**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents received services for reasonable accommodation of needs by failing to provide set-up assistance with meals for 1 (#26) of 1 residents reviewed for positioning and mobility. Findings: Review of the record for resident #26 revealed an admission date of 04/13/2012. Resident #26 had diagnoses that included flaccid hemiplegia affecting right dominant side, right hand contracture, sequelae of cerebrovascular disease, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 which indicated that resident #26 had moderate cognitive impairment. Additionally, the MDS documented that resident #26 had a one sided functional limitation in range of motion and required set-up or clean-up assistance with meals. Review of resident #26's current plan of care revealed an intervention dated 12/20/2024, per occupational therapy, staff is to assist with meal tray set-up. On 04/14/2025 at 12:15 p.m., resident #26's lunch tray was observed being delivered to his bedside table. It was observed that S9Certified Nursing Assistant (CNA) did not provide set-up assistance for resident #26 which included not opening seasoning packets or beverages. S9CNA then exited the room. Resident #26 turned his bedside table to reposition his tray in front of him. Interview at that time with resident #26 revealed staff do not assist him with opening items such as milk cartons or pepper packets. Resident #26 was observed opening a pepper packet with his teeth. Resident #26 confirmed that he does have difficulty chopping his meat and revealed that it would be helpful if staff would chop his meat. On 04/16/2025 at 8:07 a.m., resident #26 was observed in his room with his breakfast tray delivered and he had consumed approximately 50% of his meal. Further observation revealed that resident #26's milk carton had not been opened and additional fluids on the tray were still covered. S7LicensedPracticalNurse (LPN) was notified that resident #26's milk carton and fluids were not opened. On 04/16/2025 at 7:55 a.m., an interview was conducted with S7LPN regarding resident #26's requirement for assistance with meals. S7LPN confirmed that resident #26 was independent with feeding himself but staff open his drinks. On 04/16/2025 at 2:15 p.m., S1ExecutiveDirector was notified of the findings related to the facility's failure to provide reasonable accommodation of needs for resident #26 who required set-up assistance with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (#29) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment. The failed practice was evidenced by resident #29 not having bed linen on the bed. Findings: Review of the record for resident #29 revealed an admission of 01/16/2024 with diagnoses of type 2 diabetes, cerebral vascular disease and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 was cognitively intact for daily decision making. Resident #29 required two person physical assistance with bed mobility, transfers, and toilet use. On 04/14/2025 at 3:19 p.m., observation of resident #29's bed revealed there was no linen on the bed and the resident was observed lying on a draw sheet. Interview with resident #29 at that time revealed this was a frequent problem with staff failing to put linen on the bed. Resident #29 stated she had reported not having linen to the nurses and nothing had changed. Interview with S9Certified Nursing Assistant on 04/14/2025 at 4:40 p.m. confirmed that no bed linen was currently on the bed for resident #29. She revealed that this frequently occurs with residents who have a bariatric bed. On 04/16/2025 at 2:15 p.m. S1Executive Director was notified resident #29 did not have linens on her bed and she was in the bed lying on a draw sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident was free from physical restraints imposed for the purpose of discipline or convenience for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints. The facility failed to ensure that resident #31 was able to self-release his wheelchair seatbelt upon request which resulted in the failure to identify the seatbelt as a restraint. Findings: Review of the facility's Restraint Evaluation and Restraint Reduction Policy dated 08/2013 revealed: Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. The policy states that individuals responsible for restraints include all members of the interdisciplinary team (as appropriate to individual resident needs) and the Director of Nursing (DON) monitors restraints. Seatbelts that are front-fastened and can be easily unfastened by the alert and somewhat oriented resident are not included if the resident can demonstrate self-release upon request. Review of the medical record for resident #31 revealed an admission date of 08/14/2019 with diagnoses that included chronic obstructive pulmonary disease, history of falling, age related osteoporosis, and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate impaired cognition. Review of the Physician's Orders dated 01/04/2025 specified resident #31's seatbelt as: self-releasing alarming seatbelt (non-restraint) due to unawareness of physical limitations with a diagnosis of schizoaffective disorder. Review of resident #31's current plan of care revealed the self-releasing alarming seatbelt to wheelchair was a fall intervention. On 04/14/2025 at 3:47 p.m., resident #31 was observed in his wheelchair and it was noted that the wheelchair seatbelt was secured. On 04/16/2025 at 10:57 a.m., an observation of resident #31 with S3Director of Nursing Services (DNS) was conducted. Resident #31 was seated in his wheelchair with his seatbelt in place. S3DNS asked resident #31 to unbuckle his seatbelt. Resident #31 did attempt to release the seatbelt but was unable to complete the act. Resident #31 stated to S3DNS that he could not complete the task. On 04/16/2025 at 11:15 a.m., an interview with S3DNS revealed there was no supporting documentation regarding restraint reduction attempts or reassessments for resident #31. On 04/16/2025 at 2:15 p.m., S1ExecutiveDirector was notified of the findings related to the facility's failure to identify that resident #31's wheelchair seatbelt was a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a care plan had been revised for 1 (#31) of 3 (#31, #53, and #96) residents reviewed for restraints. Findings: Review of the facility's Restraint Evaluation and Restraint Reduction Policy dated 08/2013 revealed: Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. The policy states that individuals responsible for restraints include all members of the interdisciplinary team (as appropriate to individual resident needs) and the Director of Nursing (DON) monitors restraints. The policy procedure states that all residents using a restraint are to be evaluated and re-evaluated approximately every quarter. The policy procedure states that care plan updates are to occur approximately every quarter and/or as a goal or approach direction changes. Review of the medical record for resident #31 revealed an admission date of 08/14/2019 with diagnoses that included chronic obstructive pulmonary disease, history of falling, age related osteoporosis, and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated moderate impaired cognition. The MDS indicated a chair alarm in use daily, however, there was no documentation that indicated a wheelchair seatbelt was in place. Review of the Physician's Orders dated 01/04/2025 specified resident #31's seatbelt as: self-releasing alarming seatbelt (non-restraint) due to unawareness of physical limitations with a diagnosis of schizoaffective disorder. Review of resident #31's current plan of care revealed the self-releasing alarming seatbelt to wheelchair was a fall intervention. The current plan of care did not address the use of a restraint. On 04/16/2025 at 11:15 a.m., S3Director of Nursing Services confirmed that there was no supporting documentation available regarding reassessing resident #31 for restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 1 (#20) of 2 (#20, #104) residents reviewed for ADL care. The facility failed to ensure that resident #20 had neatly groomed and shaved facial hair. Findings: Review of resident #20's record revealed an admission date of 07/26/2024 with diagnoses that included unspecified psychosis, end stage renal disease, right hand contracture, type 2 diabetes mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 which indicated that resident #20 had severe cognitive impairment. Resident #20 required substantial/maximal assistance with bathing and grooming. On 04/14/2025 at 4:10 p.m., resident #20 was observed seated in a wheelchair at the nurses station and it was noted that his facial hair was poorly groomed and unshaven. On 04/15/2025 at 1:10 pm, resident #20 was observed lying in bed with his head of bed elevated. His facial hair was poorly groomed and unshaven. On 04/16/2025 at 7:44 a.m., resident #20 was observed lying in bed with his head of bed elevated. His facial hair was poorly groomed and unshaven. On 04/16/2025 at 8:01 a.m., an interview was conducted with S7LicensedPracticalNurse (LPN) who confirmed that resident #20 received a bed bath daily. S7LPN confirmed that the bed bath included a shave. On 04/16/2025 at 10:36 a.m., an interview was conducted with S8CertifiedNursingAssistant (CNA) who confirmed that resident #20 received a bath on the night shift. S8CNA confirmed that resident #20 should have been shaved. On 04/16/2025 at 2:15 p.m. S1ExecutiveDirector were notified of the findings related to the facility's failure to provide ADL care to resident #20 who was dependent for ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure that nursing staff had the appropriate competencies and skills necessary to care for resident needs. The facility failed to obtain orders and document treatment performed to a tracheostomy stoma for 1 (#34) of 2 (#34 and #60) residents reviewed for wound care. Findings: Review of the medical record revealed resident #34 was admitted to the facility on [DATE] with diagnoses that included in part, depression, schizoaffective disorder, depressive type, type 2 diabetes mellitus without complications, chronic cough, artificial opening status, and personal history of non-Hodgkin lymphoma. Review of Resident #34's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7 which indicated resident #34 had severe cognitive impairment for daily decision making. Review of Resident #34's care plan revealed the resident had a neck stoma related to an old tracheostomy and dressing to stoma was to be changed per treatment order. Review of resident #34's April 2025 physician's orders revealed the resident did not have an active wound care order for the tracheostomy stoma. On 04/15/2025 at 2:20 p.m. resident #34 was observed sitting in the day area with a dressing over his anterior throat, and the dressing was dated 04/15/2025. On 04/16/2025 at 8:10 a.m. interview with resident #34 stated the facility staff change his stoma dressing daily. On 04/16/2025 at 9:00 a.m. a review of resident #34's electronic medical records revealed no documentation of the trach stoma care being performed. On 04/16/2025 at 10:10 a.m. an interview with S1Exective Director and S2Project Manager/Regional Support confirmed the order for the tracheostomy stoma wound care was removed from the active orders and electronic treatment administration record (ETAR) on 02/27/2025 and the wound care had not been documented. On 04/16/2025 at 10:20 a.m. an interview with S4Respiratory Therapist revealed she provided tracheostomy stoma care to resident #34; however, S4 Respiratory Therapist confirmed she failed to document the treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure food was palatable, and served at an appetizing temperature. Findings: Review of the record for resident #29 revealed an admission date of 01/16/2024 with diagnoses of type 2 diabetes, cerebral vascular disease and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #29 was cognitively intact for daily decision making. Interview on 04/14/2025 at 10:00 a.m. with resident #29 revealed the food was terrible. Resident #29 stated that the taste, texture, and choices of food was poor and that no substitutions were offered. A lunch test tray was requested from S10 Dietary Manager (DM) on 04/14/2025. The test tray was placed on the hall meal cart and was observed to leave the kitchen at 12:02 p.m. Further observation revealed that the test tray was given to the surveyor by S9 Certified Nursing Assistant at 12:23 p.m. The test tray meal consisted of BBQ pork loin, beans, vegetable medley, corn bread and cake. The pork loin was tough and the vegetable medley consisted of broccoli, cauliflower and carrots. The vegetable medley was overcooked, had a mushy consistency, had no flavor or seasoning, and the food was cool to taste. On 04/15/2025 at 2:15 p.m., S10 DM was notified of the results of the test tray. On 04/16/2025 at 1:50 p.m., the Executive Director was notified of the results of the test tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#104) of 5 (#20, #33, #60, #96, and #104) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #104 revealed an admit date of 12/29/2023 with diagnoses including chronic kidney disease, chronic diastolic congestive heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #104's Brief Interview for Mental Status (BIMS) score was 14 which indicated intact cognition for daily decision making. Resident #104 was independent or required set up help only with activities of daily living. Review of the current care plan revealed resident #104 was at risk for abnormal bleeding and/or bruising related to the use of an anticoagulant. The interventions were to monitor for active bleeding/bruising or for symptoms of internal bleeding and if noted to notify the resident's physician. Review of the April 2025 physician's orders revealed an order dated 08/29/2025 for Apixaban (Eliquis, anticoagulant) 5 milligrams, give 1 tablet orally twice daily related to atrial fibrillation. Further review revealed an order dated 08/29/2025 to monitor for active bleeding or for symptoms of internal bleeding such as: abnormal bruising, black tarry stools, or bright red vomit and to notify the resident's physician if any of the above is noted. Review of the record for resident #104 revealed no documented evidence of monitoring for active bleeding/bruising or for any sign or symptoms of internal bleeding. On 04/16/2025 at 1:25 p.m., an interview with S5Clinical Operations/Regional Support confirmed there was no documentation regarding monitoring for active bleeding or for any symptoms of internal bleeding for resident #104.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by having wheelchairs in need of repair for 5 (#6, #7, #22, #32, #33) of 9 (#6, #7, #19, #22, #29, #32, #33, #80, #133) residents reviewed for environment. Findings: Resident 32 Review of the medical record for resident #32 revealed an admission date of 12/8/2015. Resident #32 had diagnoses of Parkinson's disease, diabetes mellitus, heart disease, Alzheimer's disease, vascular dementia, anxiety and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact for daily decision making. Resident #32 required extensive assistance with bed mobility, transfers and toilet use. On 04/14/2025 at 8:30 a.m. an observation of resident #32 revealed she was in a wheelchair and the armrest on the right side was missing. On 04/16/2025 at 9:15 a.m. an interview with S6Licensed Practical Nurse (LPN) confirmed the armrest on the right side of the wheelchair was missing on resident #32's wheelchair. On 04/16/2025 at 1:00 p.m. S3Director of Nursing Services (DNS) observed resident #32's wheelchair and confirmed the armrest on the right side of the wheelchair was missing on the wheelchair. Resident 22 Review of the medical record revealed resident #22 was admitted on [DATE] with diagnoses of Alzheimer's disease, respiratory failure, muscle weakness, cognitive communication deficit, atrial fibrillation, and dementia. Review of the quarterly MDS dated [DATE] revealed resident #22 was cognitively impaired for daily decision making and required extensive assistance with bed mobility, transfers and toileting. On 04/14/2025 at 8:10 a.m., 04/15/2025 at 9:33 a.m., and on 04/16/2025 at 9:00 a.m. observations of resident #22 revealed the bilateral armrests were missing on the wheelchair. On 04/16/2025 at 9:15 a.m. an interview with S6LPN confirmed bilateral armrests were missing on the wheelchair. On 04/16/2025 at 1:00 p.m. S3DNS observed resident #22's wheelchair and confirmed bilateral armrests were missing from the wheelchair. Resident 6: Review of the medical record for resident #6 revealed an admit date of 12/27/2024 with diagnoses including end stage renal disease, chronic kidney disease, and unspecified dementia. Review of the annual MDS assessment dated [DATE] revealed resident #6 was cognitively intact for daily decision making. Further review revealed resident #6 was independent and/or required supervision for activities of daily living (ADL). On 04/14/2025 at 8:25 a.m. an observation of resident # 6 revealed she was in her room in her wheelchair. The resident's right wheelchair armrest pad was missing and her arm was directly on top of the metal portion of the armrest. Resident #6 reported that her wheelchair brakes do not work very well. On 04/15/2025 at 2:45 p.m. an observation of resident # 6's right wheelchair armrest revealed the padding was missing. Also at this time, resident #6 demonstrated that her brakes were in the locked position but she was still able to roll backwards. On 04/16/2025 at 3:00 p.m. the surveyor informed S2Project Manager/Regional Support that resident #6's right wheelchair armrest was missing and her wheelchair brakes were not working properly. Resident 7: Review of the medical record for resident #7 revealed an admit date of 03/26/2019 with diagnoses including quadriplegia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, seizures and Type 2 diabetes. Review of the quarterly MDS assessment dated [DATE] revealed resident #7 was cognitively intact for daily decision making. Further review revealed resident #7 was totally dependently on staff for ADLs. On 04/14/2025 9:42 a.m. and 04/15/2025 at 9:00 a.m. observations of resident #7's wheelchair revealed his right wheelchair armrest was cracked and was in need of repair. On 04/16/2025 at 3:00 p.m. the surveyor and S2Project Manager/Regional Support observed resident #7's right wheelchair armrest and she confirmed his right wheelchair armrest was cracked and needed to be repaired. Resident 33: Review of the medical record for resident #33 revealed an admission date of 01/10/2022 with diagnoses that included spinal stenosis, type 2 diabetes mellitus, acquired absence of right leg below knee, acquired absence of other left toe, bipolar disorder, and depression. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated that resident #33 was cognitively intact. Resident #33 required partial/moderate assistance with bed mobility and transfers. On 04/14/2025 at 1:41 p.m., and 04/15/2025 at 3:53 p.m. observations of resident #33's scooter revealed the seat cushion was torn. On 04/16/2025 at 3:00 p.m., the surveyor and S2Project Manager/Regional Support observed resident #33's electric scooter cushion was torn and she confirmed that the cushion needed to be repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents were free from misappropriation of resident property for 32 (#1-#32) of 32 representative sampled residents of 132 total residents identified with an active trust fund account since [DATE]. Findings: Review of the facility's policy and procedure on Resident Trust Fund, with a revision date of 02/2024, revealed the following, in part: Disbursements: All disbursements must be authorized by the resident and/or designated representative on any one of the following: 1) Petty Cash Disbursement slip, 2) Disbursement Voucher, 3) Trust Fund Disbursement Log, or 4) Monthly Disbursement Authorization Form. Small dollar disbursement amounts can be requested from the Resident Trust Fund petty cash fund maintained by the business office. Cash Withdrawals- Petty Cash Fund: Cash withdraws made by the resident and/or designated representative or power of attorney from available individual funds (resident account balance on deposit). They are limited to fifty dollar ($50.00) increments, or $49.00 in Louisiana. Should additional funds over the fifty dollars ($50.00) or $49.00 in Louisiana limit be requested, the resident will be required to accept a check. 1) A petty cash box designated exclusively for Resident Trust Fund shall be maintained by the facility Business Office in the amount of between three hundred dollars ($300.00) and six hundred dollars ($600.00). 2) Each transaction is recorded on a Petty Cash Disbursement slip or Disbursement Log for withdrawals. The Petty Cash Disbursement or Disbursement Log should be signed by the resident and/or designated representative receiving the cash withdrawal. The signed original is retained in the petty cash box to substantiate weekly replenishments to the cash box from the Resident Trust Fund bank account, and provide support for posting to the individual resident trust account. 3) The Petty Cash box balance is maintained and replenished via a withdrawal from the Resident Trust Fund checking account as required. Trust Fund Disbursement Log revealed the following, in part: H) Have the person authorizing the disbursement sign, if resident marks with X, have this mark witnessed by 2 witnesses. Resident #1 Review of record revealed resident #1 was admitted to the facility on [DATE]. Review of resident #1's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating he was cognitively intact. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #1`s trust fund account for petty cash-vending totaling $490.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #1: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 2:30pm an interview with resident #1 confirmed he went to S3 Business Office Manager (BOM) on [DATE] and was told he did not have enough money in his account to honor his withdrawal request. Resident #1 reviewed his records and discovered there was a discrepancy in his money so he reported it to the administrator on [DATE]. Resident #1 reported his account was $490.00 short and he knew someone took his money. On [DATE] at 1:26 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #1. Resident #2 Review of record revealed resident #2 was admitted to the facility on [DATE]. Review of resident #2's admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #2's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of the resident #2's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $49.00. On [DATE] at 9:07 a.m., an interview with resident #2 revealed she was not aware of missing funds until S1Administrator came to her with the news. Resident #2 reported she could get a balance any time at her request but never really worried about it because there was not very much money in the account. On [DATE] at 1:28 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #2. Resident #3 Review of record revealed resident #3 was admitted to the facility on [DATE]. Review of resident #3's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #3 trust account for petty cash-vending totaling $972.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $26.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $15.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #3: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $26.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $15.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 1:29 p.m., an interview with S2Regional Financial Consultant confirmed resident #3's discrepancies were identified by review of the trust fund receipt book showing alleged forged witness's signatures because the witnesses claimed they did not sign the receipts. Resident #3 signed with an X thus requiring 2 witnesses to sign the trust fund receipt book. Resident #4 Review of record revealed resident #4 was admitted to the facility on [DATE]. Review of resident #4's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #4 trust account for petty cash-vending totaling $5.00 on [DATE]. Review of resident #4's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $5.00. On [DATE] at 1:37 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #4. Resident #5 Review of record revealed resident #5 was admitted to the facility on [DATE]. Review of resident #5's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #5's trust account for petty cash-vending totaling $98.00 as follows: [DATE] - $49.00 [DATE] - $49.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #5: [DATE] - $49.00 [DATE] - $49.00 On [DATE] at 1:38 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #5. Resident #6 Review of record revealed resident #6 was admitted to the facility on [DATE]. Review of resident #6's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #6's trust account for petty cash-vending totaling $234.00 as follows: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $38.