Every finding on record at Golden Age Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and plans of care. The facility failed to ensure nursing staff had competencies and skill sets to:Accurately administer insulin via insulin pens for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration; andProperly clean a non-invasive mechanical ventilation mask and tubing for 1 (#10) of 2 residents reviewed for respiratory care.Findings: 1. Review of the facility's insulin pen needle product insert revealed the following: 2. Prepare the pen needle: Check that the pen needle is attached correctly and prime the pen according to the manufacturer's instructions for use. Select the insulin dose. Review of the Regular Insulin and Insulin Aspart insulin pen manufacturer's instructions for use revealed the following: Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #12's current Physician Orders revealed the following, in part: Insulin Aspart 100 unit/mL inject 18 units subcutaneously before meals. An observation was made of S4LPN administering Insulin Aspart to Resident #12 on 03/16/2026 at 8:36 a.m. S4LPN applied an insulin pen needle to the insulin pen, dialed up 18 units of insulin, and administered the insulin to Resident #12. S4LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #12. An interview was conducted with S4LPN on 03/16/2026 at 8:47 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #12. She stated insulin pen needles did not have to be primed prior to administering insulin. Resident #129 Review of Resident #129's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #129's current Physician Orders revealed the following, in part: Regular Insulin 100 unit/mL inject per sliding scale subcutaneously before meals and at bedtime. An observation was made of S5LPN administering Regular Insulin to Resident #129 on 03/16/2026 at 11:45 a.m. S5LPN applied the insulin pen needle, dialed up 4 units of insulin, and administered the insulin to Resident #129. S5LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #129. An interview was conducted with S5LPN on 03/16/2026 at 11:52 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #129. She stated priming insulin pen needles was optional. Resident #144 Review of Resident #144's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 1 Diabetes Mellitus. Review of Resident #144's current Physician Orders revealed the following, in part: Insulin Aspart 100 unit/mL inject 14 units subcutaneously before meals and at bedtime. An observation was made of S7LPN administering Insulin Aspart 100 unit/mL inject 14 units subcutaneously to Resident #144 on 03/16/2026 at 9:20 a.m. S7LPN applied an insulin pen needle to the insulin pen, dialed up 14 units of insulin, and administered the insulin to Resident #144. S7LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #144. An interview was conducted with S7LPN on 03/16/2026 at 9:17 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #144. She stated insulin pen needles did not have to be primed prior to administering insulin. An interview was conducted with S2DON on 03/17/2026 at 10:14 a.m. She stated insulin pen needles should have been primed prior to dialing up and administering the ordered dose of insulin. She stated the nurses should have known insulin pen needles should have been primed. She explained priming an insulin pen needle was a standard of care. 2. Review of the facility's policy dated 11/04/2014 and titled, BiPAP and CPAP Machine Cleaning Policy and Procedure revealed the following, in part: Purpose: The keep BiPAP and CPAP machine and equipment clean. Policy: Resident's BiPAP and/or CPAP machine will be kept clean when in resident room. Procedure: 4. Clean the tubing daily with warm water and soap. Rinse thoroughly and air dry. 5. Clean the mask daily with warm water and soap, rinse thoroughly and air dry. Resident #10 Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Shortness of Breath. Review of Resident #10's current Physician Orders revealed the following, in part: Clean non-invasive mechanical ventilation mask every morning and let air dry. An interview was conducted with S5LPN on 03/17/2026 at 2:56 p.m. She stated she cleaned Resident #10's non-invasive mechanical ventilation mask every morning. She explained she cleaned the mask with a perineal wipe each morning and let it air dry. S5LPN retrieved wipes from a green pack, which was labeled personal cleansing wipes, and S5LPN cleaned the inside of Resident #10's non-invasive mechanical ventilation mask. S5LPN stated she had never cleaned the non-invasive mechanical ventilation tubing because she had no way to clean it. An interview was conducted with S6LPN on 03/18/2026 at 8:57 a.m. She stated she cleaned Resident #10's non-invasive mechanical ventilation mask daily. She explained when she cleaned Resident #10's non-invasive mechanical ventilation mask, she cleaned the outside of the mask with an alcohol wipe and the inside of the mask with a water soaked paper towel. She stated she then dried the mask with a dry paper towel. She stated she had never cleaned or changed the non-invasive mechanical ventilation tubing. She stated Resident #10 only had one AVAPS mask. She stated she had never received training on cleaning non-invasive mechanical ventilation masks and tubing. An interview was conducted with S3NP on 03/18/2026 at 9:06 a.m. She stated she expected the nurses to follow the facility's policy on cleaning non-invasive mechanical ventilation masks and tubing. An interview was conducted with S2DON on 03/18/2026 at 9:42 a.m. She stated she expected the nurses to clean the non-invasive mechanical ventilation equipment with soap and water as listed in the policy listed above. She stated it was not appropriate to clean the non-invasive mechanical ventilation mask with a personal cleansing wipe. She stated it was not appropriate to clean the outside of the mask with alcohol wipes and the inside of the mask with water soaked paper towels. She stated she expected the nurses be competent in cleaning and care of non-invasive mechanical ventilation masks and tubing.

Based on observations, interviews, and record reviews, the facility failed to ensure services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration.Findings: Review of the facility's insulin pen needle product insert revealed the following: 2. Prepare the pen needle: Check that the pen needle is attached correctly and prime the pen according to the manufacturer's instructions for use. Select the insulin dose. Review of the Regular Insulin and Insulin Aspart insulin pen manufacturer's instructions for use revealed the following: Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your insulin pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #12's current Physician Orders revealed the following, in part: Insulin Aspart 100 unit/mL inject 18 units subcutaneously before meals. An observation was made of S4LPN administering Insulin Aspart to Resident #12 on 03/16/2026 at 8:36 a.m. S4LPN applied an insulin pen needle to the insulin pen, dialed up 18 units of insulin, and administered the insulin to Resident #12. S4LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #12. An interview was conducted with S4LPN on 03/16/2026 at 8:47 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #12. Resident #129 Review of Resident #129's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #129's current Physician Orders revealed the following, in part: Regular Insulin 100 unit/mL inject per sliding scale subcutaneously before meals and at bedtime. An observation was made of S5LPN administering Regular Insulin to Resident #129 on 03/16/2026 at 11:45 a.m. S5LPN applied the insulin pen needle, dialed up 4 units of insulin, and administered the insulin to Resident #129. S5LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #129. An interview was conducted with S5LPN on 03/16/2026 at 11:52 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #129. Resident #144 Review of Resident #144's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis of Type 1 Diabetes Mellitus. Review of Resident #144's current Physician Orders revealed the following, in part: Insulin Aspart 100 unit/mL inject 14 units subcutaneously before meals. An observation was made of S7LPN administering Insulin Aspart to Resident #144 on 03/16/2026 at 9:20 a.m. S7LPN applied an insulin pen needle to the insulin pen, dialed up 14 units of insulin, and administered the insulin to Resident #144. S7LPN did not prime the insulin pen needle prior to dialing up the insulin and administering the insulin to Resident #144. An interview was conducted with S7LPN on 03/16/2026 at 9:17 a.m. She confirmed she did not prime the insulin pen needle prior to dialing up and administering insulin to Resident #144. An interview was conducted with S2DON on 03/17/2026 at 10:17 a.m. She stated insulin pen needles should have been primed prior to dialing up and administering the ordered dose of insulin. She explained priming an insulin pen needle was a standard of care.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 3 (#7, #98, and #144) of 3 residents reviewed for ADLs. The facility failed to ensure: Resident #7 and #144 received their shower as scheduled; and Resident #98 was dressed in clean attire daily. Findings: 1. Resident #7 Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis, which included Radiculopathy, Lumbar Region. Review of Resident #7's Quarterly MDS with an ARD of 12/12/2025 revealed BIMS of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Section GG0130. Self-Care: Partial/moderate assistance for shower/bathe self. Review of Resident #7's current Care Plan revealed the following: Focus: The resident requires staff assistance for ADL care. Interventions: Assist resident with bathing. Review of Resident #7's Shower Documentation dated March 2026 revealed she was scheduled to receive a shower every Tuesday, Thursday, and Saturday. Further review of the Shower Documentation revealed Resident #7 received two showers on the week of 03/08/2026. Resident #7 did not receive her scheduled shower on 03/14/2026. Resident #144 Review of Resident #144's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis, which included Multiple Sclerosis. Review of Resident #144's Quarterly MDS with an ARD of 01/01/2026 revealed a BIMS of 14, which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #144 required partial/moderate assistance with ADLs. Review of Resident #144's current Care Plan revealed the following: Focus: The resident requires staff assistance for ADL care. Interventions: Assist resident with bathing. Review of Resident #144 Shower Documentation dated February 2026 to present revealed she was scheduled to receive showers on Tuesday, Thursday, and Saturday. Further review of the Shower Documentation revealed Resident #144 received two showers on the weeks of 02/01/2026, 02/22/2026, and 03/08/2026. Resident #144 did not receive a shower on 02/07/2026, 02/28/2026, and 03/14/2026. On 03/15/2026 at 8:46 a.m., an interview was conducted with Resident #144. She stated she has not been receiving all of her scheduled showers. She stated her shower schedule is Tuesday, Thursday, and Saturday. She stated she did not get her scheduled shower on Saturday, 03/14/2026. On 03/15/2026 at 2:06 p.m., an interview was conducted with S9CNA. She stated Resident #7 had showers scheduled on Tuesdays, Thursdays, and Saturdays. She stated she was responsible to provide Resident #7's shower on Saturday, 03/14/2026. S9CNA stated she did not provide Resident #7's shower on 03/14/2026 as scheduled and should have. She stated Resident #144 had scheduled showers on Tuesdays, Thursdays, and Saturdays. She stated she was responsible to provide Resident #144's shower on 02/07/2026, 02/28/2026, and 03/14/2026. S9CNA stated she did not provide Resident #144's shower on 02/07/2026, 02/28/2026, and 03/14/2026 as scheduled and should have. On 03/17/2026 at 9:32 a.m., an interview was conducted with S8CNAS. She stated the CNAs were responsible to document when residents received showers. She reviewed Resident #7's shower documentation and confirmed there was no documentation Resident #7 received a shower on 03/14/2026 as scheduled. S8CNAS stated Resident #7 should have received her shower as scheduled. She reviewed Resident #144 shower documentation and confirmed there was no documentation Resident #144 received a shower on 02/07/2026, 02/28/2026, and 03/14/2026 as scheduled. She stated Resident #144 should have received her shower as scheduled. On 03/17/2026 at 9:57 a.m., an interview was conducted with S2DON. S2DON stated residents should receive their shower on their scheduled shower day. S2DON stated Resident #7 should have received her shower on Saturday, 03/14/2026 as scheduled. S2DON stated Resident #144 should have received her shower on 02/07/2026, 02/28/2026, and 03/14/2026. 2. Resident #98 Review of Resident #98's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Age-Related Osteoporosis, Transient Cerebral Ischemic Attack, and Alzheimer's Disease. Further review revealed the resident was currently on Hospice. Review of Resident #98's Quarterly MDS with an ARD of 01/28/2026 revealed BIMS of 01, which indicated the resident was severely cognitively impaired. Review of Resident #98's current Care Plan revealed the following: Focus: The resident requires staff assistance for ADL care dressing and hygiene related to Alzheimer's, Depression/Anxiety, and Hypertension. Interventions: Assist the resident with dressing. Assist the resident with hygiene and grooming task. On 03/15/2026 at 11:55 a.m., an interview was conducted with Resident #98's family member #1. She stated hospice bathed Resident #98 3 times a week on Tuesdays, Thursdays, and Saturdays. She stated when Resident #98 was bathed, she stayed in the same night gown until her next bath due to staff not changing her attire daily. She stated her last bath was on 03/14/2026. On 03/15/2026 at 11:55 a.m., an observation was made of Resident #98 in bed wearing a blue and white flower nightgown. On 03/16/2026 at 8:10 a.m., an observation was made of Resident #98 in bed wearing the same blue and white flower nightgown. On 03/16/2026 at 8:15 a.m., an interview was conducted with Resident #98's family member #2. She stated on Saturday, 03/14/2026, Resident #98 was bathed by Hospice. Surveyor observed the resident's dirty clothesbasket. There was only 1 gown in the basket. Resident #98's family member #2 stated that was the gown the resident had on 03/14/2026 before being bathed. She stated the resident had been in the same gown since Saturday 03/14/2026, and would not receive her next bath until tomorrow, 03/17/2026 from Hospice in which she would be placed in a fresh gown. She stated Resident #98 did not get changed in between Hospice coming to tend to her. On 03/16/2026 at 12:42 p.m., an observation was made of Resident #98 in bed wearing the same blue and white flower nightgown. On 03/17/2026 at 8:50 a.m., an observation was made of Resident #98 in bed wearing the same blue and white flower nightgown. On 03/17/2026 at 8:52 a.m., an interview was conducted with the Hospice CNA. She stated she was the aide who was responsible for bathing Resident #98. She stated she bathed her on Tuesdays, Thursdays, and Saturdays. She stated she bathed her this past Saturday 03/14/2026. She confirmed she dressed Resident #98 in the blue and white flower gown she was currently wearing. On 03/17/2026 at 9:57 a.m., an interview was conducted with S2DON. S2DON confirmed Resident #98 should be dressed daily in clean attire.

