Every finding on record at The Woodleigh of Baton Rouge

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency, within two hours for 1 (#R1) of 5 (#1, #2, #3, #4, and #R1) residents investigated for abuse.Findings: Review of the facility policy titled, Abuse Investigation and Reporting with a revision date of 06/2024 revealed the following, in part:All reports of resident abuse . shall be promptly reported to the local, state and federal agencies .Reporting: 1. All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility; A request was made to review reports submitted to the State Agency since 05/01/2025. On 09/25/2025 at 10:35 a.m., an interview was conducted with S2DON. S2DON confirmed there had been no reports submitted to the State Agency from 05/01/2025 to present. On 09/24/2025 at 10:05 a.m., an interview was conducted with S3LPN. S3LPN stated S4CNA was reported by a resident's anonymous, family member for hollering, in a mean tone, at Resident #R1 to go back into his room. S3LPN stated she witnessed the incident and S4CNA aggressively told Resident #R1 God D*** it get back in your room. On 09/25/2025 at 10:31 a.m., an interview was conducted with the resident's anonymous, family member. The family member reported she witnessed S4CNA yelling at Resident #R1 to go back into his room and staying on him about staying in his room. On 09/25/2025 at 12:41 p.m., an interview was conducted with S2DON. S2DON confirmed the resident's anonymous, family member reported S4CNA yelled at Resident #R1. S2DON confirmed yelling at a resident could be considered verbal abuse. On 09/25/2025 at 11:46 a.m., an interview was conducted with S1ADM. S1ADM confirmed he was responsible for submitting reports of suspected abuse to the State Agency. He confirmed yelling at a resident would be considered verbal abuse. He confirmed on 06/06/2025, a resident's family member reported S4CNA yelled down the hall at Resident #R1. S1ADM confirmed this could be considered an allegation of verbal abuse and confirmed it was not reported to the State Agency.

Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 2 (#67 and #78) of 34 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect 103 that resided in the facility. Findings: Resident #67 Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #67's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating he was cognitively moderately impaired. Review of Resident #67's physical chart revealed the following documents, in part: LaPost dated [DATE] and signed by Resident's Power of Attorney and Physician which, indicated Resident #67 was a DNR (Do Not Resuscitate). Review of Resident #67's [DATE] Physician Orders revealed: [DATE] Full Code Status. Review of Resident #67's Electronic Health Record on [DATE] revealed a Full Code Status. On [DATE] at 1:11 p.m., an interview was conducted with S11LPN. She stated in the situation a code would arise, she would follow Resident #67's LaPost on the physical chart. S11LPN reviewed Resident #67's LaPost and compared it the electronic health record and confirmed the two records did not match. On [DATE] at 1:29 p.m., an interview was conducted with S2DON. She reviewed the physician's order and LaPost for Resident #67 and confirmed all medical records should reflect Resident #67's end of life wishes and did not. Resident #78 Review of Resident #78's clinical record revealed he was admitted to the facility on [DATE] and began receiving Hospice Services on [DATE]. Review of Resident #78's Significant Change MDS with an ARD of [DATE] revealed the resident had a BIMS of 13 indicating he was cognitively intact. Review of Resident #78's physical facility chart on [DATE] revealed the following documents, in part: LaPost dated [DATE] and signed by the resident and physician which indicated Resident #78 was a full code. Review of Resident #78's Hospice Binder on [DATE] revealed the following, in part: La Post dated [DATE] and signed by Resident #78's family member and the physician which indicated Resident #78 was a DNR. Review of Resident #78's [DATE] Physician Orders revealed: [DATE]: DNR. Review of Resident #78's Electronic Health Record on [DATE] revealed a DNR code status. On [DATE] at 3:53 p.m. an interview was conducted with S8LPN. S8LPN stated in the situation a code would arise she would go to the physical chart to verify a resident's code status. S8LPN reviewed Resident #78's physical chart and confirmed the LaPost was signed as a full code. S8LPN reviewed Residents #78's EHR and confirmed he was listed as a DNR. S8LPN stated she would follow the LaPost and perform CPR on Resident #78. S8LPN reviewed resident's Hospice chart and confirmed Resident #78's LaPost indicated he was a DNR. S8LPN confirmed the charts did not match and should. On [DATE] at 3:59 p.m., an interview was conducted with Resident #78. Resident #78 confirmed he wished to have CPR if needed. On [DATE] at 4:11p.m., an interview was conducted with S7ADN. S7ADN reviewed and confirmed Resident #78's physical chart's LaPost was signed for CPR, the Hospice Chart's LaPost was signed for DNR and the EMR indicated Resident #78 was a DNR. S7ADN confirmed that the chart and order should match. On [DATE] at 4:11 p.m., an interview was conducted with S2DON. S2DON stated in the situation a code would arise she expected staff to refer to the Physician's order in the EHR for a resident's code status. She stated Resident #78's EHR indicated he was DNR. The S2DON confirmed that the EHR and all medical records should match.

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were stored safely and were kept locked by leaving medication at the bedside for 1 (#341) of 33 residents observed during the initial screening of residents upon facility entrance. Findings: Review of the facility's policy Medication Labeling and Storage, with a revised date of 02/2024, revealed, in part, the following: Policy Heading The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Review of Resident #341's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Wheezing and Acute Cough. Review of Resident #341's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/2025, revealed she had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Resident #341's current Physician Orders revealed the following, in part: Start date: 05/15/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (mg)/milliliters (mL), inhale orally three times a day for three days. An observation was made of Resident #341 on 06/02/2025 at 11:00 a.m. Further observation was made of an unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on the bedside table. Resident #341 verified the medication was her medication. An observation was made of Resident #341 on 06/03/2025 at 9:46 a.m. Further observation was made of an unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on the bedside table. An interview was conducted with S11LPN on 06/03/2025 at 9:53 a.m. She observed and verified the unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on Resident #341's bedside table. She confirmed the medication should not have been left on the bedside table. She stated the medication should have been stored in the locked medication cart and it was the nurse's responsibility to ensure medications are stored properly. An interview was conducted with S2DON on 06/03/2025 at 9:55 a.m. She confirmed medication should not have been left on the resident's bedside table. She stated the medication should have been store in the locked medication cart.

Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster. Findings: On 06/02/2025 at 9:04 a.m., an observation was made of the facility's two outdoor trash dumpsters with S3DM. One of the dumpsters was observed with the door open and a clear plastic bag containing soiled briefs and gloves hanging out of the lid. Scattered trash was observed on the ground around the dumpster including the following: plastic bag, plastic cups, plastic utensils, gloves, one green cloth, empty juice containers, and other unidentifiable paper items. On 06/02/2025 at 9:10 a.m., an interview was conducted with S3DM. She observed and confirmed the above mentioned observations of the dumpster area. She stated the dumpster door should be kept closed and the surrounding area kept free of trash. She stated maintenance was responsible for keeping the dumpster area clean. On 06/02/2025 at 10:00 a.m., an interview was conducted with S4MA. He stated he and S5MS were responsible for keeping the dumpster area clean. He stated the dumpster doors should be kept closed and there should be no trash on the ground. On 06/02/2025 at 10:20 a.m., an interview was conducted with S5MS. He stated maintenance staff were responsible for keeping the dumpster area clean. He confirmed the dumpster doors should be kept closed and there should be no trash on the ground.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure: 1. An expired medication was not available for use for Resident #54 in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed; and 2. An opened medication was labeled with an open date and not available for use in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed. Findings: On 06/02/2025 at 11:15 a.m., an observation was made of Cart B with S6LPN. The following was observed: One medication card containing 21 tablets of Hyoscyamine Sulfate Sublingual 0.125 mg tablets with a discard after date of 02/28/2025 for Resident #54; and One bottle of Vitamin D 10 mcg tablets was opened and not labelled with the open date. On 06/02/2025 at 11:20 a.m., an interview was conducted with S6LPN. She observed the above findings and confirmed the Hyoscyamine Sulfate Sublingual 0.125 mg tablets for Resident #54 were expired and available for use. She also confirmed the bottle of Vitamin D was open with no date to indicate when the bottle was opened. On 06/02/2025 at 4:00 p.m., an interview was conducted with S2DON. She stated the nurses on the hall were responsible for checking the medication carts for unlabeled and expired medications. She was notified of the above observations made of Cart B. She confirmed Resident #54's Hyoscyamine Sulfate tablets should have been discarded when expired. S2DON further confirmed the bottle of Vitamin D should have been labeled with the date when it was opened.

Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing was properly labeled for 1 (#342) of 5 (#65, #77, #84, #341, and #342) residents reviewed for oxygen therapy. Findings: Review of Resident #342's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Ischemic Cardiomyopathy, and Asthma. Review of Resident #342's Physician's Orders revealed the following, in part: Start date: 05/29/2025: Oxygen at 2 Liters per nasal cannula, as needed for Chronic Obstructive Pulmonary Disease. On 06/02/2025 at 11:45 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the date. On 06/03/2025 at 9:47 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the date. On 06/03/2025 at 9:55 a.m., an observation was made of Resident #342's oxygen tubing with S11LPN. S11LPN confirmed the oxygen tubing was not labeled with the date last changed and should have been. She stated the tubing should have been changed and labeled weekly, and it was the nurse's responsibility to do so. On 06/03/2025 at 9:59 a.m , an interview was conducted with S2DON. She confirmed nursing staff should have changed and labeled oxygen tubing weekly.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S12LPN wore proper Personal Protective Equipment (PPE) while providing urinary catheter care for 1 (#67) of 2 (#13 and #67) residents with indwelling medical devices. Findings: Review of the facility's policy, dated 08/2024, titled Enhanced Barrier Precautions, revealed, in part: Policy Interpretation and Implementation: 2. Enhanced Barrier Precautions (EBP) employ targeted gown and glove use during high contact resident care activities . 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: g) device care or use (urinary catheter .) Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms and Urinary Tract Infection. Review of Resident #67's active physician orders, dated 03/01/2025 to 06/30/2025 revealed, in part: 1. Indwelling Catheter for diagnosis of BPH with retention; 2. Clean indwelling catheter with soap and water daily and as needed. On 06/02/2025 at 11:59 a.m., an observation was made of Resident #67's room door with no EPB signage observed. On 06/02/2025 at 12:00 p.m., an interview was conducted with Resident #67. He stated he had a urinary catheter for 3 weeks. An observation was made of a urinary catheter bag attached to Resident #67. On 06/02/2025 at 12:43 p.m., an interview was conducted with S2DON. She stated any resident with an indwelling catheter should be on Enhanced Barrier Precautions. On 06/04/2025 at 8:58 a.m., an observation was made of Resident #67's door with no EPB signage observed. On 06/04/2025 at 10:01 a.m., an observation was made of S12LPN performing urinary catheter care on Resident #67. No gown was worn by S12LPN. On 06/04/2025 at 10:11 a.m., an interview was conducted with S12LPN. She stated the only PPE needed to conduct urinary catheter care was gloves. She further stated when residents were on EBP precautions a sign was placed on the resident's door. She confirmed she only wore gloves when she performed urinary catheter care on Resident #67. On 06/04/2025 at 10:27 a.m., an interview was conducted with S7ADN. She stated she was the Infection Preventionist for the facility. She reported all training for infection control was completed by all staff in their electronic training system. She further stated when residents were placed on precautions of any type, signage was placed on the resident's door, a biohazard box was placed in the resident's room, and isolation carts with PPE for staff was placed near the room for use. She confirmed residents with urinary catheters should be on Enhanced Barrier Precautions. She stated staff should wear gown and gloves when providing direct care to a resident on Enhanced Barrier Precautions. She confirmed Resident #67 had a urinary catheter. She confirmed Resident #67 was not on Enhanced Barrier Precautions and should be.

Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#34) of 34 residents reviewed during the initial pool. Findings: Review of the facility's policy titled, Call System, Residents, with a revision date of September 2022, revealed the following, in part: Policy Statement: Residents are provided with a means to call staff for assistance through a communication system which notifies a staff member or a centralized work station. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff to notify them for assistance from his/her bed, floor, and from toileting/bathing facilities. Review of Resident #34's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Need for Assistance with Personal Care, Left Hand Contracture, and Left Elbow Contracture. Review of Resident #34's current Care Plan revealed following, in part: Problem: Potential for falls related to decreased mobility, history of Cerebrovascular Accident, confusion, history of falls, left Hemiparesis, and medication effects. Interventions included to keep the call light within reach and to remind the resident to call for assistance when needed. Problem: Self-care deficit related to needs extensive assistance with Activities of Daily Living, decreased mobility, and use Hoyer lift with transfers related to diagnoses of Left Hemiparesis and Muscle Rigidity. Interventions included to keep the call light in reach. Problem: Alteration in elimination related to bowel and bladder incontinence. Interventions included to keep the call light in reach. On 06/02/2025 at 8:55 a.m., an observation was made of Resident #34 in her room. She was sitting up in bed. The call light was observed lying on the floor at the foot of the bed. An interview was conducted with Resident #34 at that time, and Resident #34 confirmed she could not reach it on the floor. On 06/03/2025 at 9:05 a.m., an observation was made of Resident #34 in her room. She was sitting up in bed. The call light was observed lying on the floor at the foot of the bed, and not in the resident's reach. On 06/03/2025 at 9:10 a.m., an observation was made of Resident #34 with S15CNA. An interview was conducted with S15CNA at that time. S15CNA confirmed Resident #34's call light was on the floor at the foot of the bed, not within reach, and should have been in reach. On 06/03/2025 at 4:18 p.m., an interview was conducted with S2DON. S2DON was notified of the above findings. S2DON confirmed Resident #34's call light should have been in reach at all times when in her room.

Based on observations, interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the assistance required for eating for 1(#1) of 4 (#1, #2, #3, and #4) sampled residents. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 03/02/2025, revealed the resident required setup or cleanup assistance for meals. On 03/26/2025 at 12:45 p.m., an observation was conducted of Resident #1 in the dining room. Resident #1 is noted with a bib on with S3CNA was feeding the resident. S9CNA held the cup for Resident #1 and placed the straw next to his lips. On 03/26/2025 at 11:19 a.m., an interview was conducted with S9CNA. She stated Resident #1 returned from the hospital on 02/28/2025 with a sling for his left upper extremity and was dependent on staff for feeding. 03/26/2025 at 12:15 p.m., an interview was conducted with S4CNA. She stated Resident #1 returned from the hospital on 02/28/2025 with a sling for his left upper extremity and was dependent on staff for feeding. On 03/26/2025 at 11:02 a.m., an interview was conducted with S10PTA. She stated Resident #1 returned from the hospital on 02/28/2025 with a sling for his left upper extremity with limited range of motion and was dependent on staff for eating. On 03/26/2025 at 11:50 a.m., an interview was conducted with S6MDS. She confirmed the ARD for the Quarterly MDS Assessment was 03/02/2025. She stated Resident #1's MDS assessment is based on the documentation in his electronic health record and the electronic health record should be accurate. She confirmed she was not aware Resident #1 was dependent on staff for meals and his MDS was inaccurately coded for assistance required for eating. On 03/26/2025 at 1:20 p.m., an interview was conducted with S2DON. She confirmed the MDS assessment was based on the ADL documentation and the ADL documentation should accurately reflect the residents' status.

