Every finding on record at Rosepine Retirement & Rehab Center, LLC

Based on observation, interview and record review, the facility failed to ensure prompt efforts to resolve grievances/complaints, voiced in The Resident Council, were addressed and acted upon for 2 (11/2025 and 12/2025) of 3 months reviewed for grievances/complaints. The facility census was 88. Findings: Review of an undated facility policy on 01/22/2026 at 4:04 p.m. titled, Grievances/Complaints revealed the following .4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; ensure that immediate action is taken if necessary to prevent further violations of any resident rights while the allegation is under investigation. Review of an undated facility policy on 01/21/2026 at 10:49 a.m. titled, Smoking Policy revealed the following .5. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas. 6. Smoking is not allowed in resident rooms or any other non-designated smoking area. Smoking areas will be designated. Review of the facility Resident Council meeting minutes revealed the following complaints in part .-Date: 11/06/2025; 11 residents in attendance; Other Business: Residents smoking out front when it is a safety hazard and they are supposed to be smoking in the covered pavilion. No documentation of complaint follow-up. -Date: 12/02/2025; 12 residents in attendance; Other Business: Would like the smokers to stay in designated area so non-smokers can enjoy sitting in the front. No documentation of complaint follow-up. Review of Resident #35's medical record revealed an admission date of 04/26/2024, which included diagnoses of Chronic Obstructive Pulmonary Disease and Cerebral Palsy. Review of Resident #35's Quarterly MDS with ARD of 12/03/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #21's medical record revealed an admission date of 10/07/2025, which included diagnoses of Impulse Disorder, Unspecified Mood Disorder, and Nicotine Dependence, other Tobacco Product, with Withdrawal. Resident #21's Quarterly MDS with ARD of 01/07/2026 revealed a BIMS score of 15, which indicated intact cognition. Resident #21's Comprehensive MDS with ARD of 06/04/2025 revealed the resident used tobacco currently.The Resident Council meeting was held at 01/20/2026 at 1:22 p.m. and 16 residents were present. Resident #35 revealed that smokers were still smoking in non-smoking areas, such as the facility front entrance. Resident #35 stated the residents would like to know what the facility is doing to fix this problem, which was voiced in the past Resident Council meetings. On 01/21/2026 at 8:16 a.m. observation of the facility's front entrance revealed a sitting area with table and chairs to the right side of the front entrance doorway. Observed Resident #21 in her wheelchair, smoking a cigarette outside the doorway of the facility entrance. No observation of staff re-directing Resident #21 to smoke in an authorized facility smoking area. In an interview on 01/21/2026 at 11:17 a.m., S1 ADM revealed he was the facility's Grievance Official, responsible for review of the monthly Resident Council meeting minutes and addressing any complaints during Resident Council. S1 ADM revealed the designated smoking areas for all smokers (residents/staff/guests) were located off of Hall X, under the covered pavilion, or located on backside of facility old porch. S1 ADM stated he expected all smokers to smoke in designated and authorized smoking areas, as the facility smoking policy stated. S1 ADM confirmed the front entrance of the facility was not an authorized smoking area and no smokers should smoke at the facility front entrance. S1 ADM confirmed he was aware of the Resident Council complaints from 11/2025 and 12/2025 regarding smokers smoking at the facility front entrance, which was an unauthorized smoking area. S1 ADM confirmed he was aware that Resident #21 still currently smoked at the facility front entrance door, which was an unauthorized smoking area. S1 ADM stated he educated Resident #21 about not smoking at the facility front entrance (no evidence of this education was provided during the survey process) to address the Resident Council concerns. On 01/22/2026 at 8:22 a.m. observation of the facility front entrance revealed Resident #21 in her wheelchair, smoking a cigarette outside the doorway of the facility entrance. No observation of staff re-directing Resident #21 to smoke in an authorized facility smoking area. On 01/22/2026 at 8:29 a.m. observation of the facility front entrance revealed Resident #21 in her wheelchair, smoking a cigarette outside the doorway of the facility entrance. No observation of staff re-directing Resident #21 to smoke in an authorized facility smoking area. During the survey process, there was no documented evidence provided to the surveyor of the facility addressing The Resident Council complaints/grievances from 11/2025 and 12/2025, which involved smokers smoking in unauthorized areas of the facility.

Based on record review and interview, the facility failed to ensure a resident's comprehensive care plan was revised to reflect the resident's current Advanced Directive status for 1 (Resident #11) of 18 sampled residents.Findings:Review of Resident #11's electronic medical record revealed an admission date of 09/25/2025, with diagnoses including, in part . Unspecified Mycosis; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; Anorexia, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of Resident #11's electronic record bed board, orders, and LaPost (Louisiana Physician Orders for Scope of Treatment) signed on 10/09/2025 by the resident's physician and Personal Health Care Representative revealed the resident had an advanced directive designation of DNR (Do Not Attempt Resuscitation Allow Natural Death). Review of Resident #11's current comprehensive care plan revealed, in part .Code Status: Full Code, with a revised date of 10/02/2025. Interview on 01/22/2026 at 12:37 p.m., with S2 DON confirmed that Resident #11's care plan stated that Resident #11 was a Full Code. S2 DON reviewed Resident #11's LaPost document and stated that the resident should have had his care plan updated to a DNR status but was not.

Based on interviews and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure an advanced directive was properly reflected in the resident's medical record for 2 (Resident #3 and Resident #44) of 18 sampled residents reviewed for advanced directive status. Findings:Resident #3 Review of Resident #3's medical record revealed an admit date of 12/29/2025 with diagnoses that included: Encounter for Other Orthopedic Aftercare; Chronic Obstructive Pulmonary Disease with (Acute) Lower Respiratory Infection; Hypertensive Heart Disease with Heart Failure; Major Depressive Disorder, Single Episode, Moderate. Review of Resident #3's electronic record dashboard/orders revealed the resident was a Full Code status. Review of Resident #3's 01/2026 physician's orders revealed the code status as Full Code signed on 01/05/2026. Review of Resident #3's care plan with the revision date of 01/11/2026 revealed the code status as Full Code. Review of Resident #3's LaPost (Louisiana Physician Orders for Scope of Treatment) document signed by the resident's physician and personal health care representative dated 01/06/2026 indicated Resident #3 selected to have an advanced directive designation of DNR (Do Not Attempt Resuscitation [Allow Natural Death]). Interview on 01/22/2026 at 12:25 p.m., with S4 LPN revealed she would look at the resident's dashboard/orders in their electronic record to determine their advance directive during a code. S4 LPN verified that Resident #3's electronic record indicated Resident #3 was a Full Code. Interview on 01/22/2026 at 12:35 p.m., with S2 DON revealed staff should look at the dashboard/orders of the resident's electronic record to determine their code status. S2 DON confirmed that Resident #3's electronic record and care plan indicated that Resident #3 was a designated a Full Code. S2 DON reviewed Resident #3's LaPost document and stated that the resident should have had her electronic record and care plan updated to a DNR status, but it had not been. Resident #44 Review of Resident #44's electronic medical record revealed an admission date of 01/05/2026. Resident #44 had diagnoses that included in part. Acute Combined Congestive Heart Failure, Pneumonia, Urinary Tract Infection, Chronic Atrial Fibrillation, Cerebral infarction, Difficulty in Walking, Major Depressive Disorder, and Dementia. Review of Resident #44's admission MDS with ARD of 01/07/2026 revealed resident had a BIMS of 11, which indicated moderate cognitive impairment. Resident #44 required; Supervision/touching assistance by staff for eating, oral hygiene, and personal hygiene. Partial/Moderate assistance by staff for toileting, showering/bathing, and dressing upper body. Substantial/Max assistance by staff for dressing lower body. Review of Resident #44's comprehensive person centered care plan with target completion date of 04/07/2026 revealed in part.Code Status: Full Code with initiation date of 01/14/2026. Interventions read in part. Ensure orders are accurate regarding code status. Ensure signed documents are in resident record regarding code status. Ensure staff are aware of code status. Review of Resident #44's January 2026 physician's orders revealed an order dated 01/05/2026, listing the code status as Full Code. Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) for Resident #44 revealed Resident #44's code status was listed as DNR (Do Not Resuscitate) and was signed by Resident #44's RP (Responsible Party) and physician on 01/07/2026. Telephone interview on 01/22/2026 at 9:49 a.m. with Resident #44's RP revealed he was the residents POA (Power of Attorney) and on admission he signed a directive and confirmed Resident #44 was to be a DNR. Interview on 01/22/2026 at 10:25 a.m. with S3LPN revealed she determined a resident's code status by reviewing the resident's EHR (Electronic Health Record) and checking the physician's orders. S3LPN reviewed Resident #44's EHR and confirmed Resident #44 was ordered and care planned for full code status, but according to Resident #44's LaPost signed by RP and physician on 01/07/2026, her code status should be DNR. S3LPN confirmed there should not be conflicting code status orders within Resident #44's medical record. S3LPN stated when the LaPost was obtained on 01/07/2026 the full code status order should have been discontinued, and a new order for DNR should have been entered, but was not. Interview on 01/22/2026 at 10:35 a.m. with S2DON confirmed once the LaPost was signed on 01/07/2026, Resident #44's medical record to reflect the appropriate code status should have been updated. S2DON confirmed Resident 44's code status was incorrect and not updated to reflect DNR status for LaPost signed on 01/07/2026.