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #6: [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $38.00 On [DATE] at 1:39 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #6. Resident #7 Review of record revealed resident #7 was admitted to the facility on [DATE]. Review of resident #7's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #7's trust account for petty cash-vending totaling $8.00 on [DATE]. Review of resident #7's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $8.00. On [DATE] at 1:40 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt books showing suspected forged signatures of Resident #7. Resident #8 Review of record revealed resident #8 was admitted to the facility on [DATE]. Review of resident #8's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #8's trust account for petty cash-vending totaling $236.00 as follows: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $34.00 [DATE] - $49.00 [DATE] - $15.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #8: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $49.00 [DATE] - $49.00 [DATE] - $34.00 [DATE] - $49.00 [DATE] - $15.00 On [DATE] at 1:42 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #8. Resident #9 Review of the record revealed resident #9 was admitted to the facility on [DATE]. Review of resident #9's most recent significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #9's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of resident #9's statement register from [DATE] through [DATE] revealed a transaction on [DATE] from petty cash-vending in the amount of $49.00. On [DATE] at 1:42 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #9. Resident #10 Review of record revealed resident #10 was admitted to the facility on [DATE]. Review of resident #10's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #10's trust account for petty cash-vending totaling $49.00 on [DATE]. Review of resident #10's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $49.00. On [DATE] at 1:43 p.m., an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book showing a forged witness signature with misspelled resident name. Resident #11 Review of record revealed resident #11 was admitted to the facility on [DATE]. Review of resident #11's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 99 indicating the assessment could not be completed. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #11's trust account for petty cash-vending totaling $114.00 as follows: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $14.00 [DATE] - $20.00 Review of the residents statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #11 totaling $114.00: [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $20.00 [DATE] - $14.00 [DATE] - $20.00 On [DATE] at 1:43p.m., an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing suspected forged signatures of resident #11. Resident #12 Review of record revealed resident #12 was admitted to the facility on [DATE]. Review of resident #12's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #12's trust account dated [DATE] for petty cash-vending in the amount of $10.00. Review of resident #12's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $10.00. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing an inconsistent (forged) resident signature and was confirmed by the family member for resident #12. Resident #13 Review of record revealed resident #13 was admitted to the facility on [DATE]. Review of resident #13's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #13's trust account for petty cash-vending totaling $78.00 as follows: [DATE]- $15.00 [DATE]- $9.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]-$9.00 [DATE]- $10.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #13: [DATE]- $15.00 [DATE]- $9.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]-$9.00 [DATE]- $10.00 An interview on [DATE] at 9:18 a.m. with resident #13 revealed she got a statement from the business office when she wanted it. Resident #13 reported when she needed money she would go to the business office and sign for the money. Resident #13 reported the facility notified her of money missing from her trust fund account. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book as follows: 1 receipt with no signature, 2 receipts with unauthorized signature by the resident's daughter, and several inconsistent (forged) resident signatures for resident #13. Resident #14 Review of record revealed resident #14 was admitted to the facility on [DATE]. Review of resident #14's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #14's trust account dated [DATE] for petty cash-vending in the amount of $20.00. Review of the resident's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $20.00 for resident #14. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing forged resident signature with the name misspelled for resident #14. Resident #15 Review of record revealed resident #15 was admitted to the facility on [DATE]. Review of resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #15's trust account for petty cash-vending totaling $58.00 as follows: [DATE]- $20.00 [DATE]- $38.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #15: [DATE]- $20.00 [DATE]- $38.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 inconsistent (forged) resident signatures compared to her prior signatures for resident #15. Resident #16 Review of record revealed resident #16 was admitted to the facility on [DATE]. Review of resident #16's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed a discrepancy for resident #16's trust account dated [DATE] for petty cash-vending in the amount of $14.00. Review of the resident's statement register from [DATE] through [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $14.00 for resident #16. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancy was identified by review of the trust fund receipt book showing S5Business Manager Assistant signed as a witness to her own signature with no other witness signature. S2Regional Financial Consultant confirmed resident #16 was unable to sign receipt physically, and required 2 witness signatures to obtain money from petty cash. Resident #17 Review of record revealed resident #17 was admitted to the facility on [DATE]. Review of resident #17's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #17's trust account for petty cash-vending totaling $368.00 as follows: [DATE]- $49.00 [DATE]- $44.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $30.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #17: [DATE]- $49.00 [DATE]- $44.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $30.00 An interview on [DATE] at 9:10 a.m. with resident #17 revealed he received his account balance monthly, and he signed when he got his money from the business office. Resident #17 reported the facility notified him that over $300 had been taken out of his account. On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing the date was changed on the [DATE] receipt, 1 receipt with an odd amount for this resident, and multiple misspelled resident signatures on the receipts for resident #17. Resident #18 Review of record revealed resident #18 was admitted to the facility on [DATE]. Review of resident #18's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #18's trust account for petty cash-vending totaling $37.00 as follows: [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $2.00 [DATE]- $5.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #18: [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $2.00 [DATE]- $5.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing inconsistent (forged) resident signatures on all receipts, and a change was made to the amount on 1 of the boxes on the receipt for resident #18. Resident #19 Review of record revealed resident #19 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Review of resident #19's significant change Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating cognitively intact. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #19's trust account for petty cash-vending totaling $83.00 as follows: [DATE]- $49.00 [DATE]- $34.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #19: [DATE]- $49.00 [DATE]- $34.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 receipts had forged resident signatures for resident #19. Resident #20 Review of record revealed resident #20 was admitted to the facility on [DATE]. Review of resident #20's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #20's trust account for petty cash-vending totaling $35.00 as follows: [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #20: [DATE]- $10.00 [DATE]- $10.00 [DATE]- $5.00 [DATE]- $5.00 [DATE]- $5.