Every finding on record at Northeast la War Veterans Home

Based on interview and record reviews, the facility failed to ensure it provided in-service training of no less than 12 hours per year that included dementia management training for 3 (S4CNA, S5CNA, S6CNA) of 3 sampled staff who had been employed greater than 1 year.Findings:Review of the personnel record revealed S4CNA had a hire date of 08/23/2023. There was no documentation that they had received annual training on dementia management. Review of the personnel record revealed S5CNA had a hire date of 08/30/2022. There was no documentation that they had received annual training on dementia management. Review of the personnel record revealed S6CNA had a hire date of 06/21/2007. There was no documentation that they had received annual training on dementia management. On 03/18/2026 at 8:10 a.m., interview with S7Human Resources confirmed S4CNA, S5CNA, S6CNA, S7CNA and S8CNA did not have annual training on dementia management.

Based on observation and interviews, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift to include the resident census, total number and the actual hours worked by licensed and unlicensed staff directly responsible for resident care in a prominent place readily accessible to residents, staff and visitors.Findings:On 03/17/2026 at 2:59 p.m., observation of the skilled resident hall revealed the daily staffing data was not posted with the resident census, total number and the actual hours worked by licensed and unlicensed staff directly responsible for resident care.On 03/17/2026 at 3:10 p.m., an interview with S8ADON revealed she posts the daily assignment sheets inside the nurses' station, but it did not have the census, total number and actual hours worked per shift for the licensed and unlicensed staff.On 03/17/2026 at 4:00 p.m., an interview with S9Assistant Administrator confirmed the daily staffing pattern was not posted outside of the nurses station in an area that was readily accessible to residents, visitors and staff with the census, the total number and actual hours worked by licensed and unlicensed staff directly responsible for resident care.

Based on observations, record reviews, and interviews, the facility failed to 1) ensure residents had a physician's order for bed rails, 2) obtain consent from the resident or resident's representative for bed rail use, and 3) assess residents for the risk of entrapment from bed rails prior to the installation of bed rails for 3 (#3, #4, and #56) of 3 (#3, #4, and #56) residents reviewed for bed rails. Findings: Resident #3 Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses including, acute metabolic encephalopathy, cerebral infarction, psychosis and delusion. Review of the admission minimum data set (MDS) dated [DATE] revealed resident #3 had a brief interview of mental status (BIMS) score of 08 which indicated that resident #3 had moderate cognitive impairment with his daily decision making skills. Further review revealed that resident #3 was independent with rolling left and right, sit-to-lying, lying to sitting on the side of bed, supervision or touching with sit to stand, and chair/chair transfer. On 03/03/2025 at 11:18 a.m. and on 03/05/2025 at 9:50 a.m., observations revealed resident #3 was lying in bed with a 1/4 bed rail raised on the left side of the resident's bed. The observations also revealed a second 1/4 bed rail that was lowered on the right side. The lowered bed rail on the right side remained attached to the bed. Review of resident #3's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent by the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #3's bed. On 03/05/2025 at 1:25 p.m., S2Director of Nursing was notified of the above findings. She confirmed resident #3's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #3's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings related to the use of bed rails for resident #3. Resident #4 Review of the medical record revealed resident #4 was admitted to the facility on [DATE] with diagnoses that included psychosis and delusion. Review of the admission Minimum Data Set, dated dated dated [DATE] revealed resident #4 had a BIMS score of 04 which indicated that resident #4 had severe cognitive impairment with her daily decision making skills. Further review revealed that resident #4 required assistance with activities of daily living. On 03/03/2025 at 9:35 a.m. and 03/05/2025 at 8:45 a.m., observations revealed resident #4 was in bed with 1/4 bed rails raised on both sides of the resident's bed. Further observation revealed the left bed was loose and wobbly. Review of resident #4's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #4's bed. On 03/05/2025 at 1:25 p.m., S2Director of Nursing was notified of the above findings. She confirmed resident #4's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #4's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings regarding resident #4. 19121 Resident #56 Review of the medical record revealed resident #56 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, depression, restless leg syndrome, insomnia, hypertension, heart failure, chronic kidney disease, history of falls, edema and Non Hodgkin's lymphoma. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed it had not been completed at this time, due to the resident being admitted on [DATE]. On 03/05/2025 at 1:25 p.m., an observation revealed resident #56 lying in bed with a 1/4 bed rail raised on the left side of the resident's bed. Review of resident #56's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #56's bed. On 03/05/2025 at 1:15 p.m., S2DON was notified of the above findings. She confirmed resident #56's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, or an assessment for the risk of entrapment prior to installation of bed rails on resident #56's bed. On 03/06/2025 at approximately 11:30 a.m., S1Administrator was notified of the findings regarding resident #56.

Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infection by, 1) having dirty and expired items inside of the medication cart, 2) having nail clippers and employee personal belongings inside of the wound care cart, and 3) having non-medication items inside of the medication storage room. Findings: On [DATE] at 9:40 a.m., observation of the medication cart with S5Licensed Practical Nurse (LPN) revealed one large medication cup holding tray that had multiple areas of an old, dried, unknown crusty substance and particles scattered throughout the tray and one box that contained multiple individualized packages of Povidone-Iodine that expired on ,d+[DATE]. S5LPN confirmed the medication cup holding tray was dirty and needed to be cleaned and the expired packages of Povidone-Iodine should not have been stored inside of the medication cart and available for resident use. On [DATE] at 10:00 a.m., observation of the wound care cart with S3LPN revealed a box that contained one tube of Silver Sulfadiazine cream 1%, two tubes of Mupirocin ointment, one non-woven dressing, one piece of Dr. Scholl's Corn Cushion, and one large pair of nail clippers. The nail clippers were in direct contact with the items inside of the box. Further observation revealed a small Ziploc bag that contained multiple pieces of Halls cough drops and Jolly Ranchers hard candy. S3LPN confirmed the bag of cough drops and hard candy belonged to her (S3LPN). On [DATE] at 10:51 a.m., S2Director of Nursing (DON) was notified of the above findings regarding the observations of the medication and wound care carts. S2DON confirmed that expired items should not be stored inside of the medication cart and available for resident use. S2DON further confirmed the pair of nail clippers should not have been stored in direct contact with the wound care supplies and S3LPN should not have stored her personal belongings inside of the wound care cart due to cross contamination. On [DATE] at 9:45 a.m., an observation of the medication storage room with S4Licensed Practical Nurse (LPN) revealed there was one large tote bag that contained two boxes of insulin syringes, one large black swivel/rolling chair, one large Christmas Tree box, one medium sized box of artificial flowers, seven Christmas stockings, one 8.4 ounce of Scope mouth wash, one 5.7 ounce of Crest tooth paste, one large book titled Mutts Comic Art of [NAME], one door hanger, one large item grabber, one New Testament Bible, and two medium sized blue therapy type floor mats. S4LPN confirmed the items should not have stored inside of the medication storage room. On [DATE] at 10:20 a.m., S2Director of Nursing was notified of the above findings from the observation in the medication storage room. She confirmed the items should not have been stored inside of the medication storage room due to cross contamination.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 (#3) of 3 (#3, #4, and #56) residents reviews for activities of daily living. Findings: Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses including in part, acute metabolic encephalopathy, cerebral infarction, and psychosis and delusion. Review of the admission Minimum Data Set, dated dated dated [DATE] revealed resident #3 had a brief mental Score of 08 which indicated that resident #3 had moderate cognitive impairment with his daily decision making skills. Review of resident #1's record revealed care planning for bathing/hygiene deficit dated 01/03/2025. The approaches included in part, total care for resident #3. Shower/clean and check fingernails. On 03/03/25 09:50 a.m., an observation revealed resident #3 lying in bed. Further observation revealed a buildup of dirt and grime observed underneath the nail beds of both his hands. On 03/03/2025 at 11:30 a.m., an observation revealed resident #3 sitting up in bed eating his lunch meal. Further observation revealed a buildup of dirt and grime under the nail beds of both of his hands. 03/03/2025 at 11:45 a.m., S2Director of Nursing was notified of the observations the buildup of dirt and grime underneath resident #3's nail beds. S2Director of Nursing observed the resident eating his lunch with the dirty fingernails. She confirmed that resident #3's fingernail beds needed cleaning. On 03/06/2025 at 11:30 a.m., S1Administrator was notified of the above findings.

Based on interview and record review, the facility failed to electronically submit accurate payroll information for the time frames of 10/01/2023 through 12/31/2023 for direct care staffing hours as required. Findings: Review of the 10/01/2023 through 12/31/2023 Payroll Based Journal (PBJ) report for the facility revealed three areas triggered; they were excessively low weekend staff, no Registered Nurse hours, and failed to have Licensed Nursing coverage 24 hours per day. On 03/25/2024 at 2:00 p.m., an interview with S1Administrator revealed she was responsible for submitting the data for the payroll based journal quarterly. S1Administrator revealed the Human Resources department had to change the personnel codes several times last year. The personnel codes were changed to ensure the staff were disclosed on the PBJ report. When the codes were changed it caused all of the staff to be entered on the report including those that did not provide patient care. Further interview with S1Administrator revealed they changed the codes again and no personnel were listed on the report. On 03/25/2024 at 3:35 p.m. S1Administrator confirmed the information submitted on the PBJ report from 10/01/2023 through 12/31/2023 was not accurate.

