How many inspection deficiencies does Cornerstone at the Ranch have?

Cornerstone at the Ranch has 60 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Cornerstone at the Ranch?

Cornerstone at the Ranch has a two-star staffing rating from CMS with 0.13 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Cornerstone at the Ranch located?

Cornerstone at the Ranch is located in Lafayette, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Cornerstone at the Ranch have?

Cornerstone at the Ranch has 148 certified beds.

Who owns Cornerstone at the Ranch?

Cornerstone at the Ranch is a for profit - corporation facility and is part of the PARAMOUNT HEALTHCARE CONSULTANTS chain.

What questions should families ask when visiting Cornerstone at the Ranch?

Families visiting Cornerstone at the Ranch should ask about staff retention and training programs, what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Cornerstone at the Ranch compare to other nursing homes?

Cornerstone at the Ranch has a 2-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Cornerstone at the Ranch

Name: Cornerstone at the Ranch
Address: 103 West Martial Ave, Lafayette, LA, 70506, US
Telephone: (337) 981-5335
Rating: 2.0

103 West Martial Ave, Lafayette, LA 70506 · (337) 981-5335

For profit - Corporation 148 Beds PARAMOUNT HEALTHCARE CONSULTANTS Data: November 2025

Trust Grade

20/100

#124 of 264 in LA

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Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Cornerstone at the Ranch has received a Trust Grade of F, indicating poor performance with significant concerns. Ranking #124 out of 264 facilities in Louisiana places it in the top half, but the overall rating suggests it still has considerable room for improvement. The facility is currently trending towards improvement, having reduced its issues from 22 in 2024 to 10 in 2025, but it still faces serious challenges, including a concerning staff turnover rate of 76%, which is well above the state average. There have been $128,349 in fines, indicating compliance problems that are higher than most Louisiana facilities. Specific incidents include a failure to properly treat a resident's pressure ulcer, resulting in harm, and issues with infection control during an influenza outbreak, where the facility did not effectively isolate infected residents or implement proper vaccination protocols. While there are some areas of average quality measures, the overall picture shows a mix of serious weaknesses alongside some signs of improvement.

Trust Score: F
In Louisiana: #124/264
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 76% turnover. Very high, 28 points above average. Constant new faces learning your loved one's needs.
Penalties: $128,349 in fines. Higher than 76% of Louisiana facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 60 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 22 issues

2025: 10 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Near Louisiana average (2.4)

Below average - review inspection findings carefully

Staff Turnover: 76%

29pts above Louisiana avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $128,349

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: PARAMOUNT HEALTHCARE CONSULTANTS

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is very high (76%)

28 points above Louisiana average of 48%

The Ugly 60 deficiencies on record

1 actual harm

Jul 2025 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from worsening. The facility failed to: 1. conduct weekly body audits;2. report new skin findings to the nurse practitioner/physician in addition to the treatment nurse; and3. administer standing wound care orders for newly identified stage I pressure ulcer for 1 (#44) of 3 (#2, #11, and #44) residents reviewed for pressure ulcers. This deficient practice resulted in actual harm for Resident #44 on 07/29/2025 when S11LPN assessed his sacral area and discovered a Stage II pressure ulcer that measured 1 cm (centimeter) x 0.5 cm to coccyx (area near base of spine). On 07/05/2025, S6LPN discovered redness to Resident #44's his sacral (area at base of spine) area and did not report it to the treatment nurse nor implement treatment as specified in the facility's wound care standing orders. S6LPN also noted redness to the same area on 07/12/2025 and again did not report to the treatment nurse nor implement the wound care standing orders. Review of Resident #44's July 2025 TAR (treatment administration record) failed to reveal that wound treatment per the facility's protocol had been provided since the identification of the redness. There was no evidence in the resident's record that a weekly body audit had been conducted after 07/12/2025. On 07/29/2025 at 9:54 a.m., Resident #44 reported to S11LPN that he had pain to his bottom. At this time, a skin observation of the resident's bottom was conducted by S11LPN in the presence of surveyor that revealed a stage II pressure ulcer to the resident's sacral area. S11LPN was unware of the resident's pressure prior to the observation.A review of Resident #44's clinical record revealed that he was admitted to the facility on [DATE] with diagnoses that included, but not limited to, type 2 diabetes mellitus, multiple sclerosis, and mild protein-calorie malnutrition. The resident also had a Stage II pressure ulcer to his sacrum upon admission that was resolved on 05/06/2025. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed his cognition was 15, indicating he was cognitively intact. The resident was independent with bed mobility and was occasionally incontinent of urine. Further review revealed he was at risk for developing pressure ulcers and had an unhealed pressure Stage II pressure ulcer upon admission. A review of Resident #44's Care Plan dated 04/25/2025 read, in part: Resident has potential for pressure ulcer/pressure injury development. Interventions read in part: Observe/document/report to physician as needed changes in skin status. On 07/05/2025, the resident had potential for impairment to skin integrity, skin tears, bruises related to age related changes to skin integrity. Interventions: middle of sacral area cleanse dry with normal saline, pat dry, apply zinc oxide or facility skin barrier and leave open to air daily. It further read in part: Resident has bladder incontinence at times. Interventions: brief use. Provide resident with briefs and incontinence aids as needed. Protective barrier cream as needed. Review of Resident #44's progress notes documented per S6LPN (Licensed Practical Nurses) dated 07/05/2025 read in part: Body Audit sacral redness in center surrounding skin is pink and margins intact. Further review of the progress notes revealed a body audit per S6LPN on 07/12/2025 read in part. sacral redness in center of surrounding skin is pink and margins intact. Resident #44's progress notes failed to reveal any additional body audits conducted after 07/12/2025. On 07/29/2025 10:15 a.m., an interview was conducted with S2DON (Director of Nursing) who stated that body audits on residents are to be done weekly. She reported that the facility had a wound care standing order protocol that required the nurses to notify the physician, treatment nurse, and initiate wound care when an area of concern was identified. Review of the facility document entitled Wound Care Standing Orders which read in part:2. Pressure Wounds: Notify physician/nurse practitioner, Responsible Party, and Treatment Nurse upon discovery. Stage I persistent reddened area that does not blanch - cleanse with normal saline, pat dry, apply zinc oxide or facility skin barrier.and leave open to air daily. Stage II - if serum filled blister - cleanse gently with normal saline and wound cleanser, gently apply skin barrier.or skin prep and leave open to air until healed. For abrasion or shallow crater: cleanse gently with normal saline or wound cleanser, apply skin barrier.mixed with collagen, cover with dry clean dressing daily and as needed until healed. On 07/30/2025 at 11:25 a.m., a phone interview was conducted with S6LPN. She stated she identified the red area on his sacral area on 07/05/2025 and 07/12/2025 but failed to notify the treatment nurse since the standing order treatment required the use of normal saline. She stated that the protocol was to identify the area; notify the nurse practitioner; initiate the treatment; and document the information into the communication log for shift to shift awareness. She confirmed that she had not notified the treatment nurse of the resident's redness.Review of the facility document entitled Weekly Pressure Wound Quality Insurance (QI) Log dated 07/09/2025 through 07/16/2025 failed to list Resident #44 for wound care treatment. The facility did not provide a log for the week of 07/23/2025. Review of physician order detail for TAR (treatment administration record) dated 07/05/2025 read in part.middle of sacral area cleanse dry with normal saline. Pat dry. Apply zinc oxide or facility skin barrier.and leave open to air daily. Review of another physician order detail for TAR dated 07/24/2025 read in part.sacrum cleanse with pat dry apply zinc oxide; leave open to air one time daily. Review of Resident #44's July 2025 TAR read in part.middle of sacral area cleanse dry with normal saline, pat dry, apply zinc oxide or facility skin barrier.and leave open to air daily with a start date of 07/05/2025. There was no discontinue date listed. Further review revealed that no staff initialed that the treatment was administered from 07/05/2025 to 07/30/2025. There was another treatment order entry dated 07/24/2025 for sacrum - cleanse with pat dry apply zinc oxide leave open to air one time a day with a start and discontinue date of 07/24/205 of which there was no staff initials that the treatment had been provided. On 07/28/2025 at 9:40 a.m., an interview was conducted with Resident #44 who stated he had a sore on his back side that was painful and wanted it to be healed. He reported that the aides were putting cream on during peri-care but the treatment nurse had not assessed the area. On 07/28/2025 at 10:00 a.m., an interview was conducted with S10LPN who stated that she was working as the treatment nurse for the day. When asked if she had Resident #44 on the wound care treatment list, she stated Resident #44 did not have a wound and was not on the wound care list. On 07/29/2025 at 9:54 a.m., an observation of Resident #44 and interview was conducted with S11LPN in the resident's room. She stated that she was filling in for the wound care nurse. S11LPN stated Resident #44 was not on the wound care list and that she had no knowledge of him having a wound. Resident #44 stated to S11LPN that he had been having pain on his bottom. S11LPN proceeded to conduct an assessment of the resident's bottom. During the observation, she saw an open, pink area on his sacrum and classified it as a Stage II ulcer. She stated that the wound care nurse and physician should have been notified of the wound. A review of a progress note dated 07/29/2025 at 10:51 a.m. per S11LPN revealed Resident #44 was discovered with a Stage II pressure ulcer that measured 1 cm (Centimeter) x 0.5 cm to coccyx (tailbone) area. On 07/29/2025 at 11:03 a.m., a follow up interview was conducted with S2DON. She confirmed Resident #44 had not been placed on the wound care list and failed to follow protocol of notifying the treatment nurse of any wound care orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure each resident's clinical record accurately reflected their advanced directives for 1 (#74) out of 1 (#74) residents reviewed for advanced directive. This deficient practice had the potential to affect the entire census of 73 residents. Findings:Review of Resident #74's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, normal pressure hydrocephalus. Review of Resident #74's admission record revealed DNR (Do Not Resuscitate) status. Review of Resident #74's record revealed a Louisiana Physician Orders For Scope of Treatment (LaPOST) checked for:A. Do Not Attempt Resuscitation (DNR)B. Medical interventions: Person has pulse or is breathing-Selective Treatment C. Artificially Administered Fluids and Nutrition-No artificial nutrition by tube. D. Summary Discussed with-Personal Health Care Representative (PHCR), signed by physician on 10/26/2024 and signed by PHCR on 10/26/2024. A review of Resident #74's facility's document titled, Care Profile Report, Special Instructions revealed: Full Code. On 07/29/2024 at 2:06 p.m., a record review and interview was conducted with S2DON (Director of Nursing). S2DON confirmed the facility's document, Care Profile Report, Special Instructions read the resident is a full code. S2DON confirmed Resident #74's admission record read the resident is a DNR. S2DON confirmed Resident #74's record revealed the LaPOST form that indicated the resident had a DNR status and was signed on 10/26/2024. She stated the facility's document, Cornerstone at the Ranch Care Profile Report should have been updated to reflect the code status to DNR status and was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#76) of 46 sampled residents.Review of Resident #76's electronic health record (EHR) revealed an admission date of 04/15/2025 and a discharge date of 05/06/2025.Review of Resident #76's Discharge Return Not Anticipated MDS dated [DATE] revealed in Section A2105 a discharge status of short-term general hospital. Review of the facility's emergency transfer logs from March 2025 to July 2025 revealed Resident #76 was not listed as going to the hospital.Review of Resident #76's progress notes dated 05/06/2025, revealed an entry by S15LPN (Licensed Practical Nurse), resident left ama (against medical advice). Checked on post dc (discharge) by administrator and resident found in good condition in safe home.On 07/30/2025 at 11:56 a.m., an interview was conducted with S16SSD (Social Services Director). She stated that Resident #76 left the facility AMA to go home and was not sent to the hospital.On 07/30/2025 at 12:15 p.m., an interview was conducted with S1ADM (Administrator) and S2DON (Director of nursing). S1ADM stated Resident #76 left the facility AMA to go home. S2DON confirmed Resident #76 left AMA for her own home and stated that the MDS was incorrectly coded.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to discard expired medication in 2 medication rooms (Room A and Med Room B/C) of 2 (Med Room A and Med Room B/C) medication rooms sampled for medication storage. Findings:On [DATE], a review of the facility's policy titled, Storage of Medication dated [DATE], revealed in part. Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation:.4 .Discontinued, outdated, or deteriorated drugs or biologicals are destroyed.On [DATE] at 12:09 p.m., an observation was conducted of Med Room A with S3ADON (Assistant Director of Nursing) which revealed the following: 1. Sodium Chloride Tablets 1 gm (gram) bottle with an expiration date of 04/20252. (6) Acetaminophen Supp (suppository) 650 mg (milligram) with an expiration date of [DATE]. (8) Bisacodly Supp (suppository) 10 mg with an expiration date of [DATE]At that time, S3ADON confirmed the above medications were expired and should have been discarded and not in the medication room.On [DATE] 12:19 p.m., an observation was conducted of Med Room B/C with S3ADON which revealed the following: 1. Ferrous Sulfate Elixir bottle with an expiration date of 06/20252. Vitamin D-3 125 mcg (microgram) 5000 IU (international units) bottle with an expiration date of 06/2025 At that time, S3ADON confirmed the above medications were expired and should have been discarded and not in the medication room.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to dispose of garbage and refuse properly in the dietary garbage disposal area.On 07/30/2025, a review of the facility's undated policy and procedure titled Policy and Procedure for: Disposing of Garbage & Refuse Properly, read in part 1. Proper Garbage Containers.b. Waste must be properly contained and covered in dumpsters or compactors.2. Sanitary Garbage Storage: a. Garbage storage areas must be maintained in a sanitary condition.Conduct regular checks of garbage containers, transport routes, and storage areas to ensure compliance.On 07/28/2025 at 9:20 a.m., an observation was made of the dietary garbage disposal area with S4DM (Dietary Manager). Used gloves and other trash items were observed on the right immediately after stepping outside the building and entering the walkway leading to the garbage dumpster. There were two gloves on the ground close to a large yellow bucket. The garbage dumpster was open, and there were three used gloves on the ground in front of the dumpster. Further observation revealed a white garbage bag containing refuse outside and to the left of the dumpster. S4DM stated that the garbage dumpster was supposed to be kept closed and the surrounding areas clean at all times.On 07/29/2025 at 10:38 a.m., an interview was conducted with S1ADM (Administrator). She stated that the dumpster was used by the kitchen staff only. She stated that it was not supposed to be left like that and that the kitchen staff was responsible for maintaining the cleanliness of the area.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed ensure that a resident's drug regimen was free from unnecessary drugs by failing to ensure gradual dose reduction forms were reviewed by the physician for 2 (Resident #11 and Resident #46) out of 6 residents (#4, #7, #11, #36, #46, and #81) reviewed for unnecessary medications.Resident #11Resident #11 was admitted to the facility on [DATE]. His diagnoses include in part, but not limited to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression;, restlessness and agitation.Review of Resident #11's annual MDS (Minimum Data Set) date 07/09/2025 revealed under Section N--Medications, the resident was taking an antipsychotic, antianxiety and antidepressant medications. Further review of the MDS revealed N0450, letter D, was marked with the number 1, indicating that a GDR had been documented by a physician as clinically contraindicated. Review of the facility's GDR binder revealed the following GDR forms dated 06/09/2025 for Resident #11 were not addressed by the physician: Psychotropic Diagnosis Request and Behavior for the use of Haldol (antipsychotic medication), Psychoactive Gradual Dose Reduction for the use of Haldol, Klonopin (antianxiety medication), Remeron and Zoloft (antidepressant medications) and, Antipsychotic Diagnosis Verification for use of Haldol. Resident #46Review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnosis included in part, but not limited to, depression, unspecified psychosis not due to a substance or known physiological condition, anxiety and senile degeneration of brain, not elsewhere classified. Further review revealed the resident was on hospice services.Review of Resident #46's quarterly MDS dated [DATE] revealed under Section N--Medications, the resident was taking an antipsychotic, antianxiety, and antidepressant medications. Further review of the MDS revealed N0450, letter D, was marked with the number 0, indicating that a GDR had not been documented by the physician as clinically contraindicated.Review of the facility's GDR binder revealed the following GDR form dated 06/09/2025 for Resident #46 was not addressed by the physician: Psychoactive Gradual Dose Reduction for the use of Quetiapine Fumarate (Seroquel) and Citalopram Hydrobromide (Celexa) (antidepressant medications) and Lorazepam (antianxiety medication). On 07/30/2025 at 5:00 P.M., S1ADM (Administrator). S1ADM stated that she was unable to provide documented evidence that Resident #11 and Resident #46's GDR(s) for June were addressed by the physician. She confirmed the GDRs should have been reviewed by now.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and, interviews the facility failed to ensure the resident's care plan and physician's orders were followed for 5 (#8, #12, #36, #72, and #74) of 46 sampled residents. This was evidenced when staff failed to:1. document the severity of edema for Residents #8 and #72,2. document fluid intake with every meal for Resident #8,3. follow physician orders by not applying swath and sling to Resident #12's left arm,4. complete vital signs every shift for Resident #36,5. update Resident #74's care plan and physician's orders with the resident's code status and admission to hospice services Resident #12 Review of Resident #12's electronic clinical record revealed an admit date of 09/29/2020 with diagnoses that included Alzheimer’s Disease, Bilateral primary Osteoarthritis of knee, Osteoarthritis, and Mild protein calorie malnutrition. Review of Resident #12’s physician orders dated July 2025 revealed the following orders: Wear swath and sling to left arm when not icing or elevating it. Review of the resident's care plan dated 06/09/2025 read in part, wear swath and sling to left arm when not icing or elevating it as tolerated. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. On 07/28/2025 at 8:50 a.m., an observation was conducted in the resident’s room. Further observation did not reveal the resident was wearing swath and sling on her left arm. No icing or elevation of the left arm were observed. On 07/28/2025 at 11:50 a.m., an observation was conducted of Resident #12 during the lunch meal. Further observation revealed that Resident #12 left arm swath and sling had not been applied. On 07/29/2025 at 9:38 a.m., another observation was conducted inside Resident #12’s room. S13HCNA (Hospice Certified Nursing Assistant) had completed her bath, and was asked about the application of the swath and sling. S13HCNA stated she did not know anything about that. She stated that she had given the resident her bath for some time now, and had never seen nor applied a swath and sling to her left arm. On 07/29/2025 at 3:30 p.m., an interview was conducted with S14RN (Registered Nurse) who stated that the resident had a physician’s order for the swath and sling, and did not have an end date. The staff were supposed to be applying the swath and sling as per physician orders and per her care plan. Resident #72 Review of Resident #72’s electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, displaced fracture of base of neck of right femur, and aftercare following joint replacement surgery. Review of Resident 72’s July 2025 physician’s orders revealed an order dated 07/27/2025 for Monitor for edema q (every) shift. Chart severity. Chart 0=No edema noted, 1=+1 Edema, 2=+2 Edema, 3=+3 Edema, 4=+4 edema noted. Review of Resident #72’s July 2025 MAR (Medication Administration Record) revealed the following: Monitor for Edema Q-Shift. Chart severity. Chart 0=No edema noted, 1=+1 Edema, 2=+2 Edema, 3=+3 Edema, 4=+4 edema noted. There was no documentation that the charting of severity was done for the resident on the dates of 07/27/2025, 07/28/2025, 07/29/2025 and 07/30/2025. On 07/30/2025 at 5:20 p.m., an interview and record review was conducted with S3ADON (Assistant Director of Nursing). She reviewed Resident #72’s MAR and confirmed the resident’s severity of edema were not charted as ordered in July 2025. Resident #74 Review of Resident #74’s electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, normal pressure hydrocephalus. Review of Resident #74’s hospice binder revealed that he was admitted to hospice services on 10/26/2024. Review of Resident #74's record revealed a Louisiana Physician Orders For Scope of Treatment (LaPOST) checked for: A. Do Not Attempt Resuscitation (DNR) B. Medical interventions: Person has pulse or is breathing-Selective Treatment C. Artificially Administered Fluids and Nutrition-No artificial nutrition by tube. D. Summary Discussed with-Personal Health Care Representative (PHCR), signed by physician on 10/26/2024 and signed by PHCR on 10/26/2024. Review of Resident #74’s July 2025 physician’s orders revealed no order for a DNR code status. Further review of Resident #74’s July 2025 physician’s order revealed no order for an admission to hospice services. Review of Resident #74’s care plan revealed no care plan had been developed for a code status. Further review of Resident #74’s care plan revealed no care plan had been developed for an admission to hospice services. On 07/29/2025 at 2:06 p.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed that Resident #74’s July 2025 physician’s orders did not reveal an order for his code status or his admission to hospice services. S2DON confirmed that a physician’s order should have been documented for Resident #74’s code status and admission to hospice services and was not. S2DON also confirmed that Resident #74’s care plan did not include a care plan for his code status or his admission to hospice services. S2DON confirmed that a care plan should have been developed for Resident #74’s code status and admission to hospice and was not. Resident #36 Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, hypertension, and dementia. Review of Resident #36’s electronic health record (EHR) revealed a physician’s order written on 06/17/2025, which read “Vitals Q shift every shift.” Further review of Resident #36’s EHR revealed in the vital signs documents for 07/2025 that vital signs were done only on the following dates: Blood pressure: 06/13/2025, 07/02/2025, 07/03/2025, 07/07/2025, and 07/22/2025; Temperature: 06/13/2025, 07/02/2025, 07/03/2025; Pulse: 06/13/2025, 07/02/2025, 07/03/2025, 07/07/2025, 07/22/2025; Respiration: 06/13/2025, 07/02/2025, 07/03/2025; and Oxygen Saturation: 06/13/2025, 07/02/2025, and 07/03/2025. Review of Resident #36’s medication and treatment administration records for 07/2025 revealed no vital signs recorded. On 07/30/2025 at 9:35 a.m. an interview and review of Resident #36’s EHR was conducted with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing). They both confirmed the above vital signs were the only ones recorded for 07/2025. They also confirmed Resident #36 had an order for vital signs to be completed every shift and they should have been completed and recorded every shift and were not. Findings: Resident #8 Review of Resident #8’s EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses including, but not limited to, end stage renal disease, essential hypertension, and chronic obstructive pulmonary disease, unspecified protein calorie malnutrition. Review of Resident #8’s July 2025 physician’s orders revealed the following orders with start date of 4/25/2025: Monitor for Edema Q-Shift (every shift) Chart Severity. Chart 0= No edema noted; 1= +1 Edema; 2= 2+ Edema, 3= 3+ Edema, 4= 4+ Edema noted. Monitor fluid intake q (every) meal; 4=100%; 3=75%; 2=50%; 1=25%; 0=0% Review of Resident #8’s plan of care revealed the following in part: Potential for weight loss r/t (related to) Unspecified Protein-Calorie Malnutrition/Vitamin Deficiency - Interventions: Res (Resident) with 6% (6lb) wt (weight) loss in less than 30 days….Will continue to monitor intake and weigh weekly. I am at risk for complications related to dialysis for the diagnosis of: End Stage Renal Disease- Resident has right wall tunnel cath (catheter) - Interventions: Monitor fluid intake q (every) meal. Review of Resident #8’s EHR failed to reveal any evidence that the resident’s edema severity was documented every shift or that the resident’s fluid intake was monitored at every meal. On 07/29/2025 at 9:12 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse). Resident #8’s physician’s orders were reviewed with S6LPN. S6LPN was asked if she had charted the severity of the resident’s edema as the physician order had stated. S6LPN was unable to provide evidence that the severity of the edema, if any, had been charted every shift. S6LPN was also asked if she monitored the resident's fluid intake and documented the percentage of fluid intake with each meal as stated in the physician’s orders. She stated that even though there was a physician’s order to monitor the resident’s fluid intake, the CNAs (Certified Nursing Assistants) were responsible for monitoring and documenting the resident’s fluid intake, and she had not documented the percentage of fluid intake with each meal. On 07/29/2025 at 9:40 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that because there had been a physician's order for monitoring the resident's fluid intake with each meal, it would have been the nurse's responsibility to monitor and document it. S2DON failed to provide evidence that Resident #8’s fluid intake had been documented with every meal. S2DON also confirmed there was no documented evidence that the nurses charted the severity of the resident’s edema each shift.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to maintain an effective QAPI (Quality Assurance and Performance Improvement) program by failing to adequately monitor QAPI projects that were opened to determine if corrections or revisions were necessary. This had the potential to affect the 73 residents that resided at the facility. Findings: On 07/30/2025 at 5:30 p.m., review of the facility's QAPI program and current performance improvement projects and interview was conducted with S2DON (Director of Nursing). S2DON stated the facility had multiple nursing QA (Quality Assurance) projects that were opened prior to the survey. A review of the open QA projects was conducted with S2DON and revealed the following: -A QA project for GDRs (Gradual Dose Reductions) to be monitored and implemented was opened on 05/22/2025. Action steps were to meet with pharmacy consultant monthly and prn (as needed). There was no monitoring or audits conducted for the QA project. S2DON stated that she had not been monitoring or conducting audits for the GDRs QA project. -A second QA project for weekly body audits was reviewed with S2DON. The project was opened on 05/28/2025 and documented as ongoing on 05/30/2025. Action steps included placing a schedule for required daily body audits at each nurses' station, in-servicing staff, and monitoring. DON or designee was to complete 2 random observations throughout the facility at minimum 3 times per week for 4 weeks and will continue as deemed necessary. A nursing in-service conducted on 05/28/2025 revealed the following: We are required to do weekly skin inspections and general notes on our residents. This is the schedule. Also, please remind CNAs (Certified Nursing Assistants) to report all skin issues- redness, bruises, abrasions, etc). Monitoring began on 06/02/2025, with the last recorded monitoring conducted on 07/10/2025. S2DON stated that her treatment nurse had been out for the last two weeks, and the monitoring for this QA project had not been done from 07/10/2025 to 7/30/25. -A third QA project was reviewed with S2DON for expired medications that was opened on 05/30/2025. The QA monitoring for the medication room read: The DON/designee will complete a minimum of 5 random observations throughout the facility weekly for 4 weeks and will continue as deemed necessary. Monitoring began on 06/02/2025, and three observations were completed. Three observations were completed on 06/10/2025, and 06/18/2025. There was no other monitoring conducted from 6/18/2025 to 7/30/2025. At this time, S2DON confirmed that she was aware of deficient practice being cited on the current survey regarding GDRs, weekly body audits, and expired medications. She confirmed that adequate monitoring of opened QA projects had not been conducted prior to the survey.