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing inconsistent (forged) resident signatures for the above receipts for resident #20. Resident #21 Review of record revealed resident #21 was admitted to the facility on [DATE]. Review of resident #21's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. Review of the petty receipt investigation by the facility revealed the following discrepancies for resident #21's trust account for petty cash-vending totaling $25.00 as follows: [DATE]- $6.00 [DATE]- $2.00 [DATE]- $17.00 Review of the resident's statement register from [DATE] through [DATE] revealed the following petty cash-vending withdrawals for resident #21: [DATE]- $6.00 [DATE]- $2.00 [DATE]- $17.00 On [DATE] at 1:45 p.m. an interview with S2Regional Financial Consultant revealed the discrepancies were identified by review of the trust fund receipt book showing 2 receipts with no signatures and 1 receipt with a forged resident signature for resident #21. Resident #22 Review of record revealed resident #22 was admitted to the facility on [DATE]. Review of resident #22's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status assessment score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #22's trust account dated [DATE] for petty cash-vending in the amount of $20.00. Review of resident #22's statement register from [DATE] to [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $20.00. On [DATE] at 1:58 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book which showed the receipt amount had been changed in the top box, and it was an irregular amount from what he would normally receive out of his account. S2Regional Financial Consultant revealed resident #22 signed for himself. Resident #23 Review of record revealed resident #23 was admitted to the facility on [DATE]. Review of resident #23's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed a discrepancy for resident #23's trust account dated [DATE] for petty cash-vending in the amount of $38.00. Review of resident #23's statement register from [DATE] to [DATE] revealed a transaction on [DATE] for petty cash-vending in the amount of $38.00. On [DATE] at 2:03 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancy was identified by review of the trust fund receipt book showing the amount was changed on the receipt and the amount not consistent with the amount resident #23 normally received from her trust account. S2Regional Financial Consultant reported the receipt was not to be modified. If an error was made on the receipt it was voided and the correct information put on a new receipt. S2Regional Financial Consultant reported resident #23 signed for herself. Resident #24 Review of record revealed resident #24 was admitted to the facility on [DATE]. Review of resident #24's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #24's trust account for petty cash-vending totaling $977.00 as follows: [DATE]- $49.00 [DATE]- $46.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 Review of resident #24's statement register from [DATE] to [DATE] revealed the following transactions for petty cash-vending withdraws: [DATE]- $49.00 [DATE]- $46.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 On [DATE] at 9:00 a.m. an interview with resident #24 revealed a lady in the office (unknown to resident) had informed her that $977.00 was stolen out of her trust fund account and S5Business Office Assistant had been fired. Resident #24 reported she was not aware of any money missing from her trust fund account until it was brought to her attention by the lady in the office. Resident #24 reported she was told they would be refunding her $977.00 but she had not received it yet. On [DATE] at 2:03 p.m. an interview with S2Regional Financial Consultant confirmed the discrepancies were identified by review of the trust fund receipt book showing forged resident signatures and an irregular amount was taken out. S2Regional Financial Consultant revealed resident #24 signed for herself. Resident #25 Review of record revealed resident #25 was admitted to the facility on [DATE]. Review of resident #25's quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Review of the petty cash receipt investigation by the facility revealed the following discrepancies for resident #25's trust account for petty cash-vending totaling $147.00 as follows: [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 Review of resident #25's statement register from [DATE] to [DATE] revealed the following transactions for petty cash-vending withdraws: [DATE]- $49.00 [DATE]- $49.00 [DATE]- $49.00 On [DATE] at 9:16 a.m. an interview with resident #25 revealed he was made aware there was $147 missing from his account. Resident #25 revealed he received a receipt whenever he got

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 1 sampled residents reviewed for misappropriation of resident funds. Findings: Review of the facility`s abuse prevention policy revealed the latest revision was made in August 2017. Review of the Reporting section of the policy contained the following requirement: Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. Review of record revealed resident #1 was admitted to the facility on [DATE]. Review of resident #1's most recent quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 indicating he was cognitively intact. On 06/17/2024 at 2:30 p.m., an interview with resident #1 confirmed he went to S3Business Office Manager (BOM) on 05/30/2024 and was told he did not have enough money in his account to honor his withdrawal request. Resident #1 reviewed his records and discovered there was a discrepancy in his money so he reported it to the administrator on 05/31/2024. Resident #1 reported his account was $490.00 short and he knew someone took his money. On 06/18/2024 at 9:55 a.m., an interview with S3BOM revealed on 05/30/2024 resident #1 came to her office to check his resident trust fund account balance. Resident #1 informed S3BOM that he should have more money in his account than the balance he was given. Resident#1 and S3BOM reviewed the petty cash receipt book and resident #1 informed S3BOM some of the signatures in the petty cash receipt book were not signed by him. S3BOM informed resident #1 that S1Aministrator was out of the facility that day and they would review the questionable withdrawals. On 06/18/2024 at 11:45 a.m., an interview with S1Administrator revealed resident #1 met with her on 05/31/2024 with copies of resident trust fund receipts. Resident #1 claimed his signature was forged on several receipts on days he did not receive money according to his receipts. S1Administrator reported allegations of misappropriation of resident property to the state survey agency, but did not report the allegations to a law enforcement entity within 24 hours of becoming aware of the misappropriation of funds allegation. S1Administrator reported the facility notified the Attorney General's office on 06/13/2024 and the local sheriff`s department on 06/14/2024 after they completed their internal investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#123) of 41 residents reviewed in the initial pool screening for advanced directives. Findings: Review of resident #123's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of sepsis and was receiving hospice care. Review of resident #123's Quarterly Minimum Data Set, dated [DATE] revealed she had a Brief Interview for Mental Status score of 15, which indicated she was cognitively intact. Further review revealed she required extensive 1 to 2 person assistance for most activities of daily living. Review of resident #123's Louisiana Physician Orders for Scope of Treatment (LaPost) dated [DATE] revealed the following in part: Do Not Attempt Resuscitation (DNR) was selected and the form was signed by resident #123's physician and family member on [DATE]. Review of resident #123's electronic medical record revealed under the Advance Directive section, the resident's Cardiopulmonary Resuscitation (CPR) Status indicated attempt CPR. On [DATE] at 1:30 p.m. an interview with resident #123's nurse, S3Licensed Practical Nurse confirmed she was not aware that resident #123's LaPost code status and her electronic record code status did not match. On [DATE] at 11:25 a.m. an interview with S2Director of Nursing (DON) revealed she was not aware of the discrepancy in resident #123's LaPost code status and her electronic record code status. S2DON confirmed resident #123's LaPost revealed she was a DNR and her electronic medical revealed to attempt CPR.

