Every finding on record at Cabell Healthcare Center

Based on observation, record review, and staff interview, the facility failed to follow physician's orders. This deficient practice had the potential to affect (three) of 25 residents reviewed in the long-term care survey sample. Resident Identifiers: #3, #5, and #9. Facility Census: 88. Findings included: a) Resident #3 Review of Resident #3's physician's orders showed an order written on 4/7/26 for Accucheck fingerstick blood glucose monitoring. The physician was to be notified if the blood glucose level was less than 60 or greater than 400. The Accucheck fingerstick blood glucose monitoring was scheduled for early morning and evening. On the Medication Administration Record (MAR) for July 2026, the entry for the early morning blood glucose monitoring had two (2) lines, one for the nurse to enter the blood glucose level and one (1) for the nurse's user identification. The entry for the evening blood glucose monitoring did not have a line for the nurse to enter the blood glucose level. There was only one (1) line for the nurse's user identification. Sometimes, the evening blood glucose level was recorded on the blood sugar tab summary located in the weights and vitals section of the electronic health record. However, for the following dates, the evening blood sugar was not recorded in July 2026:07/03/2607/04/2607/05/2607/07/2607/08/2607/09/2607/10/2607/13/2607/14/26On 07/15/2026 at 10:40, the Assistant Director of Nursing (ADON) confirmed that Resident #3's evening glucose level had not been documented on the above-referenced dates. She stated another line had been added to the MAR so the results could be recorded. No further information was provided through the completion of the survey process. b) Resident #5 Review of Resident #5's physician's orders showed an order written on 06/03/26 for Novolog insulin, inject five (5) units subcutaneously before meals and at bedtime for diabetes, if the resident's blood sugar level was greater than 150. Review of Resident #5's Medication Administration Record (MAR) for June and July 2026 showed Resident #5 had been administered insulin, despite the blood glucose level being less than 150, on the following dates and times: 06/05/26 at 11:00 AM; the blood glucose level was 12306/06/26 at 11:00 AM; the blood glucose level was 13706/14/26 at 5:00 PM; the blood glucose level was 13406/14/26 at 9:00 PM; the blood glucose level was 14706/15/26 at 11:00 AM; the blood glucose level was 13907/10/26 at 11:00 AM; the blood glucose level was 147On 07/16/2026 at 11:32 AM, the Director of Nursing (DON) confirmed that Resident #5's insulin was signed on the MAR as given despite the resident's blood glucose being less than 150. The DON stated she cannot prove that Resident #5's insulin was not given on those occasions. No further information was provided through the completion of the survey process. c) Resident #9 Review of Resident #9's physician's orders showed an order written on 08/08/25 for a right hand orthotic (carrot splint) to be worn, as tolerated, every day and night shift for contracture of the right hand. A carrot splint is a carrot-shaped splint placed in a contracted hand to prevent skin breakdown of the palm. Upon initial observation of Resident #9 on 07/13/26 at 2:30 PM, the resident did not have the carrot splint placed in her right hand. Upon observation on 07/15/2026 at 10:49 AM, the resident did not have the carrot splint placed in her right hand. Upon observation on 07/16/2026 at 09:11 AM, the resident did not have the carrot splint placed in her right hand Review of Resident #9's Treatment Administration Record (TAR) showed the carrot splint had been signed off as being in place twice daily in July 2026. On 07/16/26 at 2:07 PM, the Assistant Director of Nursing (ADON) examined Resident #9's right palm skin condition in the presence of the surveyor. The resident's palm skin condition was clean and intact. The ADON confirmed Resident #9's carrot splint was not in place. She stated she would look for the splint. On 07/16/26 at 2:27 PM, the ADON stated she had placed the resident's carrot splint in her right hand after locating the splint in the resident's room. On 07/20/2026 at 11:14 AM, Resident #9 was noted to have the carrot splint in her right hand. She appeared to be tolerating the splint well.

Based on observation, record review, staff interview and resident interview, the facility failed ensure a complete and accurate medical record for a resident by documenting blood pressures being taken in opposite arm. for a resident with an incomplete capacity form, additionally, a resident's TAR being completed for a device she no longer wore and lastly for a resident with an incorrect capacity form. This included Resident's #3, #62, #35 and #46. Facility Census 88. Findings included: a) Resident #3 - Blood Pressure -Upon review of resident's Weights and Vitals Summary on 07/15/26, it was document that resident's blood pressure was obtained in the left arm on the following dates in the last 90 days: 05/29/26 05/27/26 05/26/26 -Review of current ordered stated, Do not obtain blood pressures, lab draws, IV access sites to left arm due to AV fistula in left arm. Order date 06/19/25 -Resident had capacity to make her own health care decisions. Interview with resident on 07/15/26 at 3:15 PM who reported staff do not attempt to obtain her blood pressure in her left arm. -Interview with Administrator on 07/15/26 at 3:50 PM who acknowledge the documentation for the left arm. b) Resident #62 - Capacity incomplete -Review of resident's form Physician's Determination of Capacity dated for 02/25/26 was incomplete. The first boxes read as follows and neither box was checked: *Demonstrates CAPACITY to make decisions *Demonstrates INCAPACITY to make medical decisions etc. -Interview with Administrator on 07/15/26 at 10:00AM who acknowledge the incomplete document. c) Resident #46 Review of Resident #46's medical records showed a Physician's Determination of Capacity form dated 03/18/26. The preprinted form stated, I have interviewed the resident and have determined that he/she: The physician checked a box that stated, Demonstrates capacity to make decisions. However, the physician also checked a box that stated, Per WV code 16-30-7 I certify that have informed the patient that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding lifeprolonging intervention or mental health treatment. On 07/16/2026 at 11:09 AM, the Director of Nursing (DON) confirm Resident #46's Physician's Determination of Capacity form was incorrectly completed and gave conflicting information. The DON stated Resident #46 does have capacity to make medical decisions. No further information was provided through the completion of the survey process. d) Resident #35 Review of Resident #35's physician's orders showed an order written on 04/28/26 for Device: Left hinged knee brace locked in extension every day and night shift. The resident's Treatment Administration Record (TAR) for July 2026 showed the left hinged knee brace had been signed off twice a day as present. On 07/13/2026 at 12:06 PM, Resident #35 stated she fell out of her wheelchair and hurt her left knee several months ago. She stated she was receiving therapy and her knee was doing better. At the time of this interview, Resident #35 was not wearing a knee brace. Another observation on 07/15/26 at 12:37 PM showed Resident #35 was not wearing a knee brace. On and 07/16/26 at 12:32 PM, Resident #35 was again observed not wearing a knee brace. When questioned, the resident stated that she hadn't worn that brace in a long time because her orthopedic doctor discontinued it. On 07/16/2026 at 12:50 PM, Licensed Practical Nurse (LPN) #98 stated he didn't know anything about Resident #35's knee brace. On 07/16/26 at 12:54 PM, the Director of Nursing (DON) confirmed Resident #35 was not wearing a knee brace.On 07/16/2026 at 1:10 PM, the DON stated she talked with the orthopedic surgeon's office and the resident doesn't need the knee brace anymore. She acknowledged the TAR was signed out for a device the resident was no longer wearing. No further information was provided through the completion of the survey process.

