Flannery Oaks Guest House

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 1 (#201) of 32 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect the100 residents that resided in the facility.
Findings:
Resident #201
Review of Resident #201's clinical record revealed she was admitted to the facility on [DATE].
Review of Resident #201's Admit Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact.
Review of Resident #201's physical chart revealed no indication of Resident #201's code status.
Review of Resident #201's [DATE] Physician Orders revealed:
[DATE] CPR (Cardiopulmonary Resuscitation)
Review of Resident #201's Electronic Health Record on [DATE] revealed a Full Code Status.
On [DATE] at 10:10 a.m., an interview was conducted with S19LPN. She stated in the situation a code would arise, she would follow Resident #201's code status on the physical chart. S19LPN reviewed Resident #201's physical chart and confirmed there was no indication of Resident #201's code status.
On [DATE] at 1:51 p.m., an interview was conducted with S2DON. She confirmed the code status should be found in the physical chart and the electronic chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 of 2 (#201 and #401) residents reviewed for accommodation of needs.
Findings:
Review of the facility's policy, Resident Call Light System, dated 09/14/2022, revealed the following, in part:
Purpose: To provide a communication system with audible or visual signals to allow residents to call for staff assistance .
Procedure 6. When providing care to residents, be sure to positon the call light conveniently within reach for the resident to use.
Resident #201
Review of Resident #201's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Transient Ischemic Attack and chronic pain.
Review of Resident #201's admission MDS with an ARD of 06/17/2025, revealed a BIMS score of 15, which indicated she was cognitively intact.
Review of Resident #201's current care plan revealed the call light was to remain within reach as an established intervention for bowel/bladder incontinence.
On 06/29/2025 at 10:00 a.m., an observation was made of Resident #201 in her room. She was sitting upright in a Geri chair with the call light not within her reach. An interview was conducted with Resident #201 at this time and she confirmed the call light was not within her reach.
On 06/29/2025 at 10:45 a.m., an interview and observation was conducted with S22CNA. S22CNA confirmed Resident #201 utilizes the call light to request staff assistance. S22CNA observed Resident #201 sitting in a Geri chair in her room and she confirmed the call light was not within Resident #201's reach.
Resident #401
Review of Resident #401's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Senile Degeneration of the brain and pain in leg.
Review of Resident #401's current care plan revealed she required assistance from staff for ADLs.
On 06/30/2025 at 8:47 a.m., an observation was made of Resident #401 in her room. She was sitting upright in a Geri chair with the call light in the center of the bed, not within her reach. An interview was conducted with Resident #401 at this time and she confirmed the call light was not within her reach.
On 06/30/2025 at 8:56 a.m., an interview and observation was conducted with S7CNA. S7CNA confirmed Resident #401 utilizes the call light to request staff assistance. S7CNA observed Resident #401 sitting in a Geri chair in her room with the call light in the center of the bed. She confirmed the call light was not within Resident #401's reach.
On 06/30/2025 at 1:45 p.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. She confirmed call lights should be within a resident's reach at all times.

Based on interviews and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.
This deficient practice had the potential to affect a census of 100 residents.
Findings:
Review of the facility's policy, Quality Meeting Policy and Procedure, dated 04/28/2025 revealed, in part, the following:
Purpose: To identify, respond, track and trend, and monitor for improvement of facility potential quality deficiencies. The overall goal is to improve the quality of care for the residents of the facility.
Policy:
II. Facility will monitor performance by previous performance, established benchmarks, and/or determined by the QAA committee.
IV. The quality assessment and assurance committee will meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; such as, identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary.
Review of the facility's Quality Improvement Corrective Action Plan revealed in part, the following:
Identified Date: 05/20/2025
1. Corrective actions taken by:
a. The Nursing Facility Administrator and/or designee have initiated a quality review to determine average call light response times.
2. Identification of at-risk population: All residents have the potential to be affected by delayed call light responses and are considered potentially impacted by the deficient practice.
3. Measures and System Changes to Prevent Recurrence:
c. CNAs must ensure that call lights remain within resident's reach at all times, especially after care is completed or following transfers or repositioning.
4. Monitoring and Quality Assurance:
a. All direct care staff will be re-in serviced on proper call light placement and the expectation for immediate response.
b. The NFA or designee will audit call light weekly to evaluate response times and identify trends requiring corrective action.
e. Negative outcomes or recurrent delays in call light response will be reviewed during the Interdisciplinary Team (IDT) meetings for case-based problem-solving.
Review of the facility's in-service log revealed in part, the following:
Date completed: 06/07/2025
Topics discussed: After care call lights should be placed within reach of the resident whether the resident is in bed or in their wheelchair. If you roll a resident to their room do not forget to clip call light to resident or attach to resident's chair or blanket.
Review of the facility's monitoring forms revealed documentation for 06/07/2025 and 06/09/2025. No further documented evidence of monitoring was provided for review upon request.
Review of the facility's follow-up documentation revealed in part, the following:
Date completed: 06/26/2025
Several residents noted sleeping in chairs without call light. Expectations set and will continue with QA until no further issues noted. No further documented evidence of monitoring was provided for review upon request.
On 07/02/2025 at 11:18 a.m., an interview was conducted with S1ADM. He stated that he was responsible for the facility's QAPI program. He stated a QAPI pertaining to call light response time and placement was initiated on 05/20/2025. He stated S4CNAS was responsible for ongoing monitoring of call light response times and call light placement. He stated any identified issues were discussed in the weekly IDT meeting. He confirmed there was no documentation of monitoring after 06/09/2025, no changes were made to the corrective action plan, and he observed call lights not within several residents' reach on 06/26/2025.
On 07/02/2025 at 11:35 a.m., an interview was conducted with S4CNAS. She stated she was responsible for completing daily monitoring for call light response times and placement. She stated she had not filled out a monitoring form since 06/09/2025. She stated all issues found during her monitoring rounds were discussed in the weekly IDT meetings. She confirmed she continued to find call lights not within reach and no new changes have been made to the corrective action plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medication administration was accurately documented for 1 (#202) of 2 (#51 and #202) residents reviewed for pain.
Findings:
Review of Resident #202's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Pain.
Review of Resident #202's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2025 revealed a Brief Interview for Mental Status (BIMS) of 13, indicating the resident was cognitively intact.
Review of the facilities standing orders revealed an order for Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for general discomfort.
Review of Resident #202's June Medication Administration Record (MAR), printed and reviewed on 06/30/2025 at 3:40 p.m., revealed no documentation of an order for Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for general discomfort.
On 06/29/2025 at 10:11 a.m., an interview was conducted with Resident #202. She stated she had right foot pain and requested Acetaminophen from her nurse for the pain.
On 06/29/2025 at 10:11 a.m., an interview was conducted with S21LPN. She confirmed Resident #202 complained of right foot pain and administered Acetaminophen for Resident#202's discomfort.
On 06/30/2025 at 3:30 p.m., an interview was conducted with S20LPN. She reviewed Resident #202's physician orders and confirmed she did not have an order for Acetaminophen. She stated the Acetaminophen was a standard order. She confirmed if Acetaminophen was administered the order should have been entered in the computer in order to document the medication administration.
On 07/01/2025 at 10:27 a.m., an interview was conducted with S21LPN. She stated on the weekend of 06/21/2025-06/22/2025 and on 06/29/2025, Resident #202 complained of right foot pain and she administered Acetaminophen for discomfort. She stated the Acetaminophen was a standard order. She stated when a standing order was administered, the medication should be added to the orders and placed on the MAR so staff could document the date and time the medication was administered. She confirmed she administered 2 doses of Acetaminophen to Resident #202 and did not documented it.
On 07/01/2025 at 1:53 p.m., an interview was conducted with S2DON. She stated medication standing orders were not entered in the computer unless the medication was administered. She confirmed if staff administered Acetaminophen, the medication should have been entered and placed on the MAR, so staff could document the date and time the medication was administered.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly sealed, stored, and dated in the refrigerator and dry storage area of the facility's kitchen.
This had the potential to affect 100 residents who were served from the kitchen.
Findings:
Review of the facility's policy, titled, Food Storage Labeling, with a revised date of 10/2018, revealed, in part:
The facility will store and label all foods to ensure safety and quality.
7. Food is stored in containers that are sealable, leak proof, durable and undamaged.
Review of the facility's policy titled, Food Service Operation Standards for Purchasing, Cooking and Storage, with a revised date of 10/2018, revealed, in part:
3. Storage
a. Store food only in designated storage areas
8. Cooling and storing
g. Label and store foods with the date and time they were prepared to indicate when to discard
An initial tour of the kitchen was conducted on 06/29/2025 at 9:15 a.m. with S18CO. Observations were made of the following items:
Dry Storage:
1-gallon, ¾ full of soy sauce, opened, with no opened date and refrigerate after opening on the product label.
Refrigerator
1-packet, 1/2 full of sliced deli ham, unsealed.
On 06/29/25 at 9:26 a.m., an interview was conducted with S18CO. She confirmed the aforementioned findings, which were observed in the kitchen. She stated all food should be sealed, dated, and stored properly and was not.
On 06/30/25 at 8:26 a.m., an interview was conducted with S15DM. She confirmed all food in the dry pantry and refrigerator should be dated, stored, and sealed appropriately.

Based on observation, record review and interviews, the facility failed to post nurse staffing data on a daily basis which included the total resident census. This deficient practice had the potential to affect the 100 residents residing in the facility.
Findings:
On 06/29/2025 at 9:08 a.m., an observation was made of the Daily Staffing Reporting Form dated 06/27/2025 with no resident census listed.