Based on record reviews and interview the facility failed to implement their written policies and procedures for screening new employees for criminal history background checks for 2 Certified Nursing Assistants (CNA) (S4CNA and S5CNA) of 8 (S4CNA, S5CNA, S6CNA, S7CNA, S8CNA, S9CNA, S10CNA, S11CNA) personnel records reviewed for criminal history background checks. Findings: Review of the facility's Employee Policy Handbook with a revision date of April 2017 revealed B. Individuals employed by the Louisiana Department of Veterans Affair (LDVA) may occupy-security sensitive positions or handle confidential or sensitive information. Therefore, a criminal history check may be conducted on all new hires as well as employees changing positions including promotions, demotions, details, reassignments, and transfers, with some exceptions. Review of the personnel record for S4CNA revealed a hire date of 02/17/2019. Review of the personnel record for S5CNA revealed a hire date of 01/09/2020. Further review of the personnel records for S4CNA and S5CNA revealed there was no documented evidence of the status of the criminal history backgrounds checks obtained on the CNAs. On 03/26/2024 at 1:00 p.m., an interview with S1Administrator revealed they were unable to locate the background checks for S4CNA and S5CNA. On 03/26/2024 at 3:00 p.m., an interview with S3Human Resources Specialist revealed they are to obtain background checks on all employees.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (#105 and #106) of 2 (#105, and #106) residents reviewed for respiratory care. Findings: Resident #105 Review of the facility's Oxygen Therapy Policy with an effective date of 10/2008 and a revised date of 10/12/2022 revealed: I. Purpose To furnish a therapeutic concentration of oxygen in the treatment of disease involving anoxia. A. Nasal Cannula 11. Store nasal cannula in a plastic bag when not in use. Review of the medical record for sampled resident #105 revealed an admitted [DATE] with diagnoses including congested heart failure, edema, hypertension, cerebral infarction, thoracic aortic aneurysm, chronic respiratory failure with hypoxia, and vascular dementia. Review of the physician's orders dated 03/11/2024 revealed and order for oxygen at 3 liters per nasal cannula continuously. Review of the care plan revealed the resident's breathing patterns were impaired related to chronic respiratory failure and the resident was to receive oxygen via nasal cannula as ordered. On 03/25/2024 at 12:20 p.m. observation of resident #105 revealed the resident's portable oxygen tank was observed on the wheelchair and the oxygen nasal cannula was uncovered, rolled up and hanging from the oxygen tank flow meter. On 03/26/2024 at 7:40 a.m. observation of resident #105's room revealed the oxygen nasal cannula was on the side of the bed. Further observation of the cannula revealed it was not stored properly in a bag when not in use. On 03/26/2024 at 8:00 a.m., an observation and interview with S2Director of Nursing (DON) in resident #105's room revealed the oxygen nasal cannula was observed on the side of the bed uncovered. S2DON confirmed the nasal cannula should have been stored in a plastic bag when not in use. 41829 Resident #106 Record review revealed resident #106 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, altered mental status unspecified, type 2 diabetes mellitus without complications, dementia, essential hypertension, morbid severe obesity, cardiomegaly, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and pulmonary embolism. Review of resident #106's active March 2024 physician orders revealed an order for Oxygen (O2) at 3 liters per minute (LPM) via nasal cannula (NC). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which represents resident #106 was cognitively intact. Review of resident #106's active care plan revealed impaired breathing patterns. Further review of the care plan revealed the following approaches: Will receive Oxygen via nasal cannula as ordered. Uses O2/Nebulizer, if not in use place cannula/nebulizer tubing /mask in plastic bag. On 03/25/2024 at 08:05 a.m. an observation of resident #106's room revealed the humidification bottle that was dated 03/20/2024. The nasal cannula was uncovered and lying on the bedside dresser. Further observation revealed there was no plastic bag to store the nasal cannula. Resident #106 reported he receives oxygen at 3 LPM as needed. On 03/26/2024 at 07:38 a.m. an observation of resident #106 revealed he was eating breakfast in the dining room area. Resident #106's respirations were even and unlabored. On 03/26/2024 at 07:40 a.m. an observation of resident #106's room revealed the nasal cannula was uncovered and lying on the edge of his bed. On 03/26/24 08:00 a.m. an interview and observation with S2DON in resident #106's room revealed the nasal cannula was uncovered and lying on the edge of the bed. S2DON confirmed resident #106's nasal cannula should be stored in a plastic bag when not in use.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 (#157) of 1 (#157) residents observed during pericare by failing to ensure staff performs hand hygiene after providing resident care. Findings: Review of the medical record revealed resident #157 was admitted to the facility on [DATE]. Resident #157's diagnoses included, in part, dementia, benign prostatic hyperplasia with urinary tract symptoms, and pressure ulcer. On 06/05/2023 at 11:05 a.m., an observation revealed S3CNA (Certified Nursing Assistant) preparing to perform pericare for resident #157, with the assistance of S4CNA. After S3CNA had completed the procedure, she retrieved a bottle of perineal cleanser from the resident's bedside table and placed the bottle inside of resident #157's dresser drawer. Further observation revealed S3CNA touching the resident's clothing, bed sheets, television remote control, blanket, pillows, and brushing off the bed several times with her soiled and contaminated right gloved hand. S3CNA did not remove the dirty and contaminated gloves, wash her hands, and /or apply hand sanitizer after she had completed performing pericare. On 06/05/2023 at 12:10 p.m., S3CNA was notified of the observations during the pericare procedure. She confirmed she had not removed her soiled and contaminated gloves, washed her hands, and had not applied hand sanitizer after providing pericare for resident #157. On 06/06/2023 at 3:50 p.m., S2DON (Director of Nursing) was notified of the findings observed during the pericare procedure. S2DON confirmed S3CNA should have removed her soiled and contaminated gloves, wash her hands, and /or applied hand sanitizer after providing pericare for resident #157 due to cross contamination.