Based on record review and staff interviews the facility failed to develop care plans for Post-Traumatic Stress Disorder (PTSD) and diuretic therapy. Additionally, the facility failed to implement a designated fall intervention requiring a reacher tool to be within the resident's reach. This deficient practice was found true for (3) three of 25 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #2, #67, and #7. Facility Census: 88 Findings Include: a) Resident #67 A record review conducted on 07/16/26 at 10:00 AM, revealed a fall intervention care plan for Resident #67. The documented interventions included: Provide assistive devices as needed Perimeter mattress Wheelchair cushion reviewed reaching device non skid material applied to wheelchair An observation of Resident #67's room on 07/16/26 at 11:10 AM, revealed the resident was not in the room, and no reaching device was located in the room. Further observation of Resident #67 in the Lighthouse dining area revealed that the resident did not have the reaching device in their possession. During an observation and interview on 07/16/26 at 11:16 AM, Registered Nurse (RN) #26 located the reaching device at the bottom of Resident #67's closet. RN #26 stated, It does not look like she is using it. I am not even sure that she is capable of using it. I will check into it. b) Resident #2 A record review conducted on 07/14/26 revealed that Resident #2 had an active diagnosis of Post-Traumatic Stress Disorder (PTSD). Further review of the record revealed that Resident #2's care plan failed to include the diagnosis of PTSD or any corresponding interventions. During an interview on 07/16/26 at 10:07 AM, the Director of Social Services confirmed that PTSD was not addressed in Resident #2's care plan and stated, I will fix that, yes it should be care planned. c) Resident #7 Review of Resident #7's physicians' orders showed an order written on 03/18/26 for furosemide 40 mg twice a day for hypertension. Furosemide (Lasix) is a diuretic. Review of Resident #7's comprehensive care plan showed the following focus initiated on 12/10/24, The resident is at risk for dehydration, or potential fluid deficit, hx [history] of IV [intravenous] fluid administration. The focus had not been revised. The goal initiated on 12/10/24 was as follows: Resident will be free of s/sx [signs and symptoms] of dehydration, such as dry chapped lips, tongue dryness, sunken eyes, decreased absent, or concentrated urine output, poor skin elasticity, though review date. The interventions were as follows: Encourage resident to drink all liquids on meal tray, and provide extra fluids on nourishment pass and during social gatherings and activities. Notify medical provider with s/sx of dehydration. Obtain labs per medical providers order. Resident #7's care plan did not contain a focus or interventions related to diuretic use. On 07/20/26 at 3:21 PM, the Director of Nursing confirmed Resident #7's care plan did not contain a focus or interventions related to diuretic use. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure residents with indwelling urinary catheters had their urine collection bags concealed with a privacy cover to maintain resident dignity. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of catheters. Resident Identifiers: #82 and #93. Facility Census: 88. Findings included: a) Resident #93 Review of Resident #93's physician's orders showed an order written on 07/10/26 for Indwelling Urinary (Foley) Catheter: #16 F [French] with 10 ml [milliliter] balloon to continuous drain. Diagnosis for use urinary retention. Provide privacy bag. Upon observation 07/13/2026 at 12:25 PM, Resident #93's indwelling urinary catheter collection bag was hanging on the side of the bed facing the door. The urine collection bag did not have a privacy cover, and urine could be seen in the bag. Upon observation on 07/14/2026 at 9:34 AM, the urine collection bag continued to not have a privacy cover. On 07/14/2026 at 1:25 PM, the Infection Preventionist confirmed Resident #93's urine collection bag did not have a privacy cover. She stated she would obtain a privacy cover.No further information was provided through the completion of the survey process. b) Resident #82Review of Resident #82's physician's orders showed an order written on 03/10/25 for suprapubic cath [catheter] #18 fr [French] with 6 ml balloon to continuous drain. Diagnosis for use: neurogenic bladder. Provide privacy bag.Upon observation on 07/13/2026 at 3:08 PM, Resident #82's suprapubic catheter urine collection bag did not have a privacy cover, and urine could be seen in the bag. Upon observation on 07/14/2026 at 9:54 AM, Resident #82's urine collection bag continued to not have a privacy cover. On 07/14/2026 at 1:25 PM, the Infection Preventionist confirmed Resident #82's urine collection bag did not have a privacy cover. She stated she would obtain a privacy cover.No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to document that required information was conveyed to the receiving hospital at the time of the resident's transfer. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of hospitalization. Resident Identifier: #46. Facility Census: 88. Findings included: a) Resident #46 Review of the facility's policy titled, Transfer and Discharge Policy, with no implementation date given, stated a transfer form would be sent with the resident or as soon as practicable in the event of an emergency transfer. The transfer form would document as follows: Patient status, including baseline and current mental, behavioral and functional status and recent vital signs;Current diagnoses, allergies and reasons for transfer/discharge;Contact information of the practitioner responsible for the care of the resident;Patient representative information and contact information; Current medications, treatments, relevant lab and/or radiological findings and recent immunizations;Special instructions such as isolation precautionsSpecial risks such as risk for falls, elopement, bleeding, pressure injury, or aspirationComprehensive care plan goals Review of Resident #46's electronic health record showed the resident was transferred to the hospital on [DATE] due to abdominal pain. No transfer form was located in the health record. On 07/20/26 at 11:48 AM, the Director of Nursing confirmed that a transfer form had not been sent to the receiving hospital when Resident #46 was transferred on 04/03/26. She stated there was no documentation to show required information had been conveyed to the receiving hospital. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessment in the area of catheters. This deficient practice had the potential to affect (1) of three (3) residents reviewed for the care area of catheters. Resident Identifier: #82. Facility Census: 88. Findings included:a) Resident #82Review of Resident #82's physician's orders showed an order written on 03/10/25 for suprapubic cath [catheter] #18 fr [French] with 6 ml balloon to continuous drain. Diagnosis for use: neurogenic bladder. Provide privacy bag.On 07/13/2026 at 3:08 PM, Resident #82 was observed to have a suprapubic catheter urine collection bag.Resident #82's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 06/02/26 indicated that Resident #82 did not have an indwelling urinary catheter.On 07/14/26 at 2:45 PM, MDS Registered Nurse #50 confirmed Resident #82's MDS with ARD 06/02/26 was incorrect and should have indicated the resident had an indwelling urinary catheter.No further information was provided through the completion of the survey process.

