Waldon Health Care Center

Based on observations, interviews, and record review, the facility failed to ensure the total number and the actual hours worked for licensed and unlicensed nursing personnel was posted daily during review of nurse staffing requirements.Findings:Observation on 01/12/2026 at 8:35AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/12/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.Observation on 01/13/2026 at 10:32AM of the facility's bulletin board, near the nurse's station on Hall A, revealed a form titled, Daily Nursing Staffing Hours dated 01/13/2026. Further observation of the above mentioned form did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel.In an interview on 01/13/2026 at 10:35AM, S5Ward Clerk indicated she entered the total number of licensed and unlicensed personnel that worked on the Daily Nursing Staffing Hours form dated 01/12/2026 and 01/13/2026. S5Ward Clerk further indicated she did not include the total number of hours and the total actual hours worked for licensed and unlicensed personnel on the above mentioned form.In an interview on 01/13/2026 at 10:40AM, S3Director of Nursing indicated the total number of hours and the total actual hours worked for licensed and unlicensed personnel per shift was not included on the Daily Nursing Staffing Hours form dated 01/12/2026 and 01/13/2026.In an interview on 01/13/2026 at 1:30PM, S1Administrator indicated the total number and the total actual hours worked for licensed and unlicensed personnel per shift was not included on the Daily Nursing Staffing Hours form dated 01/12/202 and 01/13/2026, and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to:1. Ensure the Minimum Data Set (MDS) accurately reflected the diagnosis of 1(Resident #8) of 1 resident reviewed for active diagnoses;2. Ensure the MDS accurately reflected high-risk medications for 1(Resident #8) of 1 resident reviewed for medications;3. Ensure the MDS accurately reflected a Pre-admission Screening and Resident Review (PASRR) Level II for 2 (Resident #9, Resident #67) of 2 residents reviewed for PASRR Level II; and,4. Ensure the MDS accurately reflected the tobacco status of 1(Resident #67) of 1 resident reviewed for tobacco use.Findings: 1. Review of Resident #8's medical record revealed, in part, Resident #8 was admitted to the facility on [DATE], with a diagnosis of obstructive and reflux uropathy.Review of Resident #8's admission MDS with an Assessment Reference Date (ARD) of 12/10/2025 revealed, in part, Resident #8 was assessed as having no diagnosis of obstructive and reflux uropathy. Review of Resident #8's care plan, dated 12/11/2025, revealed, in part, Resident #8 had a Foley catheter related the diagnosis of obstructive and reflux uropathy. 2. Review of Resident #8's physician orders dated 12/04/2025 revealed, in part, an order dated for Buspar (a medication used to treat anxiety). Further review revealed Resident #8 had no physician orders for an antibiotic medication or an antipsychotic medication.Review of Resident #8's admission MDS with an ARD of 12/10/2025 revealed, in part, Resident #8 was assessed for taking and having indications for an antibiotic and an antipsychotic medication. Further review revealed Resident #8 was assessed as not taking and/or having indications for an anti-anxiety medication.Review of the facility's validation report for Resident #8 dated 01/14/2026, revealed, in part, Resident #8 had a modification to his admission MDS on 12/10/2025.3. Resident #9Review of Resident #9's medical records revealed, in part, Resident #9 was admitted to the facility on [DATE]. Further review revealed Resident #9 had a diagnosis of schizoaffective disorder, bipolar type dated 02/27/2023, and psychotic disorder with delusions due to known psychological condition dated 03/18/2022.Review of the Office of Behavioral Health's PASRR Level II Evaluation Summary and Determination Notice dated 03/17/2025 revealed, in part, Resident #9 had serious mental illness present.Review of Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification revealed, in part, Resident #9 was approved for admission by Level II authority for a period of 03/17/2025 through 03/16/2026.Review of Resident #9's significant change MDS with an ARD of 12/08/2025 revealed, in part, documentation which indicated that Resident #9 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Further review revealed that Resident #9's significant change MDS with an ARD of 12/08/2025 was electronically signed by S7MDSNurse on 12/11/2025.In an interview on 01/14/2026 at 2:38PM, S1Administrator confirmed Resident #9's significant change MDS with an ARD of 12/08/2025 was completed in error when S7MDSNurse documented that Resident #9 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition as Resident #9 had received his Level II PASARR on 03/17/2025.Resident #67Review of Resident #67's medical record revealed, in part, Resident #67 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia and major depressive disorder. Further review revealed Resident #67's was approved for admission by Level II Authority for a temporary period effective 01/16/2025 through 01/15/2026.Review of Resident #67's significant change MDS with an ARD of 12/29/2025 revealed, in part, Resident #67 was assessed as not having a PASRR Level II. Review of Resident #67's care plan, dated 01/12/2025, revealed, in part, Resident #67 had a PASRR Level II.Review of the facility's validation report for Resident #67 dated 01/14/2026, revealed, in part, Resident #67 had a modification to significant change MDS on 12/29/2025.4. Review of Resident #67's medical record revealed, in part, Resident #67 had a diagnosis of nicotine dependence.Review of Resident #67's significant change MDS with an ARD of 12/29/2025 revealed, in part, Resident #67 was assessed as no tobacco use.Review of Resident #67's care plan, dated 12/30/2024 and revised on 01/10/2026, revealed, in part, Resident #67 was an active safe smoker.Review of Resident #67's smoking evaluation, dated 11/06/2025, revealed, in part, Resident #67 did utilize tobacco. Review of the facility's smoking list, dated 01/06/2025, revealed, in part, Resident #67 was listed as a safe smoker.In an interview on 01/12/2026 at 10:05AM, Resident #67 indicated that she was a smoker. In an interview on 01/14/2026 at 1:55PM, S1Administrator indicated the findings for the above-mentioned residents' assessments were completed inaccurately, and should not have been.

Based on observation, interviews, and record review, the facility failed to ensure food stored in the facility's walk-in refrigerator was properly labelled and contained with an opened date and was unavailable for resident use. Findings: Review of the facility's policy, dated 01/2026 and titled Food Receiving and Storage revealed, in part, all food stored in the refrigerator will be labeled and dated.Observation on 01/12/2026 at 9:28AM revealed the facility's walk-in refrigerator had the following opened, undated and unlabeled food items:-1 package of smoked sausage; and, -2 packages of smoked sliced turkey breast.In an interview on 01/12/2026 at 9:29AM, S8Cook confirmed the above-mentioned opened food items were not dated and labeled, and should have not been available for resident use.In an interview on 01/12/2025 at 1:55PM, S1Administrator indicated the above-mentioned undated and unlabeled opened food items should have been labeled appropriately and not available for resident use.

Based on interviews and record reviews, the facility failed to implement facility policy to ensure all witness statements received verbally were titled, and signed by both the person making the statement and the witness.
Findings:
Review of the facility's Abuse, Neglect, and Misappropriation of Funds Policy and Procedure, with revised date of March 2025, if only oral information can be obtained about an allegation of abuse, the following is required, in part:
A statement must be documented signed and date; and,
The recorder and the witness to the statement must sign, date, and title statement.
Review of the facility's investigation related to an allegation of sexual abuse dated 12/04/2024, revealed S1Administrator had documented S13Housekeeper's statement regarding alleged sexual abuse; however, S13Housekeeper had not signed and dated the statement, and S1Administrator had not titled the statement.
Review of S5LPN's Sexual Abuse Allegation Statement dated 03/15/2025 revealed the statement was not signed by S5LPN, nor any witness.
Review of S12CNA's Sexual Abuse Allegation Statement dated 03/19/2025 revealed the statement was not signed S12CNA, nor any witness.
In an interview on 03/26/2025 at 5:10PM, S3Corporate Administrator indicated he took the verbal statements from S5LPN and S12CNA with S1Administrator and S2DON present, but did not get the witnesses to write a statement, nor sign the verbal documentation of the investigation.

Based on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (Resident #R1) of 7 (Resident #2, Resident #3, Resident #4, Resident #R1, Resident #R2, Resident #R3, Resident #R4) sampled residents observed during medication administration.
Findings:
Review of Resident #R1's record revealed, in part, Resident #R1 had diagnoses which included chronic diastolic congestive heart failure (condition in which the heart was unable to pump blood proficiently) and sinusitis.
Review of Resident #R1's March 2025 Physician Orders revealed, in part, Lasix (medication used to remove excess fluid from the body) 20 milligrams (mg) administer three tablets by mouth daily. Further review revealed an order for Flonase (medication used to treat allergies) 50 micrograms (mcg) per actuation one spray in both nostrils one time a day.
Observation on 03/21/2025 at 8:15AM revealed S4Licensed Practical Nurse (LPN) was unable to locate Resident #R1's Flonase and Lasix to administer.
In an interview on 03/21/2025 at 8:15AM, S4LPN indicated the facility recently had to order multiple medications from the pharmacy and was waiting for the medications to be delivered.
Review of Resident #R1's March 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #R1's Flonase and Lasix were not administered as ordered on 03/21/2025.
In an interview on 03/21/2025 at 11:51AM, S2Director of Nursing (DON) indicated the facility did not obtain the Lasix and Flonase medications in a timely manner.

Based on interview and record review, the facility failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors for 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) of 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) sampled staff reviewed for behavior training.
Findings:
Review of the facility's Facility Assessment Tool updated on 10/16/2024 revealed, in part, the facility was able to accept residents with psychiatric/mood disorders and psychiatric symptoms and behaviors would be identified and interventions implemented to help support the residents.
Review of Resident #2's Minimum Data Set Assessment Reference Date 12/24/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 8 (score of 08-12 indicated moderate cognitive impairment).
Review of Resident #2's care plan revealed, in part, Resident #2 had the potential to touch female peers inappropriately (touching a resident's arm without permission) initiated on 03/16/2025
Review of Resident #2's S13Housekeeper Verbal Witness Statement dated 12/04/2024 revealed, in part, Resident #2 exposed his penis to staff.
Review of Resident #2's Progress Note dated 12/04/2024 revealed, in part, Resident #2 was transferred to a psychiatric facility for inappropriate sexual behavior.
Review of Resident #2's Physician's Emergency Certificate (PEC) (a document used to admit a resident into a psychiatric facility) dated 12/04/2024 revealed, in part, Resident #2 had behaviors of exposing self to staff and peers and hypersexual behavior.
Review of Resident #2's PEC dated 02/05/2025 revealed, in part, Resident #2 was assessed as having hypersexual behaviors and touching others inappropriately.
Review of Resident #2's PEC dated 03/03/2025 revealed, in part, Resident #2 was hypersexual with staff and peers, with unwanted sexual advances to other residents.
In an interview on 03/20/2025 at 10:19AM, S8Porter indicated he was assigned to provide 1:1 supervision to Resident #2. S8Porter indicated no one had explained to him the reason Resident #2 was placed on 1:1 supervision, but he was instructed he was to be with Resident #2 at all times. S8Porter further indicated he had a binder with a list of questions to fill out regarding Resident #2's behaviors for every shift.
In an interview on 03/20/2025 at 3:12PM, S10Housekeeping Supervisor indicated she was assigned to 1:1 supervision of Resident #2. S10Housekeeping Supervisor further indicated she was not sure what behaviors Resident #2 displayed or how to intervene if the behavior occurred.
In an interview on 03/25/2025 at 2:40PM, S9Porter indicated last night (03/24/2025) was about the third time he was assigned to 1:1 supervision of Resident #2. S9Porter further indicated he did not receive any education on Resident #2's specific behaviors or how to intervene if the behaviors occurred.
Record review revealed no documented evidence and the facility was unable to present any evidence the above mentioned staff members received specific training Resident #2's behaviors or training on how to care for residents with psychosocial disorders.
In an interview on 03/25/2025 at 2:58PM, S2Director of Nursing (DON) indicated the facility had no documented evidence the above mentioned staff had been trained in Resident #2's behaviors prior to being assigned one on one supervision with Resident #2.
In an interview on 03/26/2025 at 2:49PM, S1Administrator confirmed the above mentioned staff provided one on one supervision for Resident #2. S1Administrator further indicated the above mentioned staff members did not receive trainings on caring for residents with mental or psychosocial disorders.

Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #84) of 3 (Resident #26, Resident #64, and Resident #84) residents investigated for abuse.
Findings:
Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Funds Program dated October 2024 revealed, in part, the facility should ensure the safety and well-being of residents was maintained at all times and was committed to zero tolerance of any form of abuse. Further review revealed, abuse was the willful infliction of injury with resulting physical harm or pain, and this applied to all residents regardless of their medical condition or mental capacity. Further review revealed, physical abuse included hitting and slapping.
Review of facility's Statewide Incident Management System (SIMS) Report investigation entered on 10/01/2024 for an incident that occurred on 10/01/2024 at 2:17 p.m. revealed, in part, Resident #64 hit Resident #84 in the face with an open hand while sitting outside in the courtyard. Further review revealed, S1Administrator determined Resident #84 was the victim of resident to resident physical abuse by Resident #64. Further review also revealed S1Administrator determined physical abuse was substantiated based on Resident #64's confession and video surveillance footage of the above mentioned incident.
Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #84 went to the nurse's station and reported she had been hit in the face by another resident while outside on the patio. Further review revealed, Resident #84 had a red mark/scratch noted to the left side of her eye.
Review of facility's incident report dated 10/01/2024 revealed, in part, Resident #64 had a documented incident of physical aggression. Further review revealed Resident #64 initiated a physical altercation by striking another resident in the face.
Review of #84's nurse's note dated 10/01/2024 revealed, in part, Resident #84 was sent out to the hospital to be evaluated for complaints of pain to Resident #84's left side of her face and her left eye.
Review of Resident #64's progress note dated 10/01/2024 revealed, in part, Resident #64 was sent out by the physician to behavioral health for an evaluation due to aggressive behavior toward another resident.
In an interview on 01/15/2025 at 9:05 a.m., Resident #64 confirmed the physical altercation with Resident #84 and indicated she hit Resident #64 in the face.
In an interview with 01/16/2025 at 8:55 a.m., S16Social Services confirmed the above mentioned incident between Resident #64 and Resident #84 that occurred on 10/01/2024.
In an interview on 01/16/2025 at 9:00 a.m., S1Administrator acknowledged the above mentioned incident had occurred on 10/01/2024 between Resident #64 and Resident #84. S1Administrator confirmed the above mentioned incident of resident to resident physical abuse was substantiated after being investigated by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident, with a new diagnosis of Schizoaffective Disorder, was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 3 (Resident #12, Resident #63, and Resident #84) sampled residents reviewed for PASARR.
Findings:
Review of Resident #63's medical record revealed, in part, Resident #63 was readmitted to the facility on [DATE]. Further review revealed Resident #63 was diagnosed on [DATE] with Schizoaffective Disorder. Further review revealed no documented evidence a PASARR Level II evaluation was completed for Resident #63.
Review of Resident #63's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed, in part, Resident #63's active diagnoses included Schizoaffective Disorder-Bipolar Type.
In an interview on 01/15/2025 at 11:20 a.m., S3Admissions Coordinator indicated a PASARR Level II evaluation was not completed for Resident #63 after Resident #63's new diagnosis of Schizoaffective Disorder on 02/27/2023.
In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed Resident #63 did not have a PASARR Level II submitted after a new diagnosis of Schizoaffective Disorder was determined on 02/27/2023 and should have.

Based on record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart c, and Medication Cart d) medication carts observed for expired medications.
Findings:
Review of the facility's policy titled, Storage of Medication Policy and Procedure, dated 10/2024, revealed, in part, expired drugs or biologicals should be returned to the dispensing pharmacy or destroyed.
Observation of Medication Cart c on 01/15/2025 at 8:39 a.m. revealed a bottle of Meclizine Hydrochloride (HCl) 12.5 milligram (mg) caplets with an expiration date of 12/2024 was available for resident use.
In an interview on 01/15/2025 at 8:41 a.m., S22Licensed Practical Nurse (LPN) confirmed the bottle of Meclizine HCl 12.5 mg caplets found stored in Medication Cart c was expired, and available for resident use, and should not have been.
In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist confirmed an expired medication should not have been stored in the Medication Cart c and available for resident use.
In an interview on 01/16/2025 at 12:45 p.m., S1Administrator indicated an expired medication should not have been stored in the Medication Cart c and available for resident use.

Based on record review and interviews, the facility failed to ensure the dietary manager had completed an approved food safety program and passed the accompanying test for 1 (S13Dietary Manager) of 1 (S13Dietary Manager) sampled dietary managers employed by the facility.
Findings:
In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated she had been the facility's dietary manager for 2 years. S13Dietary Manager further indicated she had not taken the exam for the ServSafe course.
In an interview on 01/14/2025 at 3:50 p.m., S1Administrator indicated the facility was not aware S13Dietary Manager had not completed the examination for her ServSafe course, and therefore did not have ServSafe certification.
At time of exit the facility had not presented any evidence S13Dietary Manager had passed the ServSafe examination.

Based on observations, record review, and interviews, the facility failed to ensure:
1. Food items were not placed in areas in which water had accumulated on food packaging;
2. Food items were covered in the refrigerator;
3. Expired food items were discarded and not available for use;
4. Damaged food items were not stored amongst other food items;
5. Staff had all hair restrained when in the food preparation areas;
6. Chemicals were not stored in food preparation areas;
7. Food items were labeled with an opened date and labeled with the contents of the container/bag; and,
8. Staff did not store their food items with residents' food items;
Findings:
Review of the facility's policy titled, Food Receiving and Storage Policy and Procedure, last reviewed in 01/2025 revealed, in part:
-staff were to ensure refrigerated foods were labeled, dated, and monitored so they are used by their use by date, frozen, or discarded; and,
-food may not be stored under leaking water lines, or under lines on which water has condensed.
Observation on 01/13/2025 at 9:46 a.m. with S13Dietary Manager revealed, in part:
- ice had accumulated on the left and right side of the freezer's fan and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the box;
- the facility's refrigerator had a cart with 83 uncovered containers of fruit cocktail;
- the facility's refrigerator contained three one-quart containers of heavy whipping cream with an expiration date of 01/12/2025;
-the facility's dry storage area contained a dented container of mandarin oranges on the shelf between other canned goods; and
- S13Dietary Manager's hair was not fully contained by her hairnet.
Observation on 01/14/2025 at 11:15 a.m. with S13Dietary Manager revealed, in part:
-S13Dietary Manager's hair was not fully contained by her hairnet;
-ice had accumulated on the left and right side of the freezer's fan, and a box of cut okra, a box of ground beef, a box of chocolate pudding, and a box of egg roll wraps located under the freezer's fan had approximately one-fourth of an inch of ice accumulated on top of the boxes;
-two small buckets of sanitizer were stored under the facility's food preparation table;
-the facility's refrigerator had two undated plastic containers that were not labeled with the contents of the containers and an undated bottle that was not labeled with the contents of the bottle; and,
-the facility's refrigerator had the following: an undated half-empty one gallon container of mayo; an undated half-empty five pound container of sour cream; an undated half-empty one gallon container of yellow mustard; an undated one gallon container of sweet pickles with approximately one-fourth of the container used; and an undated half-empty one gallon container of Italian dressing.
In an interview on 01/14/2025 at 11:27 a.m., S13Dietary Manager indicated the facility had to defrost the freezer approximately every two weeks due to the accumulated ice of the freezer's fans. S13Dietary Manager confirmed the bottle and two plastic containers of prepared food observed in the facility's refrigerator on 01/14/2025 belonged to the staff and should have not been in the facility's refrigerator with residents' food items. S13Dietary Manager further confirmed the above findings and indicated the above findings were deficient.
In an interview on 01/14/2025 at 3:50 p.m., S1Administrator confirmed the above findings were deficient.

Based on observations, interviews, record reviews, the facility failed to ensure:
1. A facility-wide surveillance of resident's infections were maintained (Resident #7, Resident #12, Resident #27, and Resident #84); and,
2. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care (Resident #21).
This deficient practice was identified for 4 (Resident #7, Resident #12, Resident #27, and Resident #84) of 13 (Resident #1, Resident #7, Resident #12, Resident #27, Resident #39, Resident #55, Resident #56, Resident #63, Resident #73, Resident #76, Resident #79, Resident #84, and Resident #88) sampled residents reviewed for infection surveillance; and, for 1 (Resident #21) of 2 (Resident #21 and Resident #27) residents observed during incontinence care.
Findings:
1.
Review of the facility's Antibiotic Stewardship- Review of and Surveillance of Antibiotic Use and Outcomes, with revised date of February 2024, revealed, in part:
-as part of the facility's Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee.
-all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form, and the information gathered will include, in part: resident name, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events.
Review of Resident #7's July 2024's Physician Orders revealed, in part, Resident #7 was prescribed and received Levofloxacin (antibiotic medication used to treat infections) 500 milligrams (mg) one tablet by mouth daily for 10 days for a right knee infection with a start date of 07/05/2024; and Doxycycline (antibiotic medication use to treat infections) 100mg one tablet by mouth every 12 hours for right knee wound with a start date of 07/06/2024.
Review of Resident #12's July 2024's Physician Orders revealed, in part, Resident #12 was prescribed Cefepime Hydrochloride (HCl) (antibiotic mediation used to treat infections) intravenous (IV) solution reconstituted (amount of medication dissolved in a solution) (medication administered directly into the vein) 2 grams (gm) IV one time a day related to acute osteomyelitis (infection of the bone) of the left ankle, with a start date of 07/04/2024.
Review of the facility's Infection Surveillance Map and Infection Reports for July 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #7 and Resident #12's above mentioned antibiotics and infections as part of the facility's July 2024 infection surveillance.
Review of Resident #27's August 2024's Physician Orders revealed, in part, Resident #27 was prescribed, in part, Tobradex (antibiotic medication used to treat infections) Opthalmic (medication administered into the eye) 0.3-0.1 percent ointment. Instill into left eye four times a day for 10 days with a start date of 08/01/2024 for blepharitis (inflammation and infection) of the left upper eyelid.
Review of the facility's Infection Surveillance Map and Infection Reports for August 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #27's above mentioned antibiotic and infection as part of the facility's August 2024 infection surveillance.
Review of Resident #84's November 2024 Physician Orders revealed, in part, Resident #84 was prescribed Augmentin (antibiotic, medication used to treat infections) 500/125mg one tablet by mouth twice a day for cellulitis (infection of the skin) with a start date of 11/18/2024.
Review of the facility's Infection Surveillance Map and Infection Reports for November 2024 revealed no documented evidence, and the facility presented no documented evidence, the facility had identified and included Resident #84's above mentioned antibiotic and infection as part of the facility's November 2024 infection surveillance.
In an interview on 01/16/2025 at 2:08 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) indicated the documents presented to the surveyor was all of the facility's infection surveillance for all of the facility's infections for July 2024 through January 2025. S2DON/IP further indicated after reviewing the above mentioned documents the facility was not capturing all residents' infections, and therefore the facility did not have a comprehensive facility Antibiotic Stewardship and Surveillance of Infections.
2.
Review of the facility's Handwashing and Hand Hygiene policy and procedure dated October 2024 revealed, in part, hand hygiene should be performed before moving from a contaminated body site to a clean body site during resident care.
Review of Resident #21's Minimum Data Set with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 was always incontinent of bowel and bladder. Further review revealed Resident #21 was dependent on staff for toileting hygiene.
Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care. S11CNA and S12CNA then removed Resident #21's urine and feces soiled brief, cleaned Resident #21's buttock area of feces, and placed a clean brief on Resident #21 without changing gloves or performing hand hygiene. S11CNA then disposed of Resident #21's soiled brief into the trash. S11CNA and S12CNA then manually transferred Resident #21 from the bed to a wheelchair with the same gloves used to perform incontinence care.
In an interview on 01/14/2025 at 2:25 p.m., S12CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have.
In an interview on 01/14/2025 at 2:30 p.m., S11CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #21, and should have.
In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on a resident during incontinence care.
In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed CNAs should have removed gloves, performed hand hygiene, and placed on new gloves before a clean brief was placed on resident during incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations the facility failed to:
1. Develop a person-centered care plan for a resident with dialysis and,
2. Implement interventions per the resident's plan of care.
This deficient practice was identified for 1 (Resident #27) of 1 (Resident #27) residents investigated for dialysis.
Findings:
Review of Resident #27's electronic medical record (EMR) revealed, in part, Resident #27 was admitted to the facility on [DATE] and had diagnoses, which included, in part, Diabetes Mellitus, Sacral pressure ulcer, and renal insufficiency.
Review of Resident #27's January 2025 Physician's orders revealed, in part, an order for Resident #27 to receive dialysis.
Review of Resident #27's care plan dated 07/21/2024, revealed, in part, Resident #27 received dialysis three times per week, and the facility would monitor Resident #27's intake and output.
1.
In an interview on 01/14/2025 at 9:50 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated Resident #27's care plan was generated from the dialysis care plan template and the intervention to monitor intake and output should not have been on it.
2.
In an interview on 01/14/2025 at 8:50 a.m., S2DON/Infection Preventionist indicated the facility's staff should document a resident's intake and output in the care task section of the resident's EMR.
Review of Resident #27's completed tasks revealed, in part, no documented evidence Resident #27's intake and output were monitored.
There was no documented evidence, and the facility did not present any documented evidence the facility monitored Resident #27's intake and output.
In an interview on 01/14/2025 at 9:42 a.m., S17Medical Director indicated the intervention on the care plan should have been followed as documented in the specific approaches as noted on the dialysis plan of care, he expected the facility to follow Resident #27's care plan.
In an interview on 01/14/2025 at 9:50 a.m., S2DON/Infection Preventionist confirmed the facility did not have documentation Resident #27's intake and output was required.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's blister was evaluated and treated for 1 (Resident #79) of 2 (Resident #12 and Resident #79) residents investigated for skin conditions.
Findings:
Observation on 01/13/2025 at 9:22 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters.
Observation on 01/14/2025 at 9:05 a.m. revealed Resident #79 had a blister to his right lower leg that measured approximately 3 centimeters.
Observation on 01/15/2025 at 9:09 a.m., had a blister to his right lower leg that measured approximately 3 centimeters.
Observation on 01/15/2025 at 12:20 p.m., revealed the blister to Resident #79's right lower leg blister had opened, Resident #79's skin was no longer intact, and a clear liquid drainage was observed.
Review of Resident #79's medical record revealed no documented evidence, and the provider did not present any documented evidence, an evaluation/assessment of Resident #79's right lower leg blister had been completed.
In an interview on 01/15/2025 at 12:30 p.m., S19Certified Nursing Assistant (CNA) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S19CNA further indicated she had not noticed the blister to Resident #79's lower right leg.
In an interview on 01/15/2025 at 2:30 p.m., S15Licensed Practical Nurse (LPN) indicated she was assigned the care of Resident #79 for the 7:00 a.m. to 3:00 p.m. shift on 01/15/2024. S15LPN further indicated she was unaware and was not made aware by any of the CNAs caring for Resident #79 that there were any blisters to Resident #79's 70 right lower leg. S15LPN further indicated the facility's CNA were supposed to notify the nurse of any changes in a resident's skin condition.
In an interview on 01/15/2025 at 2:45 p.m., S20LPN/Charge Nurse indicated if the above mentioned blister was present on Resident #79's right lower leg since 01/13/2025, the facility's CNAs and/or nurses should have noted and reported Resident #79's blister. S20LPN/Charge Nurse further indicated the CNAs should have noted Resident #79's right lower leg blister during his bath/shower on 01/15/2025 and reported the blister to the nurse for evaluation/assessment.
In an interview on 01/16/2025 at 11:15 a.m., S2Director of Nursing (DON)/Infection Preventionist indicated the blister on Resident #79's right lower leg was not reported to the nurse or wound care nurse until 01/15/2025 after it had opened. S2DON/Infection Preventionist further acknowledged Resident #79's blister should have been noticed and reported to her so an evaluation/assessment could be completed but it was not.

