Every finding on record at Acadia St. Landry Nursing & Rehabilitation Center

Based on interviews and record review, the facility failed to immediately inform the resident's physician of a major injury for 1 resident (#1) of 3 sampled residents. Findings: Review of the facility's policy titled Change in a Resident's Condition or Status, with a last revised date of May 2017, read in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's physical/mental condition and/or status.1. The nurse will notify the resident's Attending Physician or physician call when there has been a (an): d. significant change in the resident's physical/emotional/mental condition.2. A significant change of condition is a major decline or improvement in the resident's status that: c. Requires interdisciplinary review and/or revision to the care plan.Review of Resident #1's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] and had diagnoses including, but not limited to, displaced fracture of left tibial tuberosity , subsequent encounter for closed fracture with routine healing, anxiety disorder, unspecified dementia, and unspecified sequelae of cerebral infarction. Review of Resident #1's nursing progress notes from 05/22/2026 to 05/26/2026 revealed the following in part : -05/22/2026 3:00 a.m. S3LPN wrote: 3 a.m. called to resident room by husband(roommate). resident noted sitting on floormat with back against bed, legs extended out.head to toe assessment done. no apparent injuries noted.3:39 a.m. send secured message to S4NP to make her aware of fall. -05/22/2026 4:45 p.m. S2ADON wrote: Alerted to Resident #1's room per CNA (Certified Nursing Assistant) who stated that the residents Lt. (left) leg was swollen and painful at the knee .I assessed the resident and noted that the lateral lower area beneath the knee was swollen and painful to touch and movement. Instructed the attending LPN (Licensed Practical Nurse) S3LPN to notify the attending provider and the family of the change in status. New orders were noted.-05/22/2026 5:04 p.m. S3LPN wrote: 4 p.m. made aware by Adon (Assistant Director of Nursing) that resident was c/o (complaining of) leg pain. upon assessment resident edema noted to left leg and raised area noted below knee on left leg. resident c/o bil (bilateral) leg pain to touch. 4 p.m. phoned S4NP and made her aware of resident c/o bil leg pain. new order noted to send resident to [hospital] ER for eval (evaluation) and tx (treatment). Phoned S5AN (Administrative Nurse) and made her aware of resident condition .4:20 p.m. resident left with nh staff via stretcher-05/24/2026 8:39 a.m. S6MDS wrote: On 5/22/26, resident was transferred to [hospital ER] d/t (due to) c/o increased pain to left lower leg. Resident assessed per ADON d/t left leg swollen & painful at the knee. On 5/23/26, resident returned with CT left knee w/o (without) contrast impression: mildly displaced avulsion fx. of the tibial tuberosity. Joint effusion present. Tricompartmental degenerative changes of the knee. Left knee x-rays, 2 views d/t pain, impression: lucency of the anterior tibial tuberosity, correlate for avulsion fx (fracture). Recommend follow-up CT.-05/26/2026 3:20 p.m. S6MDS wrote: S4NP. made rounds. N. O. (New Order) increase Seroquel to 50mg (milligrams) po (by mouth) at hs (hours of sleep). Start Seroquel 25mg po q (every) a.m. dx (diagnosis) Psychosis/Mood D/O (disorder). Schedule Ortho (Orthopedic) consult with [physician] for mildly displaced avulsion fx (fracture) of the left tibial tuberosity with joint effusion & tricompartmental degenerative changes (status post fall). Resident is non-ambulatory. Hydrocodone/APAP 5/325mg 1 po q 4 hours prn (as needed) moderate to severe pain. Dispense #42 tabs, 7-day supply. Do paperwork for pain mgmt (management) for [physician] for next Tuesday. Review of Resident #1's written physician's orders revealed the following orders dated 05/26/2026: -Schedule Ortho consult with [physician] for mildly displaced avulsion fx (fracture) of the left tibial tuberosity with joint effusion & tricompartmental degenerative changes (status post fall)- Hydrocodone/APAP 5/325mg 1 po q 4 hours prn (as needed) moderate to severe pain. Dispense 42 tabs, 7-day supply- Do paperwork for pain mgmt (management) for [physician] for next Tuesday. Further review of Resident #1's physician's orders revealed the following order dated 05/28/2026: Knee immobilizer to left knee at all times , remove for bathing only, monitor q (every) shift. Review of Resident #1's plan of care and physician's orders for May 2026 reveled there were no interventions ordered for the resident's left knee fracture until 05/26/2026. Review of Resident #1's EHR failed to reveal evidence that the nurse practitioner or physician was immediately notified of the resident's fracture discovered on 05/22/2026. On 06/08/2026 at 12:45 p.m., an interview was conducted with S4NP. S4NP stated that she was not notified that Resident #1 had a left knee fracture until she made rounds at the facility on 05/26/2026. S4NP confirmed that she was the provider on call on the weekend of 05/22/2026 to 05/24/2026. She stated that the hospital did not send the resident back with any follow up orders or a knee immobilizer, so she ordered an orthopedic consult on 05/26/2026 because she felt like the resident needed that. She also ordered pain medications for the resident on 05/26/2026. S4NP stated that the facility would have needed to call her for an order for stronger pain medications. S4NP was asked if the facility should have notified her of the resident's imaging results when it was discovered that she had a fracture on 05/22/2026. S4NP stated, You would think.On 06/08/2026 at 3:26 p.m., a phone interview was conducted with S3LPN. S3LPN stated that she was the resident's nurse when she fell out of bed on 05/22/2026. When she returned for her shift later that evening, the CNA reported to S2ADON that the resident's left leg was swollen and bruised. S2ADON assessed her, and she [S3LPN] notified S4NP and received an order to send the resident out for evaluation. She stated that the ER nurse called her and told her that the resident's knee was fractured, and she notified the administrative nurse on call that night of the fracture, but she did not remember who it was. S3LPN stated she did not recall notifying S4NP of the fracture. On 06/09/2026 at 1:49 p.m., an interview was conducted with S1DON. She stated that S3LPN notified her via text message on 05/22/2026 that she had sent the resident out for evaluation of her leg and that the resident had a left knee fracture. S1DON stated that she did not notify S4NP of the knee fracture, and that was something that the resident's nurse would typically do. She stated that S3LPN should have notified the nurse practitioner that the resident fractured her knee at the time of discovery because it was a change in condition.On 06/09/2026 at 2:51 p.m., a second interview was conducted with S1DON. S1DON confirmed that S3LPN knew that Resident #1 had a fracture on 05/22/2026 and also worked with the resident again when she returned from the hospital on [DATE] and 05/24/2026. S1DON stated that when S3LPN noticed that the resident had no interventions in place, such as pain medication, a knee immobilizer, or any further instructions, S3LPN should have notified the nurse practitioner, physician, or herself that the resident had no interventions in place with a diagnosis of a left knee fracture.

Based on interviews and record review, the facility failed to provide quarterly statements to 3 (#83, #88, #89) residents of 4 (#64, #83, #88, #89) residents investigated for personal funds. Findings: Review of the facility's policy and procedure titled Resident Trust Fund Policy and Procedure, with a review date of 11/3/2025, read in part; 4. Resident Rights Regarding Personal Funds, Resident have the right to: Receive quarterly statements of their account. Review of Resident #83's EHR (Electronic Health Record) revealed an admission date of 12/02/2024 and diagnoses that included, but were not limited to, hypertensive heart disease with heart failure peripheral vascular disease, and chronic kidney disease. A review of the Resident #83's comprehensive MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11, which indicated her cognition was moderately intact. On 03/09/2026 at 10:18 a.m., an interview was conducted with Resident #83. Resident #83 stated that she had not received any quarterly statements for her money that was kept at the facility. She stated that she had never received any statements in regards to her money. On 03/11/2026 at 1:38 p.m., an interview was conducted with S7RT. S7RT stated she was responsible for providing written quarterly statements to residents in the facility. S7RT stated she had no evidence that quarterly statements were provided to residents or responsible parties. Resident #89 Review of Resident #89's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified atrial fibrillation, and cerebral ischemia. Review of Resident #89's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. On 03/09/2026 at 12:47 p.m., an interview was conducted with Resident #89. Resident #89 stated she had a personal funds account at the facility and she has not been receiving quarterly statements for her personal funds account. On 03/11/2026 at 9:33 a.m., an interview was conducted with S7RT. S7RT stated she was responsible for the personal funds accounts for the residents at the facility. S7RT stated that if a resident's BIMS score is 11 or higher she would hand the statement to the resident. S7RT stated she could not provide evidence that Resident #89 received a quarterly statement or that a quarterly statement was mailed to Resident #89's Responsible Party. Resident #88 Review of Resident #88's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, occlusion and stenosis of unspecified carotid artery, unsteadiness on feet, hypertension, and unilateral primary osteoarthritis, left knee. Review of Resident #88's quarterly MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of 12/31/2025 revealed in section C, Cognitive Patterns, she had BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. On 03/09/2026 at 10:00 a.m., an interview was conducted with Resident #88. She stated that she did not receive any statements in regards to the money she had in her account at the facility and would like to receive these statements. She further stated that she had received only one statement since her admission. On 03/11/2026 at 9:56 a.m., an interview was conducted with S7RT. She stated that she was responsible for the residents' trust funds at facility. She stated that she tried to provide residents with quarterly statements and handed those out to residents with a BIMS scores of 11-15. She confirmed that she did not have any evidence that personal funds quarterly statements were handed to Resident #88. She also confirmed that she did not have any evidence that quarterly statements were mailed to Resident #88's responsible party.

