Every finding on record at Consolata Rehab and Wellness Center on the Teche

Based on observations, policy review, record review, and interviews, the facility failed to implement and maintain an effective infection control and prevention program by failing to:1. Implement a system of surveillance that included pathogen data to properly identify possible communicable diseases or infections before they spread. 2. Ensure staff used personal protective equipment according to accepted standards of practice as evidenced by staff not wearing the appropriate Personal Protective Equipment (PPE) while providing high contact care for 2 (#27, #54) residents who were on enhanced barrier precautions. Findings: 1. A review of the facility's policy titled, Surveillance for Infections, with a last reviewed date of 02/26/2026, read in part. Policy Statement: The infection preventionist conducts ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. Data Collection and Recording. 4. For targeted surveillance using facility-created tools, follow these guidelines:. c. Monthly: Summarize monthly data for each nursing unit by site and by pathogen (e.g. (for example), Facility-Wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form). A review of the facility's form titled, Infection Surveillance Information Forms for February 2026, March 2026, and April 2026 revealed that not all pathogens from culture results were recorded for infection surveillance. Further review revealed the monthly facility infection control maps for those corresponding months did not contain the use of specific pathogens for surveillance. On 06/10/2026 at 2:45 p.m., an interview and review of infection control records was conducted with S8IC/TXN. She confirmed that there was no evidence that all specific pathogens from lab results, as indicated on the Infection Surveillance Information Forms for February 2026, March 2026, and April 2026, were recorded and used for surveillance on the monthly Infection Control Maps for the corresponding months. She further confirmed that recording and tracking these specific pathogens on the facility monthly maps was the facility's protocol for surveillance of infections. On 06/10/2026 at 3:45 p.m., an interview and review of infection control records was conducted with S1DON. She confirmed the above findings. 2. Review of a facility policy titled Enhanced Barrier Precautions, with revised date of 12/2024, read in part. Policy Interpretation and Implementation: 1. enhanced barrier precautions refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 7. Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. 8. Examples of high contact resident care activities requiring the use of gowns and gloves include: d. changing briefs or assisting with toileting; g. changing linens. Resident #27 Review of Resident #27's Electronic Medical Record (EMR) revealed an admit date of 12/11/2025 with diagnoses that included metabolic encephalopathy, gastrostomy, and Kennedy ulcers to right hip and sacrum. Resident has continuous tube feedings. Review of Resident #27's physician orders dated 01/08/2026 read in part, enhanced barrier precautions to be during resident high contact activities every shift. On 06/08/2026 at 2:24 p.m., S6CNA and S7CNA were both observed changing the resident's adult brief without wearing the appropriate personal protective equipment (PPE) by not wearing a gown while providing patient care. Resident #54 Review of Resident EMR revealed an admit date of 04/28/2026 with diagnosis that included peripheral vascular disease, atherosclerosis arteries of left leg with ulceration, and Stage IV pressure ulcer. Review of Resident #54's physician orders dated 04/29/2026 read in part, enhanced barrier precautions to be during resident high contact activities every shift. On 06/08/2026 at 2:31 p.m., S6CNA and S7CNA were observed changing Resident #54's soiled linen and changing his adult brief without the appropriate PPE. Both S6CNA and S7CNA failed to put on a gown during patient care. On 06/08/2026 at 3:10 p.m., an interview was conducted with S7CNA who stated she was not aware that Residents #27 and #54 were on enhanced barrier precautions. She confirmed that she and S6CNA should have been wearing gowns prior to changing the adult briefs and changing soiled linen. On 06/10/2026 at 8:10 a.m., an interview was conducted with S8IC/TXN who confirmed S6CNA and S7CNA should have been wearing gowns as well as gloves prior to changing Resident #54's soiled linen and changing the resident's adult briefs.

Based on record review, observation and interview, the facility failed to ensure the resident's food was palatable, prepared by methods that conserve nutritive value, and served potentially hazardous food (dairy) in a safe manner as evidenced by: 1. S4Cook failing to prepare food(s) according to the recipe, 2. Resident #38 served spoiled milk on 06/08/2026, and 3. Resident #58 served spoiled milk on 06/08/2026 and 06/09/2026.This deficient practice had the potential to affect the 70 residents who consumed food from the facility's kitchen. Findings: 1. Review of the facility's recipe titled, Mashed Potatoes DHY/Gravy included the following ingredients: potato granules, water, and soft margarine bulk. Further review of the recipe included the following instructions.1. Prepare mashed potatoes according to package instructions, omitting the salt. On 06/08/2026 at 10:40 a.m., S5Cook was observed preparing mashed potatoes without a recipe. S5Cook poured an undetermined amount of water, potato flakes, milk and salt in a container. She used a whisk and mixed all the ingredients. Then, S5Cook added an undetermined amount of granulated onion powder. She stated she used the onion powder to give the potatoes a little flavor. On 06/10/2026 at 12:30 p.m., an interview was conducted with S4DM. She stated there was a binder that contained the food recipes. She confirmed that the kitchen [NAME] should be using the recipe when preparing food. On 06/10/2026 at 12:35 p.m., an interview was conducted with S5Cook. She confirmed that she didn't use the mashed potato recipe when she prepared the mashed potatoes on 06/08/2026 and should have. 2. On 06/08/2026 at 9:10 a.m., an observation and an interview was conducted with Resident #38. The resident had her breakfast tray on her side table. She had an unfinished glass of milk on her tray. The resident stated that she liked milk, but the milk tasted sour this morning so she did not drink it. A smell test was immediately conducted revealing the resident's milk smelled spoiled. 3. Review of Resident #58's quarterly Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. On 06/08/2026 at 10:00 a.m., Resident #58 was interviewed and stated the milk he was served this morning for breakfast was not good. He stated his milk tasted spoiled and he was not able to finish drinking it. On 06/09/2026 at 8:44 a.m., Resident #58 was observed sitting in his wheelchair in his room with his breakfast meal tray. Resident #58 had a carton of milk with an expiration date of 06/10/2026 and a sour odor was present. On 06/09/2026 at 8:52 a.m., S7CNA was observed as she entered Resident #58's room and he informed S7CNA his milk smelt sour. S7CNA smelled the milk and grimaced indicating that the milk did not smell fresh. On 06/09/2026 at 9:02 a.m., S4DM was observed as she entered Resident #58's room and was informed by S7CNA that the resident's carton of milk smelled sour. S4DM smelled the Resident's carton of milk and grimaced indicating the milk was not fresh. S4DM then emptied the carton of milk down the resident's sink and provided Resident #58 with a cup of milk that did not smell sour and explained she poured his replacement of milk from a gallon. On 06/09/2026 at 11:46 a.m., an interview was conducted with S3ADM who verified S4DM informed her that Resident #58 was served milk that smelled spoiled this morning with his breakfast.

Based on observations, interviews, and record review, the provider failed to prepare, distribute, and serve food in accordance with professional food service standards by failing to ensure staff:1. Wore appropriate hair covering when entering the kitchen2. Label and date all refrigerated food opened; and3. Served potentially hazardous food (dairy) in a safe manner. Findings: 1. On 06/09/2026, a review of the facility's policy titled Hair Restraints (Hair Nets and [NAME] Guards) Policy and Procedure which was last reviewed on 05/01/2026, read in part: Procedure: 1. Requirement for hair restraints.any person entering the dietary department, whether dietary staff and non-dietary personnel, must wear a hair net prior to entry and while in the dietary area. Hair restraints include hair nets, caps, or other approved coverings that fully contain all head hair. [NAME] guards are required for all staff with facial hair (beards, goatees, or long stubble) that may come into contact with food or food-contact surfaces. On 06/08/2026 at 10:30 a.m., an observation was made of two maintenance personnel in the kitchen. One maintenance personnel had a beard. Both maintenance personnel did not have hair protection and the maintenance personnel with a beard didn't have beard protection. On 06/08/2026 at 10:58 a.m., S3ADM confirmed that any staff should wear hair and/or beard protection when they enter the kitchen. 2. Review of the facility's policy titled, Food Procurement, Receiving, Storage, and Date Labeling policy, with a review/revised date 05/01/2026 read in part. 3. Date Marking and Labeling: All refrigerated, ready-to-eat foods that are prepared, opened, or portioned must be labeled. Required Label Information: Food name, Date prepared or opened, and Expiration/discard date. 4. Opened Food Handling: Must be labeled immediately upon opening. On 06/08/2026 at 09:20 a.m., an observation was made of the facility's walk-in cooler. During the observation, a plastic bag with unwrapped slices of cheese was observed on a shelf with no open date. S4DM stated that the bag with the slices of cheese should not have been put in the cooler without an open date. 3. On 06/08/2026 at 10:20 a.m., during the initial pool screening, two residents (Resident #38 and Resident #58) reported to surveyors that they received spoiled milk on their breakfast tray. One resident received a carton of milk and the other resident received a glass of milk. On 06/08/2026 at 10:36 a.m., an interview and observation was conducted with S4DM. She stated that she poured 5-6 glasses of milk from one of the gallons of milk this morning to be served to residents that preferred their milk to be in a glass. An observation was made of a gallon of milk in the walk-in cooler approximately 3/4 empty. It had an open date 06/06/2026 and use by date 06/10/2026. S4DM stated that she had not used this gallon of milk to prepare the 5-6 glasses of milk this morning. She stated that she discarded the gallon she had used after she prepared the glasses of milk. A taste sample of the gallon of milk currenting in the walk-in cooler was performed by this surveyor and determined that the milk tasted spoiled. S4DM performed a smell test of the gallon of milk and confirmed that the milk smelled spoiled. On 06/08/26 at 10:40 a.m., an observation made of S5Cook preparing mashed potatoes. S5Cook used a carton of milk with a used by date of 06/10/2026. A smell test was conducted by this surveyor and determined that the milk smelled sour. S5Cook and S12CH performed a smell test of the milk and they both confirmed that the milk used to make the mashed potatoes had a sour odor and was spoiled. On 06/08/2026 at 10:54 a.m., an interview and observation was conducted with S3ADM. S3ADM was informed of concerns voiced by residents that the milk with 06/10/2026 used by date being spoiled. S3ADM was informed that this surveyor and S4DM had determined that the milk in one of the gallons with the 06/10/2026 used by date tasted and smelled spoiled. S3ADM was also informed that the carton of milk used by S5Cook with a 06/10/2026 used by date to make mashed potatoes had a sour smell. A smell test was conducted by S3ADM of the milk from the carton used to make mashed potatoes and four other cartons with a 06/10/2026 use by date. S3ADM stated that she didn't feel that any of the cartons of milk had a sour smell. S3ADM and S4DM were asked what the facility's plan was to ensure that the residents didn't receive any more spoiled milk since it had been determined that some of the milk, both in a gallon and carton, were found to taste and smell spoiled. S3ADM stated that she felt that the staff didn't do anything wrong because the milk had not reached the expiration date and they planned to keep the milk they had left and continue to serve it. On 06/08/2026 at 5:25 p.m., a second interview was conducted with S3ADM. S4DM was present. S3ADM was again asked how the facility was going to ensure that the residents didn't receive spoiled milk with their meal. S3ADM stated again that because the milk was not expired, there was no reason for them to think that the milk was not good. S4DM confirmed that there were 80 cartons of milk remaining and 2 gallons of milk remaining with the 06/10/2026 use by date. She confirmed again that they planned to serve the remaining 80 cartons of milk and remaining 2 gallons of milk with the use by date of 06/10/2026. On 06/09/2026 at 9 a.m., it was reported by a survey team member that Resident #58 had complaints that he received spoiled milk again for breakfast this morning. The surveyor reported that S4DM was made aware that Resident #58's carton of milk smelled sour. S3DM went to the resident's room and smelled the milk in the carton and confirmed that the milk was spoiled. On 06/09/2026 at 9:45 a.m., an interview was conducted with S4DM who confirmed that the remaining 80 cartons of milk with the used by date 06/10/20266 was served for breakfast this morning.

Based on observation, interviews, and record review, the facility failed to obtain ordered medications from the pharmacy for 1 (Resident #73) of 5 residents observed during medication administration.Findings:Review of Resident #73's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus without complications, paranoid schizophrenia, and essential (primary) hypertension.Review of Resident #73's current physician orders revealed an order, dated 06/01/2026, for Farxiga oral tablet 10 mg, give 1 tablet by mouth one time a day related to type 2 diabetes mellitus without complications.On 06/09/2026 at 8:50 a.m., an observation was made of S10LPN during morning medication administration. S10LPN administered all of Resident #73's medications except for his Farxiga oral tablet 10 mg (milligram). S10LPN stated the Farxiga was ordered last Monday (06/01/2026) but they still had not received it from the pharmacy. She was asked if the doctor had been notified that Resident #73 had not received his medication, and she stated he was not notified because she had been using Farxiga from another resident who was discharged . She further stated that she used the last one yesterday (06/08/2026).Review of Resident #73's medication administration record (MAR) revealed Farxiga 10 mg oral tablet was administered 06/02/2026 through 06/08/2026.On 06/09/2026 at 10:20 a.m., a follow up interview was conducted with S10LPN. She stated that she called the pharmacy and they reported they had not received the order for Farxiga. S10LPN stated she worked on 06/01/2026 when the order was written and was off for two days. She stated the person who followed her did not follow up with pharmacy. S10LPN was asked if she had notified S1DON and S2ADON that she did not receive Resident #73's medication from the pharmacy and had been using medications from a discharged resident and she stated she did not.On 06/09/2026 at 10:24 a.m., an interview was conducted with S2ADON. She stated she faxed the order when it was written to pharmacy last Monday (06/01/2026). S2ADON stated S10LPN did not report to her that she had not received the Resident #73's Farxiga from the pharmacy. S2ADON was asked if it was normal practice to give another resident's medication to someone else and she stated no. She stated S10LPN should have followed up with pharmacy, made her (S2ADON) aware they were unable to get the medication, and should not have used another resident's medication.

Based on record review, observation, and interview, the facility failed to ensure that residents who are unable to carry out activities of daily living (ADL) receive the necessary services to maintain grooming and oral hygiene. This is evidenced by the facility failing to ensure: Resident #27 was shaven and maintained good oral hygiene. Resident #54's adult brief and linen were clean.Findings:Review of a document titled, Activities of Daily Living (ADL), Supporting with a revision date of 04/2025, which read in part: Residents who ae unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #27 was admitted [DATE] with diagnoses that included: metabolic encephalopathy, aphasia, [NAME] pressure Ulcer to the right hip and sacrum, Type 2 Diabetes Mellitus, and dysphagia. Review of Resident #27's care plan dated 04/23/2026 read in part, ADL self-care performance deficit. Intervention read in part, oral care daily. Review of physician orders dated 06/09/2026 read in part apply Aquaphor to bilateral upper and lower extremities daily related to dryness. Review of a quarterly Minimum Data Sets (MDS) dated [DATE] read in part, cognitive skills for daily decision - severely impaired. Oral care - dependent on staff. Personal hygiene. On 06/08/2026 at 9:43 a.m., an observation of the resident revealed he was unshaven, face was dry, and lips were cracked with moderate amount of dry skin noted. On 06/08/2026 at 11:53 a.m., another observation was conducted which revealed resident remained unshaven, had cracked lips and a moderate amount of dry skin noted to lips and face. On 06/08/2026 at 3:00 p.m., an interview was conducted with S6CNA (Certified Nursing Assistant) who stated she was the aid for the hall and was responsible for caring for the residents. She stated she was supposed to provide oral hygiene to the resident and groom him but had not provided the care today. On 06/10/2026 at 8:00 a.m., an interview was conducted with S8IC/TXN (Infection Control/Treatment Nurse) who confirmed the resident was supposed to have oral care daily and he was supposed to be shaven once weekly. On 06/10/2026 at 1:38 p.m., an interview was conducted with S1DON (Director of Nursing) who confirmed staff should have been monitoring and shaving the resident at least weekly. 2. Review of Resident #54's clinical record revealed an admit date of 04/28/2026 with diagnoses that included atherosclerosis arteries of left leg with ulceration of heel and midfoot, peripheral vascular disease, and protein-calorie malnutrition. Review of Resident #54's admission MDS dated [DATE] revealed a BIMS score of 09, which indicated severe problems with thinking or memory.Functional Ability - personal hygiene: partial/moderate assistance. Toileting hygiene: dependent helper does all the effort. On 06/08/2026 at 9:43 a.m., an observation of the resident was conducted in his room. Further review revealed resident was lying on a bed spread which was being used as a incontinence pad. The bed spread had a moderate amount of a dry, dark substance, and the resident's adult brief had a light brown substance on the outside. On 06/08/2026 at 1:07 p.m., a follow up observation was conducted. The resident bed linen was observed again with a dry, dark colored substance noted on the bed spread, and a light brown substance on the outside of the adult brief. On 06/08/2026 at 3:00 p.m., an interview and observation was conducted with S6CNA who confirmed the resident had a brown substance in front of his adult brief, and a dry dark substance on the bed spread. She confirmed she should have changed the soiled linen and brief.