Based on interviews, and record review, the facility failed to ensure that a resident that was frequently incontinent was provided services to restore as much normal bowel function as possible for 1 (#1) of 4 (#1, #2, #3 and #4) residents reviewed for Bladder and Bowel Incontinence. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Septic Arthritis Of Left Shoulder, History Of Falling, Need For Assistance With Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side. Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 03/02/2025 revealed the resident was always incontinent of bowel and bladder. Further review revealed Resident #1 was assessed by the facility to have a BIMS of 11, indicating he was moderately cognitively impaired. Review of Resident #1's Care Plan revealed the following, in part: Problem: Alteration in elimination related to incontinence of bowel and bladder Interventions: adult briefs as needed, check every 2 hours, and encourage resident to call for assistance as needed with toileting. Review of Resident #1's Incident Report Logs from January 2025 to March 2025 revealed the following: Date: 08/21/2024 at 11:10 a.m. Description: Resident #1 stated he lost his balance when ambulating to the bathroom. Intervention: Educated to call for assistance. Date: 10/29/2024 at 8:30 p.m. Description: Resident #1 was found in the bathroom in front of the toilet. Intervention: Visual sign placed in room and bathroom. Date: 01/20/2025 at 1:44 a.m. Description: Resident #1 was found on the floor with his back facing the toilet. Resident #1 stated that he missed the toilet. Intervention: Bedside commode placed over toilet seat for elevation and to assist with sitting and standing. On 03/24/2025 at 11:32 a.m., an interview was conducted with Resident #1. He stated he was aware of when he needed to have a bowel movement and urinate. He stated he would rather go to the toilet then use the bathroom in his brief but was told by staff to go in the brief and they will clean him up after. Resident #1 stated he did not like having a bowel movement in the brief. On 03/24/2025 at 11:48 a.m., an interview was conducted with Resident #1's RP. She stated Resident #1 was aware of when he needed to have a bowel movement and urinate but staff told him to use it in the brief and they will clean him up afterwards. She stated Resident #1 was able to use the commode but needed assistance to transfer to the wheelchair and then to the commode. She stated Resident #1 hated using the adult briefs. On 03/24/2025 at 12:23 p.m., an interview was conducted with S4CNA. She stated Resident #1 could use the commode but she never offered to put Resident #1 on the commode. She stated she was not aware of Resident #1 being on a toileting schedule. On 03/24/2025 at 4:00 p.m., an interview was conducted with S5LPN. She stated Resident #1 required assistance with toilet transfers and knew when his brief was clean and dirty. She stated she never offered to put Resident #1 on the commode. She stated she was not aware of Resident #1 being on a toileting schedule. On 03/25/2025 at 3:13 p.m. an interview was conducted with S3CNA. He stated Resident #1 transferred to the commode with assistance. He stated he would assist Resident #1 when he requested to use the commode but he never offered to put Resident #1 on the commode. He stated he was not aware of Resident #1 being on a toileting schedule. On 03/26/2025 at 11:50 a.m., an interview was conducted with S6LPN. She stated the MDS assessment was determined by speaking with the Resident and ADL documentation from staff. She stated a bowel and bladder program to promote continence would be initiated by the nursing staff and a bowel and bladder program had not been initiated for Resident #1. On 03/26/2025 at 1:20 p.m., an interview was conducted with S2DON. She stated Resident #1 was able to participate in a bowel and bladder program. She stated there were no current interventions for Resident #1 to promote continence and he did not have a bowel and bladder program.

Based on record review and interviews, the facility failed to ensure Activities of Daily Living (ADL) care was accurately documented for 1 (#1) of 4 (#1, #2, #3 and #4) Residents reviewed for ADL care. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Septic Arthritis of Left Shoulder, Need for Assistance with Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident required limited set up/cleanup for meals. Review of Resident #1's Eating ADL log, dated 03/01/2025-03/24/2025, revealed the following: Eating: Self Performance- How resident eats and drinks Limited Assistance- Resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance. Extensive Assistance- Resident involved in activity, staff provide weight bearing support. Total Dependence- Full Staff Performance. Resident #1 was coded to require the following assistance on the following days during the 6:00 a.m. to 2:00 p.m. shift: Limited Assistance - 03/05/2025, 03/11/2025, 03/16/2025 and 03/18/2025 Extensive Assistance - 03/01/2025 through 03/04/2025, 03/06/2025 through 03/09/2025, 03/12/2025 through 03/15/2025, 03/17/2025, and 03/19/2025 through 03/23/2025 Total Dependence - 03/10/2025 and 03/24/2025 On 03/26/2025 at 12:45 p.m., an observation was conducted of Resident #1 in the dining room. Resident #1 is noted with a bib on and staff was feeding the resident. S9CNA picked up and held the cup for Resident #1, while he drank the fluids. On 03/24/2025 at 12:23 p.m., an interview was conducted with S4CNA. She stated she worked 6:00 a.m. to 2:00 p.m. shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his Left arm and his Right arm was affected from a previous stroke. She confirmed he was depended on staff for eating. On 03/24/2025 at 12:34 p.m. an interview was conducted with S8LPN. She stated she worked on the day shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his Left arm and his Right arm was affected from a previous stroke. She confirmed he was dependent on staff for eating. On 03/25/2025 at 10:02 a.m., an interview was conducted with S7PTD. She stated Resident #1 was currently receiving therapy services. She confirmed Resident #1's Left arm was in a sling and he was unable to feed himself. She stated he had limited movement to the left arm and the right arm was affected from a previous stroke. On 03/26/2025 at 11:11 a.m., an interview was conducted with S5LPN. She stated she worked on the day shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his left arm, and was dependent on staff for eating. On 03/26/2025 at 11:50 a.m., an interview was conducted with S6MDS. She confirmed she was not aware Resident #1 was dependent on staff for meals. She stated if Resident #1 was being fed by staff, his ADL documentation should be coded as Total Dependence. She reviewed the ADL documentation and confirmed the documentation was not accurate and should be.

