Every finding on record at Landmark of Acadiana

Based on observations, record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or follow physician's orders for 3 (Resident #82, Resident #11, Resident #13) out of 40 sampled residents as evidenced by:1.failing to implement the comprehensive plan of care for a floor mat when in bed for Resident #82;2.failing to develop a comprehensive plan of care for antipsychotic use for Resident #11; and3.failing to follow physician's orders for PEG (Percutaneous endoscopic gastrostomy) tube water flush for Resident #13. Findings: Resident #82: Review of Resident #82's clinical record revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to, other specified fracture of left acetabulum, subsequent encounter for fracture with routine healing, dementia, cognitive communication deficit and hypertension. Review of Resident #82's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/16/2025 revealed in Section C – Cognitive 0500 that Resident #82 had a BIMS (Brief Interview for Mental Status) of 06, indicating he was severely, cognitively impaired. Review of the facility's incident reports revealed Resident #82 had falls on 08/10/2025, 08/26/2025, and two falls on 09/13/2025. Review of Resident #82's care plan report revealed a focus that read The resident is at risk for falls related to gait/balance problems, fracture to right pubis, dementia and muscle weakness. Date Initiated: 08/08/2025. Interventions read in part, 09/13/2025 floor mat when in bed. Date initiated: 09/18/2025. On 02/09/2026 at 10:38 a.m., an observation was made of Resident #82 lying in bed. There was no floor mat near his bed or in his room. On 02/10/2026 at 2:16 p.m., an interview was conducted with S5CNA (Certified Nursing Assistant). She stated that she was familiar with Resident #82 and provided care for him. S5CNA stated that interventions in place to prevent falls included things such as, mat for his wheelchair and assisting him to the bathroom. She confirmed that Resident #82 did not have a floor mat in his room. On 02/10/2026 at 2:25 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She stated that she was familiar with Resident #82 and provided care for him. She stated that there were interventions in place that prevented Resident #82 from falls, but he did not have a floor mat in his room. On 02/10/2026 at 3:15 p.m., a second interview and observation of Resident #82's room was conducted with S5CNA. S5CNA confirmed that there was not a floor mat in the resident's room. She stated that she was responsible for getting Resident #82 to bed around 8 p.m. and there was never a floor mat in his room. Resident #11 Resident #11 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing; vascular dementia, unspecified severity, with other behavioral disturbance; and anxiety disorder. Review of Resident #11's Quarterly Minimum Data Set (Set) dated 01/26/2026, revealed in Section N0450 that the resident received antipsychotics on a routine basis. Review of Resident #11 current physician orders revealed the following orders in part: On 01/19/2026, Quetiapine Fumarate Tablet (atypical antispychotic) 50 MG (milligram) Give 1 tablet by mouth in the evening. On 02/11/2026, Risperidone Tablet (atypical antipsychotic) 0.25 MG Give 0.125 mg by mouth one time a day. Review of Resident #11's current care plan revealed the resident was not care planned for antipsychotic use. On 02/11/2026 at 3:21 p.m., an interview and review of Resident #11's current physician orders and care plan was conducted with S10MDS (Minimum Data Set). She stated she was responsible for developing Resident #11's care plan. S10MDS confirmed the resident was not care planned for her use of antipsychotics and stated that she should have been. Resident #13 A review of the facility's policy titled, Tube Feedings, with a last reviewed date of 12/2015, read in part, All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders. A review of Resident #13's record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery and encounter for attention to gastrostomy. A review of Resident #13's physician orders read in part, start date: 09/23/2025 enteral feed. flush PEG (Percutaneous Endoscopic Gastrostomy) tube with 180 cc (cubic centimeters) of water every 4 hours. On 02/10/2026 at 12:32 p.m., an observation was conducted of S3LPN (Licensed Practical Nurse), who administered 360 cc's of water flush to Resident #13's PEG tube. An interview and record review were conducted with S3LPN, who stated Resident #13's physician orders stated to flush Resident #13's PEG tube with 180 cc's of water. S3LPN confirmed she flushed Resident #13's PEG tube with 360 cc's of water and should have only administered 180 cc's of water. On 02/10/2026 at 1:12 p.m., an interview and record review were conducted with S2DON (Director of Nursing). S2DON confirmed Resident #13's physician orders stated to flush Resident #13s PEG tube with 180 cc's of water. S2DON confirmed physician's orders should be followed, and Resident #13's PEG tube should have only been flushed with 180 cc's of water not 360 cc's.

Based on observations, interviews, record review, and policy review; the facility failed to maintain an effective infection prevention and control program, by failing to ensure:1. Proper infection control techniques were practiced during catheter care for Resident #87; and2. Reusable equipment was sanitized prior to and after resident use.The facility census was 120.Findings: 1.Resident #87: Review of the facility's policy titled Perineal Care, with a last reviewed date of 01/2024, revealed in part, Purpose: to cleanse the perineum and to prevent irritation or infection. Review of Resident #87's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, retention of urine, urinary tract infection, and overactive bladder. On 02/11/2026 at 8:43 a.m., an observation was made of S8CNA (Certified Nursing Assistant) providing catheter care for Resident #87. S8CNA donned a gown and gloves and wiped Resident' #87's perineal area and indwelling catheter with a wet towel that contained perineal cleanser. S8CNA used a clean wet towel and rinsed Resident #87's perineal area and indwelling catheter. S8CNA then used a clean dry towel and dried Resident #87's perineal area and indwelling catheter. S8CNA did not change her gloves or perform hand hygiene in between cleansing, rinsing and drying Resident #87's perineal area and indwelling catheter. On 02/11/2026 at 8:50 a.m., an observation was made of Resident #87's indwelling catheter drainage bag resting on the floor while S8CNA was providing catheter care. On 02/11/2026 at 9:00 a.m., a second observation and interview was conducted with S8CNA of Resident #87's catheter drainage bag resting on the floor. S8CNA confirmed that Resident #87's indwelling catheter drainage bag was on the floor and she stated it should not have been. On 02/11/2026 at 9:10 a.m., an interview was conducted with S8CNA. S8CNA confirmed that she had not removed her gloves or performed hand hygiene between cleaning, rinsing and drying Resident #87's perineal area and indwelling catheter and she should have. On 02/11/2026 at 11:41 a.m., an interview was conducted with S7RN/IP (Registered Nurse/Infection Preventionist). S7RN/IP confirmed that Resident #87's indwelling catheter drainage bag should not have been on the floor. S7RN/IP further confirmed that S8CNA should have changed her gloves and sanitized her hands in between cleaning, rinsing and drying Resident #87's perineal area and indwelling catheter. 2. On 02/11/2026, a review of Centers for Disease Control and Prevention (CDC), Recommendations for Disinfection and Sterilization in Healthcare Facilities dated 12/07/2023 revealed in part: 4.b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA (Environmental Protection Agency)-registered hospital disinfectant using the label's safety precautions and use directions. 4.c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient.). On 02/10/2025 at 7:33 a.m., an observation and an interview was conducted with S9LPN (Licensed Practical Nurse) during medication pass on Hall W. S9LPN removed a re-usable blood pressure cuff and a reusable pulse oximeter from one of her medication cart drawers and entered Resident # 86's room. S9LPN recorded the resident's blood pressure and pulse with the equipment. S9LPN returned the blood pressure cuff and oximeter to the same drawer on her cart from which they were removed without cleaning them. S9LPN confirmed she did not clean the above equipment after use. On 02/10/2026 at 8:02 a.m., an interview was conducted with S7RN/IP (Registered Nurse/Infection Preventionist). S7RN/IP stated the equipment should have been cleaned right after S9LPN used them on the resident and then stored them.

Based on observation, record review, and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the oral status of 1 (Resident #99) of 40 sampled residents. Review of Resident #99's clinical record revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes mellitus, hypertension, dysphagia and bradycardia.A review of Resident #99's Comprehensive MDS assessment with an ARD (Assessment Reference Date) of 09/30/2025 was conducted. Section C - Cognitive Patterns 0500 revealed Resident #99 had a BIMS (Brief Interview for Mental Status) of 15, which indicated he was cognitively intact. Further review of Resident #99's MDS revealed in section L - Oral/Dental Status - L0200D, Obvious or likely cavity or broken natural teeth, not checked.On 02/09/2026 at 9:44 a.m., an interview and observation was conducted with Resident #99. He stated that he had only a few teeth in his mouth and would like to see a dentist, but had never been offered. At this time, it was observed that Resident #99 had multiple missing teeth; three broken, discolored teeth in his upper mouth and one tooth that was discolored on the bottom. There were no other teeth in Resident #99's mouth.On 02/11/2026 at 8:53 a.m., a record review, interview, and observation was conducted with S6MDS. She confirmed that she was the MDS nurse responsible for Resident #99's assessment. S6MDS confirmed that Resident #99's MDS assessment did not include any missing, broken, or discolored teeth. When Resident #99's oral status was assessed with this surveyor, S6MDS confirmed that Resident #99 had missing, broken and discolored teeth. S6MDS confirmed that the MDS assessment was not accurately coded for Resident #99's dental status.On 02/11/2026 at 09:18 a.m., an interview and observation was conducted with S2DON (Director of Nursing). She confirmed that Resident #99 had missing, broken, and discolored teeth and had been coded inaccurately on his comprehensive MDS assessment.

Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (#13) out of 40 sampled residents by failing to ensure EMAR (Electronic Medication Administration Record) was accurately documented for Resident #13.Findings:A review of the facility's policy titled, Documentation, with a last reviewed date of 09/2025, read in part, It is the policy of this facility to maintain accurate medical records.A review of Resident #13's record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery and encounter for attention to gastrostomy.A review of Resident #13's physician orders read in part, start date: 09/23/2025 enteral feed. flush PEG (Percutaneous Endoscopic Gastrostomy) tube with 180 cc (cubic centimeters) of water every 4 hours.A review of Resident #13's February 2026 EMAR revealed documentation that Resident #13's enteral feed flush PEG tube with 180 cc of water every 4 hours was administered on 02/10/2026 at 8:15 a.m. by S3LPN (Licensed Practical Nurse).On 02/10/2026 at 1:04 p.m., an interview and record review were conducted with S3LPN. S3LPN stated she did not administer Resident #13's 8:00 a.m. enteral feed water flush due to Resident #13's PEG tube residual being close to 200 cc's and he was coughing. A review of Resident #13's EMAR from February 2026 was conducted with S3LPN, and she confirmed should not have signed off on Resident #13's enteral feed water flush being administered at 8:15 a.m. On 02/10/2026 at 1:12 p.m., an interview and record review were conducted with S2DON (Director of Nursing). A review of Resident #13's physician's orders and February 2026 EMAR was conducted with S2DON. S2DON stated nurses were supposed to document medications and procedures that were administered on the EMAR. S2DON stated that since S3LPN did not administer Resident #13's enteral feed water flush at 8:00 a.m., it should not have been documented on the EMAR, and it was inaccurate documentation.

Based on observations and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk-in freezer, dry storage room, and reach-in cooler not labeled with the date and time; 2. expired food in the dry storage area; and 3. a thick layer of debris on the deep fryer cooking oil collection area. This deficient practice had the potential to affect the 117 residents who consumed food from the kitchen. Findings: On [DATE], a review of the facility's policy titled, Food Storage Labeling, with a last revision date of ,d+[DATE], last reviewed date of [DATE], revealed in part .Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling- a. All temperature controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the food, Date of Storage . 3. Rotation . b. Food stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date. Suggested time frames: Dry Storage-Weekly . On [DATE] at 8:32 a.m., a tour of the facility's kitchen was conducted with S1DM (Dietary Manager), who stated that she was responsible for the day to day management of the kitchen. On [DATE] at 8:40 a.m., an observation of the walk-in freezer was conducted with S1DM and revealed the following items were opened and not labeled with the date and time they were opened: a large bag of mixed vegetables and a large bag of broccoli. At that time, S1DM confirmed the food items listed above were opened, and not labeled with the date and time they were opened, and should have been. On [DATE] at 8:49 a.m., an observation of the dry storage room was conducted with S1DM and revealed the following: a can of tomato condensed soup with an expiration date of [DATE]. Further review of the dry storage room revealed the following items were opened but were not labeled with the date and time that they were opened: a plastic gallon bag with an opened bag of coconut flakes and a plastic gallon bag with an opened bag of bread crumbs. At this time, S1DM confirmed the soup was expired and should have been discarded. She also confirmed the food items listed above were opened, and not labeled with the date and time they were opened, and should have been. On [DATE] at 8:54 a.m., an observation of the reach-in cooler was conducted with S1DM and revealed the following items were opened but were not labeled with the date and time they were opened: (2) opened gallons of milk. S1DM confirmed the food items were opened, and not labeled with the date and time they were opened, and should have been. On [DATE] at 9:10 a.m., an observation of the deep fryer was conducted with S1DM and revealed the cooking oil collection area had a thick layer of debris. S1DM stated the deep fryer was last used on [DATE] and confirmed that it was not cleaned after it was used and should have been.

Based on record reviews, observations, and interviews, the facility failed to call light device was in reach for 2 (#49 and #86) out of 35 sampled residents. Findings: Resident #49 Review of Resident #49's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, difficulty in walking; other abnormalities of gait and mobility; other lack of coordination; pain, unspecified; and history of falling. Review of Resident #49's Quarterly MDS assessment with an ARD (Assessment Reference Date) of 01/02/2025 revealed a BIMS (Brief Interview of Mental Status) score of 7, indicating that the resident was severely cognitively impaired. Review of Resident #49's comprehensive care plan, revealed in part, Focus-The resident is at risk for falls r/t (related to) muscle weakness and lack of coordination. Interventions- Place call light within reach. On 01/13/2025 at 1:51 PM, an observation and interview was conducted with Resident #49. The resident was lying in bed with her call light device not visible. Resident #49 was not able to locate the device when asked to. On 01/13/2025 at 2:09 PM, an observation and interview was conducted with S7LPN. S7LPN (Licensed Practical Nurse) confirmed that Resident #49's call light device was not visible while she was lying in bed. S7LPN lifted up the resident's bed sheets and the call light device fell off the lower left side of the bed onto the floor. S7LPN confirmed that the resident's call light device was not in reach and it should have been. S7LPN stated that the Resident #49 does use her call light device for assistance. On 01/14/2025 at 2:27 PM, an observation of Resident #49 and interview was conducted with S7CNA (Certified Nursing Assistant). The resident's call light device was observed to be running vertical under the resident's pillow, hanging off of the left upper portion of the bed, not within reach. Resident #49 was not able to locate her call light when asked to. S7CNA confirmed that Resident #49's call light device was not in reach of the resident, and it should have been. S7CNA stated that the resident does use her call light device for assistance. Resident #86 Review of Resident #86's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, muscle weakness, other abnormalities of gait and mobility, chronic pain, and history of falling. Review of Resident #86's Quarterly MDS assessment with an ARD (Assessment Reference Date) of 11/15/2024 revealed a BIMS (Brief Interview of Mental Status) score of 6, indicating that the resident was severely cognitively impaired. Review of Resident #86's comprehensive care plan, revealed in part, Focus-The resident is at risk for falls d/t (due to) debility and lack of coordination. Interventions- Call light is within reach and encourage the resident to use it for assistance as needed. On 01/13/25 at 9:35 AM an observation of Resident #86 and interview was conducted with S6CNA. Resident #86 was sitting up in a geri chair next to her bed. Her call light device was lying on her bed behind her, not within her reach. S6CNA confirmed that Resident #86's call light device was not within her reach and should have been. She confirmed that Resident #86 does use her call light device for assistance.

Based on interview and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status by failing to ensure a resident's discharge status was accurately coded for 1 (#117) resident of 35 sampled residents. Findings: Resident #117 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, fracture of right femur, pain in right knee, and seizures. A review of Section A2105 of Resident #117's Discharge MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident was discharged to a short-term general hospital. A review of Resident #117's Physician's Orders revealed an order written on 12/23/2024 that read, DC (discharge) to home, home health skilled nurse, PT (physical therapy), OT (occupational therapy), ST (speech therapy) to eval (evaluate). A review of Resident #117's Progress Notes dated 12/23/2024 by S5LPN (Licensed Practical Nurse) read in part, . RP (responsible party) arrived to take resident home . On 01/15/2025 at 11:22 a.m., an interview and record review was conducted with S3RNCM (Registered Nurse Case Manager). S3RNCM confirmed that Resident #117 was discharged home. A review of Section A2105 of Resident #117's Discharge MDS was reviewed with S3RNCM. S3RNCM confirmed that Resident #117's discharge status read short-term general hospital. S3RNCM also confirmed that that the resident's MDS was coded incorrectly, and her discharge status should have been coded as discharge to home.

