at noon and administer Klonopin 0.5 mg 1 tablet po at bedtime. Review of resident #68's April 2023 and May 2023 MAR (Medication Administration Record) revealed no documentation of monitoring side effects and behaviors for resident #68 while taking antianxiety medication (Klonopin). Review of the Pharmacy Consultant Reports for resident #68 from January 2023- April 2023 revealed the pharmacy consultant failed to identify that facility was not monitoring for side effects and behaviors of antianxiety medication while resident was taking Klonopin. An interview on 05/23/2023 at 4:15 p.m. with S6 Corporate Compliance LPN (Licensed Practial Nurse), confirmed the pharmacy consultant failed to identify that the facility did not have monitoring of side effects and behaviors for resident #68 while resident taking an antianxiety medication (Klonopin). Resident #13 05/23/23 10:35 a.m. record review for resident #13 revealed a BIMS (Brief Interview for Mental Status) of 9 indicating moderate impairment in cognition. Resident #13 had diagnoses of Depression, Hypokalemia, Pain from osteoarthritis, Hypertension, Hepatitis C, Bit B12 Deficiencies anemia, Dementia without behavioral disturbance, unspecified intellectual disabilities, Peripheral Vascular Disease, Hyperlipidemia, Unspecified psychosis not due to a substance or known physiological condition, Insomnia and Anxiety disorder. Review of the May 2023 Physician orders in part: Klonopin 0.5 mg (milligrams) give 1/2 tab (0.25 mg) by mouth BID (twice a day) for behaviors- document outcome of behavior interventions, monitor targeted behaviors. Cymbalta 30 mg by mouth at HS (at bedtime). Review of the January 2023 DRR revealed the pharmacist requested a diagnosis for Klonopin 0.25 mg BID and Cymbalta 30 mg Q HS- further review revealed a letter was sent to the Physician for diagnoses the diagnosis on 01/26/2023. On 02/10/2023 the Physician signed the letter but failed to document a diagnoses. On 05/23/2023 at 2:22 p.m., an interview with S2 RN (Registered Nurse) Manager revealed the Physician comes every week and reviews them. S2 RN Manager confirmed the residnet's Physician did not give a diagnoses code for the medications and it must have gotten over looked. Resident #32 On 05/23/2023 at 2:39 p.m. review of the record for resident #32 revealed a BIMS of 15 indicating the resident was cognitively intact. Resident #32 had diagnosis of: Type 2 Diabetes with diabetic neuropathy, COPD (Chronic Obstructive Pulmonary Disease), Major depressive disorder, Anxiety disorder, Chronic Viral hepatitis, Sarcoid Aethropathy Morbid obesity, Schizophrenia, Mental disorder, and Xerosis cutis. Review of the Physician Orders in part revealed: Depakote DR 500 mg by mouth BID. Review of January 2023 Drug Regiment Review revealed the Pharmacist requested a diagnoses for Depakote 500mgv by mouth BID (twice daily). Review of the Pharmacist notification to the Physician dated 01/26/2023 the request for a diagnoses for the Depakote revealed it was left blank and not acted upon. The Physician signed the letter on 02/10/2023. On 05/23/2023 at 3:14 p.m., an interview with S2 RN Manager confirmed there was no diagnosis obtained for the Depakote. Based on record review and interview the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon for 4 (#13, 32, 38, 68) of 5 (#13, 32, 38, 68, 72) residents reviewed for unnecessary medications. The pharmacist failed to address a lipid panel and a liver function test was not obtained for resident #38, and failed to address no monitoring for side effects and behaviors for resident #68 receiving an antianxiety medication. The physician failed to act upon the pharmacist recommendation regarding missing diagnoses for residents #13 and #32. Findings: Resident #38 Review of the medical record for resident #38 revealed diagnoses of diabetes mellitus, pain, mood disorder, heart disease, hyperlipidemia, hypertension, anxiety, insomnia, and depressive disorder. Review of the careplan revealed at risk for medication side effects and for the pharmacist consultant to review the medications every month, and to obtain lab work as ordered and report results. Review of the quarterly MDS (Minimum Data Set) dated 04/17/2023 revealed the resident had independent cognition for daily decision making and required supervision with set up help for activities of daily living. Review of the physician's orders revealed an order dated 01/09/2023 for Gemfibrozil 600 milligrams (cholesterol lowering medication) to be given every day. Further review of the physician's orders revealed an order dated 01/09/2023 for a lipid panel to be obtained yearly in January, and a liver function test to be obtained every 6 months in January and July. Review of the lab results revealed no documented evidence of the lipid panel and a liver function test obtained in January 2023 as ordered. Further review of the lab results revealed the most recent lab results for a lipid panel was dated 01/05/2022, and a liver function test dated 07/05/2022. On 05/23/2023 at 4:10 p.m., an interview with S6 Corporate MDS (Minimum Data Set) Coordinator revealed the pharmacist did not address the labs not obtained on the monthly DRR (Drug Regime Review) for 02/23/2023, 03/23/2023 and 04/28/2023.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#68) of 5 (#13, #32, #38, #68, and #72) 5 residents reviewed for unnecessary medications. The facility failed to ensure resident #68 was monitored for side effects and behaviors while on an antianxiety medication. Findings: Resident #68 was admitted on [DATE] with diagnoses including unspecified psychosis, dementia, anxiety, anemia, hypertension, chronic pain, metabolic encephalopathy, unspecified convulsions, Alzheimer's disease, other nontraumatic intracerebral hemorrhage, and depression. Review of resident #68's May 2023 Physician's Orders revealed an order dated 02/27/2023 for Klonopin 0.25 mg (milligrams) tablet administer 1 tablet po (by mouth) at noon and administer Klonopin 0.5 mg 1 tablet po at bedtime. Review of resident #68's April 2023 and May 2023 MAR (Medication Administration Record) revealed no documentation of monitoring side effects and behaviors for resident #68 while taking antianxiety medication (Klonopin). An interview on 05/23/2023 at 4:15 p.m. with S6 Corporate Compliance LPN (Licensed Practical Nurse) confirmed the facility failed to document monitoring of side effects and behaviors for resident #68 while resident taking an antianxiety medication (Klonopin).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected multiple residents