Based on interviews and record reviews, the facility failed to ensure each nurse aide was competent when transferring a resident with the slide board for 1 (#29) of 3 (#29, #61, and #69 ) residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #29, beginning on 04/02/2024 at 4:30 p.m. when S16CNA inappropriately used the slide board during a transfer, which resulted in Resident #29 falling to the floor. On the morning of 04/03/2024, Resident #29 refused care due to severe pain when she moved. On 04/03/2024 at 12:12 p.m., Resident #29 had X-rays in the facility that revealed a Left Femur Fracture. Resident #29 was transferred to the emergency room and found to have a Left Distal Femur Fracture and a Right Displaced fracture that required surgical interventions. Review of the Facility's November 2023 Training Materials revealed the following, in part: Sliding Board Transfer 7. The caregiver should position themselves in front of the patient when performing the transfer, using proper body mechanics. Review of Resident #29's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included: Displaced Intertrochanteric Fracture of Right Femur on 04/03/2024, Unspecified Fracture of Lower End of Left Femur on 04/03/2024, and Multiple Sclerosis. Review of the Quarterly MDS with an ARD of 01/02/2024 revealed the provider assessed Resident #29 as having a BIMS of 15, which indicated the resident was cognitively intact. The resident was documented as dependent on staff for assistance with transfers. Review of Resident #29's most recent Care Plan revealed the facility included the following problems and interventions, in part: Problem: Potential for falls related to decreased mobility, medication effects, and diagnosis of Multiple Sclerosis Interventions: Use slide board for transfers Review of the Facility Incident Report revealed the following, in part: 04/02/2024 at 4:30 p.m. Description: Resident #29 observed sitting on the floor in front of wheelchair with S16CNA in the room. She denied pain or discomfort at the present time. Head to toe assessment completed, no nodule or skin tears. Resident #29 assisted to chair x 3 assist, NP notified. 04/03/2024- Fracture to left femur to ER for evaluation and treatment. Review of Resident #29's Nurse's Notes revealed the following, in part: 04/02/2024 at 4:30 p.m., Resident #29 observed sitting on floor in front of wheelchair with S16CNA in the room. She stated while being transferred by S16CNA to chair using the sliding board she slid off the board to the floor. Resident #29 denied pain or discomfort at this time, head to toe assessment completed, and no nodule or skin tears. Resident assisted to chair x 3 assist. NP notified. S23LPN 04/03/2024 at 11:21 a.m., Resident #29 in bed while CNA attempted to assist the resident with changing. Resident #29 stated too much pain to complete the task. NP notified of Resident #29's pain level. NP assessed the resident and ordered X-Ray of bilateral knees, Femur, and hips. Pain medication ordered. Local imaging agency notified. S23LPN 04/03/2024 at 2:30 p.m., Order received per NP to send Resident #29 to emergency room due to left femur fracture. Review of Resident #29's Hospital Medical Records revealed, in part, the following: 04/03/2024 Reason for Visit: Resident #29 was brought by ambulance from a local nursing home after a ground-level fall the day prior to presentation. Resident #29 received assistance yesterday with incontinent care, attempted transfer with a sliding board and fell . She received Tylenol at the nursing home and on route she received fentanyl. HPI indicated: CT scan and x-ray of the pelvis and femur with intertrochanteric right femoral fracture. Pain control with Norco, Morphine, and hydromorphone. Impression indicated acute distal femoral fracture left; acute right femoral fracture. Review of Resident #29's Radiology Report revealed, in part, the following: Left Femur CT w/o IV Contrast on 04/03/2024 There is an acute comminuted fracture distal femoral diametaphysis, 2 cm displacement, with anterior angulation/external rotation distal fracture fragment and mild impaction of the fracture fragments. There is an associated hemorrhage at the fracture sites accounting for the soft tissue density. There is mild thigh subcutaneous edema. Left Hip unilateral 1 view w/ pelvis on 04/03/2024 Impression/Plan: Intertrochanteric right femoral fracture related to ground level fall Review of Resident #29's Nurse's Notes revealed the following, in part: 04/11/2024 at 1:59 p.m., Report received from local hospital. Resident #29 will be returning to facility with closed fracture of left femur, fracture to right hip, post op closed reduction with nail placement to right femur and post op closed reduction with nail placement to left femur. Review of Resident #29's facility Nurse Practitioner progress notes revealed the following: 04/12/2024 Hospital follow up She was recently sent to the emergency department after a ground level fall and imaging at the nursing home showed Left Distal Femur Fracture. In the emergency department she was found to have a Left Distal Femur Fracture and Right Displaced Fracture. Orthopedics was consulted and Resident #29 underwent closed reduction with nail placement of the right femur on 04/04/2024 and underwent nail placement to the left femur on 04/09/2024. Tramodol as needed for pain. On 05/29/2024 at 9:44 a.m., an interview was conducted with Resident #29. She stated on 04/02/2024, S16CNA transferred her from the bed to the wheelchair via slide board. She stated during the transfer, S16CNA was standing behind her. She stated the slide board was tilted and she slid forward, falling to the ground. She stated she was initially in pain but denied the pain because she was hoping it would get better. She stated the pain did not get better and x-rays were ordered. On 05/29/2024 at 11:45 a.m., an interview was conducted with S23LPN. She stated on 04/02/2024, S16CNA called her to the room because Resident #29 had a fall. She stated Resident #29 said she fell off the board to the floor. She stated the resident did not initially complain of any pain. She said the resident began to complain of pain on the morning of 04/03/2024 and the NP was notified. On 05/29/2024 at 2:36 p.m., an interview was conducted with S20PT. She stated Resident #29 should be transferred using the slide board with max assist. She stated during the time she worked at the facility she conducted trainings with staff but could not provide any dates or names of the staff who were trained. On 05/29/2024 at 2:42 p.m., an interview was conducted with S21PTAD. She stated she worked with the facility's contracted Physical Therapy agency from 2021 until 04/30/2024. She stated in 2021, Resident #29 used the slide board for transfers. She stated she never trained any staff on the use of the slide board. On 05/30/2024 at 2:45 p.m., an interview was conducted with S26ST. She stated she began working for the facility on 05/01/2024. She confirmed she had not provided any demonstrations to staff since she began on 05/01/2024. She stated an equipment transfer demonstration should be conducted with staff annually at a minimum with a return demonstration. On 05/30/2024 at 5:12 p.m., an interview was conducted with S16CNA. She stated she received computer training on how to use the slide board/transfer in December 2023, but did not complete a return demonstration to ensure she was transferring with the slide board correctly. She stated Resident #29 used the slide board for transfers. She stated on 04/02/2024, she was transferring Resident #29 to the chair from the bed and Resident #29 fell off the slide board onto the floor. She stated she went immediately to the nurse and informed her of the fall. On 05/30/2024 at 4:20 p.m., an interview was conducted with S17CNAS. She confirmed she did not watch any staff demonstrate the slide board/transfer prior to staff being assigned to work independently on the hall after orientation or annually. On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She stated new employees completed orientation in the computer system and would be placed on the floor for 3 days with a CNA, to learn the care residents required. She confirmed new CNA employees did not complete a slide board/transfer competency skills check upon hire or annually. She stated, staff were competent if they had a license or certification. She said she conducted an in-service on safe transfers in November 2023, but staff did not complete a return demonstration to ensure competency. She stated staff verbalized understanding of the training. She confirmed S16CNA did not attend the training in November 2024, but completed the computerized training in December.

Based on interviews and record review, the facility failed to ensure all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all skills related to their expected roles for 5 out of 5 personnel files reviewed. This had the potential to affect all 89 residents residing in the facility. Findings: Review of S12CNA's personnel file revealed S12CNA's date of hire was 05/21/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S13CNA's personnel file revealed S13CNA's date of hire was 01/22/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S14LPN's personnel file revealed S14LPN's date of hire was 10/08/2021. Further review revealed no documented evidence of any competencies being completed annually. Review of S15LPN's personnel file revealed S15LPN's date of hire was 03/11/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S16CNA's personnel file revealed S16CNA's date of hire was 09/30/2022. Further review revealed no documented evidence of any competencies being completed annually. An interview was conducted with S17CNAS on 05/30/2024 at 4:20 p.m. She confirmed CNAs did not demonstrate competency skills prior to being assigned to work independently on the hall after completing orientation shifts or annually. An interview was conducted with S2DON on 05/30/2024 at 3:01 p.m. She said she conducted in-service skills trainings regularly on various topics for nursing and CNA staff, which would include lecture training and a skills demonstration by her, S2DON. She confirmed LPN and CNA employees did not demonstrate any competency skills upon hire or annually. 45270

Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 4 (#17, #35, #58, and #69) of 5 (#17, #35, #58, #64, and #69) residents reviewed . Findings: Resident #17 Review of Resident #17's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Generalized Anxiety Disorder, and Insomnia. Review of Resident #17's May 2024 Physician's Orders revealed an order written on 10/30/2023 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date. Review of Resident #17's May 2024 MAR revealed Lorazepam 1 mg tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date. Resident #35 Review of Resident #35's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Schizoaffective Disorder, Unspecified Mood Disorder, and Anxiety. Review of Resident #35's May 2024 Physician's Orders revealed an order written on 03/16/2021 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date. Review of Resident #35's May 2024 MAR revealed an order written on 03/16/2021 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath was started on 03/16/2021. Further review revealed the PRN medication had no stop date. Resident #58 Review of Resident #58's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Major Depressive Disorder, and Schizoaffective Disorder. Review of Resident #58's November 2023 Physician's Orders revealed an order written on 11/27/2023 for Lorazepam tablet 1 mg, give 1 tablet by mouth every 4 hours as needed for anxiety and/or shortness of breath. Further review revealed the PRN medication had no stop date. Review of Resident #58's May 2024 Medication Administration Record revealed an order written on 11/27/2023 for Lorazepam tablet 1 mg, Give 1 tablet by mouth every 4 hours as needed for anxiety and/or shortness of breath. Further review revealed the PRN medication had no stop date. Resident #69 Review of Resident #69's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition and Anxiety Disorder. Review of Resident #69's May 2024 Physician's Orders revealed an order written on 04/22/2024 for Lorazepam oral tablet 1 mg by mouth every 4 hours as needed for shortness of breath, anxiety and/or trouble sleeping. Further review revealed the PRN medication had no stop date. Review of Resident #69's May 2024 MAR revealed an order written on 04/22/2024 for Lorazepam tablet 1mg by mouth every 4 hours as needed for shortness of breath, anxiety and/or trouble sleeping. Further review revealed the PRN medication had no stop date. A telephone interview was conducted on 05/29/2024 at 2:35 p.m. with the pharmacist responsible for completing the facility's pharmaceutical consultation reports for MRR and GDR. He stated all PRN antipsychotic medications including lorazepam required an end date of no longer than 14 days following the start of the medication. An interview was conducted on 05/30/2024 at 2:56 p.m. with S2DON. She confirmed Lorazepam was an anxiolytic medication used to treat anxiety. She confirmed Resident #17 had an order on 10/30/2023 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #35 had an order on 03/16/2021 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #58 had an order on 11/27/2023 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #69 had an order on 04/22/2024 for PRN Lorazepam 1mg tablet with no stop date. 47732 48537

Based on observation and interview, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 90 residents residing in the facility. Findings: On 05/28/24 at 11:55 a.m., an observation was conducted of the daily nursing staff sheet located behind the nurses' station in the medical record room which was restricted to staff only. On 05/28/24 at 12:18 p.m., an interview was conducted with S2DON. She confirmed the daily nursing staff sheet was posted behind the nurses' station and was not accessible for residents or visitors to view.

Based on interviews and record reviews, the facility failed to ensure resident MDS assessments accurately reflected the resident's status for 2 of 2 (#13 and #18) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations. Findings: Resident #13 Review of Resident #13's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Major Depressive Disorder, Bipolar Disorder, Persistent Mood Affective Disorder, and Generalized Anxiety Disorder. Further review revealed an approved Level II PASRR. Review of Resident #13's Annual MDS with ARD of 12/21/2023 revealed question A1500, Resident evaluated for PASRR, was answered as no. Resident #18 Review of Resident #18's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Schizoaffective Disorder, and Bipolar Disorder. Further review revealed an approved Level II PASRR. Review of Resident #18's Annual MDS with ARD of 01/04/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. On 05/29/2024 at 2:03 p.m., an interview was conducted with S24CM. She stated comprehensive MDS assessments should include if the resident has a state level II PASRR. She confirmed Resident #13 and Resident #18 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have. On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She confirmed the MDS assessments should be accurate for residents.

Based on record review and interviews, the facility failed to make prompt efforts to resolve grievances for 1 (#3) of 2 (#3 and #29) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #3 reported a missing blanket and clothing to staff. Findings: Review of the facility's policy titled, Grievances/Complaints, Filing with a revision date of 04/2017 revealed the following, in part: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident . Policy Interpretation and Implementation: 1. Any resident .may file a grievance or complaint concerning care . or any other concerns regarding his or her stay at the facility. 8. Upon receipt of a grievance and/or complaint, the designee will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. 11. The Administrator will review the findings to determine what corrective actions, if any, need to be taken. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The Administrator, or his or her designee, will make such reports within 5 working days of the filing of the grievance or complaint with the facility. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's MDS with an ARD of 04/05/2024, revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of facility's Grievance Log from December 2023 to May 2024 revealed no documentation the facility logged a grievance for Resident #3's missing clothing and blanket. An interview was conducted with Resident #3 on 05/28/2024 at 8:42 a.m. She stated about a month ago she reported missing clothing and a blanket to staff on the hall, but could not recall who. She stated the missing clothing items and blanket were sent to the laundry and never returned to her. She stated she made a list of missing items and gave it to S6HS last month. She stated she was missing the following items: matching orange/peach shirt and pair of culottes, beige shorts, red shirt, turquoise shirt and a pair of culottes, and a blanket she received as a gift for her birthday. She stated the facility never reimbursed her for the missing clothing or blanket, nor did the facility replace the items or inform her what they would do about the missing items. An interview was conducted with S5CNA on 05/29/2024 at 9:05 a.m. She stated the facility cleaned Resident #3's laundry. She stated a couple months ago, Resident #3 reported missing several items of clothing and a blanket. She stated she looked for the missing items, could not find them, and went to the laundry room and notified S6HS of Resident #3's missing items. She stated Resident #3's blanket was never found, but was unsure about the missing clothing. An interview was conducted with S6HS on 05/29/2024 at 9:32 a.m. He stated Resident #3 reported missing a blanket a few weeks ago, but he did not recall her missing any clothing. He stated he looked for the blanket, but had not found it. He stated missing laundry items that were unable to be located, should be reported to the Administrator, who would then report it as a grievance. He confirmed he had not reported Resident #3's missing laundry items to the Administrator. An interview was conducted with S7SSD on 05/29/2024 at 2:25 p.m. She stated any staff can report a grievance. She stated when a grievance was reported for missing laundry items she, S2DON or the former Administrator opened a grievance. She stated if the missing laundry items could not be located a grievance should be opened and started the same day it was reported. She stated no staff had reported any grievances for Resident #3's missing clothing or a blanket. An interview was conducted with S2DON on 05/29/2024 at 3:55 p.m. She stated S7SSD and any department head can open a grievance. She stated S7SSD logged all grievances. She stated she was not aware of Resident #3 missing any clothing items or a blanket. She confirmed no grievances for missing clothing or a blanket had been filed for Resident #3. She stated S6HS should have reported the missing laundry items to the former Administrator when he could not find them. An interview was conducted with S1CADM on 05/29/2024 at 4:05 p.m. He stated when a resident had a complaint, a grievance should be filed, investigated, and a follow up done with the resident. He stated Resident #3's missing clothing and blanket would have been treated as a grievance, laundry and staff would look for the items, and S7SSD would have completed the grievance form. He stated S6HS should have reported Resident #3's missing laundry items to S7SSD and the former Administrator and a resolution given to Resident #3 within 3 to 5 days.

