Lafayette Manor

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 3 residents (R8, R42, and R44) reviewed for falls. R8 had a history of falls including one that resulted in a rib fracture. The facility did not complete a fall investigation, a thorough root cause analysis, or ensure that care planned interventions were appropriate and in place for R8. R42 had a fall that was not thoroughly investigated for a root cause and an intervention was not put in place to prevent further falls. The facility did not complete ongoing monitoring for R42 after his fall. R44 had a fall that was not thoroughly investigated for a root cause and an intervention was not put in place to prevent further falls. This is evidenced by:The facility policy Accidents and Supervision, dated 1/6/26, includes: [...]

Inspectors wroteBased on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census (42). The facility staff line lists do not monitor specific symptoms. Evidenced by:The facility policy entitled Infection Surveillance, dated 1/05/26, states, in part: . Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to obtain informed consent for bed rails, failed to obtain physician orders for bed rails, failed to care plan the need and use of bed rails, failed to obtain risk versus benefits for bed rails, failed to measure the gap between the mattress and bed rails for entrapment, and failed to ensure the bed dimensions were appropriate for the resident's size and weight for 9 of 14 residents (R30, R17, R6, R5, R2, R27, R8, R42, R44) reviewed for bed rails. R30 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have a bed rail assessment for entrapment, did not have proof of risk vs. [...]

Inspectors wroteBased on interview and record review, the facility did not provide the proper discharge documentation for 1 of 1 resident reviewed for discharge (R4). The facility sent R4 to the emergency room (ER) on 10/28/25 and 11/19/25. The hospital admitted R4 to the hospital both times. R4 did not receive bed hold notices either time. Evidenced by:The facility policy entitled Bed Hold Policy, dated 1/06/26, states, in part: . Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental and psychosocial needs for 1 of 14 residents (R30) reviewed for care plans. R30's care plan does not include a focus, goal, or interventions for fall risk. Evidenced by:The facility policy titled, Comprehensive Care Plans states, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure that the comprehensive care plan is reviewed and revised for 3 of 14 residents (R1, R8, R42). R8's care plan did not have safety interventions in place, had fall interventions in place that were no longer appropriate, and did not have fall interventions revised after a fall. R42's care plan did not have safety interventions in place and did not have fall interventions revised after a fall. R1 has an order for Prevalon boots to always be on. The facility did not add the order to R1's Care Plan. R1's Care Plan indicates R1 requires assistance with ambulation. R1 does not ambulate. This is evidenced by: The facility policy. entitled, Comprehensive Care Plans, dated 1/5/22, includes It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 1 of 1 resident (R7) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R7 has a diagnosis of Post Traumatic Stress Disorder (PTSD) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. Evidenced by:The facility policy entitled Comprehensive Care Plans, dated 1/06/26, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 3 of 5 residents (R50, R6, R27) reviewed for antibiotic stewardship. R50 was treated prophylactically with an antibiotic for prevention of urinary tract infections (UTI). The facility did not have an antibiotic stewardship conversation with the Provider regarding R50. R6 was treated with an antibiotic without a sensitivity completed to be able to identify what antibiotics would be susceptible to the bacteria. R27 was treated with an antibiotic that was not susceptible to the bacteria identified. Evidenced by:The facility policy entitled Antibiotic Stewardship Program, dated 1/05/26, states, in part: . Policy: [...]

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure unauthorized staff, two of two Certified Medication Aides ((CMA)1 and CMA2), did not have the keys to the locked narcotic box on the medication cart and to the medication storage room.