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an electrical outlet was sealed and secured properly into the wall in the kitchen. This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: On 06/12/2025, a review of the facility's policy titled, Quality of Life-Homelike Environment, with a last revision date of April 11, 2025, revealed in part . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment . On 06/12/2025 at 8:09 a.m., an observation of the kitchen was conducted. An electrical outlet near the food preparation area was not sealed and secured properly into the wall. The box of the outlet was protruding out of the wall, and a square hole was observed where the outlet was supposed to be secured to the wall. On 06/12/2025 at 5:08 p.m., an observation and interview was conducted with S1AssistantADM (Assistant Administrator) who confirmed the electrical outlet was not sealed and secured properly into the wall and should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen, as evidenced by: 1. the flooring was not clean; 2. rodent droppings in a storage area; 3. opened and unlabeled food items in the refrigerator designated for resident supplements; and 4. a thick layer of debris and food residue on the deep fryer. This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: On 06/16/2025 at 12:15 p.m., a review of the facility's undated policy titled, Policy and Procedure for: Food Procurement, Store/Prepare/Serve-Sanitary, revealed in part: 2. All food items in refrigerators and freezers must be labeled and dated .15. Observe for any evidence of pests in the food storage, preparation, or service areas and report to the dietary supervisor. Review of the state department Sanitarian's notice of violations revealed a routine/renewal visit was conducted on 06/05/2025 at 10:30 a.m. with non-critical items of: Floors are not clean, signed by S2DM (Dietary Manager) Review of the state department Sanitarian's notice of violations revealed a complaint visit was conducted on 06/12/2025 at 12:25 p.m. with a critical item violation described as: Rodents are present in the establishment. Non-critical item violations were described as: Non-food contact surfaces not being cleaned at a frequency necessary to preclude the accumulation of soil residues, and a repeat violation of floors not being clean. Under the comments section, read in part: Inspection: Rodent droppings were found in the kitchen storage areas. S1AssistAdmin (Assistant Administrator) signed the notice. On 06/12/2025 at 8:01 a.m. an initial tour of the kitchen was conducted. There was a separate area of the kitchen that was not in use to prep and serve food; it was used as storage. There was a commercial stationary steam table, not working, with an open section between the cold and hot well systems. The open section did not have tile on the floor, observed two single-use empty round condiment containers, a black glue rodent and insect trap, and multiple dark colored, dried droppings scattered on the floor. On 06/12/2025 at 8:03 a.m., an upright freezer/refrigerator located in the open storage area was observed. S2DM explained the freezer/refrigerator was designated for residents' supplements during meal services. Upon opening the refrigerator, an observation was made of the third shelf. The third shelf consisted of a pull-out drawer for storage. Inside the drawer, there were three storage plastic bags of lettuce; two of the bags were unlabeled and unopened. One of the plastic storage bags of lettuce was opened and not dated.S2DM confirmed the bags were not dated or labeled. S2DM immediately removed and disposed the three plastic storage bags of lettuce. On 06/12/2025 at 12:33 p.m., a follow up observation was conducted in the kitchen. A deep fryer was observed with a thick layer of debris and food residual on both sides of the fryer. The flooring underneath the fryer was observed with a dark thick layer of residue. On 06/12/2025 at 1:01 p.m., S3KS (Kitchen Staff) was observed sweeping the floor surrounding the upright freezer/refrigerator. S3KS explained the Sanitarian who was present instructed S3KS to sweep the floor due to observations of rodent droppings. S3KS explained that the items in the upright freezer/refrigerator were utilized by facility staff to grab supplements needed when serving residents their meals. On 06/12/2025 at 5:00 p.m., an observation and interview was conducted with S2DM who confirmed the sides of the fryer and the flooring underneath the fryer were not cleaned and should have been.

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify a resident's physician when a resident had a significant change in condition for 1 (#3) out of 3 (#1, #2, #3) residents sampled. Findings: A review of the facility's policy titled, Change in a Resident's Condition or Status with a last reviewed date of 01/15/2024, read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . Review of Resident #3's record revealed she was admitted to the facility on [DATE] with a diagnoses that included in part, Dementia, Human Immunodeficiency Virus, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein- Calorie Malnutrition. Resident #3 had a discharge date of 10/12/2024. Review of Resident #3's SNF (Skilled Nursing Facility) Nurses' Notes from 10/04/2024 to 10/10/2024 read in part, Gastrointestinal: 6. Does the resident have problems with consistency of bowel movement? B. Diarrhea. On 11/04/2024 at 3:21 p.m., an interview was conducted with S2CNA (Certified Nursing Assistant). S2CNA stated that she cared for Resident #3 during her stay at the facility. She stated that she had frequent loose stools every day, requiring her to change the resident 18-19 times per shift. On 11/06/2024 at 12:30 p.m., an interview was conducted with S3NP (Nurse Practitioner). S3NP stated that he had not been notified of Resident #3's episodes of diarrhea during her stay at the facility and should have been. On 11/06/2024 at 01:46 p.m., a phone interview was conducted with S1LPN (Licensed Practical Nurse). She stated that she had cared for Resident #3. She stated that she was aware of the resident's diarrhea episodes. S1LPN stated that she had not notified the physician of Resident #3's diarrhea. On 11/06/2024 at 01:58 p.m., an interview was conducted with S2CNA. She stated that she had reported twice to the nurse responsible for Resident #3's care of the resident's diarrhea episodes. On 11/06/2024 at 04:13 p.m., an interview and record review was conducted with S4CRN (Corporate Registered Nurse). She stated that she was a DON (Director of Nursing) with the corporation and would be answering questions for the facility's DON in her absence. A review of Resident #3's medical record was conducted with S4RN. She confirmed there was documentation of Resident #3's episodes of diarrhea during her stay at the facility. She also confirmed that there was no documentation that Resident #3's physician or NP was notified and should have been.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 1(#3) of 3(#1,#2, and #3) sampled residents as evidenced by failure to ensure documentation of bowel charting was accurate. The deficient practice had the potential to effect a total census of 71. Findings: A review of the facility's policy titled, Charting and Documentation with a last reviewed status of 01/15/2024, read in part, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. Review of Resident #3's record revealed she was admitted to the facility on [DATE] with a diagnoses that included in part, Dementia, Human Immunodeficiency Virus, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein- Calorie Malnutrition. Resident #3 had a discharge date of 10/12/2024. Review of Resident #3's Bowel and Bladder Charting for October 2024, revealed an area on the grid for documentation of Size (S=small, M=Medium, L=Large) and Consistency (S=Soft, H=Hard, W=Watery). Shift #1's documentation read in part: Size: a. 10/04/2024- 10/13/2024: 10 entries with the letter Y Consistency: a. 10/04/2024- 10/09/2024: 6 entries with the letter Y b. 10/10/2024- 10/11/2024: 2 entries with the letter L On 10/06/2024 at 2:45 p.m., an interview and record review of Resident #3's Bowel and Bladder Charting for October 2024 was conducted with S5ADON (Assistant Director of Nursing). S5ADON confirmed that Size was documented with Y and should have been documented with the letters S, M, or L. S. S5ADON also confirmed Consistency was documented with Y and L and should have been documented with the letters S, H, or W. S5ADON confirmed the CNA's (Certified Nursing Assistants) did not document accurately, and the key provided was not used correctly and should have been. On 10/06/2024 at 4:13 p.m., an interview and record review was conducted with S6ADM (Administrator). S6ADM confirmed that documentation by CNA's was not documented correctly by CNAs for Shift #1's Size and Consistency areas of the Bowel and Bladder Charting, for October 2024, and should have been.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #3's Electronic Medical Record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease and Type 2 Diabetes Mellitus. Review of Resident #3's September 2024 physician orders revealed an order with a start date of 07/17/2024 for Furosemide (diuretic) 20 mg (milligram) tablet one po (by mouth) QD (every day)-monitor edema prior to administering the diuretic. Review of Resident #3's September 2024 MAR revealed the resident was administered Furesomide 20 mg tablet, a diuretic, (fluid medication) every day and nursing was to monitor the resident's edema prior to administering the diuretic. The resident's edema was documented as present per S3LPN on 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24. Review of Resident #3's Daily Skilled Nursing Assessments for September 2024 revealed the resident was assessed as having no edema present on 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24. On 09/24/2024 at 12:10 p.m., an interview was conducted with S3LPN. S3LPN confirmed the resident received a diuretic daily and that the day shift nurse was to monitor and document whether or not edema was present before giving the diuretic. She confirmed the resident was skilled and that the day shift documented a skilled nursing assessment daily which included assessing the presence of edema on the resident. S3LPN confirmed the resident's September 2024 MAR and daily skilled nursing assessments for the dates of 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24 were not accurately documented to reflect the resident had edema present. On 09/24/2024 at 1:15 p.m., an observation was made of Resident #3 sitting in her wheelchair with +2 edema noted. On 09/24/2024 at 4:00 p.m., an interview was conducted with S2DON. S2DON confirmed the resident was skilled and required daily nursing assessments. S2DON verified that the monitoring of edema on the resident's MAR and daily nursing assessments should match and had not. Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 2 (#2, #3) of 3 (#1-#3) sampled residents by failing to ensure: 1. An accurate assessment of edema, and mood/behaviors was documented for Resident #2; and 2. An accurate assessment of edema was documented for Resident #3. Findings: 1. Review of the Resident #2's Electronic Medical Record revealed she was admitted to the facility on [DATE] and had diagnoses including Diabetes Mellitus Type II, Cellulitis Right Lower Extremity, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder and Congestive Heart Failure. Review of Resident #2's September 2024 physician orders revealed an order to monitor edema every shift, and monitor mood and behaviors every shift starting on 07/22/2024. Review of a facility document titled, ___ Med Progress Note, dated 08/13/2024 read in part peripheral 2 plus edema to lower extremity. Resident had increased bilateral edema and felt tight. Further review revealed a note dated 08/21/2024 which read in part .peripheral edema 2 plus to lower extremity, and chronic bilateral edema. Review of Resident #2's August 2024 Medication Administration Record (MAR) revealed S5LPN documented on 08/12/2024 and 08/21/2024 Resident #2 did not have edema. Further review revealed S4LPN documented on 08/21/2024 Resident #2 did not have edema. Review of the resident's Electronic Medical Record revealed Nursing Progress Notes dated 09/01/2024 at 1:49 p.m., and documented by S3LPN (Licensed Practical Nurse) read in part Resident #2 yelling in hallway refusing to let aid assist her to her room to receive incontinence care. Further review of S3LPN documentation revealed at 1:53 p.m., Resident #2 was yelling and cursing in dining area for breakfast because no one bought her a (soda). Resident #2 tried to throw her clothing protector at another resident. Further review of Resident #2's MAR revealed on 09/01/2024, S3LPN documented no behaviors were observed. S4LPN and S5LPN were not available for interview. On 09/24/2024 at 3:15 p.m., an interview, and observation was conducted with S3LPN who confirmed that Resident #2 had an order to monitor the edema to her lower extremities. She stated the times she had cared for Resident #2, her bilateral lower extremities were always edematous. She stated the resident always had edema to her lower extremities. S3LPN also confirmed that the documentation on 09/01/2024 regarding the resident's mood/behavior was not accurate. She stated the resident was experiencing behaviors of profanity and attempting to throw her clothing protector at another resident. She added that due to the resident's behaviors, the resident had to be sent out for a psychological evaluation that day.

Aug 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure the walls were clean in resident rooms for 2 (#3 ,#R2) out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: Review of the facility's policy titled Homelike Environment, with a last updated date of 03/12/2024, read in part: . The facility, staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. On 08/27/2024 at 10:43 a.m., an observation was made of Resident #3 and #R2's shared room. Upon entering the residents' room, the lower portion of the wall to the left of the residents' bathroom door was observed with tan stains that were in a drip-like pattern. Further observation of the room revealed the wall to the left of Resident #3's bed had light browns stains, in a drip-like pattern, that spanned from the top to the bottom of the wall, as well as dark brown and rust colored scattered stains on the lower portion of the wall. Additionally, the front wall of the residents' room had multiple scattered light brown stains that spanned from the middle to the lower portion of the wall. On 08/27/2024 at 1:10 p.m., an observation of the Resident #3 and #R2's room was conducted with S4HSKSUP (Housekeeping Supervisor). The lower portion of the wall to the left of the residents' bathroom door, the wall to the left of Resident #3's bed, and the front wall of the residents' room was observed with the S4HSKSUP. She acknowledged that the walls should have been cleaned, and this was a housekeeping responsibility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to promptly respond to a resident's call for assistance for 1 (#R1) out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: On 08/27/2024, a review of the facility's policy titled Answering the Call Light with a last reviewed date of 07/29/2023 read in part: 8. Answer the call light as soon as possible. Review of Resident #R1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, Other Acute Osteomyelitis, Cellulitis of Right Lower Limb, and Other Chronic Pain. Review of Resident #R1's baseline care plan revealed she required 1 person assist for transfers, walking, grooming, and hygiene. On 08/27/2024 at 8:42 a.m., an observation was made on D Hall. Resident #R1 activated her call light. 3 loud beeps, a pause, and 3 additional loud beeps were heard. An electronic sign at the end of the hall was observed that displayed the resident's room number, and the time 8:42 a.m. in red. At 8:50 a.m., S5LPN (Licensed Practical Nurse) was observed as she entered the nurse's station. At this time, an overhead announcement was made over the intercom stating the resident needed assistance. At 8:54 a.m., a second observation was made of S5LPN sitting in the nurse's station. An electronic board that displayed when a resident's room number when the call light was activated could be observed with the resident's room number in the nurse's station. The electronic sign on the hall remained with Resident #R1's room number and time of 8:42 a.m. At 8:57 a.m., 3 loud beeps, followed by a pause, and 3 additional beeps were heard. At 9:00 a.m., a second overhead announcement was made, stating that the resident needed assistance. At this time, an interview was conducted with Resident #R1 who stated she needed medication and needed to get up. At 9:03 a.m., the nurse practitioner was observed exiting another resident's room, went to the nurse's station and asked S5LPN for assistance. At 9:09 a.m., an interview was conducted with S5LPN in the nurse's station. She stated that there was a board in the nurse's station that displayed when a resident's call light was activated. She proceeded to show the surveyor the board, and Resident #R1's room number was on the electronic board. S5LPN stated that when she came onto the hall at 8:50 a.m., she noticed that the resident's call light was activated on the sign on the hallway and on the electronic board in the nurse's station, so she paged so that an announcement would be made over the overhead intercom that the resident needed assistance. She then stated that she made a second page at 9:00 a.m., before exiting the nurse's station to assist with another resident. S5LPN stated that when a resident calls, she waits 5 minutes to see if the light is answered, makes an overhead page for the CNA (Certified Nursing Assistant), then waits another 5 minutes and makes another overhead page for the CNA. She stated she saw the resident was calling for assistance when she came onto the hall at 8:50 a.m., and acknowledged that the resident's call light had been activated since 8:42 a.m. On 08/27/2024 at 9:13 a.m., an interview was conducted with S2DONIP (Director of Nursing/ Infection Preventionist) who stated that if a resident activated their call light for assistance, the nurse should go to assist that resident if they are available. She also stated that it is not the facility's protocol for an overhead announcement to be made and then wait 5 minutes to see if another staff member responds to the call for assistance.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#3) out of 5 (#1, #2, #3, #R1, #R2) sampled residents as evidenced by failure to: 1. ensure weekly skin assessments were completed; 2. accurately document the staging of a resident's wound; 3. update the resident's clinical record with an accurate wound status; 4. obtain physician orders to continue or discontinue wound care orders; and 5. notify the physician or Nurse Practitioner (NP) of a deteriorating wound. Findings: On 08/27/2024, a review of the facility's policy titled, Skin and Body Audit, with a last reviewed date of 01/12/2024, read in part .Policy: .2. Residents are considered high risk for skin injury if the Braden assessment score is less than 19. 3. Body audit will be performed weekly for all residents at risk for skin injury by a licensed nurse. 4. Any findings will be addressed to the resident or responsible party, and the resident's physician. The licensed nurse will document all findings in the medical chart. On 08/27/2024, a review of the facility's policy titled, Pressure Ulcer/Injury Risk Assessment, with a last reviewed date of 07/30/2024, read in part .General Guidelines .7. Perform weekly skin audits on residents who are at high risk for skin/pressure injuries .Steps in the Procedure: .b. The effects of the interventions must be evaluated .Documentation .4. Any changes in the resident's condition, if identified .12. Documentation in medical record addressing MD (Medical Doctor) notification if new skin alteration noted with change of plan of care, if indicated .Reporting .2. Report other information in accordance with facility policy and professional standards of practice .3. Notify attending MD if new skin alteration noted. Review of Resident #3's electronic health record (EHR) revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hemiplegia, Dysphagia, Aphasia, and Lack of Coordination. Review of Resident #3's August 2024 physician's orders revealed the following: order dated 08/10/2024: DTI (Deep Tissue Injury) to Left Ischium-Cleanse with Wx (wound cleanser), apply Zinc Oxide to Periwound, apply Calcium Alginate, and cover with foam border dressing every day. Review of Resident #3's care plan read in part: I have the potential for .Pressure Ulcers, Pressure Injuries .05/03/2024: DTI to left ischium .(d/c'd (discontinued) 08/10/2024) 05/03/2024: DTI to Left Ischium cleanse with Wx cleanser, apply Zinc Oxide, Cover with foam border dressing .08/10/2024: DTI to left ischium cleanse with Wx cleanser, apply Zinc oxide to periwound, apply Calcium Alginate, and cover with foam border dressing .Notify MD as needed. Review of Resident #3's EHR (Electronic Health Record) revealed the following wound assessments: 05/29/2024 that read in part .Wound Type: Pressure Ulcer .Wound Location: Left buttock, left ischium .Wound Status: Unchanged .Date wound identified: 05/03/2024 .Assessment occasion: Weekly update .Stage: 2 .Measurements: Length 0.80 cm, Width 0.90 cm. 06/05/2024 that read in part .Wound Type: Pressure Ulcer .Wound location: Left buttock, left ischium .Wound status: Improved .Date wound identified: 05/03/2024 .Assessment occasion: Weekly update .Stage: 2 .Measurements: None. Further review of Resident #3's EHR failed to reveal an initial assessment of the resident's wound when it was identified on 05/03/2024. There were also no wound assessments or weekly skin inspections completed until 08/10/2024. On 08/27/2024 at 8:40 a.m., an interview was conducted with S3TN who stated she was responsible for completing skin assessments, wound assessments, and wound care. S3TN stated weekly skin assessments were only completed on high risk residents, based on their Braden Assessment scores. When asked what made residents high risk, S3TN stated she was unsure. S3TN stated she completed the skin assessments on paper, and would provide the surveyor with the assessments. S3TN further stated if a wound was deteriorating or if she was unsure about a wound, she notified the MD (Medical Director) or NP (Nurse Practitioner). A review of the documents provided by S3TN revealed the following: A skin assessment dated [DATE], which read in part .Weekly Skin Assessment .6. Any open ulcers (indicate even if being treated) Comments: Moderate 1.5cm x1.0cm unstageable . A wound evaluation dated 08/10/2024, which read in part .Wound Location: Left ischium .Type of Wound: Pressure .Pressure: Stage 2 .General Comments: Stage 2 . A wound evaluation dated 08/22/2024, which read in part .Wound Location: Left ischium .Type of Wound: Pressure .Pressure: Stage 3 . A review of Resident #3's nursing progress notes revealed an entry dated 08/27/2024 at 7:54 a.m. by S3TN that read: Stage three pressure injury noted to left ischium. S6NP (Nurse Practitioner) notified. New orders noted and carried out. Refer to Wound Care. Further review of the resident's nursing progress notes revealed no evidence that S3TN had notified the MD, NP, or wound care specialists that the resident's wound had deteriorated upon assessment on 08/22/2024. On 08/27/2024 at 11:52 a.m., an interview and review of Resident #3's EHR and wound documents was conducted with S2DONIP (Director of Nursing, Infection Preventionist) and S3TN. S3TN stated she measured the wounds weekly, and S2DONIP stated she staged the wounds weekly. S2DONIP confirmed the DTI to the resident's left ischium was first identified on 05/03/2024 and no initial wound assessment was completed. S2DONIP also confirmed a wound assessment was not completed until 05/29/2024. She stated the initial wound assessment should have been completed on 05/03/2024, and the resident should have had weekly wound and skin assessments thereafter because he was high risk. S3TN confirmed that she inaccurately documented that the resident had an open, unstageable pressure ulcer with moderate drainage on 06/22/2024 after S2DONIP staged it as a stage 2. S3TN further stated Resident #3's wound was healed the following week, but she did not notify the MD or NP, complete an assessment, or update the resident's EHR with the resident's updated wound status. She confirmed that she did not call the physician to discontinue or get new orders after the resident's wound healed and should have. Regarding the resident's newly identified wound on 08/10/2024, S3TN confirmed the physician's order read: DTI to left ischium, cleanse with Wx cleanser, apply zinc oxide to periwound, apply calcium alginate, and cover with foam border dressing. S3TN stated she believed the resident's stage 2 pressure injury was a DTI. She confirmed the physician's orders and careplan did not accurately reflect that Resident #3 had a Stage 2 pressure injury. S2DONIP confirmed she had staged the pressure area on 08/10/2024 as a Stage 2. S3TN further stated Resident #3 returned from an inpatient hospital stay on 08/21/2024, and she completed a follow up wound assessment on 08/22/2024. She stated the wound had deteriorated during his hospital stay and progressed to a Stage 3. When asked why the NP was notified on 08/27/2024 that the resident's wound had deteriorated, instead of on 08/22/2024 upon his return assessment, S3TN stated she did not know, and should have notified the NP on 08/22/2024 and did not.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a safe and sanitary, environment to help prevent the development and transmission of communicable diseases and infections by failing to remove contaminated gloves and perform hand hygiene during wound care for 1 (#3) resident out of 5 (#1, #2, #3, #R1, #R2) sampled residents. Findings: On 08/27/2024, a review of the facility's policy titled, Handwashing/Hand Hygiene, with a last review date of 01/12/2024, read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc.i. After contact with a resident's intact skin .m. After removing gloves. Review of Resident #3's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia, Dysphagia, Aphasia, and Lack of Coordination. Review of Resident #3's August 2024 physician's orders revealed the following order dated 08/10/2024: DTI (Deep Tissue Injury) to Left Ischium-Cleanse with Wx (wound cleanser), apply Zinc Oxide to Periwound, apply Calcium Alginate, and cover with foam border dressing every day. On 08/27/2023 at 11:37 a.m., an observation was conducted of S3TN (Treatment Nurse) as she provided Resident #3's wound care treatment to his left ischium. S3TN put on a pair of gloves and removed the old dressing. She removed her gloves then put on a clean pair of gloves without performing hand hygiene and cleaned the resident's wound. S3TN removed her gloves, then put on a clean pair of gloves without performing hand hygiene, retrieved Zinc, applied it to the resident's wound, then retrieved Calcium Alginate and applied it to the resident's wound. She then realized she had forgotten the dressing. S3TN removed her gloves then put on a clean pair of gloves without performing hand hygiene, retrieved Zinc, reapplied to resident's wound, then covered the wound with a clean dressing wearing the same gloves used to apply the Zinc. S3TN did not sanitize hands after changing gloves during wound care and did not change gloves or sanitize hands after applying Zinc prior to applying the clean dressing. On 08/27/2024 at 11:43 p.m., an interview was conducted with S3TN, she confirmed she should have sanitized her hands after changing gloves during Resident #3's wound care and should have changed her gloves and sanitized her hands prior to applying the clean dressing and did not. On 08/27/2024 at 4:38 p.m., an interview was conducted with S2DONIP (Director of Nursing/Infection Preventionist), she confirmed S3TN should have properly changed gloves and sanitized her hands while providing Resident #3's wound care.