On 06/29/2025 at 9:43 a.m., an interview was conducted with S16UC. She stated she was responsible for posting the Daily Staffing Reporting Form on the weekends. She stated she turned in the Daily Staffing Reporting Forms to S2DON.
On 06/29/2025 at 9:50 a.m., a record review was conducted of the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and revealed no resident census was listed on any of the forms provided.
On 06/30/2025 at 8:26 a.m., an interview was conducted with S9UC. She stated she worked Monday through Friday and was responsible for posting the Daily Staffing Reporting Forms in the mornings. She stated S11HR collected the Daily Staffing Reporting Forms at the end of the day. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been.
On 07/01/2025 at 9:24 a.m., an interview was conducted with S2DON. She stated the Unit Clerks were responsible for completing the Daily Staffing Reporting Forms and posting it in the main lobby. She stated the Daily Staffing Reporting Form should be completed with the resident census, date, facility name and staffing information. She stated S11HR was responsible for collecting those sheets. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been.
On 07/01/2025 at 1:41 p.m., an interview was conducted with S11HR. She stated the Unit Clerks were responsible for completing and posting the Daily Staffing Reporting Form. She stated the Daily Staffing Reporting Form should be complete and accurate. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure that a resident was provided services to restore as much normal bladder and bowel function as possible for 1 (#351) of 2 (#45, and #351) residents reviewed for Bladder and Bowel Incontinence.
Findings:
Review of the facility's policy titled Bowel and Bladder Program Policy and Procedure with an effective date of 09/11/2014, revealed the following, in part:
Purpose: To potentially improve resident's bladder and/or bowel functional control and promote dignity and wellbeing through a scheduled toileting program.
Policy: To implement an individual, organized toileting program after voiding patterns have been established and a potential benefit for scheduled toileting has been identified and deemed medically appropriate.
Review of Resident #351's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder, Constipation, and Acute Cystitis.
Review of Resident #351's current Care Plan revealed the following, in part: Resident requires staff assistance for Activities of Daily Living care. Interventions included: assist resident with toilet transfers.
Review of Resident #351's Progress Notes revealed the following, in part: Brief Interview for Mental Status on 06/25/2025 revealed Resident #351 had a BIMS of 12-indicating moderately impaired cognition. Further review of notes revealed Resident #351 was admitted on [DATE] with an indwelling, Urinary Catheter, but it was removed on 06/27/2025.
An interview and observation was conducted on 06/30/2025 at 9:59 a.m. with Resident #351. Resident #351 reported she had her urinary catheter removed last week due to frequent urinary infections and staff had not been assisting her with maintaining her continence. She stated staff refused to assist her to the toilet. Observation of resident revealed she was wearing a urine soaked brief.
An interview and observation was conducted on 07/01/2025 at 10:02 a.m. with Resident #351. Resident #351 was wearing an adult brief which was soiled with urine and reported she would prefer to use the toilet but required physical assistance from staff, and stated staff did not assist her with toilet transfers. She further confirmed since admission she has not been assisted to the toilet by staff or been placed on a bowel/ bladder training program.
An interview was conducted on 07/01/2025 at 10:36 a.m. with S23LPN. She confirmed Resident #351 was incontinent. She further confirmed Resident #351 was a one person assist to transfer and if she was transferred to bathroom she could use the toilet, but she had never assisted Resident #351 to the toilet.
An interview was conducted on 07/01/2025 at 11:05 a.m. with S3ADON. S3ADON confirmed Resident #351 has not been on a bowel or bladder incontinence training program and that Resident #351 called staff for assistance when she is soiled. She confirmed resident was aware when she was soiled and further confirmed Resident #351 can stand to transfer to toilet with staff assistance.
An interview was conducted on 07/01/2025 at 3:30 p.m. with S13LPN. S13LPN confirmed Resident #351 has had foul smelling urine. She further confirmed Resident #351 requires staff assistance to transfer to toilet but has not been placed on a bowel/ bladder training program, instead she was placed in a brief.
An interview was conducted on 07/02/2025 at 8:54 a.m. with S5 LPN. S5LPN confirmed she was responsible for assessing bowel and bladder continence of Resident #351 upon admission. She reported Resident #351 told her she was soiling in her brief but would like to go on the toilet. S5LPN further confirmed Resident #351 could transfer to toilet with staff assistance, but was never placed on a bowel/ bladder training program, and should have been.
An interview was conducted on 07/02/2025 at 8:58 a.m. with S2DON. She confirmed the facility's goal was to provide services to restore as much normal bowel and bladder function as possible for each resident and that the new suggestions for Resident #351 as of 07/01/2025 was for her to use a bed pan despite resident being a one person assist to transfer. She further confirmed resident was never placed on a bowel or bladder training program to restore as much normal function as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure:
1.
Nursing staff adequately conducted full body skin assessments for 1 (#202) of 2 (#75 and #202) residents reviewed for skin injury and;
2.
Nursing staff communicated changes in resident status to oncoming nursing staff for 1 (#202) of 2 (#51 and #202) residents reviewed for pain.
Findings:
Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2024) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part:
3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities.
7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team.
Review of Resident #202's clinical record revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: Pain, Unspecified and Long Term (Current) Use of Anticoagulants.
Review of Resident #202's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2025 revealed a Brief Interview for Mental Status (BIMS) of 13, indicating resident was cognitively intact.
Review of Resident #202's current Physician Orders revealed the following, in part:
06/10/2025 weekly body audit completed on 06/22/2025 and 06/29/2025 by S21LPN.
1.
On 07/01/2025 at 10:35 a.m., an observation was conducted with S20LPN. Resident # 202 was noted lying in her bed with red gripper socks noted on her feet. S20LPN removed the sock and noted the upper right foot with red bruising, the second toe noted to be dark purple, purple bruising extended to the big toe and 3rd toe, and swelling noted to the right ankle. Resident # 202 reported pain to touch of her right foot. Resident #202 stated the second toe was better because over the weekend it was black.
On 07/01/2025 at 11:27 a.m., an interview was conducted with S21LPN. She stated Resident # 202 had weekly skin audits conducted weekly, every Sunday. She stated she completed Resident #202's weekly skin audit on 06/29/2025 and observed no skin issues. She confirmed when conducting the skin audit she did not remove Resident #202's socks and should have.
2.
On 07/01/2025 at 11:27 a.m., an interview was conducted with S21LPN. She confirmed she did not report to oncoming staff Resident #202 complained of right foot pain and swelling on 06/29/2025.
On 07/02/2025 at 8:45 a.m., an interview was conducted with S24LPN. She stated she received report from the night shift, and was not informed of Resident # 202's right foot pain, swelling, or pending x-ray results and should have been.
On 07/02/2025 at 10:06 a.m., an interview was conducted with S25LPN. She stated she provided care to Resident # 202 on the night shift of 07/01/2025. She stated she received report Resident #202 complained of foot pain and had an x-ray completed on 07/01/2025 with results pending. She confirmed she did not report the above information to the oncoming day shift staff on 07/02/2025 and should have.
On 07/02/2025 at 10:31 a.m., an interview was conducted with the S2DON. She stated skin audits were conducted weekly on an assigned day. She confirmed Resident #202's body audit was conducted on Sundays. She further confirmed weekly body audits should include visual observation of all the skin including removing the socks to observe the toes. She confirmed nursing staff should report any pending x-ray results or new bruising identified to the oncoming nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 2 (#29 and #56) of 20 residents Care Plans reviewed in the final sample. The facility failed to ensure the Comprehensive Care Plan included the following:
1.
Resident #29's discharge goals; and
2.
Resident #56's physical need for a Mechanical Lift for transfers.
1.
Review of Resident #29's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Rheumatoid Arthritis.
Review of Resident #29's most recent Care Plan revealed no documented evidence of discharge plans.
2.
Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia, Hemiparesis, Muscle Wasting to Multiple Sites, and Lack of Coordination.
Review of Resident #56's most recent Care Plan revealed no documented evidence the resident required use of Mechanical Lift for safe transfers.
An interview was conducted on 07/01/2025 at 11:21 a.m. with S3ADON. She confirmed Resident #56 required two person assist with a mechanical lift for transfers.
An interview was conducted on 07/01/2025 at 11:59 a.m. with S8LPN. She confirmed Resident #56 required two person assist with a mechanical lift for transfers. She further confirmed she was responsible for the Care Plan and Resident #56's transfer status should be documented in the Care Plan, but was not.
An interview was conducted on 07/02/2025 at 8:58 a.m. with S2DON. She confirmed all Care Plans should be developed to each resident's individualized needs. She further confirmed discharge plans should be documented in the Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with a mental disorder had an accurate Pre-admission Screening and Resident Review (PASARR) for 1 (#16) of 1 (#16) resident reviewed for PASARR.
Findings:
Review of Resident #16's Medical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Delusional Disorder.
Review of Resident #16's Level 1 Pre-admission Screening PASARR completed by a social worker at a local hospital dated 06/20/2024 revealed in part, the following:
Section III: Mental Illness - Yes
An interview was conducted on 06/30/2025 at 10:00 a.m. with S17SW. S17SW confirmed Resident #16's Pre-admission Level I PASSAR PASARR Screening dated 06/20/2024 did not contain a diagnosis of Delusional Disorder. She reviewed facility records and could not produce documentation of Level II PASARR review was requested, and confirmed it should have been.
An interview was conducted on 07/01/2025 at 2:00 p.m. with S2DON. S2DON reviewed Resident #16's Pre-admission Level I PASSAR PASARR Screening dated 06/20/2024. S2DON confirmed it did not contain her diagnosis Delusional Disorder. She confirmed the facility did not resubmit a new resident review, and should have.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#99) of 3 (#98, #99, #100) residents reviewed for closed records.