Based on observation, review of the Food and Nutrition Department Policy and Procedure and interview, the facility failed to store, prepare, distribute, and serve food in a sanitary manner by, 1) having old food crumbs and spills observed in the refrigerators, coolers, and freezers, 2) having S5RD's (Registered Dietician) personal lunch bag stored in Cooler #1, 3) having foods items that were not properly sealed and exposed to air inside of the main freezer, and 4) having a black unknown substance observed on the inside of the ice machine. There were 2 residents (#1 and #55) who received a meal from the kitchen out of a total of 3 residents who resided on the skilled unit. Findings: On 07/16/18 at 8:50AM, a tour of the kitchen with S3DM (Dietary Manager) was conducted and revealed the following: Large Reach In Refrigerator that was identified by S3DM as the large reach in box There was old food crumbs and spills observed in the bottom of the refrigerator; Second Large Reach in Refrigerator located on the serving line that was identified by S3DM as the large reach in box There was old food crumbs and spills observed in the bottom of the refrigerator; Ice Machine: There was a line of black unknown substance located on the inside of the ice machine (flap that extends downward); Walk-In Freezer / Cooler #1: There was a large tote bag sitting on the top shelf. S3DM revealed that the bag belonged to S5RD (Registered Dietician), her supervisor and that she had brought the bag from home. She further revealed that the bag contained S5RD's lunch. She confirmed that the bag should not have been stored in the cooler due to the possibility of cross contamination; Walk-In / Main Freezer: There was a large box that contained a package of Cordon Bleu chicken breast patties. There was a large box that contained a package of french toast. Both packages were open and the food items were was exposed to air. There was a large pan of chili. The pan was covered with plastic wrap. The wrap did not completely seal the pan and the chili had frost observed inside of the pan and also on the chili. There was a large pan of pork. The pan was covered with plastic wrap. There was a large hole in the wrap and the pork was exposed to air; Storage Room-Upright Freezer that was identified by S3DM as the miscellaneous box for vegetables There was old food crumbs and spills in the bottom of the freezer; Storage Room -Upright Freezer that was identified by S3DM as the miscellaneous box for meats There was old food crumbs and spills in the bottom of the freezer; Review of the Food and Nutrition Department Policy and Procedure: Food brought into the facility is not allowed to be stored in the Dietary Department. An interview with the DM confirmed the findings and further confirmed that the items needed to be cleaned and the food items should not be exposed to air due to cross contamination possibility; On 07/17/18 at 2:00PM, an interview with S1Administrator was conducted and she was notified of the findings.

Based on observation and interview, the facility failed to maintain all electrical equipment in safe operating condition, by having old grease and food particles observed on and in direct contact with electrical wiring that was located in the lower compartment of the large fryer. There were 2 (#1 and #55) residents who received a meal from the kitchen out of a total of 3 residents who resided on the skilled unit. Findings: On 07/16/18 at 8:50AM, a tour of the kitchen with S3DM (Dietary Manager) was conducted and a large fryer was observed. There was a lower compartment noted underneath the fryer. Observation of the area revealed a large amount of old grease pooled in the bottom of the compartment. The grease along with old food particles were pooled in direct contact with the wiring that was located throughout the fryer compartment. S3DM confirmed that the fryer needed to be cleaned and was not in safe working condition at the time of the observation. On 07/17/18 at 2:00PM, an interview with S1Administrator was notified of the findings.

Based on observation and interview, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#4) of 1 (#4) resident who required a gerichair in a total sample of 3 residents. Findings: Review of the medical record for resident 4 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required two person extensive assistance with bed mobility, transfer, and toilet use. The resident required one person extensive assistance with dressing and personal hygiene. The resident was always incontinent. Review of the physician orders [REDACTED]. Observation on 7/16/18 at 8:57AM revealed S6CNA (Certified Nursing Assistant) pulling resident #4 backwards in his gerichair from the dining room to his room. An interview with S4RN (Registered Nurse) on 7/16/18 at 9:02AM confirmed S6CNA should not have pulled the resident backwards from the dining room to his room.

Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment by not obtaining weekly weighs as ordered for 1 (#1) of 2 (#1 & #4) residents reviewed with weight loss in a total sample of 3 residents. Findings: Review of the medical record for resident 1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an above the left knee amputation. Review of the Minimum (MDS) data set [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required two person extensive assistance with bed mobility, transfer, and toilet use. The resident required one person extensive assistance with dressing and personal hygiene. The resident was frequently incontinent of bowel and bladder. Review of the physician orders [REDACTED]. Review of the Weight Policy revealed: weights will be obtained on skilled residents weekly. Review of resident #1's weights revealed: 5/17/18 - 151 pounds, reweighed 5/17/18 - 160 pounds, 5/18/18 - 160 pounds, 6/04/18 - 152.7 pounds, and 7/01/18 - 153.7 pounds. An interview with S2DON (Director of Nursing) on 7/16/18 at 4:30PM confirmed the resident had weekly weights ordered on [DATE]. S2DON further confirmed the resident has not received weekly weights.

Based on record review and interview, the facility failed to electronically transmit encoded, accurate, and complete MDS (Minimum Data Set) data to the CMS (Centers for Medicare and Medicaid) System in a timely manner for 4 (#3, #5, R2, R3) o 4 (#3, #5, R2, R3) out of a total of 4 residents reviewed for 14 day assessment submission. Findings: On 12/28/17 at 8:45AM, an interview with S2ADON (Assistant Director of Nursing) was conducted. She was questioned regarding the MDS submission for resident #5. She revealed that S3MDS Coordinator no longer worked for the facility. She revealed that her last working day was on 10/28/17. She revealed that two other workers had been hired since S3MDS had left, but that one of the two hired had also quit. S2ADON revealed that S4MDS Coordinator was currently in the position. An interview with S4MDS Coordinator was conducted. She revealed that her date of hire was 11/04/17. She was questioned regarding the MDS submission dates. She revealed that there were two submission dates since 10/26/17. She revealed that there was one for the date of 12/13/17 and the other was for the date of 12/15/17. She was asked for a list of resident that received skilled care services for those dates of submission. A list of the residents was provided. Review of the list revealed the following: #5 Admission Assessment required by day 14 ARD (Assessment Reference Date) date -11/01/17 The date of the assessment should have been submitted was on 11/15/17 The actual date of submission was on 12/13/17 R1 Admission Assessment required by day 14 ARD date-11/09/17 The date of the assessment should have been submitted was on 11/23/17 The actual date of submission was on 12/15/17 R2 Admission Assessment required by day 14 ARD date-10/10/17 The dated of the assessment should have been submitted was on 10/24/17 The actual date of submission was on 12/15/17 #3 Admission Assessment required by day 14 ARD date-10/16/17 The dated of the assessment should have been submitted was on 10/30/17 The actual date of submission was on 12/15/17 S4MDS Coordinator confirmed that the assessments were not submitted in a timely manner. S1Administrator was notified.

Based on record review, interview, and observation, the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to have a beveled floor mat in place, as ordered, for 1 (#17) of 2 (#13, #17) residents who met the QCLI (Quality of Care and Life Indicators)criteria for accident hazards in a total of 10 Stage 2 sampled residents. Findings: Observed Resident #17 at 3:20PM on 07/05/2017. Resident #17 was sitting in a bedside recliner watching television. Call bell was in resident's hand. Bed was noted to be in lowest position with bed alarm in place. Resident's wheelchair was noted to have a cushion in the seat with an alarm. Interviewed resident who stated that he has fallen often but has never hurt himself. Resident stated his last fall was in the bathroom and he crawled back to his bed. He stated that he is use to falling and that he works out and has good strength to pull himself back up when he falls. No beveled floor pad was observed in resident's room, as ordered. Surveyor asked Resident #17 if he had one and he stated he did but it was taken outside to clean and got rained on. Record review revealed resident #17 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Current physician's orders [REDACTED]. Review of 05/29/2017 MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status) score of 12. Reveal of current care plan revealed resident #17 is care planned for potential for falls. One of the approaches include beveled floor mat at bedside, as well as other approaches. Resident #17's accident/incident reports for the last 30 days revealed falls on 06/08/2017 and 06/29/2017. The accident report revealed resident fell off his bed on 06/08/2017 and an order was received for a beveled floor mat at bedside. Interviewed resident on 07/06/2017 at 9:54 AM who stated he hasn't had floor pad by his bed in several weeks. (Beveled floor pad not seen in room) Resident #17 states his daughter put it outside because it was dirty and it got rained on. Resident states he is supposed to call staff for help when he gets up and said he doesn't do it. On 07/06/2017 at 10:10 AM, an interview was conducted with S2LPN regarding Resident #17's history of falling. She stated he is very non-compliant and does not call for assistance and knows he is supposed to call. Interviewed S1DON on 07/06/2017 at 2:04 PM who verified Resident #17 should have a beveled floor pad in place at all times. S1DON confirmed beveled floor mat was not in Resident #17's room as ordered by the physician.