Jul 2024 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#70) out of 41 sampled residents. Findings: On 07/10/2024, review of the facility's policy titled Quality of Life - Dignity with a last updated date of 06/26/2023 read in part: 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered . Review of Resident #70's EHR (Electronic Health Record ) revealed he was admitted to the facility on [DATE] with diagnoses including Acute Kidney failure, Benign Prostatatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflex Uropathy. Review of Resident #70's plan of care revealed the following problems : -Requires assist with ADLs (Activities of Daily Living ) related to dressing, grooming, bathing, and hygiene related to left femur fracture/muscle weakness -I have a suprapubic catheter r/t (related to ) BPH/obstructive and reflex uropathy On 07/08/2024 at 11:28 a.m., an observation was made of Resident #70 sitting in his wheelchair in the dining room. The resident's catheter drainage bag was observed with approximately 300 cc's of yellow urine, facing other residents in the dining room. There was no covering over the drainage bag. On 07/08/2024 at 11:38 a.m., S1DON (Director of Nursing ) observed Resident #70's catheter drainage bag with no covering or bag. She confirmed that the resident should have had a covering or bag over his catheter drainage bag.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the cleanliness of wheelchairs for 2 (#30 and #35) out of 2 (#30 and #35) residents investigated for a safe, clean, comfortable and homelike environment, out of a total sample size of 41 residents. Findings: On 07/10/2024, a review of the facility's policy titled Wheelchair Cleaning with a last reviewed date of 01/07/2024 read in part, Policy: The purpose of this policy is to establish cleanliness of resident's wheelchairs .4.) Wheelchairs are to be cleaned weekly, when soilage, or upon request . Resident #30: Resident #30 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Muscle Weakness, Unspecified Lack of Coordination, and Occlusion and Stenosis of Right Posterior Cerebral Artery. A review of Resident #30's quarterly MDS dated [DATE], revealed in section C that she had a BIMS (Basic Interview for mental Status) of 14, indicating her cognition was intact. Further review revealed in section GG that she used a wheelchair. A review of the facility's wheelchair cleaning schedule revealed Resident #30's wheelchair was scheduled to be cleaned on Mondays and Thursdays but there was no documentation of when it was last cleaned. On 07/08/2024 at 8:44 a.m., an observation was made of Resident #30 in her wheelchair. The resident's wheelchair had a layer of dust on the metal parts of the chair that were visible. On 07/09/2024 at 07:41 a.m., a second observation was made of Resident #30 in her wheelchair. The resident's wheelchair was still dirty. The resident stated her wheelchair had never been cleaned. On 07/10/2024 at 10:40 a.m., an interview and observation of Resident #30's wheelchair was conducted with S14CNA (Certified Nursing Assistant) while the resident was outside on the patio. She confirmed the resident's wheelchair was dirty and stated it should not have been. Resident #35: Resident #35 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Major Depressive Disorder and Post-Traumatic Stress Disorder. A review of Resident #35's quarterly MDS revealed in section C that he had a BIMS of 12. Further review revealed in section GG that he used a wheelchair. A review of the facility's cleaning schedule revealed Resident #35's wheelchair was scheduled to be cleaned on Wednesday's and Saturdays, but there was no documentation of when it was last cleaned. On 07/10/2024 at 10:40 a.m., an interview and observation of Resident #35's wheelchair was conducted with S14CNA while the resident was outside on the patio. A thick layer of dust was observed on Resident #35's wheelchair. Resident #35 stated his wheelchair had never been cleaned. S14CNA confirmed Resident #35's wheelchair was dirty and stated that it should not have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a baseline care plan that addressed pain for 1(#178) out of 41 sampled residents. Findings: Resident #178. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hyperlipidemia, Diabetes, Hypertension, and Fracture Upper end of Right Humerus. Review of the resident's physician's orders revealed an order for Oxycodone 10 mg (milligrams) 1 po (by mouth) every 4 hours prn (as needed) pain. Review of the resident's baseline care plan dated 06/26/2024 revealed no evidence pain was addressed in the plan. On 07/10/2024 at 2:06 p.m., an interview was conducted with S3MDS (Minimum Data Set Coordinator). S3MDS stated that she could not provide documentation that a pain assessment was initiated on the resident. S3MDS reviewed the resident's baseline care plan and confirmed that pain was not addressed in the plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #66: Resident #66 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Heart Failure, Chronic Kidney Disease, Stage 3, Generalized Edema, and Morbid Obesity. Review of Resident #66's Quarterly MDS (Minimum Data Set) dated 04/17/2023, revealed the resident had a BIMS (Basic Interview for Mental Status) of 03, indicating his cognition was severely impaired. Review of Resident #66's physician orders failed to reveal an order for O2 (oxygen) use. On 07/08/2024 at 11:11 a.m., an observation and interview was conducted with S5LPN (Licensed Practical Nurse) of Resident #66's O2 nasal cannula and humidifier bottle. An unlabeled O2 tubing with nasal cannula was observed exposed and hanging from the O2 concentrator. Further observation revealed the humidifier bottle was also unlabeled. S5LPN confirmed Resident #66's nasal cannula should have been stored in a bag and dated. She also confirmed Resident #66's humidifier bottle should have been dated. On 07/09/24 at 8:13 a.m., an interview and observation with S11ADON (Assistant Director of Nursing) was made of Resident #66's room. Three O2 tanks were observed standing freely on the left side of Resident #66's bed. S11ADON confirmed the three free standing oxygen tanks should not be present in Resident #66's room, and should have been stored properly in the oxygen storage room. On 07/10/2024 at 1:28 p.m., an observation was made of Resident #66 with oxygen on through his nasal cannula. On 07/10/2024 at 1:31 p.m., a record review and interview was conducted with S5LPN and S1DON (Director of Nursing). Both S5LPN and S1DON both confirmed there was no physician order for O2 for Resident #66, and that there should have been a physician order to administer O2. Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#36, and #66) out of 2 residents (#36 and #66) investigated for respiratory care, by failing to: 1. label and properly store Resident #36's oxygen tubing; and 2. label and properly store Resident #66's oxygen tubing, and obtaining an order for administering oxygen. Findings: On 07/10/2024, a review of the facility's policy titled Oxygen Administration with last reviewed date of 01/07/2024 read in part, Policy: Oxygen shall only be administered by physician order, except in an emergency .Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and prn. All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly . Resident #36: Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to End Stage Renal Failure, Unspecified Diastolic Heart Failure, and Obstructive Sleep Apnea. A review of Resident #36's annual MDS (Minimum Data Set) dated 05/23/2024, revealed the resident had a BIMS (Basic Interview for Mental Status) of 15, indicating his cognition was intact. A review of Resident #36's Physician orders revealed an order for O2 (oxygen) at 2L (Liters)/NC (nasal Cannula) PRN (as needed) SOB (shortness of breath) . On 07/08/2024 at 9:31 a.m., an observation was made of Resident #36 in his room. An unlabeled O2 tubing was observed open to air, exposed and wrapped around the O2 concentrator. Further observation revealed the humidifier bottle was also unlabeled. On 07/08/2024 at 9:35 a.m., an observation of Resident #36's room and an interview was conducted with S8LPN (Licensed Practical Nurse) She confirmed the resident's O2 tubing and humidifier bottle were unlabeled, and his O2 tubing was not stored in a bag, and stated they should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that pain management was provided to residents complaining of pain for 1 (#178) out of 41 sampled residents. Findings: Resident #178. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hyperlipidemia, Diabetes, Hypertension, and Fracture Upper end of Right Humerus. On 07/10/2024 at 10:30 a.m., an interview was conducted with the resident. The resident stated that his right arm was broken and that he was having a lot of pain. The resident stated that it was painful to move his right arm and shoulder. The resident stated he was requesting pain medication for 2 days and had not received anything. The resident stated he was told that the facility ran out of his pain medication and were waiting for an order for more. Review of the resident's physician's orders revealed an order for Oxycodone 10 mg (milligrams) 1 po (by mouth) every 4 hours prn (as needed) pain. Review of the resident's MAR (Medication Administration Record) for July 2024 revealed the last dose of Oxycodone was administered on 07/05/2024 at 8:22 a.m. Further review of the resident's MAR revealed that on 07/09/2024 the resident complained of pain of 7 on a pain scale of 0-10 with 10 being the worst pain. On 07/10/2024, the resident complained of pain of 8. There was no documentation the resident received anything for pain on 07/09/2024 and on 07/10/2024. On 07/10/2024 at 11:13 a.m., an interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN stated the resident had been complaining of pain and the facility was out of Oxycodone. S5LPN stated the physician needed to write a new prescription for the pharmacy to refill the Oxycodone. S5LPN stated the resident had been out of Oxycodone and needed a new prescription since 07/05/2024. S5LPN stated she informed S11ADON (Assistant Director of Nursing) that the physician needed to write a new prescription for Oxycodone. S5LPN stated she did not receive a response from the ADON or physician concerning refilling the Oxycodone. S5LPN stated the resident had not received anything for pain since 07/05/2024. On 07/10/2024 at 11:37 a.m., an interview was conducted with S11ADON. S11ADON confirmed she was the person responsible for contacting the physician to get new prescriptions for narcotics. S11ADON stated she was not informed by anyone that the resident needed a new prescription for Oxycodone. S11ADON confirmed the resident's physician was not notified that a new prescription was needed for Oxycodone.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #61 Resident #61 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Benign Prostatic Hyperplasia, Depression, and Squamous Cell Carcinoma. A review of Resident # 61's MDS (Minimum Data Set) assessment revealed he had a BIMS (Basic Brief Interview for Mental Status) score of 3 indicating his cognition was severely impaired. On 07/08/2024 at 9:47 a.m., an interview was conducted with Resident #61's RP (responsible party). She stated it takes 30 to 45 minutes for staff to respond to the call light. She further stated it happens all the time and was especially worse on the weekends. The resident's RP stated that sometimes she went out in the hall to find staff for assistance and majority of the time she was unable to locate staff. On 07/10/2204 at 9:16 a.m., surveyor pressed the call light from Resident #61's room and no one came to answer the call light. At 9:24 a.m., surveyor walked out to the hall and observed the digital alert by the back door flashing the resident's room number. Two CNAs (Certified nursing Assistants) were observed walking down the hall and had not responded to the call light. The facility's overhead announcement system was heard announcing Resident #61's room number and need for assistance. At 9:27 a.m. another CNA walked down the opposite side of the hall and went into a room, then walked back down hallway in the opposite direction of Resident #61's room. On 07/10/24 at 9:31 a.m., an interview was conducted with the CNA who walked down the hall at 9:27 a.m. She identified herself as S16CNA. She stated that she is was made aware of resident's calls light by the digital alert and the announcements. S16CNA confirmed she did not check the digital alert when she came down the hall. S16CNA also stated she heard the announcement but did not respond because she was on another hall. On 07/10/24 at 9:34 a.m., S14CNA was observed going into Resident #61's room. An interview was conducted as she exited the resident's room. S14CNA stated she was taking care of the resident today but she was on her break. She stated that when she took her break, the other CNA on the hall was responsible for covering her residents. S14CNA was asked if she had informed the other CNA that she was going on her break, and she stated that she had not and should have. On 07/10/2024 at 3:29 p.m., an interview was conducted with S17CORP (Regional Corporate Nurse). S17CORP confirmed the facility had staffing issues. Based on observation and interviews, the facility failed to ensure staff provided services to meet the needs of residents, as evidenced by facility nursing staff failing to respond to call lights in a timely manner for 2 (#58 and #61) out of 8 (#15, #30, #35, #36, #58, #61, #62, and #178) residents investigated for sufficient staffing out of a total sample of 41 residents. Findings: Resident #58 Review of Resident #58's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Sepsis, Neuromuscular Dysfunction of Bladder, Urinary Tract Infection, Acute Cystitis with Hematuria and Quadriplegia. Review of the Resident's AM5 (5 day scheduled admission) Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating his cognition was intact. On 07/09/2024 at 4:53 p.m., an observation was made of Resident #58's suprapubic catheter tubing closest to the urinary drainage bag with dried, brown colored sediment noted on the outside of the tubing. The surveyor pressed the resident's call button. Upon pressing the resident's call button, the call system in his room immediately flashed a red light and beeped. The Surveyor waited ten minutes, but no staff answered the call button nor came to the resident's room. The Surveyor looked outside the Resident's room, into the hall and observed zero staff on the hall. On 07/09/2024 at 5:03 p.m., the surveyor walked to the nursing station to notify the nurse of the call bell being pressed, but no response was received. Upon walking to the nursing station, S15LPN was observed sitting at the desk with her head down and she was looking down on her personal cell phone. Surveyor knocked on the window to get S15LPN's attention. S15LPN immediately looked up and the surveyor asked if the call system was going off. S15LPN looked over at the notification screen of the call system and confirmed Resident #58's call bell was activated. S15LPN confirmed she did not answer the call bell and she should have answered the call bell promptly.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff provided the care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#36) of 41 sampled residents. This was evidenced by S7LPN (Licensed Practical Nurse) not administering ordered PRN (as needed) medications to treat Resident #36's itching. Findings: Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to End Stage Renal Failure, Unspecified Diastolic Heart Failure and Obstructive Sleep Apnea. A review of Resident #36's annual MDS (Minimum Data Set) dated 05/23/2024, revealed the resident had a BIMS (Basic Interview for Mental Status) of 15, indicating his cognition was intact. A review of Resident #36's Physician orders revealed an order written on 05/16/2024 for Hydrocortisone 1% (percent) cream apply to affected areas PRN itching. Further review revealed an order written on 05/16/2024 for Benadryl Allergy 25 mg (milligram) one PO (by mouth) Q4 (every 4) hours for itching. A review of Resident #36's June and July 2024 MAR (Medication Administration Record) revealed the resident had not received any of his Benadryl or Hydrocortisone for itching. On 07/08/24 at 9:31 a.m., an observation was made of Resident #36 in his room. A red rash was observed on the resident's bilateral thighs, lower legs and abdomen. The resident stated he had to get his nails cut because he was scratching it until it bled. He also stated day before yesterday (07/07/2024) he told the nurse about it. 07/08/2024 at 9:35 a.m., an observation of Resident #36's rash was made with S7LPN. She confirmed the resident's rash and itching. On 07/09/24 at 11:16 a.m., an observation was made of Resident #36 in his room. The resident confirmed he was still itchy and stated that he had not received anything for his rash and itching. On 07/09/24 at 11:30 a.m., an interview was conducted with S7LPN. She stated that she left hospice a message to report the resident itching after observing his rash and itching yesterday. S7LPN confirmed that she had not offered or administered any of Resident #36's PRN medications for his itching and stated she should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure expired medications were not stored in medication room A. Findings: On 07/10/2024 at 3:40 pm, an inspection was conducted in medication room A. A bottle of Vitamin B Complex with Vitamin C was observed on the shelf and was observed with an expiration date of 05/24. A bottle of Ferrous Gluconate 240 mg (Milligrams) with an expiration date of 05/24 was observed on the shelf in the medication room. S13LPN (Licensed Practical Nurse) was present during this observation and she confirmed that the 2 bottles of medication were expired.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to honor and accommodate food preferences for 1 (Resident #15) out of 41 sampled residents. This deficient practice had the potential to affect all residents who consumed meals from the kitchen. Findings: On 07/10/2024 a review of the facility's policy titled, Resident Food Preferences with a revised date of 01/07/2024 read in part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes Review of Resident #15's record revealed an admission date of 08/05/2021 with diagnoses that included Type 2 Diabetes Mellitus, Hyperlipidemia, and Vitamin Deficiency. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. On 07/09/24 12:07 p.m., an interview, observation, and review of Resident #15's Dietary Meal Ticket, and tray conducted with S10DM (Dietary Manager) revealed mashed potatoes was listed under the category of Dislikes. Mashed potatoes were observed on the Resident #15's meal tray. S10DM confirmed that mashed potatoes should not have been present on Resident #15's meal tray. S10DM then requested another meal tray from the dietary department. On observation of Resident #15's second meal tray, rice was observed on the tray. Further observation of Resident #15's Dietary Meal ticket revealed rice was present under the category of Dislikes. S10DM confirmed that rice was also listed as a dislike on Resident #15's Dietary Meal Ticket and should not be present on Resident #15's meal tray.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain medical records on each resident that were complete for 1 (#43) out of 41 sampled residents. Findings: Reviewed the facility's policy and procedure titled Charting and Documentation that was reviewed by facility on 01/07/2024 read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Documentation in the medical record may be electronic, manual or combination. 2. The following information is to be documented in the resident medical record: a. Objective observation; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the residents; f. Progress toward or changes in the care plan goals and objectives; and g. vital signs . Review of Resident #43's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Anemia, Idiopathic Peripheral Autonomic Neuropathy, and Rheumatoid Arthritis. Review of the resident's progress notes revealed no evidence that a nursing note was documented between 04/12/2024 and 05/14/2024. Review of the resident's nursing progress note dated 05/14/2024 at 10:33 a.m. revealed, N.O. (new order) per NP (Nurse Practitioner) Cephalexin (antibiotic) 500 mg (milligrams) Q (every) 8 hours x 7 days (for 7 days). There was no documentation of signs and symptoms the resident was exhibiting prior to order for Cephalexin. Review of the resident's nursing progress notes dated 05/24/2024 at 11:36 a.m. revealed, N.O. per Dr. __ send out to (hospital) to r/o (rule out) DVT (Deep Vein Thrombosis) to RLE (right lower extremity). There was no documentation of an ongoing assessment of the resident's right lower extremity from 05/14/2024 to 05/24/2024. On 07/09/2024 at 10:25 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN stated the resident was having redness and swelling to right lower leg for about 4 days. The LPN confirmed there was no documentation in resident #43's nurse's notes regarding her right lower leg. S9LPN stated that antibiotics was ordered to treat the resident's right lower leg. The LPN stated the resident completed the 7 day course of antibiotics. The LPN stated that a week later the resident's family was visiting and brought to their attention that the resident's right lower leg was swollen. S9LPN stated that an order was given to send the resident out to the hospital to rule out DVT. The LPN confirmed that she did not document any signs and symptoms the resident exhibited and confirmed there was no documentation of an ongoing assessment of the resident's right lower extremity from 05/14/2024 to 05/24/2024. On 07/09/2024 at 10:44 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated the nurses should document signs and symptoms the residents were exhibiting and should document ongoing assessments for effectiveness of the antibiotic treatment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the updated hospice plan of care was on file and available at the facility for 1 (#52) out of 2 (#31, #52) residents investigated for hospice services. Findings: On 7/10/2024, a review of the facility's policy titled Hospice Program with a last reviewed date of 07/16/2023, read in part: 12. Our facility has designated ____ (Name)_____(Title) to coordinate care provided to the resident by our facility staff and the hospice staff He or she is responsible for the following: d. Obtaining the following information from the hospice : 1. The most recent hospice plan of care specific to each resident. Review of Resident #52's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes, Unspecified Sequalae of Cerebral Infarction, Aphasia, and Gastrostomy Status. Review of Resident #52's July 2024 physician's orders revealed an order date 01/04/2024 that read in part: Admit to ____hospice dx (diagnosis): senile degeneration of the brain. Review of Resident #52's plan of care revealed the following: I am a Full Code. Review of Resident #52's hospice binder revealed the resident's hospice careplan with a date of 01/09/2024. Review of the hospice careplan revealed the following: Advanced directive- patient chooses resuscitation if his/her lungs stop working. On 07/09/2024 11:47 p.m., a phone interview was conducted with Resident #52's hospice nurse who confirmed that the resident's code status was DNR (Do Not Resuscitate), and it was signed by the physician on 03/26/2024. Review of Resident #52's hard chart reveal a Lapost (Lousiana Physician's Orders for Scope Of Treatment) dated 03/26/2024 that read DNR. 07/09/2024 at 11:50 p.m. an interview and record review was conducted with S1DON (Director of Nursing). The resident's hospice binder was reviewed with SS1DON. She stated the careplan that was on file in the binder was the most updated hospice careplan. The careplan was dated 01/09/2024. The resident's hospice careplan was reviewed with S1DON, revealing: Advance Directive - Patient chooses resuscitation if his/her heart or lung stopped. S1DON stated she was unaware that an updated hospice careplan with the resident's new code status was not obtained or on file at the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 Review of Resident #5's record revealed an admission date of 03/11/2024 with diagnoses that included Schizoaffective Disorder, Cognitive Communication Deficit, and Repeated Falls. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident's cognition was severely impaired. On 07/08/2024 at 9:46 a.m., an interview and observation was conducted with Resident #5. Resident #5 stated that he was able to use his call light, and then demonstrated by pressing his call light at 9:47 a.m. Surveyor waited inside of Resident #5's room from 09:47 a.m. to 10:01 a.m. No staff was observed to have addressed Resident #5's call light. On 07/08/2024 at 10:30 a.m., an interview and observation was conducted with S12MP(Maintenance Personnel). S12MP confirmed Resident #5's call light needed new batteries and was not in working condition. Resident #66 Review of Resident #66's record revealed an admission date of 07/20/2023 with diagnoses that included Chronic Kidney Disease and Morbid Obesity. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 03, which indicated the resident's cognition was severely impaired. On 07/08/2024 at 9:21 a.m., an interview and observation was conducted with Resident #66. Resident #66 demonstrated by pressing his call light at 9:21 a.m. Surveyor remained in the room. At 9:37 a.m. no staff had addressed Resident #66's call light. On 07/08/2024 at 10:25 a.m., an interview and observation was conducted with S12MP. S12MP confirmed Resident #66's call light needed new batteries and was not in working condition. S12MP confirmed that staff were unaware of Resident #66's call light due to the call light not functioning properly. Based on observations and interviews, the facility failed to ensure call systems were functioning for 3 residents (#5, #31, #66) out of a final sample of 41 residents. Findings: On 07/10/2024, a review of the facility's policy titled Answering the Call Light with a last reviewed date of 07/29/2023 read in part: 7. Report all defective call lights to the nurse supervisor promptly. Resident #31 Review of Resident #31 EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Atrial Fibrillation. Review of Resident #31's significant change MDS (Minimum Data Set ) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12 , indicating his cognition was intact. On 07/10/2024 at 8:39 a.m. Resident # 31's call bell that was hooked to his shirt was pressed. An observation was made of the screen on C hall that displayed when a resident's call bell was activated. The resident's room number was not on the screen. At 8:49 a.m., an observation and interview was conducted with S6CNA (Certified Nursing Assistant). She stated that when a call bell is pressed, the screen on the hall beeps and the resident's room number is displayed on the screen. The surveyor then asked the S6CNA to press Resident #31's call bell. She stated the resident had two call balls that he used and proceeded to press both call bells. There was no beep heard after pressing either call bell. The screen on the hall was then observed with S6CNA. She confirmed that there was no beep, and the resident's room number was not displayed on the screen. On 07/10/2024 at 8:57 a.m., an interview was conducted with S4Maintenance. He stated they did not routinely check to see if the call bells are functioning or if the batteries need to be changed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an exterior window was in good repair for 1 (Resident #66) out of 41 residents sampled. Findings: On 07/08/2024 a review of the facility's policy titled, Quality of Life- Homelike Environment with an updated date of 03/12/2024 read in part, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include in part, a. Clean, sanitary and orderly environment . On 07/08/2024 at 9:20 a.m., an observation was made of two large cracks, both roughly three feet in length on left pane of Resident #66's exterior window. Seven, thick, black pieces of tape were observed over the two large cracks. On 07/09/2024 at 8:04 a.m. and interview and observation of Resident #66's exterior window was conducted with S7AIT. S7AIT confirmed that the left pane of Resident #66's exterior window was in disrepair and should not have been in that condition.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #50. Review of Resident #50's record revealed an admission date of 11/21/2024 with diagnoses that included Dysarthria, and Anarthria and Other Sequelae of Cerebral Infarction. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired. On 07/08/24 at 10:09 a.m., an interview and observation was made with Resident #50. Resident #50's speech was very slurred and difficult to understand. Resident communicated with surveyor through writing after being offered a pen and paper. A record review of Resident #50's electronic medical record revealed a the following progress notes: Per S19SS (Social Services) on 02/21/2024 at 1:03 p.m. read in part .has trouble speaking well and hard to understand at times. Per S21LPN (Licensed Practical Nurse) on 07/09/2024 at 11:59 a.m. revealed in part .his level of communication is minimal but is not verbally expressive but nods to yes or no questions when asked. On 07/10/2024 11:37 a.m., an interview was conducted with S5LPN (Licensed Practical Nurse). She stated that Resident #50 was difficult to understand at times and that he had slurred speech and mumbled. She stated, at times, she had to use guessing or yes or no questions to communicate with the resident. On 07/10/2024 at 12:02 p.m., an interview and record review with S18ST (Speech Therapist) was conducted. S18ST stated that Resident #50 had severe dysarthria, and had very slurred speech. A review of S18ST's Discharge Recommendations revealed recommended strategies: instruction in use of direct, rather than open ended questions, to facilitate receptive skills and training in use of auditory rehearsal to facilitate successful communication exchange. On 07/10/2024 at 12:12 p.m., an interview and record review was conducted with S3MDS (Minimum Data Set). S3MDS stated that because Resident #50 had unclear speech, communication should have been addressed in the Plan of Care. She verified that speech and communication was not addressed in the Plan of Care. On 07/10/2024 at 01:33 p.m., an interview was conducted with S20CNA (Certified Nursing Assistant). She stated that she was familiar with Resident #50, and had cared for him. She further stated that he had very slurred speech that made him difficult to understand at times, therefore he would make his needs known by pointing and writing. 5. Resident #62. Review of Resident #62's record revealed an admission date of 09/29/2022 with diagnoses that included Dementia with Behavior Disturbance, Muscle Weakness, Cognitive Communication Deficit, Vitamin Deficiency, and Major Depressive Disorder. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3, which indicated the resident's cognition was severely cognitively impaired. Review of Resident #62's OSA (Optional State Assessment) dated 04/10/2024 revealed the resident required one person physical assistance when eating. Review of Resident #62's July 2024 physician orders revealed a diet order dated 02/29/2024 for nectar thick liquids/soft foods. Review of Resident #62's electronic health record revealed the following Registered Dietician (S22RD) notes: - Dated 04/10/2024 at 8:31 p.m., included in part .2. Continue to assist for all meals. - Dated 05/02/2024 at 2:40 p.m., included in part .2. Continue to assist for all meals. On 07/08/2024 at 11:45 a.m., an interview was conducted with Resident #62's two daughters. The daughters stated that the Resident #62 will eat with direction. They stated Resident #62 required assistance with eating. On 07/09/2024 at 12:16 p.m., an observation was made of Resident #62 being fed by a CNA in her room. On 07/09/2024 at 04:28 p.m., a record review and interview was conducted with S2MDS and S3MDS. S3MDS stated she had seen her being fed but does not know if she needs to be fed. The OSA MDS for 04/10/2024 was reviewed. S3MDS verified that the MDS was coded for Resident #62 receiving extensive assistance with eating. S2MDS confirmed that assistance with meals should have been addressed on the plan of care for Resident #62 and was not. 2. Resident #58. Review of Resident #58's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnosis including but not limited to Sepsis, Neuromuscular Dysfunction of Bladder, Urinary Tract Infection, Acute Cystitis with Hematuria, and Quadriplegia. Review of the Resident's AM5 (5 day scheduled admission) MDS assessment dated [DATE] revealed the resident was coded as having a urinary appliance of indwelling catheter. Review of the Resident's care plan revealed the resident had a Potential for injury (Problem onset date 06/21/2024) r/t (related to) presence of suprapubic cath (catheter) r/t neuromuscular dysfunction of bladder with an interventions to clean cath with soap and water Q (every) shift. Review of the Resident's July 2024 eMAR (electronic Medication Administration Record) revealed nursing staff were to clean the resident's suprapubic catheter with soap and water Q shift and was documented as completed on 07/08/2024 day shift and 07/09/2024 day shift per S15LPN. On 07/08/2024 at 10:20 a.m., an observation was made of Resident #58 resting in bed and his suprapubic foley catheter tubing was observed hanging on the left side of his bedrail attached to a urinary collection bag. The catheter tubing closest to the urinary drainage bag was observed to have dried, brown colored sediment noted on the outside of the tubing. On 07/09/2024 at 12:24 p.m., a follow up observation was conducted of Resident #58 resting in bed and his foley catheter tubing was observed hanging on the left side of his bedrail attached to a urinary collection bag. The catheter tubing remained with dried, brown colored sediment noted on the outside of the tubing. On 07/09/2024 at 5:06 p.m., an observation and interview was conducted with S15LPN. S15LPN confirmed the resident's foley catheter tubing closest to the urinary drainage bag was not clean and had dried, brown colored sediment present. 3. Resident #70. Review of Resident #70's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus. Review of the resident's July 2024 physician's orders revealed an order dated 06/14/2024- Change sensor (diabetic) q14days (every 14 days) on the 14th and 28th. Review of the resident's July 2024 eMAR revealed Monitor Sensor for Glucose that was documented as completed on 07/01/2024 thru 07/10/2024 at 6:00 a.m., 11:00 a.m., 4:00 p.m. and 9:00 pm. On 07/08/2024 and 07/09/2024 S15LPN documented she monitored the resident's sensor at 11:00 a.m. and 4:00 p.m. S13LPN documented that she monitored the resident's sensor at 11:00 a.m. On 07/09/2024 at 12:11 p.m., an interview was conducted with Resident #70. He stated he had not had his sensor present since he had been admitted to the facility. He further stated the nursing staff were sticking his finger to check his blood sugars and he was not aware that he could bring his glucose sensor while at the nursing facility. On 07/09/2024 at 1:25 p.m., an interview was conducted with S15LPN who confirmed Resident #70 did not have a glucose sensor and she had performed a finger stick to obtain his blood sugars. On 07/10/2024 at 2:46 p.m., an interview was conducted with S13LPN. She confirmed the resident's blood sugars were being obtained by sticking his finger because he doesn't use his glucose sensor. S13LPN further confirmed the resident did not have his glucose sensor present. On 07/10/2024 at 3:06 p.m., an interview was conducted with S2MDS who stated she was responsible for completing Resident #70's care plan. S2MDS stated she was not aware the resident didn't have his glucose sensor and confirmed his current care plan and current orders reflected a sensor being used to measure his blood sugars. S2MDS confirmed the resident's EHR did not include finger sticks as the method for measuring the resident's blood sugars. On 07/10/2024 at 3:45 p.m., an interview was conducted with S1DON. S1DON stated she was just made aware by S2MDS that Resident #70 did not have a glucose sensor as ordered. S1DON confirmed finger sticks were not ordered for the Resident and his current care plan and orders were not being followed. Based on record review and interview, the facility failed to develop and implement a comprehensive person-censtered plan of care for each resident as evidenced by: 1. failing to address Resident #38's Major Depression with Severe Psychotic Symptoms, 2. failing to ensure Resident #58's catheter tubing was cleaned as ordered, 3. failing to ensure Resident #70's diabetic sensor was implemented as ordered for blood sugar checks and, 4. failing to address Resident #50's communication, 5. failing to address Resident #62's need for feeding assistance for 5 (#38, #50, #62, #70, #58) out 41 sampled residents. Findings: 1. Resident #38. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included Major Depressive Disorder, Recurrent with Severe Psychotic Symptoms. Review of the resident's physician's orders revealed an order for Celexa (antidepressant medication) 20 mg (milligrams) one by mouth every day. Review of the resident's quarterly MDS (Minimum Data Set) dated 05/08/2024 revealed the resident was coded for being on an antidepressant medication. Review of the resident's care plan revealed no evidence Major Depression with Severe Psychotic Symptoms was addressed in the care plan. On 07/10/2024 at 9:10 a.m., an interview was conducted with S2MDS (Minimum Data Set Coordinator) and S3MDS. They both reviewed the resident's electronic clinical record and confirmed the resident's diagnosis included Major Depression Disorder, Recurrent with Severe Psychotic Symptoms. They both reviewed the resident's care plan and confirmed that it did not address the resident's diagnosis and agreed that it should have been in the care plan.

