Every finding on record at Heritage Manor of Stratmore Nursing & Rehab CTR

Based on record review, observation and interviews, the facility failed to ensure 1 (#99) of 1 resident reviewed for skin conditions received treatment and services to prevent an infection and new wounds from developing. The facility failed to assess Resident #99's skin during and following heat therapy resulting in a burn.Findings:Review of Resident #99's medical record revealed an admit date of 12/13/2023 with the following diagnoses, including in part: type 2 diabetes mellitus with other circulatory problems and diabetic peripheral angiopathy without gangrene, peripheral vascular disease, unspecified open wound lower leg initial encounter, vitamin deficiency unspecified, edema unspecified anesthesia of skin, other soft tissue disorders, other skin changes, venous insufficiency (chronic) (peripheral), moderate protein-calorie malnutrition and lymphedema not elsewhere classified.Review of Resident #99's MDS assessment dated [DATE] revealed a BIMS sore of 15 indicating cognitively intact.Review of Resident #99's comprehensive care plan revealed the following problem and approach: Resident #99 has a 2nd degree burn to right lower leg - medial and lateral (05/04/2026 changed to 3rd degree full thickness burns status post debridement) date initiated: 04/23/2026.Review of Resident #99's physician's orders revealed the following:05/04/2026 - burn to right lower leg (medial) - cleanse with wound cleanser, pat dry, apply Santyl, collagen silver and gel fiber to wound fiber to wound bed, cover with dry dressing daily until healed every day shift and as needed for soilage/dislodgment.05/04/2026 - burn to right lower leg (lateral) - cleanse with wound cleanser, pat dry, apply Santyl, collagen silver and gel fiber to wound fiber to wound bed, cover with dry dressing daily until healed every day shift and as needed for soilage/dislodgment.05/01/2026 - Cephalexin oral tablet 500 mg by mouth three times a day related to unspecified open wound, unspecified lower leg, initial encounter.05/01/2026 - consult ____wound care to evaluate and treat one time only for 1 dayObservation on 05/18/2026 at 8:10 a.m. revealed Resident #99's right medial calf and right lateral shin with dressings intact with purplish red discoloration of the lower extremity.During an interview on 05/18/2026 at 8:10 a.m. Resident #99 reported therapy applied a heating pad on his right lower leg for muscle tightness and the pad burned him. Resident #99 further reported later in the evening he noticed there was a blister filled with fluid hanging off his right leg.During an interview on 05/19/2026 at 11:08 a.m. S4 PT reported Resident #99 received moist heat therapy and would tell her if he was having any problems. S4 PT reported if a resident has diagnoses of PVD or circulation issues an assessment of the skin should be done more frequently. S4 PT further reported all resident's skin should be assessed and documented during and after a procedure. S4 PT acknowledged she did not assess Resident #99's skin because she was busy.

Based on record review and interview, the facility failed to ensure a resident with an order for a psychotropic medication was not subjected to chemical restraints for 1 (#11) of 1 resident reviewed for hospice. The facility failed to ensure Resident #11's order for a psychotropic medication was limited to 14 days. Findings: Review of Resident #11's medical record, revealed Resident #11 was admitted on [DATE] with diagnoses including generalized anxiety and bipolar disorder. Review of Resident #11's physician orders revealed in part, an order dated 12/24/2025 for lorazepam 0.5 ml every 2 hours as needed for anxiety and restlessness related to generalized anxiety disorder. Further review of Resident #11's PRN lorazepam order failed to reveal a stop date or rational for continued use. During an interview on 05/20/2026 at 1:30 p.m., S2DON confirmed Resident #11 had a PRN order for lorazepam ordered on 12/24/2025 without a stop date. S2DON further confirmed there was not a documented rational for the use of lorazepam PRN for more than 14 days and should have been.

