Every finding on record at Westwood Manor Nursing Home, Inc

Based on observation and interview, the facility failed to ensure medications and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to ensure:1. Expired medications were not available for use/administration to Resident #20;2. Resident #48's medication was properly labeled; and3. Residents (#15, #29, #72, and #77)'s insulin pen/vials were properly labeled after opening and discarded after 28days of opening. Findings:Review of an undated facility policy on 07/07/2026 at 12:47 p.m. titled Medication Storage read in part. The nursing staff shall be responsible for maintaining medication storage. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to dispensing pharmacy or destroyed. 1. Observation on 07/07/2026 at 11:35 a.m. of Medication Cart A with S4LPN revealed Resident #20 had the following expired medications available for use on cart; (1) blister pack of Hyoscyamine Sulfate Oral Tablet 0.125mg with expiration date of 02/23/2026. (1) blister pack of Promethazine HCl Oral Tablet 25mg with expiration date of 2/23/2026.Interview on 07/07/2026 at 11:39 a.m. with S4LPN confirmed Resident #20's above listed medications were expired, should not have been stored on the cart, and should have been discarded.2. Observation on 07/07/2026 at 11:40 a.m. of Medication Cart A with S4LPN revealed Resident #48 had 1 box of HyperSal Inhalation Nebulization Solution 7 % with no medication label present. S4LPN stated Resident #48 received the medication routinely. S4LPN confirmed the medication did not have a label, but should.3. Observation on 07/07/2026 at 11:42 a.m. of Medication Cart A with S4LPN revealed Resident #29 with (1) Lantus Solostar 100 Unit insulin pen, with no open date. S4LPN confirmed insulin should have an open date present to ensure it is discarded after 28 days, but it did not. Observation on 07/07/2026 at 11:43 a.m. of Medication Cart A with S4LPN revealed Resident #72 with (1) Insulin Lispro Kwikpen with 2 dates that read 12/05/2025 and 05/25. S4LPN confirmed the medication should not have been labeled with two open dates. S4LPN confirmed the insulin Kwikpen should have been discarded 28 days after the open date, but was not. Observation on 07/07/2026 at 11:49 a.m. of Medication Cart A with S4LPN revealed Resident #77 with (1) vial of Insulin Lispro with an open date of 06/02/2026. S4LPN stated the vial of insulin should have been discarded after 28 days, but was not. Observation on 07/07/2026 at 11:52 a.m. of Medication Cart A with S4LPN revealed Resident #15 with (1) vial of Insulin Lispro with an open date of 06/02/2026. S4LPN stated the vial of insulin should have been discarded after 28 days, but was not. Interview on 07/07/2026 at 12:24 p.m. with S3ADON confirmed all expired medications should have been discarded on expiration date, and the 1 box of HyperSal Inhalation Nebulization Solution 7 % had no medication label present, but should have. S3ADON confirmed all insulin stocked on the medication cart should have been labeled with an open date and discarded 28 days after the open date, but was not. S2Corporate RN acknowledged the above findings during interview.Interview on 07/07/2026 at 2:45 p.m. with S1DON acknowledged the above findings.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 90 residents that received meals prepared in the kitchen. Findings: Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Storage: Freezer revealed the following part.2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 3. Label and date all items. Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Storage: Refrigerator revealed the following in part.7. Keep refrigerated food wrapped or covered and in sanitary containers. Observation on 07/28/2025 at 8:55 a.m. of the facility kitchen accompanied by S11 Dietary Manager revealed the following: Walk-In Refrigerator: 1. One opened, unsealed, and undated cardboard box of breakfast sausage patties (over 25 individual sausage patties).2. One opened, unsealed, and undated cardboard box of hamburger patties (over 25 individual hamburger patties). Walk-In Freezer:1. One opened, unsealed, and undated cardboard box of cinnamon rolls (over 25 individual cinnamon rolls). 2. One opened, unsealed, and undated cardboard box of raw cookie dough (over 50 individual cookie doughs).3. One opened, unsealed, and undated cardboard box of pretzel breadsticks (over 25 individual breadsticks). Dry storage: 1. Three expired cartons of prune juice with an expiration date of 05/15/2025. S11 Dietary Manager confirmed all the above findings during the facility kitchen observation. S11 Dietary Manager confirmed the listed items were opened, unsealed, undated, and/or expired and should have been disposed of properly, but were not.

Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan was revised after each assessment for 1 (Resident #22) of 30 sampled residents. Review of Resident #22's medical record revealed an admission date of 03/26/2018 with diagnoses including Alzheimer's Disease, Epilepsy, Gastrostomy, and Quadriplegia. Review of Resident #22's Discharge with Return Anticipated MDS with ARD of 07/15/2025 revealed a BIMS Score was not conducted. Resident #22 did not receive Oxygen. Review of Resident #22's previous physician's orders revealed Oxygen at 2-4L NC PRN SOB and O2 sat below 95% RA as needed was discontinued on 01/29/2025.Review of Resident #22's care plan revealed the following interventions: Oxygen settings: O2 via NC at 2-4L PRN SOB or O2 less than 95% on RA; and Oxygen: Administer as ordered.Interview was conducted with S10 MDS and S13 MDS on 07/30/2025 at 1:35 p.m. S10 MDS revealed Resident #22 did not have an order for Oxygen, but was care-planned for Oxygen. S13 MDS confirmed Resident #22's care plan was not revised after each assessment, but should have been.

Based on interview and record review the Facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide nail care for 1 (#5) out of 30 sampled residents. Findings:Review of Resident #5's medical record revealed an admit date of 05/01/2025 with a re-entry date of 06/20/2025 with diagnoses which included: Disruption of Dehiscence of Closure of Internal Operation (Surgical) Wound of Abdominal Wall Muscle or Fascia, Chronic Respiratory Failure, Partial Intestinal Obstruction, Severe Protein-Calorie Malnutrition, and Hypertensive Heart Disease without Heart Failure. Review of Resident #5's admission MDS with an ARD of 05/01/2025 revealed Resident #5 had a BIMs score of 6, indicating severe cognitive impairment. Review of Resident #5's Care Plan dated 05/02/2025 revealed in part. ADL assistance needed: Moderate assist needed with toileting, personal hygiene, and staff x 1 with transfers. Observation on 07/28/2025 at 10:30 a.m. revealed Resident #5's fingernails were long in length and contained a large amount of brown substance underneath the nails. Resident #5 stated last week he requested staff to cut and clean his nails. Resident #5 reported staff did not provide ADL care as requested.Review of document titled POC Response History- Task: Hygiene revealed in part. on 07/29/2025 at 11:12 a.m. ADL care was provided for Resident #5 which consisted of: pericare, oral care, nail care, combing hair, and shaving. Interview on 07/29/2025 at 12:55 p.m. with S4 treatment nurse revealed nail care was included in residents' ADLs. S4 treatment nurse reported CNAs can cut fingernails of the residents who are not diabetic. Resident #5 did not have a diagnosis of Diabetes. Interview on 07/29/2025 at 01:04 p.m. with S5 CNA revealed in part. S5 CNA provided ADL care for Resident #5 today. S5 CNA confirmed nail care was documented as a task performed during her ADL care. S5 CNA confirmed she did not clean underneath or cut Resident #5's fingernails during ADL care. Interview on 07/29/2025 at 01:06 p.m. with S4 treatment nurse confirmed Resident #5's fingernails were long/ dirty. S4 treatment nurse confirmed Resident #5's nails should have been cleaned during ADL care. On 07/29/2025 at 01:15 p.m. S2 DON acknowledged that Resident #5's fingernails should have been cleaned by S5 CNA during ADL care.

Based on observation and interview, the facility failed to ensure expired medications were not available for administration to residents in 1 (Room A) of 1 medication room checked for safe and secure storage.Observation of Room A on 07/29/2025 at 10:00 a.m. accompanied by S14 LPN revealed Room A was used to store medications and supplements to be provided to residents. Observation revealed 2 unopened bottles of Ocuvite Adult 50+ Soft Gels with an expiration date of 06/2025, and 3 DiabetiSource AC Complete Nutrition 250mL supplements with an expiration date of 05/23/2025. An interview was conducted at this time with S14 LPN who confirmed expired medications and supplements were in Room A, but should not have been.Interview with S3 ADON on 07/29/2025 at 10:45 a.m. confirmed expired medications and supplements should not have been in Room A, available for administration to residents, but were.