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure a dementia resident received the appropriate treatment and services to attain or maintain his highest practicable level of well-being for 1 (Resident #1) out of 3 sampled residents by failing to: 1. Revise the comprehensive care plan to include interventions that addressed Resident #1's continued wandering; 2. Staff failing to report continued incidents of wandering into other resident rooms for Resident #1, and 3. Failing to provide adequate supervision of Resident #1 after complaints that he continued to wander in other resident rooms. Findings: Review of the facility's policy on 05/08/2024 titled Care Plans, Comprehensive Person - Centered read in part: A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will .m. aid in preventing or reducing decline the resident's functional status and/or functional levels. Review of Resident #1's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including, but were not limited to, Unspecified Dementia, Aphasia following Cerebral Infarction, and Mixed Receptive - Expressive Language Disorder. Review of Resident #1's plan of care revealed the following: Mental Distress- Resident gets in roommate's bed and tries to take w/c (wheelchair) and pull sheets off of roommate's bed at times. Redirect resident PRN (as needed) Resident may possibly go into other resident's room and get into other resident's bed. Staff to redirect resident to correct room if occurrence. Sign of truck placed on wall next to door to help remind resident of room location. Review of an in-service conducted by S1DON (Director of Nursing) with nurses and CNAs (Certified Nursing Assistants) dated 02/09/2024, revealed in part: 5. Everyone should know who to report things to, follow the chain of command. 6. We need to all work together to redirect residents that go into other residents' rooms and wander around the facility. On 05/08/2024 at 7:32 a.m., an interview was conducted with S2LPN (Licensed Practical Nurse). She stated that Resident #1 could propel himself in the wheelchair and get to the bed on his own when he wanted to. S2LPN further stated the resident did not try to wander outside of the facility, but did enter other residents' rooms. She stated that on 05/07/2024, she had to re-direct him from another resident's room, and he had gone into different residents' rooms on several occasions. S2LPN said that the staff simply re-directed the resident each time he wandered into another resident's room. On 05/08/2024 at 10:30 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated that the facility was first made aware of Resident #1 wandering into Resident #2's room by Resident #2's daughter in December 2023, and the intervention was to put him in his bed after lunch and increase his time in activities. Resident #1 then wandered into Resident #2's room again in February, and Resident #2's daughter reported that Resident #1 was in her bed. The new intervention was to place a picture of a truck outside of Resident #1's room door to remind him that was his room. S1DON stated that she was unaware that Resident #1 was wandering into other residents' rooms because it was not reported to her by her staff, and they should have reported the incidents to her. On 05/08/2024 at 1:38 p.m., a second interview and record review was conducted with S1DON. S1DON was asked about the facility's response to the concerns voiced by Resident #2's daughter in an email sent to the Administrator in Training on December 18, 2023. S1DON confirmed that Resident #2's daughter had notified the facility that Resident #1 had not only wandered into Resident #2's room, but into two other residents' rooms as well in her email. She stated that there were no interventions to increase supervision of Resident #1 after the first or second report of Resident #1 wandering into other residents' rooms. S1DON also stated that she did not follow up with the other residents named in the email sent by Resident #2's daughter. A review of Resident #1's plan of care was then conducted with S1DON. S1DON confirmed that the interventions to put the resident in bed after lunch and to increase his time in activities were not included in the resident's care plan.

