Every finding on record at Landmark of Lake Charles

Based on observations, interviews, and policy review, the facility failed to maintain a clean and sanitary kitchen. This deficient practice had the potential to affect 88 residents who ate out of the kitchen. The facility's census was 97.Findings:Review of the facility's policy, Sanitary Conditions of the Food Service Department, with a last review date of 01/15/2025, revealed the following in part: Policy: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. h. Cleaning and Sanitizing: a. Food contact surfaces are washed, rinsed and sanitized: i. After each use, iv. At four hour intervals while the kitchen is in use; 2. Cleaning Program, a. The Director of Food and Nutrition Services develops a master cleaning schedule that includes: i. what should be cleaned, ii. Who should clean it., iii. When it should be cleaned, iv. How it should be cleaned, b. The Director of Food and Nutrition Services supervises the daily cleaning and monitors the completion of all cleaning tasks. An initial tour of the kitchen was conducted on 09/08/2025 at 8:40 a.m. with S1DM (Dietary Manager) who observed and confirmed the following: 1. The rolling cart containing clean trays was observed with crumbs on the trays and on the bottom shelf of the cart.2. Crumbs were on the bottom shelf of the steam table.3. Crumbs and dried food debris were on the top shelf of clean dish storage shelving.4. The side of the oven/stove was observed with dried grease.5. Yellow, wet food debris was observed on the clean counter side of the dishwasher with clean trays drying in a rack placed on top of the food debris.6. A thick layer of black residue was noted on the floor/baseboard and the lower wall behind the dishwasher.7. Brown, dried food splatter residue was on the wall over/behind the microwave.8. Thick, black dried residue and white debris was on the floor behind the clean dishes shelving unit located next to the steam table. On 09/08/2025 at 3:05 p.m., an interview was conducted with S1DM. She confirmed that there should be a cleaning schedule for staff in the kitchen. She further stated that there was no cleaning schedule in use and that a cleaning schedule had not been established.

Based on record review and interviews, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 ( #24) of 3 (#3, #6 and #24) residents investigated for PASARR in a final sample of 42 residents. Findings:Review of Resident #24's electronic medical record (EMR) revealed she was admitted to the facility on [DATE], with diagnoses that included in part, schizophrenia, unspecified and major depressive disorder, unspecified.Review of Resident #24's Level I PASARR dated 07/06/2009 revealed in Section I, Question #1 A. Approved for Medicaid medical eligibility services effective 06/18/2009. No further documentation nor evidence of a Level II PASARR determination was provided.On 09/09/2025 at 12:45 p.m., an interview was conducted with S3SSD (Social Service Director). She reported she was responsible for residents' PASARRs at the facility. S4SSD stated the admission 142 form was completed for Resident #24 in 2009. She was unable to provide any proof of submission for a Level II PASARR related to the resident's qualifying diagnoses.On 09/10/2025 at 8:10 a.m., an interview was conducted S3ADM (Administrator). S3ADM could not confirm if Resident #24 had a Level II PASARR.

Based on record reviews and interviews, the facility failed to develop a person- centered care plan for 2 (#25 and #27)) out of 42 sampled residents. The deficient practice had the potential to affect a total census of 97 residents. Findings:On 09/10/2025, a review of the facility's policy titled, Care Plan Process, with a last reviewed date of 01/15/2025, read in part, the Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged and must be consistent with each resident's written plan of care.Resident #25A review of Resident #25's electronic health record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, bipolar disorder and psychotic disorder with delusions.A review of Resident #25's physician's orders revealed an order dated 05/29/2025 for Seroquel XR (extended release) 24 hour, give 200 milligrams (mg) by mouth at bedtime related to bipolar disorder, which was discontinued on 08/28/2025. Further review revealed a second order dated 08/28/2025 for Seroquel XR 24 hour, give 300 mg by mouth at bedtime related to bipolar disorder. A review of Resident #25's health record failed to reveal any focus areas or interventions related to bipolar disorder.On 09/09/2025 at 12:51 p.m., a review of Resident #25's health record was conducted with S7MDS (Minimum Data Set Nurse). She confirmed the resident received treatment for bipolar disorder. She also confirmed the resident's care plan did not address bipolar disorder and stated it should have.On 09/10/2025 at 12:10 p.m., an interview was conducted with S5DON/IP (Director of Nursing/Infection Preventionist). She confirmed Resident #25 received treatment for bipolar disorder and the resident's care plan did not address bipolar disorder.Resident #27A review of Resident #27's EHR revealed she was admitted to the facility on [DATE], with diagnosis including in part, end stage Alzheimer's disease.A review of Resident #27's health record revealed the resident had a weight loss. On 08/07/2025, the resident weighed 140 Pounds (lbs.). On 09/03/2025, the resident weighed 117 lbs. which is a -16.43% Loss.Further review of Resident #27's care plan failed to address nutrition or weight loss.On 09/10/2025 at 11:21 a.m., a review of Resident #27's health record was conducted with S8MDS. She confirmed the resident's care plan did not address nutrition and should have.On 09/10/2025 at 11:38 a.m., an interview was conducted with S5DON/IP. She confirmed Resident #27's care plan did not address nutrition and should have.

Based on observation, interview, and policy review the facility failed to establish and maintain an infection prevention and control program designed to help prevent development and transmission of disease and infection as evidence by: failing to ensure glucometer machines were cleaned and disinfected per the facility's policy and manufacturer's guidelines. This deficient practice occurred during 1 of 2 observations of glucose monitoring during medication pass. Findings:On 09/09/2025, a review of policy titled, Blood Glucose Quality Control with last review date of 07/2025 read in part, Maintenance of Blood Glucose Monitoring Systems, Always clean the meter after each use. Gently wipe and clean surface of the meter with an approved disinfectant wipe per facility policy.On 09/09/2025, a review of the manufacturer's guidelines/user instructions manual for the Assure Platinum Glucose Monitoring System read in part: cleaning and disinfecting can be completed by using a commercially available environmental protection agency- registered disinfectant or germicide wipe. On 09/09/2025 at 11:25 a.m., an observation was made of S10LPN (Licensed Practical Nurse) performing a blood glucose check on Resident #1. After checking the resident's blood sugar, S10LPN exited Resident #1's room with the glucometer in hand. S10LPN returned to the medication cart and was not observed obtaining any sort of wipes. S10LPN removed the test strip then placed the used glucometer in the medication cart drawer without cleaning and disinfecting the surface of the glucometer. On 09/09/2025 at 11:29 a.m., an interview was conducted with S10LPN. S10LPN confirmed the glucometer was not disinfected after testing Resident #1's blood sugar before placing it back in the medication cart. S10LPN then insisted she wiped the glucometer with an alcohol wipe, but confirmed did not disinfect the glucometer with a germicidal wipe.On 09/09/2025 at 12:30 p.m., a group interview was conducted with S5DON/IP (Director of Nurses and Infection Prevention Nurse) and S9CN (Corporate Nurse) who both confirmed glucometer machines should be cleaned and disinfected after each use. S5DON/IP further confirmed staff should use Sani Cloth Germicidal Wipes to disinfect the glucometer machines after each use.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of emergency transfers in writing for 1 (#24) of 2 (#24 and #102) sampled residents reviewed for transfer and discharge requirements.Findings:On 09/10/2025, a review of the facility's policy titled, Discharge Transfer and Planning, with a revision date of 08/2025, read in part.Ombudsman Notification: The community shall notify the resident and the resident's representative(s) of the transfer or discharge and the notices must be sent to the representative of the Office of the State Log-Term Care (LTC) Ombudsman. Review of Resident #24's Electronic Medical Record (EMR) revealed in part, Resident #24 was admitted to the facility on [DATE] with diagnoses that included in part, respiratory failure, unspecified with hypoxia and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Further review of the EMR revealed Resident #24 had an emergency transfer to a local hospital on [DATE]. Review of the facility's Emergency Transfer Log noting notification to the Ombudsman for transfers dated 05/01/2025-07/31/2025 failed to reveal documentation of Resident #24's transfer to the hospital on [DATE].On 09/09/2025 at 1:38 p.m., an interview was conducted with S2AM (Accounts Manager). S2AM confirmed Resident #24 was not identified on the emergency transfer log for an emergency transfer on 05/25/2025 therefore notification was not made to the Ombudsman, and should have been.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 2 (#25 and #27) out of 42 sampled residents. The deficient practice had the potential to affect a total census of 97 residents. Findings:On 09/10/2025, a review of the facility's policy titled, Resident Assessment, with a last review date of 08/28/2024, read in part. Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed.Resident #25A review of Resident #25's electronic health record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included in part, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, bipolar disorder, psychotic disorder with delusions, and history of falling.Further review of Resident #25's EHR revealed she had a fall on 08/19/2025 with no injuries.A further review of Resident #25's August 2025 Medication Administration Record (MAR) revealed the resident was administered Rexulti and Seroquel (antipsychotics) daily.A review of Resident #25's Annual Minimum Data Set with an Assessment Reference Date (ARD) of 08/26/2025 revealed the following in part: Section J1900 Number of falls since reentry. A. No injury with 1 (one fall). C. Major injury with 1 (one). Section N0415A High-risk drug classes, antipsychotic was coded with a 1 which indicated the resident was taking medications by the pharmacological classification of antipsychotic, not how it was used. Section N0450A Did the resident receive antipsychotic medications since.reentry was coded no (0). On 09/09/2025 at 12:51 p.m., a record review and review of Resident #25's MDS with ARD date of 08/26/2025 was conducted with S7MDS (Minimum Data Set Nurse). She confirmed J1900C was coded as (1) one. She stated the resident did not have a fall with a major injury and should have been coded as (0) none. During further review, S7MDS confirmed N0450A was coded as (0) no - antipsychotics were not received. S7MDS reviewed Resident #25's August MAR and confirmed the resident received antipsychotic medication. She stated N0450A should have been coded as (1) yes, antipsychotics were received on a routine basis only. On 09/10/2025 at 12:10 p.m., an interview was conducted with S5DON/IP (Director of Nursing/Infection Preventionist). She confirmed Resident #25's MDS with an ARD date of 08/26/2025 was inaccurately coded.Resident #27A review of Resident #27's EHR revealed she was admitted to the facility on [DATE] with diagnoses including in part, end stage Alzheimer's disease.A review of Resident #27's EHR revealed a physician's order dated 08/22/2025, that read in part, Admit to __ Hospice for terminal diagnosis end stage Alzheimer's disease.A review of Resident #27's significant change MDS with an ARD date of 08/28/2025 revealed Section OK1 Hospice care while a resident was coded no. On 09/10/2025 at 11:21 a.m., a review of Resident #27's significant change MDS with an ARD date of 08/28/2025 was conducted with S8MDS. She confirmed Section OK1 Hospice was coded no. She stated the resident did receive hospice services and should have been coded as yes.On 09/10/2025 at 11:38 a.m., an interview was conducted with S5DON/IP. She confirmed Resident #27 received hospice services. She stated the MDS was coded no and should have been coded yes.