Based on observation and staff interview, the facility failed to ensure the facility was as free from accident hazards as possible. A treatment cart was unlocked with no staff in attendance. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Facility Census: 88. Findings included:a) Treatment cart On 07/14/2026 at 9:39 AM, a treatment cart located in the 200 hallway was noted to be unlocked. No staff were in attendance by the cart or in the hallway. On 07/14/26 at 9:41 AM, the surveyor alerted Registered Nurse (RN) #17 that the treatment cart was unlocked. She confirmed the cart was unlocked and should be locked when staff were not in attendance. The cart was inspected and a drawer contained cleansers and creams used in wound care. RN #17 confirmed these cleansers and creams could be hazardous to residents. On 07/15/26 at 3:00 PM, the Assistant Director of Nursing (ADON) stated the facility had no written policy regarding locking the treatment cart. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure catheter treatment and care was provided within accepted standards of practice. For one (1) of three (3) residents reviewed for the care area of catheters, the urinary collection bag was on the floor. Resident Identifiers: #82. Facility Census: 88. Findings included:a) Resident #82 The facility's policy titled, Catheter Care, with no implementation date given, gave instructions to check that the collection bag was not on the floor. Upon observation on 07/13/26 at 3:08 PM, Resident #82's suprapubic catheter urine collection bag was noted to be lying on the floor of the resident's room.Upon observation on 07/14/26 at 9:54 AM, Resident #82's urine collection bag continued to be lying on the floor.On 07/14/2026 at 1:25 PM, the Infection Preventionist confirmed Resident #82's urine collection bag was lying on the floor. She stated she would move the urine collection bag off the floor. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure an error rate of less than five (5) percent. Two (2) errors were observed in 29 medication administration opportunities to give an error rate of 6.9 percent. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of medication administration. Resident Identifiers: #14 and #60. Facility Census: 88. Findings included: a) Resident #14 On 07/15/2026 at 8:00 AM, Licensed Practical Nurse (LPN) #77 was observed preparing morning medications for Resident #14. LPN #77 crushed the resident's medications and placed them in applesauce. Among the medications crushed was enteric coated aspirin, 325 milligrams (mg). Aspirin tablets are enteric coated to delay the release of the medication until it reaches the small intestine because it can be irritating to the stomach. On 07/15/2026 at 10:37 AM, LPN #77 was asked if the facility had a list of medications that should not be crushed. She stated she thought the list was in a notebook on the medication cart, but she could not locate it. On 07/15/2026 at 10:40 AM, the Director of Nursing (DON) provided a list from the American Society of Consultant Pharmacists (ASCP) titled, Medications Not to be Crushed, with revision date March 2016. Enteric coated aspirin was on the list of medications not to be crushed. This was confirmed by the DON. No further information was provided through the completion of the survey process. b) Resident #60 On 07/15/2026 at 8:15 AM, Registered Nurse (RN) #17 was observed administering medications to Resident #60. Resident #60 had her breakfast tray. Among the medications administered to Resident #60 was pantoprazole (Protonix). Resident #60's pantoprazole order, written to start on 06/20/24 at 7:00 AM, stated to give the medication for gastroesophageal reflux disease in the morning before breakfast. The medication was timed on the Medication Administration Record (MAR) to be given in the AM. According to the Mayo Clinic drug and supplements information, available on-line, pantoprazole should be taken at least 30 minutes before a meal. On 07/15/2026 at 10:40 AM, the Director of Nursing confirmed Resident #60's pantoprazole was ordered to be given before breakfast. She stated she would ask the physician if the medication needed to be given before breakfast. If so, she stated she would retime the medication on the MAR.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure a resident in enhanced barrier precautions (EBP) had proper signage to alert staff and others of the EBP. The facility also failed to maintain infection control practices during medication administration. These were random opportunities for discovery. Resident Identifiers: #93 and #60. Facility Census: 88. Findings included:a) Resident #93 The facility's policy titled, Enhanced Barrier Precautions, with no implementation date given, stated signs would be posted on the resident door as communication to staff and visitors to indicate the resident was in enhanced barrier precautions. Review of Resident #93's physician's orders showed an order written on 07/13/26 for Enhanced barrier precautions related to: indwelling foley catheter, when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. On 07/13/26 at 2:00 PM, Resident #93's room did not have signage to indicate the resident was in enhanced barrier precautions. On 07/14/26, Resident #93's physician's order was changed to, Enhanced barrier precautions related to: indwelling foley catheter, PICC [peripherally-inserted central catheter] line to RUE [right upper extremity], R [right] BKA [below the knee amputation] wound When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. On 07/14/26 at 12:30 PM, Resident #93's room did not have signage to indicate the resident was in enhanced barrier precautions. On 07/14/2026 at 1:24 PM, the Infection Preventionist confirmed Resident #93's room did not have signage to indicate the resident was in enhanced barrier precautions. She stated she had revised the resident's enhanced barrier precautions order but hadn't put up a sign yet. No further information was provided through the completion of the survey process. b) Resident #60 The facility's policy titled, Medication Administration, with no implementation date given, stated, Do not touch the medication, either when opening a liquid or dose pack. On 07/15/2026 at 8:15 AM, Registered Nurse (RN) #17 was observed administering medications to Resident #60. While pouring the medications from the medication packet into the medication cup, one medication tablet fell onto the top of the med cart. RN #17 picked up the pill with her bare hands and placed it into the cup. She stated, I shouldn't have touched that. Sorry. On 07/15/2026 at 10:40 AM, the Director of Nursing confirmed the nurse should not have touched the medication tablet with her bare hands. No further information was provided through the completion of the survey process.

Based on record review, observation, resident interview and staff interview the facility failed to ensure a resident with limited range of motion received appropriate treatment to prevent further decrease in range of motion. This failed practice was found true for (1) one of (3) three residents reviewed for the care area of limited range of motion during the Long-Term Care Survey Process. Resident identifier: #64. Facility Census: 88. Findings include: a) Resident #64 During the initial interview on 07/13/26 at 1:59 PM, Resident #64 stated, I am supposed to wear a brace on my left hand, but it went to laundry a while back and I haven't seen it since. When asked by the State Agency (SA) if the splint was worn often, Resident #64 replied, I do, when I have it. I like to wear it at night when I am sleeping. A record review on 07/14/26 revealed Resident #64 has a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the left non-dominant side. Further record review identified an active physician's order for Resident #64 dated 02/26/26, which read:Device: Patient to wear resident hand splint to L extremity as tolerated. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from February 2026 to the present revealed that this order was missing from both records. On 07/14/26 at 1:48 PM, Resident #64 was observed in her bathroom preparing for the day. The hand brace was not on the resident; instead, it was lying in a basket in the bathroom. Resident #64 stated, I came in the bathroom last night and it was lying in here. I wore it last night. I guess laundry brought it back. No, no one has offered to put it on today. During an interview on 07/14/26 at 2:53 PM, Registered Nurse (RN) #26 stated, I went and talked to her, and she said that she wore the brace last night and she just put it back on. I have now updated the order, it will show up on the TAR, so that we have accountability that she is wearing the brace.

