Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #6) of 1 (Resident #6) sampled resident investigated for the self-administration of medications. Findings: Review of the facility's Right to Self-Administration Medications policy, dated 12/05/2014 revealed, in part, residents would be assessed on admission, quarterly, annual, and any significant change in condition and as needed for self-administration of medication, if applicable. Review of Resident #6's Quarterly Minimum Data Set with an Assessment Reference Date of 05/06/2025 revealed, in part, Resident #6 had a Brief Interview for Mental Status score of 11, which indicated Resident #6 had moderate cognitive impairment. Review of Resident #6's record revealed, in part, no documented evidence and the facility was unable to present any documented evidence Resident #6 was assessed for the self-administration of medications. Observation on 06/30/2025 at 10:25AM revealed on Resident #6's bathroom counter a gray tray with 1 opened 45 gram tube of Cloderm 0.1% cream, (a cream used to treat topical skin irritation). In an interview on 06/30/2025 at 10:30AM, Resident #6 confirmed she had applied the Cloderm 0.1% cream to her hands several times. Observation on 07/01/2025 at 9:48AM revealed on Resident #6's bathroom counter a gray tray with 1 opened 45 gram tube of Cloderm 0.1% cream. Further observation revealed on Resident #6's bedside table 2 medication cups. One cup had 1 yellow and 1 light green approximately 1 half inch tablet, and the second cup had 5 tablets yellow, green and orange in color. Further observation revealed 1 bottle of pain relief roll on, 2.5 ounces, with the active ingredient lidocaine hydrochloride 4% (topical medication used for pain relief). In an interview on 07/01/2025 at 11:00AM, S7Licensed Practical Nurse confirmed Resident #6 was not assessed to self-administer medications. She further confirmed Resident #6 should not have medications left at her bedside or in her bathroom. In an interview on 07/01/2025 at 11:50AM, S2Registered Nurse/Assistant Director of Nursing confirmed Resident #6 was not assessed to self-administer medications and should not have medications left at the bedside and or the bathroom. In an interview on 07/01/2025 at 12:00PM, S1Administer confirmed Resident #6 should not have medications left at the bedside and/or bathroom.

Based on interview and record review the facility failed to ensure a resident with a new diagnosis of schizophrenia was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for PASARR requirements. Findings: Review of Resident #19's clinical record revealed an admit date of 09/03/2010. Further record review revealed on 02/27/2018, Resident #19 was diagnosed with schizophrenia. Review of Resident #19's annual Minimal Data Set with an Assessment Reference Date of 04/08/2025 revealed, in part, Resident #19 was assessed to have a Brief Interview for Mental Status score of 2 which indicated severe cognitive impairment, and had an active diagnoses of Schizophrenia without a diagnosis of Dementia. Review of Resident #19's medical record revealed, in part, a care plan was developed for alteration in behavior related to psychosis. Further review revealed an approach to place on the Memory Care Unit for consistent ongoing supervision. Review of Resident #19's record revealed, in part, no documented evidence, and the facility could not provide documented evidence a Level II PASARR was completed after Resident #19 was diagnosed with schizophrenia on 02/27/2018. In an interview on 07/02/2025 at 10:15AM, S9Social Service Director indicated Resident #19 should did not have a Level II PASARR evaluation completed after a new diagnosis of schizophrenia on 02/27/2018 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a pressure reducing mattress was inflated for a resident who was identified as at risk for skin breakdown for 1 (Resident #75) of 3 (Resident #51, Resident #75, Resident #80) sampled residents investigated Per the Surveyor Workload Report by Investigation they were investigated for Pressure Ulcer/ Injury. Findings: Review of the facility's policy, Prevention of Pressure Ulcers, revised [DATE], revealed, in part, Pressure Ulcers are usually formed when a resident remains in the same position for extended periods, causing increased pressure or decreased circulation (blood flow) to that area. Further review of the policy revealed preventative measures should include: a change in bed position every 2 hours or more, determining if the resident needs a specialized mattress, if a specialized mattress is needed, use one that contains foam, air, gel, or water, as indicated. Review of Resident #75's Electronic Medical Record revealed, in part, Resident #75 had diagnoses which included: Hemiplegia. Review of Resident #75's Minimum Data Set with an Assessment Reference Date of [DATE] revealed, in part, Resident #75 had a Brief Interview for Mental Status score of 10, which indicated Resident #75's cognition was moderately impaired. Review of Resident #75's Comprehensive Care Plan, revised [DATE], revealed, in part, Resident #75 had the potential for development of a pressure ulcer related to (r/t) incontinence, debility, and health comorbidities with an intervention for a pressure reduction mattress. Observation on [DATE] at 10:28AM revealed Resident #75's air-loss mattress had a low air pressure warning light was activated, which indicated the air-loss mattress was not inflated completely, and the bed frame was palpable when the surveyor applied pressure to the mattress. Observation on [DATE] at 4:30PM revealed Resident #75's air-loss mattress had a low air pressure warning light was activated, which indicated the air-loss mattress was not inflated completely, and the bed frame was palpable when the surveyor applied pressure to the mattress. In an interview on [DATE] at 4:30PM, Resident #75 indicated she had reported to staff she heard the air coming out of the mattress, and the staff informed Resident #75 that the air-loss mattress was plugged in. Resident #75 further indicated staff did not attempt to apply pressure to the mattress to check the inflation of the mattress. In an interview on [DATE] at 7:08AM, S8Licensed Practical Nurse (LPN) indicated Resident #75's nurse on the night shift on [DATE] and observed Resident #75's air-loss mattress had a low air pressure warning light activated. S8LPN further indicated she assessed the problem and identified that the CPR function on Resident #75's air-loss mattress was initiated, which deflated the bed. In an interview on [DATE] at 11:08AM, S2Registered Nurse/Assistant Director of Nurses (RN/ADON) confirmed Resident #75 was left lying on a deflated air mattress for over 8 hours on [DATE], and should not have been.

Based on observation, interviews and record reviews, the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into the stomach) as ordered for 1 (Resident #46) of 1 (Resident #46) sampled resident investigated for enteral nutrition requirements. Findings: Review of the facility's Enteral Nutrition policy with a revision date of 11/2018, revealed, in part, the nurse confirms the administration method and the volume/rate of administrations. Review of Resident #46's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/08/2025 revealed, in part, Resident #46 was indicated for a feeding tube. Review of Resident #46's July 2025 order summary report revealed, in part, an order with a date of 04/17/2025 for Glucerna 1.2 Cal (a tube feeding formula used to provide nutrition) 50 milliliters per hour (mL/hour ) via percutaneous feeding tube (PEG tube) over 22 hours. Observation on 07/01/2025 at 3:00PM revealed Resident #46's continuous tube feeding pump was set at 60 ml/hr. In an interview on 07/01/2025 at 3:33PM, S7License Practical Nurse (LPN) confirmed Resident #46's feeding infusion pump was infusing at 60ml/hr., and should be infusing at 50ml/hr. In an interview on 07/02/2025 at 11:10AM, S2Registered Nurse/Assistant Director of Nursing confirmed Resident #46's enteral feeding infusion pump should have been infusing at 50 ml/hr, as ordered.