Based on observation and interview the facility failed to provide personal privacy during incontinent care for 1 (#76) of 7 (#36, #38, #63, #76, #81, #88, #108) residents observed for incontinent care. Findings: On 03/05/2024 at 2:08 p.m., observation from the hallway into resident #76's room on the secured memory care unit revealed the room door was open. Further observation revealed S6Certified Nursing Assistant (CNA) and S7CNA had resident #76 standing up with no brief on and his buttocks was facing the open doorway to the hall. Resident #76 was exposed from the waist down allowing anyone that walked by the resident's room to observe the resident unclothed. As S6CNA and S7CNA exited the room the surveyor attempted to explain what was observed and both S6CNA and S7CNA just walked away without speaking to the surveyor regarding the observation. On 03/05/2024 at 2:30 p.m., an interview with S1Admininstrator confirmed the door should have been closed during care to provide privacy to resident #76.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. The facility failed to administer pain medication as needed to 1 (#437) of 1 (#437) sampled resident's reviewed for pain management. Findings: Interview conducted with resident #437 on 03/04/2024 at 9:41 a.m. revealed that she is currently experiencing back pain and back spasms. Further interview revealed that she was in a lot of pain this past weekend (03/02/2024 and 03/03/2024). Resident #437 stated she reported her pain to nursing staff and they did not administer any pain medication because they stated she did not have any pain medication available. Record review revealed resident #437 was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: spinal stenosis, neurogenic claudication; spondylolisthesis, history of falling, pain, and spinal surgery which included a lumbar 2 to pelvis posterior spinal fusion with L5-S1 transforaminal lumbar interbody fusion and L2-L4 bilateral laminectomy on 02/14/2024. Review of the baseline care plan for resident #437 revealed the following: pain in lower back related to recent spinal fusion surgery. Further review revealed interventions to administer pain medication, check pain scale, and check for pain medication effectiveness. Review of the March 2024 physician orders for resident #437 revealed the following pain medications were ordered: oxycodone-acetaminophen 7.5 milligrams (mg)-325mg tablet: give 1 tablet by mouth every 4 hours as needed for pain; Fioricet 50mg-300mg-40mg capsule: give 1 by mouth every 6 hours as needed for headaches; and Hydrocodone 7.5mg-acetaminophen 325mg: give 1 tablet by mouth every 6 hours as needed. Further review revealed to record the resident's pain level (0-10). Review of the March 2024 Medication Administration Record (MAR) for resident #437 revealed no evidence that any pain medication had been administered for following days: March 1st, 2nd, and 3rd. Further review of the March 2024 MAR revealed S5Licensed Practical Nurse (LPN) documented on 03/03/2024 that resident #437's pain level was a 7 which indicated severe pain. Review of the facility's policy for pain evaluation/management dated 01/2015 revealed the following: Policy: All residents will be elevated for pain at the time of admission, re-admission and as needed. Procedure: A. Routine Pain Evaluations: 1. Upon admission/readmission the pharmacy/facility will provide a pain scale on the MAR for the resident. 2. If a new episode of pain is noted report to the nurse and/or Executive Director. 3. Implement non-pharmacological interventions as appropriate. 4. If no relief or if the resident finds pain above acceptable levels notify the physician. 5. Notify physician if resident's response to their medication or treatment is not satisfactory to develop further interventions for relief of pain. B. Completing Pain Management Evaluation Tool: When to Evaluate: Upon admission and re-admission to the facility for all residents. Upon all new complaints of pain/discomfort from resident or resident's family. Upon a change of condition when indicated. 1. For residents cognitively intact, complete Section A of the tool. 2. After the evaluation is completed and if pain is identified, nursing will establish the problem on the resident's Plan of Care. 3. The physician will be called and the results of the pain evaluation reviewed in order to develop further interventions for relief of pain. 4. Update Care Plan. Interview with S4LPN on 03/06/2024 at 9:20 a.m. revealed resident #437 had pain medication available for 03/01/2024, 03/02/2024 and 03/03/2024 and that pain medication should have been administered when requested by resident #437. Further interview with S4LPN revealed that nursing can call the physician if pain medications are needed over the weekend and that it will be ordered promptly. Interview with S2DON on 03/06/2024 at 10:00 a.m. revealed that pain medication was not administered to resident #437. Further interview with S2DON revealed that nursing staff are able to contact her on weekends if needed and staff can contact the resident's physician for pain medication management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 1 (#120) of 4 (#21, #63, #87 and #120) records reviewed for competent staff. The facility failed to ensure resident #120 received medications as ordered by the physician. Findings: Medication Administration General Guidelines (undated) revealed Responsibility: All Licensed Nursing Personnel/Certified Medication Technician (CMT) Procedure: 1. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice. Review of the medical record for resident #120 revealed diagnoses of dementia, pain, seizures, Alzheimer's disease, schizophrenia, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was unable to be determined. Resident #120 required assistance with activities of daily living. Review of the physician's orders dated 02/09/2024 revealed an order for Trileptal 300 milligrams (mg)/5milliliters (ml) oral suspension give 5 ml via percutaneous endoscopic gastrostomy (PEG) tube three times daily. Review of the February 2024 Medication Administration Record (MAR) revealed the Trileptal 300 mg/5ml oral suspension, give 5 ml via PEG tube three times a day was not administered at 4:00 a.m. on 02/21/2024, 02/22/2024, 02/23/2024, 02/24/2024, and 02/29/2024. Review of the March 2024 MAR revealed Trileptal 300 mg/5ml oral suspension, give 5 ml via PEG tube three times a day was not administered at 4:00 a.m. on 03/01/2024, 03/02/2024 and 03/05/2024. Review of the medical record revealed no documented evidence of the reason the medication was not administered to resident #120. On 03/06/2024 at 2:50 p.m., an interview S2Director of Nursing (DON) and S1Administrator revealed the medication was not administered to resident #120 according to the physician's order. On 03/06/2024 at 3:00 p.m., an interview with S3Licensed Practical Nurse (LPN) revealed the facility had plenty of resident #120's medication and she was not sure of the reason why the medication was not given.