Dec 2023 7 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's staff failed to notify the resident's representative/RP (responsible party) of a change in the resident's condition by failing to: 1. Immediately inform Resident #6's representative when Resident #6 had tested positive for Influenza Type A and 2. Immediately inform Resident #7's representative when Resident #7 sustained injuries after an incident for 2 (#6 and #7) out of 7 (#1-#7) sampled residents. Findings: Review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical /mental condition and/or status . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Resident #6 Review of Resident #6's electronic medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of the neck and right femur, Influenza Type A, Atrial Fibrillation, and Hypokalemia. Review of Resident #6's lab report dated 11/15/2023 at 7:24 p.m. revealed the resident was positive for Influenza A. Review of Resident #6's nursing progress note dated 11/16/2023 at 8:57 a.m., read: received the result of Flu swab from (hospital name) with positive results for Influenza A. FNP (Family Nurse Practitioner) notified. There was no documentation in the progress notes that the resident's RP was notified. Review of Resident #6's physician orders revealed an order dated 11/16/2023 that read, droplet isolation for 7 days related to Influenza Type A. On 12/06/2023 at 1:15 p.m., an interview was conducted with Resident #6's responsible party. She stated she was not notified that the resident tested positive for Influenza Type A on 11/15/2023 and that the resident was in isolation. On 12/06/2023 at 1:45 p.m., a record review and interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed Resident #6 tested positive for Influenza Type A on 11/15/2023 and there was no documented evidence that the responsible party was notified. S3ADON confirmed the responsible party should have been notified of flu diagnosis and that the resident was in isolation.Resident #7 Review of Resident #7's quarterly MDS assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with a BIMS score of 15 indicating she was cognitively intact. Review of Resident #7's electronic medical record revealed the following pertinent diagnoses: Lymphedema, Long Term Use Anticoagulants, Anxiety Disorder and Obesity. Further review of Resident #7's electronic medical record revealed nursing progress notes with an entry dated 11/14/2023 at 11:11 a.m. per S18LPN (Licensed Practical Nurse) that read in part: Summoned in resident's room by S15CNA (Certified Nursing Assistant) where resident was laying on bed legs and feet dangling off side of bed, assisted S15CNA to ease resident down to floor on her knees than resident sat on buttocks, didn't hit head, resident was lifted off floor with lifter, NP (Nurse Practitioner) made aware. Both daughters contact made aware . Review of facility's Incident Report dated 11/14/2023 prepared by S18LPN revealed Incident type: Supportive/ to floor and reported to supervisor on 11/14/23 at 11:24 am Type of injury: skin tear Location: Resident room Activity at time: from bed w/ assist Witness 1 and 2: S15CNA Incident reported by: S15CNA Narrative of incident and description of injuries: Summoned to resident's room where resident was laying half way in bed legs and feet dangling on floor. Resident wasn't able to pull self to transfer to WC (Wheelchair) so Resident was eased to floor. Resident didn't hit her head. Denies any pain. Resident was lifted off floor with lift . NP (Nurse Practitioner) made aware both daughters contacted. Skin tear to right elbow and right shin. Further review of the incident report failed to include the date and time the resident's daughters were contacted. On 12/07/2023 at 9:12 a.m., a phone interview was conducted with Resident #7's first contact responsible party (RP).RP stated on Tuesday 11/14/23, facility notified her that resident slid down transfer board and CNA assisted resident to floor and she told facility to call the resident's second RP. Second RP was notified about resident sliding down transfer board. Second RP arrived shortly after notification and had observed a skin tear to one of resident's legs. Second RP confronted nursing staff why she was not notified of the skin tear and reported nursing staff stated they forgot. On 12/07/2023 at 10:55 a.m., a phone interview was conducted with Resident #7's second RP. Second RP stated she was notified by the resident's nurse in the morning of 11/14/2023 that resident fell off sliding board while CNA was assisting with transferring the resident from the bed to the wheelchair. The nurse who called failed to provider her name and assured second RP that Resident #7 was fine. Second RP arrived at facility shortly after and observed Resident #7 with a bandage to her right lower leg that was saturated. Second RP went to S5AADM (Assistant Administrator) and voiced her concerns about the resident's injury and why when she was notified the injury was not reported. S5AADM assured her if would take care of it. On 12/07/2023 at 12:05 p.m., an interview was conducted with S18LPN. S18LPN confirmed she initially notified Resident #7's two RPs that resident had no injuries. S18LPN stated the second RP arrived at the facility shortly after the notification and was upset to see the resident had a bandage on her right lower leg. S18LPN confirmed S5AADM instructed her to call Resident #7's RPs back to report the injuries. On 12/07/2023 at 12:37 p.m., an interview was conducted with S8TxLPN (Treatment Licensed Practical Nurse). S8TxLPN stated she assisted with changing Resident #7's bandage to her right lower leg on 11/14/2023. S8TxLPN stated resident's second RP was present and had voiced her frustrations that she was notified by the nurse prior to her arrival that Resident #7 had an incident without injury and was fine. On 12/07/2023 at 3:45 p.m., an interview was conducted with S5AADM. S5AADM confirmed on 11/14/2023, he spoke with Resident #7's second RP who voiced concerns that she was notified that the resident had an incident earlier that morning and no injuries were reported. S5AADM confirmed the resident's second RP visited the resident at the facility and observed the bandage to the resident's right lower leg. S5AADM confirmed S18LPN failed to notify Resident #7's RPs of the injuries sustained during the incident on 11/14/2023.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#3 and #7) out of 9 (#1-#7, R1 and R2) sampled residents. Findings: Review of the facility's policy and procedure titled, Filing Grievances/Complaints, revealed in part: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made 1. Any resident, his or her responsible party may file a grievances or complaint concerning medical care, behaviors of other residents, staff members .without the fear of threat of reprisal in any form . 3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or person filing the grievance or complaint in behalf of the resident . Resident #3 Review of Resident #3's electronic medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Influenza Type A Virus, Other Allergic Rhinitis, Polyosteoarthritis, Malaise and Obstructive Sleep Apnea. Review of facility's Grievance Logs from August 2023 to December 2023 did not reveal a grievance initiated the week of 11/08/2023 for Resident #3. On 12/04/2023 at 1:40 p.m., an interview was conducted with Resident #3 and Resident #3's RP (responsible party) in Resident #3's private room. RP stated she learned Resident #3 had not yet received the flu vaccine the week of 11/08/2023 and informed S10NP (Nurse Practitioner) who had examined the resident for a routine assessment. RP stated she immediately went to S5AADM (Assistant Administrator) and voiced her concerns about Resident #3 not yet receiving the flu vaccine. On 12/06/2023 at 10:14 a.m., an interview was conducted with S10NP who confirmed she saw Resident #3 the week of 11/08/2023 for a routine assessment. S10NP confirmed Resident #3's RP was present during the assessment and informed her that the resident had not yet received the flu vaccine. S10NP then informed S2DON (Director of Nursing) about Resident #3's RP concerned about the flu vaccine not being given. On 12/07/2023 at 3:45 p.m., an interview was conducted with S5AADM who confirmed Resident #3's RP had voiced concerns the week of 11/08/2023 about the resident not yet receiving the flu vaccine. S5AADM confirmed he had not initiated a grievance and according to the facility's policy he should have. Resident #7 Review of Resident #7's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Lymphedema, Long Term Use Anticoagulants, Anxiety Disorder and Obesity. Review of facility's Grievance Logs from August 2023 to December 2023 did not reveal a grievance initiated the week of 11/14/2023 for Resident #7. On 12/07/2023 at 10:55 a.m., a phone interview was conducted with Resident #7's second RP who stated she visited Resident #7 on 11/14/2023. The second RP further stated when she observed the resident, the resident had a bandage covering the resident's right lower leg which surprised the RP because she had not been notified of the resident having any injuries. The second RP stated she voiced her concerns to S5AADM and he assured her he would take care of it. On 12/07/2023 at 3:45 p.m., an interview was conducted with S5AADM. S5AADM confirmed on 11/14/2023, he spoke with Resident #7's second RP who voiced concerns that she was not notified of the resident's injury to the resident's right lower leg. S5AADM confirmed he had not initiated a grievance and according to the facility's policy he should have.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that services were provided according to the physician's orders for 1 (#5) out of 9 (#1-#7, #R1 and #R2) sampled residents, by failing to monitor the Resident #5's temperature for 72 hours after she received the Flu Vaccine. Findings: Review of the facility's policy titled Charting and Documentation, read in part: Policy Statement. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record . Resident #5 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes and Morbid Obesity. Review of physician's orders revealed an order written on 11/30/2023 at 2:00 p.m. for Fluzone High Dose 2023-24 administered to left deltoid 11/30/23. Monitor temperature Q (every) shift x (time) 72 hours. Monitor injection site for signs of infection. Report any adverse reactions to MD. Review of progress notes revealed that S2DON (Director of Nursing) wrote on 12/01/2023 that Fluzone High Dose 2023-24 was administered on 11/30/2023 at 1:30 p.m. - temp 97.3 (Fahrenheit). A review of Resident #5's MAR (Medication Administration Record), vital signs sheet, and progress notes revealed no further documentation of temperatures from 11/30/2023 to 12/3/2023. On 12/04/2023 at 4:30 p.m., an interview and review of Resident # 5's records were conducted with S2DON and S3ADON (Assistant Director of Nursing). S2DON and S3ADON were asked where vital signs were recorded after they were taken, and they both stated in the MAR or progress notes. A review of the resident's MAR and progress notes revealed that the temperatures were not documented. S2DON and S3ADON confirmed the physician's order for Resident #5's temperature to be monitored for 72 hours after the Fluzone was given. S2DON and S3ADON stated that they could not confirm that the temperatures were taken as they were not documented.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program as evidenced by failing to: 1. Report an influenza outbreak to the office of public health per the facility's policy; 2. Annually review and/or revise the IP program and policies; and 3. Perform hand hygiene in between direct contact with Resident #4 and Resident #5. This had the potential to affect a census of 80 residents. Findings: Review of a policy titled Outbreak of Communicable Diseases revealed in part, Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Policy Interpretation and Implementation: 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area .4. An outbreak of influenza is defined as a single case if unusual for the facility. A single case of influenza is reportable to the department of health. 5. Contacts will be assessed as appropriate to determine if any actions need to be taken. 6. Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions. 7. The administrator will be responsible for a. telephoning a report to the health department .e. discontinuing group activities, as indicated .8. The infection preventionist and director of nursing services will be responsible for: a. receiving surveillance information and tabulating data; b. maintaining a line listing of identified cases on the appropriate Line Listing Report; .e. completing the Infection Treatment/Tracking Report form, if required. 9. The nursing staff will be responsible for: a. notifying the director of nursing services of symptomatic residents; b. providing infection surveillance data in a timely manner; c. obtaining laboratory specimens as directed; d. initiating isolation precautions as directed or as necessary; and e. confining symptomatic residents to their rooms as much as feasible, when indicated . Review of the facility's list of positive staff and residents revealed the first staff tested positive for influenza on 11/03/2023 and the last staff member tested positive on 11/28/2023 and the first resident tested positive on 11/12/2023 and the last resident tested positive on 11/17/2023. The facility had a total of 6 residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. 1. On 12/06/2023 at 3:00 p.m., an interview was conducted with S2DON and S5AADM. Both confirmed they were not aware that the flu positive cases of residents and staff were to be reported to the state health department as stated in their outbreak policy. 2. On 12/06/2023 at 3:00 p.m., an interview was conducted with S2DON and S5AADM. Both stated they had not reviewed the facility's infection prevention and infection control policies. Both further stated they were not aware that they were supposed to review those policies annually and assumed the former administrative staff had done it. 3. Review of a policy titled Infection Control Guidelines for All Nursing Procedures. Purpose. To provide guidelines for general infection control while caring for residents .4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .i. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . On 12/06/2023 at 8:49 a.m., an observation was conducted of resident #4. The resident was sitting in the hallway in his wheelchair. S12LPN (Licensed Practical Nurse) was asked to wheel the resident back in his room for a confidential interview. S12LPN was observed walking down the hallway to her medication cart and on the way back she wheeled Resident #5 out of the middle of the hallway. She then proceeded down the hall to Resident #4 and without sanitizing her hands she unlocked Resident #4's wheelchair brakes, wheeled him to his room, and relocked his brakes. On 12/06/2023 at 8:53 a.m., an interview was conducted with S12LPN. She was asked why she did not sanitize her hands before unlocking resident #4's wheelchair and wheeling him into his room. S12LPN stated that it was because she was just coming to move his wheelchair. S12LPN confirmed that she did not sanitize her hands after touching Resident #5's wheelchair and before touching Resident #4's wheelchair and should have. On 12/06/2023 at 8:54 a.m. Resident #4 was observed unlocking his wheelchair brakes, then slowly wheeled himself back into the hallway by pushing the wheels of his wheelchair.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to be administered in a manner that enabled its Infection Control and Prevention Program to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. The facility failed to: 1. Obtain influenza vaccines for residents when it was seasonally available until after an influenza outbreak had occurred; 2. Effectively implement the facility's infection prevention and control program's (IPCP) policies during an influenza outbreak that included surveillance, timely corrective actions and monitoring and reporting of the outbreak; 3. Annually review and/or revise the infection prevention and control program and policies. This deficient practice had the potential to affect a census of 80 residents. Findings: Review of the facility's infection control documentation revealed the first staff tested positive for influenza on 11/03/2023 and the first resident tested positive on 11/12/2023. The facility had a total of 6 residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. 1. Cross reference F883 Review of an invoice from the facility's pharmacy revealed on 11/16/2023 a total of 57 flu vaccines were delivered to the facility. On 12/05/2023 at 10:46 a.m., a phone interview was conducted with S17Pharmacist who denied any flu vaccines being on back order or having a shortage of flu vaccines. S17Pharmacist stated S3ADON (Assistant Director of Nursing) contacted the pharmacy on 11/14/2023 and requested flu vaccines for the facility's residents and staff. The requested vaccines were delivered to the facility on [DATE]. S17Pharmacist verified that the facility had not contacted the pharmacy prior to 11/14/2023 to order flu vaccines. On 12/05/2023 at 2:48 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S3ADON. S2DON explained she began working at the facility at the beginning of July 2023 and had not been informed that she was responsible for ordering flu vaccines. S2DON stated someone from the facility's corporate office asked her in September 2023 if flu vaccines had been ordered for the facility's residents and staff. S2DON confirmed flu vaccines had not been ordered at that time. S2DON stated she was then advised to notify the corporation's clinical nurse who provided her a phone number for a pharmacy out of town. When she contacted the pharmacy, she was told that they could not provide vaccines to her facility due to the facility's location. S2DON confirmed she failed to follow up with the corporation's clinical nurse after the suggested pharmacy could not provide the vaccines. S3ADON reported that she ordered the vaccines on 11/14/2023 and received them on 11/16/2023. 2. Cross reference F880 and F882 Review of a policy titled Outbreak of Communicable Diseases revealed in part, Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Policy Interpretation and Implementation: 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area .4. An outbreak of influenza is defined as a single case if unusual for the facility. A single case of influenza is reportable to the department of health. 5. Contacts will be assessed as appropriate to determine if any actions need to be taken. 6. Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions. 7. The administrator will be responsible for a. telephoning a report to the health department .e. discontinuing group activities, as indicated .8. The infection preventionist and director of nursing services will be responsible for: a. receiving surveillance information and tabulating data; b. maintaining a line listing of identified cases on the appropriate Line Listing Report; .e. completing the Infection Treatment/Tracking Report form, if required. 9. The nursing staff will be responsible for: a. notifying the director of nursing services of symptomatic residents; b. providing infection surveillance data in a timely manner; c. obtaining laboratory specimens as directed; d. initiating isolation precautions as directed or as necessary; and e. confining symptomatic residents to their rooms as much as feasible, when indicated . On 12/05/2023 at 2:48 p.m., a joint interview was conducted with S2DON and S3ADON. Both stated there was no monitoring of flu symptoms for all residents after it was identified that facility staff first tested positive on 11/03/2023 and after the tenth facility staff tested positive on 11/28/2023. Both confirmed all residents should have been monitored for flu symptoms when the first two residents tested positive for the flu on 11/12/2023. S2DON further stated there was no documentation of the surveillance, implementation of corrective actions and monitoring of the flu outbreak nor were they aware of an Infection Treatment/Tracking Report form as listed in their outbreak policy. On 12/06/2023 at 3:00 p.m., an interview was conducted with S2DON and S5AADM (Assistant Administrator). Both confirmed they were not aware that the flu positive cases of residents and staff were to be reported to the state health department as stated in their outbreak policy. Both stated they had not reviewed the facility's infection prevention and infection control policies. Both further stated they were not aware that they were supposed to review those policies annually and assumed the former administrative staff had done it.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of Influenza in the facility by: 1. Empirically isolate Resident #1 and Resident #2 who displayed signs and symptoms of influenza during an outbreak; 2. Follow up timely on collected influenza tests which delayed isolating positive residents for Resident #2; 3. Document surveillance, implementation of corrective actions and monitoring of the outbreak; Findings: Review of a policy titled Outbreak of Communicable Diseases revealed in part, Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Policy Interpretation and Implementation: 1. An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable; .c. Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area .4. An outbreak of influenza is defined as a single case if unusual for the facility. A single case of influenza is reportable to the department of health. 5. Contacts will be assessed as appropriate to determine if any actions need to be taken. 6. Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions. 7. The administrator will be responsible for a. telephoning a report to the health department .e. discontinuing group activities, as indicated .8. The infection preventionist and director of nursing services will be responsible for: a. receiving surveillance information and tabulating data; b. maintaining a line listing of identified cases on the appropriate Line Listing Report; .e. completing the Infection Treatment/Tracking Report form, if required. 9. The nursing staff will be responsible for: a. notifying the director of nursing services of symptomatic residents; b. providing infection surveillance data in a timely manner; c. obtaining laboratory specimens as directed; d. initiating isolation precautions as directed or as necessary; and e. confining symptomatic residents to their rooms as much as feasible, when indicated . Review of the facility's list of positive staff and residents revealed the first staff tested positive for influenza on 11/03/2023 and the last staff member tested positive on 11/28/2023 and the first resident tested positive on 11/12/2023 and the last resident tested positive on 11/17/2023. The facility had a total of 6 residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. Review of the list of positive staff and residents revealed the following: S14CNA - 11/03/2023 S19AAD - 11/4/2023 S20CNA - 11/10/2023 Resident #3 - 11/12/223 Resident #4 - 11/12/2023 Resident #5 - 11/13/2023 S21Diet - 11/13/2023 Resident #1 - 11/13/2023 S22Diet- 11/14/2023 Resident #6 - 11/15/2023 S23Diet - 11/15/2023 Resident #2 - 11/17/2023 S24AIT - 11/19/2023 S25Hskp - 11/20/2023 S26AIT - 11/21/2023 S27WC - 11/28/2023 1. Resident #1 Review of Resident #1's nursing notes revealed the following: 11/12/2023 at 8:45 p.m. - Resting in bed stating she is having body aches. Will pass on in report to monitor for elevated temp (temperature). Temp now is 98.3. 11/13/2023 at 3:33 p.m.: .Flu swab collected and sent off to lab for testing. 11/13/2023 at 9:00 p.m.: Received call from lab with resident's flu results. Resident tested positive for flu A .S2DON was notified and orders were given and carried out to transfer resident's roommate (Resident #2) to different room. Review of Resident #1's electronic health record failed to reveal when the resident was placed on droplet precautions. Review of the facility's Infection Control Monthly Resident Tracking Log failed to reveal when the resident was placed on droplet precautions. On 12/06/2023 at 8:50 a.m., an interview was conducted with S13LPN. S13LPN stated Resident #1 tested positive for the Flu on 11/13/2023 and was placed on Droplet Precautions at that time. Resident #2 Resident #2 was the roommate of Resident #1 that tested positive for the flu on 11/13/2023. Review of Resident #2's nursing notes revealed the following: 11/13/2023 at 9:21 p.m.- Notified resident's husband of her room change. 11/17/2023 at 1:19 p.m. - . New order: CXR (chest x-ray) STAT (immediately), Mucinex 600 mg po BID (twice daily) x 5 days, Swab Res (resident) for flu, O2 (oxygen) per NC (Nasal Cannula) for sats (saturations) < (less than) 92%. 11/20/2023 at 11:26 p.m. - .11/18/2023 placed on droplet isolation x 7 days On 12/06/2023 at 3:00 p.m., an interview was conducted with S2DON. She confirmed she was the facility's designated IP during the flu outbreak in November 2023. S2DON also confirmed that residents with flu symptoms should have been isolated when the symptoms first appeared and that the Resident #1 and Resident #2 were not immediately isolated. 2. Review of Resident #2's flu test lab report revealed that it was collected 11/17/2023 at 3:00 p.m. collected and flu A positive reported on 11/17/2023 at 5:45 p.m. Review Resident #2's nurse's note dated 11/20/2023 at 11:26 a.m. revealed in part .Received results for flu swab on 11/18/2023. NP notified NON (New orders noted) and carried out for Tamiflu 75 mg one po BID x 5 days. Resident placed on droplet isolation x 7 days. Review of Resident #2's nurse's note dated 11/20/2023 at 12:47 p.m. per S3ADON- Res (resident) stated she felt horrible and that she wanted to be checked out at the hospital. Notified NP of resident's request. She gave orders to send resident to hospital for eval and Tx (evaluation and treatment). Res daughter and husband were present . Review of Resident #6's flu test lab report revealed it was collected on 11/15/2023 at 11:45 a.m. and reported positive for flu A on 11/15/2023 at 7:24 p.m. Review of Resident #6's nursing notes revealed the following entries: 11/15/2023 at 1:45 p.m. - Flu swab collected and sent to Lab. 11/16/2023 at 8:57 a.m. - Received the result of the flu swab with positive results for flu A. On 12/5/2023 at 2:48 p.m., an interview was conducted S2DON who explained that lab results that were faxed to the facility after hours were checked by ward clerk and nursing staff periodically for results. She further stated that staff should have notified her when flu positive results were received and confirmed she was not made aware of the resulted until she returned to work the following morning. 3. Review of the facility's Infection Control Monthly Resident Tracking Log failed to reveal when residents were placed on droplet precautions. Review of an in-service dated 11/06/2023 at 2:00 p.m. revealed the following areas of instructions were covered: All staff, CNAs (Certified Nursing Assistants), LPNs (Licensed Practical Nurses): if any resident is complaining of cold symptoms or cough please allow them to stay in rooms, notify DON (Director of Nursing) of any one symptomatic signed by S1ADM (Administrator). Review of signatures revealed all of the facility's staff were not included on the in-service attendance sheet. Review of the facility's group text message to all staff dated 11/14/2023 at 10:15 a.m. sent by S4CNASup read as follows: Effective today all residents to eat meals in rooms. Please do not bring any of your residents to dining room if you have anyone in there at this time please bring them back to their rooms. Review of the facility's group text message to all staff dated 11/14/2023 at 10:35 a.m. sent by S4CNASup read as follows: All staff must also wear surgical blue masks. Review of the facility's group nursing text message dated 11/18/2023 at 11:45 a.m. sent by S2DON read in part as follows: If you have flu symptoms .you must notify the on call nurse and I . The facility was unable to provide additional in-services or evidence of corrective measures utilized to contain influenza among residents and staff. The facility was also unable to provide evidence of ongoing influenza surveillance for residents. On 12/07/2023 at 8:31 a.m., an interview was conducted with S6AD (Activities director). S6AD stated residents played bingo as a group on the 11/13/2023. On the morning of 11/14/2023, S6AD stated she was instructed by S2DON to stop group activities and conduct in room visits. On 12/05/2023 at 2:48 p.m., a joint interview was conducted with S2DON and S3ADON (Assistant Director of Nursing). Both stated there was no monitoring of flu symptoms for all residents after it was identified that facility staff first tested positive on 11/03/2023 and after the tenth facility staff tested positive on 11/28/2023. Both confirmed all residents should have been monitored for flu symptoms when the first two residents tested positive for the flu on 11/12/2023. S2DON further stated there was no documentation of the surveillance, implementation of corrective actions and monitoring of the flu outbreak nor were they aware of an Infection Treatment/Tracking Report form as listed in their outbreak policy.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza. The facility had a total of 6 (#1, #2, #3, #4, #5, and #6) residents and 10 staff test positive for influenza from 11/03/2023 to 11/28/2023. The facility failed to:: 1. Obtain influenza vaccines when it became seasonally available until 11/16/2023 after an influenza outbreak occurred among residents and staff; and 2. Administer influenza vaccines to eligible residents after it was received on 11/16/2023 until 11/30/2023 This deficient practice had the potential to affect a census of 80 residents. Findings: Review of the facility's policy titled, Influenza Vaccine, revealed in part, all residents will be affected the Influenza Vaccine to aid in preventing infections that may be encountered in this facility and as recommended by the ACIP (Advisory Committee on Immunization Practices). The influenza vaccine will be offered during the flu season to all persons unless medically contraindicated or refused. 1. Prior to or upon admission and annually, residents will be offered the vaccine and when indicated will be administered during the flu season. 2. The vaccine consent listing contraindications will be signed and updated annually and located on the Immunization Informed Consent and placed on the chart prior to flu season . 3. The vaccine will be given in accordance with current ACIP recommendations. 4. The infections control coordinator will be responsible for maintaining current information relating to immunizations . 1. Review of the facility's infection control documentation revealed the first staff tested positive for influenza on 11/03/2023 and the first resident tested positive on 11/12/2023. Review of an invoice from the facility's pharmacy revealed on 11/16/2023 a total of 57 flu vaccines were delivered to the facility. Resident interviews: On 12/05/2023 at 9:33 a.m., a random interview was conducted with Resident #R1. The resident stated he received his flu vaccine last week which he thought was odd because it was so late compared to when he usually received it in October. On 12/05/2023 at 9:46 a.m., a second random interview was conducted with Resident #R2 who stated she had received her flu shot late. She further stated that she usually received the flu shot in October and that she found it odd that the flu shot was not given until December of this year. On 12/6/2023 at 8:54 a.m., an interview was conducted with Resident #4 in his room. The resident stated he had the flu two weeks ago and had to get oxygen and breathing treatment when he had the flu. The resident stated that he felt very bad while he had the flu and could not go to his day program. The resident stated he still hasn't received the flu shot. 12/6/2023 at 8:31 a.m., an interview was conducted with Resident #5. She stated that her family had to call S2DON to see when she could get the vaccine. The resident stated Why didn't we get the flu shot before? Staff interviews: On 12/05/2023 at 10:46 a.m., a phone interview was conducted with S17Pharmacist who denied any flu vaccines being on back order or having a shortage of flu vaccine. S17Pharmacist stated S3ADON (Assistant Director of Nursing) contacted the pharmacy on 11/14/2023 and requested flu vaccines for the facility's residents and staff. The requested vaccines were delivered to the facility on [DATE]. S17Pharmacist verified that the facility had not contacted the pharmacy prior to 11/14/2023 to order flu vaccines. On 12/05/2023 at 2:48 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S3ADON. S2DON explained she began working at the facility at the beginning of July 2023 and had not been informed that she was responsible for ordering flu vaccines. S2DON stated someone from the facility's corporate office asked her in September 2023 if flu vaccines had been ordered for the facility's residents and staff. S2DON confirmed flu vaccines had not been ordered at that time. S2DON stated she was then advised to notify the corporation's clinical nurse who provided her a phone number for a pharmacy out of town. When she contacted the pharmacy, she was told that they could not provide vaccines to her facility due to the facility's location. S2DON confirmed she failed to follow up with the corporation's clinical nurse after the suggested pharmacy could not provide the vaccines. S3ADON stated she attempted to call the corporation's pharmacy in October but the pharmacy's flu vaccines were on back order. S3ADON reported that she ordered the vaccines on 11/14/2023 and received them on 11/16/2023. 2. The facility failed to provide a list of dates when each eligible resident in the facility was administered the influenza vaccine. On 12/04/2023 at 4:00 p.m., S7IP stated flu vaccines were held after they were received and to began to administer them on 11/30/2023 because of the flu positive residents and the facility was unable to track and trace which residents had been exposed so facility made decision to hold the administration of the vaccines until facility staff felt flu exposure was decreased. On 12/05/2023 at 2:48 p.m., a joint interview was conducted with S2DON and S3ADON. S2DON and S3ADON explained they decided to delay administering the vaccines for two weeks because the facility had a flu outbreak of residents with the first cases identified in residents on 11/12/2023. On 12/06/2023 at 10:14 a.m., an interview was conducted with S10NP (Nurse Practitioner). S10NP denied being informed that the facility had received flu vaccines on 11/16/2023 nor that vaccines were held from 11/16/2023 through 11/29/2023. S10NP denied providing the facility's administrative staff with any recommendations to hold flu vaccines from 11/16/2023 through 11/29/2023. On 12/6/2023 at 10:45 a.m., S7IP confirmed that there were eligible residents in the facility who remained unvaccinated as of today. On 12/06/2023 at 11:58 a.m., an interview was conducted with S1ADM (Administrator) who stated he was not aware flu vaccines had been held. S1ADM confirmed he had not received any direction to hold flu vaccines for residents and confirmed at present there were residents who remained unvaccinated. On 12/06/2023 at 12:28 p.m., a phone interview was conducted with S11MD (Medical Director). He denied advising the facility's NP, DON or ADON to hold flu vaccines from being given to the residents nor was he aware the flu vaccines were held from 11/16/2023 through 11/29/2023.