Based on record review and staff interview, the facility failed to identify and provide needed care and services for two (2) of eight (8) residents. Resident #4 did not have a follow-up appointment after a hospitalization. One (1) of eight (8) residents did not have follow up care after blood glucose readings were crticially low. Resident Identifier: #4 and #70. Facility Census: 86. Findings include: a) Resident #4 On 08/05/25 at 2:00 PM, a record review was completed for Resident #4. The review found the resident was discharged from the acute care facility on 07/01/25 with the diagnoses of prostatitis, urinary tract infection with hematuria, hydronephrosis and hydroureter. On 08/05/25 at 3:00 PM, the Director of Nursing (DON) was asked when the resident's urology follow up appointment from discharge from the hospital was. The DON stated, Let me find out. On 08/05/25 at 4:05 PM, the resident was observed with a urinary foley catheter in place. The urinary drainage bag was noted with dark tea-colored bloody urine. On 08/05/25 at 4:10 PM, the nursing staff at the nursing station, was asked about this observation. The nursing staff at the desk stated, the resident pulled the foley catheter out with the balloon intact last night (08/04/25). On 08/05/25 at 4:10 PM, the DON stated, The office is closed .we have tried to call three (3) times, and we haven't gotten an answer. The resident was discharged from the acute care facility on 07/01/25. No follow up appointment was scheduled until after Surveyor intervention. On 08/06/25 at 9:15 AM, the DON stated, I don't know what happened with the communication. We have a call into the urologist. They show no follow up needed. The Surveyor asked the DON, Do you think the resident needs a follow up appointment, especially since he pulled out the urinary foley catheter with the balloon intact? The DON responded, Let me see what the office says. On 08/06/25 at approximately 11:00 AM, the DON stated, The follow up appointment is scheduled on 08/08/25 at 11:30 AM. b) Resident #70 On 08/07/25 at 11:10 AM record review shows that on 07/28/25 at 9:55 PM Resident #70 had a blood glucose documented as twenty nine (29). Further review shows no progress notes or communication with the Physician they were contacted. There was no glucose recheck documented on the level. There is no documentation that the resident was given anything to increase her blood glucose level. It was documented on the Vitals Summary as well as the Medication Administration on 07/28/25 as 29. The Care Plan shows the resident is at risk for hypoglycemia. Upon conversation with the Director of Nursing on 08/07/25 at 1:10 PM, she stated she recalled the incident and had spoken with the nurse on duty that documented the level of 29. She stated that the nurse stated I must have forgotten to add the zero on the end of it making it 290 and not 29. There is no documentation availabel to confirm this. There was no error documented with the corrected blood sugar. From the documentation available it appears the resident had the low glucose level and nothing was performed to increase it. This was confirmed with the Director of Nursing (DON) on 08/07/25 at 1:30 PM at which time she agreed.

Based on observation and staff interview the facility failed to ensure personal food items were stored at the correct temperature and not expired. This was true for one (1) of five (5) personal refrigerators observed. Resident Identifier: #14. Facility Census: 86 Findings Include: a) Resident #14On 08/04/25 at 12:50 PM it was observed that Resident #14 had a personal refrigerator in her room. Upon observation it was noted that it had not had the temperature checked since 08/02/25. Further observation found that two packages of yogurt expired on 07/20/25. Both findings were confirmed with Registered Nurse #59 on 08/04/25 at 12:55 PM who agreed that they were not in compliance. According to facility policy for storage of resident food it states Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > or + to 7 days . The dietary staff will monitor refrigerator contents for food safety and reserve the right to dispose of expired, unsafe foods . On 08/04/25 at 1:15 PM it was confirmed with the Director of Nursing and the Corporate Regional Nurse that the refrigerator should have had the temperature checked and recorded daily and the expired food items disposed of.

Based on record review, policy review and staff interview, the facility failed to provide an accurate and complete record for Resident #4's weights. This is true for one (1) of three (3) residents reviewed under the care area of nutrition. Resident Identifier: #4. Facility Census: 86.Findings Include:a) Resident #4On 08/04/25 at 3:31 PM, a record review was completed for Resident #4. The review found weights documented from 06/23/25 through 08/03/25. The following weights were documented:--06/23/25 190.8--07/02/25 156.6--07/06/25 154.8--07/20/25 176.7--07/27/25 175.5--08/03/25 173.8On 08/06/25 at 10:30 AM, the Regional Registered Nurse (RN) #91 was notified of the discrepencies in the documented weights. The Regional RN stated, Let look over the record and check and see if something was going on.On 08/06/25 at approximately 2:00 PM, the Regional RN #91 stated, I have reviewed all the weights of the residents throughout this time. I could not find any other issue with weights. I thought maybe something may have been wrong with the scales. The Regional RN #91 then stated, it does look like there was an error in documenting these weights.On 08/06/25 at 2:15 PM, the facility policy regarding weights was reviewed. The facility policy is entitled Resident Height and Weight. Number 3 states, Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh the resident to verify weight.

Based on observation, record review and staff interview, the facility failed to assist a dependent resident with activities of daily living (ADLs). This was true for one (1) of four (4) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 85.Findings Include: a) Resident #10 On 08/04/2025 at 4:14 PM, the resident was observed lying in bed in the resident's room and appeared to be unkempt. On 08/06/25 at 2:00 PM, the facility provided a shower schedule for Lifesteps Hall. The shower schedule indicated the resident was to have scheduled showers on Tuesdays and Fridays during day shift. The review found the resident did not receive a shower or bed bath from 07/25/25 through 08/01/25. This was a total of seven (7) days. On 08/06/25 at 2:30 PM, the Director of Nursing (DON) was asked, Do the nurse aides (NAs) follow the shower schedule? The DON replied, We don't go by that .it's more for the unit managers. However, Regional Registered Nurse (RN) #91 looked in the computer and confirmed Resident #10 should be receiving showers on Tuesday and Fridays, on dayshift. On 08/06/25 at 3:15 PM, the Regional RN #91 confirmed Resident #10 did not receive a shower or bed bath for seven (7) days.