Inspectors wroteBased on interview and record review the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented a resident-to-resident altercation, involving R4 on 8/5/25, which was not reported to the State Agency. Staff documented a resident-to-resident altercation, involving R5 on 8/5/25, which was not reported to the Administrator or State Agency. Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented an observation of a resident-to-resident altercation, involving R4 on 8/5/25, which was not investigated by the facility. Staff documented an observation of a resident-to-resident altercation, involving R5 on 8/5/25, which was not investigated by the facility. Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free from abuse, perpertrated by a Certified Nusing Assistant (CNA) for 1 of 17 sampled residents (R40). R40 had voiced to a CNA to stop during cares as the CNA was hurting him. The CNA continued providing care despite the residents request and voicing discomfort. Addtionally, staff who overheard the interaction did not intervene to protect R40. Evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure injuries (R8). R8 developed a pressure injury, and the facility did not transcribe orders, did not ensure orders were being carried out, and did not put interventions in place to help improve and heal R8's pressure injury.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 39 residents. Nutritional supplements and food items were observed with improper dates. An employee walked through the kitchen with no hairnet. A scoop was observed inside a container of sugar.

Inspectors wroteBased on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or make a concentrated effort to improve facility quality. This has the potential to affect all 39 residents. The facility does not have a Quality Assurance and Performance Improvement (QAPI) system in place and has failed to identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 39 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for any of the quarterly meetings in the past year. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 39 residents (R) in the facility. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal. The facility does not have mechanism for tracking Multi-Drug Resistant Organisms (MDRO). The facility's monthly infection control rates were not segregated for specific infection types. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 2 of 2 Medication carts reviewed and 2 of 2 medication rooms for medication storage. The 2nd floor medication cart had an undated open insulin pen for R34, and expired morphine tablets for R25. The 3rd floor medication cart had a cough syrup for R1 with no open date or expiration date. The 2nd and 3rd floor medication storage rooms had expired stock meds. Evidenced by: The Facility's Policy, entitled Labeling of Medications and Biologicals, dated 1/5/2022 with last revision date of 11/2024 states, in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 17 abuse investigations reviewed involving (R40). Facility became aware of an abuse allegation on [DATE] at 6:15 AM and did not report it to the State Agency until [DATE] at 11:14 AM. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 17 residents (R40) reviewed for abuse. Facility became aware of an abuse allegation on [DATE] and did not complete a thorough investigation. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse . V. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 4 residents (R16, R31, and R142) reviewed for falls. R142 sustained a fall on 11/27/24 and the facility failed to find a root cause or implement a new intervention. R31 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls. R16 had several falls, and the facility failed to complete a root cause analysis or implement interventions to prevent additional falls.

Inspectors wroteBased on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 of 2 residents (R35 and R17) reviewed for nutrition. R35's weights were obtained using different methods and therefore it is unclear if they are accurate. R35's physician was not updated on weight gain/loss based on these weights. R17's physician was not updated on a 21 pound weight loss and there was no documentation of trialing supplements with R17. Findings Include: The facility policy, titled, Weight Monitoring, date reviewed 11/2024, indicates, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 residents (R142) reviewed. R142 did not receive her scheduled Dupilumab (Dupixent) Subcutaneous (under the skin) Solution Auto-Injector 300mg/2ml on 12/6/24.

Inspectors wroteBased on interview and record review, the facility did not ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents reviewed for unnecessary medications (R17 and R30). R17 was taking an antipsychotic medication without appropriate diagnoses and indications for its use. R30's comprehensive care plan and documentation did not indicate what side effects of antipsychotic, benzodiazepine, or antidepressive medication that R30 should be monitored for, nor was there any documentation to indicate that R30's side effects were being monitored by staff.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 sampled residents (R1) and failed to report to the State Agency for 2 of 3 sampled residents (R2, R3). R1 had a sexual abuse allegation reported to the facility. The facility did not report this allegation to law enforcement. R2 reported that a certified nursing assistant (CNA) was rough with her. The facility did not report this allegation of abuse to the State Agency (SA) or law enforcement. R3 reported that the CNA left her unsupervised in the tub. The facility did not report this allegation of neglect to the SA. This is evidenced by: The Facility's Policy and Procedure entitled Abuse, Neglect and Exploitation dated 11/20/23 documents in part: [...]

