Every finding on record at Shreveport Manor Skilled Nursing & Rehabilitation

Based on record review and interview the facility failed to ensure a performance review was completed at least once every 12 months for 1 (S4 CNA [Certified Nursing Assistant]) of 2 CNA personnel files reviewed. Findings: Review of S4 CNA's personnel file revealed a hire date of 09/16/2016. Further review of S4 CNA's personnel file failed to reveal an annual performance evaluation had been completed since 09/01/2024. During an interview on 06/30/2026 at 4:10 p.m., S5 HR (Human Resources) confirmed S4 CNA had not had an annual performance evaluation since 09/01/2024 and further reported an annual performance evaluation should have been done annually.

Based on record review, observations, and interviews the facility failed to accommodate the needs of 2 (#37 and #48) of 4 (#6, #37, #48, and #78) residents reviewed for environment. The facility failed to ensure the residents' call lights remained in reach. Findings:Review of Resident Call Light System revised 06/2023 revealed:PurposeThe purpose of this procedure is to respond to the resident's requests and needs.Policy implementationA call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities.General Guidelines3. Return demonstration may be utilized to ensure the resident can operate the system.4. Ensure that the call light is easily reachable by the resident.Resident #37Observation on 08/27/2025 at 7:50 a.m. revealed Resident #37 was in bed and call light on the floor and not in reach.Observation on 08/27/2025 at 10:05 a.m. revealed Resident #37's was in bed and call light on the floor and not in reach.Observation on 08/27/2025 at 10:10 a.m. with S6 LPN (Licensed Practical Nurse) revealed Resident #37 was in bed and call light was on the floor and not in reach.During an interview on 08/27/2025 at 10:10 a.m. S6 LPN confirmed Resident #37 was in bed and call light was on the floor and not in reach.Resident #48Observation on 08/25/2025 at 8:35 a.m. revealed Resident #48 was in bed and call light was not plugged into the wall.Observation on 08/25/2025 at 11:28 a.m. revealed Resident #48 was in bed and call light was not plugged into wall.Observation on 08/25/2025 at 11:30 a.m. with S7 LPN revealed Resident #48 was in bed and call light was not plugged into wall.During an interview on 08/25/2025 at 11:30 a.m. S7 LPN confirmed Resident #48 was in bed, call light was not plugged in, and should have been accessible.

Based on record reviews and interview the facility failed to ensure quarterly statements for residents' personal funds entrusted to the facility were provided for 1 (#41) of 1 resident reviewed for personal funds. The facility failed to provide quarterly statements to Resident #41. Findings: Review of admission packet documents provided to residents revealed a Resident Funds Letter which included:Dear Resident:Our facility provides each resident with an opportunity to deposit his/her personal funds into a resident's trust fund account.Should you elect to deposit funds into the resident's trust fund: .You or your legal representative will receive a confidential quarterly statement of funds. Review of Resident #41's medical record revealed Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's 06/12/2025 Quarterly Minimum Data Set (MDS) revealed Resident #41 had a BIMS (Brief Interview Mental Status) score of 15, which indicated intact cognition. During an interview on 08/25/2025 at 2:43 p.m. Resident #41 reported the facility holds money for her and would not communicate how much money the facility was holding for her. During an interview on 08/26/2025 at 3:30 p.m. S5 Business Office Manager (BOM) reported she had worked at the facility for 3 years and residents with personal funds trust accounts had not been receiving quarterly statements.

Based on record reviews, observations and interviews the facility failed to ensure a resident that was cognitively impaired and at risk for falls had an environment free of accidents hazards for 1 (#48) of 2 (#31, #48) residents reviewed for accidents. Findings: Review of facility's Managing Falls and Fall Risk policy (Revised November 14, 2024) revealed:Policy StatementBased on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of Resident #48's face sheet revealed an admission date of 07/31/2023 with the following diagnoses but not limited to sequelae of cerebral infarction, generalized muscle weakness, unspecified lack of coordination, unspecified psychosis not due to a substance or known physiological condition, muscle wasting and atrophy to multiple sites, dementia, mood disturbance, anxiety, insomnia, pain, restless legs syndrome, and Alzheimer's disease. Review of Annual MDS (Minimum Data Set) dated 07/03/2025 revealed a BIMS (Brief Interview of Mental Status) of 03 indicating severely impaired cognition. Review of Resident #48's Incident Report dated 05/31/2025 revealed interventions: staff will continue to ensure bed is in lowest position and mats will remain at bedside. Staff will continue to monitor and will assist as needed. An observation on 08/25/2025 at 8:35 a.m. revealed Resident #48 resting in bed and fall mat was leaning against the wall. An observation on 08/25/2025 at 11:29 a.m. revealed Resident #48 resting in bed and fall mat was leaning against the wall. During an interview on 08/25/2025 at 11:30 a.m. S7 LPN (Licensed Practical Nurse) acknowledged Resident #48's fall mat was positioned against wall and should have been on floor next to the bed while Resident #48 was in bed.