Based on observations, interviews, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, by failing to ensure a resident who complained of nausea and vomiting received medication ordered by the physician to treat these symptoms for 1 (Resident #57) of 38 sampled residents.Findings:Review of Resident #57's electronic health record (EHR) revealed that she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to bilateral primary osteoarthritis of knee, anxiety disorder, pain unspecified, drug induced constipation and major depressive disorder.Review of Resident #57's quarterly Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed in Section C that the resident had a Brief Interview for Mental Status of 15, indicating her cognition was intact.On 06/08/2026 at 9:15 a.m., an observation and an interview were conducted with Resident #57. The resident was sitting in her recliner chair with the head laid back. Resident #57 stated she was not feeling well. She stated she had diarrhea, nausea, and vomiting since yesterday and was still having some diarrhea and some nausea. Resident #57 stated she asked the day shift nurse (06/07/2026) for some nausea medicine and was told they were out of her nausea medicine. The resident stated she still had not received it. The resident stated the last time she vomited was around 4 p.m. on 06/07/2026. She stated she ate some breakfast this morning (06/08/2026) and was trying to stay still so she didn't throw up. During the interview, Resident #57 got up with urgency and stated she had to go to the bathroom due to diarrhea. Review of Resident #57's current physician orders revealed an order written on 06/02/2026 for Ondansetron HCL (Hydrochloride) Oral Tablet 8 mg (milligram) Give 8 mg orally every 6 hours as needed for nausea; vomiting.Review of Resident #57's June 2026 Medication Administration Record (MAR) revealed Ondansetron HCL Oral tablet 8 mg with a start date of 06/02/2026 was given once on 06/02/2026. No other doses were administered. Review of Resident #57's 06/2026 progress notes revealed no entry to indicate Resident #57's nausea was identified and treated by a nurse. On 06/08/2026 at 9:52 a.m., S14RD wrote in part: Rt (resident) reported N/V/D (nausea, vomiting, diarrhea) yesterday (06/07/2026) with minimal intake. On 06/09/2026 at 10:08 a.m., an interview was conducted with S13CNA. She stated she worked on Sunday (06/07/2026) and Monday (06/08/2026) and Resident #57 was sick. She stated the resident threw up in her garbage can on Sunday (06/07/2026) and also had diarrhea. S13CNA stated she reported it to S11LPN and was not sure if the nurse gave the resident any medication for her nausea. On 06/09/2026 at 12:35 p.m., an interview was conducted with S11LPN. She stated she cared for Resident #57 on the day shift on Sunday 06/08/2026. S11LPN stated she received a call from Resident #57's Responsible Party (RP) around lunch time on 06/07/2026 notifying her that the resident had called and was complaining of nausea. She stated she checked the medication cart and the resident did not have Zofran (Ondansetron) in the cart. She stated it was her first time at the facility so she asked S15LPN who told her that pharmacy didn't pass on the weekend so she had to wait until Monday. She was asked if she went to the emergency kit and she stated that she asked about an emergency kit and no one was able to tell her if there was one. When asked, S11LPN confirmed she did not call S1DON and left work without giving the resident nausea medication.On 06/10/2026 at 8:15 a.m., an observation of Med Cart A and an interview was conducted with S10LPN. She removed a full blister pack of Ondansetron 8mg Oral tablets with Resident #57's name from the bottom drawer of the cart which she stated was the PRN (as needed) medications drawer. The medication had a delivery date of 06/02/2026. S10LPN stated that the delivery date indicated the date the medication was delivered to the facility.On 06/10/2026 at 10:28 a.m., an interview was with S1DON who stated the medication was on the cart and available for S11LPN to administer to resident #57. She stated that S10LPN was on call and if S11LPN was unsure she should have called S10LPN.

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 developing by failing to turn two dependent with pressure ulcers every two hours for 2 (Resident #27 and #54) of 2 residents investigated for pressure ulcers.Findings: Resident #27 A review of Resident #27's clinical record revealed an admit date of 12/11/2025 with diagnoses that included metabolic encephalopathy, disorders of the skin and subcutaneous tissue, type 2 diabetes mellitus, peripheral vascular disease, and [NAME] pressure ulcers to the right hip and sacral area. A review of Resident #27's Care Plan dated 02/17/2026 read, in part: I have an activity of daily living self-care performance deficit. Interventions read, in part: assist rails times two for bed mobility and repositioning. Review of Resident #27's Minimum Data Set (MDS) quarterly dated 04/16/2026 revealed his Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. On 06/08/2026 at 9:30 a.m., resident was observed lying in his bed on his left side.On 06/08/2026 at 11:53 a.m., a second observation was conducted in resident's room. Resident was observed lying on his left side. On 06/08/2026 at 1:10 p.m., a third observation was conducted in the resident's room. Resident was observed lying on his left side. On 06/08/2026 at 2:00 p.m., a fourth observation was conducted in the resident's room. Resident was observed lying on his left side. On 06/08/2026 at 2:20 p.m., a follow up observation of Resident #27 and interview was conducted with S6CNA (Certified Nursing Assistant) who confirmed the resident was supposed to be turned every two hours and she had not turned the resident in two hours. Resident #54 Review of Resident #54's clinical record revealed an admit date of 04/28/2026 with diagnoses that included atherosclerosis arteries of left leg with ulceration of heel and midfoot, peripheral vascular disease, and protein-calorie malnutrition. Review of Resident #54's Care Plan dated 05/17/2026 read, in part: I have an activity of daily living self-care performance deficit. Intervention read in part: trapeze bar to assist with bed mobility and positioning. I need reminding/assistance to reposition at least every two hours. Review of Resident #54's admission MDS dated [DATE] revealed a BIMS score of 09, which indicated severe problems with thinking or memory. On 06/08/2026 at 9:30 a.m., resident was observed lying in his bed on his right side. On 06/08/2026 at 11:53 a.m., a second observation was conducted in resident's room. Resident was observed lying on his right side. On 06/08/2026 at 1:10 p.m., a third observation was conducted in resident's room. Resident was lying on his right side. On 06/08/2026 at 2:00 p.m., a fourth observation was conducted in resident's room. Resident was lying on his right side. On 06/08/2026 at 2:20 p.m., a follow up observation of Resident #54 and interview was conducted with S6CNA (Certified Nursing Assistant) who confirmed the resident was supposed to be turned every two hours and she had not turned the resident in two hours. On 06/10/2026 at 8:00 a.m., an observation of Resident #27 and #54 and interview was conducted with S8IC/TXN (Infection Control/Treatment Nurse) and S9CNA. S8IC/TXN confirmed Resident #27 and #54 were supposed to be turned every two hours. S9CNA stated Resident #27 is supposed to be turned every two hours. She added Resident #54 needs reminding and assistance with turning.

Based on record reviews, observation, and interviews, the facility failed to ensure the resident's physician's orders for providing pudding with meals were followed for 1 (Resident #4) of 38 sampled residents.Findings: Review of Resident #4's electronic clinical record revealed an admit date of 01/02/2025 with diagnoses that included dementia with other behavioral disturbance, abnormal weight loss, mild protein calorie malnutrition. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Review of Resident #4's physician orders dated 06/09/2026 revealed the following orders: Diet: Regular - mechanical soft. Pudding with all meals. On 06/10/2026 at 8:57 a.m., an observation was conducted in Resident #4's room. Further observation revealed his breakfast tray contained a mechanical soft diet of grits, sausage, eggs, milk, orange juice, and water. The resident had not been provided with pudding. On 06/10/2026 at 9:44 a.m., an interview was conducted with S2ADON who stated Resident #4's diet was changed on 06/09/2026 to include pudding with all meals. She confirmed the resident was supposed to have pudding on his breakfast tray the morning of 06/10/2026 and he did not. On 06/10/2026 at 10:31 a.m., an interview was conducted with S4DM (Dietary Manager) who stated when a resident's diet is changed, a new diet slip is provided, and the order is entered into the computer. S4DM stated she was aware that Resident #4's diet had changed, and he was supposed to receive a pudding on all his meal trays. She confirmed Resident #4 had not received a pudding on his breakfast tray that morning of 06/10/2026 and he should have.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's rights to confidentiality of medical records for 1 (Resident #44) out of a sample of 38 residents. Findings:On 06/09/2026 at 8:38 a.m., an observation was made of a computer screen on a medication cart on Hall B. Resident #44's medication administration record (MAR) was observed on the computer which was facing the hall. The MAR contained the resident's prescribed medication. Two residents were observed walking by the cart with the computer visible in their line of sight. S10LPN walked out of a resident's room and confirmed that she did not apply her computer privacy screen when she left to go in the resident's room and should have. On 06/10/2026 at 2:45 p.m., an interview was conducted with S1DON and S2ADON. They both confirmed that S10LPN should not have left Resident #44's MAR information on her computer without applying the privacy screen.

Based on observations, interviews, and policy review, the facility failed to appropriately store over the counter (OTC) medications in the locked medication cart.Findings:On 06/08/2026 at 9:33 a.m., an observation was made of an unattended medication cart on Hall B. A bottle of Aspirin 81 mg and a bottle of Geri-Kot 8.6 mg were observed unattended on top of the cart. Two residents walked by the parked cart. S10LPN returned to the cart after 5 minutes and confirmed that she had left the medications on top of the cart and stated that she should have placed the meds in the locked cart.On 06/10/2026, a review of the facility's policy titled Medication Labeling and Storage with a last reviewed date of 02/26/2026, read in part: Policy Statement: The facility stores all medications and biologicals in locked compartments .Policy Interpretation and Implementation: Medication Storage .5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .06/10/26 at 2:45 p.m., an interview was conducted with S1DON and S2ADON. They both confirmed the nurse was not supposed to have left the medications on the cart unattended. They stated the OTC medications should have been placed in the locked cart.

Based on observation and interviews, the facility failed to ensure the soft touch call light device was within reach for 1 (Resident #27) of 38 sampled residents. Findings:Review of Resident #27's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, metabolic encephalopathy, aphasia, paranoid schizophrenia, and dysphagia. Review of Resident #27's Minimum Data Set (MDS) quarterly dated 04/16/2026 revealed his Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. Review of Resident #27's care plan, dated 02/17/2026, revealed, in part, resident has an ADL (Activities of Daily Living) self-care performance deficit. Intervention read in part: encourage me to use bell to call for assistance. On 06/8/2026 at 9:00 a.m., an observation was conducted of the resident lying in bed in his room. Further observation revealed the soft touch call bell was draped on the bed rails behind the resident. Resident not able to reach or see the call bell. On 06/08/2026 at 2:10 p.m., a second observation in the resident's room revealed resident's soft touch call bell was out of resident's view and reach. On 06/09/2026 at 8:11 a.m., a third observation of the resident in his room revealed soft touch call bell was draped on the bed rails behind the resident and out of reach of resident. On 06/10/2026 at 8:00 a.m., a fourth observation was conducted in the resident's room. The soft touch call bell was observed still draped on the outside of the bed rail, out of the resident's sight and reach. An interview was conducted with S8IC/TXN who stated the soft touch call bell should have been within the resident's reach. She stated that the resident is physically capable of utilizing the soft touch call bell.

Based on record reviews, observations, and interviews, the facility failed to treat each resident with respect and dignity by failing to ensure the room door was closed and privacy curtain was drawn while performing perineal care (peri-care) for 2 (Residents #27 and #54) of 2 residents investigated for dignity. Findings: Review of Resident #27's Minimum Data Set (MDS) quarterly dated 04/16/2026 revealed his Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment.Functional Ability - personal hygiene; dependent on staff. Review of Resident #54's Minimum Data Set (MDS) dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score of 09, which indicated severe problems with thinking or memory.Functional Abilities- toileting hygiene dependent; personal hygiene (combing hair, shaving) partial/moderate assistance is needed from staff. On 06/08/2026 2:24 p.m., an observation of S6CNA and S7CNA providing peri-care to Resident #54 who was the roommate of Resident #27. Staff were observed changing the resident's soiled linen and adult brief. Further observation revealed S6CNA and S7CNA had not closed the room door, or pulled the privacy curtain between the residents' beds, and the window blind remained up. Resident #27 genitalia was exposed. On 06/08/2026 at 2:50 p.m., an observation of S6CNA and S7CNA in Resident #27's room was conducted during peri-care. Resident #54 was in his bed during this time. Further observation revealed S6CNA and S7CNA were providing peri-care to Resident #27 while the room door was left open, privacy curtain between was not utilized, and the window blinds remained up. Resident #54's genitalia was exposed. On 06/08/2026 at 3:00 p.m., an interview was conducted with S7CNA who confirmed she and S6CNA should have pulled the privacy curtain, closed the blinds and closed the door prior to providing peri-care to the residents.