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Based on interview the facility failed to maintain an effective QAPI (Quality Assurance Performance Improvement) system to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators. Findings: On 05/23/2023 at 6:15 p.m. a request was made to review the facility QAPI (Quality Assurance Performance Improvement) plan and documentation of the implementation of the QAPI. At that time, S1 Administrator revealed he had not done any QAPI for the past year or for the identified deficiencies cited on the annual survey. S1 Administrator said the only thing he had was the quarterly QA (Quality Assurance) committee sign in sheets. He said he did not even have any minutes from the quarterly QA meetings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

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Based on interview the facility failed to coordinate and evaluate activities under the QAPI (Quality Assurance Performance Improvement) program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Findings: On 05/23/2023 at 5:32 p.m. an interview with S1 Administrator revealed he only had sign in sheets for the QA (Quality Assurance) meetings and did not have any meeting minutes. S1 Administrator also confirmed that he did not have any items or problems that identified the facility was in the process of monitoring.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 1 harm violation(s), $81,880 in fines, Payment denial on record. Review inspection reports carefully.
• 68 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $81,880 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Cypress At Lake Providence's CMS Rating?

CMS assigns Cypress at Lake Providence an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Cypress At Lake Providence Staffed?

CMS rates Cypress at Lake Providence's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Cypress At Lake Providence?

State health inspectors documented 68 deficiencies at Cypress at Lake Providence during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 63 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Cypress At Lake Providence?

Cypress at Lake Providence is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VOLARE HEALTH, a chain that manages multiple nursing homes. With 108 certified beds and approximately 67 residents (about 62% occupancy), it is a mid-sized facility located in LAKE PROVIDENCE, Louisiana.

How Does Cypress At Lake Providence Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, Cypress at Lake Providence's overall rating (1 stars) is below the state average of 2.4, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Cypress At Lake Providence?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Cypress At Lake Providence Safe?

Based on CMS inspection data, Cypress at Lake Providence has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Cypress At Lake Providence Stick Around?

Staff turnover at Cypress at Lake Providence is high. At 58%, the facility is 12 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 80%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Cypress At Lake Providence Ever Fined?

Cypress at Lake Providence has been fined $81,880 across 3 penalty actions. This is above the Louisiana average of $33,898. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Cypress At Lake Providence on Any Federal Watch List?

Cypress at Lake Providence is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 108
Avg. Residents: 67
Occupancy: 62.9%
Ownership: For profit - Corporation
Chain: VOLARE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
2 Immediate Jeopardy citations: -24
1 Actual Harm citation: -5
68 Deficiencies: -10
Fines ($81,880): -10
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

No other facilities found in this area.

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195585