Based on record review, observations and interviews the facility failed to provide appropriate infection control practices for 1(#37) of 1 resident reviewed for urinary catheter/ UTI (Urinary Tract Infection). The facility failed to ensure a resident with a supra pubic catheter received the appropriate care and services to prevent urinary tract infections by failing to ensure (1) the suprapubic catheter was properly secured in a manner to promote drainage and (2) the catheter tubing and bag did not come in contact with the floor. Findings: Review of Resident #37's face sheet revealed an admission date of 03/12/2024 with the following diagnoses but not limited to history of urinary tract infection, chronic, bladder-neck obstruction, benign neoplasm of prostate, obstructive and reflux uropathy, and benign prostatic hyperplasia without lower urinary tract symptomsReview of Resident #37's August 2025 EMAR (Electronic Medication Administration Record) revealed:03/14/2025: Catheter: urinary catheter ensure tubing anchor and privacy bag is intact and secure every shiftReview of Resident #37's care plan revealed indwelling suprapubic catheter with interventions include to position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks while providing care and each shift. Review of Resident #37's Quarterly MDS (Minimum Data Sets) dated 08/08/2025 revealed a BIMS (Brief Interview of Mental Status) of 12 indicating moderately impaired cognition. Further review of MDS revealed Resident #37 had an indwelling catheter.Observation on 08/27/2025 at 7:50 a.m. revealed Resident #37 resting in bed in lowest position with tubing and catheter bag on the floor. Observation on 08/27/2025 at 10:05 a.m. revealed Resident #37 resting in bed in lowest position with tubing and catheter bag on the floor.Observation on 08/27/2025 at 10:10 a.m. with S6 LPN (Licensed Practical Nurse) revealed Resident #37's tubing and catheter bag was on the floor. Further observation failed to reveal Resident #37's catheter tubing was secured to thigh. During an interview on 08/27/2025 at 10:10 a.m. S6 LPN confirmed Resident #37's catheter tubing should have been secured to thigh and was not. S6 LPN confirmed Resident #37's catheter tubing and bag was on the floor and should not have been.

Based on record reviews and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the low temperature dishwasher met wash cycle temperature recommendations. The deficient practice had the potential to affect the 70 residents who received meals from the kitchen as per S4 Housekeeping/Dietary Manager.Findings: Review of Policy: Mechanical Cleaning and Sanitizing of Utensils and Portable EquipmentDate approved: October 1, 2018Policy: The facility will follow the cleaning and sanitizing requirements of the state and US (United States) Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure: .If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120 degrees F (Fahrenheit). Observation on 08/27/2025 at 09:15 a.m. revealed a sticker on the front of the kitchen dishwasher which read ____________ Dishwasher Operating Requirements 1. Water temp. 120 degrees F minimum, 2. Chlorine Residual 50 PPM (parts per million) min. (minimum), 3. Min. Wash 56 sec. (seconds) rinse 24 sec. Review of completed August 1, 2025 to August 25, 2025 Dishwasher Temperature/Chemical Record revealed daily dishwasher wash temperature checks for breakfast, lunch, and dinner were below the required 120 degrees and each wash temperature was documented at 110 degrees. Review of completed July 2025 Dishwasher Temperature/Chemical Record revealed daily dishwasher wash temperature checks for breakfast, lunch, and dinner were below the required 120 degrees for the following:-Breakfast wash temperature was recorded as 100 degrees on 07/01/2025 to 07/07/2025, 07/09/2025 to 07/19/2025 and 07/21/2025; and recorded as 50 degrees F on 07/08/2025, 07/20/2025, and 07/22/2024 to 07/25/2025.-Lunch wash temperature was recorded as 100 degrees on 07/01/2025 to 07/29/2025 and recorded as 50 degrees on 07/30/2025 and 07/31/2025.-Dinner wash temperature was recorded as 100 degrees on 07/01/2025 to 07/17/2025 and 07/24/2025 to 07/29/2025; and was recorded as 50 degrees on 07/30/2024 and 07/31/2024. During an interview on 08/27/2025 at 8:40 a.m. S4 Housekeeping/Dietary Manager reported the July 2025 and August 2025 dishwasher temp logs included wash temperatures which were below 120 degrees Fahrenheit and dishwasher wash temperature should be at least 120 degrees Fahrenheit.