Inspectors wroteBased on interview and record review, the facility did not investigate an alleged violation of abuse or neglect for 2 of 3 sampled residents (R2 and R3). On 2/6/24, the facility became aware of an alleged violation of abuse to R2 and the facility did not conduct an investigation. On 5/31/24, the facility became aware of an alleged violation of neglect to R3 and the facility did not conduct an investigation. Evidenced by: Facility policy entitled, Resident and Family Grievances dated 1/30/2024, states, in part: .Take any immediate actions needed to prevent further potential violations of any resident rights. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 2 of 3 sampled residents (R3 and R1). R3 was to have an alarm on for a fall intervention according to her Plan of Care. R3 had a fall on 1/15/24 resulting in a right hip fracture. The facility did not have an alarm placed on R3 at the time of the fall. Evidenced by: The facility policy, entitled Fall Policy and Procedure, undated, states, in part: Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: Fall risk assessment: 1) Upon admission, a fall risk assessment completed. Risk will be assessed quarterly and PRN (as needed). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received a complete involuntary discharge notice including the information for the right to appeal the notice for 1 of 1 residents (R1). R1's Power of Attorney (POA) was issued an involuntary discharge notice for R1 that did include all the requirements for an involuntary discharge notice, including the right to appeal to the Division of Quality Assurance and contact information.

Inspectors wroteBased on interview and record review, the facility did not monitor antibiotic use for 1 of 2 residents (R2) reviewed for antibiotic use of a total sample of 15 residents. R2 began receiving prophylactic antibiotics for reoccurring Urinary Tract Infections (UTIs) in January of 2022. In August of 2023, R2's prophylactic antibiotic was changed to a different antibiotic without laboratory confirmation of its effectiveness and continued to receive this antibiotic prophylactically. R2 was prescribed an antibiotic to treat a UTI despite a sensitivity report indicating R2 had developed resistance to the antibiotic. The facility did not thoroughly review R2's urine cultures and sensitivity results, did not recognize bacterial strain had become resistant and continued to provide R2 with an antibiotic in two separate orders that was documented as ineffective/resistant. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 36 residents residing at the facility. Surveyor observed: -Undated, unlabeled, uncovered, expired ready to eat foods and beverages in the refrigerator. -Undated, unlabeled, uncovered, expired food, and improper storage of food in freezer -Cross Contamination -Towel Drying clean/sanitized dishes and wetsacking dishes (process of placing wet dishes in to storage) -Facility staff filling out 3 Compartment Sinks Part Per Million (PPM) Log before processes had begun. [...]

Inspectors wroteBased on interview and record review, the facility does not have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents. This has the potential to affect the census of 36 and 1 of 7 hand hygiene opportunities. Staff returned to work too early with gastrointestinal (gs) symptoms (sx) and COVID per Centers for Disease Control and Prevention (CDC) guidelines. 2 staff and 3 residents (R4, R3, R12) with positive COVID were not included on the staff line lists for surveillance. 7 residents (R4, R12, R3, R15, R18, R29, R1) were allowed off isolation for COVID too early per CDC guidelines. Resident and staff line lists were not complete with well dates and return to work dates. COVID testing was not initiated with outbreak. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's physician was consulted with a deterioration in a pressure injury for 1 of 2 Residents reviewed for pressure injuries (PI) out of a total sample of 15 Residents (R9). R9 was admitted to the facility with a pressure injury to her left elbow and the physician was not notified when the wound was not improving/worsened. This is evidenced by: The facility policy titled Documentation of Wound Treatments, with a reviewed/revised date of 4/12/23, indicates, in part: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's (R35's) right to be free from physical abuse by R33. R33 has a history of striking residents. The facility failed to put aggressive measures in place to prevent R33 from physical abusing R35. R33 entered R35's room and willfully hit R35 in the chest. The facility failed to protect R35 by not providing adequate supervision. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routine or staff. VI. Protection of Resident. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours to the state agency for 1 (R35) of 3 allegations of abuse. -The facility failed to identify and report an incident an alleged violation involving potential abuse immediately, but not later than two hours, to the administrator as well as the state survey agency. The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations of abuse were thoroughly investigated to prevent further abuse for 1 of 3 resident's (R33) reviewed for of abuse. The facility failed to complete a thoroughly investigation into the incident between R33 and R35 that occurred on 10/26/23. Evidenced by: The facility's policy, entitled Abuse, Neglect, and Exploitation revision date 7/24/23, states: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. IV. Investigation of Alleged Abuse, Neglect and Exploitation. A. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a discharge summary, with a recapitulation of the resident's stay, includes, but is not limited to: diagnosis, course of illness/treatment or therapy, pertinent lab, radiology, and consultant results was developed for 1 of 14 sampled residents (R37) reviewed for discharge summary/recapitulation. R37 did not have a recapitulation of his stay. Evidenced by The facility's policy, entitled Transfer and Discharge ., dated 4/10/23, states in part; . 14. Anticipated Transfers or Discharges . b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (R33 & R34) reviewed for supervision and accidents out of a total sample of 14. R33 had 9 falls since August 1, 2023. Facility did not identify root/cause for these falls. No new interventions or care plan updates were added with these 9 falls. R34 is known to be exit-seeking and staff did not monitor him. Evidenced by: The facility policy, entitled Fall Policy and Procedure, dated 3/2019, states, in part: . Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: Fall risk assessment: . 2. Upon assessment, staff will provide needed intervention to prevent fall. Intervention is added to care plan . [...]