Based on record reviews and interviews, the facility failed to develop and implement an individuaized comprehensive care plan to maintain a residents highest practicable physical, mental and psychosocial well-being for 2 (#11, #65) of 2 residents reviewed. The facility failed to develop fall interventions for Resident #11 and implement restorative services for Resident #65.Findings:Resident #11Review of Resident #11's medical record revealed an admit date of 01/31/2022 with the following diagnoses including in part: Parkinson's disease, dementia, and generalized anxiety.Review of Resident #11's medical record for the past six months revealed Resident #11 had a fall on 12/15/2025, 01/08/2026, 01/26/2026, 03/09/2026, 04/02/2026, 04/03/2026, 04/12/2026, 04/13/2026 and 05/04/2026. Review of Resident #11's comprehensive care plan revealed a problem for an actual fall dated 12/09/2024. Further review of Resident #11's comprehensive care plan failed to reveal interventions had been updated for each of Resident #11's falls on 12/15/2025, 01/08/2026, 01/26/2026, 03/09/2026, 04/02/2026, 04/03/2026, 04/12/2026, 04/13/2026 and 05/04/2026. During an interview on 05/20/2026 at 8:10 a.m., S8 Case Manager, acknowledged Resident #11 had a fall on 12/15/2025, 01/08/2026, 01/26/2026, 03/09/2026, 04/02/2026, 04/03/2026, 04/12/2026, 04/13/2026 and 05/06/2026. S8 Case Manager further acknowledged interventions had not been updated on Resident #11's care plan to reflect each fall and should have been. Resident #65Review of Resident #65's medical record revealed an admit date of 01/30/2025 with the following diagnoses including in part: type 2 diabetes mellitus with diabetic neuropathy unspecified, unspecified lack of coordination, muscle weakness (generalized), other abnormalities of gait and mobility and morbid (severe) obesity due to excess calories.Review of Resident #65's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognitively intact. Review of Resident #65's comprehensive care plan revealed the following problems and approaches: Restorative Nursing Program: Active Range of Motion related to - Active range of motion to bilateral lower extremities for 15 minutes per day. Active range of motion to bilateral upper extremities for 15 minutes per day. Restorative Nursing Program: Bed mobility related to - Resident to perform bed mobility exercises for 15 minutes for 6 days a week.Review of Resident #65's tasks for restorative services failed to reveal services were provided on the following days of: April 2nd, 4th, 8th, 9th, 24th, 27th, and 29th 2026; May 4th, 5th, 7th, and 8th 2026. During an interview on 05/18/2026 at 8:20 a.m. Resident #65 reported she is supposed to receive restorative therapy 6 days a week but sometimes only receives it 1 day a week.During an interview on 05/19/2026 at 3:35 p.m. S3 Restorative Aide reported Resident #65 receives restorative therapy 6 days a week Monday through Saturday. S3 Restorative Aide reported due to being pulled to the floor to work, the resident may only receive 1-3 days a week of therapy.During an interview on 05/20/2026 at 2:10 p.m. S2 DON acknowledged Resident #65 did not receive restorative services 6 days a week.

Based on record review and interviews, the facility failed to ensure a resident's indwelling urinary catheter was flushed with normal saline every shift according to physician's orders for 1 (Resident #94) of 2 sampled residents reviewed for catheter use. Findings: Review of Resident #94's medical record revealed an admit date of 05/07/2025 with a diagnosis in part of neuromuscular dysfunction of the bladder. Review of Resident #94's physician orders revealed in part an order dated 06/17/2025: Flush catheter with normal saline every shift. Review of Resident #94's medical record failed to reveal documentation Resident #94's indwelling urinary catheter had been flushed every shift with normal saline as ordered for the month of May, 2026. During an interview on 05/20/2026 at 8:15 a.m., S6LPN acknowledged Resident #94 had a physician order to flush Resident #94's catheter with normal saline every shift. S6LPN further acknowledged no documentation of the flushes could be found in Resident #94's medical record for the month of May, 2026. S6LPN reported Resident #94's catheter flushes should be documented on the MAR and were not. During an interview on 05/20/2026 at 10:40 a.m., S2DON acknowledged Resident #94 had a physician order to flush Resident #94's indwelling urinary catheter with normal saline every shift. S2DON reported she could not produce documentation Resident #94's catheter flushes had been completed for the month of May, 2026.

Based on record review, observations and interviews the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards by failing to properly store CPAP face device for 1 (#122) of 1 residents reviewed for respiratory care. Review Resident #122's medical diagnosis included, but not limited to obstructive sleep apnea, dementia with anxiety, asthma and depression.Review of Resident #122's physician's orders dated 03/26/2026 revealed the following: CPAP setting 10 cm with H2O at bed time and remove CPAP every morning.Review of Resident #122's MDS dated [DATE] revealed the following:BIMS score 04 severe cognitive impairmentDuring an observation on 05/18/2026 at 9:30 a.m. in Resident # 122's room revealed a CPAP mask and machine on the bedside table. The CPAP face mask was sitting on top of the CPAP machine and not stored in any type of container.During an observation on 05/19/2026 at 9:20 a.m. in Resident #122's room revealed CPAP face mask sitting on top of a plastic bag, on top of CPAP machine, not stored in any type of container.During an observation on 05/20/2026 at 7:40 a.m. in Resident #122's room revealed CPAP face mask sitting on top of CPAP machine, not stored in any type of container.During an interview on 05/19/2026 at 9:20 a.m. S7 LPN acknowledged Resident #122's CPAP mask should have been stored in a bag or container and was not.During an interview on 05/20/2026 at 7:35 a.m. S2 DON acknowledged that when a resident's CPAP mask is not in use, the CPAP mask should be stored in a container or bag.

Based on record review and interview, the facility failed to ensure a resident's MDS were transmitted within the required timeframe for 1 (#8) of 2 (#8, #121) residents reviewed for assessments. Review of Resident #8's medical record revealed in part resident was admitted to the facility on [DATE] and left the facility with a Discharge Return Anticipation MDS on 12/22/2025.Review of Resident #8's MDS dated [DATE] revealed status was not accepted.During an interview on 05/20/2026 at 11:45 a.m. S5 Case Manager confirmed that Resident #8's MDS was not sent and should have been.