Based on record reviews, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices to prevent infection and cross contamination. The facility failed to ensure:(1) PPE (Personal Protective Equipment) was used during contact with contaminated medical equipment and hand hygiene performed, and(2) Proper cleaning and disinfection of medical equipment Findings:Review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy revised 10/2018 revealed: Policy Interpretation and Implementation2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.Review of facility's Handwashing/Hand Hygiene policy revised 12/22/2023 revealed: This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.8. Hand hygiene is the final step after removing and disposing of personal protective equipment.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.10. Single-use disposable gloves should be used:b. When anticipating contact with blood or body fluids.Review of facility's Personal Protective Equipment - Using Gloves policy revised 11/2010 revealed: Objectives1. To prevent the spread of infection;3. To protect hands from potentially infectious material. Equipment and Supplies4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces.5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.)When to Use Gloves1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin;4. When cleaning potentially contaminated items. Hall A An observation on 08/25/2025 at 1:08 p.m. revealed Hall A gray shower chair had brown, hard, and dried residue in holes and blue chair had brown, hard, and dried residue on inside and outside of chair. An observation on 08/25/2025 at 2:45 p.m. S7 LPN (Licensed Practical Nurse) reported shower chairs should be cleaned between resident use. S7 LPN acknowledged Hall A shower gray and blue chairs had brown residue and should have been cleaned. Hall BAn observation on 08/25/2025 at 2:35 p.m. revealed Hall B white shower chair had brown, hard, and dried residue on top of chair and in holes. During an interview on 08/25/2025 at 2:36 p.m. S8 Housekeeping confirmed Hall B white shower chair had brown residue. S8 reported he cleaned Hall B chair yesterday and it should be cleaned again. S8 Housekeeping reported housekeeping is responsible for cleaning shower chairs. An observation on 08/25/2025 at 2:36 p.m. revealed S8 Housekeeping cleaned chair with foaming cleaner and a rag. S8 Housekeeping did not use gloves and did not use hand hygiene after cleaning.During an interview on 08/25/2025 at 2:36 p.m. S8 Housekeeping reported he should have worn gloves while cleaning Hall B shower chair and performed hand hygiene after cleaning.During an interview on 08/25/2025 at 2:40 p.m. S9 CNA (Certified Nursing Assistant) reported housekeeping is responsible for cleaning shower chairs. S9 CNA will contact housekeeping for cleaning between resident showers. During an interview on 08/26/2025 at 2:30 p.m. S4 Housekeeping/Dietary Manager reported S8 had multiple discussions concerning hand hygiene and infection control practices. S4 Housekeeping/Dietary Manager reported S8 Housekeeping should have worn gloves while cleaning and performed hang hygiene after cleaning Hall B shower chair.During an interview on 08/25/2025 at 2:30 p.m. S10 Care Plan Nurse reported CNAs are responsible for cleaning chairs between residents.

Based on interviews and observations, the facility failed to post the correct telephone number of pertinent state agencies in a form and manner accessible and understandable to residents/resident representatives. Findings:During an interview on 08/26/2025 at 3:01 p.m. S1 DON (Director of Nursing) reported the state complaint hotline number for nursing homes was posted on the main hallway bulletin board.Observation on 08/26/2025 at 3:02 p.m. with S2 Corporate Nurse failed revealed to reveal the correct number to file a complaint with the state survey agency was posted. During an interview on 08/26/2025 at 3:02 p.m. S2 Corporate Nurse verified the number was incorrect by calling the posted number, on speaker, in the presence of surveyors.Observation on 08/27/2025 at 11:30 a.m. revealed hand written state complaint hotline number for nursing homes was only posted on main dining room hallway bulletin board and was above eye level while standing.During an interview on 08/27/2025 at 11:32 a.m. S3 Human Resources reported the state complaint hotline number for nursing homes was only posted on main dining room hallway bulletin board, should have been posted in other places, and was above eye level while standing.

