Every finding on record at Southwest Louisiana War Veterans Home

Based on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect 2 (#11 and #14) of the 2 (#11 and #14) residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2025, Quarter 2 (January 01 - March 31) revealed the following: -Failed to Submit Data for the Quarter -One star staffing rating, triggered. On 06/16/2025 at 4:14 p.m., during an interview with S1ADM (Administrator), she stated she had reported to the PBJ for the second quarter. Upon review of the documentation submitted, she confirmed the information she provided in April 2025 was for the dates ranging from 10/01/2024 to 12/31/2024. She confirmed the information that should have been submitted in April 2025 was for the dates ranging from 01/01/2025 to 30/31/2025, and further confirmed the required information was not submitted to the PBJ.

Based on observations and interview, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff utilized appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) while administering medication and bolus tube feeding for 1 (#14) out of 1 (#14) resident sampled for tube feeding. Findings: On 06/17/2025, a review of the facility's policy titled, Enhanced Barrier Precautions (EBP's), with an effective date of 09/27/2024, read in part: Purpose: to ensure EBP's are implemented appropriately. Definitions: EBP's involve gown and glove use during high-contact resident care activities for residents known to be colonized with a MDRO (Multidrug Resistant Organism), as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). High-contact resident care activities include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Review of Resident #14's electronic medical record revealed an admission date of 01/08/2025 with diagnoses which included, but were not limited to unspecified protein-calorie malnutrition and dysphagia oral phase. Review of Resident #14's physician's orders revealed orders written on 04/21/2025 - EBP, NPO***PEG (Percutaneous Endoscopic Gastrostomy) tube status, Jevity 1.5 cal liquid per PEG via gravity - give 400 ML (milliliters) per PEG TID (3 times a day), PEG tube water flushes at 150 ml per PEG via gravity every 4 hours and PEG Protocol. On 06/17/2025 at 6:16 a.m., an observation was made of S3LPN (Licensed Practical Nurse), administering medication and bolus feeding via PEG tube to Resident #14. S3LPN entered Resident #14's room and did not utilize a gown while administering his medication and bolus feeding. On 06/17/2025 at 7:17 a.m., an interview was conducted with S3LPN, she confirmed she did not use a gown while administering Resident #14's medication and bolus feeding per PEG tube. S3LPN confirmed she should have used a gown while providing care to Resident #14 because he was on EBP. During an interview with S2ICP (Infection Control Preventionist) on 06/17/2025 at 8:45 a.m., she confirmed a gown and gloves should be worn when administering medication and bolus feeding via PEG tube to residents on EBP.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#1) out of 1 (#1) residents investigated for environment. The sample resident size was 9. Findings: Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Candidiasis, Cerebral Infarction, Spastic Hemiplegia and Pressure Ulcer Sacral Region. On 07/23/2024 at 10:27 a.m., an observation was made of Resident #1's bedroom. The resident was not in his room, his bed was made. The resident's pillow case revealed 2 nickel sized, and 6 small dots of a dried brown colored stain. On 07/23/2024 at 11:40 a.m., a second observation of Resident #1's bedroom was conducted with S3CNA. S3CNA confirmed the resident's bed was made this morning and the pillow case had multiple brown stains on the pillow case. She confirmed the pillow case should have been changed when the bed was made. On 07/24/2024 at 12:45 p.m., an interview was conducted with S2DON, she confirmed stained bed linens should be changed, when found while making a bed.

Based on record reviews and interviews, the facility failed to ensure Agency CNA's (Certified Nursing Assistant's) completed annual in-service training including Dementia, Resident Rights, Infection Control, and Abuse/Neglect/Exploitation for 3 (S2CNA, S3CNA, S4CNA) out of 4 sampled Agency CNA's personnel files reviewed. Findings: Review of S2CNA's personnel file revealed a first start date at the facility of 09/26/2022. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of S3CNA's personnel file revealed a first start day at the facility of 08/10/2023. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of S4CNA's personnel file revealed a first start day at the facility of 03/04/2023. Further review of personnel file revealed no education verification provided for Dementia training, Resident Rights, Infection Control or Abuse/Neglect/Exploitation. Review of the facility's monthly in service trainings signage sheets failed to reveal S2CNA and S4CNA completed monthly trainings for Resident Rights in February 2023, Abuse/neglect/Exploitation in March 2023, and Dementia training in Month 2023. On 08/22/2023 at 4:30 p.m., during an interview with S1ADM, she confirmed she had no additional in-service trainings for the unlicensed agency staff.

Based on record review and interviews, the facility failed to ensure alleged violation of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#11) out of 4 sampled residents. This had the potential to effect a census of 4 residents. Findings: Review of Resident #11's medical record revealed he was admitted to facility on 05/24/2023 with diagnoses that included in part: Right femur fracture, Unspecified Dementia, CVA, Abnormal Gait, Dysphagia and Alcohol Abuse. Review of Resident #11's MDS (Minimum Data Set) revealed the BIMS (Brief Interview for Mental Status) indicating a moderately impaired cognition. Review of the facility's resident grievance/theft-loss report, revealed Resident #11 had grievance dated 06/05/2023 at 3:21 p.m., with subject report of disrespect and physical harm. Further review of the grievance report revealed the allegation of physical harm was not reported to the State Survey Agency. On 08/22/2023 at 3:35 p.m., and interview was with S6RN, SNF coordinator, she reported she did recall an incident of the abuse allegation for Resident #11. She reported she was made aware of the allegation when she returned to work on Monday, as resident had informed CNA on the Saturday before. She stated she had spoken with the resident and asked him to give her the details of what happen. She stated she did ask him who the CNA was, he could only describe her, did not know her name. She reported she had told him if he saw the person or something happened again to be sure to tell a nurse, at that time. She stated she had spoken to him daily for several days, to ask if he had seen the person and each time he told her no. She said for about a week, she would ask the nurses if Resident #11 had reported any concerns to them and each time the answer was no. She reported all residents on that unit were interviewed to see if they had witnessed or had been abused by a staff person, an all other residents denied any issues. She stated she did do a full body assessment on resident #11 on the Monday she was informed of the incident and did not identify any signs of abuse. On 08/22/2023 3:45 p.m., an interview was conducted with S7RN, she reported that on 06/04/2023 she was the evening supervisor, and as she was leaving, S8CNA, approached her at the exit door and stated she might have something to tell her about Resident #11. She informed S8CNA, she was off work and there was an RN on duty she could talk to about any resident concerns. She stated when she returned to work the next day, she had inquired about if anyone had gotten a report from S8CNA about something, and no one knew anything about it. She went to S8CNA to find out if she had reported her concern from the night before to the RN and she stated she had not. S7RN observed Resident #11 sitting alone at a table in the dining room area. She stated she walked over to him and asked him if he had any concerns he would like to talk to her about. She stated he began to tell her what happened. After she had finished getting his story, she began an investigation, and obtained witness statements. On 08/22/2023 at 4:03 p.m., during an interview with S1ADM, she stated she had spoken to state office, to get access for reporting critical incidents. She stated as of 08/14/2023 she did not have access, so she sent an email again and did not get a response until 08/22/2023, but still had no access to reporting critical incidents. She reported she had been the administrator since April 2022 and that she had not applied for critical incident reporting until June 9th, 2023.

