Every finding on record at Prairie Manor Nursing Home

Based on interview and record review the facility failed to ensure an allegation of staff to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident physical abuse allegation was discovered, for 1 (Resident #1) of 3 sampled residents. Findings: A review of an undated facility's policy titled, Abuse/Neglect Policy, revealed in part.Investigation of Alleged Abuse, Neglect or Misappropriation of Belongings: All reports of alleged violations involving abuse, neglect, misappropriation of belongings is to be investigated.written statements are obtained immediately & included in report to LDH (Louisiana Department of Health). Interview on 06/17/2026 at 3:00 p.m. with S2 ADON revealed that on 05/11/2026 during a Staffing Meeting held with staff, Resident #1's wife, and other family members present, Resident #1's wife made an allegation of staff physical abuse involving Resident #1, which had allegedly occurred on 04/21/2026 in the dining room. S2 ADON reported the allegation to S1 Admin and S3 DON on 05/11/2026 immediately after the staffing meeting by telephone, who were not present at the meeting, and started the abuse allegation investigation on 05/11/2026. Interview on 06/17/2026 at 3:15 p.m. with S1 Admin revealed that the facility had not entered the allegation made by Resident #1's wife of the staff physical abuse into the SIMS (Statewide Incident Management System) immediately upon discovery or within 2 hours after the allegation of physical abuse was made by Resident #1's wife but should have.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 79 residents that received meal prepared by the facility kitchen. Findings: Review of the facility's undated policy titled: Food Nutrition Service read in part.Scoop sizes are to be followed as stated on the menus provided. Review of the facility's approved lunch menu revealed on 12/15/2025 the lunch menu consisted of, in part.Red beans and Sausage 6oz, steamed rice 1/2 cup, mashed potatoes (alternate) 1/2 cup, and cornbread 1 square. An observation on 12/15/2025 at 10:40 a.m. of S4 [NAME] and S5 Dietary Aide preparing trays on the serving line revealed S4 [NAME] used a 4 oz. scoop for red beans and sausage, 2 2/3 scoop for the rice and mashed potatoes. No bread was served. An interview on 12/15/2025 at 10:50 a.m., S4 [NAME] stated that the 2 2/3 oz. scoop is what is typically used for serving rice and potatoes. S4 [NAME] confirmed that she did not look at the recipes prior to serving trays, but should have. An interview on 12/15/2025 at 10:55 a.m., S5 Dietary Aide stated that she will at times select the scoop for serving meals. S5 Dietary Aide stated that she does not look for the correct sizes on the recipes and just goes by what she is used to using. An interview on 12/15/2025 at 11:00 a.m. S2 DM confirmed that the staff served the red beans/sausage, rice, potatoes and used the incorrect serving size and failed to serve bread with lunch, but should not have.

Based on observation and interview, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with current accepted professional principles. The facility failed to: 1. Ensure expired medications were not available for use in the medication room. 2. Ensure medications were properly labeled. Findings:1.On 12/17/2025 at 8:45 a.m., an observation of the medication room revealed expired medications available for use, including: Three (3) Bisacodyl suppositories with an expiration date of 02/2025Two (2) Bisacodyl suppositories with an expiration date of 06/2025Two (2) Bottles of Glucerna 1.5 cal tube feeding with an expiration date of 11/2025 On 12/17/2025 at 9:00 a.m., an interview with S1ADON confirmed the above findings and acknowledged that the expired medications should have been discarded, but were not. 2. On 12/17/2025 at 8:45 a.m., an observation revealed one (1) open tube of Mupirocin ointment that was not labeled with resident identifier information or an open date. On 12/17/2025 at 9:00 a.m. An interview with S1ADON confirmed that the Mupirocin ointment should have included both a resident identifier and an open date, but did not.

Based on observation and interview the facility failed to ensure that residents requiring assistance with meals were treated with respect and dignity by failing to ensure residents were not labeled and their names displayed on a list according to their care needs on 1 (Hall #Z) of 3 (Hall #X, Hall #Y and Hall #Z) halls. Findings: Review of the facility's undated policy titled Policy 49 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Observations on 08/26/2024 at 1:30 p.m. and 08/27/2024 at 3:05 p.m., revealed a sheet of paper posted at the Kiosk station on Hall #Z with 4 resident names labeled as feeders. This was visible to anyone passing on the hall. An interview on 08/27/2024 at 3:15 p.m. with S8 LPN revealed that the 4 resident names that was labeled as feeders were viewable from anyone passing on the hall, and stated that there are a lot of family members down this hall. An interview on 08/28/2024 at 8:11 a.m. with S2 DON, revealed that S8 LPN made her aware yesterday (08/27/2024) of the sheet of paper hanging at the kiosk on Hall #Z. S2 DON stated resident information including labeling resident's as feeders was inappropriate and should not have been hanging at the kiosk station.

Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner for 1 (Resident #55) reviewed for Beneficiary Notification. Findings: Review of Resident #55's Beneficiary Notification Review revealed in part .Resident #55's Medicare covered Part A services started on 07/05/2024 and her last Medicare Part A covered day was 07/18/2024. Review of Resident #55's NOMNC revealed in part .Resident #55's last covered day of Medicare Part A service was 07/18/2024. Resident #55's NOMNC revealed Resident #55's signed the NOMNC on 07/17/2024 to acknowledge she received and understood the notice. Review of the above mentioned NOMNC revealed the facility did not issue Resident #55's NOMNC at least two days prior to the end of Medicare Part A coverage to allow her the right to appeal the discharge. Interview on 08/28/2024 at 9:19 a.m. with S4 SSD revealed she was currently responsible for issuing NOMNC's to the resident/and or resident representative when the facility initiated a Medicare Part A discharge. S4 SSD confirmed she did not issue a NOMNC to Resident #55 at least two days prior to their Medicare Part A discharge as required.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#81) of 1 sampled Resident with MDS record over 120 days old. Findings: Review of the clinical record for Resident #81 revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Type 2 Diabetes, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side. Review of Resident #81's Discharge MDS Assessment with ARD (Assessment Reference Date) of 04/26/2024 revealed the assessment had been transmitted. Review of the facility's MDS transmission reports revealed Resident #81's Discharge Assessment with ARD of 04/26/2024 had been transmitted on 08/28/2024. Interview on 08/28/2024 at 10:41 a.m. with S5 LPN/MDS Nurse confirmed Resident #81's 04/26/2024 Discharge MDS was completed but never transmitted. Interview on 08/28/2024 with S2 DON revealed Resident #81's Discharge MDS with ARD date of 04/26/2024 was not transmitted in a timely manner, but should have been.