Based on record review, observation, and interview the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (#11) of 2 (#11 and #23) residents reviewed for nutrition. The facility failed to provide ordered dietary supplements for a resident with significant weight loss. Findings: Resident #11 Review of the Resident #11's medical record revealed an admitted [DATE] with a reentry date of 03/18/2022. Diagnoses included .Parkinson's Disease, Mild Protein-Calorie Malnutrition, Dysphagia - Oropharyngeal Phase, and Muscle Wasting and Atrophy. Review of Resident #11's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #11 required extensive assistance by one person with eating. Review of Resident #11's medical record revealed the resident was care planned for a nutritional problem related to a diagnosis of Protein Calorie Malnutrition, no salt on tray, and mechanical soft diet. Interventions included in part: Monitor, record, and report to Medical Director as needed signs and symptoms of malnutrition .significant weight loss greater than 10% in 6 months . Registered Dietician to evaluate and make diet change recommendations as needed .provide and serve diet as ordered . monitor intake and record every meal. Review of Resident #11's progress notes revealed the following: 09/26/2024: Nutrition/Dietary Note by S13 RD: Resident weight changes -12.62% X 180 days . continues no salt on tray diet, mechanical soft texture with varied by mouth intake .on multiple supplements . mighty shake three times daily .will monitor weight changes, labs, and by mouth intake .recommend to continue the current plan of care .Registered Dietician to monitor. Review of Resident #11's current physician's orders revealed to give a mighty shake three times a day, with an order date of 08/28/2024. Review of Resident #11's weights revealed on 04/03/2024, Resident #11 weighted 136.1 lbs., and on 10/02/2024, Resident #11 weighted 119 lbs., which revealed a significant weight loss of 12.56% over the past six months. In an observation on 10/14/2024 at 12:30 p.m., Resident #11's lunch tray was noted with no mighty shake. In an interview on 10/15/2024 at 9:05 a.m., Resident #11 stated she has poor appetite. On 10/15/2024 at 11:57 a.m., Resident #11's lunch tray was observed and noted with no mighty shake. In an interview on 10/15/2024 at 11:57 a.m., Resident #11 stated she does not get any shakes or supplements. Observation on 10/15/2024 at 12:08 p.m., revealed Resident #11's lunch tray after lunch was observed after lunch was completed. Approximately 25% of meal was consumed. No mighty shake noted to her lunch tray. In an interview on 10/15/24 at 1:15 p.m., S9 LPN stated the nurses give the house supplements to the residents and the mighty shakes come from the kitchen. S9 LPN stated the kitchen sends the mighty shakes on the meal carts delivered to the resident rooms. S9 LPN confirmed physician orders that Resident #11 should receive a mighty shake three times a day. In an interview on 10/15/2024 at 1:20 p.m., S8 Dietary Manager stated that when the nurses receive an order for a mighty shake, they are to complete a diet slip and turn it in to the Dietary Manager. S8 Dietary Manager stated once the diet slip is received, the tray cards are updated in the record to reflect the new orders for supplements. S8 Dietary Manager stated that the process relies heavily on the nurses to communicate any updates regarding changes to supplements for weight loss. S8 Dietary Manager stated the dietary staff are aware to follow the tray cards and place any supplements on the meal carts as needed. Review of Resident #11's tray card on 10/15/2024 at 1:34 p.m. revealed no evidence of a mighty shake listed under the supplements category. In an interview on 10/15/2024 at 1:43 p.m., S8 Dietary Manager stated a mighty shake should be placed under the supplement category of the tray card. S8 Dietary Manager confirmed that Resident #11's tray card did not have a mighty shake noted to the supplement category. S8 Dietary Manager stated the dietary staff would not have placed a mighty shake on Resident #11's meal tray because it was not listed on her tray card. S8 Dietary Manager stated Resident #11's tray card had not been updated since September 2024; therefore, Resident #11 would not have gotten a mighty shake since September 2024.

38894 44315 Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, to help prevent the development and transmission of infection for 3 (#26, #45, and #72) of 4 (#26, #45, #72, and #83) residents reviewed for infection control. The facility failed to: 1. Ensure staff wore proper PPE while providing wound care to Resident #26; 2. Ensure staff wore proper PPE while proving personal hygiene to Resident #45; and 3. Ensure staff performed proper hand hygiene and maintained a clean technique while performing wound care for Residents #26 and #72. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions read in part . It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 46. Enhanced Barrier Precautions - a. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: i. Wounds and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the facility's undated policy titled, Skin Program, Pressure Ulcers and Other Wounds revealed in part . 21. Clean technique, using a no touch method to avoid contaminating the wound is usually adequate for wound treatments. Clean technique and supplies will be used unless otherwise ordered . 48. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy tubes, h. Wound care: any skin opening requiring a dressing. Resident #45 Review of Resident #45's EHR revealed an admitted [DATE], with diagnoses that included: UTI and Neuromuscular Dysfunction of Bladder; Review of Resident #45's Quarterly MDS with an ARD of 08/21/2024, revealed a BIMS score of 8 (which indicated moderate cognitive impairment). Resident #45 had an indwelling Suprapubic catheter, and was always incontinent of bowel. The MDS revealed Resident #45 was at risk for pressure ulcers. Review of Resident #45's 10/2024 Physician's Orders revealed the following: 08/28/2024 - turn and reposition every 2 hours. 09/03/2024 - 22FR/10CC Suprapubic Catheter change every 3 weeks and prn leakage, occlusion, dislodgment. 09/03/2024 - Admit to hospice. 09/03/2024 - Enhanced barrier precautions related to catheter and wound. 10/07/2024 - PU Sacrum: Clean with wound cleaner, apply Mesalt and Honey to Slough, and cover with dry dressing daily. Review of Resident #45's Care Plan with target date of 11/21/2024, revealed the following in part . 1. Urinary Catheter - Indwelling: 22 FR/10CC Suprapubic Foley catheter. Dx - Neuromuscular Dysfunction of Bladder, and enhanced barrier precautions. Observation on 10/16/2024 at 11:30 a.m., revealed Resident #45's Hospice CNA was in the room, wearing scrubs, touching the resident and leaning over him while he was in the bed. The Hospice CNA was not wearing PPE equipment. Interview on 10/16/2024 at 11:31 a.m. with S12 MDS Nurse, confirmed there was someone in Resident #45's room dressed in scrubs, and leaning over the resident. S12 MDS Nurse revealed she did not know who the person was, but stated that she should be wearing a gown and gloves since Resident #45 was on enhanced barrier precautions. Interview on 10/16/2024 at 11:40 a.m. with Resident #45's Hospice CNA in Resident #45's room revealed she was Resident #45's Hospice CNA. She was observed carrying towels and washcloths, and stated she was preparing to give Resident #45 a bath. There was a basin at the resident's bedside with a used toothbrush noted in the basin. She was not wearing a gown and stated she was unaware that she should be wearing one. Resident #26 Review of Resident #26's Medical Record revealed an admitted [DATE], with diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, History of Falling, Non-Pressure Chronic Ulcer of part of right lower leg with unspecified severity, Obesity due to excess calories and Unsteadiness on feet. Review of Resident #26's current Physician's Orders revealed the following orders in part . 10/16/2024: Enhanced Barrier Precautions (EBP) related to wound. 10/15/2024: Cleanse skin tear to RLE with wound cleanser, apply collagen and cover with dry dressing every day until resolved. 10/06/2024: Cleanse skin tear to RLE with wound cleanser, apply TAO and collagen and cover with dry dressing every 3 days until resolved. 09/24/2024: Right lower leg ulcer, cleanse with wound cleanser apply collagen and cover with dry dressing every day until healed. Review of Resident #26's Quarterly MDS with an ARD of 09/18/2024, revealed a BIMS score of 04, indicative of severe cognitive impairment. Review of the Skin Conditions section of the MDS, revealed Resident #26 had one venous/ arterial ulcer present, and received application of nonsurgical dressings and ointments/medications, other than to feet. Review of Resident #26's Care Plan with a Target date of 12/18/2024, revealed in part . 1. 03/04/2022 - Tissue integrity, impaired risk for fragile skin, history PU, history incontinent episodes, weakness, decreased mobility, cellulitis, candidiasis and abscess. 2. 10/07/2024 - Resident #26 with potential/actual impairment to skin integrity related to fragile skin, decreased mobility, and history of pressure ulcers, history of incontinent episodes, weakness, candidiasis and history of abscess. 10/06/2024: Clean skin tear to RLE with wound cleanser, apply TAO and collagen, and cover with dry dressing every 3 days until resolved. Interview on 10/15/2024 at 9:05 a.m. of S10 LPN, revealed the top wound was a skin tear that occurred over the past weekend. S10 LPN stated the wound to the right lower leg is an ulcer wound that she and the DON had assessed last week. Observation at that time revealed there was no EBP signage on Resident #26's door, and that S10 LPN entered without applying a gown. In an observation on 10/15/2024 at 9:05 a.m., S10 LPN performed wound care on Resident #26. S10 LPN set up the wound care supplies directly on the resident's over bed table, without a drape or clean field between the supplies and table. During wound care, S10 LPN removed the collagen from the RLE skin tear wound, then changed gloves without sanitizing hands after doffing the dirty gloves, and prior to donning new gloves. S10 LPN then cleaned the RLE wound with wound cleanser soaked gauze, and changed gloves again without sanitizing before donning new gloves. S10 LPN dried the wound with 4x4s, and changed gloves without sanitizing in between. S10 LPN then applied dry dressing to RLE wound, and began wound care to right lower leg ulcer wound after changing gloves and sanitizing. S10 LPN removed the old dressing from right lower leg ulcer wound, and changed gloves. S10 LPN removed the collagen and cleaned the wound with wound cleanser soaked 4x4s, and changed gloves without sanitizing her hands. S10 LPN dried the right lower leg ulcer wound with 4x4s, and changed gloves again without sanitizing hands. S10 LPN then applied dry dressing over the right lower leg ulcer wound. Interview on 10/15/2024 at 3:36 p.m. with S2 DON, confirmed Resident #26 was not on EBP for the venous ulcer wound to her right lower extremity, because the last treatment nurse had initiated the wound care order, but did not implement the order for EBP on resident's Physician's Orders for EBP, and should have. In an interview on 10/15/2024 at 3:50 p.m., S2 DON reported S10 LPN became the wound care nurse a couple of weeks ago, and was trained by the previous wound care nurse. S2 DON confirmed S10 LPN should have performed hand hygiene after doffing her gloves and setting up supplies on a clean field. S2 DON stated S10 LPN should not have touched the contaminated surfaces with her gloves while performing wound care. Resident #72 Review of Resident #72's medical record revealed an admitted [DATE], with diagnoses that included in part .Pressure Ulcer of right buttock, Pressure Ulcer of sacral region, and Chronic Pain Syndrome. Review of Resident #72's Quarterly MDS with an ARD of 09/20/2024, revealed a BIMS score of 15 (which indicated intact cognition). Review of the MDS revealed Resident #72 required supervision with eating, total dependence on two person physical assistance with toilet use, and extensive assistance by two persons with bed mobility. Review of Resident #72's current Physician's Orders revealed the following: 10/14/2024: Sacrum: Cleanse with normal saline, pat dry, apply Mesalt to wound bed, and cover with dry foam dressing daily every day shift. 10/14/2024: Right Gluteal fold: Cleanse with normal saline, pat dry, apply Mesalt to wound bed, and cover with dry foam dressing daily every day shift Review of Resident #72's care plan revealed a problem of: Risk for impaired skin integrity, with a review date of 10/17/2024. Interventions included in part .following the wound care orders, providing pressure reducing surfaces to bed and chair, and repositioning schedule. Observation of wound care for Resident #72, performed by S10 LPN, revealed the following: S10 LPN set up the wound care supplies directly on the resident's over bed table with no drape or clean field between the supplies and table. During wound care, S10 LPN removed the Mesalt from the right gluteal fold wound, then changed gloves without sanitizing hands after doffing the dirty gloves, and prior to donning new gloves. S10 LPN then cleaned the wound with normal saline soaked gauze, and changed gloves again without sanitizing hands and donning new gloves. S10 LPN dried the wound with 4x4s, and changed gloves without sanitizing in between. S10 LPN laid the new dressings in their package directly on the resident's bed sheet. S10 LPN changed gloves again without sanitizing, then picked up the scissors off the over bed table, (not on clean field) and opened and cut a piece of foam with the dirty scissors, and then covered the resident's gluteal wound with the foam and a dry dressing. S10 LPN began wound care to sacrum after changing gloves and sanitizing. S10 LPN removed the old dressing from sacrum and changed gloves. S10 LPN removed the Mesalt that was packed in the sacral wound, cleaned the wound with normal saline soaked 4x4s, and changed gloves without sanitizing her hands. S10 LPN dried the sacral wound with 4x4s, and changed gloves again without sanitizing hands. S10 LPN placed the dressings directly on the bed sheet in their packages. With the same gloves on that had touched the cart, dressings, and bed sheet, S10 LPN opened the Mesalt package, removed the Mesalt, and pushed the Mesalt into the sacral wound with her gloved fingers. S10 LPN then put the foam and dressing over the sacral wound. In an interview on 10/15/2024 at 3:50 p.m., S2 DON reported S10 LPN became the wound care nurse a couple of weeks ago, and was trained by the previous wound care nurse. S2 DON confirmed S10 LPN should have performed hand hygiene after doffing her gloves and setting up supplies on a clean field. S2 DON stated S10 LPN should not have touched the contaminated surfaces with her gloves while performing wound care.