Findings:
Review of Resident #99's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/03/2025 revealed Resident #99 was discharged to a Short-Term General Hospital.
Review of Resident #99's Nurse's Notes revealed the following, in part:
04/03/2025 at 2:19 p.m. Resident #99 discharged home with wife via personal transportation.
On 07/01/2025 at 1:45 p.m., an interview was conducted with S2DON. She stated she expected MDS nurses to complete all assessments to accurately reflect each residents' discharge status.
On 07/01/2025 at 2:03 p.m., an interview was conducted with S6LPN. She reviewed Resident #99's Nurse's notes and confirmed he discharged to home/community. She reviewed Resident #99's Discharge MDS with an ARD of 04/03/2025 and confirmed it indicated he discharged to a Short-Term General Hospital. She confirmed Resident #99's discharge status was not coded correctly and should have been coded as discharged to home/community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by S5CNA.
The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
A review of the facility's policy dated 03/05/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part:
Purpose: Each resident has the right to be free from abuse .No one shall abuse a resident .This policy applies to facility staff
Policy:
3. Physical Abuse includes hitting, slapping .
A review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. The resident had diagnoses, which included Vascular Dementia, Depression, and Anxiety Disorder.
A review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/2024 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact.
A review of the facility's Self-Reported Incident Report, dated 12/22/2024, revealed the following, in part:
Victim: Resident #2
Accused: S5CNA
Allegations: Physical abuse
Incident Occurred: 12/22/2024
A review of Resident #2's Nurse's Note dated 12/22/2024 at 8:10 a.m. revealed the following, in part:
Resident #2 was upset because he didn't receive coffee on his breakfast tray. Resident #2 threatened to hit S5CNA in the face. Resident #2 hit S5CNA, and S5CNA hit Resident #2. Resident #2 and S5CNA were separated. Resident #2 denies injury. Police, NP, RP, and S1ADM notified.
A review of S5CNA's written statement dated 12/22/2024 revealed the following: Resident #2 said he would hit me. Resident #2 hit me, and I responded with my hand, popping Resident #2.
A review of S7HK's written statement dated 12/22/2024 revealed the following: Resident #2 slapped S5CNA in the face, and S5CNA hit Resident #2.
On 12/30/2024 at 10:50 a.m., an interview was conducted with S7HK. She stated she was working on 12/22/2024, and she witnessed the physical altercation between Resident #2 and S5CNA. She stated Resident #2 hit S5CNA in her face. She stated S5CNA hit Resident #2 on his forehead with the palm of her hand. She stated she separated Resident #2 and S5CNA. She stated S5CNA hitting Resident #2 was abuse. She stated she received in-services on abuse prevention and prohibition on 12/22/2024.
On 12/30/2024 at 11:05 a.m., an interview was conducted with S2DON. She stated on 12/22/2024, S1ADM called her and notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated she assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by herself and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated she received the in-service on 12/22/2024 by S1ADM. She stated Resident #2 was assessed daily by herself for 3 days and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified.
On 01/02/2025 at 8:30 a.m., an interview was conducted with S1ADM. He stated on 12/22/2024, he was notified of the altercation between Resident #2 and S5CNA. He stated he reviewed camera footage, which revealed Resident #2 hit S5CNA in her face, and then S5CNA hit Resident #2 on his forehead. He stated he saw S7HK separate Resident #2 and S5CNA. He stated S5CNA was sent home as soon as the incident occurred and was terminated. He stated it was never appropriate for a staff member to hit a resident. He stated S2DON assessed Resident #2, and no injuries were noted. He stated police, Resident #2's RP, and state office were notified on 12/22/2024. He stated following the incident all staff received in-services on abuse prevention and prohibition with a posttest given by himself and S2DON starting on 12/22/2024 with 100% completion by 12/25/2024. He stated he received the in-service on 12/22/2024 by corporate. He stated all staff had a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition. He stated Resident #2 was assessed daily for 3 days by S2DON and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. He stated random residents were interviewed daily for 2 weeks to monitor for further abuse allegations by S2DON, with none identified. He stated in morning meetings, he followed up for 2 weeks to ensure a resident had not voiced concerns of potential abuse, with none identified.
On 01/02/2025 at 8:33 a.m., an interview was conducted with Resident #2. He stated on 12/22/2024, he hit S5CNA in the face and S5CNA hit him in the forehead with her hand. He stated S5CNA was taken out of the facility and terminated. He stated S2DON assessed him for injuries and checked on him daily since 12/22/2024. He stated the social worker interviewed him multiple times following the incident.
On 01/02/2025 at 9:02 a.m., an interview was conducted with S8SSD. She stated on 12/22/2024, S2DON notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated S2DON assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by S2DON and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated Resident #2 was assessed daily by S2DON for 3 days and interviewed by herself 3 times a week for 2 weeks to monitor for changes, with none identified. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified.
On 01/02/2025 at 9:19 a.m., an interview was conducted with S3RN. She stated she received in-services on 12/23/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON.
On 01/02/2025 at 9:22 a.m., an interview was conducted with S6RN. She stated she received in-services on 12/22/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON.
Throughout the survey from 12/30/2024 to 01/02/2025, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, and the effect of staff approach in relation to resident's behaviors. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately.
The facility had implemented the following actions to correct the deficient practice:
1. Corrective actions were accomplished for residents found to be affected by the alleged deficient practice include:
a. Resident #2 and S5CNA separated. Resident #2 brought to a safe place. S5CNA was escorted outside of the facility.
b. Administrator notified.
c. Police notified.
d. Head to toe assessment completed on Resident #2.
e. Resident #2 and S5CNA interviewed and statements received.
f. In-service all staff regarding policy and procedure for abuse prevention and prohibition.
2. All residents have the potential to be affected by this alleged deficient practice.
3. The measures put into place to prevent this alleged deficient practice from re-occurring:
a. In-service all staff regarding policy and procedure for abuse prevention and prohibition.
b. Residents with a BIMS of 9-15 interviewed by staff to ensure that the resident has not felt abused and that each resident feels safe.
c. Resident #2 interviewed by social services 3 times a week for 2 weeks to ensure Resident #2 does not have any psychological concerns following the incident.
d. Head to toe assessment completed by nurse daily for 3 days to ensure Resident #2 does not have any physical concerns following the incident.
4. Facility will monitor its performance to ensure sustained compliance by the following:
a. Administrator and or designee will have a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition.
b. Administrator and or designee will follow-up in morning meeting and with weekend supervisor for 2 weeks and as needed to ensure a resident has not voiced concerns of potential abuse.
c. Additional in-servicing and/or progressive disciplinary action will occur if further noncompliance is noted.
5. Corrective action will be completed by 01/07/2025.

Based on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment.
Findings:
Review of the facility's policy titled, MDS Policy and Procedure with an effective date of 06/25/2015 revealed the following, in part:
Policy Statement:
All Minimal Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual.
Resident #1
On 01/02/2025, a review of Resident #1's MDS assessment revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 12/18/2024. Further review revealed the MDS assessment was not completed by 01/01/2025.
Resident #3
On 01/02/2025, a review of Resident #3's MDS assessment revealed a Quarterly MDS with an ARD of 12/11/2024. Further review revealed the MDS assessment was not completed by 12/25/2024.
An interview was conducted on 01/02/2025 at 11:50 a.m. with S4MDS. He confirmed all Quarterly Assessments should be completed within 14 days of the ARD. He confirmed Resident #1's MDS should have been completed by 01/01/2025, but was not completed timely. He further confirmed Resident #3's MDS should have been completed by 12/25/2024, but was not completed timely.
An interview was conducted on 01/02/2025 with S2DON. She confirmed Quarterly MDS Assessments should be completed within 14 days of the ARD. She further confirmed Resident #1 and Resident #3's Quarterly MDS Assessments were not completed timely, but should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a therapeutic diet for 2 (#9 and #78) of 3 (#9, #70 and #78) residents reviewed for nutritional status.
Findings:
Resident #9
Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Dementia; Alzheimer's; Delusional Disorders; Aphasia; and Dysphagia.
Review of Resident #9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, which indicated resident had severe cognitive impairment. Further review revealed, in part, Resident #9 received a therapeutic diet.
Review of Resident #9's current Physician Orders revealed, in part, the following:
02/01/2024: Pudding with Lunch and Dinner;
02/26/2024: Protein Juice with all Meals; and
10/03/2023: Ice Cream with Lunch and Supper.
Review of Resident #9's Nutrition Assessment, dated 01/29/2024, revealed, in part, the following:
Nutrition Diagnosis: Inadequate energy intake due to condition .
Nutrition Interventions: . Receiving ice cream with lunch and supper. Significant weight loss of 5% in 49 days. Continue to encourage intake.
Review of Resident #9's Care Plan, revealed, in part, the following:
I am at risk for weight loss related to poor intake. (Created 11/15/2023.)
I need my meals served as ordered by my physician; and
Provide my supplements to me as ordered.
Review of Resident #9's meal ticket revealed no documentation of the need for protein juice drink with all meals, pudding with lunch and dinner or ice cream with lunch and supper.
An observation was conducted on 05/13/2024 at 12:10 p.m. with S10CNA. Resident #9 was observed in bed with S10CNA seated at bedside feeding her. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray.
An observation was conducted on 05/14/2024 at 11:35 a.m. with S12CNAS. Resident #9 was observed seated in her wheelchair in the main dining room. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray. S12CNAS confirmed there was not a protein juice, pudding or ice cream present on Resident #9's meal tray. S12CNAS confirmed she was not aware of any orders for Resident #9 to receive extra items with meals.