Based on interview and record review the facility failed to develop/implement a person-centered care plan for 1 (Resident #53) of 2 (Resident #26 and Resident #53) sampled residents to include respiratory care for Resident #53. Total sample size was 27. Findings: Review of Resident #53's Clinical Record revealed an admitted [DATE] with diagnoses that included in part . Dysphagia Oropharyngeal Phase, Disturbance of Salivary Secretion, Gastrostomy status, and Cough Unspecified. Review of Resident #53's Annual MDS with an ARD of 06/18/2024 revealed Resident #53 had a BIMS score of 99 (which indicated a resident's interview was incomplete). The MDS revealed Resident #53 was coded as Dependent for oral hygiene, toileting hygiene, shower/bath, and personal hygiene Record review of Physician orders dated 08/2024 for Resident #53 read in part . change suction canister and tubing every 48 hours. If suction machine was used and as needed. Review of Resident #53's Care Plan revealed no documentation of suctioning or a suction machine maintenance. Interview on 08/28/2024 at 10:41 a.m. with S7 LPN MDS confirmed a care plan had not been developed for the use of Resident #53's suctioning or maintenance of respiratory equipment and it should have been.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #10 and Resident #67) of 2 (Resident #10 and Resident #67) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored and labeled. Findings: Review of the facility's policy titled, Care of Respiratory Equipment read in part . Any resident receiving any type of respiratory treatment on a continuous or PRN basis is to have said treatment listed on his treatment sheet. All respiratory equipment is to be maintained by nursing. Oxygen nasal cannulas are to be changed at least every 72 hours, labeled and dated. Oxygen concentrator canisters are to be changed every 3 months, labeled and dated. Review of the facility's policy titled, Oxygen Concentrator read in part . Procedure: 4. Nasal cannula is to be checked daily and changed every 3 days (minimum) when in use and to be kept clean and functional. When not in use, cannula is to be stored in Zip lock bag. Resident #67 Review of Resident #67's medical record revealed an admitted [DATE] with diagnoses that included Alzheimer's disease with late onset, Chronic Diastolic Congestive Heart Failure, Atrial Fibrillation, Essential Primary Hypertension, Chronic Obstructive Pulmonary Disease (COPD) and other nonspecific abnormal findings of lung field. Review of Resident #67's Physician's Orders for 08/2024 revealed an order to administer oxygen at 3 liters for saturation 92% or less as needed. Review of Resident's Quarterly MDS with an ARD of 07/30/2024 revealed a BIMS score of 03, indicative of severe cognitive impairment. Review of MDS revealed Resident #67 received hospice services. Review of Resident #67's Care Plan with review date 10/30/2024 revealed in part . I have COPD, Pulmonary Nodules and Chronic Diastolic Congestive Heart Failure. Interventions included in part . to administer oxygen if ordered. Change my oxygen tubing (if oxygen is ordered) per protocol and as needed (such as if it falls on floor or I do not store tubing in appropriate place/ manner). Staff will educate/ encourage/ redirect me frequently and not to take my oxygen off without calling for staff assistance for and infection control. Observation on 08/26/2024 at 11:30 a.m. of Resident #67 awake lying in bed. Oxygen nasal cannula and tubing observed left open to air, not contained or labeled with date lying on oxygen concentrator at bedside. Humidifier water bottle and tubing observed to be attached to oxygen concentrator without a label with date. Observation on 08/27/2024 at 9:17 a.m. revealed Resident #67 awake lying in bed. He stated he had used oxygen a couple of days ago. Observation of oxygen nasal cannula and tubing noted left open to air, not stored or dated and lying on top of the oxygen concentrator. Oxygen water humidifier bottle not dated attached to concentrator. Observation and interview in Resident #67's room on 08/27/2024 at 11:28 a.m. with S3 LPN revealed Resident #67's oxygen tubing and nasal cannula not contained or labeled with a date and left open to air lying on top of his oxygen concentrator at bedside. S3 LPN revealed that his hospice nurse may have changed out humidifier and placed Resident #67 on oxygen when she came yesterday morning around 09:30 a.m. S3 LPN revealed it was overlooked on her part and she should have dated and placed Resident #67's oxygen nasal cannula and tubing in a Zip Lock bag and did not. Interview on 08/27/2024 at 11:57 a.m. with S2 DON confirmed the above findings. S2 DON revealed that the oxygen equipment storage policy is to have tubing placed in a sealed bag, dated with tape on tubing and change out tubing every three days by the nurse on duty and was not done. 44844 Resident #10 Review of Resident #10's Clinical Record revealed an admitted [DATE] with diagnoses that included in part .Alzheimer's Disease with Late Onset, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Pneumonia Unspecified, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Review of Resident #10's Physician orders for August 2024 revealed in part .Budesonide Inhalation Suspension 0.5 MG/2ML (breathing treatment). 1 vial orally via nebulizer two times a day related to Chronic Obstructive Pulmonary Disease. Review of Resident #10's care plan with a Target date of 10/16/2024 revealed in part .I require oxygen therapy. I sometimes experience Shortness of Breath upon exertion or while lying flat, with interventions that included: Administer me oxygen if ordered. Change my oxygen tubing per protocol and as needed (such as if it falls or I do not store the tubing in the appropriate place/manner). I have Congestive Heart Failure administer my medication if ordered. Observation and interview on 08/26/2024 at 9:55 a.m. revealed Resident #10 was in bed. Nebulizer mask lying on top of a refrigerator uncovered. Resident #10 revealed she received breathing treatments every day. Observation on 08/28/2024 at 9:20 a.m. revealed Resident #10's nebulizer mask was lying uncovered on top of her refrigerator. Observation and interview on 08/28/2024 at 9:26 a.m. with S6 LPN revealed Resident #10 received nebulizer treatments every 6 hours. Observation of Resident #10's nebulizer mask with S6 LPN revealed it was lying uncovered on top her refrigerator. S6 LPN confirmed Resident #10's nebulizer mask was uncovered and it should not have been. Interview on 08/28/2024 at 9:37 a.m. with S2 DON revealed the floor nurses were responsible for maintaining and changing respiratory equipment. S2 DON confirmed Resident #10's nebulizer mask should not have been lying uncovered on top of her refrigerator.