Based on observations, interviews, and record reviews, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 2 of 2 (#5 and #58) residents reviewed for environment. Resident #5 Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Idiopathic Peripheral Autonomic Neuropathy, Chronic Ischemic Heart Disease, Morbid Severe Obesity due to Excess Calories, and Acute on Chronic Diastolic Congestive Heart Failure. Review of Resident #5's Quarterly MDS with an ARD of 03/04/2026 revealed a BIMS of 13, which indicated the resident was cognitively intact. An observation was made on 03/15/2026 at 1:26 p.m. of Resident #5's room. Behind her bed was a brown substance splattered on the wall. An interview was conducted on 03/15/2026 at 1:27 p.m. with Resident #5. She stated the brown substance had been on the wall for months. She stated she had asked staff to clean it, but no one ever had. An observation was made on 03/16/2026 at 9:02 a.m. of Resident #5's room. Behind her bed was a brown substance splattered on the wall. An interview was conducted on 03/16/2026 at 9:06 a.m. with S16CNA while in Resident #5's room. S16CNA confirmed the above observations. She stated, That has been there. She stated it was the housekeepers' responsibility to clean it. An interview was conducted on 03/16/2026 at 9:22 a.m. with S10HSK. She stated it was the housekeepers' responsibility to clean all of the residents' rooms including the walls if something was visibly dirty. An interview was conducted on 03/16/2026 at 9:14 a.m. with S1ADM while in Resident #5's room. He confirmed the above observations. He stated it was the housekeepers' responsibility to clean the resident's rooms. He confirmed resident's rooms should be cleaned daily including the walls when visible substances were on them. Resident #58Review of Resident #58's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's Disease.Review of the Quarterly MDS with ARD of 01/21/2026 revealed a BIMS of 5, which indicated the resident was severely cognitively impaired.An observation was made on 03/15/2026 at 10:45 a.m. of Resident #58's room. Observed resident's pillow with no pillow case at this time and had multiple areas of red, brown, and yellow dried substances. Observed dried brown substance located on both of the resident's bed rails. An interview was conducted on 03/15/2026 at 10:45 a.m. with Resident #58's daughter visiting Resident #58. Resident #58's daughter stated she visited Resident #58 every weekend and multiple days during the week. Resident #58's daughter stated during most of her visits, Resident #58 did not have a clean pillow case on her pillow and the bed rails were not cleaned.An observation was made on 03/16/2026 at 9:50 a.m. of Resident #58's room. Observed resident's pillow with no pillow case at this time and had multiple areas of red, brown, and yellow dried substances. Observed dried brown substance located on both of the resident's bed rails.An interview was conducted on 03/16/2026 at 9:51 a.m. with Resident #58. She stated she would like a pillow case because that is nasty.An interview was conducted on 03/16/2026 at 9:58 a.m. with S13HSK. She observed the resident's pillow and bed rails. She stated it was housekeeping's responsibility to clean the resident's bed rails daily. She confirmed there was a dried brown substance located on both of the resident's bed rails. She stated it was the aide's responsibility to place clean linens on the resident's bed which included the pillow case.An interview was conducted on 03/16/2026 at 10:02 a.m. with S8CNAS. She observed the resident's pillow and bed rails. She stated it was housekeeping's responsibility to clean the resident's bed rails daily. She confirmed there was dried brown substance located on both of the resident's bed rails. She confirmed the pillow did not have a pillow case in place and the pillow was stained with a brown, red, and yellow dried substance. She stated it was the aide's responsibility to place clean linens on the resident's bed which included the pillow case.An interview was conducted on 03/16/2026 at 10:15 a.m. with S1ADM. He stated he would get staff to get her a clean pillow immediately. He stated housekeeping was responsible for cleaning the resident's bed rails daily.

Based on observation, interviews, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan by failing to properly clean non-invasive mechanical ventilation equipment for 1 (#10) of 2 residents reviewed for respiratory care.Findings: Review of the facility's policy dated 11/04/2014 and titled, BiPAP and CPAP Machine Cleaning Policy and Procedure revealed the following, in part:Purpose: The keep BiPAP and CPAP machine and equipment clean.Policy: Resident's BiPAP and/or CPAP machine will be kept clean when in resident room.Procedure:4. Clean the tubing daily with warm water and soap. Rinse thoroughly and air dry.5. Clean the mask daily with warm water and soap, rinse thoroughly and air dry. Resident #10Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Shortness of Breath. Review of Resident #10's MDS with an ARD of 01/23/2026 revealed she utilized a non-invasive mechanical ventilator and Oxygen therapy. Review of Resident #10's current Physician Orders revealed the following, in part:AVAPS-AE ventilator (non-invasive mechanical ventilation) for home use at bedtime full face mask; andClean non-invasive mechanical ventilation mask every morning and let air dry. Review of Resident #10's current Care Plan revealed the following, in part:Problem: The resident has Chronic Obstructive Pulmonary Disease. She has a non-invasive mechanical ventilation machine as ordered. Tubing and humidification changed per protocol. An interview was conducted with S5LPN on 03/17/2026 at 2:56 p.m. She stated she cleaned Resident #10's non-invasive mechanical ventilation mask every morning. She explained she cleaned the mask with a perineal wipe each morning and let it air dry. S5LPN retrieved wipes from a green pack, which was labeled personal cleansing wipes. S5LPN used the personal cleansing wipes and cleaned the inside of Resident #10's non-invasive mechanical ventilation mask. S5LPN stated she had never cleaned the non-invasive mechanical ventilation tubing because she had no way to clean it. An interview was conducted with S6LPN on 03/18/2026 at 8:57 a.m. She stated she cleaned Resident #10's non-invasive mechanical ventilation mask daily. She explained when she cleaned Resident #10's non-invasive mechanical ventilation mask, she cleaned the outside of the mask with an alcohol wipe and the inside of the mask with a water soaked paper towel. She stated she then dried the mask with a dry paper towel. She stated she did not use soap to clean the mask. She stated she had never cleaned or changed the AVAPS tubing. She stated she had never received training on cleaning non-invasive mechanical ventilation masks and tubing. An interview was conducted with S3NP on 03/18/2026 at 9:06 a.m. She stated she expected the nurses to follow the facility's policy on cleaning non-invasive mechanical ventilation masks and tubing. An interview was conducted with S2DON on 03/18/2026 at 9:42 a.m. She stated she expected the nurses to clean the non-invasive mechanical ventilation equipment with soap and water as listed in the policy listed above. She stated it was not appropriate to clean the non-invasive mechanical ventilation mask with a personal cleansing wipe. She stated it was not appropriate to clean the outside of the mask with alcohol wipes and the inside of the mask with water soaked paper towels.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care for 2 (#6 and #45) of 3 residents observed who required EBP; and2. Performed appropriate Standard PPE glove precautions during incontinence care for 1 of 1 (#45) residents observed for urinary catheter care.Review of the facility's policy titled Enhanced Barrier Precautions Policy and Procedure dated 04/01/2024 revealed in part, the following:EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.1. EBP are indicated for residents with any of the following:ii. Indwelling medical device examples include central lines and urinary catheters.4. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities:f. Changing briefs or assisting with toileting.g. Device care or use (central line, urinary catheter)Resident #6Review of Resident #6's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed she currently had a Peripherally Inserted Central Catheter (PICC) line inserted.An observation was made on 03/15/2026 at 9:55 a.m. of Resident #6 in her room. No EBP signage was observed on the resident's door or in the resident's room. S15LPN entered the room, with only gloves applied, disengaged an antibiotic from Resident #6's PICC line, and flushed the PICC line with Heparin. S15LPN did not wear a gown during this direct care for Resident #6.An interview was conducted on 03/15/2026 at 10:00 a.m. with S15LPN. She stated Resident #6 did not require EBP, did not have an EBP sign, and did not have any physician orders for EBP. She stated she would wear a gown and gloves if a resident required EBP. She stated Resident #6 had the PICC line for approximately 3 days.Resident #45Review of Resident #45's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Retention of Urine. Further review revealed she currently had a urinary catheter in place.Review of Resident #45's current Physician Orders revealed in part, the following:Enhanced barrier precautions: utilize gown and gloves during high contact care activities for residents with indwelling medical devices. Start date: 02/23/2026.An observation was made on 03/17/2026 at 9:30 a.m. of S12LPN and S14CNA performing catheter care and incontinence care for Resident #45. There was an EBP sign on her door which read, in part Enhanced Barrier Precautions. When providing high contact care, staff must: wear gown and wear gloves. Examples of high contact care: device care and changing briefs. Resident #45 was observed to have had a bowel movement in her brief. S12LPN and S14CNA applied gloves, changed Resident #45's soiled brief, cleaned her perineal area with wipes, performed urinary catheter care, and disposed the soiled brief in the trash. S12LPN and S14CNA then, without changing gloves, retrieved a clean brief and applied it to Resident #45. S12LPN and S14CNA did not wear gowns during this direct care for Resident #45.An interview was conducted on 03/17/2026 at 9:40 a.m. with S12LPN. She stated Resident #45 was on EBP, which consisted of staff wearing gown and gloves when direct care was provided. She stated she should have worn a gown during urinary catheter care and incontinence care. She stated she should have changed her gloves after cleaning the feces soiled brief from the resident, before performing urinary catheter care, and again before touching a clean brief.An interview was conducted on 03/17/2026 at 9:42 a.m. with S14CNA. She stated Resident #45 was on EBP, which consisted of staff wearing gown and gloves when direct care was provided. She stated she should have worn a gown during urinary catheter care and incontinence care. She stated she should have changed her gloves after cleaning the feces soiled brief from the resident and before touching a clean brief.An interview was conducted on 03/17/2026 at 11:25 a.m. with S2DON. She confirmed residents with a PICC line or a urinary catheter required EBP. She stated medical devices requiring EBP was discussed in morning meetings. She stated Resident #6's PICC line had been in place for 3 days. She stated EBP initiation for Resident #6 was missed. She confirmed EBP consisted of wearing a gown and gloves and should have been worn during direct resident care. She stated she expected staff to change their gloves after cleaning feces from a resident, before performing urinary catheter care, and again before touching a clean brief.

Based on interviews and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for dignity. The facility failed to ensure staff treated Resident #5 with respect and dignity.Review of Resident #5's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis of Unspecified Dementia. Review of Resident #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/25/2025 revealed Resident #5 had a BIMS (Brief Interview for Mental Status) of 11, which indicated the resident had moderately impaired cognition. Further review revealed Resident #5 required substantial assistance for ADLs.Review of the most current Care Plan for Resident #5 revealed the following:Problem: Resident #5 required assistance with ADLs. Interventions: Assist with ADLsOn 08/26/2025 at 9:46 a.m., an interview was conducted with Resident #5. She stated on 08/08/2025, S3CNA grabbed her arm rough when assisting her. She stated she removed S3CNA's hand grip with her other hand and told her, You are being too rough. After S3CNA left the room, Resident #5 told S2LPN that S3CNA was always rude and disrespectful when she provided care to her. On 08/27/2025 at 3:34 p.m., an interview was conducted with S3CNA. She stated on 08/08/2025, she and S4CNA had just exited Resident #5's room from providing incontinent care and placing Resident #5 in her bed. She stated S4CNA stood outside of Resident #5's room and called her over to observe Resident #5. She stated she and S4CNA observed Resident #5 sitting on the side of her bed after they had just laid her down in the bed. S3CNA stated she entered Resident #5's room and asked, what are you doing?. She stated Resident #5 told her she wanted to go for a walk. S3CNA told Resident #5 she could not go for a walk because she cannot walk. S3CNA stated the nurse came into the room and before she grabbed Resident #5's arm to assist in transferring her, Resident #5 stated you are being too rough. S3CNA stated she exited the room at that time. On 08/27/2025 at 10:27 a.m., an interview was conducted with S4CNA. She stated on 08/08/2025, she and S3CNA had just exited Resident #5's room from providing incontinent care and placing Resident #5 in her bed. S4CNA stated she was standing outside of Resident #5's room and called S3CNA over to observe Resident #5. S4CNA stated she and S3CNA observed Resident #5 sitting on the side of her bed after they had just laid her down in the bed. S4CNA stated S3CNA entered Resident #5's room, she observed from outside of the room, and called S2LPN over because Resident #5 was not following S3CNA's request. S4CNA stated S3CNA and Resident #5 were verbally going back and forth disagreeing. On 08/26/2025 at 3:02 p.m., an interview was conducted with S2LPN. She stated on 08/08/2025, S3CNA observed S4CNA and Resident #5 in the residents room and called her to assist with Resident #5. She stated when she entered Resident #5's room, she heard S3CNA telling Resident #5 to stop in an aggravated and frustrated tone of voice. S2LPN intervened by speaking calmly and explaining to Resident #5 they would assist her getting up. She stated when she and S3CNA began to assist Resident #5 transfer to the wheelchair, Resident #5 told S3CNA to stop because she was being too rough. She stated S3CNA exited the room at that time. She stated she did not see S3CNA grab Resident #5's arm because she was assisting on her side but S3CNA was visibly frustrated and exhibited aggravation by her tone of voice and body language when she entered Resident #5's room. She stated after S3CNA left the room, Resident #5 stated S3CNA was always rude when she provided care. S2LPN confirmed S3CNA's behaviors were not appropriate when providing care to residents. On 08/27/2025 at 2:50 p.m., an interview was conducted with S1DON. He confirmed staff should never argue or disagree with residents and all residents should be treated with dignity and respect.

