Based on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 15 (#3, #8, #16, #21, #33, #34, #36, #53, 56, #63, #66, #71, #73, #76, #291) out of 15 residents reviewed for advanced directives. Findings: Review of Resident #3's medical record revealed resident was admitted to facility on 03/02/2015 with re-entry on 05/16/2016. Further review of Resident #3's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #8's medical record revealed resident was admitted to facility on 09/23/2019. Further review of Resident #8's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #16's medical record revealed resident was admitted to facility on 09/05/2021 with re-entry on 07/02/2024. Further review of Resident # 16's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #21's medical record revealed resident was admitted to facility on 03/12/2015. Further review of Resident #21's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #33's medical record revealed resident was admitted to facility on 01/30/2019. Further review of Resident #33's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #34's medical record revealed resident was admitted to facility on 09/26/2018. Further review of Resident #34's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #36's medical record revealed resident was admitted to facility on 05/15/2022. Further review of Resident #36's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #53's medical record revealed resident was admitted to facility on 02/05/2021. Further review of Resident #53's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #56's medical record revealed resident was admitted to facility on 02/02/2022. Further review of Resident #56's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #63's medical record revealed resident was admitted to facility on 05/04/2022. Further review of Resident #63's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #66's medical record revealed resident was admitted to facility on 07/01/2022 with re-entry on 02/03/2025. Further review of Resident #66's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #71's medical record revealed resident was admitted to facility on 11/29/2023. Further review of Resident #71's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #73's medical record revealed resident was admitted to facility on 10/26/2023. Further review of Resident #73's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #76's medical record revealed resident was admitted to facility on 10/18/2023. Further review of Resident #76's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. Review of Resident #291's medical record revealed resident was admitted to facility on 01/20/2022 with re-entry 06/24/2025. Further review of Resident #291's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. During an interview on 07/01/2025 at 10:38 a.m. S3 Business Office Manager confirmed Resident #3's, #8's, #16's, #21's, #33's, #34's, #36's, #53's, 56's, #63's, #66's, #71's, #73's, #76's, and #291's medical record failed to reveal documentation the resident or resident's representative was provided written information concerning advance directives.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#24) of 19 care plans reviewed. Findings: Review of Resident #24's medical record revealed an admit date of 02/14/2025 with diagnoses that include in part chronic pain, dependence on supplemental oxygen, heart failure, essential hypertension, major depressive disorder and generalized anxiety disorder. Review of Resident #24's physician orders revealed in part an order dated 6/26/2025 Hydrocodone-Acetaminophen oral tablet 7.5-325 MG (milligram) Give 1 (one) tablet by mouth every morning and at bedtime for pain related to other chronic pain. Review of Resident #24's comprehensive care plan failed to reveal a care plan had been implemented with appropriate approaches for chronic pain. During an interview on 07/01/2025 at 11:30 a.m. S2 Licensed Practical Nurse/Minimum Data Set Coordinator reviewed Resident #24's care plan and verified Resident #24 had not been care planned with appropriate interventions for chronic pain and should have been. During an interview on 07/01/2025 at 11:40 a.m. S1 Director of Nursing reviewed Resident #24's care plan and verified Resident #24 had not been care planned for chronic pain and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an out of state, delegated resident's legal guardian had been validated by the residing state court and had the necessary authority to exercise the resident's rights for 1 (Resident #1) of 3 (Resident #1, #2, #3) sampled residents. Findings: Review of the facility's Residents' [NAME] of Rights policy with an effective date of 01/01/2004 revealed in part: Policy: Each resident will be treated as an individual with consideration, respect and full recognition of his/her dignity. A. Facility Residents shall have the right to: 5. Privately talk and/or meet with and see anyone . C. Any reduction in Resident's rights based upon medical consideration or the rights of other residents shall be explicit, reasonable and appropriate to the justification, and the least restrictive response feasible. Resident #1was admitted to the facility on [DATE] with diagnoses, which included in part, schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, unspecified dementia and catatonic disorder due to known physiological condition. Review of Resident #1's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 00 out of 15 indicating severe cognitive impairment. Review of Resident #1's current plan of care revealed in part, Resident #1 was at risk for alteration in psychosocial well-being and received care on the behavioral unit 24 hours a day, 7 days a week with supervision on and off the unit. Resident #1 had safety precautions in place which included no visits or phone calls from anyone except court appointed guardians. Review of Resident #1's medical record revealed Resident #1's Responsible Party was named as S3Legal Guardian. Review of Resident #1's medical record revealed a notification alert dated 05/28/2021, which read in part, no visitors or phone calls from anyone except court appointed guardians. Further review revealed the contact information for S3Legal Guardian. Further review of Resident #1's medical record revealed a [NAME] County, Texas court document titled Letters of Guardianship Case Number ____, which read in part: I, _________, Clerk for the County Court of [NAME] County, Texas, do hereby certify that on the 31st day of March, 2021, S3Legal Guardian was duly appointed Guardian of the - Person of Resident #1, an incapacitated person, by _____, County Court at Law Judge of said county with those powers and duties that have been specified as set out in article 1106 of Texas Estates Code . Further review of Resident #1's medical record revealed a [NAME] County, Texas court document titled Order - Status Conference, Case Number ____, which read in part: On November 17, 2023 the court conducted a status conference and received a report from guardian of the person S3Legal Guardian. The guardian's (S3Legal Guardian) report indicates that: 1. Resident #1 continues to reside in a behavioral health unit at a facility in the _______, Louisiana area. 2. S3Legal Guardian recommends that visitation with Resident #1 remain suspended, except for the visitation by the ward's (Resident #1) two children, _____ and _____, and by her husband _____ specified below in this order. The court orders that: 1. Visitation with Resident #1 by her friends and family remains suspended, except for the visitation by the ward's (Resident #1) two children, _____ and _____, and by her husband _____. 2. The prohibition on visitation includes all forms of contact, including but not limited to personal visits to the facility, phone calls and mail . Observation on 02/18/2025 at 9:00 a.m. revealed Resident #1 was lying in bed and dressed in clean, appropriate daytime clothing. Resident #1 was awake but failed to establish eye contact or respond to verbal stimuli. During an interview on 02/18/2025 at 9:10 a.m., S4Unit Manager reported Resident #1 has been receiving a visit about every 2 weeks from her husband, daughter and son. S4Unit Manager further reported no other family members or friends were allowed to visit Resident #1. During an interview on 02/19/2025 at 2:30 p.m., S2DON (Director of Nursing) and S5Corporate Nurse acknowledged Resident #1 does not have any court documents from a Louisiana court acknowledging or validating the guardianship of Resident #1 by S3Legal Guardian. S2DON and S5Corporate Nurse further acknowledged the facility was following the state of Texas' court orders for Resident #1's guardianship and the allowances/restrictions to Resident #1's visitation rights. During an interview on 02/19/2025 at 3:10 p.m., S1Administrator reported she was not aware of Resident #1's Texas appointed guardianship disposition or any visitation restrictions. S1Administrator reported she was unsure if a Louisiana court order was needed to validate or transfer the guardianship. During a telephone interview on 02/19/2025 at 3:30 p.m., S6Legal Representative for the facility, acknowledged there was no indication the out of state, Texas court ordered guardianship for Resident #1 had been processed by the state of Louisiana. S6Legal Representative reported she recently found out from a LDH (Louisiana Department of Health) attorney that an out of state guardianship needed to be registered in the state of Louisiana. S6Legal Representative reported Resident #1's guardianship and visitation were outlined in the Texas court documents, signed by a judge and she was not going question the validity or change the policy of the facility.

Based on record review and interview, the facility failed to ensure 1 (#5) resident out of 6 ( #1, #2, #3, #4, #5, #6 ) residents reviewed were free of physical abuse by another resident. Findings: Review of the facility's Abuse Prevention policy revealed the following: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: other residents. Definitions: a. Physical Abuse: This includes, but is not limited to hitting, slapping, pinching, and kicking. Review of resident #2's medical record revealed an admit date of 04/02/2024 with diagnoses of in part; Pressure ulcer stage 4 right heel and right hip, muscle wasting and atrophy, type 2 diabetes, adjustment disorder with depressed mood, major depressive disorder, and dysphagia. Review of resident #2's MDS (minimum data set) revealed resident was assessed to have a BIMS (brief interview mental status) score of 11 indicating moderately impaired cognitions. Review of resident #2's interdisciplinary care team noted on 06/24/2024 at 6:15 p.m. revealed resident #2 reported to the DNS (director of nursing services) resident #5 had come into his room and told him to stop beating on the d__n wall, before I slap you. Resident #2 further reported, resident #5 slapped resident #2 on the right jaw. At the time of the survey resident #2 was not in the facility and unavailable for interview. Review of resident #5's medical record revealed an admit date of 04/14/2024 with diagnoses in part; generalized anxiety disorder, nicotine dependence, depression, opioid dependence, and cannabis abuse. Review of resident #5's MDS revealed resident #5 had BIMS score of 15 indicating intact cognition. During an interview resident #5 confirmed he rolled into resident #2's room and told resident #2, stop beating on the wall before I slap you. Resident #5 further confirmed, In an attempt to scare (resident #2), I slapped him (resident #2) on the arm and then left the room. During an interview on 08/05/2024 at 3:07 p.m. S2 CNA (Certified Nursing Assistant) reported she was at the end of the hallway and saw resident #5 at resident #2's door. S2 CNA reported she saw resident #5 enter resident #2's room. S2 CNA further reported resident #2 told her resident #5 had come in his room and hit him on the arm and told him to stop beating on the wall. During an interview on 08/06/2024 at 9:32 a.m. S3 LPN (Licensed Practical Nurse) reported resident #2 told him that resident #5 came into his room and told him, stop beating on the wall and hit him (resident #2) on the arm. S3 LPN reported he assessed resident #2 and did not find any evidence of injuries. During an interview on 08/05/2024 at 2:30 p.m. S1 DNS (Director of Nursing Services) reported she was notified by the S2 CNA that resident #5 went in resident #2's room. S1 DNS further reported resident #2 told S2 DNS that resident #5 came into his room and told him to stop hitting the on the wall or he would slap him, and then slapped him in the face. S1 DNS further reported S3 LPN told her that resident #2 had told S3 LPN that resident #5 had hit him on the arm.