Based on observation, interview, and record review, the facility failed to ensure a resident received and the facility provided liquids consistent with resident needs for 1 (Resident #52) resident investigated for hydration. The sample size was 30 residents.Review of Resident #52's medical record revealed an admission date of 12/16/2020 with diagnoses including, in part.Dementia, Mild Protein-Calorie Malnutrition, and Aphasia. Review of Resident #52's Quarterly MDS with ARD of 06/06/2025 revealed a BIMS Score of 99. Resident #52 required substantial/maximal assistance with eating and did not have a swallowing disorder. Review of Resident #52's active physician's orders revealed the following: 09/03/2024: 360mL fluid of choice po TID with med pass; and 09/03/2024: Give 360mL fluid of choice po BID at snack times. Review of Resident #52's care plan revealed the following: 12/01/2021: 360mL fluid of choice po TID with med pass; and 12/07/2021: Give 360mL fluid of choice po BID at snack times. Review of Resident #52's 07/2025 MAR revealed the following: 360mL fluid of choice po TID with med pass; and Give 360mL fluid of choice po BID at snack times. Review of Resident #52's 07/2025 Task: Daily Fluid Requirement flowsheet revealed Resident #52 did not meet his daily fluid requirement on 07/03/2025, 07/04/2025, 07/13/2025, 07/25/2025, and 07/26/2025.Review of Resident #52's 07/2025 Task: Intake-Fluid-CNA flowsheet revealed the resident did not refuse nor consume 360mL of fluid BID at snack times on 06/30/2025, 07/01/2025, and 07/26/2025. Review of Resident #52's 07/2025 Task: Intake-Fluid-Nurse flowsheet revealed the resident did not refuse nor consume 360mL of fluid TID with med pass on 06/30/2025, 07/04/2025, 07/06/2025, 07/09/2025, 07/11/2025, 07/12/2025, 07/14/2025, 07/16/2025, 07/19/2025, 07/23/2025, 07/25/2025, and 07/29/2025.Interview with S15 CNA on 07/30/2025 at 10:21 a.m. revealed the CNAs monitored the fluid intake of each resident during meals and snack times. The amount (mL) of fluid consumed during meals and snack times was documented on the resident's electronic Tasks: Intake-Fluid-CNA flowsheet.Interview with S16 LPN on 07/30/2025 at 11:47 a.m. revealed she crushed Resident #52's medications and provided them mixed with pudding. S16 LPN confirmed she did not provide 360mL of fluid when she provided Resident #52's medications. Interview with S2 DON on 07/30/2025 at 1:50 p.m. confirmed Resident #52 did not receive the quantity of fluids ordered each day, but should have.

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 95 residents who resided in the facility.Findings: Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Trash revealed the following part.All garbage and trash will be placed in a dumpster in a convenient area near the facility. The lid to the dumpster is to be kept closed at all times. Observation on 07/28/2025 at 9:36 a.m. of the facility dumpsters accompanied by S11 Dietary Manager and S12 Maintenance Supervisor revealed 3 facility dumpsters. Observed dumpster #1 with the top lid opened, dumpster #2 with the side lid open, and dumpster #2 with 1 full, large black garbage bag placed directly on the ground in front of the dumpster. Observed multiple pieces of debris/trash on the ground in the surrounding dumpster area such as straws, plastic lids, silver spoons, napkins, and other paper products. S12 Maintenance Supervisor revealed the facility occasionally has raccoons in the dumpster area and the raccoons made the mess in the dumpster area. Observed 1 small black garbage bag placed directly on the ground in the dumpster area near the back door of the facility. S11 Dietary Manager and S12 Maintenance Supervisor confirmed all the above findings during the time of observation. S11 Dietary Manager and S12 Maintenance Supervisor confirmed all employees were responsible for their own trash and should have placed facility trash inside the dumpster and close the dumpster lids, but had not. S12 Maintenance Supervisor confirmed the dumpsters' surrounding area should have been kept clean and the debris picked up in the surrounding area, but had not.

Based on record review and interview, the facility failed to transmit an admission MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #33) of 1 sampled residents with a MDS record over 120 days old. Findings:Review of the Facility's undated policy titled: MDS 3.0 Completion read in part Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. 2. admission Assessment- completed 14 days of admission counting the day of admission as day #1. The admission assessment must be accepted with a transition time line of 14 days. Review of Resident #33's medical record revealed an admission date of 07/03/2025. Review of Resident #33's MDS on 07/29/2025 revealed the admission MDS with ARD (Assessment Reference Date) of 07/09/2025 was open and had not been transmitted. An interview on 07/29/2025 at 2:10 p.m. with S10 LPN confirmed that Resident #33's admission MDS with ARD of 07/09/2025 should have been signed as completed and transmitted by 07/22/2025, but had not been.

Based on interview and record review, the facility failed to ensure a resident received reasonable needs for 1 (Resident #32) of 1 residents reviewed for accommodation of needs. The facility failed to ensure Resident #32 received a Geriatric chair as requested.Findings:Review of the Facility's undated policy titled Accommodation of Needs read in part.Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. 4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. Review of Resident #32's medical records revealed an admit date of 04/02/2024 with diagnoses that included: Type 2 Diabetes Mellitus, Unspecified Osteoarthritis, Morbid Obesity, Muscle Spasms of Back, Chronic Pain Syndrome, and Restless Leg Syndrome. Review of Resident #32's Quarterly MDS with an ARD of 05/30/2025 revealed a BIMS of 15, indicating Resident #32 was cognitively intact. Resident #32 utilized a wheelchair. Review of Resident #32's Care plan with a review date of 10/10/2025, read in part.The resident has limited physical mobility related to contractures and foot drop to right foot. Interventions: Provide supportive care and assistance with mobility as needed. During an interview on 07/28/2025 at 10:37 a.m. Resident #32 stated she can only get up in a wheelchair for about 15 minutes due to back pain. Resident #32 stated she would like to get up more and requested a geri chair a few months ago to staff (cannot remember who), but has not had anyone offer her a geri chair since then. During an interview on 07/29/2025 at 10:20 a.m. S6 LPN stated Resident #32 does not stay up long in wheelchair because she has chronic pain from a car accident. S6 LPN stated she had not been notified of Resident #32 requesting a geri chair. During an interview on 07/29/2025 at 10:30 a.m. S7 SSD stated that she had not received a grievance or been notified of a request for a geri chair for Resident #32. During an interview on 07/29/2025 at 10:34 a.m. S8 CNA stated she heard ( could not remember when) Resident #32 stating that she would like to try a geri chair so she can be more comfortable when she gets up because of the pain in her legs. S8 CNA stated she thought S9 CNA told S6 LPN, but did not know for sure. During an interview on 07/29/2025 at 12:15 p.m. S9 CNA stated that she could remember Resident #32 mentioning something about a geri chair months ago, but did not notify the nurse or any other staff. S9 CNA stated thought S8 CNA had notified the nurse at the time. During an interview on 07/29/2025 at 12:25 p.m. S2 DON stated that she had not been notified by anyone that Resident #32 requested a geri chair. During an interview on 07/30/2025 at 10:34 a.m. S2 DON stated that when any staff are notified of a complaint or a request, management staff should be notified in a timely manner. S2 DON confirmed that she had not been notified of Resident #32's request for a geri chair by any staff in the facility.

Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 1 (#96) of 2 (#45, #96) Residents reviewed for dignity in a total sample of 29. The facility failed to ensure Resident #96 was dressed appropriately. Findings: Review of Resident #96's EHR (Electronic Health Record) revealed an admitted [DATE] with diagnoses including in part . Hypertensive Heart Disease, Chronic Kidney Disease Stage 2, Gastrostomy Status, Parkinson's Disease, Adult Failure to Thrive, Major Depressive Disorder, Unspecified Severe Protein- Calorie Malnutrition, Anxiety Disorder, and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Review of Resident #96's Quarterly MDS with ARD of 04/17/2024 revealed Resident #96 was non-interviewable with a BIMS of 99 (unable to assess mental status). Resident #96 was dependent on staff for oral hygiene, toileting, showering/bathing, dressing upper and lower body, and personal hygiene. Resident #96 received Hospice Services. Review of Resident #96's Comprehensive Care Plan with start date of 03/02/2024 and review date of 07/25/2024 revealed Resident required assistance for all ADL's which included dressing. Observation on 05/13/2024 at 12:40 p.m. revealed Resident #96 was non-interviewable and was lying in bed, uncovered, and clothed with only a diaper. Observation on 05/14/2024 at 1:29 p.m. revealed Resident #96 was lying in bed, without clothing, and only a diaper on. Interview on 05/14/2024 at 1:34 p.m. with S6 CNA revealed he did not dress Resident #96 because the resident pulls clothes off when he attempts to dress him. Telephone interview on 05/14/2024 at 2:43 p.m. with Resident #96's RP revealed she had asked numerous times to place a gown on Resident. Resident #96's RP stated she wanted him to be dressed, and Resident #96 would have always wanted to be dressed. Interview on 05/14/2024 at 3:08 p.m. with S3 LPN revealed Resident #96 was care planned for behaviors of being aggressive towards staff occasionally, but she was unaware of Resident #96 having behaviors of undressing himself. Interview on 05/14/2024 at 3:19 p.m. with S2 DON revealed Resident #96 had behaviors at times in which he acted out against staff, but she was unaware of him pulling his clothing off. S2 DON acknowledged Resident #96 should be covered or dressed appropriately.

Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#96) of 2 (#96, #352) Residents reviewed for advance directives. The total sample size was 29. The facility failed to ensure all medical records regarding code status consistently reflected the Resident's wishes to be a DNR (Do Not Resuscitate). Findings: Review of Resident #96's EHR (Electronic Health Record) revealed an admitted [DATE] with diagnoses including in part . Hypertensive Heart Disease, Chronic Kidney Disease Stage 2, Gastrostomy Status, Parkinson's Disease, Adult Failure to Thrive, Major Depressive Disorder, Unspecified Severe Protein- Calorie Malnutrition, Anxiety Disorder, and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Further review of Resident #96's EHR- Bed board revealed a code status of CPR. Review of Resident #96's Quarterly MDS with ARD of [DATE] revealed Resident #96 was non-interview able with a BIMS of 99. Resident #96 was dependent on staff for oral hygiene, toileting, showering/bathing, dressing upper and lower body, and personal hygiene. Resident #96 received Hospice Services. Review of Resident #96's Comprehensive Care Plan with start date of [DATE] and review date of [DATE] revealed no evidence of Resident's code status. Review of Resident #96's current [DATE] physician's orders revealed there was no order for code status. Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) for Resident #96 revealed Resident #96's code status was listed as DNR (Do Not Resuscitate) and was signed by Resident #96's sister on [DATE]. Interview on [DATE] at 2:54 p.m. with S4 LPN revealed she determined a Resident's code status by reviewing the EHR bed board in computer, or by pulling the hard chart if a computer is not around. S4 LPN reviewed Resident #96's EHR and it stated full code-CPR. S4 LPN reviewed Resident #96's hard chart and the LaPOST stated DNR. S4 LPN confirmed Resident #96's medical record contained conflicting information for code status, and should not. Interview on [DATE] at 2:56 p.m. with S5 LPN confirmed Resident #96 did not have an active order for code status, but should. Interview on [DATE] at 3:19 p.m. with S2 DON revealed each resident should have an order for code status within their medical record. S2 DON confirmed Resident #96's order for code status was not updated after receiving LaPOST, but should have been.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment, by failing to ensure a resident's bed linens were clean for 1 (Resident #18) of 4 (Resident #10, Resident #18, Resident #49 and Resident #55) sampled Residents. Total sample size was 29. Findings: Review of Resident #18's medical record revealed an admitted [DATE], with diagnosis which included: Major Depressive Disorder, Heart Failure Unspecified, Vascular Dementia Unspecified, Overactive Bladder and Unspecified Dementia. Review of Resident #18's Quarterly MDS with an ARD of 04/03/2024 revealed a BIMS score of 12 indicating mildly impaired cognition. The MDS revealed Resident #18 required supervision or touching assistance with bathing, independent with eating and toileting hygiene; set-up or clean up assistance with personal hygiene. Review of Resident #18's Care Plan with a review date of 07/31/2024, revealed he required supervision to limited assistance with ADL's with interventions to assist as needed. Observation and interview on 05/13/2024 at 10:44 a.m. revealed Resident #18 in bed. Resident #18's sheets were visibly soiled and stained from the top to the bottom. Resident stated he had wasted food and drink on the sheets. The bottom sheet had black streaks at the foot. Resident #18 stated it had been over 3 weeks since his sheets had been changed. Observation and interview on 05/13/2024 at 10:46 a.m. with S9 CNA in attendance confirmed Resident #18's sheets were visibly soiled and stained. S9 CNA stated she did not know when Resident #18's sheets had been changed. Interview on 05/15/2024 at 12:00 p.m. with S2 DON confirmed Resident #18's sheets should have been changed on Resident's bath days and as needed.

Based on interview and record review, the facility failed to ensure a prompt resolution of an allegation of missing property for 1 (Resident #13) of 1 resident reviewed for grievances by failing to initiate a grievance for Resident #13. Total sample size was 29. Findings: Review of the Facility's Grievance/Complaint Policy (no review date) revealed in part . 1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility other entity that hears grievances concerning treatment, medical care, behavior of other residents, staff members, theft of property, and other concerns regarding their LTC facility stay without fear of threat or reprisal in any form. 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations. Review of Resident #13's clinical record revealed an admitted [DATE] with diagnosis which included: Neuromuscular Dysfunction of Bladder, Multiple Sclerosis, Hypertensive Heart Disease, Anxiety Disorder and Anemia. Review of Resident #13's Quarterly MDS with an ARD of 03/26/2024 revealed Resident #13 had a BIMS score of 15 indicating intact cognition. Resident #13's MDS revealed she required partial to moderate assistance with toileting, bathing and personal hygiene; independent with eating. Interview on 05/13/2024 at 12:03 p.m. with Resident #13 revealed she had a pair of blue capris that had been missing since December 2023 and a blanket that she sent to laundry over a week ago had not been returned. Interview on 05/14/2024 at 11:45 a.m. with Resident #13 revealed she had reported the missing items to S1 Administrator in writing, but had not received any response from him. Interview on 05/14/2024 at 1:07 p.m. Interview with S1 Administrator revealed Resident #13 had communicated with him via a letter, but was not aware of the missing capris or blanket. S1 Administrator provided surveyor with the letter which Resident #13 had sent him. Review of the letter written and dated 05/11/2024 by Resident #13 revealed in part .Immediate attention: I have been asking for my blue/navy capris for months. I have asked multiple times. This has been of no avail. 0n 05/08/2024 my favorite Christmas blanket fell on the floor and became saturated with urine .housekeeper took it to the laundry and it was not returned. I want my things returned. My blanket is very special to me. In an interview on 05/15/2024 at 9:45 a.m., S1 Administrator acknowledged Resident #13 had written him a letter on 05/11/2024 complaining of her blue capris pants and blanket being missing. S1 Administrator confirmed he did not initiate a grievance at that time.

Based on record review and interview, the facility failed to develop and implement a CPOC (Comprehensive Person Centered Care Plan) to meet Resident's medical needs for 2 (#47, #96) of 29 sampled residents. The facility failed to: 1. Ensure Resident #47 was transferred with a mechanical lift by 2 person assist as specified in the resident's physician's orders and CPOC, and 2. Ensure Resident #96 had a CPOC to address the Resident's code status of DNR. Findings: Resident #47 Review of Resident #47's medical record revealed an admitted [DATE] with diagnoses that included in part .Urinary Tract Infection, Acquired absence of left and right leg above knee, Hemiplegia, COPD, Major Depressive Disorder, Morbid Obesity, and Muscle Weakness. Review of Resident #47's current physician's orders revealed the following: [DATE]: X 2 mechanical lift with transfers Review of Resident #47's Quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required substantial/maximal assistance with showering/bathing self and chair/bed to chair transferring and was always incontinent of bladder and bowel. Review of Resident #47's care plan with a start date of [DATE] and a review date of [DATE] revealed the resident was care planned for Requires extensive with ADLs: Requires extensive assistance with bed mobility, transfers x 2 person assistance, dressing, toileting, wheelchair mobility, bathing and hygiene . Resident is bilateral above knee amputation with right upper extremity weakness related to right-sided hemiplegia. Interventions included to assist with ADLs as needed. In an interview on [DATE] at 11:10 a.m., Resident #47 stated she just finished getting bathed. Resident #47 stated S8 CNA used the lift beside her bed to put her in the shower chair to take her to the shower. In an interview on [DATE] at 11:17 a.m., S8 CNA confirmed she had just bathed Resident #47. S8 CNA stated used the lift in Resident #47's room to transfer her from the bed to the shower chair to take her to bathe. S8 CNA confirmed she transferred Resident #47 from the bed to the shower chair using the lift without any assistance. S8 CNA confirmed she should you have had another staff member assist her when using the lift to transfer Resident #47. In an interview on [DATE] at 11:20 a.m., S2 DON confirmed there should have been two staff members using the mechanical lift to transfer Resident #47. S7 Corporate Nurse confirmed there should be two staff present when operating the lift. 47004 Resident #96 Review of Resident #96's EHR (Electronic Health Record) revealed an admitted [DATE] with diagnoses including in part . Hypertensive Heart Disease, Chronic Kidney Disease Stage 2, Gastrostomy Status, Parkinson's Disease, Adult Failure to Thrive, Major Depressive Disorder, Unspecified Severe Protein-Calorie Malnutrition, Anxiety Disorder, and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Further review of Resident #96's EHR- Bed board revealed a code status of CPR. Review of Resident #96's Quarterly MDS with ARD of [DATE] revealed Resident #96 was non-interview able with a BIMS of 99. Resident #96 was dependent on staff for oral hygiene, toileting, showering/bathing, dressing upper and lower body, and personal hygiene. Resident #96 received Hospice Services. Review of Resident #96's Comprehensive Care Plan with start date of [DATE] and review date of [DATE] revealed no evidence of Resident's code status. Review of Resident #96's [DATE] physician's orders revealed there was no order for code status. Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) for Resident #96 revealed Resident #96's code status was listed as DNR (Do Not Resuscitate) and was signed by Resident #96's sister on [DATE]. Interview on [DATE] at 3:08 p.m. with S3 LPN revealed she was responsible for developing resident's care plans. S3 LPN confirmed each resident's care plan should reflect resident's wishes for code status. S3 LPN confirmed Resident #96 was not care planned for code status, but should be.