Based on record review and interview, the facility failed to address and act upon grievances that were voiced during the resident council meeting. Findings: Review of the Resident Council Minutes dated 5/16/19 revealed, .Staff is taking money out of the shirt pockets of veteran's shirts while they are sleeping. Everyone in attendance was encouraged to file a grievance with the appropriate department head as soon as possible . There was no documentation that the facility addressed and conducted an investigation concerning the resident council's grievance. On 8/6/19 at 9:30 am, a meeting was conducted with the resident council. During the meeting, several residents in attendance stated that there were several veterans who had money missing. The residents stated that staff has been taking money out the veteran's shirt pockets while they are sleeping. The residents stated that the problem has not improved. On 8/7/19 at 1:10 pm, S1SSD stated that she was present during the resident council meeting on 5/16/19. S1SSD stated that she documented the resident's grievances voiced during that meeting. S1SSD stated that an individual resident did not report that their money was taken, so an investigation was not done. S1SSD stated that the residents were encouraged to file a grievance. On 8/7/19 at 1:25 pm, S2SSD stated that she instructed the residents to report stolen money when it happens. S2SSD stated that she needs more information in order to determine that the staff is stealing their money. S2SSD stated that she needs to know the names of the residents in order to investigate that their money was stolen. Review of the facility's Grievances/Theft and Loss Policy revealed, .4. The Social Worker, Social Service designee, Recreations Director or designee are appointed by the Administrator to work with the Resident Council to receive grievances and recommendations by residents, or any group or individual designated by the resident and his/her representative. These grievances will be entered by Social Services in Pioneer under the Grievance/Theft and Loss Report section and shall be directed to the appropriate Department Head and/or Administrator for investigation and follow-up according to the following procedure: a. Upon receipt of a grievance, an investigation led by the Administrator and Department Head based on the allegations will be forth. b. The Administrator and/or designee(s) will conduct an impartial investigation of the allegations and will commit the finding and recommendations using the Pioneer system/Grievance/Theft and loss Report within five (5) working days of receiving the complaint, to the complaint . e. In all grievance cases, the resident and/or legal representative will be informed of the result of the investigation (Investigative findings on the Grievance/Theft and Los Report), the recommendations made by the investigating parties, and of the action(s) contemplated by the Administrator and/or designee.

Based on interview, the Facility failed to ensure residents are furnished with and informed of the location of written descriptions of the required notices of legal rights which includes a list of names, addresses (mailing and email), and telephone numbers of all resident advocacy groups including the State Long-Term Care Ombudsman program by failing to ensure the residents were made aware of the posted location of the State Long-Term Care Ombudsman program's information. The deficient practice had the potential to affect 7 (#6, #10, #14, #17, #22, #26, #27) of 7 (#6, #10, #14, #17, #22, #26, #27) sampled residents. Findings: During an interview on 8/15/17 at 10:00 a.m. with the facility's Resident Council President, he stated that the residents did not know where the ombudsman's information was posted in the facility. He stated that he would have to ask S2SW to find out this information. During an interview on 8/15/17 at 2:57 p.m. with S2SW, she confirmed that the residents did not know where the ombudsman's information was posted in the facility and that she could not even remember where the information was posted.

Based on observation, record review and interview, the facility failed to ensure that residents received necessary services to maintain grooming and personal hygiene by failing to ensure that resident's fingernails were cleaned and groomed for 1 (#10) of 17 Stage 2 sample residents. Findings: Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revealed ADL (Activities of Daily Living)/Self Care Deficit: Check nails daily. On 08/14/17 at 1:34 p.m., an observation was made of Resident #10 outside on the patio. His fingernails were long and had a dark, brown substance under his nails. During an interview with Resident #10 on 08/14/17 at 1:34 p.m., he stated that his fingernails were too long and dirty and he was unable to cut his own nails. He stated that his nails were not trimmed unless he asked the staff to do so. On 08/15/17 at 2:30 p.m., an observation was made of Resident #10's fingernails. All of his fingernails were long and had a dark brown substance under them. On 08/15/17 at 3:00 p.m., an interview was conducted with S1LPN (Licensed Practical Nurse). She stated the facility didn't have a set schedule for trimming Resident #10's fingernails. She observed Resident #10's fingernails at that time and verified that his nails were long and had a dark, brown substance under his nails. She stated the fingernails needed to be cleaned and trimmed.