Based on record review, observations, and interviews the facility failed to ensure individual resident's narcotic records were maintained and reconciled for 2 of 3 medication carts reviewed. The facility failed to ensure an accurate count of controlled medications was maintained. Findings: Review of the facility's Drug-Controlled Substances Policy dated 11/17 revealed the following: Controlled medications are to be signed out on Form NS-618--Individual Residents Narcotic Record at the time they are to be administered. RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) only will sign out for and/or administer controlled medications, recording the date, time, resident's name, and signature of the administering nurse on the narcotic count sheet. The administering nurse will also check for the accuracy of the remaining count. Observation of the medication cart for 800 hall on 03/05/2025 at 8:15 a.m. with S2 LPN revealed resident #50's medication card for Norco 10/325 mg (milligrams) had a count of 6. Observation of medication pass on 03/05/2025 at 8:15 a.m. revealed S2 LPN administered resident #50's Norco 10/325 mg one tablet for pain without signing it out on resident #50's Individual Residents Narcotic Record. Observation on 03/05/2025 at 8:17 a.m. of resident #50's Individual Residents Narcotic Record for Norco 10/325 mg with S2 LPN revealed a count of 5, failing to reconcile with the count of 6 on resident #50's medication card for Norco 10/325 mg. During an interview on 03/05/2025 at 8:17 a.m. S2 LPN reported she had signed out resident #50's Norco 10/325 mg prior to administering it and confirmed it should have signed out at the time of administration. Observation on 03/06/2025 at 8:05 a.m. with S3 LPN of the medication cart for 1000 hall revealed resident #121's medication card for Modafinil 200 mg had a count of 4, and resident #121's Individual Resident Narcotic Record had a count of 5 and failed to reconcile. Further observation revealed a medication cup on the top of the medication cart with 5 tablets inside that included a white oval pill that S3 LPN identified as resident #121's Modafinil 200 mg tablet. During an interview on 03/06/2025 at 8:05 a.m. S3 LPN reported, she had already pulled resident #121's Modafinil 200 mg up, and pointed to a cup of tablets on the top of the medication cart. S3 LPN stated, I just hadn't signed it out. S3 LPN confirmed resident #121's medication should not have been pre-pulled up and resident #121's Modafinil 200 mg should have been removed and signed out of locked narcotic stock at the time of administration and not before. During an interview on 03/06/2025 at 11:30 a.m. S1 DON (Director of Nurses) confirmed controlled medications, including resident #50's Norco 10/325 mg and resident #121's Modafinil 200 mg should have been signed out on each residents Individual Narcotic Records at the time of administration. S1 DON further confirmed the count of resident #50 and resident #121's controlled medications should have reconciled.

Based on record reviews and interviews, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted within 14 days of completion for 2 (#85 and #279) of 3 (#67, #85, and #279) residents who were reviewed for Resident Assessment. Findings: Resident # 279 Review of resident #279's Admission MDS with a care plan completion date of 12/13/2022 failed to reveal a transmission date. Resident #85 Review of resident #85's Discharge MDS with an ARD (Assessment Reference Date) of 9/12/2022 failed to reveal a completion or transmission date. During an interview on 1/11/2023 at 10:30 a.m. S7 MDS Nurse confirmed resident #279's MDS had not been transmitted and should have been. During an interview on 1/11/23 at 3:45 p.m. S9 MDS Nurse confirmed resident #279's admission MDS had not been transmitted and should have been. S9 MDS Nurse further confirmed resident #85's discharge MDS had not been transmitted and should have been.

Based on observations and interviews the facility failed to ensure food was served in accordance with professional standards for food service safety for the 114 residents served a meal tray from the kitchen. There were a total of 114 residents receiving meal trays from the kitchen according to the Resident Census and Conditions of Residents form dated 01/09/2023. Findings: Review of the facility's Monitoring Temperatures of Cooked Foods policy revealed in part: Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than six hours. Procedure: 1. Potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees F or higher. 2. The temperature of each potentially hazardous food will be taken at the following times. a. When the cooking process is completed. Foods must be cooked to the proper internal temperature for fifteen seconds. Food will be placed in hot holding equipment immediately after the cooking process is completed. b. When the food is placed in the hot holding equipment . 3. Cooking, holding and storage temperatures should be recorded on a Food Temperature Monitoring Log. Review of the facility's Daily Food Temperature Monitoring Logs for December 2022 and January 2023 revealed: 12/08/2022 - 12/12/2022 - Temperatures for Dinner meals had not been documented. 12/13/2022 - 12/14/2022 - Temperatures for Breakfast, Lunch, and Dinner meals had not been documented. 12/15/2022 - 12/19/2022 - Temperatures for Dinner meal had not been documented. 01/01/2023 - Temperatures for Dinner meal had not been documented. 01/06/2023 - Temperatures for Lunch meal had not been documented. 01/07/2023 - Temperatures for Breakfast and Lunch meals had not been documented. During an interview on 01/09/2023 at 8:30 a.m. S5 DM (Dietary Manager) and S6 ADM (Assistant Dietary Manager) reviewed the December 2022 and January 2023 Daily Food Temperature Monitoring Logs. S5 DM and S6 ADM acknowledged temperatures had not been monitored for prepared meals and should have been.

