Every finding on record at St Joseph of Harahan

Based on observations, interviews, and record reviews the facility failed to:1. Ensure dishware and cookware were cleaned with the correct sanitizer levels to prevent foodborne illnesses; and,2. Ensure the kitchen food storage pantry was maintained in a clean and sanitary manner. Findings:1.Review of the facility's Cleaning and Sanitizing Equipment policy and procedure, dated 01/2007 and revised on 10/2018, revealed, in part, sanitization of food contact surfaces should be performed with a chemical sanitizer of chlorine at a minimum of 50-100 parts per million (ppm) or quaternary ammonium (QA) sanitizer solution at a minimum of 150-200 ppm. Review of the facility's Machine Warewashing policy and procedure, dated 01/2007 and revised on 10/2018, revealed, in part, dishes should be washed according to machine directions. Further review revealed staff should ensure the proper chlorine concentration of the rinse water for each meal. Observation on 06/16/2026 at 8:58AM revealed S10Culinary [NAME] was actively using the three compartment sanitizer sink to sanitize cookware and dishware. Observation of the facility's three compartment sanitizer sink on 06/16/2026 at 9:00AM revealed an empty container of QA sanitizer solution attached to the three compartment sanitizer sink sanitizer dispensing line. Observation on 06/16/2026 at 9:02AM revealed S4Culinary Supervisor (CS) performed a sanitizer solution test strip chemical test on the water in the sanitizer section of the three compartment sanitizer sink. Further observation revealed the chemical test strip read 0 ppm. In an interview on 06/16/2026 at 9:03AM, S4CS confirmed the chemical test strip used in the above mentioned test of the three compartment sink should have read between 150-200 ppm. S4CS further confirmed the QA sanitizer solution for the three compartment sanitizer sink had been empty since at least 06/15/2026. S4CS further confirmed the facility did not have any QA sanitizer solution on hand to replace it. Observation of the facility's kitchen dishwasher machine on 06/16/2026 at 9:04AM revealed a placard which indicated a sanitizer solution minimum 50-100 ppm was required. Observation on 06/16/2026 at 9:05AM revealed S4CS attempted three times to perform a sanitizer solution test strip chemical test on the dishwasher in the rinse water solution and once on the surface of the dishes. Further observation revealed the chemical test strips from the 4 attempts all read 10 ppm in the rinse water and on the dishes. In an interview on 06/16/2026 at 9:08AM, S4CS confirmed the chemical test strip used in the above mentioned tests of the dishwashing machine sanitizer solution read 10 ppm. S4CS further confirmed the dishwashing machine used a chlorine chemical sanitizer solution for dishware sanitization which should have read between 50-100 ppm on the chemical test strip during the rinse cycle and on the dishes afterwards, and it did not. 2.Review of the facility's Sanitary Conditions of the Food and Nutrition Services Department policy and procedure, dated 01/2007 and revised on 10/2018, revealed, in part, the facility should ensure the facilities and equipment used in the preparation and service of food provided to residents were safe and sanitary. Further review revealed the facility should ensure the food and nutrition director developed a master cleaning schedule that included what should be cleaned, who should clean it, when it should be cleaned, and how it should be cleaned. Further review revealed the food and nutrition director should supervise the daily cleaning and monitor the completion of all cleaning tasks. Observation of the facility's kitchen food storage pantry on 06/16/2026 at 8:40AM revealed an unknown wet black grainy substance along the left wall floor. Observation of the facility's kitchen on 06/17/2026 at 10:30AM revealed no kitchen cleaning schedule posted. Observation of the facility's kitchen food storage pantry with S4CS on 06/17/2026 at 10:55AM revealed an unknown wet black grainy substance along the left wall floor. In an interview on 06/17/2026 at 11:00AM, S4CS confirmed there was an unknown wet black grainy substance along the left wall floor of the food storage pantry. S4CS further indicated the food storage pantry should have been maintained in a clean and sanitary manner. S4CS further indicated there was no kitchen cleaning schedule to determine who was responsible for cleaning certain areas of the kitchen, when those areas should have been cleaned, and there should have been. In an interview on 06/17/2026 at 12:55PM, S1Administrator was presented with the above mentioned findings. S1Administrator indicated the kitchen should have been maintained in a clean and sanitary manner.

Based on observations, interviews, and record reviews, the facility failed to ensure staff completed hand hygiene while performing incontinence care for 2 (Resident #2, Resident #4) of 2 sampled residents observed for incontinence care. Findings:Review of the facility's Hand Hygiene policy and procedure, dated 07/01/2020, revealed, in part, hand hygiene shall be performed if the staff's hands would be moving from a contaminated body site to a clean body site during patient care. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, staff should decontaminate their hands if moving from a contaminated body site to a clean body site during patient care. Resident #2Observation on 06/16/2026 at 3:16PM revealed S8Certified Nursing Assistant (CNA) entered Resident #2's room to perform incontinence care. Further observation revealed S8CNA removed Resident #2's soiled diaper and wiped feces off of Resident #2's buttocks and perineal area. Further observation revealed S8CNA did not change her gloves and/or perform hand hygiene. S8CNA then applied powder to Resident #2's buttocks, placed a clean diaper on Resident #2, rolled Resident #2, and covered Resident #2 with clean linen with her contaminated gloved hands. In an interview on 06/16/2026 at 3:23PM, S8CNA indicated she did not change her gloves or perform hand hygiene after handling Resident #2's soiled diaper and before handling clean items. S8CNA further indicated she should have changed her gloves and performed hand hygiene since her gloves were contaminated after touching Resident #2's soiled brief and wiping the feces off of Resident #2. Resident #4Observation on 06/17/2026 at 9:14AM revealed S7CNA and S9CNA entered Resident #4's room to perform incontinence care. S7CNA removed Resident #4's soiled diaper, wiped feces off of Resident #4's buttocks and perineal area, and then handed Resident #4's soiled diaper to S9CNA to throw away. Further observation revealed S7CNA and S9CNA did not change their gloves and/or perform hand hygiene. S7CNA and S9CNA then placed a clean diaper on Resident #4, rolled Resident #4, placed a clean pad under Resident #4, repositioned Resident #4, and covered Resident #4 with clean linen. S7CNA then touched Resident #4's television remote control, bedside table, drink container, and newspaper with her contaminated gloved hands. In an interview on 06/17/2026 at 9:21AM, S7CNA indicated she did not change her gloves or perform hand hygiene after handling Resident #4's soiled diaper and before handling clean items. S7CNA further indicated she was unaware she needed to change her gloves and perform hand hygiene during incontinence care when she moved from a contaminated body area to a clean body area. In an interview on 06/17/2026 at 10:06AM, S5CNA Supervisor indicated the above mentioned CNAs should have changed their gloves and performed hand hygiene during incontinence care when they moved from a contaminated body area to a clean body area and/or clean resident items. In an interview on 06/17/2026 at 10:49AM, S2Director of Nursing confirmed the above mentioned CNAs should have changed their gloves and performed hand hygiene during incontinence care when they moved from a contaminated body area to a clean body area and/or clean resident items. In an interview on 06/17/2026 at 12:55PM, S1Administrator was presented with and acknowledged the above mentioned findings.

Based on observations, interview, and record review, the facility failed to ensure the facility's dumpsters and kitchen garbage cans were maintained properly. Findings:Review of the facility's Sanitary Conditions of the Food and Nutrition Services Department policy and procedure, dated 01/2007 and revised on 10/2018, revealed, in part, the facility should ensure garbage containers have tight fitting lids. Further review revealed the facility should ensure outdoor trash receptacles are kept covered at all times. Observation on 06/16/2026 at 8:51AM revealed the facility's two outside trash dumpsters were both uncovered with visible garbage and refuse inside both dumpsters. Observation on 06/16/2026 at 11:38AM revealed the garbage can in the food preparation area of the kitchen was uncovered with visible garbage and refuse inside the garbage can. Observation on 06/17/2026 at 10:40AM revealed one of the facility's outside trash dumpsters was uncovered with visible garbage and refuse inside the dumpster. Observation on 06/17/2026 at 10:45AM revealed the garbage can in the food preparation area of the kitchen was uncovered and had garbage overflowing the brim of the garbage can. In an interview on 06/17/2026 at 11:00AM, S4Culinary Supervisor (CS) confirmed the kitchen garbage cans and the outside trash dumpsters should have been covered at all times. S4CS further indicated the kitchen did not have any lids available for the trashcans and should have.

Based on observations, interviews, and record reviews, the facility failed to ensure heparin (a medication used to prevent blood clots) was stored in a locked compartment and only accessible to authorized personnel for 1 (Resident #3) of 3 sampled residents observed for nursing services. Findings:Review of the facility's Medication Administration policy and procedure, dated 10/04/2024, revealed, in part, medications must be secured at all times. Further review revealed medications shall not be left unattended on counters or at workstations. Review of Resident #3's medical record revealed, in part, Resident #3 was admitted on [DATE] and readmitted on [DATE] with a diagnosis of osteomyelitis (an infection of the bone). Further review revealed Resident #3 had a peripherally inserted central catheter (PICC) line in order to receive intravenous antibiotics. Review of Resident #3's June 2026 physician's orders revealed, in part, an order dated 06/04/2026 to administer 5 milliliters (mL) of heparin sodium injection solution intravenously via Resident #3's PICC line every shift. Observation of Resident #3's room on 06/15/2026 at 11:45AM revealed an unused, unsecured, and unattended blue syringe labeled heparin 50 units/5mL flush lying on Resident # 3's bedside table. Observation of Resident #3's room on 06/15/2026 at 2:00PM revealed an unused, unsecured, and unattended blue syringe labeled heparin 50 units/5mL flush lying on Resident # 3's bedside table. In an interview on 06/15/2026 at 2:15PM, S6Licensed Practical Nurse (LPN) accompanied this surveyor to Resident #3's room and confirmed there was an unused, unsecured, and unattended syringe of 50 units/5mL heparin lying on Resident # 3's bedside table. S6LPN further indicated the syringe of heparin should not have been left on Resident #3's bedside table. In an interview on 06/17/2026 at 10:44AM, S3Assistant Director of Nursing (ADON) indicated on 06/15/2026, S3ADON left a syringe of heparin 50 units/5 mL lying unsecured and unattended on Resident #3's bedside table and should not have. In an interview on 06/17/2026 at 10:49AM, S2Director of Nursing confirmed a syringe of heparin should not have been left unsecured and unattended on Resident #3's bedside table. In an interview on 06/17/2026 at 12:55PM, S1Administrator acknowledged a syringe of heparin was left unattended on Resident #3's bedside table and should not have been.