Based on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse and psychological harm for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for sexual abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in actual psychological harm on 02/11/2025, when Resident #2, a cognitively intact resident, stated a visitor of the facility showed her unwanted pictures of his penis and then later forced his penis into Resident #2's mouth. Resident #2 reported the incident to the facility on [DATE] and stated she did not report it sooner because she was embarrassed. Resident #2 experienced psychosocial harm describing the sexual abuse as horrible and becoming tearful when speaking of it. Findings: Review of the facility's policy dated 03/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure revealed in part, the following: Purpose: Each resident has the right to be free from abuse. No one shall abuse a resident. This policy applies to anyone else present in our facility. Types of Abuse: 2. Sexual Abuse includes but is not limited to, sexual coercion or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Other Specified Depressive Episodes. Review of Resident #2's Minimum Data Set with an ARD of 03/05/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #2 had no issues with memory/recall ability and no behaviors noted. Review of Resident #2's Psychiatric Progress Note dated 03/21/2025 revealed in part, the following: Chief complaint: Resident reports: I am okay. I went to S3SW because something bad happened 5-7 days before Valentine's Day. I was sexually assaulted by someone. I used to know his mom and it was horrible. During the visit, the resident becomes tearful when speaking of the situation. She denies memory impairment. Review of Resident #2's third party counseling social services psychiatric evaluation dated 03/26/2025 revealed in part, the following: I went to S3SW because something bad happened 5-7 days before Valentine's Day. I was sexually assaulted by someone. I used to know his mom and it was horrible. I saw him outside and he said he was going to sit with me. Then he showed me a picture of his private parts on his phone. She stated she pushed the phone away. He asked her if she was ready to go in and offered to push her back to her room. She reports she was seated in her chair in her room and he forced his penis in her mouth. When he finished, he told her not to tell anyone. She states she told the accused's sister and then told S3SW the next day 03/20/2025. Patient has a history of sexual abuse and reports the incident has brought her sexual trauma back up. Review of the facility's visitor sign in log book for February-March 2025 revealed in part, the following: 02/11/2025: Time In: 1:34 p.m. Time Out: 2:20 p.m. Visitor Name: Accused Resident that you are visiting: Resident #2 Review of document titled [NAME] Parish Sheriff's Office Records Section dated 04/01/2025, revealed in part, the following: Date & time reported: 03/20/2025 12:25 p.m. Offense: First Degree Rape/Oral Location: facility's address Arrestee: Accused Remarks: On 03/20/2025 at approximately 12:25 p.m., I was dispatched to facility in reference to a sex offense complaint. An interview was conducted on 03/31/2025 at 12:01 p.m. with Resident #2. She stated before Valentine's Day, the accused came and visited her in the smoker's patio area. She stated while they were outside, the accused showed her a picture of his penis on his phone. She stated she pushed the phone away and told him I don't want to see that. She stated they sat outside talking a little longer, and then the accused asked her if she was ready to go back to her room. She stated when they entered her room, he shut the door, pulled out his penis, and forced it in her mouth. Resident #2 was tearful during interview with surveyor. She stated this was sexual abuse and she did not want him to do this. She stated when he was done, he left the room, and she had not seen him since. She stated she did not tell anyone because she was embarrassed. She stated on 03/20/2025, she made the S1ADM and S3SW aware of the incident. She stated she only cries when she talks about the incident. She stated she was now seen daily by S3SW and S1ADM. She stated she was also seen by a Psychiatric Nurse Practitioner and a counselor weekly, which she felt like was helping. She stated she was not fearful of being at the facility. She stated she was happy the accused was now in jail. An interview was conducted on 03/31/2025 at 11:42 a.m. with S4CNA. She stated Resident #2 was cognitively intact and did not have a history of making false accusations. She stated she was assigned to Resident #2 on 02/11/2025 when the accused visited Resident #2 outside on the patio. She stated they were outside laughing and talking, she stated she saw the accused push Resident #2 in her wheelchair back to her room. She stated there had been no changes observed with Resident #2 from 02/11/2025 and 03/20/2025. She stated she had not seen the accused since that day and he was not allowed to be a visitor at the facility anymore. She verbalized different types of abuse to surveyor and stated all allegations of abuse should be reported immediately to S2DON and S1ADM. She confirmed a visitor forcing his penis into a resident's mouth was sexual abuse. She stated all staff received in-services related to the types of abuse and immediately reporting any allegation. An interview was conducted on 03/31/2025 at 11:45 a.m. with S5LPN. She stated Resident #2 was cognitively intact and did not have a history of making false accusations. She stated she was assigned to Resident #2 on 02/11/2025 when the accused visited Resident #2 outside on the patio. She stated she saw them hug when he first walked up to Resident #2. She stated they were outside laughing and talking. She stated she saw the accused push Resident #2 back to her room in her wheelchair, but she never noticed when he left. She stated she did not see any signs of sadness or distress, nor did Resident #2 report any issues or sexual abuse to her. She stated there had been no changes noted in Resident #2 from 02/11/2025 and 03/20/2025. She stated she had not seen the accused since that day, and he was not allowed to be a visitor at the facility anymore. She verbalized different types of abuse to surveyor and stated all allegations of abuse should be reported immediately to S2DON and S1ADM. She confirmed a visitor forcing his penis into a resident's mouth was sexual abuse. She stated all staff recently received in-services related to the types of abuse and immediately reporting any allegation. She stated S3SW and S1ADM check on Resident #2 daily. She stated Resident #2 received counseling therapy sessions weekly. An interview was conducted on 03/31/2025 at 1:07 p.m. with S3SW. She stated Resident #2 was cognitively intact and did not have a history of making false accusations. She stated on 03/20/2025, Resident #2 came into her office. She stated Resident #2 told her the accused came and visited with her outside in the patio area before Valentine's Day. She stated Resident #2 told her the accused showed her a picture on his phone of his penis. She stated the accused then wheeled her wheelchair back into her room, shut the door, and then forced his penis in Resident #2's mouth. She stated she reported this to S1ADM immediately. She stated S1ADM then called the police. She stated Resident #2 did become tearful when she was talking about the incident. She stated the accused was put in jail on 03/28/2025 for this charge. She stated she asked Resident #2 why she waited to report this incident to anyone, and Resident #2 stated because she was embarrassed. She stated the accused had never been seen acting inappropriately before while at the facility. She stated 02/11/2025 was the only time the accused had visited just Resident #2 and no one saw anything other than them sitting outside having friendly conversation. She stated she and S1ADM check on Resident #2 daily. She stated Resident #2 was rounded on hourly by nursing staff. She stated Resident #2 was seen by a Psychiatric Nurse Practitioner and received counseling by a third party weekly. An interview was conducted on 03/31/2025 at 1:30 p.m. with S1ADM. He stated Resident #2 was cognitively intact and did not have a history of making false accusations. He stated on 03/20/2025 around lunch, he was called into S3SW's office. He stated Resident #2 then began to tell him about an incident which occurred before Valentine's Day with a visitor. He stated Resident #2 told him the accused came and visited with her outside in the patio area. He stated Resident #2 told him the accused showed her a picture on his phone of his penis. He stated the accused then pushed her in her wheelchair back into her room, shut the door, and then put his penis in Resident #2's mouth. He stated he called the police immediately. He stated he immediately reported the incident to state office. He stated he called the accused and asked him if this incident had occurred, which the accused denied anything occurred other than conversation with Resident #2. He stated he told the accused he could not be a visitor any longer. He stated staff placed a picture at the front desk of the accused and all staff were made aware the accused was not to enter the facility and to contact him immediately if he was seen. He stated he called the accused's sister who would also visit with Resident #2 and she stated to him that she knew nothing about this until Resident #2 told her when she was visiting with her on 03/19/2025 and she told Resident #2 that she needed to report this. He stated the sheriff deputy came to the facility 3 times to interview Resident #2 and staff. He stated all staff were immediately in-serviced on reporting abuse and about all types of abuse. He stated staff were interviewed and had no knowledge of the incident. He stated video footage was no longer available for viewing due to the system only saving the past 7 days of footage. He stated he asked Resident #2 if she wanted him to call her family about the incident even though Resident #2 was her own Responsible Party and she said yes. He stated he called her family and no one was aware of this incident. He stated he interviewed random residents to see if they had ever been visited by the accused or seen him show any signs related to abuse or inappropriate behaviors, all of which said no. He stated he reviewed the visitor log and the accused had not visited with Resident #2 other than 02/11/2025. He stated staff now round on Resident #2 every hour and document this and any mood changes in the clinical record. He stated there had been no changes noted in Resident #2 from 02/11/2025 and 03/20/2025. He stated the accused was placed in jail on 03/28/2025 for this charge. He stated he asked Resident #2 why she waited to report this incident to anyone and Resident #2 stated because she was embarrassed. He stated the accused had never been seen acting inappropriately before while at the facility. He stated he and S3SW check on Resident #2 daily. He stated Resident #2 was rounded on hourly by nursing staff. He stated Resident #2 was seen by a Psychiatric Nurse Practitioner and received counseling by a third party weekly. An interview was conducted on 04/01/2025 at 1:40 p.m. with the public records custodian for the local sheriff's office. She stated the accused was arrested on 03/28/2025 with a first degree charge of rape/oral. She stated he remained in jail at this time. Throughout the survey from 03/31/2025 to 04/01/2025, record review and staff interviews revealed staff received training on the facility's abuse policies and procedures. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective action was taken for the affected resident by: a. All staff in-serviced on abuse on 03/20/2025. b. The accused was immediately banned from the facility. Staff in-serviced on how to identify the accused. c. Sheriffs' office notified immediately of alleged abuse. d. Trauma informed care assessment performed on resident on 03/21/2025. e. Daily Social Services rounds on resident initiated. f. Hourly rounds on resident immediately initiated. g. Nursing staff in-serviced on trauma informed care on 03/21/2025. h. Resident referred to behavior counseling services. i. Visitor log reviewed on 03/20/2025. j. Resident seen per psychiatric services on 03/21/2025. 2. All residents with visitors have the potential to be affected. 3. The measure that will be put in place or the system changes that will be made to ensure that the deficient practice will not recur: a. All staff in-serviced on abuse on 03/20/2025. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: a. S1ADM or designee will conduct interviews with 5 residents 6 times a week to ensure there are no further allegations of abuse. b. Interdisciplinary Team to discuss ongoing issues during daily Quality Analysis meeting Monday thru Friday. 5. Corrective action was achieved and there were no further issues related to abuse by 03/21/2025.

Based on observation, interviews, and record review, the facility failed to maintain a sanitary environment for 1 (#163) of 3 (#56, #59, and #163) residents reviewed for environment in the final sample. Findings: Review of Resident #163's Clinical Record revealed an admitted [DATE]. Review of Resident #163's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/31/2024 revealed he was frequently incontinent of bowel. On 02/17/2025 at 10:09 a.m., observation of Resident #163's room revealed 8 quarter sized spots of dried brown liquid stool on the floor between his bed and the bathroom door. Observation further revealed a dried brown smear on the fitted sheet on Resident #163's bed. On 02/17/2025 at 10:11 a.m., an interview was conducted with Resident #163. He stated he an episode of stool incontinence on Saturday, 02/15/2025, evening while getting to the restroom. He stated staff did not clean all of the liquid stool from the floor and left his fitted sheet soiled. On 02/17/2025 at 10:23 a.m., an observation was made of S7CNA entering Resident #163's room. Surveyor entered the room and an interview was conducted with S7CNA. She stated she first noticed the stool on Resident #163's floor and fitted sheet between 8:00 a.m. and 9:00 a.m. on 02/17/2025 and did not clean it. She confirmed the brown stool on Resident #163's floor and fitted sheet should have been cleaned as soon as a staff member was made aware of it and had not been. On 02/19/2025 at 3:25 p.m., an interview was conducted with S1ADM. He stated it was the responsibility of the nursing staff, including the CNAs (Certified Nursing Assistants), to promote a clean, homelike environment. He confirmed it was not appropriate for stool to remain on a resident's floor or sheets and he expected nursing staff to clean up bodily fluids immediately when observed.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#23) of 3 (#23, #75, and #135) residents reviewed for hospice. The facility failed to ensure Resident #23 was coded correctly for hospice. Findings: Review of Resident #23's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Adult Failure to Thrive. Review of Resident #23's Physician Orders revealed in part, the following: Admit to Hospice, active 05/31/2024. Review of quarterly MDS assessment with ARD of 07/30/2024 revealed in Section O0110.K1. Hospice care: While a resident: No. Review of quarterly MDS assessment with ARD of 10/02/2024 revealed in Section O0110.K1. Hospice care: While a resident: No. An interview was conducted on 02/18/2025 at 2:15 p.m. with S4MDS. She reviewed Resident #23's MDS assessments dated 07/30/2024 and 10/02/2024. She confirmed both quarterly MDS assessments were not coded correctly for Hospice and should have been. An interview was conducted on 02/19/2025 at 11:15 a.m. with S2DON. She reviewed Resident #23's MDS assessments dated 07/30/2024 and 10/02/2024. She confirmed both quarterly MDS assessments were not coded correctly for Hospice and should have been.

Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-Admission Screening and Resident Review (PASRR) Level II by failing to incorporate a PASRR Level II determination and recommendations into a resident's care plan for 1 (#167) of 4 (#23, #50, #108, and #167) residents reviewed for PASRR. Findings: Review of Resident #167's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Generalized Anxiety Disorder, Schizophrenia, and Paranoid Schizophrenia. Further review revealed he was approved for admission by Level II Authority for a temporary period effective 12/07/2024 through 12/06/2025. Review of Resident #167's Level II Evaluation Summary & Determination Notice revealed the following, in part: OBH approving 365 days for nursing facility placement and the following to occur: Behavioral Health IOP, Crisis Planning, and Assessment for Dementia. On 02/19/2025 at 8:55 a.m., review of Resident #167's current Care Plan revealed no documentation of a PASRR Level II determination and recommendations. On 02/19/2025 at 1:22 p.m., an interview was conducted with S6SSD. She stated she was responsible for incorporating recommendations for residents from their PASRR Level II determinations. She verified Resident #167 had a current PASRR Level II with recommendations. She stated if a resident had a PASRR Level II, the recommendations should be incorporated into the resident's care plan. She stated the care plan nurse was responsible for adding the PASRR Level II information to the resident's care plan. On 02/19/2025 at 2:18 p.m., an interview was conducted with S5MDS. She stated she was responsible for completing Resident #167's care plan. She verified Resident #167 had a PASRR Level II. She reviewed Resident #167's current care plan and stated prior to today, Resident #167's PASRR Level II determination and recommendations were not incorporated into his care plan and should have been. On 02/19/2025 at 2:36 p.m., an interview was conducted with S4MDS and S2DON. They verified Resident #167 had a PASRR Level II. They confirmed Resident #167's care plan should have been updated to incorporate the PASRR Level II determination and recommendations in December 2024 when the facility received the PASRR Level II from OBH, and it was not.

Based on interviews and record review the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled showers for 1 (#56) of 4 (#56, #57, # 63, and #110) residents reviewed for ADLs. Findings: Review of facility's policy titled, Bath, Shower Policy and Procedure, dated 09/14/2014 revealed the following in part: Policy: Showers are to be given as scheduled and/or as needed. Resident #56 Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Orthopedic Surgery, Seizures, Morbid Obesity, and Unsteadiness on feet. Review of Resident #56's Quarterly MDS with ARD of 01/01/2025 revealed a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she used a wheelchair for mobility and required supervision or touching assistance with showering. Review of Resident #56's Current Care Plan revealed the following, in part: Problem: Problem: Resident has an ADL self-care performance deficit r/t right shoulder fracture, Osteoarthritis debility, and generalized weakness. Staff assists with bed mobility, transfers, eating, toileting, bathing, personal hygiene, dressing and grooming. Review of Resident #56's ADL Documentation revealed she was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. Further review of ADL Documentation revealed she did not receive her scheduled shower on Saturday 02/08/2025 which left her without a shower for 4 days. On 02/17/25 at 01:59 p.m. an interview was conducted with Resident #56. She stated she did not get a shower for a week when shower aide was scheduled off for vacation. She stated she was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays and she never refused her showers. On 02/18/25 at 12:50 p.m. an interview was conducted with S12CNA. She stated she was one of two shower aides in the facility. She stated she was on vacation from 02/07/2025 to 02/16/2025, returning on 02/17/2025. She stated when she is off the hall CNAs should shower the residents. She stated if a resident refused a shower she would let the CNA or nurse on the hall know and it was documented in the computer under ADLs. She confirmed Resident #56 received showers on Tuesdays, Thursdays, and Saturdays. She stated Resident #56 informed her she did not receive a shower for the week she was out on vacation. She further stated Resident #56 never refused a shower. She stated there should be documentation if a resident misses a shower and a reason given. On 02/18/25 at 1:15 p.m. an interview was conducted with S14SUP. She stated hall CNAs assist residents with showers if the shower aid is out. She stated residents should receive showers on their assigned days and it should be documented in the computer. On 02/19/25 at 1:59 p.m. an interview was conducted with S11CNA. She confirmed she was one of the aides assigned to Resident #56's hall. She stated it was her responsibility to shower residents if the shower aide was off. She further stated she always documented when a shower was given or a reason a shower was not given. She confirmed if there was no documentation on the ADL Documentation, then the shower was not given. On 02/19/2025 at 1:45 p.m. an interview was conducted with S10CNA. She confirmed she was one of the aides assigned to Resident #56's hall. She stated it was her responsibility to shower residents if the shower aid was off. She stated she had not showered Resident #56 at all in the month of February 2025. She confirmed if there was no documentation on the ADL Documentation, then the shower was not given. On 02/18/25 at 1:34 p.m. an interview was conducted with S13ADON. She reviewed Resident #56's ADL Documentation and confirmed there was no documentation for a shower being given on Saturday 02/8/2025. She confirmed if a shower was given there should have been documentation. She stated Resident #56 should have received a shower on Saturday 02/8/2025 and according to documentation she did not.

Based on observation, interviews and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1(#57) of 1(#57) residents reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor, flush, and replace the saline lock IV access site according to professional standards. Findings: Review of the undated facility Policy Titled, Intravenous Therapy Flush and Dressing Protocol revealed, in part: Peripheral Device: 1. Follow SASH protocol daily and as needed. Flush device with 3ML Normal Saline and 2ML Heparin 100 units/ML 2. Change dressing every three days and as needed according to policy. 3. IV site to be monitored for complications. 4. IV site to be rotated every three days and as needed as appropriate. Review of Resident #57's Medical Record revealed the resident was admitted to the facility on [DATE] with a diagnoses which included Pneumonia and Dehydration. Review of Resident #57's MDS (Minimum Data Set) ARD (Assessment Reference Date) 01/20/2025 revealed BIMS (Brief Interview for Mental Status) of 15 indicating Resident #57 was cognitively intact. Review of Resident #57's physician orders, dated February 2025, revealed an order on 02/11/2025 and 02/12/2025 for Resident #57 to receive IV fluids. Further review revealed no physician orders for an assessment daily, flushing daily, or discontinuation of Resident #57's peripheral IV site. Review of Resident #57's Medication Administration Record (MAR), dated February 2025, revealed no documented evidence of an assessment daily, flushing daily, or discontinuation of Resident #57's peripheral IV site. On 02/17/2025 at 12:06 p.m., an observation of Resident #57's peripheral IV site to his right forearm was not visible and covered with an undated non-transparent, elastic ace dressing. On 02/18/2025 at 10:49 a.m., an observation of Resident #57's peripheral IV site to his right forearm was not visible and covered with an undated non-transparent, elastic ace dressing. An interview was conducted at this time, Resident #57 stated his IV hurt when he moved his hand and it had not been changed, flushed, or used since 02/12/2025 when he received IV fluids. On 02/18/2025 at 3:00 p.m., an observation of Resident #57's peripheral IV site to his right forearm was not visual and covered with an undated non-transparent, elastic ace dressing. On 02/18/2025 at 3:15 p.m., an observation of Resident #57's IV site was conducted with S8LPN. S8LPN confirmed Resident #57's peripheral IV site to his right forearm was not visual and covered with an undated non-transparent, elastic ace dressing. An interview was conducted at this time with S8LPN who stated she was assigned to Resident #57 on 02/17/2025 and 02/18/2025. She stated she did not know when Resident #57 received the peripheral IV site or when the last time the site was flushed. She confirmed she did not flush Resident #57's peripheral IV site on 02/17/2025 and 02/18/2025. On 02/18/2025 at 4:50 p.m., an interview was conducted with S2DON. S2DON confirmed Resident #57's IV site was inserted in his right forearm on 02/11/2025 and it was discontinued on 02/18/2025. She stated IV sites should be assessed and flushed daily and changed every 3 days. She further stated the above should be documented on the MAR. S2DON confirmed there was no documented evidence Resident #57's IV site was assessed or flushed daily and should have been changed or removed by 02/14/2025.

Based on observations and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labeled and stored in unit refrigerators. This deficient practice had the potential to affect 81 residents who were able to store and consume food in the facility's unit refrigerator. Findings: Review of the facility's policy titled Use and Storage of Food from Outside the Facility dated 12/11/2017 revealed the following, in part: Procedure: 1. The resident may maintain food brought in by family or visitors .in the facility refrigerator as long as it is maintained/stored in a sanitary conditions: a. storage conditions: i. Sealed container, with resident's name and date. On 02/17/2025 at 11:15 a.m., a tour was made of NS1 with S3LPN. An observation was made of the resident's unit refrigerator which contained the following items: 1 brown paper bag with a wrapped breakfast sandwich with no date or name; 1 plastic container with a lid containing an unknown food with no date; 1 plastic container with a lid containing an unknown food with no date or name; 1 20 ounce foam cup with a lid containing a pink liquid with no date or name; and 1 plastic container with a lid containing an unknown food with no date or name. On 02/17/2025 at 11:18 a.m., an interview was conducted with S3LPN. She stated staff should label all outside food items with the resident's name and a date. S3LPN confirmed the above mentioned items were not properly labeled and should have been. On 02/18/2025 at 1:25 p.m., an interview was conducted with S2DON. She stated she was made aware of the unlabeled resident food items stored in the unit refrigerator located in NS1. She confirmed any food items brought in from outside of the facility should be labeled with a date and the resident's name when stored in the unit refrigerator located in NS1.

Based on observations, interviews, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible by failing to implement an intervention after a fall for 1 (#6) of 3 (#1, #3, and #6) residents reviewed for accidents. Findings: Review of the facility's policy titled, Incident and Accident Policy and Procedure dated 05/08/2018 revealed the following, in part: Purpose: To assure that any resident who is involved in an incident or accident is evaluated and received treatment as warranted and that we monitor the resident's status with appropriate intervention applied to prevent further incidents. Procedure: 4. Investigative Action: c. The Director of Nursing or designee ensures that the resident is assessed for intervention to prevent future incidents. 7. Instructions for further follow-up by Director of Nursing or designee: a.This discussion should include intervention and update of plan of care. b. The Director of Nursing or designee should review incidents and accidents in high risk meeting to follow up and evaluate the effectiveness of interventions implemented. Review of Resident #6's Clinical Record revealed an admitted [DATE] and diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, History of Falling, and Generalized Muscle Weakness. Review of Resident #6's Current Physician Orders dated October 2024 revealed the following, in part: Start date: 09/25/2024 - Chair alarm to wheelchair Review of Resident #6's Quarterly MDS with an ARD of 09/11/2024 revealed, in part, a BIMS summary score of 13, which indicated she was cognitively intact. Review of Resident #6's Incident Report dated 09/23/2024 revealed the following, in part: Description: Called by CNA to resident's room at 10:50 p.m. Upon arrival, resident was lying on the floor. Review of the Incident Audit Report for incident date of 09/23/2024 revealed the following, in part: Nurse Practitioner ordered chair alarm to be placed in wheelchair. Review of Resident #6's current Care Plan revealed the following, in part: Problem: The resident at risk for falls related to Bilateral Below the Knee Amputations. 09/23/2024 Resident was found on the floor in her room. Interventions: 09/23/2024 - Chair alarm to wheelchair An observation and concurrent interview was conducted with Resident #6 on 10/09/2024 at 9:10 a.m. She was seated in her room in her wheelchair. There was no alarm in her wheelchair. Resident #6 stated she had not had an alarm in her wheelchair. An observation was made of Resident #6 on 10/09/2024 at 9:18 a.m. with S2DON present. S2DON confirmed Resident #6 did not have a wheelchair alarm present. An interview was conducted with S10CNA on 10/09/2024 at 9:30 a.m. She stated Resident #6 fell recently. She stated she always encouraged Resident #6 to call for assistance before trying to get up on her own, however, a lot of times Resident #6 performed things without calling for assistance. She confirmed Resident #6 did not have a wheelchair alarm in her chair. An interview was conducted with S6LPN on 10/09/2024 at 9:21 a.m. She stated Resident #6 had a fall recently. She reviewed Resident #6's current Physician Orders and confirmed there was an order for a chair alarm to her wheelchair. She stated the wheelchair alarm was an intervention to help prevent Resident #6 from falling, and it should have been implemented. She confirmed Resident #6 had been up in her wheelchair today and had not had a wheelchair alarm. An interview was conducted with S7ADON on 10/09/2024 at 10:16 a.m. She stated the intervention for Resident #6's fall on 09/23/2024 was a chair alarm in her wheelchair. She stated the wheelchair alarm should have been in place to help prevent falls for Resident #6, and it was not.