On 03/05/2024 at 2:08 p.m., an observation from the hallway into Resident # 76's room on the secured memory care unit revealed the room door was open. Further observation revealed S6Certified Nursing Assistant (CNA) and S7CNA had Resident #76 standing up with no brief on and his buttocks was facing the open doorway to the hall. Further observation revealed a dirty brief was noted on the floor and S6CNA picked up the dirty brief and placed it in a trash can with a liner. Further observation revealed S7CNA was wiping Resident #76 with multiple incontinent wipes and throwing away the dirty wipes in a trash can with no liner. A new brief was placed on Resident #76 by both S6CNA and S7CNA and Resident #76's pants were pulled up and Resident #76 walked out of the room into the hallway. At that time S6CNA picked up the trash can with the dirty wipes and dumped them into the trash can with the liner in it. As S6CNA and S7CNA exited the room the surveyor attempted to explain what was observed and both S6CNA and S7CNA just walked away without speaking to the surveyor regarding the observation. On 03/05/2024 at 2:30 p.m. an interview with S1Administrator revealed the door should have been closed and the dirty wipes should not have been placed in the trash can without a liner and the dirty brief should not have been placed on the floor. Based on observations and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing 1) to ensure the whirlpool room on the secured unit was clean, and 2) to ensure staff discarded contaminated items in a sanitary manner. Findings: On 03/06/2024 at 10:20 a.m., an observation with S2Director of Nursing (DON) of the whirlpool room on the secured unit revealed a Hoyer lift and a sit to stand lift in the whirlpool room contained dirt and grime on the legs and handles of the lifts. Further observation of the whirlpool room revealed the floors had dirt, and grime on the floors. A dirty towel was observed on the floor by the whirlpool tub, pieces of paper were noted on the floor, and hair was noted in the sink and on the whirlpool tub. A storage shelf was noted against the wall that had two pairs of shoes on the bottom self, and a three tiered storage unit had dirt and grime on the outside of the storage unit. On 03/06/2024 at 10:20 a.m., an interview with S2Director of Nursing (DON) revealed the whirlpool room was in need of cleaning.

Based on record reviews and interview, the facility failed to ensure resident received accommodation of needs for 1 (#5) out of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure Resident #5 was transported to a scheduled doctor's appointment. Findings: Review of Resident #5's Medical Records revealed an admit date of 06/21/2023 and a discharge date of 10/07/2023 with the following diagnoses, in part: essential (primary) hypertension, disorder of urinary system/unspecified, pain/unspecified, End Stage Renal Disease, heart failure/unspecified, morbid (severe) obesity due to excess calories, Chronic Obstructive Pulmonary Disease/unspecified, anemia/unspecified and Type 2 diabetes mellitus with diabetic chronic kidney disease. Review of Facility's Transportation Log revealed an appointment for Resident #5 dated October 03, 2023 - 7:00 am slot. Review of Resident #5's Day Surgery Instructions revealed in part, a date of surgery of 10/03/2023 - Tuesday. During an interview on 10/19/2023 at 9:05 a.m. S1 Administrator reported the van driver was new and did not tell the facility that a sitter was required to be with Resident #5 on 10/03/2023. S1 Administrator further reported she will coordinate the sitters, but the van driver did not let her know and the appointment was missed because of this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to provide ordered supplements for a resident with significant weight loss for 1 (#116) of 4 (#28, #47, #97, #116) residents reviewed for nutrition. Findings: Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of metabolic encephalopathy, dementia, pain, and gas pain. Review of the physician orders for March 2023 revealed an order dated 10/28/2022 for a regular diet with thin liquids small sips/no straw, ice cream with lunch. Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required supervision for eating. Review of the weights revealed: 08/31/2022 - 137 09/28/2022 - 126.6 10/26/2022 - 120.8 11/30/2022 - 117.2 12/28/2022 - 117.4 01/25/2023 - 121 02/01/2023 - 119 03/10/2023 - 120 03/15/2023 - 119.7 On 08/31/2022, the resident weighed 137 pounds. On 03/15/2023, the resident weighed 119.7 pounds which is a -12.63% loss. Review of the care plan revealed: on regular diet with small sips, no straw, ice cream at lunch and staff to monitor at meal time, routine use of diuretic meds, I do not always eat my meal tray when delivered. Further review of the care plan revealed the following intervention: regular diet with ice cream at lunch. Observations on 03/20/2023 at 12:30 p.m., 03/21/2023 at 12:05 p.m., and 03/22/2023 at 12:00 p.m. revealed the resident was sitting in her wheelchair in the dining room. The resident did not receive her ice cream with her lunch trays. An interview with S6CNA (Certified Nursing Assistant) on 03/22/2023 at 1:38 p.m., confirmed the ice cream was not on her diet card or on her lunch tray. An interview with S5Dietary Manager on 03/22/2023 at 12:35 p.m., revealed she did not receive a communication form from the nurse to add the ice cream to the diet card; therefore, the ice cream was not provided on the lunch tray for the resident. An interview with the S2DON (Director of Nursing) on 03/22/2023 at 2:00 p.m., confirmed the resident should have received her ice cream on her lunch trays on 03/20/2023, 03/21/2023, and 03/22/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to implement a comprehensive person-centered care plan for 1 (#97) of 4 (#28, #47, #97, #116) residents reviewed for nutrition. The facility had no documented evidence of the resident's meal intake percentages. Findings: Record review revealed Resident #97 was readmitted on [DATE]. Further record review revealed, in part, diagnoses of gastroesophageal reflux disease, major depressive disorder, schizophrenia, dementia, dysphagia (11/10/2022) and peg (percutaneous endoscopic gastrostomy) tube. Review of the monthly weights revealed: 08/08/2022 - 194.40 09/07/2022 - 189 10/05/2022 - 189.80 11/02/2022 - 189.40 12/20/2022 - 171.90 01/04/2023 - 177.80 02/01/2023 - 184.20 02/08/2023 - 184.20 02/15/2023 - 185.00 02/22/2023 - 181.80 02/28/2023 - 180.60 03/08/2023 - 184.80 Review of the record revealed that while resident was hospitalized from [DATE]-[DATE], resident #97 experienced significant weight loss and a peg tube was placed. Review of the monthly physician orders for March 2023 revealed an order on 01/11/2023 for a regular diet and an order on 02/01/2023 to discontinue the bolus gastrostomy tube feedings. Review of the dietary note on 02/24/2023 revealed the peg tube was