Based on observations, interviews, record reviews, and policy review, the facility failed to ensure call systems in resident bathrooms were functional and accessible to residents at all times for 7 residents (#4, #23, #75, #112, #130, #132, and #133) out of a final sample of 48 residents. Findings: A review of the facility's policy titled Call Bell Policy with a last reviewed date of 11/03/2025 read in part, Policy Statement: The facility will maintain an effective call-light system that allows residents to summon staff assistance at any time. Resident #4Review of Resident #4's electronic health record revealed an admission date of 07/13/2023 with diagnoses that included but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, acute kidney failure, and diabetes mellitus due to underlying condition with diabetic neuropathy. Review of Resident #4's 5 day MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMS (Basic Interview for Mental Status) score of 11, indicating her cognition was moderately impaired. The MDS assessment Section GG also revealed Resident #4 required partial/moderate assistance with toilet transfer. On 03/09/2026 at 9:22 a.m., an observation was made of Resident #4's bathroom. The call bell pull cord was disconnected from the wall unit, near the resident's toilet, wrapped around the metal grab bar next to the toilet. On 03/10/2026 at 3:31 p.m., an interview was conducted with Resident #4. She stated that she had to constantly place the pull cord back into the call bell system's unit on the wall near her toilet. She stated that every time she pulled the cord, it disconnected from the wall unit. Resident #23 Review of Resident #23's electronic health record revealed an admission date of 02/10/2022 with diagnoses that included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease, stage 3B, and unspecified dementia. On 03/09/2026 at 10:27 a.m., and observation was made of Resident #23's bathroom. The resident's bathroom call bell pull cord was disconnected from the call bell system's wall unit and in a box on the sink counter. On 03/10/2026 at 2:51 p.m., an interview and observation was made of S13CNA assisting resident #23 to the toilet. She stated that Resident #23 was able to use the call bell pull chord located next to the resident's toilet for assistance. Resident # 75 Review of Resident #75's electronic health record revealed an admission date of 02/23/2026 with diagnoses that included but were not limited to, unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing and type 2 diabetes mellitus without complications. Review of Resident #75's day MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMS (Basic Interview for Mental Status) score of 10, indicating her cognition was moderately impaired. The MDS assessment's Section GG also revealed Resident #75 required substantial/maximal assistance with toilet transfer. On 03/09/2026 9:27 a.m., an observation was made of Resident #75's bathroom. The resident's call bell pull cord was disconnected from the call bell's wall unit. The pull cord was located on the floor near the toilet. Resident #112 Review of Resident #112's electronic health record revealed an admission date of 12/18/2025 with diagnoses that included but were not limited to, heart failure and cerebral palsy. Review of Resident #112's 5 day MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMS (Basic Interview for Mental Status) score of 12, indicating her cognition was moderately impaired. The MDS assessment's Section GG revealed Resident #112 required supervision or touching assistance with toilet transfer. On 03/09/2026 9:29 a.m., an observation was made of Resident #112's bathroom. The resident's call bell pull cord was disconnected from the wall unit, near the resident's toilet, wrapped around the metal grab bar next to the toilet. On 03/09/2026 12:56 p.m., an interview was conducted with Resident #112. She stated that she had not placed the pull chord's string around the metal grab bar. She stated it had been wrapped up like that since she returned from her last hospital stay. On 03/11/2026 at 5:30 p.m. a record review and interview was conducted with S2ADON. She confirmed that Resident #112 last returned from the hospital to the facility on [DATE]. Resident # 130 Review of Resident #130's electronic health record revealed an admission date of 02/28/2026 with diagnoses that included but were not limited to, displaced fracture of lateral condyle of right tibia, subsequent encounter for closed fracture with routine healing. Review of a Skilled Evaluation nursing note dated 03/09/2026 at 11:23 p.m., read in part, Mental Status: Alert and Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Resident is alert and oriented x3. Oriented to place. Oriented to person. Oriented to time. Genitourinary: Resident is continent of urine. Resident voids via toilet. On 03/09/2026 at 9:40 a.m., an observation was made of Resident #130's bathroom. The resident's call bell pull cord was connected to the call bell wall unit near the toilet, but wrapped around the bar next to the toilet. Resident #132Review of Resident #132's electronic health record revealed an admission date of 08/22/2024 with diagnoses that included but was not limited to heart failure. Review of a Skilled Evaluation nursing note dated 03/09/2026 at 11:00 p.m., read in part, Gastrointestinal: Continent of bowel: Yes, Genitourinary: Resident is continent of urine. Resident voids via toilet. On 03/09/2026 9:52 a.m., an observation was made of Resident #132's bathroom. The resident's call bell pull cord was disconnected from the wall unit near the toilet, wrapped around the metal grab bar next to the toilet. Resident #133 Review of Resident #133's electronic health record revealed an admission date of 02/27/2026. Review of a Skilled Evaluation nursing note dated 03/05/2026 at 11:45 p.m., read in part, Mental Status: Alert and Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Resident is alert and oriented x3. Oriented to person. Oriented to place. Oriented to time. Gastrointestinal, continent of bowel- yes; Genitourinary: Resident is continent of urine. Resident voids via toilet.On 03/09/2026 at 10:02 a.m., an observation was made of Resident #133's bathroom. The resident's call bell pull cord was disconnected from the call bell wall unit and located on the floor near the toilet. On 03/09/2026 at 12:35 p.m., a tour was conducted with S6MD of the referenced residents' bathrooms. S6MD confirmed the observations made of the call bell pull cords near the residents' toilets in their respective bathrooms. He confirmed that the residents' call bell pull cords were not accessible if the residents were positioned on the floor, disconnected or when wrapped around the metal grab bar next to the toilet. S6MD demonstrated how the residents' bathroom pull cords easily detached from the wall unit. On 03/10/2026 9:36 a.m., an interview was conducted with S14CNA. She stated that she cared for Resident #4, Resident #75, Resident #112, Resident #130, Resident #132, and Resident #133. She confirmed these residents used the toilet in their bathrooms and have been left unassisted during times when doing so. She further confirmed that these residents utilized the call bell system with pull cords next to their toilets. On 03/10/2026 at 3:27 p.m., an interview was conducted with S15LPN. She stated that she cared for Resident #4, Resident #75, Resident #112, Resident #130, Resident #132, and Resident #133. She confirmed these residents used the toilet in their bathrooms and have been left unassisted at times when doing so. She further confirmed that these residents utilized their bathrooms' call bell pull cord next to their toilets. On 03/10/2026 at 3:58 p.m., an interview was conducted with S1DON. She confirmed that residents' bathroom call bell pull cords should be accessible to residents. S1DON further confirmed the residents' bathroom pull cords were not functional when the pull cords were located on the floor in the bathroom, were disconnected from the call bell system's wall unit or when wrapped around the metal grab bar near the toilet.

Based on observations and interview, the facility failed to ensure there was sufficient space in the dining room to accommodate residents who required assistance with feeding. This deficient practice had the potential to affect 14 residents who required assistance with feeding. Findings: On 03/09/2026 at 11:25 a.m., Resident #3 and Resident #35 were observed sitting in the adjoining T.V. (television) activity section of the dining room. Other residents were eating lunch in the dining room at this time. S10TN told a CNA (Certified Nursing Assistant) that Residents #3 and #35 were waiting to eat at the table for residents who were required to be fed. On 03/09/2026 at 11:45 a.m., Resident #3 and Resident #35 were placed at the table for residents who were required to be fed when space became available. On 03/10/2026 at 11:25 a.m., another observation was conducted in the dining room during lunch. Resident #35 was waiting in the adjoining TV activity section of the dining room to eat. On 03/10/2026 at 11:31 a.m., an interview was conducted with S10TN who was the nurse responsible for overseeing dining activities at that time. S10TN was asked why residents were waiting in the T.V. activity section of the dining room to eat. S10TN stated that the facility did not have enough space to seat all residents who were required to be fed at the feeding table all at once, so staff rotated the residents out. She further stated that when one resident was finished eating, they were removed from the table and another resident was then placed in that spot at the table to eat. An observation was then made of the area of the dining room for residents who were required to be fed. A large round table and small square table were observed. There was no space for any additional residents or staff members to sit at the tables, and no space for any additional tables to be placed in that area. On 03/11/2026 at 11:35 a.m., Resident #121 was observed waiting in T.V. activity section of the dining room to eat. There were no available seats at the feeding table at this time. On 03/11/2026 at 11:43 a.m., an interview was conducted with S1DON. S1DON stated that because there were 16 residents who had to be fed, it was not feasible for all of them to sit at the table at one time. She stated the CNAs brought all of the residents that were required to be fed to the dining room at one time to ensure that everyone ate. Staff seat them in the T.V. activity section of the dining room while they wait for space to become available at the feeding table. S1DON agreed that the residents who had to wait in the T.V. activity section of the dining room were able to see other residents eating at the tables in the adjoining dining area, and because there was an influx of residents that were required to be fed, they could not all be seated at the table and fed at the same time.