Based on record reviews and interviews, the facility failed to develop a comprehensive person-centered care plan for 1 (#67) of 35 sampled residents. The facility failed to develop a focus area with interventions related to hospice services for Resident #67. On 01/15/2025, a review of the facility's policy titled, Care Plan Process with a last revision date of 12/2024, read in part, The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situations. 10. Assess and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. A review of Resident #67's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, type 2 diabetes mellitus with hyperglycemia, hypokalemia, and non-rheumatic aortic valve stenosis. A review of Resident #67's Significant Change Minimum Data Set (MDS) assessment dated [DATE], read in part, Section O: Special Treatments, Procedures, and Programs hospice care was selected. A review of Resident #67's Physician's Orders revealed an order written on 12/06/2024 that read in part, Admit to Healthcare and Hospice . A review of Resident #67's comprehensive care plan failed to reveal a focus area or interventions related to Resident #67's receiving hospice services. On 01/14/2025 at 12:27 p.m., an interview and record review was conducted with S4LPNMDS (Licensed Practical Nurse Minimum Data Set) who confirmed Resident #67 was receiving hospice services. She confirmed receiving hospice services should have been developed in the resident's comprehensive care plan with interventions, but it was not. On 01/14/2025 at 3:30 p.m., an interview was conducted with S2DON (Director of Nursing). She confirmed that if a resident is receiving hospice services this should have been developed in the resident's comprehensive care plan with interventions.

Based on observation, interviews, and record review, the facility failed to ensure a resident who was visually impaired received necessary services to maintain good nutrition for 1 (#9) of 2 (#8 and #9) residents investigated for Comm-sensory (communication and sensory) out of a total of 35 sampled residents. Findings: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Legal Blindness and Unspecified Dementia. Review of Resident #9's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/24/2024, revealed in section B that his vision was severely impaired. Review of Resident #9's care plan revealed a focus dated 08/27/2024 that the resident was able to feed self with set up and supervision, and another on 08/28/2024 that the resident had impaired visual function related to blindness. On 01/13/2025 at 8:55 a.m., an observation was conducted of Resident #9 in his room. The resident was alone with his breakfast tray set up in front of him. The resident's milk box was in his grits, an entire metal spoon was immersed in the grits, and his shirt was covered with multiple food crumbs. The resident also had a full container of orange juice. Resident #9 was asked if he could see surveyor or his food and he responded no. On 01/13/2025 at 9:00 a.m., S5LPN (Licensed Practical Nurse) walked into Resident #9's room and confirmed the findings above. On 01/13/2025 at 11:34 a.m., an interview was conducted with Resident #9's RP (Responsible party). She stated that she was at the facility once a week on Sunday afternoons. When asked if Resident #9 needed someone to assist him with eating and setting up meals, the RP stated definitely. She further stated that the resident was blind and there is no way he can eat on his own. She stated if she handed him something to eat he can hold and eat it but he needed someone there to help him. During a follow up interview with S5LPN on 01/13/2025 at 11:49 a.m., S5LPN stated that if the resident refused to be fed the CNA would report it. S5LPN further stated I'm not going to lie nobody reported that the resident refused to be fed his breakfast. 01/15/2025 at 8:09 a.m., an observation and interview was conducted with S6CNA (Certified Nursing Assistant) in the assistance dining room while she was observed feeding Resident #9. S6CNA was observed taking the food up to the resident's mouth then asking him to open his mouth. The resident did not react to food when it was brought to his lips until S6CNA asked him to open his mouth. She was asked if the resident can feed himself and she stated he always needed someone with him to supervise his meals.

Based on record reviews, observations, and interviews, the facility failed to accurately document on the Nurse Data Collection and Screening Form for bed rails for Resident #39 and Resident #49 out of a finalized sample of 35 residents. Findings: Resident #39 Review of Resident #39's medical record revealed an admitted [DATE] with diagnoses including, which were not limited to, cerebrovascular disease affecting right dominant side, aphasia, muscle weakness, weakness, unspecified lack of coordination, and history of falling. Review of Resident #39's comprehensive care plan, revealed in part, Focus- Resident's Current Safety Devices and Special Equipment with an intervention- Assist Rail. Review of Resident #39's medical record revealed a Nurse Data and Collection Screening assessment dated [DATE] completed by S8LPN (Licensed Practical Nurse). Review of the assessment revealed in part: Section titled Restraint Necessity/Positioning Device C. Restraints: A. Bed rail was documented as 0. Not used. Resident #49 Review of Resident #49's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, difficulty in walking; other abnormalities of gait and mobility; other lack of coordination; pain, and history of falling. Review of Resident #49's comprehensive care plan, revealed in part, Focus- Resident's Current Safety Devices and Special Equipment with an intervention- Assist Rail. On 01/14/2025 at 4:24 PM., an observation was made of Resident #49 in bed with both upper quarter side rails in the upward position. Review of Resident #49's medical record revealed a Nurse Data and Collection Screening assessment dated for 01/02/2025 completed by S10LPN. Review of the assessment revealed in part: Section titled Restraint Necessity/Positioning Device C. Restraints A. Bed rail was documented as 0. Not used. On 01/15/2025 09:40 AM, an interview was conducted with S9ADON (Assistant Director of Nursing). S9ADON confirmed that both Resident #39 and Resident #49 used upper quarter side rails while in bed. On 01/15/2025 02:04 PM, an interview was conducted with S3RNCM (Registered Nurse Case Manager). S3RNCM confirmed that Resident #39 and Resident #49 both should have been coded for Bed rail on this form and were not.