Based on record review, observation and interviews the facility failed to accommodate the needs of 1(#49) resident out of 3 (#17, #49, #93) residents reviewed for environment. The facility failed to ensure a bedside table was available for resident #49. Findings: Review of resident #49's Medical Diagnoses revealed unspecified dementia and type 2 diabetes mellitus. Review of resident #49's MDS (Minimum Data Sets) dated 03/20/2024 revealed a BIMS (Brief Interview of Mental Status) of 13 out of 15 indicating cognitively intact. Review of resident #49's functional status revealed resident #49 required supervision and set up help only with eating. Review of resident #49's Care Plan revealed resident #49 required supervision to extensive assistance with activities of daily living related to impaired cognition, impaired mobility, dementia, schizoaffective disorder, and anxiety with approaches to setup assist with eating. Observation on 06/11/2024 at 8:45 a.m. revealed resident #49 in bed with eyes closed. Further observation revealed resident #49's uneaten breakfast tray on a rolling walker on the side of resident #49's bed. During an interview on 06/11/2024 at 8:45 a.m. S5 LPN (Licensed Practical Nurse) observed resident # 49's uneaten breakfast tray on rolling walker and reported breakfast was served on the hall this morning about 8:00 a.m. S5 LPN confirmed resident # 49 required assistance with meal set up and meal trays should have been placed on residents' bedside table not rolling walker. During an interview on 06/11/2024 at 8:50 a.m. S6 CNA (Certified Nurse Assistant) reported resident #49 did not have a bedside table and resident #49's breakfast was served on rolling walker this morning. S6 CNA confirmed resident #49's breakfast should have been served on a bedside table.

Based on record reviews, observations and interviews the facility failed to ensure respiratory care was consistent with professional standards of practice by failing to ensure 1 (#54) of 3 (#15, #28, #54) sampled residents reviewed for respiratory care. The facility failed to ensure Resident #54's continuous positive airway pressure (CPAP) mask was cleaned and/or discarded if (when) visibly soiled. Findings: Review of Facility's Oxygen Policy and Procedure (01/15) revealed Guidelines for Frequency Changes of Respiratory Supplies: item - CPAP/BIPAP Mask - discard when visibly soiled, damaged and/or inoperable, per manufacture guidelines/physician orders. Review of Resident #54's medical records revealed admit date of 03/07/2022 with the following diagnoses, in part: other specified disorders of nose and nasal sinuses, obstructive sleep apnea (OSA) (adult) (pediatric), Alzheimer's disease/unspecified, unspecified dementia/unspecified severity with other behavioral disturbance, major depressive disorder/recurrent/severe with psychotic symptoms, dependence on other enabling machines and devices and morbid (severe) obesity with alveolar hyperventilation. Review of Resident #54's Physician's Orders revealed an order dated 03/09/2024 - antibiotic ointment apply to nasal passages QID (four times a day) prn (when needed) may keep at bedside for other specified disorder of nose and nasal sinuses. Further review revealed an order dated 05/19/2022 - Bi-PAP (bilateral positive airway pressure) on while sleeping- OSA. Observation on 06/11/2024 at 8:50 a.m. revealed Resident #54's CPAP mask with nose piece noted to have black particles inside the mask and the strap to be stained brown. Observation on 06/11/2024 at 2:30 p.m. revealed Resident #54 lying in bed wearing CPAP mask. Observation on 06/12/2024 at 9:00 a.m. revealed Resident #54 lying in bed wearing CPAP mask. Observation on 06/13/2024 at 8:55 a.m. S2 DON (Director of Nursing) observed the black particles inside the CPAP nose mask and the straps with brown stains. During an interview on 06/13/2024 at 8:55 a.m. S2 DON reported _____company comes out and services the CPAP machines but was unable to tell surveyor how often. S2 DON further reported she thinks they have to call them when needed. S2 DON acknowledged Resident #54's CPAP nose mask has black particles and the strap was dirty with brown stains and should be cleaned. During an interview on 06/13/2024 at 9:30 a.m. S1 Administrator acknowledged the facility's policy guidelines provided to surveyor state the CPAP/BIPAP mask should be discarded when visibly soiled.

Based on record review and interviews, the facility failed to maintain an accurate count of the disposition of controlled medications for 1 (Resident #36) of 5 (#1, #28, #36, #54 and #82) residents reviewed for unnecessary medications. Findings: Review of the facility's Controlled Medications Administration policy dated 08/2016 revealed in part: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure: 4. Medications listed in Schedules I, II, III, IV and V dispensed by the pharmacy are adequately documented and reconciled consistent with law and regulation . 6. When administering controlled medication, the authorized personnel records the administration on the MAR (Medication Administration Record) /e-Mar (Electronic Medication Administration Record) and enters all of the following information on the Controlled Drug Record: a. Date and time of administration b. Amount administered c. Signature of the person preparing the dose d. Quantity reconciled 9. Any discrepancy in a controlled substance medication count is reported to the Director of Nursing immediately. The Director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies . Review of Resident #36's physician orders revealed an order dated 11/12/2020, which read, Lorazepam 1 mg. (milligram) tablet; give one tablet po (by mouth) bid (two times a day). Review of Resident # 36's individual Controlled Drug Record with S3LPN (Licensed Practical Nurse) on 06/13/2024 at 12:45 p.m. revealed 7 Lorazepam tablets remained available with the last dose documented as administered on 06/13/2024 at 8:00 a.m. Review of Resident #36's Lorazepam blister pack revealed 8 Lorazepam tablets remained available. During an interview on 06/13/2024 at 12:45 p.m., S3LPN acknowledged the controlled substance count discrepancy for Resident #36. S3LPN reported she had not administered the 06/13/2024 8:00 a.m. dose of Lorazepam to Resident #36 and should not have documented as administered. During an interview on 06/13/2024 at 12:50 p.m., S4LPN Unit Manager, acknowledged Resident #36's available dose discrepancy of Lorazepam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set) assessment was accurate for 1 (#2) of 3 (#1, #2, #3) sampled residents. The facility failed to include Resident #2's wheelchair alarm on MDS assessment. Findings: Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] and had diagnoses that included, in part, history of falling, schizoaffective disorder, unspecified dementia, unspecified psychosis, psychotic disorder with delusions due to known physiological condition, other encephalopathy, and type 2 diabetes mellitus. Review of Resident #2's physician orders revealed an order dated 01/30/2024 for wheelchair clip alarm to wheelchair. Observations conducted at the following dates/times revealed a wheelchair alarm was in place for Resident #2. 