Based on record review and interview, the facility failed to ensure the services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care, by failing to document Foley catheter care daily for 1 (#11) of 3 ( #11, #13, #17) residents who's QCLI's Exceeded the Threshold for Urinary Catheter Use out of a total sample of 13. Findings: Review of the medical record revealed that resident #11 was admitted to the facility on [DATE]. Review of the Foley Catheter Protocol dated 07/05/16 revealed that resident #11 was to have a Foley catheter to gravity drainage due to [MEDICAL CONDITION], related to [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].>Review of the medical record revealed care planning that included: Foley catheter with related [DIAGNOSES REDACTED]. Documented approaches included catheter care daily. Review of the July 2016 nurses' notes, medication administration, and the the CNA (certified nursing assistant) Flowsheet revealed no documented evidence of Foley catheter care being performed daily. On 08/17/16 at 11:00AM, a record review and interview with S1MDS/LPN (minimum data set / licensed practical nurse) was conducted. She stated that Foley catheter care is to be documented on the CNA Flowsheet. After the review, she confirmed that there was no documented evidence of daily Foley catheter care as per resident #11's written plan of care.

Based on observation and interview, the facility failed to ensure nurse aides demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments,and described in the plan of care by having 1 Certified Nurse Aide (CNA) that failed to encourage and assist with feeding as necessary for 1 (#20) of 3 (#6, 20, 21) residents reviewed for Nutrition with a stage 2 sample of 12. Findings: Resident #20 was a [AGE] year old male admitted [DATE] with [DIAGNOSES REDACTED]. On 9/9/15 at 11:15AM, Resident #20 was observed sitting in a wheelchair in the dining area. On 9/9/15 at 11:30AM, the lunch tray was delivered and set up by a S2CNA. On the lunch tray there was 2 fried chicken legs, rice and gravy, steamed cabbage, corn bread, one 8 ounce bottle of chocolate Ensure, one 8 ounce carton of milk, 8 ounce glass of water and a cup of pudding. Resident #20 did not pick up a spoon or fork to eat and S2CNA did not offer him any food on a utensil. At 11:45AM, S2CNA placed a chicken leg in the left hand of resident #20 and he raised it and took a bite and did get some of the meat in his mouth and most fell to the floor. S2CNA did not pull the meat from the bone and did not use a spoon or fork to offer the resident any rice and gravy, cabbage or corn bread. At 11:50AM, S2CNA gave resident #20 2 bites of pudding with a spoon. That was all the resident ate and the mealtime was finished. During an interview at that time with S2CNA, she stated the meal intake was 1 or 2%. Review of the physicians orders dated 9/2015 revealed the diet for resident #20 was No added salt with chopped meats. Review of the dietary card revealed the diet was No added salt with chopped meats. On 9/10/15 at 1:10PM, during an interview with S1RN, she confirmed she had also observed S2CNA feeding resident #20 the day before and confirmed S2CNA did not feed resident #20 appropriately. S1RN confirmed S2CNA did not offer any rice/gravy, cabbage or corn bread in a utensil and only offered 2 bites of pudding in a spoon. S1RN confirmed S2CNA did not cut up the meat from his chicken for resident #20 to eat as the physician had ordered.

Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility is free of pests in the Wing-1 dining room. This issue had the potential to effect 7 (#3, #4, #6, #7, #18, #22, and # 23) of 7 (#3, #4, #6, #7, #18, #22, and # 23) sampled residents who have access to the dining room area. The facility has a total census of 7 (#3, #4, #6, #7, #18, #22, and # 23). Findings: On 07/28/14 at 11:45AM, during the dining room observation, flies were observed in the dining room area for Wing-1. The flies were observed flying on and around sampled resident #6's food. Further observation revealed flies in other areas of the Wing -1 dining room and also on the top of another resident's juice glass. The resident's family member was observed swatting at the fly. Further observation revealed a opened fly swatter located directly on top of the dining table where resident were eating their lunch. During the meal service observation, two visitors reported to the surveyor that flies were observed frequently during meal services. On 07/29/14 at 11:35AM, an observation of the dining room on Wing-1 revealed a fly swatter laying on the dining room table next to resident's while they were eating their lunch. On 07/30/14 at 10:20AM, during an interview with S1 Administrator, an observed revealed a fly landing on the administrator's forehead. He had to swat the fly away with his hand. On 07/30/14 at 2:30PM, an observation of the Wing-1 dining room revealed three flies flying throughout the dining area and also landing on the table tops where a resident was seated at. On 07/30/14 at 3:20PM, an interview with S1 Administrator and S2 DON (director of nursing) was held and they were notified of the surveyor's observations of the Wing -1 dining room area. S1 Administrator and S2 DON both confirmed that the fly swatter should not have been placed on the top of the dining table where the residents sit and eat their meals and that the facility did not have an effective pest control system in place.