44965 Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #7) of 6 (#1, #2, #3, #6, #7, and #8) residents reviewed for comprehensive care plans. The facility failed to ensure the following Physician Orders were implemented: 1. Resident #6's wheelchair alarm and visual cue to wheelchair brakes; and 2. Resident #7's TED hose. Findings: 1. Resident #6 Review of Resident #6's Clinical Record revealed an admitted [DATE] and diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, History of Falling, and Generalized Muscle Weakness. Review of Resident #6's Current Physician Orders dated October 2024 revealed the following, in part: Start date: 09/25/2024 - Chair alarm to wheelchair Start date: 06/03/2024 - Visual cue to wheelchair brakes Review of Resident #6's Quarterly MDS with an ARD of 09/11/2024 revealed, in part, a BIMS summary score of 13, which indicated she was cognitively intact. An observation and concurrent interview was conducted with Resident #6 on 10/09/2024 at 9:10 a.m. She was seated in her room in her wheelchair. There was no alarm in her wheelchair. There was no visual cue for her wheelchair brakes present. Resident #6 stated she had not had an alarm in her wheelchair. An observation was made of Resident #6 on 10/09/2024 at 9:18 a.m. with S2DON present. S2DON confirmed Resident #6 did not have a visual cue for wheelchair brakes or a wheelchair alarm present. An interview was conducted with S6LPN on 10/09/2024 at 9:21 a.m. She reviewed Resident #6's current Physician Orders and confirmed there were orders for visual cue to wheelchair brakes and a chair alarm to wheelchair. She confirmed Resident #6 had been up in her wheelchair today and had not had a wheelchair alarm and no visual cue to wheelchair brakes. She confirmed the orders should have been implemented and were not. An interview was conducted with S7ADON on 10/09/2024 at 10:16 a.m. She confirmed the orders for Resident #6's wheelchair alarm and wheelchair brake cues should have been implemented as ordered. 2. Resident #7 Review of Resident #7's Clinical Record revealed an admitted [DATE] and diagnoses, which included Encounter for Other Orthopedic Aftercare. Review of Resident #7's current Physician's Orders dated October 2024 revealed, in part, to apply TED hose in the morning and remove at bedtime. An observation was made of Resident #7 on 10/08/2024 at 3:20 p.m. Resident #7 did not have on her TED hose. An observation was made of Resident #7 on 10/08/2024 at 3:26 p.m. with S8CNA present. Resident #7 did not have on her TED hose. S8CNA confirmed Resident #7 was not wearing the TED hose. S8CNA located Resident #7's TED hose on the top of the microwave and stated they were in the same place she put them yesterday evening. An interview was conducted with S9LPN on 10/09/2024 at 3:23 p.m. She confirmed she was the day nurse for Resident #7 on 10/08/2024. She confirmed Resident #7 did not have on her TED hose on 10/08/2024 as ordered and should have. An interview was conducted with S2DON on 10/09/2024 at 3:28 p.m. She confirmed if a resident had TED hose ordered, they should have been on the resident as ordered.

Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a resident's significant change in condition to the physician when a nurse identified a deformity in a resident's leg for 1 of 1 (#3) residents reviewed for an injury of unknown origin. Findings: Review of the facility policy titled, Change in Condition Policy and Procedure with a revision date of 08/27/2018 revealed the following, in part: Procedure: 3. The resident's primary physician or designated alternative will be contacted promptly of a significant change in the resident's status. Review of Resident #3's clinical record revealed the Resident was admitted to the facility on [DATE] and had diagnoses, which included Restless Leg Syndrome, Pain Unspecified, Thrombocytopenia Unspecified, and Age-Related Osteoporosis without Current Pathological Fracture. Review of Resident #3's Quarterly MDS with an ARD of 07/10/2024 revealed a BIMS of 6 which indicated severe cognitive impairment. On 10/08/2024 at 9:27 a.m., an interview was conducted with S3LPN. S3LPN stated the aide reported Resident #3's left leg looked deformed early in the morning on 09/26/2024. S3LPN stated she assessed Resident #3's left leg and it was deformed. S3LPN was unable to provide an exact time this occurred. S3LPN stated Resident #3 never complained of pain on her shift S3LPN confirmed Resident #3's deformed left leg was not reported to the physician. S3LPN confirmed she should have reported Resident #3's deformed left leg to the physician. On 10/08/2024 at 12:49 p.m., an interview was conducted with S5NP. S5NP confirmed S3LPN did not report Resident #3's left leg deformity. S5LPN confirmed she was made aware of Resident #3's left leg deformity when S4LPN notified her mid-morning on 09/26/2024. S5NP stated Resident #3 was not in pain. S5NP stated when she attempted to move the left leg the resident only winced and said ooh. S5NP stated Resident #3 did not holler during the assessment. S5NP confirmed she would have expected S3LPN to report Resident #3's deformed left leg. On 10/08/2024 at 10:02 a.m., an interview was conducted with S2DON. S2DON confirmed S3LPN did not report Resident #3's left leg deformity. S2DON confirmed if staff saw the deformity of Resident #3's left leg she would expect staff to notify her and the Nurse Practitioner.

Based on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 1 (#1) of 2 (#1 and #2) residents reviewed for incontinent care. Finding: Review of the facility's policy labeled, Hand Hygiene with no revision date, revealed the following: Policy: Hand Hygiene shall be performed: 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 8. Before and after assisting a resident with personal care 14. Before and after assisting a resident with toileting 18. After contact with a resident's mucous membranes and body fluids or excretions 19. After handling soiled or used linens 22. After removing gloves 23. If hands will be moving from a contaminated body site to a clean body site during patient care. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. On 06/26/2024 at 9:31 a.m., an observation was made of S3CNA and S4CNA performing incontinent care on Resident #1. With clean gloves, S3CNA and S4CNA removed soiled top sheet and blanket off of Resident #1. S3CNA unfastened Resident #1's stool soiled brief. S3CNA and S4CNA both cleaned Resident #1's perineum area, then Resident #1 turn to her left side. S3CNA then wiped resident's sacrum removing the stool, while S4CNA assisted her by disposing the soiled wipes. S3CNA then tucked the stool soiled brief, bed pad, and fitted sheet under the resident towards her left side. With the same soiled gloves, S4CNA then handed S3CNA the clean fitted sheet, bed pad, and brief. S3CNA applied the clean items under the right side of Resident #1. Resident #1 then turned to her right side while S4CNA removed the dirty linen from under resident completely, and finished applying the new fitted sheet, bed pad, and brief under Resident #1. Resident #1 then turned on to her left side again and S3CNA grabbed the resident's barrier cream, applied it to her sacral area, then removed only her right glove that had the cream residue on it, reapplied a new glove to her right hand without performing hand hygiene, grabbed the resident's lotion and applied lotion to residents back per resident's request with the left hand which had the same glove she used to provide incontinence care. Then without removing soiled gloves or performing hand hygiene, S3CNA and S4CNA fastened each side of resident's brief. S3CNA then went into the bathroom, grabbed resident's clean gown and applied it to Resident #1 with S4CNA's assistance. S4CNA then grabbed the Resident's bed remote to adjust the bed, and applied the clean top sheet to Resident #1. S3CNA then removed soiled gloves, performed hand hygiene and stepped out to grab the linen bin. S4CNA grabbed the soiled linen put it in the linen bin and removed her soiled gloves and without performing hand hygiene, repositioned the bedside table over resident, and exited room to grab a blanket for the resident. S4CNA returned to resident's room and applied blanket to resident. On 06/26/2024 at 9:46 a.m., an interview was done with S3CNA. S3CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief, linen, cleaning the stool from Resident #1's sacrum, and before touching the resident or her belongings. She also confirmed she did not remove her left glove, or perform hand hygiene at all during the entire care and before applying lotion to the resident, and should have. On 06/26/2024 at 9:50 a.m., an interview was conducted with S4CNA. S4CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief, linen, cleaning the stool from Resident #1's sacrum, and before touching the resident or her belongings. She confirmed she did not perform hand hygiene after incontinence care was completed and prior to exiting Resident #1's room and should have. On 06/26/2024 at 12:05 p.m., an interview was conducted with S1DON. She stated staff should perform hang hygiene and apply clean gloves upon entering a resident's room, when going from soiled to clean during incontinence care, after completing incontinence care, and prior to exiting the resident's room. S1DON confirmed staff should not touch the resident or their belongings with soiled gloves. S1DON confirmed staff were trained to perform hand hygiene correctly and should have done so during incontinence care.

Based on interviews and record reviews, the facility failed to ensure a resident received the necessary services to maintain personal hygiene for 1(#3) of 3(#1, #2, and #3) residents reviewed for Activities of Daily Living. Findings: Review of the facility's policy titled, Bath, Shower Policy and Procedure, dated 09/04/2014 revealed the following, in part: Policy: Showers are to be given as scheduled and/or as needed. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Admission MDS with an ARD of 05/22/2024 revealed Resident #3 required substantial/maximum assistance with bathing. Review of Resident #3's Care Plan revealed the following, in part: Onset: 05/29/2024 Problem: Require staff assistance with ADLs Interventions: I prefer morning showers and assist me with bathing, I require assistance with ambulation. On 06/26/2024 at 1:22 p.m., an interview was conducted with S7CNA. She stated the bath aides were only responsible for providing showers and the floor aides were responsible for performing bed baths. She stated either the bath aide or the floor aides could document when a resident received a bath or a shower; however, she documented when she administered a shower. She confirmed Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated Resident #3 did not ever refuse a shower and if she had she would have documented the refusal. Review of Resident #3's Bath log dated 05/01/2024 through 05/31/2024 revealed Resident #3 did not receive a bath on 05/20/2024. On 06/26/2024 at 4:50 p.m., a telephone interview was conducted with S5CNA. She confirmed she was assigned Resident #3 on 05/20/2024. She stated Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated the bath aides were responsible for administering all baths. She stated the bath aide or the floor aide would document if they administered the baths. She stated Resident #3 never refused a bath. She stated she does not recall if she gave Resident #3 a bath on 05/20/2024, but if she administered a bath she would have documented it. On 06/26/24 at 1:42 p.m., an interview was conducted with S2ADON. She stated the bath aides were responsible for showers and floor aides were responsible for bed baths. She stated either could document baths depending on who administered the bath. She stated she expected staff to document the task if it was performed. She stated Resident #3 did not refuse baths. She confirmed Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. After reviewing the bath logs dated 05/01/2024 through 05/31/2024, S2ADON confirmed Resident #3 did not received a bath on 05/20/2024 and should have. On 06/26/2024 at 4:00 p.m., an interview was conducted with S1DON. She stated Resident #3's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated she expected Resident #3, who was admitted on [DATE], to have been bathed on 05/20/2024, her scheduled bath day, and confirm she was not. She stated she expected staff to document care provided.