Based on record reviews and interviews, the facility failed to develop and implement an individualized care plan for 1 (#52) out of 29 total sampled residents reviewed. The facility failed to develop Resident #52's care plan for dependent assistance with activities of daily living (ADL) and refusal to wear socks and shoes.Findings:Review of Resident #52's medical records revealed an admit date of 07/11/2025 with the following diagnoses, including in part: other impulse disorders, other disorders of psychological development, developmental disorder of scholastic skills unspecified and other specified anxiety disorders.Review of Resident #52's MDS (Minimum Data Set) assessment dated [DATE] revealed a functional status of dependent with eating, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene.Review of Resident #52's comprehensive care plan revealed the following problem and approach for ADL self-care performance deficit .(initiated 7/11/25) - dressing: Resident is independent with dressing. No assistance required. Eating: Resident is independent with eating. No assistance required. Personal hygiene: Resident is independent with personal hygiene. No assistance required. Toilet use: Resident is independent in toilet use. Bathing: Resident is independent in bathing. Dressing: Resident is independent in dressing. Observation on 08/25/2025 at 10:30 a.m. revealed Resident #52 sitting in wheelchair in common area with no socks or shoes on and feet touching the floor.Observation on 08/26/2025 at 8:25 a.m. revealed Resident #52 sitting in wheelchair in common area with no socks or shoes on and feet touching the floor.During an interview on 08/26/2025 at 3:12 p.m. S12 CNA (Certified Nursing Assistant) reported Resident #52 would take off his socks if you put them on and most times would not let you put shoes or socks on him. During an interview on 08/27/2025 at 8:22 a.m. S11 LPN (Licensed Practical Nurse) reported Resident #52 would not wear shoes or socks and would throw the shoes across the room.During an interview on 08/27/2025 at 8:35 a.m. S10 LPN Care Plan Nurse acknowledged Resident #52 was dependent for all ADLs and the care plan was incorrect. S10 LPN Care Plan Nurse further reported she was unaware Resident #52 refused to wear socks and shoes and should have been care planned for this.

Based on record review and interview the facility failed to ensure nurses had the appropriate competencies and skilled sets to provide nursing and related services necessary to care for resident's needs. The facility failed to ensure lab blood work had been completed as order for 1 (#1) of 3 (#1, #2 and #3) sample residents. Findings: Review of resident #1's medical record revealed an admitted [DATE] and diagnoses which included, in part, iron deficiency anemia, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints. Review of resident #1's current Physician orders revealed the following active orders: Order date 07/26/2022 CBC (complete blood count) every month Order date 08/16/2022 Lipid Panel yearly in August Review of resident #1's medical record revealed the results of a CBC dated 12/22/2024 which had been completed during a hospitalization stay. Review of resident #1's medical record failed to reveal a CBC had been completed for the months of January, February, and March 2025. Further review of resident #1's medical record revealed no monthly CBCs and no annual lipid panel had been completed by the facility in August 2024 as ordered. During an interview on 4/8/2025 at 10:03 a.m. S4 Nurse Auditor reported the monthly CBC or yearly lipid panel had not been completed as ordered. S4 Nurse Auditor agreed the physician orders for lab work remained active and should have been completed.

Based on record review, observation, and interviews the facility failed to accommodate the needs of 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure resident #1's call light was within reach. Findings: The facility's Resident Call Light System policy/procedure (revised date 06/2023) presented by the S1 Corporate Nurse revealed in part: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Policy Implementations: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. General Guidelines: 4. Ensure that the call light is easily reachable by the resident. Resident #1 was admitted to this facility 07/14/2022. Diagnoses included rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 12/20/2024 revealed resident #1 had a BIMS (brief interview for mental status) score of 13 indicating moderate cognitive impairment. Further review of quarterly MDS dated [DATE] revealed resident #1 required two plus persons for physical assist with bed mobility and toileting use. Observation on 04/07/2025 at 12:30 p.m. revealed resident #1 sitting at the bedside in a wheelchair. Further observation revealed resident #1's call light hanging on the head of the bed on the opposite side of the bed from resident #1 and was out of resident #1's reach. During an interview on 04/07/2025 at 12:30 p.m. resident #1 reported she was unable to reach her call light. During an interview on 04/07/2025 at 12:40 p.m. S2 CNA (Certified Nursing Assistant) entered the room and was asked if resident #1 could reach the call light. S2 CNA agreed resident #1 would not be able to reach the call light from where it was placed. S2 CNA reported maybe she or therapy had placed the call light there this morning.