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #25, Resident #45, Resident #47, and Resident #65) of 4 (Resident #25, Resident #45, Resident #47, and Resident #65) residents reviewed for transmission based precautions. The facility failed to have an infection control policy for transmission based precautions which included the disposal of regulated medical waste and failed to properly dispose the regulated medical waste of Resident #25, Resident #45, Resident #47, and Resident #65. Findings: Review of the facility's policy titled Isolation Precautions revealed in part . Trash will be kept in a basket in the residents' room. Basket is lined with large trash bag. The basket will be checked by housekeeping personnel daily and staff as needed. Trash will be disposed of per facility protocol. Interview on 08/08/2022 at 8:58 a.m. with S7 LPN/IP revealed the facility had two COVID-19 positive residents, Resident #45 and Resident #65. Observation on 08/08/2022 at 10:16 a.m. of Resident #65's room revealed he was on droplet isolation and two silver trash cans were noted outside of the room with white trash bags. Further observation revealed one trash can was labeled linen and the other one was labeled trash and no biohazard bags were noted. Observation on 08/08/2022 at 10:16 a.m. of Resident #45's room revealed he was on droplet isolation and two silver trash cans were noted outside of the room with white trash bags. Further observation revealed no biohazard bags were in use. Interview on 08/08/2022 at 1:30 p.m. with S11 CNA revealed when residents are on isolation for COVID-19, any trash is bagged in the resident's room and taken directly outside and placed into the trash can by the resident's door. S11 CNA reported whenever the trash can outside the door is full, it was then taken directly outside by using the door on the COVID-19 area. Observation on 08/08/2022 at 1:50 p.m. revealed two red dumpsters on wheels outside of the door by the COVID-19 area. Interview on 08/08/2022 at 2:01 p.m. with S1 Administrator revealed the red dumpsters outside the COVID-19 area were emptied by the maintenance men every morning and every evening. S1 Administrator reported they hook up a golf cart and bring it around to the main dumpster. S1 Administrator stated they take out the trash bags from the red dumpster by hand and move it to the main dumpster. Interview on 08/08/2022 at 2:03 p.m. with S12 Maintenance revealed the aides and housekeepers place trash in the red dumpsters outside. S12 Maintenance reported when he comes to work every morning, he attaches a golf cart to the red dumpsters and pulls them over to the main dumpster. S12 Maintenance stated he puts on gloves and grabs the bags from the red dumpster and places them in the main dumpster. S12 Maintenance reported he did not wear a mask, face shield, or a gown. S12 Maintenance stated he moves the trash from the red dumpsters to the main dumpsters every morning and every evening. Interview on 08/08/2022 2:08 p.m. with S13 HSK revealed she took the trash from Resident #45's room and Resident #65's room and placed it in the red dumpsters outside. Interview on 08/08/2022 at 2:09 p.m. with S14 CNA revealed she took the trash from Resident #45's room and Resident #65's room and placed it in the red dumpsters outside. Observation 08/09/2022 at 12:28 p.m. of Resident #65's room revealed a trash can for trash outside the door with a white trash bag. Further observation revealed no biohazard bags were in use. Observation 08/09/2022 at 12:28 p.m. of Resident #45's room revealed a trash can for trash outside the door with a white trash bag. Further observation revealed no biohazard bags were in use. Interview on 08/09/2022 at 12:35 p.m. with S7 LPN/IP revealed Resident #45 tested positive for COVID-19 on 08/06/2022 and Resident #65 tested positive for COVID-19 on 08/07/2022. Interview on 08/09/2022 at 12:50 p.m. with S15 LPN revealed the COVID-19 positive residents' trash is placed outside the door in the silver trash can. S15 LPN stated when the trash can was full, the CNAs took the trash outside and placed it in the red dumpsters. S15 LPN reported she did not use biohazard bags for anything on her hall. Observation of the storage room located in the COVID-19 area with S15 LPN revealed two open cardboard boxes with red biohazard bags that were empty and never used. S15 LPN stated a while ago at the facility, they were using the red biohazard bags for the trash of COVID-19 positive residents. S15 LPN reported now they have just been using the trash cans with regular trash bags. 08/09/22 01:44 PM Interview with S7 LPN/IP confirmed the facility did not have a policy or protocol for trash as stated in their policy titled Isolation Precautions but they should have had one. S7 LPN/IP reported the waste from residents on isolation was supposed to go outside of their room in a regular trash bag and when it was full, staff was to put it in a biohazard bag in a cardboard box. S7 LPN/IP stated when biohazard bags are full, the cardboard box is closed and the maintenance man puts it in his shop until it is picked up by the company that picks up the facility's biohazardous waste. S7 LPN/IP confirmed the waste of the residents on isolation should not have gone in the red dumpster outside with the regular trash and should have been placed in biohazard bags to be contained. Observation on 08/09/2022 at 2:05 p.m. revealed Resident #47's room had two trash cans outside the door with white trash bags. Further observation revealed no biohazard bags were in use. Observation on 08/09/2022 at 2:05 p.m. revealed Resident #25's room had two trash cans outside the door with white trash bags. Further observation revealed no biohazard bags were in use. Interview on 08/09/2022 at 2:25 p.m. with S10 ADON revealed Resident #47 was placed on transmission based precautions when she returned from the hospital because she was not vaccinated for COVID-19. S10 ADON stated Resident #25 was on transmission based precautions because she had ESBL in her urine.

Based on observation, record review and interview, the Facility failed to provide respiratory care consistent with professional standards of practice for 4 (Resident #11, Resident #47, Resident #54, and Resident #75) of 6 (Resident #11, Resident #13, Resident #46, Resident #47, Resident #54 and Resident #75) sampled Residents reviewed for respiratory care. Findings: Resident # 47 Review of the Facility's Policy/Procedure titled Oxygen Concentrator revealed in part: 5. Nasal cannula is to be checked daily and changed every 3 days (minimum) and to be kept clean and functional. When not in use, cannula is to be stored in a zip lock bag. Observations on 08/09/2022 at 10:36 a.m. and 1:10 p.m. revealed Resident #47 lying in bed with supplemental Oxygen at 3Liters/minute per nasal cannula. There was a wheelchair positioned at her bedside with a nasal cannula noted to be opened to air connected to a portable Oxygen tank. An interview with Resident #47 at the time of the observation revealed she was placed on portable Oxygen whenever she left the facility ([CONDITION(S)], and Doctor's appointment). Resident #47 stated she used a different nasal cannula on the portable Oxygen and the cannula on the Oxygen concentrator stayed connected to it. Observation on 08/10/2022 at 8:35 a.m. revealed Resident #47 lying in bed with supplemental Oxygen at 3Liters/minute per nasal cannula. There was a wheelchair positioned at her bedside with a nasal cannula noted to be opened to air connected to a portable Oxygen tank. Observation on 08/10/2022 at 8:45 a.m. accompanied by S2 DON confirmed the nasal cannula was open to air and should have been stored in a zip lock bag and dated. Review of Resident #47's Medical Records revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Physician's orders for August 2022 revealed: Oxygen at 3Liters per nasal cannula continuous- Dx. (Diagnosis) [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) Change tubing every 3 days. Review of Resident #47's Significant Change in Status MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/03/2022 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (which indicated intact cognition). Further review of the MDS revealed that Resident #47 was on [CONDITION(S)] and Oxygen Therapy. Resident #75 Observation on 08/08/2022 at 11:35 a.m. revealed Resident #75 sitting in a recliner in his room, there was a wheelchair