677 Based on observations, interviews, and record reviews, the facility failed to ensure residents, who were unable to carry out ADLs, received the necessary services to maintain personal hygiene for 1 (#44) of 4 (#44, #63, #78 and #93) residents reviewed for ADLs. Findings: Review of Resident #44's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Hemiplegia unspecified affecting Left Side, Muscle Weakness, and Difficulty Walking. Review of Resident #44's Admission MDS with an ARD of 12/15/2023 revealed she had a BIMS of 15 indicating she was cognitively intact. Further review revealed she required maximal assistance to complete the activity of a shower/bath. Review of the facility's January and February 2024 Shower Logs revealed Resident #44 did not receive baths on the following scheduled days: Bath Day Roster: January 2024 01/02/2024 - No bath given 01/04/2024 - No bath given 01/07/2024 - No bath given 01/09/2024 - No bath given 01/14/2024 - No bath given 01/16/2024 - No bath given 01/18/2024 - No bath given 01/21/2024 - No bath given 01/23/2024 - No bath given 01/25/2024 - No bath given 01/28/2024 - No bath given 01/30/2024 - No bath given February 2024 02/01/2024 - No bath given 02/04/2024 - No bath given 02/06/2024 - No bath given 02/11/2024 - No bath given 02/13/2024 - No bath given 02/18/2024 - No bath given 02/20/2024 - No bath given 02/22/2024 - No bath given Review of Resident #44's Nurses Notes from December 2023 to March 2024 revealed documentation of Resident #44 refusing one bath. On 03/04/24 at 12:26 p.m. an observation was made of Resident #44 in her room. She was in soiled clothes, unclean, and her hair was matted and oily. There was a foul odor in the room. On 03/05/24 at 8:39 a.m. an observation was made of Resident #44. She was in soiled clothes, unclean, and her hair was matted and oily. There was a foul odor in the room. On 03/06/24 at 2:19 p.m. an observation was made of Resident #44. She was in soiled clothes, unclean, and her hair was oily. There was a foul odor in the room. On 03/06/2024 at 2:45 p.m., an interview was conducted with Resident #44's resident representative. He stated when he visited his wife on several occasions, her hair was dirty and there was an odor in her room. On 03/04/2024 at 12:26 p.m., an interview was conducted with Resident #44. She stated she asked multiple nursing staff for a bath on her scheduled bath days, which were Tuesday, Thursday, and Sunday. She stated she was rarely given one. She stated she was left dirty most of the time, and went days in the same clothes. She stated she felt frustrated at times due to the situation. On 03/06/2024 at 10:31 a.m., an interview was conducted with S13LPN. She stated Resident #44 bath schedule was on Tuesday, Thursday and Sunday evening. She stated S11CNA was the CNA responsible for bathing Resident #44 on her scheduled days in January. She stated the CNA's who performed baths for Resident #44 documented every time they gave her a shower/bath. She stated if CNAs did not document the shower/bath, it was not done. On 03/06/2024 at 10:52 a.m., an interview was conducted with S9CNA. She stated she cared for Resident #44. She stated Resident #44's bath schedule was Tuesday, Thursday, and Sunday. She stated she noticed Resident #44 was not receiving her baths. She stated she has seen Resident #44 with dirty hair, dirty clothes and unclean on many of her scheduled shifts. When she noticed Resident #44 dirty, she gave her a wipe down. She stated she did not report it, because it was known by nursing staff she was not getting her baths. She stated the resident had the same clothes on for days at a time. She stated if the baths were not documented, the baths were not given. On 03/06/2024 at 1:16 p.m., an interview was conducted with S4CNA. She stated CNAs were responsible for bath/showers. She stated she expects the CNAs to document when they give baths/showers. She stated if it was not documented it was not done. She stated S11CNA on the 400 Hall was responsible for giving the baths to Resident #44 and she did not. On 03/06/2024 at 1:46 p.m., an interview was conducted with S11CNA. She stated she was listed on the schedule in January to give baths to Resident #44, she confirmed she did not give Resident #44 baths as scheduled. On 03/06/2024 at 2:31 p.m., an interview was conducted with the S1DON. She confirmed the evening shift CNA was responsible for giving Resident #44 baths as scheduled. S1DON further confirmed if the bath was not documented, it was not done.

Based on observation, interview, and review, the facility failed to identify the need to supervise staff to ensure staff was aware of how to use a mechanical lift and followed manufacturer's guidelines for safety when transferring residents using a mechanical lift to prevent accidents for 1 (#47) of 10 (#6, #47, #73, #78, #121, #136, #139, #146, #159 and #164) residents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #47 on 01/31/2020 at 9:31 a.m. when S9CNASUP and S13CNA transferred Resident #47 from the Geri-chair to the bed and then back from the bed to the Geri-Chair with a mechanical lift. The CNAs did not widen the legs on the base of the mechanical lift as recommended by the Mechanical Lift Manufacturer Manual. The mechanical lift titled with the right leg of the base lifting approximately 3 inches from the floor and nearly falling over with Resident #47 suspended in the lift at approximately 3 ½ feet in the air. S1ADM was notified of the Immediate Jeopardy situation on 01/31/2020 at 2:40 p.m. The Immediate Jeopardy was removed on 01/31/2020 at 5:07 p.m., when the facility submitted an acceptable Plan of Removal. Observations, interviews and record reviews, confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Review of the Plan of Removal revealed the following: Transfer of Residents: The following measures will be but in place to ensure All residents who are affected by the deficient practice will be transferred safely and effectively while using a hoyer lift. *The facility's corporate Quality Assurance Nurse will ensure the DON and ADON are trained effectively according to the manufacturer guidelines to ensure residents are transferred safely according to the residents plan of care. Inservice began on 01/31/2020 at 4:00 p.m. This will be completed by 01/31/2020 by 6:00 p.m. *The DON and or ADON will ensure ALL nursing staff have been trained effectively on how to transfer resident safely while using a hoyer lift according to the residents plan of care. All staff will have documented return demonstration to identify the proper use of the hoyer lift. The DON and ADON will visualize the transfer occur. Inservice began on 01/31/2020 at 4:00 p.m. This will be completed by 02/03/2020 by 5:00 p.m. *DON or ADON will identify residents who require the use of a hoyer lift. This was completed on 01/31/2020 at 4:00 p.m. *DON and ADON will ensure any resident with a hoyer lift is documented in the residents plan of care and noted on the kiosk for staff awareness. This was completed on 01/31/2020 at 4:00 p.m. *DON and or ADON will daily interview 5 nursing staff members to ensure they are aware of the residents plan of care noted on the kiosk. *The DON and or ADON will perform daily random audits on 3 residents on various shifts to ensure nursing staff is properly trained on how to safely transfer residents who require a hoyer lift. This will begin on 01/31/2020. *The DON or ADON will monitor all nursing staff to ensure they are effectively trained and competent on using and operating the hoyer lift. This will begin on 01/31/2020 and completed by 02/03/2020. Further education will be provided if the staff member is unable to effectively demonstrate utilization of the hoyer lift. *The DON and ADON will audit 3 residents on various shifts on 02/01/2020 and 02/02/2020 to ensure the weekend nursing staff is trained and competent on using the hoyer lift. This will begin on 02/01/2020. *Further education will be provided if the staff member is unable to effectively demonstrate utilization of the hoyer lift. Random audits were started at 01/31/2020 at 4:00 p.m. This will be completed by 02/15/2020 at 5:00 p.m. The deficient practice continued at a potential for more than minimal harm for the other 16 residents identified by the facility as requiring a mechanical lift for transfers. Findings: Review of the Policy titled Transferring a Resident Policy and Procedure included the following: Purpose: To provide the most effective means of moving a resident with diminished lower body sensation, weakness, immobility or injury. Policy: Residents will be transferred as safely as possible. Procedure: Mechanical Lift Transfer: 7. Follow Manufacturer's Guideline Review of the Mechanical Lift Manufacturer Manual included the following: Transfer Procedures Page 12 Transfer from a Chair or Wheelchair 10) Move the mechanical lift into position with the hang bar assembly about 15 inches in front of the patient's chin. Open the base to its widest position. Page 14 Transfer from a Bed or Stretcher 11) Move the mechanical lift into position with the hanger bar assembly about 15 inches above the patient's stomach. Open the base to its widest position. Review of In-service Log Form dated 01/13/2020 revealed the following in part: Topics Discussed: Transfer training; proper technique, safety, proper body mechanics, fall prevention, proper footwear, precautions. Hoyer lift use as needed. Under Personnel in Attendance the following names were not found: S13CNA S24CNA S25CNA S26CNA S27CNA Review of In-service Log Form dated 01/17/2020 revealed the following in part: Topic(s) Discussed: Know your residents transfer status. Know where/How to find residents transfer status *one person *two person *Hoyer Under Personnel in Attendance the following names were not found: S13CNA S24CNA S25CNA S26CNA S27CNA Review of the current employee list revealed S13CNA, S24CNA, S25CNA, S26CNA, and S27CNA were still employed at the facility. On 01/30/2020 at 2:48 p.m., an interview was conducted with S28LPN. She stated she had worked in the Staff Development position since July 2019. She stated orienting staff on specific residents would have been left up to the LPN and other CNA staff to train new CNAs on how to transfer residents properly. On 01/30/2020 at 3:00 p.m., an interview was conducted with S20CNA. She stated she began working at the facility on January 16th of 2020. When asked for S20CNA to access the kiosk and show how she would determine a resident's transfer needs, she stated I do not have a login yet and cannot access the kiosk. She confirmed she was assigned as one of the two CNA's on the hall and did not have anyone training her. She stated the other CNA on the hall told her which residents required a Hoyer lift. She confirmed that other than another staff member telling her the transfer status, she would have no way of knowing how to transfer a resident. She stated she would look at a resident's size, compare it with her size, and determine if she could transfer them by herself. On 01/31/2020 at 8:22 a.m., an interview was conducted with S9CNASUP. She stated she had been in the position since May of 2019 and she was the CNA Supervisor for all CNA staff on all shifts. She stated when new CNAs are hired they are trained by the CNA on the hall on how to work the hall, showers, lifts and kiosk. She explained that she had not gone into resident rooms to monitor staff while they were transferring residents with mechanical lifts. She said she could not remember the last time she had done this, and she had no documentation to reflect when she had done it in the past. On 01/31/20 at 8:48 a.m., an interview was conducted with S3ADON. She explained S9CNASUP and S14CNA are supposed to be monitoring the CNA staff to ensure transfers with mechanical lifts are performed correctly and according to the residents' plans of care. On 01/31/2020 at 9:09 a.m., an interview was conducted with S2DON. He stated he, S2ADON and S9CNASUP can train CNAs how to properly transfer residents and check the kiosk but at the end of the day the CNA staff working in the facility make their own decisions. He stated he could not control what the CNAs did in the rooms with transfers. He stated S9CNASUP and S14CNA were responsible for monitoring staff for proper transfers. He stated the MDS Coordinators checked quarterly, when performing their assessments, to ensure accuracy of transfers. He said he did not go in the residents' rooms to observe transfers but S9CNASUP and S14CNA were responsible for doing this. On 01/31/2020 at 09:13 a.m., an interview was conducted with S1ADM. He stated he had observed one transfer of Resident #57 to see if the CNA transferred them properly. He stated he did not remember the name of the CNA. On 01/31/2020 at 9:21 a.m., an interview was conducted with S14CNA. She stated she had been assisting S9CNASUP for about 6 months but started working at the facility in February of 2017. She stated she had not done any monitoring of staff transferring residents and had not been directed to do so. Review of Resident #47's current Care Plan included the following: Problem/Onset 11/25/2019 I have a fracture to my Right tib/fib. Intervention: 11/25/2019 mechanical lift for transfers Review of Resident #47's MDS revealed 01/28/2020 Quarterly BIMS 99, Transfers extensive assistance 2+ person (still open and not yet transmitted) Quarterly MDS with ARD of 08/27/2019 revealed Resident #47 was totally dependent on staff for transfers and required 2+ person assistance. On 01/31/2020 at 9:31 a.m., an observation was made of S9CNASUP and S13CNA transferring Resident #47 with a mechanical lift. S6LPN was present observing the transfer. The mechanical lift was positioned at the right side of Resident #47's Gerichair. Resident #47's sling pad was attached to the bar and the resident was lifted by S9CNASUP. S9CNASUP did not widen the base of the mechanical lift. S9CNASUP guided the mechanical lift to the right side of the bed and S13CNA guided Resident #47. S9CNASUP lowered Resident #47 into the bed. Immediately following the completion of the transfer, S9CNASUP stated Resident #47 would be transferred back into the Gerichair for lunch. S9CNASUP lifted Resident #47 from the bed as S13CNA guided the resident. S9CNASUP guided and positioned the mechanical lift to the right side of the Gerichair. S9CNASUP lowered Resident #47 as S13CNA guided Resident #47 over the chair. As Resident #47 was lowered the mechanical lift tilted to the left and almost fell with Resident #47 suspended in the sling pad at approximately 3 ½ feet in the air. The right mechanical lift base leg lifted approximately 3 inches from the floor. S9CNASUP and S13CNA regained control of the mechanical lift and Resident #47 was lowered into the Gerichair. The base of the mechanical lift was not widened at any time during either transfer and remained in the narrowest position. On 01/31/2020 at 9:42 a.m., an interview was conducted with S9CNASUP. S9CNASUP confirmed the base of the mechanical lift base was not widened during the transfer of Resident #47 from the Gerichair to the bed then back to the Gerichair. S9CNASUP stated the only time she spreads the base of the mechanical lift is when she is transferring a resident to or from a wheelchair. S9CNASUP stated she was trained on the lift [AGE] years ago. On 01/31/2020 at 11:14 a.m., an interview was conducted with S3ADON. S3ADON confirmed S9CNASUP should have widened the base of the mechanical lift during Resident #47's transfers because it increases the stability of the lift. S3ADON stated S9CNASUP should know the base of the mechanical lift needs to be widened. On 01/31/2020 at 12:18 p.m., an interview was conducted with S2DON. S2DON confirmed S9CNASUP should have widened the base of the mechanical lift during Resident #47's transfers. S2DON verified widening the mechanical lift's base increases the stability of the lift.