Jun 2023 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 (#64) out of 36 sampled residents. The facility census was 86. Findings: Review of Resident #64's clinical record revealed that she was admitted to the facility on [DATE]. Her diagnoses include, in part, Alzheimer's Disease, Hallucination, Anxiety Disorder and Muscle Weakness. Review of the resident's Significant Change MDS (Minimum Data Set) dated 06/09/2023 revealed she had a BIMS (Brief Interview for Mental Status) score of 4, severely cognitively impaired. Further review revealed that she required limited assistance with one person physical assistance for person hygiene. She was occasionally incontinent of her bladder. She was current on hospice services. Review of the resident's plan of care revealed she was care planned for occasional episodes of urinary incontinence related to loss of bladder muscle tone and her interventions included in part .change soiled clothing after each incontinent episode . On 06/26/2023 at 10:55 a.m., upon entering Resident #64's room, an observation was made of the resident's daughter removing the sheets and blanket off the resident's bed. A strong urine odor noted. The resident's daughter stated that when she came in at 9 a.m., she found the resident in bed and her sheets were wet and had BM on them. She stated that the resident's socks and pants were also soaked with urine. She had to change the resident's diaper because it was soiled with bowel movement. She also had to change the resident's clothes because they were wet with urine. Resident #64 was observed sitting on the couch in her room. She was unable to effectively answer any question regarding the incident . At that time, an observation made of the resident's bed. The sheet and blanket was wet and the sheet had a brown colored spot near the head of the bed. The blue under pad was observed saturated. There were socks, pants and a shirt observed on the bathroom floor. The resident's daughter stated that this was not the first time that she has come to visit with the resident and found her wet. The resident's daughter stated that when she changed the resident, her incontinent brief was not saturated with urine. She stated that someone had changed the resident's incontinent brief but left the wet bed linen on the bed and the wet pants and socks on the resident. On 06/27/23 at 11:14 a.m., a review of the camera footage of the resident's room on the resident's daughter phone was conducted. Review of the camera footage revealed on 6/25/2023 at 9:00 p.m., the resident's private sitter was observed putting the resident in bed. Further review revealed that CNA staff did not enter the resident's room until 8:30 a.m. on 06/26/2023. The staff was observed only changing the resident's incontinent brief before leaving the room. On 06/27/2023 at 11:10 a.m., S25HS entered Resident #64's room. She was informed that the resident's daughter had found the resident with wet clothing and soiled incontinent brief. She was also informed that the resident's bed and bed linen was also found wet. S25HS made an observation of the resident's bed and bed linen. She confirmed that the resident's sheet, blanket and foam mattress were wet. S25HS agreed that the CNA (Certified Nursing Assistant) had change the resident and left the wet sheet, blanket and under pad on the resident's bed. She confirmed that the staff should have changed the wet bed linen and the resident's clothes when the resident's incontinent brief was changed. The CNA was unavailable for an interview. On 06/28/2023 at 10:30 a.m., an interview was conducted with S25HS. She stated that the CNA who went in the resident's room on 06/26/2023 stated that she did not change the resident's wet linen and clothes. The CNA stated she thought because the resident had a private sitter, the sitter would take care of it when she came in. On 06/27/23 at 11:30 a.m., an interview was conducted with S2DON. She agreed that the CNA should have changed the resident's bed linen and clothing if they were wet when she changed the resident's incontinent brief.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, the facility failed to follow its policy and procedure in regards to tube feeding for 1 (#7) out 1 (37) resident investigated for tube feeding. This deficient practice had a potential to affect 6 residents who recieved tube feedings. Finding: Resident #7. Review of the facility's policy and procedure titled Care of Tube Feeding . revealed, .Procedure: Ready to Hang Formula . Complete and label with the following; 1. Resident Name 2. Resident Room # 3. Time & date . 4. Rate of Flow 5. Nurses Initials . On 6/26/2023 at 9:34 a.m., the resident was observed lying down bed with the head of bed up. An unlabeled bag of tube feeding was observed infusing at 30 cc (cubic centimeter)/hr. per pump. The bag of tube feeding did not include a label with the date and time the feeding started, resident name, rate of flow, nurse initials, or the name of the tube feeding. On 6/27/2023 at 8:10 a.m., the resident was observed in bed with head of bed up. An unlabeled bag of tube feeding was observed infusing at 30cc/hr. per pump. On 6/27/2023 at 9:10 a.m., an observation was made of the resident's tube feeding with S5LPN. The LPN confirmed the tube feeding was Glucerna. S5LPN confirmed the tube feeding bag was not labeled per policy because it did not include name of tube feeding, date and time tube feeding started, rate of flow, and the nurse's initials that hung the tube feeding.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that nursing staff possess competencies and skill sets necessary to provide nursing services to assure residents' safety, and maintain the highest practicable physical well-being for 1 (#35) of 36 sampled residents. This was evidenced by Mucinex and Melatonin pills left at Resident #35's bedside. Findings: Review of the Facility's Medication Administration Policy read in part .Medications shall be administered in a safe and timely manner, and as prescribed .Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders, including any required time frame .9. Medications may not be prepared in advance and must be administered within (1) hour of their prescribed time, unless otherwise specified . A review of Resident #35's record revealed she was admitted to the facility on [DATE], with diagnoses including Insomnia, Hypertension, Type 2 Diabetes, and Generalized Anxiety Disorder. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 10, indicating that the resident's cognition was moderately impaired. Review of physician's orders revealed the following orders: -An order was written on 04/27/2022 for Melatonin 10 mg (milligrams) capsule 1 PO (by mouth) QHS (every night at bedtime); and -An order was written on 03/21/2022 for Mucinex ER (extended release) 600 mg 1 PO Q12H (every 12 hours) PRN (as needed) d/t (due to) cough. Review of the resident's June 2023 MAR (Medication Administering Record) revealed that Melatonin 10 mg was administered on 06/25/2023 at 8:00 p.m. by S17LPN. Further review of the June 2023 MAR revealed that the PRN Mucinex had not been administered. On 06/26/2023 at 10:48 a.m., an observation and interview was conducted with Resident #35. A clear medicine cup with a white capsule was noted on the resident's bedside table. A blue oval pill was noted on a small pink tray on the resident's over bed table. The resident stated that it was her sleeping pill from the night before that the nurse brought. The resident stated that she had forgotten to take it. The resident stated that her CNA (Certified Nursing Assistant) and nurse were in the room that morning and the pills had been in the same place. On 06/26/2023 at 11:00 a.m., an interview was conducted with S24LPN (Licensed Practical Nurse). S24LPN entered the residents room and confirmed that the pills were left at the resident's bedside and should not have been left there. S24LPN stated that Resident #35 had met her at her room door this morning, and she (S24LPN) had administered her medications there. She stated that she did not enter the resident's room and her bedside table was not in her sight when she administered the medications. On 06/26/2023 at 11:05 a.m., an interview was conducted with S3ADON (Assistant Director of nursing), in Resident #35's room. She observed the medications that had been left on her bedside tables. S3ADON identified the medications as Melatonin and Mucinex and stated that medications should have been administered as ordered and not left at the resident's bedside. 0n 06/26/2023 at 11:15 a.m., S3ADON confirmed that the white capsule was Melatonin that was scheduled to be given at 8:00 p.m., and the blue pill was Mucinex which was scheduled to be given PRN.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure kitchen staff wore hair coverings over facial hair while in the kitchen; 2. Ensure expired food items were removed from the dry goods storage room; This deficient practice had the potential to affect a census of 86 residents. Findings: Review of the facility's policy titled Refrigerators and Freezers read in part .The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .8. Supervisors will be responsible for ensuring food items in pantry, refrigerator, and freezers are not expired or past perish dates No policy for sanitary conditions/use of hair covering while in the kitchen was provided to surveyor by survey exit. On 06/26/2023 at 8:45 a.m., an observation of the kitchen was conducted with S14DM (Dietary Manager). Upon entering the kitchen, S14DM, S15DS (dietary staff) and S16DS did not have facial hair coverings. S14DM, S15DS and S16DS confirmed that they were not wearing hair coverings and stated they were unaware they should have been wearing facial hair coverings while in the kitchen. On 06/26/2023 at 9:05 a.m., an observation of the dry good pantry was conducted with S14DM. Observation of the pantry revealed the following expired food items: 1 - 8 pack loaf of hot dog buns with best used by date of 06/02/2023 1 - 8 pack loaf of hot dog buns with best used by date of 05/30/2023 6 - packs of small tortilla's with expiration date of 05/31/2023 S14DM confirmed the expired food items should not be in the pantry and should have been removed. S14DM further stated that he was responsible for checking the cooler, refrigerator, and dry goods storage area for any expired food items.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to evaluate the mental and physical competency to self-administer medications for 1 (#84) resident out of a total of 36 sampled residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. This facilty had a census of 86 residents. Findings: Review of the facility's policy and procedure titled Self Administration of Medication revealed in part, .The purpose of this procedures is to establish uniform guidelines concerning the self -administration of drugs. 1. A Resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician .Reporting and Documentation The following information should be reported to the staff/charge nurse and should be documented in the resident's medical record: 1. The name and strength of the medication taken by the resident and the route of administration. 2. The date and time the medication was administered. 3. Any inspections made of the medication(s) and quantity on hand .7. The signature and title of the person recording the data .These type items will be addressed in the plan of care .If self administration is accomplished, the resident care plan will describe which medications and routes of administration this applies to . Resident #84 was admitted to the facility on [DATE] with the following pertinent diagnoses: Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis of Vertebra, Sacral and Sacral-coccygeal Region and Multiple Sclerosis. Review of Resident #84's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating his cognition was moderately impaired. Review of Resident #84's June 2023 physician's orders revealed an order entry dated 03/20/2023 for Copaxone (medication to treat Multiple Sclerosis) 40 mg/mL (milligrams per milliliters) syringe. Inject 40 mg (milligrams) SQ (subcutaneous) MWF (Monday, Wednesday and Friday). Family will supply medication. Review of Resident #84's care plan failed to address the resident self -administering medications. On 06/28/2023 at 9:12 a.m., Resident #84 was observed awake and alert in his bed watching television with his bedside table within his reach. An observation was made of an opened syringe resting on top of the bedside table and a black storage bag near the opened syringe. Resident #84 stated he gave himself his injection of Copaxone 40 mg/ml. He explained one of his siblings visited him every Sunday and delivered the week's dose of Copaxone and the nurse stored the medication in the medication cart in his black storage bag. Resident denied facility staff evaluating him to self -administer the medication. On 06/28/2023 at 12:16 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse) who stated Resident #84 had administered his own injection of Copaxone earlier this morning. S3LPN accompanied surveyor to Resident #84's room and confirmed the injection syringe and supplies should not have been left on the resident's bedside table. S3LPN was unable to recall if the resident had been assessed to safely self-administer his medication. On 06/28/2023 at 1:55 p.m., an interview was conducted with S9MDS (Minimum Data Set Nurse) who stated she was responsible for care plans and confirmed Resident #84's current care plan had not addressed self-administration of medication. On 06/28/2023 at 2:40 p.m., S3ADON confirmed there was no evidence that Resident #84 had been evaluated to self-administer medication.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to consider the views of the residents and act promptly upon the grievances concerning issues of resident care and life in the facility as evidenced by the facility failing to address the complaints verbalized by multiple residents from 01/18/2023 through 06/13/2023 during the Resident Council meetings. The deficient practice had the possibility to affect the entire census of 86 residents. Findings: Review of the facility's policy titled Filing Grievances/Complaint included: Policy Statement. Our facility will help residents, their representatives, other interested family members, or resident advocates file grievances or complaints when such requests are made. The Policy Interpretation and Implementation included, in part: 1. Any resident, his or her representative (sponsor) family member or appointed advocate may file a grievance or complaint .; 3. Grievances and/or complaints may be submitted orally or in writing .; 4. The Administrator has delegated the responsibility of the grievance or complaint investigation to Social Services Director .; 5. Upon receipt of grievance and/or complaint SSD will 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 .; 6. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken .; and 7. 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. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident and a copy will be filed in the business office. Review of the facility's policy titled Grievance Complaint Log included, in part: 1. The disposition of all resident grievances and or will be recorded on our facility's Resident Grievance/Complaint Log. Review of the facility's policy titled Grievance/Complaints - Staff Responsibility, included, in part: 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of others residents, etc. the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how to file a written complaint with the facility. Review of the facility's policy titled Investigating Grievances/Complaints included, in part: Policy Statement: Our facility investigates all grievances and complaints filed with the facility. 1. The Administrator has assigned the responsibility of investigating grievances and complaints to Social Services Director .; 2. Upon receiving a grievance and complaint report, SSD will begin an investigation into the allegations .; 3. The Resident Grievance/Complaint Investigation Report Form must be filed with the Administrator within five (5) working days of the incident .; 4. The resident will be informed of the findings of the investigation, as well as any corrective actions recommended, within 5 working days of the filing .; and 6. Copies of all reports must be signed and will be made available to the resident . A review of the minutes from Resident Council Meetings (RCM) that occurred between 01/18/2023 and 06/13/2023 was conducted. The RCM conducted on 01/18/2023 indicated that residents #6, #30, #45, #53, and #62 had been in attendance. Staff in attendance included S11Office Manager, who was the previous Activity Director. The former Administrator was noted as being in attendance. Old business included, in part: Call lights not being answered; not enough workers; CNAs (Certified Nursing Assistants) hiding in rooms. New business included, in part: CNA not answering call bells in a timely manner; agency CNA coming in rooms with phone in their hands and ear pieces; not enough lifter pads; staff not reading meal cards; residents on Hall 1 and Hall 2 are receiving the wrong meals. The form was reviewed and signed by the former Administrator on 02/14/2023. The RCM conducted on 02/02/2023 indicated that residents included #6, #12, #30, #45, #53, and #62 had been in attendance. Staff in attendance included S11Office Manager and S26Activity. New business included, in part: having trouble with CNA not showing up for their shift at correct time and no one aware of staff not being here; staff still not reading meal cards Hall 1 and Hall 2; CNA hiding in rooms; Hall 3 resident too long to receive their meds; A hall nurse would not pass meds until 11:30 (a.m. or p.m. not indicated); Hall 1 staff are not answering call lights. The form was reviewed and signed by the former Administrator and dated 02/14/2023. The RCM conducted on 03/07/2023 indicated that residents included #6, #12, #26, #30, #35, #53, and #62. Staff in attendance were S11Office Manager. New Business included, in part: call bells are still not being answered fast enough; Hall 3 has to do without CNA if someone calls in on another hall; weekends are horrible with no staffing; some residents are complaining of not getting the help they need with ADLs (Activities of Daily Living) on Hall 1, CNAs are telling residents they are shorthanded; residents pressed their call lights to get up no one comes; trays (meal) are still being left in rooms sometimes they have 3 left in rooms. The form was reviewed and signed by S1ADM on 03/10/2023. The RCM conducted on 04/11/2023 indicated that residents in attendance included #6, #12, #26, #30, #45, #53, and #62. Staff in attendance included S11Office Manager. Old business included: call bell response taking too long; why if they have a call in they pull CNA from Hall 4; weekends are horrible because of staff calling in; residents stated that some aren't getting the help they need with ADLs; CNA saying they are short staffed. No new business was noted. The form was reviewed and signed by S1ADM on 04/14/2023. The RCM conducted on 05/12/2023 indicated that residents in attendance included #6, #12, #26, #30, #45, #53, and #62. Staff in attendance was S11Office Manager. No old business was noted. New business included that they feel there are not enough lifters; meal trays are not being picked up; and employees need to have name tags. The form was reviewed and signed by S1ADM and not dated. The RCM conducted on 06/13/2023 indicated that resident in attendance included #6, #12, #18, #26, #30, #35, #45, #53, and #62. Staff in attendance were S26Activity and S13AIT. Old business included: See attached. No document had been provided. New Business included: need more help with CNA- waited too long for call bell with CNA. The form was reviewed and signed by S13AIT on 06/13/2023. A review of facility's Grievance and Complaint Log was conducted. No entries concerning the multiple or repetitive residents' complaints from the RCM meetings from 1/18/2023 to 6/13/2023 were noted. On 06/27/23 at 10:30 a.m., a meeting was conducted with the Resident Council. Residents #6, #12, #18, #26, #30, #35, #45, #53, and #62 were present. They stated that most of the issues come down to lack of staff, especially during the weekends. They stated that the facility used agency staff a lot. The agency staff do not know them, do not care about them, and are not invested in them like the regular employees. The residents who stated they were more dependent on staff have had to wait extended times, sometimes up to an hour and a half, for ADL care or to have their call bells answered. One female resident stated that she waited until after 9:00 p.m. to be put back into her bed. She stated that a male worker that was passing by assisted her into her bed and she could not wait any longer to be changed so he assisted her. Residents stated that they were unable to attend lunch in the dining room because they required staff to get them out of bed and there was no one available to assist them. The residents stated that they have verbalized their concerns during the Resident Council Meetings over and over and nothing has changed. They stated that they have spoken to S1ADM and S13AIT and have been told they would look into it, but nothing had got better. Many of the residents in the meeting were visibly upset. One resident stated that they were frustrated of bringing the same issues forward and not being heard by anyone. They stated that this did not feel like it was their home. On 06/28/2023 at 10:30 a.m., an interview was conducted with S27SSD. She stated that she had been the Social Services Director for one year, since June of 2022, and that she was the staff that handled grievances and complaints for the facility. S27SSD stated that all oral complaints and grievances regarding residents that were received from the staff, including S1ADM or S13AIT, were to be reported to her so that the procedures for the grievance and complaints could be implemented. She stated that upon receipt of a complaint, a written report would be generated, an investigation would be conducted, and the results and resolutions would be made available in writing to the persons/residents involved. She stated the results of the investigations would be presented to the Administrator for his review within 5 days after the complaint would have been received. She stated that the Grievance Complaint Log that was presented for review held all the complaints that she had been made aware of. The RCM minutes from 01/18/2023 through 06/13/2023 were presented to S27SSD. She reviewed the minutes and stated that these had never been presented to her, and that this was the first time she had seen the complaints made by the residents during the resident council meetings. She confirmed that the residents had verbalized complaints, some repetitive, that had not been investigated. She stated that she should have been made aware of the complaints, investigations should have been conducted, results given to the Administrator for review, and resolutions discussed with the residents. She confirmed that multiple staff were present during the meetings and further stated that these staff should have brought these complaints and grievances to her to be investigated. On 06/28/2023 at 10:50 a.m., an interview was conducted with S1ADM. He stated that S27SSD had made him aware of the grievance/complaint issues that this surveyor had discussed with her earlier. He reviewed the RCM and confirmed that issues verbalized by the residents included complaints that call lights not being answered in a timely manner repeated over multiple months; not enough workers; repeated complaints that CNAs (Certified Nursing Assistants) were hiding in rooms; agency CNAs coming into residents' rooms while using their cell phones; repeated complaints that staff were not reading meal cards and the residents were receiving the wrong meals; having trouble with CNAs not showing up for their shift at the scheduled time and that no one was aware that staff was not there; residents waiting too long to receive their medications; nurses not passing medications until 11:30 a.m.; multiple complaints regarding CNA shortages; weekends are horrible with no staffing; repeated complaints that residents were not getting the help they need with ADLs (Activities of Daily Living); multiple complaints that CNAs were telling residents they are shorthanded; residents pressing their call lights to get up and no one coming to assist them; repeated complaints that meal trays were left in the residents' rooms sometimes they have 3 trays left in rooms; and employees not having name tags on. S1ADM confirmed that he had signed the May and June 2023 RCM meetings, indicating that he had reviewed the minutes from the meetings. He confirmed that the RCM minute forms from 01/18/2023 through 06/13/2023 identified numerous complaints and grievances verbalized by the residents. He confirmed that none of the residents' complaints that had been verbalized in the Resident Council Meetings from 01/18/2023 through 06/13/2023 had ever been addressed by the facility. S1ADM stated that as Administrator of the facility, it was his responsibility to ensure that the grievance policies and procedures were followed and that the residents' complaints were addressed. He confirmed that he had failed to ensure the residents' grievances were addressed.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed: 1. to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility, and complaint investigations made respecting the facility during the 3 preceding years; and 2. failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Findings: A review of surveys conducted in the facility during the last 3 years revealed the following: Complaint surveys had been conducted on 05/31/2023, 03/14/2023, 01/31/2023, 01/4/2023, 01/27/2022, 05/12/2021, 01/6/2021, 11/6/2020, and 07/24/2020; and Recertification surveys had been conducted on 05/25/2022 and 05/19/2021. On 06/27/2023 at 11:30 a.m., an observation of a binder labeled Annual Inspection/Survey Results was made in the front lobby area of the facility. The contents of the binder included only Recertification Surveys conducted on 05/25/2022 and 05/19/2021. The binder did not hold any other surveys conducted during the 3 preceding years. Further review of the area where the binders were held failed to reveal any information regarding other surveys, including complaint investigations. No posting of a notice of availability of such reports was observed. On 06/27/2023 at 11:45 a.m., an interview was conducted S13AIT. He reviewed the binder labeled Annual Inspection/Survey Results and confirmed that the only survey information in the binder were the recertification surveys conducted on 05/25/2022 and 05/19/2021. He reviewed the area where additional information was readily available, and stated that there were no reports regarding any other surveys conducted posted there, including the complaint surveys that had been conducted. S13AIT confirmed that no notice had been posted in a place that was readily accessible, regarding the availability of such reports.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#6) out of 2 (#6, #27) sampled residents reviewed for advanced directives. The deficiency had the potential to effect a census of 86. Findings: Review of the facility's policy titled Advance Directives read in part: 7. The interdisciplinary team will review annually with the resident his or her advance directive to ensure that directives are still the wishes of the resident. Such review will be made during the annual assessment process and recorded on the MDS (Material Data Set). 9. The Director of Nursing (DON) or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included, but not limited to Edema, Morbid Obesity, Peripheral Vascular Disease and Sleep Apnea. Review of the most current MDS (Material Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 11 which indicated resident was moderately impaired. Further review of the admission MDS dated [DATE] revealed a BIMS score of 11, indicated the resident was moderately impaired. Review of Resident #6's Physician Orders dated [DATE] revealed the following: [DATE] - Do Not intubate. Review of Resident #6's LaPOST (Louisiana Physician Orders for Scope of Treatment) dated [DATE] revealed the following in part: A. Cardiopulmonary Resuscitation (CPR)/attempt resuscitation (requires full treatment in section B), box is marked with as X. B. Medical Interventions: . Full Treatment . Use mechanical ventilation, advanced airway intervention , box is marked with and X. Selective Treatment Do not intubate. Generally avoid intensive care. This box is not marked with an X. The LaPOST is signed by the resident's daughter, on [DATE] and by the physician on [DATE]. During an interview on [DATE] at 9:35 a.m. with S5LPN, she reported the resident did have a LaPOST and the resident's code status is FULL CODE. S5LPN the reviewed the resident's MD orders with the surveyor and confirmed the resident had an order for DO NOT INTUBATE, that was written on [DATE] making the physician order and LaPOST having two different resuscitation directives. On [DATE] at 1:20 p.m., an interview conducted with Resident #6's daughter. She confirmed she had signed the LaPOST, with CPR and Full treatment on [DATE].