Based on record review and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S6HSK, S7HSK, and S8FS were competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility's kitchen. Findings:Review a document titled Cleaning Policies and Procedures no review date read in part: Once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry; the use of towels may re-contaminate sanitized surfaces. An interview was conducted with S10HSKS on 04/13/2026 at 8:31 a.m. S10HSKS stated that since 01/2026 the kitchen staff needed assistance. She stated some staff that work in housekeeping would help in the kitchen on their days off. S10HSKS stated S6HSK, S7HSK, and S8FS helped in the kitchen by washing dishes. S10HSKS stated she had not trained S6HSK, S7HSK or S8FS on the proper procedure of washing dishes. An interview was conducted with S11C on 04/13/2026 at 10:14 a.m. S11C stated staff from other departments had been helping out in the kitchen when they were short staffed. S11C confirmed that staff should not use a towel to finish drying the dishes when the dishwasher is completed. She stated dishes should not be put away wet but a towel should not be used.An interview was conducted with S6HSK on 04/13/2026 at 12:51 p.m. S6HSK confirmed that she helped in the kitchen by washing dishes when S5C was working alone in the kitchen. She stated S9D showed her how to operate the dish washing machine. She confirmed that S9D did not train her in ensuring the temperature of the water was appropriate, and she was not trained on ensuring the chemical reading was adequate for sanitation. S6HSK stated after initiating the wash cycle, when the dishes had completed the rinse cycle, the dishes came out with a lot of steam, but the dishes were not dry completely. She stated S9D instructed her to use a dry towel to ensure the plates and cups were completely dry before she replaced them inside the cabinet. An interview was conducted with S7HSK on 04/13/2026 at 12:57 p.m. S7HSK confirmed on some of her days off, she helped in the kitchen by washing dishes. She stated S9D instructed her how to load the machine and how to clear the rack when the cycle was completed. S7HSK stated S9D had instructed her to use a dry towel to ensure after the completion of the cycle to ensure the dishes were completely dry prior to placing the dishes in the cabinet. S7HSK stated she was not trained on how to check the temperature on the dishwashing machine, or how to check the chemicals for proper sanitation. An interview was conducted with S8FS on 04/13/2026 at 1:05 p.m. S8FS confirmed on some of his days off he helped in the kitchen by washing dishes. S8FS stated S9D had instructed him about the temperature. He stated he was told about the chemicals, but he guessed someone else had checked the chemicals of the dishwasher. He stated he had not checked the temperature or the chemicals for the dishwasher. S8FS stated he used the dry towel to completely dry the plates and cups before he put them in the cabinet.An interview was conducted with S9D on 04/13/2026 at 3:04 p.m. S9D confirmed that he instructed S6HSK, S7HSK, and S8FS on how to use the dishwashing machine. He confirmed that he should not have instructed the above staff to use a dry towel to complete drying the dishes after removing the clean dishes from the rack.

Based on record review, observations, interviews, the facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility's kitchen. Findings: A review of the facility's dietary schedule for 04/01/2026 - 04/15/2026 revealed on 04/2, 04/03, 04/04, 04/05, 04/08, 04/09, 04/10, 04/11, 04/14, and 04/15 one staff was scheduled for the morning shift. On 04/13/2026 at 8:40 a.m., an observation was conducted in the kitchen. S5C and S11C were observed in the kitchen. An interview was conducted with S11C. She stated many days they had to work short. She stated staff from other departments came to the kitchen to help them. She confirmed that the staff from other departments are not trained on kitchen procedures, but they are just shown how to wash the dishes. On 04/14/2026 at 6:15 a.m., an observation of the kitchen was conducted. S5C was observed preparing breakfast for the residents. Further observation revealed no other dietary staff was in the kitchen or scheduled to be in the kitchen. S5C was observed preparing grits, oatmeal, biscuits, toast bread, eggs, sausage, puree sausage, chopped sausage, and puree eggs. On 04/14/2026 at 6:22 a.m., an interview was conducted with S5C who stated she was working in the kitchen by herself. She confirmed S3DM was aware since 04/13/2026 that she was on the schedule as the only staff for that morning. She added if anyone was supposed to help her, they would have been in the kitchen by now. S5C stated many times when she did not have help in the kitchen, she called S2DON and S2DON would have staff from other departments come to the kitchen to assist by washing the dishes. On 04/14/2026 at 4:20 p.m., an interview was conducted with S13D who stated many times the staff in the kitchen had been working short staffed. She stated staff from other departments come to the kitchen to help wash dishes. S13D confirmed the staff from other departments were not trained in the kitchen.

Based on observations and interviews, the facility failed to ensure kitchen equipment was maintained in a safe operating condition by failing to ensure:A leak beneath the ice machine was reported to maintenance in a timely manner.Staff monitored equipment to ensure that it was functioning properly. Findings:1. On 04/13/2026 at 11:33 a.m., an observation of the kitchen was conducted which revealed an ice machine that had a large puddle of water pooled beneath the machine. On 04/13/2026 at 11:36 a.m., an observation and interview was conducted with S3DM. S3DM was unaware of the leak beneath the ice machine. On 04/13/2026 at 12:03 p.m., an interview was conducted with S12M. S12M stated that kitchen staff had not reported a leak beneath the ice machine to him, nor did they write it in his maintenance logbook. On 04/14/2026 at 10:50 a.m., an interview was conducted with S5C who stated that the ice machine has had a leak for at least three months. She stated she did not report this to S12M, she thought S3DM would get that taken care of. 2. On 04/13/2026 at 11:33 a.m., further observation of the kitchen revealed the three-compartment sink. S5C was observed squeezing the bottle of soap, which read pot and pan dish soap, into the basin of water. When S5C was asked why she was squeezing the soap into the basin, and not using the machine dispensing the soap automatically, she stated the dispenser had been broken for at least three months. When asked how she knew how much soap to dispense and how much she had actually dispensed, she stated she did not know how much soap she was adding to the basin. On 04/13/2026 at 12:21 p.m., an interview was conducted with S3DM. S3DM was asked if she was aware the three-compartment sink was not working properly, she stated she was not aware the three-compartment sink was not working properly.

Based on record review, observation, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight of the kitchen's practices for safe food service. The deficient practice had the potential to affect the 74 residents who consumed meals prepared from the facility's kitchen. Findings:Review of a document titled Ice Scoop Storage with no revision date read in part: Policy - ice scoops must be stored and maintained to prevent contamination. Ice is considered a food item and must be protected. Procedure: 1. Approved storage methods - store ice scoops in a clean holder outside the ice machine or in a clean container. 3. Cleaning and Sanitizing - clean and sanitize scoops daily or when contaminated. Storage containers must be cleaned routinely. Review of a document titled Dishware/Utensils Storage Policy with no revision date read in part: Policy - all dishes, glassware, cups shall be properly cleaned, sanitized, dried, and stored in a manner that protects them from contamination and ensures resident safety. Procedure: 3. Storage requirements - store dishware at least 6 inches off the floor in clean, dry areas, protected from contamination. Items must be stored inverted or covered. Review of the facility's policy titled Three Compartment sink with no review date read in part. we test the water in our three compartment sink daily for the QAC (Quaternary Ammonium Compounds). Accurate testing requires a minimum of five full pumps of the sanitizer to the 1/2 full sink compartment. We are looking for a reading of 200 p.p.m (parts per million). On 04/13/2026 at 8:35 a.m., a tour of the facility's kitchen revealed a black fan in use. The fan was set at medium speed and dust could be seen on the grill of the fan. S5C was observed standing with her back to the fan as she was slicing a lemon pie on the prep table. S5C was observed placing the slices of lemon pie into individual bowl for the residents. Further observation revealed a black open shelf. Upon this shelf were a stack of clear plastic cups which were not stored invertedly or covered. On 04/13/2025 at 11:25 a.m., continued observation of the kitchen revealed a white plastic bucket uncovered. The white bucket contained three scoops. Two large scoops and one smaller scoop not covered. A large puddle of water was observed on the floor beneath the ice machine. On 04/13/2026 at 11:30 a.m., review of the facility's form titled temperature log which was used for the food line revealed documentation for 03/28/2026. No other documentation was provided on the facility form. Review of the facility's form titled Daily Kitchen Cleaning Schedule revealed an entry on 04/12/2026 that indicated the dish area and coffee station were mopped. No other documentation was observed on the document. Review of the facility's form titled 3 Compartment QAC revealed on 03/29/2026 and 03/30/2026 S11C documented no strips. No further entries were documented. Review of the facility's document titled Refrigerator Temperature Log dated 03/2026 revealed temperature entries from 03/15/2026 - 03/31/2026. No further entries or documentation were provided. Review of a document titled Coffee/Hot Beverages Temperature Log dated 03/2026 revealed no logged temperatures for 03/012026 - 03/02/2026, 03/04/2026, 03/06/2026 - 03/12/2026, 03/15/2026 - 03/16/2026, 03/19/2026- 02/21/2026, 03/23/2026 - 03/24/2026, 03/26/2026 - 03/31/2026. On 04/14/2026 at 6:34 a.m., observation of S5C utilizing the three-compartment sink. S5C was observed squeezing the soap into the basin of water. When asked why she was squeezing the soap into the water, she stated because the dispenser was not working. She stated it had not been functioning properly for about three months. She added that the facility did not have any strips to test the chemicals since 03/30/2026. She stated she had been requesting more forms to record the temperatures on the food line, but staff had not received them yet. She stated staff had been writing the temperatures on a napkin. On 04/14/2026 at 8:39 a.m., a phone interview was conducted with S14RD. S14RD stated she had little oversight of S3DM. She stated she performs a walk-through of the kitchen checking for cleanliness. She stated she makes her rounds twice monthly. She stated her duties were to review and sign the menus, complete annuals, review the residents who are on tube feedings, and review the residents who had weight loss. She stated she was not aware of the issues in the kitchen. She stated she relies on the dietary managers to ensure the kitchen is well maintained and running properly. On 04/14/2026 at 10:04 a.m., an interview was conducted with S3DM. S3DM stated she was not aware that staff had not been conducting the necessary temperature and chemical checks. An observation of the incomplete forms was conducted with S3DM, who asked where the forms had come from. She stated she had not seen these in the kitchen. When asked who oriented her to the kitchen and had oversight, she stated no one oriented her to the kitchen. She stated she used the years of experience to navigate her duties and responsibilities in the kitchen. When asked if she was aware of the three-compartment sink not working properly, she stated she was not aware the three-compartment sink did not function properly. She stated she was not aware staff did not have the strips necessary to test the chemical in the three-compartment sink. She stated someone placed the empty bottle on the top of her desk, so she just ordered a new bottle. She stated she was not aware staff did not have the forms to record the food line temperatures. On 04/14/2026 at 1:09 p.m., an interview was conducted with S1RADM who stated he was not aware of all the different issues that were discussed above. S1RADM confirmed he was not aware that some of the kitchen equipment was not working properly. S1RADM stated that S14RD is contracted with the facility, and she is also responsible for ensuring the dietary manager is doing what she is required of her.