An interview was conducted on 05/15/2024 at 8:50 a.m. with S4NP. She confirmed Resident #9 had some weight loss since the beginning of the year and should be receiving ice cream with lunch and supper, pudding with lunch and dinner and a protein juice with all meals. She confirmed if she was not receiving the extra food/beverage items as ordered, this could be a contributing factor to her weight loss. S4NP confirmed she would expect staff to follow orders as written.
Resident #78
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy.
Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed, in part, Resident #78 received a therapeutic diet.
Review of Resident #78's current Physician Orders revealed, in part, the following:
03/19/2024: Protein Juice Drink with all Meals;
02/09/2024: Pureed Soup with Lunch and Dinner; and
10/03/2023: Ice Cream with Lunch and Supper.
Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following:
Problem: Nutrition/Hydration diminished due to disease progression.
Goal: For facility staff to adjust to changing nutritional needs, ongoing.
Review of Resident #78's meal ticket revealed no documentation of the need for protein juice drink with all meals, pureed soup with lunch and dinner or ice cream with lunch and supper.
An observation was conducted on 05/13/2024 at 12:05 p.m. of Resident #78's bedside table sitting next to the bed with his lunch tray sitting on top. No protein juice, ice cream or soup was noted on his meal tray.
An observation was conducted on 05/14/2024 at 11:25 a.m. with S10CNA. Resident #78's meal tray was observed arriving to his room without protein juice, ice cream or soup on his meal tray. S10CNA confirmed Resident #78's meal tray did not contain a protein juice, ice cream or soup. S10CNA confirmed Resident #78 did not typically receive those items and she was not aware he should.
An interview was conducted on 05/15/2024 at 9:50 a.m. with Resident #78's hospice nurse. She confirmed Resident #78 was one of her patients. She confirmed the hospice agency expected the facility staff to follow all of Resident #78's orders as written.
An interview was conducted on 05/14/2024 at 11:40 a.m. with S12CNAS. S12CNAS confirmed the dietary staff were in charge of placing the appropriate food and beverage items on each resident's tray to match their orders.
An interview was conducted on 05/15/2024 at 12:40 p.m. with S11DS. S11DS confirmed she was aware of a history of weight loss for Resident #9 and Resident #78 but was not aware of any current dietary addition orders for either of them. S11DS provided a copy of Resident #9 and Resident #78's meal tickets, which did not accurately reflect the resident's current dietary orders. S11DS stated she and S2DON met weekly to discuss residents at high risk for weight loss. S11DS stated during this weekly meeting, S2DON provided her with a list of each resident's orders for additional food and beverage items so she could add it to each resident's meal ticket. S11DS stated the meal tickets were then printed for each resident for the week and were used by her staff to accurately prepare every meal tray leaving the kitchen. S11DS confirmed the dietary staff would not know to add the necessary additions if she were not told of the orders by S2DON.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. S2DON confirmed Resident #9 had the following active orders; pudding with lunch and dinner, ice cream with lunch and supper and protein juice with all meals. S2DON confirmed Resident #78 had the following active orders; protein juice drink with all meals, pureed soup with lunch and dinner, and ice cream with lunch and supper. She confirmed she and S11DS met weekly to discuss residents at high risk for weight loss. S2DON confirmed she was responsible for providing S11DS with any additions or changes in dietary orders during their weekly meeting and she must have missed Resident #9 and Resident #78's. S2DON confirmed she would expect staff to implement all dietary orders as written, especially when a resident had a recent history of weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 1of 1(#86) resident reviewed for Post-Traumatic Stress Disorder (PTSD).
Findings:
Review of Resident #86's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included the following: Bacteremia, Benign Prostate Hyperplasia, Lack of Coordination, and PTSD.
Review of Resident #86's most recent Care Plan revealed, Resident #86 was not care planned for PTSD.
Review of Resident #86's Social assessment dated [DATE] revealed the Trauma Informed Care screening questions were answered no.
Review of Resident #86's physician progress notes dated 03/19/2024 to current revealed Resident #86's history of present illness included a PTSD diagnosis.
Review of Resident #86's Psychiatric Notes dated 03/15/2024 revealed, in part, other comorbidities PTSD.
On 05/14/2024 at 10:56 a.m., an interview was conducted with S20CNA. She stated she was Resident #86's aide. S20CNA stated she was not aware of Resident #86's diagnosis of PTSD.
On 05/14/2024 at 11:04 a.m., an interview was conducted with S13LPN. She stated she was aware of Resident #86's PTSD diagnosis. S13LPN confirmed there were no interventions in place to address Resident #86's history of PTSD.
On 05/14/2024 at 2:01 p.m., an interview was conducted with S2DON. She stated when a resident had a diagnosis of PTSD, a routine social assessment should be completed and the facility's provider should review the assessment. She stated when a new resident was admitted the Social Services department was responsible for completing the assessment.
On 05/15/2024 at 11:56 a.m., an interview was conducted with Resident #86's Responsible Party (RP). She stated Resident #86's was diagnosed with PTSD. She stated no one at the facility had spoken to her about Resident #86's PTSD diagnosis.
On 05/15/2024 at 1:35 p.m., a telephone interview was conducted with S21SW. She stated when a resident was admitted to the facility with a diagnosis of PTSD, she would speak to the resident about the nature of events, triggers, etc. and then refer the resident to be seen by the psychiatric nurse practitioner. S21SW confirmed she completed Resident #86's Social assessment on 03/21/2024. S21SW confirmed she completed the assessment, but was not aware the resident had a history or diagnosis of PTSD.
On 05/16/2024 at 9:28 a.m., a telephone interview was conducted with the Psychiatric Nurse Practitioner. She stated she was aware of Resident #86's diagnosis of PTSD. She stated the facility staff should have been aware of the PTSD diagnosis. She confirmed when she evaluated Resident #86 on 03/16/2024, she did not evaluate the resident for PTSD due to him only being oriented to self. She stated when a resident had an active diagnosis or history of PTSD, a PTSD evaluation should be completed. She confirmed a PTSD evaluation should have be completed for Resident #86 and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#63, #78) of 3 (#63, #80, and #78) residents reviewed receiving hospice services.
Findings:
Resident #63
Review of Resident #63's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder, Delusional Disorders, Major Depressive Disorder, and Restlessness and Agitation.
Review of Resident #63's May 2024 Physician's Orders revealed an order written on 03/13/2024 for Ativan 1 mg tablet, one tablet by mouth every 4 hours as needed (PRN) for anxiety/agitation. Further review revealed the PRN medication had no stop date.
Review of Resident #62's May 2024 Medication Administration Record (MAR) revealed an Ativan 1 mg tablet by mouth every for hours as needed for anxiety/agitation was started on 03/13/2024. Further review revealed the PRN medication had no stop date.
Resident #78
Review of Resident #78's clinical record revealed the resident was admitted to the facility on [DATE] and admitted to a local hospice agency on 02/08/2024.
Review of Resident #78's May 2024 Physician's Orders revealed an order written on 05/08/2024 for Ativan 1mg tablet, administer 1 tablet by mouth every 4 hours PRN for anxiousness. Further review revealed the PRN medication had no stop date.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed Ativan was a psychotropic medication. She confirmed Resident #63 had an order on 03/13/2024 for PRN Ativan 1mg tablet with no stop date. She confirmed Resident #78 had an order on 05/08/2024 for PRN Ativan 1mg tablet with no stop date.

Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (MR1) of 2 (MR1 and MR2) medication storage rooms observed. The facility failed to ensure a urine specimen was labeled with resident's first and last name, include a second identifier, and include the date and time of specimen collection.
Findings:
Review of the lab provider's policy, titled Urine Specimens, reviewed 05/14/2024, dated 01/2024, revealed, in part:
Urinalysis and Culture and Susceptibility-Submit a urinalysis preservative tube and culture and susceptibility preservative tube. Label both tubes with the patient's first and last name and a second identifier. Include the date and time of specimen collection on each specimen container.
On 05/14/2024 at 8:27 a.m., an observation was made of MR1 with S3IP. In the refrigerator labeled Specimens, a clear bag with two tubes filled with yellow fluid was discovered. Both tubes did not have a resident's name, date and time collected, or a second identifier.
On 05/14/2024 at 8:28 a.m., an interview was conducted with S3IP. She confirmed both specimen tubes did not have a resident's name, date and time collected, or a second identifier. She stated specimens collected should have a date, time, and resident's name on it when collected.
On 05/14/2024 at 9:30 a.m., an interview was conducted with S2DON. She verbalized she would expect all staff would label specimens with the resident's name, date and time collected, and a second identifier. She verbalized labeling specimens was common professional standard.
On 05/14/2024 at 9:32 a.m., an interview was conducted with S1ADM. He confirmed he would expect all specimens collected would be labeled with the resident's name, date and time collected, and a second identifier.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (#24) of 5 (#23, #24, #47, #62, #80) resident's reviewed for unnecessary medications.
Findings:
Review of Resident #24's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders (onset 04/14/2023), and Major Depressive Disorder.
Review of Resident #24's May 2024 Physician's orders revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnosis Major Depressive Disorder.
Review of Resident #24's May 2024 MAR revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnoses Major Depressive Disorder
Review of Resident #24's Pharmaceutical Consultant Report, Antipsychotic Diagnosis Request, dated 05/02/2023 revealed the physician documented the diagnosis of Delusional Disorder as the reason the resident was receiving Risperdal.
An interview was conducted with S2DON on 05/15/2024 at 10:00 a.m. She stated each prescribed psychotropic medication should have an appropriate diagnoses linked to it to indicate what the medication was being used to treat. She stated medical records was responsible for reviewing resident's pharmaceutical consultant reports and adjusting the diagnosis in the system.