Based on observation, interview and record review, the facility failed to implement the comprehensive person-centered care plan for 1 (#83) of 4 (#17, #21, #76 and #83) sampled residents reviewed for care plans. The facility failed to monitor a medication that was self-administered by a resident. Findings: Review of the facility's policy titled, Medication - Self-Administration with no date, revealed the following, in part: .The nurse will check with the resident each day and document on the MAR if the medication was taken as reported by the resident . Review of Resident #83's medical record revealed an admitted [DATE] with diagnoses that included in part .Major Depressive Disorder, Hypertensive Heart Disease without Heart Failure, Obstructive and Reflux Uropathy, Shortness of Breath and Pain. Review of Resident #83's Admission MDS with an ARD of 09/09/2024 revealed a BIMS summary score of 15, indicating Resident #83 was cognitively intact. Review of Resident #83's current care plan with a start date of 09/07/2024, revealed Resident #83 may keep Albuterol inhaler at bedside for self-use, and nursing staff was to assist with recording and monitor usage. Review of Resident #83's physician's orders dated 09/07/2024 revealed .may keep Albuterol inhaler at bedside, nursing staff to assist with reordering and monitor usage. Review of Resident #83's Medication Administration Record (MAR) from 09/07/2024 through 10/14/2024 revealed no documentation indicating that Resident #83 used his Albuterol inhaler. Observations on 10/15/2024 09:48 a.m. revealed an Albuterol inhaler on Resident #83's bedside table. An interview with Resident #83 at that time, revealed he self-administers his Albuterol inhaler 3 to 4 times a week at night. An interview on 10/15/2024 at 10:48 a.m. with S9 LPN, revealed he has been taking care of Resident #83 for approximately a month. S9 LPN indicated that he was not aware Resident #83 had an Albuterol inhaler at his bed side. An interview on 10/15/2024 at 10:50 a.m. with S2 DON, confirmed that Resident #83 was able to self-administer his Albuterol inhaler, and it was not being documented on the MAR. S2 DON indicated the nurses should have been asking Resident #83 if he self-administered his Albuterol inhaler and documenting his response on the MAR.

Resident #47 Based on observation, record review and interview, the facility failed to ensure a resident received proper treatment and an assistive device to maintain and/or improve hearing for 1 (#47) resident reviewed for communication and sensory problems out of a total sample of 21 residents. Findings: Review of Resident #47's Medical Record revealed an admitted [DATE] with diagnoses that included in part . Benign Paroxysmal Vertigo, Unspecified Ear, Age-related Cataracts, Bilateral, Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus, Parkinson's disease and Speech and Language Deficits following unspecified Cerebrovascular Disease. Review of Resident #47's Quarterly MDS with an ARD of 07/25/2024 revealed a BIMS score of 15, indicative of intact cognition. Review of MDS revealed resident with moderate difficulty with ability to hear and speaker has to increase volume and speak distinctly. Resident did not use a hearing aid or other hearing appliance. Review of Resident #47's Care Plan with a Target date of 10/25/2024 revealed in part . Resident with difficulty hearing related to minimally Hard of Hearing, does not wear hearing aids and to refer to hearing center for hearing aid program. Review of Care Plan revealed an appointment on 02/26/2024 with hearing center today, cleaned ears bilaterally, noted significant hearing loss both ears, recommend trial with amplifier. Resident given (Louisiana Commission for the Deaf) LCD, meets criteria for hearing aid program. Contact hearing center to start process. Review of Resident #47's Progress notes per MD dated 02/26/2024 revealed: Clean ears bilaterally. Recommend trial with amplification. Patient given LCD/ referral. Review of email correspondence regarding Resident #47 dated 10/15/2024 at 3:25 p.m. titled, LCD Hearing Aid Program- Application Received revealed application received on 10/15/2024. Interview on 10/14/2024 at 10:18 a.m. with Resident #47 reported that she went to get tested back in February 2024 and never got a follow up appointment to get hearing aids and she needs them because she is hard of hearing. Interview with 10/15/2024 at 3:41 p.m. with S1 Administrator presented with receipt of application received by LCD Hearing Aid program dated 10/15/24 at 03:25 PM. S1 Administrator stated the program will contact us. Interview on 10/15/2024 at 3:45 p.m. with S11 SSD revealed that she had made a telephone call to a hearing aid program in Lake [NAME] after resident's appointment back in February for a hearing aid and not heard back from them and overlooked checking back with them. She stated she submitted an application for a hearing aid today with another program. S11 SSD confirmed that she did not follow up with the LCD Hearing Aid Program to assist Resident #47 in obtaining an assistive hearing device and should have.

FACILITY QAPI and QAA Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's quarterly committee meetings. Findings: Review of the facility's 4th Quarterly Quality Assessment and Assurance (QAA) committee sign in sheet conducted on January, 06, 2024 revealed staff in attendance was the facility's Medical Director, Infection Preventionist, staff RN and a staff LPN. Interview on 10/16/2024 at 2:40 p.m. with S2 DON revealed that she was present as a staff RN at the time of the 4th Quarterly QAA meeting was held but the DON at that time was not present. During an joint interview on 10/16/2024 at 2:43 p.m., S1 Administrator and S2 DON indicated that the other members were not available at the time of the QAA meeting scheduled with the facility's Medical Director. S1 Administrator confirmed the required staff members were not in attendance for the Quarterly QAA meetings and should have been.