Based on observation, record review and staff interviews, the facility failed to ensure all residents were provided with services and assistance to ensure they had no complications of vision loss. Resident #21 was wearing glasses which were in poor repair. She had seen the eye doctor in December, but the facility failed to follow through to ensure she received new glasses. This was true for one (1) of one (1) resident reviewed for the care area of Vision/hearing during the long term care survey process. Resident identifier: #21. Facility Census: 86. Findings Include: a) Resident #21 An observation of Resident #21 at 4:03 PM on 08/04/25 found the right lens of her eyeglasses was either scratched or broken near the center of the lens. A review of Resident #21's medical record found the resident was seen by the eye doctor in house on 12/18/24. A review of the consult found the following, History of Present Illness: 1. Decreased vision The [AGE] year old client presents for evaluation of Decreased vision in the right > left. It affects both near and far vision. The condition is significant. History of trauma with a BB gun per resident od. The consultation contained a prescription for new glasses. Below the prescription the following was written, New glasses will be ordered pending insurance/payer approval.An interview with the Business office manager on 08/05/25 at 12:35 PM confirmed she had not had a remedial (an adjustment the facility can request for the resident to lower her Medicaid resource amount to allow her to pay for the glasses) adjustment for glasses.An additional observation of Resident #21 glasses at 12:45 pm on 08/05/25 with the Regional Director of Clinical Observations #91 confirmed the resident's glasses were in poor repair and needed replacement. An interview with the Director of Nursing (DON) on the afternoon of 08/05/25 found the eye doctor's office sent an invoice for Resident #21's glasses in 12/2024. She stated they had talked to the son, and he did not want to pay for them at the time. The DON was asked if the facility had explained to the son that a Remedial Adjustment could be made to her Medicaid resource amount to cover the amount of the glasses and she stated she did not know what that was and would have to check with the business office. An interview with Resident #21's son Via Telephone on 08/05/25 at 1:31 PM confirmed, no one ever called him about his mom being seen for glasses and he wanted her to have anything she needed, and he would not have said no to that. He stated, I would like her to have new glasses.

Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of one (1) resident reviewed during the survey process. Resident Identifier: #10. Facility Census: 86. Findings Include:a) Resident #10On 08/07/25 at 9:00 AM, a record review was completed for Resident #10. The review found the PASARR dated 02/22/24 did not include all psychiatric diagnoses. The diagnoses not included were Generalized Anxiety Disorder documented as of 02/08/17 and Hallucinations which was documented as of 01/02/25. The resident is being treated with Klonopin (antianxiety) and Seroquel (antipsychotic) for bipolar disorder, which includes hallucinations.On 08/07/25 at 10:41 AM, the Social Services Director (SSD) #48 confirmed all the diagnoses were not listed on the PAS.

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 88. Findings included: a) Kitchen tour During the kitchen tour on 02/12/24 at 11:30 AM, it was discovered the drip pan to the stove was heavily soiled and needed to be cleaned. The floors to the walk-in freezer and cooler had debris under the storage racks and the beverage pitchers were stored rim down on a rusted shelf. The Dietary Manager observed the issues on 02/12/24 at 11:40 AM and verified the drip pan and floors needed to be cleaned. He also verified the beverage pitchers were stored rim down on a rusted shelf.

Based on observation, resident interview, and staff interview, the facility failed to treat each resident with dignity and respect by failing to knock, announce themselves, and receive permission from each resident before entering their rooms. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident Identifier: #12. Facility census: 88. Findings included: a) Resident #12 At approximately 11:51 AM on 02/12/24, Resident #12 expressed concern that staff would enter the room without knocking first. Resident #12 stated, Most of the time I don't know when they're coming in here. I'll be by myself one second, and when I look up, there will be a staff member, and I never knew they were coming in here. During the interview with Resident #12, the door to the room opened and Nurse Aide (NA) #36 entered unannounced, without knocking. When NA #36 realized an interview was taking place with Resident #12, NA #36 stated Sorry, I didn't know anyone else was in here, I'll wait out in the hallway. An interview was conducted with NA #36 at the end of the resident interview in which the NA #36 stated I just flung the door open and went in, I know I'm supposed to knock before I go in the rooms, I just didn't.

Based on resident and staff interviews, the facility failed to protect each resident's property from being lost or stolen. The facility did not follow proper processes when Resident #82 reported a puzzle missing. This was true for one (1) of three (3) residents reviewed for personal property during the Long-Term Care survey process. Resident identifier: #82. Facility census: 88. Findings included: a) Resident #82 At approximately 12:58 PM on 02/12/24, an interview was conducted with Resident #82. Resident #82 stated during the interview that there were issues with their personal property disappearing and staff failing to follow up on their concerns. Specifically, Resident #82 stated a puzzle that was brought to them by a family member was taken and thrown away while the resident was working on it. Resident #82 stated they reported the puzzle to Nurse Aide (NA) #93 and NA #104 during the evening shift a couple weeks ago. Resident #82 stated there was no grievance form filled out, nor was there any follow up from the facility. At approximately 9:30 AM on 02/13/24, an interview was conducted with Social Services Designee (SSD) #70 and Social Worker (SW) #62. During the interview, both SSD #70 and SW #62 stated they were unaware of any issues regarding the puzzle for Resident #82, stating they would check into the issue immediately. At approximately 9:43 AM on 02/14/24, an interview was conducted with SSD #70 and SW #62 regarding the missing property of Resident #82. SSD #70 and SW #62 stated they had not followed up on the concern, nor had they met with Resident #82 to have them fill out a grievance form.