An interview was conducted with S5MR on 05/15/2024 at 10:20 a.m. She stated she was not responsible for reviewing the pharmaceutical consultant reports and updating or changing diagnoses attached with psychotropic medications.
An interview was conducted with S2DON on 5/15/2024 at 10:25 a.m. She reviewed Resident #24's pharmaceutical consultant report and confirmed, on 05/02/2023, the physician documented the Risperdal was to be administered to treat the diagnosis of Delusional Disorder. She reviewed Resident #24's Physician's orders and MARs and confirmed Risperdal was documented as being administered to treat the diagnosis of Major Depressive Disorder. She confirmed the records were inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #86) residents observed with an indwelling catheter.
Findings:
A review of Resident #86's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses included the following: Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, and Cystitis.
A review of Resident #86's MDS, with an ARD of 04/22/2024, indicated the resident had a BIMS of 7, which indicated he had severe cognitive impairment. Further review revealed he had an indwelling urinary catheter.
On 05/13/2024 at 8:40 a.m., an observation was made of Resident #86 ambulating in his room, the indwelling catheter bag was hooked to the trash can.
On 05/13/2024 at 11:20 a.m., an observation was made of Resident #86 ambulating in his room. The resident was dragging the indwelling catheter bag on the floor.
On 05/15/2024 at 9:35 a.m., an observation was made of Resident #86 sitting on his bed. The indwelling catheter bag was set in the bed. Indwelling catheter bag was not below the level of the bladder and half full of urine which was flowing back.
On 05/15/2024 at 9:36 a.m., an interview was conducted with S13LPN. Upon entering Resident #86's room, S13LPN observed Resident #86's indwelling catheter bag in resident's bed. She stated Resident #86 puts his catheter bag in the trash can. S13LPN confirmed the indwelling catheter bag should be kept below the level of the bladder, out of the trash can, and off the floor.
On 05/15/2024 at 2:22 p.m., an interview was conducted with S2DON. S2DON confirmed the indwelling catheter bag should be kept below the bladder, out of trash can, and off the floor due to increased risk of infection.

Based on record reviews and interviews, the facility failed to develop procedures to ensure 2 (#51 and #62) of 5 (#9, #51, #62, #70 and #90) resident's records had documentation indicating resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Findings:
Review of the facility's policy, titled Pneumococcal Vaccination of Resident Policy and Procedure, reviewed 05/14/2024, dated 08/01/2022, revealed, in part:
Purpose: It is the policy of this facility that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the resident also will be used to determine immunization status.
Procedure:
2. Facility will document pneumonia vaccine administration on Form Immunization Record and Form Vaccination [NAME] Roster.
Review of Resident #51's clinical record from 10/01/2023 to 05/13/2024 revealed no documentation of pneumococcal immunization status.
Review of Resident #62's clinical record from 10/01/2023 to 05/13/2024 revealed no documentation of pneumococcal immunization status.
On 05/14/2024 at 12:58 p.m., an interview was conducted with S3IP. She confirmed she was responsible for obtaining consents, documentation, and administration of pneumococcal vaccines for all residents. She reported the pneumococcal vaccine was available in the pharmacy for administration between 10/01/2023 to 05/14/2024. She confirmed all pneumococcal immunization administration and documentation was not complete for all residents at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with orders written for dining for 1 (#78) of 2 (#9 and #78) residents reviewed for requiring feeding assistance.
Findings:
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy.
Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed he required supervision or touching assist with eating.
Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following:
Physician's Orders:
Patient must be fed all meals.
Problem:
Nutrition/Hydration diminished due to disease progression.
Goal:
For facility staff, family/friends, patient, adjust to changing nutritional needs, ongoing.
Review of Resident #78's Weight Log, dated 02/14/2024 through 04/16/2024, revealed, in part, the following:
02/14/2024: 128.6 pounds;
03/19/2024: 123.6 pounds; and
04/16/2024: 123.2 pounds.
An observation was conducted on 05/13/2024 at 10:45 a.m. of a sign hanging on the wall in Resident #78's room indicating he should be fed all meals.
An observation was conducted on 05/13/2024 at 12:05 p.m. of Resident #78 seated in bed attempting to feed himself with no staff present in the room. Throughout the course of lunch service, no staff arrived to feed Resident #78.
An observation and interview was conducted on 05/14/2024 at 11:25 a.m. of S10CNA delivering Resident #78's meal tray to his bedside table then exiting his room. She stated Resident #78 did not require feeding assistance with meals and never had.
An interview was conducted on 05/15/2024 at 10:50 a.m. with S9LPN. She confirmed Resident #78 had a current order to be fed all meals by staff.
An interview was conducted on 05/15/2024 at 9:50 a.m. with Resident #78's hospice nurse. She confirmed Resident #78 had an order to be fed all meals because frequently he would not eat if staff were not there to assist and provide encouragement. She confirmed if the hospice agency wrote an order, the hospice agency expected the facility staff to follow them as written.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed Resident #78 had an active order to be fed all meals. She confirmed she would expect staff to implement orders as written.

Based on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality of professional standards. The facility failed to obtain physician's orders when the facility received medications from the pharmacy for 1 (#23) of 5 (#23, #51, #26, #294, and #47) residents reviewed for medication administration.
Findings:
Review of Resident #23's Clinical Record revealed a facility admit date of 10/01/2023 with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections.
Review of the yearly MDS with ARD of 04/17/2024 revealed Resident #23 had a BIMS of 15, which indicated she was cognitively intact.
Review of the most recent Care Plan revealed the following:
Onset: 04/01/2024
Problem: I am at risk for infection returning
Intervention: Administer my medications as ordered
Onset: 11/28/2023
Problem: I have overactive bladder
Intervention: Administer my medications as ordered
On 05/13/2024 at 8:46 a.m., an interview was conducted with Resident #23. She stated she had an appointment with her urologist on Wednesday, 05/08/2024 and received a prescription for an antibiotic, but had not received the antibiotic as of this morning, Monday, 05/13/2024. She stated she had asked about the medication and was told there was something wrong with how the prescription was written, which was delaying her getting the medication.
On 05/14/2024 at 9:57 a.m., an interview was conducted with S3IP. She stated Resident #23 had an appointment with her urologist last week. She stated the facility's pharmacy delivered Levaquin, Pyridium and Macrobid for Resident #23 on Friday, 05/10/2024, but there were no physician orders for the medications. She stated on Monday, 05/13/2024, the facility contacted the urologist and obtained orders for the medications received.
On 05/14/2024 at 2:30 p.m., an interview was conducted with S4NP. She stated she was unaware the facility had received medications ordered by Resident #23's urologist on 05/10/2024 for Levaquin, Pyridium and Macrobid. She stated on 05/13/2024, orders were obtained from Resident #23's urologist, and medications were started on the evening of 05/13/2024. She stated she was not informed medications were delivered on 05/10/2024 without physician orders, and should have been.
On 05/15/2024 at 9:00 a.m., a telephone interview was conducted with the medical assistant at Resident #23's urologist's office. She confirmed Resident #23 was seen in the clinic on 05/08/2024. She stated on 05/10/2024, Resident #23's urologist electronically prescribed Levaquin, Macrobid and Pyridium to the facility's pharmacy. She stated she did not have any missed calls or voicemails from staff from the facility on 05/10/2024. She stated she received a call on 05/13/2024 from the facility requesting orders for Levaquin, Macrobid and Pyridium.
On 05/15/2024 at 9:15 a.m., a telephone interview was conducted with the pharmacist at the facility's pharmacy. She stated an electronic prescription was received for Resident #23's Levaquin, Macrobid and Pyridium on 05/10/2024 at 9:49 a.m. and was sent out for facility delivery on the first truck which left the pharmacy on 05/10/2024 at 12:00 p.m. She stated the facility should have received the medication by 2:00 p.m. on 05/10/2024. She stated the Levaquin and Pyridium prescriptions were to be started upon receipt of the medications and the Macrobid was to be started once the Levaquin prescription was completed.
On 05/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She stated if medications were delivered to the facility for a resident with no physician's orders, she would expect the nurse to obtain orders from the ordering physician. She stated nursing staff should have obtained orders for the antibiotics as quickly as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 2 (#23, #86) residents out of a 25 total sampled residents. The facility failed to:
1. Report Resident #23's urinalysis results to the consulting provider as ordered; and
2. Ensure care plan was comprehensive and individualized for Resident #86 whom exhibited frequent refusals and behaviors.
Findings:
1.
Review of the facility's policy titled, Notifying Clinicians - Laboratory/Diagnostic Testing Policy & Procedure revealed the following:
Procedure:
I. Laboratory Services (483.50)
d. The facility must promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results . per the ordering physician's orders.
Process:
III. Once the laboratory . test is completed the results will be reported to the order physician, physician assistant, or nurse practitioner in a timely manner.
Review of Resident #23's Clinical Record revealed she was admitted on [DATE] with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections.
Review of the most recent Care Plan the following:
Onset: 04/01/2024
Problem: I am at risk for infection returning
Intervention: My labs need to be done as ordered by my MD; notify my MD of significant changes
Review of the most recent Physician Orders, dated November 2023 through current, revealed the following:
05/09/2024 U/A with C&S - Fax results to urologist fax number
Review of the Nurses/Care Team Notes, dated November 2023 through current, revealed the following:
On 05/08/2024 at 8:47 p.m. Resident returned from urology appointment with new order for urine culture and to fax results to urologist fax number. Signed by: S3IP
Review of Laboratory Results ordered on 05/09/2024 by Resident's urologist for urinalysis revealed the specimen was collected on 05/09/2024, sent to the facility's outside lab company and reported to the facility on [DATE].