Based on record review and interview the facility failed to administer the Pneumococcal Vaccine after receiving consent for 1 (#45) of 5 (#2, #45, #57, #66 and #352) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations. Findings: Review of the facility's policy titled Pneumococcal Vaccine (Series) with a review date of 05/2024 revealed in part .It is our policy to offer our residents, staff and volunteer workers immunization against Pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: 2. Each resident will be offered a Pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered. Review of Resident #45's clinical record revealed an admitted [DATE] with diagnosis which included: COVID-19, Heart Failure Unspecified, Acute Upper Respiratory Infection Unspecified, and Other General Symptoms and Signs. Review of Resident #45's clinical record revealed no evidence that she had received the Pneumococcal Vaccine. Resident #45's clinical record had a signed consent dated 11/29/20218 for her to receive the Pneumococcal Vaccine. Interview on 05/15/2024 at 12:03 p.m. with S2 DON confirmed Resident #45 had a signed consent dated 11/29/2018 to receive the Pneumococcal Vaccine but had not received it. S2 DON stated she did not know why Resident #45 had not received the Pneumococcal Vaccine, but she should have.

Based on observation, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#47, #49) of 2 residents reviewed for Activities of Daily Living (ADLs). Findings: Resident #47 Review of Resident #47's medical record revealed an admitted [DATE] with diagnoses that included in part .Urinary Tract Infection, Acquired absence of left and right leg above knee, Hemiplegia, Major Depressive Disorder, Morbid Obesity, and Muscle Weakness. Review of Resident #47's Quarterly MDS with an ARD of 04/15/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed rejection of care was coded as behavior not exhibited. The MDS revealed the resident required substantial/maximal assistance with showering/bathing self and chair/bed to chair transferring and was always incontinent of bladder and bowel. Review of Resident #47's care plan with a start date of 02/07/2024 and a review date of 07/25/2024 revealed the resident was care planned for Requires extensive with ADLs: Requires extensive assistance with bed mobility, transfers x 2 person assistance, dressing, toileting, wheelchair mobility, bathing and hygiene . Resident is bilateral above knee amputation with right upper extremity weakness related to right-sided hemiplegia. Intervention included to assist with ADLs as needed. In an interview on 05/13/2024 at 12:00 p.m., Resident #47 stated staff are not bathing her. In an interview on 05/15/2024 at 9:10 a.m., Resident #47 stated she hadn't been bathed since last week and only gets bathed when she forces the issue. Resident #47 stated this had been a problem since she was admitted to the facility. Resident #47 stated staff do not offer to bathe her. Resident #47 stated she was supposed to be bathed on Tuesdays, Thursdays, and Saturdays. Resident #47 stated she had never refused to be bathed and staff had not offered to bathe her since last Thursday. Resident #47 stated she required assistance with showering. Review of Resident #47's Bathing Roster for the last 30 days (04/15/2024 through 05/15/2024) revealed documentation the resident had received 4 baths in that period, two of which were bed baths. Review of the Bathing Roster on 05/15/2024 revealed Resident #47 was last bathed on 05/09/2024. Review of the Bathing Roster and interview on 05/15/2024 at 10:30 a.m. with S7 Corporate Nurse revealed there were only 4 baths documented for the 30 day period and S7 Corporate Nurse stated the facility had documentation issues. In an interview on 05/15/2024 at 11:10 a.m., Resident #47 stated she just finished getting bathed. Resident #47 stated this was her first shower since last Thursday, 05/09/2024, and she had never received a bed bath. In an interview on 05/15/2024 at 11:20 a.m., S2 DON interviewed confirmed Resident #47 should be bathed three times per week or anytime she asked to be bathed. S2 DON confirmed there was no documentation that Resident #47 was receiving showers/baths as scheduled. 46773 Resident #49 Review of Resident #49's medical record revealed an admitted [DATE] with diagnoses that included Frontotemporal Neurocognitive Disorder, Unspecified Mood Disorder, Major Depressive Disorder, Anxiety Disorder, Essential Hypertension, and Cognitive Communications Deficit. Review of Resident #49's Quarterly MDS with an ARD of 04/15/2024 revealed a BIMS score of 0, which indicated the resident had severe cognition impairment. The MDS revealed the resident was dependent on staff for eating, oral hygiene, toilet hygiene, shower/bath, personal hygiene and dressing. Review of Resident #49's care plan with a review date of 06/30/2024 read in part . ADL assistance needed. Resident #49 dependent x1 staff assist with transfers and other ADL's. Observation on 05/13/2024 at 11:30 a.m. revealed Resident #49's fingernails were 1/4 inch long, jagged with brown substance observed under nails. Interview on 05/13/2024 at11:40 a.m. with S4 LPN revealed Resident #49's nails are long, jagged and have brown substance under them and should have been trimmed and cleaned but had not been. Interview on 05/15/2024 at 10:20 a.m. with S10 Corporate Nurse stated there is no documentation in Resident #49's chart or EChart to suggest there was nail care provided recently but should have been.

Based on observation and interview the facility failed to provide a safe, functional, sanitary, comfortable environment for residents by failing to adequately clean the community shower and bath rooms in the facility. This had the ability to affect all 92 residents in the facility. Findings: Review of the facility's Routine Cleaning and Disinfection Policy revealed in part . Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Observation on 08/14/2023 at 9:17 a.m. of the shower room on Hall X revealed 2 dirty towels and a dirty diaper on the floor. Interview at this time with S4 LPN confirmed these findings. She stated these items should not be on the floor. Observation on 08/14/2023 at 11:20 a.m. of the shower room on Hall X revealed a dirty towel on the floor. Observation on 08/14/2023 at 11:27 a.m. of the community shower/bath room on Hall W revealed a hair brush full of hair in the sink. There was a hair net on the floor by the shower. There was a bandage on the floor in the shower. There were numerous pieces on long hair on the shower floor beneath the shower chair. Interview on 08/14/2023 at 11:30 a.m. with S3 ADON who went into the bathroom to wash her hands after eating lunch confirmed these findings. S3 ADON walked into the shower/bath room and immediately reached into the sink and threw the hair brush which was in the sink into the trash. S3 ADON stated these items should have been picked up and the area cleaned. S3 ADON stated this room was used by staff and residents in the facility. Review of the facility's 07/2023 - 08/2023 Resident Council Meeting Minutes revealed in part . 07/10/2023 - Hall W's shower was very dirty and messy by the shower area. 08/06/2023 - Still an issue and towels from previous shower(s) are on the floor 08/07/2023 - Hall W's shower room is dirty & shower towels/rags are all over floor. Interview on 08/14/2023 at 11:52 a.m. with S9 Activity Director revealed he scheduled and directed the facility's Resident Council Meetings. S9 Activity Director confirmed the Resident Council Meeting Minutes above.