Based on observation, resident interview, record review, and staff interview, the facility failed to ensure three (3) of three (3) residents reviewed for the care area of Abuse during Stage 2 of the survey were free from mental abuse and/or involuntary seclusion. -- Resident #125 was not free from involuntary seclusion and mental abuse. When she was admitted to the facility, she did not have capacity to make medical decisions. After she regained this capacity, and voiced a desire to go home, the facility made no effort toward discharging the resident. This alert and oriented individual resided on the Lighthouse Unit, a locked dementia care unit. The resident's Medical Power of Attorney, not the resident, made the decision for the resident to be on dementia unit. The resident suffered harm, beginning 08/30/13, when she became capable of making her own health care decisions, but was not afforded that opportunity by the facility. -- Residents #77 was not free from mental abuse. She was not assisted in toileting as requested. Staff insisted she go to the bathroom when she wanted to use a bedpan. This resulted in an episode of incontinence. -- Resident #18 was not free from mental abuse. She was not assisted in using the bed pan as requested. Staff informed her she could not be assisted until she, her roommate, and all other residents on her hall were finished eating. Resident Identifiers: #125, #77, and #18. Facility Census: 85. Findings Include: a) Resident #125 Employee #116, a physician, was interviewed at 1:45 p.m. on 01/20/14. He stated Resident #125 did not belong on a locked unit. Resident #125's medical record was reviewed at 8:22 a.m. on 01/21/14. This review revealed the resident was admitted to the Lighthouse Unit (Dementia Care Locked Unit) on 07/30/13. Upon her admission to the facility, the resident lacked capacity to make medical decisions. She had a determination of incapacity for medical decision-making completed on 07/25/13 at a local area acute care hospital. This determination was in effect until 08/30/13, when a facility physician reviewed the resident for capacity and determined the resident had regained capacity to make medical decisions. As of 08/30/13, the resident should have been afforded the right to make her own heath care decisions. Further review of the medical record revealed a from titled, "Special Care Unit Consent." This form contained the following text: "I give my consent for (Resident #125's Name) to be placed on a Special Care Unit for his/her safety and security due to his/her present status with dementia. I understand that he/she will be evaluated Quarterly according to facility policy for continued stay. If the evaluation team finds that continued stay on the unit is no longer appropriate, the resident and/or the resident representative will be informed." This form was signed by the resident's Medical Power of Attorney (MPOA) on 07/30/13. The form was also signed by Employee #28, the Lighthouse Unit director. There was no evidence this consent for placement on the Special Care Unit was reviewed with, or discussed with, the resident after the resident was deemed capable of making medical decisions. At 10:41 a.m. on 01/21/14, Resident #125 was interviewed in her room on the Lighthouse Unit. The resident stated being in the facility, "Makes me feel like I am confined to some place I can't get out of." The resident stated, "I am angry about how I am being treated." When asked if it was her intention to remain in the facility she stated, "No I am locked in and can't go anywhere or do anything without someone being with me." She stated, "It has been my intention from day one to go home. I never agreed to stay here long term." She further stated, "I do not want to be here. I do not belong here. The doctor came in here the other day and told me I did not belong here." When asked how long she has wanted to go home, she replied, "I have wanted to go home from the beginning. I know I needed some therapy, but I have been done with that for months now. I want to go to somewhere like assisted living. It will only cost me $4,000 a month instead of $8,000 a month plus I will have more freedom and independence. I hate it here. I am sad and angry I am still here." The resident stated the facility staff only recently began talking to her about going home. She stated, "I understand I don't have the home I had before I came in here, but I do not belong here. I don't know why they waited so long to start talking to me about this." Finally the resident stated, "I am fed up with being here and I want to be out of here before I have to give them another dime of my money." The following progress notes, written by Employee #28, the Lighthouse Unit Director, were in the resident's medical record: Note dated 07/31/13: "Resident's daughter came to talk to me and is worried about her Mom. She said (Resident Name) told her that she is unhappy here, and she wanted to go home..." Note dated 08/14/13: "... She does believe she is going home soon, and states she is going to work hard to get there..." Note dated 09/04/13: "(Resident Name) son and daughter requested to this staff member that we have a meeting with (Resident Name) to discuss her long term plan because she continues to ask them when she gets to go home. Meeting was held with (Resident Name) and family, and options were discussed. She stated that it bothers her to live here with the other people because it makes her sad to see what could happen to her. She states she understands that she has dementia, and she realizes she can not safely live by herself. She would prefer to move to an assisted living situation where she would have her own room, or go home with caregivers, (Resident Name) son explained to resident that her financial status would prevent this from being a long term plan, and they would prefer she stay in the Lighthouse Unit. (Resident Name) responded by saying she just wanted to way (sic) her options, and see what she could do. Her family stated that a decision did not have to be made at this time, and they would inquire at a couple of places to what cost was, and they would talk about it with her. She seemed to accept that. Not in (Resident Name) presence, the MPOA (Medical Power of Attorney), (name of resident's son) stated that their wishes remain that she continues to be a resident on the Lighthouse Unit." Note dated 11/05/13 (Quarterly review): "...She wants to go home, but currently understands her financial situation, and that there is no one to live {with} her. She show minimal deficits at this time with no behaviors. Her children visit often, and she does go out of the facility with them to shop, eat, etc. She does cooperate well with care, and is very independent with activities of daily living." Note dated 01/07/14: "(Resident Name) has been very upset yesterday and today crying. This staff member spoke with her regarding what is wrong, and she states she is unhappy here, and wants to have her own place. She has been doing well overall until right around Christmas time, which is the first anniversary of the death of her husband. She feels like her children has 'abandoned her and don't give a damn.' She stated that she has some friends looking for her an apartment in (town and state). She currently retains capacity, but her son (name) holds Durable Power of Attorney. He lives in (town and state) and her daughter also lives away from here. (Name of son) takes care of her finances currently. Spoke with (name of son) regarding her feelings. He stated, 'I understand, but being home by herself is what put her in the hospital. She is doing so much better now.' This staff member explained that we could make a referral to (a specialized program), just to see what options are available. He was in agreement, though voiced reservation because he would prefer she stay here. She is currently staged at a 4, and does display memory deficit. This staff member spoke with social worker and (Resident Name) and discussed the plan. (Resident Name) seemed pleased, and stated 'My husband and I worked hard all of our lives for our money and I want to be at home.' Staff will continue to monitor." Note dated 01/16/14: "(Resident Name) asked this morning if the ombudsman was going to visit with her today, (Resident Name) stated that the ombudsman has told her she would check back in with her today. This staff member stated that I hadn't heard from the ombudsman yet today, but if she doesn't come we will call her. She stated that would be fine. She will wait and see if she comes today. She has been very social this week, and is enjoying her new kindle that she got for Christmas. She plays a game called Candy Crush that she enjoys very much. She reads a lot, and bought several books on her last outing." Note dated 01/21/14: "(Resident Name) has voiced being upset today about the meeting from yesterday with her children, granddaughter, myself, and Social Services. The meeting was discussing (Resident Name) desire to leave the facility. She states she wants more freedom, and doesn't feel like she belongs here. Her son told her he had moved to (town and state) and she was previously unaware of that. He also told her he had sold most of her things. She stated, "All of my clothes too?" He stated that the clothes that were there were too large for her anyway, and she could just buy new clothes if she wanted. There was obvious tension between (Resident Name) and her family, and both (Resident Name), (son), and (daughter) raised their voices during the meeting. (Resident Name) does not believe she has any deficits, and her children are concerned with her long term safety, as they both live away, as well as long term financial plan. It was concluded in the meeting that Social Services would contact some assisted living facilities to check availability, and also find out prices. (Resident Name) showed a specific interest in (local assisted living facility). Her family stated they would go with her to tour some facilities...." On 01/21/14 at 10:00 a.m., the Lighthouse Unit Director, Employee #28, was interviewed. She confirmed Resident #125 was not appropriate for the Lighthouse unit. Employee #28 stated this was a recent change. She stated Resident #125 was not allowed to have the code to get out off the unit because she was giving it to other residents. Employee #28 stated she explained this to Resident #125. She stated they did not give Resident #125 the code to get off the unit after they spoke to her about giving other residents the code. She said to her knowledge, anytime Resident #125 wanted off the unit,staff opened the door and let her leave the unit. When asked about the, "Special Care Unit Consent," Employee #28 stated, "I never thought