Based on observation, record reviews, and interviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #21) of 2 (Resident #21 and Resident #27) sampled residents observed during incontinence care.
Findings:
Review of the facility's undated Resident [NAME] of Rights revealed, in part, staff shall protect the right to privacy of the resident's body during toileting, bathing, and other activities of personal hygiene.
Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) score of 04, which indicated Resident #21 had severe cognitive impairment. Further review revealed Resident #21 was dependent on staff assistance for toileting hygiene.
Observation on 01/14/2025 at 2:04 p.m. revealed S11Certified Nursing Assistant (CNA) and S12CNA entered Resident #21's room to perform incontinence care while Resident #21's roommate, Resident #46, remained in the room. Further observation revealed S11CNA and S12CNA did not close Resident #21's bedside privacy curtain and proceeded to remove Resident #21's pants, remove Resident #21's incontinence diaper and start Resident #21's incontinence care. Further observation revealed Resident #21's genitalia remained uncovered during the entire incontinence care process.
In an interview on 01/15/2025 at 9:05 a.m., S11CNA confirmed she did not close Resident #21's bedside curtain to ensure Resident #21's privacy during incontinence care and should have.
In an interview on 01/16/2025 at 12:15 p.m., S2Director of Nursing/Infection Preventionist indicated the CNAs should have ensured a resident's privacy was maintained during incontinence care.
In an interview on 01/16/2025 at 12:45 p.m., S1Administrator confirmed a resident's privacy should have been maintained during incontinence care by closing the resident's privacy curtain since another resident was in the room.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error was not greater than 5% for 2 (Resident #R3 and Resident #R4) of 10 (Resident #1, Resident #3, Resident #R1, Resident #R2, Resident #R3, Resident #R4, Resident #R5, Resident #R6, Resident #R7, and Resident #R8) sampled residents observed during medication administration.
Findings:
Review of the facility's undated Medication Pass Administration policy and procedure revealed, in part, medications were to be administered within 60 minutes before or after scheduled time.
Review of Resident #R3's December 2024 Physician's Orders and electronic Medication Administration Record (eMAR) revealed Resident #R3 had an order for Sodium Bicarbonate (medication used to treat low sodium levels) 650 milligrams (mg), administer one tablet by mouth three times a day at 5:00 AM, 11:00 AM, and 8:00 PM.
Observation on 12/26/2024 at 1:17 PM revealed S3Licensed Practical Nurse (LPN) administered Sodium Bicarbonate 650 mg one tablet by mouth to Resident #R3.
Review of Resident #R4's December 2024 Physician's Orders and eMAR revealed Resident #R4 had the following orders, in part: Furosemide (medication used to remove excess fluid from the body) 20 mg, administer one tablet by mouth daily at 8:00 AM; Potassium Chloride (CL) Extended Release (ER) 20 milliequivalents (meq) (medication used to replace low potassium levels), administer one tablet by mouth daily at 8:00 AM; Oxycodone-Acetaminophen (APAP) (medication used to treat pain) 7.5/325 mg, administer one tablet by mouth three times a day at 8:00 AM, 2:00 PM, and 8:00 PM; Albuterol Sulfate (medication used to open the airway) 90 micrograms (mcg) per actuation (pump of inhaler), administer two actuations every six hours as needed for wheezing; and, Budesonide-Fumoterol Fumarate Aerosol (medication used to treat constricted airways) 106-4.5 mg/actuation, administer one puff two times a day at 8:00 AM and 4:00 PM.
Observation on 12/27/2024 at 9:29 AM revealed S4LPN administered Resident #R4 the following medication, in part: Furosemide 20mg one tablet by mouth; Potassium CL ER 20 meq one tablet by mouth; Oxycodone-APAP 7.5/325 mg one tablet by mouth; Albuterol Sulfate 90 mcg two inhalations. Further observation revealed S4LPN did not administer Resident #R4's Budesonide-Fumoterol Fumarate.
There were 27 medication administration opportunities for error, with 6 observed errors for a medication administration error rate of 22%.
In an interview on 12/27/2024 at 11:27 AM, S4LPN indicated she administered Resident #R4 an Albuterol inhaler today and had not administered the Budesonide-Formoterol inhaler today as ordered. S4LPN further indicated she had not assessed Resident #R4 for wheezing nor had Resident #R4 requested the as needed Albuterol inhaler prior to administration.
In an interview on 12/30/2024 at 11:46 AM, S2Director of Nursing (DON) indicated medications should be administered within one hour prior to or one hour after the physician ordered medication time, and it was not for neither Resident #R3 nor Resident #R4.
In an interview on 12/30/2024 at 11:47 AM, S1Administrator confirmed Resident #R3 and Resident #R4's medications were not administered as per the physician's orders.
In an interview on 12/30/2024 at 12:43 AM, S4LPN indicated she had residents on two halls and was not sure which medication were scheduled for 8:00 AM and which medications were scheduled for 9:00 AM. S4LPN further indicated she was late with medication administration for Resident #R4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's abuse policy to protect residents from potential neglect (S3LPN and S4LPN).
Findings:
Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Funds Program, last revised in 01/2024, revealed, in part, all incidents or suspected incidents of neglect or mistreatment will be investigated immediately as directed by the Administration and/or the Director of Nursing. Further review revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Further review revealed the facility's staff would immediately correct and intervene in reported or identified situations in which neglect is at risk for occurring. Further review revealed all allegations involving staff will necessitate immediate suspension without pay, pending completion of the investigation. Further reviewed revealed the administrator will take actions necessary to ensure that abuse, neglect or mistreatment does not continue.
Review of the facility's Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards and the facility's policies and procedures. Review also revealed the nurse's responsibility was to routinely make rounds to observe and evaluate residents' physical and emotional status.
Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to elopement risk, and census checks to be conducted on Resident #1 every two hours.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, S4LPN was assigned to the care of the residents in Room Assignment u from the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's time sheet report dated 08/28/2024 revealed, in part, S4LPN clocked in at 8:41 a.m., clocked out at 4:26 p.m., clocked in at 4:56 p.m., and clocked out at 9:55 p.m.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 time sheet reports, revealed, in part, S3LPN clocked in at 11:30 p.m. on 08/28/2024 and clocked out at 7:15 a.m. on 08/29/2024.
Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m. Further review revealed S4LPN went into Resident #1's room on 8/29/2024 at 5:29 p.m. Further review revealed S3LPN went into Resident #1's room on 08/29/2024 at approximately 12:03-12:04 a.m. Further review revealed S3LPN went into Resident #1's room [ROOM NUMBER] times on 08/29/2024 between 6:04 a.m. and 6:34 a.m. Further review revealed no other evidence that S3LPN and or S4LPN went into Resident #1's room at any other part of their assigned shifts.
Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4LPN was seen entering Resident #1's room on 08/28/2024 at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed S3LPN looked into Resident #1's room on 08/29/2024 at 12:04 a.m. and 6:15 a.m. Further review revealed S3LPN only entered Resident #1's room at 6:04 a.m., 6:14 a.m., and 6:35 a.m. on 08/29/2024.
The facility was unable to provide any evidence S3LPN and/or S4LPN rounded (performed a visual inspection of Resident #1) on Resident #1 every 2 hours as per the physician's orders on 08/28/2024 and 08/29/2024.
Observation on 08/30/3034 at 9:50 a.m., revealed S4LPN was working in the facility.
In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift on 08/28/2024 through 08/29/2024. S3LPN further indicated had she looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), the oncoming nurse, and/ or Certified Nursing Assistant (CNA) she was working with.
In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him all night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notifying administration she was not able to locate him.
In an interview on 08/30/2024 at 2:43 p.m., S1Administrator indicated that S3LPN worked last night on 8/29/2024 and was scheduled to work tonight on 08/30/2024.
In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours per the physician's orders. S1Administrator further indicated when she watched the facility's surveillance footage, she was preoccupied with seeing what time Resident #1 eloped, and had not noticed how often the staff monitored him.
In an interview on 09/05/2024 at 3:18 p.m., S1Administrator indicated during the investigation, the facility's focus was on finding Resident #1. S1Administrator further indicated as soon as she would have identified the issues of the nurses not rounding on and/or locating Resident #1 during their shifts, she would have immediately suspended them, but because the focus was so much on finding Resident #1, their suspension was an oversite.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to deliver care per professional standards by failing to ensure:
1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); and,
2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate.
S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m.
The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit.
This deficient practice had the likelihood to cause more than minimal harm to all 110 residents that were reported to reside in the facility on 08/30/2024.
Findings:
Review of Louisiana's R.S. 37:961, last amended in 2020, revealed, in part, the practice of practical nursing means the performance for compensation of any acts, in the care, treatment, or observation of persons who are ill, injured, or infirm and for the maintenance of the health of others and the promotion of health care, including the administration of medications.
Review of the Louisiana State Board of Practical Nurse Examiners Scope of Practice revealed, in part, practical nursing is the performance, for pay, of acts in the care, treatment or observation of the ill and for the maintenance of the health of others and the promotion of health care.
Review of the facility's undated Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards, and the facility's policies and procedures. Review also revealed the nurse's responsibility was to routinely make rounds to observe and evaluate residents' physical and emotional status.
1.
Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] from a short term hospital stay with diagnoses, which included, unspecified dementia of an unspecified severity (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), major depressive disorder, and unspecified alcohol abuse.
Review of Resident #1's Psychiatric Progress note dated 10/03/2023 revealed, in part, Resident #1 continued with intermittent confusion and continued to be fixated with leaving the facility. Further review revealed Resident #1 continued to appear anxious, restless, and wanted to leave the facility. Further review revealed Resident #1 had poor insight and was disoriented to time, place, and situation.
Review of Resident #1's Psychiatric Progress note dated 03/20/2024 revealed, in part, Resident #1 continued with fixation about leaving the facility.
Review of Resident #1's Psychiatric Progress note dated 05/22/2024 revealed, in part, Resident #1 was documented to have a bizarre affect with thought blocking, and refused medications and treatment over the previous few weeks. In addition, it was documented that Resident #1 reported he thought he should drink alcohol more to relax, had poor insight, and judgement with impaired memory.
Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to being an elopement risk, and census checks to be conducted on Resident #1 every two hours.
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part, Resident #1 had fluctuating disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) present.
Review of Resident #1's most recent Care Plan revealed, in part, Resident #1 had impaired cognition. Further review revealed an intervention to observe Resident #1's whereabouts and document per the physician's orders initiated on 08/07/2024. Further review revealed a goal with a target date of 11/05/2024 that Resident #1 would not leave the facility unattended.
Review of Resident #1's progress note dated 08/29/2024 at 8:33 a.m. revealed, in part, a Certified Nursing Assistant (CNA) alerted S24Licensed Practical Nurse (LPN) at 8:31 a.m. that Resident #1 was not in his room. Further review revealed S24LPN entered Resident #1's room and noted Resident #1's bed was empty and his bedding was neatly arranged.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, S4LPN was assigned to the care of the residents in Room Assignment u (where Resident #1 resided) from the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u (where Resident #1 resided) for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m.
Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4 LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed S3LPN looked into Resident #1's room on 08/29/2024 at 12:04 a.m. and 6:15 a.m. Further review revealed S3LPN entered Resident #1's room at 6:04 a.m., 6:14 a.m., and 6:35 a.m. on 08/29/2024.
The facility was unable to provide any evidence S3LPN and/or S4LPN rounded (performed a visual inspection of Resident #1) on Resident #1 every 2 hours as per the physician's orders on 08/28/2024 and 08/29/2024.
In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 until 7:00 a.m. on 08/29/2024. S3LPN further indicated she had looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the oncoming nurse, and / or Certified Nursing Assistant (CNA) she was working with.
In an interview on 08/30/2024 at 12:18 p.m., S24LPN (the on-coming assigned shift nurse for Resident #1 on 08/29/2024) indicated S3LPN had not reported that she had not been able to visualize Resident #1 during her shift, nor that she was unable to locate Resident #1 at 6:00 a.m. for medication administration. S24LPN further indicated S3LPN should have reported Resident #1's absence.
In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so.
In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1.
In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders.
In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders.
2.
Review of Resident #1's August 2024 physician's orders revealed, in part, orders to administer Resident #1 Atorvastatin Calcium (a medication used to manage cholesterol) 10 mg tablet daily at bedtime, Quetiapine Fumarate (a medication used to treat depression) 25 mg tablet daily at bedtime, Mirtazapine Tartrate (a medication used to treat depression) 15 mg tablet daily, and to check for placement of Resident #1's wander guard bracelet every shift.
Review of Resident #1's August 2024 electronic Medication Administration Record revealed, in part, S4LPN documented she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:00 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:00 p.m. on 08/28/2024, and one Quetiapine Fumarate 25 mg tablet at 8:00 p.m. on 08/28/2024. Further review revealed, S3LPN documented she checked placement of Resident #1's wander guard bracelet on the night shift of 08/28/2024.
Review of the facility's Medication Administration Audit Report from 08/27/2024 to 08/28/2024 for Resident #1 revealed, in part, S4LPN documented that she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:23 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:23 p.m. on 08/28/2024, one Quetiapine Fumarate 25 mg tablet at 8:23 p.m. on 08/28/2024. Further review revealed S3LPN documented that she checked placement of Resident #1's wander guard bracelet on 08/29/2024 at 1:49 a.m.
Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed S4 LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed no other evidence S4LPN entered Resident #1's room at any other time during her shift.
In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was did not visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 to 7:00 a.m. on 08/29/2024.
The facility was unable to produce any evidence that S4LPN administered Resident #1's medications as documented above.
In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time. S2DON further indicated that S3LPN should not have documented she checked the placement of Resident #1's wander guard when she had never visualized Resident #1.