Based on interviews, record reviews and review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses, the facility failed to provide services that met professional standards of care. The facility failed to conduct sufficient wound assessments and develop an interim plan of care to meet the needs of a newly admitted resident for 1 (#4) of 5 residents (#1, #2, #3, #4, #5) by: 1.) failing to follow the correct process for checking the accuracy of the physician orders [REDACTED]. 2.) failing to conduct a complete skin assessment on admission by not removing Resident #4's wound dressing to visually assess the wound site; 3.) failing to notify the physician to clarify wound orders for Resident #4's right hip wound; 4.) failing to conduct ongoing skin assessments of Resident #4's right hip surgical wound from 3/5/12 to 3/10/12; 5.) failing to notify the wound care nurse of the presence of Resident #4's wound for continued treatment. Resident #4 was in Immediate Jeopardy on 03/05/12 at the time of admission to the facility when the right hip dressing was noted during the nursing admission assessment and the nurse did not remove the dressing to visually assess the surgical wound site. The hospital discharge orders for wound care to the right hip surgical incision were not transcribed onto the facility admission orders [REDACTED]. There was no wound care provided to the right hip surgical site from 3/05/12 to 3/10/12. Assessment of the wound and care of the surgical site did not begin until 03/10/12 when Resident #4 was found with bloody drainage to his right post-operative hip incision dressing. On 03/11/12, Resident #4 was again found with a large amount of bloody drainage from the right hip incision. On 03/11/12 Resident #4 was transferred to a local hospital where he was diagnosed with [REDACTED]. The Immediate Jeopardy situation ended for Resident #4 on 3/11/12 when the resident was sent to the hospital. The deficient practice continues at a level of actual harm for Resident #4. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (March, 2012) Subpart, I. Practical Nurse, subchapter E. Curriculum Requirements revealed: 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team. Resident #4 Review of the hospital discharge summary for Resident #4 dated 03/05/12 documented a brief hospital course revealing he underwent right hip surgery on 03/01/12. The discharge [DIAGNOSES REDACTED]. Review of the hospital discharge orders written by S13NP documented wound care orders for wound care "(R) (Right) hip daily". Review of the facility's document entitled, "Admit/Return From Hospital Doctor's Order Sheet" dated 03/05/12 revealed no transcription of the orders for the right hip care ordered by S13NP. On 05/30/12 at 2:00 p.m. an interview was conducted with S4LPN. She stated she did recall taking care of Resident #4 but couldn't remember specifics regarding his care. She was asked what the procedure was when receiving a resident with a dressing. She stated there should be orders for the type of care to be provided. She stated if there are no wound care orders, the nurse should notify the physician for orders. She stated the nurse usually receives orders from the hospital and the data entry nurse transcribes the orders into the computer system. She stated when a resident is admitted the nurse performing the initial assessment should remove the dressing and the wound. S4LPN was asked to review the clinical record for Resident #4. She stated it did not look like he had treatment orders for the right hip. She was asked to compare the hospital discharge orders with the transcribed orders. She stated, "The wound care order was not transcribed onto our orders." S4LPN verified, "03/10/12 was the first order received for the right hip care." She stated the initial nurse doing the assessment should have removed the dressing to see what was under the dressing and documented that in the nursing notes. On 05/30/12 at 2:26 p.m. an interview was conducted with S6LPN. S6LPN was asked what her position was at the facility. She stated she had only been working in a transcription/data entry position since October. She stated she was previously working night shift but had been assigned to transcribe physician orders [REDACTED]. She stated she receives a copy of the hospital discharge orders for new admissions. She stated she initiates an "Admit/Return From Hospital Doctor's Order Sheet". She verified this was a form used by the facility to transcribe orders. S6LPN stated she transcribes the orders from the hospital discharge orders to the new admit/return form. She stated she faxes the orders to pharmacy and inputs the new orders into the facility's computer. S6LPN further explained once the data is entered into the computer she gives the newly transcribed orders and the discharge orders to the nurse on duty. S6LPN stated the nurse on duty compares the hospital discharge orders to ensure the physician's orders [REDACTED]. In further interview with S6LPN on 05/30/12 at 2:26 p.m., she was asked how she ensured the admission orders [REDACTED]. She stated she gave the orders to the nurse on duty at the time she completed the data entry. She stated the nurse on duty is suppose to confirm the orders were transcribed correctly. She stated she checks to see if the nurse on duty has confirmed the transcribed orders. She was asked to provide evidence of the transcription verification. Review of the document entitled, "Admit/Return From Hospital Doctor's Order Sheet" revealed no documented evidence another Licensed Practical Nurse signed and verified the transcription of the admission orders [REDACTED]. She stated she did not know. She was asked to review the hospital discharge orders dated 03/05/12 for Resident #4. She verified the hospital discharge orders for Resident #4 documented "wound care to right hip daily". She confirmed she did not transcribe the wound care orders to the facility's admission orders [REDACTED]. She stated, "Because the box was not checked for wound care". S6LPN was asked did she call the physician to clarify the written order for wound care. She stated she did not. Review of the Nursing Admission assessment dated [DATE] for Resident #4 revealed in part the following: ...... Bowel and Bladder: Occasionally incontinent; Skin: Surgical Incision/Sutures and Hematoma/Bruise...... Skin Finding Details revealed in part the following documentation: ..... "bandage right hip/bandage clean, dry and intact,".... There was no documented evidence the nursing assessment included a visual observation of the surgical incision to Resident #4's right hip. Review of the documents entitled, "Departmental Notes" for Resident #4 dated 03/06/12 through 03/09/12 revealed in part the following nurse documentation: 03/06/12 ....."noted dressing to right hip"..."continent of bowel/bladder, uses urinal but d/t (due to) unable to aim requires assistance holding urinal in place." 03/07/12....."noted dressing to right hip" 03/08/12....."noted dressing to right hip" 03/09/12....."noted dressing to right hip" There was no documented evidence in the Departmental Notes of a visual assessment of the surgical incision to the right hip. Review of the interim care plan dated 03/05/12 for Resident #4 revealed he was assessed as continent of bladder and continent of bowel. Further review of the interim care plan revealed the following items were checked for skin care: dry, [MEDICAL CONDITION], site: LE (lower extremities) Bilaterally. There was no documented evidence of Resident #4's right hip surgical incision. Further review of the Departmental Notes dated 03/10/12 revealed the following documentation: ".......called to resident room per CNA (Certified Nursing Assistant). Noted small amount of bloody drainage to right hip surgical line....... Notified (S13NP) on call. New orders noted.......wears incontinent briefs,..... Also uses urinal at bedside." Review of the Physician's Telephone Order dated 03/10/12, five days following Resident #4's admission to the facility, revealed in part the following wound care order: "Cleanse surgical line to right hip with WC (wound cleanser) dry and apply dressing every day until healed." Review of the Departmental Notes for nursing dated 03/11/12 at 3:56 p.m. revealed the following: "called to resident room. noted large amount of bloody drainage from right hip surgical line.....notified (S13NP) ordered to send to ER (emergency room ) for evaluation. Review of a facility document entitled, "Grievance/Complaint" dated 03/12/12 (the following day) revealed in part the following complaint initiated by Resident #4's son-in-law: Explanation/Nature of Complaint: "(name of #4's son-in-law) upset when he visited on 03/11/12, he said both times he visited (Resident #4) was in the same position in bed. He was soaking wet when he visited early on 03/11/12." On 05/30/12 at 2:50 p.m. an interview was conducted with S5LPN. She was asked if she admitted Resident #4 on 03/05/12. S5LPN confirmed that she was the nurse who admitted Resident #4 on 03/05/12. She was asked if she remembered this resident. She stated she could vaguely recall this resident. She was asked if she had removed his hip dressing when she conducted her initial assessment. She stated, "I probably did not remove the dressing because at that time I thought the wound care nurse did this." S5LPN stated she had recently been informed it is her responsibility to remove a dressing on a new resident and document what is under the dressing. On 05/30/12 at 3:00 p.m. an interview was conducted with S11LPN. She was asked what her role was and how she would be notified if a resident required wound care. She verified she is the wound care nurse for the facility. She stated the hall nurse completes an assessment and if there is a resident that needs to be seen they let me know in our morning meeting. She stated then she would assess the resident for wound care. She was asked if she had evaluated Resident #4 upon admission. She stated no. On 05/30/12 at 3:15 p.m. an interview was conducted with S2DON. He was asked what the policy was for the assessment of incision/wounds on residents with dressings. He stated the nurse does a full head to toe assessment on every resident. He stated if the resident has a dressing on, the nurse is expected to remove the dressing to assess what is under the dressing. He stated if further wound care is needed the physician can be contacted for orders and/or the wound care nurse can become involved. He stated, "I would expect them to remove a dressing assess the site and determine what other care is needed." On 05/31/12 at 10:10 a.m. another interview was conducted with S11LPN. She now stated she recalled assessing Resident #4's right hip on 03/06/12. S11LPN was asked if she had documented this assessment on 03/06/12. She stated she did not document this assessment anywhere because she was not providing any care for Resident #4. Review of the facility's Skin Care Policy and Procedure revealed the following: Procedure: 1. All residents will have a skin assessment upon admit, quarterly, and as needed. 2. All residents will have a body audit to assess skin integrity. 3. The interdisciplinary team will meet and discuss residents with impaired skin integrity. 4. An RN or wound consultant will stage all wounds 5. An individual wound documentation log will be completed for each wound.

Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to effectively maintain the highest level of practical well-being for 1 (Resident #4) of 5 (#1, #2, #3, #4, #5) residents reviewed by failing to ensure professional standards of care were maintained. The facility: 1.) failed to have a system in place to ensure wounds were assessed on admission to the facility; 2.) failed to conduct an accurate initial assessment of Resident #4's post-op right hip incision; 3.) failed to have a system in place to ensure resident hospital discharge orders are transcribed accurately onto the resident's physician orders [REDACTED]. 4.) failed to verify Resident #4's hospital discharge admission orders [REDACTED] 5.) failed to perform daily assessments of Resident #4's post op right hip incision; 6.) failed to follow the facility's policy and procedure for wound care; 7.) failed to ensure the physician's admission orders [REDACTED] 8.) failed to ensure the staff followed the facility's policy and procedure for skin assessment;and 9.) failed to ensure wound care was provided as ordered. Resident #4 was in Immediate Jeopardy on 03/05/12 at the time of admission to the facility when the right hip dressing was noted during the nursing admission assessment and the nurse did not remove the dressing to visually assess the surgical wound site. The hospital discharge orders for wound care to the right hip surgical incision were not transcribed onto the facility admission orders [REDACTED]. There was no wound care provided to the right hip surgical site from 3/05/12 to 3/10/12. Assessment of the wound and care of the surgical site did not begin until 03/10/12 when Resident #4 was found with bloody drainage to his right post-operative hip incision dressing. On 03/11/12, Resident #4 was again found with a large amount of bloody drainage from the right hip incision. On 03/11/12 Resident #4 was transferred to a local hospital where he was diagnosed with [REDACTED]. The Immediate Jeopardy situation ended for Resident #4 on 3/11/12 when the resident was sent to the hospital. The deficient practice continues at a level of actual harm for Resident #4. Findings: On 05/30/12 at 2:50 p.m. an interview was conducted with S5LPN. She was asked if she admitted Resident #4 on 03/05/12. S5LPN confirmed that she was the nurse who admitted Resident #4 on 03/05/12. She was asked if she remembered this resident. She stated she could vaguely recall this resident. She was asked if she had removed his hip dressing when she conducted her initial assessment. She stated, "I probably did not remove the dressing because at that time I thought the wound care nurse did this." S5LPN stated she had recently been informed it is her responsibility to remove a dressing on a new resident and document what is under the dressing. She stated if more care is needed the wound care nurse is notified. On 05/30/12 at 3:00 p.m. an interview was conducted with S11LPN. She was asked what her role was and how she would be notified if a resident required wound care. She stated the hall nurse completes an assessment and if there is a resident that needs to be seen they let me know in our morning meeting. She stated then she would assess the resident for wound care. She was asked if she had evaluated Resident #4 upon admission. She stated no. On 05/30/12 at 3:15 p.m. an interview was conducted with S2DON. He was asked what the policy was for the assessment of incision/wounds on residents with dressings. He stated the nurse does a full head to toe assessment on every resident. He stated if the resident has a dressing on, the nurse is expected to remove the dressing to assess what is under the dressing. He stated if further wound care is needed the physician can be contacted for orders and/or the wound care nurse can become involved. He stated, "I would expect them to remove a dressing assess the site and determine what other care is needed." On 05/31/12 at 3:15 p.m. S2DON was asked to review the document entitled "Interim Care Plan" for Resident #4. He was asked if the resident's right hip was documented as part of the admission plan of care. He confirmed the interim care plan documented skin: [MEDICAL CONDITION] site: LE (lower extremities) bilaterally. He verified the interim care plan did not include an assessment or plan of care for Resident #4's right hip incision. During this interview, S12CN was present and she was observed to take the interim care plan document from S2DON. After reviewing, she stated, "There are regulations that allow us 14 days to develop a care plan". She was asked if the right hip care should be addressed on Resident #4's plan of care. S12CN stated, "no, not under the skin section". She stated, "This would probably be documented under locomotion". On 05/31/12 at 4:00 p.m. an interview was conducted with S2DON. He was asked to provide a copy of any policies and procedures the facility utilized for the following: Admission of New Residents, Assessment of New Residents, and Transcription of Physician Orders. On 05/31/12 at 4:15 p.m. S2DON provided a copy of the facility's Policy & Procedure entitled, "Skin Care Policy and Procedure". He stated this was the policy available from the request. Review of the Policy and Procedure entitled "Skin Care Policy and Procedure" revealed in part the following: Purpose: To maintain and prevent further skin breakdown. The facility will accomplish these goals through prevention, assessment, and treatment. Procedure: 1.) All residents will have a skin assessment upon admit, quarterly, and as needed. 2.) All residents will have a body audit to assess skin integrity......... Review of CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual (dated April 2012), Chapter 2.7 entitled, "The Care Areas Assessment (CAA) Process and Care Plan Completion" revealed in part the following: "It is important to note that for an Admission assessment, the resident enters the nursing home with a set of physician-based treatment orders. Nursing home staff should review these orders and begin to assess the resident and to identify potential care issues/priority issues prior to completion of the final care plan.".....