Based on observations, interviews, and record reviews, the facility failed to ensure a dependent resident received:1) assistance with incontinence care (Resident #106); and,2) assistance with dressing (Resident #142). This deficient practice was identified for 2 (Resident #106, Resident #142) of 3 sampled residents reviewed for activities of daily living. Findings:Resident #106Review of Resident #106's quarterly Minimum Data Set with and Assessment Reference Date of 02/04/2026 revealed, in part, Resident #106 had a Brief Interview of Mental Status score of 13, which indicated Resident #106's cognition was intact. Further review revealed Resident #106 had a diagnosis of hemiplegia following a cerebral infarction affecting the right dominant side (severe weakness and muscle stiffness caused by a brain injury), was always incontinent (having insufficient or no control over urination and/or bowel movements) of bowel and bladder, and required substantial/maximal assistance from staff with toileting. Review of Resident #106's care plan revealed, in part, Resident #106 required staff assistance with activities of daily living related to hemiplegia. Further review revealed Resident #106 was incontinent of bowel and bladder and staff were to provide incontinence care after each incontinent episode. Further review revealed staff were to provide prompt responses to all requests for assistance. Observation on 03/02/2026 at 10:50AM revealed Resident #106's call light was alarming. Observation on 03/02/2026 at 10:53AM revealed S8Licensed Practical Nurse entered Resident 106's room. Observation on 03/02/2026 at 10:57AM revealed a staff member used the overhead monitor to alert staff that Resident #106 needed assistance. Observation on 03/02/2026 at 11:10AM revealed Resident #106's call light was alarming. Observation on 03/02/2026 at 11:12AM revealed S7Certified Nursing Assistant entered Resident #106's room and asked Resident #106 what assistance he required. Further observation revealed Resident #106's call light stopped alarming. In an interview on 03/02/2026 at 11:18AM, Resident #106 indicated he had a bowel movement and had been waiting at least an hour for his adult brief to be changed. Resident #106 further indicated he had reported to multiple staff members that he needed his adult brief to be changed. Resident #106 further indicated the staff members entered his room and turned off his call light without providing incontinence care. In an interview on 03/02/2026 at 12:55PM, Resident #106 indicated he was still waiting for staff to provide incontinence care. In an interview on 03/02/2026 at 12:59PM, S8Licensed Practical Nurse confirmed she entered Resident #106's room when his call light was alarming and Resident #106 reported he needed his adult brief to be changed. S8Licensed Practical Nurse indicated she made an overhead page to alert staff Resident #106 required staff assistance. In an interview on 03/02/2026 at 1:03PM, S7Certified Nursing Assistant indicated she entered Resident #106's room when his call light was alarming and Resident #106 reported his adult brief needed to be changed. S7Certified Nursing Assistant indicated she turned off Resident #106's call light alarm and told S6Certified Nursing Assistant that Resident #106 required assistance with incontinence care.In an interview on 03/02/2026 at 2:15PM, S6Certified Nursing Assistant indicated sometime after 11:00AM she entered Resident #106's room and he reported he needed his adult brief to be changed. S6Certified Nursing Assistant indicated she did not change Resident #106's adult brief at that time because she was assisting other residents. S6Certified Nursing Assistant confirmed she changed Resident #106's adult brief at approximately 1:00PM and his adult brief was soiled. S6Certified Nursing Assistant indicated Resident #106 should not have waited 2 hours to receive incontinence care.Resident #142Review of Resident #142's quarterly Minimum Data Set with an Assessment Reference date of 02/18/2026 revealed, in part, Resident #142 had a Brief Interview of Mental Status score of 3, which indicated Resident #142's cognition was severely impaired. Further review revealed Resident #142 required partial to moderate assistance with upper body dressing and substantial to maximal assistance with lower body dressing and transfers. Observation on 03/02/2026 at 10:31AM revealed Resident #142 was in bed wearing only an adult brief. In an interview on 03/02/2026 at 10:31AM, Resident #142 indicated she had been waiting for staff to assist her with dressing. Observation on 03/02/2026 at 10:49AM revealed Resident #142 was lying in bed wearing only an adult brief. Observation on 03/02/2026 at 11:18AM revealed Resident #142 was lying in bed wearing only an adult brief. Observation with S6Certified Nursing Assistant on 03/02/2026 at 11:33AM revealed Resident #142 was lying in bed wearing only an adult brief. In an interview on 03/02/2026 at 11:35AM, S6Certified Nursing Assistant confirmed Resident #142 was lying in bed wearing only an adult brief, and should not have been. In an interview on 03/02/2026 at 1:28PM S1Director of Nursing indicated the nursing staff should have provided Resident #106 with timely incontinence care and Resident #142 with timely dressing assistance.

Based on observations, interviews, and record reviews, the facility failed to:1. Store oxygen tubing and nebulizer mouthpiece per facility policy (Resident #1 Resident #126); 2. Label oxygen tubing and nebulizer mouthpiece per facility policy (Resident #1, Resident #126); and,3. Administer oxygen as per physician orders (Resident #126). This deficient practice was identified for 2 (Resident #1, Resident #126) of 3 sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Oxygen Concentrator Cleaning Policy and Procedure, dated 11/16/2014 revealed, in part, oxygen tubing, nasal cannula, and facemask should be stored in a plastic bag when not in use. Further review revealed oxygen tubing, nasal cannula and facemask should be changed weekly and as needed. Review of the facility's Nebulizer Machine Cleaning Policy and Procedure, dated 11/04/2014 revealed, in part, nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. Further review revealed the tubing, mouthpiece and facemask should be changed weekly and as needed. 1. Review of Resident #1's medical record revealed, in part, Resident #1 had a diagnosis of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of Resident #1's March 2026 Physician orders revealed, in part, Ipratropium-Albuterol nebulizer solution (a medication primarily used to treat respiratory conditions) 0.5milligram (mg) per 2.5millitleter (ml) inhale orally via nebulizer every 6 hours via nebulizer related to COPD and oxygen at 2 liters per minute per nasal cannula. Review of Resident #1's March 2026 electronic Medication Administration Record revealed, in part, Resident #1 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml as ordered every 6 hours. Observation on 03/01/2026 at 10:30AM revealed Resident #1's oxygen tubing was on Resident #1's bed and was not stored in a plastic bag. Further observation also revealed Resident #1's nebulizer facemask was observed stored on Resident #1's nightstand and was not stored in a plastic bag. Observation on 03/02/2026 at 8:45AM revealed Resident #1's nebulizer facemask was observed stored on Resident #1's nightstand and was not stored in a plastic bag. Observation on 03/02/2026 at 2:45PM revealed Resident #1's nebulizer facemask was observed stored hanging on Resident #1's bedrail and was not stored in a plastic bag. Further observation also revealed Resident #1's oxygen tubing was observed stored on Resident #1's oxygen concentrator and was not stored in a plastic bag. In an interview on 03/02/2026 at 2:45PM, S3Licensed Practical Nurse indicated oxygen tubing and nebulizer facemask should be stored in a plastic bag when not in use. S3Licensed Practical Nurse confirmed Resident #1's oxygen tubing and nebulizer facemask was not stored properly and indicated Resident #1's oxygen tubing and nebulizer facemask should have been stored in a plastic bag when not in use. Review of Resident #126' medical record revealed, in part, Resident #126 had a diagnosis of respiratory disorders of chronic obstructive pulmonary disease, and emphysema. Review of Resident #126's physician orders dated 3/02/2026 revealed, in part, Ipratropium-Albuterol Inhalation (breathing treatment medication per nebulizer facemask) solution 0.5-2.5 (3) mg3ml one vial inhale orally every 6 hours as needed for interstitial pulmonary edema, emphysema, and chronic respiratory failure with hypoxia. Review of Resident #126's quarterly Minimum Data Set with an Assessment Reference Date of 01/20/2026 revealed, in part, a brief interview mental status of 15 which indicated Resident #126 was cognitively intact. Further review of Resident #126's Minimum Data Set revealed Resident #126 required oxygen therapy. Observation on 03/01/2026 at 9:35AM revealed Resident #126's nebulizer facemask with tubing was uncontained. Observation on 03/02/2026 at 11:15AM revealed Resident #126's nebulizer facemask was not contained in a plastic bag on Resident #126's nightstand. In an interview on 03/02/2026 at 11:45AM, S5Licensed Licensed Practical Nurse indicated Resident #126's nebulizer facemask was not contained in a plastic bag as required. In an interview on 03/02/2026 at 1:18PM, S1Director of Nursing indicated Resident #126's nebulizer facemask should have been contained in a plastic bag. 2. Observation on 03/01/2026 at 10:30AM revealed Resident #1's oxygen tubing and nebulizer facemask was not dated. Observation on 03/02/2026 at 8:45AM revealed Resident #1's oxygen tubing was not dated. Observation on 03/02/2026 at 2:45PM revealed Resident #1's oxygen tubing was not dated. In an interview on 03/02/2026 at 2:45PM, S3Licensed Practical Nurse indicated oxygen tubing and nebulizer facemask should be changed and dated weekly. S3Licensed Practical Nurse confirmed Resident #1's oxygen tubing and nebulizer facemask was not dated as required. In an interview on 3/2/2026 at 3:13PM, S1Director of Nursing indicated oxygen tubing and nebulizer tubing should be stored in a plastic bag when not in use and should be change and dated weekly. Review of Resident #126's physician orders dated 3/02/2026 revealed, in part, change nasal cannula every week and as needed. Observation on 03/01/2026 at 9:35AM revealed Resident #126 was wearing undated nasal cannula tubing. In an interview on 03/02/2026 at 11:00AM, S4Licensed Practical Nurse indicated Resident #126's nasal cannula tubing was not dated as required. In an interview on 03/02/2026 at 3:13PM, S1Director of Nursing indicated Resident #126's nasal cannula oxygen tubing should have been dated. 3. Review of Resident #126's physician orders dated 3/02/2026 revealed, in part, oxygen at 3 liters per minute per nasal cannula (NC) continuous. Review of Resident #126's quarterly Minimum Data Set with an Assessment Reference Date of 01/20/2026 revealed, in part, a brief interview mental status of 15 which indicated Resident #126 was cognitively intact. Further review of Resident #126's Minimum Data Set revealed Resident #126 required oxygen therapy. Review of Resident #126's care plan initiated on 09/27/2024 revealed, in part, oxygen settings per nasal cannula as ordered. Observation on 03/02/2026 at 11:04AM revealed Resident #126 had oxygen in progress with a flow rate of 4 liters per minute per nasal cannula. In an interview on 03/02/2026 at 11:48AM, S5Licensed Practical Nurse indicated Resident #126's oxygen flow rate was set at 4 liters per minute and should have been set at 3 liters per minute per physician's orders. In an interview on 03/02/2026 at 1:18PM, S1Director of Nursing indicated Resident #126's physician order was for 3 liters per minute per nasal cannula, and not 4 liters per minute per nasal cannula.

