Ascension Oaks Nursing & Rehab Center

Based on observations and interviews, the facility failed to ensure a resident in a semiprivate room had a ceiling suspended curtain around the bed for 1 (Resident #79) of 14 (Resident #2, Resident #8, Resident #13, Resident #26, Resident #27, Resident #37, Resident #38, Resident #60, Resident #71, Resident #77, Resident #79, Resident #81, Resident #83, Resident #302) sampled residents observed for privacy.
Findings:
Observation on 06/09/2025 at 10:28AM revealed Resident #79 did not have a ceiling suspended privacy curtain suspended around Resident #79's bed as required, to ensure privacy.
Observation on 06/10/2025 at 10:40AM revealed Resident #79 did not have a ceiling suspended privacy curtain suspended around Resident #79's bed as required, to ensure privacy.
In an interview on 06/10/2025 at 11:08AM, S11Certified Nursing Assistant (CNA) indicated Resident #79 was in a semi-private room and currently had a roommate. S11CNA further indicated Resident #79's ceiling suspended privacy curtain was missing and should not have been.
In an interview on 06/11/2025 at 2:22PM, S1Administrator confirmed a resident in a semiprivate room should have a ceiling suspended privacy curtain suspended around their bed to ensure privacy, and acknowledged Resident #79's privacy curtain was missing.

Based on observation, interviews and record reviews, the facility failed to ensure staff performed hand hygiene between glove changes when performing wound care for 1 (Resident #2) of 2 (Resident #2, Resident #40) residents observed for wound care.
Findings:
Review of the facility's undated Universal Precautions policy and procedure, revealed, in part, handwashing was to be performed before and after each contact with a resident whether gloves are worn or not, and handwashing was to be performed following exposure of hands to body fluids, blood, excretions, or other contaminates (see Handwashing Technique policy and procedure).
Review of the facility's undated Handwashing Technique policy and procedure revealed, in part, hands must be washed during performance of duties such as handling dressings.
Observation on 06/11/2025 at 9:14AM revealed S12Wound Care Nurse sanitized her hands and applied a gown and gloves before she performed Resident #2's right foot dressing change. Further observation revealed S12Wound Care Nurse removed Resident #2's right foot dressing and placed the dressing into a biohazard bag. Further observation revealed S12Wound Care Nurse removed her gloves and put on a new pair of gloves without performing hand hygiene after handling Resident #2's right foot dressing. Observation then revealed S12Wound Care Nurse cleaned Resident #2's wound with normal saline, removed her gloves, and put on a new pair of gloves without performing hand hygiene.
In an interview on 06/11/2025 at 11:55AM, S12Wound Care Registered Nurse confirmed she did not perform hand hygiene in between glove changes during Resident #2's right foot dressing change, and she should have.
In an interview on 06/11/2025 at 12:02PM, S13Licensed Practical Nurse/Infection Preventionist confirmed hand hygiene should have been performed in between glove changes during Resident #2's right foot dressing change.
In an interview on 06/11/2025 at 12:28PM, S2Director of Nursing confirmed hand hygiene should have been performed between glove changes during Resident #2's right foot dressing change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a resident with a serious mental illness was referred to the Louisiana Office of Behavioral Health for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #85) of 2 (Resident #2, Resident #85) sampled residents reviewed for PASARR.
Findings:
Review of Resident #85'a clinical record, reveled, in part, Resident #85 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a serious mental illness that causes mood swings).
Review of Resident #85's Minimum Data Set with an Assessment Reference Date of 4/15/2025 revealed, in part, Resident #85 had an active diagnosis of bipolar disorder.
There was no documented evidence, and the facility did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASARR program regarding Resident #85's diagnosis of bipolar disorder since admission on [DATE] as required.
In an interview on 06/11/2025 at 12:38PM, S16Social Worker indicated she was responsible to initiate a Level II PASARR referral for residents. S16Social Worker confirmed Resident #85 had a diagnosis of bipolar disorder since admission on [DATE] and had not been referred to the Louisiana Office of Behavioral Health for a Level II PASARR review, as required.

Based on observations and interviews, the facility failed to serve residents' food at an acceptable temperature as required.
Findings:
In an interview on 06/09/25 at 10:20 AM, Resident #71 (who resided on Hall a) indicated the facility's food is terrible and cold.
Observation on 06/11/2025 at 11:51AM revealed a facility staff member transported the lunch trays down Hall a on a tray cart. Further observation revealed the door to the tray cart was left opened and Resident #72's lunch tray could be visualized.
On 06/11/2025 at 11:51AM the surveyor collected Resident #72's lunch tray to be used as a test tray. Upon sampling the food on Resident #72's tray, surveyors found the black eyed peas, fried pork fritter, and cooked turnip greens to be lukewarm (not at a temperature consistent with a palatable food temperatures).
Observation on 06/11/2025 at 11:55AM, revealed S14DM checked the temperatures of the food on Resident #72's above mentioned lunch tray. Further observation revealed the black eyed peas were 103 degrees Fahrenheit, the cooked turnip greens were 107 degrees Fahrenheit, and the fried pork fritter was 99 degrees Fahrenheit.
In an interview on 06/11/2025 at 11:57AM, S14Dietary Manager indicated she expected the food to be around 120 degrees Fahrenheit when it was served to the residents. S14DM further indicated the lunch trays for Hall a exited the kitchen at 11:35AM on 06/11/2025. S14DM acknowledged that it was an issue that the lunch trays for Hall a had exited the kitchen at 11:35AM and had not yet been served to all the residents on Hall a at 11:51AM on 06/11/2025.
In an interview on 06/11/2025 at 12:00PM, Resident #13 (who resided on Hall a) indicated that her food for lunch today was not hot/lukewarm.
In an interview on 06/11/2025 at 12:01PM, Resident #40 (who resided on Hall a) indicated that her lunch today was served cold.

Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure food stored in the facility's freezer was properly contained and labeled with an opened date; and,
2. Ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware.
Findings:
1.
Review of the facility's Storage of Frozen Food policy and procedure revised on 12/2012 revealed, in part, the facility ensured the quality and safety of frozen food through accepted storage practices. Further review revealed the facility staff were to ensure no food was left uncovered and opened boxes of frozen foods should be closed and sealed tightly, and dated when opened.
Observation of the facility's freezer with S14Dietary Manager on 06/09/2025 at 9:31AM, revealed an opened box of okra. Further observation revealed the bag of okra was not closed and was unlabeled with an opened date.
In an interview on 06/09/2025 at 9:31AM, S14Dietary Manager indicated the bag of frozen okra was not sealed and was not labeled with an opened date, and should have been.
2.
Review of the facility's undated manufacturer's instructions for the proper steps to clean dishes using the 3 compartment sink revealed, in part, the water and sanitizer should be kept at proper temperatures and concentrations. Further review revealed staff should keep the water in the rinse compartment of the 3 compartment sink to be at least 110 degrees Fahrenheit and keep the water in the sanitization compartment of the 3 compartment sink at 75 degrees Fahrenheit. Further review revealed dishes should be left in the sanitization compartment of the 3 compartment sink for 45 seconds.