05/06/2024 at 1:26 p.m. 05/06/2024 at 2:25 p.m. 05/06/2024 at 4:10 p.m. 05/07/2024 at 10:38 a.m. 05/07/2024 at 12:20 p.m. 05/07/2024 at 3:15 p.m. 05/08/2024 at 1:35 p.m. Review of Resident #2's Quarterly MDS dated [DATE], Section P Restraints revealed Chair Alarm was marked as not used. During an interview on 05/07/2024 at 12:59 p.m. S1 DON (Director of Nursing) confirmed Resident #2's chair alarm had been placed on 1/30/2024 after Resident #2 had a fall. During an interview on 05/07/2024 at 5:00 p.m. S2 MDS Coordinator confirmed Resident #2 had a chair alarm in place. After review of Resident #2's 04/09/2024 quarterly MDS S2 MDS Coordinator further confirmed the restraints section did not have a check by chair alarm and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the residents' environment remained free of hazards for 4 (Resident #1, #2, #3, and #4) of 4 (Resident #1, #2, #3, and #4) residents reviewed for safe smoking. The facility failed to: 1. ensure Resident #1, Resident #2, Resident #3, and Resident #4 were supervised while smoking and; 2. ensure Resident #1, Resident #2 and Resident #4's smoking materials were secure according the facility's policy and the residents' plan of care. Findings: Review of the facility's Smoking Policy dated 05/2022 revealed in part: Policy: No smoking or use of smoking materials will be allowed inside the building . Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Evaluation Tool. Responsibility: All staff, monitored by management. Procedure: 1. All residents who smoke will be evaluated for his/her ability to smoke safely, the ability to handle smoking material and the level of supervision while smoking. The Smoking Evaluation Tool will be completed upon admission, re-admission, quarterly, annually and as needed. 2. The facility staff will store smoking materials and identify designated times for smoking. 3. Assistance with lighting tobacco products, assistance to hold cigarettes, supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the Smoking Evaluation Tool will be provided. Resident #1 Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included in part, paraplegia, unspecified psychosis, generalized anxiety disorder, nicotine dependence, and other psychoactive substance abuse. Review Resident #1's MDS (Minimum Data Set) dated 01/9/2024 revealed, in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Review of Resident #1's comprehensive care plan revealed, in part, a potential for injury related to smoking cigarettes with approaches including, all smoking materials to be kept at the nurse's station and supervised smoking per smoking schedule. Review of Resident #1's Smoking Evaluation Tool dated 02/13/2024 revealed, in part, Resident #1 required general supervision and staff to light cigarettes. Observation of the smoking patio on 03/19/2024 at 9:18 a.m. revealed Resident #1 smoking unsupervised until S3LPN (Licensed Practical Nurse) entered the smoking patio on 03/19/2024 at 9:30 a.m. Observation on 03/19/2024 at 3:30 p.m. revealed a cigarette lighter sitting on Resident #1's bedside table. Further observation revealed Resident #1 grabbed the lighter and tucked it under his pillow as surveyor neared. During an interview on 03/19/2024 at 3:30 p.m., Resident #1 acknowledged he should not have a cigarette lighter in his room. Resident #2 Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included in part, parkinson's disease, anxiety, and major depressive disorder. Review of Resident #2's MDS dated [DATE] revealed, in part, Resident #2 had a BIMS score of 15, indicating intact cognition. Review of Resident #2's comprehensive care plan revealed, in part, a potential for injury related to smoking cigarettes with approaches including, all smoking materials to be kept at the nurse's station and supervised smoking per smoking schedule. Review of Resident #2's Smoking Evaluation tool dated 01/30/2024 revealed, in part, Resident #2 was unable to safely utilize a lighter. Resident #2 required supervision and assist of 1 staff for smoking and staff to light cigarettes. Observation of the smoking patio on 03/19/2024 at 9:18 a.m. revealed Resident #2 smoking unsupervised until S3LPN entered the smoking patio on 03/19/2024 at 9:30 a.m. Observation on 03/19/2024 at 9:25 a.m. revealed Resident #2 smoking a self-rolled cigarette. During an interview on 03/19/2024 at 9:25 a.m., Resident #2 reported he had rolled the cigarette in his room prior to coming out to the patio and was allowed to keep his tobacco in his room. During an interview on 03/19/2024 at 1:00 p.m., Resident #2 pointed to a red bag in the corner of his room and reported it contained his menthol tobacco. Observation on 03/19/2024 at 1:30 p.m. revealed Resident #2 sitting in wheel chair on the front porch smoking a cigarette. Further observation revealed no staff was present for supervision. During an interview on 03/19/2024 at 1:30 p.m., S3LPN acknowledged Resident #2 was on the front porch smoking and was unsupervised. S3LPN reported Resident #2 has his own smoking materials, including a lighter, which Resident #2 keeps in his room. Resident #3 Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included in part, schizoaffective disorder, bipolar disorder and type 2 diabetes. Review of Resident #3's MDS dated [DATE] revealed, in part, Resident #3 had a BIMS score of 