Based on observation, interview, and record review the facility failed to ensure a functional call light was available for 2 (Resident #142, #156) of 6 sampled residents investigated for call lights. Findings:Review of the facility's Resident Call Light System Policy and Procedure dated 09/14/2022 revealed, in part, the purpose was to provide a communication system that was in proper working order to allow residents to call for staff assistance from their bedside. Further review revealed when staff were providing care they were to position the call light conveniently within reach for the resident to use. Resident #142Review of Resident #142's care plan revealed, in part, Resident #142 had limited physical mobility and staff were to ensure Resident #142's call light was in reach. Observation on 03/02/2026 at 10:31AM revealed Resident #142 was lying in bed and Resident #142's call light was observed on the floor. In an interview on 03/02/2026 at 10:31AM, Resident #142 indicated she did not know where her call light was. Observation on 03/02/2026 at 10:49AM revealed Resident #142 was lying in bed and Resident #142's call light was observed on the floor. Observation on 03/02/2026 at 11:18AM revealed Resident #142 was lying in bed and Resident #142's call light was observed on the floor. Observation on 03/02/2026 at 11:33AM with S6Certified Nursing Assistant present, revealed Resident #142 was lying in bed and Resident #142's call light was observed on the floor. In an interview on 03/02/2026 at 11:35AM, S6Certified Nursing Assistant confirmed Resident #142 was lying in bed and Resident #142's call light was observed on the floor, and should not have been. In an interview on 03/02/2026 at 11:35AM, S9Licensed Practical Nurse indicated Resident #142's call light should have been within reach to allow her to call for staff assistance. In an interview on 03/02/2026 at 1:28PM, S1Director of Nursing confirmed Resident #142's call light should have been within reach to allow her to call for staff assistance. Resident #156Review of Resident #156's quarterly Minimum Data Set with an Assessment Reference Date of 02/11/2026 revealed, in part, Resident #156 had a Brief Interview for Mental Status score of 10, which indicates moderate cognitive impairment. Further review revealed Resident #156 required substantial/maximal assistance with transfers, toileting, and dressing. Review of Resident #156's care plan revealed Resident #156 required staff assistance with activities of daily living. Further review revealed staff were to ensure Resident #156's call light was within reach and provide prompt response to all requests. Observation on 03/01/2026 at 9:08AM revealed Resident #156's was lying in bed, and his call light cord was on the floor under his bed. Further observation revealed Resident #156's call light cord was severed and had no button attached. In an interview on 03/01/2026 at 9:08AM, Resident #156 indicated he did not have a call light for a few days and indicated he had to holler out when he needed assistance. Observation on 03/02/2026 at 10:29AM revealed Resident #156 was lying in bed, and his call light cord was on the floor under his bed. Further observation revealed Resident #156's call light cord was severed and had no button attached. In an interview on 03/02/2026 at 10:29AM, Resident #156 indicated he still did not have access to a call light to ask for assistance. Observation on 3/02/2026 at 3:53PM with S1Director of Nursing present, revealed Resident #156 was lying in bed and his call light cord was on the floor under his bed. Further observation revealed Resident #156's call light cord was severed and had no button attached. In an interview on 03/02/2026 at 3:53PM, S1Director of Nursing indicated Resident #156's call light should have been functional and available for use to call staff for assistance. In an interview on 03/03/2026 at 1:25PM, S2Corporate Nurse indicated Resident #156's call light should have been functional and available for use to call staff for assistance.

Based on interviews, and record review, the facility failed to provide the resident representative (RR) with the facility's written bed-hold policy at the time of transfer to the hospital as required for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge rights. Findings: Review of the facility's Resident Leave and Bed-Hold Policy and Procedure effective 04/27/2020 revealed, in part, the bed-hold policy must be issued at the time of the transfer from the facility. Further review revealed in cases of emergency transfer, notice at time of transfer meant family, surrogate, or representative were provided with written notification within 24 hours of the transfer. In an interview on 05/20/2025 at 12:08PM, S2Social Services (SS) indicated Resident #2 had an emergency transfer to the hospital due to behaviors on 02/27/2025. S2SS further indicated she mailed the facility's bed-hold policy to Resident #2's RR. S2SS indicated she did not call Resident #2's RR to see if Resident #2's RR received the mailed bed-hold policy. There was no documented evidence, and the facility was unable to present any documented evidence, the facility provided Resident #2's RR the written bed-hold policy within 24 hours of Resident #2's emergent transfer to the hospital. In an interview on 05/20/2025 at 12:39PM, S1Administrator indicated the bed- hold policy was included in Resident #2's transfer packet which was given to the behavioral health hospital. S1Administrator further indicated Resident #2 would probably not be able to understand the facility's bed-hold policy.

Based on interviews and record reviews, the facility failed to immediately notify the resident's representative of a resident's injury of unknown origin for 1 (Resident #1) of 2 (Resident #1, Resident #2) sampled residents investigated for injuries of unknown origin. Findings: In an interview on 04/16/2025 at 8:30AM, S5Licensed Practical Nurse (LPN) indicated on 04/02/2025 at 8:04AM she assessed Resident #1 with right arm immobility and pain, and administered a standing order of Tylenol. S5LPN indicated Resident #1 had complaints of pain later in the day, and an x-ray was ordered at 1:30PM by Resident #1's physician. S5LPN confirmed Resident #1's daughter who was Resident #1's Responsible Party (RP) was not notified of Resident #1's change in condition or of the new physician's orders. Review of Resident #1's record revealed no documented evidence, and the facility was unable to present any documented evidence Resident #1's RP was notified of Resident #1's change in condition or new physician's orders. In an interview on 04/15/2025 at 2:51PM, Resident #1's RP indicated she was informed of Resident #1's right arm fracture on 04/02/2025 at approximately 6:00PM. Resident#1's RP indicated she wondered why she was notified at 6:00PM when Resident #1's arm pain began at 8:00AM in the morning. In an interview on 04/16/2025 at 3:15PM, S3Director of Nursing (DON) indicated Resident #1's Representative was notified at 6:00PM, after the facility received the results of the x-ray and not when Resident #1 was assessed with right arm immobility and pain or when Resident #1's x-ray order was placed.

Based on interviews and record reviews, the facility failed to implement its policy for Abuse Prevention and Prohibition by not thoroughly investigating an injury of unknown origin for 1 (Resident #1) of 2 (Resident #1, Resident #3) sampled residents investigated for injuries of unknown origin. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part, the facility's process following an injury of unknown origin was that the Administrator would complete a thorough investigation. In an interview on 04/14/2025 at 12:50PM, S1Administrator indicated she was made aware of the results of Resident#1's x-ray, which revealed a fractured right arm, at 5:20PM on 04/02/2025, and S1Administrator began an investigation due to Resident #1's identified injury of unknown origin. S1Administrator indicated her review of surveillance camera footage revealed on 04/02/2025 at 7:00AM Resident #1 was ambulating out of her room using a rollator with no apparent issues, assisted into shower room by S10Shower Aide at 7:00AM approximately. Further review revealed surveillance camera footage showed Resident #1 was assisted out of shower room at 7:45AM by S10Shower Aide and left seated on her rollator in hallway. In an interview on 04/16/2025 at 12:04PM, S1Administrator indicated she thought her investigation of the facility video surveillance footage was thorough because she used the facility's video surveillance footage to pinpoint a time when the resident showed a change in condition related to her right arm. S1Administrator further indicated during her investigation, she observed Resident #1 enter the shower room and exit the shower room. S1Administrator indicated she did not consider or had a reason to determine if Resident #1 could have been left alone in the shower room. S1Administrator indicated she only viewed Resident #1's condition upon entrance and exit of the shower room, but not when S10CNA entered and exited the shower room. S1Administrator indicated she viewed the surveillance camera video at 16 speed the normal video speed and may have missed if S10CNA left Resident #1 unattended in the shower room. S1Administrator indicated the video surveillance footage was no longer available, and S1Administrator was unable to determine if Resident #1 was left unattended in the shower room.