Based on record reviews and interview the facility failed to ensure certified nursing assistants (CNAs) were provided Quality Assurance and Performance Improvement (QAPI) training for 4 (S6CNA, S31CNA, S32CNA, and S33CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs reviewed for training requirements as required.
Findings:
Review of S6CNA's Personnel File revealed S6CNA had a date of hire of 12/30/2021. Further review of S6CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S6CNA had received QAPI training as required.
Review of S31CNA's Personnel File revealed S31CNA had a date of hire of 04/11/2024. Further review of S31CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S31CNA had received QAPI training as required.
Review of S32CNA's Personnel File revealed S32CNA had a date of hire of 06/20/2024. Further review of S32CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S32CNA had received QAPI training as required.
Review of S33CNA's Personnel File revealed S33CNA had a date of hire of 08/15/2024. Further review of S33CNA's Personnel File revealed no documented evidence, and the facility presented no documented evidence, S33CNA had received QAPI training as required.
In an interview on 09/04/2024 at 12:24 p.m., S34Human Resources Director indicated the facility did not have documented evidence of QAPI training for the above mentioned employees.
In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated she had no additional documentation to present regarding the above mentioned deficient practice.
In an interview on 09/05/2024 at 4:39 p.m., S2Director of Nursing (DON) indicated the facility did not have evidence of the above mentioned employees had QAPI training as required.

Based on record reviews and interviews the facility failed to ensure its Quality Assessment and Assurance Committee met at least quarterly to evaluate the activities under the Quality Assurance and Performance Improvement (QAPI) program.
Findings:
Review of the facility's Quality Assurance Committee sign in sheets revealed the only Quality Assurance Committee meetings documented were on 11/14/2023 and 06/28/2024. Further review revealed no documented evidence, and the facility presented no documented evidence, a Quality Assurance Committee meeting was held between 11/14/2023 and 06/28/2024 to meet the requirement of quarterly meetings.
In an interview on 09/05/2024 at 10:25 a.m., S1Administrator indicated the facility had no documented evidence a Quality Assurance Committee meeting had been held between 11/14/2023 and 06/28/2024.
In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated she had no additional documentation to present regarding the above mentioned deficient practice.

Based on record reviews and interviews, the facility failed to:
1. Maintain a system to periodically reconcile controlled drugs for 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances; and
2. Administer a resident's medication per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
1.
Review of the facility's undated Storage of Medications Policy and Procedure revealed, in part, controlled medications must be counted at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty determine the count together.
Review of the facility's 2024 Floor Nurse Job Description/Responsibility revealed, in part, a narcotic (controlled substance) count must be performed at ongoing and off going of the shift, and the nurse must sign in the appropriate spot on the Controlled Drugs-Count Record.
Review of the facility's August 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs:
-08/09/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/09/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/12/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/30/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/31/2024 on the 7:00 a.m. to 3:00 p.m. shift; and
-08/31/2024 on the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's August 2024 Medication Cart b Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs:
-08/09/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/09/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/14/2024 on the 7:00 a.m. to 3:00 p.m. shift;
-08/14/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/15/2024 on the 7:00 a.m. to 3:00 p.m. shift;
-08/15/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/16/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/17/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/18/2024 on the 7:00 a.m. to 3:00 p.m. shift;
-08/30/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/31/2024 on the 7:00 a.m. to 3:00 p.m. shift; and,
-08/31/2024 on the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's August 2024 Medication Cart c Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs:
-08/01/2024 on the 7:00 a.m. to 3:00 p.m. shift;
-08/10/2024 on the 7:00 a.m. to 3:00 p.m. shift;
-08/14/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/16/2024 on the 11:00 p .m. to 7:00 a.m. shift; and,
-08/17/2024 on the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's August 2024 Medication Cart d Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs:
-08/05/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/05/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/12/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/12/2024 on the 11:00 p.m. to 7:00 a.m. shift;
-08/19/2024 on the 3:00 p.m. to 11:00 p.m. shift;
-08/19/2024 on the 11:00 p.m. to 7:00 a.m. shift; and,
-08/26/2024 on the 11:00 p.m. to 7:00 a.m. shift.
In an interview on 09/04/2024 at 1:51 p.m., S9Licensed Practical Nurse (LPN) indicated nurses were required to reconcile controlled substances with the off-going nurse at the beginning of their shift and reconcile control substances with the on-coming nurse at the end of their shift. S9LPN confirmed she has had occurrences where the assigned nurse she was relieving left the facility without reconciling controlled substances with her as required.
In an interview on 09/05/2024 at 9:55 a.m., S2Director of Nursing (DON) indicated whenever there was a change in nurses from shift to shift, the off-going nurse was supposed to verify the controlled substance count with the oncoming nurse. S2DON indicated the narcotic count sheet should be filled out in its entirety to ensure the reconciliation of controlled drugs was completed as required.
2.
Review of the facility's undated Floor Nurse Job Description revealed, in part, the nurse's duties were to provide skilled nursing care according to the physician's orders, established standards, and the facility's policies and procedures.
Review of Resident #1's August 2024 physician's orders revealed, in part, orders to administer Resident #1 Atorvastatin Calcium (a medication used to manage cholesterol) 10 mg tablet daily at bedtime, Quetiapine Fumarate (a medication used to treat depression) 25 mg tablet daily at bedtime, Mirtazapine Tartrate (a medication used to treat depression) 15 mg tablet daily.
Review of Resident #1's August 2024 electronic Medication Administration Record revealed, in part, S4LPN documented she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:00 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:00 p.m. on 08/28/2024, and one Quetiapine Fumarate 25 mg tablet at 8:00 p.m. on 08/28/2024.
Review of the facility's Medication Administration Audit Report from 08/27/2024 to 08/28/2024 for Resident #1 revealed, in part, S4LPN documented that she administered Resident #1 one Atorvastatin Calcium 10 mg tablet at 8:23 p.m. on 08/28/2024, one Mirtazapine 15 mg tablet at 8:23 p.m. on 08/28/2024, one Quetiapine Fumarate 25 mg tablet at 8:23 p.m. on 08/28/2024.
Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed S4LPN was seen entering Resident #1's room at 5:31 p.m. and exiting Resident #1's room at 5:32 p.m. on 08/28/2024. Further review revealed no other evidence S4LPN entered Resident #1's room at any other time during her shift.
The facility was unable to produce any evidence that S4LPN administered Resident #1's medications as documented above.
In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time.

Based on observations and interviews, the facility failed to ensure the daily nurse staffing information was posted daily as required.
Findings:
Observation on 09/01/2024 at 10:14 a.m. revealed the facility's daily nurse staffing information was dated 08/30/2024.
Observation on 09/04/2024 at 9:05 a.m. revealed the facility's daily nurse staffing information was dated 09/03/2024.
Observation on 09/05/2024 at 8:40 a.m. revealed the facility's daily nurse staffing information was dated 09/04/2024.
In an interview on 09/05/2024 at 10:45 a.m., S8Ward Clerk confirmed she was responsible for updating the nurse staffing information daily on weekdays.
In an interview on 09/05/2024 at 11:10 a.m., S2Director of Nursing indicated S9Certified Nursing Assistant was responsible for posting the nurse staffing information on the weekend. S2Director of Nursing confirmed the daily nurse staffing information should be posted as required.

Based on record review and interview, the facility failed to ensure the Facility Assessment Tool:
1. Was reviewed and updated as necessary annually;
2. Addressed contracts;
3. Had involvement from the certified nursing assistants (CNAs); and
4. Used input from residents and residents' representatives.
Findings:
1.
Review of the Facility Assessment Tool revealed the facility assessment date or update date was documented as 07/24/2023.
In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not reviewed or updated the Facility Assessment since 07/24/2023.
2.
Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, of facility contracts required for resident care.
In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not included information about contract services as part of the facility assessment.
3.
Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, the facility had involvement from the certified nursing assistants for the development of the facility assessment.
In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not involved the certified nursing assistants in the development of the Facility Assessment.
4.
Review of the Facility Assessment Tool dated 07/24/2023 revealed no documented evidence, and the facility presented no documented evidence, the facility had used input from residents and residents' representatives for the development of the facility assessment.
In an interview on 09/03/2024 at 2:38 p.m., S1Administrator indicated the facility had not included input from the residents and/or residents' representatives for the development of the facility assessment.