15, indicating intact cognition. Review of Resident #3's comprehensive care plan revealed, in part, a potential for injury related to smoking cigarettes with approaches including, all smoking materials to be kept at nurse's station and supervised smoking per policy. Review of Resident #3's Smoking Evaluation Tool dated 02/22/2024 revealed, in part, Resident #3 was unable to safely utilize a lighter. Resident #2 required supervision and assist of 1 staff for smoking and staff to light cigarettes. Observation of the smoking patio on 03/19/2024 at 9:18 a.m. revealed Resident #3 smoking unsupervised until S3LPN entered the smoking patio on 03/19/2024 at 9:30 a.m. During an interview on 03/19/2024 at 9:30 a.m., S3LPN acknowledged Resident #1, Resident #2 and Resident #3 had been left unsupervised for approximately 12 minutes and should not have been. S3LPN reported residents should be supervised at all times while smoking. During an interview on 03/19/2024 at 4:00 p.m., S1Administrator, acknowledged smokers are to be supervised by staff at all times per policy and the residents should not have been left unattended during the morning smoke break. Resident #4 Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included in part, anxiety disorder, chronic pain, type 2 diabetes, and depression. Review of Resident #4's MDS dated [DATE] revealed, in part, Resident #4 had a BIMS score of 13, indicating intact cognition. Review of Resident #4's comprehensive care plan revealed, in part, a potential for injury related to smoking cigarettes with approaches including, all smoking materials to be kept at nurse's station and supervised smoking per policy. Review of Resident #4's Smoking Evaluation dated 02/28/2024 revealed, in part, Resident #4 required general supervision and staff to light cigarettes. Observation on 03/20/2024 at 8:15 a.m. with S4LPN revealed Resident #4 smoking on the front patio, in his wheelchair, unsupervised. During an interview on 03/20/2024 at 8:15 a.m., S4LPN reported she had no idea who lit Resident #4's cigarette. S4LPN acknowledged Resident #4 should be supervised by staff while smoking. During an interview on 03/20/2024 at 8:17 a.m., Resident #4 reported he keeps his lighter and cigarettes on him at all times and pulled the lighter out of his front pocket for view. During an interview on 03/20/2024 at 10:00 a.m., S1Administrator acknowledged Resident #1, Resident #2, Resident #3 and Resident #4 had been unsupervised while smoking and should always be supervised by staff. S1Administrator further acknowledged Resident #1, Resident #2 and Resident #4 had been observed in possession of smoking materials. S1Administrator reported smoking materials were to be kept securely at the nurse's station and acknowledged the facility had not been following the Smoking Policy. During an interview on 03/20/2024 at 11:45 a.m., S2DON (Director of Nursing) acknowledged some residents had smoking items in their possession and this could pose an accident hazard. S2DON further acknowledged facility was not following the Smoking Policy.

Based on record reviews, observations and interviews the facility failed to provide services that met professional standards during medication administration for 3 (#33, #42, #80) of 4 (#33, #42, #72, #80) residents observed for medication administration. The facility failed to follow policies and procedures to ensure safe medication administration practices. Findings: Review of the facility's Medication Administration policy revealed in part: 2.) Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. 11.) The resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log. Resident #33 Review of Resident #33's Physician Orders revealed the following orders: 1.) Order dated 11/23/2020 for 4 oz. (ounce) Med Plus PO (by mouth) BID (twice a day) with medications 2.) Order dated 03/17/2023 for Incruse Ellipta 62.5 mcg (micrograms) INH (inhaler) inhale 1 puff QD (everyday) 3.) Order dated 03/17/2023 for Zinc 10 mg (milligrams) PO QD An observation on 05/16/2023 at 8:02 a.m. revealed S10 LPN (Licensed Practical Nurse) failed to administer the following medications to Resident #33: 1.) 4 oz. Med Plus PO BID with medications 2.) Incruse Ellipta 62.5 mcg INH, inhale 1 puff QD 3.) Zinc 10mg PO QD During an interview on 05/16/2023 at 2:00 p.m., while reviewing the MAR, S10 LPN acknowledged he had initialed the MAR but had not administered the following medications to Resident #33 and should have: 1.) 4oz. Med Plus PO BID with medications 2.) Incruse Ellipta 62.5 mcg INH, inhale 1 puff QD 3.) Zinc 10mg PO QD Resident #42 Record review of Resident #42's Physician Orders revealed an order dated 04/25/23 for Spiriva Respimat 2.5 mcg/actuation 1 puff daily. An observation on 05/16/2023 at 7:30 a.m. revealed S11 LPN administered 1Spiriva 18 mcg capsule (cap) via inhaler to Resident #42. During an interview on 05/17/2023 at 8:30 a.m. S12 LPN confirmed Spiriva 18 mcg cap was an incorrect medication for Resident #42 and the Spiriva Respimat 2.5 mcg INH, as ordered by the physician, had not been available in the facility. During an interview on 05/17/2023 at 8:45 a.m. S1 Administrator and S2 DON (Director of Nursing) confirmed the medication Spiriva 18 mcg HandiHA that had been administered should have been Spiriva Respimat 2.5 mcg INH 1 puff. Resident #80 Review of Resident #80's Physician Orders revealed the following orders: 1.) Order dated 06/10/2021 for B12 500 mcg tablet, give 1 tablet by PO QD. 2.) Order dated 06/16/2022 for Folic Acid 1 mg tablet, give 1 tablet PO daily. 3.) Order dated 04/21/2023 for Flomax 0.4mg PO daily An observation on 05/16/2023 at 8:02 a.m. revealed S10 LPN failed to administer Flomax 0.4 mg PO to Resident #80. During an interview on 05/16/2023 at 2:00 p.m. S10 LPN confirmed Flomax 0.4 mg PO had not been administered to Resident #60 and should have been. During an interview on 05/16/2023 at 2:00 p.m. S10 LPN confirmed he had administered the wrong dose on the following medications to Resident #80: 1.) B12 1000 mcg 1 tab PO had been given and B12 500mcg 1 tab PO should have been administered. S10 LPN reported he did not have a pill splitter so he gave 1000 mcg. 2.) Folic Acid 400 mcg 1 tab PO and Folic Acid 1mg 1 tab PO had not been administered and should have been.