Based on interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #115) of 2 (Resident #115, Resident #165) sampled residents reviewed for wandering behaviors. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 03/05/2025 at 8:46PM, when Resident #115, identified as a wanderer with dementia and cognitive communication deficits requiring supervision with walking, was unsupervised when she wandered into Resident #105's room and sustained a fall. Resident #115's fall resulted in an acute right femur fracture that required surgical intervention and rehabilitation. As a result of the fall, Resident #115 was required to use a wheelchair and experienced decreased mobility and independence. S1Administrator was notified of the Immediate Jeopardy on 03/26/2025 at 3:05PM. The Immediate Jeopardy was removed on 03/27/2025 at 10:35AM, after it was verified through observations, interviews, and record reviews, that the facility implemented an acceptable Plan of Removal prior to the exit of the survey. This deficient practice had the likelihood to cause more than minimal harm to the 12 residents who resided in the facility and were identified as wanderers. Findings: Review of Resident #115's hospital record dated 03/06/2025 revealed, in part, Resident #115 was diagnosed with a displaced fracture of right femoral neck. Further review revealed Resident #115 had a right hip hemiarthroplasty (partial hip replacement surgery) to repair fracture. Review of Resident #115's Electronic Medical Record (EMR) revealed, in part, Resident #115 was admitted to the facility on [DATE] with a diagnoses of dementia, and cognitive communication deficit. Review of Resident #115's Minimum Data Set with an Assessment Reference Date of 02/26/2025 revealed, in part, Resident #115's Brief Interview for Mental Status should not be conducted and Resident #115 is rarely or never understood. Further review revealed Resident #115 required staff supervision or touching assistance with walking 10 feet, 50 feet, and 150 feet. Review of Resident #115's care plan with a revision date of 01/09/2025 revealed, in part, Resident #115 was at risk for falls r/t confusion and poor communication/comprehension. Review of Resident #115's Long Term Care Evaluation dated 01/23/2025 revealed, in part, Resident #115 wanders at night. Review of Resident #115's progress note dated 03/05/2025, revealed, in part, on 03/05/2025 at 8:46PM, revealed Resident #115 wandered into another residents (Resident #105) room and when he (Resident #105) was trying to get her (Resident #115) out of his room she (Resident #115) fell on the ground. Review of the facility's incident report submitted on 03/10/2025 revealed, in part, Resident #115 had a fall on 03/05/2025 and returned to the facility with a fracture to the right hip. Further review revealed, in part, S1Administrator wrote: Resident #115 was found on the floor in Resident #105's room. S11CNA reported that Resident #105 pushed Resident #115 to the floor, but S11CNA did not see this happen. Resident #115 does have behavior of wandering throughout the day. Further review revealed after the fall, Resident #115 was noted to have pain to the right leg and back upon initial assessment and was sent to the Emergency Department. Resident #115 was not able to state what occurred. S11CNA stated that she observed Resident #115 walking in and out of resident's rooms about 30 minutes prior to incident. S11CNA said she saw Resident #105 walking toward Resident #115 with his hands up, when he was close enough he put his hands on her shoulder. The amount of force, if any, that Resident #105 used when he touched Resident #115's shoulder cannot be determined. Review of S11CNA's written and signed fall investigation questionnaire revealed, in part: -What was Resident #115 doing? Resident #115 was walking in and out of rooms. Review of S15Licensed Practical Nurse (LPN) written and signed fall investigation questionnaire revealed, in part: -What time did you last see Resident #115 before the fall? The last time I saw Resident #115 before she fell , Resident #115 was walking down towards the end of the hall. -What was Resident #115 doing? Resident #115 was walking into different resident rooms. In an interview on 03/24/2025 at 10:28AM, S22Rehab Director indicated Resident #115 had a right hip fracture after a fall. S22Rehab Director further indicated since the fall rehab staff have been working on Resident #115's gait (refers to the manner or style of a person's walking or movement), balance, transfers and bed mobility. In a telephone interview on 03/25/25 at 3:33PM, S11CNA indicated that she tried to redirect Resident #115 several times but she did not stop wandering in other residents rooms. S11CNA further indicated while doing rounds she heard Resident #105 telling Resident #115 to get out of his room. S11CNA indicated when she arrived to Resident #105's room, she observed Resident #105's hands extended in front of him out towards Resident #115 while she was falling to the floor. S11CNA indicated she did not witness Resident #105 push Resident #115 to the floor. S11CNA indicated Resident #115 wandered into other resident's rooms most times she has worked with her. In a telephone interview on 03/25/25 at 10:06AM, S15LPN indicated on 03/05/2025 prior to Resident #115's fall, Resident #115 was re-directed a few times from walking into other resident's room. S15LPN indicated later in the shift S11CNA informed her that Resident #115 fell inside Resident #105's room. S15LPN indicated Resident #115 was guarding and grimacing after the fall and had to be sent to the hospital. S15LPN indicated it was hard to supervise Resident #115 because she wandered a lot. In interview on 03/25/2025 at 1:39PM, S1Administrator stated staff was redirecting and providing activities to Resident #115 to keep her from wandering, but Resident #115 continued to walk the halls and go into other resident's rooms. S1Administrator further indicated they did everything they possibly could short of 1:1 supervision to keep the resident safe. In interview on 03/26/25 at 11:27AM, S3DON stated that the fall occurred after supper and staff were rounding and getting residents ready for bed. S3DON also indicated Resident #115 can be redirected and put in her bed, but would still wander. S3DON further indicated the next level of supervision would be 1:1 supervision but we don't provide 1:1 supervision at the facility, and there were a lot of residents that wander. A Plan of Removal was accepted on 03/27/2025 at 10:35AM, which included the following actions to correct the deficient practice: The facility identified those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: -12 Residents have been identified as wanderers, identified as Residents 1-12. One of these residents is currently in the hospital. Date completed 03/26/2025. Actions that the facility will take: -Photos taken of all residents and made available at nurses' stations and the reception desk to identify residents 1-12 who are at risk for wandering. Date completed 03/26/2025. -Additional staff, hall monitor, added to stay on the 2nd floor hall and visually observe and document observation of residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. During meal times, the monitoring of residents 1-12 will be handed off to CNA's and LPNs assigned to monitor the dining room and the hall monitor will remain on the hall to continue monitoring any of residents 1-12 that remain in their room for meals. Date begun 03/26/2026 and ongoing. Education/Training Plan: -Staff will be in-serviced on who the 12 residents are that are at risk for wandering, the need to visually observe residents 1-12 to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls, and methods for cueing, redirection, offering activities/snacks, and for what to do if a resident cannot be redirected. Date begun 03/26/2025 and ongoing until all staff are in-serviced. -Hall monitor will be trained on residents 1-12 at risk for wandering. How to monitor residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. How to cue, redirect or offer activities/snacks, how to document on monitoring form, and how to handle meal time. Also trained on what to do if a resident cannot be redirected. Date begun 03/26/2025 and ongoing with each new hall monitor assigned. The facility asserts that the likelihood of serious harm to residents no longer exist as of 03/26/2025 at 6:00PM.

Based on observations, interviews, and record review, the facility failed to maintain adequate dietary staffing levels to ensure the timely preparation and delivery of resident meals by failing to ensure: 1. breakfast was served in a timely manner; and 2. lunch was served at an appropriate palatable temperature. Findings: 1. Review of the facility's posted undated Meal Times form revealed the following, in part: Dining Room II: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:00PM Dining Room I: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:30PM West I : Breakfast 7:45AM, Lunch 12 noon, and Supper 5:45PM Observations in the kitchen on 3/24/25 at 8:40AM, revealed 2 staff preparing meals for hallway carts. In an interview on 03/24/2025 at 8:40AM, S7Assistant Dietary Manager indicated one staff member called in, the Dietary Manager was on her way back from an appointment, and the kitchen was already short staffed. Observations during dining facility task on 3/24/25 starting at 12:50PM, revealed some residents had not been served in both dining areas. Further observations revealed meal carts had arrived to the first and second floor hallways after 1:00PM. Observations on 03/24/2025 at 1:20PM, revealed 2 staff members started to pass trays on the second floor east hall. S9Certfied Nursing Assistant (CNA) indicated meals had just been passed on the second floor west hall. When asked about meal times, S9CNA answered that for the last month or two the breakfast carts have arrived on the floor around 9:00AM on most days, and the lunch carts have arrived around 12:45PM. Observations were continued until 1:54PM when the last tray remained and the surveyor requested the tray for further observation. In an interview on 3/24/25 at 1:40PM, Resident #164 indicated he eats in his room and breakfast and lunch are always late. Resident #164 indicated breakfast was after 930AM and lunch is after 1:45PM at least 3 days per week. Observation on 03/24/25at 1:29PM, revealed, in part, food cart for 100 hall arrived and trays were passed out to Residents in their rooms by S25CNA. In an interview on 3/24/25 at 2:10PM, Resident #134 indicated breakfast and lunch were always late. Resident #134 stated he ate in the dining area so he could get his meals faster. Resident #134 indicated if he ate in his room, breakfast would not get to him until 9:30AM-9:45AM and it would be cold and the grits would be hard as a rock; and lunch would definitely be served closer to 2:00PM at least 2-3 days per week. Observation on 03/25/2025 at 8:20AM, revealed breakfast trays were placed on hall carts and sent out from the kitchen by kitchen staff. In an interview on 03/26/2025 at 7:25AM, S6Dietary Manager acknowledged that breakfast was not served in the dining areas by 7:45AM and on the halls by 8:30AM. S6Dietary Manager further indicated lunch was not served by 12:45PM on 03/24/2025. S6Dietary Manager also indicated the kitchen has had daily call-ins from staff, and the kitchen was already not sufficiently staffed. Observation on 03/26/25 at 8:20AM, revealed breakfast trays were placed on hall carts and sent out from the kitchen by kitchen staff. In an interview on 03/27/2025 at 3:45PM, S7Assistant Dietary Manager indicated the posted meal time form times were correct, and [NAME] 1 represented the hallways. S7Assistant Dietary Manager acknowledged that breakfast was not served at 7:00AM, and lunch was not served at 12:00PM, the times listed on the Meal Time form. S7Assistant Dietary Manager further indicated that breakfast has been served after 8:30AM and lunch has been served after 1:00PM for the past few weeks. In an interview on 03/27/2025 at 4:10PM, S2Assistant Administrator indicated the meal time form presented at entrance has not been changed or modified, so the breakfast times were 7:00AM for dining rooms, 7:45AM for [NAME] 1 and halls, and lunch was 12:00Pm everywhere. 2. Observation on 03/24/2025 at 1:42PM of last tray passed on hall b, delivered by S25CNA, for room a, revealed the food was not at a palatable temperature. Observation on 03/24/2025 at 1:45PM revealed in part, S6Dietary Manager performed temperature checks to the above mentioned tray. Further observation revealed the macaroni temperature was 90 degrees Fahrenheit and the okra temperature was 88 degrees Fahrenheit. In an interview on 03/24/2025 at 1:45PM, S6Dietary Manager indicated the macaroni and the okra temperatures were not palatable and the temperatures should be maintained between 160 degrees Fahrenheit - 165 degrees Fahrenheit until served. In an interview on 03/24/25 at 2:10PM, Resident #134 indicated if he ate in his room, breakfast would not get to him until 9:30AM-9:45AM and it would be cold and the grits would be hard as a rock. 49259