Based on record review and interview the facility failed to implement the plan of care for 1 (#8) of 5 (#5, #8, #17, #20, #26) residents reviewed for unnecessary medications in stage 2 out of a total sample of 13 by failing to obtain laboratory results according to the physician's order [REDACTED]. This deficient practice had the potential to affect 11 residents residing in the facility' s SNF (skilled nursing facility) unit. Findings: On 8/9/16 a record review of Resident #8's physician's order [REDACTED]. During an interview on 8/9/16 at 2:45 p.m., S1 LPN was asked to locate the HBA1c results for May 2016 in Resident #8's chart. She stated the results should be on the chart but she was unable to locate them. She stated she would check with a local hospital to see if those labs were drawn while the resident was hospitalized up until May 15, 2016. During an interview on 8/10/16 at 9:21 a.m. S1 LPN was unable to locate the May 2016 laboratory results for the T4, TSH, Lipids and [MEDICATION NAME]. She stated the order should have been drawn in May and that they were missed and not completed. During an interview on 8/10/16 at 1:30 p.m., S1 LPN verified the HBA1c, T4, TSH, Lipids and [MEDICATION NAME] for May 2016 were not drawn while Resident 8 was admitted to a local hospital until the time he was discharged back to this facility on May 15, 2016.

Based on record review and interview, the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons in accordance with each resident ' s written plan of care as evidence by failing to document additional information in the nursing progress notes regarding behaviors and side effects as identified on the MAR (Medication Administration Record) and by failing to notify the physician of changes in the behavior of 1 resident (#14) out of 5 ( #14, #26, #43,#45, #46) residents investigated for unnecessary medications during Stage II, which had the potential to effect 5 residents receiving antidepressant medications. FINDINGS: Resident #14 was admitted the the facility's SNF (Skilled Nursing Facilty) unit on 7/2/14 and had the following Diagnoses: [REDACTED].) Record review of Resident #14 ' s July 2014 and August 2014 physician's orders [REDACTED]. [MEDICATION NAME] 50mg (milligrams) tablet, Give 1 tablet by mouth q (every) day, [MEDICAL CONDITION] Behaviors: Monitor for Target Behaviors. If not present document "0". If present, list appropriate # & do;cument additional info in nursing progress notes: (1) Biting (2) Spitting (3) Hitting (4) Kicking (5) Pinching (6) Slapping (7) Rummaging (8) Scratching (9) Wandering/Pacing (10) Disrobing (;11) Making sexual advances (12) Pulling Lines-Catheter, IV (Intravenous), PEG (Percutaneous Endoscopy Gastrotomy) (13) Verbal Abuse (14) Paranoia (15) Delusional (16) Depressed (17) Agitated (18) Refuse meds (19) Refuses meals. Side effects: Monitor for side effects. If not present document "0". If present, list appropriate # & document additional info in nursing progress notes: (1) Sore Throat (2) URI (Upper Respiratory Infection) (3) Rash (4) Increased Falls/Dizziness (5) Dry Mouth (6) Nasal Congestion (7) Constipation (8) Blurred Vision (9) Confusion (10) Reduced Social Contact (11) Loss Muscle Tone (12) Drooling (13) [MEDICAL CONDITION] (14) Lethargy (15) Disturbed Gait (16) Nausea/Vomiting (17) Stiff Neck (18) Hand/Arm Tremors (19) Involuntary Movement Tongue/Face (20) [MEDICAL CONDITION] Record review revealed the resident was care planned on 7/2/14 for " [MEDICAL CONDITION] Drug Use with Goal: Will remain free of complications associated with [MEDICAL CONDITION] medication used everyday through next review date with Approaches: Behaviors: Monitor for targeted behaviors using behavior list on MAR. If behavior present, list appropriate # and document additional comments on EMAR (Electronic Medication Administration Record). If no behaviors present, document a "0" on EMAR in appropriate area; Side Effects: Monitor for side effects using side effects code list on EMAR. Document additional comments in appropriate place on EMAR. If new occurrence or increase in severity, notify MD. If no side effects present, document "0" on EMAR in appropriate place; Assess, Record, and report to MD any drug related complications, any difference in ADL performance, [MEDICAL CONDITION], depression, withdrawal, delusions, [MEDICAL CONDITION], and any change in mood and behavior ... " Record review of Resident #14 ' s July 2014 and August 2014 MARs (Medication Administration Record) revealed on 7/17/14 during the 7:00 AM-7:00 PM shift, a #15 was documented under the Behaviors section because the resident displayed delusional behavior. Record review of the 7/17/14 nursing progress notes failed to reveal documentation of additional information regarding the delusional behavior or any documentation that the physician was notified of a new occurrence in the resident ' s behavior. On 7/23/14 during the 7:00 PM-7:00 AM shift, a #15 and #17 was documented because the resident displayed delusional and agitated behavior, also a #9 was documented under the Side Effects section because the resident displayed signs of confusion. Record review of the 7/23/14 nursing progress notes failed to reveal documentation of additional information regarding the delusional and agitated behaviors and a side effect of confusion or any documentation that the physician was notified of a new occurrence in the resident ' s behavior. During an interview with S2RNSUP on 8/13/14 at 11:20 AM, he confirmed that the nurse failed to document further information on the 7/17/14 and 7/23/14 nurse's progress notes additional information regarding the behavior changes and side effects, did not perform any interventions, did not notify the physician of the new occurrence in behavior and side effects, and did not follow Resident #14 ' s care plan. During an interview with S1DON on 8/13/14 at 11:35 AM, she confirmed that there was no documentation in the 7/17/14 and 7/23/14 nurse's progress notes, facility ' s physician communication log or the social service notes regarding the resident ' s new behaviors and side effects or any documentation of notification to the resident ' s physician regarding the new behavior occurrences. S1DON stated that she had just spoken to S3LPN, who worked with Resident #14 on 7/23/14, and S3LPN informed her that she had only documented the behaviors and side effects on the MAR and had not written any additional information in the nurse ' s progress notes. During the interview, S1DON also stated that these behaviors were not usual behaviors for Resident #14.