Based on record review, observation and interview the facility failed to ensure 1 (#1) of 3 (#1, #2 and #3) sampled residents who were unable to carry out ADL (activities of daily living) received the necessary services to maintain good grooming and personal hygiene. Findings: Review of resident #1's medical record revealed an admitted [DATE] and diagnoses which included, in part, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints. Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 12/20/2024 revealed resident #1 had a BIMS (brief interview for mental status) score of 13 indicating moderate cognitive impairment. Further review of quarterly MDS dated [DATE] revealed resident #1 required two plus persons for physical assist with bed mobility and toileting use. Observation on 04/07/2025 at 12:30 p.m. revealed resident #1's fingernails were jagged, uneven, long, and extended well over the tip of her fingers. Further observation revealed resident #1's fingernails had a brown substance underneath the nails. During an interview on 04/07/2025 at 12:30 p.m. resident #1 reported she had asked for her fingernails to be trimmed but so far no one had trimmed them. Review of resident #1's current Physician orders revealed an order dated 08/26/2024 trim fingernails every two weeks. Review of resident #1's care plan revealed an identified problem of self-care performance deficit related to impaired mobility due to generalized weakness to upper and lower extremities. Interventions included extensive assist with all ADL's. Resident #1 is totally dependent in bathing, bed mobility, dressing and personal hygiene. Review of resident #1's March 2025 and April 2025 TAR (Treatment Administration Record) failed to reveal any documentation her fingernails had been trimmed every two weeks as ordered by the physician. During an interview 04/08/2025 at 8:30 a.m. S3 LPN (Licensed Practical Nurse) observed resident #1 fingernails and agreed they needed trimming. S3 LPN reported resident #1's fingernails should have been trimmed by the floor nurse every two weeks. During an interview on 04/08/2025 at 12:39 p.m. S4 Nurse Auditor reviewed resident #1's TARs and confirmed there was not documentation resident #1's fingernails had been trimmed every two weeks. S4 Nurse Auditor confirmed resident #1's fingernails should have been trimmed as ordered.

Based on record reviews, observations, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (#53, #57, #221) of 4 (#5, #53, #57, #221) residents reviewed for ADLs (activities of daily living). The facility failed to ensure nail care was provided. Findings: Resident #53 Review of resident #53's medical record revealed an admitted [DATE] with a diagnoses of, but not limited to, unspecified dementia, major depressive disorder, recurrent, severe with psychotic symptoms, unspecified dementia, mild, with mood disturbance, unsteadiness on feet, and cognitive communication deficit. Review of resident #53's quarterly MDS (minimum data set) dated 05/10/2024 revealed a BIMS (brief interview mental status) of 4 indicating severely impaired cognition. Review of resident #53's comprehensive plan of care revealed resident #53 had a self-care deficit, was totally dependent and required assistance with bathing and personal hygiene. Observation on 07/28/2024 7:45 a.m. with S5 LPN (licensed practical nurse) revealed resident #53's fingernails protruded past nailbeds and had not been trimmed. During an interview on 07/28/2024 at 7:35 a.m. S5 LPN confirmed resident #53's fingernails should have been trimmed. Resident #57 Review of resident #57's medical record revealed an admitted [DATE] with a diagnoses of, but not limited, to Alzheimer's disease, unspecified need for assistance with personal care, essential hypertension, Parkinson's disease and anxiety disorder. Review of resident #57's quarterly MDS (minimum data set) dated 05/07/2024 revealed resident #57 did not have a BIMS (brief interview mental status) because resident #57 was rarely or never understood. Review or resident #57's comprehensive plan of care revealed resident #57 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene. Observation on 07/28/2024 at 7:55 a.m. with S5 LPN revealed resident #57's fingernails on both hands had not been trimmed and protruded past the nailbeds. During an interview on 07/28/2024 at 7:55 a.m. S5 LPN confirmed resident #57's fingernails should have been trimmed. Resident #221 Review of resident #221's medical record revealed an admitted [DATE] with a diagnoses of, but not limited, muscle wasting and atrophy, lack of coordination, unspecified conversion disorder with seizures or convulsions, schizoaffective disorder, bipolar type, chronic hepatitis, and essential hypertension. Review of resident #221's quarterly MDS (minimum data set) dated 05/14/2024 revealed resident #221 had BIMS (brief interview mental status) score of 10, indicating moderately impaired cognition. Review of resident #221's comprehensive plan of care revealed resident #221 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene. Observation on 07/28/2024 at 8:00 a.m. revealed resident #221 had fingernails that protruded past his nailbeds on both hands. During an interview on 07/28/2024 at 8:00 a.m. S5 LPN confirmed resident #221's fingernails should have been trimmed.