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure Resident #47's care planned fall interventions were implemented; and 2. Ensure Resident #115 a known wanderer, had a care plan developed for wandering. This deficient practice was identified 2 (Resident #47, Resident #115) of 5 (Resident #30, Resident #47, Resident #51, Resident #115, Resident #187) sampled residents reviewed for accidents. Findings: 1. Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 had an unwitnessed fall on 03/05/2025 while transferring from her bed to her wheelchair unassisted. Further review revealed Resident #47's fall on 03/05/2025 resulted in a left hip fracture. Review of Resident #47's Significant Change Minimum Data Set (MDS) and State Optional Assessment with an Assessment Reference Date (ARD) of 03/18/2025 revealed, in part, Resident #47 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #47 was cognitively intact, required extensive assistance with two person physical assistance for transfers, toileting, and had a hip fracture. Review of Resident #47's physician orders revealed, in part, an order for a fall mat every shift with a start date of 03/07/2025. Review of Resident #47's care plan revealed, in part, a plan of care was initiated 09/30/2024 for risk for falls related to deconditioning, and gait/balance problems. The plan of care was revised on 03/05/2025 due to an unwitnessed fall which included an intervention for bright colored tape to #47's wheelchair brakes. Observation on 03/25/2025 at 4:00PM revealed, in part, there was no fall mat in Resident #47's room. Observation on 03/26/2025 at 8:40AM revealed, in part, Resident #47 was sitting in wheelchair there was no fall mat in Resident #47's room, and there was no bright colored tape on the brakes of Resident #47's the wheelchair. Observation on 03/27/2025 at 10:00AM revealed, in part, Resident #47 was lying in bed. Further observations revealed no fall mat in Resident #47's room, and there was no bright colored tape on the brakes of Resident #47's wheelchair. In an interview on 03/26/2025 at 8:45AM, S10Certified Nursing Assistant indicated she was not aware Resident #47 required a fall mat in her room or bright colored tape to her wheelchair to decrease the risk of falls. In an interview on 03/27/2025 at 10:00AM, Resident #47 indicated she never had a fall mat next to her bed, or bright colored tape to the brakes on her wheelchair to decrease the risk of falls with injury. In an interview on 03/27/2025 at 10:10AM, S8Licensed Practical Nurse (LPN) indicated he was not aware Resident #47 had orders for a fall mat, or required bright colored tape to the brakes on her wheelchair to decrease the risk of falls with injury. In an interview on 03/27/2025 at 10:20AM, S3Director of Nursing (DON), confirmed Resident #47 did not have a fall mat in her room, and did not have bright colored tape to the brakes of Resident #47's wheelchair. S3DON furthered indicated Resident #47 should have had a fall mat and bright colored tape to the brakes of her wheelchair as specified in the physician's orders and care plan. 2. Resident #115 Review of Resident #115's medical record revealed, in part, Resident #115 had an unwitnessed fall on 03/05/2025 while wandering in another resident's (Resident #105) room. Further review revealed Resident #115 had a fall in Resident #105's room on 03/05/2025 that resulted in a right hip fracture. Review of Resident #115's medical record revealed, in part, Resident #115 was admitted to the facility on [DATE] with a diagnoses of dementia, and cognitive communication deficit. Review of Resident #115's Minimum Data Set with an Assessment Reference Date of 02/26/2025 revealed, in part, Resident #115's Brief Interview for Mental Status should not be conducted and Resident #115 is rarely or never understood. Review of Resident #115's Long Term Care Evaluation dated 01/23/2025 revealed, in part, Resident #115 wanders at night. Review of Resident #115's care plan revealed no documented evidence and the facility did not present any documented evidence Resident #115 had a care plan developed to address the risks and interventions for wandering. In an interview on 03/26/2025 at 11:27AM, S3DON indicated Resident #115 was a known wanderer and was not care planned for wandering but should have been. In an interview on 03/27/2025 at 3:01 PM, S18Minimum Data Set (MDS) Nurse indicated Resident #115 was not care planned for wandering and should have been. 44336

Based on record reviews and interviews, the facility failed to administer a medication as ordered by the physician for 1 (Resident #116) of 4 (Resident #97, Resident #116, Resident #177, Resident #204) sampled residents reviewed for hospitalization . Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #116's medical record revealed he had the following diagnoses, in part, of Congestive Heart Failure, Hypertensive Heart Disease with Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident #116's physician orders dated 11/12/2024, revealed, in part, to increase Digoxin (medication used to treat congestive heart failure) to 250 micrograms (mcg) to three times a day and repeat Digoxin level (a blood test to determine the amount of digoxin in your body at a certain time) on 11/21/2024. Record review revealed on 11/20/2024, revealed Resident #116 was transferred to a local hospital per physician orders for an elevated Digoxin Level of 4.2 nanograms per milliliter (ng/ml). Further review revealed the normal range was 0.9-2.0 ng/ml. In an interview on 03/27/2025 at 11:22AM, S3Director of Nursing (DON) indicated Resident #116 did not receive the correct dose of Digoxin as ordered by the physician. S3DON also indicated on 11/12/2024 the physician wrote an order to increase Resident #116's Digoxin to 250mcg three times a day and the order for 125mcg three times a day should have been discontinued. S3DON indicated the order for Digoxin 125mcg three times a day was not discontinued, so Resident #116 received Digoxin 250mcg and Digoxin 125 mcg by mouth three times a day from 11/12/2024 at 8:00PM to 11/18/2024 at 2:00PM. In an interview on 03/27/2025 at 6:20PM, S24Licensed Practical Nurse (LPN) acknowledged Resident #116 did not get her Digoxin medication as ordered by the physician, and should have.

Based on interview and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hour timeframe for 2 (Resident #105, Resident #115 ) of 4 (Resident #51, Resident #105, Resident #115, Resident #187) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part, the administrator shall immediately initiate a Statewide Incident Management System (SIMS) report to the Louisiana Department of Health, but not less than 2 hours after forming a suspicion of a crime if the alleged violation involves abuse (physical abuse) or results in serious bodily injury. Review of the Louisiana Department of Health (LDH) Health Standards Incident Report #272956 revealed, in part, an allegation of physical abuse involving Resident #115 and Resident #105: -Occurred on 03/05/2025 at 11:14 PM; -Was entered into the SIMS reporting system on 03/10/2025 at 4:40PM. In an interview on 03/25/2025 at 10:48AM, S1Administrator confirmed the facility did not report an allegation of physical abuse involving Resident #115 and Resident #105 to the State Survey Agency within two hours and should have.

Based on observations and interviews, the facility failed to ensure maintenance staff secured electrical wall sockets in 3 (Room a, Room b, and Room c) of 4 (Room a, Room b, Room c, and Room d) rooms; and 2 (Hall X and Hall Y) of 4 (Hall W, Hall X, Hall Y, and Hall Z) halls observed for physical environment. Findings: Observation on 10/28/2024 at 9:15 a.m., revealed an electrical wall socket located in Room a was not secured to the wall. Observation on 10//28/2024 at 10:15 a.m. of the Hall W, Hall X, Hall Y, and Hall Z revealed the following: - Hall X had one electrical wall socket not secured to the wall; and - Hall Y had three electrical wall sockets not secured to the wall. Observation of Room b on 10/28/2024 at 10:15 a.m., revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Observation on 10/28/2024 at 10:25 a.m. of Room c revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Further observation revealed on the wall opposite the head of the bed revealed an electrical wall socket not secured to the wall. Observation of Room b on 10/28/2024 at 2:30 p.m. revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Observation on 10/28/2024 at 2:40 p.m. of Room c revealed the electrical wall socket located at the head of the bed was not secured to the wall. Observation also revealed there were two electrical plugs which were plugged into the electrical socket. Further observation revealed on the wall opposite the head of the bed revealed an electrical wall socket not secured to the wall. In an interview on 10/28/2024 at 3:30 p.m., S3Maintenance Supervisor indicated the electrical wall sockets in Hall X, Hall Y, Room a, Room b, and Room c were not secured to the wall, and should have been. In an interview on 10/29/2024 at 9:50 a.m., S4CNA indicated she had noted electrical wall sockets in the hallways were not secured to the wall when plugging and unplugging the microwave during meal service. In an interview on 10/29/2024 at 9:45 a.m., S7Licensed Practical Nurse (LPN) indicated he noted an electrical wall socket in Hall X was not secured to the wall. In an interview on 10/29/2024 at 10:30 a.m., S2Administrator indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:31 a.m., S5Regional Maintenance Director indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:33 a.m., S6Electrical Contractor indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:35 a.m., S1Regional Administrator indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been.

Based on record review and interviews, the facility failed to ensure a resident received care and services to prevent falls as much as possible by failing to develop new individualized interventions after a resident sustained a fall. This deficient practice was identified for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for falls. Findings: A review of the facility's incident reports for the past 60 days revealed, in part, a fall by Resident #1 on 08/06/2024; falls by Resident #2 on 08/12/2024, 08/22/2024, and 08/30/2024; and falls by Resident #3 on 07/26/2024, 08/02/2024, and 09/01/2024. Review of the facility's Fall Prevention Program Policy and Procedure (10/22/2014) revealed, in part, the fall prevention program is an individualized daily plan to promote safety of residents who have been identified as high risk for Falls via interdisciplinary team determination. All residents will be assessed upon readmit, quarterly, annually, if significant change occurs, and as needed; residents on the program will have care plan addressing goals and approaches. Review of the facility's Care Plan Policy and Procedure (05/22/2017) revealed, in part, the care plan will be revised on an on-going basis to reflect changes in the resident and the care that the resident is receiving; interventions are to be implemented to prevent avoidable declines, and to reserve and build resident strengths. Resident #1 Resident #1, a [AGE] year old English-speaking African American female, was admitted [DATE] with readmission on 08/18/2024, with diagnoses which included hypertensive heart disease without heart failure and dementia. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part; Resident #1 had a Brief Mental Status exam score of (BIMS) 4, which indicated severe cognitive impairment, with no signs or symptoms of delirium; Patient Health Questionnaire (PHQ9) of 0, which indicated there were no symptoms of depression; no hallucinations, delusions, or potential indicators of psychosis. Resident #1 did not reject care or wander. Resident #1 was able to make her needs known, although she was confused about actual events occurring. Resident #1 had a fall on 08/06/2024, which resulted in hospital admission. She was readmitted to the facility on [DATE]. New interventions were not implemented on Resident #1's care plan to prevent future falls. Review of Resident #1's medical record revealed a fall risk assessment dated [DATE] with a score of 10; resident was added to the fall program due to her recent fall. On 09/04/2024 at 1:09 p.m., S5LPN indicated Resident #1 mostly takes care of herself, ambulates, changes herself, feeds herself, and doesn't need much assistance from staff. In an interview on 09/04/2024 at 1:20 p.m., S4CNA stated Resident #1 was pretty independent, and was trying to move herself into her own wheelchair when she fell to the floor. She was sent to the hospital for evaluation. Resident #2 Resident #2 is a [AGE] year-old African American English-speaking male, admitted on [DATE], with admitting diagnosis of Pneumonia. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024 revealed, in part; Resident #2 had a BIMS of 10, PHQ9 of 00, with no hallucinations, delusions, or indications of psychosis. Resident #2 did not reject care or wander. Resident #2 is able to make his needs known. Resident #2 had falls on 07/05/2024, 07/10/2024, 07/26/2024, 08/02/2024, and 09/01/2024. New interventions were not implemented on Resident #2's care plan after each fall to prevent future falls. Review of Resident #2's medical record revealed a fall risk assessment dated [DATE] with a score of 12; resident was not added to the fall program. In an interview on 09/04/2024 at 1:24 p.m., S6LPN stated Resident #2 falls often because he tries to go to the bathroom unassisted, not calling for help; he thinks he can do it alone. S6LPN stated Resident #2 has left sided weakness s/p CVA, that his expectations are not realistic. Resident #3 Resident #3 is a [AGE] year-old English-speaking white female of Hispanic/Latin/Spanish origin who was admitted to the facility on [DATE], with readmission on 09/25/2022; with diagnoses which include acute on chronic diastolic heart failure, schizophrenia, sepsis, shortness of breath. Review of Resident #3's Minimum Data Set (MDS) Assessment Reference Date (ARD) 08/24/2024 revealed, in part; Resident #3 had a BIMS of 10, and a PHQ9 of 0; No hallucinations or delusions, no potential indicators of psychosis; no physical, verbal, or other behavioral symptoms exhibited; no rejection of care; no wandering exhibited. Resident #3 is able to make her needs known, although she is often confused about events occurring and will at times exhibit behaviors (e.g. throwing herself on the floor). Resident #3 had falls on 07/07/2024, 08/22/2024, 08/23/2024, and 08/30/2024. New interventions were not implemented on Resident #3's care plan after each fall to prevent future falls. Review of Resident #3's medical record revealed a fall risk assessment dated [DATE] with a score of 7; resident was not added to the fall program. In an interview on 09/04/2024 at 1:36 p.m., S7LPN stated resident #3 is always confused. For her recent fall, the care manager said she needed help to reposition her, because she said she would throw herself on the floor - and then she did throw herself on the floor, within 1 minute of making the statement. She did the same the next day. In an interview on 09/06/2024 2:30 p.m. S3Assistant Director of Nursing stated the facility had recently begun implementing new procedures regarding interventions for falls in June. She acknowledged that not all the falls listed on the care plans since June had appropriate individualized interventions for each fall sustained, and they should. In an interview on 09/06/2024 2:33 p.m. S2DON acknowledged not all the falls listed on the care plans since June had appropriate individualized interventions for each fall sustained, and they should.

Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene prior to providing catheter care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's Catheter Care, Indwelling Catheter Policy and Procedure dated 08/24/2016 revealed, in part, hand hygiene should be performed and gloves put on prior to the procedure. Further review the next step was to inspect the catheter at the urinary meatus and not any problems, then cleanse the perineal area with soap and water or a perineal wipe taking care to wash from front to back. Cleanse the area well at the insertion site and remove all debris form the insertion site. Further review revealed to then rinse well with warm water and pat dry. Further review revealed to then empty, clean and store bedpan or measuring device properly and then ensure the catheter is secured to the resident's thigh as appropriate. Further review revealed to then remove gloves into an appropriate container and then perform hand hygiene. Review of Resident #1's record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis, in part, of neuromuscular dysfunction of the bladder (a condition in which a person lacks control of the bladder). Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 06/05/2024, revealed, in part, Resident #1 had an indwelling catheter for urinary elimination. Further review revealed Resident #1 was always incontinent of bowel. Review of Resident #1's Physician's Orders revealed, in part, an order for catheter care , which included cleaning the insertion site with soap and water and rinse well every shift starting on 01/25/2023. Observation on 07/02/2024 at 10:20 a.m., revealed S6Certified Nursing Assistant (CNA) and S7CNA providing Resident #1 after having a bowel movement. Further observation revealed after Resident #1 was cleaned, S6CNA removed her gloves used to perform incontinent care and applied a new pair of gloves without performing hand hygiene. Observation then revealed S6CNA perform catheter care for Resident #1. In an interview on 07/02/2024 at 10:28 a.m., S6CNA confirmed that she changed her gloves but did not perform hand hygiene in between cleaning Resident #1 and performing catheter care for Resident #1. S6CNA further indicated she should have performed hand hygiene when she changed her gloves. In an interview on 07/02/2024 at 10:30 a.m. S4Wound Care Nurse confirmed the above mentioned observation and then indicated hand hygiene should have been performed after cleaning resident from having a bowel movement and before providing catheter care. In an interview on 07/02/2024 at 10:42 a.m., S8CNA Supervisor confirmed hand hygiene should be performed when changing gloves between incontinent care and catheter care. In an interview on 07/02/2024 at 1:30 p.m., S9Infection Control Nurse confirmed hand hygiene should be performed when changing gloves between incontinent care and catheter care.

Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, each resident has the right to be free from abuse. Further review revealed verbal abuse was defined as the use of oral, written or gestural language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability and examples included name calling, cursing, or yelling at a resident in anger. Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnosis, in part of Alzheimer's Dementia. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 06/12/2024 revealed, in part, he had a Brief Interview Mental Status Score of 7 which indicated moderate cognitive impairment. Review of S5Certified Nursing Assistant's (CNA) separation notice dated 06/21/2024 revealed, in part, the reason for separation was verbal abuse towards a resident. Further review revealed the Director of Nursing (DON) overhead S5CNA telling a resident to Shut the F*** up and when the DON questioned her, S5CNA indicated the resident cursed her so she told him to Shut the F*** up. In an interview on 07/02/2024 at 12:21 p.m., S2DON indicated she overheard S5CNA tell Resident #3 to Shut the F*** up when she was passing by the room. S2DON further confirmed this was considered verbal abuse and it should not have occurred.

Based on record review and interview the facility failed to ensure a resident was provided with restorative services for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of Resident #5's Physical Therapy Discharge Summary dated 04/29/2024 revealed, in part, Resident #5 was discharged from physical therapy with restorative nurse program to facilitate Resident #5 maintaining current level of performance and in order to prevent a decline with ambulation, bed mobility, and transfers. Review of Resident #5's Occupational Therapy Discharge Summary dated 04/30/2024 revealed a discharge recommendation for 24 hour care and participation in the restorative nurse program. In an interview on 05/16/2024 at 11:26 a.m., S7Restorative CNA indicated Resident #5 was not on the restorative CNA program at this time, and had not been since admit. In an interview on 05/16/2024 at 12:19 p.m., S2DON confirmed Resident #5 was not provided restorative series as recommended by therapy staff.