Based on observations, interviews, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 4 residents were observed during the facility's medication administration by 2 LPN's (Licensed Practical Nurse) on 05/16/2023. A total of 33 opportunities were observed which included 7 errors with 3 residents (#33, #42, #80), for a medication error rate of 21.21%. Findings: Review of the facility's Medication Administration policy revealed in part: 2.) Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. 11.) The resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log. Resident #33 Review of Resident #33's Physician Orders revealed the following orders: 1.) Order dated 11/23/2020 for 4 oz. (ounce) Med Plus PO (by mouth) BID (twice a day) with medications 2.) Order dated 03/17/2023 for Incruse Ellipta 62.5 mcg (micrograms) INH (inhaler) inhale 1 puff QD (everyday) 3.) Order dated 03/17/2023 for Zinc 10 mg (milligrams) PO QD An observation on 05/16/2023 at 8:02 a.m. revealed S10 LPN (Licensed Practical Nurse) failed to administer the following medications to Resident #33: 1.) 4 oz. Med Plus PO BID with medications 2.) Incruse Ellipta 62.5 mcg INH, inhale 1 puff QD 3.) Zinc 10mg PO QD During an interview on 05/16/2023 at 2:00 p.m., while reviewing the MAR, S10 LPN acknowledged he had initialed the MAR but had not administered the following medications to Resident #33 and should have: 1.) 4oz. Med Plus PO BID with medications 2.) Incruse Ellipta 62.5 mcg INH, inhale 1 puff QD 3.) Zinc 10mg PO QD Resident #42 Record review of Resident #42's Physician Orders revealed an order dated 04/25/23 for Spiriva Respimat 2.5 mcg/actuation 1 puff daily. An observation on 05/16/2023 at 7:30 a.m. revealed S11 LPN administered 1Spiriva 18 mcg capsule (cap) via inhaler to Resident #42. During an interview on 05/17/2023 at 8:30 a.m. S12 LPN confirmed Spiriva 18 mcg cap was an incorrect medication for Resident #42 and the Spiriva Respimat 2.5 mcg INH, as ordered by the physician, had not been available in the facility. During an interview on 05/17/2023 at 8:45 a.m. S1 Administrator and S2 DON (Director of Nursing) confirmed the medication Spiriva 18 mcg HandiHA that had been administered should have been Spiriva Respimat 2.5 mcg INH 1 puff. Resident #80 Review of Resident #80's Physician Orders revealed the following orders: 1.) Order dated 06/10/2021 for B12 500 mcg tablet, give 1 tablet by PO QD. 2.) Order dated 06/16/2022 for Folic Acid 1 mg tablet, give 1 tablet PO daily. 3.) Order dated 04/21/2023 for Flomax 0.4mg PO daily An observation on 05/16/2023 at 8:02 a.m. revealed S10 LPN failed to administer Flomax 0.4 mg PO to Resident #80. During an interview on 05/16/2023 at 2:00 p.m. S10 LPN confirmed Flomax 0.4 mg PO had not been administered to Resident #60 and should have been. During an interview on 05/16/2023 at 2:00 p.m. S10 LPN confirmed he had administered the wrong dose on the following medications to Resident #80: 1.) B12 1000 mcg 1 tab PO had been given and B12 500mcg 1 tab PO should have been administered. S10 LPN reported he did not have a pill splitter so he gave 1000 mcg. 2.) Folic Acid 400 mcg 1 tab PO and Folic Acid 1mg 1 tab PO had not been administered and should have been.

Based on an observation and interview the facility failed to ensure drugs were stored properly in accordance with current accepted professional principles by having medications stored in the employee refrigerator which contained food. Findings: Review of the facility's Medication Storage policy revealed in part: 9.) Medications in the refrigerator are kept in closed, labeled containers or compartments. Internal and external medications within the refrigerator must also be separated. All of these medications must be separate physically from juices, applesauce, yogurts, shakes, and other foods for medication administration that are kept in this refrigerator. Observation on 05/17/2023 at 12:00 p.m. with S3 Unit Manager revealed the following medications were stored in the employee refrigerator which contained food items: 4 boxes of Trulicity and 1 box of Invega. During an interview on 05/17/2023 at 12:01 p.m. S3 Unit Manager reported Trulicity and Invega should not be stored in the employee refrigerator and the refrigerated medications should be stored in the Medication Storage room.