In an interview on 06/11/2025 at 2:32PM, S15Cook indicated she routinely washed dishes in the 3 compartment sink. S15Cook further indicated the temperature of the wash compartment of the 3 compartment sink should be kept at 75 degrees Fahrenheit. S15Cook further indicated she did not soak dishes in the sanitization compartment of the 3 compartment sink for any specific amount of time.
Observation on 06/11/2025 at 2:32PM, with S14Dietary Manager indicated S15Cook only tested the temperature of the wash compartment of the 3 compartment sink and did not test the temperature of the rinse and sanitization compartments of the three compartment sink.
In an interview on 06/12/2025 at 2:45PM, S14Dietary Manager indicated the dishes should have been submerged in the sanitization compartment of the 3 compartment sink for at least 30 seconds.
In an interview on 06/12/2025 at 2:25PM, S17Regional Director of Operations, indicated dishes should be soaked in the sanitization compartment of the 3 compartment sink for at least 45 seconds.

Based on interview and record reviews the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) were maintained and accurately documented for 2 (Resident #38, Resident #60) of 22 (Resident #2, Resident #3, Resident #8, Resident #13, Resident #19, Resident #21, Resident #22, Resident #26, Resident #27, Resident #37, Resident #38,Resident #40, Resident #41, Resident #53, Resident #60, Resident #71, Resident #77, Resident #79, Resident #81, Resident #83, Resident #85, and Resident #302) sample residents reviewed for accurate records.
Findings:
Review of the facility's undated General Medical Records policy/procedure revealed, in part, staff were to record all care given, including medication and treatments. Further review revealed staff were to record any adverse reactions, anything abnormal, or anything out of the ordinary.
Review of Resident #38's June 2025 physician's orders revealed, in part, the following orders:
-Mirtazapine (a medication used to treat insomnia) 15 milligrams (mg) by mouth (po) at bedtime for insomnia;
-Sennosides-Docusate Sodium (a medication used to treat constipation) 2 tablets 8.6-50 mg by mouth (po) at bedtime;
-Lactulose solution (a medication used to treat constipation) 15 milliliters (ml) by mouth (po) two times a day;
-Tramadol (a medication used to treat pain) 50 mg by mouth (po) two times a day;
-TwoCal house supplement (a nutritional supplement) 6 ounces (oz) by mouth (po) three times a day;
-Depakote DR (a medication used to treat a mood disorder) 500 mg by mouth (po) three times a day;
-Seroquel (a medication used to treat a mood disorder) 100 mg by mouth (po) three times a day;
-Seroquel (a medication used to treat a mood disorder) 50 mg by mouth (po) three times a day; and,
-Xanax (a medication used to treat anxiety) 0.5 mg by mouth (po) three times a day.
Review of Resident #38's eMAR revealed, in part, there was no documented evidence, and the provider did not present any documented evidence Resident #38's medications/supplements were administered and/or not given for the following medications:
- Mirtazapine 15 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM;
- Sennosides-Docusate Sodium 8.6-50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM;
- Lactulose solution 15 ml po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM;
- Tramadol 50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM;
- TwoCal house supplement 6 ounces po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM;
- Depakote DR 500 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM;
- Seroquel 100 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM;
- Seroquel 50 mg po on 05/13/2025, 05/15/2025, and 05/16/2025 at 9:00 PM; and,
- Xanax 0.5 mg po three times a day on 05/13/2025, 05/15/2025, and 05/16/2025 at 5:00 PM.
Review of Resident #60's June 2025 physician's orders revealed, in part, the following orders:
-Trazodone HCI (a medication used to treat insomnia) 100 mg by mouth (po) at bedtime; and,
-Eliquis (a medication used to thin blood) 5 mg by mouth (po) two times a day.
Review of Resident #60's eMAR revealed, in part, there was not documented evidence, and the provider did not present any documented evidence Resident #60's medications/supplements were administered and/or not given for the following medications:
- Trazodone HCI 100 mg po on 05/05/2025 and 05/16/2025 at 9:00 PM; and,
- Eliquis 5 mg po on 05/05/2025 and 05/16/2025 at 9:00 PM.
In an interview on 06/12/2025 at 12:09 PM, S2Director of Nursing (DON) indicated staff should have documented on Resident #38 and Resident #60's eMAR if medication/supplements were administered or not administered. S2DON further indicated there should not be any missing documentation of signatures for any Resident's eMAR.

Based on interview and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying that coffee temperatures needed to be monitored.
Findings:
Review of the facility's undated Quality Assessment and Performance Improvement (QAPI) Guidelines policy revealed, in part, the policy was to establish procedures within the facility for QAPI by incorporating monitoring. Further review revealed the facility should put in place systems to monitor care and services. Further review revealed the facility would use performance indicators to monitor care process and outcomes, and review findings.
Review of the facility's In-Service Training Report dated 05/28/2025 revealed, in part, staff were to allow coffee to cool to a temperature of 120 to 140 degrees Fahrenheit before serving to residents.
Review of the facility's QAPI plan related to coffee temperatures dated May 2025 revealed, in part, coffee temperatures were obtained daily from 05/28/2025 through 06/12/2025 from 3 coffee pots labeled A, B, and C and documented on an audit form titled, Coffee Temperature served from Kitchen. Further review revealed on 06/10/2025 at 6:30AM the temperature of coffee obtained from coffee pot C was documented as 149.1 degrees Fahrenheit. Further review revealed S14Dietary Manager documented that a coffee temperature of 149.1 degrees Fahrenheit was in normal range and did not indicate a corrective action was taken.
In an interview on 06/12/2025 at 10:00AM, S14Dietary Manager indicated she was in-serviced to ensure coffee was served to residents at a temperature that ranged between 120 to 140 degrees Fahrenheit.
In an interview on 06/12/2025 at 10:30AM, S14Dietary Manager indicated she was responsible for monitoring the temperature of coffee before it was served to the residents and documenting the temperature obtained. S14Dietary Manager confirmed on 06/10/2025 she documented on the audit form the temperature of the coffee in coffee pot C was 149.1 degrees Fahrenheit.
Record review revealed no documented evidence, and the facility did not present any documented evidence, the coffee temperatures obtained during audits were monitored and/or evaluated by the QAPI committee to ensure the coffee was served to residents at the appropriate temperature. Further review revealed no documented evidence, and the facility did not present any documented evidence showing how the QAPI committee monitored the effectiveness of the coffee temperature in-service training.
In an interview on 06/12/2025 at 11:05AM, S2Director of Nursing (DON) indicated after S14Dietary Manager completed the coffee temperature audit forms, S2DON placed the forms into the QAPI binder. S2DON further indicated there was no staff member assigned to monitor and/or evaluate the coffee temperatures obtained or evaluate effectiveness of in-service trainings to ensure coffee was served to residents at the appropriate temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for use to decrease the risk of falls for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accident hazards.