On 05/14/2024 at 9:40 a.m., an interview was conducted with S14LPN. After reviewing Resident #23's chart, she stated the results of the UA collected on 05/09/2024 were not in Resident #23's chart at this time.
On 05/15/2024 at 9:00 a.m., a telephone interview was conducted with the medical assistance for Resident #23's urologist. She confirmed Resident #23 was seen in the clinic by her urologist on 05/08/2024 and was sent back to the facility with an order for a urinalysis with culture and sensitivity and request of the results to be faxed to the clinic office once received. She stated the clinic still had not received the results of the urinalysis.
On 05/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She stated she was responsible for checking for resulted lab tests and ensuring the results are sent to providers once resulted. She stated there is a lab notification log kept at the front nurses' station with the ward clerk. She stated when a nurse gets an order for a lab, they are to notify the ward clerk of the order so they can notify the facility's outside lab company. If the specimen to be collected is urine, the nurse will write on the notification log the date and time the specimen was collected. She stated she checks the log daily to check to see if the lab company has resulted the pending specimen sample(s). She confirmed she did not send the results of Resident #23's urinalysis as ordered by the urologist.
2.
Review of Resident #86's Clinical Record revealed he was readmitted on [DATE] with diagnoses which included Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, Cystitis, and Gastrostomy Status.
Review of the 5 day MDS with ARD of 04/22/2024 revealed Resident #86 had a BIMS of 7, which indicated the resident was severely cognitively impaired. Review of Section GG - Functional Abilities and Goals revealed Resident #86 required partial/moderate assistance with toileting. Review of Section H - Bladder and Bowel revealed Resident #86 had an indwelling urinary catheter. Review of Section K-Swallowing/Nutritional Status revealed Resident #86 had a feeding tube.
Review of the most recent Care Plan the following revealed that Resident #86 was not care planned for refusal of care related to his PEG and catheter or behaviors.
Review of the Nurses/Care Team Notes, dated March 2024 through current, revealed the following:
On 03/27/2024 at 12:49 p.m. Resident #86 refused tube feeding.
On 04/01/2024 at 4:45 p.m. Resident #86 was redirected and educated not to pull on his PEG tube or catheter.
On 04/09/2024 at 8:28 a.m. Resident #86 noted pulling at catheter.
On 04/09/2024 at 8:28 p.m. Resident #86 pulled catheter.
On 04/19/2024 at 5:38 a.m. Resident #86 refused bolus feeding.
On 04/22/2024 at 8:42 a.m. Resident #86 refused morning feeding.
Review of the 24 hour Communication Report log dated 05/01/2024 to current revealed on 05/10/2024 resident #86 refused care and slammed door on CNA hand.
On 05/14/2024 at 11:04 a.m., an interview was conducted with S13LPN. She stated Resident #86 constantly puts his indwelling catheter bag in the trash can and she has to constantly educate him to remove the catheter bag from the trash can. S13LPN stated Resident #86 had orders to apply a leg beg every morning, but he often refused to have it applied.S13LPN stated Resident #86 also frequently refused this PEG tube feedings and flushes. She stated she documented refusals of care and behaviors in nurse's notes and sometimes on the 24 hour Communication Report log.
On 05/15/2024 at 9:50 a.m., an interview was conducted with S6MDS. She stated she was responsible for care plans. S6MDS stated the process for care plan updating or revisions was for her to get updates in the morning meeting and reviewing the 24 hour Communication Report logs daily. She stated then she would update the care plan by adding interventions. S6MDS confirmed she was not aware of Resident #86's frequent refusals and behaviors.
On 05/15/2024 at 2:22 p.m., an interview was conducted with S2DON. She confirmed staff should be documenting refusals of care on the MAR, Nurses' notes, and 24 hour Communication Report log. S2DON confirmed if a resident was frequently refusing care and exhibiting behaviors MDS should be made aware in the morning meeting using the 24 hour Communication Report logs and refusals and behaviors should be properly care planned. After reviewing Resident #86's current care plan, S2DON confirmed Resident #86 was not care planned for frequent refusals and behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#8) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.
Findings:
Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Schizophrenia (Onset Date: 07/27/2006).
Review of Resident #8's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Further review revealed, in part, the following:
Section I:
I6000: Schizophrenia - Checked.
Review was attempted of Resident #8's Pre-admission PASRR Level 1 Screening and Determination Review Form with no documentation available for review.
An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #8 had an active diagnosis of Schizophrenia. He confirmed Schizophrenia was one of the relevant mental illnesses listed on the Level I PASRR Screen and Determination. He confirmed the facility did not have a copy of Resident #8's most recent Level 1 PASRR Screen and Determination. He confirmed the facility had not submitted a Level 1 PASRR Screen and Determination for Resident #8 when she was admitted to the facility on [DATE].

**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 newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 1 (#36) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.
Findings:
Review of Resident #36's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Psychosis not due to a substance or known physiological condition (Onset Date: 08/25/2017).
Review of Resident #36's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 08/18/2017.
Review was attempted of Resident #36's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 08/25/2017 with no documentation available for review.
Review of Resident #36's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 0, indicating the resident was significantly cognitively impaired. Further review revealed, in part, the following:
Section I: Diagnoses
I5950: Psychotic Disorder (other than Schizophrenia) - Checked.
I8000: Additional ICD Diagnosis - F29 Unspecified Psychosis not due to a substance or known physiological condition.
An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #36's Pre-admission Level I PASRR Screen and Determination was most recently submitted on 08/18/2017. He confirmed on 08/25/2017, Resident #36 received a new diagnosis of a relevant mental illness; Unspecified Psychosis not due to a substance or known physiological condition. He confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure:
1.Staff accurately marked a resident was evaluated for PASRR on 2 (#62, #66) of 4 (#8, #36, #62, #66) resident's reviewed for PASRR; and
2.Staff accurately reflected the discharge status for 1 (#91) of 5 (#38, #84, #88, #91, #92) residents reviewed for discharge; and
3.Staff accurately reflected a resident had pressure ulcers for 1 of 1 (#43) resident reviewed for pressure ulcers.
1.
Resident #62
Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Borderline Personality Disorder.
Review of Resident #62's clinical record revealed a Level II PASRR with approval dates of 04/03/2024 through 04/02/2024.
Review of Resident #62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no.
Resident #66
Review of Resident #66's clinical record revealed the resident was admitted to the facility on [DATE] with Diagnoses which included Paranoid Schizophrenia.
Review of Resident #66's clinical revealed a Level II PASRR with approval dates of 05/09/2023 through 05/07/2024.
Review of Resident #66's yearly MDS with ARD of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no.
An interview was conducted with S7MDS on 05/14/2024 at 3:20 p.m. She reviewed Resident #62's and Resident #66's clinical records and confirmed both had been evaluated for a Level II PASRR. She reviewed Resident #62's and Resident #66's MDS both dated 02/07/2024. She confirmed both Resident #62's and Resident #66's MDS revealed question A1500, Resident evaluated for PASRR, was answered as no. She confirmed both Resident #62 and Resident #66 MDS was inaccurate.
An interview was conducted with S2DON on 05/15/2024 at 2:10 p.m. She confirmed MDS staff were expected to accurately capture resident's information on the assessments. She confirmed the MDS should accurately reflect if a resident was evaluated for PASRR.
2.
Resident #91
Review of Resident #91's clinical record revealed the resident was admitted to the facility on [DATE] and discharged to home on [DATE].
Review of Resident #91's Discharge MDS with an ARD of 03/19/2024 indicated the following:
A2000: discharge date - 03/19/2024; and
A2105: Discharge Status - 4. Short Term General Hospital.
Review of Resident #91's Nurse Notes revealed a note written on 03/19/2024 at 9:52 p.m. indicated at 10:00 a.m. resident was discharged to home.
An interview was conducted on 05/15/2024 at 1:45 p.m. with S13LPN. S13LPN confirmed she was Resident #91's nurse at the time of her discharge. S13LPN confirmed Resident #91 discharged to home from the facility.
An interview was conducted on 05/15/2024 at 1:40 p.m. with S6MDS. S6MDS confirmed Resident #91's MDS Discharge Assessment revealed Resident #91 was discharged to the hospital which was incorrect. S6MDS confirmed Resident #91's MDS Discharge Assessment should have been coded correctly.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed she would expect MDS Assessments to be coded accurately and Resident #91's was not.
3.
Resident #43
Review of Resident #43's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Cutaneous Abscess of Buttock.
Review of the current Physician Orders revealed in part:
04/23/2024-Right Medial buttock Stage 3 clean with wound cleanser, pat dry, apply sodium chloride dressing, and cover with dry dressing until resolved.
05/13/2024 Stage 3 to right heel, clean with wound cleanser, pat dry, paint with gentian violet and leave open to air.
Review of current wound log dated revealed Resident #43 had a right buttock Stage 3 with identified date of 02/27/2024, and Unstageable to right heel identified date of 04/27/2024.
Review of Resident #'s 43 admission MDS with an ARD of 03/04/2024 indicated the following:
M0100A: Risk determination: has PU/injury, scar, dressing - Unchecked
Further review of Section I-Active Diagnoses revealed no diagnosis for Pressure Ulcers.
An interview was conducted on 05/15/2024 at 10:26 a.m. with S19WCN. She confirmed Resident #43 had a Right Medial buttock Stage 3 and Stage 3 to right heel.
An interview was conducted on 05/15/2024 at 10:38 a.m. with S6MDS. S6MDS confirmed if a resident was receiving wound care and had a current pressure ulcer there should be an active diagnosis for wounds. After reviewing Resident #43's admission MDS with ARD of 03/04/2024 Section M, S6MDS confirmed Resident #43 did not have an active diagnosis and was not checked for having a pressure ulcer and should have.