at the foot of the bed. The wheelchair was noted to have a nasal cannula open to air draped over the front of it. An interview with Resident #75 at the time of the observation revealed he used the Oxygen whenever he left his room and the facility. Observation on 08/09/2022 at 10:31 a.m., accompanied by S2 DON confirmed the nasal cannula was open to air and should have been stored in a zip lock bag and dated. Review of Resident #75's Medical Records revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's Physician's orders for August 2022 revealed: Oxygen at 3 L per nasal cannula continuous during the day. Change tubing every 3 days. Review of Resident #75's Quarterly MDS with an ARD of 06/22/2022 revealed the resident had a BIMS score of 13 (which indicated intact cognition). #54 Observation on 08/08/2022 at 11:18 a.m. revealed a suction machine at Resident #54's bedside with 50 cc yellow fluid in the suction canister. There was an opened wrapper with a suction [MEDICATION(S)] connected to the suction machine tubing which was undated. Observation on 08/09/2022 at 8:42 a.m. revealed a suction machine on Resident #54's bedside table. There was 50 cc of yellow fluid in the collection canister. The suction [MEDICATION(S)] had been opened, was connected to suction tubing, had been used and was not dated when opened. Review of Resident #54's EHR revealed an admitted [DATE]. Resident #54 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Care Plan with an ongoing target date revealed no interventions pertaining to suctioning. Review of Resident #54's Yearly MDS with an ARD of 07/06/2022 revealed the following in part: Section C - Cognitive Pattern - The Resident's BIMS score was 8 (indicating Resident #54 had moderate cognitive impairments). Review of Resident #54's 08/2022 MD Orders revealed the following in part: 11/11/2021 - Head of bed elevated at 45 degrees at all times 11/18/2021 - Change nebulizer set up q week 01/23/2022 - Change oxygen tubing every 3 days if in use. 03/08/2022 - Oxygen 2L/min via NC prn for SOB 07/01/2022 - Iprat-Albut 0.5-3(2.5) mg/3 ml administer 1 vial per nebulizer for inhalation q 6 hours prn coughing/wheezing Review of Resident #54's 06/2022-08/2022 Progress Notes revealed no documentation that Resident #54 had been suctioned. Review of the Facility's Suction Machine Policy revealed the following in part .Note: Suction catheters should not be cleansed with germicidal solution' change catheter every use. Interview on 08/09/2022 at 12:22 p.m. with S7 LPN/IP confirmed that there was a suction machine at Resident #54's bedside with 50 ccs of yellow fluid in the suction canister. S7 LPN/IP further confirmed that the suction [MEDICATION(S)] was opened, was connected to the suction machine, had been used, and was undated. S7 LPN/IP stated that if it had been her, she would have done away with the canister and replaced it with a new one. #11 Review of the clinical record revealed Resident #11 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled: Administering Nebulizer Treatments with Aerosol Mask or Mouthpiece revealed in part . 6. The aerosol mask/mouthpiece and tubing are then disconnected from nebulizer and cleaned. Once cleaned, place mask/mouthpiece in a storage bag at bedside. Observation on 08/08/2022 at 12:10 p.m. revealed Resident #11 awake in bed watching television. An Aerosol mask attached to a nebulizer machine was observed on Resident #11's nightstand OTA. Observation on 08/09/2022 at 9:13 a.m. revealed Resident #11 awake in bed wearing supplemental oxygen. An Aerosol mask attached to nebulizer machine was observed on Resident #11's nightstand OTA. Interview with Resident #11 at the time of observation revealed he used the nebulizer 2 -3 times a day. Resident #11 stated he last had a nebulizer treatment at around 7:30 a.m.-8:00 a.m. that morning. Interview on 08/09/2022 at 9:16 a.m. with S5 LPN confirmed the above findings. S5 LPN stated Resident #11's Nebulizer mask should be bagged after each use and was not.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents' assistive devices were maintained in good working condition for 2 (#39, and #75) of 34 sampled Residents. Findings: Resident #39 Observation on 08/08/2022 at 11:40 a.m. revealed Resident #39 sitting in a wheelchair in the hallway. The wheelchair was noted to have multiple tears on the right and left armrests. Observation on 08/09/2022 at 9: 30 a.m. revealed Resident #39 lying in bed with a wheelchair positioned at the foot of her bed. The wheelchair was noted to have multiple tears on the right and left armrest. Interview with Resident #39 at the time of the observation revealed she was unable able to walk so she uses the wheelchair to move around her room and the facility. Interview conducted on 08/09/2022 at 10:25 a.m. with S2 DON confirmed that after inspecting the wheelchair for Resident #39, the wheelchair was in need of repairs and or needed to be replaced. Resident #75 Observation on 08/08/2022 at 11:35 a.m. revealed Resident #75 sitting in a recliner in his room eating lunch with a wheelchair positioned by his bed. The wheelchair was noted to have multiple tears on the seat cushion. Interview with Resident #75 at the time of observation revealed he uses the wheelchair to move around the facility. Observation on 08/09/2022 at 10:02 a.m. revealed Resident #75 ambulating in the hallway assisted by a Physical Therapist with a Certified Physical Therapist Assistant pushing a wheelchair behind the Resident. The wheelchair was noted to have multiple tears on the seat cushion. Interview conducted on 08/09/2022 at 10:31 a.m. with S2 DON confirmed that after inspecting the wheelchair for Resident #75, the wheelchair was in need of repairs and or needed to be replaced.

Based on observations, interview, and record review, the facility failed to provide services with reasonable accommodation of needs for 1 Resident (#10) out of 34 sampled Residents. The facility failed to ensure the call light was within reach for Resident #10 to call for assistance when needed. Findings: Review of Resident #10's Face sheet revealed she was a [AGE] year old female admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) 05/18/2022 revealed Resident #10 was interviewble with a BIMS (Brief Interview for Mental Status) of 13 (intact cognition). Resident #10 required limited assistance with 1 person assistance for transfer, walking in room. Resident was coded as being highly involved in activity with staff providing guidance. Resident is not steady to stand alone only able to stabilize with human assistance. On 08/08/2022 at 11:15 a.m., an observation was made of Resident #10 up in a recliner in her room with a padded call light draped over a wall mounted blood pressure manometer. When asked if resident was able to use a call light, she stated Yes, but I can't reach it. Resident stated she had no means to call for assistance if needed. Resident stated she needed staff assistance with transfer. On 08/09/2022 at 9:40 a.m., an observation was made of Resident #10 up in recliner with a padded call light positioned on her bed. The Resident's recliner was positioned approximately 4-5 feet away from the bed, out of her reach. When asked if she was able to reach the call light, she stated No I can't get it. On 08/09/2022 at 10:35 a.m., an interview was conducted with S2 DON. Observation at the time of interview revealed Resident #10 was seated in her recliner, and her padded call light was positioned on her bed. S2 DON confirmed that Resident #10's padded call light was not within her reach for assistance and should have been.