about having her sign the consent when she regained her capacity to make medical decisions." At 2:54 p.m. on 01/21/14, Employee #88, the Social Service Director, was interviewed. The Social Service Director agreed Resident #125 was not appropriate for the Alzheimer's Unit. She agreed if a resident who had capacity was not allowed to leave the Lighthouse unit as they chose, she were involuntarily secluded from the rest of the facility. Employee #88 said she began discharge planning for the resident on 01/07/14. The Social Service Director stated, "This was when her strong vocalizations about going home began." She said the resident had been upset and crying for two (2) days over her desire to go home. The Social Service Director said she was not aware of Residents #125's vocalizations about wanting to go home, despite the fact they were noted in the medical record, by Employee #28, the Lighthouse unit Director, on 07/31/13, 08/14/13, 09/04/13 and 11/05/13. Social Service Note dated 08/06/13: "SW (social worker) also completed the social services initial history on this date. The resident reported she wants to return home but her MPOA plans for her to remain in long term care." Social Service Note dated 01/07/14: "Social Work (SW) has been advised by the Lighthouse Unit director that (Resident Name) has recently became (sic) verbal about wanting to leave (facility name) and move into her own residence. Resident lived independently in her own residence before her placement at (facility name) in July of last year. SW made referral to the regional office of (name of agency) today to see if they could be of assistance. SW spoke with (agency representative) at this agency who reported the resident does not qualify for (name of program) because she is not on Medicaid. They have no other assistance program to offer as the Medicaid Wavier program remains frozen for new referrals. SW has learned that the the resident is paying privately for her care and should have the means to move back into a residence of her own or assisted placement if she would be agreeable. (Resident Name) is noted to still have decision making per MD (medical doctor) evaluation shortly after her admission to (name of facility). She is reported to be a high functioning dementia patient but to have some memory deficit. A full-time supervised living situation would be ideal for her but she has the right to leave if she wishes. SW met with the resident at length this afternoon to discuss her situation and options. She was adamant that she wants to leave and verbalized she does not feel the Lighthouse unit is the appropriate place for her at this time. She also verbalized that she is unhappy that she does not have control of her finances. Her son (name) is her DPOA (durable power of attorney) and assumed responsibility for her checkbook and paying her bills after she was placed at (name of facility). SW inquired if she might be able to live with any family but she is opposed to this idea and verbalized .... 'they have their own lives.' She has some close friends in (town) (friends last name) whom she reported would be willing to help her find a suitable place to rent. SW spoke with the her about the need to work out all the practical details before she is discharged from (facility name). The main issue may be her resuming control of her finances. The resident may need outside advocacy and SW made a consult to the Regional NH (nursing home) ombudsman to consult with the resident." Social Service Note dated 01/17/14: "The regional nursing home ombudsman, (Name), met with the resident last week and again today to discuss her request for discharge to the community and to provide (Resident Name) with options regarding local assisted living facilities. Social Work (SW) spoke with the ombudsman today regarding her consultations and she reported she believes the resident would be very appropriate for assisted living placement. She also reported (Resident Name) has identified, (the names of three (3) separate local assisted living facilities) as her preferences for placement. (Resident Name) verbalized she would like to tour the facilities. SW spoke with the ombudsman about the need to involve the resident's son in the planning since he currently controls her finances. SW contacted resident's son (Name) to discuss the situation. He is opposed to the plan and questions that his mother is mentally competent. SW explained to him that his mother has been determined to have decision making capacity and that she has the right to make her own decisions. He agreed to attend a meeting with his mother and this has been scheduled for Monday, 01/20, at 11 am. SW has left message for the ombudsman about the time because she has requested to attend. The resident verbalized to (ombudsman) that she would like to leave by the end of the month." Social Service Note dated 01/21/14: "SW made a follow up call to the regional ombudsman office to relay the outcome of yesterday's family meeting. (Ombudsman) was out of the office and SW left a voice message for her requesting a return call. The LHU (Lighthouse Unit) Director and the undersigned social worker met with the resident and family (son, daughter, and granddaughter) at length yesterday to discuss (name of resident) desire to return to the community. The family voiced opposition to the plan, particularly the son who is concerned his mother's safety needs will not be met away from secure dementia unit. He also questioned the doctor's decision about his mother's competence. Both SW and LHU director emphasized with the family that (name) has been determined to have decision making capacity and that she has the right to determine where she lives. (Name) is independent with ambulation and ADL's (activities of daily living) but does have some cognitive deficits related to early stage dementia, primarily memory loss. Both SW and LHU director verbalized to the family that (name) would be a good candidate for assisted living. She would have more privacy and freedoms in the type of setting. (Name) is agreeable to this plan and her daughter reported she would be available next week to take her mother to tour some facilities. SW has contacted two assisted living facilities the resident has expressed interest for placement...." . . b) Resident #77 On 01/16/14 at 12:40 p.m., a Licensed Nurse (Employee #68) was observed administering medications to Resident #77. Upon entering the room to administer the medications, the resident's call light was observed on and the resident was calling out for assistance. When the nurse entered the room, the resident asked the nurse, "could you get me the bedpan?" The nurse informed the resident she had not been using the bedpan, and had been getting up and going to the bathroom. The resident said, "I do not want to get up and go to the bathroom, I want the bedpan." The nurse informed Resident #77 she was going to give her medications and then she would get someone to come and take her to the bathroom. The resident again stated, "I do not want to go to the bathroom, I want the bedpan." The nurse then said, "Your daughter wants you to get up and go to the bathroom, and does not want you to use the bedpan." The resident replied, " I will just use my Depends then." Employee #68 then administered the medication to Resident # 77. This took seven (7) minutes. After the nurse was finished, she told the resident, "I will go get someone to take you the bathroom now." Resident #77 said, "You can forget it. I do not need to go now. I just used my diaper." A nursing assistant (Employee #65) came into the resident's room at 12:55 p.m. She said, "I will take you to the bathroom before you eat." The resident stated, "I do not need to go, I just used my diaper. You can just change it now." The resident said they have told her before to just use her diaper, so it should not matter. The nursing assistant told Resident #77 the other nursing assistants probably just told her that because they did not want her to suffer. The nursing assistant said "Your daughter does not want you to use the bedpan. She wants you to go to the bathroom." Resident #77 replied, "My daughter is not my boss and can not tell me when and where to p_ _ _." Employee #65 then told the resident she would change her. The resident was interviewed at 1:00 p.m. on 01/16/14. When questioned about the amount of toileting assistance she required, she stated she had a hurt foot. She said she did not want to get back up after she laid down just to use the bathroom, because it was a lot of trouble. The resident said she knew when she needed to go to the bathroom, but getting someone to take you was "Another story." She stated, "They do not care anyway, because they tell you to just go ahead and use your diaper." . . c) Resident #18 Review of the resident's medical record, on 01/16/14, revealed a nursing note, dated 09/11/13 at 6:31 p.m. (Typed as written), "Resident asked CNA (certified nursing assistant) for place her on bedpan during dinnertime when dinner trays were still on the floor and staff was still assisting residents that required assistance to eat, CNA asked resident if she was finished with her dinner, resident stated that she was not finished with dinner, but needed the bedpan anyway. CNA explained to resident that she could not stop assisting other residents at this time to place her on bedpan. CNA came to this nurse for advise, and this nurse agreed that since it was [MEDICATION NAME], and she did use the bedpan approximately thirty minutes prior to dinner, that CNA should wait until she finished her dinner, and other residents, including her roommate, was finished with dinner." According to a physician's determination of capacity, dated 11/02/12, the resident demonstrated capacity to make medical decisions. The resident was not provided the code to get out of the door, and had to ask to leave the unit. Staff did not always open the door for her. This practice resulted in psychological harm to the resident. Further review of the medical record [MEDICATION NAME] mg. (milligrams) was prescribed on 09/12/13 for seven (7) days for treatment of [REDACTED]. During an interview with the director of nursing (DON), on 01/16/14 at 12:31 p.m., she verified she was unaware of the nursing note. The DON stated the staff member should have toileted the resident when the resident asked. She said the information provided to the nursing assistant by the nurse was incorrect. The social services director, Employee #88, verified on 01/20/13 at 12:34 p.m., she was unaware of the nursing note. The social worker stated the information given to the nursing assistant was incorrect. Employee #88 said, "Residents should be taken to the bathroom anytime they ask." .