Based on record reviews and interviews, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 ( #2, #3) of 6 (#1, #2, #3, #R1, #R2, #R3) residents investigated for PASARR in a final sample of 6 residents. Findings: Review of Resident #2's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, major depressive disorder with severe psychotic symptoms, mood disorder, and generalized anxiety disorder. Review of Resident #2's Level I PASARR dated 04/15/2024 revealed section III, Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. No was indicated. Further review of Resident #2's records revealed no evidence that Level II PASARR had been submitted to the appropriate state-designated authority with those psychiatric diagnoses identified. Review of Resident #3's EHR revealed she was admitted to the facility on [DATE] and later received diagnoses on 06/30/2023 that included in part, Generalized Anxiety Disorder, Psychotic Disorder with Delusions, and Delirium. Review of Resident #3's Level I PASARR dated 01/24/2020 revealed section III Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. No was indicated. On 07/01/2025 at 10:45 a.m., a group interview was conducted with S1ADM (Administrator) and S4LPN (Licensed Practical Nurse, Admissions Nurse). S4LPN stated she was responsible for the PASARR's for residents at the facility. S4LPN reviewed both Resident #2 and Resident #3's EMR diagnosis list and confirmed the resident did have qualifying diagnoses that should have been indicated on the PASARR evaluation form. S4LPN then viewed the issue dates of both Residents' PASARR's and confirmed both resident's received these qualifying diagnoses after the PASARR issue date. S4LPN further confirmed that the Level I should have been resubmitted for review to indicate the newly qualifying diagnoses for a Level II determination and had not been.

Based on interviews and record reviews, the facility failed to ensure it employed a qualified social worker (SW) on a full-time basis. The facility had 130 licensed beds. Findings: On 06/30/2025 at 10:00 a.m., during an interview with S1ADM (Administrator), a request was made for the facility SW's credentials. On 06/30/2025 at 12:30 p.m., an interview was conducted with S3SS (Social Services). She confirmed she was SW for the facility. She stated she had a bachelor's degree in social work. At that time, a request for her credentials was made. She stated she would have to look for her diploma. S3SS stated she could provide her unofficial transcript. On 07/01/2025 at 8:50 a.m., during an interview with S3SS, she confirmed she did not have a copy of her diploma. A request for her transcript was made. On 07/01/2025 at 9:15 a.m., S3SS provided a copy of a receipt for a request for her diploma. A second request for her transcript was made. On 07/01/2025 at 11:25 a.m., an interview with S3SS was conducted. S3SS confirmed she did not have a copy of her transcript nor had received a copy of her diploma. On 07/01/2025 at 11:30 a.m., during an interview with S2AADM (Administrative Assistant), a request for S3SS's credentials was made. On 07/01/2025 at 11:45 a.m., an interview was conducted with S1ADM. He stated he was not able to locate S3SS's credentials. He confirmed the facility could not provide S3SS's qualifying credentials.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1(#1) of 6 (#1, #2, #3, #R1, #R2, #R3) sampled residents. Findings: A review of Resident #1's medical records revealed an admission date of 08/14/2024 with diagnoses which included but were not limited to current episode depressed, severe, with psychotic features; major depressive disorder recurrent, severe with psychotic symptoms; persistent mood [affective] disorder, unspecified; borderline personality disorder; anxiety and bipolar disorder. A review of Resident #1's Pre admission Screening and Assessment Resident Review (PASARR), dated 08/12/2024, revealed a Level II determination that read, Individual meets state law criteria for intellectual/developmental disability . A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 09/10/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 11/07/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. A review of Resident #1's MDS with an ARD (Assessment Reference date) date of 12/13/2024, section A1500 revealed the following: Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 07/01/2025 at 12:27 p.m., an interview and review of Resident #1's MDS for the above referenced ARD's was conducted with S5LPN (Licensed Practical Nurse). She confirmed that the PASARR was incorrectly coded and did not reflect that the resident was considered by the state level II PASARR process to have serious mental illness, and should have been.

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. a thick layer of debris on the deep fryer cooking oil collection area; 2. expired foods from the kitchen walk in cooler, and dry storage area; 3. opened food items not labeled with the date and time; and 4. sticky residue with food debris on the cart used to bring food items from one part of the kitchen to another. This deficient practice had the potential to affect the 87 residents who consumed food from the kitchen. Findings: On [DATE] at 8:33 a.m., a tour of the facility's kitchen was conducted with S1DS (Dietary Supervisor), who stated that she was responsible for the day's management of the kitchen. On [DATE] at 8:39 a.m., an observation of the deep fryer was conducted with S1DS that revealed the cooking oil collection area had a thick layer of debris. S1DS stated the deep fryer was last used on [DATE] and confirmed that is was not cleaned after it was used and should have been. On [DATE] at 8:48 a.m., an observation of the walk in cooler was conducted with S1DS and revealed the following: 1. (7) unopened squeeze bottle containers of strawberry jam with an expiration date of [DATE] 2. large opened container of caesar dressing with an expiration date of [DATE] 3. large opened container of mayonnaise tarter dressing with an expiration date of [DATE] 4. opened gallon of milk with an expiration date of [DATE] 5. large container of cherries with the opened date of [DATE] Further observation of the cooler revealed the following items were opened but were not labeled with the date and time they were opened: 1. large bag of garlic bread toast 2. large bag of hot dog buns 3. large container of sour cream S1DS confirmed the food items were expired and should have been removed from the walk in cooler and 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 9:09 a.m., an observation of the dry storage room was conducted with S1DS and revealed the following: 1. plastic gallon bag with an opened bag of blueberry muffin mix dated [DATE] 2. (2) plastic gallon bags with opened bags of white frosting mix, one dated [DATE], and one dated [DATE] 3. plastic gallon bag with an opened bag of cheese cake mix dated [DATE], with an expiration date of [DATE] S1DS confirmed the food items were expired and should have been discarded. On [DATE] at 12:48 p.m., an observation of the food service line was conducted. Food trays were placed on a cart for tray distribution. Further observation of the cart revealed multiple areas of a sticky residue and food debris on both sides and front of the cart. At 12:49 p.m., an interview and cart observation was conducted with S1DS, who stated that the carts were to be cleaned after each use and confirmed the cart was not cleaned from previous use and should have been.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for Hospice care for 1 (Resident #83) out of 29 sampled residents. Findings: Review of Resident # 83's electronic health record revealed he was admitted to the facility on [DATE]. Further review of his record revealed a Physician's order dated 06/06/2024 for Admit to Hospice with terminal diagnosis of End Stage Neural Vascular Dementia. Review of Resident #83's Quarterly MDS assessment, with an ARD (Assessment Reference Date) of 09/09/2024, revealed: Section O for Special Treatments, Procedures, and Programs .K1. Hospice Care . B. While a Resident . Coded as No. On 09/25/2024 at 08:45 a.m., an interview and record review was conducted with S2LPN (Licensed Practical Nurse). She confirmed that Resident #83 was admitted to hospice care on 06/06/2024. She then reviewed Resident #83's Quarterly MDS, with ARD of 09/09/2024 and confirmed that hospice care was coded inaccurately as not receiving while a resident.

Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 ( #19) of 1 (#19) residents investigated for PASARR in a final sample of 29 residents. Findings: Review of Resident #19's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Major Depressive Disorder and Dementia; with Psychotic Disorder with Delusion added on 09/19/2023. Review of Resident #19's Level I PASARR dated 08/04/2023 revealed section III, Question #1 Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? Include mental disorders that may lead to chronic disability. If yes, please check the diagnosis below. Answer checked was No. Further review of Resident #19's records revealed no evidence that Level II PASRR had been submitted to the appropriate state-designated authority with those psychiatric diagnoses identified. On 09/23/2024 at 12:45 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse, Admissions Nurse). She reported she was responsible for the PASARR's for residents at the facility. S3LPN reviewed Resident #19's EMR diagnosis list and confirmed the resident did have a diagnosis of Major Depressive Disorder on 08/14/2024 and Psychotic Disorder on 09/19/2023. S3LPN then reviewed the Level I PASARR and confirmed the diagnosis of Major Depressive Disorder and Psychotic Disorder were not identified on the Level I screening. S3LPN also confirmed the Level I should have been resubmitted with the new diagnoses for a Level II determination and was not.

Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice as evidenced by failing to ensure the resident's oxygen equipment was stored properly for 1 (#77) out of 2 (#77, #84) residents reviewed for respiratory care, with the potential to effect 14 residents receiving oxygen therapy. Findings: Review of the facility's policy titled Infection Control Oxygen Equipment Cleaning with a revision date of 06/2014, last review dated of 01/24/2024 revealed in part: 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Review of Resident #77's electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses, not limited to, Acute Respiratory Failure with Hypoxia, Vascular Dementia and Dyspnea. Review of Resident #77's Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating a moderately impaired mental status. Review of the physician's orders for Resident #77 revealed an order dated 07/26/2024 for Oxygen at 2 liters/nasal cannula (L/NC), as needed (PRN) for dyspnea. On 09/23/2024 at 9:07 a.m., an observation of Resident #77's oxygen tubing was laying over the oxygen concentrator machine, not in the bag that is hanging off side of machine. On 09/24/2024 at 8:10 a.m., a second observation was made of Resident #77's oxygen tubing laying over the concentrator, not in a storage bag. On 09/24/2024 at 8:30 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed the oxygen tubing for Resident #77's was laying over the top of the concentrator and should have been stored in the bag. She confirmed the resident's oxygen is PRN and was not used all the time, and unable recall the last time he had used the oxygen.