Based on record review and interview, the facility failed to notify the resident ' s physician of a significant change in the resident ' s mental status by failing to notify the resident ' s physician of a new occurrence of delusional and agitated behaviors and a side effect of confusion for 1 resident (#14) out of 5 ( #14, #26, #43,#45, #46) residents investigated for unnecessary medications during Stage II, which had the potential to effect a total of 8 residents that resided on the SNF (Skilled Nursing Facility) unit, according the facility ' s Resident Census and Conditions of Residents form. FINDINGS: Resident #14 was admitted the facility's SNF (Skilled Nursing Facility) unit on 7/2/14 and had the following Diagnoses: [REDACTED].) Record review of Resident #14 ' s July 2014 and August 2014 physician's orders [REDACTED]. [MEDICATION NAME] 50mg (milligrams) tablet, Give 1 tablet by mouth q (every) day, [MEDICAL CONDITION] Record review revealed the resident was care planned on 7/2/14 for " [MEDICAL CONDITION] Drug Use " with the approach: Behaviors: Monitor for targeted behaviors using behavior list on MAR (Medication Administration Record). If new occurrence or increase in severity, notify MD (Medical Doctor). Assess, record, and report to MD any drug related complications, [MEDICAL CONDITION], depression, withdrawal, delusions, [MEDICAL CONDITION], and any change in mood and behavior. Record review of Resident #14 ' s July 2014 and August 2014 MARs revealed on 7/17/14 during the 7:00 AM-7:00 PM shift, documentation under the Behaviors section showed the resident displayed delusional behavior. Record review of the 7/17/14 nursing progress notes failed to reveal documentation that Resident #14 ' s physician was notified of a new occurrence in the resident ' s behavior. On 7/23/14 during the 7:00 PM-7:00 AM shift, documentation under the Behaviors section showed the resident displayed delusional and agitated behavior and had a Side Effect of confusion. Record review of the 7/23/14 nurse ' s progress notes failed to reveal documentation that the physician was notified of a new occurrence in the resident ' s behavior. From 7/1/14 to 8/13/14, 7/17/14 and 7/23/14 were the only two dates the resident showed signs of a change in behavior or of side effects. During an interview with S2RNSUP on 8/13/14 at 11:20 AM, he confirmed that the nurse failed to notify Resident #14 ' s physician of the new occurrence in behavior and side effects, and did not follow Resident #14 ' s care plan. During an interview with S1DON on 8/13/14 at 11:35 AM, she confirmed that there was no documentation in the 7/17/14 and 7/23/14 nurse's progress notes, facility ' s physician communication log or the social service notes that the resident ' s physician was notified of the resident ' s change in behavior. During the interview, S1DON also stated that delusional, agitation, and confusion were not usual behaviors for Resident #14.

Based on observation, record review, and interview, the facility failed to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers for resident #7 and by failing to ensure that a resident without a pressure ulcer does not develop a pressure ulcer unless unavoidable for resident #6 for 2 out of 3 sampled residents with pressure ulcers out of a total sample of 22 residents. (#7, #6) Findings: 1. Resident #7. Review of the resident's clinical records revealed that the resident was admitted to the facility on [DATE]. The resident has a [DIAGNOSES REDACTED]. Further review of the resident's admission assessment revealed no documentation that the resident was admitted with a pressure ulcer. Review of the resident's Braden Scale For Predicting Pressure Sore Risk assessment dated [DATE] revealed that the resident scored a 15, which is a low risk for developing pressure ulcers. Review of the resident's care plan with a begin date of 3/27/13 revealed that potential for impaired skin integrity was addressed in the care plan. The approaches identified to prevent the development of pressure ulcers included turning the resident every 2 hours, pillow between legs and behind back when lying down, pressure relieving device to bed/chair and report any red or open areas. Review of the resident's MDS (minimum data set) dated 4/3/13 revealed that the resident was coded to need extensive assistance for bed mobility and transfer with 2 plus persons assistance for bed mobility and transfers. Review of the resident's nurse's note dated 4/8/13 at 3:42 am revealed, ".........CNA reported to this nurse that veteran's right heel had a darkened area to it. Upon assessment, suspected deep tissue injury noted. Reported to ........ RN. Measures 8cm x 4cm. Floating the heels and heel protectors were not interventions that were implemented prior to the development of the suspected deep tissue injury to the resident's right heel. Review of the resident's nurse's note dated 4/8/13 at 9:57 am revealed, ".........Injuries: Suspected Deep tissue injury to right heel 8cm x 4cm. 50% of wound bed pale and mushy and the other 50% is dusky in color....." Review of the resident's nurse's note dated 4/10/13 a 2:10 pm revealed, ".....Upon assessment noted new wounds. Suspected deep tissue injury 0.3/2.8cm suspected deep tissue injury to left lateral calf ..........Stage 2 pressure ulcer (closed blister) to tip of right foot ......" There was no documentation of new interventions to prevent further development of pressure ulcers. Review of the resident's nurse's note dated 4/11/13 at 3:34 am revealed, "Upon weekly body assessment by.......LPN and summoned me to the room to assess new opened skin areas. Upon assessment stage II ulcer noted to right and left elbow. The right elbow measures 0.7 x 0.5cm and the left elbow measures 1.5 x 0.5cm. No drainage or redness noted to either pressure ulcer......." Review of the resident's nurse's note dated 4/16/13 at 4:17 pm revealed, "When showering resident stage 2 pressure ulcer to coccyx found. Approximately 4x 2.5cm.........Four blisters also found to ble. Approximately 1x 1.5cm, 1x0.2cm, 0.2 x 0.4 cm and 0.5 cm x 1 cm......." Review of the resident's care plan revealed that it was updated on 4/16/13 with a new intervention for an air mattress to be applied to the resident's bed to assist in the prevention of skin breakdown after the resident developed multiple pressure ulcers. On 9/19/13 at 12:25 pm, S1DON (Director of Nurses), S3RN, and S2ADON (Assistant Director of Nurses) stated that if a resident was coded on the MDS (minimum data set) to require extensive assistance with 2 plus person assist for bed mobility and transfer would be considered a high risk for pressure ulcer development. They confirmed that the interventions for floating the heels and heel protectors and the air mattress were implemented after the resident developed multiple pressure ulcers. 2. Resident #6. During an interview of S4LPN on 9-17-13 at 3:10 p. m, she stated that resident #6 had a Stage II pressure ulcer to the top of his penis which was caused by pressure from his indwelling urinary catheter. A review of resident #6's record revealed a Braden Scale for Predicting Pressure Ulcers dated 7-29-13 which documented a score of 17 which represented a Low Risk of developing a pressure ulcer. The Quarterly MDS (minimum data set) with a signature date of 7-31-13 coded the resident's functional status as requiring extensive assistance with two person physical assist for bed mobility, transfers, dressing, toilet use, and limited assistance with one person physical assist for personal hygiene. He was coded as total dependence for bathing, had functional limitations in both lower extremities, was chair bound, and had an indwelling catheter for [DIAGNOSES REDACTED]. He had a [DIAGNOSES REDACTED]. Resident #6 was coded as having pressure ulcers on previous MDS assessment. physician's orders [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's Nurse's Notes revealed an entry dated 9-13-13 and timed for 7:34 a. m, which documented the following entry. Pressure area to top of the shaft of vet's penis found upon brief change. An 8:17 a. m. documented entry on the same date, documented the Registered Nurse's assessment of the wound as follows: Stage II Pressure Ulcer to top of his penis, measuring 8.5 CM x 1 CM and appears to be caused by pressure from the catheter tubing. Observation of the resident's pressure wound and wound care by S4LPN with S3RN present on 9-17-13 at 4:00 p. m, revealed the following findings. The resident's pressure wound to the top of his penis was noted to involve the entire length of the resident's penis on the proximal aspect of the penile shaft. The wound was without odor or drainage. S3RN viewed the wound and stated that the wound had no change since his last assessment on 9-13-13 which documented the measurements as; 8.5 CM Length, 1.0 CM Width, and 0.10 CM Depth. S3RN confirmed the resident's Stage II pressure ulcer to his penis was acquired with-in the facility. An interview on 9-19-13 at 1:00 p. m, with S1DON, S2ADON, and S3RN verified that the facility staff provided all aspects of care for the resident's indwelling urinary catheter and the resident's Stage II pressure ulcer to the top of his penis was acquired with-in the facility.