This deficient practice resulted in actual harm on 02/21/2024 at 6:26 p.m. when S2Certified Nursing Assistant (CNA) removed Resident #1's wheelchair from her room and placed it in the hallway. Resident #1 was unable to access her wheelchair to assist with mobility. On 02/21/2024 at 7:48 p.m. Resident #1 was found sitting on a fall matt next to her bed. On 02/22/2024 Resident #1 complained of pain in the left upper leg and was diagnosed with a left femur fracture which required hospitalization and surgical repair. Resident #1 had a decline in functional mobility and continence due to the fall and resulting fracture.
Findings:
Review of the facility's undated Fall Prevention Program policy on 03/05/2024 at 1:05 p.m. revealed, in part, the facility's goal was to prevent falls by enabling staff to recognize those residents identified as high risk for potential falls to ensure appropriate interventions were implemented. Further review revealed assistive devices would be kept within residents reach for easy access.
Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 01/03/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 3 indicating severe cognitive impairment. Further review revealed Resident #1 used a wheelchair for mobility, required partial to moderate assistance with transfers, supervision or touch assistance with walking, and had one fall without injury since the previous assessment.
Review of Resident #1's Fall Risk assessment dated [DATE] revealed Resident #1 required the use of an assistive device and had problems with balance when standing and/or walking. Further review revealed Resident #1 had a risk assessment score of 16 indicating resident was assessed as being high risk for falls.
Review of Resident #1's fall care plan with a start date of 11/01/2019 revealed, in part, Resident #1 was high risk for falls with a goal to have no falls with injuries. Further review revealed the following active interventions:
On 11/01/2019 Staff to keep Resident #1's assistive devices in reach;
On 11/01/2019 Resident #1 had the falling star program in place;
On 04/06/2023 Wheelchair provided to Resident #1 for safety; and,
On 02/22/2024 Gerichair to assist Resident #1 with positioning when out of bed.
Review of Resident #1's nurse note dated 02/23/2024 at 11:04 a.m. revealed, in part, a late entry nurse note for 02/21/2024 at 7:52 p.m. which revealed the nurse was called into Resident #1's room by the CNA, and Resident #1 was found next to her bed on the fall mat.
Review or Resident #1's nurse note dated 02/22/2024 at 8:57 a.m. revealed, in part, Resident #1 complained of left upper leg pain and had decreased range of motion. Further review revealed an order was obtained for an x-ray of the left upper leg and hip.
Review of hospital record dated 02/22/2024 revealed, in part, Resident #1 had a left femur fracture which required surgical intervention.
Review of the facility's investigation documentation entered on 02/27/2024 at 11:16 a.m. revealed in part, Resident #1 sustained a fall on 02/21/2024 and was found to have a left femur fracture on 02/22/2024. Further review revealed prior to the above mentioned fall Resident #1 was ambulating with assistance. Due to the fall and fracture Resident #1 was now unable to bear weight on the left leg and had a decline functional in activities of daily living (ADL's).
Review of Resident #1's Voiding Status Summary from February 2024 through March 5, 2024 revealed, in part, Resident #1 was generally continent with occasional episodes of incontinence from 02/01/2024 through 02/21/2014. Further review revealed from 02/27/2023 through 03/05/2023 at 12:33 p.m. Resident #1 was incontinent with no episodes of continence documented.
Review of the facility's record titled Timeline of camera footage reviewed and documented by S1DON and S6Assistant Administrator on 02/22/2024 revealed, in part, the following:
6:18 p.m. through 6:21 p.m. - Resident #1 ambulated from the dining room down the hallway holding onto the wheelchair;
6:22 p.m. - CNA propelled Resident #1 to her room; and,
6:26 p.m. - CNA took the wheelchair out of Resident #1's room for an intervention to prevent Resident #1 from getting up without assistance.
In an interview on 03/05/2024 at 1:22 p.m., S4Licensed Practical Nurse (LPN) indicated prior to Resident #1's left femur fracture she observed Resident #1 using her wheelchair as a walker to ambulate to her restroom. S4LPN indicated if Resident #1 had to go to the restroom and the wheelchair was not available it would have made it more difficult and, Resident #1 would have attempted to ambulate without the wheelchair.
In an interview on 03/05/2024 at 1:50 p.m., S3CNA stated prior to Resident #1's left femur fracture Resident #1 would ambulate down the hallway using her wheelchair for balance and support. S3CNA stated Resident #1 needed some type of device to help her walk. S3CNA stated if Resident #1 did not have her wheelchair, Resident #1 would still have tried to ambulate to the restroom without it.
In an interview on 03/05/2024 at 4:30 p.m., S5CNA indicated she would often find Resident #1 pushing her wheelchair into the restroom unassisted by staff. S5CNA indicated she never removed the wheelchair from Resident #1's room because that would have made the situation worse. S5CNA stated Resident #1 could not walk without something to hold onto. S5CNA indicated since Resident #1's left leg fracture, Resident #1 was now in a Gerichair for mobility, was always incontinent, and relied on staff for all personal care.
In an interview on 03/05/2024 at 4:48 p.m., S1Director of Nursing (DON) indicated prior to Resident #1's fall on 02/21/2024 Resident #1 used the wheelchair as a walker to ambulate. S1DON confirmed Resident #1's was care planned to keep the assistive devices within reach. S1DON confirmed S2CNA should not have removed Resident #1's wheelchair from her room. S1DON confirmed Resident #1 had a decline in functional ADL's and required a Gerichair for mobility.

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 2 (Resident #29 and Resident #65) of 4 (Resident #9, Resident #20, Resident #29, and Resident #65) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse and Neglect Policy revealed, in part, residents must not be subjected to abuse including abuse from other residents. Further review revealed, physical abuse included hitting.
Resident #29
Review of the facility's Incident Report for Resident #20 dated 07/19/2023 at 4:35 p.m. revealed, in part, Resident #20 hit another resident on her arm.
Review of Resident #20's Care plan revealed, in part, on 07/19/2023 Resident #20 hit another resident.
Review of Resident #20's nurse's note dated 07/19/2023 at 11:22 p.m. revealed, in part, nurse was told Resident #20 hit another resident on her arm. Further review revealed, when Resident #20 was asked why she hit another resident, she stated, She called me a B----.
Review of Resident #20's nurse's note dated 07/20/2023 revealed, in part, Resident #20 was noted with increase agitation and hitting.
In an interview on 08/16/2023 at 3:50 p.m., S7LPN stated she saw Resident #20 hit Resident #29 on 07/19/2023. S7LPN stated on 07/19/2023 Resident #20 stated she hit Resident #29 because she called her a b----
In an interview on 08/17/2023 at 8:45 a.m., S3Assistant Director of Nursing (ADON) stated it was reported to her that Resident #20 hit Resident #29.
In an interview on 08/17/2023 at 11:55 a.m., S1Administrator stated upon review of the surveillance footage, he determined there was no contact made between Resident #20 and Resident #29, and that Resident #20 did not hit Resident #29.
S1Administrator reviewed the facility's surveillance footage from 07/19/2023 with two surveyors on 08/17/2023 which showed, as Resident #29 wheeled herself past Resident #20, Resident #20 swung and made contact with Resident #29's right arm. Further review revealed, Resident #20 unsuccessfully tried to hit Resident #29 again, and then backed Resident #29 against the wall and continued to swing at Resident #29.