Based on observations and interviews, the facility failed to ensure the residents had a safe, clean, comfortable homelike environment by failing to maintain a clean environment in resident bathrooms for 5 (Resident #35, Resident #61, Resident #74, Resident #91, Resident #93) out of 37 sampled residents. This deficient practice had the potential to affect a total census of 103. Findings: Resident #35 On 10/23/2023 at 12:34 p.m., an observation was made of Resident #34's bathroom. The bathroom toilets seat, rim, and inside/outside of bowl was soiled with thick black and brown substances. On the inside of the toilet bowl, at the water line, there was a ring of black mildew. On 10/24/2023 at 8:40 a.m., a second observation was made of Resident #34's bathroom. The bathroom toilet seat, rim, and inside/outside of bowl was soiled with thick black and brown substances. On the inside of the toilet bowl, at the water line, there was black mildew. Resident #61 On 10/23/2023 12:10 p.m., an observation was made of Resident #61's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 8:39 a.m., a second observation was made of Resident #61's bathroom toilet. On the inside of the toilet bowl, at the water line, the black mildew ring remained. Resident #74 On 10/23/2023 at 11:54 a.m., an observation was made of Resident #74's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 at 8:37 a.m., a second observation was made of Resident #74's bathroom. On the inside of the toilet bowl, at the water line, the ring black mildew remained. Resident #91 On 10/23/2023 at 12:40 p.m., an observation was made of Resident #91's bathroom. On the inside of the toilet bowl, at the water line, there was a ring black mildew. On 10/24/2023 at 8:43 a.m., a second observation was made of Resident #91's bathroom. On the inside of the toilet bowl, at the water line, the ring black mildew remained. Resident #93 On 10/23/2023 at 11:49 a.m., an observation was made of Resident #93's bathroom. On the inside of bathroom toilet bowl, it was heavily soiled with black mildew, 3-4 inches in width around water line. There was 1 full, tied bag of trash on floor and the trash can was full with discarded trash. The bathroom had foul odor. On 10/24/2023 at 8:35 a.m., a second observation was made of Resident #93's bathroom. On the inside of bathroom toilet bowl, it was heavily soiled with black mildew, 3-4 inches in width around water line. There was 1 full, tied bag of trash on floor and the trash can was full with discarded trash. The bathroom had foul odor. On 10/24/2023 at 8:45 a.m., observations and an interview was conducted with S4HSK (Housekeeper). She confirmed that during the resident room cleaning process; the resident bathroom toilets should be cleaned daily and the trash should be emptied and taken out of the room daily. She also confirmed that when cleaning the resident bathroom toilets, the housekeeper should clean both inside and outside the toilet bowl and the toilet seat. She confirmed that Resident #35's, Resident #61's, Resident #74's, Resident #91's and Resident #93's bathrooms and bathroom toilets were soiled and should not be. She confirmed that no toilets should have mildew or any dried substances on them and there should be no trash bags left on resident bathroom floors. On 10/24/2023 at 2:30 p.m., an interview was conducted with S3HSK (Housekeeping Supervisor). He confirmed that during the residents room cleaning process; the residents bathroom toilets, inside and outside of the bowl, should be cleaned daily and the trash should be taken out daily. He confirmed that Resident #35's, Resident #61's, Resident #74's, Resident #91's and Resident #93's bathrooms and bathroom toilets were soiled and should not be. He confirmed that if the resident bathrooms and bathroom toilet had been cleaned daily, they would not have mildew or trash on the floor.

Based on record review and interview, the facility failed to accurately code the resident's MDS (Minimum Data Set) assessment for 1 (#104) out of 37 sampled residents. This deficient practice had the potential to affect a census of 103. Findings: Review of Resident 104's medical record revealed he was admitted on [DATE] and discharged on [DATE]. Resident #104's nursing progress noted dated 09/29/2023 at 10:41 a.m., indicated he had discharged to his home. Review of the facility's Detail Admission/Discharge Report dated 07/01/2023 through 10/23/2023 revealed on 09/29/2023 Resident's discharge location was home. Review of Resident 104's Discharge MDS with an ARD (Assessment Reference Date) of 09/29/2023 revealed a planned discharge, return not anticipated assessment was completed. Section A-Identification Information, A2100 Discharge Status was coded 03, indicating acute hospital. On 10/24/2023 at 3:50 p.m., an interview and record review was conducted with S5ALPN (Assessment Licensed Practical Nurse). She confirmed that Resident #104 was discharged from the facility on 09/29/2023 to his home. S5ALPN reviewed Resident #104's Discharge MDS with an ARD of 09/29/2023 and confirmed his discharge status indicated he was discharged to an acute hospital instead of the community (private home).

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards for 1 (#76) of 37 sampled residents. This deficient practice was evident when facility staff failed to ensure respiratory suction equipment was properly stored for Resident #76. Findings: On 10/24/2023 at 1:15 p.m. and on 10/25/2023 at 12:00 p.m., a request was made for S2DON (Director of Nursing) to provide the facility's policy regarding proper storage of respiratory suction equipment. By time of exit on 10/26/2023, the facility failed to provide the requested policy. Review of Resident #76's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Functional Quadriplegia, and Generalized Muscle Weakness. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1 indicating his cognition was severely impaired. Review of resident's comprehensive care plan revealed no plan for the use of suction or respiratory equipment. On 10/23/2023 at 12:06 p.m., an observation was made in Resident #76's room. A suction machine was located on her bedside table with the yanker (suction mouth piece) not bagged, open to air lying on the base of the suction machine which had a thick layer of dust. On 10/24/2023 at 1:05 p.m., a second observation was made in Resident #76's room. Again, the suction machine was located on her bedside table with the yanker (suction mouth piece) not bagged, open to air lying on the base of the suction machine which had a thick layer of dust. On 10/24/2023 at 1:10 p.m., an observation and interview was conducted with S4LPN (Licensed Practical Nurse). She confirmed the yanker mouth piece was not bagged and was lying on the dust lined base. She confirmed the yanker should not be open to air and should be stored in a bag when not in use. She confirmed that Resident #76 was unable to move herself or the suction machine.

Based on record review, policy review, and interviews, staff failed to implement its policy for incident invesitgation and reporting when staff failed to immediately report alleged staff-to-resident verbal and physical abuse to administrative staff for 1 resident (#3) out of a total of 5 (#1-#5) sampled residents Findings: Review of the facility's policy titled Review of the facility's policy titled Incident Investigation and Reporting (LA ONLY) Policy revealed the following: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse . (State Survey Agency) .To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. Relevant terms: Verbal Abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents ., regardless of their age, ability to comprehend, or disability. Physical Abuse: This includes but is not limited to hitting, slapping, kicking. It also includes controlling behavior through corporal punishment . 3. Abuse .are crimes and shall be reported to proper authorities as such. In the event of any incident involving an allegation or suspicion of .abuse, .each occurrence will be reported immediately to the Administrator of the facility . Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety and Depression. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/05/2022 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 04, indicating the resident was severely cognitively impaired. Review of a written statement by S4Dietary dated 12/19/2022 revealed, in part: She (S5LPN) told the lady (Resident #3) f*** you and she told her she didn't care who she told, and the nurse start turning her in her wheel chair and told her she didn't care who in the f*** she told. And then she stepped on the resident's foot and cursed her again. Review of a written statement by S6CNA read: As I was getting the cart and coming out the door Resident #3 was in the way so asked her to move for me to come out and she wouldn't. Then the nurse move her and turn her around a couple of times; signed and no date present. Review of a written statement by S5LPN read: On 12/18/2022 at approx. 6:45p resident #3 was sitting in middle of hallway. While CNA was attempting to push meal cart out of DR. This nurse redirected resident. Resident #3 refused to move so this nurse moved resident. Resident's hands were on wheels so we went in a circle. Resident #3 was parked near nursing cart. CNA proceeded to push med (medication) cart out of room. Resident #3 sat in hall near nursing cart. On 1/25/2023 at 1:20 p.m., a phone interview was conducted with S6CNA. S6CNA reported she was working the evening shift on 12/18/2022 and was asked to return the dining meal cart. S6CNA reported she walked out and returned the cart to the kitchen and that's when S4Dietary asked her if she had seen S5LPN cuss out Resident #3 and step on the resident's bare foot. S6CNA reported she had not informed her supervisor of the abuse allegations made towards S5LPN and stated It was none of my business. On 1/25/2023 at 1:52 p.m., an interview was conducted with S4Dietary who reported she remembered working on 12/18/2022 and an incident involving S5LPN and Resident #3. S4Dietary reported she had finished her work in the kitchen and was waiting for the last dining meal cart to be returned from the secure unit. S4Dietary reported she was walking to the unit when one of the CNAs (S6CNA) was coming out the unit with the dining meal cart leaving a little crack in the door. S4Dietary reported she had stood there and watched S5LPN because S5LPN was cussing at Resident #3 and telling the resident I don't give a f*** who you tell and then swung her in the wheelchair. S4Dietary continued to watch S5LPN and reported witnessing S5LPN point her finger in Resident #3's face stating go tell your people that; I don't give a f*** who you tell. S4Dietary reported that Resident #3 wasn't wearing any socks or shoes when she saw S5LPN step on Resident #3's bare foot. S4Dietary further explained she had asked S6CNA if she had seen S5LPN twist Resident #3 around in the wheelchair and then asked for S5LPN name. S4Dietary confirmed she had not reported the alleged verbal and physical abuse immediately and should have. On 1/25/2023 at 4:23 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S3CRN (Corporate Registered Nurse). S2DON reported S4Dietary had informed her of the alleged abuse on 12/19/2022 involving Resident #3 being cussed at and foot stepped on by S5LPN during the evening shift on 12/18/2022. S3CRN reported all staff were educated that any allegations of abuse were to be reported immediately. S2DON and S3CRN confirmed S4Dietary had not reported the allegations immediately and should have.