Based on record reviews and interviews, the facility failed to ensure every resident and/or their representatives had the opportunity to participate in quarterly meetings held for each resident's care planning process for 6 (# 38, #41, #75, # 27, #86, and #56) of 6 residents that were reviewed for participation in care planning, of a total survey sample of 43 residents in a facility with a census of 123 residents. Findings: Review of the provider's care plan policy revealed in part . 6.The Social Service Designee/ Social Worker will invite families and residents to participate in the care planning process. Resident #38 Review of the facility's comprehensive record for resident #38 revealed the resident was admitted on [DATE] with diagnoses in part including Stage 4 Chronic Kidney Disease, Metabolic Encephalopathy, Anemia in Chronic Kidney Disease, Diabetes Mellitus Type 2, Hypomagnesemia, Diabetic Neuropathy, and Bilateral below the Knee Amputee. Review of the latest Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview Mental Score (BIMS) of 15 which meant she was cognitively intact, and had the mental capacity for some personal decision making. During an interview with the Resident #38 on 12/11/23 at 9:30 a.m. she stated she was not made aware of nor invited to care plan meetings. She denied knowing she had the opportunity to participate in her personal care plan. On 12/12/23 at 03:58 p.m., during a telephone interview, Resident #38's family representative denied ever receiving a care plan meeting invitation by phone call or mail in the past two years. Resident # 41 Review of the medical record for Resident #41 revealed she was admitted to the facility on [DATE] with diagnoses included in part of Multiple Sclerosis, Essential Hypertension, Muscle weakness, Anxiety Disorder, Acute Metabolic Acidosis, and Urinary Tract Infection. Review of her most recent Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview Mental Score (BIMS) was a 14 meaning she was mentally cognizant. During an interview on 12/11/23 at 09:31 a.m., Resident #41 revealed she was not aware of or invited to quarterly care plan meetings about her care in the facility. On 12/13/2023 at 10:54 a.m. a telephone interview was conducted with Resident #41's family representative who denied receiving an invitation to attend the resident's care plan meeting either by mail or by telephone. She stated she has received other mail from the facility, therefore they have her address, but never had she received an invitation to attend a care plan meeting. Resident #75 Review of Resident # 75's record revealed she was admitted to the facility on [DATE] with diagnosis in part of: Cerebral vascular accident, Bipolar Disorder, Major Depressive Disorder, Gastrointestinal Hemorrhage, and Anxiety Disorder. Review of the latest MDS assessment dated [DATE] revealed she had a BIMS score of 15 meaning she was mentally intact. During an interview on 12/11/2023 at 02:10 p.m., Resident #75 denied ever being made aware of, or invited to her care plan meeting. On 12/11/23 at 04:34 p.m., during an interview S5SSD stated both she and S4SSD would send out the letters to resident representatives to invite them to their resident's care plan meetings that are held quarterly. She further stated the social service department's responsibility was just to mail out an invitation letter to the representatives, they did not invite the resident to the meetings. On 12/12/23 at 09:08 a.m., during an interview S4SSD stated social services usually doesn't document about or attend resident care planning meetings. She further stated the social service department's responsibility regarding resident care plan meetings was simply to mail the invitation letters to each resident's representative a week before the date of the meeting. On 12/12/23 at10:44 a.m., S LPN and S LPN both confirmed they were primary care nurses for residents and denied they had ever attended or participated in any care plan meeting for the residents they provide care to. They confirmed they do communicate the resident's needs and or condition to their physicians. On 12/12/23 09:13 a.m., during an interview, S6MDS revealed any of the case manager nurses could provide documentation of care plan meetings for the residents they were responsible for managing the care of. She then provided documents that revealed resident signatures as attendees to their care plan meetings. When asked why all 6 residents would deny having attended care plan meetings or knowing they could participate in their care, S6MDS stated she may not have identified the meeting as a care plan meeting. She confirmed she should have provided a detailed explanation for the purpose for the meetings to ensure each resident understood and could actively participate. 47251 Resident #27 Review of Resident #27 electronic health record revealed she was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Anxiety Disorder, Mood Affective Disorder and Major Depressive Disorder. Further review of her yearly MDS (Minimum Data Set) dated 10/19/2023 revealed a BIMS (Brief Interview of Mental Status) score of 15, meaning she was cognitively intact. On 12/12/2023 at 12:51 p.m., an interview was conducted with Resident #27. She stated that she had never attended or been invited to attend any care plan meeting or any type of meeting where her care was discussed. On 12/13/2023 at 11:34 a.m., a phone interview was conducted with Resident #27's RP (Responsible Party). He denied attending or being invited to attend any meetings to discuss the care of his mother. Resident #86 Review of Resident #86's electronic medical record revealed the resident was admitted on [DATE] with diagnoses that included Chronic Kidney Disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Hypertension, Anxiety Disorder and Atrial Fibrillation. Further review of Resident #86's quarterly MDS (Minimum Data Set) dated 10/19/2023 revealed a BIMS (Brief Interview of Mental Status) score of 14, meaning she was cognitively intact. On 12/12/23 at 2:56 p.m., an interview was conducted with Resident #86. She stated that she has never participated in a care plan meeting, nor was she invited to attend one. She further stated that her RP had never attended any meeting. She stated that no one had invited her to attend a group meeting to discuss her care, nor had she gone to any room to meet with a group. On 12/13/23 11:37 a.m., a phone interview with Resident #86's RP was conducted. She denied receiving anything in the mail inviting her to a care plan meeting or meeting to discuss her sister's care. On 12/12/2023 at 3:15 p.m., an interview with S14CNA (Certified Nursing Assistant) was conducted. She stated that she was in attendance for this care plan meeting on 10/26/2023 that was held in the assessment office. S14CNA stated Resident #86 was not present at the meeting. 47965 Resident #56 Resident #56 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Dementia. The resident had a BIMS (Brief Interview of Mental Status) of 12, suggesting her cognition was moderately impaired. On 12/13/2023 at 8:43 a.m., an interview was conducted with Resident #56's RP (Responsible Party). When asked if she had been invited to a care plan meeting, she stated that she was never invited to a care plan meeting, and if she knew there was one she would take the day off work to attend it. On 12/13/2023 at 9:15 a.m., an interview was conducted with S3ADON and S2DON (Director of Nursing). S2DON was asked why the resident's RP was not invited to a care plan meeting, and she stated she would find out. In a follow up interview with S2DON on 12/13/2023 at 9:23 a.m., she stated that social service was responsible for sending care plan invitations to residents and their RPs. On 12/13/2023 at 9:23 a.m., an interview was conducted with S4SSD (Social Services Director). She stated that she restarted sending care plan meeting invitations by mail after the COVID pandemic ended and that the resident's RP had been invited. S4SSD was unable to provide proof that an invitation was mailed to the resident's RP for the meeting on 11/02/2023 or any prior meetings.

Based on record review and interview, the facility failed to refer residents with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 3 (#11, #75, #91) out of 4 (#11, #21, #75, #91) sampled residents investigated for PASARR in a final sample of 43 residents. Findings: Review of the facility's Initial Admission Process/Pre-Admission Screening Policy revealed, a change in status referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASRR to have mental illness, intellectual disability/developmental disability, or a related condition in the following circumstances: A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). Resident #11 A review of Resident #11's record revealed an admitted [DATE]. Further review revealed the resident was diagnosed with Major Depressive Disorder on 10/27/2021, Schizophrenia on 10/21/2021, and Psychosis on 09/04/2021. A review of Resident #11's current physician's orders December 2023 revealed the resident had been prescribed the antipsychotic medication Seroquel 100mg (milligrams) related to the diagnosis of Schizophrenia. Further review of Resident #11's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 04/28/2021. There was no evidence a Level II PASARR had been submitted to the appropriate state-designated authority after new diagnoses of Major Depressive Disorder, Schizophrenia, and Psychosis diagnosis. Resident #75 A review of Resident #75's record revealed an admitted [DATE]. Further review revealed he was diagnosed with Bipolar Disorder on 07/27/2022. A review of the Resident #75's current physician's orders December 2023 revealed the resident had been prescribed the antipsychotic medication Seroquel 25mg (milligrams) related to the diagnosis of Bipolar Disorder. Further review of Resident #75's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 02/01/2021. There was no evidence a Level II PASARR had been submitted to the appropriate state-designated authority after the resident was diagnosed with Bipolar Disorder. Resident #91 A review of Resident #91's record revealed an admitted [DATE]. Further review revealed he was diagnosed with Bipolar Disorder on 04/12/2022. A review of the Resident #91's current physician's orders December 2023 revealed she had been prescribed the antipsychotic medication Seroquel 25mg (milligrams) related to the diagnosis of Bipolar Disorder. Further review of Resident #91's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 11/12/2021. There was no evidence a Level II PASARR had been submitted to the appropriate state-designated authority after the resident was diagnosed with Bipolar Disorder. On 12/13/2023 at 9:15 a.m., an interview was conducted with S4SSD (Social Services Director). S4SSD stated she did not send referrals for Level II PASARR evaluations for residents with a new MD or ID diagnosis. S4SSD reviewed Residents #11, # 71, and #91's record and confirmed referrals had not been submitted to the appropriate state-designated authority for Level II PASARR evaluation and determination for these residents as required.

Based on observations, interviews, and record review, the facility failed to ensure that services were provided as ordered by the physician for 1(#60) of 43 sampled residents by failing to ensure that Resident #60's wound dressing was changed every three days. Findings: Resident #60 was admitted to the facility on [DATE] with Diagnoses including Cellulitis of Left Lower Limb, Rash and other Nonspecific Skin Eruption. Review of Physician's Orders dated 12/03/2023 at 12:00 a.m., revealed an order to clean skin tear to LLE (left lower extremity) with wound cleanser, pat dry, apply dry cover dressing Q (every) 3 days and PRN (as needed) until healed. Review of a wound assessment dated [DATE] revealed the resident had a left shin skin tear On 12/11/2023 at 9:23 a.m., an observation was conducted of Resident #60 in her room. A white dressing with a small amount of dark, dry, old blood dated 12/06/2023 was observed on the resident's left shin. She stated she is not sure who put the dressing on her leg but they did not come back to change it. On 12/12/2023 at 2:37 p.m., a second observation was conducted of Resident #60 in her room. A dressing was observed to her left shin dated 12/12/2023. On 12/12/2023 at 3:00 p.m., an interview was conducted with S9RN/WC, (Registered Nurse/Wound Care Nurse). S9RN/WC stated that on 12/12/2023 she removed the dressing dated 12/06/2023 and replaced it. She further stated that it was ordered to be changed every 3 days and should have been changed on 12/09/2023 but was not. On 12/12/2023 at 3:05 p.m., an interview was conducted with S2DON (Director of Nursing), S10RN/QI (Registered Nurse/Quality Improvement) and S9RN/WC. S9RN/WC reported that the resident's dressing had not been changed since 12/06/2023. S10RN/QI stated the resident's dressing should have been changed on 12/09/2023 and instructed S9RN/WC to call the physician and report the incident.

Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#88) of 43 sampled residents. This was evidenced by S7LPN (Licensed Practical Nurse) finding Resident #88's medication at the bedside. Findings: A review of the facility's policy titled Monitoring Medication Pass read in part .12. No medications left at bedside. Resident #88 was admitted to the facility on [DATE] with diagnoses including Constipation, Diarrhea, Major Depressive Disorder, Dyspnea, and Paroxysmal Atrial Fibrillation. Review of the resident's physician orders dated 12/2023 revealed the following order: - Colace 100mg (milligrams) capsule 1 by mouth twice a day for Constipation. On 12/11/2023 at 9:56 a.m., an observation was made of Resident #88 in her room. 2 red gel pills in plastic medication cup were noted at the bedside. S7LPN inspected the pills comparing them to the Resident #88's EMAR and confirmed the pills were Colace. Resident #88 stated the night nurse left them there and she didn't take them. S7LPN confirmed the medication should not have been left at the resident's bedside. On 12/13/2023 at 12:01 p.m., an interview was conducted with S2DON (Director of Nurses). S2DON confirmed that no nurse should ever leave any type of medications at the bedside.