Based on record reviews and interviews, the facility failed to:
1. Ensure the facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024, 08/14/2024, and 08/21/2024); and,
2. Ensure a nurse assigned to a group of residents did not leave the facility before the scheduled oncoming nurse arrived at the facility to assume the responsibility of the group of residents (08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024).
This deficient practice was identified for 13 (08/08/2024, 08/13/2024, 08/14/2024, 08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024) of 30 (08/01/2024, 08/02/2024, 08/03/2024, 08/04/2024, 08/05/2024, 08/06/2024, 08/07/2024, 08/08/2024, 08/09/2024, 08/10/2024, 08/11/2024, 08/12/2024, 08/13/2024, 08/14/2024, 08/15/2024, 08/16/2024, 08/17/2024, 08/18/2024, 08/19/2024, 08/20/2024, 08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024) days reviewed for sufficient staffing.
Findings:
Review of the facility's Facility Assessment Tool completed on 07/24/2023 revealed, in part, the facility's average daily census was 90-120. Review of the facility's Major RUG-IV Categories (a Centers for Medicare and Medicaid classification system used to determine payment based on the average resources needed to care for someone with similar needs) revealed a number/average of 10 residents for Rehabilitation services, a number/average of 2 residents for Extensive Services, a number/average of 2 residents for Special Care High services, a number/average of 3 residents for Special Care Low services, a number/average of 17 residents for Clinically Complex services, a number/average of 5 residents for Behavioral Symptoms and Cognitive Performance services, and a number/average of 23 residents for Reduced Physical Function services. Further review revealed the facility's staffing plan was to have 2 to 4 licensed nurses providing direct care during the day shift (7:00 a.m. to 3:00 p.m.), 2 to 4 licensed nurses providing direct care during the evening shift (3:00 p.m. to 11:00 p.m.) and 2 to 3 licensed nurses providing direct care during the night shift (11:00 p.m. to 7:00 a.m.).
Review of the facility's Census and Conditions of Residents dated 09/05/2024 revealed, in part, the facility had a total of 98 residents. Further review revealed 2 residents had an indwelling or external catheter, 90 residents were occasionally or frequently incontinent of bladder, and 77 residents were occasionally or frequently incontinent of bowel. Review revealed 71 residents were in a chair all or most of the time and 5 residents ambulated with assistance or assistive devices. Review revealed 31 residents had a psychiatric diagnosis, 19 residents had dementia, and 11 residents had behavioral healthcare needs. Further review revealed 2 residents had pressure ulcers, 5 residents received hospice care, 4 residents received dialysis treatments, 1 resident required the administration of intravenous (into the vein) medication, 10 residents required respiratory treatments, and 2 residents required ostomy (a surgical opening in the abdomen that changed the way waste exited the body) care. Further review revealed 21 residents required medication injections, 3 residents required tube feedings, and 33 residents required rehabilitative services.
Review of the facility's 2024 Floor Nurse Job Description revealed, in part, the staff nurse assigned to each section was designated as the floor nurse and was responsible for supervision of the total nursing activities regarding their assigned section. Further review revealed it was unacceptable to clock out of the facility and leave their assigned residents without changeover of care. Review also revealed a proper shift report must be given to the nurse that would hold responsibility for the assigned residents until the next oncoming nurse arrived.
1.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/08/2024 the facility's census was documented as 108 residents.
Review of the facility's 08/08/2024 time sheet reports revealed, in part, from 7:00 a.m. until 7:05 a.m., S3Licensed Practical Nurse (LPN) was the only documented nurse assigned to direct resident care present in the facility.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/13/2024 the facility's census was documented as 112 residents.
Review of the facility's 08/13/2024 time sheet reports revealed, in part, from 7:00 a.m. until 7:07 a.m., S3LPN was the only documented nurse assigned to direct resident care present in the facility.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/14/2024 the facility's census was documented as 113 residents.
Review of the facility's 08/14/2024 time sheet reports revealed, in part, from 7:03 a.m. until 7:10 a.m., S3LPN was the only documented nurse assigned to direct resident care present in the facility. Further review revealed from 7:10 a.m. until 7:18 a.m., there was no documented nurse assigned to direct resident care present in the facility.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form revealed, in part, on 08/21/2024 the facility's census was 109 residents.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, from 11:31 p.m. until 12:00 a.m. on 08/22/2024, S14LPN was the only documented nurse assigned to direct resident care present in the facility.
There was no documented evidence, and the facility did not present any documented evidence that sufficient direct care nursing staff was provided to residents during the above mentioned time periods.
In a telephone interview on 09/01/2024 at 3:11 p.m., S14LPN indicated it was not safe for her to have 50 to 60 or more residents assigned to her.
In an interview on 09/04/2024 at 11:52 a.m., S20Assistant Director of Nursing (ADON) indicated that when she arrived to the facility on the morning shifts, she did not accept the responsibility of residents' direct care. S20ADON further indicated that more than 1 direct care nurse was needed for 109 to 110 residents. S20ADON confirmed she assigned 3 direct care nurses for a night shift with 109 to 110 residents.
In an interview on 09/04/2024 at 12:04 p.m., S29Agency LPN indicated that the facility had a problem with nurses arriving to their assigned shift late or leaving their assigned shift early.
2.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment w for the 7:00 a.m. to 3:00 p.m. shift and S10LPN was the nurse assigned to the residents in Room Assignment w for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:17 p.m. and S10LPN did not clock in at the facility until 3:30 p.m., leaving the residents in Room Assignment w without an assigned nurse for 13 minutes.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S11LPN and S12LPN were the nurses assigned to the residents in Room Assignment z for the 3:00 p.m. to 11:00 p.m. shift and S13LPN was the nurse assigned to the residents in Room Assignment z for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 10:47 p.m. and S12LPN clocked out of the facility at 11:03 p.m. Further review revealed S13LPN did not clock into the facility until 12:00 a.m. on 08/22/2024, leaving the residents in Room Assignment z without an assigned nurse for 57 minutes.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment s for the 3:00 p.m. to 11:00 p.m. shift and S13LPN was the nurse assigned to the residents in Room Assignment s for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:30 p.m., and S13LPN did not clock into the facility until 12:00 a.m. on 08/22/2024, leaving the residents in Room Assignment s without an assigned nurse for 30 minutes.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment t on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment t on the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:30 p.m. Further review revealed no documented evidence S3LPN worked at the facility on 08/21/2024 from 11:00 p.m. to 7:00 a.m. on 08/22/2024.
There was no documented evidence, and the facility was unable to present any documented evidence a nurse was assigned to the residents in Room Assignment t on 08/21/2024 from 11:30 p.m. until 7:00 a.m. on 08/22/2024.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment u for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:13 p.m. Further review revealed no documented evidence S3LPN worked at the facility on 08/21/2024 from 11:00 p.m. to 7:00 a.m. on 08/22/2024.
There was no documented evidence, and the facility was unable to present any documented evidence a nurse was assigned to the residents in Room Assignment u on 08/21/2024 from 11:30 p.m. until 7:00 a.m. on 08/22/2024.
In an interview on 09/04/2024 at 12:00 p.m., S20ADON confirmed there was no documented evidence S3LPN worked on 08/21/2024 as scheduled.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S13LPN was the nurse assigned to residents in Room Assignment i for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment i on the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S13LPN clocked out of the facility at 5:50 a.m. on 08/22/2024.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:16 a.m., leaving residents in Room Assignment i without an assigned nurse for 1 hour and 26 minutes.
Review of the facility's 08/21/2024 Daily Nursing Assignment revealed, in part, S13LPN was the nurse assigned to residents in Room Assignment ee for the 11:00 p.m. until 7:00 a.m. shift.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment ee on the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/21/2024 time sheet reports revealed, in part, S13LPN clocked out of the facility at 5:50 a.m. on 08/22/2024.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:03 a.m., leaving the residents in Room Assignment ee without an assigned nurse for 1 hour and 13 minutes.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to residents in Room Assignment o for the 7:00 a.m. to 3:00 p.m. shift and S10LPN was the nurse assigned to residents in Room Assignment o for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:04 p.m. and S10LPN did not clock into the facility until 3:09 p.m., leaving the residents in Room Assignment o without a nurse for 5 minutes.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment l on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the assigned nurse to the residents in Room Assignment l on the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 10:58 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/23/2024, leaving the residents in Room Assignment l without an assigned nurse for 1 hour and 2 minutes.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m on the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the assigned nurse to the residents in Room Assignment m on the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:21 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/23/2024, leaving the residents in Room Assignment m without an assigned nurse for 2 hours and 39 minutes.
Review of the facility's 08/22/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment ff for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment ff for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/22/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:12 a.m. on 08/23/2024.
Review of the facility's 08/23/2024 time sheet reports revealed, in part, S11LPN did not clock into the facility until 7:49 a.m., leaving the residents in Room Assignment ff without an assigned nurse for 37 minutes.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift, and S16LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/23/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 3:03 p.m. and S16LPN did not clock into the facility until 3:42 p.m., leaving the residents in Room Assignment g without an assigned nurse for 39 minutes.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S10LPN was the nurse assigned to the residents in Room Assignment l for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/23/2024 time sheet reports revealed, in part, S10LPN clocked out of the facility at 11:00 p.m. and S3LPN did not clock into the facility until 12:15 a.m. on 08/24/2024, leaving the residents in Room Assignment l without an assigned nurse for 1 hour and 15 minutes.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/23/2024 time sheets revealed, in part, S4LPN clocked out of the facility at 9:11 p.m. and S3LPN did not clock into the facility until 12:15 a.m. on 08/24/2024, leaving the residents in Room Assignment m without an assigned nurse for 3 hour and 4 minutes.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/23/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:55 a.m. on 08/24/2024.
Review of the facility's 08/24/2024 time sheet reports revealed, in part, S11LPN clocked into the facility at 7:05 a.m., leaving the residents in Room Assignment f without an assigned nurse for 10 minutes.
Review of the facility's 08/23/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S17LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/23/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:55 a.m. on 08/24/2024.
Review of the facility's 08/24/2024 time sheet reports revealed, in part, S17LPN clocked into the facility at 7:15 a.m., leaving the residents in Room Assignment g without an assigned nurse for 20 minutes.
Review of the facility's 08/24/2024 Daily Nursing Assignment revealed, in part, S11LPN was the nurse assigned to the residents in Room Assignment n for the 7:00 a.m. to 3:00 p.m. shift and S22LPN was the nurse assigned to the residents in rooms Room Assignment n for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/24/2024 time sheet reports revealed, in part, S11LPN clocked out of the facility at 2:56 p.m. and S22LPN did not clock into the facility until 3:43 p.m., leaving the residents in Room Assignment n without an assigned nurse for 47 minutes.
Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S17LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift and S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/25/2024 time sheet reports revealed, in part, S17LPN clocked out of the facility at 10:09 p.m. and S14LPN did not clock into the facility until 10:45 p.m., leaving the residents in Room Assignment g without an assigned nurse for 36 minutes.
Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S15LPN was nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/25/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:45 a.m. on 08/26/2024.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:11 a.m., leaving the residents in rooms Assignment f without an assigned nurse for 26 minutes.
Review of the facility's 08/25/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/25/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:45 a.m. on 08/26/2024.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:30 a.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 45 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. and S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 9:09 p.m. and S14LPN did not clock into the facility until 10:46 p.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 37 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S26Minimum Data Set Licensed Practical Nurse (MDSLPN) was the nurse assigned to the residents in Room Assignment l for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S26MDSLPN clocked out of the facility at 11:15 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/27/2024, leaving the residents in Room Assignment l without an assigned nurse for 45 minutes.
Review of the facility's Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S15LPN clocked out of the facility at 11:23 p.m. and S3LPN did not clock into the facility until 12:00 a.m. on 08/27/2024, leaving the residents in Room Assignment m without an assigned nurse for 37 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment f for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment f for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:48 a.m. on 08/27/2024.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:03 a.m., leaving the residents in Room Assignment f without an assigned nurse for 15 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment g for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 6:48 a.m. on 08/27/2024.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:19 a.m., leaving the residents in Room Assignment g without an assigned nurse for 1 hour and 31 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment l for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility 08/27/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment l for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:11 a.m. on 08/27/2024.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:15 a.m., leaving the residents in Room Assignment l without an assigned nurse for 4 minutes.
Review of the facility's 08/26/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S24LPN was the nurse assigned to the residents in Room Assignment m for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/26/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:11 a.m. on 08/27/2024.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S24LPN did not clock into the facility until 7:18 a.m., leaving the residents in Room Assignment m without an assigned nurse for 7 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment g for the 7:00 a.m. to 3:00 p.m. shift and S16LPN was the nurse assigned to the residents in Room Assignment g for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S25LPN clocked out of the facility at 3:18 p.m. and S16LPN did not clock into the facility until 3:52 p.m., leaving the residents in Room Assignment g without an assigned nurse for 34 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment o for the 7:00 a.m. to 3:00 p.m. shift and S27LPN was the nurse assigned to the residents in Room Assignment o for the 3:00 p.m. to 11:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S9LPN clocked out of the facility at 3:47 p.m. and S27LPN did not clock into the facility until 5:01 p.m., leaving the residents in Room Assignment o without an assigned nurse for 1 hour and 14 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S4LPN was the nurse assigned to the residents in Room Assignment m for the 3:00 p.m. to 11:00 p.m. shift and S3LPN was the nurse assigned to the residents in Room Assignment m for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S4LPN clocked out of the facility at 8:07 p.m. and S3LPN did not clock into the facility until 11:30 p.m., leaving the residents in Room Assignment m without an assigned nurse for 3 hours and 23 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment p for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment p for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:09 a.m., leaving the residents in Room Assignment p without an assigned nurse for 3 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment q for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment q for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:25 a.m., leaving the residents in Room Assignment q without an assigned nurse for 1 hour and 19 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment p for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S15LPN was the nurse assigned to the residents in Room Assignment p for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S15LPN did not clock into the facility until 7:09 a.m., leaving the residents in Room Assignment p without an assigned nurse for 3 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S14LPN was the nurse assigned to the residents in Room Assignment q for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S25LPN was the nurse assigned to the residents in Room Assignment q for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S14LPN clocked out of the facility at 7:06 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S25LPN did not clock into the facility until 8:25 a.m., leaving the residents in Room Assignment q without an assigned nurse for 1 hour and 19 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment t for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S9LPN was the nurse assigned to the residents in Room Assignment t for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:15 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S9LPN did not clock into the facility until 7:20 a.m., leaving the residents in Room Assignment t without an assigned nurse for 5 minutes.
Review of the facility's 08/27/2024 Daily Nursing Assignment revealed, in part, S3LPN was the nurse assigned to the residents in Room Assignment u for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S24LPN was the nurse assigned to the residents in Room Assignment u for the 7:00 a.m. to 3:00 p.m. shift.
Review of the facility's 08/27/2024 time sheet reports revealed, in part, S3LPN clocked out of the facility at 7:15 a.m. on 08/28/2024.
Review of the facility's 08/28/2024 time sheet reports revealed, in part, S24LPN did not clock into the facility until 7:21 a.m., leaving the residents in Room Assignment u without an assigned