Based on observation, record review, and interview, the facility failed to maintain acceptable parameters of nutritional status by failing to have a functional system to assess significant weight changes. The facility failed to assess weights and intervene when significant and severe weight loss occurred for 5 (#4, #36, #40, #59, #74) of 5 (#4, #36, #40, #59, #74) residents investigated for nutritional status. This deficient practice has the likelihood for the facility's 94 residents, who require weekly and/or monthly weights, to experience undetected, significant weight loss. Findings: Record review of the facility's Policy titled Weight Evaluation read in part, Accurate .weights are determined for all residents. Weights are monitored to identify significant changes or residents with nutrition problems. Procedure: 1. A designated Weight Team is established which consists of at least two designated nurse aides and DON or Nurse Designee who will weigh residents on admission and each month and/or each week as needed. Members of the weight team are trained in the correct method for weighing residents accurately 4. All residents will be routinely weighed each month .6. Any variation from the DBW (Desirable Body Weight) is addressed in the medical record and if determined as a legitimate Need by the interdisciplinary team, is identified on the care plan as appropriate .9. As the weight team takes weights the nurse is present and monitors accuracy by comparing the current weight with prior weights. If there is a weight difference of three or more pounds the resident must be promptly reweighed and the weight verified. Once the team nurse verifies the weight, it is recorded in the medical record as soon as possible. All weights recorded are considered accurate. 10. The schedule for weights is developed by the weight team nurse, to include monthly weights . 11. All unplanned weight deviations plus or minus 5% or more per month, or 10% of body weight over a six month period or with insidious weight loss, require completion of a weight evaluation by the facility weight evaluation team .12. The Director of Food and Nutrition Services (Dietary Manager) refers newly identified residents with significant weight loss to the RD (Registered Dietician). 13. The weight team nurse and Director of Food and Nutrition Services are responsible for monitoring resident weight histories to determine a significant weight loss. This review is done each time a resident is weighed. If the resident has a history of gradual weight loss that is not significant, this is addressed in the medical record. 14. Documentation regarding weight status is documented in the medical record by nursing and the Director of Food and Nutrition Services and RD (Registered Dietician). Review of the facility's policy titled, Dietary Services read in part: Food likes, dislikes, and eating habits are assessed by the Nursing and Dietary Departments. This information is recorded in the resident's Medical Record. Resident #4 Review of the clinical record for Resident #4 revealed she was admitted to the facility on [DATE] to the Alzheimer's Unit. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimal Data Set), dated 09/16/2022, revealed a BIMS (Brief Interview for Mental Status) score of 8, meaning she had moderate cognitive impairment. Record review of Resident #40's Electronic weight history read, 09/09/2022 169.4 lbs. 10/04/2022 156.8 lbs. Resident #4 had a 7.44% severe weight loss in one month from 09/09/2022 to 10/04/2022. Record review of S22RD (Registered Dietician)'s Notes for Resident #4, read in part, 3/29/22 NAS (No Added Salt) /Regular diet. PO (by mouth) Intake 75-100% of meals, admitted to Memory Unit. No RD changes at this time. Continue POC (Plan of Care). Further review of S22RD's notes revealed no documentation for Resident #4 after 3/29/22. Record review of Resident #4's clinical record from 01/2022 to 10/26/22 revealed no documentation from S20FSS (Food Service Supervisor). On 10/25/22 at 10:55 a.m., S18LPN reviewed Resident #4's electronic weights and confirmed the resident had lost 7.44 % of body weight in one month. On 10/25/22 at 3:49 p.m., S3ADON reviewed Resident #4's electronic weight record and confirmed the resident had lost 7.44% in one month. She stated when she ran the weight reports the computer should have flagged the resident for weight loss. She stated that she was not aware that the resident had weight loss. Resident #36 Review of the clinical record revealed Resident #36 was admitted on [DATE] to the Alzheimer's unit with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS, dated [DATE], revealed a BIMS Score was 3 meaning severe cognitive impairment. Record review of Resident #36's Electronic weight history read, 04/04/2022 134.2 lbs. 05/02/2022 133.8 lbs. 06/03/2022 128 lbs. 07/05/2022 128.8 lbs. 08/16/2022 120 lbs. 09/09/2022 117.4 lbs. 10/06/2022 118.4 lbs. Resident #36 had a 13.01% severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Record review of S22RD's Notes read in part, 10/24/22 (18 days after the last weight was obtained) Weight Changes -11.51 % in 157 Days. Staff continue to encourage intake of meals. Record review of Resident #36's Care Plan, dated 05/13/2021, read in part, Potential for weight loss. Resident is on a therapeutic Diet: Regular: Observe weight as ordered, Refer to RD (Registered Dietician) for Evaluation and recommendation as needed. Further review revealed no new interventions when weight loss occurred. Review of Resident #36's record from 01/2022 to 10/26/2022 revealed no documentation by S20FSS. On 10/25/22 at 4:01 p.m., S3ADON reviewed Resident #36's electronic weights and stated the resident had lost 13% body weight in 6 months. She stated when she ran the 1 month and 6 month weight reports, the computer did not pick up Resident #36's 13% weight loss in 6 months. Resident #40 Review of the clinical record revealed Resident #40 was admitted on [DATE] to the Alzheimer's Unit, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #40's MDS, dated [DATE], revealed a BIMS score of 3, which indicated severe impaired cognition. Record review of Resident #40 Electronic weight history read, 11/06/21 146.6 lbs. 12/23/21 143.8 lbs. 01/07/22 140 lbs. 02/01/22 135 lbs. 03/04/22 141.4 lbs. 04/04/22 138.6 lbs. 05/02/22 140.2 lbs. 06/03/22 138.8 lbs. 07/05/22 135 lbs. 08/16/22 130.4 lbs. 09/09/22 129.4 lbs. 10/06/22 122.8 lbs. Resident #40 had a 5.10% severe weight loss in one month from 09/09/2022 to 10/06/2022. She had a 11.56 % severe weight loss in 6 months from 04/04/2022 to 10/06/2022. Review of S22RD's notes, dated 10/24/2022, read in part, Weight change: -10% in 27 Days. -11.53% in 125Days. -12.41% 157 Days. Rec: Increase House Supplement to 240cc TID (three times a day) for Sign (significant) weight change. RD review and recommendation was 18 days after the last recorded weight on 10/6/22. Record review of Resident #40's Care Plan read in part, Resident needs assist with eating. Resident eats in Unit dining room and occasionally needs to be fed d/t (due to) occasional tiredness in the morning. Further review revealed no new interventions with the continued weight loss. Review of Resident #40's record from 01/2022 to 10/26/2022 revealed no documentation from S20FSS. On 10/25/22 at 3:57 p.m., S3ADON reviewed Resident #40's electronic weights and confirmed the resident lost 5.10% weight in one month and 11.56 % weight in 6 months She stated she ran the weight report on 10/11/2022 for a one month report and six month report and the computer did not pick up the weight loss. Resident #74 Review of the clinical record revealed Resident #74 was admitted on [DATE] to the Alzheimer's unit with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MDS, dated [DATE], revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #74 electronic weight history read, 09/09/2022 125.4 lbs. 10/04/2022 118.4 lbs. Resident #74 had a 5.58% severe weight loss in 1 month from 09/09/2022 to 10/04/2022. Review of S22RD's Notes read in part, 04/12/22 Mech (mechanical) soft/Puree meat diet. MD ordered a house supplement due to sign (significant) weight loss from Hospital. Further review revealed no other RD notes. On 10/26/22 at 4:28 p.m., an interview withS22RD revealed she visited the nursing home on 10/24/2022 and did not look at Resident #74 for weight loss. Record review of Resident #74's Care Plan read in part, Resident has a potential for weight loss due to disease process. On mechanical soft diet with pureed meats Further review revealed no changes in the care plan when weight loss occurred. Review of Resident #74's record from 01/2022 to 10/26/22 revealed no documentation from S20FSS. On 10/25/22 at 3:57 p.m., S3ADON reviewed Resident #74's electronic weights and stated the resident had lost 5.58 % body weight in one month. She stated she ran the weight report on 10/11/2022 and the computer did not pick up the weight loss. On 10/25/22 at 3:29 p.m., an interview with S3ADON revealed she was in charge of the resident's monthly weights. She stated all the residents in the facility were weighed monthly. On the 4th of every month she went to the units to ensure all residents were weighed accurately by the CNAs (Certified Nursing Assistants). She stated that she put weights into the computer, and was able to tell at that time if the residents had weight loss. She stated that she ran weight reports for one month and six months and the computer calculated the weight loss or gain and printed out a list. She stated she brought the residents with weight loss or gain to the attention of the Registered Dietician. She stated the Food Services Supervisor should be reviewing the residents' weights and if he noticed a weight loss or gain, he should have brought it to the attention of the registered dietician. On 10/26/22 at 9:11 a.m., S20CNA confirmed that S3ADON supervised and assisted CNAs with obtaining accurate resident weights. On 10/26/22 at 11:39 a.m., an interview with S20FSS (Food Service Supervisor) confirmed that he was part of the Weight Team. He stated S3ADON weighed the residents and put the results in the computer. He stated the RD assessed the residents' weights with him. He stated he reviewed weights for new admissions, hospital returns, and quarterly. He monitored residents' weights monthly to ensure there was no weight loss. He stated the Weight Team had meetings once a month. S20FSS stated he was not aware Resident #40 had a 5.10 % weight loss in one month or 11.56% in 6 months. He was not aware Resident #4 had a 7.44% weight loss in 1 month, was not aware Resident #74 had a 5.58% weight loss in 1 month, or that Resident #36 had a 13.01% weight loss in 6 months. He stated he did not run the weight report. He stated he looked at the weights in the computer and should have recognized the weight losses when reviewing the weights monthly. He stated he was behind on all of his quarterly assessments and had not done any quarterly assessments for Resident #4, #36, #40 and #74 this year. On 10/26/22 at 4:28 p.m., a phone interview with S22RD confirmed she went to the facility 3 times a month to assess the residents. She stated S20FSS and S3ADON left her a log of residents to be seen. She stated the facility's computer had an algorithm that calculated weight gain and loss. She stated, if the residents had a weight gain or loss within 31 days or 6 months, this program should have picked them up. She stated that on 10/20/22 she pulled a weight report for 6 months, from 4/2022 to 10/20/2022. She stated Resident #74 had a -11.5 % weight loss in 157 days, and Resident #40 had a 5.1% loss in 27 days and -12.41 % in 157 days. She stated she did not see Resident #4 or Resident #36 on 10/24/2022, when she visited the facility. She stated if a resident had a significant weight loss for 6 months or for 1 month, they should have an intervention done to prevent further weight loss. She stated she did not get any reports of resident weight loss from the S3ADON or S20FSS that Residents #4, #36, #40 and #74 had lost any weight. She stated she did not attend any weight loss meetings at the facility on a monthly bases. She stated if the facility had a Weight Team, and had meetings, she was not aware of them. She stated the facility's computer algorithm should have picked up if residents had weight gain or loss at 31 days and within 6 months. Resident #59 review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident's cognition was moderately intact. Review of the resident's weights April 2022-October 2022 revealed: 10/4/22 143 pounds, BMI (Body Mass Index) 21.74 No weight documented for September 8/1/22 162.2 pounds BMI 24.66 7/6/22 168.6 pounds 6/2/22 168.2 pounds 5/9/22 171.4 pounds 4/1/22 171 pounds On 04/01/2022, the resident weighed 171 lbs. On 10/04/2022, the resident weighed 143 pounds which was a -16.37 % severe weight loss in 6 months. Review of the S22RD's (Registered Dietitian) notes for the past year revealed one note, dated 10/24/22, that revealed in part: PO (oral) intake ~25-100% of meals recorded looking back 14 days .weight changes -11.84% in ~64 days. -15.18% in ~90 days, -16.57% in ~148 days. Review of the resident's nutritional care plan revealed interventions that included: determine food preferences, observe weight as ordered, refer to RD (Registered Dietitian) for evaluation and recommendation as needed, supplements as ordered. Further review revealed no interventions and no documentation regarding the resident's nutritional status in regards to her significant weight loss. Review of the resident's Dietary Notes for the past year of the resident's stay revealed no documentation of dietary assessments or assessment of food prefrences. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed no further orders for nutritional supplements, weights or nutritional interventions addressing the resident's weight loss. Review of the resident's MAR (Medication Administration Record) September 2022-October 2022 revealed no nutritional supplements were administered. On 10/26/22 at 10:07 a.m., S13MDS stated that there were no dietary notes in Resident #59's medical record for the last year. On 10/26/22 at 11:24 a.m., an interview and observation of Resident #59 was conducted. The resident was wearing jeans that fit a little baggy. Resident #59 stated that she had desired to lose weight and was much smaller now than she was before. When asked what she did to lose the weight, the resident stated that she ate less during meals or skipped some meals. She further stated that it seemed like none of the staff noticed she lost weight because none of them commented about it. She stated that she did not tell the staff about her desire to lose weight and that no one asked her about it or counseled her about it. Resident #59 stated that no one from the Dietary Department nor S22RD spoke to her about her weight loss or had ever spoken to her about her food preferences. On 10/26/22 at 11:44 a.m., an interview was conducted with S16LPN and S23CNA who stated that the resident did not have any visible weight loss that they had noticed. S16LPN stated she had not noticed a difference in the way the resident's clothes fit and there were no changes in the resident's appetite that she noticed. S16LPN stated that the CNAs (Certified Nursing Assistants) did not report any issues to her and no other staff reported to her the resident wasn't eating enough. S23CNA and S16LPN stated that no one reported to them that Resident #59 had a significant weight loss. S16LPN stated resident #59 is not on any nutritional supplements. S16LPN and S23CNA stated that the resident had never told them that she was intentionally losing weight or expressed desired weight loss. S16LPN stated the resident has never had any weight issues since her admission to the the facility. On 10/26/22 at 12:06 p.m., F20FSS stated he was responsible for assessing residents' food preferences and dietary needs upon admission and when their required assessments were due- quarterly and annually. S20FSS stated that he would provide copies of dietary and food preference assessments for Resident #59. On 10/26/22 at 12:18 p.m., S20FSS returned without documentation of Resident #59's dietary assessments. S20FSS stated that he was not made aware that Resident #59 had any weight loss. On 10/26/22 at 12:21 p.m., an interview and review of Resident #59's medical record was conducted with S3ADON, who stated that she played an active part in obtaining residents' weights. She further stated that she was solely responsible for tracking residents' weights and weight comparisons. She stated that if a weight change was identified she was responsible for notifying S22RD of the weight change. She stated that S22RD came into the facility three times a month to assess residents. On the 10th day of each month or the week of the 10th of each month, S22RD assessed significant weight changes. She reviewed Resident #59's weight history and confirmed there was no weight documented for September 2022. S3ADON stated that she ran a weight report on 10/11/22 and had not noticed Resident #59's weight loss because the resident's name did not show up on the weight change report. The facility's electronic health record system was down the week of 10/10/22, so S22RD had to come back to the facility later in the month to complete her assessments. She stated she did not notice Resident #59 had a weight loss until S22RD entered her note on 10/24/22. She stated she was not sure if the physician reviewed S22RD's dietary recommendations yet and was not sure when the physician was due to return to the facility to review them. She stated that had she caught Resident #59's weight loss sooner, she would have notified S22RD as soon as possible. She reviewed S22RD's note and the calculations of the resident's weight loss and confirmed the resident's weight loss was significant. She reviewed the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed there were no dietary notes for the resident for the last year. On 10/26/22 at 01:28 p.m., S3ADON provided copy of her weight change report dated 10/11/22 and Resident #59's September 2022 weight that she had handwritten on a log as 195 w/ chair - 38. S3ADON stated that the resident's weight minus 38 which was the weight of the wheelchair which equaled 157 pounds. A comparison of the September 2022 with the October 2022 weight revealed: On 09/08/2022, the resident weighed 157 lbs. On 10/04/2022, the resident weighed 143 pounds which is a -8.92 % loss in 1 month. On 10/26/22 at 01:49 p.m., a follow-up interview was conducted with S3ADON who confirmed the resident had a significant weight loss of greater than 5% in one month that was missed because the resident's September weight had not been entered into the resident's record. She stated the reports for weights would have been looked at on 10/04/22. She recalculated and ran another report and stated that the system is still not working. After reviewing the report, the resident was still not showing up as having a weight change. She stated that she had to get with the administrator to contact support to see what's going on with the system because she thought it was working. She stated that there was no other way to check to see if any resident had a significant weight loss without manually calculating weights for each resident since the system was not working properly. On 10/26/22 at 04:20 p.m., S2DON stated that due to the facility's issues with the electronic health record system, the resident's significant weight loss was not identified by staff timely. On 10/26/22 at 04:30 p.m., a phone interview and record review was conducted with S22RD who stated that she had access to the resident's record remotely. She was asked if she attended or participated in the facility's weight committee meetings. S22RD stated she had no idea if they have weight team meetings and that she didn't have time to wait for weight team meetings with her workload. She stated she reviewed Resident #59 for weight changes on 10/20/22 when she ran the weight change report. When she ran the report on 10/20/22 she saw that the resident had a 15.1% weight loss in 90 days. She stated that the weight loss was considered severe. She had not received any notification from S20FSS nor S3ADON that the resident had a significant weight loss prior to 10/20/22. She then wrote her recommendations on 10/24/22 (20 days after the last weight was obtained on 10/4/22) when she reviewed the resident's record. When asked why the resident lost weight, she stated that it was due to decreased oral intake per the resident's record. When asked if she spoke to the resident on 10/24/22 when she made her recommendations, she replied no. She stated that she had not spoken to the resident and had only reviewed her record and was unsure of any other reason she may have lost weight. S22RD stated that her latest weight report noted the weight for May 2022 and she was not aware of what the resident's weight was in April. Therefore, she was not able to assess the 6 month weight loss. She further stated that she did not have a weight recorded for September 2022 to do a 1 month weight comparison. S22RD stated she was not aware that Resident #59 had an 8.92 % weight loss in one month from September 2022-October 2022. She stated that an 8.92% weight loss in 1 month was significant and had it been caught by S20FSS or S3ADON, she would have put in recommendations/interventions sooner.