Based on record review and interviews, the facility failed to ensure the plan of care/physician orders were implemented for 1 (Residents #2) out of 48 sampled residents. The facility failed to apply topical cream to a suprapubic site, irrigate a suprapubic catheter, and document suprapubic catheter output for Resident #2.Findings:Review of Resident #2's electronic health record revealed an admission date of 08/27/2024 with diagnoses that included but were not limited to, calculus in bladder and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMS (Basic Interview for Mental Status) score of 11, indicating his cognition was moderately impaired. Review of Resident #2's current plan of care revealed in part: Focus- urinary catheter (suprapubic); Interventions- Document suprapubic cath (catheter) output q (every) shift, Irrigate suprapubic cath with 60cc (cubic centimeter) NS (normal saline) bid (twice a day), and Medications as ordered. Review of Resident #2's March 2026 physician orders revealed:1. Dated 09/06/2024 for Clotrimazole External Cream 1% (Clotrimazole Topical) Apply to suprapubic catheter site topically two times a day related to candidiasis of skin and nail,2. Dated 01/24/2025 for Irrigate suprapubic catheter with 60cc NS two times a day, and 3. Dated 10/04/2025 for Document suprapubic cath output q shift. Review of Resident #2's TARs (Treatment Administration Record) for the months of November 2025, December 2025, January 2026, February 2026 and March 2026 revealed the following ordered treatments:1. Clotrimazole External Cream 1% (Clotrimazole (Topical) Apply to suprapubic catheter site topically two times a day related to candidiasis of skin and nail,2. Irrigate suprapubic catheter with 60cc NS two times a day and3. Document suprapubic cath output q shift.Further review of Resident #2's TAR for failed to include nurses' initials or evidence that the three treatments, as mentioned above, were performed as ordered on the following dates: 1. Application of ordered topical cream to Resident #2's suprapubic catheter site failed to include documentation care was completed for: November 2025: a. 6:30 a.m. - 11/12/2025 and 11/13/2025 b. 6:30 p.m. - 11/05/2025, 11/11/2025, 11/12/2025, 11/17/2025, 11/22/2025, 11/23/2025, and 11/26/2025 December 2025: a. 6:30 a.m. - 12/03/2025, 12/05/2025, 12/09/2025, and 12/21/2025 b. 6:30 p.m.- 12/02/2025, 12/03/2025, 12/06/2025, 12/07/2025, 12/08/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/25/2025, 12/30/2025, and 12/31/2025 January 2026: a. 6:30 a.m.- 01/01/2026, 01/12/2026, 01/14/2026, 01/16/2026, and 01/23/2026 b. 6:30 p.m.- 01/03/2026, 01/04/2026, 01/10/2026, 01/12/2026, 01/16/2026, 01/25/2026, 01/26/2026, and 01/28/2026 February 2026: a. 6:30 p.m.- 02/01/26, 02/03/2026, 02/11/2026, 02/13/2026, 02/19/2026, 02/20/2026, 02/21/2026, 02/22/2026, and 02/24/2026 March 2026: a. 6:30 p.m.- 03/03/2026, 03/04/2026, and 03/08/2026 2. Irrigation of the resident's suprapubic catheter with 60cc NS twice a day failed to include documentation care was completed for: November 2025: a. 7:30 a.m. - 11/12/2025 and 11/13/2025 b. 2:30 p.m. - 11/01/2025, 11/02/2025, 11/11/2025, 11/12/2025, 11/15/2025, 11/23/2025, 11/26/2025, and 11/29/2025 December 2025: a. 7:30 a.m. - 12/03/2025, 12/05/2025, 12/21/2025, and 12/29/2025 b. 2:30 p.m.- 12/01/2025, 12/02/2025, 12/05/2025, 12/06/2025, 12/07/2025, 12/09/2025, 12/11/2025, 12/12/2025, 12/13/2025, 12/14/2025, 12/18/2025, 12/19/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/25/2025, 12/26/2025, 12/27/2025, 12/29/2025, and 12/31/2025 January 2026: a. 7:30 a.m.- 01/01/2026, 01/12/2026, 01/14/2026, 01/16/2026, and 01/23/2026 b. 2:30 p.m.- 01/01/2026, 01/03/2026, 01/04/2026, 01/10/2026, 01/12/2026, 01/13/2026, 01/15/2026, 01/16/2026, 01/17/2026, 01/19/2026, 01/20/2026, 01/22/2026, 01/23/2026, 01/24/2026, 01/25/2026, 01/26/2026, 01/29/2026, 01/30/2026, 01/31/2026 February 2026: a. 7:30 a.m.- 02/07/26 b. 2:30 p.m.- 02/01/26, 02/03/2026, 02/04/2026, 02/05/2026, 02/06/2026, 02/07/2026, 02/08/2026, 02/12/2026, 02/13/2026, 02/14/2026, 02/18/2026, 02/21/2026, and 02/22/2026 March 2026: a. 2:30 p.m.- 03/07/2026, 03/08/2026, and 03/10/2026 3. Documentation of resident's suprapubic cath output ever shift failed to include documentation care was completed for: November 2025: a. 5:00 a.m. - 11/02/2025, 11/12/2025, 11/13/2025, 11/15/2025, 11/16/2025, 11/18/2025, 11/20/2025, 11/22/2025, 11/23/2025, 11/26/2025, 11/27/2025, and 11/30/2025 b. 1:00 p.m. - 11/11/2025, 11/12/2025, 11/17/2025, 11/22/2025, 11/23/2025, and 11/26/2025 c. 9:00 p.m.- 11/01/2025, 11/11/2025, 11/12/2025, 11/13/2025, 11/14/2025, 11/16/2025, 11/19/2025, 11/20/2025, 11/23/2025, 11/24/2025, 11/25/2025, 11/26/2025, 11/27/2025 December 2025: a. 5:00 a.m. - 12/03/2025, 12/05/2025, 12/06/2025, 12/07/2025, 12/08/2025, 12/09/2025, 12/11/2025, 12/12/2025, 12/17/2025, 12/18/2025, 12/19/2025, 12/21/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/26/2025, 12/29/2025, 12/30/2025, and 12/31/2025. b. 1:00 p.m.- 12/02/2025, 12/03/2025, 12/06/2025, 12/08/2025, 12/11/2025, 12/13/2025, 12/18/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/25/2025, 12/30/2025, and 12/31/2025 c. 9:00 p.m.- 12/06/2025, 12/13/2025, 12/15/2025, 12/20/2025, 12/23/2025, 12/24/2025, 12/28/2025, and 12/30/2025 January 2026: a. 5:00 a.m.- 01/01/2026, 01/02/2026, 01/04/2026, 01/05/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026, 01/12/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/23/2026 b. 1:00 p.m.- 01/04/2026, 01/10/2026, 01/12/2026, 01/13/2026, 01/15/2026, 01/16/2026, 01/17/2026, 01/20/2026, 01/21/2026, 01/23/2026, 01/24/2026, 01/25/2026, 01/26/2026, 01/28/2026, and 01/29/2026 c. 9:00 p.m.- 01/01/2026, 01/10/2026, 01/16/2026, 01/20/2026, 01/21/2026, 01/22/2026, 01/27/2026, and 01/29/2026 February 2026: a. 5:00 a.m.- 02/27/26 b. 1:00 p.m.- 02/03/26, 02/05/2026, 02/11/2026, 02/13/2026, 02/19/2026, 02/20/2026, 02/21/2026, 02/22/2026 c. 9:00 p.m.- 02/03/26, 02/09/2026, 02/11/2026, 02/17/2026, 02/18/2026, 02/20/2026, and 02/22/2026, March 2026: a. 1:00 p.m.- 03/01/2026, 03/02/2026, and 03/03/2026, 03/04/2026, and 03/08/2026 b. 9:00 p.m.- 03/01/2026 and 03/08/2026On 03/11/2026 at 12:16 p.m. an interview was conducted with Resident #2. He stated that facility staff were irrigating his suprapubic catheter and applied cream around his suprapubic site mostly once a day, rarely twice a day. On 03/11/2026 at 3:45 p.m. an interview and review of Resident #2's TARs was conducted with S1DON. S1DON confirmed that the nurses' initials on the above respective dates were missing. She further confirmed that without the signatures present on the TAR, there was no evidence that the above orders had been implemented for those dates. S1DON stated Resident #2 was a reliable source of whether catheter irrigation and application of cream around his suprapubic site had been implemented as ordered.

Based on observations, record reviews, and staff interviews, the facility failed to ensure that services were provided to meet professional standards of quality for 2 (#7 and #54) out of 48 sampled residents as evidenced by:1. Failing to ensure Resident #7 swallowed all medications before the nurse exited the room, and2. Failing to ensure Resident #54's tube feeding bottle was labeled with the date and time it was hung and the nurse's initials.Findings: Resident #7 Review of a facility policy titled Administration of Drugs from Medication Carts, with a last reviewed date of 11/03/2025, revealed in part, 12. Never leave the drugs at the bedside or in the patient's hand or mouth. The patient must take the medicine while the nurse is present. Review of Resident #7's medical record revealed an admit date of 08/06/2008 with diagnoses that included, in part, artherosclerotic heart disease of native coronary artery without angina pectoris, chronic pain syndrome, and hypokalemia. Review of Resident #7's MDS (Minimum Data Set) dated 01/14/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. On 03/11/2026 at 1:01 p.m., an observation and interview was conducted with Resident #7. An observation was made of a medicine cup containing tablets and capsules on Resident #7's bedside table. The tablets and capsules in the medicine cup were clumped together and some of the tablets had started to dissolve. No nurse was present in the resident's room. Resident #7 stated he tried to swallow his medications and the medications got wet. Resident #7 stated he choked on his medications and had to spit the medications out. Resident #7 stated that his nurse put the medications in the medication cup on his bedside table then left his room. Resident #7 stated his nurse did not watch him take his medications. On 03/11/2026 at 1:07 p.m., an interview and observation was conducted with S2ADON in Resident #7's room. S2ADON confirmed that there were medications in the medicine cup on Resident #7's bedside table. S2ADON confirmed that resident's nurse should not have left medications at the bedside and should have remained in the room and observed the resident take his medications. On 03/11/2026 at 1:22 p.m., an interview was conducted with S11LPN. S11LPN confirmed that she was Resident #7's nurse and that she administered Resident #7's morning medications to him today. S11LPN stated she put the medications in Resident #7's mouth and exited his room. S11LPN confirmed that the medications on Resident #7's MAR dated 3/11/2026 and signed with her initials were the tablets and capsules that were administered during the morning med pass and in Resident #7's medicine cup at his bedside. On 3/11/2026 at 1:25 p.m., a review of Resident #7's March 2026 MAR (Medication Administration Record) was conducted with S11LPN and the following medications were documented as administered to Resident #7 on the morning of 03/11/2026: Allopurinol oral tablet 100 mg (milligram); 2 Azo oral tablets 95 mg; Calcium Citrate + oral tablet 315-5 mg-mcg (microgram); Cholecalciferol oral tablet 5000 units; Gabapentin oral tablet 600 mg; Hydrocodone-Acetaminophen oral tablet 5-325 mg; Mirabegron ER (extended release) oral tablet 50 mg; Pantoprazole Sodium EC oral tablet 40 mg; Potassium Chloride oral tablet 20 meq (milliequivalent); Sotalol HCL oral tablet 80 mg; Sucralfate oral tablet 1 gram; Tamsulosin HCL oral capsule 0.4 mg; 3 Tart Cherry oral capsules; Venlafaxine HCL ER oral capsule 75 mg; Verapamil HCL ER oral tablet 180 mg; and Vitamin B Complet oral tablet. On 03/11/2026 at 4:45 p.m., an interview was conducted with S2ADON. S2DON stated the nurses use a facility document titled Med Pass Tips during orientation. A review was conducted of the facility document titled, Med Pass Tips, which revealed in part, watch resident swallow all meds. Do not leave meds at bedside unless there is an order to do so. Resident #54 Review of Resident #54's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, encounter for attention to gastrostomy and dysphagia. Review of Resident #54's physician's orders revealed the following order dated 11/17/2025: Enteral Feed, every shift, Jevity 1.2 at 70(cubic centimeters) per hr (hour) continuous to provide 2016 Kcal 93 gm (gram) protein, 20ml (milliliter) H2O (water) flush q (every ) hour to provide 1836 ml free H2O. On 03/09/2026 at 9:08 a.m., an observation was made of Resident #54's room tube feeding setup. There was no label on the tube feeding bottle that identified the date and time it was started or the nurse's initials. On 03/09/2026 at 11:57 a.m., an observation was made of Resident #54's tube feeding bottle. The resident's tube feeding bottle was infusing at this time. The tube feeding bottle was not labeled with the date and time that it was started, or nurse's initials. On 03/09/2026 at 12:04 p.m., an observation was made of Resident #54's tube feeding bottle with S8LPN. She stated that she did not setup the tube feeding bottle, but it should have been labeled with the date and time it was hung and nurse's initials. On 03/09/2026 at 12:06 p.m., an interview was conducted with S1DON who stated the tube feeding formula bottle should have been labeled with the date and time it was started and nurse's initials.