Based on observations and interview the facility failed to ensure residents' environment remained free of accident hazards on the locked memory unit by failing to ensure all rooms had a door handle. This had the potential to effect 14 residents residing on the memory care unit. Findings: Observation on 07/28/2024 at 8:00 a.m. on the locked memory unit revealed room A failed to have a door handle in place, exposing a sharp edge. Observation on 07/29/2024 at 8:15 a.m. with S8 Maintenance Supervisor on the memory unit revealed room A failed to have a door handle in place, exposing a sharp edge. During an interview on 07/29/2024 at 8:15 a.m. S8 Maintenance Supervisor reported the door handle to room A had been off since the unit was established and confirmed the door handle should have been repaired.

Based on observations, record reviews and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 2 (#20, #67) of 2 (#20, #67) residents reviewed for respiratory services. The facility failed to ensure resident's hand held nebulizer (HHN) masks and tubing were dated and stored in a plastic bag. Findings: Review of the facility's Departmental Respiratory Therapy Policy (revised November 2021) revealed: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection control considerations related to medication nebulizers/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Resident #20 Review of Resident #20's medical record revealed an admitted [DATE] with the following diagnoses, in part: chronic obstructive pulmonary disease/unspecified, acute and chronic respiratory failure with hypoxia, panlobular emphysema, and encounter for attention to tracheostomy. Review of Resident #20's physician's orders revealed an order dated 04/26/2022 for Acetylcysteine Inhalation Solution 20% 3 ml (milliliter) inhale orally three times a day related to acute and chronic respiratory failure with hypoxia. Observation on 07/28/2024 at 8:40 a.m. revealed Resident #20's HHN on bedside table. Further observation revealed mask and tubing sitting on top of the machine with no date and not stored in a plastic bag. Resident #67 Review of Resident #67's medical records revealed an admit of 06/19/2024 with the following diagnoses, in part: Alzheimer's disease/unspecified, chronic obstructive pulmonary disease/unspecified, and acute and chronic respiratory failure with hypoxia. Review of Resident #67's physician's orders revealed orders dated 07/19/2024 for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (microgram/actuation) (Ipratropium- Albuterol) 1 puff inhale orally every 6 hours as needed for wheezing and Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG/DOSE 1 inhalation inhale orally every 12 hours for wheezing. Observation on 07/28/2024 at 9:15 a.m. revealed Resident #67's HHN on bedside table. Further observation revealed mask and tubing sitting on top of the machine with no date and not stored in a plastic bag. During an interview on 07/28/2024 at 9:20 a.m. S4 LPN (Licensed Practical Nurse) acknowledged Resident #20 and Resident #67's HHN mask and tubing should be dated and stored in a plastic bag.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31). Findings: Review of the facility Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 2 2024 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the facility's weekend staffing pattern forms for FY Quarter 2 2024 revealed hours of direct care provided exceeded the hours of care required. During an interview on 07/29/2024 at 8:05 a.m. S3 Director of Nursing reported she did not understand why the facility triggered for low staffing and did not know why the data entered would be incorrect because the facility always overstaffs. During an interview on 07/30/2024 at 10:45 a.m. S2 Corporate Nurse reported she did not know why the PBJ Staffing Data Report for FY Quarter 2 2024 to CMS shows low weekend staffing.