Based on record review, observations and interviews, the facility failed to distribute, store, and serve food in accordance with professional standards for food service safety by failing to ensure:1. The food service area remained in a sanitary condition during the meal prep process.2. The ice scoops were stored away properly to prevent or minimize the spread of foodborne illnesses.3. Residents cups were stored inverted or covered.4. Staff monitored equipment to ensure that it was functioning properly.This deficient practice had the potential to affect the 74 residents who were served food from the kitchen. Findings: Review of the facility's policy titled Ice Scoop Storage with no revision date read in part: Policy - ice scoops must be stored and maintained to prevent contamination. Ice is considered a food item and must be protected. Procedure: 1. Approved storage methods - store ice scoops in a clean holder outside the ice machine or in a clean container. 3. Cleaning and Sanitizing - clean and sanitize scoops daily or when contaminated. Storage containers must be cleaned routinely. Review of the facility's policy titled Dishware/Utensils Storage Policy with no revision date read in part: Policy - all dishes, glassware, cups shall be properly cleaned, sanitized, dried, and stored in a manner that protects them from contamination and ensures resident safety. Procedure: 3. Storage requirements - store dishware at least 6 inches off the floor in clean, dry areas, protected from contamination. Items must be stored inverted or covered. On 04/13/2026 at 11:10 a.m., an observation in the kitchen was conducted which revealed a black fan located about two feet away from the prepping table. Upon further observation it was revealed that the fan had small amounts of visible dust on the fan grill and fan blades. S5C was observed cutting a lemon pie and placing its slices into individual white bowls. The black fan was observed blowing directly towards the prepping table where S5C was slicing lemon pie and placing them into small individual bowls. On 04/13/2026 at 11:15 a.m., further observation revealed an uncovered white plastic bucket. The white plastic bucket was observed on the second shelf of a table which was used for prepping and the placement of condiments. Further observation revealed three scoops inside the uncovered bucket. Two large scoops and one small silver scoop. S9D was observed using the large silver scoop to put ice into the residents' drinking cups. After filling the cups with ice, S9D was observed placing the scoop back inside the uncovered white bucket. On 04/13/2026 at 11:25 a.m., continued observation of the kitchen revealed a black shelf which contained residents' cups that were stored facing upward and were not covered. On 04/13/2026 at 11:56 a.m., an interview was conducted with S4IC. S4IC confirmed the black fan should not be directed toward the area where food was prepared, and the fan should have been cleaned and without visible dust. He stated the scoops inside the white bucket should have been covered. She added that ice is considered a food item and the scoops should have been covered while not in use. S4IC stated the cups were supposed to be facing downward, inverted and not facing upward to prevent contamination. On 04/13/2026 at 11:58 a.m., an interview was conducted with S3DM who stated she was not aware that the scoops were supposed to be inside a plastic bag or covered while not in use. She stated she was not aware that cups had to be stored inverted or covered. She confirmed that a fan should not have been utilized in the kitchen area especially during meal prep.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' right to participate in the facility's residents group, Resident Council, as evidenced by administrative staff failing to consider and act upon voiced grievances during monthly Resident Council meetings for 3 of 3 residents (#2, #6 and #16) actively involved in the facility's Resident Council. This deficient practice had the potential to affect the 60 residents who resided in the facility. Findings: Review of the facility's resident council meeting minutes from October 2024 through March2025 revealed: Dated 10/03/2024 per S17AD (Activity Director) revealed Resident #16 accepted the President position and Resident #6 accepted the [NAME] President position. New issues voiced by one of the 13 residents in attendance was to please make sure the CNAs (Certified Nursing Assistants) make sure the lifter battery is on charge correct, so they can be charged for when needed the next day. There was no evidence that the voiced concern was neither addressed nor was a rationale provided by facility staff to the residents during the following five monthly meetings. Dated 11/05/2024 per S17AD revealed a guest was also present during the meeting. The old issues voiced by the residents during the previous meeting on 10/03/2024 were reviewed. There was no evidence facility staff addressed the voiced concern at the previous month's meeting. There was no rationale or response from the facility staff as to why the concern was not addressed. Further review of the minutes from meeting dated 11/05/2024 per S17AD revealed new issues voiced by 4 of the 12 residents in attendance, including Residents #2 and #16: the food is not good, request to meet with the guest after meeting, CNAs not picking up dirty clothes-it has not gotten any better, CNAs on their cell phones and don't get off, whirlpool issues, and smoking on the weekend. New issues given to S20FormerDON (Former Director of Nursing). Late entry: S17AD attempted to notify S2DON/FormerNFA (Director of Nursing/Former Nursing Facility Administrator) but was unsuccessful due to S2DON/FormerNFA being on a phone call. There was no evidence of the facility addressing or rationale for not addressing the residents' voiced concerns regarding whirlpool issues and smoking on the weekend. Dated 12/03/2024 at 2:15 p.m. per S17AD revealed 11 residents in attendance, including Residents #2, #6 and #16. Old issues reviewed- picking up clothes is still not any better, phone issues are not any better. New issues voiced included staff parking in handicap spaces Will follow up with Department Heads and S20FormerDON concerning old and new issues. Attached was an in-service training for facility staff dated 12/04/2024 including phone use in resident care areas and handicap parking was for visitors not for facility staff. There was no evidence of S2DON/FormerNFA addressing the resident council's request to be present nor was there evidence of rationale as to why there was no response from S2DON/FormerNFA. Dated 01/07/2025 at 2:01 p.m. per S17AD revealed a guest was present in addition to othe 17 residents in attendance, including Residents #2, #6 and #16. Old issues were reviewed and handicap parking issues was not resolved. New issues voiced by residents included: beds are not being stripped, what time does whirlpool start, they feel that whirlpool should not be cancelled because they are short; there should be a replacement. Dietary issues voiced by residents of why there is not enough coffee in the morning, why is milk not given at supper time. Housekeeping issues with trash not being emptied. Maintenance concerns were voiced regarding not having a maintenance staff in the facility on the weekends, inquired if maintenance was on call on the weekends. Resident council president, Resident #16, requested S2DON/FormerNFA be present at the next meeting. Response from S20FormerDON revealed whirlpool is cancelled when CNA is needed to cover the floor with explanation of using agency staff to help assist with the staffing. Response from dietary department failed to include rationale as to why consumption of coffee was being monitored and why it was restricted to one canister of coffee at 7:00 a.m. and one at 2:00 p.m. Maintenance department's response included a maintenance staff is on call on the weekends. Response from maintenance failed to include rationale as to why maintenance staff is not present in the building on the weekend. Dated 02/04/2025 at 2:00 p.m. per S17AD revealed a guest was present. A total of 20 residents were in attendance, including Residents #2, #6 and #16, as well as S2DON/FormerNFA. Old issues were reviewed of cell phone issue has not improved and input from residents for facility to let the whole area in the front parking lot where handicap sign is be used for handicap parking. There was only evidence of S2DON/FormerNFA addressing the coffee and residents said ok. There was no response to the old issues nor was there a rationale for the response addressing the coffee. Dated 03/05/2025 at 2:10 p.m. per S17AD revealed 12 residents in attendance, including Residents #2, #6 and #16. Old issues were reviewed of staff still using their cell phones-not gotten any better and would one side of circle be used for visitor handicap parking. Attached was response from housekeeping department. There was no evidence of a facility addressing the old issues of staff cell phone use or consideration of handicap parking for visitors. On 04/01/2025 at 11:15 a.m., surveyor conducted a resident council meeting with Residents #2, #6, and #16. Residents voiced complaints with the facility's call bell system. They reported that when corporate took over on July 1, 2022 that the previous call bell system that was working was removed and replaced with a cheaper call bell system. They explained the old call bell system had the audio capability where when they pressed their call bell, staff at the nursing desk would answer and ask what type of assistance was needed. The current call bell system does not have audio capability to speak to the desk. The residents also voiced frustration with whirlpool as they were supposed to have whirlpool three times a week but now only have it one day a week if the staff showed up. They also reported a guest had to come to some of their meetings. Review of the facility's policy and procedure titled, Answering the Call Light with a revised date of 02/03/2025 revealed: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the procedure 1. Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name . On 03/31/2025 at 01:00 p.m., an interview was conducted with Resident #46, who stated there are times when I push the button and it takes a few hours for someone to reply. They are out on the side smoking and I can hear them. On 04/01/2025 12:50 p.m., Resident #260's call bell was triggered by pressing the button and a light was activated, there was no audio capability nor was there any noise indicating the call bell was activated. Call bell response time was at 1:22 p.m. Resident stated it takes staff approximately 30 minutes to answer his call light, sometimes they do not answer the call light at all. Resident stated one night he was on the toilet using the restroom, he pulled the call bell string and after he received no answer from the staff, he called his wife and she called the facility to ask someone to please go and assist him off the toilet. Resident #260 stated the facility's call light system was not a system where it alerted the nurse's station or made any type of noises when pressed. He stated the call light system only displayed a light on the outside of his door when activated. Resident #260 further stated the facility staff does not sit at the nurse's station down Hall D so they are not able to always see when the call bell has been activated. On 04/02/2025 at 09:39 a.m., an interview was conducted with S18RCNA (Restorative Certified Nursing Assistant) who stated she had been staffed at the facility for approximately three weeks. She explained that when a resident's call light went off, the ward clerk announced overhead which room number needed to be seen at that moment. S18RCNA verified the resident's call light system did not have audio capability nor did the call bell make noise when activated. She state that there was simply the light activated above the resident's door to signal activation. On 04/02/2025 at 2:45 p.m., an interview was conducted with S21CNA who stated she really wished the facility's corporation would bring back the old call light system because the current call light system was not effective. The current call light system doesn't make any noise so if working on a separate wing, she sometimes was unable to hear the overhead page. S21CNA explained if she was assisting a resident in their room and needed additional help then she called staff from her personal cell phone due to the inability to speak through the call light system. On 04/02/2025 at 2:55 p.m., an interview was conducted with S22CNA who stated she preferred the old call light system because it had the audio capability. S22CNA added the current call bell system was not effective and she was not sure why the old call bell system was replaced. S22CNA stated sometimes the overhead page was not heard if working on a separate wing. On 04/02/2025 at 3:04 p.m., an interview was conducted with S17AD who has been working at the facility for approximately [AGE] years. S17AD explained she was the secretary maintaining the Resident Council's monthly meeting minutes by handwriting old issues and new issues voiced by the residents and guest(s) in attendance and after the meeting she shared her notes with the designated department heads. S17AD confirmed a guest was present during the monthly meetings that took place on 11/05/2024, 01/05/2025 and on 02/04/2025. S17AD stated at the January 2025 meeting, she was instructed to use a specific form titled, Resident Council Meeting Minutes, moving forward. S17AD verified there was not a process in place when voiced concerns were not addressed or a response failed to include a rationale to the voiced concerns. On 04/02/2025 at 3:45 p.m., an interview was conducted with S2DON/FormerNFA. She explained that she started working at the facility in August 2024 as the facility's administrator until February 2025 she then became the facility's DON. S2DON/Former NFA explained multiple nursing department heads were terminated or resigned and she was in the process of hiring new nursing department head staff. She explained S3ADON (Assistant Director of Nursing), S4MDS/LPN (Minimum Data Set Licensed Practical Nurse) and S5SSD (Social Services Director) were all new to the facility. She stated she identified problems with the previous staff and was currently investigating how to educate staff to perform duties correctly and efficiently. However, she verified due to nursing and CNA staff not showing up to work, she had to pull S3ADON and S4MDS/LPN to work on the floor to care for the residents. S2DON/FormerNFA explained she identified the ward clerk's position included other duties besides monitoring the call light system and paging the need for assistance overhead; therefore leaving the call light system unwatched at times. S2DON/FormerNFA was monitoring the call light system earlier in the shift because the system was unattended. She also stated that it was impossible to correct a year's worth of issues in six weeks. S2DON/FormerNFA was not made aware by staff or residents that the current call light system was not working effectively nor that the system was not audio capable.

Based on observations, interviews and record reviews, the facility failed to ensure that residents received respiratory care according to professional standards of practice, the physician's order, and the comprehensive person-centered care plan for 3 (#11, #14, and #19) of 3 (#11, #14, and #19) residents investigated for respiratory care, as evidenced by failing to: 1. Ensure Resident #11's humidifier bottle was changed when it was empty, and Oxygen tubing changed weekly; 2. ensure Resident #19's oxygen nebulizer mask, nasal cannula, and suction cannula were stored in a bag when not used; and 3. date and label oxygen tubing and ensuring oxygen was delivered at the ordered rate for Resident #14. Findings: On [DATE], a review of the facility's policy titled Oxygen Administration, read in part, Policy: Oxygen shall only be administered by physician order .All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. 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 in a zip lock bag .Oxygen equipment .humidifier bottles and other related items should be checked prn for proper functions. 1. Resident #11 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and morbid obesity with alveolar hypoventilation. A review of Resident #11's care plan revealed a focus area dated [DATE]: COPD/SOB (chronic obstructive pulmonary disease/shortness of breath) (Albuterol, O2 (oxygen) therapy. Goal: Exhibits no shortness of breath. Interventions included, but were not limited to: Provide humidification, ensure that supply is available at all times, and change tubing per facility protocol. On [DATE] at 10:30 a.m., an observation was made of Resident #11 in her room. The resident was receiving oxygen via nasal cannula with the tubing attached to an empty humidifier bottle on an oxygen compressor. On [DATE] at 10:30 a.m., an interview was conducted with S9CNA (Certified Nursing Assistant). She confirmed the humidifier bottle was empty and tubing was labeled ,d+[DATE]. On [DATE] at 10:32 a.m., an interview was conducted with S8TXLPN, (Treatment Licensed Practical Nurse). S8TXLPN stated she was not responsible for oxygen care. She also stated the night nurse handled the changing of tubes and humidifiers. On [DATE] at 9:25 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing), who stated that she was made aware of the outdated oxygen tubing and empty humidifier bottle on [DATE]. S3ADON stated that the night nurse is responsible for making any changes that need to be done on Wednesdays, but if the tubing is expired and the humidifier bottle is empty, anyone can change it, and that includes the treatment nurse and the resident's hall nurse. 2. Resident #19 was admitted to the facility on [DATE], with diagnoses which included but were not limited to, atherosclerotic heart disease of native coronary artery without angina pectoris and Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. A review of physician orders revealed an order written on [DATE] for Xopenex Nebulization Solution 0.63 MG (milligram)/3 ML (milliliter) (Levalbuterol HCL [hydrochloride]) 1 vial inhale orally via nebulizer as needed for wheezing. A review of the facility's standing orders revealed the following: Oxygen: O2 at 2L (liter) via nasal cannula prn (as needed) for dyspnea, hypoxia (O2 saturation < (less than) 90% [percent]) or acute angina to keep O2 saturations > (greater than) 90% . On [DATE] at 11:34 a.m., an observation was made of Resident #19 in his room. The resident was lying in his bed. The resident's O2 nasal cannula is observed on his over bed table which is pushed up against the wall. The resident's shoes were on top of the tubing on his over bed table. Further observation revealed a nebulizer mask on the floor underneath the resident's rolling table, and a suction tube connected to a portable suction machine on the floor. The nasal cannula, nebulizer mask, and suction cannula were not stored in a bag. During an interview with S12LPN (Licensed Practical Nurse) on [DATE] at 11:41 a.m., she confirmed the above findings and stated the nasal cannula, the nebulizer mask, and the suction cannula were used by the resident and should have been stored in a bag. 44269 3. Review of Resident #14's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to Asthma, acute respiratory failure with hypoxia, acute ischemic heart disease, obstructive sleep apnea and chronic systolic (congestive) heart failure. Review of the physician's orders revealed an order written on [DATE] for O2 (Oxygen) @ (at) 2L (liter) via (through) NC (nasal cannula) continuous every shift. Review of Resident #14's person-centered care plan revealed the following: At risk for SOB (shortness of breath) r/t (related to) respiratory failure. Interventions included, provide with humidification, change O2 humidifier and tubing every week on Wednesday and prn as need, and administer oxygen therapy as ordered 2L /NC. On [DATE] at 11:35 a.m., Resident #14 was observed in his wheelchair receiving oxygen at 4L via NC. The tubing and humidifier bottle were not labeled or dated. On [DATE] at 8:44 a.m., Resident #14 was observed in bed receiving Oxygen at 4L via NC and the tubing and humidifier bottle remained undated and not labeled. On [DATE] at 8:50 AM S13LPN (Licensed Practical Nurse) confirmed Resident #14 was receiving 4L oxygen via NC. She also confirmed the tubing and humidifier bottle were not labeled or dated. S13LPN stated night shift was responsible for changing tubing on Wednesdays. On [DATE] at 8:52 a.m., S3ADON confirmed that oxygen tubing should be labeled and dated and O2 delivered according the physician's orders.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of 4 Residents (#13, #23, #27, and #39) medical records. This deficient practice had the potential to affect all of the 60 residents in the facility. Findings: A review of the facility's policy titled, Confidentiality of Information and Personal Privacy with a last review date of 01/15/2025, read in part, Our facility will protect and safeguard resident confidentiality and personal privacy. The policy also indicated general guidelines, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Computer screens will be closed or in locked position when not in use or in the presence of a nurse or unauthorized personnel. On 04/01/2025 at 8:14 a.m., an observation on Hall W revealed that the laptop on top of Med Cart A was unattended. Further observation revealed Resident #13, #23, #27, and #39's first and last name, their picture, room number, and MRN (Medical Record Number) was visible on the laptop screen. On 04/01/2025 at 8:22 a.m., an observation and interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed that S13LPN (Licensed Practical Nurse) should have initiated the privacy screen before she left Hall W to protect the resident's private medical information.