Based on observation and interview, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect as evidenced by observing staff entering resident's rooms and common bathroom areas without knocking on the door and not providing residents privacy in the showers for 3 of 22 sampled residents. (#55, #6, #29) Findings: 1. Resident #55. On 9/16/13 at 2:10 pm, S3RN and S7RN were observed to enter the resident's room without knocking on the door while the resident interview was being conducted. The resident was in his wheelchair at the foot of the bed behind the door when S3RN opened the door. The surveyor informed S3RN that the resident was behind the door. S3RN stuck his head in the room and told the resident to move so that he could enter and talk to the resident's roommate. The resident moved his wheelchair and S3RN and S7RN entered the room during the resident interview. On 9/18/13 at 1:00 pm, S1DON (Director of Nurses) stated that the staff should knock on the resident's door before entering the resident's room. 2. Resident #6. During an interview of resident #6 in his room on 9-16-13 at 1:55 pm S6CNA was observed to push the resident's room door open and walk in without knocking or getting permission from the resident to enter the room. After S6CNA left the room, resident #6 was asked if he had heard S6CNA knock on the door before entering his room. Resident #6 replied "No" and stated that they, (staff) do that all the time, enter without knocking. During an additional interview with resident #6 on 9-17-13 at 2:27 p. m, resident #6 was asked about facility staff entering his room without knocking before entering his room. Resident #6 replied that some staff do knock and some staff do not knock before entering his room. An additional observation on 9-16-13 at 2:27 p. m. noted facility staff as they assisted a resident in a common bathroom, entering and exiting that bathroom with supplies. That common bathroom was next to a common sitting area adjacent to the nurse's station. S6CNA was observed as she approached the common bathroom with supplies to assist the resident with-in, and opened the door of the occupied bathroom without knocking. The door of the common bathroom was located within a hallway adjacent to a common sitting area. The bathroom was noted to have no privacy curtain which could have obscured the view of others in the hall or common sitting area. 3. Resident #29. An interview was conducted on 9-16-13 at 4:44 p.m. with Resident #29. When questioned about dignity, the resident responded that he was not always treated with dignity related to privacy. He stated that there are four stalls in the shower room. He stated that he has been in the shower room with three other men with four CNAs (certified nursing assistant) bathing the four residents. He then stated that curtains are not drawn and that the door leading to the hall is sometimes left open. He further stated that the CNAs have conversations that don't include any of the residents and that they are often loud and noisy. Resident #29 then stated that he was on the toilet in his bedroom bathroom with a CNA standing by to assist him. He stated that he ended up with four CNAs in his bathroom while his assigned CNA assisted him to clean up and adjust his clothing. He further stated that the staff were talking among themselves and no one was speaking to him. Resident #29 then stated that he never realized how modest he can actually be and that the situations embarassed him. He denied having reported the situations to anyone. An interview was conducted on 9-19-13 at 10:40 a.m. with S8Administrator. He stated that he was unaware of any privacy issues in the facility. An interview was conducted on 9-19-13 at 10:50 a.m. with S9SSD (Social Service Director). She stated that Resident #29's wife had lodged two complaints in 2013, but that they were unrelated to privacy. She further stated that she was unaware of any type of privacy issues in the facility.