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #76: Review of Resident #76's electronic record revealed the resident was admitted to the facility on [DATE]. His diagnoses included the following, in part, Human Immunodeficiency Virus (HIV), Pneumocytosis, Essential Hypertension, Neurosyphilis and Anxiety Disorder. Review of Resident #76's June 2023 physician orders revealed no order for an anticoagulant medication. Review of Resident #76's quarterly MDS dated [DATE] under Section N-Medications revealed the resident was assessed for having received an anticoagulant medication during the last 7 days. On 06/28/2023 at 4:22 p.m., an interview was conducted with S8MDS. She reviewed Resident #76's May and June physician orders and she reviewed the resident's quarterly MDS dated [DATE]. She confirmed, based on the physician orders, that the resident was not prescribed an anticoagulant. She also confirmed that the resident's MDS assessment conducted on 05/24/2023 was not accurate for the use of an anticoagulant. Based on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 2 (#7, #76) out of 36 sampled residents. The facility had a census of 86 residents. Findings: Resident #7. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Cerebral Infarction, Shortness of Breath, Congestive Heart Failure, Diabetes, Atrial Fibrillation, and Respiratory Failure. Correct all the dates to be consistent in form for both resident's information On 6/27/2023 at 8:36 am, the resident was observed lying down in bed during this observation. S6CNA (Certified Nursing Assistant) was observed in the room with the resident at that time. S6CNA confirmed the resident's lower extremities were contracted bilaterally. On 6/27/2023 at 10:00 am, an interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed the Resident #7's lower extremities were contracted. Review of the resident's quarterly MDS (Minimum Data Set) dated 6/7/2023 revealed the resident was coded for having no impairment to lower extremity. On 6/27/2023 at 12:30 pm, an interview was conducted with S8MDS. She reviewed the Resident #7's quarterly MDS dated [DATE] and confirmed the resident was coded for not having any impairments to lower extremity. S8MDS confirmed the quarterly MDS assessment was inaccurate because the resident had contractures to both lower extremities.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care for 2 (#7 and #84) residents out of a sample of 36 residents by: 1. Failing to address contractures for Resident #7; and 2. Failing to implement physician's orders for the correct infusion rate for Resident #7's tube feeding; and 3. Failing to implement physician's orders for Resident #7's left hip wound; and 4. Failing to implement physician's orders to administer a medication for Resident #84 when his feet were swelling. Findings: 1. Resident #7. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Cerebral Infarction, Shortness of Breath, Congestive Heart Failure, Diabetes, Atrial Fibrillation, and Respiratory Failure. Review of the resident's care plan revealed no care plan for contractures. On 6/27/2023 at 8:36 am, the resident was observed lying down in bed. S6CNA (Certified Nursing Assistant) was observed in the room with the resident at that time. S6CNA confirmed the resident's lower extremities were contracted bilaterally. On 6/27/2023 at 10:00 am, an interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed the resident's lower extremities were contracted. On 6/27/2023 at 12:35 pm, an interview was conducted with S9MDS (Minimum Data Set). She reviewed the resident's current care plan and confirmed that contractures to the resident's lower extremities were not addressed in the care plan. 2. Review of Resident #7's progress notes dated 6/13/2023 at 8:25 p.m. revealed, . FNP (Family Nurse Practitioner) notified of Registered Dietitian recommendation. NON (New order noted) and carried out to increase glucerna 1.5 to 35 cc/hr to better meet nutritional needs . Review of the resident's current physician's orders for June 2023 revealed an order dated 6/13/2023 for Glucerna 1.5 at 35 cc/hr. The previous order was Glucerna 1.5 30cc/hr that started on 2/3/2023 and was discontinued on 6/13/2023. On 6/26/2023 at 9:34 a.m., the resident was observed lying down bed with the head of bed up. An unlabeled bag of tube feeding was observed infusing at 30cc/hr per pump. On 6/27/2023 at 8:10 a.m., the resident was observed in bed with head of bed up. An unlabeled bag of tube feeding was observed infusing at 30cc/hr per pump. On 6/27/2023 at 9:10 am, an observation was made of the resident's tube feeding with S5LPN. The LPN confirmed the tube feeding was Glucerna and that it was infusing at 30cc/hr. She confirmed the tube feeding was infusing at the wrong rate and that the rate should have been set at 35cc/hr as ordered by the physician. 3. Review of Resident #7's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 00, indicating severely impaired cognition. The resident is total dependence and required extensive assistance. The resident required over 51% of calories through feeding tube, was at risk for pressure ulcer and received an application of dressing and ointments. Review of physician's orders revealed an order written on 05/15/2023 to clean left hip s/t (skin tear) with WC (wound cleanser) and apply TAO (triple antibiotic ointment) and cover with DCD (dry clean dressing) daily. Review of Resident #7's plan of care revealed the resident was care planned for impaired skin integrity with an intervention to clean left hip skin tear with wound cleanser and apply TAO and cover with DCD daily. Review of Resident #7's eTAR (Electronic Medical Record) revealed green check marks and initials for S7RN (Registered Nurse) on 06/24/2023 and 06/25/2023, and a green check mark for S4LPN (Licensed practical Nurse) on 06/26/2023, indicating that they changed the resident's dressing on those days. On 06/27/2023 at 9:54 a.m., a congruent observation and interview was conducted with S4LPN during Resident #7's dressing change. S4LPN stated she changed the resident's dressing on 06/26/2023. When the resident was turned, the old dressing on the resident's left hip was intact and dated 05/25/2023 with initials from S7RN. S4LPN stated that S7RN worked on the weekend and must have written the wrong month. S4LPN confirmed that she should have changed the resident's dressing yesterday and did not. 4. Resident #84. Review of the resident's electronic health record revealed Resident #84 was admitted to the facility on [DATE] with the following pertinent diagnoses: Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis of Vertebra, Sacral and Sacral-coccygeal Region, Multiple Sclerosis, Presence of Cardiac Pacemaker and Moderate Protein-Calorie Malnutrition. Review of Resident #84's current June 2023 physician's orders revealed an order entry dated 04/21/2023 for Furosemide 40 mg (milligram) tab (tablet) take 40 mg as needed daily for feet swelling: Select amount of edema present. Review of Resident #84's electronic health record revealed he was care planned for diuretic therapy and at risk for skin breakdown r/t (related to) needs assist with bed mobility and decreased mobility. Resident #84's care plan included interventions to give Furosemide as ordered. Review of Resident #84's eMAR (electronic Medication Administration Record) revealed Furosemide 40 mg tablet had not been administered for the month of June 2023. On 06/28/2023 at 9:12 a.m., Resident #84 stated he had not received any Furosemide while residing at the facility and denied facility staff addressing his current feet swelling. On 06/28/2023 at 3:03 p.m., an interview was conducted with S12LPN who stated she had recently received change of shift report that did not include Resident #84 having swelling to his feet and that she had not yet assessed him. On 06/28/2023 at 3:05 p.m., a joint interview and observation was made of Resident #84 with S12LPN. Resident #84 was observed in bed watching television and had heel boots to both feet. S12LPN removed Resident #84's heel boots and observed the swelling to his left foot. Resident #84 stated to S12LPN that usually his right foot had the swelling not his left foot and that he had a medication called Furosemide to take when he had the swelling. S12LPN confirmed the resident had pitting edema and had not received Furosemide during the previous shift.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and provide the needed care and services in accordance with professional standards of practice to meet the highest practicable physical well-being of residents for 1 (#6) of 1 (#6) sample residents for skin conditions by failing to conduct weekly fully body assessment. The deficiency had the potential to affect a census of 86. Findings: Review of the facility's policy titled Pressure Injury Prevention and Management revealed in part: Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of two components: Prevention/Screening and Treatment/Evaluation. Screening: On a weekly basis, the treatment nurse will conduct a full body skin assessment on all residents . Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included in part: Edema, Morbid Obesity, Peripheral Vascular Disease and Sleep Apnea. Review of the most current MDS (Material Data Set) dated 05/03/2023 revealed a BIMS (Brief Interview of Mental Status) of 11 which indicated resident was moderately impaired. Further review of the MDS revealed Resident #6 required extensive, two plus person assist for bed mobility, transfers, and toileting. Review of the physician orders revealed an order dated 06/23/2023 Cipro (antibiotic) 500 mg po BID for infected toe to stop 07/04/2023. On 06/26/2023 at 1:55 p.m., an interview with Resident #6, she stated over the past weekend, her left foot was hurting and when she removed the covers her foot was red and green. She continued to say her left great toenail was infected. Review the resident's nurses notes and skin and wound assessment revealed no documentation of an assessment of the left foot/great toe during the month of June 2023. Further review of the wound/skin assessments revealed the resident did have any documentation of weekly full body skin assessments. On 06/28/2023 at 9:35 a.m., an interview was conducted with S5LPN. She stated the weekly skin assessments were done by the treatment nurse. She stated she was unaware of the skin issue with the residents left great toe prior to being placed on antibiotics. On 06/28/2023 at 1:25 p.m., an interview was conducted with S2DON. She confirmed S4LPN was responsible for completely weekly skin assessment on all residents. On 06/28/2023 at 2:03 p.m., an interview was conducted with S4LPN. She confirmed weekly skin assessments had not been performed on Resident #6 for the month of June 2023.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure that a resident received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 1 resident (#84) out of a total of 36 sampled residents. Findings: Review of the facility's policy titled Pressure Injury Prevention and Management revealed in part: Skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of two components: Prevention/Screening and Treatment/Evaluation .Screening: On a weekly basis, the treatment nurse will conduct a full body skin assessment on all residents. Resident #84 was admitted to the facility on [DATE] with the following pertinent diagnoses: Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis of Vertebra, Sacral and Sacral-Coccygeal Region and Multiple Sclerosis. Review of Resident #84's admission (Minimum Data Set) MDS dated [DATE] revealed under Section M, Skin Conditions, Resident #84 was assessed at risk for developing pressure ulcers. Review of Resident #84's electronic medical record revealed no evidence that clinical skin assessments were conducted since the resident was admitted to the facility. Review of Resident #84's June Physician's Orders revealed no treatment orders for a wound to the left ankle. Review of Resident #84's June TAR (Treatment Administration Record) revealed the resident had no wound care orders for a wound to the left ankle. On 06/28/2023 at 9:12 a.m., an observation and interview was conducted with Resident #84. He stated that his left foot felt different and was observed with heel boots to both feet. On 06/28/2023 at 12:16 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated S4LPN was responsible for conducting weekly skin assessments. On 06/28/2023 at 1:25 p.m., an interview was conducted with S2DON(Director of Nursing/ Infection Preventionist) who confirmed S4LPN, was responsible for completing weekly skin assessment on all residents. On 06/28/2023 at 2:54 p.m., an interview was conducted with S4LPN who stated she was informed on Monday, 06/26/2023, that she was responsible for conducting weekly skin assessments. An observation was made with S4LPN of Resident #84's left foot and she confirmed he had a wound to his left outer ankle bone with pedal swelling. Resident #84 asked S4LPN where the wound came from and S4LPN explained it was from too much pressure to that area. S4LPN confirmed she had not been notified of a wound to Resident #84's left ankle and this was the first time she had seen the wound.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviews, and interviews the facility failed to ensure respiratory equipment was properly stored when not in use and failed to ensure nursing staff changed respiratory mask and tubing per facility's protocol for 1 (#19) of 1 (#19) residents investigated for respiratory care out of a total sample of 36 residents. Findings: Review of the facility's policy titled CPAP/BiPAP Support (Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure) read in part: .9. When CPAP or BiPAP is not in use, place the face mask securely in a zip lock or plastic bag. 10. Replace CPAP or BiPAP masks, nasal pillows, and tubing are to be changed once every 3 months. Resident #19 was admitted to the facility on [DATE] with a diagnosis in part: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of Resident #19's MDS (Minimum Data Set) dated 03/09/2023 Section C revealed the Resident's BIMS score (Brief Interview for Mental Status used to score cognitive ability) was 11 which indicated the resident's cognition was moderately intact. Section O for Special Treatments showed that the resident had a Non-Invasive Mechanical Ventilator (BiPAP/CPAP). Section G for Functional Status revealed the resident required extensive assistance from one staff member for personal hygiene (for activities such as combing hair and brushing teeth) and had impairment on one side of the upper extremity. Review of Resident #19's Care Plan revealed he was Care Planned for altered breathing pattern related to COPD (Chronic Obstructive Pulmonary Disease) with interventions that included in part: .Change any O2 (Oxygen) tubing or nebulizer tubing and CPAP/BiPAP mask/tubing per facility protocol and PRN (as needed). Review of Resident #19's June 2023 Physician's Orders revealed no physician's orders for changing or the storage of respiratory equipment when not in use. Review of Resident #19's June MAR (Mediation Administration Record) and June TAR (Treatment Administration Record) revealed no evidence that the respiratory mask or tubing had been changed nor were there orders for the storage of the respiratory equipment when not in use. On 06/26/2023 at 9:45 a.m., an interview/observation was made of Resident #19 in his room. A BiPAP machine was noted on the nightstand with the tubing draped across the table, the mask was hanging and not in a bag. The mask was open to air and not labeled with a date. Grey-white dried substance was noted on the inside of the mask. The resident confirmed that he was unable to apply or remove the BiPAP mask on his own and that this was done per nursing staff. On 06/27/2023 at 11:03 a.m., a second observation observation was made of Resident #19's room. The BiPAP machine was on the nightstand with the tubing and the mask draped across it. The mask was not in a plastic bag, and was not labeled with the date. There was dried, grey-white substance on the inside of the mask. On 06/27/2023 at 11:06 a.m., an interview and observation was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated that oxygen tubing and masks were changed by treatment nurse unless soiled, then it can/should be done by the floor nurse. S3LPN observed Resident #19's respiratory equipment and confirmed that Resident #19's BiPAP mask was visibly dirty and should have been in a plastic bag because it was not in use. S3LPN stated the resident does not wear the BiPAP at all during daytime hours for rest periods (naps) so the mask should not have been open to air during the daytime. S3LPN also confirmed that Resident #19 was not capable of applying or removing his respiratory mask. S3LPN stated the nursing staff performs both tasks of applying and removing the residents BiPAP mask. On 06/28/2023 at 12:10 p.m., an interview was conducted with A3ADON. S3ADON stated that in order for a task to populate on the MAR or TAR, a Physician's Order would have to be written. Resident #19's Physician's Orders for the month of June were reviewed with S3DON. S3ADON confirmed there were no Physician's Orders for changing, cleaning or storing the BiPAP mask and tubing. S3ADON then reviewed Resident #19's MAR and TAR for the month of June and confirmed there were no tasks for changing, cleaning or storing the Resident's BiPAP mask and tubing.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance meetings at least quarterly. This deficient practice has the potential to affect a census of 86 residents. Findings: A review of the facility's Quarterly Quality Assessment and Assurance meetings revealed meetings dated of 10/18/2022, 01/20/2023 and 04/26/2023, had no evidence or signature, indicating the medical director was in attendance of the quarterly meetings. On 06/28/2023 at 3:30 p.m., during an interview with S1ADM, he confirmed the medical director did not attend the quarterly quality assessment and assurance meetings.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure there was evidence that CNAs (Certified Nursing Assistants) and LPNs (Licensed Practical Nurse), including agency or contracted CNAs and LPNs, received in-service training regarding abuse/neglect/exploitation, resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs for 4 (S18LPN, S19CNA, S20CNA, S21CNA) out of 5 (S4LPN, S18LPN, S19CNA, S20CNA, S21CNA) personnel records reviewed. Findings: Review of S18LPN's personnel record revealed that she was an agency LPN. There was no start of contract date noted in the LPN's personnel record. Further review of the LPN's personnel record revealed that there was no evidence of current training within the year on abuse/neglect/ exploitation and infection control. There was no evidence of training on resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs in the personnel record. Review of S19CNA's personnel record revealed that she was an agency CNA. There was no start of contract date noted in the CNA's personnel record. Further review of the CNA's personnel record revealed that there was no evidence of training on resident rights, dementia care, communication, behavioral health, and specific resident needs in the personnel record. Review of S20CNA's personnel record revealed that she was an agency CNA. Further review of the CNA's personnel record revealed that there was no evidence of current training within the year on abuse/neglect/exploitation and infection control. There was no evidence of training on dementia care, infection control, communication, behavioral health, and specific resident needs in the personnel record. Review of S21CNA's personnel record revealed that she was an agency CNA. Further review of the CNA's personnel record revealed that there was no evidence of current training within the year on abuse/neglect/exploitation and infection control. There was no evidence of training on dementia care, infection control, communication, behavioral health, and specific resident needs in the personnel record. On 6/28/2023 at 4:00 pm, an interview was conducted with S22Asst ADM (Assistant Administrator). She confirmed she could not provide evidence the agency staff completed the trainings.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on record review and interview, the facility failed to ensure there was a sufficient number of staff to care for the resident's needs as identified in the facility assessment which has the potential to affect the care for the 86 residents in the facility. Finding: Review of the facility's Facility Assessment 2023 that was dated 1/22/2023 revealed the assessment was based on a census of 53. The Facility Assessment revealed that 3 nurses were needed on the day, evening and night shift. Review of the facility's work/staff schedule revealed that on 5/14/2023 (Sunday) there were 2 LPNs on the evening shift. On 5/20/2023 (Saturday) there were 2 LPNs on the night shift. On 5/21/2023 (Sunday), there were 2 LPNs on the night shift. On 5/27/2023 (Saturday), there 2 LPNs on the night shift. On 5/28/2023 (Sunday), there were 2 LPNs on the night shift. On 6/3/2023 (Saturday) there were 2 LPNs on the evening and night shift. On 6/4/2023 (Sunday), there were 2 LPNs on the evening and night shift. On 6/24/2023 (Saturday), there were 2 LPNs on the night shift. On 6/25/2023 (Sunday), there were 2 LPNs on the night shift. On 6/28/2023 at 4:50 pm, S1ADM (Administrator) reviewed the Facility Assessment and confirmed that the Facility Assessment was dated 1/22/2023 and was based on a census of 53. He confirmed that the assessment revealed a need for 3 nurses. S1ADM stated the census was currently 86 and that 2 nurses were scheduled to work the night shifts. He stated the Facility Assessment was based on the previous administration's assessment. S1ADM confirmed that he did not complete a current Facility Assessment since he has been the administrator because he did not have time.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Storage of Medications read in part .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Resident #7 was admitted to the facility on [DATE] with diagnoses including Chronic Diastolic Heart Failure, Type 2 Diabetes Mellitus, Seizures, Gastro-Esophageal Reflux Disease, and Vitamin Deficiency. Review of Resident #7's Physician's orders revealed the following in part: Generics may be used . 05/15/2023 Lt (left) hip s/t (skin tear): clean with WC (wound cleanser). Apply TAO (Triple Antibiotic Ointment) & covered with DCD (dry clean dressing) daily. Review of Resident # 7's plan of care revealed the following in part: Impaired skin integrity, actual related to skin failure, with an intervention to clean left hip skin tear with wound cleanser and apply TAO and cover with DCD daily. On 06/27/2023 at 9:54 a.m., an observation was made of S4LPN (Licensed Practical Nurse) performing Resident #7's dressing change. S4LPN removed a tube of A&D ointment from the treatment cart and used a tongue depressor to scoop some out and placed in a clear medicine cup. The A&D ointment was noted to be cut across at the top and left open. S4LPN placed the tube back in the treatment cart. On 06/27/2023 at 10:05 a.m., a congruent observation of the A&D ointment tube and an interview was conducted with S4LPN. The top of the tube was cut off, the foil on the original opening was punctured, the cap was missing, there was no opening date on the tube, and there was about ¼ of ointment left in the tube. S4LPN stated she has been using the tube like that for two weeks, but is not the one who cut it. S4LPN stated that the tube should have been labeled, and should not have been cut and left open in the cart. On 06/27/2023 at 2:15 p.m., an interview was conducted with S2DON (Director of nursing and Infection Preventionist) and S3ADON (Assistant Director of Nursing). S3ADON stated that the tube should have been dated when opened, and should not have been cut open and left in the cart. S2DON stated that the A&D ointment tube should have been labeled with an opening date and not left open in the cart Based on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program by: 1. Failing to have a description of the building water systems using text and flow diagrams, knowing the acceptable ranges of the temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread, or ways to intervene when control limits were not met. 2. Failing to use nationally recognized surveillance criteria to define infections 3. Failing to ensure that wound care ointment used on Resident #7 was stored in a sanitary manner. This deficient practice had the potential to affect the 86 residents residing in the facility. Findings 1. Review of the facility's policy titled Legionella read: Purpose: To ensure water safety from Legionella. General Guidelines: 1. No large holding tanks on premises 2. On city water 3. Weekly testing of water temperatures 4. Mixing valves on all boilers and hot water tanks 5. In lieu of a boil advisory, facility will use emergency water or boil water. Water testing will be done daily during boil advisory and an additional week after boil advisory lifted. On 06/27/2023 at 11:00 a.m., an interview was conducted with S1ADM (Administrator) who stated the Maintenance Supervisor was responsible for the facility's water management to prevent the growth of Legionella. Requested copy of the facility's assessed description of the building water systems using text and flow diagrams where Legionella and other opportunistic waterborne pathogens can grow and spread. S1ADM stated the facility had no water storage tanks on site and was unable to produce the required text and flow diagrams requested. On 06/28/2023 at 9:06 a.m., an interview was conducted with S10Maintenace who stated he tested the facility's water temperatures daily and that he did not know the acceptable ranges of temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread. S10Maintanence did not know any ways to intervene when control limits were not met. 2. Record review of facility's infection surveillance revealed monthly monitoring and tracking of infections but did not include a tool for defining infections based on nationally recognized surveillance criteria. On 06/26/2023 at 4:20 p.m., an interview was conducted with S2DON (Interim Director of Nursing/Infection Preventionist) stated she was the facility's designated Infection Preventionist (IP) and was new to the position. S2DON further stated the former IP recently resigned and took all binders and resources used for the facility's Infection Control Program. S2DON was unable to determine if a nationally recognized surveillance criteria (McGeer's surveillance criteria for infections) was used for defining infections. On 06/28/2023 at 4:29 p.m., S1ADM stated all policies and procedures provided to the survey team were pulled from the facility's policies and procedures binder that had been last reviewed on 01/06/2023 by the former Administrator. S1ADM further stated the facility was using a new program that was implemented in May 2023 with updated policies and procedures that only he had access to.