Inspectors wroteBased on observation, interview, and record review. The facility did not ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence for 1of 3 resident's (R33) reviewed for bowel and bladder program. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2. The facility failed to implement and conduct a toileting program for R33 after an assessment indicated that R33 is categorized as being a candidate for scheduled toileting. Staff did not remove gloves per standards of practice when providing catheter care for 1 of 1 residents with a catheter R2.

Inspectors wroteBased on interview and record review, the facility did not ensure prescribing provider evaluated the resident and documented a clinical rationale for extending as needed (PRN) anti-psychotic medication beyond 14 days for 1 resident (R33) of 5 residents reviewed for unnecessary medications. The facility failed to implement and document nonpharmacological interventions before administering PRN psychotropic medications to R33. Facility administered PRN Lorazepam past the 14-day limitation, failed to follow the facility's use of psychotropic medication policy, evaluate the effects of PRN psychotropic medication use and respond to/provide reasoning for not following Dementia Stabilization Unit (DSU) recommendations to decrease R33's PRN psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 4 errors in 27 opportunities that affected 2 out of 5 residents (R7 & R25) included in the medication pass task, which resulted in an error rate of 14.81%. Staff mixed R7's Valproic Acid, clonidine, and tizanidine together and administered through R7's gastrointestinal tube (g-tube). R25 received senna plus and R7's physician order was for senna. Evidenced by: Example 1 The facility policy, entitled Medication Administration via Enteral Tube, dated 1/1/23, states, in part: . Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . Policy Explanation and Compliance Guidelines: . 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R1) of 4 residents sampled for abuse. R2 has a history of agitation and abuse. R2 struck R1 in the face, causing a bloody lip. Evidenced by: The facility's policy titled, Abuse, Neglect, and Exploitation no date, states in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that grievances were filed per facility policy for 1 of 1 sampled residents (R3).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents and hazards for 1 of 1 resident reviewed (R6). -R6 left 3rd floor 2 times using the staircase without complete supervision. -R6 eloped from the building -R6 left 3rd floor 1 time using elevator unsupervised. -R6 left 3rd floor 1 time using unknown route. -R6 wandered into other residents' room [ROOM NUMBER] times. -R6 hit staff or was physically aggressive towards.

Inspectors wroteBased on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents reviewed (R4). R4 did not receive all medications as ordered on 9/10/23 and 9/11/23. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible .c. Document actions taken in the medical record. d. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices in 1 of 2 residents reviewed (R5). R5's Medication Administration Record (MAR) had documentation of medication administration that did not occur. This is evidenced by: The facility policy titled, Medication Errors, with a reviewed/revised date of 6/12/23, indicates, in part: .Policy Explanation and Compliance Guidelines: .7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration. b. Right resident and right documentation . On 9/12/23 Surveyors requested a list of medication errors from the facility. [...]