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision.
This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate.
S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m.
The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit.
This deficient practice had the likelihood to cause more than minimal harm to the remaining 2 residents (#2, #3) who resided in the facility, were identified as a wandering/elopement risks, and were physically able to open and climb out of a window.
Findings:
Review of the facility's policy titled, Wandering and Elopements, last revised in 03/2019, revealed, in part, if a resident was missing, staff should initiate the missing resident emergency procedure. Further review revealed the staff should determine if the resident was out on an authorized leave or pass, and if the resident was not authorized to leave, staff would initiate a search of the building and premises. Further review revealed if resident was not located, staff should notify the Administrator, the Director of Nursing (DON), the resident's legal representative, the resident's attending physician, and law enforcement as necessary.
Review of Resident #1's electronic medical record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] from a short term hospital stay with diagnoses, which included, unspecified dementia of an unspecified severity (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), major depressive disorder, and unspecified alcohol abuse.
Review of Resident #1's Psychiatric Progress note dated 10/03/2023 revealed, in part, Resident #1 continued with intermittent confusion and continued to be fixated with leaving the facility. Further review revealed Resident #1 continued to appear anxious, restless, and wanted to leave the facility. Further review revealed Resident #1 had poor insight and was disoriented to time, place, and situation.
Review of Resident #1's Psychiatric Progress note dated 03/20/2024 revealed, in part, Resident #1 continued with fixation about leaving the facility.
Review of Resident #1's Psychiatric Progress note dated 05/22/2024 revealed, in part, Resident #1 was documented to have a bizarre affect with thought blocking, and refused medications and treatment over the previous few weeks. In addition, it was documented that Resident #1 reported he thought he should drink alcohol more to relax, had poor insight, and judgement with impaired memory.
Review of Resident #1's August 2024 Physician's Orders revealed, in part, an order dated 07/19/2024 for Resident #1 to have a wander guard bracelet secondary to being an elopement risk, and census checks to be conducted on Resident #1 every two hours.
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part, Resident #1 had fluctuating disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) present.
Review of Resident #1's most recent Care Plan revealed, in part, Resident #1 had impaired cognition. Further review revealed an intervention to observe Resident #1's whereabouts and document per the physician's orders initiated on 08/07/2024. Further review revealed a goal with a target date of 11/05/2024 that Resident #1 would not leave the facility unattended.
Review of Resident #1's progress note dated 08/29/2024 at 8:33 a.m. revealed, in part, a Certified Nursing Assistant (CNA) alerted S24Licensed Practical Nurse (LPN) at 8:31 a.m. that Resident #1 was not in his room. Further review revealed S24LPN entered Resident #1's room and noted Resident #1's bed was empty and his bedding was neatly arranged.
In an interview on 08/30/2024 at 8:28 a.m., S1Administrator indicated Resident #1 entered his room on 08/28/2024 at 5:17 p.m. and never exited his room per her review of the facility's surveillance footage. S1Administrator further indicated she believed Resident #1 exited through his bedroom window because of the missing window screen and dirty windowsill. S1Administrator further indicated by interviewing staff and review of the facility's surveillance footage, she was able to determine that resident was last seen by S6CNA at 4:41 a.m. on 08/29/2024.
Review of the facility's 08/28/2024 Daily Nursing Assignment revealed, in part, S3LPN was assigned to the care of residents in Room Assignment u (where Resident #1 resided) for the 11:00 p.m. to 7:00 a.m. shift.
Review of the facility's 08/28/2024 time sheet reports, revealed, in part, S3LPN clocked in at 11:30 p.m. on 08/28/2024 and clocked out at 7:15 a.m. on 08/29/2024.
Review of the facility's timeline from surveillance footage completed by S1Administrator on 08/29/2024 revealed, in part, Resident #1 was captured on footage exiting his room on 08/28/2024 5:16 p.m. Further review of the video footage documentation revealed Resident #1 entered his room again on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024. Further review revealed the staff identified resident was not in his room [ROOM NUMBER]/29/2024 at 8:55 a.m.
Review of the facility's surveillance footage from 08/28/2024 at 3:00 p.m. until 08/29/2024 at 8:41 a.m. revealed, in part, Resident #1 exited his room on 08/28/2024 at 5:16 p.m. and re-entered his room on 08/28/2024 at 5:17 p.m. Further review revealed Resident #1 did not exit his room again after 5:17 p.m. on 08/28/2024.
In a telephone interview on 08/30/2024 at 11:56 a.m., S3LPN indicated she was unable to visualize Resident #1 on any of her rounds during her scheduled shift from 11:00 p.m. on 08/28/2024 until 7:00 a.m. on 08/29/2024. S3LPN further indicated she had looked into Resident #1's room, but did not see Resident #1 and assumed he was in the bathroom. S3LPN further indicated because she did not visually see Resident #1 during her shift, she had not completed the census check for Resident #1 every two hours as ordered. S3LPN further indicated when she could not locate Resident #1 during her 6:00 a.m. medication administration rounds, she checked the list of residents on facility pass, and did not locate Resident #1's name on the list. S3LPN indicated she was unaware of what to do when she was unable to locate Resident #1 throughout her shift and at 6:00 a.m. during medication administration rounds. S3LPN further indicated she did not report Resident #1's absence to the facility's Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the oncoming nurse, and / or Certified Nursing Assistant (CNA) she was working with.
In an interview on 08/30/2024 at 12:18 p.m., S24LPN (the on-coming assigned shift nurse for Resident #1 on 08/29/2024) indicated S3LPN had not reported to her that she had not been able to visualize Resident #1 during her shift, nor that she was unable to locate Resident #1 at 6:00 a.m. for medication administration. S24LPN further indicated S3LPN should have reported Resident #1's absence.
In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so.
In a telephone interview on 08/30/2024 at 12:29 p.m., S6CNA (Resident #1`s CNA scheduled from 11:00 p.m. on 08/28/2024 to 7:00 a.m. on 08/29/2024) indicated Resident #1 was to have visual checks every 2 hours. S6CNA further indicated S3LPN did not notify her when she was unable to visualize Resident #1 during her rounds. S6CNA further indicated S3LPN should have notified staff when she was unable to locate Resident #1 so all staff could have been notified by an announcement overhead of a wandering resident being missing, and ensure S1Administrator was notified.
In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1.
In a telephone interview on 08/30/2023 at 7:14 p.m., S38LPN indicated on 08/29/2024 at 6:00 a.m., she was following S3LPN during medication administration rounds. S38LPN indicated she had not visualized Resident #1 during medication rounds. S38LPN indicated she was unaware S3LPN did not visualize Resident #1 during her shift. S38LPN further indicated, if she would have been aware Resident #1 was unable to be located she would have notified other facility staff to assist with attempts to locate Resident #1.
In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders.
In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders.
Resident #2
Review of Resident #2's record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of, in part, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and syncope and collapse (condition where the resident loses consciousness briefly).
Review of Resident #2's MDS with an ARD dated 06/25/2024 revealed, in part, Resident #2 was assessed with a Brief Interview for Mental Status (BIMS) score of 13 (score of 13-15 indicated Resident #2 was cognitively intact).
Review of Resident #2's Elopement Risk Assessment completed on 03/23/2024 revealed, in part, Resident #2 was documented as cognitively impaired with poor decision making skills and had pertinent diagnoses. Further review revealed Resident #2 ambulated independently. Review of Resident #2's Elopement Risk Assessment summary/conclusions revealed wander guard placement.
Review of Resident #2's nurse's note dated 06/25/2024 revealed, in part, Resident #2 had a wander guard on which was to be checked daily. Further review revealed Resident #2 was sometimes confused and was observed going to the exit doors.
Review of Resident #2's most recent Care Plan revealed a focus of Resident #2 had exit seeking behaviors and was considered an elopement risk and had a wander guard with a focus onset date of 07/23/2021 and a target date of 09/2/2024. Further review revealed interventions included, in part, monitor Resident #2 every 2 hours and as needed; apply a wander guard to Resident #2; check Resident #2's wander guard placement every shift; photographic documentation of Resident #2 in the elopement binder; and alert staff of Resident #2's high risk for elopement.
Review of Resident #2's August 2024 Physician's Orders revealed, in part, the following: check Resident #2's wander guard every day for proper operation; wander guard for safety with visual checks every 2 hours and as needed daily due to Resident #2's poor impulse control; and, visual checks every hour and as needed daily due to Resident #2 wandered in other residents rooms.
Observation on 08/30/2024 at 9:36 a.m. revealed Resident #2's two windows in his room were able to be unlocked and fully opened. Observation further revealed Resident #2's window opened into the facility's outdoor courtyard.
In an interview on 08/30/2024 at 9:40 a.m., S35Certified Nursing Assistant (CNA) Supervisor confirmed Resident #2 ambulated without assistance or assistive devices.
In an interview on 08/30/2024 at 9:41 a.m., S9Licensed Practical Nurse (LPN) confirmed Resident #2 was able to walk independently.
Observation on 08/30/2024 at 9:42 a.m. revealed Resident #2 ambulated in his room independently without staff assistance or mobility devices.
In an interview on 08/30/2024 at 9:44 a.m., S15LPN indicated Resident #2 was independent with ambulation. S15LPN further confirmed Resident #2 had a wander guard bracelet present.
In an interview on 08/30/204 at 11:32 a.m., S37CNA confirmed she was assigned to Resident #2. S37CNA failed to identify Resident #2 as an elopement risk and was unsure if Resident #2 wore a wander guard. S37CNA indicated if Resident #2 was an elopement risk, they would check on Resident #2 often and round at least every 2 hours.
Resident #3
Review of Resident #3's record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, in part, major depressive disorder; pseudobulbar affect (condition characterized by episodes of sudden uncontrollable inappropriate laughing or crying); bipolar disorder (condition characterized by unusual shifts in a person's mood); and traumatic brain injury (condition caused by injury to the brain).
Review of Resident #3's MDS with an ARD dated 06/12/2024 revealed, in part, Resident #3 was assessed with a BIMS of 6 (a score of 00-07 indicated a severe cognitive impairment). Further review revealed Resident #3 required partial to moderate assistance with dressing the lower half of her body; and, Resident #3 required partial to moderate assistance with walking 10 feet in the room or corridor. Review revealed Resident #3 used a wander/elopement alarm daily.
Review of Resident #3's Psychiatric Progress Note dated 02/21/2024 revealed, in part, Resident #3 was fixated on returning home.
Review of Resident #3's Elopement Risk assessment dated [DATE] revealed, in part, Resident #3 was cognitively impaired due to traumatic brain injury. Further review revealed Resident #3 was an elopement risk due to unsuccessful attempts to enter codes on exit doors. Review of Resident #3's Elopement Risk Assessment further revealed interventions of wander guard personal safety alarm device applied; photo of Resident #3 on the wander list, and staff were aware of Resident #3's wander risk.
Review of Resident #3's most recent Care Plan revealed a focus of Resident #3 was at risk for elopement with a target date of 09/10/2024. Further review revealed interventions of, in part, apply wander guard as ordered; notify staff Resident #3 was at risk for elopement; observe Resident #3's whereabouts and safety every shift and as needed; and obtain a physician order and written family consent for wander guard.
Review of Resident #3's August 2024 and September 2024 Physician's Orders revealed, in part, Resident #3 was to have a wander guard bracelet to her left wrist with placement check every shift, Resident #3 was to have a census check every 2 hours, and wander guard check every day for proper operation.
Observation on 08/30/2024 at 9:38 a.m. revealed Resident #3's bed was next to the window which was capable of being unlocked and fully opened to the outside. Further observation revealed Resident #3's windows exited to an unsecured location outside of the facility.
In an interview on 08/30/2024 at 9:40 a.m., S35Certified Nursing Assistant (CNA) Supervisor confirmed Resident #3 ambulated without assistance or assistive devices.
In an interview on 08/30/2024 at 9:46 a.m., S15Licensed Practical Nurse (LPN) confirmed Resident #3 was independent with ambulation. S15LPN indicated she was not sure if Resident #3 wore a wander guard bracelet and would have to check the elopement risk binder.
In an interview on 08/30/2024 at 11:11 a.m., Resident #3 indicated she did not want to be at the facility and if she could leave right now she would.
Observation on 08/30/2024 at 11:19 a.m. revealed Resident #3 walked independently up and down the hall near her room with a steady gait.
In an interview on 08/30/2024 at 12:14 p.m., S36CNA indicated Resident #3 was fully independent with ambulation. S36CNA further indicated she was unsure if Resident #3 was at risk for wandering but would have to check the elopement binder.