1. Based on observation and interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection by 1. failing to implement handwashing procedure prior to and during pericare for 3 (#4, #6, and #22) of 3 (#4, #6, and #22) sampled residents who were observed during pericare and sharing personal hygiene items and storing these items on the clean linen cart inbetween resident use. 2. by failing to implement interventions for infection prevention once infection concerns were identified through tracking and trending; 3. by having flies in the Wing-1 dining room during and inbetween meal services and by having a fly swatter located on the dining room tables. Items 2 and 3 of the deficient practice has the potential to effect all skilled care residents in the facility. The facility has a total census of 7 (#3, #4, #6, #7, #18, #22, and # 23). Findings: 1. Resident #22 An observation of pericare performed by S8CNA and assisted by S9CNA for resident #22 on 07/29/14 at 3:20PM revealed that S8CNA gathered supplies from the clean linen cart including a previously opened bottle of periwash and a previously opened tube of skin protectant. S8CNA placed these items in the resident's reclining chair and continued to provide pericare with the assistance of S9CNA. Furthermore, S8CNA nor S9CNA were not observed washing their hands prior to the procedure. S8CNA touched the bottle of periwash and the tube of skin protectant multiple times with her gloved hands during the procedure. S8CNA did not wash her hands or use hand sanitizer after removing the residents soiled brief and cleaning the resident's periarea and prior to applying the resident's clean brief. S8CNA nor S9CNA washed their hands or hand sanitizer at any time while providing pericare to the resident. After the procedure, S8CNA placed the tube of skin protectant and the bottle of periwash on the clean linen cart and assisted another resident in the hallway with his oxygen tubing prior to washing her hands. An interview with S8CNA on 07/29/14 at 3:35PM confirmed that the bottles of periwash and tubes of skin protectant are kept on the clean linen cart and used for all residents. S9CNA was present during the interview and agreed that used supplies are kept on the clean linen cart. Further interview with S8CNA on 07/29/14 at 3:35PM revealed that when confronted that she had not washed or used hand sanitizer on her hands during the procedure, she stated that normally she would but she had forgotten the hand gel on the clean linen cart. An observation of the clean linen cart on 07/30/14 at 11:15AM revealed 4 opened tubes of skin protectant, 2 bottles of opened periwash, a large tube of used toothpaste, and a bottle of opened mouth wash was stored in a bath basin on the top self of the clean linen cart along with bottles of antiperspirant spray and unopened toothbrushes. An interview with S10RN on 07/30/14 at 11:25AM confirmed that opened and previously used items were stored on the clean linen cart. S10RN stated that these item should not be stored on the clean linen cart. Resident #4 An observation of pericare performed by S11CNA and assisted by S12CNA on 07/30/14 at 2:35PM for resident #4 revealed the S11CNA did not wash her hands or use hand sanitizer after removing the resident's soiled brief and cleaning the resident's periarea and prior to applying the resident's clean brief. S11CNA nor S12CNA washed their hands or used hand sanitizer at any time while providing pericare to the resident. 2. A review of the tracking and trending log book revealed that the facility identified an increase in infections on the Wing 1-B hall that consists of the skilled unit as far back as January 2014. In June 2014 there were 4 residents identified with infections, 3 of which were urinary tract infection. In May 2014 6 residents were identified with infections, 5 of which were urinary tract infections. In April 2014 6 residents were identified with infections, 1 of which was a urinary tract infection. In March 2014 8 resident were identified with infections, 3 of which had urinary tract infections. In February 2014 7 residents were identified with infections, 6 of which were urinary tract infections. In January 2014 6 residents were identified with infections, 6 of which were urinary tract infections. The facility personal provided an inservice dated 11/13/13 which covered infection prevention and tracking urinary tract infections in the nursing home. An interview with S2DON on 07/31/14 at 1:00PM confirmed that the facility had not had any inservices since 11/13/13 pertaining to infection control or urinary tract infections. She stated that no interventions have been placed at this time to address the increase in urinary tract infections or pericare. 1. Resident #6 On 07/30/14 at 2:55PM, an observation of sampled resident #6's pericare revealed the following: S4 CNA (certified nursing assistant) was asked by the surveyor what she was going to use to clean the resident and she stated that she was going to clean him with a pericare no-rinse wash and afterwards, she was also going to apply a barrier cream to the buttocks area. S4 CNA donned a pair of clean gloves and assisted the resident into a standing position, then to the bed. After preparing sampled resident #6 for the procedure, S4 CNA stated that she needed some linen. S4 CNA then pulled her gloves off walked out of the resident's room and into the hallway to the clean linen cart. S4 CNA did not wash her hands prior applying the clean gloves or after removing them. S4 CNA retrieved the towels from the clean linen cart with her bare hands and then returned to the resident's room. S4 CNA walked into the resident's bathroom and wet a wash cloth with water and soap from the bathroom's soap dispenser. S4 CNA then took the wet soapy wash cloth and cleaned the resident's anterior portion of the lower body including the genital and scrotal areas using only one wash cloth for the entire area. After cleaning the resident, S4 CNA then removed the dirty contaminated pair of gloves and donned a clean pair of gloves. She did not wash her hands after removing the dirty contaminated gloves. After donning the clean pair of gloves, S4 CNA walked to the bathroom and wet a second wash cloth. She returned to the resident's bedside and positioned him and began wiping off his buttocks and anal areas. After she finished wiping the areas, S4 CNA removed her dirty gloves and donned a clean pair, but did not wash her hands after removing the dirty contaminated pair of gloves. S4 CNA took a tube a Aloe Vista skin barrier cream and applied it to the resident's groin, buttocks, and anal areas. After she had finished applying the barrier cream, S4 CNA removed her dirty gloves. With a newly gloved left hand, S4 CNA took the trash bag containing the dirty contaminated items including the gloves, briefs and wash clothes out of the trash can and walked out of the resident's room and down wing 1 hallway and into the whirlpool room where she then looked into a cabinet and retrieved a clean glove to dispose of the dirty bagged items. S4 CNA did not wash her hands prior to retrieving the clean glove from the cabinet. The CNA then returned to the hallway and walked to the inures' station where she was observed to wash her hands. On 037/30/14 at 3:00PM, an interview with S4 CNA confirmed that she was supposed to use pericare wash to clean sample resident #6, but she did not because she didn't have any with her at that time. Review of the facility's handwashing policy and procedure revealed documentation that hands should be washed before and after resident care and after removing gloves. On 07/30/14 at 3:30PM, an interview with the S1 Administrator and S2 DON (director of nursing) confirmed that S4 CNA should have washed her hands prior to performing pericare on sampled resident #6 and after the removal of her dirty, contaminated gloves. Further interview confirmed that S4 CNA should have cleaned the resident with the pericare no rinse wash and not the antibacterial soap from the resident's bathroom soap dispenser. 3. On 07/28/14 at 11:45AM, during the dining room observation, flies were observed in the dining room area for Wing-1. The flies were observed flying on and around sampled resident #6's food. Further observation revealed flies in other areas of the Wing -1 dining room and also on the top of another resident's juice glass. The resident's family member was observed swatting at the fly. Further observation revealed a opened fly swatter located directly on top of the dining table where resident were eating their lunch. During the meal service observation, two visitors reported to the surveyor that flies were observed frequently during meal services. On 07/29/14 at 11:35AM, an observation of the dining room on Wing-1 revealed a fly swatter laying on the dining room table next to resident's while they were eating their lunch. On 07/30/14 at 10:20AM, during an interview with S1 Administrator, an observed revealed a fly landing on the administrator's forehead. He had to swat the fly away with his hand. On 07/30/14 at 2:30PM, an observation of the Wing-1 dining room revealed three flies flying throughout the dining area and also landing on the table tops where a resident was seated at. On 07/30/14 at 3:20PM, an interview with S1 Administrator and S2 DON was held and they were notified of the surveyor's observations of the Wing -1 dining room area. S1 Administrator and S2 DON both confirmed that the fly swatter should not have been placed on the top of the dining table where the residents sit and eat their meals. This has the potential to effect 7 (#3, #4, #6, #7, #18, #22, and # 23) of 7 (#3, #4, #6, #7, #18, #22, and # 23) sampled residents who have access to the dining room area. The facility has a total census of 7 (#3, #4, #6, #7, #18, #22, and # 23).