Based on interview and record review, the facility failed to ensure that a resident received the necessary care and treatment for a pressure ulcer consistent with professional standards of practice evidenced by the nurse failing to conduct accurate weekly skin/ body audit assessment, and complete comprehensive weekly wound assessments for 1 (Resident #9) out of 3 (#9, #10, #109) residents investigated for pressure ulcers out of a total sample of 48 residents. Findings:Review of Resident #9's electronic medical record revealed she was admitted on [DATE] with diagnoses that included, but were not limited to spina bifida, unspecified, type 2 diabetes mellitus without complications, unspecified and paraplegia, unspecified. Review of the facility's policy with a review date of 11/03/2025, titled Pressure Ulcer/Skin Breakdown Risk Assessment read in part, Steps in the Procedure, 4. a. Conduct a comprehensive weekly skin assessment/body audit. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a facility wound assessment related to the type of alteration in skin. Review of the facility's policy with a review date of 11/03/2025, titled Wound Care revealed in part, Steps in procedure: Documentation: The following information should be recorded in the resident's medical record; 4. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. Review of Resident #9's care plan revealed she was care planned for impaired skin integrity to her right foot with a goal to be free of skin breakdown through review date. Initiated on 04/15/2025 and revised on 02/17/2026. Interventions/Tasks included in part, monitor and measure wound (s) weekly. Review of the physician's progress note dated 02/02/2026 revealed in part; Reason for Visit: Evaluate and treat. Order for wound care; Right heel: apply aquacel and mepilex border 6 x 6, every other day and as needed.Review of Resident #9's weekly skin assessment audits dated February 2026 and March 2026 revealed no pressure ulcer was present to the right heel for dates; 02/04/2026, 02/11/2026, 02/18/2026, 02/25/2026 and 03/04/2026. Review of the wound rounds for February 2026 and March 2026 for Resident #9 failed to identify a wound/pressure ulcer to the right heel for Resident #9. On 03/11/2026 at 9:51 a.m., an interview and record review with S12LPN/TN was conducted. She stated that she was responsible for conducting skin assessment audits for residents. She stated that for the above dates she had assessed Resident #9 and had not identified her stage 2 pressure ulcer to the right heel. S12LPN/TN stated that a treatment was provided for this pressure ulcer and she had not placed it on the weekly skin assessments for the above dates. She also stated that she had not conducted any wound rounds for the right heel. S12LPN/TN confirmed that wound rounds should be conducted weekly for residents with pressure ulcers or wounds that require treatment and should include a picture with assessment of wound including measurements to determine healing progress. She confirmed that she had not performed any wound rounds for Resident #9's right heel pressure ulcer until 03/11/2026. On 03/11/2026 at 11:24 a.m., an interview and record review was conducted with S1DON. She confirmed that Resident #9 had a stage 2 pressure ulcer on 02/02/2026 that had not been placed on the skin assessment audits for the above dates and had also not been placed on the weekly wound rounds and should have been.

Based on observations, interviews, and review of records and policies and procedures, the facility failed to implement care plan interventions to ensure the resident's environment remained free of hazards for 1(#66) out of 9 residents investigated for accidents.Findings:Review of the facility's policy titled Smoking Policy - Residents with a last reviewed date of 11/03/2025, read in part: Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation .7. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan.Review of Resident #66's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease; cerebral infarction; muscle wasting and atrophy, not elsewhere classified, right hand; and muscle wasting and atrophy, not elsewhere classified left hand.Review of Resident #66's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Further review revealed the resident was a current tobacco user.Review of Resident #66's plan of care revealed a focus area initiated on 01/29/2026 which read, Resident smokes and potential for injury r/t smoking. Further review revealed an intervention initiated on 02/04/2026 Cigarettes and Lighter kept at desk.On 03/10/2026 at 3:30 p.m., an observation was made of Resident #66 smoking in the designated smoke room. There were no staff members observed in the smoke room. The resident was interviewed regarding smoking supplies. She stated she kept her cigarettes and lighter in her room. On 03/11/2026 at 8:17 a.m., a second observation was made of Resident #66, now in her room eating breakfast. An open pack of cigarettes was observed on the right side of the resident's bed, and a lighter observed on her night stand. On 03/11/2026 at 8:27 a.m., an interview and review of the resident's care plan was conducted with S9MDS who stated she was responsible for updating care plans. She confirmed the resident was care planned for her cigarettes and lighters to be kept at the nurse's desk. S9MDS stated Resident #66's cigarettes and lighter should not have been in the resident's room. On 03/11/2026 at 8:29 a.m., an interview was conducted with S8LPN. She confirmed Resident #66 should not have cigarettes and lighter in her room. She stated the CNAs (Certified Nursing Assistants) and nurses were responsible for checking the resident's room for cigarettes and lighters. On 03/11/2026 at 8:30 a.m., an observation of Resident #66's room was conducted with S3CN/IC, who stated she was the charge nurse. She entered the resident's room and returned with a pack of cigarettes and two lighters. S3CN/IC stated the resident was new at the facility and required staff to monitor her behaviors through her next assessment period in April of 2026 to determine if she was a safe smoker. She stated at this time Resident #66 should not have cigarettes and/or lighters in her room.

Based on record review and interviews the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs as evidenced by failing to adequately monitor for anticoagulant side effects for 1 (#5) out of 5 residents investigated for unnecessary medications.Findings:Review of the facility's policy titled, Anticoagulation-Clinical Protocol, with a last reviewed date of 11/03/2025, revealed in part, 5. The staff.will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.Review of Resident #5's medical record revealed resident was admitted to the facility on [DATE] with the following diagnoses including, but not limited to: atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complications, and hyperlipidemia.Review of Resident #5's MDS (Minimum Data Set) dated 01/14/2026 revealed, Section N-Medications, High-Risk Drug Classes: Use and Indication, E. Anticoagulant-is taking.Review of Resident #5's Care Plan revealed, At risk for bleeding r/t anticoagulant/blood thinner use. Goal: free of bleeding or bruising. Interventions: .Observe for bruising or signs of bleeding and notify MD.Review of Resident #5's Order Summary Report revealed an order dated 08/14/2024 that read, Rivaroxaban (anticoagulant) Tab 2.5 mg, give 1 tablet by mouth two times a day related to Athscl (artherosclerotic) heart disease of native coronary artery w/o (without) [NAME] pctrs (angina pectoris). Further review revealed no order for anticoagulant monitoring.Review of Resident #5's Medication Administration Record (MAR) from January 2026 to March 10, 2026 revealed documentation that Resident #5 had received Rivaroxaban 2.5 mg, 1 tablet by mouth two times a day. Further review of Resident #5's MAR from January 2026 to March 10, 2026 failed to reveal evidence of anticoagulant monitoring for Resident #5.On 03/11/2026 at 4:30 p.m., an interview was conducted with S16LPN. A review was conducted with S16LPN of Resident #5' MAR. S16LPN confirmed that Resident #5 was receiving an anticoagulant medication. S16LPN confirmed that there was no evidence of anticoagulant monitoring on Resident #5's MAR and there was no order for anticoagulant monitoring in Resident #5's physician's orders. On 03/11/2026 at 5:18 p.m., an interview was conducted with S1DON. S1DON confirmed that there was no evidence that Resident #5 had been adequately monitored for side effects of anticoagulants.

Based on observations, interview and review of the facility's policy and procedures, the facility failed to maintain sanitary conditions in the kitchen by failing to ensure all staff wore a hair covering when entering the kitchen.127 residents consumed foods from the kitchen.Findings:On 03/09/2026, a review of the facility's policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices with a reviewed date of 11/03/2025, read in part: Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation .12. Hair nets or caps and/or bead restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.On 03/09/2026 at 10:43 a.m., an observation was made of S6MD entering the kitchen and walking to the stove where there was an uncovered pot with bite-sized meat simmering. S6MD stood at the stove near the pot. S6MD had a full head of hair. He was not wearing any hair covering. S6MD was asked if he knew not to enter the kitchen without hair covering and he stated he usually wore a hat, but today he did not. On 03/09/2026 at 11:00 a.m., an interview was conducted with S5DM who was responsible for the kitchen and kitchen staff. She stated that everyone, including maintenance, was aware they are not supposed to enter the kitchen without hair covering. She stated that S6MD should not have entered the kitchen without hair covering.

Based on interviews and record reviews, the facility failed to protect the resident's right to be free from neglect for 1 (#105) of 39 sampled residents. S8CNA failed to obtain the appropriate number of persons required to utilize a mechanical lift to transfer Resident #105. This deficient practice resulted in actual harm for Resident #105 on 09/13/2024 at approximately 6:35 AM when S8CNA (Certified Nursing Assistant) moved the resident from a lying position to sitting position in preparation to transfer him into a chair without the assistance of a second person or a mechanical lifter as required by his plan of care. When S8CNA turned away from the resident to get his chair, he fell on the floor and hit his head resulting in a laceration to his right eyebrow and right cheek that required stitches. Findings: Review of Resident #105's clinical records revealed an admitted [DATE] with diagnoses which included but were not limited to unspecified dementia, psychotic disturbance and anxiety, and repeated falls. Review of Resident #105's State Optional MDS dated [DATE] revealed the following: Section G: Section G0110 A - Bed mobility Two + persons physical assist. B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) Two + persons Physical assist. Review of Resident #105's quarterly MDS (Minimum Data Set) dated 01/01/2025 revealed in Section C, his BIMS (Basic Interview of Mental Status) interview was unable to be completed and his cognitive skills for daily decision making were severely impaired. Further review revealed in Section GG that the resident was dependent in chair/bed transfer, and the ability to move from lying on the back to sitting on the side of the bed with no back support was not attempted due to medical condition and safety concerns. Review of Resident #105's care plan revealed a focus problem of ADL self-care performace related to limited mobility and limited range of motion intiated 07/01/2024 and revised on 07/22/2024. Interventions included the resident has contractures of the right and left knee and right and left hand .requires mechancial lift with 2 staff assistance for transfers. Review of the facility's investigative report revealed in part that on 09/13/2024 at 6:35 AM, S24LPN (Licensed Practical Nurse) was called into Resident #105's room by S8CNA and observed the resident lying on his right side on the floor with hematoma under Resident #105's right eye and laceration on right forehead. Bleeding noted. Further review revealed a witness statement written by S8CNA on 09/13/2024 which read in part, I S8CNA sat Resident #105 on side of bed and then turned around to put chair closer to transfer him into chair. When I turned back to him, he had leaned on his side and rolled onto the floor . Review of the hospital records dated 9/13/2024 at 7:30 AM, revealed the resident arrived at the ED (Emergency Department) on 09/13/2024 at 6:57 AM with chief complaint of laceration to right eyebrow and right cheek. Treatment: Suture repair, tissue adhesive closure - 5 sutures. Head CT (cat scan), normal, no abnormalities noted. discharged in stable condition. During a phone interview with S8CNA on 02/11/2025 at 2:45 PM, she confirmed that she was caring for Resident #105 when he fell on [DATE]. S8CNA stated that she was trying to transfer the resident from his bed to his chair. She stated she sat him at the side of the bed then turned away to grab the chair. She explained that the resident was on the floor when she turned back around. S8CNA was asked how she knew how to transfer the resident and she stated it is on a dot that indicated his transfer needs over Resident #105's bed but she didn't check it because it is usually the same. S8CNA stated that she did not bring the lifter to Resident #105's room to transfer him nor did she have another CNA in the room to help her. She stated that she had asked S22CNA to help her, but she was helping another resident. S8CNA stated she wanted to get her work done and decided to transfer Resident #105 by herself when he fell . During an interview and review of Resident #105's MDS with S2DON and S3IP on 02/12/2025 at 10:22 AM, S2DON and S1IP both agreed that because Resident #105 was coded in the MDS as not attempted transfer from lying to sitting at bedside due to safety concerns. Both confirmed that S8CNA should not have transferred the resident by herself. During a follow-up interview on 02/12/2025 at 4:41 PM, with S2DON, and S3IP. S2DON stated that S8CNA had been working at the facility since 1996 and should have known better. She stated S8CNA should not have gotten the resident from his bed to sit at the side of the bed without assistance of another person. S2DON and S3IP both stated that S8CNA should have waited for assistance before getting the resident out of bed.