Based on record reviews and interview the facility failed to ensure State Registry verifications were completed prior to hire for 2 [S3 CNA (Certified Nursing Assistant) and S4 CNA] of 5 CNA personnel files reviewed. Findings: 1. Review of S3 CNA's personnel file revealed a hire date of 07/28/2022. Further review of S3 CNA's personnel file revealed CNA Registry check was completed on 08/10/2022. 2. Review of S4 CNA's personnel file revealed a hire date of 11/08/2018. Further review of S4 CNA's personnel file revealed Criminal Background and Sex Offender Registry checks were completed on 11/09/2022. During an interview on 01/11/2023 at 2:00 p.m. S2 HR (Human Resources) acknowledged State Registry verifications were not completed prior to hire for S3 CNA and S4 CNA and should have been.

Based on observation, record reviews and interviews, the facility failed to ensure the plan of care was implemented and developed for 2(#102, #126) of 4 (#67, #102, #126, #279) residents reviewed for accidents. 1. The facility failed to ensure x-rays were done as ordered by a physician. 2. The facility failed to develop a plan of care for resident #126's use of a wanderguard bracelet for safety. Findings: Resident #102 Review of the facility's Incident Log revealed resident #102 had a fall on 1/1/2023 at 10:30 p.m. and was found on the floor. Review of resident #102's nurse's notes dated 1/2/2023 at 4:51 a.m. revealed on 1/1/2023 at 10:30 p.m. resident #102 was found lying on the floor. Resident #102's physician was notified and a new order was given for x-rays on resident #102's left hip and left knee. Review of the resident's #102's medical record failed to reveal x-rays on resident #102's left hip and left knee had been done. During an interview on 1/11/2023 at 10:52 a.m., S8 Corporate Nurse confirmed resident #102 did not get x-rays of the left hip and left knee as ordered by the physician. Resident #126 Observation on 1/9/2023 at 2:13 p.m. revealed resident #126 had a wanderguard bracelet placed to the left ankle. Review of resident #102's BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. During an interview on 1/9/2023 at 2:13 p.m., resident #126 reported she fell outside. Resident #126 further reported a wanderguard bracelet was placed on her ankle after the incident. Review of resident #126's care plan failed to reveal a care plan for use of a wanderguard bracelet. During an interview on 1/11/2023 at 3:25 p.m., S7 MDS nurse confirmed resident #126 was not care planned for use of a wanderguard bracelet and should have been. During an interview on 1/11/2023 at 3:30 p.m., S1 Administrator confirmed resident #126 should have been care planned for use of a wanderguard bracelet.

Based on observation, interviews and record reviews, the facility failed to ensure 1 (#40) of 1(#40) resident received reasonable accommodation of needs by failing to ensure the resident's call button was within reach. Findings: Observation on 1/9/2023 at 8:40 a.m. revealed resident #40 yelling Help! Help! Help! from the resident's room. Upon entering the room, an observation was made of resident #40's call button on the floor out of the resident reach. Review of resident #40's BIMS (Brief Interview Mental Status) revealed a score of 10 indicating mildly impaired. Review of resident #40's MDS (Minimum Data Set) revealed resident #40 requires extensive assistance with bed mobility. Review of resident #40's record revealed a diagnosis of dementia and anxiety. Review of resident #40's medical record revealed resident #40 was care planned for risk of falls with an intervention which included placing the call light/button within reach. During an interview on 1/9/2023 at 8:42 a.m. S10 CNA (Certified Nurse Assistant) confirmed the call light should have been within the resident's reach.