Resident #65
Review of the facility's incident log revealed, in part, Resident #9 and Resident #65 had a resident to resident physical incident on 07/28/2023 at 5:30 p.m.
Review of the facility's Resident Incident Report dated 07/28/2023 for Resident #9 revealed, in part, Resident #9 was observed in the dining room striking another resident in the back. Further review revealed the facility's surveillance footage was reviewed, and it was noted that Resident #9 struck another resident on the buttock.
Review of Resident #9's nurse's notes dated 07/28/2023 revealed, in part, Resident #9 was being combative and argumentative with staff and residents in the dining room around 5:30 p.m. Further review revealed Resident #9 was arguing with another resident when Resident #65 went to hug and comfort the other resident. Further review revealed, Resident #9 hit Resident #65 in the back area and stated, I will keep on hitting you.
Review of Resident #65's nurse's notes dated 07/28/2023, revealed, in part, Resident #65 was hugging a resident in the dining room at around 5:30 p.m. Further review revealed, Resident #9 swung her arm and hit Resident #65 in the back area. Further review revealed Resident #65 turned around and hit Resident #9 in self-defense, held onto Resident #9, and said don't you ever hit me again.
In an interview on 08/16/2023 at 9:55 a.m., Resident #65 stated Resident #9 was known for being mean and rude, and the other residents avoid her. Resident #65 stated that Resident #9 struck her when she was attempting to comfort another resident that Resident #9 made cry.
In an interview on 08/16/2023 at 10:42 a.m., S1Administrator stated the incident between Resident #9 and Resident #65 was a resident to resident altercation, and the incident between Resident #9 and Resident #65 was not how S14Licensed Practical Nurse (LPN) portrayed the incident in her 07/28/2023 nurse's note. S1Administrator stated when he watched the facility's surveillance footage, Resident #65 was leaning over a table and bumped into Resident #9, and, in turn, Resident #9 swatted Resident #65 on the backside. S1Administrator further stated that Resident #65 grabbed Resident #9 by the wrist in order to prevent Resident #9 from hitting her further.
In an interview on 08/16/2023 at 4:10 p.m., S14LPN stated Resident #9 stated to Resident #65 I will keep on hitting you, and that Resident #9 intentionally hit Resident #65 because she was in her way.
In an interview on 08/17/2023 at 11:57 a.m., S1Administrator stated that he would not consider the altercation where Resident #9 swatted at, and made physical contact with, Resident #65's backside as abuse because it was a reaction to being bumped by Resident #65.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an alleged incident of physical abuse was reported to the State Survey Agency as required for 2 out of 2 facility incidents that required notifying the State Survey Agency
Findings:
Review of the facility's Abuse/Neglect Investigation, Protection, and Reporting Policy revealed, in part, in the event of any evidence involving abuse, an occurrence would have been reported immediately to the Administer or designee of the facility, who would have immediately notified the appropriate state officials per state guidelines. Further review revealed, in part, the facility would have thoroughly investigated all alleged violations under the direct supervision of the Administrator. Further review revealed, in part, the administrator would have investigated the alleged violation: by interviewing all parties having knowledge or information about the occurrence, including residents. Further review revealed written statements would have been obtained from all persons having knowledge of the incident or who were witnesses to the abuse. Further review revealed statements would have been descriptive, outline the incident in detail, and included the signature and title of the employee as well as the date. Further review revealed written statement would have been obtained from the alleged perpetrator. Further review revealed full and final report of the investigation would have been submitted to the Department of Health and Hospital Online Tracking Incident System ([NAME]) according to reporting guidelines within five working days of the occurrence or discovery of the incident.
07/28/2023 Incident:
Review of the facility's Resident Incident Report dated 07/28/2023 for Resident #9 revealed, in part, Resident #9 was observed in the dining room striking another resident in the back. Further review revealed the facility's surveillance footage was reviewed, and it was noted that Resident #9 struck another resident on the buttock.
In an interview on 08/16/2023 at 3:26 p.m., S1Administrator stated he thought only allegations that caused serious injury should be reported on-line to the state survey agency within 2 hours, and all other reportable incidents were to be reported within 24 hours.
In an interview on 08/16/2023 at 4:10 p.m., S14LPN stated Resident #9 stated to Resident #65 I will keep on hitting you, and that Resident #9 intentionally hit Resident #65 because she was in her way.
In an interview on 08/17/2023 at 11:57 a.m., S1Administrator stated that he would not consider the altercation where Resident #9 swatted at, and made physical contact with, Resident #65's backside as abuse because it was a reaction to being bumped by Resident #65. S1Administrator further stated that because he did not consider the above incident abuse, he did not report the above mentioned incident on-line to the state survey agency.
7/19/2023 Incident:
Review of the facility's Incident Report for Resident #20 dated 07/19/2023 at 4:35 p.m. revealed, in part, Resident #20 hit another resident on her arm.
In an interview on 08/16/2023 at 3:50 p.m., S7LPN stated she saw Resident #20 hit Resident #29 on 07/19/2023. S7LPN stated on 07/19/2023 Resident #20 stated she hit Resident #29 because she called her a b----.
In an interview on 08/17/2023 at 11:55 a.m., S1Administrator stated upon review of the surveillance footage, he determined there was no contact made between Resident #20 and Resident #29, and that Resident #20 did not hit Resident #29.
S1Administrator reviewed the facility's surveillance footage from 07/19/2023 with two surveyors on 08/17/2023 which showed, as Resident #29 wheeled herself past Resident #20, Resident #20 swung and made contact with Resident #29's right arm. Further review revealed, Resident #20 unsuccessfully tried to hit Resident #29 again, and then backed Resident #29 against the wall and continued to swing at Resident #29.
In an interview on 08/17/2023 at 11:57 a.m., S1Administrator stated he did not notify the state survey agency regarding the above mentioned incident between Resident #20 and Resident #29, because he determined that Resident #20 did not hit Resident #29.

Based on record review and interview, the facility failed to ensure an alleged incident of resident to resident physical abuse was thoroughly investigated for 1 (Resident #29) of 4 (Resident #9, Resident #20, Resident #29, and Resident #65) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse/Neglect Investigation, Protection, and Reporting Policy revealed, in part, in the event of any evidence involving abuse, an occurrence would have been reported immediately to the Administer or designee of the facility, who would have immediately notify the appropriate state officials per state guidelines. Further review revealed, in part, the facility would have thoroughly investigated all alleged violations under the direct supervision of the Administrator. Further review revealed, in part, the administrator would have investigated the alleged violation: by interviewing all parties having knowledge or information about the occurrence, including residents. Further review revealed written statements would have been obtained from all persons having knowledge of the incident or who were witnesses to the abuse. Further review revealed statements would have been descriptive, outline the incident in detail, and included the signature and title of the employee as well as the date. Further review revealed a written statement would have been obtained from the alleged perpetrator.
Review of Resident #20's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/2023 revealed, in part, Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment.
Review of Resident #29's MDS with an ARD of 06/22/2023 revealed, in part, Resident #29 had a BIMS score of 3, which indicated Resident #29 had severe cognitive impairment.