Based on record reviews and interviews, the facility failed to ensure the residents received mail on Saturdays. The deficient practice had the potential to affect 121 residents residing in the facility. Findings: A review of Resident #55's Quarterly MDS (Minimum Data Set) dated 11/27/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 12, indicating she had moderately impaired cognition. A review of Resident #63's Quarterly MDS dated [DATE] revealed she had a BIMS of 13, indicating her cognition was intact. A review of Resident #99's Quarterly MDS dated [DATE] revealed she had a BIMS of 15, indicating her cognition was intact. On 02/10/2025 at 02:46 PM, during the resident council meeting, Resident #55, Resident #63, and Resident #99 stated they did not receive or were unsure if they received mail on Saturdays. On 02/11/2025 at 12:50 PM, an interview was conducted with S10T/SSA (Transportation/Social Services Assistant). S10T/SSA confirmed she is responsible for delivering mail to residents Monday through Friday. S10T/SSA confirmed she does not work on Saturday and Saturday's mail is held and delivered on Monday.

Based on observations and interviews, the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by: 1. having loose pills in 2 (Cart A and Cart B) of 2 medication carts checked for safe and secure storage; 2. failing to ensure expired medications were not available for administration to residents in 2 (Cart A and Cart B) of 2 medication carts checked for safe and secure storage; and 3. failing to ensure medications were stored at the proper temperatures to preserve their integrity. This deficient practice had the potential to affect 121 residents residing in the facility. Findings: On 02/12/2025, a review of the facility's undated policy entitled, Storage of Medications, revealed, in part, drugs are stored at the proper temperature. Drugs are stored in the packaging, containers or other dispensing systems in which they are received. Nursing staff is responsible for maintaining medication storage areas in a safe manner. Outdated drugs are returned to the pharmacy or destroyed. Medications requiring refrigeration are stored in the refrigerator. Observation of Cart A on 02/11/2025 at 9:38 AM with oversight from S25LPN (Licensed Practical Nurse) revealed 3 unidentified and loose tablets in the bottom of the 2nd drawer of the cart. Observation revealed 1 bottle of Folic Acid 1000mg (milligram) tablets with an expiration date of 10/2024 and 1 bottle of Vitamin B6 100mg tablets with an expiration date of 11/2024. An interview was conducted with S25LPN at this time who confirmed the loose tablets and expired medications were in the medication cart and should not have been. Observation of Medication Storage Room A on 02/11/2025 at 10:15 AM with oversight from S25LPN revealed two unopened boxes Latanoprost solution 0.005% eye drops labeled refrigerate in an unrefrigerated drawer. S25LPN confirmed the two medications labeled refrigerate should have been stored in the refrigerator but were not. Observation of Cart B on 02/11/2025 at 11:30 AM with oversight from S26LPN revealed 4 unidentified and loose tablets in the bottom of the 2nd drawer of the cart. Observation revealed 1 bottle of Nasal Moisturizing Spray with an expiration date of 01/2025, 1 bottle of Lutein 15mg tablets with an expiration date of 12/2024, and one bottle of Vitamin E 450mg tablets with an expiration date of 10/2024. An interview was conducted with S26LPN at this time who confirmed the loose tablets and expired medications were in the medication cart but should not have been. An interview on 02/11/2025 at 2:55 PM was conducted with S2DON (Director of Nursing). She confirmed loose tablets and expired medications should not be in the medication carts. She confirmed medications labeled refrigerate should have been stored in the refrigerator.

Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and store and serve meals in accordance with professional standards for food service safety. The deficient practice had the potential to effect the 118 residents who consumed meals prepared from the facility's kitchen. On 02/10/2025 at 8:35 AM, an initial tour of the kitchen was conducted with S17DM (Dietary Manager) and revealed the following: 1. Food storage: A. Refrigerated items: 1. One bottle of lemon juice with an expiration date of 12/14/2024 2. One bottle of barbecue sauce with an expiration date of 09/11/2024 3. One bottle of whipped topping with an expiration date of 06/27/2024 4. One container of sour cream with an expiration date of 01/27/2025 5. One container of sour cream with an expiration date of 01/27/2025 6. One bag of cabbage with an expiration date of 01/19/2025 7. A freezer burned box of pies 8. Opened and undated beef B. Dry storage: 1. Ten individually packed soft baked cookies with an expiration date of 09/25/2024 2. Three individually packed soft baked cookies with an expiration date of 10/19/2024 3. One individually packed soft baked cookie with an expiration date of 12/03/2024 4. One dead cockroach under a shelf 5. Crumbs and dirt on the floor under shelving units 6. Dried substances on the light switches and face plate over the light switches 7. Dried substances on a double light switch outside of the door C. Food preparation station: 1. Dried food debris on the facing of a drawer under the table 2. Dusty dishes and dish covers on the counter 3. Dried food debris on a wall over the station 4. Crumbs on the bottom shelf 2. Equipment: A. Dirt and trash debris on a maintenance double shelved rolling cart B. Yellow particles in a watery liquid in the collection tray of the steamer C. [NAME] debris on the ice scoop D. [NAME] debris on the bottom of the ice scoop container E. Dirt and dried food debris on the bottom exterior edges of the large, rolling, warming cart F. Food debris and dirt on the bottom interior and orange shelving of the large, rolling, warming cart G. Dried food debris on the front facing of the large, rolling, warming cart H. Dried food debris on the front facing of the microwave oven I. Dried food debris and crumbs inside the microwave oven J. Dried food debris and crumbs on the waffle maker K. Crumbs on a blender L. Crumbs and dust on a food scale M. Dust on an electric can opener N. Dried food debris and grease on the fryer O. Dried food debris on the faces of the ovens P. Dried food debris on the front and side facing of the refrigerator Q. Dust and crumbs on the bottom ventilation cover of the refrigerator R. Orange, dried, food debris on the face plate of the mixer S. Crumbs and dried food debris on the slicer T. Black substance on a return ventilation cover 3. Unopened Items: A. Two bags of hamburger buns, opened and not dated B. Two bags sliced bread, opened and not dated C. Two bags of hot dog buns opened and not dated 4. Storage Containers: A. Dust, dirt, and debris on the lid of the frosting mix storage container B. Dust, dirt, and debris on the lid of the white/yellow cake storage container C. Dust, dirt, and debris on the lid of the frosting mix storage container D. Dust, dirt, and debris on the lid of the cornbread mix storage container E. Dust, dirt, and debris on the lid of the blueberry muffin/brownie mix storage container F. Dust, dirt, and debris on the lid of the blueberry muffin/brownie mix storage container G. Dust, dirt, and debris on the lid of the grits storage container H. Dust on the lid of the cheese cake mix/chocolate cake mix storage container I. Dust on the lid of the pancake mix storage container J. Crumbs and dust on the lid of the sliced potatoes storage container K. Crumbs and dust on the lid of the diet cake mix storage container L. Crumbs and dust on the lid of the diet cheese cake/lemon cake/ gingerbread mix storage container M. Crumbs and dust on the lid of the cookies storage container N. Dried brown food residue on the side of the flour storage bin O. Dried brown food residue on the side of the sugar storage bin P. Crumbs on the lid of the rice storage bin 5. Dishwashing station: A. Dried, yellow food debris on the left adjacent wall to the three compartment sink B. Black substance resembling mold/dirt on the wall over the backsplash in the dish washing room C. [NAME] and brown debris on the floor underneath the automatic dishwasher D. A thick, black substance was on the floor and baseboards of the dishwashing room E. A box on the lower shelf of the three compartment sink contained pot holders with a plunger on top of the potholders. 6. Other surfaces: A. Crumbs on stored, clean serving containers B. Crumbs on a shelf storing clean pots and pans C. Dirty floor underneath the pots and pans storage shelf D. Crumbs on a tray holding clean utensils 7. Food temperatures served from mobile food cart on Hall A: A. Rice with sausage served at 129 degrees B. Black eyed peas served at 108 degrees C. Collard greens served at 109 degrees D. Milk served at 51 degrees S17DM confirmed findings during the tour. On 02/10/2025 at 12:10 PM, an interview was conducted with S17DM. She stated that there were no specific cleaning schedules documented for review. She stated that the cook and one dietary aid were responsible for cleaning the pots, pans, and serving dishes and the dietary aids were responsible for cleaning the food carts after meals. She stated that these were the only specific cleaning duties assigned. She was unaware of any policies related to cleanliness in the kitchen. On 02/10/25 at 12:27 PM, an interview and observation was conducted with S17DM on HallA. Food temperatures of the last tray served on Hall A were taken by S17DM which included: rice with sausage at 129 degrees; black eyed peas at 108 degrees; collard greens at 109 degrees; and milk at 51 degrees. S17DM confirmed that these were not appropriate temperatures to serve.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight of the kitchen's cleanliness, sanitation, and practices for safe food service. The deficient practice had the potential to effect the 118 residents who consumed meals prepared from the facility's kitchen. Findings: Cross Reference F812 On [DATE] at 8:35 AM, an tour of the facility's kitchen revealed surfaces with an accumulation dust, dirt, food residue and other debris and expired food items. In addition, a meal was served at temperatures that were not within an appropriate range during distribution of hall trays. Review of the facility's State of Louisiana Department of Health, Office of Public Health, Retail Food Notice of Violations dated [DATE] at 12:30 PM, read in part: Non-Critical Items: Description of Violations: Non-food contact surfaces of equipment have an accumulation of dust, dirt, food residue and other debris. Food carts are not clean. Floors are not clean. (Corrected). Floors along the walls under the dishwashing machine and in the dishwashing room are not clean. (Repeated) Review of the facility's State of Louisiana Department of Health, Office of Public Health, Retail Food Notice of Violations dated [DATE] at 10:00 AM, read in part: Non-food contact surfaces of equipment have an accumulation of dust, dirt, food residue and other debris. Inside the microwave oven and seasoning cabinet are not clean. (Repeat). Floors are not clean. Floors are not clean along the walls under the shelves in the walk in cooler, walk in freezer and the dishwashing area (Repeat). On [DATE] at 4:30 PM, an interview was conducted with S1ADM (Administrator). S1ADM confirmed the presented findings in the kitchen. On [DATE] at 9:43 AM, an interview was conducted with S1ADM. He stated he was unaware of any inspection performed by OPH (Office of Public health) since 2023. S1ADM stated that S17DM had been notified of the results but had not relayed those results to him. He stated that S17DM (Dietary Manager) was responsible for all activities in the kitchen, including ensuring cleanliness, however, he had total oversite of the kitchen.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to ensure contact precautions were followed for 1 (#74) of 4 (#21, #27, #74 and #273) residents on contact precautions. Findings: On 02/13/2025, a review of the facility's policy titled Application of Transmission-Based Precautions with a revised date of 11/05/2024, read in part .Contact Precautions: Intended to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment. Staff caring for residents on Contact Precautions should wear gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Resident # 74 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to urinary tract infection, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident #74's quarterly MDS dated [DATE] revealed he had an indwelling catheter. A review of Resident #74's care plan revealed a focus area dated 01/28/2025 for Contact Isolation precaution. Interventions included in part, signs placed outside of resident's room to alert staff visitors to check with nurse before entering room and proper PPE (Personal Protective Equipment) required before entering room. On 02/10/2025 at 10:20 AM, an observation was made of Resident #74's room. A large sign was observed on the door that read in part: Contact Precautions Everyone Must .Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . During an interview with S7ResCNA (Restorative Certified Nursing Assistant) on 02/10/2025 at 10:20 AM, S7ResCNA stated that Resident #74 was at therapy. When asked if the resident still went to therapy while on contact precautions, she stated He has been going to therapy. S7ResCNA opened the resident's door and confirmed he was not in the room. On 02/10/2025 at 10:28 AM, an observation was made of the therapy room. S21PTTech (Physical Therapy Tech) was pushing the resident in his wheelchair and was not wearing gown or gloves. S21PTTech stated she was taking the resident back to his room. When asked stated she was unaware he was on Contact Precautions. On 02/10/2025 at 11:06 AM S22CNA (Certified Nursing Assistant) was observed in Resident #74's room without gown or gloves. She was pushing the resident in his wheelchair towards his door. S3IP (Infection Preventionist) confirmed S22CNA did not have a gown or gloves on while in the resident's room. On 02/10/2025 at 11:09 AM, Resident #74's was asked who took him to therapy in the morning, and he stated S7ResCNA took him to therapy. During an interview with on 02/10/2025 at 10:58 AM with S3IP, she confirmed Resident #74 was on Contact Precautions. She stated that he had ESBL (Extended spectrum beta-lactamase) in his urine and was on antibiotics. S3IP stated the resident should not have gone to therapy due to risk of contamination. During a follow-up interview with S7ResCNA on 02/11/2025 at 10:50 AM, stated that she was aware the resident was on Contact Precautions but confused it for enhanced barrier. S7ResCNA stated she should not have taken the resident out his room because he was on Contact Precautions. During an interview with S23OT (Occupational therapist) on 02/11/2025 at 2:10 PM, she stated Resident #74 received physical, occupational and speech therapy. She stated that therapy staff never goes to his room to get him, so they were unaware that he was on contact precautions and were not using gown or gloves. She further stated that the infection preventionist usually makes them aware, but she did not.