Based on record review and interview, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents as evidenced by resident #1's wheelchair flipping backward while being transferred up on a van ramp for 1 out of 3 residents with falls out of a total sample of 22 residents. (#1) Findings: Review of the resident's clinical records revealed that the resident was admitted to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] revealed that the resident's score was 14, which was identified as a high risk for falls. Review of the resident's MDS (minimum data set) dated 8/12/13 revealed that the resident was coded as being totally dependent for transfer and requiring 2 plus person assist for transfers. Review of the resident's weight record revealed that the resident weighed 235 pounds on 8/30/13. Review of the resident's nurse's notes dated 8/30/13 at 6:45 pm revealed, "When CNA was assisting veteran into van at dialysis, his wheelchair flipped back while CNA was loading him. Assisted per dialysis staff to get wheelchair to upright position...............A dark reddened area to right forearm skin intact..................Resident Statement: The wheelchair just went back........" Review of the resident's care plan updated 8/31/13 revealed documentation that the resident had an actual fall with minor injury on 8/30/13............." Review of the resident's Incident Report dated 8/30/13 revealed, "When CNA was assisting veteran into van at dialysis, his wheelchair flipped back while CNA was loading him. Assisted per dialysis staff to get wheelchair to upright position........ A dark reddened area to right forearm. Skin intact. A 12cm x 2cm dark reddened area noted to right forearm." Review of the facililty's Fall Investigation Report dated 8/30/13 revealed that the contributing factor of the fall was that the loading ramp on the rental van was difficult to maneuver. Review of the witness statement dated 8/30/13 at 4:00 pm revealed, "When I was assisting (resident #1) into van at dialysis, his chair flipped back while I was loading him. I checked to make sure he was ok. Then went to get help. And was assisted by employee at dialysis center. We got him back in his chair.............." On 9/18/13 at 10:10 am, S10CNA Supervisor1 stated that the CNA was transporting the resident back from dialysis in the van. S10CNA Supervisor1 stated that the CNA was transferring the resident into the van on a ramp and when she was wheeling the resident up the ramp into the van over the hump the resident fell forward in the van. On 9/18/13 at 10:20 am, S1DON stated that the CNA was transporting the resident back from dialysis in the van. S1DON stated that the CNA was using the ramp from the van to transfer the resident into the van. S1DON stated that because of the weight of the resident's upper body being large that the CNA had trouble wheeling the resident over the hump to get him into the van. S1DON stated that as a result of the CNA having trouble to wheel the resident into the van that the resident's wheelchair rolled backwards on the ramp and the wheelchair fell backwards toward the CNA. On 9/18/13 at 10:25 am, S2ADON confirmed the above statement by the DON. On 9/18/13 at 10:35 am, S1DON that the van the resident was being transported in on 8/30/13 was a rental van. Also, S1DON confirmed that the CNA had difficulty maneuvering the resident on the ramp.

Based on observation, policy review and interview, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection by not following facility policy for the proper storage of resident use equipment when not in use for (Resident #14) out of 22 sampled resident in a facility. Findings: During an observation of the room belonging to resident's #14 and #6 on 9-16-13 at 1:55 p. m, an oxygen concentrator was observed next to resident #14's bed. The nasal cannula connected to the concentrator was draped over the top and down the back of the unit, un-covered with the nasal prongs of the cannula observed to be in contact with the floor in the back of the concentrator. Resident #6 was present with-in the room at the time and stated that resident #14 had been in the hospital for about 4 days. An interview with S5LPN on 9-16-13 at 12:30 p. m. had verified that resident #14 was admitted into the hospital and had been out of the facility for 4 days. Additional observations of the un-covered nasal cannula in contact with the floor were made on 9-17-13 at 3:00 p. m. and at 4:00 p. m. On 9-17-13 at 4:20 p. m, during an interview and observation of resident #14's room with S3RN, S3RN observed and verified the un-covered nasal cannula remained draped over the top and back of the oxygen concentrator and the nasal prongs of the device were in contact with the floor. S3RN stated that resident #14 was in the hospital as he verified the observation and and picked up the un-covered nasal cannula off the top of the concentrator. He verified the nasal cannula nor the humidifier was labeled with the date of device set-up or the resident owner's initials. S3RN then was observed as he replaced the un-covered nasal cannula back over the top of and draped down the back of the concentrator. S3RN was asked how long the un-covered nasal cannula and the humidifier had been connected on the oxygen concentrator. S3RN verified neither the nasal cannula tubing of the humidifier was labeled with a date or the initials of which staff person set up the oxygen supplies. S3RN then left the resident's room leaving the oxygen supplies in the same un-covered position of which they were observed to have been found. During interviews on 9-18-13 at 2:10 p. m. with S1DON and S2ADON, both verified the nasal cannula should not have been draped over the oxygen concentrator and should have been placed with-in a plastic bag. S1DON stated that the facility's policy was that such devices should be stored with-in a plastic bag even though the resident was not in house at the time and any of the facility's staff have the ability and skill to remove any non-covered potentially contaminated device. S1DON stated and verified that resident #14 was hospitalized since 9-10-13. An interview on 9-18-13 at 2:45 p. m. with S3RN confirmed that he observed and verified resident #14's nasal cannula and tubing draped over the oxygen concentrator with the nasal prongs in contact with the floor on 9-17-13. He also confirmed he (at the time of the verified observation) picked up the nasal cannula off the oxygen concentrator and floor, then replaced the un-covered nasal cannula in the same position of which it was found, over the top and draped down the back of the oxygen concentrator, then exited the room with the surveyor on 9-17-13 leaving the un-covered device in the same position it was found.