Review of Resident #20's nurse's progress note dated 07/19/2023 at 11:22 p.m. written by S7Licensed Practical Nurse (LPN) read: Resident #20 was asked why she hit another resident, Resident #20 stated, She called me a B----.
In an interview on 08/16/2023 at 3:50 p.m., S7LPN stated she saw Resident #20 hit Resident #29 on 07/19/2023. S7LPN stated on 07/19/2023 Resident #20 stated she hit Resident #29 because she called her a b----.
In an interview on 08/17/2023 at 8:45 a.m., S3Assistant Director of Nursing (ADON) stated it was reported to her that Resident #20 hit Resident #29. S3ADON stated she interviewed Resident #20 but Resident #20 was unable to recall what happened. S3ADON stated she also interviewed Resident #29 but Resident #29 was unable to recall the incident. S3ADON stated she did not have any documentation of the interviews she completed with Resident #20 and Resident #29.
In an interview on 08/17/2023 at 11:55 a.m., S1Administrator stated upon review of the surveillance footage, he determined there was no contact made between Resident #20 and Resident #29, and that Resident #20 did not hit Resident #29.
The facility did not present any documented evidence that a thorough investigation was completed which the above mentioned requirements/components per policy.
S1Administrator reviewed the facility's surveillance footage from 07/19/2023 with two surveyors on 08/17/2023 which showed, as Resident #29 wheeled herself past Resident #20, Resident #20 swung and made contact with Resident #29's right arm. Further review revealed, Resident #20 unsuccessfully tried to hit Resident #29 again, and then backed Resident #29 against the wall and continued to swing at Resident #29.
In an interview on 08/17/2023 at 11:57 a.m., S1Administrator stated he did not interview any of the staff who separated Resident #20 and Resident #29. S1Administrator further stated he had no documentation of a completed investigation.

Based on observations, interviews, and record review the facility failed to:
1.
Ensure staff locked the kitchen doors to prevent a confused and wandering resident (Resident #33) from entering/exiting the kitchen (Door j and Door k)
2.
Ensure free standing oxygen cylinders were secured (Lounge d) in a manner that prevented the potential for serious harm or injury for all 96 residents; and
3.
Ensure electrical rooms and/or housekeeping closets (Electrical Room a, Electrical Room b, Electrical Room c, and Closet e) were secured. This deficient practice was identified for 4 rooms. There were 9 residents identified as being confused and have the ability to wander (Resident #14, Resident #20, Resident #22, Resident #28, Resident #33, Resident #45, Resident #57, Resident #71, and Resident #89) of 9 (Resident #14, Resident #20, Resident #22, Resident #28, Resident #33, Resident #45, Resident #57, Resident #71, and Resident #89) as documented on the facility's Physician Orders list for Wanderguards.
Findings:
1.
Review of Resident #33's Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/03/2023 revealed, in part, Resident #33 had a Brief Interview for Mental Status (BIMS) of 9, which indicated Resident #33 had moderate cognitive impairment.
Review of nurse's note dated 08/14/2023 at 4:34 a.m. written by S5Licensed Practical Nurse (LPN) read: at approximately 4:00 a.m. Resident #33 was seen sitting in her wheelchair on the outside of the Door g.
In an interview on 08/15/2023 at 5:13 a.m., S10Dietary Manager (DM), stated Door j was left unlocked on 08/13/2023 because the nighttime cook thought that the morning cook did not have a key to the facility. S10DM further stated that Resident #33 was able to get through the door and outside of the facility through the kitchen.
In an interview on 08/15/2023 at 10:05 a.m., S21Licensed Practical Nurse (LPN) stated she was not aware of Resident #33 having wandering behaviors. S21LPN stated Resident #33 can propel herself in her wheelchair.
In an interview on 08/16/2023 at 8:50 a.m., S20Certified Nursing Assistant (CNA) stated Resident #33 can ambulate herself around the facility in her wheelchair.
In an interview on 08/16/2023 at 1:40 p.m., S5LPN stated Resident #33 was disoriented with Dementia. S5LPN stated she saw Resident #33 outside near Door g.
In an interview on 08/16/2023 at 2:10 p.m., S6LPN stated he was unaware of any interventions in place for Resident #33 other than Resident #33 wearing the wander guard to prevent Resident #33 from getting out of the facility.
In an interview on 08/17/2023 at 11:12 a.m., S1Administrator stated he was notified Resident #33 was found outside of Door g on 08/14/2023 around 4:00 a.m. S1Administrator stated he reviewed the camera footage and noted a CNA interacting with Resident #33 in the dining room, then Resident #33 entered the kitchen around 3:00 a.m. and remained in the kitchen for some time. S1Administrator stated Resident #33 went out of Door k on 08/14/2023 at 3:35 a.m. S1Administrator stated Resident #33 was seen passing Door h then at Door g when S5LPN saw Resident #33 at Door g right before 4:00 a.m. S1Administrator stated Resident #33 was unsupervised during this time for approximately 24 minutes on 08/14/2023. S1Administrator stated Resident #33 was outside unsupervised for approximately 24 minutes. S1Administrator stated Resident #33 should not have been in the kitchen unsupervised.
2.
Observation on 08/15/2023 at 6:04 a.m., revealed Lounge d's door was unlocked and was being used as a storage room. Further observation revealed, two oxygen cylinders were free standing and unsecured.
Observation on 08/16/2023 at 9:30 a.m., revealed Lounge d's door was unlocked and was being used as a storage room. Further observation revealed, two oxygen cylinders were free standing and unsecured.
Observation on 08/16/2023 at 12:37 p.m., revealed Lounge d's door was unlocked and was being used as a storage room. Further observation revealed, two oxygen cylinders were free standing and unsecured.
In an interview on 08/17/2023 at 8:30 a.m., S18CNA stated all oxygen cylinders should be stored in the oxygen storage area.
Observation on 08/17/2023 at 8:34 a.m. revealed Lounge d's door was unlocked and was being used as a storage room. Further observation revealed, two oxygen cylinders were free standing and unsecured.
In an interview on 08/17/2023 at 8:56 a.m., S2Director of Nursing (DON) stated oxygen cylinders should be stored in the oxygen storage room and should be secured and not freestanding.
Observation on 08/17/2023 at 8:59 a.m. with S1 Administrator, revealed Lounge d's door was unlocked and was being used as a storage room. Further observation revealed, two oxygen cylinders were free standing and unsecured.
In an interview on 08/17/2023 at 8:59 a.m., S1Administrator was asked to confirm if the oxygen cylinder in Lounge d was free standing and unsecured. S1Administrator stated to surveyor you have eyes, don't you and that he would pick up the oxygen cylinders.
3.
Observation on 08/15/2023 at 6:07 a.m., revealed door to Closet e was propped open with a blue rag and unattended. Further observation revealed the area contained a ½ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a ¾ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a full gallon bottle of Comet Disinfecting-Sanitizing Bathroom Cleaner, and a full gallon bottle of Spin and Span All Purpose Cleaner.
Observation on 08/15/2023 at 6:17 a.m., revealed Electrical Room a's door was unattended. Further observation revealed the area contained a large air conditioning unit.
Observation on 08/15/2023 at 6:18 a.m., revealed Electrical Room c's door was unlocked and unattended. Further observation revealed the area contained a large air conditioning unit with a white pipe leading to the ground.