Based on record review, observation, and interviews, the facility failed to ensure a resident's change in condition was immediately reported for 2 (#43, #82) of 2 (#43, #82) residents as evidenced by: 1. Staff failing to report bilateral lower extremity edema for Resident #43 and; 2. S10T (Transportation) failing to notify the physician of failed attempts to complete a consult for Resident #82's left shoulder pain. Findings: Review of the facility's policy titled Change in Resident's Condition or Status, with a last reviewed date of 05/2017, read in part . Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician, or physician on call when there has been a(n): d. significant change in the resident's physical, emotional, mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self- limiting); 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status. 1. Resident #43 Review of Resident #43's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, atherosclerotic heart disease, and coronary artery without angina pectoris. Review of Resident #43's most recent Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. Review of Resident #43's physician orders dated 02/2025 did not reveal interventions or medications related to edema. Review of Resident #43's care plan dated 12/03/2024 did not reveal any interventions for edema. Review of the facility's progress notes dated 12/16/2024 per S9LPN (Licensed Practical Nurse) read in part .resident had a 2+ pitting edema to her bilateral lower legs. Further review of S9LPN's progress note dated 02/06/2025 read in part .resident had a 2+ pitting edema to her bilateral lower legs. Review of S11MD's (Medical Doctor) progress note dated 12/17/2024 read in part .Extremities: edema was absent. Further review of S11MD progress noted dated 02/06/2025 read in part .Extremities: edema was absent. On 02/11/2025 at 12:12 PM, an interview was conducted with S9LPN who stated she had observed Resident #43's bilateral lower extremities with 2+ pitting edema and confirmed she had not made the physician aware of the new onset of edema. On 02/12/2025 at 3:20 PM, an interview was conducted with S11MD who confirmed that staff had not made him aware of Resident #43's bilateral lower extremity edema and he should have been notified. 2. Resident #82 Review of Resident #82's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses that included in part, peripheral vascular disease, neuropathy, and left shoulder pain secondary to a fall. Review of Resident #82's most recent OBRA (Omnibus Budget Reconciliation Act) Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. Review of Resident #82's physician order dated 02/05/2025 read in part .consult (local orthopedic physician) for left shoulder pain. On 02/11/2025 at 12:00 PM, an interview was conducted with Resident #82 who stated he had xray's completed on his left shoulder and he was told it was arthritis. The resident went on to state that his shoulder hurts with movement and his movement was limited to his left arm. He stated no one had told him what the doctors were going to do about his left shoulder pain. On 02/11/2025 at 3:00 PM, an interview was conducted with S13WC (Ward Clerk) who stated she had received the consult orders from the physician for Resident #82, and then sent the consult to S10T/SSA (Transportation/Social Services Assistant), so that they could make the appointment. On 02/11/2025 at 3:04 PM, an interview was conducted with S10T/SSA who stated she received the consult and the information to arrange an appointment for the resident with the local orthopedic physician. She added the local orthopedic physician's nurse stated the resident could not be seen while he was in rehab. S10T/SSA was asked if she notified the nurse that the consult could not be completed and she stated she tried to call the nurse on 02/07/2025, but the nurse didn't respond. When asked if she tried again to notify the nurse that the consult could not be completed, she stated no. On 02/11/2025 at 3:12 PM, an interview was conducted with S11MD (Medical Doctor) who stated he was not aware that the consult was not completed and staff should have informed him of that so that he could have made different arrangements.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#22, #74) of 3 (#22, #74 and #89) residents investigated for PASARR in a final sample of 39 residents. Findings: Resident #22 Review of Resident #22's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Insomnia and Anxiety Disorder. Review of Resident #22's EHR revealed a Level I PASARR screening was completed on 02/07/2023 by the hospital case manager that the resident was admitted from. Further review of Resident #22's EHR revealed the resident was later diagnosed with Unspecified Psychosis on 12/08/2023. Review of Resident #22's February 2025 physician's orders revealed an order dated 02/15/2024 for an antipsychotic medication of Olanzapine tab (tablet) 5 MG (milligrams)- Give 1 tablet by mouth at bedtime related to Unspecified Psychosis. Review of Resident #22's EHR failed to reveal evidence that the facility referred the resident to the appropriate state-designated authority for Level II PASARR after being diagnosed with psychosis. On 02/12/2025 at 3:20 PM, an interview was conducted with S15LPN (Licensed Practical Nurse). She stated that she was responsible for the Resident Review and confirmed she only completed the Resident Review Form if the resident was readmitted to the facility from a Mental Health Hospital. S15LPN further stated she was not aware that a new Level II resident review diagnosed with serious mental disorder, intellectual disability, or a related condition. S15LPN confirmed no Level II review was completed after the new diagnosis of psychosis for Resident #22. 51596 Resident #74 Review of Resident #74's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnosis: Psychosis. Review of Resident #74's EHR revealed a PASARR Level I was completed on 08/02/2024 and indicated Resident #74 had not been diagnosed as having a mental illness. Review of Resident #74's Order Summary Report dated 02/12/2025 revealed an order for Quetiapine Fumarate 50mg give 1 tablet by mouth at bedtime for Unspecified Mood Disorder with an order date of 08/27/2024. Review of Resident #74's EHR failed to reveal evidence that the facility referred the resident to the appropriate state-designated authority for Level II PASARR after being diagnosed with psychosis. On 02/12/2025 at 3:09 PM, an interview was conducted with S14AADM. She confirmed Resident #74 did not have a PASARR Level II review. On 02/12/2025 at 3:17 PM, an interview was conducted with S15LPN. S15LPN confirmed no Level II review was completed after the new diagnosis of psychosis for Resident #74. On 02/12/2025 at 5:10 PM, S5LPN/Adm confirmed the facility did not have a PASARR policy.

Based on record review and interviews, the facility failed to ensure a resident's plan of care was implemented for 1 (#107) out of 1 (#107) resident out of 39 sampled residents. The facility failed to ensure Resident #107's weekly weights were completed as ordered. Findings: A review of Resident #107's Admission Record, revealed she was admitted to the facility on [DATE] with diagnoses that included in part, gastrostomy status and acute kidney failure. A review of Resident #107's most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated the resident's cognition was moderately impaired. A review of Resident #107's Order Summary Report revealed a physician's order, dated 09/20/2024 that read, weekly weight Q (every) Friday every evening shift every Friday. A review of Resident #107's weights in the EHR (Electronic Health Record) failed to reveal weekly weights on 10/04/2024, 10/11/2024, 10/18/2024, 11/01/2024, 11/08/2024, 11/15/2024, 11/22/2024, 12/06/2024, 12/13/2024, 12/20/2024, 01/03/2025, 01/10/2025, 01/17/2025, 01/24/2025, and 02/07/2025 On 02/12/2025 at 9:20 AM, an interview was conducted with S7ResCNA Restorative Certified Nursing Assistant. She stated residents' weights are documented in a book, then put into the kiosk, and then the nurse puts them into the EHR. A record review of Resident #107's weights conducted at this time with S7ResCNA and weekly weights from October 2024 to February 2025 were not completed. She stated she was never notified about the resident being on weekly weights. On 02/12/2025 at 10:46 AM, an interview and record review were conducted with S2DON (Director of Nursing) She stated Resident #107's weights were ordered weekly by the physician. After reviewing the resident's medical records she confirmed Resident #107's weights were not completed weekly from October 2024 to February 2025 and should have been.