Based on observations, interviews, and record review, the facility failed to ensure a resident was cared for with respect and dignity by failing to provide a privacy covering for a urinary catheter bag for 1 resident (#221) out of 4 (#35, #38, #42, #221) residents reviewed for dignity out of a total of 31 sampled residents. Findings: Review of resident #221's medical record revealed an admitted [DATE] with a diagnoses of, but not limited to, unspecified conversion disorder with seizures, bladder-neck obstruction, urinary tract infection and schizoaffective disorder bipolar type. Review of resident #221's Quarterly MDS (Minimum Data Set) dated 01/14/2024 revealed resident #221 had a BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired cognition. Review of resident #221's July Physician's Orders revealed an order for: Catheter: Urinary Catheter ensure tubing anchor and privacy bag is intact and secure every shift. Observation on 07/28/2024 at 8:00 a.m. revealed resident #221 was up in his room in the wheelchair. Resident #221's door was open and resident #221's catheter bag did not have a privacy cover over it. Observation on 07/28/2024 at 11:49 a.m. with S6 CNA (certified nursing assistant) revealed resident #221's catheter bag did not have a privacy cover over it. During an interview on 07/28/2024 at 11:45 a.m. resident #221 reported, I don't know why I don't have a blue cover over the bag, I get embarrassed especially when I am up front with the other people. During an interview on 07/28/2024 at 11:49 a.m. S5 LPN (licensed practical nurse) confirmed resident #221 should have a privacy cover on his catheter bag.

Based on observations and interview the facility failed to accommodate the needs of 1 (#57) resident out of 4 (#20, #55, #57, #67) residents reviewed for environment. The facility failed to ensure resident #57's call device was within reach. Findings: Review of resident #57's medical record revealed an admitted [DATE] with a diagnoses of, but not limited to, Alzheimer's disease, unspecified need for assistance with personal care, essential hypertension, Parkinson's disease and anxiety disorder. Review of resident #57's quarterly MDS (minimum data set) dated 05/07/2024 revealed resident #57 did not have a BIMS (brief interveiw mental status) score because resident #57 was rarely or never understood. Review of resident #57's comprehensive plan of care revealed resident #57 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene. Observation on 07/28/2024 at 7:45 a.m. revealed resident #57 in bed with his breakfast tray in front of him. Further observation revealed resident #57's call device was on the floor underneath his bed out of resident #57's reach. Observation with S5 LPN (licensed practical nurse) on 07/28/2024 at 7:45 a.m. revealed resident #57's call device was on the floor underneath his bed and out of resident #57's reach. During an interview on 07/28/2024 at 7:45 a.m. S5 LPN confirmed resident #57's call device should have been placed within resident #57's reach.

Based on observations and interview the facility failed to ensure the most current survey results were posted in a place readily accessible to the residents, family members or anyone to review. Findings: Observation on 07/28/2024 at 11:45 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review. Observation on 07/28/2024 at 11:45 a.m. with S1 Administrator revealed the most recent survey results were not posted in a place that was readily available for review. During an interview on 07/28/2024 at 11:45 a.m. S1 Administrator confirmed the most recent survey results should have been posted for residents, family and anyone to review.

Based on observations, record reviews and interviews the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#35) of 2 (#5, #35) residents reviewed for position and mobility. The facility failed to ensure Resident #35's splint was in place to treat a contracture. Findings: Review of Resident #35's medical record revealed an admitted [DATE] with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, direct infection of unspecified hand in infectious and parasitic diseases classified elsewhere, need for assistance with personal care, contracture/right hand and unspecified lack of coordination. Review of Resident #35's comprehensive care plan revealed at risk for complications due to right hand decreased strengthening and positioning - 06/26/2024 right palm pressure ulcer treat as ordered per medical director. Review of Resident #35's physician's orders revealed an order dated 07/10/2024 - May use/wear right hand orthotic daily as tolerated every shift r/t (related to) contracture right hand .every day as tolerated. Review of Resident #35's Nurse Practitioner's progress note dated 07/01/2024 revealed chief complaint of right hand wound infection .New finding of right palm wound likely 2/2 (secondary to) contracture Observation on 07/28/2024 at 8:55 a.m. failed to reveal a splint in Resident #35's right hand. Observation on 07/28/2024 at 2:30 p.m. failed to reveal a splint in Resident #35's right hand. Observation on 07/29/2024 at 11:00 a.m. failed to reveal a splint in Resident #35's right hand. Observation on 07/29/2024 at 3:30 p.m. failed to reveal a splint in Resident #35's right hand. During an interview on 07/29/2024 at 8:15 a.m. S4 LPN (Licensed Practical Nurse) reported Resident #35 should have a splint in her right hand. S4 LPN confirmed a splint should have been placed in Resident #35's right hand and was not. During an interview on 07/29/2024 at 10:20 a.m. S7 OT (Occupational Therapy) reported Resident #35 had a splint that was to be placed in her right hand for a contracture. S7 OT further reported her right hand was in a tight fist and her nails dug into her palm.