Based on observation, record review, and interview the facility failed to review and revise a Resident's Care Plan to include suctioning for 1 Resident (#54) and failed to ensure a Resident's Care Plan included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: #54 Observation on 08/08/2022 at 11:18 a.m. revealed a suction machine at Resident #54's bedside. There was 50 cc's of yellow fluid noted in the collection canister Observation on 08/09/2022 at 8:42 a.m. revealed a suction machine on Resident #54's bedside table. There was 50 cc of yellow fluid noted in the collection canister. Review of Resident #54's EHR revealed an admitted [DATE]. Resident #54 had the following diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's Care Plan with an ongoing target date for [CONDITION(S)], Aspiration and Cough revealed no intervention noted pertaining to suctioning. Review of Resident #54's Yearly MDS with an ARD of 07/06/2022 revealed the following in part: Section C - Cognitive Pattern - The Resident's BIMS score was 8 (indicating Resident #54 had moderate cognitive impairment). Review of Resident #54's 08/2022 MD Orders revealed the following in part: 11/11/2021 - Head of bed elevated at 45 degrees at all times 11/18/2021 - Change nebulizer set up q week 01/23/2022 - Change oxygen tubing every 3 days if in use. 03/08/2022 - Oxygen 2L/min via NC prn for SOB 07/01/2022 - Iprat-Albut 0.5-3(2.5) mg/3 ml administer 1 vial per nebulizer for inhalation q 6 hours prn coughing/wheezing Review of the Resident #54's 05/2022 - 08/2022 Progress Notes revealed no documentation that Resident #54 had been suctioned. Interview on 08/09/2022 at 12:22 p.m. with S7 LPN/IP confirmed there was a suction machine at Resident #54's bedside with 50 ccs of yellow fluid in the suction canister. S7 LPN/IP further confirmed that the suction [MEDICATION(S)] was opened, was connected to the suction machine, had been used, and was undated. Interview on 08/10/2022 at 10:44 a.m. with S6 LPN/MDS confirmed there was no information concerning suctioning in the Resident's Care Plan and there should have been. #18 Review of the clinical record revealed Resident #18 admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/08/22 at 12:23 p.m. revealed Resident #18 in bed yelling out for her mother, asking for help, and shouting profanities. Observation on 08/08/2022 at 12:34 p.m. revealed S9 LPN entering Resident #18's room and attempting to redirect Resident #18. Resident #18 began banging on a bedside table and yelling, where's my mother. Review of Resident #18's Physician's Progress Notes revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the progress notes revealed they had been signed off by S8 LPN. Review of Resident #18's CPOC with a target date of 09/07/2022 revealed no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 08/09/2022 at 3:00 p.m. with S8 LPN revealed she was responsible for reviewing progress notes and taking off any new orders. She stated that after signing off the progress notes she scans them to the MDS/coding office. Interview on 08/09/2022 at 3:10 p.m. with S9 LPN revealed he was responsible for updating plans of care and MDS's as needed. He stated Resident #18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/09/2022 at 3:21 p.m. with S2 DON confirmed Resident #18 had not been care planned for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview the Facility failed to formulate an advanced directive for 1 (Resident #46) of 1 sampled Resident records reviewed for Advanced Directives. Findings: Review of Resident #46's Medical Record revealed no documentation Resident #46 or Resident #46's Representative had signed an Advanced Directive. Further review revealed Resident #46's family had signed a LaPost Acknowledgment Form and had checked the statement which said I wish to complete a LaPost/Advance Directive at this time. Interview on 08/09/2022 at 12:15 p.m. with S16 SSD revealed during the admittance of a Resident, the family is ask if they would like to sign an Advanced Directive. If so, this information is passed on to the nursing department for completion of a LaPost form. S16 SSD confirmed at this time the LaPost Acknowledgment Form was checked that the resident wished to have an Advanced Directive completed and there was not one on the Resident's record. Interview on 08/09/2022 at 12:17 p.m. with S6 LPN/MDS confirmed that there was no Advanced Directive/LaPost form signed in Resident #46's record and it should be.

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 73 residents that received meals prepared by the kitchen. Findings: Initial tour of the kitchen on 08/08/2022 at 9:00 a.m. accompanied by S4 DM revealed the following: 1 opened, undated loaf of wheat bread, 1 opened, undated pack of hamburger buns and 1 opened, undated 25lb bag of fish fry on a counter in the kitchen. Findings confirmed with S4 DM at the time of observation. Observation of the facility cooler on 08/08/2022 at 9:30 a.m. accompanied by S4 DM revealed it contained the following items on a shelf for use: 1 quart of tuna salad undated and uncovered, 1 quart of whipped topping opened and undated. Findings confirmed with S4 DM at the time of observations. S4 DM stated all food items should be dated after opening and stored items in the cooler should be covered and dated as well.

Based on record review and interview, the facility failed to ensure 1 Resident (Resident #32) of 34 Sampled Residents was free from misappropriation of resident property. The facility substantiated an allegation from Resident #32 against S3 LPN regarding medication administration. Findings: Review of a facility policy titled Abuse/Neglect Policy revealed in part .the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and/or psychosocial well-being. The policy further defined misappropriation of personal belongings as a patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without resident or responsible party's consent. Review of a facility investigation dated 07/05/2022 revealed Resident #32 reported she may have received the wrong pain medication from S3 LPN on 07/04/2022 at 12:00 a.m. and 6:00 a.m. Resident #32 reported the pain medication administered by S3 LPN was bigger than the one she normally received, and her pain was not relieved as well with this medication. Further review of the investigation revealed Resident #32 saved the pain medication S3 LPN administered on 07/04/2022. The facility determined the medication was an OTC pain medication. Resident #32 had [MEDICATION(S)]/Acetaminophen 10-325 mg one tab ordered every 6 hours for pain. [MEDICATION(S)]/Acetaminophen 10-325 mg was signed out from the narcotics sheet on 07/04/2022 at 12:00 a.m. and 6:00 a.m. by S3 LPN. The facility interviewed S3 LPN on 07/05/2022, and S3 LPN verbally admitted she took Resident #32's [MEDICATION(S)]/Acetaminophen 10-325 mg tablets for herself. S3 LPN stated she administered Resident #32 OTC Acetaminophen 325 mg tablets in place of the ordered pain medication. S3 LPN also sent this admission by text to the Administrator. Interview with S1 Administrator on 08/08/2022 at 3:00 p.m. revealed S3 LPN admitted to taking Resident #32's [MEDICATION(S)]/Acetaminophen 10-325 mg for herself and administering OTC Acetaminophen 325 mg to Resident #32 in place of the ordered pain medication. S1 Administrator revealed S3 LPN's employment with the facility was terminated on 07/05/2022 due to misappropriation of Resident #32's medication.