Based on observation, interviews, and record review, the facility failed to serve food in a sanitary manner for 1 (Resident #51) of 10 (Resident #10, Resident #26, Resident #41, Resident #50, Resident #51, Resident #54, Resident #74, Resident #83, Resident #88, Resident #92) sampled residents investigated for dining observation. Findings: Review of the 2022 Food Code U.S. Food and Drug Administration revealed, in part, employees were to prevent cross-contamination of ready-to-eat food with bare hands, and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Observation on 07/01/2025 at 12:01PM revealed S5Certified Nursing Assistant (CNA) served Resident #51 her lunch tray. S5CNA brought Resident #51's lunch tray to her room. S5CNA, with bare hands, removed Resident #51's insulated cover off of her plate and revealed a lunch which consisted of chicken tenders, french fries, and a can of soda. S5CNA placed Resident #51's lunch tray on Resident #51's bedside table. S5CNA then repositioned Resident #51's feet with bare hands. S5CNA, with bare hands, picked up a chicken tender off of Resident #51's plate and placed it in Resident #51's hand. S5CNA then opened Resident #51's soft drink and 2 packets of ketchup. Observation then revealed Resident #51 dropped the chicken tender on her bedside table and S5CNA, with bare hands, picked up the chicken tender and placed it on Resident #51's plate. S5CNA did not perform hand hygiene during the above documented observation. At no time during the above documented observation did S5CNA perform hand hygiene. In an interview on 07/01/2025 at 12:07PM, S5CNA confirmed she touched Resident #51's food with bare hands and she should not have. In an interview on 07/02/2025 at 9:47AM, S4Licensed Practical Nurse (LPN) Supervisor indicated staff should not touch a resident's food with bare hands during meal service. In an interview on 07/02/2025 at 10:06AM, S3Registered Nurse / Infection Preventionist (RN/IP) indicated it was not appropriate for a staff member to touch a resident's food with bare hands. In an interview on 07/02/2025 at 11:06AM,S2RN /Assistant Director of Nursing indicated S5CNA should not have touched Resident #51's food with bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: 1. ensure the facility completed evaluations after a resident sustained a fall per policy (Resident #17 and Resident #75); 2. ensure a resident's care plan was revised with new individualized interventions after a resident sustained a fall (Resident #17 and Resident #75); 3. ensure oxygen tanks were secured and not free standing (Resident #102). This deficient practice was identified for 3 (Resident #17, Resident #75, Resident #102) of 5 (Resident #6, Resident #17, Resident #31, Resident #75, Resident #102) sampled residents reviewed for accident hazards. Findings: Resident #17 Review of facility's policy titled Falls - Clinical Protocol revised October 2010 revealed, in part, Residents should be evaluated for a risk of falling, the staff and physicians would identify pertinent interventions, if the cause was not identified staff would try relevant interventions, based on assessments and the nature or category of falling. For any resident who had fallen, staff would attempt to define possible causes within 24 hours of the fall, based on preceding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff would monitor and document the individual's response to the fall interventions intended to reduce falling. Review of Resident #17's record revealed, in part, a Fall Risk assessment dated [DATE] with a score of 17, which indicated at risk for falls. Review of Resident #17's care plan revealed, in part, Resident #17's was high risk for falls related to confusion, incontinence, medication effects, cognition, and impulsive behaviors. Review of Resident #17's record revealed, in part, Resident #17 sustained a fall on 02/09/2025, 02/20/2025 and 05/27/2025. Review of Resident #17's record revealed, in part, there was no documented evidence and the facility did not present any documented evidence an evaluation was completed on the above mentioned falls per facility policy. Review of Resident #17's care plan revealed, in part, there was no documented evidence and the facility did not present any documented evidence that Resident #17's care plan was revised to include new individualized interventions after the above mentioned falls. In an interview on 07/02/2025 at 2:15PM, S2Registered Nurse/Assistant Director of Nursing confirmed there were no documented evidence and the facility could not provide documented evidence of fall evaluations being completed, and Resident #17's care plan revised with new interventions after Resident #17 sustained falls on 02/09/2025, 02/20/2025, and 05/27/2025, and this should have been done. Resident #75 Review of Resident #75's Fall Risk Evaluation dated 04/29/2025 revealed, in part, Resident #75 was high risk for falls. Review of Resident #75's progress notes revealed, in part, Resident #75 had falls on 01/20/2025, 03/30/2025, 04/20/2025, and 05/05/2025. Review of Resident #75's fall care plan revealed, in part, there was no documented evidence and the facility did not present any documented evidence that Resident #75's care plan was revised to include new individualized interventions after Resident #75 fell on [DATE], 03/30/2025, and 05/05/2025. Review of Resident #75's record revealed, in part, there was no documented evidence and the facility did not present any documented evidence an evaluation was completed on Resident #75's falls on 03/30/2025, and, or 04/20/2025. In an interview on 07/01/2025 at 2:20PM S2Registered Nurse/Assistant Director of Nursing (RN/ADON) indicated all interventions for Resident #75 would have been in Resident #75's care plan. In an interview on 07/02/2025 at 12:32PM, S2RN/ADON confirmed the facility has no documented evidence that Resident #75's fall on 03/30/2025 and 04/20/2025 were investigated and evaluated for the root cause after the above mentioned falls. S2RN/ADON further confirmed that Resident #75's falls which occurred on 01/20/2025, 03/30/2025, and 05/05/2025 did not have a new interventions in the care plan to prevent further falls. Resident #102 Review of the facility's Oxygen Administration policy and procedure, revised October 2010, revealed, in part, portable oxygen cylinders are to be strapped to the oxygen cylinder stands. Observation on 07/01/2025 at 10:58AM revealed, in part, a free standing oxygen tank located in the corner of Resident #102's room, sitting on the floor, and not strapped to an oxygen cylinder stand. Observation on 07/02/2025 at 9:10AM revealed, in part, a free standing oxygen tank located in the corner of Resident #102's room, sitting on the floor, and not strapped in an oxygen cylinder stand. In an interview on 07/02/2025 at 9:13AM, S11Licensed Practical Nurse indicated oxygen tanks should be strapped in an oxygen cylinder stand or in the cage located in the medication storage room off of the floor when not in use. In an interview on 07/02/2025 at 9:15AM, S2Registered Nurse/Assistant Director of Nursing confirmed that oxygen tanks should be strapped in a oxygen cylinder stand or in the cage located in the medication storage room when not in use.