Based on record review and interview the facility failed to immediately report all alleged violations of abuse to the administrator, and other officials including the State Survey Agency in accordance with State law when 1 (#3) of 5 sampled residents (#1, #2, #3, #4, and #5) was observed being slapped on the back by staff for taking yogurt from the supper cart. The facility further failed to: A. Provide evidence that a thorough investigation was done. B. Failed to ensure that a potential employee was screened and had not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment of [REDACTED]. There are a total of 86 residents residing in the facility. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #3 that started on 9-17-17 at around 6:00 PM to 6:30 PM when S9DW (Dietary Worker) slapped Resident #3 on her back when she was taking a yogurt from the supper cart in the dining room. The facility failed to protect the resident after S8DW witnessed and reported the abuse. The facility failed to thoroughly investigate the abuse as required by the policies and procedures and allowed S9DW (the accused employee) to continue to work at the facility with the residents. S1ADM was informed of the IJ situation on 9-29-17 at 5:00 PM. The IJ situation was removed on 10-2-17 at 3:45 PM when the administration provided the Plan of Removal which read in part: Upon notification by the survey team on 9/29/17 of the concerns over actions of employee (S9DW), the employee was immediately advised to leave the facility (2:44 P.M.) The employment of (S9DW) has been terminated. An OTIS Report has been filed 0n 10/2/17 with the (State Agency) regarding the incident cited on 9/17/17. In-services for all employees will be conducted starting Sunday, October 1 to review (Provider) policies regarding resident abuse/neglect, along with the proper procedures for reporting and investigating any future allegations. The in-services will be completed by Thursday, October 5, 2017 (to Insure that all employees, including those on days off, attend). The Administrator began contacting surveillance vendors on Monday, October 2, 2017 to get information regarding installation of video cameras throughout the facility. The Administrator along with members of the Quality Assurance (QA) Committee met at 1:30 PM October 2, 2017 to review our current policies and procedures for monitoring, reporting and handling any future allegations of resident abuse/neglect so that they are handled both timely and properly. The committee also discussed the reasons for the lapse in thoroughly and properly investigating and reporting the incident involving (Resident #3) which took place on the evening of September 17, 2017. All QA members were provided a copy of the Abuse Policy for (Provider) to review, so that we can meet again to discuss any updates/changes which need to be made in order to insure compliance and the safety of our residents. A follow-up meeting will be held on Friday, October 6. We have contacted our Ombudsman (____) who has agreed to provide an in-service for all of our employees on October 19, 2017. (This is her first available date). (Ombudsman) will conduct the ANNUAL MANDATORY INSERVICE on Residents Rights and Abuse. This deficient practice remains at a level of more than minimal harm for all 86 residents residing in the facility. Findings: A.) Review on 10/2/17 of the facility's policies and procedures entitled, Abuse Policies and Procedures revealed the following in part: a. ABUSE is defined as the willful infliction of injury: unreasonable confinement; intimidation; punishment with physical harm, pain, or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident . Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by the state or local laws within 24 hours of the results of the completion of the investigation. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 days of the reported incident . Record review of Resident #3's Medical Record revealed Resident #3 was [AGE] years old. She was admitted to the nursing facility on 10-22-12. Her [DIAGNOSES REDACTED]. Record review of Resident #3's MDS (Minimum Data Set) dated 7-29-17 under Section C titled Cognitive Patterns revealed Resident #3's BIMS (Brief Interview Mental Status) score was 11(cognition - moderately impaired). Record review of Resident#3's Care Plan read as followed: - Inappropriate behavior - Hoarding cups, napkins, sugar packets etcetera. Staff to clean out Resident #3's room periodically and discourage hoarding. Do not argue with Resident #3 or treat her like a child. Explain and reaffirm as frequently as necessary that such behavior is not acceptable and will not be tolerated. - Resident has memory problems related to Dementia as evidenced by forgetful at times. Allow Resident ample time to absorb and respond to information. Provide a calm, therapeutic environment and structured routine. - Resident has a history of Depression. Be empathetic towards client but do not reward her misery, Give lots of reinforcement and praise. Record review of Progress Notes by Resident read as follows, 9-17-17 10:56 PM Resident was taking a yogurt out of the kitchen when Kitchen staff (S9DW) slapped her hand. S9DW denies hitting resident, but staff said it was witnessed by another kitchen staff S8DW. Did not get a chance to talk with S8DW. No apparent Injuries noted. Signed by S7LPN. Record review of the Document titled, Resident Concern/Grievance Report revealed the following documentation: Date of Concern: 9-17-17 . Time of Concern 3-11Shift . Resident was seen reaching for a yogurt on the food line and a Dietary employee (S9DW) was observed by another employee (S8DW) slapping her hand and saying 'you can't do that' or something to that affect. (S2DON received this report on 9-18-17 at 7:30 AM). S2DON documented, on 9-18-17 at 10:00 AM (S3ADON) called Resident #3's Daughter. Under comments read, I informed daughter about the incident. She (Daughter) said she was here this AM (Morning) and her mother (Resident #3) never mentioned it. She further said her mother can pretty much take care of herself so if she saw no need to tell her, it must have not been anything to worry about. On the back of this form was S2DON investigations that read as follows, 9-18-17 at 9:30 AM I spoke with Resident #3 and she acknowledged that a dietary employee slapped her hand. She said she wasn't hurt, but 'It made me mad and I gave her a piece of my mind.' I asked if she would like to make a report or have anything done about the incident and she said no. It was over and she had taken care of it. Another interview read as follows, 9-18-17 Spoke to employee (S8DW) in dietary who said that (S9DW) had slapped Resident #3 on her back when she was trying to get yogurt off the supper cart. Interview with (S9DW) who denied slapping Resident #3. Stated she was just trying to keep Resident #3 from digging in the supper cart. S1ADM wrote a statement that read, 9-18-17 Resident #R1 approached me in the dining room and stated he was right there when the incident occurred and was a witness to the incident. He stated with certainty that S9DW did not slap Resident #3. Under Section 4 of this document revealed a check mark on the line that stated Concern & Grievance resolved: S1ADM had signed and dated this document. Documentation under this read, 9-19-17 Administrator counseled employee S9DW who voiced understanding of proper conduct towards resident. Record review of a statement from S8DW read as follows, On 9-17-18 between 6:00 PM and 6:30 PM I witnessed S9DW pull a bucket from Resident #3's hands and slap her on the shoulder back area. On 9-29-17 at 9:00 AM an interview with Resident #3 revealed she was sitting at the table with Residents #4 and #5 by the warming table. She revealed there was a tray with pink packages of artificial sugar, packages of cream and stirring straws. She revealed she was taking some of the condiments and S9DW came to take it away from her and slapped her hand and stated, That's not yours. She stated it bothered her that she would slap her hand. On 9-29-17 at 10:48 AM interview with S8DW revealed that on 9-17-17 around 6:00 PM to 6:30 PM she was cleaning the steam table at the end of the line by the dishwasher's window. She stated S9DW was in the dishwasher room and Resident #3 was in the dining room by the window of the dishwasher room. There was a bucket with milk, yogurt, and juice on a table and Resident #3 was digging in the bucket. Resident #3 does this often and the staff have to correct her. When S9DW saw her from the window of the dishwasher room she came running around from the dishwasher room passing by me near the steam table pushing me out the way. This called my attention to what was about to happen. She revealed she looked over and S9DW grabbed the bucket with one hand from Resident #3 and swung with her other hand slapping Resident #3 on the shoulder near her back. At this time Resident #3 screamed immediately loud enough for S10LPN to hear and she came to see what was going on. S10LPN immediately asked Resident #3 what happened and Resident #3 screamed that She (S9DW) slapped me. S8DW revealed S7LPN talked to S9DW and said he was going to report the incident. S8DW stated she told him that she had witnessed the incident and would be willing to give a statement. She revealed S7LPN did not question her after the incident. She revealed the very next morning she reported the incident to her Supervisor (S6FSS); and then later that morning S3ADON called her to her office and asked her to explain what had occurred. S8DW revealed about two hours later S1ADM called her into his office and she told him what happened. S8DW revealed he had her write a brief statement. She further revealed S11DW was in the dining room and heard the incident. On 9-29-17 at 11:26 AM interview with S9DW revealed on 9-17-17 she just finished serving supper. She revealed after the trays were picked up it was her job to pick up the buckets and silverware. S9DW stated Resident #3 takes the silverware and digs in the milk buckets. She revealed that day she saw Resident #3 rolling her wheel chair toward the bucket so she left the dishwashing area and went to pick up the bucket. When she got to Resident #3 she grabbed the bucket with both hands and Resident #3 screamed, You hit me, you slapped me, and she kept screaming. She revealed she did not make physical contact with Resident #3. On 9-29-17 at 11:40 AM an interview with Resident #R1 revealed on Monday or Wednesday he was entering the dining room's main entrance and saw Resident #3 between three long tables and S9DW was behind a pole. He revealed Resident #3 had the habit of taking cream and sugar from the tables. He revealed he saw S9DW picking up the basket with cream and sugar to keep them away from Resident #3. When S9DW picked up the second basket Resident #3 started fussing at the worker. He revealed he did not see S9DW slap Resident #3 or hear Resident #3 say, Don't slap me. He revealed Resident #3 wasn't trying to get anything out of the ice bucket. He further revealed there was no ice bucket around at that time. He revealed the incident did not occur around the steam table or the window of the dishwashing area. This occurred on the other end of the dining room after lunch. On 9-29-17 at 11:48 AM, an interview with S10 LPN revealed the incident occurred on a weekend. She revealed she was coming back from rolling a Resident to their room. She revealed before entering the dining room she heard Resident #3 yelling. She revealed when she entered the dining room she saw Resident #3 and she was saying that S9DW had hit her hand because she was trying to get a yogurt. She revealed Resident #3 told her that S9DW can't slap her like that. S10LPN revealed she asked Resident #3 what happened and she replied, She hit my hand. S10LPN revealed she then called S7LPN which was Resident #3's nurse. S7LPN then informed S10LPN that he would handle it. At this time, he went and talked to Resident #3 and S9DW. On 9-29-17 at 11:58 AM, S11DW revealed on Sunday 9-17-17 after supper she was picking up supper trays in the dining room. She revealed she saw Resident #3 picking things off the supper trays. She then heard Resident #3 yell, Do not slap me. She then looked up at Resident #3 and saw S9DW standing by Resident #3 holding a bucket with both hands. She further revealed Resident #3 has a habit of taking things from the dining room. On 9-29-17 at 2:56 PM an interview with S7 LPN revealed he was taking care of Resident #3 on 9-17-17 on the 3-11 shift. He revealed S10 LPN had informed him that S9DW had slapped Resident #3 on the hand. He asked Resident #3 and she said S9DW slapped her on her hand when she was trying to get a yogurt. He revealed he was told by another kitchen worker S11DW that S8DW had seen S9DW slap Resident #3 on the back. He revealed he did not complete an Incident Report or report the incident immediately to his supervisor. He revealed he documented the incident in the progress notes and did not report the incident until the next day. On 10-3-17 at 9:32 AM, an interview with S3ADON revealed the incident occurred on 9-17-17 around 6:30 PM. The Administrator and the DON were not notified until the following day on 9-18-17 at around 7:30 AM. She revealed they found out because it was on the 24-hour report. She revealed she found out about the incident from staff talking amongst themselves. S3ADON revealed she realized there was a witness in the progress notes that S7LPN had written. S3ADON stated she called S8DW to her office to find out what had happened. S8DW stated she was by the steam table and S9DW was in the dishwashing room and saw Resident #3 reach into the bucket. S8DW said she saw S9DW pull the bucket away from Resident #3 and slap her on her back. She informed S8DW to tell S1ADM what she had seen. S3ADON stated she called S1ADM and he said he was going to talk to S8DW. She revealed S7LPN should have called the supervisor because Resident #3 was his Resident. S3ADON stated she considered this incident to be abuse. She stated the DON or the Administrator should do a thorough investigation; and the allegations of abuse should be reported to the state. S3ADON replied, we are to notify the Family and Ombudsman and the police. On 9-29-17 at 1:14 PM an interview with S2DON revealed she found out about the incident on the 24 Hour Report the next day that Resident #3 grabbed food off the line; and S9DW slapped her hand. She revealed she talked to Resident #3 about the incident and asked her if she was hurt and she said No. She said it made her mad and she gave S9DW a piece of her mind. S2DON revealed she did no further investigating into the incident. S2DON stated that S1ADM probably investigated the incident. On 9-29-17 at 1:23 PM an interview with S1ADM revealed an incident occurred on 9-17-17. He revealed he was told about the incident on 9-18-17 that S8DW had observed S9DW slapping Resident #3 across her back. He revealed he did not get a written statement from S9DW regarding the incident. He revealed he spoke with S9DW and she said she did not slap Resident #3. He revealed the only written statement that he got was a short statement from S8DW. He stated he questioned S10LPN and she said she heard Resident #3 holler that S9DW had slapped her hand but she did not witness what had happened. He revealed he did not report the incident to the state through OTIS. He revealed he was approached by Resident #R1 and was told he witness the whole thing and that Resident #3 was digging in the bucket and he did not see S9DW slap Resident #3's hand. He further revealed he came to the conclusion that he couldn't prove the abuse one way or another. So he just counseled S9DW. At 1:30 PM on this day, Resident #R1 was brought into S1ADM Office. Resident #R1 informed S1ADM that the incident they talked about was when S9DW had taken sugar and cream from the client. He revealed during this incident S9DW did not slap Resident #3's hand. He stated this was after lunch on a weekday. He revealed he did not see an incident that happened on the weekend where Resident #3 was taking a yogurt out of a bucket; and S9DW slapped her on the back. At this time S1ADM stated he did not look into the incident any further after Resident #R1 stated he had seen the incident. He revealed he did not realize that he was talking about a different incident. S1ADM revealed he did not thoroughly question Resident #R1 regarding the incident on 9-17-17 to ensure this was the same incident. S1ADM stated if he knew these were two different incidents he would have come to the conclusion that the allegation of abuse that had apparently happened. S1ADM revealed if he had substantiated the allegations of abuse he would have notified the State through OTIS. He further revealed he would then report the abuse to the local authorities. B.) Review on 10/2/17 of the personnel file for S13DW revealed a hire date of 10/31/14. Review of the Louisiana State Police (LSP) report dated 10/15/14 of the criminal background check of S13DW revealed the following documentation: We received your request for a background check on the applicant (S13DW) listed above and have conducted a search of our database . Please provide a set of two (2) fingerprint cards on the applicant listed above. A speedy reply to this request for fingerprints will expedite our response regarding your applicant . There was no evidence in this file of any results of the criminal background check. An interview was conducted on 10/3/17 at 10:25 AM with S23SEC (Secretary). S23SEC stated that she had reviewed the personnel file of S13DW; and could not find evidence that the requested fingerprints for the background check were submitted. S23SEC reported that usually a copy of the fingerprints card remained in the personnel file but no copy was found. S23SEC confirmed that no criminal background results were available for S13DW. S23SEC replied, I don't know how she fell through the cracks. Review on 10/2/17 of the facility's policies and procedures entitled, Abuse Policies and Procedures revealed the following in part: Background Screening Investigations Our facility will not knowingly hire any individual who has a history of abusing another person. This facility will conduct employment background screening checks, reference checks, and criminal convictions investigation checks on individuals making application for employment with this facility. 1. The person designated by the administrator, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprints as required by the state law) on persons making application for employment as required by law. Such investigation will be initiated within 5 working days of employment or offer of employment. 2. The business office and human resources will use tracking logs to track all criminal background checks to ensure that background checks are processed and handled in a timely manner .