Based on medical record review, staff interview, review of the facility abuse/neglect files, and family interview, the facility failed to implement measures to prevent the development of pressure ulcers and failed to identify pressure ulcers promptly when they developed. Resident #79 experienced a mobility decline after suffering from a [MEDICAL CONDITION]. Measures were not implemented following the identification of increased risk factors for skin breakdown. She subsequently developed pressure ulcers on her heels and on her coccyx that were determined to be preventable. This was identified for one (1) of ten (10) sampled residents. Resident identifier: #79. Facility census: 82. Findings include: a) Resident #79 During a review of the medical record it was identified this resident had a [DIAGNOSES REDACTED]. The resident experienced a fall on 06/16/13 resulting in a [MEDICAL CONDITION]. The resident was admitted to the hospital 06/17/13 for repair of her hip. She was re-admitted to the facility on [DATE] following the hip repair and had a physician's orders [REDACTED]. The skin assessment completed at the time of her re-admission from the hospital did not reflect the presence of pressure ulcers. According to the medical record, she had a decline in mobility and she was to receive therapy for her mobility decline. A 5-day minimum data set (MDS) assessment, with an assessment reference (ARD) date of 06/28/13, indicated in Section "G" this resident did not walk in her room or in the corridor during the of seven (7) day look-back period of the assessment. Walking was coded 8/8 meaning it did not occur. The quarterly MDS, with an assessment reference date (ARD) of 03/25/13, completed prior to the resident's hospitalization , indicated the resident only required the limited assistance of one (1) person for ambulation in her room and in the corridor. Review of the medical record, for the period from 06/17/13 to 07/01/13, found no evidence this resident's increased risk for skin breakdown was addressed. It was not evident in the care plan that interventions were put in place at that time to address her decreased mobility and increased risk for skin breakdown. A nursing entry, on 07/02/13 at 6:36 a.m., noted "Yesterday evening it was brought to my attention by the staff while they were getting resident ready for bed that she has pressure ulcers on both of her heels. It is said that she did not have the areas the night before and that therapy got her ready for the day and took her to therapy that morning. She did wear shoes, the director of nursing (DON) was here and I brought the areas to her attention also. Will be discussed in the morning meeting." This was the first time the resident's skin breakdown was mentioned in the record. It was also the same day the family filed a complaint about the resident's care. The resident was sent to a scheduled doctor's appointment at 9:30 a.m. on 07/02/13. It was identified the resident's physician's office had called to inform the facility the resident was being sent to the hospital for an evaluation of her left hip. She was subsequently admitted to the hospital where it was determined her hip was fractured. A nursing note, written on 07/02/13 at 11:40 p.m., stated (typed as written) "Addendum to note entered by this nurse on 07/02/13 at 6:36 a.m. findings occurred 07/01/13 at 730 p.m. It was brought to my attention by an aid when they were getting resident ready for bed and I observed the areas to both of residents heels, they were soft and did not blanche, suspected deep tissue injury from diabetes. Heels remain elevated and abduction pillow was in place, resident was turned every two hours to prevent breakdown. Immediate treatment to heels was skin prep to both areas, Reported to the DON (director of nursing) and area is awaiting RN's (registered nurse's ) evaluation to stage the areas in question and measure the areas. . . ." During a review of the resident's hospital admission records, it was identified the resident had a Stage II pressure ulcer present on her coccyx and a deep tissue injury present to her right and left heels at the time of her admission to the hospital on [DATE]. A review of the facility's abuse/neglect investigation revealed there were two (2) witness statements collected from the nursing assistants who provided care to this resident. During this investigation conducted by the facility it was verified that Resident #79's heels were identified as being soft on 06/28/13 by the nursing assistants. The nursing assistants reported that the LPN (licensed practical nurse) was notified. There was no evidence the nurse observed the resident's heels at that time or implemented any measures to prevent further skin breakdown or communicated to others this resident's heels were soft at that time. During a family interview on 07/16/13 at 6:30 p.m., they confirmed the resident had large purple areas on her heels and an open area on her coccyx when she arrived at the hospital. The family said they had never observed the resident's heels elevated when they visited and had not seen the resident being turned. The first measurements of these wounds were dated 07/04/13, which was approximately two (2) weeks after the resident returned from the hospital. The measurements of the wounds at that time were the left heel - 4.0 cm x 5.0 cm, the right heel was 4.0 cm x 3.0 cm, and the Stage II area present on the coccyx was 5.5 cm x 4.3 cm with necrosis and slough. During an interview with the physician, on 07/17/13 at 10:00 a.m., he was questioned about the pressure ulcers. He verified he was not made aware of these areas until the family informed him. He was asked whether he felt these were preventable ulcers. He stated he felt these areas were preventable. The physician stated he felt the resident returned from the hospital with a mobility decline, had the abduction pillow, and did not have anything to prevent pressure to her heels. .