Based on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Nebulizer Machine (a machine that turns liquid medicine into a mist, allowing it to be inhaled directly into the lungs) Cleaning policy and procedure, dated 11/04/2014 revealed, in part, nebulizer machines and equipment should be kept clean and the nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. Further review revealed the tubing, mouthpiece and mask should be changed weekly and as needed. Resident #51 Review of Resident #51's June 2025 Physician orders revealed, in part, Ipratropium-Albuterol nebulizer solution (a medication primarily used to treat respiratory conditions) 0.5milligram (mg) per 2.5millitleter (ml) inhale orally via nebulizer every 8 hours as needed for wheezing. Review of Resident #51's Care Plan revealed, in part, Resident #51 had shortness of breath with a documented intervention to change all respiratory tubing and equipment per facility policy. Observation on 06/30/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag was dated of 05/25/2025. Observation on 07/01/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag had a date of 05/25/2025. Review of Resident #51's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 06/01/2025, 06/03/2025, 06/07/2025 and 06/12/2025 per nebulizer. In an interview on 07/01/2025, S6Licensed Practical Nurse (LPN) confirmed Resident #51's nebulizer was stored in a plastic bag and the plastic bag had a date of 05/25/2025. In an interview on 07/02/2025 at 9:47AM, S4LPN Supervisor indicated Resident #51's nebulizer tubing and mouthpieces should be changed weekly and should be stored in a plastic bag. S4LPN further indicated staff should document the date it was changed on the eMAR. Review of Resident #51's June 2025 and July 2025 eMAR revealed no documented evidence, and the provider did not present any documented evidence, Resident #51's nebulizer tubing and mouthpiece had been changed since 05/25/2025. In an interview on 07/02/2025 at 10:10AM, S3Registered Nurse/Infection Preventionist (RN/IP) indicated nebulizer tubing and mouthpieces should be changed per the facility policy. S3RN/IP further indicated there was no documented evidence Resident #51's nebulizer tubing and mouthpiece had been changed since the date of 05/25/2025. Resident #79 Review of Resident #79's Physician's orders dated 06/26/2025 revealed, in part, Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ml 1 vial inhale orally every 6 hours as needed for wheezing. Observation on 06/30/25 at 11:19AM revealed, Resident #79 had an uncontained nebulizer mask lying on Resident #79's lap. Observation on 07/01/2025 at 10:49AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Observation on 07/02/2025 at 8:48AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Review of Resident #79's July 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #79 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 07/01/2025 and 07/02/2025 per the nebulizer. In an interview on 07/02/2025 at 9:10AM S10Licensed Practical Nurse confirmed Resident #79's nebulizer mask should been stored in a plastic bag when not in use. In an interview on 07/02/2025 at 9:15AM S2Registered Nurse/Assistant Director of Nursing confirmed nebulizer masks should been stored in a plastic bag when not in use. Based on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Nebulizer Machine (a machine that turns liquid medicine into a mist, allowing it to be inhaled directly into the lungs) Cleaning policy and procedure, dated 11/04/2014 revealed, in part, nebulizer machines and equipment should be kept clean and the nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. Further review revealed the tubing, mouthpiece and mask should be changed weekly and as needed. Resident #51 Review of Resident #51's June 2025 Physician orders revealed, in part, Ipratropium-Albuterol nebulizer solution (a medication primarily used to treat respiratory conditions) 0.5milligram (mg) per 2.5millitleter (ml) inhale orally via nebulizer every 8 hours as needed for wheezing. Review of Resident #51's Care Plan revealed, in part, Resident #51 had shortness of breath with a documented intervention to change all respiratory tubing and equipment per facility policy. Observation on 06/30/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag was dated of 05/25/2025. Observation on 07/01/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag had a date of 05/25/2025. Review of Resident #51's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 06/01/2025, 06/03/2025, 06/07/2025 and 06/12/2025 per nebulizer. In an interview on 07/01/2025, S6Licensed Practical Nurse (LPN) confirmed Resident #51's nebulizer was stored in a plastic bag and the plastic bag had a date of 05/25/2025. In an interview on 07/02/2025 at 9:47AM, S4LPN Supervisor indicated Resident #51's nebulizer tubing and mouthpieces should be changed weekly and should be stored in a plastic bag. S4LPN further indicated staff should document the date it was changed on the eMAR. Review of Resident #51's June 2025 and July 2025 eMAR revealed no documented evidence, and the provider did not present any documented evidence, Resident #51's nebulizer tubing and mouthpiece had been changed since 05/25/2025. In an interview on 07/02/2025 at 10:10AM, S3Registered Nurse/Infection Preventionist (RN/IP) indicated nebulizer tubing and mouthpieces should be changed per the facility policy. S3RN/IP further indicated there was no documented evidence Resident #51's nebulizer tubing and mouthpiece had been changed since the date of 05/25/2025. Resident #79 Review of Resident #79's Physician's orders dated 06/26/2025 revealed, in part, Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ml 1 vial inhale orally every 6 hours as needed for wheezing. Observation on 06/30/25 at 11:19AM revealed, Resident #79 had an uncontained nebulizer mask lying on Resident #79's lap. Observation on 07/01/2025 at 10:49AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Observation on 07/02/2025 at 8:48AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Review of Resident #79's July 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #79 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 07/01/2025 and 07/02/2025 per the nebulizer. In an interview on 07/02/2025 at 9:10AM S10Licensed Practical Nurse confirmed Resident #79's nebulizer mask should been stored in a plastic bag when not in use. In an interview on 07/02/2025 at 9:15AM S2Registered Nurse/Assistant Director of Nursing confirmed nebulizer masks should been stored in a plastic bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was not required to supply a personal sitter (a caregiver who provides bedside assistance and supervision for safety) as a condition of continued stay for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for resident rights. Findings: Review of the facility's Resident Rights policy statement, amended on 09/2016, revealed, in part, non-covered special care services such as privately hired nurses or aides may be charged to residents' funds if the services are requested by a resident. Further review revealed the facility must not require a resident to request services as a condition of admission or continued stay. Review of Resident #2's clinical record revealed, in part, Resident #2 was admitted