Based on interview and record review, the facility failed to ensure an incident of suspected misappropriation of property and exploitation of a resident was reported to the State Survey Agency within the required time frame for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed. Findings: Review of Resident #1's medical record revealed an admitted [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS with an ARD of 04/28/2022 revealed a BIMS Summary score of 15 (indicative of intact cognition). Review of the facility's Abuse/ Neglect Policyrevealed in part . All reports of alleged abuse, neglect, misappropriation of belongings is to be investigated, and this is to start immediately upon receipt of such, even if DON or NFA are not in house The [NAME] Online Incident Tracking System is initiated within 24 hours of the alleged incident The family and physician are to be notified immediately with physician's remarks or results of exam to be part of investigative report. Review of the Reasonable Suspicion of Crimes Committed against a Resident Policy revealed in part .Reports of reasonable suspicion of a crime against a resident must be reported to State Survey Agencies and Law Enforcement. Section 1150B establishes two time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion. If the events that cause the reasonable suspicion results in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion. Review of a Grievance form/ Investigation report dated 02/08/2022 and signed by S1 Adm read in part .S1Administrator received a call from a sheriff's officer regarding an old employee that was terminated on 08/24/2021. The officer told me that S4 CNA was suspected of stealing the identity of several nursing home residents throughout the area, and asked if Resident #1 was a resident here because Resident #1's name had surfaced in the investigation. The officer stated she would contact the facility if something else came up regarding Resident #1. Investigation in house: S1 Adm contacted Resident #1's daughter at this time and explained to her what the officer told me. S1 Adm asked her if her mom has any credit cards or checkbook in her room, she said that if she does, it is very old and she would check, she did not seem concerned at all. S1 Adm gave Resident #1's daughter the officer's name and asked her to call and please let me know if she noticed any strange activity in mom's account. Plan of Correction: Upon admission, we encourage and stress the importance of resident's not keeping cards or checkbooks or any forms of identity in their rooms. Residents are offered a nightstand that locks or a key to their closets. 02/16/2022 - No more calls and Resident #1's daughter still has not noticed anything suspicious. Review of a Grievance form/ Investigation report dated 04/12/2022 revealed in part S1 Adm received another call from the officer this morning in regards to S4 CNA. The officer said she noticed S4 CNA had this facility as a place of employment on her Facebook page, and asked if family had noticed any activity in Resident #1's account. S1 Adm told the officer that Resident #1's daughter would call if she noticed anything or received any mail. Resident #1's daughter has stated she does not always go through mail. S1 Adm tried to call Resident #1's daughter on this date with no answer. Plan of Correction: Follow-up dated 04/13/2022. S1 Adm reached out to Resident #1's daughter and informed her that S1 Adm received another call from the officer from the Sheriff's department. S1 Adm asked Resident #1's daughter if she had noticed any activity on her mom's account since we spoke previously. S1 Adm stated that Resident #1's daughter was not concerned and asked her to please let me know if something else came up. The family is not very cooperative and does not seem concerned at all. The officer told S1 Adm that the facility would be notified if anything or activity surfaced on Resident #1. Resolved. Observation of Resident #1 on 05/11/2022 at 9:35 a.m. revealed her awake and alert, and sitting in her recliner in her room. Resident #1 stated she has not had anything missing while here at the nursing home. Interview on 05/11/2022 at 11:05 a.m. with S1 Administrator revealed she did not have any SIMS reports for the past 6 months. Telephone interview with Resident #1's daughter/POA on 05/11/2022 at 2:00 p.m. revealed she stated her mother did not have a checking account or a credit card. Resident #1's daughter/POA stated she is not aware of, or been notified of any suspicious activities or transactions with her mother's name, and would let S1 Adm know if she became aware of such. Interview on 05/11/2022 at 2:30 p.m. with S1 Adm revealed she completed an investigation after having received a telephone call from the parish's Sheriff's Office on February 08, 2022, questioning the employment of S4 CNA. S1Adm stated she informed the Sheriff's Office that S4 CNA was hired on 06/30/2021 and terminated on 08/24/2021 for falsification of her COVID-19 screening. S1 Adm stated the officer informed her that Resident #1's name surfaced during an investigation, and Resident #1's account may have been compromised. S1Adm stated she notified Resident #1's daughter/POA of her telephone call from the Sheriff's Officer and provided Resident #1's daughter/POA with the officer's contact information. S1 Adm stated she asked Resident #1's daughter/POA to check with the bank regarding her mother's account, and let her and the officer know if she found any suspicious activity or transactions. S1 Adm stated that she received another telephone call from the same officer on 04/12/2022 asking if S4 CNA had been rehired, if the daughter/POA or facility had found fraudulent activity in Resident #1's account, and informing her of Facebook postings regarding S4 CNA's arrest. S1 Adm stated she contacted Resident #1's daughter/POA on 04/13/2022 to let her know of the telephone call from the Sheriff's officer questioning if she had found any suspicious activity on the Resident #1's account. Resident #1's daughter/POA stated her mother did not have any accounts and was not aware of any fraudulent activity. S1 Adm stated the resident's daughter/POA was uncooperative, appeared bothered and was not concerned with the matter. S1 Adm stated that she had given the sheriff's officer's number to the Resident #1's daughter/POA again and asked the Resident #1's daughter/POA to please let her know or the sheriff's officer know if she found anything in regards to her mother's name or bank accounts. S1 Adm stated she completed her investigation on the matter with a resolved date of 04/13/2022 due to findings not found. Interview on 05/12/2022 at 1:45 p.m. with S1 Adm revealed she did not do a SIMS report because she felt she did not have to report anything to the state if she didn't have evidence of fraudulent activity or identity theft in regards to S4 CNA and Resident #1. Interview on 05/16/2022 at 3:45 p.m. with S1 Administrator confirmed that she did not submit a SIMS report to the State Agency when she was notified by the Sheriff Department and became aware of possible exploitation of Resident #1 by S4 CNA, and should have.

Based on observation and interview the facility failed to ensure that expired medications/biologicals were not available for use/administration to residents for 1 of 1 medication storage rooms and 1 of 4 medication carts. The Resident Census and Conditions of Resident form dated 05/24/2021 revealed the facility's total census was 70. Findings: Observation of the facility's medication storage room on 05/25/2021 at 2:18 p.m. accompanied by S3 LPN revealed it contained the following: (1) 8 ounce bottle of [MEDICATION(S)] DM cough syrup that expired 06/2020, (1) 40 count box [MEDICATION(S)] DM that expired 03/2021, (9) 8 ounce boxes of Glucerna 1.2 supplement that expired 03/01/2021, (4) 8 ounce boxes of Glucerna 1.2 supplement expired 04/01/2021, (1) 100 ml bottle of sterile water that expired 05/01/2021, (1) opened 10 ml vial of [MEDICATION(S)] that expired 09/2020, (3) [MEDICATION(S)] 2.5 mg/3 ml nebulizer treatments that expired 01/2020, (20) [MEDICATION(S)] 1.25 mg/3 ml nebulizer treatments expired 01/2021, (25) [MEDICATION(S)] BR 0.02%/3 ml nebulizer treatments that expired 01/2021, (1) box of 30 single use 5 ml [MEDICATION(S)] syringes 100 mg/ml that expired 4/30/2020. Medication room findings confirmed per interview with S2 DON at 2:00 p.m. on 05/25/2021. She stated expiration dates should be checked by nurses every time they remove a medication or supplement from the shelves. Observation of the D hall medicine cart on 05/27/2021 at 8:45 a.m., accompanied by S4 LPN, revealed it contained: (1) opened 15 ml bottle of Sterile Lubricant eye drops with an expiration date of 07/2019 and (1) opened 100 count bottle of gas relief chewable tablets with an expiration date of 03/2021. Findings confirmed with S4 LPN at the time of observation.