Based on observations and interviews, the facility failed to ensure dietary services were provided in a sanitary environment to prevent potential food borne illness for the 94 residents served a meal tray from the kitchen as reported by S4 Dietary Manager. The facility failed to ensure opened food items were labeled and dated; failed to ensure the dishwasher reached the appropriate temperature and chemical level to sanitize and sterilize dishes; failed to ensure all staff wore a hair covering in the kitchen; and failed to ensure dry goods boxes were stored in a sanitary manner off the floor. The facility's census was 94 as documented on the facility's Resident Census and Condition of Residents form dated 05/15/2023. Findings: Observation on 05/15/2023 at 6:30 a.m. revealed partially used food items without an opened date which included; 2-16 ounce (oz) bottles of ground mustard, Mediterranean style ground Oregano, 2 bottles of Cinnamon, 2 bottles of Ground Thyme, 3 bottles of Ground Basil Leaves, Italian Seasoning, Ground cayenne pepper, 2 bottles of Garlic Powder, Onion powder, Rubbed Sage, Black Pepper, 2.75 oz. Paprika and 3 bottles of Chili powder, 10 oz. Parsley flakes, 4.5 oz. seasoned salt, a 5 pound (lb) tub of peanut butter, and a 12 oz. jar of honey. Observation of the reach-in refrigerator revealed a gallon jug of Thousand Island dressing and dill pickle chips opened and not dated. During an interview on 05/15/2023 at 8:45 a.m. S4 Dietary Manager reported staff knew to date food items when opened, and acknowledged it was not done and should have been. Observation on 05/15/2023 at 7:00 a.m. with S7 Dishwasher staff revealed the dishwasher temperature failed to reach the required 150 degrees F (Fahrenheit), and multiple chemical test strips failed to reveal a color change indicating no sanitizing chemicals were present. Observation on 05/15/2023 at 7:30 a.m. revealed S4 Dietary Manager walked through the kitchen and food prep area not wearing a hair covering. During an interview on 05/15/2023 at 7:35 a.m. S4 Dietary Manager acknowledged everyone must cover hair in the kitchen and she did not. Observation on 05/15/2023 at 8:00 a.m. with S4 Dietary Manager and S7 Dishwasher staff, revealed the dishwasher failed to reach a temp above 150 degrees F, and no color change on the chemical control test strips indicating no sanitizing chemicals were present. Observation of the kitchen dry storage room on 05/16/2023 at 9:00 a.m. with S8 Maintenance and S4 Dietary Manager revealed a large puddle of water on the floor running from one side of the room to the other. Further observation revealed the drywall appeared wavy and wet with a water mark approximately 1-2 feet up the side wall. Further observation revealed a black fuzzy substance going approximately 6 feet up the same wall in the corner above the water puddle. Three large boxes were on the floor. One of the boxes was wavy and appeared wet with discoloration. During an interview on 05/16/2023 at 9:00 a.m. S4 Dietary Manager reported the water was just condensation from the water pipes. S8 Maintenance reported that's mold on the wall and it looks like there's a water leak, more than just condensation. S4 Dietary Manager acknowledged boxes should not be on the floor. During an interview on 05/16/2023 at 10:30 a.m. S6 Maintenance Supervisor acknowledged the dishwasher water temperature was not getting hot enough. Observation on 05/16/2023 at 1:00 p.m. S4 Dietary Manager made multiple attempts to test the dishwasher chemicals but failed to achieve a color change reaction on the test strips indicating sanitizing chemicals were not present in the dishwasher. During an interview on 05/16/2023 at 2:00 p.m. S6 Maintenance Supervisor acknowledged the dishwasher wasn't getting any chemicals to sterilize and sanitize the dishes and it should have been.

Based on observations and interviews, the provider failed to ensure the facility was free of flying pests, insects and rodents by failing to maintain an effective pest control program. The deficient practice had the potential to affect the 94 residents residing in the facility according to the Census and Condition form. Findings: Kitchen Observations of the facility's kitchen on 05/15/2023 at 6:30 a.m., revealed multiple large, brown bugs and small black insects crawling on the spice shelves in the food prep area, along with multiple black flying insects in the food prep area, cleaning area, and food serving area. Further observation revealed the kitchen's exit door leading to the outside of the facility was propped open with a dishtowel. During an interview on 05/15/2023 at 6:30 a.m. S5 Head [NAME] reported staff knew they were not supposed to prop the door open, but they come in and out that door, which lets the flies in. During an interview on 05/15/2023 at 8:45 a.m., S4 Dietary Manager acknowledged insects were in the kitchen and should not have been. An observation on 05/15/2023 at 11:30 a.m. revealed the kitchen's back door propped open with a towel. During an interview on 05/16/2023 at 8:40 a.m., S6 Maintenance Supervisor acknowledged the current pest control service was ineffective. Facility An observation on 05/15/2023 at 7:15 a.m. revealed multiple black flying bugs in Resident #30's room. An observation on 05/15/2023 at 7:15 a.m. revealed multiple black flying bugs in Resident #73's room. An observation on 05/15/2023 at 8:30 a.m. revealed multiple black flying bugs which appeared to be flies, in Resident #7's room. Further observation revealed Resident #7 was sleeping in the bed and a black insect with wings was on his left foot. During an interview on 05/15/2023 at 10:30 a.m., Resident #63 and Resident #51 reported a problem with flies. Resident #63 and Resident #51 further reported when they ate their meals, they had to swat at flies. An observation on 05/15/2023 at 12:05 p.m. revealed Resident #25 sitting on his bedside in his room eating lunch. A sticky trap was noted on the floor underneath the air conditioner with a large amount of black round objects and small to medium