to the facility's dementia unit on 04/07/2025 and was discharged from the facility on 04/08/2024. Further review revealed Resident #2 had a diagnosis of unspecified dementia. Review of Resident #2's progress notes dated 04/07/2025 revealed, in part, Resident #2 became verbally and physically aggressive towards staff. Review of Resident #2's progress notes dated 04/08/2025 revealed, in part, Resident #2 continued to be verbally and physically aggressive towards staff. Further review revealed Resident #2 was issued a Psychiatric Emergency Certificate (a legal document that authorizes a healthcare professional to detain and treat a patient in a psychiatric emergency) and was transferred to a behavioral health hospital for treatment. In an interview on 04/30/2025 at 2:28PM, Resident #2's daughter/Resident Representative (RR) indicated she was contacted by the facility on 04/08/2025 and notified Resident #2 had been combative with the staff and was transferred to a behavioral health hospital. Resident #2's daughter/RR further indicated she was informed by a nurse, who she could not name, that Resident #2 could not return to the facility without a personal sitter supplied by Resident #2. Resident #2's daughter/RR further indicated she had to bring Resident #2 home because she could not afford to pay for a personal sitter. In an interview on 05/01/2025 at 11:15AM, S4Social Worker indicated she was responsible to coordinate all planned resident transfers and discharges from the facility. S4Social Worker indicated S3Assistant Director of Nursing (ADON) emailed her and requested S4Social Worker reach out to Resident #2's daughter/RR to inform her Resident #2 required a personal sitter when Resident #2 returned to the facility from the behavioral health hospital. Review of S4Social Worker's email correspondence with S3ADON dated 04/09/2025 revealed, in part, S3ADON indicated she spoke to Resident #2's daughter/RR regarding Resident #2's daughter/RR having to obtain a personal sitter for Resident #2 when Resident #2 returned to the facility from the behavioral health hospital. Further review revealed S3ADON indicated she was not sure if Resident #2's daughter/RR would be able to afford the personal sitter services. Review of Resident #2's behavioral health hospital's multidisciplinary note dated 04/09/2025 revealed, in part, the facility would allow Resident #2 to return to the facility provided Resident #2's family supplied a personal sitter. In an interview on 05/05/2025 at 11:23AM, the behavioral healthcare hospital Clinical Director indicated the behavior health hospital nurse who made rounds at the facility told her Resident #2's family would have to supply a personal sitter if Resident #2 returned to the facility. The behavioral health hospital Clinical Director further indicated Resident #2 discharged to home from the behavioral health hospital on [DATE] with Resident #2's daughter/RR. In an interview on 05/05/2025 at 11:48AM, the behavioral health hospital nurse indicated S2Director of Nursing informed her that she contacted Resident #2's daughter/RR and informed her Resident #2 could return to the facility, but Resident #2's family would have to supply a personal sitter until Resident #2 adjusted to the nursing home setting. In an interview on 05/05/2025 at 12:04PM, S2DON indicated she spoke to Resident #2's daughter/RR days after Resident #2 transferred to the behavioral health hospital to inform Resident #2's daughter/RR that Resident #2 required a personal sitter when she returned to the facility to monitor Resident #2's behaviors until she adjusted. In an interview on 05/06/2025 at 1:23PM, S1Administrator confirmed the facility had notified Resident #2's daughter/RR Resident #2 required a personal sitter if Resident #2 returned to the facility to monitor Resident #2's behaviors. In an interview on 05/06/2025 at 2:57PM, S5Admissions Coordinator indicated on 04/16/2025 Resident #2's daughter/RR had informed her she was in the facility to pick up Resident #2's belongings and indicated she could not afford to pay for a personal sitter for Resident #2. S5Admissions Coordinator further indicated she then notified S2DON that Resident #2's daughter/RR was taking Resident #2 home because Resident #2's daughter/RR could not afford to pay for a personal sitter. S5Admissions Coordinator indicated S2DON responded that it was Resident #2's daughter/RR's, right to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify a resident's representative and the State's Long-Term Care Ombudsman in writing of a resident transfer for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for transfer and discharge requirements. Findings: Review of Resident #2's electronic medical record (EMR) revealed, in part, Resident #2 was admitted to the facility on [DATE] and was discharged from the facility on 04/08/2025. Review of Resident #2's nurse's note dated 04/08/2025 at 5:06PM revealed, in part, Resident #2 was transferred on 04/08/2025 at 2:30PM to a behavioral health hospital for treatment. Review of Resident #2's clinical record revealed no documented evidence, and the facility did not present any documented evidence, Resident #2's representative and the State's Long-Term Care Ombudsman were notified in writing of Resident # 2's transfer to a behavioral health hospital on [DATE], as required. In an interview on 05/06/2025 at 10:35AM, the facility's assigned Ombudsman indicated she had not received a written transfer notice from the facility when Resident #2 was transferred from the facility to a behavioral health hospital on [DATE]. In an interview on 05/06/2025 at 11:48AM, Resident #2's daughter/Resident Representative indicated she had not received a written transfer notice from the facility when Resident #2 was transferred from the facility to a behavioral health hospital on [DATE]. In an interview on 05/06/2025 at 2:48PM, S1Administrator indicated the facility had not issued a written notice to Resident's #2's representative or the facility's assigned Ombudsman when Resident #2 transferred to a local behavioral health hospital on [DATE], as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure insulin (a medication used to lower blood sugar) was discarded within 28 days of the date it was opened on 1 (Cart a) of 3 (Cart a, Cart b, and Cart c) medication carts observed for medication storage. Findings: Observation on [DATE] at 10:30 a.m. of medication cart a, Resident #42's Insulin Aspart Pen 100 unit/1millimeter had an open date of [DATE] and was available for use. Further observation revealed Resident #97's Lantus Solostar (Insulin Glargine) Pen 100unit/1millimeter had an open date of [DATE] and was available for use. In an interview on [DATE] at 10:29 a.m., S2Licensed Practical Nursing (LPN) confirmed the dates written on Resident #42 and Resident #97's insulin pens as [DATE]. S2LPN further indicated Resident #42 and Resident #97's insulin pens should have been discarded, not used and switched out with new pens because they were expired. In an interview on [DATE] at 3:10 p.m., S1Director of Nursing (DON) indicated Resident #42 and Resident #97's insulin pens should have been discarded within 28 days after the date it was opened. S1DON further indicated Resident #42 and Resident #97's insulin pens should not have been available for use.

Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure raw chicken was thawed in a sanitary manner; 2. Ensure the walk in cooler was kept clean and sanitary; 3. Ensure the walk in freezer was free of excessive ice accumulation; and, 4. Ensure water temperature and the concentration level of the sanitizing solution in the facility's 3 compartment sink and dishwasher were monitored and at the level required per the manufacture's guidelines. Findings: 1. Observation of the facility's kitchen on 07/08/2024 at 8:33 a.m. revealed a metal container which contained raw chicken submerged in water. In an interview on 07/08/2024 at 8:40 a.m., S3Chef confirmed the above mentioned raw chicken was submerged in water to thaw and should not have been. In an interview on 07/08/2024 at 8:42 a.m., S5Cook indicated she placed the raw frozen chicken in warm water to thaw. S5Cook further indicated the chicken should have been thawed under running water. 2. Observation of the facility's walk in cooler on 07/09/2024 at 12:04 p.m. revealed a foul odor inside. Further observation of the right side of the walk in cooler revealed a brown colored unknown liquid pooled on the floor below a shelf of produce, an unknown clear wet gelatinous (the consistency of jelly) substance along the top of the baseboard tiles, and a buildup of an unknown black, brown, and/or white substance along the wall where the wall and the baseboard tiles met. In an interview on 07/09/2024 at 12:07 p.m., S3Chef confirmed the walk in cooler had a foul odor, was unsanitary, and needed to be cleaned. 3. Observation of the facility's walk in freezer on 07/08/2024 at 8:30 a.m. revealed a thick layer of ice was built up on the freezer's floor, walls, shelves, ceiling, and the freezer's fan. In an interview on 07/08/2024 at 9:05 a.m., S3Chef confirmed there was a thick layer of ice on the freezer's floor, walls, shelves, ceiling, and the freezer's fan, and that there should have not been. 4. Review of the facility's policy titled, Machine Warewashing, dated 09/2012, revealed, in part, dishes should be washed according to the manufacturer's directions. Further review revealed the dishwasher machine operator should document the machine temperature and concentration of sanitizing solution for ware washing for each meal on the sanitizer solution log. Review of National Sanitization Foundation (NSF) Data plate attached to dishwasher machine revealed, in part, NSF operational requirements for the dishwasher machine using chemical sanitizing are as follows: wash minimal temperature is 140°F, final rinse minimal temperature of 120°F and sanitizer minimum 50 parts per million (ppm) available chlorine. Review of the facility's May, June, and July 2024's Sanitizer Solution Logs, revealed in part, no documented evidence, and the provider did not present any documented evidence that the sanitization level and/or the water temperature of the facility's 3 compartment sink and dishwasher were checked for each meal as required. Observation on 07/10/2024 at 12:25 p.m. revealed S3Chef tested the sanitization level of the dishwasher rinse cycle and the chlorine concentration read less than 50 ppm. In an interview on 07/10/2024 at 12:30 p.m., S3Chef confirmed the chlorine concentration level during the dishwasher rinse cycle was less than 50 ppm and should not have been.

Based on observation, record review, and interview, the facility failed to ensure a resident's medication was available to be administered for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for pharmaceutical services. Findings: Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 10/24/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status of 14 which indicated Resident #1 was cognitively intact. Review of Resident #1's January 2024 Physician's Orders revealed, in part, an order for Bisacodyl (a laxative used to treat constipation) 10 milligrams (mg) suppository, insert 1 per rectum each night dated 10/11/2023. In an interview on 01/17/2024 at 2:38 p.m., Resident #1 stated she had not been receiving a Bisacodyl suppository as ordered. Review of Resident #1's January 2024 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1's Bisacodyl 10mg suppository was not administered on 01/06/2024, 01/07/2024, 01/08/2024, 01/13/2024, 01/14/2024, and 01/15/2024 because the medication was reordered and awaiting arrival. In an interview on 01/18/2024 at 9:59 a.m., S3Licensed Practical Nurse stated there was no Biscodyl 10mg suppository available on the medication cart. S3Licensed Practical Nurse confirmed Resident #1 had an order to receive a Biscodyl 10mg suppository nightly. In an interview on 01/18/2024 at 10:05 a.m., Resident #1 stated she did not receive a Biscodyl suppository on the night of 01/17/2024 because the medication was not available. Observation on 01/18/2024 at 10:23 a.m., revealed there was no Biscodyl 10mg suppositories available in the facility's stock medication room. In an interview on 01/18/2024 at 10:25 a.m., S2Medical Records Coordinator stated the Biscodyl 10mg suppositories were on back order. S2Medical Records Coordinator confirmed the Bisacodyl 10mg suppositories were not available for administration to residents. In an interview on 01/18/2024 at 2:10 p.m., S1Director of Nursing confirmed the facility did not have Biscodyl 10mg suppositories available for administration. S1Director of Nursing further stated Resident #1's Biscodyl 10mg suppositories should have been available for administration. S1Director of Nursing confirmed Resident #1 did not receive Biscodyl 10mg suppository nightly as ordered on 01/06/2024, 01/07/2024, 01/08/2024, 01/13/2024, 01/14/2024, 01/15/2024, and 01/17/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of drugs for 1 (Resident #81) of 23 sampled residents. Findings: Resident #81 was admitted to the facility on [DATE] with diagnoses of, in part, Adult Failure to Thrive, Hypertension, Protein-Calorie Malnutrition, and Dysphagia. Review of Resident #81's Minimum Data Set (MDS) with an Assessment Reference Date of 05/23/2023 revealed a Brief Interview for Mental Status Exam (BIMS) score of 11. A score of 11 indicated Resident #81 had moderate impaired cognition. Review of Resident #81's August 2023 Physician Orders revealed an order for artificial tears, with a start date of 5/14/2020, administer one drop in each eye as needed. Observation on 08/21/2023 at 1:09 p.m. revealed Resident #81 had a container of soothe PM eye ointment, systane eye drops and genteal tears on his bedside table. In an interview on 08/21/2023 at 1:09 p.m., Resident #81 stated he was a retired pharmacist and administered eye drops independently. Observation on 08/22/2023 at 10:30 a.m. revealed Resident #81 had a container of soothe PM eye ointment, systane eye drops and genteal tears on his bedside table. Observation on 08/23/2023 at 11:15 a.m. revealed Resident #81 had a container of soothe PM eye ointment, systane eye drops and genteal tears on his bedside table. Review of Resident #81's clinical record revealed no documented evidence, and the facility did not provide documented evidence, Resident #81 had been assessed and approved by the interdisciplinary team to self-administer the eye drops that were observed on the bedside table. In an interview on 08/23/2023 at 11:01 a.m., S6 Licensed Practical Nurse (LPN) stated she was not aware Resident #81 had eye drops at his bedside and he had self-administered the eye drops. In an interview on 08/23/2023 at 11:09 a.m., S4LPN confirmed Resident #81 had eye drops at his bedside and stated she was not aware he had eye drops at the bedside. S4LPN further stated Resident #81 had not been assessed for self-administration of medications and was not care planned to keep eye drops at the bedside. In an interview on 08/23/23 at 2:09 p.m., S2 Director of Nursing (DON) stated she was made aware Resident #81 had eye drops at his bedside on 08/22/2023. S2DON stated a resident must be assessed to self-administer medications with appropriate interventions put into place to ensure safety. S2DON confirmed Resident #81 had not been assessed for self-administration of medications; therefore, medications, inclusive of eye drops, should not be at the bedside.