Based on observations, interviews, and record review, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a nutritional supplement for 1 (#3) of 5 (#3, #35, #44, #64 and #79) residents reviewed for nutritional status. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis, which included Unspecified Protein-Calorie Malnutrition. Review of Resident #3's MDS with an ARD of 04/05/2024, revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #3 received a therapeutic diet. Review of Resident #3's current Physician Orders revealed the following, in part: Start date 05/17/2024 House Shake Supplement three times a day related to Unspecified Protein-Calorie Malnutrition; give 1 carton strawberry with all meals. Review of Resident #3's Nutrition Assessment Notes, dated 05/16/2024, revealed, in part, the following: She is a very picky eater . She is eating meals in her room and is feeding herself. Skin Stage 4 pressure ulcer to right heel . Recommendation: Resume Strawberry House Shakes with all meals related to diagnosis of Unspecified Protein-Calorie Malnutrition. Review of Resident #3's Care Plan, revealed, in part, the following: Problem: Alteration in nutrition . Interventions: Provide supplements as ordered An observation and interview was conducted with Resident #3 on 05/29/2024 at 7:40 a.m. She stated she had finished eating breakfast. An observation was made of the meal ticket on the breakfast tray with documentation noted for a strawberry Mighty Shake. Resident #3 did not have a Mighty Shake on her tray and had consumed approximately 25% of the meal. She stated she was supposed to get a Mighty Shake with all meals, but did not always get it. She stated she had lost weight over the last few months, and her appetite and weight had been fluctuating. An interview was conducted with S4CNA on 05/29/2024 at 7:55 a.m. She stated Resident #3 had a decreased appetite and the kitchen was supposed to send a Mighty Shake with her meals. She observed Resident #3's breakfast meal tray, and confirmed the Mighty Shake was not on the tray and should have been. An interview was conducted with S5CNA on 05/29/2024 at 9:05 a.m. She stated Resident #3 had a decreased appetite and a Mighty Shake was supposed to be sent with her meal trays. She stated Resident #3 did not have a Mighty Shake on her breakfast tray and should have. An interview was conducted with S3LPN on 05/29/2024 at 10:20 a.m. She stated Resident #3 had a decreased appetite, weight loss, and was placed on Mighty Shakes with all meals. She stated the kitchen staff should have sent a Mighty Shake on Resident #3's breakfast tray this morning. She stated if Resident #3 did not have a Mighty Shake on her meal tray, the CNAs should have went to the kitchen and got one. An interview was conducted with S8DM on 05/30/2024 at 3:00 p.m. She stated when a resident had weight loss, she sent recommendations to nursing for supplements, who then received an order from the physician. She stated after the supplement was ordered, she updated the resident's meal tickets, and notified the kitchen staff of the new order. She stated the kitchen staff should ensure the supplements were on the meal trays. She stated if the supplement was not placed on the tray, the CNA or nurse on the hall should come get the supplement from the kitchen and provide it to the resident. She stated she resumed the order for Resident #3's Mighty Shake on 05/16/2024, because the resident had lost weight after a hospitalization . She stated a Mighty Shake should have been provided to Resident #3 for each meal. An interview was conducted with S2DON on 05/29/2024 at 3:55 p.m. She stated the kitchen staff were responsible for sending the Mighty Shake supplements on the resident's meal trays. She verified Resident #3 was ordered Mighty Shakes with all meals and should have had one on her breakfast tray.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#13) of 2 (#13, and #23) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #13. Findings: Review of the facility's policy titled, Care of Fingernails/Toenails and dated February 2018, revealed the following, in part: General Guidelines 1. Nail care includes daily cleaning and regular trimming. Review of Resident #13's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Non-traumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. Review of Resident #13's Quarterly MDS with an ARD of 03/08/2024 revealed Resident #13 had a BIMS of 15, which indicated intact cognition. Further review revealed Resident #13 required moderate assistance for ADLs. Review of Resident #13's care plan revealed the following: Problem: Diagnosis Diabetes Mellitus Interventions: Nursing to provide nail care Problem: Self-care deficit related to needs assistance with ADLs Goal: Resident will be well groomed daily this quarter Interventions: Assist with ADLs as needed Review of the current Physician Orders for Resident #13 revealed no orders for nail care. On 05/28/2024 at 8:37 a.m., an observation was conducted of Resident #13 sitting in his wheelchair outside of the shower room. His fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. He stated he was waiting for his shower and would like his nails trimmed and cleaned. On 05/28/2024 at 2:54 p.m., an observation was conducted of Resident #13 sitting in his wheelchair in his room. His fingernails are noted to be 1/2 to 1 cm long. Resident #13 stated he went to the shower room every other day. He stated he had his shower this morning and his nails were cleaned but were not trimmed. He stated his nails were too long and he wanted them trimmed. On 05/28/2024 at 3:03 p.m., an interview was conducted with S25CNA. She stated CNAs clean the resident's fingernails and toe nails. She stated nurses trim the resident's fingernails and toenails because the CNA's did not know which residents were Diabetic. On 05/28/2024 at 3:10 p.m., an interview was conducted with S17CNAS. She stated if a Diabetic resident's fingernails needed to be trimmed she would expect the CNA to report this to the nurse. On 05/28/2024 at 3:24 p.m., an interview was conducted with S23LPN. She stated if residents were Diabetic, the nurse or wound care nurse would provide fingernail care. She confirmed the CNA had not reported that Resident #13 needed fingernail care. On 05/30/2024 at 9:56 a.m., an interview was conducted with S10LPN. She stated Resident #13 did not refuse care. She stated the nurse or wound care nurse would complete fingernail care if residents were diabetic. She said fingernails would be assessed daily with normal rounds. On 05/30/2024 at 10:06 a.m., an interview was conducted with S22CNA. She stated Resident #13 faithfully went to the shower room [ROOM NUMBER] times per week. She stated the nurse or wound care nurse would complete fingernail care for Diabetic residents. On 05/30/2024 at 2:36 p.m., an interview was conducted with S17CNAS. She confirmed she observed Resident #13's fingernails on 05/28/2024 and they needed to be trimmed, and should have been trimmed prior to getting that long. On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She stated the process for fingernail care was that any staff could trim the fingernails, regardless if they are Diabetic. She stated fingernails should be trimmed when a resident requested them to be trimmed. She said if a resident requested the nails to be trimmed and they were 1 cm long, then she would expect them to be trimmed.

Based on record review, observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1 (#64) of 24 residents observed during the initial screening of residents upon facility entrance. Findings: Review of the facility's policy titled, Medication Administration Policy with a revision date of 04/2019 revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Review of Resident #64's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Polyneuropathy, Acquired Absence of Right Leg Above Knee, Acquired Absence of Left Leg Above Knee, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Moderate Protein Calorie Malnutrition, Peripheral Vascular Disease, and Unspecified Pain. Review of Resident #64's Quarterly MDS with an ARD of 02/20/2024, revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #64's current Physician Orders revealed the following, in part: Start date 07/23/2022 Flomax 0.4 mg give 2 capsules by mouth one time a day. Start date 05/12/2023 Meloxicam 7.5 mg give 1 tablet by mouth one time a day. Start date 07/21/2023 Gabapentin 600 mg give 1 tablet by mouth three times a day. Start date 07/22/2023 Thera Tablet give 1 tablet by mouth one time a day. Start date 03/25/2024 Methocarbamol 750 mg give 2 tablets by mouth three times a day. An observation was made of Resident #64 on 05/28/2024 at 8:24 a.m. He was observed awake and alert lying in bed. A plastic medication cup containing 7 pills was observed on the bedside table. He verified the medications in the plastic cup were his morning medications. He stated S3LPN left the medications this morning to take when he was ready, because he was nauseated. An interview was conducted with S3LPN on 05/28/2024 at 8:35 a.m. She observed and verified the plastic medication cup containing 7 pills on Resident #64's bedside table. She confirmed the medications in the cup were Methocarbamol 750 mg, Gabapentin 600 mg, Mobic 7.5 mg, Flomax 0.4 mg, and Therapeutic Vitamin. She confirmed she did not observe Resident #64 take his morning medications and should have. An interview was conducted with S2DON on 05/29/2024 at 4:00 p.m. She confirmed medications should not have been left at the resident's bedside and the nurse should have observed Resident #64 take his medications.