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program to ensure the residents had a pest free environment. The deficient practice had the potential to affect all residents in the facility. Findings: Review of Resident #2's EHR Annual MDS with an ARD of 07/18/2023 revealed a BIMS of 15 (cognitively intact). Interview with Resident #2's wife on 08/14/2023 at 8:47 a.m. revealed a pest problem existed at the facility with flies,gnats, cockroaches and June bugs. Observation on 08/14/2023 at 8:50 a.m. of Resident #2's room revealed the trash can overflowing with trash; the floor filthy with trash, food debris, and grime; spider webs with small black specks located in the crevices along both sides of the air condition unit; 2 dead brown bugs underneath the air condition unit on the floor; and flies and gnats flying around in the room. There was a dead cockroach on the bathroom floor in front of the toilet. Interview with Resident #2 on 08/14/2023 at 8:50 a.m. revealed he had seen cockroaches, gnats, flies and June bugs in his room and the bathroom. Resident #2 stated his trash cans are not always emptied and the trash can sometimes contains food, coffee and other liquids. Resident #2 stated that the trash is causing the problems with the flies and gnats. Resident #2 stated he reported this to the nurse and the nurse replied I know they are all over this building because this is an old building. Resident #2 stated he was unable to recall when and what nurse he had spoken to. Observation on 08/14/2023 at 9:45 a.m. of a storage room located on Hall X labeled storage, revealed 4 shelves with boxes of gloves. The floor was noted to have an unopened box of extra-large gloves (10 boxes), trash, and pieces of paper, dead crickets and June bugs on it. Interview on 08/14/2023 at 9:48 a.m. with S2 DON, after observing the storage room on Hall X confirmed the floor was dirty with trash, dead bugs and the box of gloves should have been unpacked, gloves placed on the shelf and the box should not have been stored on the floor. Observation on 08/14/2023 at 9:55 a.m. of the inside of the bilateral wooden hand rails located in the corridor on Hall X across from the supply room revealed small dead bugs (s), pieces of paper, candy wrappers, and cigarette butts. There was an empty box of large gloves with candy wrappers, plastic wrap, and an opened drinking straw inside of the box. S2 DON confirmed the findings at the time of the observation. S2 DON stated this was unacceptable and trash should be placed in the trash receptacle. Observation on 08/14/2023 at 10:05 a.m. accompanied by S2 DON of the facility's supply room located on the corridor of Hall X revealed patient care supplies and personal hygiene items. The floor had a grayish film with large black footprints on it. There was a small plastic trash can near the door overflowing with trash which contained mouth swabs, opened alcohol pads, plastic cups, 4 ounces can of spray deodorant. There was a urinal in an open box, incontinent briefs(4), intake/output toilet measuring cup, bed alarm pad, an K-95 face mask, 1 pack lemon glycerin swabs, 2 ounce roll-on deodorant, 4 pink denture cup holders, on the floor. There were spider webs, large gray dust particles in the cracks and crevices of the walls with a few small tiny black bugs also on the floor underneath the shelves. S2 DON stated the room was a disaster. S2 DON confirmed the storage room was in need of being cleaned, supplies should not have been opened and left on the floor, spider webs and dead bugs should not have been in the room. S2 DON stated she would have to make the pest control representative aware to carefully inspect the supply room. Observation on 08/14/2023 at 10:34 a.m. of Resident #2's room accompanied with S3 ADON, confirmed the room needed to be cleaned, the dead cockroach on the bathroom floor, spider webs near air condition unit, dead fly on the floor and 2 dead brown bug underneath the air condition. S3 ADON stated the facility had a contract with a pest control company that sprayed monthly. S3 ADON stated there had been issues with cockroaches, June bugs, flies, and gnats in the past but she was not aware of any current pesticide issues Observation of the facility's kitchen on 08/14/2023 at 11:26 a.m. accompanied by S2 DON revealed the dietary workers preparing lunch trays. The floors were noted to have trash underneath all of the surfaces. There were 2 dead bugs, flies, and brown bug wings on the floor in the corner next to the juice machine. There were flies and gnats flying around in the kitchen area. S2 DON at the time of the observation confirmed there were dead bugs on the floor with flies and gnats flying around and the kitchen floor was in need of being cleaned. S2 DON stated the facility had a contract with a pest control company. S2 DON stated a representative visited monthly spraying the interior and exterior of the facility. S2 DON stated the facility was provided with a report after each visit. S2 DON stated the last on-site visit was 07/14/2023. Interview on 08/14/2023 at 11:45 a.m. with S6 CNA stated she had been employed at the facility for approximately one year. S6 CNA stated there had been a problem with insects since she started working at the facility. S6 CNA stated just yesterday (08/13/2023), there were german roaches crawling in the hallway on Hall W. S6 CNA stated she had seen spiders, german roaches, house flies and gnats in some of the residents' rooms. S6 CNA stated she reported the issues to the nurse and maintenance. S6 CNA stated she had seen a pest control man spraying the residents' rooms, showers hallways and around the building. Interview on 08/14/2023 at 12:12 p.m. with S7 CNA revealed she had been employed at the facility for approximately 2 months. S7 CNA stated the facility has an issue with June bugs, little black water bugs, flies and gnats in the residents' rooms and hallways. S7 CNA stated the office personnel was aware of the problem. Interview on 08/14/2023 at 12:14 p.m. with S8 CNA stated she has been employed at the facility for approximately 2 months. S8 CNA stated the facility had an issue with flies, gnats, cockroaches and June bugs. S8 CNA stated she had seen dead cockroaches and June bugs in the residents' rooms, shower, and doorways. S8 CNA stated some of the residents don't say anything and others reports it to the CNA. S8 CNA stated whenever a resident and/or family member complained about the bugs, she told the nurse on duty. Review of the facility's service log revealed a service contract with a Pest Control Company to provide pest control service monthly with a printed service report provided after each visit. Review of the June and July 2023 report revealed the following: 06/23/2023 report read in part: NyGuard IGR concentrate applied; target pest- flies small, location applied- bathroom/locker, and interior kitchen Alpine WSG insecticide; target pest- cockroaches, Location applied- bathroom/locker, room interior, break, dining room, door introduction, lobby, maintenance area, office area, patient/guest rooms- interior, rear, side door, and hallways- interior 7/14/2023 report read in part: Advion Ant gel bait; target pest- ants, location applied- patient/guest rooms- interior additional detail- Room A. Alpine WSG insecticide; target pest- cockroaches, location applied- bathroom/locker, room interior, break, dining room, door introduction, lobby, maintenance area, office area, patient/guest rooms- interior, rear, side door, hallways- interior. Stealth Maxima glue board; target pest- large flies, location applied- kitchen. Interview on 08/14/2023 at 1:40 p.m. with S1 Administrator revealed the facility had a contract with a pest control company who provided monthly services for pest control. S1 Administrator stated the representative had never informed him of any identified issues with any type of rodent and/insect issues. S1 Administrator stated none of the facility staff had ever reported any issues with rodents and insects, only one family member has report an issue with ants in Room A. S1 Administrator stated the resident's daughter reported this morning that she saw an ant in Room A. S1 Administrator stated he was called to the room, inspected it and no ants were seen.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to: 1. Maintain soiled linen in a sanitary manner; 2. Store clean linen in a sanitary manner; 3. Ensure staff were consistent with infection control practices for cleaning Residents' shower; and 4. Ensure staff changed gloves and performed hand hygiene after touching contaminated area during wound care for a resident who was diagnosed with MRSA (Methicillin-Resistant Staphylococcus Aureus) (#65). Findings: 1. Observation on 04/25/2023 at 9:50 a.m. revealed 18 soiled linen containers outside of the laundry area. Two of the soiled linen containers containing soiled linens were uncovered without lids attached. Interview and observation on 04/25/2023 at 10:20 a.m. with S1 Administrator outside of the laundry area revealed two soiled linen containers containing soiled linens were uncovered without lids attached. S1 Administrator confirmed the soiled linen container lids should be attached to contain the soiled linen, but they were not. Observation on 04/26/2023 at 8:12 a.m. revealed 21 soiled linen containers outside of the laundry area. Three of the soiled linen containers were uncovered with soiled linen hanging out of the sides and were without lids attached. 