Based on record review, observations, and interview, the facility failed to maintain an infection prevention and control program by: 1. Failing to ensure hand hygiene was maintained while performing wound care identified for 1 (Resident #26) of 1 (Resident #26) resident reviewed for wound care; and, 2. Failing to ensure hand hygiene was completed and a sanitary environment was maintained while performing tube feeding and medication identified for 1 (Resident #81) of 1 (Resident #81) resident reviewed for gastrostomy tube feeding administration. Findings: Resident #26 Review of the facility's Hand Hygiene Policy and Procedure revealed, in part, hand hygiene shall be performed: before and after performing any invasive procedure, before and after assisting a resident with personal care, and before and after changing a dressing. Observation on 08/22/2023 at 9:32 a.m. of Resident #26's wound care revealed S5Treatment Nurse did not perform hand hygiene before, during and after the completion of Resident #26's wound care. In an interview on 08/22/2023 at 9:45 a.m., S5Treatment Nurse confirmed she did not wash her hands before, during, or after Resident #26's wound care. In an interview on 08/23/2023 at 11:13 a.m., S2Director of Nursing (DON) stated S5Treatment Nurse should have washed her hands before putting on gloves, after removing dirty gloves and putting on clean gloves. Resident #81 Observation on 08/22/2023 at 11:39 a.m. revealed S3Licensed Practical Nurse (LPN) didn't complete hand hygiene prior to preparing the medications. Further observation revealed S3LPN then unlocked the narcotics drawer of the medication cart and retrieved two medication cards and obtained a pill from each of the cards and placed the pills into a medication cup. S3LPN then retrieved a 250milliliter (ml) carton of Resident #81's tube feeding formula and entered Resident #81's room. S3LPN did not perform hand hygiene prior to the application of gloves, and then S3LPN entered Resident #81's bathroom. Observation revealed three plastic measuring cups on a paper towel on Resident #81's bathroom counter which were covered with a mesh dome. S3LPN removed the mesh dome and grabbed the three plastic measuring cups. Observation revealed one of the cups was labeled water, and S3LPN filled the cup labeled water with 275ml of water from the bathroom lavatory. S3LPN poured the 250ml carton of Resident #81's tube feeding formula into one of the measuring cups and brought the cups to Resident #81's bedside. Resident #81 had attached the gastrostomy tube to his gastrostomy access and S3LPN checked tube placement, flushed the tube with water, administered medications and formula, and then flushed Resident #81's gastrostomy tubing. Resident #81 removed the gastrostomy tubing and placed it on a paper towel on the bedside table. Resident #81 stated he always stored the gastrostomy tubing on his bedside table on a paper towel. In an interview on 08/22/2023 at 11:50 a.m., S3LPN confirmed she did not perform hand hygiene prior to, during, and after administration of Resident #81's medications and tube feeding formula. S3LPN confirmed the three plastic cups were stored in the bathroom on a paper towel covered with a mesh dome. In an interview on 08/23/23 at 2:09 p.m., S2 Director of Nursing (DON) stated hand hygiene should have been performed prior to and after administration of Resident #81's medication and tube feeding formula. S2DON confirmed the supplies used for administration of Resident #81's tube feeding should not be maintained in the bathroom under a mesh cover, and Resident #81's gastrostomy tubing should not should not be kept on Resident #81's bedside table.

Based on observations, record reviews, and interview, the facility failed to store and distribute food in a manner to prevent the possibility of food contamination. Findings: Observation of the facility's cooler on 08/21/2023 at 9:32 a.m. revealed, in part, 1 bag of shredded cheese not dated, 6 breaded cutlets in a pan covered with clear wrap not dated, 6 packages of tortillas not dated, a bag of shredded lettuce not dated, 6 containers of strawberries with a buildup of a grayish color substance and 5 cucumbers with soft spots. Observation of the automated dishwasher on 08/21/2023 at 9:43 a.m. revealed the temperature gauges did not work when the wash cycle was initiated. Observation of the facility's walk in freezer on 08/21/2023 at 9:50 a.m. revealed an accumulation of ice on the freezer floor. S4Executive Chef was observed with a long handled tool with a straight edge as he attempted to break up the ice with the straight edge. In an interview on 08/22/2023 at 11:24 a.m., S4Executive Chef stated the freezer had not functioned properly and had maintained a buildup of ice for a long time. In an interview on 08/21/2023 at 9:45 a.m., S7Diet Aide stated the porters were responsible to monitor the dishwasher temperatures and sanitizer levels of the three compartment sink and document the results on a log which was maintained in a binder. S7Diet Aide presented the surveyor with the binders and acknowledged the last documented dishwasher temperatures and sanitizer levels of the three compartment sink was on 06/30/2023. In an interview on 08/24/2023 at 10:28 a.m. S4Executive Chef confirmed the dishwasher temperatures and sanitizer levels of the three compartment sink logs were not documented since 06/30/2023 and stated he did not know the temperature gauge of the dishwasher did not work. S4Executive Chef stated food in the refrigerator should be dated and discarded when not appropriate for resident use. S4Executive Chef confirmed the strawberries and the cucumbers were not appropriate for resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to: 1. Protect the resident's right to be free from verbal abuse by a staff member for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and, 2. Protect the residents' rights to be free from physical abuse by a resident for 2 (Resident #3 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of facility's Abuse/Neglect Reporting Policy revealed, in part, 1. Each resident residing in this facility has the right to be free from verbal abuse, sexual, mental, physical abuse, including corporal punishment, involuntary seclusion and/or misappropriation of property. Training on workplace violence and abuse preventions will be included in orientation of new employees at least annually. Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the Administrator or his designee of the facility. The appropriate state officials per stated guidelines must be notified within 24 hours of occurrence or discovery of such alleged incident. 1. Resident #1 Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnosis, in part, of unspecified injury to the spinal cord, venous insufficiency, viral hepatitis and Paraplegia. Review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/06/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Review of Resident #1's Comprehension Care Plan revealed, in part, a plan of care was developed on 01/12/2022 for Resident #1 exhibiting behaviors of being verbally aggressive behavior towards staff. Interventions include, do not argue and talk in a calm voice when Resident #1's behavior is disruptive. Review of Resident #1's written statement of the incident on 06/13/2023 at 9:50 a.m., revealed Resident #1 questioned S6Former Tech about talking about him and S6Former Tech walked away yelling I'm going to get my pistol. In an interview on 07/25/2023 at 9:58a.m., Resident #1 stated he had an argument with R6Former Tech. Resident #1 stated during the argument S6Former Tech walked away and stated he was going get his pistol. Resident #1 stated S6Former Tech yelled and cursed as he walked away. Resident #1 stated S6Former Tech attempted to scare him by threatening to go get a pistol. Resident #1 stated he heard S6Former Tech cursing and saying he had been to the penitentiary and he would mess me up as he walked away. Review of S6Former Tech's written statement of the incident on 06/13/2023 revealed, in part, Resident #1 yelled and cursed at S6Former Tech. S6Former Tech acknowledged in the written statement that he raised his voice at Resident #1 and admitted he was wrong for raising his voice at Resident #1. Review of S4Social Worker (SW) written statement dated 06/14/2023, S4SW wrote, Yesterday I was in my office when I overheard S6Former Tech cursing loudly, such as: he don't know who he is fu****** with, he got me twisted I am a convicted felon, I will f**** him up. In an interview of 07/25/2023 at 1:30 p.m., S4SW stated on 06/13/2023 at 9:30 a.m. she was in her office with the door closed and heard loud voices in the hall. S4SW stated when she looked out her office she saw S6Former Tech walking away from Resident #1. S4SW stated S6Former Tech yelled, He got me f'ed up! I am not the one to play with! I am a felon! He don't know me! S4SW stated Resident #1 was sitting in his wheelchair near the door of his room and also yelled and used profanity. In an interview on 07/26/2023 at 10:40 a.m., S3Assistant Director of Nursing (ADON) acknowledged based on the facility's policy and the regulations Resident #1 was verbally abused by S6Former Tech on 06/13/2023. In an interview on 07/27/2023 at 11:51 a.m., S1Administrator confirmed based on the facility's policy and the regulations the incident on 06/13/2023 between Resident #1 and S6Former Tech was considered staff to resident verbal abuse. S6Former Tech resigned from his position while out on suspension. S6Former Tech was banned from the premises and security and the entrance was given S6Former Tech's picture and identification information and informed not to all S6Former Tech on the premises. 