Based on record review and interview, the facility failed to ensure that an assessment of the resident's worsening condition during the night was documented. As a result of the resident's deteriorating condition, the resident was transferred to the hospital and diagnosed with [REDACTED].#50, #8, #41, #16) out of at total sample of 27 sampled residents. (#16) Findings: 1. Resident #16. Review of the resident's Admission physician's orders [REDACTED]. Review of the resident's Nursing Progress Notes dated 6/6/12 at 10:45 am revealed, "Noted on monthly wt review that veteran gained 4 lbs in 1 month. Assessment of veteran revealed lung sounds are clear, no [MEDICAL CONDITION] to (upper) or (lower) extremities. States he is eating much better since his diet changed. Notified Dr.......... New order for wkly wts obtained. Notified RP ....... of wt gain, diet change & fathers status of eating & [MEDICAL CONDITION]." Review of the resident's MAR (medication administration record) vital sign flow sheet for June 2012 revealed that weekly weights were being monitored. Review of the resident's nursing progress notes dated 6/23/12 at 2400 revealed, "SOB & abdominal breathing noted........... Sent to (hospital) per ambulance....." Review of the resident's nursing progress notes dated 6/23/12 at 0419 revealed, "admitted to (hospital) Rm #211 due to SOB & [MEDICAL CONDITIONS].." Review of the resident's nursing progress notes dated 7/19/12 at 9:45 am revealed, "Reviewed the 4lb gain c the RD. N.O. TO (change) diet form regular to cardiac to (lower) the Na content. Also, Dr...... will evaluate his diuretic medication which is [MEDICATION NAME] 40 mg q day..........." Review of the resident's nursing progress notes dated 7/31/12 at 2000 revealed New orders: "C x R stat. [MEDICATION NAME] 40 mg 1 po BID x 3 days." Review of the chest x-ray report revealed, "History: Cough-Congestion-Shortness of Breath............. Findings: Single view chest without comparison shows the cardiac silhouette is markedly enlarged in size. There is mild [MEDICAL CONDITION] vascular congestion seen. Cardiac generator is seen with distal leads overlying the right atrium and ventricle. The [MEDICATION NAME] aorta is tortutous and coars and enlarged in size........... Impression: 1. Marked cardiomegaly with mild congestive failure. 2. Enlarged tortuous [MEDICATION NAME] aorta is seen. Follow-up recommended." There was no documentation that the physician was notified concerning the results of the chest x-ray report. Review of the resident's nursing progress notes dated 8/1/12 at 0730 revealed, "Received report that vet had SOB all night despite the (increase) in [MEDICATION NAME], and that calls to MD were not returned per ......... LPN. Notified ........ (nurse from doctor's office) to please have one of the NP see vet as soon as they get here. .......... stated that NP ..... would be here in about 10 min. Vet currently lying in bed c 2LNC humidifid O2 c labored breathing....... Vet has some exp wheezing as well. ..........RN stated vet received neb tx around 0615." Review of the resident's nursing progress notes dated 8/1/12 at 0745 revealed, "Went to vet's room to do EKG. Vet's breathing still labored and it was evident vet was tiring out of working so hard to breath. While awaiting EKG to read and print, vet became very quiet and had a period of apnea that was disrupted c verbal and tactile stimulation. Vet was startled and encouraged to breathe. I called for help from more nurses." Review of the resident's nursing progress notes dated 8/1/12 at 0755 revealed, "..........NP and .......NP in room assessing vet. Vet placed on ventimask at 10L per ..........NP. Cont. to encourage vet to breath. Review of the resident's nursing progress notes dated 8/1/12 at 0800 revealed, "Ambulance services called." The resident was transferred out to the hospital and admitted with [MEDICAL CONDITION]. There was no documentation concerning the resident's condition on the night shift on 7/31/12 after 10:15 pm. On 8/23/12 at 12:30 pm, S7RN stated that on 8/1/12, when she first came on to start her shift, S8RN had reported off to her and told her that S9LPN had reported that the resident was short of breath all night. Also, S7RN stated that it was reported to her that multiple calls were placed to the physician and that the physician did not return any of the calls. S7RN stated that the resident was in poor condition that morning when she assessed him and that she was uncomfortable with the resident's condition. S7RN stated that the resident was deteriorating right before her eyes. S7RN stated that she called for the nurse practioner to assess the resident and the resident was sent out to the hospital. S7RN stated that she would have used her nursing judgment concerning the resident's condition and would have sent him out to the hospital that night. On 8/23/12 at 12:40 pm, S2DON and S3RN both confirmed that their was no documentation concerning the resident's condition on the night shift of 7/31/12 in the resident's clinical record. They both stated that if the resident's condition was deemed to be poor that the RN could transfer the resident to the hospital. On 8/23/12 at 1:15 pm, S10ADON and S2DON stated that they were not an acute facility and that if a resident was in a condition that the physician needed to be called multiple times that the resident should have been sent out to the hospital. On 8/23/12 at 2:00 pm, S9LPN stated that on 8/1/12 on the night shift, he went to the resident's room at 10:00 pm and saw the resident on the floor. S9LPN stated that the resident was breathing hard, but he did not feel like it was bad enough to send the resident to the hospital. S9LPN stated that he called the physician that night. S9LPN stated that the physician did not call back. S9LPN stated that he only reported to S8RN that he was monitoring the resident. S9LPN stated that he does not remember what he told S7RN when he reported off the next morning.