Based on interview and record review, the facility failed to provide form CMS (Centers for Medicare and Medicaid Services) 10123- Notice of Medicare Non Coverage (NOMNC) as required for 1 Resident (#97) out of 3 (#13, #97 and #107) residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Notification. The facility had a census of 121 residents. A review of Resident #97's SNF Beneficiary Notification Review form revealed that the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. Resident #97 was discharged from Medicare Part A services on 1/31/2025. Further review of Resident #97's EHR failed to reveal that a Notice of Medicare Non Coverage (NOMNC) form was provided to the resident. On 02/12/2025 at 3:19 PM, an interview was conducted with S19MDS/LPN (Minimum Data Set/Licensed Practical Nurse). S19MDS/LPN stated Resident #97's discharge was facility initiated, and the resident also had skilled benefit days remaining at the time of the discharge. S19MDS/LPN confirmed she did not provide Resident #97 a NOMNC form, and Resident #97 did not sign a NOMNC form.

Based on record review and interviews, the facility failed to develop a comprehensive person-centered care plan for foot care and treatment for a diabetic resident for 1 (Resident #3) of 6 (Resident #1, #2, #3, #R1, #R2, and #R3) sampled residents reviewed. This deficient practice resulted in an actual harm for Resident #3, a cognitively impaired diabetic with neuropathy to the lower extremities. Resident #3 was admitted on [DATE] without preventative food care ordered. On 11/19/2024 the resident's skin evaluation assessment by S2LPN/TN (Licensed Practical Nurse/Treatment Nurse) revealed left & right 2nd (second) & 5th (fifth) toes are black . Resident #3 was assessed by S3NP (Nurse Practitioner) on 11/22/2024, who evaluated the second digit of the right foot and noted Resident #3 had a fungus skin/nail over the nail bed. S3NP removed the fungus skin/nail and observed a foul smell from the second digit of the right foot, and bone of the second digit knuckle; dry hard skin to the right lateral heel SDTI (Suspected Deep Tissue Injury); and hard dry skin to left heel SDTI. S3NP transferred Resident #3 to Center A on 11/22/2024 due to the condition of her feet. Center A's notes revealed in part, the resident was prescribed antibiotics and consults were made to Center A's wound care center for prompt follow up regarding the toe infection. Resident #3 returned to the nursing home on 11/22/2024. On 11/27/2024 Resident #3 was evaluated by Center B's physician whose note read in part, that the resident would need an amputation on the right toe. Findings: Cross Reference: F-658 and F-687. Review of Resident #3's medical record revealed an admitted [DATE] and diagnoses including Type 2 Diabetes Mellitus, Neuralgia and Neuritis, and Idiopathic Neuropathy. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 10/09/2024 indicated Resident #3 had a BIMS (Brief Interview Mental Status) score of 07, which indicated severe cognitive impairment. Review of Resident #3's physician orders failed to reveal orders to consult a podiatrist, orders to provide nail care, nor orders for proper shoe fitting and assessment. Review of Resident #3's nurse's progress notes failed to show evidence of routine nail care, proper shoe fitting assessment, or routine preventive foot care treatment and/or assessments. Review of Resident #3's care plan failed to reveal evidence a care plan had been developed for treatment and prevention of complications from conditions such as diabetes, and or providing foot care. There were no interventions for assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists and arranging for transportation to and from such appointments if applicable. On 12/09/2024 at 11:26 a.m., an interview was conducted with S1DON (Director of Nursing). She confirmed Resident #3's was diabetic and her medical records failed to include evidence that proper measures were taken to provide Resident #3 with the necessary foot care and treatment needed for a diabetic resident.

Based on interviews, record review,and observation the facility failed to ensure services provided met professional standards of quality by failing to ensure nursing staff identified skin changes timely for 1 (Resident #3) of 6 (Residents #1, #2, #3, #R1, #R2, and #R3) sampled residents. This deficient practice resulted in an actual harm for Resident #3, a diabetic with neuropathy to the lower extremities. Review of the resident's weekly skin evaluations 9/1/2024 through 11/18/2024 revealed the resident did not have any skin issues. On 11/19/2024 the resident's skin evaluation assessment by S2LPN/TN (Licensed Practical Nurse/Treatment Nurse) revealed left & right 2nd (second) & 5th (fifth) toes are black . Resident #3 was assessed by S3NP (Nurse Practitioner) on 11/22/2024, who evaluated the second digit of the right foot and noted Resident #3 had a fungus skin/nail over the nail bed. S3NP removed the fungus skin/nail and observed a foul smell from the second digit of the right foot, and bone of the second digit knuckle; dry hard skin to the right lateral heel SDTI (Suspected Deep Tissue Injury); and hard dry skin to left heel SDTI. S3NP transferred Resident #3 to Center A on 11/22/2024 due to her condition. Center A's notes revealed in part, the resident was prescribed antibiotics and consults were made to Center A's wound care center for prompt follow up regarding the toe infection. Resident #3 returned to the nursing home on 11/22/2024. On 11/27/2024 Resident #3 was evaluated by Center B's physician whose note read in part, that the resident would need an amputation on the right toe. Findings: Review of Resident #3's medical record revealed an admitted [DATE] and diagnoses including Type 2 Diabetes Mellitus, Neuralgia and Neuritis, and Idiopathic Neuropathy. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 10/09/2024 indicated Resident #3 had a BIMS (Brief Interview Mental Status) score of 07, which indicated severe cognitive impairment. Review of Resident #3's care plan revealed in part .Problem: risk for skin breakdown r/t (related to) diabetes mellitus, intervention weekly body audits to address any skin problems, notify MD of abnormal findings as needed. Review of Resident #3's weekly skin evaluations for September 2024 - October 2024 revealed the resident did not have any skin issues. Further review of Resident #3's weekly skin evaluations conducted by S2LPN/TN revealed in part: 11/04/2024: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. No current skin issues noted at this time. Skin note: No skin issues. 11/11/2024: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time. Skin note: No current skin issues. 11/18/2024: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. No current skin issues noted at this time. Skin note: no skin issues. 11/19/2024: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Discoloration. Skin issue location: right 2nd & 5th toe. Skin Issue: Discoloration. Skin issue location: left 2nd & 5th toe Skin note: left & right 2 & 5th toes are black not sure why will have S3NP look at them. On 12/04/2024 at 11:52 a.m., an interview was conducted with S2LPN/TN. S2LPN/TN confirmed she conducted Resident #3's assessments every Monday of every week. She then proceeded to say she had conducted a skin evaluation for Resident #3 on 11/18/2024, and she stated the residents bilateral feet, toes, and heel did not have a skin color changes. S2LPN/TN stated on 11/19/2024 she had been informed by the shower aide to examine Resident #3's right foot. She reported upon evaluation, she observed the skin on the right second toe was black, which was not observed the previous day on 11/18/2024 when she performed the resident's skin evaluation. She further stated she notified S3NP to evaluate the change in skin condition. She stated when S3NP evaluated the Resident #3's feet on 11/22/2024, S3NP had removed the skin/nail from the resident's second toe on the right foot. S2LPN/TN noted there was foul smell and you could see the bone on the second toe was visible. Review of Resident #3's Wound Assessment Details Report, dated 11/22/2024 read in part . date identified: 11/19/2024, wound: right 2nd toe, classification: infectious, and source: facility-acquired. Photo for Resident #3's right 2nd toe was attached to the report. Review of Resident #3's Wound Assessment Details Report, dated 11/28/2024 read in part . date identified: 11/22/2024, wound: right lateral heel, classification: callous, source: facility-acquired, and size cm (centimeters): 1.50 x 1.60 x 0.00 (L (length)x W (width)x D (depth)). Photo for Resident #3's right lateral heel was attached to the report. Review of Resident #3's Wound Assessment Details Report, dated 11/28/2024 read in part . date identified: 11/22/2024, wound: left heel, classification: Callous, source: facility-acquired, and size cm 2.50 x 7.00 x 0.00 (L x W x D). Photo for Resident #3's left heel was attached to the report. Review of S3NP progress note dated 11/22/2024 at 12:00 p.m., read in part . notified per nursing staff that resident had nail avulsion to right foot second digit and toe was dark in color, resident seen and examined, she had thick, long, fungused nails. When S3NP trimmed 2nd digit right foot nail to be avulsed and toe with necrosis and foul smelling. Right heel with dry skin to lateral heel and feels boggy. Left heel with dry, hard skin is dark in color and boggy. Review of nursing progress notes dated 11/22/2024 at 11:30 a.m. read in part . VORB (Verbal Order Read Back) S3NP Rounding on resident looking at residents discolored feet send to hospital (Center A) for eval (evaluation) & treat of necrotic 2nd digit of right foot (not sure how long toe has been necrosis. Will need Osteo (osteomyelitis) workup & arterial U/S's (ultrasounds) of BLE's (bilateral lower extremities) has dry hard skin to left heel SDTI & hard dry skin to R (right) lateral heel SDTI. Review of Resident #3's Center A Medical Records with a date of 11/22/2024 revealed the following in part: Physician Assistants Note: Patient presented with right toe pain. The onset unknown . The character of symptoms is discoloration, macerated, exudate . brought to the ED (Emergency Department) by RP (responsible party) for evaluation of a black toe/toe wound to the right second toe. XR (X-Ray) Right foot: impression nonvisualization of second toe distal phalangeal region as described above. Clinical correlation and for concerns regarding osteomyelitis. Further review revealed the ED prescribed the resident antibiotics and required prompt follow-up with wound care prior to discharge. The resident returned to the nursing home the same day of the ED visit on 11/22/2024. On 12/04/2024 at 12:48 p.m., an interview was conducted with S3NP. S3NP stated prior to 11/19/2024 she was not notified of the Resident having any type of wounds, or discoloration to feet. S3NP stated she had received a communication sheet on 11/19/2024 that noted Resident #3 had a toe that was discolored on the right and left foot, but she stated there was no mention of the severity. During her rounds on 11/22/2024, she evaluated Resident #3 and observed discoloration on the second digit of the right foot, which she initially suspected was onychomycosis. She noted that the skin/nail on the second digit of the right foot overlapped the toe, so she removed the skin and toe nail. Upon removal, she observed a foul odor from the right toe wound where nail/skin was removed, and an open wound exposing the bone in the second digit. She also stated the second digit on the right toe was red, warm, and edematous (indicating an active infection). Due to these findings, she transferred Resident #3 to Center A on 11/22/2024 for evaluation of both of feet and a work up for osteomyelitis. S3NP expressed that she believed she should have been notified of the resident's foot condition before 11/19/2024. She stated that, in her professional opinion, the appearance of the feet and osteomyelitis would have taken weeks or months to develop. Review of Resident #3's Center B Medical Records with a date of 11/27/2024 revealed the following in part: Doctors Note: it appeared the tuft of the second right toe is completely dissolved by osteomyelitis. Arterial ultrasounds show poor visualization of the right anterior tibial artery. Assessment: 1. Type 2 diabetes mellitus with foot ulcer, 2. Non-pressure chronic ulcer of other part of unspecified foot with unspecified severity. Plan consult cardiologist as soon as possible, the patient will need an amputation. Review of Resident #3's Center C Medical Records with a date of 12/03/2024 revealed the following in part: Cardiologist Note: may proceed with amputation if warranted. 2. Osteomyelitis- plan for possible right toe amputation. On 12/04/2024 at 3:21 p.m., S3NP stated that per the cardiologist's recommendation, she reassessed the resident's feet. Her findings included dry skin on the left heel, and the left toes had a dark cuticle bed. She also noted the right heel had a DTI (deep tissue injury), and the right lateral foot had dried dark callus. On 12/04/2024 at 3:35 p.m., Resident #3 was observed in her room. When attempting to speak to her she made eye contact briefly, but did not respond. On 12/05/2024 at 12:00 p.m., Resident #3 was observed in her room. When attempting to interview the resident, she made eye contact briefly, but did not respond verbally. On 12/09/2024 at 9:13 a.m., phone interview was conducted with S6MD (Medical Doctor), he stated he was very familiar with Resident #3. S6MD confirmed he saw the Resident in his clinic twice in the past two weeks. He stated the second toe on the right foot its distal phalange lacked blood flow. S6MD stated he referred Resident #3 to a cardiologist to assess blood flow to the right foot to determine the extent of the amputation required. He identified diabetes mellitus as the resident's primary contributing factor. When asked if the facility should have identified the condition sooner, he stated, it was picked up when it was picked up, and declined to provide a definitive answer. On 12/09/2024 at 1:09 p.m., an interview was conducted with S1DON. She stated that S3NP had informed her on 11/22/2024 about the condition of Resident #3's feet. She stated there was a discrepancy, as S2LPN/TN had reported no issues during the 11/18/2024 skin evaluation but had identified significant issues on 11/19/2024.