Based on interviews and record reviews, the facility failed to ensure a resident was free from accidents hazards during a transfer for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1 on [DATE] at 10:20 a.m., when S2CNA (Certified Nurse Assistance) transferred the resident from bed to chair without assistance of another person and without using the mechanical lift. S2CNA slipped and fell causing Resident #1 to fall with her during a manual transfer. Resident #1 was transferred to the hospital on [DATE] and diagnosed with bilateral closed proximal tibial fractures and expired on [DATE] at 8:00pm. S2CNA failed to follow the resident's care plan of using two-person staff assistance to transfer the resident via mechanical lift. 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. Findings: A review of the facility's Lifting Policy revealed the following, in part: Procedures: 2. Staff will follow the documented lifting protocol deemed appropriate for each resident as noted on their ADL (Activities of Daily Living) information. This information is documented in the resident's chart on the ADL sheets and, via a color coded sticker system. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include which sling size is appropriate for each resident. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] with the following diagnoses but not limited to: primary generalized (osteo) arthritis, difficulty in walking, heart failure/unspecified, unspecified [CONDITION(S)], essential hypertension, [CONDITION(S)] (chronic obstructive pulmonary disorder), muscle weakness/generalized, other lack of coordination, cognitive communication deficit, and other reduced mobility. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE], revealed: Section C: Cognitive Patterns: BIMS 05 (Brief Interview for Mental Status) - severely impaired cognition. Section G: Functional Status: ADLs - transfers - extensive/2 person assist. Review of Resident #1's current Care Plan revealed the following, in part: - Onset [DATE] - Lift/transfer: red -total lift staff assistance w/lift x 2 manual staff assistance; red -total lift and provide lift/transfer assistance per lifting plan Review of Resident #1's Nursing Notes revealed the following, in part: - [DATE] at 1:17pm - Nurse's Note - Writer alerted to room by CNA. Resident on floor lying on R side in fetal position near w/c (wheelchair). CNA states that when transferring resident from bed to chair CNA loss footing and fell with the resident. Resident obtained laceration to L forearm from falling against door hinge striking L arm. Bleeding and c/o (complain of) pain noted site cleansed and pressure done. sent to ___hospital for eval & tx . - [DATE] at 2:44pm - Nurse's Note - Late entry [DATE] - Writer informed by resident daughter____. Resident has expired . Review of Resident #1's Hospital Records dated [DATE] revealed Resident #1 expired on [DATE] at 8:00 p.m. with final diagnosis in part, of (1) bilateral closed proximal tibial fracture, (2) PNA (pneumonia), and (3) [CONDITION(S)]. Review of facility's investigation following Resident #1's fall on [DATE] revealed: - Narrative of investigation: Upon reviewing statements of incident, S2CNA solo transferred resident without assistance or utilizing the total lift. S2CNA stated that she slipped in water possibly from bathing water. S2CNA stated that resident hit arm against door handle causing laceration to resident arm during fall . Resident was assessed in a head to toe assessment then transported to ___ hospital per MD (Medical Director) orders. Resident expired at hospital. - Incident witness statement: Around 10:15am I was transferring Resident #1 from the bed to her wheelchair while turning I slipped on some water on the floor. I fell to the right at the bathroom door trying to keep Resident #1 from getting hurt. She has a skin tear on her arm. I notified the nurse S2CNA During an interview on [DATE] at 9:40am S1Administrator reported Resident #1's fall was caused by S2CNA not following protocol for the lift. S1Administrator further reported Resident #1 transfer lift status changed 2 weeks prior to the fall on [DATE] to being a total lift with two people. S1Administrator reported following the fall on [DATE], S2CNA was terminated and all staff were inserviced on the lift policy. S1Administrator further reported observations were conducted on use of the mechanical lift and residents were interviewed regarding transfers. S1Administrator reported any staff not using the mechanical lift safely will be terminated. During a telephone interview on [DATE] at 4:40pm S2CNA reported on [DATE] she was going to transfer Resident #1 from the bed to the chair using the mechanical lift. S2CNA further reported Resident #1 begged and pleaded for her not to use the lift, so instead she transferred Resident #1 without using the lift. S2CNA reported she slipped on something and lost her footing and they both fell . S2CNA reported she regrets not following the rules and confirmed Resident #1 had a red dot over her bed indicating a two person transfer with the mechanical lift. S2CNA confirmed when a resident has a red dot you are always supposed to transfer with two people and she did not. Multiple nurses and CNAs were interviewed about the mechanical lift. All staff confirmed they received training on the mechanical lift and an inservice on the lifting policy. All staff were knowledgeable of resident transfer status using color codes and about the facility's policy that two trained staff members should be present when lifting a resident using the mechanical lift. Two random residents, who required use of a mechanical lift for transfers, were observed on [DATE] and [DATE] having two or more staff members present. No issues were noted. Further observations revealed color code transfer status posted in each resident room above the bed. The facility implemented the following actions on [DATE] to correct the deficient practice and prevent further reoccurrence: 1. Enforce lift policy, ensure lift color codes are posted per facility policy 2. Facility wide audit of lift/transfer screen to ensure proper lift color codes are posted 3. Inservice nursing staff on lifting policy 4. Each nurse and nursing assistant to re-sign the lifting policy acknowledgement form 5. Random direct observation of direct care staff following lift policy and utilizing 6. Enforce the buddy system for direct patient care - assignments made in TEAMS 7. Administrator and/or designee to perform random interviews on how residents are being transferred.

Based on policy review, record review and interviews, the facility failed to inform the resident's physician and responsible party (RP) of a resident's change in condition for 1 (#1) out of 5 sampled residents reviewed for notification of change. Findings: Review of the facility's policy for Change in Resident Medical Status revealed a change in medical status is defined as any physical, psychological and/ or medical deviation as compared to the resident's status as noted in the initial assessment. A facility must immediately inform the resident; consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) Review of Resident #1's nurses notes revealed S3 LPN (Licensed Practical Nurse) and S4 LPN failed to notify resident #1's physician and RP when resident #1 had skin changes and discoloration to lips/ corners of the mouth and arms. During an interview on 1/16/2022 at 9:45 am S3 LPN reported she was notified of bruise on Resident #1 lip. Resident #1 was assessed and found to have a small bruise on the left side of her lip. S3 LPN confirmed Resident #1's physician and RP should have been notified and was not. During an interview on 2/16/2022 at 10:30 AM S4 LPN reported he was informed during shift report Resident #1 had bruising to her lips. S4 LPN reported during his assessment he noted bruising to both arms, and swelling to resident #1's left arm with a round lump measuring about 2 inches in diameter. S4 LPN confirmed he did not notify resident #1's physician or RP of the bruising to Resident #1 lips and arms or the swelling to Resident #1 left arm. During an interview on 2/16/2022 at 3:30 PM S1 Administrator confirmed Resident #1's physician and RP should have been notified of bruising and swelling to Resident #1 skin.