Based on record review and interview, the facility failed to ensure that each resident receive the necessary care and services to attain or maintain the highest practicable physical well-being by failing to have an assessment of the resident's worsening condition during the night. As a result of the resident's deteriorating condition, the resident was transferred to the hospital and diagnosed with [REDACTED].#50, #8, #41, #16) out of at total sample of 27 sampled residents. (#16) Findings: 1. Resident #16. Review of the resident's Admission physician's orders [REDACTED]. Review of the resident's Nursing Progress Notes dated 6/6/12 at 10:45 am revealed, "Noted on monthly wt review that veteran gained 4 lbs in 1 month. Assessment of veteran revealed lung sounds are clear, no [MEDICAL CONDITION] to (upper) or (lower) extremities. States he is eating much better since his diet changed. Notified Dr.......... New order for wkly wts obtained. Notified RP ....... of wt gain, diet change & fathers status of eating & [MEDICAL CONDITION]." Review of the resident's MAR (medication administration record) vital sign flow sheet for June 2012 revealed that weekly weights were being monitored. Review of the resident's nursing progress notes dated 6/23/12 at 2400 revealed, "SOB & abdominal breathing noted........... Sent to (hospital) per ambulance....." Review of the resident's nursing progress notes dated 6/23/12 at 0419 revealed, "admitted to (hospital) Rm #211 due to SOB & [MEDICAL CONDITIONS].." Review of the resident's nursing progress notes dated 7/19/12 at 9:45 am revealed, "Reviewed the 4lb gain c the RD. N.O. TO (change) diet form regular to cardiac to (lower) the Na content. Also, Dr...... will evaluate his diuretic medication which is [MEDICATION NAME] 40 mg q day..........." Review of the resident's nursing progress notes dated 7/31/12 at 2000 revealed New orders: "C x R stat. [MEDICATION NAME] 40 mg 1 po BID x 3 days." Review of the chest x-ray report revealed, "History: Cough-Congestion-Shortness of Breath............. Findings: Single view chest without comparison shows the cardiac silhouette is markedly enlarged in size. There is mild [MEDICAL CONDITION] vascular congestion seen. Cardiac generator is seen with distal leads overlying the right atrium and ventricle. The [MEDICATION NAME] aorta is tortutous and coars and enlarged in size........... Impression: 1. Marked cardiomegaly with mild congestive failure. 2. Enlarged tortuous [MEDICATION NAME] aorta is seen. Follow-up recommended." There was no documentation that the physician was notified concerning the results of the chest x-ray report. Review of the resident's nursing progress notes dated 8/1/12 at 0730 revealed, "Received report that vet had SOB all night despite the (increase) in [MEDICATION NAME], and that calls to MD were not returned per ......... LPN. Notified ........ (nurse from doctor's office) to please have one of the NP see vet as soon as they get here. .......... stated that NP ..... would be here in about 10 min. Vet currently lying in bed c 2LNC humidifid O2 c labored breathing....... Vet has some exp wheezing as well. ..........RN stated vet received neb tx around 0615." Review of the resident's nursing progress notes dated 8/1/12 at 0745 revealed, "Went to vet's room to do EKG. Vet's breathing still labored and it was evident vet was tiring out of working so hard to breath. While awaiting EKG to read and print, vet became very quiet and had a period of apnea that was disrupted c verbal and tactile stimulation. Vet was startled and encouraged to breathe. I called for help from more nurses." Review of the resident's nursing progress notes dated 8/1/12 at 0755 revealed, "..........NP and .......NP in room assessing vet. Vet placed on ventimask at 10L per ..........NP. Cont. to encourage vet to breath. Review of the resident's nursing progress notes dated 8/1/12 at 0800 revealed, "Ambulance services called." The resident was transferred out to the hospital and admitted with [MEDICAL CONDITION]. There was no documentation concerning the resident's condition on the night shift on 7/31/12 after 10:15 pm. On 8/23/12 at 12:30 pm, S7RN stated that on 8/1/12, when she first came on to start her shift, S8RN had reported off to her and told her that S9LPN had reported that the resident was short of breath all night. Also, S7RN stated that it was reported to her that multiple calls were placed to the physician and that the physician did not return any of the calls. S7RN stated that the resident was in poor condition that morning when she assessed him and that she was uncomfortable with the resident's condition. S7RN stated that the resident was deteriorating right before her eyes. S7RN stated that she called for the nurse practioner to assess the resident and the resident was sent out to the hospital. S7RN stated that she would have used her nursing judgment concerning the resident's condition and would have sent him out to the hospital that night. On 8/23/12 at 12:40 pm, S2DON and S3RN both confirmed that their was no documentation concerning the resident's condition on the night shift of 7/31/12 in the resident's clinical record. They both stated that if the resident's condition was deemed to be poor that the RN could transfer the resident to the hospital. On 8/23/12 at 1:15 pm, S10ADON and S2DON stated that they were not an acute facility and that if a resident was in a condition that the physician needed to be called multiple times that the resident should have been sent out to the hospital. On 8/23/12 at 2:00 pm, S9LPN stated that on 8/1/12 on the night shift, he went to the resident's room at 10:00 pm and saw the resident on the floor. S9LPN stated that the resident was breathing hard, but he did not feel like it was bad enough to send the resident to the hospital. S9LPN stated that he called the physician that night. S9LPN stated that the physician did not call back. S9LPN stated that he only reported to S8RN that he was monitoring the resident. S9LPN stated that he does not remember what he told S7RN when he reported off the next morning.

Based on observation on 8/19/12 and 8/20/12 the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly and comfortable interior as evidenced by the presence of an accumulation of dust on resident wheelchairs of 4 sampled residents (#16,, #17,#19, and #48) and the presence of cracks in the armrests of the wheelchair utilized by Resident #16. Findings:On 8/19/12 the wheelchairs being utilized by sample residents #17 and #19 were observed to have a build up of dust on the framework or the chairs. The wheelchairs utilized by sample residents #16 and #48 were observed on 8/20/12 and a build up of dust was noted on the framework of the wheelchair utilized by Resident #48, and a build up of dust was noted on the framework of the wheelchair utilized by Resident #16. The arm rests on the wheelchair utilized by Resident #16 were observed to have cracks in the covering material.

Based on observation and interview the facility failed to provide comfortable and safe temperature levels and to maintain a temperature range of 71 - 81? Fahrenheit as evidenced by the complaints of residents #16, and #19 that it was too cold, and by room air temperatures recorded between 67 degrees Fahrenheit and 69.5 degrees Fahrenheit in a Hall 2 resident room, in the Hall 2 dining area, and in the Therapy Room on 8/23/12. Findings: 1. On 8/19/12 at 12:33 PM during an interview with the family of resident #19, the family member stated that it was kind of chilly in the resident's room. Resident #16 was interviewed in his room on Hall 2 at 9:37 AM on 8/20/12 and the resident stated that it was too cold in the the room. 2. On 8/23/12 at 12 noon S4 Facility Maintenance utilized a thermometer gun to monitor the air temperatures on Hall 2 and in the Therapy area. The air temperature in the room occupied by sample residents #1 and #40 was recorded at 67 degrees Fahrenheit. Temperatures on the hall ways on Hall 2 ranged from 68 degrees to 68.5 degrees Fahrenheit. In the dining area of Hall 2 the air temperature was registered as 69 degrees Fahrenheit.

Based on interview and record review on 8/23/12 the facility failed to train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures as evidenced by S5 Custodian had not been trained in emergency procedures when she began to work in the facility. Findings: 1. On 8/23/12 at 10:50 AM S5 Custodian who had a date of hire of 7/2/2012 was interviewed in reference to - What to do if there is a chemical spill. S5 Custodian responded that she has worked here 2 months and all she knows is to put out signs and to call the supervisor. 2. S6 Housekeeping Supervisor was interviewed by telephone on 8/23/12 at 2:30 PM and she stated that she had not trained S5 Custodian on the emergency procedure for dealing with a chemical spill. The S6 Housekeeping Supervisor added that there is a black box in the storage room that contains all of the items to be used when a chemical spill has occurred. 3. The list of chemicals utilized in the facility was reviewed and contained products that have the potential to cause respiratory irritation, and skin irritation. The list included Discover Disinfectant, Gentle Fresh Sanitizer, NDC Neutral Disinfectant Cleaner, D-STORY, Discover Disinfectant, and No-Mix TERG-O-CIDE,