removed on 02/15/2023. Review of care plan, in part, revealed problem onset 01/04/2023 - I am on a mechanical soft diet; Goal date of 03/29/2023. Interventions included: provide diet as ordered, monitor and document percentage of intake. Review of the nursing notes from 03/01/2023-03/21/2023 revealed there was no documented evidence of meal intake percentages. Interview on 03/21/2023 at 1:00 p.m. with S1Administrator confirmed there was no documented evidence of meal intake percentages for Resident #97 from 03/01/2023-03/21/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #59 Review of the medical record for resident #59 revealed the resident was admitted on [DATE] with diagnoses of dementia, depression, pain, schizoaffective disorder, bipolar disorder, muscle spasm, and insomnia. Review of the Minimum Data Set, dated [DATE] revealed the resident was independent with cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility and toilet use and one person limited assistance with transfers, dressing, and personal hygiene. Review of the physician orders for March 2023 revealed orders dated 01/26/2023 for Norco 10-325 mg (milligrams) - give 1 tablet by mouth every 8 hours prn (as needed) for pain and Tylenol extra strength 500 mg - give 2 tablets by mouth every 8 hours prn pain. Review of the Medication Administration Record for March 2023 revealed the resident received Norco 10-325 mg 23 times. Further review revealed there was no documented evidence of the effectiveness of the pain medication for 22 administrations. Review of the MAR (Medication Administration Record) for March 2023 revealed the resident received Tylenol extra strength 500 mg 7 times. Further review revealed there was no documented evidence of the effectiveness of the pain medication for 7 administrations. Review of the care plan revealed the resident was at risk for altered levels of comfort related to pain. Further review of the care plan revealed the following interventions: 1.) resident is prescribed Tylenol extra strength when, document pain scale every shift, 0 none, 1-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-10 very severe pain, 2.) resident is prescribed Voltaren arthritis pain, 3.) resident is prescribed Norco, 4.) attempt non pharmacological interventions for pain relief when appropriate, such as changing body positions, 5.) pain/assessment/evaluation per policy, 6.) administer pain med as ordered. Review of the facility's Medication Administration - General Guidelines Policy revealed the following: 13. when PRN (when necessary) medications are administered, the following documentation is provided: a. date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. complaints or symptoms for which the medication was given. c. results observed from giving the dose and the time results were noted. d. resident pain evaluation per facility policy, if applicable. e. signature or initials of person recording administration and signature or initials of person recording effects, if different person administering. An interview with S4RN (Registered Nurse) on 03/22/2023 at 1:20PM revealed she did not document the effectiveness of Norco following administering the pain medication. S4RN confirmed the effectiveness should be documented on the prn sheet or the MAR or the nurses notes. An interview with S2 Director of Nursing on 03/22/2023 at 2:00PM confirmed the nurses should document effectiveness following administration of a pain medication. Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 3 (17, 27 and 59) of 6 (17, 27, 59, 77, 91, and 95) residents reviewed for unnecessary medications. The facility failed to 1) obtain a Depakote level and Vitamin D level as ordered for resident #27, 2) monitor blood pressure for resident #17, and 3) failed to monitor the effectiveness of pain medicine given to resident #59. Findings: Resident 17 Review of the medical record for sampled resident #17 revealed an admission date of 04/09/2019 with diagnoses of chronic kidney disease, depression, dementia, hypertension, atrial fibrillation, edema, and hypokalemia. Review of the March 2023 physician orders revealed an order dated 04/09/2019 for Catapres TTS-3 patch - apply 1 patch transdermal every week on Wednesday. Review of the care plan revealed the resident was at risk for decreased cardiac output related to diagnoses of hypertension, atrial fibrillation and edema. The care plan goal was to maintain blood pressure within individual acceptable range, monitor response to medications. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had severe cognitive impairment for daily decision making and required assistance with activities of daily living. Review of the medical record revealed no documented evidence of the resident's blood pressure was monitored. On 03/21/2023 at 4:15 p.m., an interview with S3LPN (Licensed Practical Nurse) revealed they are not checking resident #17's blood pressure. S3LPN further revealed the resident is receiving an antihypertensive medication and his blood pressure should be monitored. On 03/22/2023 at 11:30 a.m., an interview with S2DON (Director of Nursing) confirmed resident #17's blood pressure was not being monitored and that the resident receives an antihypertensive medication. On 03/23/2023 at 1:00 p.m., S1Administrator was notified of no documented evidence of resident #17's blood pressure being monitored. Resident 27 Review of the medical record for sampled resident #27 revealed an admission date of 11/11/2021 with diagnoses of asthma, vitamin deficiency, dementia, depression, diabetes mellitus, hyperlipidemia, osteoarthritis, delusional disorder and rheumatoid arthritis. Review of the March 2023 physician orders revealed an order dated 01/04/2023 for calcium 600 with Vitamin D3 400 caplet at hour of sleep, and 03/17/2022 for Divalproex Sodium ER 500 milligrams at hour of sleep. Further review of the physician orders revealed an order dated 03/17/2022 to obtain a Depakote level and Vitamin D level in February, March, August and November. Review of the care plan revealed resident #27 was at risk for behaviors related to diagnoses of dementia with behaviors and depression. The resident routinely takes antipsychotic and antidepressant medications. The resident is on a regular diet and to monitor labs, and provide Calcium with Vitamin D3 as ordered by the physician. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident was cognitively intact for daily decision making and required assistance with activities of daily living. Review of the laboratory results revealed no documented evidence of a Depakote level and Vitamin D level obtained for February 2023 as ordered. On 03/21/2023 at 2:30 p.m., an interview with S2DON confirmed a Depakote level and vitamin D level was not obtained for February 2023. On 03/22/2023 at 1:00 p.m., S1Administrator was notified of the Depakote level and a vitamin D level was not obtained in February for sampled resident #27.