Based on observation, interviews and record reviews, the facility failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new ulcers by failing to: 1. Identify and document a resident's change in skin status when a resident was observed with boggy and mushy toes for 1 (Resident #3) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for skin issues; 2. Failed to ensure the nurse assessed a resident's skin after the Certified Nursing Assistant (CNA) notified the nurse of a new skin issue for 1 (Resident #1) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for skin issues; 3. Failed to notify the resident's physician of a new wound and obtain wound care orders for 2 (Resident #1 and Resident #3) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for skin issues; and 4. Failed to provide care and treatment to prevent a decline in wounds for 2 (Resident #1 and Resident #3) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for skin issues. This deficient practice resulted in an Immediate Jeopardy on 01/14/2022 when Resident #3's daughter discovered a wound to his right foot which she described as dried, dark drainage on Resident #3's right sock in the lateral toe area. Resident #3's daughter stated when she removed Resident #3's sock the last 3 toes and lateral side of the right foot near the toes were dark maroon like color, with dark reddish brown drainage, open areas and scabs noted. Resident #3's daughter requested Resident #3 be sent to the emergency room for evaluation. Resident #3 was evaluated and hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 underwent surgery on 01/21/2022 for the amputation of the 4th and 5th toes of the right foot. This deficient practice had the potential to affect 111 residents at risk for pressure ulcers according to the facility Pressure Ulcer Risk Report out of a total census of 162 per Facility Census report. This deficient practice resulted in a Harm for Resident #1 on 02/16/2022 when Resident #1 was identified as having a new skin issue to the lower back by S21CNA and not assessed or provided treatment until 02/18/2022 when S7RN/Treatment Nurse was notified of the wound and Resident #1 was sent to the hospital on 02/18/2022 with a foul smelling decubitus wound and was hospitalized for treatment. S1Administrator was notified of the Immediate Jeopardy on 03/31/2022 at 3:53pm. The Immediate Jeopardy was removed on 03/31/2022 at 6:20pm, after it was determined through observation, interview, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. DON or designee/wound care nurse to initiate in-service on 03/31/2022 with all nursing staff/Certified Nursing Assistants (CNA) on accurately completing body audits on all residents as scheduled and to notify the Medical Doctor (MD) of any skin integrity issues and obtain orders immediately. All nurses to be in-serviced prior to working their next scheduled shift. 2. DON or designee/wound care nurse to initiate in-service on 03/31/2022 with all nursing staff/CNAs on notifying a residents MD immediately when any skin integrity issues are discovered. All nurses/CNAs to be in-serviced prior to working their next scheduled shift. 3. DON or designee/wound care nurse to begin complete facility wide body audit on 03/31/2022 and to complete by end of day of 04/01/2022. If new wounds are discovered or any skin issues, DON or designee will contact the MD immediately to obtain orders. 4. DON or designee/wound care nurse to complete 5 random body audits 3 times a week starting on 03/31/2022 through 04/20/2022 to ensure compliance. If DON or designee identifies new wounds or any skin issues, they will contact the MD immediately to obtain orders. If the DON or designee identifies that nursing staff is non-compliant with body audits and notifying the MD immediately, progressive disciplinary action will be taken. 5. DON or designee/wound care nurse to review body audit schedule daily beginning on 03/31/2022 through 04/20/2022 and ensure floor staff is compliant with completing body audits. Failure of staff compliance will result in progressive disciplinary action. 6. Interdisciplinary Team (IDT) to discuss body audit compliance and immediate MD notifications weekly during QA meeting starting 03/31/2022 through 04/20/2022. 7. IDT to discuss body audit compliance and immediate MD notification quarterly with Medical Director starting 03/31/2022. 8. DON or designee/wound care nurse to ensure Resident #3 has preventative measures in place by 03/31/2022, heel protectors, wedge pillow for repositioning, pressure reducing mattress and cushion, body audits completed 3 days/week. Facility will begin coordinating with Resident #3's hospice company on 03/31/2022 to discuss any changes in condition to ensure immediate intervention and MD notification. 9. An observation on 03/31/2022 at 6:05pm revealed heel protectors, wedge pillow for repositioning, pressure reducing mattress and cushion for Geri Chair were in place for Resident #3. Resident #3 was positioned supine with the head of the bed elevated approximately 40 to 45 degrees with a wedge pillow behind Resident #3's back. Offloading boots on bilateral feet. Resident #3 was lying on a pressure reducing mattress. Resident #3's feet were not touching the footboard of the bed. 10. There will be no further issues regarding pressure ulcer timely identification and MD notification by 04/20/2022. Findings: Resident #3 Review of Resident #3's record revealed Resident #3 was admitted with diagnosis, in part, Unspecified Dementia without behavioral disturbance; Type 2 Diabetes Mellitus without complications; Stage 3 Pressure Ulcer of Left Buttock, Unstageable Pressure Ulcer of other side, history of [CONDITION(S)] and Cerebral Infarction without residual deficit. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 02/02/2022 revealed, in part, a Brief Interview of Mental Status score of 99, unable to complete interview; total dependence with a 2 person assist for bed mobility, transfers, personal hygiene, and bathing. Resident #3 was always incontinent of bowel and bladder, had not received any pain medications in the 7 days prior to the assessment, and was receiving nutrition per feeding tube. Resident #3 was at risk for pressure ulcers with 1 unstageable pressure ulcer that was present on admission and 1 surgical wound. A pressure reducing mattress, pressure reducing cushion for Resident #3's chair, a turn/repositioning program and pressure ulcer/injury care was indicated. Review of Resident #3's Care Plan revealed, in part, a problem of impaired skin integrity with interventions of a pressure reducing device/product on his bed/chair as appropriate; provide assistance with repositioning to avoid skin friction; observe skin when providing routine care; a full skin evaluation as appropriate; pillows or other supporting devices to assist with positioning; and repositioning every 2 hours and as appropriate. Review of Resident #3's record revealed, in part a Braden Risk Assessment (tool to evaluate risk for developing a pressure ulcer) dated 12/28/2021with a result of 12 (high risk for pressure ulcers) performed by the assessment nurse. Review of Resident #3's record revealed, in part, a Weekly Skin Inspection Report completed by S11LPN on 01/10/2022 stating Skin Not Intact-Existing. Review of Resident #3's completed care revealed, in part, documentation of a bed bath on 01/13/2022 signed off by S20CNA. Review of Resident #3's Nurses Notes by S14RN revealed, in part: An entry on 01/14/2022 5:45pm revealed, in part, Late entry-At 3:25pm called to hallway outside resident room by Resident #3's daughter. Daughter stated Resident #3's foot on the right side is leaking and necrotic (dead nonviable tissue). Educated the Daughter that I can send her father to the emergency room if she feels he needs immediate attention. Daughter stated to send him to local emergency room for treatment and evaluation. Review of Resident #3's hospital record revealed, in part, an Emergency Department note dated 01/14/2022 at 4:47pm admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's hospital record revealed, in part, a Podiatry Consult Note dated 01/15/2022 which the examination of Resident #3's right foot with the following documented: maceration (broken down skin due to moisture), [CONDITION(S)] (bacterial skin infection), skin changes, abnormal color, ulcer (open sore on external and/or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal), [CONDITION(S)] (superficial reddening of the skin, usually in patches, as a results of injury or irritation causing dilatation of the blood vessel) 3rd, 4th, and 5th toes, no drainage and skin not intact. Pulses in feet were 3 +. Eschars (dead, scab like tissue) of the right toes 3-5, 5th toe with ulcer to the bone, with broken down skin due to moisture in between the 3rd and 4th toes. Magnetic Resonance Imaging (medical imaging technique used in radiology to form pictures of the body and the process of the body) MRI of the right foot on 01/15/2022 revealed, in part: Acute [CONDITION(S)] (OM) (infection of the bone) 4th and 5th toes. Resident #3 was started on antibiotic therapy, a consult was ordered by Vascular Surgery, and a plan for surgical intervention. Resident #3 will likely require debridement (removal of damaged tissue) and amputations (removal of a body part such as the toe) of the right 5th toe and possibly the right 4th toe. Review of Resident #3's hospital record revealed, in part, a consult with vascular surgery dated 01/17/2022 at 7:57am which included the following: Palpable (able to feel) 3+ pulses in the feet, Skin is warm and dry; Triphasic PT signals (normal peripheral artery flow), capillary refill takes less than 2 seconds; and Right foot 3rd-5th toes with pressure ulcers on lateral (outer) aspect of toes. Review of Resident #3's hospital surgical procedure note dated 01/21/2022 revealed, in part, Resident #3 underwent surgical removal of the 4th and 5th toe of the right foot and surgical removal of damaged tissue to the right foot. In an interview on 03/28/2022 at 10:59am S7Registered Nurse (RN)/Treatment Nurse stated she was not aware of a wound or pressure ulcer to Resident #3's right foot until he returned from the hospital on 01/24/2022 when Resident #3's 4th and 5th toes were surgically removed. In an interview on 03/29/2022 at 10:12am, S20CNA stated in January of 2022 she cared for Resident #3 several times. She stated she remembered Resident #3 having a wound to one of his feet, but not on both feet until he returned from the hospital after he had surgery. In an interview on 03/29/2022 at 10:34am, S21CNA stated Resident #3 received his baths on Mondays, Wednesdays, and Fridays. S21CNA stated she mainly gave Resident #3 a bed bath. S21CNA stated she cannot remember if Resident #3 had any skin condition or wound to his right foot. S21CNA further stated when she performs a bed bath, she removes his protective boots and socks to wash his feet. S21CNA stated Resident #3 was a tall man and he slides down the bed where his feet touch the foot board. S21CNA further stated if she would note anything unusual on Resident #3's body or skin she would inform the nurse. In a telephone interview on 03/29/2022 at 11:27am, S30CNA stated when she gives a complete bed bath she washes the residents complete body. S30CNA further stated she would remove offloading boots, socks and wash the resident's feet and between the toes. S30CNA stated she could not remember on 01/13/2022 giving Resident #3 a bed bath. S30CNA further stated if she noted anything unusual on Resident #3's skin or body she would report it to the nurse. In an interview on 03/29/2022 at 11:40am, S7RN/Treatment Nurse stated she was never notified of Resident #3 having a wound on the right foot. S7RN/Treatment Nurse further stated until Resident #3 went to the hospital she was treating a wound to his left buttocks and left foot. S7RN/Treatment Nurse further stated she was not aware of Resident #3 having a wound to his right foot until he returned from the hospital on 01/25/2022. She further stated on the Skin Inspection Report the entry skin not intact-existing meant existing wounds being treated with wound care. In a telephone interview on 03/29/2022 at 2:40pm, S11LPN stated she performed a skin inspection on Resident #3 on 01/10/2022 and from what she could remember the area around his right great toe and 2nd toe was mushy. S11LPN stated if she found anything unusual when performing skin assessments she would put a message in the treatment book or leave a message for the wound care nurse. S11LPN further stated she could not remember if she reported anything unusual for Resident #3's skin inspection on 01/10/2022. S11LPN stated on the skin inspection report the entry skin not intact-existing meant a wound that was being treated by wound care. In an interview on 03/29/2022 at 2:50pm, S14RN stated on 01/14/2022 Resident #3's daughter was clipping Resident #3's toes. S14RN stated Resident #3's daughter called her to his room and stated there was drainage from his right foot and to look at his foot. S14RN stated upon inspection of Resident #3's right foot she noted purulent drainage under Resident #3's pinky toe in the crease. S14RN stated she did not note any open wounds or scabs. S14RN stated Resident #3's daughter requested Resident #3 be sent to the hospital for evaluation. S14RN stated she called for an ambulance, the emergency room , and the Director of Nursing (DON). In a telephone interview on 03/30/2022 at 8:30am, Resident #3's responsible party/daughter stated on 01/14/2022 was the first time she went to visit Resident #3 since the first or second week of December 2021. Resident #3's daughter stated prior to this, she would usually visit her father weekly on Fridays and on the days she visited she always washed his feet and applied lotion because it seemed his feet were never washed. Resident #3's daughter stated on 01/14/2022 Resident #3 was in a geri-chair in the hallway with no protective boot on either leg. Resident #3's daughter stated she obtained a basin of warm water and a towel to clean Resident #3's feet and on Resident #3's right foot she noted dried, dark drainage on the right sock in the lateral toe area. Resident #3's daughter stated she gently removed the sock, which appeared stuck to the right 4th and 5th toe area. Resident #3 stated the last 3 toes and lateral side of the foot near the toes of Resident #3's foot was dark maroon like color, with dark reddish brown drainage noted. Resident #3's daughter further stated on his right foot the last 3 toes appeared dark burgundy/black in color with what looked like scabs on top and yellow to clear drainage noted and she called for staff and a nurse came. Resident #3's daughter stated the nurse asked her if she wanted her father to go to the emergency department to have the foot check and she replied yes. In an interview on 03/31/2022 at 12:30pm, S3Director of Nursing (DON) and S4Assistant Director of Nursing (ADON) stated they were not aware of the wound to Resident #3's right foot until 01/14/2022 when Resident #3 was sent to the emergency room . S3DON stated the wound should have been identified and treatment initiated to prevent Resident #3's surgical procedure which resulted in the removal of Resident #3's 4th and 5th toes. In a telephone interview on 03/29/2022 at 11:19am, S5Medical Director stated based on medical research it had been shown [CONDITION(S)], with a wound, typically occurred 5-7 days after the wound occurred. Resident #1 Review of Resident #1's hospital discharge paperwork for hospitalization on [DATE]-[DATE] revealed Resident #1 was hospitalized for [CONDITION(S)] association with DMII. Further review revealed diagnoses, in part, biventricular automatic implantable cardioverter defibrillator at end of life. Review of Resident #1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) dated 02/04/2022 revealed Resident #1 had short and long term memory problems with moderate impairment of cognitive skills for daily decision making moderately impaired per staff interview. Review revealed Resident #1 required extensive assistance of one person for bed mobility, and required total assistance of one person for bathing and personal hygiene. Further review revealed Resident #1 was at risk for developing pressure ulcers. Review of Resident #1's Care Plan, with goal date of 05/25/2022, revealed Resident #1 was at high risk for skin breakdown related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Wound Assessment Report, dated 01/29/2022 through 02/16/2022 completed by S7RN/Treatment Nurse, revealed no documented evidence of any skin issues present to Resident #1's anterior or posterior trunk, sacrum, and/or buttock. Review of Resident #1's Skin Inspection Reports, dated 01/29/2022 and 02/05/2022 completed by S32RN, and 02/12/2022 completed by S3DON revealed no documented evidence of identification of a wound to Resident #1's lower back/sacral area. Review of Resident #1's Bath and ADL (Activities of Daily Living) Reports revealed S21CNA provided personal care to Resident #1 on 02/16/2022. Review of Resident #1's Record revealed on 02/16/2022, S27LPN was Resident #1's assigned nurse. Review of Resident #1's Hospital Record, dated 02/18/2022, revealed Resident #1 presented to the hospital with altered mental status of unknown duration, [CONDITION(S)] (low blood pressure) with a blood pressure of 65/36mmHg (millimeters of mercury), tachypnea (fast breathing) and a low-grade fever of 99.4° Fahrenheit. Review revealed Resident #1 had a foul smelling decubitus wound. Further review revealed Resident #1's family declined invasive measures and requested comfort care/hospice services. In an interview on 03/29/2021 at 10:20am, S21CNA stated Resident #1 had a wound to his lower back side. At this time, S21CNA pointed to the area on her back which was between the lower back and sacrum. S21CNA described the wound as open and oozing with yellowish, greenish drainage, with reddened skin around the wound. S21CNA stated she was unable to remember or describe the size or color of the wound. S21CNA stated she was unable to recall the exact date she identified Resident #1's wound, but she stated it was on the day shift, and it was prior to the day of his re-hospitalization . S21CNA further stated she informed Resident #1's nurse, however she was unsure of the nurse's name. In an interview on 03/29/2022 at 3:42pm, S27LPN (Licensed Practical Nurse), stated she did not remember any reports by the CNA staff of new wounds while providing care to the resident on 02/16/2022. S27LPN stated she was not aware of Resident #1 had any wounds to his anterior or posterior trunk, sacrum, or buttock area. In an interview on 03/29/2022 at 10:05am, S20CNA stated she provided personal care to Resident #1 on 02/17/2022. S20CNA further stated she was unaware Resident #1 had any wounds on his buttock area. In an interview on 03/29/2022 at 2:03pm, S28CNA stated she cared for Resident #1 on 02/17/2022 and 02/18/2022 and noted Resident #1 had a little dark line to his right buttock. S28CNA stated she had informed either S29CNA Wound Care Assistant or S26LPN of Resident #1's skin issue. In an interview on 03/31/2022 at 11:01am, S29CNA Wound Care Assistant stated the last day Resident #1 was at the facility, 02/18/2022, S28CNA notified her Resident #1 had a new skin issue to his sacrum. S29CNA Wound Care Assistant stated the area was a large, flat, dark, open area without drainage that appeared new, but also appeared to be deteriorating fast. S29CNA Wound Care Assistant stated Resident #1's wound looked like what R7RN (Registered Nurse)/Treatment Nurse usually called a deep tissue injury, but the wound was more black than purple and was red around the edges. In an interview on 03/31/2022 at 1:20pm, S7RN/Treatment Nurse stated Resident #1 did not have any wounds to his anterior or posterior trunk or buttock area upon admission. S7RN/Treatment Nurse stated the evening shift nurse on 02/18/2022 notified the wound care department Resident #1 needed a dressing applied to his lower back and buttock area. S7RN/Treatment Nurse stated when she went to assess the wound she knew Resident #1 needed to go to the hospital for evaluation of the wound due to the wound's size and appearance. S7RN/Treatment Nurse stated Resident #1's wound was deep dark purple, almost black, and appeared to be worse than a deep tissue injury. S7RN/Treatment Nurse confirmed the first time she was notified of the wound to Resident #1's lower back area was on 02/18/2022. In an interview on 03/30/2022 at 3:30pm, S6Medical Director confirmed he was not notified of a wound to Resident #1's lower back/sacrum until he was readmitted on [DATE].