Based on observation and interview, the facility failed to follow their scheduled lunch menu for all residents who received a pureed diet. The deficient practice had the potential to affect all that received a pureed diet. Findings: Review of the facility's menu dated Monday, December 11, 2023 revealed a pureed lunch menu that included ham and beans, rice, seasoned greens, dinner roll, plain bread pudding and milk/water. On 12/11/2023 at 10:30 a.m., an observation was made of S13DC (Dietary Cook) puree the meal for all residents who received a pureed diet. There were no observations made of pureed dinner rolls. On 12/11/2023 at 11:40 a.m., an observation was made of the dietary cooks serving the pureed diets to residents. The meal served included ham and beans, rice, bread pudding, and seasoned greens. It did not include a dinner roll. On 12/11/2023 at 4:11 p.m., an interview was conducted with S12DM (Dietary Manager). She confirmed that the residents ordered a pureed diet did not receive a pureed dinner roll and should have.

Based on observation and interview, the facility failed to protect confidential information for 1 (Resident #88) out of 43 sampled residents by failing to initiate the computer's privacy screen during a medication pass. The deficient practice had the potential to affect a total census of 123. Findings: Review of the facility's policy and procedure titled Confidentiality of Resident Information read in part .4. All information contained in the health record is confidential. Resident #88 was admitted to the facility on [DATE] with diagnoses including Constipation, Diarrhea, Major Depressive Disorder, Dyspnea, and Paroxysmal Atrial Fibrillation. On 12/11/23 10:12 a.m., an observation was made of S7LPN standing at her medication cart with her laptop computer and a Resident #88's EMAR (Electronic Medication Administration Record) visible facing the hallway. S7LPN stepped away from the cart to enter a nearby room, leaving the work laptop unattended with private resident information visible. On 12/11/23 at 10:13 a.m., an interview was conducted with S7LPN. She confirmed she left the laptop unattended with resident information visible and the privacy screen should have been initiated when she left the laptop unattended.

Based on record review and interview, the facility failed to notify the residents' responsible party representatives of a fall for 2 (#4 and #5) out of 5 ( #1, #2, #3, #4 and #5) sampled residents by failing to contact the responsible party in a timely manner after the fall occurred. Findings: The facility's policy titled, Accident/Incident Reporting revealed in part, 1. All accidents/incidents including residents will be reported to the appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Accident/Incident is defined as an unexpected happening which may or may not have caused loss or injury to a resident .6. Information regarding accidents/incidents that involve a resident will be recorded in the resident's medical record .the resident representative will be notified of the accident/incident according to state guidelines . Resident #4 Resident #4 was admitted to the facility on [DATE] with the following pertinent diagnoses: Muscle Weakness, Other Lack of Coordination, Difficulty in Walking, Cognitive Communication Deficit, and Anxiety Disorder. Review of the Incident and Accident Report prepared by S3LPN (Licensed Practical Nurse) and dated 03/02/2023 at 11:40 a.m. revealed: The resident was found on the floor in her room by S9CNA (Certified Nursing Assistant). S3LPN performed a full body assessment and found no signs and symptoms of pain or discomfort. Twenty-four hour follow up revealed slight swelling to the right side of resident's face. Resident's family was notified on 03/03/2023 at 10:00 a.m. Review of grievance prepared by S2DON (Director of Nursing) dated 03/04/2023 revealed that Resident #4's daughter came to the facility upset that staff did not call informing her of her mother's fall when it happened on 03/02/2023, and requesting to see cameras. On 05/31/2023 at 9:04 a.m., a phone interview was conducted with Resident #4's daughter, who stated that she filed a grievance because the facility did not call her or her brother after her mother's fall on 03/02/2023. Review of an Employee Warning Report dated 03/03/2023 and signed by S3LPN, revealed that S3LPN received a warning from administration for violation of company policies or procedures for failing to document and complete incident report, and failing to notify resident's daughter of incident. Resident #5 Resident #5 was initially admitted to the facility on [DATE] with a reentry from an acute hospital on 04/30/2023 with the following pertinent diagnoses: Generalized Muscle Weakness, Repeated Falls, Other Disorder of Bone Density and Structure, Anemia, Cognitive Communication Deficit and Hip Fracture. Review of the facility's Accident/Incidents log dated 01/01/2023 thru 05/30/2023 revealed Resident #5 was found on the floor in the resident's room on 04/12/2023 at 6:30 a.m. Review of Resident #5's Accident/Incident report dated 04/12/2023 revealed S6LPN (Licensed Practical Nurse) was summoned to the resident's room by S10CNA (Certified Nursing Assistant) at 6:30 a.m. Upon entering the resident's room, S6LPN observed the resident lying on the floor next to her bed .Family notified on 04/18/2023 at 8:45 p.m. A phone interview was conducted with Resident #5's representative on 05/31/2023 at 9:26 a.m., who stated the facility never notified her of the resident being found on the floor on 04/12/2023. Resident #5's representative further stated, the facility notified her on Tuesday night, 04/18/2023, that the resident's x-ray report showed a right hip fracture and would need to go to the hospital in the morning. On 05/31/2023 at 11:20 a.m., an interview was conducted with S2DON who stated S6LPN failed to notify Resident #5's representative of the incident that happened on 04/12/2023 when the resident was found lying on the floor in her room. On 05/31/2023 at 4:15 p.m., an interview was conducted with S1ADM (Administrator) who stated that he counseled S6LPN with a warning for violating the facility's policy and procedure when S6LPN did not notify Resident #5's family of the incident on 04/12/2023. 47965