Based on observations, record review and interviews the facility failed to ensure residents who were unable to complete their activities of daily living (ADLs) received the necessary services to maintain grooming and hygiene for 2 (#28, #115) of 2 residents reviewed for ADLs. The facility failed to ensure: 1. Resident #28's fingernails were trimmed. 2. Resident #115's fingernails were trimmed and facial hair was removed. Findings: 1. Review of Resident#28's medical record revealed and admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's Care Plan revealed Resident #28 needed assistance with ADLs secondary to [CONDITION(S)] and Dementia. Review of Resident #28's 9/15/21 Quarterly MDS (Minimum Data Set) revealed Resident #28 had a BIMS (Brief Interview Mental Status) score of 00, which indicated severe cognitive impairment. Further review of the 9/15/21 Quarterly MDS further revealed Resident #28 was totally dependent with personal hygiene. Review of Resident #28's medical record revealed a 12/14/2020 resident history form which indicated Resident #28 liked nails short. Observation on 1/10/22 at 4:05pm revealed Resident #28's fingernails were all well past the tips of her fingers. During a phone interview on 1/10/22 at 4:12pm Resident #28's family member reported Resident #28's nails were not being trimmed. During interview on 1/12/22 at 7:44am S4 LPN (Licensed Practical Nurse) reported Resident #28's nails were long and should have been cut. 2. Review of medical record revealed Resident #115 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #115's Care Plan revealed Resident #115 needed assistance with ADLs. Review of Resident #115's 10/20/21 Quarterly MDS revealed Resident #115 had a BIMS score of 15, indicating Resident #115 was cognitively intact. Observation on 1/10/22 at 2:19pm revealed Resident #115's fingernails extended well past the fingertips. During an interview on 1/10/22 at 4:05pm Resident #28 indicated her nails were too long and she would like her fingernails clipped. Observation on 1/11/22 at 1:23pm revealed all of Resident #115's fingernails continued to extend well past the fingertips and Resident #115's chin had multiple salt and pepper colored chin hairs approximately 3/4 inch long. During an interview on 1/12/22 at 7:49am Resident #115 reported her chin hairs bothered her because she likes to look neat and she would like them removed. During an interview on 1/12/22 at 8:04am S4 LPN observed Resident #115's nails and long chin hairs and reported the nails were long and should have been clipped and the chin hair should have been removed.

Based on record review and interviews, the facility failed to ensure services were provided to meet professional standards of quality as evidenced by failing to accurately document the significant change assessment and code status for 1 (#104) of 1 (#104) resident reviewed for death. S3 SW documented an inaccurate code status and assessment note without resident/family participation. Findings: Review of medical record revealed resident #104 was admitted to ______ Hospice on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed Resident #104 expired on [DATE]. Review of SC (Significant Change) MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #104 had a BIMS (Brief Interview for Mental Status) summary score of 00 out of 15, indicating severely impaired cognition. Further record review revealed Resident #104 or family member had not participated in the SC assessment on [DATE]. Review of [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care plan revealed: [DATE] Resident #104 is a DNR status with interventions including honor resident's wishes, review advance directive with resident/family on admission and maintain appropriate resident code status identification. Review of LaPOST (Louisiana Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #104's RP (Responsible Party). Review of the Code Binder at the nurses' station revealed Resident #104's Code Status had not been updated since 2017 and the 2017 Code Status in the binder revealed Resident #104's code status was Full Code. Review of S3 SW's (Social Worker) note dated [DATE] at 1:50 p.m. revealed in part: Resident #104 presents as alert yet is rarely/never understood or understands. Resident #104 had a recent stay in ______ _____ hospital ([DATE]-[DATE]) having been readmitted back to this facility with N/O (new order) to receive ______ Hospice services as resident's physical status has worsened. RP signed required paperwork with Hospice Agency on [DATE] . Resident #104's RP/______/______ makes decisions on behalf of Resident #104. RP chooses for resident to remain in this facility as a LTC (Long Term Care) resident as well as continuing to choose Resident #104 remain at a: FULL CODE status. During an interview on [DATE] at 11:00 a.m. S3 SW acknowledged she completed a Significant Change in Condition assessment note for Resident #104 on [DATE] to show the resident was admitted to hospice services on [DATE]. S3 SW reviewed the assessment note and agreed the note indicated Resident #104's RP wanted Resident #104 to continue services with a Full Code status. S3 SW confirmed she had not discussed Resident #104's change in condition or code status with Resident #104's RP. S3 SW confirmed she is responsible for updating the binders at the nurses' station that provide each resident's code status and would have notified the Physician of any changes. S3 SW further confirmed she completes the section on the MDS related to Advance Directives. S3 SW stated she had copied and pasted the assessment note from a previous entry and further stated the note on [DATE] had been totally mis-documented. During an interview on [DATE] at 11:35 a.m. S2 DON (Director of Nursing) verified the Code Binder had not been kept up to date. During an interview on [DATE] at 12:00 p.m. Resident #104's RP reported the social worker had not met with her regarding Resident #104's significant change or code status after Resident #104 had been admitted to hospice services.