Based on record review and interview, the facility failed to : 1. Assess a resident when a bandage was observed on the resident's left hand middle finger (Resident #2); and, 2. Notify the physician when a bandage was observed on a resident's left hand middle finger for an unknown reason. The deficient practice was identified for 1 (Resident #2) of 6 sampled residents reviewed. The deficient practice resulted in an Immediate Jeopardy for Resident #2 which began on 03/20/2022 (exact time unknown) when S31Licensed Practical Nurse (LPN) observed Resident #2 with a coban (a type of bandage that coheres to itself but does not adhere well to other surfaces) dressing wrapped around the middle finger of the left hand. The Immediate Jeopardy ended for Resident #2 on 03/22/2022 at 11:16am, when a LPN assessed Resident #2's left hand middle finger and observed dried blood, which had a coban dressing in place and tenderness. The coban dressing was unable to be removed because Resident #2 was in pain. Resident #2 was transferred to the hospital via ambulance. Resident #2 underwent an amputation to the middle finger of the left hand on 03/28/2022. The facility fully implemented a corrective action plan which was completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2022 revealed, in part, the following: Section C (Cognition): Brief Interview for Mental Status Exam score of 99. A score of 99 indicates the resident was unable to complete the interview; Section G (Activities of Daily Living): Bed Mobility was coded as required extensive assistance of one person, Transfer was coded as required extensive assistance of one person, Dressing was coded as required total assistance of one person, Eating was coded as required extensive assistance of one person, Toilet Use was coded as required extensive assistance of one person, and Personal hygiene and bathing were coded as total assistance of one person. Resident #2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Nurses Notes revealed, in part, the following: 03/21/2022 at 10:44pm: Resident #2 returned from a medical appointment at 4:50pm. Resident #2's finger had dried blood and Resident #2 would not allow S8LPN to assess the finger. The Nurses Note was signed by S8LPN; 03/22/2022 at 10:45am: Resident #2's left hand middle finger swollen with a purple/blue coban dressing observed. Resident #2 to the emergency room . The Nurses Note was signed by S13LPN; 03/22/2022 at 11:16am: Resident #2's left hand middle finger was swollen, painful to touch, dressing with dried blood noted, purple/blue coban observed secured tight, tender to touch. Transferred to emergency room per ambulance; and 03/22/2022 2:36pm: (Late entry for 03/20/2022) Upon assisting CNA with perineal care for Resident #2 observed blue coban wrapped around middle finger of Resident #2's left hand. Review of Resident #2's hospital records dated 03/30/2022 revealed, in part, Resident #2 was brought into the emergency department on 03/22/2022 with a necrotic left middle finger, tightly wrapped with a coban dressing at the nursing home. Further review revealed, in part, Resident #2's left hand middle finger was amputated on 03/28/2022. In an interview on 03/28/2022 at 12:31pm, S15CertifiedNursingAssistant(CNA) stated on 03/21/2022 she observed a blue dressing wrapped around Resident #2's middle finger of the left hand and reported the finding to S13LPN. In an interview on 03/28/2022 at 12:22pm, S13LPN stated on 03/21/2022 she observed a blue coban dressing wrapped around Resident #2's left hand middle finger. S13LPN stated she did not know why Resident #2 had the dressing on, and the dressing did not have a date, time or initials on it. S13LPN stated on 03/21/2022 she did not attempt to remove the dressing, nor did she attempt to notify Resident #2's physician regarding the dressing wrapped around the middle finger of the left hand. S13LPN further stated on 03/22/2022, Resident #2 screamed out in pain when she touched the dressing to the middle finger of the left hand. S13LPN stated she called the physician and 911 to have Resident #2 transferred to the Emergency Department. In an interview on 03/28/2022 at 12:30pm, S3Director of Nursing (DON) stated on 03/22/2022 she and S4Assistant Director of Nursing/ Licensed Practical Nurse (ADON/LPN) attempted to assess Resident #2's middle finger of the left hand but they could not remove the dressing due to Resident #2's pain level. S3DON stated she agreed it was best for Resident #2 to be transferred to the Emergency Department. S3DON further stated the dressing on Resident #2's middle finger of the left hand was wrapped tight like a tourniquet. S3DON further stated any nurse who observed Resident #2's dressing should have assessed the finger and notified the physician. In an interview on 03/28/2022 at 3:00pm, S8LPN stated on 03/21/2022 Resident #2 returned from a doctor's appointment, and she had a blue coban dressing wrapped around the middle finger of the left hand. S8LPN stated she did not know why the coban dressing was present, did not attempt to remove the coban dressing to assess the finger, and did not notify Resident #2's physician of the dressing. S8LPN stated she attempted to call S3DON to report the dressing and the unknown reason for the dressing; however, S3DON did not answer the telephone. S8LPN further stated she erroneously documented that she notified S3DON. In an interview on 03/31/2022 at 10:00am, S4ADON/LPN stated on 03/22/2022 Resident #2's Responsible Party requested he assess Resident #2's middle finger of the left hand. S4ADON/LPN stated Resident #2 was guarding her left hand and appeared to be in discomfort. S4ADON/LPN stated there was blue coban wrapped around the middle finger, and there was swelling at the base of the finger. In a telephone interview on 03/29/2022 at 11:19am, S5Medical Director stated he was not aware of an issue with Resident #2's middle finger on her left hand until he was called by a nurse on 03/22/2022. S5MedicalDirector stated he gave a verbal order to send Resident #2 to the hospital for an evaluation. S5MedicalDirector stated it is his expectation for nursing staff to notify him if they observe a dressing and they do not know why the dressing is present. S5MedicalDirector stated it is of his medical opinion if coban would have been tightly applied to Resident #2's finger, it could have interfered with arterial circulation, and it is conceivable the application of the coban may have contributed to the necrosis of the tissue and subsequent amputation. In an interview on 03/29/2022 at 9:56am, S2CorporateRN/Quality Improvement Nurse stated a Quality Assurance Plan of Correction was immediately implemented when the issue of the dressing was discovered. S2CorporateRN/QI Nurse further stated nurses must report when they observe something they are not aware of, and they need to assess to determine the issue. S2CorporateRN/Quality Improvement Nurse stated the corrective components of the plan were implemented by 03/23/2022; however, the facility will continue to complete spot checks from this time through 04/22/2022 to ensure there is no re-occurrence of the issue. Review of the facility's Plan of Action: 1. DON or designee to in-service nursing staff on ensuring they assess areas that are bandaged in a timely manner and notify the provider in a timely manner; 2. DON or designee to perform a facility wide body audit by end of day 03/23/2022; 3. DON or designee to spot check 5 residents 3 times a week to ensure all bandages have appropriate documentation; 4. If bandages are identified without proper documentation, DON, or designee will ensure the area is assessed and the MD is notified. Also, progressive disciplinary action will be taken with the staff member that is noncompliant; 5. Ongoing issues to be discussed with IDT weekly; and, 6. Goal - There will be no recurring issues by 04/22/2022.