Based on record review and interviews, the facility failed to ensure that 1 (#3) of 5 sampled residents (#1, #2, #3, #4, and #5) was free of physical and psychological abuse. There is a total of 86 residents residing in the facility. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #3 that started on 9-17-17 at between 6:00 PM and 6:30 PM when S9DW (Dietary Worker) slapped Resident #3 on her back when she was taking a yogurt from the supper cart in the dining room. The facility failed to protect the resident after S8DW witnessed and reported the abuse. The facility failed to thoroughly investigate the abuse as required by their policies and procedures and allowed S9DW (the accused employee) to continue to work at the facility with residents. S1ADM was informed of the IJ situation on 9-29-17 at 5:00 PM. The IJ situation was removed on 10-2-17 at 3:45 PM when the administration provided the Plan of Removal which read in part: Upon notification by the survey team on 9/29/17 of the concerns over actions of employee (S9DW), the employee was immediately advised to leave the facility (2:44 P.M.) The employment of (S9DW) has been terminated. An OTIS Report has been filed 0n 10/2/17 with the (State Agency) regarding the incident cited on 9/17/17. In-services for all employees will be conducted starting Sunday, October 1 to review (Provider) policies regarding resident abuse/neglect, along with the proper procedures for reporting and investigating any future allegations. The in-services will be completed by Thursday, October 5, 2017 (to Insure that all employees, including those on days off, attend). The Administrator began contacting surveillance vendors on Monday, October 2, 2017 to get information regarding installation of video cameras throughout the facility. The Administrator along with members of the Quality Assurance (QA) Committee met at 1:30 PM October 2, 2017 to review our current policies and procedures for monitoring, reporting and handling any future allegations of resident abuse/neglect so that they are handled both timely and properly. The committee also discussed the reasons for the lapse in thoroughly and properly investigating and reporting the incident involving (Resident #3) which took place on the evening of September 17, 2017. All QA members were provided a copy of the Abuse Policy for (Provider) to review, so that we can meet again to discuss any updates/changes which need to be made in order to insure compliance and the safety of our residents. A follow-up meeting will be held on Friday, October 6. We have contacted our Ombudsman (____) who has agreed to provide an in-service for all of our employees on October 19, 2017. (This is her first available date). (Ombudsman) will conduct the ANNUAL MANDATORY INSERVICE on Residents Rights and Abuse. This deficient practice remains at a level of more than minimal harm for all 86 residents residing in the facility. Findings: Review on 10/2/17 of the facility's policies and procedures entitled, Abuse Policies and Procedures revealed the following in part: a. ABUSE is defined as the willful infliction of injury: unreasonable confinement; intimidation; punishment with physical harm, pain, or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident . Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by the state or local laws within 24 hours of the results of the completion of the investigation. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 days of the reported incident . Record review of Resident #3's Medical Record revealed Resident #3 was [AGE] years old. She was admitted to the nursing facility on 10-22-12. Her [DIAGNOSES REDACTED]. Record review of Resident #3's MDS (Minimum Data Set) dated 7-29-17 under Section C titled Cognitive Patterns revealed Resident #3's BIMS (Brief Interview Mental Status) score was 11(cognition - moderately impaired). Record review of Resident#3's Care Plan read as followed: - Inappropriate behavior - Hoarding cups, napkins, sugar packets etcetera. Staff to clean out Resident #3's room periodically and discourage hoarding. Do not argue with Resident #3 or treat her like a child. Explain and reaffirm as frequently as necessary that such behavior is not acceptable and will not be tolerated. - Resident has memory problems related to Dementia as evidenced by forgetful at times. Allow Resident ample time to absorb and respond to information. Provide a calm, therapeutic environment and structured routine. - Resident has a history of Depression. Be empathetic towards client but do not reward her misery, Give lots of reinforcement and praise. Record review of Progress Notes by Resident read as follows, 9-17-17 10:56 PM Resident was taking a yogurt out of the kitchen when Kitchen staff (S9DW) slapped her hand. S9DW denies hitting resident, but staff said it was witnessed by another kitchen staff S8DW. Did not get a chance to talk with S8DW. No apparent Injuries noted. Signed by S7LPN. Record review of the Document titled, Resident Concern/Grievance Report revealed the following documentation: Date of Concern: 9-17-17 . Time of Concern 3-11Shift . Resident was seen reaching for a yogurt on the food line and a Dietary employee (S9DW) was observed by another employee (S8DW) slapping her hand and saying 'you can't do that' or something to that affect. (S2DON received this report on 9-18-17 at 7:30 AM). S2DON documented, on 9-18-17 at 10:00 AM (S3ADON) called Resident #3's Daughter. Under comments read, I informed daughter about the incident. She (Daughter) said she was here this AM (Morning) and her mother (Resident #3) never mentioned it. She further said her mother can pretty much take care of herself so if she saw no need to tell her, it must have not been anything to worry about. On the back of this form was S2DON investigations that read as follows, 9-18-17 at 9:30 AM I spoke with Resident #3 and she acknowledged that a dietary employee slapped her hand. She said she wasn't hurt, but 'It made me mad and I gave her a piece of my mind.' I asked if she would like to make a report or have anything done about the incident and she said no. It was over and she had taken care of it. Another interview read as follows, 9-18-17 Spoke to employee (S8DW) in dietary who said that (S9DW) had slapped Resident #3 on her back when she was trying to get yogurt off the supper cart. Interview with (S9DW) who denied slapping Resident #3. Stated she was just trying to keep Resident #3 from digging in the supper cart. S1 ADM wrote a statement that read, 9-18-17 Resident #R1 approached me in the dining room and stated he was right there when the incident occurred and was a witness to the incident. He stated with certainty that S9DW did not slap Resident #3. Under Section 4 of this document revealed a check mark on the line that stated Concern & Grievance resolved: S1ADM had signed and dated this document. Documentation under this read, 9-19-17 Administrator counseled employee S9DW who voiced understanding of proper conduct towards resident. Record review of a statement from S8DW read as follows, On 9-17-18 between 6:00 PM and 6:30 PM I witnessed S9DW pull a bucket from Resident #3's hands and slap her on the shoulder back area. On 9-29-17 at 9:00 AM an interview with Resident #3 revealed she was sitting at the table with Residents #4 and #5 by the warming table. She revealed there was a tray with pink packages of artificial sugar, packages of cream and stirring straws. She revealed she was taking some of the condiments and S9DW came to take it away from her and slapped her hand and stated, That's not yours. She stated it bothered her that she would slap her hand. On 9-29-17 at 10:14 AM interview with S6FSS revealed Resident #3 hoards silverware, packages of sugar, salt, and cream to bring to her room. Sometimes when you were trying to take it from her she gets a little angry and loud. She revealed she tells the staff what Resident #3 has in her hands do not try to take it from her or she will get mad. She revealed on 9-17-17 after supper meal an incident occurred in the dining room. She revealed she was not in the facility on that evening. She revealed S7LPN had reported it to the supervisors the next morning. S6FSS revealed S9DW should not have slapped Resident #3's hand because she was reaching into the bucket. She replied she would consider this abuse, Can't call it nothing else. On 9-29-17 at 10:48 AM interview with S8DW revealed that on 9-17-17 around 6:00 PM to 6:30 PM she was cleaning the steam table at the end of the line by the dishwasher's window. She stated S9DW was in the dishwasher room and Resident #3 was in the dining room by the window of the dishwasher room. There was a bucket with milk, yogurt, and juice on a table and Resident #3 was digging in the bucket. Resident #3 does this often and the staff have to correct her. When S9DW saw her from the window of the dishwasher room she came running around from the dishwasher room passing by me near the steam table pushing me out the way. This called my attention to what was about to happen. She revealed she looked over and S9DW grabbed the bucket with one hand from Resident #3 and swung with her other hand slapping Resident #3 on the shoulder near her back. At this time Resident #3 screamed immediately loud enough for S10LPN to hear and she came to see what was going on. S10LPN immediately asked Resident #3 what happened and Resident #3 screamed that She (S9DW) slapped me. She continued to say She (S9DW) was not supposed to slap me, she shouldn't put her hands on me. S8DW stated Resident #3 was really upset at what had happened. S8DW stated she told him that she had witnessed the incident and would be willing to give a statement. She revealed S7LPN did not question her after the incident. She revealed the very next morning she reported the incident to her Supervisor (S6FSS); and then later that morning S3ADON called her to her office and asked her to explain what had occurred. S8DW revealed about two hours later S1ADM called her into his office and she told him what happened. S8DW revealed he had her write a brief statement. She further revealed S11DW was in the dining room and heard the incident. S8DW revealed she would call what S9DW done abuse. She revealed S9DW has continued to work in the facility even after the incident. On 9-29-17 at 11:26 AM interview with S9DW revealed on 9-17-17 she just finished serving supper. She revealed after the trays were picked up it was her job to pick up the buckets and silverware. S9DW stated Resident #3 takes the silverware and digs in the milk buckets. She revealed that day she saw Resident #3 rolling her wheel chair toward the bucket so she left the dishwashing area and went to pick up the bucket. When she got to Resident #3 she grabbed the bucket with both hands and Resident #3 screamed, You hit me, you slapped me, and she kept screaming. She revealed she did not make physical contact with Resident #3. She revealed she had witnesses that she did not slap Resident #3. S9DW stated S10LPN saw the incident and she can say what happened because she was by the nursing station observing what was going on in the dining room. She also revealed Resident #R1 was in dining room and he saw what happened; and S11DW was in the dining room and seen what happened. She revealed S7LPN questioned her about what had happened. S9DW stated S7LPN told her he had to write something up even though it did not happen to prove that he was doing his job. On 9-29-17 at 11:40 AM an interview with Resident #R1 revealed on Monday or Wednesday he was entering the dining room's main entrance and saw Resident #3 between three long tables and S9DW was behind a pole. He revealed Resident #3 had the habit of taking cream and sugar from the tables. He revealed he saw S9DW picking up the basket with cream and sugar to keep them away from Resident #3. When S9DW picked up the second basket Resident #3 started fussing at the worker. He revealed he did not see S9DW slap Resident #3 or hear Resident #3 say, Don't slap me. He revealed Resident #3 wasn't trying to get anything out of the ice bucket. He further revealed there was no ice bucket around at that time. He revealed the incident did not occur around the steam table or the window of the dishwashing area. This occurred on the other end of the dining room after lunch. On 9-29-17 at 11:48 AM, an interview with S10 LPN revealed the incident occurred on a weekend. She revealed she was coming back from rolling a Resident to their room. She revealed before entering the dining room she heard Resident #3 yelling. She revealed when she entered the dining room she saw Resident #3 and she was saying that S9DW had hit her hand because she was trying to get a yogurt. She revealed Resident #3 told her that S9DW can't slap her like that. S10LPN revealed she asked Resident #3 what happened and she replied, She hit my hand. S10LPN revealed she then called S7LPN which was Resident #3's nurse. S7LPN then informed S10LPN that he would handle it. At this time, he went and talked to Resident #3 and S9DW. On 9-29-17 at 11:58 AM, S11DW revealed on Sunday 9-17-17 after supper she was picking up supper trays in the dining room. She revealed she saw Resident #3 picking things off the supper trays. She then heard Resident #3 yell, Do not slap me. She then looked up at Resident #3 and saw S9DW standing by Resident #3 holding a bucket with both hands. She further revealed Resident #3 has a habit of taking things from the dining room. On 9-29-17 at 2:56 PM an interview with S7 LPN revealed he was taking care of Resident #3 on 9-17-17 on the 3-11 shift. He revealed S10 LPN had informed him that S9DW had slapped Resident #3 on the hand. He revealed he questioned S9DW and she said she did not slap the Resident's hand. He asked Resident #3 and she said S9DW slapped her on her hand when she was trying to get a yogurt. He revealed he was told by another kitchen worker S11DW that S8DW had seen S9DW slap Resident #3 on the back. He revealed he did not complete an Incident Report or report the incident immediately to his supervisor. He revealed he documented the incident in the progress notes and did not report the incident until the next day. He revealed the facility's policy was if there was an allegation of abuse to report the incident immediately to his supervisor and fill out an Incident Report. On 10-3-17 at 9:32 AM, an interview with S3ADON revealed the incident occurred on 9-17-17 around 6:30 PM. The Administrator and the DON were not notified until the following day on 9-18-17 at around 7:30 AM. She revealed they found out because it was on the 24-hour report. She revealed she found out about the incident from staff talking amongst themselves. S3ADON revealed she realized there was a witness in the progress notes that S7LPN had written. S8DW had told S6FSS at the beginning of her shift the next day (9-18-17) about the abuse. S3ADON stated she called S8DW to her office to find out what had happened. S8DW stated she was by the steam table and S9DW was in the dishwashing room and saw Resident #3 reach into the bucket. S8DW said she saw S9DW pull the bucket away from Resident #3 and slap her on her back. She informed S8DW to tell S1ADM what she had seen. S3ADON stated she called S1ADM and he said he was going to talk to S8DW. She revealed there was no incident report filled. She revealed S7LPN should have called the supervisor because Resident #3 was his Resident. S3ADON revealed she gets the incident reports and turns them over to the Administrator and DON and they decide who will investigate the incident. S3ADON stated she considered this incident to be abuse. She revealed she would have suspended S9DW and sent her home because it was witnessed. If the abuse was substantiated she would have terminated S9DW. She stated the DON or the Administrator should do a thorough investigation; and the allegations of abuse should be reported to the state. S3ADON replied, we are to notify the Family and Ombudsman and the police. On 9-29-17 at 1:14 PM an interview with S2DON revealed she found out about the incident on the 24 Hour Report the next day that Resident #3 grabbed food off the line; and S9DW slapped her hand. She revealed she talked to Resident #3 about the incident and asked her if she was hurt and she said No. She said it made her mad and she gave S9DW a piece of her mind. S2DON asked Resident #3 if there was something she wanted her to do about the incident and she said No. She revealed she called Resident #3's daughter that day about what happened. The daughter said she visited her mother that morning and her mother never mentioned anything about the incident. The daughter said if it didn't bother her mother then she was comfortable with what her mother wants. S2DON revealed she did no further investigating into the incident. S2DON stated that S1ADM probably investigated the incident. On 9-29-17 at 1:23 PM an interview with S1ADM revealed an incident occurred on 9-17-17. He revealed he was told about the incident on 9-18-17 that S8DW had observed S9DW slapping Resident #3 across her back. He revealed he did not get a written statement from S9DW regarding the incident. He revealed he spoke with S9DW and she said she did not slap Resident #3. He revealed the only written statement that he got was a short statement from S8DW. He stated he questioned S10LPN and she said she heard Resident #3 holler that S9DW had slapped her hand but she did not witness what had happened. He revealed he spoke to S2DON who spoke to Resident #3 and her daughter and they were okay with the incident. He revealed S9DW was not put on suspension. He revealed S9DW continued working in the facility until present day. He revealed he did not report the incident to the state through OTIS. He revealed he was approached by Resident #R1 and was told he witness the whole thing and that Resident #3 was digging in the bucket and he did not see S9DW slap Resident #3's hand. He further revealed he came to the conclusion that he couldn't prove the abuse one way or another. So he just counseled S9DW. At 1:30 PM on this day Resident #R1 was brought into S1ADM Office. Resident #R1 informed S1ADM that the incident they talked about was when S9DW had taken sugar and cream from the client. He revealed during this incident S9DW did not slap Resident #3's hand. He stated this was after lunch on a weekday. He revealed he did not see an incident that happened on the weekend where Resident #3 was taking a yogurt out of a bucket; and S9DW slapped her on the back. At this time S1ADM stated he did not look into the incident any further after Resident #R1 stated he had seen the incident. He revealed he did not realize that he was talking about a different incident. S1ADM revealed he did not thoroughly question Resident #R1 regarding the incident on 9-17-17 to ensure this was the same incident. S1ADM stated if he knew these were two different incidents he would have come to the conclusion that the allegation of abuse that had apparently happened. S1ADM revealed if he had substantiated the allegations of abuse he would have notified the State through OTIS. He revealed he would have suspended the employee and finished the investigation. Then based on the conclusion, S9DW would be terminated. He further revealed he would then report the abuse to the local authorities.