black insects. Further observation revealed multiple, small to medium black insects crawling on the floor near the sticky trap. During an interview on 05/15/2023 at 12:05, p.m., Resident #25 reported the facility put the sticky traps down for mice and roaches and if one is caught, they let maintenance know. Resident #25 reported maintenance had caught a couple this week but there was a little mouse that came out every night and ran around. Resident #25 further reported the black spots on the trap were rat droppings and roaches. Resident #25 indicated he did not like having pests in his room. An observation on 05/16/2023 at 8:09 a.m. revealed Resident #73 lying in bed with his breakfast tray on the bedside table, and 3 black winged insects were flying around in Resident #73's room. Observation on 05/16/2023 at 11:30 a.m. revealed Resident #43 resting quietly in bed with their eyes closed, while 5 black winged insects were lit on Resident #43's bedspread. During an interview on 05/16/2023 at 11:30 a.m., S9 LPN confirmed black winged insects were on Resident #43's bedspread. An observation on 05/16/2023 at 3:50 p.m. revealed 5 black winged insects flying around in Resident #7's room. An observation on 05/16/2023 at 3:50 p.m. revealed multiple black flying insects in Resident #30's room. During an interview on 05/16/2023 at 4:20 p.m., Resident #55 reported maintenance had changed out the sticky trap in their room last night because they caught another mouse and the trap had a bunch of roaches on it. Resident #55 further reported he would eat in the dining room because the sticky traps made his room feel dirty. An observation on 05/17/2023 at 8:15 a.m. revealed 3 black winged insects flying around in Resident #73's room. An observation on 05/17/2023 at 8:50 a.m. revealed Resident #43 swatting at a black winged insect as it flew by her face. During an interview on 05/17/2023 at 1:58 p.m., S6 Maintenance Supervisor reported S8 Maintenance has been monitoring the mice situation, and acknowledged the current pest control service was ineffective. Observations made during the survey conducted from 05/15/2023 through 05/17/2023 revealed black winged insects flying around in hallways, residents' rooms, and the dining room. During an interview on 05/17/2023 at 1:40 p.m., S1 Administrator reported the facility did not have a Pest Control policy. S1 Administrator acknowledged current pest control measures were not adequate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report resident to resident abuse without serious bodily harm within 24 hours to the State Survey Agency as required for 1 (#3) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of facility's Abuse Prevention policy revealed: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. PROTECTION: . 2. Suspected or substantiated cases of resident abuse .shall be thoroughly investigated, documented, and reported . as required by state guidelines. Review of Resident #3's medical record revealed Resident #3 was readmitted to the facility's behavioral unit on 11/23/2020 with diagnoses including but not limited to schizoaffective disorder, anxiety disorder, and mood disorder. Review of Resident #3's yearly MDS (Minimum Data Set) dated 12/21/2022 revealed, in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 11 out of 15 indicating Resident #3's cognition was moderately impaired. Further review of Resident #3's MDS dated [DATE] revealed Resident #3 did not have any mood or behavioral problems during the 7 day MDS look back period. During an interview on 03/01/2023 at 10:05 a.m. S2 CNA (Certified Nursing Assistant) reported she was assisting another resident down the hall when the incident between Resident #1 and Resident #3 occurred and didn't see the incident happen. S2 CNA further reported staff were able to intervene and redirect Resident #1 his room. S2 CNA reported Resident #3 was assessed by the nurse and Resident #3 denied having pain in the chest area after the incident but a chest x-ray was done. Review of Resident #3's medical record revealed chest x-ray dated 01/27/2023 with results as follows: No acute pneumonia, no mediastinal or hilar masses are visualized. No acute bony pathology noted. No pneumothorax is visualized. Cardiac silhouette upper limits of normal. Review of Resident #1's medical record revealed Resident #1's was initially admitted to the facility on [DATE] and was discharged to ____ ____ behavioral center on 01/27/2023 after the incident with Resident #3. Further review of Resident #1's medical record revealed Resident #1 had diagnoses that included dementia with other behavioral disturbance, anxiety disorder, major depressive disorder recurrent, unspecified mood [affective] disorder, unspecified psychosis not due to a substance or known physiological condition, and insomnia. Review of Resident #1's notes revealed the following: 01/27/2023 at 9:00 p.m. nurse note - CNAs were redirecting resident #1 to his room and on the way there, Resident #1 yelled at another resident and kicked her in the chest for no reason. 01/27/2023 at 4:45 p.m. progress note - Writer notified by CNA workers Resident #1 kicked Resident #3 in the chest while she was sitting on the floor. During an interview on 02/27/2023 at 3:55 p.m. S3 MDS Coordinator reported she did not have a BIMS score for Resident #1 prior to the 01/27/2023 incident as Resident #1 had just been admitted to the facility on [DATE]. Review of facility's SIMS (Statewide Incident Management System) report revealed resident to resident abuse occurred on 01/27/2023 at 4:45 p.m., was discovered on 01/30/2023 at 8:00 a.m., and was entered into the system on 01/30/2023 at 9:04 a.m. During an interview on 02/28/2023 at 12:50 p.m. S1 Administrator reported Resident to Resident incident involving Resident #1 and Resident #3 was not reported within 24 hours and should have been. S1 Administrator further reported staff were to report to her immediately when an incident occurred and staff had her phone number to call if she was not in the facility at the time of the incident.