Based on record review and interview, the facility failed to notify the resident's family and/or responsible party as well as the resident's physician of significant weight loss for 3 (#40,#59 and #74) out of 6 final sample residents with a significant weight loss. The total census was 94. This deficient practice had the potential to affect a census of 94 residents. Findings: Review of the facility policy titled, Change in Resident Medical Status read in part, a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting 2. Impacts more than one area of the resident's health status; A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is . 2. A significant change in the resident's physical, mental, or psychosocial status; (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . Resident #40: Review of Resident 40's medical record revealed she was admitted to the facility on [DATE]. Her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her BIMS (Brief Interview for Mental Status) score was 3 meaning she had impaired cognition. Review of the resident's weights from April 2022 through October 2022 revealed the following weights: 4/04/22 - 138.6 pounds; 5/02/22 - 140.2 pounds; 6/03/22 to138.8 pounds; 7/05/22 - 135 pounds; 8/16/22 - 130.4 pounds; 9/09/22 - 129.4 pounds; and 10/06/22 - 122.8 pounds. This resulted in a 5.10% weight loss in one month from 9/9/22 to10/6/22 and 11.56% loss in six months from 4/4/22 to 10/6/22. Resident #59: Review of Resident 59's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her BIMS (Brief Interview of Mental Status) was 11, indicating the resident's cognition was moderately intact. Review of the resident's weights from April 2022 - October 2022 revealed the following weights: 4/1/22 - 171 pounds; 5/9/22 - 171.4 pounds; 6/2/22 - 168.2 pounds; 7/6/22 - 168.6 pounds; 8/1/22 - 162.2 pounds; 9/8/22-157 pounds; 10/4/22-143 pounds. This resulted in an 8.92% weight loss in one month (9/8-10/4//22) and 16.37% weight loss over six months from 4/1/22-10/4/22. Resident #74: Review of Resident 74's medical records revealed she was admitted to the facility on [DATE]. Her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her BIMS score was 6, indicating severe cognitive impairment. Review of the resident's weights from September 2022 through October 2022 revealed the following weights: 9/09/2022 - 125.4 pounds and 10/04/2022 - 118.4 pounds. This resulted in a 5.58% weight loss in one month. The facility was made aware of Residents #40, #59, and #74 weight loss on 10/24/22. Review of Resident #40, #59 and #74's medical records on 10/26/22 revealed no documented evidence that the residents' family and/or responsible party were notified of their weight loss. An interview was conducted on 10/26/22 at 4:30 p.m. with S3ADON. S3ADON stated that she was responsible for contacting the resident's family and/or responsible party when there was a change in the resident's weight and the nurses were responsible for making sure that the physician was made aware of any dietician recommendations. She stated that the process was to notify the resident's family and/or responsible party by phone. S3ADON confirmed that she did not notify Resident #40, #59 or #74's family and/or their responsible party nor had their physician been notified that there was significant change in the their weight.

Based on record review and interview, the facility failed to ensure staff who have the skills and qualifications to assess relevant care areas and who were knowledgeable about the resident ' s status, needs, strengths and areas of decline, accurately completed the resident assessment for 3 (#61, #86, #91) of 44 final sampled residents. Findings: Resident #86 Review of the resident's electronic health record revealed she was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MAR (Medication Administration Record) for September - October 2022 revealed [MEDICATION(S)] was administered on 9/16/22 through 9/30/22. Further review revealed the resident continued to receive [MEDICATION(S)] through October 2022. Review of section N - Medications of the resident's Significant Change MDS (Minimum Data Set) assessment dated [DATE] revealed: No - Antipsychotics were not received. On 10/25/22 at 03:15 p.m., an interview and review of Resident #86's medical record was conducted with S15MDS. She confirmed Resident #86 was prescribed [MEDICATION(S)], an antipsychotic medication, on 9/16/22. S15MDS reviewed Resident #86's September MAR and Significant Change MDS assessment dated [DATE]. She confirmed antipsychotic medication was administered to the resident on 9/16/22 through 9/30/22. She confirmed the MDS assessment was coded as the resident did not receive any antipsychotic medication. S15MDS confirmed the assessment was not accurate and that the assessment should have been coded yes for receiving an antipsychotic. Resident #61 A review of a document, provided by the facility, for CMS 802 titled Matrix for Providers indicated resident #61 had Physical Restraints. A review of Resident #61's clinical record indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of resident #61's electronic clinical record for a Significant Change Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 07/18/2022, revealed, in part: Section G for Functional Status . Bed Mobility . Extensive one-person assistance. Section N for Medications . Medications Received. Indicate the number of Days the resident received the following medications during the last 7 day E. Anticoagulants . Coded for 7 days. Section P for Restraint Physical Restraints .Used in bed .A. bed rail 1. Used less than daily A review of resident #61's electronic medication administration record for July 2022 revealed no anticoagulants administered during the 7 day lookback period of ARD 7/18/2022. An observation of resident #61's bed on 10/25/2022 revealed partial bed rails located on the upper half of her bed. The partial side rails did not interfere with her freedom of movement. On 10/25/2022 at 9:28 a.m., an interview was conducted with S13MDS. She verbalized resident #61's bed rails were utilized for positioning and bed mobility, did not restrict her freedom of movement, and were not considered a restraint. She confirmed her Significant Change MDS with ARD of 7/18/22 was incorrectly coded for restraints regarding bed rail usage. S13MDS reviewed resident #61's medication administration record for July 2022 and confirmed residents anticoagulant was discontinued prior to the 7-day look back period of the MDS and should not have been coded as receiving anticoagulants for 7 days. On 10/25/2022 at 10:18 a.m. an interview was conducted with S2DON (Director of Nursing) who confirmed the facility is restraint free and no residents should be documented as having a restraint for bed rails. Resident #91 Resident #91 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #91's October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #91's quarterly MDS (Minimum Data Set) dated 9/26/22 under the medication received section revealed that zero was entered for the number of days that the resident received an antipsychotic medication. Review of Resident #91's October 2022 MAR (Medication Administration Record) revealed that the resident received [MEDICATION(S)] daily.