2. Observation on 04/25/2023 at 9:54 a.m. revealed large amounts of clean linen along the right wall of the clean side of laundry room. The clean linens were unfolded and in several large piles along the wall in bins. The clean linens were uncovered, open, and exposed to the large amounts of lint and debris that was noted on floor and ceiling. S16 Laundry Worker stated that the linens in the bins were clean, needed to be hung, and returned to the residents. Interview and observation on 04/25/2023 at 10:22 a.m. of the clean laundry area with S1 Administrator revealed there were large amounts of unfolded clean linen, in large piles, in bins exposed to the large amounts of lint and debris that was noted on floor and ceiling. S1 Administrator confirmed clean linen must be stored in a sanitary manner, but it was not. 3. Review of the Facility's policy titled Infection Control-Precautions-Standard read in part . Resident-Care Equipment: b. Ensure that reusable equipment is not used for the care of another Resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. Review of the Facility's policy titled Equipment & Medical Devices read in part . All facility equipment, such as Whirlpools, etc. will be used, cleaned, and maintained according to the manufacturer's instructions. Review of Spic and Span Disinfecting All Purpose Cleanser Spray and Glass Cleaner Manufacturer's Instructions for use revealed in part . To disinfect: For visibly soiled areas, a preliminary cleaning is required. Spray 6-8 inches from hard, non-porous surfaces. Treated surfaces must remain wet for 10 minutes. Wipe with a paper towel, lint-free cloth, or allow to air dry. Interview on 04/25/2023 at 10:00 a.m. with S10 CNA in Hall B shower room revealed S10 CNA is responsible for cleaning and disinfecting the residents' showers between each resident use. S10 CNA stated she wipes everything down with Dial Body Wash and then has a Housekeeper come to clean shower with chemicals. Observation revealed signage on the shower door that stated: Clean shower/whirlpool surfaces with spic and span disinfecting all-purpose spray and glass cleaner after each use. Leave chemical on surfaces for at least 10 minutes. Rinse. S10 CNA stated she did not refer to this signage. A shower chair in Hall B shower room was observed with a soft cushion surface and discoloration was noted around stitching. Interview on 04/25/2023 at 10:05 a.m. with S17 Housekeeper on Hall B revealed the CNAs are responsible for cleaning the resident's showers after each resident use. S17 Housekeeper stated she cleaned the showers every morning, but not after each resident use. S17 Housekeeper stated to clean/disinfect residents' showers she uses spic and span disinfectant. She sprays the chemical, lets it stay on surface a couple of minutes, and then rinses. Interview on 04/25/2023 at 10:43 a.m. with S18 CNA in Hall A shower room revealed she was responsible for cleaning the residents' showers after each resident use. S18 CNA stated after each resident use, she sprays a chemical and lets the chemical sit for 30 minutes, and then rinses. S18 CNA was unable to recall what chemical she uses for disinfecting the Facility shower. Spic and Span disinfectant was not available in this shower area. S18 CNA showed surveyor a bottle of Xpress White n Brite chlorinated hard surface cleaner, and stated this is what she uses to clean/disinfect Facility shower. Review of product label read: let chemical sit 1-2 minutes. Interview and observation on 04/25/2023 at 10:54 a.m. with S19 CNA in Hall C shower room revealed a strong urine odor. S19 CNA stated she uses spic and span to clean the residents' showers after each resident use. S19 CNA stated she would let the spic and span sit for 5-7 minutes and then rinse it before the next resident use. Interview on 04/25/2023 at 11:09 a.m. with S20 CNA in Hall D shower room revealed he used Spic and Span for shower cleaning/disinfectant. S20 CNA stated he let the Spic and Span sit for 3-4 minutes, and then rinsed it. Observation revealed signage with instructions for cleaning/disinfecting shower on the door of the shower room of Hall D which stated: Attention staff: Shower Chair/Whirlpool instructions. Spray surfaces with spic and span disinfecting all-purpose spray and glass cleaner after each use. Leave chemical on surfaces for at least 10 minutes. Rinse. A shower chair was observed in Hall D shower room with a soft cushion surface and discoloration was noted around stitching. Interview and observation on 04/25/2023 at 12:40 p.m. with S4 ADON in Hall B shower room revealed there was no Spic and Span disinfectant in the shower room and a gallon sized bottle of dial soap was present in the shower room. Informed S4 ADON of S10 CNA's reported process for cleaning/disinfecting showers. S4 ADON confirmed this was not the correct process for cleaning/disinfecting facility showers. Observation of Hall B shower room revealed the shower chair had a soft cushion seat that was discolored near stitching. S4 ADON confirmed this shower chair should have a non-porous surface in order to be properly disinfected, but did not. Interview and observation on 04/25/2023 at 12:45 p.m. with S4 ADON in Hall A shower room revealed there was no Spic and Span disinfectant in the shower room and a spray bottle of Xpress White n Brite chlorinated hard surface cleaner was present in the shower room. Informed S4 ADON of S18 CNA's reported process for cleaning/disinfecting showers. S4 ADON confirmed that was not the correct chemical or process for cleaning/disinfecting facility showers. Review of the facility's shower schedule revealed there were 89 Residents on the facility's Shower Schedule. The facility's shower schedule was completed per hallway and according to days, and times. Interview on 04/26/2023 at 2:37 p.m. with S2 DON revealed the 89 Residents on the Shower Schedule received showers. S2 DON stated the Shower Schedule was accurate, and if a Resident had a special request such as daily showers, it would be noted on the shower schedule. S2 DON stated the Residents were scheduled for Saturday/Tuesday/Thursday Showers, or Wednesday/Friday/Sunday Showers, and the Resident's went according to their scheduled time. 46773 4. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included in part . MRSA (Methicillin-Resistant Staphylococcus Aureus) to both Right and Left heel wounds dated 04/24/2023. Review of Resident #65's Quarterly MDS with an ARD of 02/23/2023 revealed a BIMS score of 12 (intact cognitively). Resident #65's MDS revealed he required extensive 2+ person physical assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #65 was coded as having 1 venous/arterial ulcer. Review of Resident #65's comprehensive plan of care revealed in part . a problem of risk for infection due to diagnosis of Cellulitis, MRSA, right heel wound infection. Interventions included in part . Invanz 1 gm IM daily times 7 days, Dx: Heel Infection, and contact precautions times 7 days due to MRSA in heel wounds. Review of Resident #65's nurse's note dated 04/24/2023 revealed Resident #65 was diagnosed with MRSA to Right and Left heel wounds. New orders included: 1. Bactrim DS (antibiotic) BID x 7 days for Right and Left Heel. 2. Invanz 1 gm IM (antibiotic) daily x 7 days. 3. Contact precautions x7 days due to MRSA in right and left heel wounds. Review of Resident #65's medical record revealed wound care was required for the following areas: Right lateral 5th toe, Right lateral upper foot, Left heel, Right heel, 4th and 5th toe of right foot, and 5th lateral toe of left foot. Observation of wound care for Resident #65 performed by S14 Treatment Nurse on 04/24/2023 at 10:35 a.m. revealed S14 Treatment Nurse cleaned the right heel wound with a normal saline soaked 4x4 gauze, and discarded the soiled 4x4 gauze in a biohazard bag. S14 Treatment nurse then reached over the clean field without changing soiled gloves or sanitizing hands and removed a 4x4 gauze from its multiuse package before patting the wound dry. On 04/24/2023 at 10:40 a.m., S14 Treatment Nurse was notified by this surveyor that she failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and patting wound dry. S14 Treatment Nurse confirmed that she should have removed the soiled gloves and sanitized her hands prior to obtaining new supplies from the clean area and patting wound dry, and she did not.