Based on record review and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evidenced by the failure of the administration to: 1. Thoroughly investigating allegations of abuse; 2. Ensuring the safety of the residents from abuse; 3. Reporting allegations of abuse to the state and other authorities. 4. Ensure the staff implemented the facility's policy and procedure on abuse. This had the potential to affect 86 Residents that resided in the facility. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #3 that started on 9-17-17 at between 6:00 PM and 6:30 PM when S9DW (Dietary Worker) slapped Resident #3 on her back when she was taking a yogurt from the supper cart in the dining room. The facility failed to protect the resident after S8DW witnessed and reported the abuse. The facility failed to thoroughly investigate the abuse as required by the policies and procedures and allowed S9DW (the accused employee) to continue to work at the facility with the residents. S1ADM was informed of the IJ situation on 9-29-17 at 5:00 PM. The IJ situation was removed on 10-2-17 at 3:45 PM when the administration provided the Plan of Removal which read in part: Upon notification by the survey team on 9/29/17 of the concerns over actions of employee (S9DW), the employee was immediately advised to leave the facility (2:44 P.M.) The employment of (S9DW) has been terminated. An OTIS Report has been filed 0n 10/2/17 with the (State Agency) regarding the incident cited on 9/17/17. In-services for all employees will be conducted starting Sunday, October 1 to review (Provider) policies regarding resident abuse/neglect, along with the proper procedures for reporting and investigating any future allegations. The in-services will be completed by Thursday, October 5, 2017 (to Insure that all employees, including those on days off, attend). The Administrator began contacting surveillance vendors on Monday, October 2, 2017 to get information regarding installation of video cameras throughout the facility. The Administrator along with members of the Quality Assurance (QA) Committee met at 1:30 PM October 2, 2017 to review our current policies and procedures for monitoring, reporting and handling any future allegations of resident abuse/neglect so that they are handled both timely and properly. The committee also discussed the reasons for the lapse in thoroughly and properly investigating and reporting the incident involving (Resident #3) which took place on the evening of September 17, 2017. All QA members were provided a copy of the Abuse Policy for (Provider) to review, so that we can meet again to discuss any updates/changes which need to be made in order to insure compliance and the safety of our residents. A follow-up meeting will be held on Friday, October 6. We have contacted our Ombudsman (____) who has agreed to provide an in-service for all of our employees on October 19, 2017. (This is her first available date). (Ombudsman) will conduct the ANNUAL MANDATORY INSERVICE on Residents Rights and Abuse. This deficient practice remains at a level of more than minimal harm for all 86 residents residing in the facility. Findings: 1. Cross reference to findings at F223 2. Cross reference to findings at F225 3. Cross reference to findings at F226 Review on 10/2/17 of the facility's policies and procedures entitled, Abuse Policies and Procedures revealed the following in part: a. ABUSE is defined as the willful infliction of injury: unreasonable confinement; intimidation; punishment with physical harm, pain, or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident . The individual conducting the investigation will, at a minimum: a) Review the completed Resident Abuse Report Form: b) Review the resident's medical record to determine events leading up to the incident: c) Interview the person (s) reporting the incident: d) Interview any witnesses to the incident: e) Interview the resident (as medically appropriate): f) Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident: g) Interview the resident's roommate, family members, and visitors: h) Interview other residents to whom the accused employee provides care or services: and i) Review all events leading up to the alleged incident . Any employee of this facility who has been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the administrator has reviewed the results of the investigation. Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by the state or local laws within 24 hours of the results of the completion of the investigation. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 days of the reported incident . Record review of Progress Notes by Resident read as follows, 9-17-17 10:56 PM Resident was taking a yogurt out of the kitchen when Kitchen staff (S9DW) slapped her hand. S9DW denies hitting resident, but staff said it was witnessed by another kitchen staff S8DW. Did not get a chance to talk with S8DW. No apparent Injuries noted. Signed by S7LPN. Record review of the Document titled, Resident Concern/Grievance Report revealed the following documentation: Date of Concern: 9-17-17 . Time of Concern 3-11Shift . Resident was seen reaching for a yogurt on the food line and a Dietary employee (S9DW) was observed by another employee (S8DW) slapping her hand and saying 'you can't do that' or something to that affect. (S2DON received this report on 9-18-17 at 7:30 AM). S2DON documented, on 9-18-17 at 10:00 AM (S3ADON) called Resident #3's Daughter. Under comments read, I informed daughter about the incident. She (Daughter) said she was here this AM (Morning) and her mother (Resident #3) never mentioned it. She further said her mother can pretty much take care of herself so if she saw no need to tell her, it must have not been anything to worry about. On the back of this form was S2DON investigations that read as follows, 9-18-17 at 9:30 AM I spoke with Resident #3 and she acknowledged that a dietary employee slapped her hand. She said she wasn't hurt, but 'It made me mad and I gave her a piece of my mind.' I asked if she would like to make a report or have anything done about the incident and she said no. It was over and she had taken care of it. Another interview read as follows, 9-18-17 Spoke to employee (S8DW) in dietary who said that (S9DW) had slapped Resident #3 on her back when she was trying to get yogurt off the supper cart. Interview with (S9DW) who denied slapping Resident #3. Stated she was just trying to keep Resident #3 from digging in the supper cart. S1 ADM wrote a statement that read, 9-18-17 Resident #R1 approached me in the dining room and stated he was right there when the incident occurred and was a witness to the incident. He stated with certainty that S9DW did not slap Resident #3. Under Section 4 of this document revealed a check mark on the line that stated Concern & Grievance resolved: S1ADM had signed and dated this document. Documentation under this read, 9-19-17 Administrator counseled employee S9DW who voiced understanding of proper conduct towards resident. On 10-3-17 at 9:32 AM, an interview with S3ADON revealed the incident occurred on 9-17-17 around 6:30 PM. The Administrator and the DON were not notified until the following day on 9-18-17 at around 7:30 AM. She revealed they found out because it was on the 24-hour report. She revealed she found out about the incident from staff talking amongst themselves. S3ADON revealed she realized there was a witness in the progress notes that S7LPN had written. S8DW had told S6FSS at the beginning of her shift the next day (9-18-17) about the abuse. S3ADON stated she called S8DW to her office to find out what had happened. S8DW stated she was by the steam table and S9DW was in the dishwashing room and saw Resident #3 reach into the bucket. S8DW said she saw S9DW pull the bucket away from Resident #3 and slap her on her back. She informed S8DW to tell S1ADM what she had seen. S3ADON stated she called S1ADM and he said he was going to talk to S8DW. She revealed there was no report filled. She revealed S7LPN should have called the supervisor because Resident #3 was his Resident. S3ADON stated she considered this incident to be abuse. She revealed she would have suspended S9DW and sent her home because it was witnessed. If the abuse was substantiated she would have terminated S9DW. She stated the DON or the Administrator should do a thorough investigation; and the allegations of abuse should be reported to the state. S3ADON replied, we are to notify the Family and Ombudsman and the police. On 9-29-17 at 1:14 PM an interview with S2DON revealed she found out about the incident on the 24 Hour Report the next day that Resident #3 grabbed food off the line; and S9DW slapped her hand. She revealed she talked to Resident #3 about the incident and asked her if she was hurt and she said No. She said it made her mad and she gave S9DW a piece of her mind. S2DON asked Resident #3 if there was something she wanted her to do about the incident and she said No. She revealed she called Resident #3's daughter that day about what happened. The daughter said she visited her mother that morning and her mother never mentioned anything about the incident. The daughter said if it didn't bother her mother then she was comfortable with what her mother wants. S2DON revealed she did no further investigating into the incident. S2DON stated that S1ADM probably investigated the incident. On 9-29-17 at 1:23 PM an interview with S1ADM revealed an incident occurred on 9-17-17. He revealed he was told about the incident on 9-18-17 that S8DW had observed S9DW slapping Resident #3 across her back. He revealed he did not get a written statement from S9DW regarding the incident. He revealed he spoke with S9DW and she said she did not slap Resident #3. He revealed the only written statement that he got was a short statement from S8DW. He stated he questioned S10LPN and she said she heard Resident #3 holler that S9DW had slapped her hand but she did not witness what had happened. He revealed he spoke to S2DON who had spoken to Resident #3 and her daughter and they were okay with the incident. He revealed S9DW was not put on suspension. He revealed S9DW continued working in the facility until present day. He revealed he did not report the incident to the state through OTIS. He revealed he was approached by Resident #R1 and was told he witness the whole thing and that Resident #3 was digging in the bucket and he did not see S9DW slap Resident #3's hand. He further revealed he came to the conclusion that he couldn't prove the abuse one way or another. So he just counseled S9DW. At 1:30 PM on this day Resident #R1 was brought into S1ADM Office. Resident #R1 informed S1ADM that the incident they talked about was when S9DW had taken sugar and cream from the client. He revealed during this incident S9DW did not slap Resident #3's hand. He stated this was after lunch on a weekday. He revealed he did not see an incident that happened on the weekend where Resident #3 was taking a yogurt out of a bucket; and S9DW slapped her on the back. At this time S1ADM stated he did not look into the incident any further after Resident #R1 stated he had seen the incident. He revealed he did not realize that he was talking about a different incident. S1ADM revealed he did not thoroughly question Resident #R1 regarding the incident on 9-17-17 to ensure this was the same incident. S1ADM stated if he knew these were two different incidents he would have come to the conclusion that the allegation of abuse that had apparently happened. S1ADM revealed if he had substantiated the allegations of abuse he would have notified the State through OTIS. He revealed he would have suspended the employee and finished the investigation. Then based on the conclusion, S9DW would be terminated. He further revealed he would then report the abuse to the local authorities.

Based on record review and interview, the facility failed to implement written policies and procedures that prohibit abuse/neglect by failing to ensure an allegation of abuse was thoroughly investigated related to a dietary worker slapping a resident on the back when the resident was taking yogurt from the supper cart in the dining room. The deficiency affected 1(#3) of 5 sampled residents (#1, #2, #3, #4, and #5). The facility failed to ensure that: 1. Staff is adequately trained in the facility's policy and procedure on abuse, 2. An allegation of alleged abuse is reported to the administrator and other officials including the State Survey Agency, 3. The alleged abuse is thoroughly investigated, 4. The protection of resident # 3 and other residents in the facility by allowing the accuser to continue working in the facility. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #3 that started on 9-17-17 at around 6:00 PM to 6:30 PM when S9DW (Dietary Worker) slapped Resident #3 on her back when she was taking a yogurt from the supper cart in the dining room. The facility failed to protect the resident after S8DW witnessed and reported the abuse. The facility failed to thoroughly investigate the abuse as required by the policies and procedures and allowed S9DW (the accused employee) to continue to work at the facility with the residents. S1ADM was informed of the IJ situation on 9-29-17 at 5:00 PM. The IJ situation was removed on 10-2-17 at 3:45 PM when the administration provided the Plan of Removal which read in part: Upon notification by the survey team on 9/29/17 of the concerns over actions of employee (S9DW), the employee was immediately advised to leave the facility (2:44 P.M.) The employment of (S9DW) has been terminated. An OTIS Report has been filed 0n 10/2/17 with the (State Agency) regarding the incident cited on 9/17/17. In-services for all employees will be conducted starting Sunday, October 1 to review (Provider) policies regarding resident abuse/neglect, along with the proper procedures for reporting and investigating any future allegations. The in-services will be completed by Thursday, October 5, 2017 (to Insure that all employees, including those on days off, attend). The Administrator began contacting surveillance vendors on Monday, October 2, 2017 to get information regarding installation of video cameras throughout the facility. The Administrator along with members of the Quality Assurance (QA) Committee met at 1:30 PM October 2, 2017 to review our current policies and procedures for monitoring, reporting and handling any future allegations of resident abuse/neglect so that they are handled both timely and properly. The committee also discussed the reasons for the lapse in thoroughly and properly investigating and reporting the incident involving (Resident #3) which took place on the evening of September 17, 2017. All QA members were provided a copy of the Abuse Policy for (Provider) to review, so that we can meet again to discuss any updates/changes which need to be made in order to insure compliance and the safety of our residents. A follow-up meeting will be held on Friday, October 6. We have contacted our Ombudsman (____) who has agreed to provide an in-service for all of our employees on October 19, 2017. (This is her first available date). (Ombudsman) will conduct the ANNUAL MANDATORY INSERVICE on Residents Rights and Abuse. This deficient practice remains at a level of more than minimal harm for all 86 residents residing in the facility. Findings: Review on 10/2/17 of the facility's policies and procedures entitled, Abuse Policies and Procedures revealed the following in part: a. ABUSE is defined as the willful infliction of injury: unreasonable confinement; intimidation; punishment with physical harm, pain, or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident . The individual conducting the investigation will, at a minimum: a) Review the completed Resident Abuse Report Form: b) Review the resident's medical record to determine events leading up to the incident: c) Interview the person (s) reporting the incident: d) Interview any witnesses to the incident: e) Interview the resident (as medically appropriate): f) Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident: g) Interview the resident's roommate, family members, and visitors: h) Interview other residents to whom the accused employee provides care or services: and i) Review all events leading up to the alleged incident . Any employee of this facility who has been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the administrator has reviewed the results of the investigation. Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by the state or local laws within 24 hours of the results of the completion of the investigation. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 days of the reported incident . Record review of Resident #3's Medical Record revealed Resident #3 was [AGE] years old. She was admitted to the nursing facility on 10-22-12. Her [DIAGNOSES REDACTED]. Record review of Resident #3's MDS (Minimum Data Set) dated 7-29-17 under Section C titled Cognitive Patterns revealed Resident #3's BIMS (Brief Interview Mental Status) score was 11(cognition - moderately impaired). Record review of Resident#3's Care Plan read as followed: - Inappropriate behavior - Hoarding cups, napkins, sugar packets etcetera. Staff to clean out Resident #3's room periodically and discourage hoarding. Do not argue with Resident #3 or treat her like a child. Explain and reaffirm as frequently as necessary that such behavior is not acceptable and will not be tolerated. - Resident has memory problems related to Dementia as evidenced by forgetful at times. Allow Resident ample time to absorb and respond to information. Provide a calm, therapeutic environment and structured routine. - Resident has a history of Depression. Be empathetic towards client but do not reward her misery, Give lots of reinforcement and praise. Record review revealed on 10-22-12 Resident #3 signed an acknowledgement that she was made aware that she shall have the right to be free from physical abuse, mental abuse, and corporal punishment. Record review of Progress Notes by Resident read as follows, 9-17-17 10:56 PM Resident was taking a yogurt out of the kitchen when Kitchen staff (S9DW) slapped her hand. S9DW denies hitting resident, but staff said it was witnessed by another kitchen staff S8DW. Did not get a chance to talk with S8DW. No apparent Injuries noted. Signed by S7LPN. Record review of the Document titled, Resident Concern/Grievance Report revealed the following documentation: Date of Concern: 9-17-17 . Time of Concern 3-11Shift . Resident was seen reaching for a yogurt on the food line and a Dietary employee (S9DW) was observed by another employee (S8DW) slapping her hand and saying 'you can't do that' or something to that affect. (S2DON received this report on 9-18-17 at 7:30 AM). S2DON documented, on 9-18-17 at 10:00 AM (S3ADON) called Resident #3's Daughter. Under comments read, I informed daughter about the incident. She (Daughter) said she was here this AM (Morning) and her mother (Resident #3) never mentioned it. She further said her mother can pretty much take care of herself so if she saw no need to tell her, It must have not been anything to worry about. On the back of this form was S2DON investigations that read as follows, 9-18-17 at 9:30 AM I spoke with Resident #3 and she acknowledged that a dietary employee slapped her hand. She said she wasn't hurt, but 'It made me mad and I gave her a piece of my mind.' I asked if she would like to make a report or have anything done about the incident and she said no. It was over and she had taken care of it. Another interview read as follows, 9-18-17 Spoke to employee (S8DW) in dietary who said that (S9DW) had slapped Resident #3 on her back when she was trying to get yogurt off the supper cart. Interview with (S9DW) who denied slapping Resident #3. Stated she was just trying to keep Resident #3 from digging in the supper cart. S1 ADM wrote a statement that read, 9-18-17 Resident #R1 approached me in the dining room and stated he was right there when the incident occurred and was a witness to the incident. He stated with certainty that S9DW did not slap Resident #3. Under Section 4 of this document revealed a check mark on the line that stated Concern & Grievance resolved: S1ADM had signed and dated this document. Documentation under this read, 9-19-17 Administrator counseled employee S9DW who voiced understanding of proper conduct towards resident. On 9-29-17 at 11:48 AM, an interview with S10 LPN revealed the incident occurred on a weekend. She revealed she was coming back from rolling a Resident to their room. She revealed before entering the dining room she heard Resident #3 yelling. She revealed when she entered the dining room she saw Resident #3 and she was saying that S9DW had hit her hand because she was trying to get a yogurt. She revealed Resident #3 told her that S9DW can't slap her like that. S10LPN revealed she asked Resident #3 what happened and she replied, She hit my hand. S10LPN revealed she then called S7LPN which was Resident #3's nurse. S7LPN then informed S10LPN that he would handle it. At this time, he went and talked to Resident #3 and S9DW. On 9-29-17 at 2:56 PM an interview with S7 LPN revealed he was taking care of Resident #3 on 9-17-17 on the 3-11 shift. He revealed S10 LPN had informed him that S9DW had slapped Resident #3 on the hand. He revealed he questioned S9DW and she said she did not slap the Resident's hand. He asked Resident #3 and she said S9DW slapped her on her hand when she was trying to get a yogurt. He revealed he was told by another kitchen worker S11DW that S8DW had seen S9DW slap Resident #3 on the back. He revealed he did not complete a report or report the incident immediately to his supervisor. He revealed he documented the incident in the progress notes and did not report the incident until the next day. He revealed the facility's policy was if there was an allegation of abuse to report the incident immediately to his supervisor and fill out an Incident Report. On 10-3-17 at 9:32 AM, an interview with S3ADON revealed the incident occurred on 9-17-17 around 6:30 PM. The Administrator and the DON were not notified until the following day on 9-18-17 at around 7:30 AM. She revealed they found out because it was on the 24 hour report. She revealed she found out about the incident from staff talking amongst themselves. S3ADON revealed she realized there was a witness in the progress notes that S7LPN had written. S3ADON stated she called S8DW to her office to find out what had happened. S8DW stated she was by the steam table and S9DW was in the dishwashing room and saw Resident #3 reach into the bucket. S8DW said she saw S9DW pull the bucket away from Resident #3 and slap her on her back. She informed S8DW to tell S1ADM what she had seen. S3ADON stated she called S1ADM and he said he was going to talk to S8DW. She revealed there was no report filled. She revealed S7LPN should have called the supervisor because Resident #3 was his Resident. S3ADON stated she considered this incident to be abuse. She stated the DON or the Administrator should do a thorough investigation; and the allegations of abuse should be reported to the state. S3ADON replied, we are to notify the Family and Ombudsman and the police. On 9-29-17 at 1:14 PM an interview with S2DON revealed she found out about the incident on the 24 Hour Report the next day that Resident #3 grabbed food off the line; and S9DW slapped her hand. She revealed she talked to Resident #3 about the incident and asked her if she was hurt and she said No. She said it made her mad and she gave S9DW a piece of her mind. She revealed she called Resident #3's daughter that day about what happened. The daughter said she visited her mother that morning and her mother never mentioned anything about the incident. The daughter said if it didn't bother her mother then she was comfortable with what her mother wants. S2DON revealed she did no further investigating into the incident. S2DON stated that S1ADM probably investigated the incident. On 9-29-17 at 1:23 PM an interview with S1ADM revealed an incident occurred on 9-17-17. He revealed he was told about the incident on 9-18-17 that S8DW had observed S9DW slapping Resident #3 across her back. He revealed he did not get a written statement from S9DW regarding the incident. He revealed he spoke with S9DW and she said she did not slap Resident #3. He revealed the only written statement that he got was a short statement from S8DW. He stated he questioned S10LPN and she said she heard Resident #3 holler that S9DW had slapped her hand but she did not witness what had happened. He revealed he spoke to S2DON who had spoken to Resident #3 and her daughter and they were okay with the incident. He revealed S9DW was not put on suspension. He revealed S9DW continued working in the facility until present day. He revealed he did not report the incident to the state through OTIS. He revealed that he just counseled S9DW. At 1:30 PM on this day Resident #R1 was brought into S1ADM Office. Resident #R1 informed S1ADM that the incident they talked about was when S9DW had taken sugar and cream from the client. He revealed during this incident S9DW did not slap Resident #3's hand. He stated this was after lunch on a weekday. He revealed he did not see an incident that happened on the weekend where Resident #3 was taking a yogurt out of a bucket; and S9DW slapped her on the back. At this time S1ADM stated he did not look into the incident any further after Resident #R1 stated he had seen the incident. He revealed he did not realize that he was talking about a different incident. S1ADM revealed he did not thoroughly question Resident #R1 regarding the incident on 9-17-17 to ensure this was the same incident. S1ADM stated if he knew these were two different incidents he would have come to the conclusion that the allegation of abuse that had apparently happened. S1ADM revealed if he had substantiated the allegations of abuse he would have notified the State through OTIS. He revealed he would have suspended the employee and finished the investigation. Then based on the conclusion, S9DW would be terminated. He further revealed he would then report the abuse to the local authorities.