Based on record reviews, interviews, and observations, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#2) of 3 (#1, #2, #5) residents reviewed for accidents. The facility failed to ensure that adequate supervision was provided when Resident #2 was transferred using a mechanical lift without 2 staff members. The facility had a total of 12 residents that required 2 person assistance during transfers using a mechanical lift as identified by S2DON. On 7/7/15, an actual harm occurred when Resident #2, assessed by the facility as 2 person transfer, was transferred by 1 staff member using a mechanical lift. Resident #2 fell during the transfer, resulting in hospitalization in the intensive care unit for a subarachnoid hemorrhage (bleeding between the brain and the tissues that cover the brain, and may extend into the cerebrospinal fluid) with a subdural hematoma (a collection of blood on the surface of the brain) and a left mastoid (back part of the temporal bone) fracture. Findings: Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 6/15/15, revealed that Resident #2 required extensive or total assistance for activities of daily living (ADL's), including bed mobility and transfer. Further review of the MDS noted that Resident #2 required 2 or more persons physical assist for bed mobility and transfers. A Resident Handling Evaluation, dated 6/10/15 and signed by S5Restorative, indicated Resident #2 required 2-person assist and mechanical lift. Review of hospital records revealed Resident #2 was admitted to the intensive care unit of a local hospital on [DATE] for monitoring due to a head injury. Admission [DIAGNOSES REDACTED]. The initial Computerized Tomography (CT) scan revealed a subdural hematoma. A follow-up CT scan, as noted by the neurosurgery service progress note on 7/7/15, revealed a subarachnoid hemorrhage (SAH) to right anterior cranial fossa with an anterior parafalcine subdural hematoma (SDH) and a left mastoid fracture. An ENT consult on 7/8/15 revealed that CT scan showed a SAH and SDH, as well as fluid in left mastoid antrum. A progress note dated 7/8/15 revealed Resident #2 had an SDH and a mastoid fracture. A discharge progress note dated 7/10/15 noted that Resident #2 had a traumatic SDH. An investigation report, completed by S3RiskManager, revealed that Resident #2 had a fall on 7/7/15 at 11:15 AM. The report revealed that, when S3RiskManager responded to a call for help, Resident #2 was found lying on the floor in his room with a moderate amount of blood noted to the left ear with no lacerations, abrasions, or skin tears. The report also contained a witness statement, from S4CNA, that the resident slipped from the sling when she had transferred him by herself. Review of the personnel file of S4CNA revealed a Notice of Disciplinary Action, dated 7/7/15, which indicated S4CNA was suspended for failing to transfer residents using proper transfer protocol, causing resident fall with injury. Further review of S4CNA's personnel file revealed an Investigation of Concern, completed by S3RiskManager, of an occurrence on 7/7/15 at 11:10 AM. It noted in the findings of investigative process that the Hoyer lift was being used on transfer with wrong size pad and only one person. During an interview on 8/6/15 at 11:38 AM, S6LPN revealed Resident #2 required total assistance for ADL's, including 2-person assist and a mechanical lift for transfers. S6LPN stated she was taking care of Resident #2 on the day that he was sent to the hospital. S6LPN revealed that she responded to S4CNA's call for help and found Resident #2 on the floor in his room with blood coming from his left ear. S6LPN stated that Resident #2 had fallen while being transferred by S4CNA using the mechanical lift alone. During an interview on 8/6/15 at 12:18 PM, S5Restorative revealed she assessed all new admits to determine assistance required by the resident, including transfers. S5Restorative further revealed that her assessment was used on the Kardex, the tool CNA's referred to for resident care. S5Restorative verified the Resident Handling Evaluation, dated 6/10/15, revealed Resident #2 required 2-person assist and mechanical lift. During an interview on 8/6/15 at 12:43 PM, S2DON stated that she was called by S6LPN to the room of Resident #2. She recalled Resident #2 lying on the floor next to his bed with a large amount of blood near the left side of his head. She further revealed that, after cleaning him up, no obvious lacerations or abrasions could be found. S2DON stated he was transferred to the hospital via ambulance. She further stated that an investigation, performed by herself and S3RiskManager, concluded that Resident #2 fell because S4CNA had transferred him using the mechanical lift by herself. S2DON verified that Resident #2 was discharged from the hospital with the [DIAGNOSES REDACTED]. During an interview on 8/6/15 at 1:10 PM, S7PT revealed that transfer of a resident using a mechanical lifts always required 2 people for safety reasons. During a telephone interview on 8/7/15 at 10:05 AM, S3RiskManager stated her responsibilities included investigations of accidents, including falls. She verified she had completed the investigation report detailing the investigation of a fall on 7/7/15 by Resident #2. S3RiskManager recalled assisting S2DON and S6LPN assess Resident #2 directly after the fall, and stated that there was a moderate amount of blood that seemed to be coming from Resident #2's left ear. She stated after Resident #2 was transported to the hospital, S4CNA acknowledged transferring Resident #2 with a mechanical lift by herself. S3RiskManager acknowledged S4CNA should have had assistance while using a mechanical lift. S3RiskManager further stated that transfers using a mechanical lift required 2 staff members for safety. During an interview on 8/7/15 at 10:20 AM, S8OT verified Resident #2 required use of a lift for transfers. S8OT revealed that, for safety reasons, 2 persons were necessary when using a mechanical lift. S8OT explained that one person guides the resident in the sling, while the second person operates the electric control. During an interview on 8/7/15 at 10:27 AM, S2DON verified that the use of a mechanical lift required 2 persons for safety. S2DON further verified that Resident #2 required hospitalization for a SAH with a SDH and a mastoid fracture, as a result of S4CNA transferring him by herself using a mechanical lift. During an interview on 8/7/15 at 11:28 AM, S1Admin revealed that when a mechanical lift for transfer was required, there should always be 2 staff members present. S1Admin verified that Resident #2's fall on 7/7/15 was caused by S4CNA, when she transferred him using a mechanical lift, by herself. S1Admin further acknowledged that the fall resulted in Resident #2 being hospitalized in the intensive care unit for a subarachnoid hemorrhage with a subdural hematoma and a mastoid fracture.