Based on interview and record review, the facility failed to ensure facility staff used a mechanical lift with two person assist during transfer from the bed to chair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for accidents. The facility census was 84. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on 05/19/2024 between 10:00 a.m. and 11:00 a.m., when S3 CNA attempted to transfer Resident #2, who required a Mechanical lift with 2 person assistance, without the use of the lift and assistance of another staff. Resident #2 sustained a fall during the attempted transfer by S3 CNA. Resident #2 was sent to the local ER following the fall due to complaint of pain to both knees. Resident #2 was diagnosed with a fracture of the Left Femur and Right Tibia, and sent to another facility for a higher level of care. Resident #2 required Closed Reduction surgery to Left Femur on 05/24/2024. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's undated policy titled Safe Lifting and Movement of Residents, read in part . In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess the individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included in part . Generalized Muscle Weakness, Difficulty in Walking, Unsteadiness on Feet, Other Specified Disorders of Bone Density and Structure. Review of Resident #2's Comprehensive Risk Assessment completed on 04/03/2024, revealed Resident #2 was high risk for falls, and required mechanical lift for transfers. The assessment revealed a score of 10 or higher indicated a high risk for falls. Resident #2's score was 12. Review of a Quarterly MDS Assessment with an ARD of 04/03/2024, revealed Resident #2 had a BIMS score of 9 (Moderate Cognitive Impairment). Resident #2 was totally dependent upon staff, and required 2 + person physical assist for transfers. Review of Resident #2's Care Plan with a target date of 07/12/2024, revealed a problem of: 1. Extensive assistance with ADL's - Wheelchair for Mobility, Does not ambulate, and History of falls. Interventions included: Assist as needed, and Mechanical lift x 2 people. 2. Falls - History of falling. Interventions included: Hoyer mechanical lift X 2 people for transfers. Review of Resident #2's Progress Notes read in part . 05/19/2024 at 11:25 a.m., documented by S5 LPN, read in part . Resident #2 complained of increased pain to bilateral knees and nausea. Three loose bowel movements this morning. S8 NP made aware, and received orders to apply Biofreeze (topical analgesic) to bilateral knees x 1, KUB, and check for impaction. 05/19/2024 at 2:50 p.m. - Radiology in facility. During X-rays Resident #2 complained of severe pain to left knee. Moaning and guarding noted during repositioning. S8 NP made aware, and received orders to X-ray bilateral knees. Swelling noted above left knee. S8 NP ordered x1 dose of Norco (pain medication). 05/19/2024 at 5:32 p.m. - Contacted imaging in regard to x-ray results, results not finalized at this time. S8 NP made aware and voiced understanding. 05/19/2024 at 6:38 p.m. - Resident #2 noted with increased pain at this time to legs. Restless in bed. Reporting severe pain behind left leg. S8 NP made aware and gave orders to send to ER with family permission. 05/19/2024 at 7:24 p.m. - Resident #2 left facility via ambulance. 05/20/2024 at 5:52 a.m., documented by S6 LPN - Called for update. Resident #2 sent to higher level of care hospital for further evaluation and surgery consideration. 05/31/2024 at 12:36 p.m., documented by S7 LPN - Received report from nurse at hospital. Resident #2 was admitted for Left Femur Fracture, Right Proximal Tibia Periprosthetic Fracture, Anemia, and Elevated Troponin. Resident #2 required surgery and received a Left Intramedullary Nail on 05/24/2024, and has staples in place from the outer top hip to knee. Follow up needed for orthopedic in 2-3 weeks. Right leg has an immobilizer in place, with order to be non-weight bearing to left and right side lower extremities. Review of a statement dated 05/19/2024, and written by S3 CNA, read as follows in part .I (S3 CNA) attempted to get Resident #2 up for bible study. I (S3 CNA) called S4 CNA for help for a 2 person transfer from bed to chair. As we attempted, her knees buckled. We did not get her up; we put her back in the bed. I (S3 CNA) reported to S5 LPN. Review of a statement dated 05/19/2024, and written by S4 CNA, revealed in part . I (S4 CNA) was asked to assist with Resident #2's transfer. S4 CNA documented that she entered the room, and Resident #2 was sitting on the side of the bed with wheelchair nearby. S3 CNA and I (S4 CNA) started 2 person assist. Resident #2 bared weight then started to fall. S3 CNA and I (S4 CNA) helped Resident #2 to the floor, and got Resident #2 back to the bed, then went to tell the nurse. Review of a statement dated 05/19/2024 written by S5 LPN, revealed in part . Notified by S3 CNA that Resident #2 had difficulty transferring, increasing bilateral knee pain, nausea, and diarrhea. S3 CNA and S4 CNA reported when Resident #2 complained of pain during transfer, they stopped and placed her back in bed. Upon assessment, Resident #2 did complain of bilateral knee pain and nausea. S8 NP made aware, and orders received. Continuous monitoring of Resident #2 was performed. No deformities noted to bilateral lower extremities during assessment. S8 NP requested CNA's be asked if any fall had occurred to which both denied. S3 CNA summoned nurse during KUB, and increase pain to left lower extremity noted at this time, with swelling above left knee. S8 NP made aware and received further x-ray orders. A dose of pain medication administered. Telephone interview on 06/11/2024 at 11:00 a.m. with S3 CNA, revealed on Sunday 05/19/2024, she went to get Resident #2 up for bible study at approximately 10:00 a.m. S3 CNA stated she dressed resident in bed, then called for S4 CNA to come assist her with transferring Resident #2 from her bed to wheelchair. S3 CNA stated she and S4 CNA did not use the mechanical lift to transfer Resident #2, but should have. S3 CNA stated she did know that a lift was to be used for Resident #2, but the resident had previously been able to bear weight on other occasions for transfers, so she attempted to transfer without the lift. S3 CNA stated Resident #2 did not fall. S3 CNA stated Resident #2's knees buckled when she stood, but she did not touch the ground. S3 CNA stated she immediately put Resident #2 back to bed when they could not transfer her. S3 CNA stated she called S5 LPN to Resident #2's room to come assess Resident #2, as the resident complained of knee pain. S3 CNA stated she was trained by the facility on using the lift and on how to transfer residents. S3 CNA stated she had not followed the plan of care for Resident #2, and she should have used the lift with 2 person assist to transfer Resident #2. Interview on 06/10/2024 at 12:10 p.m. with S1 Administrator, confirmed on 05/19/2024, Resident #2 had a fall in room when S3 CNA attempted to transfer Resident #2 by herself without the assistance of another staff member, and without the mechanical lift. S1 Administrator stated initially, the facility did not know Resident #2 had a fall, as S3 CNA and S4 CNA denied a fall occurred. S1 Administrator stated S3 CNA and S4 CNA informed S5 LPN that they attempted to transfer Resident #2, but she began to complain of knee pain, so resident was put back to bed. S1 Administrator stated S5 LPN notified S8 NP and got x-rays ordered. S1 Administrator stated when the facility was informed Resident #2's X-ray reports, the facility immediately began an investigation on 05/19/2024. S1 Administrator stated the facility had staff write statements, and S2 DON began in-services. S1 Administrator stated during the investigation, S4 CNA informed them that she was coming to assist S3 CNA with transferring Resident #2. S4 CNA stated as she entered the room, she saw Resident #2 on her knees. S4 CNA stated she helped S3 CNA get Resident #2 into bed, and that S3 CNA had attempted to transfer Resident #2 alone, without a lift. Interview on 06/11/2024 at 2:20 p.m. with S2 DON, revealed staff were to follow residents' plans of care in regards to transfers. S2 DON stated that staff failed to do so on 05/19/2024 resulting in a fall for Resident #2. Throughout the survey from 06/10/2024 thru 06/12/2024, random interviews of staff were conducted. Staff stated that they had previously received training on transferring residents with mechanical lifts, and had been recently in-serviced on the use of mechanical lifts. Review of a list of residents who required a mechanical lift for transfers, revealed 18 residents required the use of a lift for transfers. Random interviews with cognitive residents who required the use of a lift for transfers were conducted, and revealed staff utilized the mechanical lift with 2 people when transferring them. The facility has implemented the following actions to correct the deficient practice: 1. A Root Cause Analysis was completed, and it was determined that S3 CNA did not request assistance with mechanical lift transfer x 2 person assist, and attempted to transfer Resident #2 independently without a lift. 2. All residents requiring use of mechanical lift for transfers were audited to ensure the following was within their medical record: physician order, care plan, Smart Chart documentation, signage above head of bed, and information on transfer type added to resident specific rounding sheet. Results: all 18 residents who require a lift for transfer were in compliance. Completed 05/20/2024. 3. Staff in-services immediately initiated regarding where to find transfer status, proper use of lift, reporting of falls, reporting of lowering residents to ground, and accurate charting of ADL's. Initiated 05/19/2024 and completed 05/23/2024. 4. Policy/Procedure: Lift transfer policy reviewed on 05/202/2024 with no changes. 5. Monitoring: DON, or Designee will observe and supervise as necessary 8 lift transfers per week for 8 weeks. Any concerns identified will be reported and appropriate action taken to include retraining, further observations etc. The results of the observations will be reviewed with the QA Committee weekly for review of continued compliance. Monitoring initiated 05/27/2024 and is ongoing. 6. Corrective Action Plan effective as of 05/19/2024 with completion date of 05/23/2024.