Based on interviews and record reviews, the facility failed to ensure resident assessments accurately reflected the residents' status due to improper coding of hearing aid, toileting use, schizophrenia and chronic renal failure diagnosis for 3 (#30, #53, #84) of 31 sampled residents. Findings: Resident #30 Review of Resident #30's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Resident #30's clinical record revealed the Schizophrenia diagnosis resolved on 12/15/2022. Review of the S12 PSY (Psychiatrist), Nurse Practitioner's notes dated 12/07/2022 and 01/18/2023 indicated no documented evidence of Schizophrenia diagnosis. Review of the telephone order dated 12/07/2022 for Resident #30 revealed S12 PSY, Nurse Practitioner ordered to remove diagnosis of Schizophrenia. Review of Resident #30's Quarterly MDS (Minimum Data Set) with the ARD (assessment reference date) of 03/10/2023 revealed, in part: Section C, Bims (Brief Interview Mental Status), indicated Resident #30 was cognitively intact with a score of 15, and Section I indicated diagnosis of Schizophrenia was active. Review of Resident #30's Annual MDS with ARD of 12/15/2022 revealed, in part: Section C, the BIMS indicated Resident #30 cognitively intact with a score of 15, and Section I indicated diagnosis of Schizophrenia as active. In an interview on 04/25/2023 at 3:50 p.m., Resident #30 indicated he has never been treated or diagnosed with schizophrenia. In an interview on 04/25/2023 at 9:40 a.m., S7 LPN MDS Nurse confirmed Resident #30's diagnosis of schizophrenia was resolved on 12/15/2022. S7 LPN MDS Nurse confirmed Resident #30's Quarterly MDS with ARD 03/10/2023, and Annual MDS with ARD 12/15/2023 had schizophrenia coded inaccurately. In an interview on 04/26/2023 at 8:07 a.m., S2 DON (Director of Nursing) and S3 Corporate Nurse confirmed that Resident #30's diagnosis of Schizophrenia was resolved on 12/15/2022. S3 Corporate nurse confirmed that Schizophrenia was coded inaccurately as an active diagnosis in Section I of the Quarterly MDS with ARD 03/10/2023, and the Annual MDS with ARD 12/15/2022. Resident #53 Review of Resident #53's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, in part: Schizoaffective disorder, Recurrent Frontotemporal Dementia, Anxiety, and Depression. Resident #53's clinical record revealed Schizoaffective disorder resolved 10/03/2022. Review of Resident #53's Quarterly MDS with an ARD of 03/10/2023 revealed, in part: Section B Communication indicated unclear speech, rarely/never understood and sometimes understands; Section C BIMS was unable to be completed, but staff assessment revealed short and long term memory problem, and severely impaired decision making; Section G functional status indicated total dependent with transfers, extensive assistance with bed mobility and activity did not occur for toilet use; and, Section H Bladder and Bowel revealed always incontinent. Review of Resident #53's Significant Change MDS with an ARD of 12/14/2022 revealed in part: Section G functional status indicated extensive assistance with bed mobility, transfer, and toileting; and, Section I Diagnosis indicated diagnosis Schizophrenia/Schizoaffective as active. In an interview on 04/25/2023 at 9:40 a.m., S7 LPN MDS Nurse confirmed that Resident #53's diagnosis of Schizoaffective disorder was resolved on 10/03/2022. S7 LPN MDS Nurse confirmed the Significant Change MDS with ARD of 12/14/2022 had Schizophrenia/Schizoaffective inaccurately coded as active in section I. In an Interview on 04/25/2023 at 9:45 a.m., S8 RN(Registered Nurse) MDS Nurse confirmed that Resident #53 was coded activity did not occur for Toileting in Section G of Quarterly MDS with ARD of 03/10/2023, and it was coded inaccurately. S8 RN MDS Nurse acknowledged the documentation on Resident #53 showed incontinence on every shift during 03/04/2023-03/10/2023, and toileting should have been coded with a level of assistance instead of activity did not occur in section G. In an Interview on 04/25/2023 at 10:40 a.m., S10 CNA indicated resident #53 was incontinent of bowel and bladder, and required total staff assistance for toileting and incontinence needs. S10 CNA indicated she was not aware that toileting on ADL documentation included the assistance resident needs to clean self and manage briefs. In an Interview on 04/25/2023 at 10:45 a.m., S9 LPN indicated Resident #53 was incontinent of bowel and bladder and was on a check and change every 2 hours and as needed. S9 LPN indicated Resident #53 needs to be changed at least once a shift. In an Interview on 04/25/2023 at 3:55 p.m., S11 CNA indicated Resident #53 requires extensive to total assistance including incontinence care with her toileting needs. S11 CNA indicated he was not aware that Toileting on ADL documentation included assistance resident needs to clean self and manage brief. In an Interview on 04/25/2023 at 9:45 a.m., S8 RN(Registered Nurse) MDS Nurse confirmed that Resident #53 was coded Activity did not occur for Toileting in Section G of Quarterly MDS with ARD of 03/10/2023, and it was coded inaccurately. S8 RN MDS Nurse acknowledged the documentation on Resident #53 showed incontinence on every shift during 03/04/2023-03/10/2023, and Toileting should have been coded with a level of assistance instead of coded as activity did not occur in section G. In an interview on 04/26/2023 at 8:07 a.m., S2 DON confirmed that Resident #53's diagnosis of Schizoaffective disorder was resolved 10/03/2022. S3 Corporate Nurse confirmed that Schizophrenia was coded inaccurately as an active diagnosis in Section I of the Significant Change MDS with ARD 12/14/2022. In an interview on 04/26/2023 at 9:15 a.m., S3 Corporate Nurse indicated she spoke with S13 Nurse Practitioner who indicated that S13 Nurse Practitioner removed the diagnosis of Schizoaffective Disorder on Resident #53 in October 2022. Resident #84 Review of Resident #84's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, in part: Chronic Kidney Disease and Dependence on Renal Dialysis. Review of the physician progress notes for Resident #84 dated 02/22/2023 and 03/24/2023 indicated ESRD (End Stage Renal Disease) as a diagnosis. Review of Resident #84's Quarterly MDS with ARD 03/24/2023 revealed, in part: Section B Hearing revealed moderately difficulty hearing and no hearing aid used; Section C indicated cognitively intact with BIMS score of 15; and Section I Diagnoses revealed, in part: the active diagnoses of Renal failure, and Chronic Kidney disease stage 3. In an interview on 04/24/2023 at 1:50 p.m., Resident #84 indicated he was hard of hearing and does wear a hearing aid in his right ear. In an Interview on 04/26/2023 at 11:45 a.m., S8 RN MDS Nurse confirmed that Resident #84 Quarterly MDS with ARD of 3/24/2023 was coded inaccurately for hearing aid in Section B, and Section I was coded inaccurately with Chronic Kidney Disease Stage 3 instead of End Stage Renal disease.