Based on record review and interview the facility failed to maintain the highest practicable well being for 1 (#3) of 5 (#1, #2, #3, #5, #6) residents reviewed who required staff assistance with transfers. The facility failed to ensure: 1. The CNAs used precautions while moving the resident from a Geri-chair to the bed to avoid injury during a transfer to her contracted lower extremities. (Resident #3). 2. The CNAs were aware of how to assist a resident with limited range of motion in her lower extremities when her leg became lodged under the bed during a transfer from a Geri-chair to the bed. (Resident #3). This resulted in actual harm to Resident #3 when on 2/19/13, during a transfer, the resident's right leg became lodged under the bed and the CNA heard a "pop" when she removed the resident's leg from this position. Resident #3 sustained a right femur fracture that required hospitalization and surgery. Findings: Review of the clinical record for Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS with an ARD of 11/23/12 revealed a BIMS was not conducted because the resident was rarely/never understood and her cognitive skills for daily decision making were severely impaired. The same MDS revealed the resident rarely/never understood others. The functional status for the resident on the 11/23/12 MDS revealed the resident was coded for transfers as total dependence-full staff performance every time during entire 7 day period with two plus person physical assist for support provided. The MDS also coded the resident's Functional Limitation in Range of Motion as having impairment on both sides for the resident's lower extremities. Review of Resident #3's Handling Evaluation form, dated 11/23/12, revealed the following documentation: Conditions that are likely to affect the equipment, aids, and techniques required for resident handling was listed [MEDICAL CONDITION] contractures. The evaluation form indicated the level of assistance was dependent. Dependent was defined on the form as 'resident requires caregiver to lift more than 35 pounds of resident's weight or is unpredictable in amount of assistance offered'. Weight-bearing capability on the form was indicated as 'none' . Level of cooperation was uncooperative and handling was listed as 2 person assist. Review of the Nursing Evaluation form, dated 11/18/12, revealed the resident was total dependence of 2 (people) for transfers. Further review of the form revealed the resident's mobility was scored as very limited; makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. Review of the facility Injury Log dated 1/1/3-3/4/13 revealed Resident #3 listed on 2/19/13 6:30 p.m. with injuries (R/O fracture) at Leg/Foot, right hip. Review of the resident's Nurse Physician Communication Record dated 2/19/13 at 6:30 p.m. revealed the following: Reason you are calling/current condition: Suspected fracture to right hip Primary Diagnoses: [REDACTED]. Resident ' s previous condition: (declining/improving/stable): confused Previous/current mental status (note changes): stable LOC status/changes: disoriented to place, time and person Nursing Evaluation: ....Pain: 2 Location: Right hip ... Fall Related: Location of Fall: Not fall related Current ROM abilities: Limited ... What have you done so far: Did not move resident, called MD. Assessed resident. The form also revealed the resident was sent to the hospital emergency room for evaluation due to right hip injury. The Narrative Nursing Notes of the form revealed, in part, the following entry: 2/19/13 6:30 p.m. My attention was called to the resident's room by the aide taking care of resident. The aide reports that while she was putting resident in bed with the assistance of another CNA, resident's right leg hang under bed and her right hip was affected. Upon assessment, right hip was noted swollen and resident has history of right [MEDICAL CONDITION]. The NP on call-B ...M. was contacted an order was given to send resident to ER for evaluation. 6:45 p.m. A ... Ambulance called 7:00 p.m. A ... Ambulance arrived Review of the Witness Statement written by S12CNA revealed, in part, the following: Resident: Resident#3. Date Incident Witnessed 2/19/13 Time: 6:30 p.m. Detailed Statement of Event: When transfer Resident #3, S13CNA and I was on each side of her. We was so busy trying to make sure she get in the bed correctly we didn't notice that her leg was stuck underneath the bed. I heard something pop and I ask S13CNA what was that. She said that her leg was stuck. S13CNA removed her leg from underneath the bed and went get the nurse immediately. I stayed with Resident #3. S14LPN came in and looked at Resident #3 she told me that she needed to notify the doctor and family. The ambulance came and S13CNA and I help the paramedics transfer Resident #3. The statement was signed by S12CNA. Review of the Witness Statement written by S13CNA revealed, in part, the following: Resident: Resident #3. Date Incident Witnessed: 2/19/13. Time 6:30 p.m. Detailed Statement of Event: Me and S12CNA was doing a two person transfer on Resident #3. I was on one side and S12CNA was on another. We was transferring her from the chair to the bed and doing the transfer once we got her in the bed we was trying to make sure she was on the bed and didn't notice her leg was catch. I knew her leg were stuck so I told S12CNA let me get her leg from stuck and that we heard a pop and S12CNA asked me were there a pop and I told her yes and that when I went got the nurse and S12CNA stayed with Resident #3 and the nurse said she had to contact the family and doctor and that when the ambulance came and me and S12CNA help them transfer her to the stretcher. The statement was signed by S13CNA. An interview was held on 3/6/13 at 10:35 a.m. with S2DON. She stated she was notified by S14LPN on 2/19/13 of the incident with Resident#3. The DON explained the resident's right leg got caught on the bed during a transfer and her right hip was visibly swollen. She continued to say she spoke with the CNAs involved with the transfer the next morning and asked them what had happened. S2DON said the CNAs were transferring Resident #3 from a Geri-chair to the bed and each CNA was assisting the resident by holding her under the arms. She continued to explain the CNAs sat the resident on the bed and "scooted" her in. She said when the CNAs proceeded to move the resident's legs over the bed they heard a "pop" . S2DON further said she had the CNAs reenact the transfer they performed with the resident, but by transferring her instead. She explained the resident's legs were "contracted" and when the CNAs transferred her the way they transferred the resident, she noticed her ankle hit at the frame of the bed. The DON stated from this reenactment she could see that it would be possible for the resident's leg to get caught and fractured during the transfer. An interview was held on 3/6/13 at 2:10 p.m. with S13CNA. She confirmed she was working the evening shift at the facility on 2/19/13. She continued to say she assisted S12CNA to transfer Resident #3 from a Geri-chair to the bed at 6:30 p.m. after the supper meal. S13CNA explained she and S12CNA got on each side of the resident and made sure the resident's legs touched the floor and "were straight" before they transferred her. She continued to explain the 2 CNAs picked the resident up by holding her under the arms and when they moved her to the bed, they saw the resident's legs were under the edge of the bed. She stated her right leg was "held up under the bed" and she proceeded to remove the leg from that position. She said when she moved the resident's right leg she heard a "pop". S13CNA said after she heard the resident's leg "pop" she finished laying her down and notified S14LPN. The CNA said an ambulance came and the resident was transferred to the hospital. A telephone interview was held on 3/6/13 at 2:45 p.m. with S12CNA. She stated she was assigned to Resident #3 during the evening shift on 3/19/13. S12CNA explained she had asked S13CNA to assist her with transferring Resident #3 from a Geri-chair to the bed after the evening meal. She continued to explain the resident was "kind of contracted in her legs" and when the CNAs transferred the resident, her right leg "got stuck under the bed" . She stated she did not realize the resident's leg was stuck at first. S12CNA said when S13CNA moved the resident's right leg from underneath the bed they both heard a "pop" . She revealed S13CNA notified the nurse and she stayed with the resident. She said the nurse called an ambulance and the resident was transferred to the hospital. Review of the Hospital Record for the resident revealed, in part, the following: Emergency Department Physician Notes dated 2/19/13 at 8:12 p.m. History of present illness: The patient presents following a fall. Onset prior to arrival. The patient fell when the staff at the nursing home transferred the patient from a chair to the bed. The staff stated they "heard a pop" . The patient complained of right leg and ankle pain. The onset was just prior to arrival. The occurrence was single episode. Transfer from chair to bed. The location where the incident occurred was at a nursing home. Location: right leg/ankle. The character of symptoms is pain. The degree at present is moderate. Exacerbating factors consist of none ...Femur x-ray findings: ...mid shaft comminuted displaced femur fracture ... Consultation dated 2/20/13: Past Medical History 1. Severe advanced Alzheimer dementia ...2. History of [MEDICAL CONDITION]. 3. Hypertension. 4. Bilateral total knee replacement. 5. Right femur fracture with repair by Dr. G ... Physical Examination: General: A contracted African American female, in no acute distress resting comfortably ... Neurological: The patient does not respond to verbal cues, but she does have a slight wince whenever I grab her right thigh. Hospital Operative Report dated 2/21/13: Procedure performed: 1. Removal of hardware deep, screws from plate. 2. Intramedullary nail right femur. Indications: The patient is an [AGE] year-old who had a total knee arthroplasty. I fixed her prosthetic supracondylar femur fracture with a plate and screws. She subsequently had a fall at the nursing home recently and had a fracture above the most recent plate. An interview was conducted on 3/7/13 at 10:50 a.m. with S2DON. She stated an in-service was held on 2/26/13 for CNAs on the different types of transfers. S2DON confirmed that not all CNAs had attended an in-service on transfers since the incident with Resident #3 on 2/19/13. She stated that because of time constraints, the facility had not re-inserviced all CNAs on transfers. The DON confirmed the following CNA's had worked at the facility, but had not been in-serviced on transfers after the injury occurred to Resident #3 on 2/19/13: S15CNA, S16CNA, S17CNA, S18CNA, S19CNA, S20CNA, S21CNA, S22CNA, S23CNA, S24CNA, S25CNA and S26CNA.