Observation on 08/15/2023 at 6:19 a.m., revealed Electrical Room b's door was unlocked and unattended. Further observation revealed the area contained a large breaker box and a spray bottle of Febreeze air freshener on top of a bucket on the floor.
Observation on 08/15/2023 at 10:30 a.m., revealed door to Closet e was propped open with a blue rag and unattended. Further observation revealed the area contained a ½ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a ¾ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a full gallon bottle of Comet Disinfecting-Sanitizing Bathroom Cleaner, and a full gallon bottle of Spin and Span All Purpose Cleaner.
Observation on 08/16/2023 at 9:28: a.m., revealed door to Closet e was propped open with a blue rag and unattended. Further observation revealed the area contained a ½ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a ¾ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a full gallon bottle of Comet Disinfecting-Sanitizing Bathroom Cleaner, and a full gallon bottle of Spin and Span All Purpose Cleaner.
Observation on 08/16/2023 at 10:00 a.m., revealed Electrical Room a's door was unattended. Further observation revealed the area contained a large air conditioning unit.
Observation on 08/16/2023 at 10:00 a.m., revealed Electrical Room c's door was unlocked and unattended. Further observation revealed the area contained a large air conditioning unit with a white pipe leading to the ground.
Observation on 08/16/2023 at 10:00 a.m., revealed Electrical Room b's door was unlocked and unattended. Further observation revealed the area contained a large breaker box and a spray bottle of Febreeze air freshener on top of a bucket on the floor.
Observation on 08/16/2023 at 1:43 p.m., revealed Electrical Room c's door was unlocked and unattended. Further observation revealed the area contained a large air conditioning unit with a white pipe leading to the ground.
Observation on 08/16/2023 at 1:43 p.m., revealed Electrical Room b's door was unlocked and unattended. Further observation revealed the area contained a large breaker box and a spray bottle of Febreeze air freshener on top of a bucket on the floor.
Observation on 08/16/2023 at 2:35 p.m., revealed Electrical Room a's door was unattended. Further observation revealed the area contained a large air conditioning unit.
In an interview on 08/17/2023 at 8:30 a.m., S18CNA stated the facility had wandering residents and that the Housekeeping closets should be locked because they contained chemicals that could harm the residents.
In an interview on 08/17/2023 at 8:32 a.m., S21LPN stated there were wandering residents in the facility and to protect these residents, the housekeeping closets and electrical rooms should be locked because they can contained hazards to residents.
In an interview on 08/17/2023 at 8:35 a.m., S20CNA stated housekeeping closet doors should be locked, because they contained chemicals and residents could get into them.
In an interview on 08/17/2023 at 8:37 a.m., S15Housekeeper stated the housekeeping closet doors should be locked so that residents cannot get into chemicals.
In an interview on 08/17/2023 at 8:39 a.m., S17Housekeeper stated the housekeeping closet doors should be locked so the wandering residents cannot get to harmful chemicals.
Observation on 08/17/2023 at 8:41 a.m., revealed Closet e was unattended. Further observation revealed a housekeeping cart contained a can of Endust aerosol dusting spray, Glade aerosol air freshener, and a spray bottle that was ½ full of an unidentified yellow liquid. Further observation revealed the area contained a ½ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a ¾ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a full gallon bottle of Comet Disinfecting-Sanitizing Bathroom Cleaner, and a full gallon bottle of Spin and Span All Purpose Cleaner.
In an interview on 08/17/2023 at 8:47 a.m., S21CNA stated the facility had wandering residents. S21CNA further stated the facility's staff have to make sure the doors to the housekeeping closets are locked because residents could go in them and hurt themselves.
Observation on 08/17/2023 at 8:48 a.m., revealed Electrical Room c's door was unlocked and unattended. Further observation revealed the area contained a large air conditioning unit with a white pipe leading to the ground.
Observation on 08/17/2023 at 8:49 a.m., revealed Electrical Room b's door was unlocked and unattended. Further observation revealed the area contained a large breaker box and a spray bottle of Febreeze air freshener on top of a bucket on the floor.
In an interview on 08/17/2023 at 8:50 a.m., S16Housekeeper stated the chemicals that the housekeepers used should be locked up.
Observation on 08/17/2023 at 8:51 a.m., revealed Electrical Room a's door was unattended. Further observation revealed the area contained a large air conditioning unit.
In an interview on 08/17/2023 at 8:52 a.m., S19CNA stated the facility has wandering residents and that in order to protect them, the housekeeping room doors should be locked to keep residents safe. S19CNA further stated that the facility's electrical room doors were supposed to be locked.
In an interview on 08/17/2023 at 8:56 a.m., S2DON stated that the housekeeping closets did not have to be locked if there were no cleaning materials stored in there.
Observation on 08/17/2023 at 8:57 a.m. with S1Administrator revealed, Closet e contained a can of Endust aerosol dusting spray, Glade aerosol air freshener, a spray bottle that was ½ full of an unidentified yellow liquid, a ½ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a ¾ full gallon bottle of P&G Proline Disinfecting Floor and Surface Cleaner II, a full gallon bottle of Comet Disinfecting-Sanitizing Bathroom Cleaner, and a full gallon bottle of Spin and Span All Purpose Cleaner.
In an interview on 08/07/2023 at 8:57 a.m., S1Administrator stated that housekeeping closets should be locked if they contained chemicals.
Observation on 08/17/2023 at 9:00 a.m. with S1Administrator revealed, Electrical Room c's door was unlocked and a large air conditioning unit was inside with white pipe leading to the ground.
Observation on 08/17/2023 at 9:00 a.m. with S1Administrator revealed, Electrical Room b's door was unlocked and unattended. Further observation revealed the area contained a large breaker box and a spray bottle of Febreeze air freshener on top of a bucket on the floor.
In an interview on 08/17/2023 at 9:00 a.m., S1Administrator confirmed a spray bottle of Febreeze air freshener was on top of a bucket on the floor inside Electrical room b.
Observation on 08/17/2023 at 9:01 a.m., revealed Electrical Room a's door was unattended. Further observation revealed the area contained a large air conditioning unit.
In an interview on 08/17/2023 at 9:02 a.m., S1Administrator confirmed the doors to Electrical room a, Electrical room b, and Electrical room c were unlocked.
In an interview on 08/17/2023 at 1:53 p.m., S2DON stated that the facility's QA did not cover leaving doors to areas that could cause accidents and hazards to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to ensure expired medications were not available for administration to residents on 1 (Treatment Cart f) of 1 (Treatment Cart f) treatment carts and 3 medication carts observed for expired medications. There was a total of 1 treatment cart and 3 medication carts in the facility.
Findings:
Observation on 08/16/2023 at 10:15 a.m. revealed the Treatment Cart contained 1 tube of DermaSyn/Ag (a silver antibacterial woundgel) with an expiration date of 07/22/2023, 1 vial of Gentian [NAME] 1% Solution (a solution used as a skin barrier or to treat skin infections) with an expiration date of 07/01/2023, and 1 opened bottle of [NAME] 10% Povidone Iodine (an antiseptic to disinfect skin) with an expiration date of 07/2023.