2. Resident #3 Review of Resident #3's record revealed, in part, Resident #3 was admitted to the Alzheimer's Unit on 04/29/2022 with diagnoses of, in part, Unspecified Dementia and Alzheimer's. Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of Resident #3's Care Plan dated 04/29/2022 revealed, in part, Resident #3 displays behaviors such as wandering, inappropriate physical and verbal behaviors towards staff and others at times with interventions which included try to distract resident or steer them to something else; Encourage discussion and verbalization of feelings if resident is able to communicate; Be firm with resident and tell resident that inappropriate behaviors towards others is not acceptable; and Observe resident for tendency to wander in order to re-direct to assure resident's safety. Review of Resident #3's Care Plan revision dated 06/29/203 revealed, in part, Behaviors wandering: Resident #3's wandering intrudes on other resident's privacy. 06/29/2023 wandering into other resident's room. Further review revealed Resident #3 will not wander into unsafe situations by 09/29/2023 with interventions which include redirect Resident #3 when wandering into other resident's rooms. Review of Incident/Accident note dated 07/05/2023 at 2:37 a.m., revealed, in part, on 07/04/2023 at 9:30 p.m., S9LPN observed Resident #3 at the other end of the hallway opening the door. S9LPN heard yelling looked out and saw Resident #3 being pushed onto the floor. In an interview on 07/26/2023 at 12:39 p.m. S3Assistant Director of Nurses stated S9Licensed Practical Nurse (S9LPN) reported to her Resident #5 had pushed Resident #3 down to the floor on 07/04/2023. In an interview on 07/27/2023 at 10:23 a.m., S9LPN stated on 07/04/20023 Resident #5 was in her room when Resident #3 opened her door. S9LPN further stated Resident #5 admitted that she shoved Resident #3. In an interview on 07/27/2023 at 11:49 a.m. S1Administrator acknowledged he substantiated Resident #5 physically abused Resident #3 on 07/04/2023. 3. Resident #4 Review of Resident #4's record revealed, in part, Resident #4 was admitted to the Alzheimer's Unit on admitted [DATE] with a diagnoses, in part, of Alzheimer's, Major Depressive Disorder, and Unspecified Dementia. Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/27/2023 revealed, in part, a BIMS score of 4, which indicated severe cognitive impairment. Review of record dated 06/14/2023 at 1:45 p.m., upon returning to unit S8Certified Nursing Assistant reported S7Housekeeper called her for assistance after witnessing Resident #4 being hit with cane multiple times by Resident #3 in hallway on 06/14/2023. Review of record dated 06/15/2023 at 12:12 p. m., revealed, in part, Resident #4 had deep purple bruising to right middle finger. Further review revealed Resident #4 was guarding middle finger and difficulty with bending. In an interview on 07/26/2023 at 1:45 p.m., S7Housekeeper stated she witnessed Resident #3 hit Resident #4 with a cane several times on 06/14/2023. In an interview on 07/26/2023 at 12:26 p.m., S3Assistant Director of Nurses stated on 06/14/2023 she was informed the S7Housekeeper was in the door of the room when she observed Resident #3 hit Resident #4 with a cane several times. In an interview on 07/27/2023 at 11:51 a.m., S1Administrator confirmed the incident between Resident #3 and Resident #4 was resident to resident physical abuse on 06/14/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident was free from sexual abuse for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. This deficient practice had the potential to affect any of the 20 residents who resided on the secured care unit. Findings: Review of the facility's Abuse and Neglect reporting policy revealed, in part, each resident residing in this facility has the right to be free from verbal, sexual, mental, physical abuse, including corporal punishment, involuntary seclusion and/or misappropriation of property. These terms are defined as follows, in part, sexual abuse: this includes but is not limited to sexual harassment, sexual coercion or sexual assault. Review of Resident #1's record revealed she was admitted to the facility on [DATE] with a diagnoses of dementia and resided on the secured care unit. Review of Resident #1's Care Plan revealed impaired cognition with the inability to make herself understood and/or understand others. Review of the facility's incident log for the time period of 04/01/2023 thru 05/30/2023 revealed Resident #1 had physical contact on 04/06/2023 at 10:02 a.m. with Resident #2. Review of the facility's incident report dated 04/06/2023 revealed S5Certified Nursing Assistant(CNA) reported when she made rounds she witnessed Resident #2 touch Resident #1's left breast. Review of Resident #2's Nurse's Notes dated 04/06/2023 at 10:09 a.m. revealed, in part, Resident #2 was sitting in dining area next to a female resident (Resident #1) when Resident #1's private sitter observed Resident #2 fondle Resident #1's left breast. In an interview on 05/30/2023 at 10:00 a.m., Resident #1's private sitter stated on 04/06/2023 she worked on the secured care unit with Resident #1. Resident #1's private sitter stated she was in a chair in the secured care unit dining room to the left of Resident #1, and she vacated the chair to go to the restroom. Resident #1's private sitter stated when she returned from the restroom Resident #2 had sat in the chair that she had vacated; therefore, she sat across from Resident #1. Resident #1's private sitter stated Resident #1 dropped a toy so she walked to Resident #1 and picked the toy up off of the floor and when she stood up Resident #2 had his right hand on Resident #1's left breast. Resident #1's private sitter stated she hollered out and S4Licensed Practical Nurse(LPN) reacted immediately. Resident #1's private sitter stated S5CNA was assigned as a 1:1 CNA for Resident #2; however, S5CNA was at another table assisting a different resident. In an interview on 05/30/2023 at 10:15 a.m., S4LPN confirmed she worked on the secured care unit on 04/06/2023. S4LPN stated on 04/06/2023 she was in the corner of the secured care unit's dining room and Resident #1 and Resident #2's backs were to her. S4LPN stated she heard Resident #1's private sitter holler out and when she looked she saw Resident #2's right hand on Resident #1. S4LPN stated Resident #1's private sitter reported what happened between Resident #1 and Resident #2. S4LPN stated S5CNA was Resident #2's 1:1 CNA; however, S5CNA was at a different table feeding a different resident at the time of the incident. S4LPN stated Resident #2 had a 1:1 CNA due to the fact he was a wanderer and experienced sexual and aggressive behaviors. In an interview on 05/30/2023 at 12:38 p.m., S2Director of Nursing(DON) stated Resident #2 was assigned a 1:1 CNA due to a history of behaviors. S2DON stated Resident #2's 1:1 CNA was assigned to assist and monitor Resident #2. In an interview on 05/30/2023 at 12:44 p.m., S5CNA confirmed she was Resident #2's 1:1 CNA on 04/06/2023. S5CNA stated she was responsible to assist and monitor Resident #2. S5CNA stated on 04/06/2023 Resident #1's private sitter had gone to the restroom and Resident #2 sat next to Resident #1. S5CNA stated she bent down to tie her shoe and when she looked up Resident #2 had grabbed Resident #1's left breast. In an interview on 05/31/2023 at 9:21 a.m ., S1Administrator confirmed the incident on 04/06/2023 between Resident #1 and Resident #2 was considered abuse.

Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for allegations of abuse for 2 (Resident 1 & Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. This deficient practice had the potential to affect any of the 112 residents who reside in the facility as identified on the facility's alphabetical census listing. Findings: Review of the facility's Abuse/Neglect Reporting policy revealed, in part, the facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. Resident #1 Review of the Louisiana Department of Health Standards Incident Report (SIMS) incident ID #91187 revealed an allegation of sexual abuse occurred on 04/06/2023 at 10:00 a.m. Resident #1 was identified as the victim and Resident #2 was identified as the accused. Further review of the SIMS report revealed S5Certified Nursing Assistant(CNA) reported while making rounds that she witnessed Resident #2touch Resident #1's left breast. S5CNA immediately escorted Resident #2 to his room and notified the charge nurse and Resident #2 was placed with a 1:1 CNA staff until further notice. Further review revealed documentation that the investigation included staff who worked on the secured care unit where Resident #1 and Resident #2 resided. Review of the information presented to the surveyor by S1Administrator included written statements from Resident #1's private sitter, S5CNA and a copy of Resident #2's Nurses Notes from 04/06/2023. Review of the handwritten statement from S5CNA dated 04/06/2023 revealed, in part, the following: I, S5CNA, was watching Resident #2 at 10:02 a.m. I bent down to tie my shoe when I looked up Resident #2 was touching Resident #1's left breast. After telling him to stop I escorted him to his room and stayed with him until he left. Review of the undated handwritten statement from Resident #1's private sitter revealed, in part, the following: Resident #1 and myself were sitting in the dining room area. I reached down to pick up the toy that she was playing with and when I looked up Resident #2 was touching her left breast until I told him to stop. Review of Resident #2's Nurses notes dated 04/06/2023 at 10:09 a.m. revealed Resident #2 was sitting in dining area next to the female resident (Resident #1) when residents sitter observed Resident #2 fondle Resident #1's left breast. On 05/30/2023, S2Director of Nursing(DON) presented the surveyor with a list of names of employees who worked on the secured care unit on 04/06/2023 at the time of the alleged abuse. Review of the list of staff included S4LPN, S5CNA, S7CNA and S8CNA. In an interview on 05/30/2023 at 1:30 p.m., S2Director of Nursing(DON) reported there were 19 residents on the secured care unit on 04/06/2023 and of the 19 residents she confirmed one resident had a Brief Interview for Mental Status(BIMS) score of 11. A BIMS score of 11 indicated mild cognitive impairment. S2DON confirmed the resident with a BIMS score of 11 would have been able to be interviewed for the investigation In an interview on 05/30/2023 at 2:04 p.m., S1Administrator stated S3Assistant Director of Nursing(ADON) gathered written statements from the witnesses; however, she did not interview all staff who worked on the secured care unit on 04/06/2023. S1Administrator further confirmed the resident with a BIMS score of 11 was not interviewed. In an interview on 05/30/2023 at 2:08 p.m., S3ADON stated she obtained written statements from S5CNA and Resident #1's private sitter; however, she did not interview them nor did she get a written statement or interview S4LPN as well as the other staff who worked on the secured care unit on 04/06/2023. S3ADON confirmed there were 19 residents who resided on the secured unit on 04/06/2022 and she did not attempt to interview any of them which included a resident with a BIMS score of 11. In an interview on 05/31/2023 at 9:21 a.m, S1Administrator confirmed the investigation into the events on 04/06/2023 did not include statements and/or interviews from all staff who were present on the secured unit and did not include any of the residents who resided on the secured care unit. Resident #5 Review of the Louisiana Department of Health Standards Incident Report (SIMS) incident ID 103733 revealed resident to resident abuse event occurred 05/11/2023 at 10:00 p.m. Review of the SIMS report revealed the victim wandered into the room of Resident #5 and the victim was found sitting on the floor in Resident #5's room. When asked how the victim got on floor, the victim responded she was pushed by Resident #5. S1Administrator's incident investigation revealed both Resident #5 and the victim have dementia, reside on the secured care unit and therefore were unable to provide a statement about the incident. Staff that were interviewed did not witness the altercation between Resident #5 and the victim. Further review revealed S1Administrator indicated in the investigation that Resident #5 was in bed at time when the victim was found in room on floor but the victim was not near Resident #5's bed. Review of Resident #5's Incident Report for 05/11/2023 revealed the incident occurred on 05/11/2023 at 08:00 p.m. Further review revealed Resident #5 was accused of pushing another resident on to the floor. The incident which was reported by S6CNA was unwitnessed and occurred in Resident #5's room. The nurse observed the victim on the floor and assisted to get her up. . In an interview on 05/30/2023 at 11:09 a.m., Resident #5 stated she has never pushed anyone or hurt anyone and no one has ever hurt her. Review of the statement from S6CNA in regards to the incident on 05/11/2023 between Resident #5 and the victim revealed S6CNA was with other residents in dining area when S6CNA suddenly observed coworkers walking hastily to the direction of Resident #5's room. S6CNA followed and observed the victim was sitting on floor in Resident #5 room saying She pushed me, she pushed me. S6CNA asked Resident #5 what happened and Resident #5 did not answer and Resident #5 just walked away. In an interview on 05/31/2023 at 09:42 a.m., S3ADON revealed she did not have a statement from the nurse in charge of Resident #5 in regards to the incident on 05/11/2023 and only had nursing notes written on 05/11/2023. Review of Resident #5's nurse's notes dated 05/11/2023 at 11:39 p.m. revealed Resident #5 was accused of pushing the victim on to the floor in Resident #5's room. The incident was unwitnessed. Resident #5 was in bed asleep. In an interview on 05/31/2023 at 10:55 a.m., S1Administrator, indicated he was unsure if statements were obtained from other employees besides S6CNA. In an interview on 05/31/2023 at 12:06 p.m., S3ADON indicated and confirmed the only written statement she had was from S6CNA. S3ADON confirmed there was no documentation or had proof of interview from other coworkers who were involved with incident. S3ADON confirmed the only documentation from Resident #5 and the victim's nurse was what was documented in nurses' notes which S3ADON confirmed was not specific.