Based on record review and interview the facility failed to provide care in accordance with the resident's written plan of care for 1(#188) of 34 sampled residents by failing to administer pain medication as ordered by the physician. Actual Harm occurred to the resident when the pain medication was not provided as ordered and the resident was crying, anxious and complaining of excruciating pain. This deficient practice had the potential to affect all residents in the facility. According to the Resident Census and Conditions provided by the facility on 9/15/14 there were 149 residents. Findings: Resident #188 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The September, 2014 Physician orders [REDACTED]. The resident's Care Plan read: Potential for alteration in comfort r/t [MEDICAL CONDITION], Lupus, Fx right hip. Interventions read: Meds as ordered. During an interview with Resident #188 on 9/18/14 at 9:10 a.m. she stated she came to the facility last Tuesday ( 9/9/14) from the hospital where she had her right hip replaced 5 days earlier. She stated she also had lupus and [MEDICAL CONDITION] which caused her almost continuous general body pain. She stated she had cried in pain the entire evening of admission because the facility did not have her pain medication. The resident stated staff informed her that the pharmacy was closed and they could not get her medicine. She stated she had not received her pain medication until the next day. The resident further stated that she had a problem receiving her pain medication on another day last week and she could not recall the day of the week. She stated she had again been crying in pain and she requested pain medication from S4LPN and she had not received it for hours after requesting it. She stated on this day the physical therapist (named the staff) came into her room while she was crying in pain and the therapist went and asked the nurse if she could have pain medication before going to therapy. She stated the therapist had to ask twice before she received her medication. During an interview with S3LPN on 9/18/14 at 2:15 p.m. in the presence of 4 surveyors, she stated she had admitted Resident #188 on 9/9/14 and stated the resident was crying in pain and very anxious. She further stated if the resident could have rated her pain an 11 on a scale of 1-10 she would have. She stated [MEDICATION NAME] was ordered for pain but was not available. She stated the resident had cried all evening in pain. She stated she had given the resident plain Tylenol from the facility ' s standing orders but it had not helped. The September, 2014 EMAR was reviewed. The first pain medication ([MEDICATION NAME]) documented as administered according to the EMAR was 9/10/14 at 12:12 p.m. During an interview with S1DON on 9/18/14 at 2:10 p.m. she provided a document titled Completed Care Tasks which read at 04:01 AM on 9/10/14 Resident #188 had joint pain. She stated this was when the first dose of [MEDICATION NAME] was administered to Resident #188. She confirmed this dose would have been approximately 12 hours after the resident was admitted to the facility. During an interview and review of the narcotic log for Resident #188 with S2 ADON at 12:30 p.m. on 9/18/14, she verified that ___ (Name of Pharmacy) delivered medications to the facility on the 10 pm - 6 am shift. The narcotic log revealed that the [MEDICATION NAME] was logged in as received on 9/9/14 (no time listed). S2 confirmed that a [MEDICATION NAME] 10-325 was signed out by the night shift nurse at 4:00 a.m. on 9/10/14. During an interview with S1DON on 9/18/14 at 4:30 p.m. she stated an alternative local pharmacy was available if medications were needed for a resident until their medications arrived during the night. S1 confirmed that the alternative pharmacy had not been utilized to obtain Resident #188 ' s medications on 9/9/14. The Physical Therapy Schedule was reviewed and identified S5PT (name of person identified by the resident) had worked with the client on 9/12/14. During an interview with S5PT at 11:55 a.m. on 9/18/14 she stated she had worked with the resident last week and recalled an incident with the resident but was not sure what day. She stated when she entered the resident ' s room the resident was crying, very depressed, anxious and c/o severe generalized pain. She stated she had gone to the nurse and asked her if the resident could get a pain pill, the nurse stated she was checking and then told S5 the resident could have it in 10 - 15 minutes. S5 stated the resident had mentioned she had requested her medication earlier in the day and was about an hour since she had requested it. When asked what time this had occurred S5 stated she marked the times she saw residents on her documented resident list. The documented resident list was reviewed with S5 and she confirmed the date as 9/12/14 and the time of 9:15 am - 9:30 a.m. A review of the EMAR for 9/12/14 read [MEDICATION NAME] had been given at 2:04 a.m. The next pain medication on this date was not given until 9:37 a.m. which was 7 1/2 hours after the previous dose and not in 6 hours as prescribed by the physician. During an interview with S4LPN on 9/18/14 at 3:15 p.m. she stated Resident #188 requested her pain medication as frequently as she could get it. S4 confirmed the medication for pain was ordered q 6 hrs. S4 stated she recalled the therapist asking her about pain medication but she was not sure of the date. She stated on that day she had given the resident the pain medication as soon as she could have it. She confirmed according to the MAR indicated [REDACTED] The facility provided a written statement from S3LPN after they had been informed of the investigation findings. The statement signed by S3LPN read the resident stated that she was in extreme pain when she was admitted on [DATE]. It further read the resident was given Tylenol 500 mg II tabs po and when this nurse checked with the resident the pain was better but not completely alleviated. The facility provided multiple staff interview statements after the facility was informed the investigation had been completed.

Based on interview and record review the facility failed to provide the necessary care and services for 1 (#188) resident to maintain their highest practicable physical, mental and psychosocial well being out of a sample population of 34 residents when the facility failed to provide the resident timely and adequate pain and anxiety management. The resident sustained [REDACTED]. Findings: Resident #188 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During an interview with Resident #188 on 9/18/14 at 9:10 a.m. she stated she came to the facility last Tuesday ( 9/9/14) from the hospital where she had her right hip replaced 5 days earlier. She stated she also had lupus and [MEDICAL CONDITION] which caused her almost continuous general body pain. She stated she had received pain medication right before being discharged from the hospital. She stated when she arrived at the facility a few hours later she thought the medications provided at the hospital would be available when she arrived at the facility. She further stated she had cried in pain the entire evening of admission and had not received pain medication until the following day (9/10/14). The resident stated staff informed her that the pharmacy was closed and they could not get her medicine. The resident further stated that she had a problem receiving her pain medication on another day last week and she could not recall the day of the week. She stated she had again been crying in pain and she requested pain medication from S4LPN and she had not received it for hours after requesting it. She stated on this day the physical therapist (named the staff) came into her room while she was crying in pain and the therapist went and asked the nurse if she could have pain medication before going to therapy. She stated the therapist had to ask twice before she received her medication. A review of the resident ' s September, 2014 physician orders [REDACTED]. The orders also read: [MEDICATION NAME] 0.5 mg po qid for anxiety with a start date of 9/9/14; [MEDICATION NAME] 50 mg po q hs for depression with a start date of 9/9/14 and [MEDICATION NAME] 10 mg po q 8 hrs for muscle spasms with a start date of 9/9/14. The September, 2014 Departmental Notes, SNF documentation record dated 9/2/14 at 4:30 p.m., Registered Nurse assessment dated [DATE] at 5:23 p.m., and the Nursing Data Collection Tool dated 9/9/14 at 10:48 p.m. were reviewed. There was no documentation of an assessment of the resident ' s pain on 9/9/14. The first departmental note read on 9/10/14 at 12:12 a.m. the resident was resting quietly in bed. The first assessment describing the resident ' s pain was dated 9/10/2014 at 1:39 p.m. at which time the resident identified her pain as sharp and stabbing, had facial grimacing and identified her pain as a 6 . The resident identified medications for pain as a method to improve her pain. The resident identified that anxiety made her pain worse. During an interview with S3LPN on 9/18/14 at 2:15 p.m. in the presence of 4 surveyors, she stated she had admitted Resident #188 on 9/9/14 and stated the resident was crying in pain and very anxious. She further stated if the resident could have rated her pain an 11 on a scale of 1-10 she would have. She stated [MEDICATION NAME] was ordered for pain but was not available. She stated the resident had cried all evening in pain. She stated she had given the resident plain Tylenol from the facility ' s standing orders but it had not helped. S3 further stated the resident ' s physician ' s office was closed at this time and she had left a message on the nurse ' s voicemail to inform her that the resident was in excruciating pain. S3 also stated she had notified the nursing supervisor but did not recall who this was. S3 stated she had also notified the night nurse in shift report that the resident was having excruciating pain. The nurse ' s notes and EMAR were reviewed with S3LPN at this time. She confirmed the Tylenol administration was not documented on the MAR . She further verified there was no documentation in the nursing notes about the resident ' s pain, or documentation of notification of the physician or supervisor. S3 further stated she had completed the SNF documentation record on 9/9/14 at 4:30 p.m. and the documented entry date of 9/2/14 was incorrect. She stated she had also completed the Nursing data collection tool on the evening of admission and verified none of these assessments had any reference to the resident ' s pain. The September, 2014 EMAR was reviewed. For [MEDICATION NAME] 0.5 mg po qid - the 8:00 pm dose was marked with a N. The narrative read the dose was not administered because the medication was not available. There was 2 separate descriptions of the [MEDICATION NAME] as follows: (1) [MEDICATION NAME] 10-325 tablet 1 tab po q 6 hrs prn pain with a start date of 9/9/14 and an end date of 9/10/14; (2) [MEDICATION NAME] 10-325 tablet 1 tab po q 6 hrs prn pain with a start date of 9/10/14. There were no initials with either [MEDICATION NAME] order identifying that the medication had been given on 9/9/14. The first pain medication documented as administered according to the EMAR was 9/10/14 at 12:12 p.m. at which time the resident ' s pain level was documented as a 6. Additionally the EMAR read: [MEDICATION NAME] (Tylenol)325 mg tablet give two tablets po q 4 hrs prn mild pain with a start date of 9/14/14. The first documented dose of [MEDICATION NAME] was 9/14/14 at 8:34 a.m. During an interview and review of the narcotic log for Resident #188 with S2 ADON at 12:30 p.m. on 9/18/14, she verified that ___ (Name of Pharmacy) delivered medications to the facility on the 10 pm - 6 am shift. The narcotic log revealed the [MEDICATION NAME] was logged in as received on 9/9/14 (no time listed). S2 confirmed a [MEDICATION NAME] 10-325 was signed out by the night shift nurse at 4:00 a.m. on 9/10/14. There was no documentation of the resident receiving this dose of [MEDICATION NAME] on the EMAR and no documentation on the narrative EMAR administrative record or Nurse ' s notes of a follow-up pain assessment after the resident received the medication. During an interview with S1DON on 9/18/14 at 2:10 p.m. she provided a document titled Completed Care Tasks which read at 04:01 AM on 9/10/14 Resident #188 had joint pain. She stated this was when the first dose of [MEDICATION NAME] was administered to Resident #188. She confirmed this dose would have been approximately 12 hours after the resident was admitted to the facility and further confirmed that according to the EMAR the 1st dose of [MEDICATION NAME] had not been administered until 12:12 p.m. on 9/10/14. During an interview with S1DON on 9/18/14 at 4:30 p.m. she stated an alternative local pharmacy was available if medications were needed for a resident until their medications arrived during the night. S1 confirmed the alternative pharmacy had not been utilized to obtain any of Resident #188 ' s medications on 9/9/14. She stated the nurse had provided the resident with the prescribed [MEDICATION NAME] and [MEDICATION NAME] on the evening of 9/9/14 and was not sure where the nurse had obtained these medications. The Physical Therapy Schedule was reviewed and identified S5PT (name of person identified by the resident) had worked with the client on 9/12/14. During an interview with S5PT at 11:55 a.m. on 9/18/14 she stated she had worked with the resident last week and recalled an incident with the resident but was not sure what day. She stated when she entered the resident ' s room the resident was crying, very depressed, anxious and c/o severe generalized pain. She stated she had gone to the nurse and asked her if the resident could get a pain pill, the nurse stated she was checking and then told S5 the resident could have it in 10 - 15 minutes. S5 stated the resident had mentioned she had requested her medication earlier in the day and was about an hour since she had requested it. When asked what time this had occurred S5 stated she marked the times she saw residents on her documented resident list. The documented resident list was reviewed with S5 and she confirmed the date as 9/12/14 and the time of 9:15 am - 9:30 a.m. A review of the EMAR for 9/12/14 read [MEDICATION NAME] had been given at 2:04 a.m. The next pain medication on this date was not given until 9:37 a.m. During an interview with S4LPN on 9/18/14 at 3:15 p.m. she stated Resident#188 requested her pain medication as frequently as she could get it. S4 confirmed the medication for pain was ordered q 6 hrs. S4 stated she recalled the therapist asking her about pain medication but she was not sure of the date. She stated on that day she had given the resident the pain medication as soon as she could have it. She confirmed according to the MAR on 9/12/14 the resident had received the pain medication at 2:04 a.m. and she then gave it at 9:37 a.m. She confirmed the resident could have received the medication at 8:04 a.m. The facility provided multiple staff interview statements after the facility was informed the investigation had been completed.