May 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure residents maintain the highest practicable physical, mental, and psychosocial well-being of as evidence by not having the prescribed medication Alprazolam available for administration when it was not reordered appropriately, and by failing to transcribe orders for Lasix and blood work for one (#1) resident of a sample of 6 (#1-6) residents. The total census was 94 residents. Findings: A review of the facility's policy and procedure titled Physician Orders/Transcribing included the following: Purpose: To accurately transcribe and carry out physician's orders. Method: Transcribe the medication orders to the medication [NAME] or MAR (Medication Administration Record). A review of the facility's policy and procedure titled Medication and Treatment Orders. Policy Interpretation and Implementation. 11. Drugs and Biologicals that are required to be refilled must be recorded from the issuing pharmacy not less than three (3) days to the last dosage being administered to ensure that refills are readily available. A review of Resident #1's printed Physician's Orders included the following: An order dated 06/21/2021 for the Alprazolam 0.5 mg (milligrams) one tab po (by mouth) QIC (four times a day), for Generalized Anxiety Disorder. A discontinue date of 04/19/2023 was noted for this order; and A handwritten Physician's Telephone Order dated 03/22/2023 for start Lasix 20 mg one po qd (every day) (edema of LE's), and Repeat BMP (Basic Metabolic Panel-blood work) Q (every) week x 3 weeks. A review of Resident #1's care plan revealed the following in part: I have to potential for Anxiety and I have the potential for trauma related to medication administration with same approach to administer medications as ordered: Xanax (Alprazolam) 0.5 mg (milligrams) po (by mouth) QID (four times daily). A review of Resident #'1 March 2023 MAR (Medication Administration Record) failed the order for Lasix 20 mg one po qd from 03/22/2023 nor the administration of the medication. A review of Resident #'1 April 2023 MAR revealed the order for Alprazolam 0.5 mg tab one tab by mouth 4 times daily with a discontinue date of 04/19/2023. Further review revealed N documented at 8:00 AM on 04/05/2023, 04/07/2023, 04/08/2023, and 04/10/2023; N documented at 12:00 PM from 04/05-08/2023; N documented at 4:00 PM on 04/07/2023, 04/08/2023, and left blank on 04/18/2023; N documented at 8:00 PM on 05/08/2023. The review revealed that 12 doses of the ordered benzodiazepine had not been administered in as ordered. Additionally, the MAR failed to reveal the Lasix order nor the administration of the medication. Prescriptions noted in Resident #1's chart were dated 01/27/2023 to dispense 120 tablets of Xanax (Alprazolam) 0.5 mg one po QID, and 02/22/2023 to dispense 120 tablets of Xanax 0.5 mg one po QID. Further review failed to reveal a prescription for Xanax in March or April 2023. A review of Individual Resident's Controlled Substance Medication Record for Resident #1's Alprazolam (Xanax) with a start date of 04/1/2023 was conducted. On 04/01/2023, the resident had 11 remaining after a 4P administration. On 04/04/2023 at 4 PM one tab was administered and 0 was documented as the amount remaining. No further administration was noted to this medication record. The next Individual Resident's Controlled Substance Medication start date was 04/10/2023 with an amount on hand as 120. On 05/3/12023 at 8:00 a.m., an interview was conducted with S1DON. She confirmed that on 03/22/2023, S7NP had ordered Lasix 20 mg q day for Resident #1's edema to her bilateral lower extremities and to repeat a BMP Q wk x 3 weeks. S1DON reviewed Resident #1's March and April 2023 MARs (Medication Administration Record) and confirmed the Lasix had not been administered as ordered. She presented lab results dated 03/23/2022 and confirmed that staff had failed to conduct additional labs after this date as S7NP had ordered. On 5/31/2023 9:00 a.m., an interview was conducted with S1DON. She reviewed Resident #1's April 2023 MAR (Medication Administration Record) and confirmed that N documented by the nurse for Alprazolam indicated that the medication had not been administered to the resident. She presented a prescription from S7NP for Xanax 0.5 mg one QID dated 4/10/2023. She confirmed the previous prescriptions dated 01/27/2023 and 02/22/2023 for the Xanax. S1DON confirmed the nurse failed to ensure that a March order was secured for continuation of Xanax administration. She stated that as per the facility policies and procedures the nurse failed to ensure the refill when there were three tablets left to administer. On 05/31/2023 at 11:00 a.m., an interview was conducted with S6LPN. She reviewed the Physician's Telephone Order and confirmed that she had taken the order for Lasix 20 mg, one tablet daily and the BMP blood work on 03/22/2023 to be drawn weekly for 3 weeks from S7NP. She reviewed the orders for March and April 2023 and confirmed the lack of orders. She reviewed the March and April 2023 MARs and confirmed that Lasix was not on the MAR, and had not been administered as ordered. She stated that she had failed to transcribe the orders into the computer resulting in the medication not being administered and the blood work not being drawn as ordered. On 05/31/2023 at 11:30 a.m., concurrent interviews were conducted with S2ADON and S3ADON. They stated that S6LPN took care of her getting her prescriptions for her residents on her own, from the physicians or nurse practitioner. On 05/31/2023 at 11:45 a.m., an additional interview was conducted with S6LPN. She reviewed Resident #1's April 2023 MAR and confirmed the multiple entries of N documentation for Alprazolam during April. She stated that N meant that the medication was not administered to the resident. S6LPN stated that the medication was not administered because the medication was not available for the resident, and that they had run out of the medication for her and had failed to get the March prescription for Alprazolam from the S7NP.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected most or all residents

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Based on record review and interview, the facility failed to implement the comprehensive person-centered care plan for one (#1) resident, as evidenced by failing to administer medications as ordered, observe for edema, ensure blood work was conducted as ordered, and provide weekly skin audits, out of a sample of 6 residents (#1-6). The total census was 94 residents. Findings: A review of the facility's policy and procedure titled Edema/Measuring/Assessing included the following: Purpose: Accurate assessment of edema Procedure: a. Observe areas and assess 2. Document #1. A review of the facility's policy and procedure titled Skin Care included the following: Purpose: To maintain healthy skin integrity, to prevent skin breakdown the facility will accomplish these goals through prevention, assessment . 4. Weekly skin report. A review of Resident #1's record revealed an admission date of 04/01/2020 with diagnoses including General Anxiety Disorder, Psychotic Disorder, Coronary Artery Disease Disorientation, and Edema. A review of Resident #1's care plan revealed the following in part: I have to potential for Impaired Skin Integrity with an approach to provide weekly skin audits; I have the potential for altered cardiac output with an approach to observe for excessive fluid retention, edema and document deviations from baseline; and I have to potential for Anxiety and I have the potential for trauma related to medication administration with same approach to administer medications as ordered: Xanax (Alprazolam) 0.5 mg (milligrams) po (by mouth) QID (four times daily). A review of Resident #1's printed Physician's Orders included the following: An order dated 06/21/2021 for the benzodiazepine Alprazolam 0.5 mg one tab po QID, for Generalized Anxiety Disorder. A discontinue date of 04/19/2023 was noted for this order; An order dated 04/19/2023 for Alprazolam 0.5 mg one QID; and A handwritten Physician's Telephone Order dated 03/22/2023 for start Lasix 20 mg one po qd (every day) edema of LE's (lower extremities), and Repeat BMP (Basic Metabolic Panel-blood work) Q (every) wk x 3 weeks (week for 3 weeks) Further review of Resident #1's orders failed to reveal an order to conduct weekly skin checks or to monitor edema. A review of S7NP's (Nurse Practitioner) Medical Progress Note date 03/05/2023 revealed that Resident #1 had been assessed with trace edema of bilat LE's (bilateral lower extremities). A review of S7NP's Medical Progress Note date 03/22/2023 revealed that Resident #1 had been assessed with +2 edema of bilat LE's. A review of S7NP's Medical Progress Note date 03/31/2023 revealed that Resident #1 had been assessed with trace edema of bilat LE's. A review of Resident #'1's January 2023 MAR (Medication Administration Record) revealed the order for Alprazolam 0.5 mg tab one tab by mouth 4 times daily. Further review revealed N documented at 4 pm on 01/11/2023, indicating that the medication had not been administered. A review of Resident #'1 March 2023 MAR revealed the order for Alprazolam 0.5 mg tab one tab by mouth 4 times daily. Further review revealed N documented at 4 pm on 03/12/2023. Further review of the March MAR failed to reveal the administration of Lasix 20 mg on or after 03/22/2023. A review of Resident #'1 March 2023 MAR and TAR failed to reveal monitoring of the resident's edema. A review of Resident #'1 April 2023 MAR revealed the order for Alprazolam 0.5 mg tab one tab by mouth 4 times daily with a discontinue date of 04/19/2023. Further review revealed the following: N documented at 8:00 AM on 04/05/2023, 04/07/2023, 04/08/2023, and 04/10/2023; N documented at 12:00 PM from 04/05-08/2023; N documented at 4:00 PM on 04/07/2023, 04/08/2023, and left blank on 04/18/2023; N documented at 8:00 PM on 05/08/2023. Further review of the April 2023 MAR revealed and order dated 04/19/2023 for Alprazolam 0.5 mg one by mouth 4 times day. There was no documented evidence that the medication was administered at 4:00 PM on 04/21/2023, or from 04/24/2023 to 04/27/2023. The review revealed that 17 doses of the ordered Alprazolam had not been administered in April as ordered. Additionally, the MAR failed to reveal that Lasix 20 mg daily had been administered, nor had the resident been monitored for edema. A review of Resident #'1 April 2023 TAR failed to reveal monitoring of the resident's edema. A review of the January to April 2023 Nursing Notes failed to reveal entries regarding the Alprazolam or Lasix not being administered, skin checks, or monitoring of edema for Resident #1. A review of the January to April 2023 Administration Records failed to reveal entries regarding the Alprazolam or Lasix not being administered, skin checks, or monitoring of edema for Resident #1. On 05/30/2023 at 3:45 p.m., an interview was conducted with S4LPN, who was the facility's wound care nurse. She stated that routine body audits were conducted on the residents only upon admit, readmit, or if their Braden score was high. S4LPN stated that if a change was noted in the residents' skin, only then would she conduct weekly skin checks. She further stated that she did not conduct weekly skin checks to assess healthy skin integrity herself, but that she relied on the aides identifying and reporting skin issues to her. S4LPN provided a Braden assessment report on Resident #1 dated 01/24/2023. S4LPN stated that she had assessed the resident as a mild risk with a Braden score of 18. She confirmed that she had not conducted weekly skin checks on Resident #1. On 05/31/2023 at 8:00 a.m., an interview was conducted with S1DON. She confirmed that on 03/22/2023, S7NP ordered Lasix 20 mg every day for Resident #1's edema to her bilateral lower extremities and to repeat a BMP every week for three weeks. S1DON reviewed Resident #1's March and April 2023 MARs (Medication Administration Record) and confirmed the Lasix had not been administered as ordered. She reviewed the lab results dated 03/23/2023 and confirmed that staff had failed to conduct additional labs after this date as S7NP ordered. She confirmed that Resident #1 had been care planned for edema and staff were to monitor her. She stated the monitoring would be reflected on the MAR and confirmed that the staff had not been conducting this necessary monitoring of edema, as care planned. On 05/31/2023 at 9:00 a.m., and interview was conducted with S1DON. She reviewed the January-April 2023 MARs for Resident #1. She confirmed the N documented and the missing documentation for the Alprazolam 0.5 mg four times per day. She stated that the reason may not be on the Administration Records but in the Nursing Notes. On 05/31/2023 at 10:50 a.m., an interview was conducted with S6LPN. She reviewed Resident #1's April 2023 MAR and confirmed the missing documentation of administration of Alprazolam 0.5 mg four times daily during that month. She stated that the medication had not been administered to Resident #1 on these dates because the facility had run out of the medication and they had none to give to her. S6LPN reviewed Resident #1's March and April 2023 MARs and confirmed that no Lasix had been administered as ordered on 03/22/2023. She confirmed that the resident had not been monitored for edema. She confirmed that no blood work had been conducted for 3 weeks as ordered on 03/22/2023. On 05/31/2023, at 11:00 a.m., concurrent interviews were conducted with S2ADON and S3ADON. They reviewed Resident #1's care plan and confirmed that staff should have been monitoring the resident for edema. They stated that a special requirement should have been selected for that monitoring to populate on the MAR, and staff had failed to select this, resulting in the lack of required monitoring of edema. On 5/31/2023 at 12:00 p.m., an interview was conducted with S1DON. She reviewed Resident #1's care plan and confirmed that she should be monitored for edema, and that weekly skin checks should have been conducted on the resident per her care plan. She presented the policy and procedures for transcribing the orders received by a physician. She stated that the receiving nurse (S6LPN) was to put the orders for Lasix and blood work ordered on 03/22/2023 into the computer, which would have populated the orders onto the MAR. She stated that this failure lead to the orders not being transcribed appropriately and these orders were never carried out. She reviewed the policy and procedure for Skin Care and confirmed that weekly skin care reports were to be conducted on all residents. She confirmed that S4LPN was to be conducting weekly skin audits on all residents herself, and not relying on reports from aides, and she had failed to do so. She reviewed the policy and procedure of Edema and confirmed that nursing staff were to assess Resident #1 for edema and document that assessment, and they had failed to do so. S1DON confirmed that staff had failed to administer Lasix 20 mg as ordered beginning on 03/22/2023. She confirmed that staff had failed to administer Resident #1's Alprazolam, when they failed to reorder it appropriately.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess a resident as having received dialysis services on the comprehensive admission Minimum Data Set (MDS) assessment for 1 (#5) of 5 (#1-#5) sampled residents. Findings: Review of Resident #5's clinical records revealed he was admitted to the facility on [DATE] with diagnoses including Sepsis, Acidosis, End Stage Renal Disease (ESRD), and Stage 3 Chronic Kidney Disease. Further review revealed the resident was discharged on 12/27/22. Review of the resident's December 2022 physician's orders revealed an order dated 12/22/22 Dialysis MWF (Monday, Wednesday, and Friday) at 11 a.m. Review of the care plan revealed the resident required renal dialysis for ESRD. Review of the skilled nursing note dated 12/23/22 revealed Resident #5 went to dialysis as ordered. According to the resident's Medication Administration Record (MAR) for December 2022, the resident went to dialysis on Monday 12/23/22 and Friday 12/26/22. Review of the resident's hospital record dated 12/27/22 revealed the resident was diagnosed with ESRD in June 2022 and placed on hemodialysis on a MWF schedule. Further review revealed his last session was on 12/26/22. Review of the resident's 5 day admission/discharge (AM5DE) MDS assessment dated [DATE] revealed Section O - Special Treatments/Procedures/Programs - dialysis unchecked. On 01/30/23 at 4:10 p.m., a phone interview was conducted with Resident #5's family member who stated that the resident received dialysis on his scheduled days during his admission at the nursing home. On 01/31/23 at 11:31 a.m., a phone interview was conducted with S1LPN who stated that she was the resident's nurse. S1LPN stated that Resident #5 was dialyzed on his scheduled days while a resident on 12/23/22 and 12/26/22. On 01/31/23 at 12:43 p.m., an interview was conducted with S2MDS who stated that she completed Resident #5's MDS assessment dated [DATE]. During the interview, Resident #5's clinical record was reviewed with S2MDS. S2MDS confirmed she had completed Section O of Resident #5's MDS dated [DATE] and that she had coded Resident #5 as not having received dialysis while a resident. She confirmed that it was documented the skilled nursing note that the resident went to dialysis on 12/23/22. S2MDS was informed that the resident's nurse stated he went to dialysis on his scheduled days on 12/23/22 and 12/26/22. She confirmed she did not go through the resident's record to see if he actually went to dialysis prior to submitting his MDS assessment. She confirmed that the MDS assessment date was 12/27/22 and that Resident #5 had received dialysis during the 7 day look back period.

Jan 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on interview and record reviews, the facility failed to ensure each resident was free of significant medication error. The facility failed to ensure 1 (#1) out of 5 (#1, #2, #3, #4, #5) residents reviewed for medication administration was administered their medications as ordered by the physician. This deficient practice had the potential to effect the 79 residents residing in the facility. Finding: A review of the policy titled Administering Medications included the following, in part: Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of Resident #1's clinical record revealed an admit date of 4/1/2020 with diagnosis including Parkinson's disease. On 6/4/21, resident #1 was admitted to hospice services related to diagnosis of Parkinson' disease. A review of the written physician orders revealed a telephone order dated 11/17/22 at 8:40 a.m. for the following: 1) Robitussin DM 10 milliliters (ml) by mouth every four (4) hours. 2) Bedside suction, suction routinely as needed to oropharyngeal with yankuer and to mouth. 3) Duoneb respiratory treatments three times per day (TID) Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) 3 milligram (mg) /3 milliliters (ml). A review of Resident #1's Medication Administration Record (MAR) dated November 2022 revealed the medications: 1) Robitussin DM 10 ml by mouth every four hours with an order and start date of 11/18/22; and 2) Ipratropium bromide/Albuterol sulfate 0.5-3(2.5) mg/3 ml give 1 vial every day three times per day with an order and start date of 11/18/22 and scheduled dose for 11/19/22 at 8:00 A.M. was not administered as evidenced by an N marked in box on MAR. A review of Resident #1's hospice nursing visit notes by S2HN revealed on 11/17/22, a telephone order for Duoneb respiratory treatment three times a day and Robitussin DM 10 mls every four hours was written and S2HN notified facility staff of orders. Hospice nursing visit notes on 11/18/22 by S2HN, revealed the nebulizer machine was at bedside in packaging and Duoneb had not been administered per order on 11/17/22. On 1/4/23 at 10:46 a.m., a telephone interview was conducted with S2HN who confirmed she wrote an order for Resident #1 for Robitussin and Duoneb on 11/17/22. S2HN stated on her hospice visit on 11/18/22 at 10:00 a.m., the orders written on 11/17/22 had not been initiated or administered. On 1/3/23 at 3:10 p.m. an interview was conducted with S1ADM, she verified a signed physician order for Resident #1 was written on 11/17/22 for Robitussin DM and Duoneb respiratory treatments. S1ADM confirmed Resident #1's November 2022 MAR revealed that these medications were not administered on 11/17/22 as ordered.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 harm violation(s), $128,349 in fines, Payment denial on record. Review inspection reports carefully.
• 60 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $128,349 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
• Grade F (20/100). Below average facility with significant concerns.

Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Cornerstone At The Ranch's CMS Rating?

CMS assigns Cornerstone at the Ranch an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Cornerstone At The Ranch Staffed?

CMS rates Cornerstone at the Ranch's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 76%, which is 29 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Cornerstone At The Ranch?

State health inspectors documented 60 deficiencies at Cornerstone at the Ranch during 2023 to 2025. These included: 1 that caused actual resident harm and 59 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Cornerstone At The Ranch?

Cornerstone at the Ranch is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PARAMOUNT HEALTHCARE CONSULTANTS, a chain that manages multiple nursing homes. With 148 certified beds and approximately 76 residents (about 51% occupancy), it is a mid-sized facility located in Lafayette, Louisiana.

How Does Cornerstone At The Ranch Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, Cornerstone at the Ranch's overall rating (2 stars) is below the state average of 2.4, staff turnover (76%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Cornerstone At The Ranch?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Cornerstone At The Ranch Safe?

Based on CMS inspection data, Cornerstone at the Ranch has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Cornerstone At The Ranch Stick Around?

Staff turnover at Cornerstone at the Ranch is high. At 76%, the facility is 29 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Cornerstone At The Ranch Ever Fined?

Cornerstone at the Ranch has been fined $128,349 across 2 penalty actions. This is 3.7x the Louisiana average of $34,362. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Cornerstone At The Ranch on Any Federal Watch List?

Cornerstone at the Ranch is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 148
Avg. Residents: 76
Occupancy: 51.5%
Ownership: For profit - Corporation
Chain: PARAMOUNT HEALTHCARE CONSULTANTS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -10
1 Actual Harm citation: -5
60 Deficiencies: -10
Fines ($128,349): -15
Final Score: 20/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195565