Based on observation, record review and interview the facility failed to ensure services were provided according to the residents' plans of care for 2 (#12 and #64) of 19 sampled residents. The facility failed to supervise resident #12's meals, and failed to ensure resident #12 received meals according to her plan of care. The facility failed to ensure resident #64 was provided assistance during meals according to her plan of care. The facility's census was 70 residents, according to the Resident Census and Conditions of Residents provided by the facility. Findings: 1. Review of resident #12's medical record revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Annual MDS assessment dated [DATE] revealed the resident needed extensive assistance with meals. Further review of the MDS revealed the resident needed supervision to include verbal cues or touching assistance during meals. Review of the resident's Care Plan with an onset date of 06/09/2021 revealed she was at risk for aspiration and dysphagia. The Care Plan revealed altered nutrition related to history of weight loss, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches revealed serve diet as ordered, assist with meal setup, prefer to eat all meals in TV lobby or bedroom, and to supervise meal intake. Review of a Nutritional Risk assessment dated [DATE] revealed the resident had mild/moderate impairment with swallowing and needed meal assistance. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 05/24/2021 at 11:33 a.m., and on 05/25/2021 at 11:25 a.m. revealed resident #12 was served her lunch in her room. Resident #12 did not receive double portions and she did not receive two 16 oz. glasses of milk. She was observed to eat in her room unsupervised by staff. Interview on 05/26/2021 at 11:04 a.m. with S12 CNA revealed resident #12 ate all meals in her room. She revealed resident #12 was on aspiration precautions and staff had to be present the entire meal. Interview on 05/26/2021 at 11:40 a.m. with S13 Cook revealed she was responsible for plating the food. She stated if the resident came to the dining area, she would not give double portions until they asked for it. However, the hall trays had double portions. S13 Cook stated she just forgot to give resident #12 double portions. Interview on 05/26/ at 1:00 p.m. with S11 LPN revealed the resident eats in her room. She stated the resident should be monitored in her room during meals. Interview on 05/26/2021 at 1:15 p.m. S14 DM revealed resident #12 should have received double portions and 2 glasses of milk with her meal. She confirmed it was the responsibility of all staff on the serving line to ensure the resident was served food according to her diet order. Interview on 05/26/2021 at 1:30 p.m. with S1 DON confirmed the staff should have monitored the resident in her room during meals. She confirmed the kitchen staff was responsible for ensuring the resident received food according to her diet orders. Interview on 05/28/2021 at 11:00 a.m. with S15 ST revealed resident #12 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of resident #64's medical record revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Discharge MDS assessment dated [DATE] revealed the resident needed supervision during meals. Further review of the MDS revealed the resident needed oversight, encouragement and cueing during meals. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/24/2021 at 11:49 a.m. revealed resident #64 was seated in the dining room. The resident was observed to fed herself. There were several staff present in the dining room; however, no staff assisted the resident with her meal. Interview on 05/26/2021 at 11:00 a.m. with S12 CNA revealed the resident was a feeder, and she ate her meals in the dining room. Interview on 05/26/2021 at 1:30 p.m. with S1 DON confirmed the resident should have been feed by nursing staff in accordance with her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed to ensure 1 (#14) of 19 sampled residents had the right to have her personal property. According to the Resident Census and Conditions of Residents Form the total facility census was 70. Findings: Review of resident #14's Quarterly MDS dated [DATE] revealed she had a BIMS score of 14. Interview with resident #14 on 05/24/21 at 11:03 a.m. revealed she had lost her hearing aid about a month ago, maybe longer. She stated she had taken it out of her ear and put it on her bedside table and when she woke up in the middle of the night it was gone. She stated she told the nurse, and they looked for the hearing aid, but they did not find it. The resident stated she informed S17 SSD about her missing hearing aid, and the SSD told her the facility was not responsible for replacing the hearing aid. She stated S17 SSD told her she would check with Medicare to see if the hearing aid was insured and could be replaced. She stated she had not heard anything from S17 SSD since she informed her, and it had been at least a month. Further interview revealed she could not understand the overhead intercom without the hearing aid, and she would like to have an update on the status of replacing the hearing aid. Review of a form titled Equipment Inventory Sheet, revealed the type of equipment brought in upon admission was one hearing aid for the right ear. The form was not dated. Interview with S2 DON and S1 Administrator on 05/25/2021 at 1:45 p.m. revealed they were not aware the resident was missing her hearing aid. S2 DON stated S17 SSD was currently hospitalized but she was going to call one of the social workers to see about the status of the hearing aid. Interview with S2 DON and S1 Administrator on 05/26/2021 at 10:40 a.m. revealed they did not have a policy that addressed whether they replaced lost or misplaced items. They stated the policy encouraged residents to lock up belongings. S1 Administrator stated it depended on the situation whether or not they replace items. S2 DON and S1 Administrator stated they could not find any documentation from S17 SSD regarding the hearing aid, and they could not get in touch with S17 SSD. They stated the facility's system was that residents report missing items to the SSD. The SSD then was responsible for completing the follow up regarding missing items and she had not.

Based on record review and interview the facility to ensure that a resident received adequate supervision and assistance devices to prevent accidents for 1 (#4) of 5 (#1, #2, #3, #4, and #5) residents reviewed. According to the Resident Census and Conditions of Residents form provided by the facility and dated 1/31/17, the facility's total census was 93 residents. This failed practice resulted in an actual harm situation when resident #4 was transferred manually from her gerichair to the bed by S4 and S5 CNAs (Certified Nursing Assistants) on 1/9/17 at 2:35 p.m. Resident #4, who was bed/chair bound, and unable to bear her own weight was transferred to bed on 1/9/17 without the use of the mechanical lifter, as written in her Plan of Care. During the transfer, the resident had to be lowered to the floor. At 8:10 p.m. the resident complained of pain to the right lower leg and right ankle areas. The resident agreed to go to the emergency room and was found to have sustained an oblique spiral, non-displace fracture in the mid to distal tibia. Findings: Review of the accumulative [DIAGNOSES REDACTED]. Further review revealed [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set assessment with an Assessment Reference Date of 11/22/16 revealed the resident was assessed to have limited Range of Motion in her upper and lower extremities, and required extensive assistance of 2 persons for transfers. The assessment revealed a Brief Interview of Mental Status summary score of 12, which indicated the resident's cognition was moderately impaired. Further review revealed the resident was able to repeat and recall three words, report the correct month accurately within 5 days, and report the correct day of the week. Review of the Departmental Notes for January 2017 revealed the following entries: 1/10/17 at 1:02 a.m. - Late entry for 1/9/17 at 8:10 p.m. completed by S6 LPN (Licensed Practical Nurse): Resident complaining of pain to right lower leg and right ankle area at this time. Resident's bilateral lower extremities in a contracted state. Resident assessed and raised area noted to right lateral ankle area and tender to touch. Resident stated that she hurt right leg when she was transferred to gerichair today. Resident refusing to go to ER (emergency room ) for evaluation. Resident educated on risks of not being evaluated. Will notify MD (Medical Doctor) right away. Resident has difficulty to move right lower extremity independently or with supportive assistance. No edema or discoloration to bilateral lower extremities noted. 1/10/17 at 1:11 a.m. - Late entry for 1/9/17 at 8:15 p.m. completed by S6 LPN: Physician notified of resident's complaints and assessment findings. New order noted to send to emergency room for evaluation. Resident made aware and still refusing to go. Will notify responsible party. 