In an interview on 08/16/2023 at 10:15 a.m., S4Licensed Practical Nurse (LPN) confirmed the 1 tube of DermaSyn/Ag Silver Antibacterial Wound Gel expired on 07/22/2023, the 1 vial of Gentian [NAME] 1% Solution expired on 07/01/2023, and the 1 opened bottle of [NAME] 10% Povidone Iodine expired 07/2023.
In an interview on 08/16/2023 at 10:20 a.m., S2Director of Nursing (DON) confirmed the 1 tube of DermaSyn/Ag Silver Antibacterial Wound Gel, the 1 vial of 1% Gentian [NAME] Solution, and 1 bottle of [NAME] 10% Povidone Iodine were expired. S2DON further stated the expired items should not have been available for use.

Based on observations, interview, and record review, the facility failed to:
1. Properly label and date foods in the kitchen's Walk-In Refrigerator;
2. Maintain dishwasher temperatures per manufacture recommendation; and,
3. Ensure a fan in the kitchen was clean and not blowing over food for resident consumption.
Findings:
1.
Review of the facility's Storage of Refrigerated Foods policy revealed, in part, all non-hazardous, opened foods were labeled with the date.
Observation of the facility's Walk-In Refrigerator on 08/14/2023 at 9:17 a.m., revealed a gallon bag with a light brown substance with no open date labeled, and an open bag of seasoning blend with no open date labeled.
Observation of the facility's Walk-In Refrigerator on 08/15/2023 at 5:15 a.m., revealed a gallon bag with a light brown substance with no open date labeled, and a bag of seasoning blend with no open date labeled.
In an interview on 08/15/2023 at 5:15 a.m., S10Dietary Manager stated the bag of brown substance was white beans, and should have been labeled with an open date, and the bag of seasoning blend should have been labeled with an open date.
2.
Review of the facility's Machine Warewashing Policy revealed, in part, if a chemical sanitizer is used, the temperature of the rinse cycle is to be at least 120 degrees Fahrenheit and should meet the temperature posed on the machine.
Observation on 08/15/2023 at 1:40 p.m., revealed S10Dietary Manager washed a rack of dishes in the facility's dishwasher. Further observation revealed the temperature of the dishwasher's water during the rinse cycle did not rise above 110 degrees Fahrenheit.
In an interview on 08/16/2023 at 1:40 P.M., S10DietaryManager stated the temperature of the dishwasher's rinse cycle water did not match the minimum rinse cycle temperature of 120 degrees Fahrenheit that was posted on the dishwasher's instructions located on the dishwasher itself and the wall next to dishwasher. S10DietaryManager further stated that if the temperature of the dishwasher's water during the rinse cycle was not hot enough, the dishes were not sanitized properly.
3.
Observation on 08/14/2023 at 9:17 a.m., revealed an unknown gray substance on a white box fan blowing over the steam table where resident's food was to be served.
Observation on 08/14/2023 at 11:47 a.m., revealed an unknown gray substance on a white box fan blowing over the steam table where lunch was currently being served.
Observation on 08/15/2023 at 7:08 a.m., revealed an unknown gray substance on a white box fan blowing over the steam table where a staff member was preparing toast, and blowing over the steam table that had food waiting to be served.
Observation on 08/15/2023 at 12:23 p.m. revealed an unknown gray substance on a white box fan blowing over the steam table where lunch was currently being served.
In an interview on 08/15/2023 at 12:24 p.m., S10 Dietary Manager stated that the box fan should not be blowing over the steam table where food is being served to facility's residents.

Based on record review and interview the facility failed to ensure the facility had eight consecutive hours per day of registered nurse (RN) for 2 of 25 weekend staffing hours reviewed for RN coverage as documented on the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form. Findings:
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Report Form for weekends only for the time period of 01/01/2023 to 03/31/2023 revealed there were no documented evidence that a Registered Nurse worked on 02/04/2023 and 03/26/2023.
There was no documented evidence and the facility did not present any documented evidence of having RN coverage for the above mentioned dates and/or had a waiver to exempt the facility from having RN coverage as required.
In an interview on 07/19/2023 at 3:58 p.m. S1Administrator confirmed the facility did not provide the required minimum RN staffing hours on the above mentioned days.

Based on observation, record review and interview, the facility failed to ensure:
1. Walk in cooler and freezer temperatures were being monitored;
2. Dishwasher sanitizer parts per million (ppm) levels were maintained at acceptable ranges; and
3. Dishwasher operating temperatures were maintained within acceptable ranges per policy.
This deficient practice was identified for 1 of 1 walk-in coolers, 1 of 1 freezers, and for 1 of 1 dishwashers, but had the potential to affect any of the 101 residents who consume meals at the facility as identified by the facility's Resident Census and Conditions form (CMS 672).
Findings:
Review of the facility's Machine Warewashing policy (SIC 8) revealed, in part, that if a chemical sanitizer is used the temperature of the rinse cycle is to be at least 120 to 140 degrees Fahrenheit (F) or should meet the temperature posted on the machine.
Observation on 09/08/2022 at 2:02 pm revealed the dishwasher minimum rinse temperature posted on dishwasher was 120 degrees F. Further observation revealed, the sanitizer minimum ppm concentration posted as 100 ppm.
Observation on 09/06/2022 at 11:10 am revealed no thermometer inside the walk-in freezer.
Review of the kitchen temperature log from 09/01/2022 - 09/06/2022 revealed, in part, that only morning walk-in freezer and cooler temperatures were documented on the kitchen temperature log from 09/01/2022 - 09/03/2022. There was no documented evidence and the facility did not present any documented evidence that walk-in cooler and freezer temperatures were being monitored from 09/04/2022 - 09/06/2022.
In an interview on 09/06/2022 at 11:20 am S4Dietary Manager indicated that the system for ensuring refrigerated and frozen stored foods remained at a safe temperature is that kitchen staff reads the thermometer inside the walk-in cooler and freezer. The temperature should be logged in the temperature log book three separate times per day. S4Dietary Manager indicated a thermometer should be in the walk-in freezer but was unable to locate the thermometer. S4Dietary Manager further indicated that the temperature log book needed to be filled out completely but was not.
Observation on 09/08/2022 at 2:00 pm revealed the dishwasher reached a maximum temperature of 100 degrees Fahrenheit. Further observation revealed after three washes the dishwasher reached a maximum temperature of 110 degrees Fahrenheit. After the dishwashing cycle, S4Dietary Manager then measured the sanitizer concentration level with the sanitizer test strip which measured 10 PPM.
In an interview on 09/08/2022 at 2:10 pm S4Cook indicated that the dishwasher maximum operating temperature was consistently 110 degrees F. S4Cook further indicated that was the hottest that she has seen the dishwasher rinse temperature get to.
In an interview on 09/08/2022 at 2:15 pm S4Dietary Manager indicated that the sanitizer ppm of the kitchenware after completion of the dishwasher sanitization cycle was consistently below acceptable levels as indicated on the sanitizer test strips. S4Dietary Manager further indicated that when the morning ppm checks are performed the kitchenware being tested would need to be run through the wash and sanitization cycle up to 5 times in order to achieve the acceptable ppm levels. S4Dietary Manager indicated that not all kitchenware is washed and sanitized 5 times and that the sanitizer ppm was below acceptable levels.