Based on record review, observation, and interviews the facility failed to ensure the resident's environment remains as free of accident hazards as is possible by not identifying appropriate interventions to reduce the risk of falls for 3 (#2, #4, #5 ) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of the facility's Fall Risk Screening revealed, in part: Residents identified as being at high risk for falls .3. Care Plan shall include all specific interventions appropriate to resident in order to prevent falls . Resident #2 Review of the medical record revealed the resident was admitted on [DATE]. The resident's diagnoses included, but not limited to the following: Encephalopathy, Cerebrovascular disease, Disorientation, and Cognitive communication deficit. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 8 which is moderately impaired cognitive skills for daily decision making. The resident required extensive supervision with bed mobility, toilet use, and transfers. The resident was always incontinent of bladder, and frequently incontinent of bowel. Review of the fall risk assessments dated 04/11/2022, revealed that the resident was not a fall risk. Additional fall risk assessments were completed on 02/07/2023 and 05/02/2023 which both revealed the resident was identified as high risk for falls. Review of the care plan revealed the following: falls - potential for related to impaired balance and unsteady gait. Review of the interventions revealed: 01/01/2023 Call before you fall and stop sign placed in room, 02/16/2023 staff to assist resident every 2 hours and as needed, 02/20/2023 staff to encourage resident not to lean forward while on toilet, 04/11/2023 remind/encourage resident to sit with her back against the wheelchair before attempting to propel herself with her feet, 04/22/2023 remind resident not to use public restroom without staff assistance. Review of the Incident and Accident Reports revealed: On 01/01/2023 at 1:15 p.m. Resident was found on the floor in bathroom in front of wheelchair next to toilet in sitting position. No apparent injuries. Interventions were to place a stop sign in room as a reminder to call for assistance. On 02/16/2023 at 6:25 p.m. Resident lying on the floor on her left side near wheelchair in doorway. No injuries noted. Intervention: Staff to assist to restroom every two hours and as needed. On 2/20/2023 at 2:40 p.m. Resident lying on the floor face down in front of toilet. Staff left resident in the bathroom alone to give her privacy. Resident sent to the emergency room and admitted with syncope and acute kidney injury. Intervention: Encourage resident not to lean forward while on toilet. On 04/11/2023 at 1:15 p.m. Resident lying in supine position in hallway. No injuries noted. Intervention: Encourage resident to sit all the way back in wheelchair to prevent further incidents. On 04/22/2023 at 3:05 p.m. revealed resident found lying on floor in front of toilet on her right side. No injuries noted. Intervention: Remind resident not to use restroom without assistance. An interview was conducted on 05/31/2023 at 9:25 a.m. with S7CNA (Certified Nursing Assistant) who stated that Resident #2 was able to transfer to the commode with one person assist, but she needed two person assist to get off of the commode. S7CNA confirmed that other interventions needed to be in place to help prevent further incidents. An interview was conducted on 05/31/2023 at 9:27 a.m. with S6LPN. S6LPN stated that in her opinion, placing signs in the resident's room and interventions of reminding the resident to call for assistance was not effective because the resident would not remember to call nor would she read the sign in her room to call before she falls. 47965 Resident #4: Review of the record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, in part: Muscle Weakness, Other Lack of Coordination, Difficulty in Walking, Cognitive Communication Deficit, and Anxiety Disorder. Review of the MDS (Minimum Data Set) dated 04/25/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 99, indicating severely impaired cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers dressing, and toilet use, and was always incontinent of bowel and bladder. The resident had falls since admit. Review of the fall risk assessment dated [DATE] revealed the resident was identified as high risk for falls and required high risk fall prevention interventions. Review of the Care Plan revealed: On 05/14/2020 the Resident was at risk for falls d/t (due to) impaired balance and gait abnormalities, and impaired cognition. No falls noted prior to admission - interventions to encourage to ensure wheelchair is locked before attempting transfers, fall risk assessment quarterly and as needed, and place call light within reach. Review of the Incident and Accident Report prepared by S3LPN and dated 03/02/2023 at 11:40 a.m. revealed: The resident was found on the floor in her room by S9CNA. S3LPN performed a full body assessment and found no s/s (signs or symptoms) of pain or discomfort. Twenty-four hour follow up revealed slight swelling to the right side of resident's face. Review of the resident's Care Plan revealed a new intervention to remind and encourage resident to ask for staff assist with transfers and reorient to call bell as needed. Review of the nurse's notes revealed a late entry on 03/03/2023 at 10:41 a.m. written by S3LPN stating that the resident was unable to follow commands. Review of the Incident and Accident Report prepared by S3LPN and dated 03/27/2023 at 7:30 a.m. revealed that the resident slid out of her wheelchair and onto floor as she was appearing to reach for her water bottle. Resident was noted to not hit her head, and without signs of pain or injuries. Review of the resident's Care Plan revealed a new intervention on 03/27/2023 to encourage resident to ask for staff assistance when reaching for personal items. Review of the nurse's note written on 03/27/2023 at 1:27 p.m. by S3LPN revealed that the resident was unable to make needs known. Review of the Incident and Accident Report prepared by S3LPN and dated 05/15/2023 at 10:00 a.m. revealed that the resident was found sitting on the floor in the day room. She was assessed by S3LPN and found to have no apparent injuries. Review of the resident's Care Plan revealed a new intervention to encourage resident to sit all the way back while in her wheelchair. Review of the nurse's note written on 05/15/2023 at 10:09 a.m. by S3LPN revealed that the resident was confused and unable to make needs known. On 05/30/2023 at 4:57 p.m., an observation and interview was conducted with S8CNA. Resident was observed being wheeled back from dining room by S8CNA. Resident did not respond when asked how she was doing. S8CNA stated that resident does not understand what is being said to her, and does not respond verbally. On 05/31/2023 at 9:30 a.m., an observation was made of resident sitting in wheelchair in TV room. Resident was not pushed up against a table. On 05/31/2023 at 9:33 a.m., an interview was conducted with S3LPN. S3LPN stated that she had been working at the facility for five years and was familiar with resident. S3LPN stated that the resident stopped walking over a year ago, was always disoriented and was unable to follow directions. S3LPN was asked about care planned interventions to prevent resident from falling. She stated that she reminded resident to use the call light but resident did not understand. An interview was conducted with S5CNA on 05/31/2023 at 9:41 a.m. S5CNA stated she had been working at the facility for 2 years and was familiar with the resident. She stated the resident was a two person assist, and did not understand what was going on. She further stated resident did not know how to use the call light. 44269 Resident #5 Resident #5 was initially admitted to the facility on [DATE] with a reentry from an acute hospital on 04/30/23 with the following pertinent diagnoses: Generalized Muscle Weakness, Repeated Falls, Other Disorder of Bone Density and Structure, Anemia, Cognitive Communication Deficit and Hip Fracture. Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 05, indicating severely impaired cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, dressing, and toilet use. The resident's fall history since reentry revealed fracture during prior 6 months. Review of the fall risk assessment dated [DATE] revealed the resident was identified as high risk for falls and required high risks fall prevention interventions. Review of the care plan revealed Resident #5 was at risk for falls due to generalized muscle weakness, lack of coordination, history of falls prior to admit and last fall on 05/25/2023. Interventions included: place call light within reach, Fall Risk assessment quarterly and as needed, 04/12/2023 1/4 rail up while in bed, 04/18/2023 X-ray as ordered due to complaint of pain- Hospital Stay 04/18/2023 to 04/21/2023 related to Right Femoral Neck Fracture and Right Hip Hemiarthroplasty (right hip surgical repair), floor mat bedside per family request and 05/25/2023- Staff to transfer resident back to Geri chair after appointments. Review of the Incident and Accident Report prepared by S6LPN and dated 04/12/2023 at 6:30 a.m. revealed that the resident was found sitting on the floor in her room by S10CNA. Incident was not reported to supervisor. S2DON completed an incident investigation that revealed Resident #5 was noted with right hip pain on 04/18/2023 and a x-ray was performed which resulted a right femoral neck fracture requiring surgical repair on 04/19/2023. Through S2DON's investigation, it was revealed that Resident #5 was found on the floor in her room on 04/12/2023 by S10CNA. S10CNA notified S6LPN. S6LPN completed assessment and determined there were no injuries and resident had not complained of pain. S6LPN did not initiate an incident report. Additional follow ups included interventions implemented on 04/19/2023 were quarter rails while in bed, Xray ordered and resident sent to emergency room and was admitted for surgical repair. Review of the Incident and Accident Report prepared by S11LPN and dated 05/25/23 at 3:30 p.m. revealed the resident was found sitting on the floor, leaning on her wheelchair by S12CNA. S11LPN recorded that upon entering Resident #5's room, the resident was noted sitting on the floor leaning on her wheelchair; resident was unable to explain what happened. Assessment done with no apparent injuries noted. Resident denied any pain and able to move all extremities. Resident assisted up to bed. Neuro Checks initiated. Review of 24 hour follow up: Resident denies any pain at this time. ROM intact to all ext (extremities) and hips in proper alignment. No bruises or skin breaks noted. Neuro checks in progress and intact. Incident addressed in Care Plan on 05/25/2023 with added intervention for staff to ensure resident transferred back to geri-chair after appointments. On 05/30/2023 at 4:12 p.m., an interview was conducted with S13CNA who stated that Resident #5 needed two person assist for bed mobility, transfers and toileting. S13CNA stated resident never used her call bell and that sometimes the resident yelled when she needed something. On 05/31/2023 at 10:00 a.m., an interview was conducted with S6LPN who stated Resident #5 would not use her call bell and continued to crawl out of her bed at times. S6LPN stated the resident required extensive assistance with bed mobility, transfers and toileting. S6LPN was unsure why other interventions were not added to prevent future falls and that resident would benefit from a chair or bed alarm. On 05/31/2023 at 1:15 p.m., a phone interview was conducted with Resident #5's responsible party representative who stated she was not notified when the resident was found on the floor on 04/12/2023 and had not received requested information regarding prevention of future falls from S2DON. She further stated that she had to tell the facility staff that Resident #5 needed a fall mat on the floor near her bed and was not sure why other measures were not being considered like an alarm. On 05/31/2023 at 4:20 p.m., during the exit, a joint interview was conducted with S1ADM (Administrator) and S2DON who confirmed they were responsible for updating the residents' care plan interventions after a fall occurred. S2DON stated that sometimes the interventions worked and sometimes they don't. S1ADM voiced that he disagreed with the survey team findings and felt interventions were appropriate.