Based on record review and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) received ethics training for 1 (S6CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs' personnel files reviewed for training requirements.
Findings:
Review of S6CNA's personnel file revealed S6CNA had a date of hire of 12/30/2021. Further review revealed no documented evidence, and the facility presented no documented evidence S6CNA had received ethics training.
In an interview on 09/04/2024 at 12:24 p.m., S34Human Resources Director indicated the facility did not have any documented evidence S6CNA had received ethics training as required.
In an interview on 09/05/2024 at 3:42 p.m., S1Administrator indicated the facility had no additional documentation to present regarding the above mentioned deficient practice.

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure:
1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1);
2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents; and,
3. Staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision;
4. The facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024, 08/14/2024, and 08/21/2024): and,
5. A nurse assigned to a group of residents did not leave the facility before the scheduled oncoming nurse arrived at the facility to assume the responsibility of a group of residents (08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024).
This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate.
S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m.
The Immediate Jeopardy was removed on 09/04/2024 at 4:51 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit.
This deficient practice had the likelihood to cause more than minimal harm to all 110 residents that were reported to reside in the facility on 08/30/2024.
1.
Cross Reference F658
In an interview on 08/30/2024 at 12:20 p.m., S1Administrator indicated when S3LPN was unable to locate and visualize Resident #1 during rounds, S3LPN should have notified her and the DON, but failed to do so.
In an interview on 08/30/2024 at 2:40 p.m., S1Administrator indicated S3LPN had neglected Resident #1 by not visually checking him throughout the night on 08/28/2024 during her 11:00 p.m. to 7:00 a.m. shift, nor notified administration when she was unable to locate Resident #1.
In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders.
In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders.
2.
Cross Reference F658
In an interview on 09/05/2024 at 12:35 p.m., S2DON indicated S4LPN should not have documented she gave medication to Resident #1 at 8:23 p.m. on 08/28/2024 when she did not enter Resident #1's room at that time. S2DON further indicated that S3LPN should not have documented she checked the placement of Resident #1's wander guard when she had never visualized Resident #1.
3.
Cross Reference F689
In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated due to Resident #1's wander guard/elopement status, the nurse should have completed a visual check of Resident #1 every 2 hours as per the physician's orders.
In an interview on 09/05/2024 at 12:35 p.m., S2Director of Nursing (DON) indicated nurses should be rounding on residents identified as wanderers/elopement risk every 2 hours as per the physician's orders.
4.
Cross Reference F725
In an interview on 09/04/2024 at 11:52 a.m., S20Assistant Director of Nursing (ADON) indicated that when she arrived to the facility on the morning shifts, she did not accept the responsibility of residents' direct care. S20ADON further indicated that more than 1 direct care nurse was needed for 109 to 110 residents. S20ADON confirmed she assigned 3 direct care nurses for a night shift with 109 to 110 residents.
5.
Cross Reference F725
In an interview on 09/05/2024 at 9:55 a.m. S2Director of Nursing (DON) indicated if a nurse had to leave during their assigned shift or if the oncoming nurse was running late to their assigned shift, the nurse should notify administrative staff so a nurse could be assigned to the group of affected residents. S2DON further indicated residents should not be without an assigned nurse at any time. S2DON indicated on 08/21/2024 she had identified that nurses were leaving their assigned shift prior to the oncoming nurse arriving at the facility, leaving residents without an assigned nurse. S2DON confirmed administrative staff was not made aware of the above mentioned time periods where residents were left without an assigned nurse to care for them. S2DON indicated she was unaware of how frequently nurses were leaving residents without an assigned nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to obtain a final disposition for a fugitive charge that appeared on a Certified Nursing Assistant's (CNA) criminal background check.
This deficient practice was identified for 1 (S2CNA) of 5 (S2CNA, S3CNA, S4CNA, S5CNA, and S6CNA) personnel records reviewed for personnel requirements.
Findings:
Review of S2CNA's Personnel Record revealed a hire date of 07/07/2023.
Review of S2CNA's criminal background check dated 06/30/2023 revealed, in part, the following:
10/17/2016 CCRP 575 Fugitive (Louisiana Code of Criminal Procedure Article 575); 1 charge and 1 count.
Review of Louisiana State Government Legislature Law website revealed, in part,
CCRP 575 Art. 575. Interruption of time limitations.
The periods of limitation established by this Chapter shall be interrupted when the defendant:
(1) For the purpose of avoiding detection, apprehension or prosecution, [NAME] from the state, is outside the state, or is absent from his usual place of abode within the state; or
(2) Lacks mental capacity to proceed at trial and is committed in accordance with Article 648 of this Code.
Further review revealed no final disposition for the above mentioned charge.
There was no documented evidence and the facility did not present any documented evidence that a final disposition was obtained upon hire to determine if S2CNA's fugitive status involved a conviction which barred employment.
In an interview on 07/30/2024 at 3:02 p.m., S1Administrator indicated she did not have documented evidence of a final disposition for S2CNA's charge of CCRP 575 Fugitive and did not know if the charge barred employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure a resident did not sustain an injury when staff placed a rolling bedside table in front of a resident to prevent a fall.
This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accidents.
Findings:
Reviewed Facility's Incident/Accident Log revealed, in part, Resident #1 experienced an unwitnessed fall with head injury on 07/14/2024.
Record review revealed, in part, Resident #1's was admitted to the facility on [DATE] with a history of falls.
Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2024 revealed, in part, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 04 which indicated her cognition was severely impaired. Further review revealed she was not ambulatory, sustained previous falls with injury, used a wheelchair, and required moderate assistance by staff with transfers.
Review of facility's Incident/Accident Log dated 07/14/2024 revealed, in part, Resident #1 experienced a fall.
Review of the facility's Fall Risk assessment dated [DATE] revealed, in part, Resident #1 had one and up to two falls in the past three months, was chair bound, and was identified as being at high risk for falls.
In a telephone interview on 07/30/2024 at 10:19 a.m., S3Certified Nursing Assistant (CNA) indicated on 07/14/2024, she placed Resident #1 in her wheelchair and then positioned her rolling bedside table in front of her to prevent her from falling forward and injuring herself. S3CNA further indicated she discovered Resident #1 slumped over the rolling bedside table, did not see any injury to Resident #1, and Resident #1 did not complain of any pain.
Review of the facility's CNA Communication Log dated 07/14/2024 revealed, in part, S3CNA discovered Resident #1 was face down on the bedside table.
In an interview on 07/29/2024 at 2:42 p.m., S9CNA indicated shortly after 7:20 a.m. on 07/14/2024, she entered Resident #1's room and wheeled Resident #1 to the dining area for breakfast. S9CNA further indicated Resident #1's hand covered her face and did not see any bruising or injury to Resident #1's face.
In a telephone interview on 07/30/2024 at 9:37 a.m., S7Licensed Practical Nurse (LPN) indicated she was working Monday on 07/14/2024, and S2CNA, S4CNA, and S8Woundcare Treatment Nurse wheeled Resident #1 from the dining room to be assessed for bruising. S9LPN further indicated Resident #1 had bruising noted to the left side of the mouth and left shoulder with blood noted to the upper oral cavity (space).
Review of Resident #1's Hospital Emergency Department Report dated 07/14/2024 revealed, in part, Resident #1 was examined and diagnosed with bruising to left side of lip and jaw and an abrasion of the upper oral cavity.
In an interview on 07/30/2024 at 8:30 a.m., S1Administrator indicated Resident #1's facial bruising was a linear bruise with a curved edge that resembled the curve of a bedside table. S1Administrator further indicated a bedside table should not be used as a fall precaution intervention.

Based on record review and interview, the facility failed to ensure an injury of unknown origin was reported to the state survey agency no later than 2 hours after it was discovered for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of the facility's incident documentation dated 04/11/2024 at 3:01 p.m., revealed, in part, sustained a fracture of unknown origin. Further review revealed, the type of incident was bruising/swelling.
Review of Resident #2's MDS(Minimum Data Sheet) with an ARD (Assessment Reference Date) of 04/03/2024, revealed in part, Resident #2 had a BIMS (brief interview mental status) score of 03 indicating she had severe cognitive impairment.
Review of Resident #2's care plan revealed Resident #2 had a history of falls and was identified as being at high risk for falls related to poor safety awareness
Review of the facility's report to the state agency revealed, in part, Resident #2 had a major injury of unknown origin that was discovered on 04/11/2024 at 3:00 p.m. Further review revealed the incident was not reported to the state until 04/13/2024 at 10:02 a.m.
In an interview on 04/15/2024 at 12:02 p.m., S1Administrator indicated she did not report Resident #2's fracture to the state within two hours of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pain medication when a nonverbal resident showed signs and symptoms of pain for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
This deficient practice resulted in actual harm for Resident #2 beginning on 04/09/2024 when S4Occupational Therapist (OT) reported to S3Licensed Practical Nurse (LPN) Resident #2 had facial grimacing with movement of the right lower extremity with no intervention to manage Resident #2's pain.
Findings:
Review of the facility's policy titled, Pain Management dated January 2024 revealed, in part, identifying pain in a non-verbal resident was observing for facial grimacing and being resistive to movement and care. Further review revealed pain can be managed by pharmacological interventions such as prescribed medication. Further review revealed interventions for pain would need to be reassessed and if it has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.
Review of Resident #2's record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, in part, of aphasia (a condition in which a person is unable to express themselves verbally) and a history of Polio (a virus that may cause muscle pain, joint pain, loss of bone density, and osteoporosis related fractures).
Review of Resident #2's Polio care plan initiated on 12/06/2023 revealed, in part, an intervention for staff to observe Resident #2 for muscle, bone or joint pain and medicate as ordered.
Review of Resident #2's April 2024 Physician's orders revealed, in part, an order with a start date of 11/18/2019 for Acetaminophen (a medication given for pain) 325 milligrams (mg) tablet give 2 tablets every 6 hours as needed for pain.
Review of Resident #2's Occupational Therapist note dated 04/09/2024 revealed Resident #2 had appeared uncomfortable and was grimacing with right lower extremity movement.
Review or Resident #2's nurse's notes dated 04/10/2024 at 3:23 p.m., revealed S3Licensed Practical Nurse (LPN) documented Resident #2 was complaining of pain to the right lower leg.
Review of Resident #2's April 2024 Electronic Medication Administration Record (EMAR) revealed no documented evidence and the facility was unable to provide any documented evidence Resident #2 received pain medication.
Review of Resident #2's x-ray results dated 04/11/2024 revealed, in part, a subacute fracture of the left distal femur (bone in upper leg) which required surgery.
In an interview on 04/16/2024 at 2:16 p.m., S4OT indicated she worked with Resident #2 on 04/09/2024. S4OT further indicated when she went to take Resident #2's legs off of the leg rest and Resident #2 grimaced in pain. S4OT stated she notified S3LPN of Resident #2's pain.
In an interview on 04/16/2024 at 2:54 p.m., S5Certfiied Nursing Assistant (CNA) indicated on 04/10/2024, Resident #2 pushed her a way when S5CNA would touch or try to reposition Resident #2. S5CNA further indicated Resident #2 displayed facial grimacing.
In an interview on 04/17/2024 at 1:00 p.m., S5CNA indicated on 04/11/2024, Resident #2 did not want to be touched, and she reported Resident #2's pain to S7CNA Supervisor. S5CNA further indicated S7CNA Supervisor instructed her to report Resident #2's pain to the Director of Nursing (DON).
In an interview on 04/17/2024 at 1:10 p.m., S2DON indicated she went to assess Resident #2 after S5CNA reported Resident #2 did not want to be touched, and S2DON noticed bruising and swelling to Resident #2's left lower leg. S2DON further indicated she notified Resident #2's doctor after her assessment, and the doctor ordered an x-ray, which revealed a fracture.
In an interview on 04/17/2024 at 3:20 p.m., S3LPN indicated a nonverbal sign of pain was facial grimacing. S3LPN confirmed she did not give Resident #2 any pain medication on 04/09/2024 or 04/10/2024 following staff's reports of Resident #2's pain. S3LPN further indicated she should have given Resident #2 pain medication.
In an interview on 04/17/2024 at 4:27 p.m., S2Director of Nursing indicated the nurse should have administered pain medication to Resident #2.