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 all 70 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facility's approved Menu Matrix revealed: Lunch: Fried Chicken 4oz. Instructions read in part Serve 4oz breaded portion=3oz meat 1 Breast or 1 Thigh + 1 Drumstick An observation on 10/30/2023 at 12:00 p.m. in the dining room during lunch revealed dietary staff preparing resident plates in the kitchen area. The meal included fried chicken. An observation of a resident plate revealed 1 drum stick as the only meat serving on the plate. The plate was covered and placed on the meal cart for facility residents dining in their room. An interview on 10/30/2023 at 12:05 p.m. with S3 Dietary Manager revealed there was no scale in the facility to weigh serving sizes and that staff usually just eye ball the food items that was being served to the residents. S3 Dietary Manager stated if staff do not feel like the meat serving size is big enough, dietary staff will serve 2 pieces of meat. S3 Dietary Manager confirmed there was not enough meat being served on the tray and 2 pieces of meat should have been given but it had not been. An interview on 10/30/2023 at 12:10 p.m. with S1 Administrator stated the piece of chicken served did not appear to be 4 ounces. S1 Administrator confirmed the correct serving size of 4 ounces of fried chicken was not served and should have been.

Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #223) of 2 (Resident #12 and Resident #223) Residents sampled for dignity, by failing to ensure she was free of facial hair. Total sample size was 23. Findings: Review of Resident #223's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, Depression Unspecified, Mild-Protein Calorie Malnutrition, Anemia, Age-Related Physical Debility and Unspecified Atrial Fibrillation. Review of Resident 223 #'s Annual MDS with an ARD of 09/26/2023 revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #223 required two person physical assistance with bed mobility and transfers; total dependence with toilet use, bathing and personal hygiene and one person physical assistance with dressing. Resident #223 was coded as having no behaviors. Review of Resident #223's Care Plan with a review date of 12/06/2023 revealed she required assistance with all ADL's and interventions to assist Resident with ADL's as needed. Observation and interview on 10/30/2023 at 9:40 a.m. revealed Resident #223 in bed. Resident #223 noted have long facial hair approximately 1-inch long. Resident #223 stated she would like the facial hair to be removed. Observation on 10/30/2023 at 11:05 a.m. revealed Resident #223 sitting in a wheelchair in the front lobby. Resident #223 was noted to have long facial hair approximately 1-inch long. Observation and interview on 10/30/2023 at 11:17 a.m. with S2 DON in attendance revealed Resident #223 sitting in a wheelchair in the front lobby with long facial hair approximately 1-inch long. S2 DON confirmed Resident #223 had long facial hair and she should not. Interview on 11/30/2023 at 11:36 a.m. with S9 CNA revealed she had provided morning care for Resident #223 which included perineal care, lotion and clean clothes. S9 CNA stated she had not attempted to remove the facial hair from Resident #223 and she should have.

Based on interview and record review the facility failed to ensure a resident's right to be free from unsolicited sexual abuse (touching) for 1 (Resident #60) of 1 sampled residents. The facility failed to protect Resident #60 from sexual abuse by Resident #48 on 07/01/2023. Total sample size was 23. Findings: The review of the facility's policy titled Abuse Prevention and Investigation read in part . Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #60 Review of Resident #60's clinical record revealed an admitted [DATE] with diagnoses which included: Major Depressive Disorder, Unspecified Dementia, and Vascular Dementia. Review of Resident #60's Quarterly MDS with an ARD of 08/14/2023 revealed a BIMS score of 3 (indicating severe cognitive impairment). Review of Resident #60's Care Plan with a review date of 11/14/2023 revealed a problem of Altered Cognition related to diagnosis of Dementia, Depression and Suicidal Ideations with interventions that included: Ask simple questions with visual cues if possible and to assist with decision making as needed or enlist family to do so. Resident #48 Review of Resident #48's clinical record revealed an admitted [DATE] with diagnoses which included: Dementia Unspecified, Mild Cognitive Impairment of uncertain or unknown etiology, Cognitive Communication Deficit, and Mood Disorder due to known physiological condition unspecified. Review of Resident #48's Annual MDS with an ARD of 09/13/2023 revealed a BIMS score of 4 (indicating severe cognitive impairment). Review of Resident #48's Care Plan with a target date of 12/13/2023 revealed a problem of Disturbed thought process related to short-term memory/long-term memory deficits; impaired decision making skills secondary to diagnosis of Dementia, Cerebral Infarction, Depression, Anxiety, and Schizoaffective Disorder with interventions which included: Counseling as needed for noncompliance or inappropriate behavior; to redirect to not touch others, staff to do every 30 minute checks on Resident #48 (implemented after incident on 07/01/2023). Interview on 10/30/2023 at 2:48 p.m. with S1 ADM revealed on 07/01/2023 Resident #60's groin area was touched while in the front lobby of the facility by Resident #48. S1 ADM revealed this incident of Resident to Resident Sexual Abuse was witnessed by S10 CNA. S1 ADM confirmed Resident #60 was not cognitively intact to consent to being touched by Resident #48. Interview on 10/31/2023 at 10:05 a.m. with Resident #60 revealed no one at the facility had ever done anything inappropriate to him. Resident #60 stated no staff or Resident had ever made him feel uncomfortable or touched him anywhere he didn't want to be touched. Resident #60 stated he felt safe at the facility. Telephone interview on 10/31/2023 at 10:18 a.m. with S10 CNA revealed she was walking through the front lobby going to the dining room to get supper trays on 07/01/2023 when she witnessed Resident #48 touching Resident #60 in his groin area. S10 CNA stated she instructed Resident #48 to remove her hand from Resident #60's groin area and Resident #48 slid her hand to Resident #60's thigh area. S10 CNA stated she separated the two residents and notified S11 LPN of the incident. Interview on 10/31/2023 at 10:41 a.m. with S2 DON revealed she received a telephone call on 07/01/2023 around supper time from S11 LPN stating Resident #48 had touched Resident #60 in the groin area. S2 DON stated she instructed S11 LPN to separate Resident #48 and Resident #60; put Resident #48 on 1:1 supervision; and notify the doctor. S2 DON stated she then notified S1 ADM of Resident #48 touching Resident #60 in the groin area. Interview on 10/31/2023 at 10:51 a.m. with S9 CNA stated she was at the nurse's station the evening of 07/01/2023. S9 CNA stated Resident #48 and Resident #60 were both sitting on the couch, in the front lobby. S9 CNA stated S10 CNA came to the nurse's station and reported to S11 LPN she had witnessed Resident #48 touching Resident #60 in the groin area. S9 CNA stated she observed Resident #48's hand on Resident #60's thigh when S10 reported the incident to S11 LPN. Telephone interview on 10/31/2023 at 11:01 a.m. with S11 LPN stated she was the evening shift nurse for Resident #48 and Resident #60 on 07/01/2023. S11 LPN stated she was at the nurse's station when S10 CNA reported to her that Resident #48 had just touched Resident #60 in his groin area. S11 LPN stated Resident #48 and Resident #60 were both sitting on the couch, in the front lobby. S11 LPN stated she had been monitoring all residents in the front lobby. S11 LPN stated when the incident was reported to her Resident #48 and Resident #60 were separated and Resident #48 was put on every 30 minute checks. S11 LPN stated she called S2 DON and was instructed to separate Resident #48 and Resident #60; put Resident #48 on 1:1 supervision; and notify the doctor. S11 LPN stated she received orders to send Resident #48 to the behavioral hospital and Resident #48 left later that night. Interview on 11/01/2023 at 9:16 a.m. with Resident #48 revealed she had no recollection of the incident which occurred on 07/01/2023 involving Resident #60. Resident #48 stated she knew Resident #60, but did not know if he resided at the facility.

Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 1 (#60) of 1 residents reviewed for abuse in a total of 23 sampled residents. Interview on 10/30/2023 at 2:48 p.m. with S1 ADM revealed on 07/01/2023 at 6:00 p.m. Resident #60's groin area was touched by Resident #48. S1 ADM revealed this incident of resident to resident non- consensual sexual contact was witnessed by S10 CNA. S1 ADM confirmed Resident #60 was not cognitively intact to consent to being touched by Resident #48. Review of the SIMS (Statewide Incident Management System) report dated 07/11/2023 revealed the allegation of sexual abuse for Resident #60 had been substantiated by the facility. Documentation on the SIMS report reflected the discovery date and time of sexual abuse for Resident #60 was on 07/01/2023 at 6:03 p.m. The SIMS entry time was noted as 07/02/2023 at 2:31 p.m. Interview on 10/31/2023 at 2:48 p.m. with S1 ADM confirmed the allegation of resident to resident sexual abuse was substantiated by the facility. S1 ADM confirmed a SIMS report was not entered immediately or within 2 hours after discovery of abuse because there was no serious bodily injury.

Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a magnifying glass was followed for 1 (Resident #52) resident. Total sample size was 23. Findings: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Legal Blindness Review of Resident #52's Annual MDS with an ARD of 07/26/2023 revealed resident had a BIMS score of 12 (which indicated moderately impaired cognition), and exhibited no behaviors or rejection of care. The MDS revealed Resident #52's vision was coded as being moderately impaired-limited vision, not able to see newspaper headlines but can identify objects. Review of Resident #52's Care Plan with a Review date of 01/11/2024 read in part .resident had impaired vision: Legally blind in right eye, left eye vision adequate, does not wear glasses with interventions that included provide large print materials and a magnifying reading glass to read smaller print. Observation and interview on 10/30/2023 at 10:29 a.m. of Resident #52 revealed she was unable to see out of her right eye but could see out of her left eye. Resident #52 revealed she could not see the clock on the wall which was positioned over her bathroom door approximately 12 feet from her bed. Resident #52's activity calendar was noted to be taped to the bathroom door and was in small print. When given the activity calendar Resident #52 was unable to read the small print. No magnifying glass noted in Resident #52's room at this time. Observation and interview on 10/31/2023 at 1:00 p.m. with S6 SSD revealed she was unsure if Resident #52 had a magnifying glass in her room. S6 SSD was unable to locate a magnifying glass in Resident #52's room. Resident #52 stated it had been a while since she had a magnifying glass but would have liked one, because she had a lot of books to read. S6 SSD confirmed Resident #52 did not have a magnifying glass in her room and she should have. S6 SSD confirmed Resident #52's activity calendar was not in large print and it should have been. Interview on 10/31/2023 at 1:15 p.m. with S7 Activity Director stated she was not aware that Resident #52 should have had a large printed activity calendar. S7 Activity Director stated she did not attend Care Plan meetings. Interview on 10/31/2023 at 1:20 p.m. with S8 RN MDS revealed she was unsure if Resident #52 had a magnifying glass. S8 RN MDS confirmed the Care Plan read to provide Resident #52 with a magnifying glass and large print materials.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 3 (Resident #2, Resident #18 and Resident #52) of 6 (Resident #2, Resident #11, Resident #18, Resident #26, Resident #35 and Resident #52) residents reviewed for ADL care. Findings: Review of the Facility's Nail Care read in part . Policy: The Purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail Care will be provided between scheduled occasions as the need arises. #2 Review of Resident #2's Care plan with a review date of 12/20/2023 revealed in part Self-care deficit related to generalized ? requires supervision and assistance with ADL's. Fingernails to be checked and cleaned daily. An observation and interview on 10/30/2023 at 10:16 a.m. revealed Resident #2 with long fingernails with a brown substance noted under fingernails. Resident #2 stated staff typically cut his nails but had not cut them lately. An interview on 10/30/2023 at 10:34 a.m. with S4 LPN confirmed Resident #2's nails are long with a brown substance noted under fingernails and should have been cleaned and cut but had not been. #18 Review of Resident #18's Care plan with a review dated of 11/9/2023 revealed in part . Resident requires assistance with ADL's. Assist with ADL's as needed. An observation on 10/30/2023 at 10:21 a.m. revealed Resident #18 nails were long and jagged. Resident # 18 stated she would like her nails clipped but was unsure who to ask. An interview on 10/30/2023 at 10:32 a.m. with S4 LPN confirmed Resident #18's finger nails were long and jagged needing to be cut and had not been. 44844 #52 Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Phantom Limb Syndrome with Pain, Other Reduced Mobility, Major Depressive Order, Legal Blindness and Acquired Absence of Left Leg below the Knee. Review of Resident #52's Yearly MDS with an ARD of 07/26/2023 revealed resident had a BIMS score of 12 (which indicated moderately impaired cognition), and exhibited no behaviors or rejection of care. The MDS revealed Resident #52 was coded as requiring extensive assistance with personal hygiene. Review of Resident #52's Care Plan with a Review date of 01/11/2024 revealed resident required extensive to total assistance with all ADL's with interventions that included to assist with ADL's as needed. Observation on 10/20/2023 at 10:05 a.m. revealed Resident #52 in bed. Resident noted to have long fingernails approximately 1-inch long with a black substance under them. Resident #52 stated the nurse was supposed to have trimmed her fingernails a couple of weeks ago, but didn't. Resident #52 stated she would have liked her nails trimmed. Observation and interview on 10/20/2023 at 11:20 a.m. revealed Resident #52 had been bathed, but her fingernails were still approximately 1-inch long with a black substance under them. Observation and interview on 10/30/2023 at 11:29 a.m. with S5 LPN confirmed Resident #52's fingernails were long with a black substance under them and it should not have been. S5 LPN stated the treatment nurse or hall nurse was responsible for trimming Resident #52's fingernails.

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Parkinson's disease, Mild Cognitive Impairment and Difficulty in Walking. Review of Resident #1's Quarterly MDS with an ARD date of 02/27/2023 revealed a BIMS score of 13, indicating intact cognition. Resident #1 required extensive assistance with 2+ person physical assistance with bed mobility, transfers and toilet use. Review of Resident #1's Physician orders dated 05/02/2023 revealed an order for Levaquin 750 mg IVPB q 24 hours x 7 days. Review of Resident #1's Nurses Notes and Medication Administration Record revealed the Levaquin was administered IVPB on 05/03/2023 at 10:20 a.m. by S1 DON. Interview on 05/09/2023 at 11:11 a.m. with S3 NP revealed Resident #1 was transferred to a local hospital on 05/01/2023. S3 NP stated Resident #1 had an increased temperature on arrival to the hospital and a chest X-ray revealed early infiltrates. S3 NP stated the hospital initiated IV antibiotics and it was decided that Resident #1 would return to the facility and continue the course of IV antibiotics. Interview on 05/09/2023 at 12:56 p.m. with S1 DON revealed Resident #1 returned to the facility in the evening on 05/01/2023 from the hospital after starting IV antibiotics and was to continue IV antibiotics at the facility. S1 DON stated the Levaquin ordered should have been administered at 9:00 p.m. on 05/02/2023 in order to continue the timed IV antibiotic therapy started in the hospital. S1 DON stated the evening nurse did not administer the Levaquin at 9:00 p.m. on 05/02/2023 and stated the reason was because she could not find an IV pole. Interview on 05/09/2023 at 12:58 p.m. with S1 DON confirmed the evening nurse did not administer the Levaquin at 9:00 p.m. on 05/02/2023, but should have. S1 DON stated that was a medication error.

Based on record review and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of the facility's Safe Resident Handling/Transfers policy revealed in part .The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. The resident's mobility needs will be addressed on admission and reviewed quarterly . Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Parkinson's disease, Mild Cognitive Impairment and Difficulty in Walking. Review of Resident #1's Quarterly MDS with an ARD date of 02/27/2023 revealed a BIMS score of 13, indicating intact cognition. Resident #1 required extensive assistance with 2+ person physical assistance with bed mobility, transfers and toilet use. Review of Resident #1's Care Plan with a target date of 05/27/2023 revealed in part: At risk for falls with injury related to history of falls .2 person assist with transfers. Goal: Resident will remain safe in environment with least restrictive means. Interview on 05/09/2023 at 1:25 p.m. with S2 CNA revealed she transferred Resident #1 from the bed to the shower chair without assistance on 04/29/2023. S2 CNA stated she noticed a skin tear on Resident #1's leg immediately after the transfer. S2 CNA stated she was aware Resident #1 required two people for transfers. Interview on 05/09/2023 at 2:20 p.m. with S1 DON revealed Resident #1's MDS and care plan stated Resident #1 required two people for transfers. S1 DON confirmed S2 CNA transferred Resident #1 to the shower chair without assistance, but should not have.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions and 2) ensure food stored was dated and expired food was disposed of. 3) preparation equipment was clean. This deficient practice had the potential to affect the 83 Residents that received meals prepared in the kitchen. Findings: Review of the Facility's Policy titled Cleaning Equipment/Wiping Clothes read in part: Policy: A detailed procedure for cleaning each piece of equipment should be maintained in the Dietary Department and reviewed periodically with the staff. 2. All parts should be cleaned and sanitized like kitchen utensils. 5. Allow to air dry. Review of the Facility's Policy titled Storage: Refrigerator read in part: 7. Keep refrigerated food wrapped or covered and in sanitary containers. Review of the Facility's Policy titled Storage: Freezer read in part: 3. Label and date all items. Review of the Facility's Policy titled Ice Pass, Water Pitchers, & Ice Machines read in part: 7. Scoop must be placed in clean plastic bag or clean holder when not in use. 9. Ice machines must be emptied and cleaned according to the manufacturer's instructions at least monthly. Observation of the kitchen on [DATE] at 10:35 a.m. accompanied by S5 RN revealed the following: 1. Two 32 qt. clean pots on a storage cart were stacked on top of one another and were wet. 2. A storage cart with 20 clean steam line pans stacked inside one another on a storage cart with 11 of the pans noted to have dried food items and/or greasy film in the bottom and around the rim. 3. Ten 4.0 qt. food warmer pans, (2) 6.0 qt. food warmer pans, and (2) 9.3 qt. food warmer pans were stored on a 3 tier stationary cart stacked inside one another were noted to have been stored wet. 4. Bottles of imitation flavors were opened, undated, expired were stored on a shelf for use: (1) 10 oz. bottle of imitation rum flavor-expired on [DATE]. (1) 10 oz. bottle of almond flavor- expired on [DATE]. (1) 10 oz. bottle of banana flavor- expired on [DATE]. 5. The following food items were stored in refrigerator opened and undated: (1) gal. jar of Acteo Balsamico DI [NAME]. (1) qt. jar of gray master. (1) 10 oz. bottle maraschino cherries. (1) 9 qt. container of dill pickles. (1) gal. jar of soy sauce. (1) 5 lbs. plastic bucket of pimento cheese spread. (1) gal jar of honey mustard. 6. Deep fryer and stove were noted to have layers of thick brownish gel-like substance caked on the back panel and on the floor surrounding the areas of the legs of both. 7. Ice scoop was stored opened on top of the ice machine on a plastic serving tray. 8. Ice machine inner door panel, grooves and gasket with thick dark black substance. Interview on [DATE] at the time of the observations accompanied by S5 RN, confirmed the above findings.

Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents for 1 (#48) of 1 sampled residents for incidents and accidents. The facility failed to ensure Resident #48 had a bed alarm applied to prevent falls after sustaining a fall with major injury. Findings: Review of Resident #48's clinical record revealed an admitted [DATE] with diagnoses that included: Type II Diabetes Mellitus, History of falling, [CONDITION(S)] and Depression. Interview on 09/19/2022 at 11:44 a.m. with Resident #48 revealed she had fallen in her bathroom a few weeks ago and broke her leg. Observation at the time of interview revealed the resident seated in a wheelchair at her bedside with an immobilizer on her right leg. Further observation revealed no presence of fall mats or bed/chair alarms in use. Review of the clinical record revealed Resident #48 was hospitalized from 08/22/2022 through 08/27/2022 after falling in her bathroom and sustaining a right femur fracture that required an open reduction with internal fixation surgery. Review of Resident #48's CPOC with target date of 11/06/2022 revealed in part Falls: At risk for falls, falls will not occur. 08/27/2022 Add pressure pad alarm to bed related to recent fall. Observation on 09/20/2022 at 8:00 a.m. revealed Resident #48 asleep in bed. Resident #48's call light was within reach and no bed alarm devices observed in use. Observation on 09/20/2022 at 10:35 a.m. revealed Resident #48 asleep in bed. A bed exit alarm was observed in place on the resident's bed. Interview on 09/20/2022 at 10:40 a.m. with S7 CNA revealed he was assigned to Resident #48. He confirmed the resident did not have a bed alarm earlier this morning and he was unsure who had put the alarm on the resident's bed. Interview on 09/20/2022 at 10:42 a.m. with S6 LPN revealed she was the nurse assigned to Resident #48 and was not aware the resident had a bed alarm. She stated she had not applied a bed alarm to the resident's bed this morning and was not sure who had. Review of facility camera footage from the resident's hall accompanied by S1 Administrator revealed S3 LPN/Admission Nurse entered Resident #48's room at 9:56 a.m. on 09/20/2022 with a bed exit alarm and then exited moments later without it. Interview on 09/20/2022 at 10:53 a.m. with S3 LPN/Admission Nurse revealed she was told by the S2 DON to apply a bed exit alarm to Resident #48's bed earlier that morning. She confirmed Resident #48 did not have a bed exit alarm in place prior to her applying the alarm and she should have.

Based on record review and interview the facility failed to complete a significant change MDS within 14 days after determining there was a significant change in 1 (#48) of 25 sampled resident's physical conditions after a fall with major injury Findings: Review of Resident #48's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an MDS Assessment with an ARD of 08/22/2022 revealed Resident #48 required limited assistance for transfers, walking in room, hygiene and toileting. Further review revealed Resident #48 required supervision for locomotion on and off the unit, physical help in part of bathing activity and no upper or lower extremity functional limitations in ROM. Review of a Significant Change MDS Assessment with an ARD of date of 08/31/2022 revealed Resident #48 required extensive assistance for toileting, and hygiene. Further review revealed Resident #48 was total dependence for bathing and had lower extremity ROM impairment on one side. Continued review of the assessment revealed only sections C and D were complete. Interview on 09/20/2022 at 4:43 p.m. with S4 LPN/MDS Nurse revealed the resident's Significant Change MDS Assessment with ARD of 08/31/2022 had not been completed within 14 days of significant changes in resident's status and should have been.