Based on record review, interview and observation, the facility failed to provide services that meet professional standards of quality. The facility failed to assess a resident's foot following a procedure at a physician's office, and failed to identify a bandage which had been placed on a resident's toe for 24 days following a procedure for 1 resident (#4) out of 5 sampled residents (#1-5). This deficient practice resulted in actual harm to Resident #4 when the resident was hospitalized for [REDACTED]. There were a total of 139 residents residing in the facility, which this deficient practice has the potential to affect. Resident #4 had an office visit on 11/26/13 with a podiatrist. At that visit, the resident's toenail of the third toe on the right foot was trimmed, and a bandage was placed on the toe. The resident returned to the facility the same day with the bandage. The facility failed to assess, and care for the toe when the resident returned from the podiatrist's office, and, were not aware of the bandage on the toe until the date of 12/18/13, 24 days later. On 12/18/13 the bandage on the toe was discovered, the toe had turned black, and the resident was sent to the hospital for IV (Intravenous) antibiotics. The resident was hospitalized from [DATE] to 12/27/13, during which time the third toe of the right foot had to be amputated. According to the resident's MDSs (Minimum Data Sheet), prior to the hospitalization and amputation of the resident's toe, the resident was able to walk in her room, walk in the corridor and on the unit with independence and without help from staff, and required supervision and set up help with bed mobility, transfers, dressing, eating, personal hygiene and bathing. Following her hospitalization , the resident required assistance and help with one staff member with bed mobility, walking on and off the unit, dressing, personal hygiene and bathing. Resident #4 now also requires extensive assist with transfers and toileting, and uses a wheelchair for locomotion on and off the unit. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part: 3. ...development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self-awareness, sound judgement, prudence, ethical thing and behaviors, problem solving and critical thinking abilities... 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to: the performance of basic and advanced nursing skills....communication and documentation, and writing as member of the interdisciplinary health care team... Record review revealed Resident #4 has [DIAGNOSES REDACTED]. The resident resides on the Alzheimer's unit of the facility, and has a BIMS (Brief Interview of Mental Status) score of "0". Observation of the resident on 1/6/14 revealed the resident receiving Physical Therapy. The resident was noted to be in a wheelchair, able to follow simple commands, and was orientated to her name. On 1/7/14 at 12:14 p.m., the resident was in bed covered up, and easily awoken. When questioned if the doctor had trimmed her toenails, she stated he did not trim them, he cut one off. The resident also said she did not have to tell the doctor it hurt, because he knew it hurt. During this interview, she stated she was not in pain. A Physician's Progress Note from a podiatrist dated 8/14/13 indicated the resident had debridement of toenails 1-10 with no signs of infection. An order attached to the note indicated to discontinue current shoes. "They are too narrow causing pressure areas...Rx (prescription): New pair of tennis shoes which are deep and wide enough to accommodate the hammer toes and bunion." A Physician's Progress Note, from the podiatrist, dated 11/26/13 indicated "Debridement of nails TA-T9 (symbol for "and") no signs of infection." There was no order noted on the Progress Note. A review of facility Computerized Departmental Notes from the dates of 11/9/2013 through 12/17/13 did not reveal any documentation of the resident's visit to the podiatrist, or an assessment of the resident's feet, or toe, until 12/18/13. The note dated 12/18/13 and timed 3:54 p.m. read "Notified this morning to assess right 3rd toe. Black necrotic tissue noted. Scant amount of drainage to base of toe. Resident denied pain. Notified nurse and MD (Medical Doctor)"... signed S4Treatment Nurse/RN. On 1/6/14 at 3:15 p.m., S9LPN stated she became aware of the bandage to Resident #4's toe for the first time on 12/18/13. S9 also verified she had not assessed the resident's foot after she returned from the podiatrist's office on 11/26/13. On 1/6/13 at 3:45 p.m., S4 Treatment Nurse stated on 12/18/13 a CNA came to her to remove a bandage on Resident #4's toe so she could bath the resident. S4 Treatment Nurse stated Resident #4 was noted to have a red bandage on the third toe of her right foot. She indicated she had no knowledge of the bandage, and had not assessed or did any treatments to the toe. She stated when residents go to the podiatrist to have their nails or toenails trimmed, if there is a bandage put on it, the doctor would usually send an order with instructions for treatment. She did not receive any orders for treatment of [REDACTED]. The CNAs should also let her, or the nurse, know about any new issues or anything different on a resident. S4 also added the bandage was red in color, and the facility did not use that color, nor that type of bandage, but the podiatrist office did. Therefore, she stated the bandage was assumed to have been placed on the resident's toe at the podiatrist's office on the last visit. She indicated when she took the bandage off, the toe was black. She notified S6LPN and the resident's physician. The resident's physician referred the resident to the podiatrist, was seen that day by the podiatrist, and admitted to the hospital. On 1/7/14 at 9:48 a.m. S6LPN stated Resident #4 had her toenails debrided about every 3 - 6 months. When the resident returned from the doctor's office, if there were new orders she would transcribe the order, and notify the treatment nurse. S6LPN stated there were no new orders sent back with the resident on 11/26/13 after the office visit, and she had not assessed the resident's toenails, since there were no new orders. S6LPN indicated the aides would also let the nurse know if they saw anything different on any resident, adding 12/18/13 was the first time she was made aware of the bandage on the residents toe. A request was made for any other information from the podiatrist office visit on 11/18/13. S3ADON indicated there was no other documentation of the office visit, or procedure, in the resident's facility chart, but she would contact the doctor's office, and request a summary of the office visit. S3ADON also stated she had not been aware of a bandage to the resident's toe, until 12/18/13. On 1/7/14 at 11:10 a.m., S1Administrator, presented a "Chart Sheet " from the podiatrist's office. The sheet indicated the Date of Service as 11-26-13, and listed the resident's [DIAGNOSES REDACTED]. The resident's DP/PT was non-palpable b/l (bilaterally). The Chart Sheet read: Subjective: "...painful long thick ingrown toenails of a gradual onset and duration. The pt (patient) relates that the intensity of pain from the thick ingrown toenails increase with WB (weight bearing) in closed toed shoes and makes ambulation difficult. The pt has bunions and hammertoes and states they do not bother her. Her wide (sic) have been helping since last visit ..." Objective: ... " upon debridement of toenails, there is redness and trace amounts of ecchymosis in the deep nail grooves or indentations left by the ingrown toenails. This is indicative of pre-ulcer " Plan: ... "Power and manual debridement of nails (TA-T9) down to viable nails and to patient's tolerance without incidence. Sprayed with antiseptic... informed pt that thickened (incurvated) nails could lead to increased subungal pressure, thus subungal ulcers. Pt is aware and understands ... Advised pt against self-tx of nails due to risk of infection/bleeding if he/she should ever accidentally cut himself/herself ...Applied band-aid to 3rd toe right foot for extra padding of the toe. Avoid tight fitting shoes to prevent abrasions and [MEDICAL CONDITION]. Reappt (reappointment): PRN (as necessary). Review of the resident's Weekly Body Audit Roster, completed by S5LPN, on the dates of 11/3/13; 11/10/13; 11/17/13; 11/24/13; 12/1/13; 12/8/13; 12/15/13; 12/29/13; and 1/5/14 all read "No new skin issues noted." On the date of 12/18/13 the Audit indicated resident was not available/resident in the hospital/return 12/26/13, 3:15 PM. Review of the resident's Bath Roster indicated the resident had been given a shower or bed bath on 11/27/13; 11/29/13 (bed bath and shower); 12/2/13; 12/4/13; 12/6/13; 12/9/13; 12/11/13; 12/13/13; and 12/16/13. On 12/18/13 at 9:52 a.m., the roster indicated the resident had a shower, and another entry on the bath roster, with the same date of 12/18/13 timed 4:10 P indicated "not available" - "resident in the hospital" - " Return 12/26/13 3:15 PM." There were three different CNAs who were documented as having given the resident a bath/shower during this time, none of whom reported to the nurse of the bandage on the resident's toe. Review of the resident's Skin Roster from the dates of 11/26/13 through 12/18/13 indicated that "No skin concerns" had been entered into the computer on those dates. According to this Skin Roster, there were a total of 11 different CNAs who cared for the resident, and failed to report that Resident #4 had a bandage on her toe. Review of the resident's ETAR (electronic treatment administration record) for the month of November 2013 did not reveal any treatment or assessment of the toe, which had been debrided on 11/26/13. The December 2013 ETAR indicated on 12/28/13 treatment began as follows: "Surgical incision to right third toe-cleanse with wound cleanser, apply gauze, wrap with dry dressing daily until resolved. Start date 12/27/13" On 1/7/14 at 12:40 p.m., S11Assessment Nurse/LPN verified all of the nurses' notes, the Weekly Body Audit Roster, Skin Roster, Bath Roster, and ETARs for the resident from November 2013 to January 7, 2014 had been presented. Review of a Physician's Progress Note dated 12/18/13 read "Wet gangrene of 3rd toe Right Foot to base of the toe. (+) [DIAGNOSES REDACTED] indicative of [MEDICAL CONDITION] on dorsum and plantar aspect of Right Forefoot. Non palpable PT and DP (R) foot but warm to touch. Foul odor. - Will need to be admitted with IV antibiotics and General Surgeon to remove the gangrenous toe (R) foot. May also need vascular to evaluate for potential healing." Review of a Consultation Report from the hospital dated 12/19/13, indicated the Assessment and Plan as follows: "We will continue to follow the progression of the gangrene. If the [MEDICAL CONDITION] begins to resolve, we can consider amputation of the toe over the weekend and continue to watch this..." Review of a Physician's Note dated 12/27/13, following the resident's return to the facility, indicated "1. s/p R (status/post right) third toe amputation. Dressing (symbol for change) ...; 2. Confirm NWB (non weight bearing); 3. follow up ___ 1/6/13... 4. Clean with ns (normal saline) - cover with gauze..."