Based on interviews and record reviews, the facility failed to ensure that residents received preventative foot care to avoid complications from the resident's medical condition such as diabetes and circulatory disorders. The facility failed to provide appropriate preventative foot care for 1 (Resident #3) of 6 (#Resident #1, #2, #3, #R1, #R2, and #R3) sampled residents. This deficient practice resulted in an actual harm for Resident #3, a cognitively impaired diabetic with neuropathy to the lower extremities. Resident #3 was admitted on [DATE] without preventative food care ordered. On 11/19/2024 the resident's skin evaluation assessment by S2LPN/TN (Licensed Practical Nurse/Treatment Nurse) revealed left & right 2nd (second) & 5th (fifth) toes are black . Resident #3 was assessed by S3NP (Nurse Practitioner) on 11/22/2024, who evaluated the second digit of the right foot and noted Resident #3 had a fungus skin/nail over the nail bed. S3NP removed the fungus skin/nail and observed a foul smell from the second digit of the right foot, and bone of the second digit knuckle; dry hard skin to the right lateral heel SDTI (Suspected Deep Tissue Injury); and hard dry skin to left heel SDTI. S3NP transferred Resident #3 to Center A on 11/22/2024 due to the condition of her feet. Center A's notes revealed in part, the resident was prescribed antibiotics and consults were made to Center A's wound care center for prompt follow up regarding the toe infection. Resident #3 returned to the nursing home on 11/22/2024. On 11/27/2024 Resident #3 was evaluated by Center B's physician whose note read in part, that the resident would need an amputation on the right toe. Findings: A review of the facility's policy Diabetic Skin and Foot Care, with a last review date of 12/05/2024, revealed in part .Skin and Foot Care 5. Encourage the use of non-constricting well-fitting shoes, slippers and hose. 7. Toenails should only be trimmed by personnel qualified to do so (this can be regular associates, and does not have to be by a podiatrist). Review of Resident #3's medical record revealed an admitted [DATE] and diagnoses including Type 2 Diabetes Mellitus, Neuralgia and Neuritis, and Idiopathic Neuropathy. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 10/09/2024 indicated Resident #3 had a BIMS (Brief Interview Mental Status) score of 07, which indicated severe cognitive impairment. Review of Resident #3's physician orders failed to reveal orders to consult a podiatrist, orders to provide nail care, nor orders for proper shoe fitting and assessment. Review of Resident #3's care plan failed to reveal evidence a care plan had been developed for treatment and prevention of complications from conditions such as diabetes, and or providing foot care. Review of Resident #3's nurse's progress notes and assessments from 06/07/2023 to November 2024 failed to show evidence of a shoe fitting assessment, routine toe nail care, or routine preventive foot care treatment and/or assessments. Review of Resident #3's TAR (treatment administration records) failed to show evidence of routine nail care, proper shoe fitting assessment, or routine preventive foot care treatment and/or assessments. Review of Resident #3's Wound Assessment Details Report, dated 11/22/2024 read in part . date identified: 11/19/2024, wound: right 2nd toe, classification: infectious, and source: facility-acquired. Photo for Resident #3's right 2nd toe was attached to the report. Review of Resident #3's Wound Assessment Details Report, dated 11/28/2024 read in part . date identified: 11/22/2024, wound: right lateral heel, classification: callous, source: facility-acquired, and size cm (centimeters): 1.50 x 1.60 x 0.00 (L (length)x W (width)x D (depth)). Photo for Resident #3's right lateral heel was attached to the report. Review of Resident #3's Wound Assessment Details Report, dated 11/28/2024 read in part . date identified: 11/22/2024, wound: left heel, classification: Callous, source: facility-acquired, and size cm 2.50 x 7.00 x 0.00 (L x W x D). Photo for Resident #3's left heel was attached to the report. Review of nursing progress notes dated 11/22/2024 at 11:30 a.m. read in part . VORB (Verbal Order Read Back) S3NP Rounding on resident looking at residents discolored feet send to hospital for eval (evaluation) & treat of necrotic 2nd digit of right foot (not sure how long toe has been necrosis. Will need Osteo (osteomyelitis) workup & arterial U/S's (ultrasounds) of BLE's (bilateral lower extremities) has dry hard skin to left heel SDTI & hard dry skin to R (right) lateral heel SDTI. On 12/04/2024 at 11:52 a.m., an interview was conducted with S2LPN/TN (Licensed Practical Nurse/Treatment Nurse). She stated on 11/19/2024 she had been informed by the shower aide to examine Resident #3's right foot. She reported upon evaluation, she observed the skin on the right second toe was black. She stated when S3NP (Nurse Practitioner) evaluated the Resident #3's feet on 11/22/2024, S3NP had removed the skin/nail from the resident's second toe on the right foot. S2LPN/TN noted there was foul smell and you could see the bone on the second toe was visible. On 12/04/2024 at 12:48 p.m., an interview was conducted with S3NP. S3NP stated she had received a communication sheet on 11/19/2024 that said Resident #3 had a toe that was discolored on the right and left foot, but she stated there was no mention of the severity of it. During her rounds on 11/22/2024, she evaluated Resident #3 and observed discoloration on the second digit of the right foot, which she initially suspected was onychomycosis. She noted that the skin/nail on the second digit of the right foot overlapped the toe, so she removed the skin and toe nail. Upon removal, she observed a foul odor from the right toe wound where nail/skin was removed, and an open wound exposing the bone in the second digit. She also stated the second digit on the right toe was red, warm, and edematous (indicating an active infection). S3NP stated that she believed she should have been notified of the resident's foot condition before 11/19/2024. She stated that, in her professional opinion, the osteomyelitis would have taken weeks or months to develop. S3NP stated she was unsure if the resident was receiving routine foot care/assessments/ or nail trimmings, she recalled trimming Resident #3's toenails over 3 months ago, but she stated she hadn't documented it. On 12/05/2024 at 12:00 p.m., an interview was conducted with Resident #3's RP (Responsible Party) in the resident's room. He stated he is unsure when the issues with the resident's feet had started. Resident #3's RP stated the resident would wear socks and tennis shoes almost every time he would come see her, though he did not believe the shoes were properly fitted. He also stated he was unaware of the last time her toenails had been trimmed. On 12/05/2024 at 2:02 p.m., an interview was conducted with S5RN (Registered Nurse) and S1DON (Director of Nursing). S5RN stated she was responsible for performing toe nail trimmings for diabetic residents in the facility. S5RN state she had never trimmed Resident #3's toe nails. S1DON was then asked if she knew when the last time the residents toe nails had been trimmed and she stated she was unsure. S1DON stated the resident frequently wore shoes, even while napping or in bed. When questioned about whether the resident had received proper shoe fitting, S1DON stated she was unsure. On 12/09/2024 at 9:13 a.m., phone interview was conducted with S6MD (Medical Doctor), he stated he was very familiar with Resident #3. S6MD confirmed he saw the Resident in his clinic twice in the past two weeks. He stated the second toe on the right foot its distal phalange lacked blood flow. S6MD stated he referred Resident #3 to a cardiologist to assess blood flow to the right foot to determine the extent of the amputation required. He identified diabetes mellitus as the resident's primary contributing factor. When asked if the facility should have identified the condition sooner, he stated, it was picked up when it was picked up, and declined to provide a definitive answer. On 12/09/2024 at 11:26 a.m., an interview was conducted with S1DON. She confirmed there was no proper shoe fitting assessment for Resident #3, and that Resident #3 had not been seen by a podiatrist, and that the date of the resident's last toenail trimming was unknown. She confirmed Resident #3's was diabetic and her medical records failed to include evidence that proper measures were taken to provide Resident #3 with the necessary foot care and treatment needed for a diabetic resident.