1/10/17 at 1:12 a.m. - Late entry for 1/9/17 at 8:20 p.m. completed by S6 LPN: Notified responsible party of resident's complaints of right lower leg and ankle pain and order to send to emergency room , and that resident is refusing to go. 1/10/17 at 1:18 a.m. - Late entry for 1/9/17 at 8:25 p.m. completed by S6 LPN: Resident agreed to go to emergency room at this time. 1/10/17 at 1:25 a.m. - Late entry for 1/9/17 at 11:55 p.m. completed by S6 LPN: ER nurse called report at this time. Stated that the resident has a spiral fracture to right tibia near midshaft, and that a posterior lower leg splint with ace wrap was applied. 1/10/17 at 3:00 a.m. - completed by S6 LPN: 2:45 a.m. Resident returned to facility. Smiling and in good spirits. No complaints of pain or discomfort. Splint to right lower leg intact and circulation, movement, sensation check within normal limits. Condition stable. Review of the January 2017 electronic Medication Administration Record revealed the resident was administered Narco 5/325 milligrams 1 by mouth on 1/9/17 at 6:20 p.m. for a complaint of pain rated 6 out of 10 on the pain scale. There was no documentation noting why the resident was complaining of pain. Review of the January 2017 physician's orders [REDACTED]. Review of a Resident Transfer Form dated 1/9/17 revealed resident #4 was transferred from the facility to the emergency room due to a complaint of right leg and ankle pain. The documentation revealed the resident was in a contracted state with a raised area noted to the right posterior ankle. Review of X-Ray results dated 1/9/17 revealed under the Impressions section, that the resident had an oblique spiral, non-displace fracture in the mid to distal tibia. Review of facility OTIS (Online Tracking and Incidents System) reports for January 2017 revealed a report for resident #4 noting an event occurred on 1/9/2017 at 2:35 p.m., but was not discovered until 1/9/17 at 11:55 p.m. The documentation revealed the event was reported in the facility on 1/10/17 at 8:00 a.m. Further review revealed the event was entered into the OTIS system on 1/10/17 at 11:30 a.m. with a CEO finding/determination date of 1/12/17, substantiating an allegation of caregiver neglect against two CNAs (S4 CNA and S5 CNA). Review of the Description section of the above report revealed that at 8:00 a.m. in the morning of 1/10/17, S3 ADON and S2 DON were informed that resident #4 had two fractures to the right ankle, which had occurred on 1/9/17. Upon investigation it was discovered that the resident stated she was injured while the CNAs working on the 7:00 a.m. to 7:00 p.m. shift on 1/9/17 were transferring her back to bed from the gerichair without the use of the lifter. The documentation revealed the CNAs were called into the office and statements were written by both (S4 and S5 CNA). The CNAs' statements were consistent with what the resident reported. The documentation revealed the lifter was not used during the transfer by the two CNAs, resulting in the resident's injury. Review of the Summary section of the OTIS report revealed the investigation determined the resident sustained [REDACTED]. Review revealed written statements were obtained from each CNA, which coincided with the resident's report. The CNAs were terminated due to not following policy and procedures, causing injury to the resident. Review of the written statement dated 1/10/17 by S5 CNA revealed resident #4 wanted to go to bed, so she and S4 CNA pushed the resident to her room. The documentation revealed the resident was in her gerichair, and the two CNAs picked the resident up from the gerichair, under her arms, without supporting her bottom. The resident started to fall and the CNAs lowered her to the floor. The CNAs then proceeded to manually picked the resident up again, and placed her in the bed. Further review of the statement revealed the resident stated that her right leg hurt, but that it was due to it having been broken before. S4 CNA offered to call the nurse, but the resident refused and stated to rub some cocoa butter on it. Review of a written statement dated 1/10/17 by S4 CNA revealed that when transferring the resident, the CNAs attempted to transfer the resident manually, not supporting her lower extremities. The statement revealed the resident's legs were dangling. The CNAs pivoted and placed the resident on the bed. The statement revealed that upon changing the resident, she started to complain about her right leg. The CNA's documentation indicated that this was when she (S4 CNA) knew something was wrong. Further review of the documentation revealed S4 CNA confirmed the lifter was not used as required, and the injury was not reported right away. The CNA offered to call the nurse, and informed the resident that the nurse could send her to the hospital to have her leg checked out, but the resident refused. The resident asked the CNA to apply cocoa butter to her leg. Further review of the OTIS investigative documentation for the incident revealed both CNAs received Disciplinary Warning Notices. The documentation revealed the CNAs failed to transfer resident #4, whom was bedbound, safely by not using the lifter. Review of the OTIS investigative report revealed this caused actual harm to the resident on 1/9/17. Review of the current plan of care with a goal date of 2/22/17 revealed the following: 1. A problem of Total dependence on staff times 1-2 with cueing, supervision and set-up for ADLs (Activities of Daily Living) due to impaired mobility, with a problem onset date of 10/10/14. Bed/Chair bound; contractures to hand and joint stiffness to the knees. Slight contractures to bilateral knees. Review of the interventions revealed the resident required assistance with bed mobility, and required a mechanical lift for transfers times 2 staff. 2. A problem of At risk for falls with potential for injury due to history of falls, impaired mobility, and daily use of psychotropic medication with a problem onset date of 8/3/15. Review of the interventions revealed 2 CNAs were to assist the resident with all transfers and the mechanical lift. Further review revealed that on 1/9/17 the resident had an actual fall, and the staff was educated/inserviced to use a mechanical lifter with all transfers. Interview on 1/31/17 at 11:11 a.m. with S2 DON and S3 ADON confirmed resident #4 was care planned to be transferred with the use of the mechanical lifter and had been for years. S2 DON stated S4 and S5 CNAs chose not to use the lifter to transfer the resident, because they didn't want to walk to retrieve it. Observation and interview of the resident on 1/31/17 at 12:40 p.m. revealed she was seated in the gerichair in the lobby area of the facility. The resident denied any c/o except that her right leg hurt at times. She stated she had the cast to her right leg, because she broke her leg when the CNAs transferred her from the gerichair to the bed a couple of weeks prior. The resident stated she was always transferred to and from bed with the mechanical lift and she didn't know why the CNAs chose to transfer her on their own. She stated that was the only time she had been transferred without the lift. Interview on 1/31/17 at 1:10 p.m. with S1 Administrator confirmed the documentation findings of the OTIS investigation. She stated the CNAs didn't use the mechanical lifter and stated it was because they were being lazy. She also confirmed the CNAs did not report the incident and that it was the night shift LPN who discovered something was wrong with the resident's leg. She stated the facility staff were aware that they are to report any incidents immediately. Telephone interview on 2/1/17 at 1:20 p.m. with S5 CNA confirmed the documentation in her written statement. She confirmed resident #4 was not able to stand and bear her own weight, and that she was aware that the mechanical lift should have been used to transfer the resident. Further interview revealed S5 CNA was assisting S4 CNA. She stated she asked S4 CNA how they were going to transfer the resident and she (S4 CNA) stated they didn't need the lift; they would just transfer her under her arms. Telephone interview on 2/1/17 at 1:59 p.m. with S7 LPN (Agency nurse who worked 7:00 a.m. to 7:00 p.m. with the resident on 1/9/17) revealed she was not aware of any incidents involving the resident. Confirmed nothing was reported to her by the CNA staff or the resident regarding any incident(s) or injury. Interview on 2/1/17 at 2:10 p.m. with S8 Charge CNA revealed she worked on 1/9/17. She stated S4 CNA reported to her later in the day on 1/9/17 that the resident was complaining of leg pain. She stated the CNA did not inform her of how they had transferred the resident back to bed, nor that something had occurred during the transfer. She stated she reported the resident's complaint to the nurse on duty. Further interview confirmed the mechanical lift should have been used to transfer the resident, because she was unable to bear weight.