Based on observations, interviews and record reviews the facility failed to ensure dishwasher temperature gauges were maintained in proper working order and maintain the ice machine and water dispenser in a sanitary manner.
Findings:
Review of the manufacturer's dishwasher operational sign revealed, in part, the dishwasher temperatures should be at a minimum of 120 degrees Fahrenheit.
Observation on 01/31/2024 at 9:30 a.m., during kitchen tour, revealed the facility's dishwasher temperature gauge did not go above 115 degrees Fahrenheit after 4 attempts of restarting the dish cycle by S5Dietary Manager.
In an interview on 01/31/2024 at 9:32 a.m., S5Dietary Manager acknowledged the dishwasher temperature should be at a minimum 120 degrees Fahrenheit or above to properly clean dishes. S5Dietary Manager acknowledged after 4 attempts at temperature checks, the dishwasher temperature gauge did not get above the minimum 120 degrees Fahrenheit.
In an interview on 01/31/2024 at 10:41 a.m., S4Maintenance Supervisor acknowledged the temperature gauge on the facility's dishwasher was not working properly.
In an interview on 01/31/2024 at 1:57 p.m., Contracted Dishwasher Company Service Representative stated the temperature valve on the facility's dishwasher was not functioning properly.
Observation on 01/30/2024 at 12:06 p.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser.
Observation on 01/31/2024 at 11:33 a.m. revealed S10Certified Nursing Assistant (CNA) filled an ice pitcher with ice from Ice Machine A and water from the water dispenser on Hall X.
In an interview on 01/31/2024 at 11:34 a.m. S10CNA confirmed Ice Machine A and the water dispenser on Hall X was utilized to fill residents' ice pitchers.
Observation on 01/31/2024 at 11:35 a.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser.
Observation on 02/01/2024 at 10:12 a.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had dried a brown substance and a dried white substance on the front of the dispenser.
Observation on 02/01/2024 at 1:19 p.m. revealed the front of Ice Machine A had a dried and discolored white substance on the front of the machine. Observation further revealed the front of the water dispenser on Hall X had a dried brown substance and a dried white substance on the front of the dispenser.
In an interview on 02/01/2024 at 1:20 p.m., S2Director of Nursing confirmed Ice Machine A and the water dispenser on Hall X were unsanitary and needed to be cleaned.

Based on interviews and observations, the facility failed to ensure food was palatable to residents in temperature. This deficient practice had the potential to affect any of the 101 residents who receive food from the facility's kitchen.
Findings:
Review of Resident #1's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact.
In an interview on 01/30/2024 at 1:28 p.m., Resident #1 stated the food was often cold and that she would like to have a hot meal.
On 01/31/2024 at 12:13 p.m., the last resident food tray on Food Cart F was tasted by 6 surveyors. The food tray contained meatloaf, gravy, loaded mashed potatoes, and mixed vegetables. All six surveyors agreed the food was lukewarm to room temperature.
In an interview on 01/31/2024 at 12:23 p.m., S5Dietary Manager stated she had a couple complaints about breakfast being cold and she gave those residents another tray.
In an interview on 02/01/2024 at 12:45 p.m., Resident #1 stated her lunch today was lukewarm at best and she would have preferred her food to be hotter. Resident #1 further stated her breakfast was cold and she would have preferred to have a hot breakfast.
On 02/01/2024 at 12:14 p.m., the last resident food tray on Food Cart F was tasted by 4 surveyors and all 4 surveyors agreed the food was lukewarm to room temperature. The food tray contained pulled pork, a hamburger bun, and pork and beans.
In an interview on 02/01/2024 at 12:18 p.m., S5Dietary Manager stated the resident food trays were placed correctly on Food Cart F today and she did not know why the food was not warm.

Based on record reviews and interviews, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified on hire and/or every 6 months for 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) of 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) personnel records reviewed.
Findings:
Review of S3CNA Supervisor's personnel record revealed a hire date of 05/23/2013. Further review revealed the last CNA Registry verification was completed on 01/25/2014.
Review of S6CNA's personnel record revealed a hire date of 11/01/2021. Further revealed the last CNA Registry verification was last completed on 01/22/2019.
Review of S7CNA's personnel record revealed a hire date of 12/09/2019. Further review revealed the last CNA Registry verification was last completed on 12/05/2019.
Review of S8CNA's personnel record revealed a hire date of 08/10/2021. Further review revealed no documented evidence the CNA Registry was verified on hire or until 01/30/2024.
Review of S9CNA's personnel record revealed a hire date of 04/06/2023. Further review revealed the last CNA Registry verification was completed on 04/03/2023.
In an interview on 01/31/2024 at 11:44 a.m., S11Human Resources stated she was unaware the CNA Registry was supposed to be verified every 6 months. S11Human Resources confirmed the facility did not have proof the above mentioned CNAs had a current CNA certification.
In an interview on 01/31/2024 at 2:25 p.m., S1Administrator confirmed the CNA Registry verifications should have been conducted to ensure CNA certifications were valid and current.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with identified mental health diagnosis were referred for a preadmission screening and resident review (PASARR) Level II evaluation as required for 2 (Resident #47 and Resident #54) of 4 (Resident #42, Resident #47, Resident #54, and Resident #58) sampled residents reviewed for PASARR.
Findings:
Resident #47
Review of Resident #47's medical record revealed, in part, Resident #47 was readmitted to the facility on [DATE] with a diagnosis of Bipolar (a mental disorder).
Review of Resident #47's Level I PASARR evaluation prior to admission revealed, in part, Resident #47 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review.
Review of Resident #47's pre-admission Level II PASARR revealed documentation of no mental illness, a categorical determination of Primary Dementia, and level II is not required.
Resident #54
Review of Resident #54's medical record revealed, in part, Resident #54 was readmitted to the facility on [DATE] with a diagnosis of Unspecified Mood (affective disorder).
Review of Resident #54's Level 1 PASARR evaluation prior to admission revealed, in part, Resident #54 was not diagnosed with a mental illness, therefore, no psychiatric disability diagnoses were selected to review.
Review of Resident #54's active diagnoses list revealed, in part, a diagnosis of Bipolar with onset date of 04/03/2023. Further review revealed no documented evidence and the facility did not present any documented evidence that a Level II PASARR was completed for Resident #54.
In an interview on 02/01/2024 at 12:20 p.m., S12Admissions Coordinator stated she was responsible for obtaining PASARRs. S12Admissions Coordinator further stated she reviews the PASARRs for accuracy and to obtain corrections as applicable. S12Admissions Coordinator further stated when a resident is diagnosed with a new mental disorder, the nurse is responsible for notifying the physician to obtain a new PASSAR.
In an interview on 02/01/2024 at 2:38 p.m., S1Administrator stated the facility did not have a policy for PASARRs. S1Administrator acknowledged the Level I and Level II PASARRs for Resident #47 were inaccurate, and needed to be resubmitted. When asked what is done if a resident develops a mental disorder or an intellectual disability during their stay after admit, S1Administrator stated she did not know what needed to be done. S1Administrator further stated she did not realize a Level II PASARR needed to be resubmitted for Resident #54 with a new diagnosis of Bipolar Disorder.

Based on record reviews and interviews, the facility failed to:
Maintain ongoing communication regarding a resident's condition prior to leaving the facility for dialysis treatments for 1 (Resident #21) of 1 (Resident #21) sampled residents investigated for dialysis services.
Findings:
Review of the facility's Care of a Resident with End-Stage Renal Disease Policy and Procedure revealed, in part, agreements between the facility and the dialysis facility must include all aspects of how the resident's care will be managed, including how information will be exchanged between the facility and the dialysis facility.
Review of Resident #21's Dialysis Care Plan revealed, in part, an intervention for Resident #21 to attend dialysis on Monday, Wednesday and Friday's as per the physician's order.
Review of Resident #21's January 2024 Physician's Order's revealed, in part, an order for Resident #21 to attend dialysis on Mondays, Wednesdays and Fridays.
Review of Resident #21 dialysis communication binder revealed the communication forms were not completed prior to Resident #21 leaving for the dialysis on Monday, Wednesday and Friday for the months of October 2023, November, 2023, December 2023 and January 2024.
In an interview on 02/01/2024 at 2:45p.m., S13Licensed Practical Nurse stated the facility used a dialysis communication form to communicate back and forth with dialysis regarding a dialysis resident's condition. S13LPN acknowledged she did not complete the dialysis communication.
Review of the dialysis communication binder revealed no documented evidence and the facility was unable to provide any documented evidence of communication between the facility and the dialysis facility regarding Resident #21's condition before leaving the facility for dialysis on Monday, Wednesdays and Fridays.
In an interview on 02/01/2024 at 4:00 p.m., S1Administrator and S2Director of Nursing (DON) stated communication with dialysis centers should have been completed by use of the dialysis communication forms. S2DON further stated the dialysis communication form should have been completed and signed by the nurse before Resident #21 exited the facility for dialysis.

Based on record reviews and interviews, the facility failed to ensure a resident had a comprehensive care plan that addressed her sexual health care needs for 1 (Resident #1) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) residents reviewed in the sample for care planning.
Findings:
Review of Resident #1's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 11/07/2023 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) of 14, which indicated her cognition was intact.
Review of Resident #1's care plan with a target date of 02/16/2024 revealed, in part, Resident #1 did not have a care plan to address her sexual activity and sexual healthcare needs.
In an interview on 12/07/2023 at 1:45 p.m., S3Certified Nursing Assistant (CNA) stated she was aware of Resident #1's sexual activity with a male resident who lived across the hall from her. S3CNA stated she reported the sexual activity to the nurse.
In an interview on 12/07/2023 at 2:50 p.m., S2Licensed Practical Nurse (LPN) stated she was aware of Resident #1's sexual activity on two separate occasions with two different male residents (Resident #3 and Resident #5). S2LPN stated she confirmed with Resident #1 she had sexual intercourse with him. S2LPN stated she reported the sexual activity to the nurse supervisor. S2LPN confirmed the administrative staff was aware of Resident #1's sexual activity.
In an interview on 12/07/2023 at 3:20 p.m., Resident #1 stated she was sexually active with other male residents in the facility. Resident #1 stated the administrative nurses and staff were aware of her sexual activity and she had many conversations with the staff about maintaining privacy.
In an interview on 12/07/2023 at 4:30 p.m., S4Corporate MDS (Minimum Data Set) Nurse stated she did not implement a care plan to address sexual health for Resident #1 because she was not aware Resident #1 was sexually active. S4Corporate MDS nurse stated Resident #1's care plan should have addressed her sexual health care needs.
In an interview on 12/07/2023 at 4:46 p.m., S1Administrator stated the facility had not confirmed Resident #1 was having sex with other male residents in the facility because no sexual acts were observed by the staff.
S1Administrator stated she was not aware nursing employees were knowledgeable about Resident #1's sexual activity. S1Administrator confirmed Resident #1 did not have a care plan to address her sexual health needs and should have.