Based on observations, interviews and record reviews, the facility failed to ensure that nursing staff possess competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and attain or maintain the highest practicable physical well-being for 2 (#1 and #5) of 5 (#1, #2, #3, #4 and #5) sampled residents. This was evidenced by: 1. S4LPN (Licensed Practical Nurse) leaving Resident #1's Colace, Keppra, Celexa, Sotalol, Eliquis, Tylenol, and Trazodone at her bedside and 2.S6LPN failing to complete an incident report and initiate neurological checks on 04/12/2023 when Resident #5 was found lying on the floor in her room. The facility had a census of 120 residents. Findings: Resident #1 Review of Facility's Administration of Medications Policy and Procedure read in part .Procedure .3. Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time on the order .5. Medications shall not be pre-poured. Review of physician's orders dated 05/2023 revealed the following orders: -Trazodone 50 mg tablet 1 by mouth every night. -Keppra 250 mg tablet x 1 tablet by mouth 2 times a day. -Colace 100mg capsule give1 by mouth twice a day for constipation. -Acetaminophen 325 mg tablet x 2 tablets by mouth 2 times a day. -Celexa 20 mg tablet x 1 tablet by mouth every night at bedtime. - Betapace 80 mg tablet x 1 tablet by mouth 2 times a day Hold for SBP < 100. - Eliquis 2.5 mg tablet x 1 tablet by mouth 2 times a day. Review of the resident's MAR (medication administration record) revealed that all seven medications were scheduled to be given at 8 p.m. and were not signed off as administered. Resident #1 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Other Lack of Coordination, Other Abnormalities of Gait and Mobility, and Unspecified Osteoarthritis. Review of the resident's Minimum Data Sets (MDS) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating that the resident is cognitively intact. 05/30/2023 at 4:24 p.m., an interview and observation was conducted with Resident #1. A clear medicine cup with seven pills was noted on the resident's bedside table. Resident #1 stated they were her pills to be taken before she goes to bed, and were left there by her nurse. Resident stated her nurse always left her night time pills in her room early. 05/30/2023 at 4:50 p.m., an observation and interview of Resident #1's room was conducted with S2DON (Director of Nursing). S2DON asked Resident #1 what the pills were for, and she stated that her nurse left them for her to take before going to bed. S2DON took the pills and told the resident that the nurse would bring them back to her when they were due. The resident asked S2DON if this was going to be something new? S2DON stated no, the medication should not have been left at your bedside. S2DON was asked if the resident had an order to self-administer her pills, and he stated that she did not and the pills should not have been left at her bedside. 05/30/2023 at 5:00 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed that Resident #1 did not have a doctor's order to self-administer her medications. S4LPN stated that she left Colace, Tylenol, Celexa, Sotalol, Eliquis, Trazadone, and Keppra at the resident's bedside. She further stated that the medications were scheduled for 8 p.m. S4LPN confirmed that she should not have left the medication at the resident's bedside. 44269 Resident #5 Review of the facility's policy titled, Accident/Incident Reporting revealed in part, 1. All accidents/incidents including residents will be reported to the appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Accident/Incident is defined as an unexpected happening which may or may not have caused loss or injury to a resident .3. An incident report will be completed on any accident/incident that occurs within the facility .6. Information regarding accidents/incidents that involve a resident will be recorded in the resident's medical record . Review of the facility's policy titled, Falls revealed in part, Purpose: To evaluate extent of injury and to prevent complications .Procedure .9. If the fall was unwitnessed or involved a potential head injury, initiate neurological checks .13. Document all appropriate information in medical record . Resident #5 was initially admitted to the facility on [DATE] with a reentry from an acute hospital on 04/30/23 with the following pertinent diagnoses: Generalized Muscle Weakness, Repeated Falls, Other Disorder of Bone Density and Structure, Anemia, Cognitive Communication Deficit and Hip Fracture. Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 05, indicating severely impaired cognitive skills for daily decision making. The resident required extensive assistance with bed mobility, transfers, dressing, and toilet use. The resident's fall history since reentry revealed fracture during prior 6 months. Review of the care plan revealed Resident #5 was at risk for falls due to generalized muscle weakness, lack of coordination, history of falls prior to admit and last fall on 05/25/2023. Interventions included: place call light within reach, Fall Risk assessment quarterly and as needed, 04/12/2023 1/4 rail up while in bed, 04/18/2023 X-ray as ordered due to complaint of pain- Hospital Stay 04/18/2023 to 04/21/2023 related to Right Femoral Neck Fracture and Right Hip Hemiarthroplasty (right hip surgical repair), floor mat bedside per family request and 05/25/2023- Staff to transfer resident back to Geri chair after appointments. Review of the facility's report to the State Survey Agency revealed an incident for Resident #5 was discovered on 04/18/2023 at 8:45 p.m. and entered on 04/19/2023 at 8:30 a.m. per S1ADM (Administrator). On 04/18/2023, the resident was found to have pain to her right hip. X-ray was taken and revealed the resident had a right femoral neck fracture. During the investigation it was determined from interviews that the resident had an undocumented incident on 04/12/2023 where the resident was found on the floor by S6LPN. Disciplinary action for S6LPN was taken on 04/21/2023 regarding importance of reporting and documentation of all incidents and following proper policy and procedure of the facility. Review of Employee Warning Report read in part: Employees receiving this warning report are hereby put on notice of a violation of our organization's rules and/or standards of employee conduct for S6LPN dated 04/21/2023 for Violation of Company Policy and Procedures . date of violation 04/12/23- Resident had fall on 04/12/23. Employee did not do documentation or incident report at time of incident .Signed by S2DON, S1ADM and S6LPN on 04/21/23. Review of Resident #5's electronic health record failed to include documentation that neurological checks were initiated after resident was found lying on the floor in her room on 04/12/2023. On 05/31/2023 at 11:20 a.m., an interview was conducted with S2DON who stated neurological checks were to be initiated when a resident had an unwitnessed fall or incident. S2DON confirmed Resident #5 had an unwitnessed incident on 04/12/2023 and neurological checks were not initiated. S2DON stated S6LPN was counseled for failing to complete an incident report and failing to initiate neurological checks for Resident #5 on 04/12/2023.

Based on observation, review and interview, the facility failed to ensure food products that were stored in the dry storage room were dated when the package was opened this deficient practice has the potential to effect the 118 residents that eat meals in the facility. Findings: Review of the facility's policy and procedure for Food Storage Labeling.find the food being stored, pick the storage area, document the date the food is being stored on the documentation label . On [DATE] at 8:40 a.m., a tour of the kitchen was conducted with S6DM (Dietary Manager). During the initial tour, observations were made in the dry storage room. A bottle of Oregano seasoning was observednon the shelf opened, without a date of when the bottle was opened. S6DM confirmed there was no date written on the bottle of Oregano. A bottle of Lemon Pepper seasoning was observed on the shelf with an expiration date of [DATE]. S6DM confirmed the seasoning was expired and remained on the shelf for use. On [DATE] at 9:16 a.m., an observation was made of their seasoning shelf. Bottles of Honey, Chili Powder, and Paprika were on the shelf opened and no dates were noted on the bottle. S6DM was present during observation she verified that Honey, chili powder and paprika were open and had no label indicating the dates they were open.