Based on record review, interview and observation, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for the resident. The facility failed to assess a resident's foot following a procedure at a physician's office, and failed to identify a bandage which had been placed on a resident's toe for 24 days following a procedure for 1 resident (#4) out of 5 sampled residents (#1-5). This deficient practice resulted in actual harm to Resident #4 when the resident was hospitalized for [REDACTED]. There were a total of 139 residents residing in the facility, which this deficient practice has the potential to affect. Resident #4 had an office visit on 11/26/13 with a podiatrist. At that visit, the resident's toenail of the third toe on the right foot was trimmed, and a bandage was placed on the toe. The resident returned to the facility the same day with the bandage. The facility failed to assess, and care for the toe when the resident returned from the podiatrist's office, and, were not aware of the bandage on the toe until the date of 12/18/13, 24 days later. On 12/18/13 the bandage on the toe was discovered, the toe had turned black, and the resident was sent to the hospital for IV (Intravenous) antibiotics. The resident was hospitalized from [DATE] to 12/27/13, during which time the third toe of the right foot had to be amputated. According to the resident's MDSs (Minimum Data Sheet), prior to the hospitalization and amputation of the resident's toe, the resident was able to walk in her room, walk in the corridor and on the unit with independence and without help from staff, and required supervision and set up help with bed mobility, transfers, dressing, eating, personal hygiene and bathing. Following her hospitalization , the resident required assistance and help with one staff member with bed mobility, walking on and off the unit, dressing, personal hygiene and bathing. Resident #4 now also requires extensive assist with transfers and toileting, and uses a wheelchair for locomotion on and off the unit. Findings: Record review revealed Resident #4 has [DIAGNOSES REDACTED]. The resident resides on the Alzheimer's unit of the facility, and has a BIMS (Brief Interview of Mental Status) score of "0". Observation of the resident on 1/6/14 revealed the resident receiving Physical Therapy. The resident was noted to be in a wheelchair, able to follow simple commands, and was orientated to her name. On 1/7/14 at 12:14 p.m., the resident was in bed covered up, and easily awoken. When questioned if the doctor had trimmed her toenails, she stated he did not trim them, he cut one off. The resident also said she did not have to tell the doctor it hurt, because he knew it hurt. During this interview, she stated she was not in pain. A Physician's Progress Note from a podiatrist dated 8/14/13 indicated the resident had debridement of toenails 1-10 with no signs of infection. An order attached to the note indicated to discontinue current shoes. "They are too narrow causing pressure areas...Rx (prescription): New pair of tennis shoes which are deep and wide enough to accommodate the hammer toes and bunion." A Physician's Progress Note, from the podiatrist, dated 11/26/13 indicated "Debridement of nails TA-T9 (symbol for "and") no signs of infection." There was no order noted on the Progress Note. A review of facility Computerized Departmental Notes from the dates of 11/9/2013 through 12/17/13 did not reveal any documentation of the resident's visit to the podiatrist, or an assessment of the resident's feet, or toe, until 12/18/13. The note dated 12/18/13 and timed 3:54 p.m. read "Notified this morning to assess right 3rd toe. Black necrotic tissue noted. Scant amount of drainage to base of toe. Resident denied pain. Notified nurse and MD (Medical Doctor)"... signed S4Treatment Nurse/RN. On 1/6/14 at 3:15 p.m., S9LPN stated she became aware of the bandage to Resident #4's toe for the first time on 12/18/13. S9 also verified she had not assessed the resident's foot after she returned from the podiatrist's office on 11/26/13. On 1/6/13 at 3:45 p.m., S4 Treatment Nurse stated on 12/18/13 a CNA came to her to remove a bandage on Resident #4's toe so she could bath the resident. S4 Treatment Nurse stated Resident #4 was noted to have a red bandage on the third toe of her right foot. She indicated she had no knowledge of the bandage, and had not assessed or did any treatments to the toe. She stated when residents go to the podiatrist to have their nails or toenails trimmed, if there is a bandage put on it, the doctor would usually send an order with instructions for treatment. She did not receive any orders for treatment of [REDACTED]. The CNAs should also let her, or the nurse, know about any new issues or anything different on a resident. S4 also added the bandage was red in color, and the facility did not use that color, nor that type of bandage, but the podiatrist office did. Therefore, she stated the bandage was assumed to have been placed on the resident's toe at the podiatrist's office on the last visit. She indicated when she took the bandage off, the toe was black. She notified S6LPN and the resident's physician. The resident's physician referred the resident to the podiatrist, was seen that day by the podiatrist, and admitted to the hospital. During an interview on 1/7/14 at 9:15 a.m., S10CNA stated she notified the treatment nurse about the bandage on Resident #4's toe, after she noticed the bandage on 12/18/13. She also added, on Monday (12/16/13), she saw the bandage on the resident's toe but did not report it to the nurse, because other staff said the nurses already knew about the bandage. S10CNA added the bandage was red in color and had a little blood on it. S10CNA stated she then realized that S4Treatment Nurse, and S6LPN had not known about the bandage. On 1/7/14 at 9:48 a.m. S6LPN stated Resident #4 had her toenails debrided about every 3 - 6 months. When the resident returned from the doctor's office, if there were new orders she would transcribe the order, and notify the treatment nurse. S6LPN stated there were no new orders sent back with the resident on 11/26/13 after the office visit, and she had not assessed the resident's toenails, since there were no new orders. S6LPN indicated the aides would also let the nurse know if they saw anything different on any resident, adding 12/18/13 was the first time she was made aware of the bandage on the residents toe. During an interview on 1/7/14 at 10:15 a.m., S8CNA verified she had been the shower aide for the hall that the resident was on. S8 stated she would give the resident her towel, and make sure she took her shower, indicating the resident did not want her to touch her toes. S8 stated she had not seen the bandage on the resident's toe. During an interview on 1/7/14 at 10:25 a.m., S7 stated she would assist Resident #4 to the bathroom, help with her hygiene, and dress her, adding she would have to cue the resident to what day of the week it was, mealtime, and daily events. S7 stated the resident would sometimes complain about her feet hurting when she walked a longer distance, but was able to walk with an unsteady, slow gait. S7 also stated she had never seen the bandage on the resident's toe. A request was made for any other information from the podiatrist office visit on 11/18/13. S3ADON indicated there was no other documentation of the office visit, or procedure, in the resident's facility chart, but she would contact the doctor's office, and request a summary of the office visit. S3ADON also stated she had not been aware of a bandage to the resident's toe, until 12/18/13. On 1/7/14 at 11:10 a.m., S1Administrator, presented a "Chart Sheet " from the podiatrist's office. The sheet indicated the Date of Service as 11-26-13, and listed the resident's [DIAGNOSES REDACTED]. The resident's DP/PT was non-palpable b/l (bilaterally). The Chart Sheet read: Subjective: "...painful long thick ingrown toenails of a gradual onset and duration. The pt (patient) relates that the intensity of pain from the thick ingrown toenails increase with WB (weight bearing) in closed toed shoes and makes ambulation difficult. The pt has bunions and hammertoes and states they do not bother her. Her wide (sic) have been helping since last visit ..." Objective: ... " upon debridement of toenails, there is redness and trace amounts of ecchymosis in the deep nail grooves or indentations left by the ingrown toenails. This is indicative of pre-ulcer " Plan: ... "Power and manual debridement of nails (TA-T9) down to viable nails and to patient's tolerance without incidence. Sprayed with antiseptic... informed pt that thickened (incurvated) nails could lead to increased subungal pressure, thus subungal ulcers. Pt is aware and understands ... Advised pt against self-tx of nails due to risk of infection/bleeding if he/she should ever accidentally cut himself/herself ...Applied band-aid to 3rd toe right foot for extra padding of the toe. Avoid tight fitting shoes to prevent abrasions and [MEDICAL CONDITION]. Reappt (reappointment): PRN (as necessary). Review of the resident's Weekly Body Audit Roster, completed by S5LPN, on the dates of 11/3/13; 11/10/13; 11/17/13; 11/24/13; 12/1/13; 12/8/13; 12/15/13; 12/29/13; and 1/5/14 all read "No new skin issues noted." On the date of 12/18/13 the Audit indicated resident was not available/resident in the hospital/return 12/26/13, 3:15 PM. Review of the resident's Bath Roster indicated the resident had been given a shower or bed bath on 11/27/13; 11/29/13 (bed bath and shower); 12/2/13; 12/4/13; 12/6/13; 12/9/13; 12/11/13; 12/13/13; and 12/16/13. On 12/18/13 at 9:52 a.m., the roster indicated the resident had a shower, and another entry on the bath roster, with the same date of 12/18/13 timed 4:10 P indicated "not available" - "resident in the hospital" - " Return 12/26/13 3:15 PM." There were three different CNAs who were documented as having given the resident a bath/shower during this time, none of whom reported to the nurse of the bandage on the resident's toe. Review of the resident's Skin Roster from the dates of 11/26/13 through 12/18/13 indicated that "No skin concerns" had been entered into the computer on those dates. According to this Skin Roster, there were a total of 11 different CNAs who cared for the resident, and failed to report that Resident #4 had a bandage on her toe. Review of the resident's ETAR (electronic treatment administration record) for the month of November 2013 did not reveal any treatment or assessment of the toe, which had been debrided on 11/26/13. The December 2013 ETAR indicated on 12/28/13 treatment began as follows: "Surgical incision to right third toe-cleanse with wound cleanser, apply gauze, wrap with dry dressing daily until resolved. Start date 12/27/13" On 1/7/14 at 12:40 p.m., S11Assessment Nurse/LPN verified all of the nurses' notes, the Weekly Body Audit Roster, Skin Roster, Bath Roster, and ETARs for the resident from November 2013 to January 7, 2014 had been presented. Review of a Physician's Progress Note dated 12/18/13 read "Wet gangrene of 3rd toe Right Foot to base of the toe. (+) [DIAGNOSES REDACTED] indicative of [MEDICAL CONDITION] on dorsum and plantar aspect of Right Forefoot. Non palpable PT and DP (R) foot but warm to touch. Foul odor. - Will need to be admitted with IV antibiotics and General Surgeon to remove the gangrenous toe (R) foot. May also need vascular to evaluate for potential healing." Review of a Consultation Report from the hospital dated 12/19/13, indicated the Assessment and Plan as follows: "We will continue to follow the progression of the gangrene. If the [MEDICAL CONDITION] begins to resolve, we can consider amputation of the toe over the weekend and continue to watch this..." Review of a Physician's Note dated 12/27/13, following the resident's return to the facility, indicated "1. s/p R (status/post right) third toe amputation. Dressing (symbol for change) ...; 2. Confirm NWB (non weight bearing); 3. follow up ___ 1/6/13... 4. Clean with ns (normal saline) - cover with gauze..."