Based on record review and interview, the facility failed to ensure the facility's grievance policy was followed for 1 (#28) resident out of a total sample of 62 residents. The facility failed to complete a grievance report in response to complaint from Resident #109's family member. Findings: Review of Policy titled Grievances-Residents revealed: All residents are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other resident's and other concerns regarding their facility stay, in the event that they have a need to make a concern known. . -Residents may present grievances, on behalf of themselves or others, to the facility staff . Family members, visitors or others may also present grievances on behalf of residents. Grievances may also be made anonymously using the suggestion box. The facility shall make prompt efforts to resolve the grievances. . -Upon receipt of a grievance/complaint the staff receiving the complaint will initiate the Grievance/Complaint Form NS-795. An investigation led by the Administrator based on the allegations will be set forth. NS-795 will be completed electronically in the Quality Assurance module. Review of Resident #28's medical record revealed an admitted [DATE]. During a phone interview on 1/10/22 at 4:12pm Resident #28's family member reported Resident #28's nails were not being trimmed. Review of Resident #28's Medical Record revealed a 12/4/21 nursing note that indicated Alarmed by family members while visiting that resident toenails need to be cut by podiatrist and that they have been complaining about this for a few weekends. Review of Grievance Log from 1/10/2021 to 1/10/2022 failed to reveal any complaint/grievance was filed in regard to Resident #28. During an interview on 1/12/22 S1 Administrator reported she was not aware of any complaint/grievance that had been filed in regard to Resident #28's toenails not being clipped. Further reported the person who became aware of the grievance should have notified the Social Services person or Administrator regarding the complaints so the complaint could be followed up.

Based on record reviews and interviews, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs by failing to monitor for side effects or behaviors for a resident receiving [MEDICAL CONDITION] or antidepressant medications. The facility failed to monitor 2 (#276, #112) of 5 (#25, #67, #89, #112, #276) residents reviewed for unnecessary medications. Findings: Resident #276 Review of Resident # 276's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 276's February 2020 physician orders [REDACTED].>1/21/2020 [MEDICATION NAME] 10 mg (milligram) tablet one tab by mouth daily at bedtime. Monitor for target behaviors hallucinations Review of Resident # 276's January and February 2020 Medication Administration Records failed to reveal monitoring for behaviors or side effects from [MEDICAL CONDITION] medication use. Review of Resident # 276's Admission Nursing Screening completed on 1/21/2020 revealed mild cognitive impairment and intermittent confusion. During an interview on 2/6/2020 at 10:15 AM S3 LPN (Licensed practical nurse) acknowledged that Resident # 276 receives [MEDICATION NAME] and is not being monitored for behaviors and side effects and should be. During an interview on 2/6/2020 at 10:20 AM S2 DON (Director of Nursing) acknowledged anytime a resident is on an antipsychotic or [MEDICAL CONDITION] medication they should be monitored and it was not done for Resident # 276 and should have been. Resident #112 Review of Resident #112's Medical Records revealed a [DIAGNOSES REDACTED]. Review of Resident #112's February 2020 physician's orders [REDACTED]. Review of Resident #112's Comprehensive Care Plan revealed potential for medication side effects r/t (related to) antidepressants: document side effects of medications q (every) shift and document target behaviors q shift. (Onset 08/08/19) Review of Resident #112's August 2019 - January 13, 2020 MAR's (Medication Adminsitration Record) failed to reveal monitoring for behaviors and side effects of antidepressants. During an interview on [DATE]20 at 11:40 AM S2 DON acknowledged Resident #112 was not monitored for behaviors or side effects while receiving antidepressant [MEDICATION NAME] from 08/08/19 - 1/13/2020 and should have been.