An interview was conducted on 05/15/2024 at 11:00 a.m. with S2DON. She stated MDS was made aware of new wound care orders and new wounds in the morning meetings and 24 hour communication report sheet. She stated she expected resident's MDS to be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to electronically transmit a subset of items upon a resident's discharge for 2 (#38, #84) of 5 (#38, #84, #88, #91, and #92) residents reviewed for discharge.
Resident #38
Review of Resident #38's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/31/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment.
Resident #84
Review of Resident #84's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/23/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment.
An interview was conducted with S6MDS on 05/15/2024 at 12:38 p.m. She reviewed Resident #38's clinical record. She stated the resident was discharged on 01/31/2024 and a discharge assessment was not electronically transmitted. She confirmed a discharge assessment should have been completed on 01/31/2024. She reviewed Resident #84's clinical record. She stated the resident was discharged from the facility on 01/23/2024 and a discharge assessment was not electronically transmitted. She confirmed a discharge assessment should have been completed for Resident #84 on 01/23/2024.
An interview was conducted with S2DON on 05/15/2024 at 2:10 p.m. She confirmed MDS staff should have completed and transmitted a discharge assessments after a resident was discharged from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an alleged violation of physical abuse was reported within 2 hours to the State Survey Agency after an allegation was made for 1 (#295) of 3 (#5, #294, and #295) residents reviewed for abuse.
Findings:
Review of the facility's policy titled Abuse - Prevention and Prohibition Policy and Procedure revealed the following:
Purpose:
Each resident has the right to be free from abuse . This policy applies to covered individuals (the owner, operator, employees, managers, vendors, agency staff, agents, or contractors) . present in our facility.
Policy:
To provide a safe, abuse-free environment for all residents. If you suspect physical abuse of a resident contact the Administrator immediately.
I. Types of Abuse:
3. Physical Abuse may including hitting, slapping, pinching, biting, shoving, and kicking.
II. Procedures
7. Reporting/Response
The facility employee or covered individual who becomes aware of abuse shall immediately report the matter to the facility administrator.
The Administrator shall immediately initiate a report to the State Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical abuse .) .
All covered individuals are required by law to report any suspected abuse or neglect.
Review of Resident #295's Clinical Record revealed she was admitted to the facility on [DATE] with Diagnoses which included Dementia and Traumatic Subdural Hemorrhage.
Review of the admission MDS with ARD of 05/10/2024 revealed the provider assessed Resident #295 as having a BIMS of 4, which indicated the resident had severe cognitive impairment.
Review of the Nurses/Care team notes revealed the following:
05/12/2024 9:01 p.m. LATE ENTRY FROM 05/11/2024 2:00 p.m.: While resident was sitting in the lobby near the television area next to Resident #80, Resident #295 began hitting Resident #80 in the face and was witnessed by S15CNA who removed resident along with S16RNS. Resident #295 was placed in her room and monitored for the remainder of the shift. Signed by: S17LPN
Review of the facility's Incident Log, dated November 2023 through current, revealed no documented incident between Residents #295 and #80.
Review of the facility's state agency reported incidents for the past six months revealed no reports of the above incident.
On 05/14/2024 at 12:08 p.m., an interview was conducted with S15CNA. She stated she witnessed the incident between Resident #295 and Resident #80 on 05/11/2024. She stated Resident #295 and #80 were seated in the day room area near NSB. She stated she saw Resident #295 slapping Resident #80 in the face. S15CNA stated she immediately separated Resident #295 from Resident #80 and brought her to her room. She stated what she witnessed was physical abuse. She stated once she separated the residents, she immediately reported the incident to her supervisor.
On 05/14/2024 at 12:57 p.m., an interview was conducted with S1ADM. He stated he was made aware of the incident between Residents #295 and #80 sometime around 12:30 p.m. on 05/11/2024 by a staff member. He stated it was reported to him Resident #295 was hitting Resident #80. He stated he did not consider the incident to be physical abuse and did not report it to the state agency.

Based on observations and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure:
1. The can opener was properly cleaned and free of a sticky black substance;
2. The juice machine was properly cleaned and free of a brownish red substance;
3. The juice machine filter was properly cleaned and free of a brown and black substance; and
4. The juice machine connecters and tubing were properly cleaned and free of a black substance.
Findings:
An initial tour of the kitchen was conducted on 04/24/2023 at 8:40 a.m., with S16DS. The following observations were made:
On 04/24/2023 at 8:45 a.m., the can opener was observed attached to a stainless steel food preparation counter with a large amount of a sticky black substance on the blade. S16DS confirmed the observation and stated the can opener should be cleaned daily and it had not been.
On 04/24/2023 at 9:10 a.m., the juice machine was observed on a counter in the kitchen. The juice machine filter was observed with a large amount of a brown and black substance. The outside of the juice machines three connectors and tubing were observed with a black substance. The outside of the juice machine had a dry brownish red substance on it. S16DS stated she was not sure when the last time the juice machine was cleaned. She confirmed the observations and stated the juice machine, tubing, connectors, and its filter were not clean and should have been.
On 04/24/2023 at 9:15 a.m., an interview was conducted with S16DS. S16DS confirmed the above findings. She stated 93 Residents were served meals from the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#80) of 4 (#2, #80, #413, and #414) residents reviewed for pressure ulcers. The facility failed to ensure Resident #80 did not acquire a pressure ulcer while using a heel offloading device.
Review of Resident #80's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition. Further review revealed she had diagnoses of Pressure Induced Deep Tissue Damage of Other Site, Unspecified Soft Tissue Disorder Related to Use/Pressure, Left Lower Leg and Unspecified Soft Tissue Disorder Related to Use/Pressure, Right Lower Leg with an onset date of 04/14/2023.
Review of Resident #80's MDS with an ARD of 03/06/2023 revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed Resident #80 required extensive 2-person physical assistance with bed mobility and toilet use. She was totally dependent on staff for transfers, locomotion on and off the unit, dressing, personal hygiene and bathing. Resident #80's skin condition was coded as at risk for developing pressure ulcers/injuries.
Review of Resident #80's current Care Plan revealed the following, in part:
01/11/2023 Problem: Resident is at risk for skin breakdown.
Approaches: Turn and reposition resident every 2 hours and as needed.
04/14/2023 Problem: Resident has a Deep Tissue Injury to Right Inner Shin and Left Lateral shin.
Approaches: Turn and reposition resident per schedule.
Review of Resident #80's Braden Scale Assessments dated 01/12/2023, 01/19/2023, 02/01/2023, and 02/06/2023 revealed she was at risk for development of Pressure Ulcers. Further review revealed Resident #80 was considered high risk for the development of Pressure Ulcers on 03/06/2023.
Review of Resident #80's Physician Orders dated April 2023 revealed the following, in part:
04/25/2023 Deep Tissue Injury to Right and Left Calf - Clean with wound cleanser, pat dry, paint with betadine, apply abdominal pad, wrap with rolled gauze and secure with tape daily until resolved.
Review of Resident #80's Nurses' Notes dated April 2023 revealed the following, in part:
04/14/2023 at 1:50 p.m. Resident noted with Deep Tissue Injury to Left and Right Lower Legs. Wound care notified. Heels remain floated on pressure reducing device. Signed S10LPN.
04/14/2023 at 4:16 p.m. Upon assessment it appeared resident had Deep Tissue Pressure Injuries to Bilateral Lower Extremities. Resident had been utilizing a heel monitor for heel pressure relief per standing order from S6NP. Signed S5LPN
Review of Resident #80's Wound Assessment Report revealed the following:
Date of assessment: 04/14/2023
Wound type: Pressure Ulcer to Left Lateral Shin and Right Inner Shin.
Date wound identified: 04/14/2023
Present on admission: No
Assessment occasion: New wound
Stage: Unstageable Due to Suspected Deep Tissue Injury
Measurements: Right Inner Shin: length - 4.5 cm, width - 1.7 cm, depth - 0 cm
Left Lateral Shin: length - 6.0 cm, width - 2.0 cm, depth - 0 cm
An interview was conducted on 04/24/2023 at 10:00 a.m. with S8CNA. She said she provided care to Resident #80. She said Resident #80 had Bilateral Pressure Ulcers to her Lower Extremities for two weeks. She said Resident #80 used the heel offloading device under her calves all day, every day, since March 2023. She said she was never instructed to remove the heel offloading device. She said the wounds to Resident #80's Bilateral Lower Extremities were from the heel offloading device that was placed under her calves.
An interview was conducted on 04/25/2023 at 10:05 a.m. with S9CNA. She said she provided care to Resident #80. She said Resident #80 used a heel offloading device continuously under her lower legs to elevate her heels. She reported Resident #80 had the heel offloading device to elevate her calves 24 hours a day, 7 days a week. She said she was never instructed to remove the heel offloading device. She said Resident #80 had Bilateral Pressure Ulcers to her Calves for the last 2 weeks. She said the wounds to Resident #80's Bilateral Lower Extremities were from the heel offloading device that was placed under her calves.
An interview was conducted on 04/25/2023 at 11:00 a.m. with S4LPN. He said he provided care to Resident #80. He said Resident #80 was high risk for developing Pressure Ulcers. He said prior to the identification of the Bilateral Lower Extremity Pressure Wounds, Resident #80 used a heel offloading device under her legs to lift her heels off the mattress. He said she had the heel offloading device in place 24 hours a day, 7 days a week. He said Resident #80's Pressure Ulcers to her Left and Right Calves were caused by constant pressure from the heel offloading device.