Based on record review and interview, the facility failed to ensure a resident remained free from physical abuse by staff for 1 (Resident #46) of 25 residents who were sampled residents during the investigative phase of the annual survey.
Findings:
Review of Resident #46's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 07/01/2022 revealed Resident #46 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident #46 was cognitively intact.
Review of the facility's incident report revealed, in part, Resident #46 reported to S1Administrator that S7Houskeeper grabbed her by the forearm and shoved her out of the restroom on 08/21/2022.
Review of the facility's abuse policy, in part, revealed physical abuse includes inappropriate physical contact that is harmful or likely to cause harm to a resident.
In an interview on 09/06/2022 at 2:55pm Resident #46 stated S7Housekeeper came into her room and went into the bathroom S7Housekeeper grabbed her arms and shoved her out of the bathroom. Resident #46 further stated she had bruises to both her arms after this occurred.
Review of Resident #46's physician's orders, in part, revealed an order to monitor bruising Resident #46's left forearm and right forearm daily with a start date of 08/22/2022.
In an interview on 09/09/2022 at 11:47am S1Administrator stated he watched the video recordings on 08/21/2022 and he saw Resident #46 exit and return to her room with no marks on her arms. S1Administrator further stated he then saw S7Housekeeper enter Resident #46's room and the next time Resident #46 exited her room she had bruising on both her arms. S1Administrator confirmed S7Houskeeper should not have physically abused Resident #46 and S7Housekeeper was terminated for the abuse.
Review of S7Housekeeper's personnel file revealed she was terminated on 08/29/2022 for improper conduct and substantiated allegation of abuse.
In an interview on 09/09/2022 at 2:07pm S2Director of Nursing stated the nurse that worked on 08/21/2022 did not know S7Housekeeper put her hands on Resident #46 until after the investigation. S2Director of Nursing confirmed S7Housekeeper should not have physically abused Resident #46.

Based on observation, record review and interview the facility failed to apply a left hand splint as ordered by the physician for 1 of 1 residents investigated for range of motion in a total sample of 35, but had the potential to affect any of the 25 residents identified as having contractures as documented on the facility's Resident Census and Conditions of Residents (Form CMS-672).
Findings:
Review of Resident #14's record revealed an active diagnosis of Hemiplegia following cerebral infarction affecting left non-dominate side.
Review of Resident #14's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 06/13/2022 revealed, in part, the following: Resident #14 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitive impairment; and impaired range of motion in bilateral upper and lower extremities.
Review of Resident #14's August 2022 Physician's Orders revealed, in part, an order to apply left hand splint 6-8 hours a day as tolerated.
Review of Resident #14's Care Plan revealed, in part, the following problems and interventions: Resident #14 had physical mobility impairments related to cerebrovascular disease with left sided hemiplegia with a goal to maintain current level with no decline in function and an intervention for nursing to apply a left hand splint 6-8 hours a day as tolerated.
Review of Electronic Medication Administration Record for August and September 2022 revealed, in part, Resident #14's left hand splint was not applied on 09/06/2022.
In an interview and observation on 09/06/2022 at 2:25pm, Resident #14 was lying in bed with her left hand clinched and her left arm pulled into the left side of her abdomen. Resident #14 explained she could not use the left side of her body and the staff did not use a towel roll or a splint in her left hand. Resident #14 then used her right hand to slightly pry open her fingers from her left palm and acknowledged she would like to use a splint in her left hand.
Observation on 09/07/2022 at 12:16pm, Resident #14's left hand remained clinched and her left arm was drawn into the left side of her abdomen. Resident #14 did not have a hand splint and/or any type of supportive device in her left hand.
Observation on 09/08/2022 at 11:40am, Resident #14 had a yellow paper labeled Communication Sheet posted on her closet door which read to apply left hand splint as tolerated. Further observation revealed Resident #14's left hand remained clinched and her left arm was drawn into the left side of her abdomen. Resident #14 did not have a hand splint and/or any type of supportive device in her left hand.
In an interview on 09/09/2022 at 10:30am, S8LPN (Licensed Practical Nurse) was unable to verify if Resident #14 used a splint in her left hand daily.
In an interview on 09/09/2022 at 10:35am, S2DON (Director of Nursing) acknowledged the restorative aids were responsible for placing the hand splint to Resident #14's left hand.
In an interview on 09/9/2022 at 10:38am, S7CNA (Certified Nurse Assistant) and S9CNA both acknowledged Resident #14 had not received restorative services since she was admitted to hospice services (09/08/2020).
In an interview on 09/09/2022 at 10:45am, S2DON explained the application of the left hand splint was a nursing order and even though the order reads to apply the left hand splint the nurses did not have to apply it. S2DON further explained the nurses sign the splint order every shift only to acknowledge there was an order. S2DON did not provide an explanation as to why Resident #14 did not have the left hand splint applied as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident identified as an unsafe smoker wore a smoking apron as ordered and was not allowed to smoke alone for 1 of 9 (Resident #71) smokers residing in the facility as documented on the facility's list of smokers.
Findings:
Review of active diagnosis revealed, in part, Resident #71 had a diagnosis of Non-exudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement.
Review of the facilities Smoking Policy revealed, in part, it may be necessary to place smoking restrictions on individual residents because of safety reasons. Do not allow residents who have been classified as non-responsible to smoke alone.
Review of Resident #71's August 2022's Physician Orders revealed, in part, Resident #71 had an order with a start date of 10/04/2021 as follows: Resident was an (unsafe) smoker and needs a smoking apron.
Review of Safe Smoking assessment dated [DATE] revealed, in part, Resident #71 was an unsafe smoker and required a smoking apron.
Review of Care Plan revealed, in part, Resident #71 had a potential for injury related to smoking and was an unsafe smoker with an intervention indicating Resident #71 needed a smoking apron. Further review of care plan revealed, in part, Resident #71 had a visual deficit related to resident was blind and can only see shapes.
In an interview on 09/06/2022 at 1:00pm, Resident #71 acknowledged she could not hold her cigarette to light it because sometimes she would light it in the middle of the cigarette instead of on the end. Resident #71 further acknowledged she asked other residents to light her cigarette for her.
Observation on 09/07/2022 at 10:45am, Resident #71 was outside smoking and was not using a smoking apron.
In an interview on 09/09/2022 at 10:52am, S5Clinical Care Coordinator (CCC) acknowledged Resident #71 was an unsafe smoker due to visual impairments and can only see shadows. S5CCC indicated Resident #71 needed assistance lighting her cigarettes and asks other residents to light them for her. S5CCC further acknowledged resident was occasionally non-compliant and did not always use the smoking apron.
In an interview on 09/09/2022 at 10:55am, S2Director of Nursing (DON) acknowledged Resident #71 was visually impaired, classified as an unsafe smoker, and required the use of a smoking apron. S2DON indicated that if Resident #71 was unable to light her own cigarette she required supervision and assistance from staff to light her cigarette.