Based on observation and interview the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 6 (#3, #4, #6, #7, #18, #33) of 6 (#3, #4, #6, #7, #18, #33) residents who receive meals from the kitchen out of a total of 7 residents on the skilled unit. The facility failed by having expired foods available for resident consumption and by having powered sugar stored in a dirty container. Findings: A tour of the kitchen was conducted on 07/28/14 at 8:50 AM. S6DM and S7RD was present during the tour. The following observations were made: 1) 2 containers of expired sour cream were found in the small white storage refrigerator with expiration dates of 06/24/14 and 07/07/14. 2) 2 bottles of expired classic Caesar dressing dated 01/26/14 were on the shelf in the dry storage area. 3) a 50 gallon white container labeled powdered sugar had old food particles spilled and dried to the inside of the container where bulk storage of powdered sugar was held. 4) an expired container of yogurt was found on a food cart that was inside the walk-in refrigerator and had an expiration date of 7/19/14, furthermore an individual bowl of yogurt was prepared and sitting on the cart with the expired container of yogurt. S6DM confirmed that this bowl contained the yogurt in question. 5) 4 large dinted cans of vegetables were found in the dry storage room stored alongside the cans available for consumption. S6DM confirmed that these cans should be stored separate from those ready for consumption. An interview on 07/28/14 at 9:10AM with S6DM and S7RD confirmed that expired foods were present and available for resident consumption. S6DM stated that the powered sugar should not be stored in a dirty container.