Based on interviews and record reviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #4) of 5 (#1, #2, #3, #4, #5) residents by: 1.) failing to follow the correct process for checking the accuracy of the physician orders [REDACTED]. 2.) failing to conduct a complete skin assessment on admission by not removing the wound dressing to visually assess the wound site; 3.) failing to notify the physician to clarify wound orders for the resident's right hip; 4.) failing to conduct ongoing skin assessments of resident's right hip surgical wound from 3/5/12 to 3/10/12; and 5.) failing to notify the wound care nurse of the presence of wound for continued treatment. Resident #4 was in Immediate Jeopardy on 03/05/12 at the time of admission to the facility when the right hip dressing was noted during the nursing admission assessment and the nurse did not remove the dressing to visually assess the surgical wound site. The hospital discharge orders for wound care to the right hip surgical incision were not transcribed onto the facility admission orders [REDACTED]. There was no wound care provided to the right hip surgical site from 3/05/12 to 3/10/12. Assessment of the wound and care of the surgical site did not begin until 03/10/12 when Resident #4 was found with bloody drainage to his right post-operative hip incision dressing. On 03/11/12, Resident #4 was again found with a large amount of bloody drainage from the right hip incision. On 03/11/12 Resident #4 was transferred to a local hospital where he was diagnosed with [REDACTED]. The Immediate Jeopardy situation ended for Resident #4 on 3/11/12 when the resident was sent to the hospital. The deficient practice continues at a level of actual harm for Resident #4. Findings: Resident #4 Review of the hospital discharge summary for Resident #4 dated 03/05/12 documented a brief hospital course revealing he underwent right hip surgery on 03/01/12. The discharge [DIAGNOSES REDACTED]. Review of the hospital discharge orders written by S13NP documented wound care orders for wound care "(R) (Right) hip daily". Review of the facility's document entitled, "Admit/Return From Hospital Doctor's Order Sheet" dated 03/05/12 revealed no transcription of the orders for the right hip care ordered by S13NP. On 05/30/12 at 2:00 p.m. an interview was conducted with S4LPN. She stated she did recall taking care of Resident #4 but couldn't remember specifics regarding his care. She was asked what the procedure was when receiving a resident with a dressing. She stated there should be orders for the type of care to be provided. She stated if there are no wound care orders, the nurse should notify the physician for orders. She stated the nurse usually receives orders from the hospital and the data entry nurse transcribes the orders into the computer system. She stated when a resident is admitted the nurse performing the initial assessment should remove the dressing and assess the wound. S4LPN was asked to review the clinical record for Resident #4. She stated it did not look like he had treatment orders for the right hip. She was asked to compare the hospital discharge orders with the transcribed orders. She stated, "The wound care order was not transcribed onto our orders." S4LPN verified, "03/10/12 was the first order received for the right hip care." She stated the initial nurse doing the assessment should have removed the dressing to see what was under the dressing and documented that in the nursing notes. On 05/30/12 at 2:26 p.m. an interview was conducted with S6LPN. S6LPN was asked what her position was at the facility. She stated she had only been working in a transcription/data entry position since October. She stated she was previously working night shift but had been assigned to transcribe physician orders [REDACTED]. She stated she receives a copy of the hospital discharge orders for new admissions. She stated she initiates an "Admit/Return From Hospital Doctor's Order Sheet". She verified this was a form used by the facility to transcribe orders. S6LPN stated she transcribes the orders from the hospital discharge orders to the new admit/return form. She stated she faxes the orders to pharmacy and inputs the new orders into the facility's computer. S6LPN further explained once the data is entered into the computer she gives the newly transcribed orders and the discharge orders to the nurse on duty. S6LPN stated the nurse on duty compares the hospital discharge orders to ensure the physician's orders [REDACTED]. In further interview with S6LPN on 05/30/12 at 2:26 p.m., she was asked how she ensured the admission orders [REDACTED]. She stated she gave the orders to the nurse on duty at the time she completed the data entry. She stated the nurse on duty is supposed to confirm the orders were transcribed correctly. She stated she checks to see if the nurse on duty has confirmed the transcribed orders. She was asked to provide evidence of the transcription verification. Review of the document entitled, "Admit/Return From Hospital Doctor's Order Sheet" revealed no documented evidence another Licensed Practical Nurse signed and verified the transcription of the admission orders [REDACTED]. She stated she did not know. She was asked to review the hospital discharge orders dated 03/05/12 for Resident #4. She verified the hospital discharge orders for Resident #4 documented "wound care to right hip daily." She confirmed she did not transcribe the wound care orders to the facility's admission orders [REDACTED]. She stated, "Because the box was not checked for wound care". S6LPN was asked did she call the physician to clarify the written order for wound care. She stated she did not. Review of the Nursing Admission assessment dated [DATE] for Resident #4 revealed in part the following: ...... Bowel and Bladder: Occasionally incontinent; Skin: Surgical Incision/Sutures and Hematoma/Bruise...... Skin Finding Details revealed in part the following documentation: ..... "bandage right hip/bandage clean, dry and intact,".... There was no documented evidence the nursing assessment included a visual observation of the surgical incision to Resident #4's right hip. Review of the documents entitled, "Departmental Notes" for Resident #4 dated 03/06/12 through 03/09/12 revealed in part the following nurse documentation: 03/06/12 ....."noted dressing to right hip"..."continent of bowel/bladder, uses urinal but d/t (due to) unable to aim requires assistance holding urinal in place." 03/07/12....."noted dressing to right hip" 03/08/12....."noted dressing to right hip" 03/09/12....."noted dressing to right hip" There was no documented evidence in the Departmental Notes of a visual assessment of the surgical incision to the right hip. Review of the interim care plan dated 03/05/12 for Resident #4 revealed he was assessed as continent of bladder and continent of bowel. Further review of the interim care plan revealed the following items were checked for skin care: dry, [MEDICAL CONDITION], site: LE (lower extremities) Bilaterally. There was no documented evidence of Resident #4's right hip surgical incision. Further review of the Departmental Notes dated 03/10/12 revealed the following documentation: ".......called to resident room per CNA (Certified Nursing Assistant). Noted small amount of bloody drainage to right hip surgical line....... Notified S13NP on call. New orders noted.......wears incontinent briefs,..... Also uses urinal at bedside." On 05/31/12 at 11:02 a.m. a phone interview was conducted with S7LPN. She was asked if she had provided care for Resident #4. She stated she could recall being called to room, she stated she couldn't remember who called her to the room. She stated she couldn't remember if the resident had a dressing on at the time but does remember there was bloody drainage to the top of the incision. She stated she called and received wound care orders on 03/10/12. S7LPN stated, "there was a lot of drainage coming from such a small pin hole." Review of the Physician's Telephone Order dated 03/10/12, five days following Resident #4's admission to the facility, revealed in part the following wound care order: "Cleanse surgical line to right hip with WC (wound cleanser) dry and apply dressing every day until healed." Review of the Departmental Notes for nursing dated 03/11/12 at 3:56 p.m. revealed the following: "called to resident room. noted large amount of bloody drainage from right hip surgical line.....notified S13NP ordered to send to ER (emergency room ) for evaluation. Review of Emergency Department Record dated 03/11/12 revealed in part the following physician documentation: Physician Exam: ...."Right hip surgical wound......1cm (centimeter) area of dehiscence on cephalad aspect of wound with copious red, brown drainage....Approximately 100-200 ml of drainage was expressed after previous pads already reported soaked." Physician Notes: Consult hospitalist- wound infection Diagnosis: [REDACTED]. Review of a facility document entitled, "Grievance/Complaint" dated 03/12/12 (the following day) revealed in part the following complaint initiated by Resident #4's son-in-law: Explanation/Nature of Complaint: "(Name of resident's son-in-law) upset when he visited on 03/11/12, he said both times he visited (Resident #4) was in the same position in bed. He was soaking wet when he visited early on 03/11/12." On 05/30/12 at 2:50 p.m. an interview was conducted with S5LPN. She was asked if she admitted Resident #4 on 03/05/12. S5LPN confirmed that she was the nurse who admitted Resident #4 on 03/05/12. She was asked if she remembered this resident. She stated she could vaguely recall this resident. She was asked if she had removed his hip dressing when she conducted her initial assessment. She stated, "I probably did not remove the dressing because at that time I thought the wound care nurse did this." S5LPN stated she had recently been informed it is her responsibility to remove a dressing on a new resident and document what is under the dressing. She stated if more care is needed the wound care nurse is notified. On 05/30/12 at 3:15 p.m. an interview was conducted with S2DON. He was asked what the policy was for the assessment of incision/wounds on residents with dressings. He stated the nurse does a full head to toe assessment on every resident. He stated if the resident has a dressing on, the nurse is expected to remove the dressing to assess what is under the dressing. He stated if further wound care is needed the physician can be contacted for orders and/or the wound care nurse can become involved. He stated, "I would expect them to remove a dressing assess the site and determine what other care is needed." On 05/31/12 at 11:49 p.m. an interview was conducted with S8MD. He verified he was the orthopedic surgeon who performed the right hip hemiarthroplasty for Resident #4 on 03/01/12. S8MD also verified he was the surgeon who removed Resident #4's right hip hemiarthroplasty on 03/12/12. He was asked if the family had voiced any concerns regarding Resident #4's care. He stated the family had voiced some concern regarding the care the resident was receiving at the nursing home. He stated the resident's hip culture from 03/11/12 identified proteus vulgaris which he had never seen before. He stated this was unusual because this usually comes from the bowel. He stated this was his first surgical site infection. S8MD was asked if this was a surgical site infection or was it from the nursing home. He stated he could not verify without visually seeing the resident at the nursing home. The surveyor informed S8MD a grievance complaint from the family related to Resident #4 being found soaking wet had been verified, there was lack of evidence of a daily assessment of the right hip incision, and there was no evidence of wound care started until 03/10/12. S8MD stated there was a possibility the infection could have been acquired in the nursing home if the resident had been found in a "dirty state". On 5/30/12 at 4:00 p.m. an interview was conducted with S3SS. S3SS was asked if she had completed an assessment on Resident #4. She was asked if the family was satisfied with his care. She stated after Resident #4 was sent to the hospital the family did return to the facility to file a grievance. She stated the family was concerned because they found him soaked upon two separate visits. She was asked what was done to address the concerns. She stated an inservice was given to the CNA's about how to care for Resident #4. On 05/31/12 at 12:30 p.m. an interview was conducted with S2DON in the presence of S1Adm and S12CN. S2DON was asked what was the process for ensuring admission orders [REDACTED]. He stated she transcribes the admission orders [REDACTED]. He was asked to review the hospital discharge order for Resident #4's wound care. He confirmed there was a wound care order upon admission to the facility that read "right hip daily". He was asked to review the facility's transcribed admission orders [REDACTED]. S2DON verified there was no documentation of an assessment of the incision to the right hip. He stated, "there is only documentation that a dressing was intact." He stated, "There is no assessment of the incision site". He stated, "there should have been an assessment of the incision and the staff should have taken the dressing off and assessed the wound". S1Adm asked the surveyor if she would accept an assessment of Resident #4's wound that was conducted by S11LPN. The surveyor informed S1Adm, S11LPN was already interviewed and verified she did not document the assessment of Resident #4's wound on 03/05/12. S1Adm verified the document he was presenting to the surveyor was documented by S11LPN on 05/31/12. During the interview with S2DON he was asked if Resident #4's admission order for wound care was clarified by the admitting nurse, he stated no. S12CN responded and asked the surveyor if she could provide additional information regarding the admission orders [REDACTED]'s NP (S13NP). S12CN verified she spoke with S13NP on 05/31/12. She stated S13NP stated he did not mean to write a wound care order for Resident #4. S12CN stated S13NP told her he only meant for the nurses to observe the right hip daily. Review of the hospital discharge summary dated 03/05/12, dictated by S13NP, revealed in part the following: "Recommending right hip wound care daily."