Based on record review and interview, the facility failed to provide the necessary care and services for 1 of 5 sampled residents (#4) to maintain the highest practicable physical well-being. The facility failed to communicate between staff the level of supervision resident #4 required when up in his wheelchair after a right BKA. The resident was placed in his wheelchair, unattended, for longer than the length of time he had been assessed by the PT to be safe (10 minutes). As a result, the resident fell out of his wheelchair, received a laceration to the top of his head requiring staples and sustained a C1 and C2 spinal fracture. After the fracture, he had difficulty swallowing and required a feeding tube for nutrition. The total facility census was 90 residents. Findings: Review of resident #4's medical record revealed he was admitted to the facility on [DATE]. Review of his Face Sheet revealed [DIAGNOSES REDACTED]. Review of the resident's Care Plan with a goal date of 12/19/15 revealed he had a left BKA in April 2014. Documentation also revealed he was admitted to the facility with diabetic and arterial ulcers to his right foot. Review of the Departmental Notes revealed he returned from a hospital stay on 10/5/15 due to Pneumonia. Review of a Departmental Note dated 10/7/15 at 10:31 a.m. revealed the resident was assessed to have a BIMS score of 11; indicating moderate cognitive impairment. Documentation also revealed that his speech was clear and understandable. Review of a Departmental Note dated 10/7/15 at 2:18 p.m. revealed the resident was in bed and stated he hurt all over and did not feel good. He was receiving oxygen at 2 l/NC at that time, and his oxygen saturation was 89%. His oxygen was increased to 3 l/NC and after 4 minutes, his oxygen saturation increased to 94%. The physician was notified, and a new order was given to send the resident to the hospital. A subsequent Departmental Note dated 10/7/15 at 2:53 p.m. revealed resident #4 left the facility per ambulance and was transported to the hospital. A Departmental Note dated 10/16/15 at 4:28 p.m. revealed the resident returned from his hospital stay (which began on 10/7/15). While he was hospitalized , he received a right BKA due to an infection in the right foot. Review of a Comprehensive Risk assessment dated [DATE] at 5:00 p.m. revealed the resident was assessed by S1 LPN. The assessment revealed the resident was alert and cooperative and returned from the hospital with a right BKA. He had a previous left BKA. His plan included use of 1/4 side rails to help aid with bed mobility, turn and reposition every 2 hours, pressure pad alarm to bed and PT/OT to evaluate and treat. The assessment revealed he was not at high risk for falls. However, the assessment did not address the resident's ability to sit independently in his wheelchair. Interview with S1 LPN on 12/21/15 at 2:03 p.m. confirmed she assessed the resident upon return from the hospital on [DATE]. She confirmed her comprehensive assessment did not include his ability to sit independently in his wheelchair. She stated that although she did not document it; she did not feel he should be transferred out of bed to his wheelchair until PT/OT could evaluate his status. She stated that she verbally communicated to the CNAs on duty that the resident should remain in bed until an evaluation by PT/OT was completed. S1 LPN further stated that the CNAs she gave this information to should have in turn passed this information on in report to the oncoming shift of CNAs. S1 LPN confirmed she did not report this information to the nurse on duty at the time; she only communicated this to the CNAs. Interview with S2 LPN on 12/22/15 at 11:40 a.m. confirmed that she worked with resident #4 on 10/17, 10/18 and 10/19/15 (Saturday, Sunday and Monday) from 6:00 a.m. to 6:00 p.m. She stated that no one had ever told her in report or otherwise that resident #4 should remain in bed until a PT/OT evaluation was completed. She confirmed that the resident did not get out of bed on those days due to the fact that she felt it was common sense that he remain in bed. She stated he was tired. Interview with S3 CNA on 12/22/15 at 12:00 p.m. confirmed she worked with the resident on 10/17/15 (Saturday) from 6:00 a.m. to 2:00 p.m. She stated that the resident was in bed when she arrived to work that Saturday morning. She stated that the CNA she was relieving did not tell her that resident #4 should stay in bed; however, she confirmed she did not get him up out of bed that day. She confirmed that she was never told by any staff that the resident should remain in bed until a PT/OT evaluation was conducted. She also stated that CNAs are supposed to give shift reports between each shift; however, this did not always occur. She stated that sometimes, CNAs are running late or trying to get their work done, and no report is given between shifts. Review of the Physical Therapy Plan of Care revealed the PT evaluation was completed by S4 PT on 10/19/15. The documented Reason for Referral was due to hospitalization and recent amputation of right leg below the knee resulting to regression with functional mobility, strength, balance, coordination and activity tolerance. The resident required total assist with all transfers and bed mobility and was noted to not be able to tolerate sitting for more than 10 minutes due to low activity tolerance. Further documentation on the Physical Therapy Plan of Care revealed that therapy was necessary to increase his level of independence and in preparation for prosthetic training. Without therapy, the resident is at risk for falls, immobility and onset of secondary medical conditions. Prior to the right BKA, the resident used his wheelchair as the primary means of locomotion. S4 PT documented precautions for the resident as Fall Risk. She also documented he was alert and oriented to person, facility, nursing/family and time. Review of the resident's Current Level of Function documented on 10/19/15 by S4 PT revealed he currently exhibited limited upright sitting tolerance in chair/wheelchair and was noted to maintain upright sitting posture for 10 minutes, and exhibited limitation in upper body trunk strength, sitting tolerance and interactions in his environment. Further documentation under the Current Level of Function revealed he currently rolled side to side with the need for total assistance, transitioned from supine to sitting position with total assist, exhibited BLE residual limb strength to 3/5; fair and transferred from sitting to standing with the need for total assistance. Interview with S4 PT on 12/21/15 at 2:15 p.m. confirmed she evaluated resident #4 on 10/19/15 after his right BKA. She stated that he was very weak and not able to hold his upper trunk up independently. She stated that he required 2 staff to assist him from a lying position to sitting on the side of the bed. Also, he required assistance to sit on the side of the bed. He could not sit up independently on the side of the bed. She stated that after her evaluation, , she did not recommend him getting up in his wheelchair. She stated that she felt he would have been unsafe if he was up in his wheelchair. When asked how she communicated this information to the staff, S4 PT stated she communicated this in the facility's daily 2:00 p.m. meetings. She stated that she, the nurses and the CNAs meet daily to discuss residents' conditions at 2:00 p.m. She confirmed she told the nurses and CNAs on 10/19/15 at the 2:00 p.m. meeting that they should leave the client in his bed due to his weakness and poor tolerance. She confirmed that there was no discussion at that time regarding his transportation to [MEDICAL TREATMENT] the next day. Interview with S5 DON on 12/21/15 at 2:26 p.m. revealed she was not in the 2:00 p.m. meeting on 10/19/15. She confirmed she had never been told by any nurses, CNAs or by S4 PT that the resident should remain in bed. She stated that the nurses in the meeting should have communicated the information to her after the meeting. S5 DON stated that she was not aware of the client's physical status because she had not been providing care for him directly. She stated that nurses should communicate pertinent information regarding residents through their verbal report between shifts or 24 hour sheets. Additional interview with S4 PT on 12/22/15 at 11:00 a.m. revealed she needed to change her interview she had given to the surveyors on 12/21/15. She stated she did evaluate the resident on 10/19/15 to be able to tolerate sitting in his wheelchair for 10 minutes. She stated she communicated to the nurses and CNAs in the 2:00 p.m. meeting on 10/19/15 that the resident was only safe to be in his wheelchair for 10 minutes. She did not state whether he needed a seat belt or direct supervision while up in his chair. She also stated that she told the staff he could go by wheelchair to [MEDICAL TREATMENT] on Tuesday, 10/20/15. She stated when she told staff the resident could go by wheelchair to [MEDICAL TREATMENT], she assumed the staff would get the resident up in his wheelchair and immediately bring him to the van for [MEDICAL TREATMENT]. She did not ask the staff whether he would be in his wheelchair, unsupervised, for greater than 10 minutes. She confirmed she did not ask or discuss with the staff the length of time or the supervision that would be given to the resident when he was placed in his wheelchair for [MEDICAL TREATMENT]. Interview with S2 LPN on 12/22/15 at 11:40 a.m. confirmed that she worked with the resident on Monday, 10/19/15 from 6:00 a.m. to 6:00 p.m. This was the same day S4 PT evaluated the resident according to the documentation. S2 LPN confirmed that she was in the 2:00 p.m. daily meeting that day and no one told her the resident should remain in bed. She stated S4 PT never communicated her evaluation findings that day. She stated prior to his right BKA, the resident was normally up in his wheelchair daily, and staff normally assisted him with mobility in his chair. S2 LPN also confirmed that the resident did not get up in his wheelchair on Monday during her shift due to his weakness. Review of a Departmental Note dated 10/20/15 at 8:00 a.m. revealed that S6 LPN made an entry. Her entry revealed that she was informed at 7:10 a.m. that day that resident #4 was on the floor. Upon arrival to the room, she found he was lying on his right side. The resident told her he fell asleep in his wheelchair and fell out of the chair. She assessed a 1 - 2 inch gash to the top of his head actively bleeding. He also had blood on the tip of his tongue; however, he denied any pain. An ambulance was called at 7:15 a.m. to transport the resident to the ER. The ambulance arrived at the facility at 7:25 a.m. The resident denied any pain or headache. Documentation revealed 2 EMTs transferred the resident from the floor to the stretcher; no cervical collar in place. The resident was joking and laughing with the EMTs and staff according to the documentation. At 7:36 a.m., the ambulance left with the resident, and S6 LPN notified the resident's wife, who was his responsible party at that time. Review of the Departmental Notes dated 10/20/15 at 9:30 a.m. revealed S6 LPN made an entry. Her entry revealed that the ER called at 8:55 a.m. to inform her that they had stapled the gash on top of the resident's head and further testing had indicated that the resident fractured his C1 and C2 in his neck. They were transferring the resident to another hospital for further evaluation. Interview with S7 CNA on 12/22/15 at 10:00 a.m. revealed that she did get resident #4 out of bed with the help of S3 CNA on the morning of 10/20/15. She stated they used the lift to get the resident out of bed. S7 CNA also stated that prior to getting the resident out of bed, she asked S6 LPN if the resident could get up to his wheelchair, and S6 LPN stated the resident could get up in his wheelchair. However, interview with S6 LPN on 12/22/15 at 10:51 a.m. revealed S7 CNA did not ask her if she could get the resident out of bed that morning. Further interview with S7 CNA at that time revealed that when she got the resident up to his wheelchair the morning of 10/20/15, he appeared to be stable in his wheelchair. She confirmed this was the first time she got the resident up to his wheelchair since his right BKA. She was not aware if he had been up in his wheelchair prior to that morning. She confirmed he did not have his left prosthesis on that morning when she put him up in his wheelchair. She stated he was laughing and joking and was oriented to person, place and time. She stated he was up in his wheelchair while she gave his room mate a bed bath. She confirmed he was up in his wheelchair at least 30 minutes, without any seat belt or prosthesis, while she bathed his room mate. After bathing his room mate, she left resident #4 up in his wheelchair unattended in his room. She stated shortly after leaving his room, she was notified that he had fallen out of his chair and was on the floor. Interview with S6 LPN on 12/22/15 at 10:51 a.m. confirmed that the last time she had worked with resident #4 was on 10/16/15 (Friday) from 6:00 a.m. to 6:00 p.m. That was the day he returned to the facility from his right BKA. After that date, she returned to work on 10/20/15 to work 6:00 a.m. to 6:00 p.m. She stated that when she arrived to work on 10/20/15, she did not receive any communication from the previous shift in regards to resident #4 being able to get out of bed and sit in his wheelchair. She stated that she knew the resident had [MEDICAL TREATMENT] that day, and there was no ambulance scheduled to pick him up for transport to [MEDICAL TREATMENT]. Therefore, she assumed he would be going by wheelchair and facility van. She stated that S7 CNA who was working with the resident that morning, 10/20/15, did not ask her if the resident could get up to his wheelchair. S6 LPN confirmed that she did not have time to see or assess resident #4 the morning of 10/20/15 prior to the CNA getting him up to his wheelchair. She confirmed the first time she saw the resident on 10/20/15 was when she was called to his room, and he was on the floor. Further interview with S6 LPN at that time revealed she was not aware if the resident had been out of bed since his right BKA prior to the morning of 10/20/15. She stated that while he was on the floor waiting on the EMTs, he was joking and laughing. He did not want to go to the ER. He denied any pain and was oriented. She stated she sent him to the ER due to the gash on the top of his head and for an evaluation since he hit his head. She confirmed the EMTs did not place a cervical collar on the resident when they transferred him from the floor to the stretcher. According to documentation in the Departmental Notes dated 10/23/15 at 6:51 p.m., the resident returned to the facility with a C-collar in place. Documentation in the notes dated 10/26/15 at 4:03 p.m. revealed the resident required staff to feed him because it was difficult for him to feed himself with the C-collar in place. The resident complained of being uncomfortable in the C-collar. Review of a Departmental Note dated 10/28/15 at 2:24 p.m. revealed the resident was tolerating his diet with some difficulty chewing and swallowing with the C-collar in place. Review of Speech Therapy Plan of Care dated 10/28/15 revealed the resident was referred and seen by the ST that day. The resident was referred to ST services as a result of nursing observation and resident reporting an increased difficulty with swallowing following admission to the hospital for C1-C2 spinal fracture secondary to a fall. The resident initially reported no Dysphagia upon return to the facility after the fracture. However, he is now reporting difficulty with mastication, swallow initiation and pharyngeal motility. Further review of the ST Plan of Care revealed skilled services were necessary to assess the functional swallow mechanism, determine the safest and least restrictive diet and to improve functional tolerance of oral intake. Without skilled ST services, the resident was at risk for aspiration and weight loss. Other underlying impairments included the C-collar caused decreased mandibular ROM and increased difficulty with mastication. Recommendations on that date by the ST included a mechanical soft diet with thin liquids and treatment by the ST 5 times a week for 4 weeks. On 10/29/15, a new physician's orders [REDACTED]. His diet was also changed that day to puree with thin liquids and high protein (3 grams per day). On 10/30/15, The Physician ordered nectar thick liquids according to ST recommendations. Review of the results of the Speech-Language Pathology Modified [MEDICATION NAME] Swallow Study dated 11/4/15 revealed the resident's [DIAGNOSES REDACTED]. The medical history revealed the resident was s/p cervical spine fracture from a fall requiring cervical bracing. The complaint was that the resident was experiencing Oropharyngeal Dysphagia and aspiration signs and symptoms due to a recent fall and s/p cervical spinal fracture. The results of the study were Profound Pharyngeal phase Dysphagia. The recommendations were for alternative means of nutrition to ensure adequate hydration and caloric intake during the healing process/time then reassess for swallow function. According to documentation in the Departmental Notes dated 11/5/15 at 5:55 p.m., S8 ST documented the resident had a MBSS done. The recommendation from the test was for an alternative method of feeding given the resident's severity of Dysphagia and his significant aspiration risk. The resident and his family were informed of the results and educated that the hope was to use alternative means of nutrition as the resident healed from the spinal injury and his swallowing improved. S8 ST was unavailable for interview. Review of a Departmental Note dated 11/7/15 revealed the resident returned to the facility that day with a new PEG tube to his mid abdomen area. Review of a Departmental Note dated 11/14/15 at 11:54 a.m. revealed that the resident was assessed to have a BIMS score of 11; his speech was clear and understandable.