An interview was conducted on 04/25/2023 at 11:15 a.m. with S5LPN. She said on 04/14/2023, she was informed by S10LPN that Resident #80 had bruising to the back of her calves. She said upon assessment, Resident #80 had Deep Tissue Pressure Injuries to Bilateral Lower Extremities. She said Resident #80 was high risk for developing Pressure Ulcers. She said prior to identification of the Bilateral Deep Tissue Pressure Injuries, Resident #80 always used a heel offloading device under her Bilateral Calves. She said the constant pressure from the heel offloading device caused the Pressure Wounds to her Bilateral Calves.
An interview was conducted on 04/25/2023 at 11:30 a.m. with S6NP. She said she provided care to Resident #80. She said she was informed by S5LPN on 04/14/2023 that Resident #80 had Deep Tissue Wounds to her Bilateral Calves. She said she could not confirm the pressure injuries were caused by the heel offloading device but since there was no other culprit, she assumed the heel offloading device was the cause of the Bilateral Pressure Wounds. She said upon each assessment of Resident #80, the heel offloading device was in place under her calves. She said Resident #80 was high risk for developing Pressure Ulcers.
An interview was conducted on 04/25/2023 at 3:00 p.m. with S2ADM. She confirmed Resident #80 sustained Bilateral Pressure Ulcers from the heel offloading device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure:
1. 1 (#21) of 3 (#21, #59, and #91) residents reviewed for falls were assessed with neurological checks following an unwitnessed fall; and
2. 1 (#103) of 2 (#103 and #363) residents reviewed for catheters were monitored for urinary retention after a urinary catheter was discontinued.
Findings:
Review of the facility's policy titled Falls revealed the following, in part:
Purpose
To evaluate extent of injury.
To prevent complications.
Procedure
9. If the fall was un-witnessed or involved a potential head injury, initiate neurological assessment checks.
13. Document all appropriate information in medical record.
1.
Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included; Metabolic Encephalopathy, Muscle Wasting and Atrophy, Other Lack of Coordination, and Unspecified Abnormalities of Gait and Mobility.
Review of Resident #21's Nurses Note written by S11LPN, dated 03/26/2023 at 1:24 a.m., indicated resident was found sitting on the floor by S12CNA on 03/25/2023 at approximately 4:30 a.m.
Review of the facility's Fall Log revealed Resident #21 had an unwitnessed fall on 03/25/2023 at 4:31 a.m.
Review of the facility's Incident Report for Resident #21 revealed the following, in part:
Date/Time: 03/25/2023 at 4:31 a.m.
Incident Location: Resident's room
Incident Level: Non-Witnessed
Incident Reported by S12CNA
Report prepared by S11LPN
Narrative of Incident and Description of Injuries: S12CNA informed me that resident was sitting on floor.
Review of Resident #21's Neurological Observations Head Injury Form revealed neurological checks were initiated at 10:45 a.m. on 03/25/2023.
On 04/26/2023 at 8:05 p.m., a telephone interview was conducted with S12CNA. She said on 03/25/2023 around 4:30 a.m. she found Resident #21 on the floor in her room, sitting on her buttocks. She said the resident told her she had fallen after getting out of bed without calling staff for assistance.
On 04/27/2023 at 10:35 a.m., a telephone interview was conducted with S11LPN. She said when a resident had a fall, neurological checks were to be initiated and documented every 15 minutes x 4, every 30 minutes x 4, every 1 hour x 4, and then once a shift for the next 72 hours. She verified she worked on 03/25/2023 when S12CNA found Resident #21 sitting on the floor. She confirmed she did not initiate and document neurological checks for Resident #21 following her unobserved fall.
On 04/27/2023 at 10:47 a.m., an interview was conducted with S7LPN. She confirmed S11LPN had not immediately initiated neurological checks following Resident #21's unwitnessed fall at 4:30 a.m. on 03/25/2023. She stated neurological checks were not initiated for Resident #21 until 10:45 a.m. on 03/25/2023. She confirmed following any unobserved fall, neurological checks should be immediately initiated and documented for 72 hours.
On 04/27/2023 at 11:15 a.m., an interview was conducted with S3DON. She said after a resident had an unobserved fall the nurse should initiate neurological checks and document them on the Neurological Observations Head Injury Form. She verified Resident #21 had an unobserved fall on 03/25/2023 at 4:31 a.m. She reviewed the Neurological Observations Head Injury Form dated 03/25/2023 for Resident #21 and verified neurological checks were not initiated immediately following an unwitnessed fall but should have been.
2.
Review of Resident #103's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included; Unspecified Retention of Urine.
Review of Resident #103's Physician's Orders dated March 2023 revealed the following:
03/22/2023: Catheter: 16 French, 10 CC Indwelling Foley. DX: Urinary Retention. Discontinued 03/28/2023.
03/30/2023: Check Resident for urine output. If no urine output perform in and out catheter, replace Foley catheter if residual is greater than 400 ml, offer bedpan prior to performing in and out cath.
Review of Resident #103's Nurse's Notes dated 03/28/2023-03/30/2023 revealed the following, in part:
03/28/2023 at 3:47 p.m. by S7LPN: New order received to discontinue Foley catheter.
03/30/2023 at 9:16 p.m. by S13LPN: 4:30 p.m. In and out catheter performed, 600 cc of urine collected. S6NP notified.
Further review revealed no entries between the above two entries regarding on-going monitoring for urinary retention or if the resident voided after the urinary catheter was removed.
Review of the Resident Care Details Did Resident Void Bladder dated 03/28/2023-03/29/2023 for Resident #103 revealed:
Task Date and Time 03/28/2023 10:00 p.m.;
Documentation Date and Time-03/29/2023 5:50 a.m.; Answer-No; Documented by: S12CNA
Task Date and Time 03/29/2023 6:00 a.m.;
Documentation Date and Time-03/29/2023 3:27 p.m.; Answer-No; Documented by: S14CNA
On 04/26/2023 at 11:30 a.m., an interview was conducted with S7LPN. She verified she worked on 03/28/2023 and 03/29/2023 and was assigned to Resident #103. She did not recall if she discontinued Resident #103's urinary catheter on 03/28/2023 or if the resident voided or not. She did not recall S14CNA reporting Resident #103 could not urinate on 03/28/2023 or 03/29/2023. She confirmed when a urinary catheter was removed the resident should be monitored for urinary retention.
On 04/26/2023 at 12:17 p.m., a telephone interview was conducted with S15LPN. She verified she worked on 03/28/2023 and 03/29/2023 and was assigned to Resident #103. She said Resident #103's urinary catheter was removed on 03/28/2023 but she did not recall what time. She was not aware of Resident #103's lack of urination during her shifts on 03/28/2023 and 03/29/2023. She said the hall CNA should have notified her if Resident #103 was not urinating but did not.
On 04/26/2023 at 3:14 p.m., an interview was conducted with S13LPN. She verified she worked on 03/30/2023 and was assigned to Resident #103. She said Resident #103 complained of back pain and not being able to urinate. She said Resident #103 had not urinated on her shift. She said she notified the NP, performed an in and out catheter on Resident #103, and removed 600 cc of urine. She confirmed when a urinary catheter was removed the resident should be monitored for urinary retention.
On 04/26/2023 at 7:55 p.m., a telephone interview was conducted with S12CNA. She verified she worked at the facility on 03/28/2023. She was notified of her documentation on the Resident Care Summary Did Resident Void Bladder dated 03/28/2023 for Resident #103. She said if she documented No that meant Resident #103 did not urinate on her shift. She said the only time she notified the nurse a resident did not urinate was if the nurse asked her to. She said she did not recall if she notified the nurse Resident #103 did not urinate during her shift.
On 04/27/2023 at 8:27 a.m., an interview was conducted with S14CNA. She verified she worked on 03/29/2023 and was assigned to Resident #103 from 6 a.m. to 10 p.m. She confirmed during her shifts, Resident #103 did not void. She said she notified S7LPN that Resident #103 had not urinated during her shift.
On 04/27/2023 at 9:50 a.m., an interview was conducted with S6NP. She confirmed Resident #103 had a urinary catheter in place upon admission due to urinary retention. She said on 03/28/2023 she gave an order for the nursing staff to remove Resident #103's urinary catheter. She said she did not recall what day but stated she received a call from a nurse reporting Resident #103 had not urinated in 6-8 hours. She said she gave orders for the nurse to perform an in and out catheter on Resident #103. She said she was notified over 300 cc of urine was obtained so she ordered to have the urinary catheter reinserted. She said she would expect the nursing staff to monitor a resident for urinary retention after removing a urinary catheter. She would expect the nursing staff to notify the NP on call if a resident had not urinated within 6 to 8 hours after a urinary catheter was removed.
On 04/27/2023 at 11:20 a.m., an interview was conducted with S3DON. She reviewed Resident #103's electronic clinical record and verified the urinary catheter order was discontinued on 03/28/2023 at 2:50 p.m. She reviewed the nurses notes dated 03/28/2023 to 03/30/2023 for Resident #103 and verified there was no documentation of monitoring for urinary retention or if the resident did or did not urinate after the catheter was removed. She reviewed the Resident Care Summary for Resident #103 dated 03/28/2023 to 03/30/2023 and confirmed S12CNA documented No to the resident urinating on the 10 p.m. to 6 a.m. shift on 03/28/2023. She reviewed and confirmed S14CNA documented No to the resident urinating on the 6 a.m. to 2 p.m. shift on 03/29/2023. She said she expected the nurses to monitor a resident for urinary retention after removing a urinary catheter and to document in the nurse's notes whether or not the resident urinated. She said she could not determine whether or not Resident #103 urinated after her urinary catheter was removed on 03/28/2023 to 03/29/2023.