Based on record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to obtain a 3/8/18 final urine culture for 1 (#2) of 5 (#1-#5) sampled residents investigated for Quality of Care and Treatment. This deficient practice resulted in actual harm for Resident #2 when the facility obtained a urine culture on 3/5/18 but did not follow-up with the lab for the results of the final report on 3/8/18. The final urine culture revealed > 100,000 colonies/ml [MEDICATION NAME] faecalis (bacteria). The resident was transported to the emergency room (ER) on 3/26/18 for evaluation due to elevated temp and generalized weakness. In the ER the resident was found to have a low blood pressure and was given IV (intravenous) fluids and transferred to the intensive care unit [MEDICAL CONDITION] secondary to a urinary tract infection. Findings: Review of Resident #2's record revealed the resident was an [AGE] year old male with the following Diagnoses: [REDACTED]. Record review of _______ (local hospital) records for Resident #2's hospitalized from [DATE]-3/30/18 revealed in part: 3/26/18 emergency room documentation: Patient presented with nausea, vomiting, weakness, fever. Triage B/P: 90/40 mmHg (millimeters of mercury). The 3/26/18 ______ (local hospital) ED (Emergency Department) Clinical Summary revealed that the ER doctor reviewed the resident's electronic health records which indicated Resident #2 had several positive urine cultures with the last one noted (MONTH) 5, (YEAR) for [MEDICATION NAME] faecalis. In the note he revealed that he asked the daughter about the positive urine culture on (MONTH) 5, and that she did not believe that the resident was treated. He documented that he would obtain blood cultures and a urine culture and give a dose of antibiotics on the presumption that the resident had [MEDICATION NAME]. A review of the Intensive Care Unit's Discharge Document dated 3/30/18 revealed the following documentation in part: XXX[AGE] year-old Caucasian male .presented to ____ (local hospital) on 3/26/18 with complaints of nausea, vomiting, shortness of breath, dark urine, and fever and sweats. Patient has a recent history of UTI with [MEDICATION NAME] faecalis sensitive to [MEDICATION NAME] (antibiotic). It apparently wasn't clear if patient was treated for [REDACTED]. In ER patient was found to have a low blood pressure and was given IV (intravenous) fluids and [MEDICATION NAME] (protein found in blood) and then transferred to ICU for septic shock secondary to UTI and placed on vasopressors (medication that raised blood pressure) Patient's urine culture has grown out [MEDICATION NAME] faecalis sensitive to [MEDICATION NAME]. Patient's initial blood culture grew out E. coli (Escherichia Coli-bacteria) but subsequent blood culture was negative. Patient was initially started on [MEDICATION NAME] switched to [MEDICATION NAME] (antibiotic) per ID (infectious disease) Discussed case with _____ (Infectious Disease doctor) and he recommends switching IV [MEDICATION NAME] to oral [MEDICATION NAME] 500mg by mouth twice a day for 10 days for UTI and aspiration pneumonia. He states E. coli in the blood is not of any significance as repeat blood cultures were negative while on [MEDICATION NAME] alone. And according to sensitivity reports the E. coli is resistant to [MEDICATION NAME]. Nurse's notes for Resident #2 revealed in part: 3/5/18 at 6:01 a.m. - Collected urine clean catch, for monthly UA (urinalysis). 3/23/18- [MEDICATION NAME] administered for complaints of stomach upset/cramps. Medication follow-up: resident vomited after administration. New orders received from nurse practitioner for [MEDICATION NAME] 8mg X 1 PO Q6H prn vomiting . 3/24/18- Resident fell . Was trying to get in his wheelchair to go to the bathroom and slipped. Neuro checks started. VS (vital signs) BP (blood pressure) 130/74. P (pulse) 92. T (temperature) 97.6. R (respirations) 18. 3/25/18 4:00 p.m. - Resident noted with tan colored emesis (vomit) in basin. Prn [MEDICATION NAME] administered. PO (by mouth) fluids given. 3/25/18 11:00 p.m. - .BP 108/74, P 89, T 97.4, R 18 . 3/26/18 8:00 a.m. - Resident lying in bed at this time with eyes open. Alert and awake. Oriented to person. Noted speaking with low tone of voice at this time. Noted with generalized weakness at this time. Neurochecks in place at this time. VS B/P 107/61 T 97.8 P 102 R 18. 3/26/18 10:30 a.m. - Resident noted with generalized weakness and difficulty grasping object with left hand at this time. Noted with increase pulse of 124 at this time. Noted with low B/P. 84/48. T 102.5. P 124. Called placed to S5MD office at this time and left message to return call at this time. 3/26/18 11:30 a.m. - B/P reassessed and noted 122/89 at this time. Oral fluids encouraged at this time and tolerated well. 3/26/18 12:03 p.m. - Received call from S5MD. Notified of new orders to transfer to ER for evaluation due to elevated temp and generalized weakness at this time . 3/26/18 12:45pm - _____ (emergency medical service) arrived at this time and resident transferred to _____ (local hospital) at this time. 3/30/18 10:07 p.m. revealed: 5:32PM - Resident returned from hospital via family's personal vehicle . Record review of the Resident #2's (MONTH) (YEAR) physician's orders [REDACTED]. 10/19/18 - Standing order for UA (urinalysis), PRN (as needed)/Change in MS (mental status) or daughter's request. 3-26-18 - Okay to transfer to ER (emergency room ) for eval (evaluation) due to generalized weakness, vomiting and elevated temp (temperature) 3/30/18 - [MEDICATION NAME] (antibiotic) 500-125mg tablet X 1 by mouth every 12 hours for 10 days for UTI (urinary tract infection) Follow-up with Dr.______ (Infectious Disease doctor) R/T (related to) recent hospital stay for urosepsis (a life-threatening infection of the urinary tract). Review of laboratory reports for Resident #2 revealed: 3/5/18 Urinalysis - Results showed WBC (white blood cells) 20-30 with a reference range of 0-2. Moderate bacteria. Order comments read: Urinalysis Complete a reflex to culture. The report was signed at bottom (name unknown). Bottom of report read-Printed: 3/6/18. 3/6/18 Urine Culture Preliminary Report - Preliminary culture results revealed: No growth @ (at) 24hrs. No signature was noted on the report. Bottom of report read-Printed: 3/6/18. 3/7/18 Urine Culture Preliminary Report - Preliminary culture results revealed > 100,000 colonies/ml (milliliter) Gamma Streptococcus (bacteria). No signature was noted on the report. Bottom of report read-Printed: 3/7/18. 3/8/18 Urine Culture Final Report - Final culture results revealed > 100,000 colonies/ml [MEDICATION NAME] faecalis (bacteria). No signature was noted on the report. Bottom of report read-Printed: 3/27/18. During an interview on 4/10/18 at 4:43 p.m. with S1LPN, she stated that all laboratory results were sent to the fax machine at the nurse's station. She stated that the ward clerk or nurses got the results off the fax machine and gave them to the residents' nurse, but there wasn't a designated person assigned to do this. She stated that sometimes S4DON got a positive result somehow through email and gave it to the nurse. She stated that sometimes they would call the lab to get the results faxed if they had not gotten the results. She stated that when a urinalysis was ordered for Resident #2, they called the MD with the results, and if the urinalysis was positive and a C & S (culture and sensitivity) was needed, they called the MD with the preliminary and final culture results. She stated that if the nurses or doctors did not sign off on the lab report and there was no documentation in the nurses' notes of the doctor being notified, then that meant the doctor was not aware of the results. She reviewed Resident #2's 3/5/18-3/8/18 lab reports and stated that no one had signed off on the 3/6/18, 3/7/18 or 3/8/18 lab results and that if someone would've reviewed these then something would've been done. S1LPN noted and confirmed that the printed date at the bottom of the lab reports was the date the lab report was sent by fax to the nursing home. She noted that the 3/8/18 lab result had a printed date of 3/27/18 and stated that the result was requested on 3/27/18 because of how the fax looked. She reviewed Resident #2's nurse's notes and confirmed that nothing was documented regarding the progression of the urine culture results and stated there should've been some form of communication regarding the positive results. During an interview on 4/11/18 at 12:54 p.m. with S2LPN, he stated that when a urinalysis was ordered, a urine specimen was collected and sent to the lab; the preliminary results were sent to the fax; the ward clerk would put the results on their desk; the resident's nurse would get it off the fax; or a nurse would give it to the nurse that had the resident. He stated that if a urine culture was needed, the preliminary and final results were called in to the doctor. He further stated that Resident #2 had an order to get UA as needed or per family request. He stated that this was done routinely at the beginning of each month. S2LPN reviewed the 3/5/18 UA report and stated that the signature on the report was for the MD's nurse practitioner. He reviewed the 3/6/18, 3/7/18, and 3/8/18 urine culture results and noted that they were not signed off. He stated that either the nurse practitioner or doctor overlooked them or the lab results were not called in to the doctor. He stated that the date at the bottom of the report was the result date and the day the result was sent to the nursing home. He stated that he was not sure why the 3/8/18 final culture result had a date of 3/27/18 at bottom. S2LPN reviewed his nurse's note entries for the shifts he worked with Resident #2 during the period of 3/5/18-3/7/18 and confirmed he had not documented anything regarding Resident #2's urinalysis or urine culture results. During an interview on 4/11/18 at 1:35 p.m. with the resident's MD, he stated that he was not made aware of Resident #2's 3/6/18, 3/7/18 or 3/8/18 urine culture results. He stated that if he would have been notified of 3/8/18's final urine culture which showed [MEDICATION NAME] faecalis, he would have treated the resident. He stated that he saw Resident #2 on 3/19/18 for pain and that he would have re-checked the resident's urine, if he would have known of the positive culture results for 3/8/18. He further stated that, during Resident #2's hospitalization on [DATE], [MEDICATION NAME] faecalis was found in the urine culture and E. Coli was found in the blood culture. During an interview on 4/11/18 at 2:27 p.m. with S4DON, he stated that when a urinalysis was ordered, the procedure was as follows: the urine was collected and sent to the lab, the results were faxed to the nurse's station and put in a bin for the nurses to review. He stated that he was the backup to obtain all lab results and he did this through a computer program linked to the specific lab they used. He stated that staff was responsible for notifying the doctor of the lab results. He stated he reviewed all the labs days, too. He confirmed that Resident #2's preliminary urine culture results for 3/6/18 and 3/7/18 were not addressed. He confirmed that the final urine culture result for 3/8/18 was not obtained or reported to the resident's MD. He stated that either a fax of the results was not sent or there was a glitch in the computer system that he used to obtain lab results. He stated that the facility had no policy for the process for obtaining lab results.