Based on observation, record review, and interview the facility failed to ensure residents were adequately supervised and assistance devices were used to prevent accidents by failing to use a lift device to transfer a resident from the bed to the chair as according to the resident's Plan of Care for 1(#3) of 5 (#1, #2, #3, #4, #5) sampled residents. The Facility failed to: 1. ensure the CNA staff followed the facility's policy and procedures for resident #3 who was care planned for transfers with the use of a lift. The CNA staff failed to transfer resident #3 from her bed to the chair and back to bed with the use of a lift. The facility's CNAs manually lifted the resident from bed to chair then back to bed; 2. ensure the LPN provide adequate supervision and monitoring to prevent an incident/accident for a resident who required the use of a lift got transfer. The facility's failures placed resident #3 in an actual harm situation. The resident was guided to the floor with her legs folded beneath her resulting in a fracture to the left tibia/fibula. The resident experienced increased anxiety and pain, had to have corrective surgery to the fractured area, was placed in a long leg cast with no weight bearing precautions. The total facility's Census was 92 residents with 10 of the 92 residents requiring the use of a lift for transfer. Findings: Review of resident #3's face sheet reflected an admitted [DATE] and a readmitted [DATE]. The [DIAGNOSES REDACTED]. Review of the resident's MDS Cognitive Patterns dated 7/15/14 reflected a BIMS score of 11 out of 15. Review of the care plan with a goal date of 10/15/14 reflected a problem of physical mobility impaired r/t Generalized Weakness, Debility, History of Sacral Fracture, Osteoporosis. The care plan further reflected to transfer with a lift times 2 person assist. Further review of the care plan reflected the staff was to provide extensive weight assist times 1-2 staff for transfers, bed mobility, and toileting. Review of the Departmental Notes dated 8/7/14 at 3:30 p.m. reflected "CNAs reported while transferring the resident from the wheelchair to the bed, the resident lifted her legs and they had to sit her on the floor. CNAs stated the resident's legs went under her and to the right. The resident's right knee rested on one of the CNA's shoe. CNAs stated there was no lift sheet under the resident at the time and they had to manually transfer her". Review of the Departmental Notes dated 8/8/14 at 1:16 a.m. reflected the resident returned from the E.R. per ambulance via stretcher with a knee immobilizer on her left leg due to a left tibia fracture. Review of the hospital's radiology report dated 8/7/14 at 18:19 p.m. reflected resident #3 had X-Rays to Tibia and Fibula due to bilateral knee pain after a fall. Further review of the report reflected "the attendants at the nursing home have asked that this study be reviewed. Apparently they have been told by the E.R. that a fracture was present". The report further reflected "an unusual appearance at the medial aspect of the distal femur where there may be a small chip fracture through a large marginal osteophyte. Clinical correlation is needed. I am told that the nurses were contemplating bringing the patient for an orthopedic visit. I believe that probably is a good idea whether or not this represents a fracture considering the amount of pain that the patient is apparently suffering". Review of the physician's orders [REDACTED]. Further review of the orders reflected Lidocaine 5% patch apply to affected area every day, apply one patch to both knees every day in the morning then leave on for 12 hours and off at 8 p.m. and leave off for 12 hours for [DIAGNOSES REDACTED]. Review of the July 2014 MARs reflected the resident had no PRN pain medication and had not received a PRN Xanax for anxiety. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Continue review of the physician's orders [REDACTED]. Review of the Radiology report dated 8/12/14 at 13:13 p.m. reflected the following: CT of the lower extremity with an impacted comminuted angle fracture at the Tibial metaphysis. There is a minimal fracture seen at the head of the fibula. This is also an impaction fracture and show no significant displacement. Impression: Fracture of the proximal tibia and fibula. Review of the Departmental notes dated 8/13/14 at 11:49 a.m. reflected the resident returned from the doctor office with orders to be NPO after midnight r/t surgery on 8/14/14 to correct fracture. Review of the Departmental Notes dated 8/14/14 at 10:33 a.m. reflected the hospital called and reported the resident went through surgery and was resting. The notes reflected the resident's left leg was cast after a closed reduction was done Review of the MDS dated [DATE] reflected the resident's Functional Status was transfer with 2 persons physical assist with a mechanical lift. Review of the revised approaches dated 8/12/14 to the care plan reflected CT scan showed fracture of the left tibular/fibular and the resident was going to the Dr. on 8/13/14. Further review of the approaches dated 8/13/14 reflected Surgery at the hospital on [DATE] for corrective surgery on fracture. An approach dated 8/14/14 reflected no weight bearing to left lower extremity, cast to left leg, monitor cast every shift, f/u with orthopedic in one month. Observation of resident #3 on 8/18/14 at 10:40 a.m. revealed her lying in bed with O2 per nasal cannula intact. The resident was observed to have a wedge pillow to her upper back and she was turned to the right side. Observation revealed a left leg cast from the left heel to the left upper thigh. The call light was within reach and bilateral ? side rails were elevated. Further observation revealed the resident had a Foley catheter present, draining yellow urine. Interview on 8/18/14 at 10:45 a.m. with resident #3 revealed that on 8/7/14 the staff lifted her up to put her in the bed and she fell on the floor. The resident stated she did not remember anything else. The resident stated she did not get up much before the fall except to go to the doctor's office and to the beauty shop to get her hair done. The resident stated she had not gone to the beauty shop since her fall and now she only went to the doctor by stretcher. The resident stated that her left leg hurts a lot mostly when staff moved her. The resident also stated because of the pain, she preferred not going to the beauty shop until her left leg healed. Interview on 8/18/14 at 11:00 a.m. with S1 DON revealed S8 CNA and S9 CNA provided care for the resident on 8/7/14 and the Nurse was S5 LPN. Telephone interview on 8/18/14 at 11:15 a.m. with S8 CNA revealed the resident only wanted to get out of bed to go to the beauty shop and to the doctor. S8 CNA stated on 8/7/14, the resident wanted to get her hair done. S8 CNA stated she and S9 CNA lifted the resident, without the lift, and put her in the wheelchair, lifted the resident again and put her in the beauty shop chair to get her hair washed and then lifted her and put her back in the wheelchair. S8 CNA stated they did not use the lift anytime while transferring the resident. S8 CNA stated she didn't know the resident was to be transfer with the lift. S8 CNA stated when the resident was admitted to the facility she was walking, but the resident had a fall last year and now she was no longer able to walk. S8 CNA stated she didn't remember being told to use a lift on the resident. S8 CNA stated she was in-serviced on how to use the lift, however, she and S9 CNA always lifted the resident without the lift because they knew how to handle the resident. S8 CNA stated the resident was to receive a perm on 8/7/14 and the hairdresser had not finished by the end of their shift, so they were not able to put the resident back to bed. S8 CNA stated the 2pm-10pm shift put the resident back to bed. S8 CNA also stated she was not aware the resident was to be transferred with the lift; however she stated she was told by S1 DON that she checked yes on the ADL task sheet indicating that she was aware the resident was to be transfer with a lift. Telephone interview on 8/18/14 at 11:25 a.m. with S9 CNA revealed she was working another hall when asked by S8 CNA to assist with transferring the resident from the bed to the chair. S9 CNA stated she and S8 CNA picked up the resident, without a lift, and put her in the wheel chair. They also picked up the resident again and put her in the beauty shop chair. S9 CNA state they usually do the lifting on the resident. S9 CNA stated she was never told the resident should only be transferred using a lift. S9 CNA stated the resident was totally dependent with transfers and she was unaware the resident's task sheet included to transfer with a lift. S9 CNA stated she was in-serviced on how to use the facility's lift. A telephone interview on 8/18/14 at 12:03 p.m. with S12 CNA revealed that she was walking around the corner and heard the resident yelling out for help. S12 CNA stated she went in the room and found the resident on the floor with her knees under her. S12 CNA stated she grabbed the resident under the left arm with S11 CNA and they assisted the resident onto the bed. S12 CNA stated she went and told the nurse what happened. Telephone interview on 8/18/14 at 12:10 p.m. with S10 CNA revealed she arrived to work on 8/7/14 at 2:00 p.m. S10 CNA stated the resident was sitting up in her wheelchair in her room requesting to go to bed. S10 CNA stated the resident did not have a lift sheet under her so she went to get S11 CNA to assist her with the transfer. S10 CNA stated the resident's wheelchair was positioned lengthwise her bed. S10 CNA stated she positioned her arm under the resident's left arm and S11 CNA positioned his arm under the resident's right arm. S10 CNA stated when they lifted up on the resident, the resident bent her legs under her, causing the CNAs to bear all the resident's weight. S10 CNA stated they were not able to hold the resident up so they lowered her to the floor in front of the wheelchair. S10 CNA stated she was not aware the resident was to be lifted only with the facility's lift. S10 CNA stated she was in-serviced on how to use the lift and she had used the lift with other residents. S10 CNA also stated she only worked part time and had worked with the resident 3 times, and had never put her in bed before. A telephone interview on 8/18/14 at 12:15 p.m. with S4 LPN revealed at 3:30 p.m. she had just gotten report and was starting her medication pass when S10 CNA and S11 CNA told her they were transferring the resident and in the middle of the transfer they sat the resident on the floor with her left knee landing on S11 CNA's shoe. S4 LPN stated S12 CNA was passing by and helped the other CNAs assist the resident to her bed. S4 LPN stated she went to the resident's room to assess the resident and look at her knee. S4 LPN stated she did not see any swelling or bruises at that time. S4 LPN stated the resident complained that her leg was sore. S4 LPN stated at approximate 4:00 p.m. the resident was yelling out and complaining that her leg was hurting, so she went back to reassess the resident's leg. S4 LPN stated at that time the resident's legs were bruised and she noted the left leg had begun to swell. S4 LPN stated the resident had no pain medication previously ordered so she sent the resident to the E.R. to have X- Rays taken and get an order for [REDACTED]. Interview on 8/18/14 at 1:20 p.m. with S7 CNA Supervisor revealed the CNAs had a daily meeting at 2:00 p.m. with S6 LPN and a monthly in-service. S7 CNA Supervisor stated the CNAs were in-serviced to only transfer the resident using a lift. S7 CNA Supervisor stated the CNAs charted in their task sheet/smart charting that they were aware the resident was to be transfer only by a lift. S7 CNA Supervisor stated she monitored the CNAs to ensure residents were turned, repositioned, and the lift was used to transfer residents that required it. S7 CNA Supervisor stated the CNAs were to leave the lift pad under the residents while they were up in the chair so it could be used to transfer the residents back to bed. S7 CNA Supervisor stated she usually looked to see that all residents who were transferred by the lift had lift pads in their chair. S7 CNA Supervisor stated she was not aware that resident #3 had no lift pad in her chair. Review of the CNAs Completed Care Task Sheet reflected documentation of "yes" on most days in March, April, May, June, July and August 2014 to the task question of " Transfer with a lift X 2 person assist ". Interview on 8/18/14 at 1:45 p.m. with S2 Corporate Nurse revealed a "yes" answer on the CNA's Task Sheet indicating they were aware that resident #3 was to be transferred with a lift. S2 Corporate Nurse also stated the LPNs were to monitor that the CNAs were using a lift on residents that needed it. Interview on 8/18/14 at 1:47 p.m. with S7 LPN revealed the CNAs were in-serviced during their 2:00 p.m. meeting on any changes in residents' conditions. S7 LPN stated the CNAs were also to look at the resident's ADL task sheet in the electronic charting system and get report from the off going CNA regarding the resident. S7 LPN stated the CNAs were in-serviced to asked the nurse if they did not know something about the resident. S7 LPN also stated the CNAs were trained in orientation on how to use the electronic charting system and transfer residents using the lift. Interview on 8/18/14 at 2:05 p.m. with S1 DON revealed that at 4:30 p.m. on 8/7/14, S6 LPN asked her to assess the resident because she had fallen earlier and was in a lot of pain. S1 DON stated the resident's knees were bruised, she noted some swelling more on the left knee than the right knee. The resident was giving a PRN Tylenol as per Standing Orders. S1 DON stated the Doctor was called and the resident was sent to the E.R. and X-rays were taken. Interview on 8/18/14 at 2:10 p.m. with S3 LPN revealed he worked 6 days a week and he was the resident's nurse when he worked. S3 LPN also stated the resident got up to go to the beauty shop on either Monday, Tuesdays, or Wednesday and when she went for doctor's appointments. S3 LPN stated the nurses were to monitor and ensure residents who were transferred by the lift had lift pads under them. S3 LPN stated resident #3 had not gotten up since her fall on 8/7/14 and now she was transferred only by stretcher to Doctors appointment Telephone interview on 8/18/14 at 2:15 p.m. with S5 LPN revealed she was the resident's nurse on 8/7/14. S5 LPN stated some CNAs would use the lift and some CNAs wouldn't use the lift on the resident. S5 LPN stated the CNAs had gotten the resident out of bed later that day and she observed the resident in her wheelchair right before shift changed. S5 LPN stated she did not notice if the resident had a lift pad under her. Telephone interview on 8/18/14 at 2:45 p.m. with S11 CNA revealed on 8/7/14 he was asked by S10 CNA to assist her in putting the resident back to bed. S11 CNA also stated he knew the resident was supposed to be lifted with a lift, however, the resident did not have a lift pad under her. S11 CNA stated he pick the resident up by her arms and her feet touch the ground, but the resident was not able to bear weight on her feet and the resident's legs folded under her and he eased the resident down to the floor. S11 CNA stated the resident's left knee was on the floor and her right foot was on top of his foot. S11 CNA stated the resident's legs were bent backwards and she was leaning to the right side. S11 CNA stated S12 CNA came in the room when she heard the resident holler and assisted them in lifting the resident off the floor onto the bed. S11 CNA stated when the resident was positioned in the bed, she complained of hurting and stated "I' m hurting, hurting, hurting". S11 CNA stated he observed the resident's left knee to be swollen and bruised. S11 CNA stated S4 LPN was informed and the resident was later sent to the hospital complaining of knee pain. Interview on 8/19/14 at 9:50 a.m. with S6 LPN revealed on 8/7/14 at 4:15 p.m. she was in the Social Worker office, which was across from the resident's room, and she heard the resident hollering for help. S6 LPN stated she entered the resident's room and the resident told her she had fallen and was hurting from the fall. S6 LPN stated she looked at the resident's left leg and saw it was swelling, so she went to get S1 DON to assess the resident. Interview on 8/19/14 at 10:00 a.m. with S1 DON revealed the nurses were to monitor the residents who needed transfer with the lift by ensuring a lift pad was under the resident. S1 DON stated the nurses were constantly on the hall and if they were to see any resident that required transferring with a lift, and had no lift pad under them, the Nurses were to assist that resident back to bed, and counsel and/or write up the CNAs.