Based on record reviews and interview, the facility failed to ensure the pharmacist's recommendations for gradual dose reductions were reviewed and completed by the attending physician for 2 (#89, #112) residents receiving [MEDICAL CONDITION] medications out of 5 (#25, #67, #89, #112, #276) residents reviewed for unnecessary medications. Findings: Resident #89 Review of Resident #89's Medical Records revealed [DIAGNOSES REDACTED]. Review of Resident #89's February 2020 physician's orders [REDACTED]. Review of Resident #89's Pharmaceutical Consultant Reports for gradual dose reductions dated 01/21/2020 and 0[DATE] for [MEDICATION NAME] 10mg, [MED] 100mg, and Klonopin 0.5mg failed to reveal a response to review, rationale if indicated and a physician signature. During an interview on [DATE]20 at 11:30 AM S2 DON (Director of Nursing) acknowledged Resident #89's Pharmaceutical Consultant Reports for gradual dose reductions dated 01/21/2020 and 0[DATE] for [MEDICATION NAME] 10mg, [MED] 100mg, Klonopin 0.5mg were not completed with a response to review, rationale if indicated and a physician signature and should have been. Resident #112 Review of Resident #112's Medical Records revealed [DIAGNOSES REDACTED]. Review of Resident #112's February 2020 physician's orders [REDACTED]. Review of Resident #112's Pharmaceutical Consultant Report for gradual dose reduction dated 08/08/19 for [MEDICATION NAME] 15mg and [MEDICATION NAME] 20mg failed to reveal a response to review, rationale if indicated and date of physician review. During an interview on [DATE]20 at 11:30 AM S2 DON acknowledged Resident #112's Pharmaceutical Consultant Report for gradual dose reduction dated 08/08/19 for [MEDICATION NAME] 15mg and [MEDICATION NAME] 20mg was not completed with a response to review, rationale if indicated and date of physician review and should have been.

Based on record review, observations and interviews the facility failed to provide care according with professional standards of practice for 1 of 1 residents observed with a J (Jejunostomy) tube (feeding tube) by not ensuring an abdominal binder was in place at all times. According to the Resident Census and Conditions of Residents form dated 2/3/2020, there was a total of 2 residents who had a feeding tube in the facility. Findings: Review of Resident #101's February 2020 Physician order [REDACTED]. -9/20/19: 12 French Jejunosotomy tube -9/26/19: NPO (nothing by mouth) -[DATE]: Tube feeding formula [MEDICATION NAME] 1.5 at 40 ml (milliliters)/ hour -[DATE]: Flush J tube with 100 ml of water every 6 hours Review of MDS (Minimum Data Set) revealed Resident #101 was discharged to an acute hospital on [DATE], 11/12/19, & 12/11/19 related to feeding tube displacement. Review of Resident #101's Nurses Notes revealed the following entries dated: -9/30/19 at 8:54 PM: Writer walked in resident's room to give medications and J tube was seen on floor. -11/12/19 at 9:30 PM: Resident is being transported to local hospital to have J tube replaced. -11/12/19 at 10:40 PM: Note reflects 9:15 PM. Writer was notified by aide that resident's J tube was displaced. Writer entered resident's room to find J tube displaced from site, hanging from bedside. -12/11/19 at 9:28 PM: Resident J tube is displaced. -12/11/19 at 10:21 PM: Note reflects 9:30 PM Writer was helping aide provide perineal care due to resident pushing arms downward while trying to provide care and attempting to place binder to abdomen. While turning resident from side J tube slipped out. -1/12/2020 at 5:57 PM: Upon doing rounds, writer noted resident to be tampering with peg (Percutaneous endoscopic [MEDEQUIP]) tubing and had pulled two tubing pieces apart causing gastric juices to come out of tube and milk to flow on to bed. Review of Care Plan failed to reveal a revision/ update of Resident #101 pulling on feeding tube, displacement of feeding tube and use of abdominal binder. Observation on 2/4/2020 at 3:15 PM revealed Resident #101 had tube feeding infusing as ordered by the feeding pump to J tube. Further observation revealed abdominal binder on Resident #101's over bed table. Observation on 2/5/2020 at 1:00 PM revealed Resident #101 had tube feeding infusing as ordered by the feeding pump to J tube. Further observation revealed abdominal binder on Resident #101's over bed table. Observation on 2/5/2020 at 1:05 PM with S9 CNA revealed Resident #101 was fidgeting under the covers. Observation on 2/5/2020 at 1:10 PM with S6 LPN failed to reveal Resident #101 had an abdominal binder in place. During an interview on 2/5/2020 at 1:05 PM S9 CNA (Certified Nursing Assistant) stated an abdominal binder should be in place to prevent Resident #101 from pulling on the feeding tube especially when the feeding is not in progress. During an interview on 2/5/2020 at 1:10 PM S6 LPN (License Practical Nurse) stated abdominal binder should be in place at all times except for when she is taking a shower to prevent Resident #101 from pulling out her feeding tube. During an interview on 2/6/2020 at 1:00 PM S7 MDS (Minimum Data Set) Nurse stated she did not update/or revise Resident # 101 care plan when changes occurred. During an interview on 2/6/2020 at 1:15 PM S1 Administrator reported the facility used an abdominal binder to prevent the displacement of a feeding tube. During an interview on 2/6/2020 at 1:20 PM S2 DON (Director of Nursing) stated the abdominal binder should be in place to prevent Resident # 101 feeding tube from being displaced. S2 DON further stated an abdominal binder is a nursing measure does that not require a physician order.