Based on observation, record review, and staff interview, the facility failed to follow the plan of care for inspecting the resident's skin weekly, which resulted in actual harm when the resident developed a pressure ulcer on his heel. The pressure ulcer was not identified by the facility until it was 3.0 centimeters by 3.5 centimeters with a necrotic (death of a portion of tissue) area for 1 resident (F10) out of 3 residents reviewed for pressure ulcers, out of a total sample of 11 residents. This deficient practice had the potential to affect the 95 residents residing in the facility. Findings: An observation of resident F10 was made on 6-16-11 at 11:20 a.m. of the resident sitting in a gerichair in the dining room. The resident was observed to have heel protectors on his feet bilaterally. The record review revealed a history and physical exam signed by a physician for Hospice care dated 6-1-11 which had documentation that the resident had an area of skin necrosis approximately 2 centimeters in size over the right heel. Further review of the physician's orders [REDACTED]. A review of the initial wound assessment and weekly charting form, obtained from the treatment nurse, revealed that on 6-7-11, there was documentation that the resident had a wound on the right heel that measured 3.0 centimeters by 3.5 centimeters with 50% [MEDICATION NAME] tissue and 50 % necrotic tissue with a small amount of serous drainage with black tissue noted to the center of the wound. An interview was held with S1 LPN treatment nurse on 6-16-11 at 1:00 p.m., and she revealed that she began treatment to the resident's heel on 6-7-11 after it was reported to her by the LPN working with the resident. She stated that the hospice doctor ordered wool for the heels on 6-1-11, but she was not made aware of the wound until 6-7-11. An interview was held with S2 DON on 6-16-11 at 2:05 p.m. and she stated that the CNAs and the LPNs were responsible for skin assessments. She stated that each shift of CNAs had a day when they were responsible for skin assessments. She also stated that the LPNs were responsible for doing skin assessments once a week on their residents. At that time, S2 DON verified that no one identified anything on resident F10 on the weekly skin assessments. At that time the DON also presented skin assessment sheets completed by the CNAs and the LPNs. The review of the CNA's skin assessment sheets revealed that the area for no skin breakdown was checked on 5-20-11 and 5-23-11. On 5-25-11 everything was blank, on 5-27-11, there was a signature and a date, and no skin breakdown was checked, on 5-29-11, there was a signature, but nothing checked, on 6-1-11, everything was blank, on 6-3-11, there was a signature with no other information noted, and on 6-5-11, the area for no skin breakdown was checked with a signature noted. The review of the LPN weekly skin assessment documentation presented by the DON, revealed that skin assessments were done on 5-12-11, 5-19-11, 5-26-11, and 6-2-11. There were no problems documented on the assessments concerning the right heel, including the one done on 6-2-11, the day after the physician had identified the wound. The review of the resident's careplan revealed that the resident had a problem of potential for skin breakdowns, and interventions included to inspect and chart skin integrity every week. An observation was made of the wound on 6-16-11 at 3:30 p.m. with the DON. A black necrotic area was noted on the heel of the resident about the size of a quarter and was slightly raised. The surrounding edge was noted to have some pink around the edges, with the outer edge of the wound being white in color. At that time S2 DON stated that the white area was maceration around the necrotic area. The S2 DON measured the wound, at that time, and the necrotic area measured 2.5 centimeters by 2.5 centimeters. The whole wound bed measured 3 centimeters by 2.5 centimeters. There was serous drainage noted on the dressing. S2 DON was interviewed on 6-16-11 at 100 p.m. and she stated that the CNAs and the LPNs did not identify the wounds on the right heel before 6-7-11. The plan of care was not followed for this resident for inspecting the skin integrity.

Based on observation, staff interview and record review, the facility failed to assure a resident would receive the necessary services to prevent pressure sores by failing to adequately assess 1 resident's (F10) skin, which resulted in an actual harm when the facility failed to identify a pressure area on the resident's right heel. The area on the right heel was identified by the hospice physician per the history and physical progress note dated 6-1-11 as an area of skin necrosis over the right heel that was approximately 2 centimeters in diameter, but was not identified by the facility until 6-7-11. At that time the wound measured 3.0 centimeters by 3.5 centimeters, with necrotic tissue (death of a portion of tissue), and had serous drainage. Resident (F10) had a history of [REDACTED]. Resident F10 was 1 of 3 resident's reviewed for pressure sores out of a total of 11 sampled residents. This deficient practice had the potential to effect a total of 95 residents residing at the facility. Findings: Resident F10: An observation was made on 6-16-11 at 11:20 a.m. of the resident sitting in a gerichair in the dining room. The resident was observed to have heel protectors on his feet bilaterally. The record review revealed a history and physical exam signed by a physician for Hospice care dated 6-1-11, which had documentation that the resident had an area of skin necrosis over the right heel that measured 2 centimeters in diameter. Further review of the physician's orders [REDACTED]. A review of the initial wound assessment and weekly charting form, obtained from the treatment nurse, revealed that on 6-7-11, there was documentation that the resident had a wound on the right heel that measured 3.0 centimeters by 3.5 centimeters with 50% [MEDICATION NAME] tissue and 50 % necrotic tissue with a small amount of serous drainage with black tissue noted to the center of the wound. An interview was held with S1 LPN treatment nurse on 6-16-11 at 1:00 p.m., and she revealed that she began treatment to the resident's heel on 6-7-11 after it was reported to her by the LPN working with the resident. She stated that the hospice doctor ordered wool for the heels on 6-1-11, but she was not made aware of the wound until 6-7-11. An interview was held with S2 DON on 6-16-11 at 2:05 p.m. and she stated that the CNAs and the LPNs were responsible for skin assessments. She stated that each shift of CNAs had a day when they were responsible for skin assessments. She also stated that the LPNs were responsible for doing skin assessments once a week on their residents. At that time, S2 DON verified that no one identified anything on resident F10 on the weekly skin assessments. At that time the DON also presented skin assessment sheets completed by the CNAs and the LPNs. The review of the CNA's skin assessment sheets revealed that the area for no skin breakdown was checked on 5-20-11 and 5-23-11. On 5-25-11 everything was blank, on 5-27-11, there was a signature and a date, and no skin breakdown was checked, on 5-29-11, there was a signature, but nothing checked, on 6-1-11, everything was blank, on 6-3-11 there was a signature with no other information noted, and on 6-5-11 the area for no skin breakdown was checked with a signature noted. The review of the LPN weekly skin assessment documentation presented by the DON, revealed that skin assessments were done on 5-12-11, 5-19-11, 5-26-11, and 6-2-11. There was no evidence on the assessments that the area on the right heel had been identified, including the one done on 6-2-11, the day after the physician had identified the wound. S2 DON verified that the physician for Hospice had documented on 6-1-11 that the resident had an area on his right heel and had written orders for lambskin and to continue the skin care per the treatment nurse. She stated that the LPN assigned to the resident wrote the order for the lambskin, and to continue the skin care per the treatment nurse on the Medication Administration Record, [REDACTED]. The Hospice physician did not communicate the presence of the necrotic area on the heel to the facility at that time and the History and Physical was not received by the facility until 6-14-11. S2 DON stated on 6-16-11 at 2:20 p.m., that she was not sure who had discovered the wound on 6-7-11, but that the LPN on the floor had notified the treatment nurse about the wound. S2 DON stated at that time that the CNAs were responsible for floating the heels and the LPN was responsible for monitoring that this was done. She also stated that the resident had resisted care at times and had kicked the pillows out from under his legs, but she was unable to find anything on the careplan that addressed this. S2 DON stated that she was unable to stage the wound because she was not sure what was under the bed of the wound. She also stated that the resident had a history of [REDACTED]. The review of the resident's careplan revealed that the resident had a problem of potential for skin breakdowns, and interventions included to inspect and chart skin integrity every week. The review of the pressure ulcer risk assessment revealed that the resident was assessed as high risk for developing pressures ulcers on 5-20-11 and had a score of 14 (total score of 8 or above represents high risk). An observation was made of the wound on 6-16-11 at 3:30 p.m. with the DON. A black necrotic area was noted on the heel of the resident about the size of a quarter and was slightly raised. The surrounding edge was noted to have some pink around the edges, with the outer edge of the wound being white in color. At that time S 2 DON stated that the white area was maceration around the necrotic area. The DON measured the wound, at that time, and the necrotic area measured 2.5 centimeters by 2.5 centimeters. The whole wound bed measured 3 centimeters by 2.5 centimeters. There was serous drainage noted on the dressing.

Based on staff interview and record review, the facility failed to ensure that a resident who enters the facility without a pressure sore does not develop a pressure sore by failing to implement interventions when the resident was assessed as high risk for pressure ulcer development for 1 of 2 sampled residents out of a universe of 8 .(#111) Findings: A review of Resident #111's clinical record revealed that she is an [AGE] year old female with accumulative [DIAGNOSES REDACTED]. Resident # 111 was admitted to the facility on [DATE]. A review of Resident #111's MDS (Minimum Data Set) dated 3/21/11 indicates a BIMS (Brief Interview for Mental Status) score of 9, which is moderately impaired. A review of Resident #111's Pressure Ulcer Risk Assessment done on 1/27/11 revealed a score of 8, which indicates High Risk. The Pressure Ulcer Risk Assessment done for Resident #111 on 2/3/11 is coded as a 9, which is High Risk. The Pressure Ulcer Risk Assessment form reads: " If the total score is 8 or greater, the resident should be considered at HIGH RISK for skin breakdown and a prevention protocol should be initiated immediately. " A review of the facility's Skin Care Policy and Procedure reads: Each resident will be evaluated for special needs at the time of admission. Every effort will be made to prevent skin breakdown. [MEDICAL CONDITION] which are present, or which develop later will be followed carefully and treated according to medical direction. This care will be documented on the weekly wound assessment worksheets. The Nursing Department's procedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The Nursing Department is responsible for the maintenance of skin integrity by the following means: - With medically directed treatment for [REDACTED]. - With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being high risk. A review of Resident #111's Admission Assessment and Interim Care Plan body audit diagram, dated 1/27/11,revealed no evidence of pressure ulcers upon admit. A review of Resident #111's progress note signed by S18, ANP, dated 1/31/11 (not timed) reads: Diagnosis-Stage II decub x 2 w suspected DTI. Also written on the bottom right corner and margin of the form reads: Has B stage II heel decu w suspected DTI. L (greater than sign) R= Dark purple fluid filled blistering . Mushy and painful on palpation. A review of Resident #111's Daily Skilled Nurses Notes dated 1/31/11 for the day, evening , and night shift, reveals check marks for the Skin section indicating "Skin normal color", Decubitus Wound section not checked on the day, evening , and night shift. Further review of 1/31/11 comments section does not mention any skin issues. A review of Resident #111's Daily Skilled Nurses Notes dated 2/1/11 for the day, evening, and night shift has check marks on the Decubitus Wound section and indicates "Bil heels". Narrative comments on 2/1/11 at 1430 reads:........ bilateral water blisters noted to heels. Left heel 4.5 cm X 3.0. Right heel 2.0 X 1.5 cm RP informed TX provided....... A review of Resident #111's clinical record revealed no preventative treatment for [REDACTED]. A review of the physician's order [REDACTED].@ all times; Turn q 2 h when in bed. During an interview on 4/14/11 at 10:30 am, S1, RN DON confirmed that Resident #111 ' s pressure ulcers were identified on 1/31/11 and interventions and treatment did not begin until 2/1/11. S1, RN DON confirmed that resident #111's Pressure Risk Assessment done on 1/27/11 deemed resident was a high risk for pressure ulcer development. S1, RN DON verified that care plan for "Potential for Skin Breakdown" was not initiated until 2/4/11, which was after Resident #111 developed bilateral Stage II ulcers to heels. S1, RN DON confirmed that the Daily Skilled Nurses Notes form dated 1/31/11 did not reveal the presence of pressure ulcers during the day, evening, or night shift. After a review of the clinical record for Resident #111, S1, RN DON confirmed that preventative measures for pressure ulcer development, as per facility policy, were not initiated upon admit when the resident was assessed as a high risk for the development of pressure ulcers. S1, RN DON also verified that the facility failed to identify the presence of pressure ulcers for Resident #111, prior to being evaluated by S18, ANP on 1/31/11. S1 RN DON confirmed that she was unable to find any documentation of wound care being initiated by the facility until 2/1/11.