Every finding on record at Landmark of Rayne

Based on record reviews, observations, and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices when staff failed to immediately sign out narcotic medications on the narcotic record form at the time they were administered for the for 5 residents (#23, #29, #71, #76 and #77). Findings: A review of the facility's policy titled Drug- Controlled Substances with a last review date of 01/29/2026, read in part, Regulation requires that the community has a system in place to account for the receipt, usage, disposition, and reconciliation of all controlled medications. These systems include the following: Controlled medications are to be signed out on the Individual Resident Narcotics Record (Form NS-618) at the time they are administered. Review of Resident #23's physician orders revealed an order dated 04/17/2024 for Acetaminophen w/ Codeine Tab (Tablet) 300-30 MG (milligrams), Give 1 tablet by mouth two times a day related to other chronic pain. Review or Resident #23's MAR (Medication Administration Record) for May 2026 revealed that Acetaminophen w/ Codeine 300-30 MG (milligrams), 1 tab was administered at on 05/13/2026 at 8:00 a.m. Review of Resident #29's physician orders revealed an order dated 05/06/2024 for Alprazolam tab (tablet) 0.5 mg (Milligrams), Give 1 tablet by mouth four times a day related to anxiety disorder. Review or Resident #29's MAR (Medication Administration Record) for May 2026 revealed that Alprazolam 0.5 mg tablet, 1 tablet was administered on 05/13/2026 at 9:00 a.m. and at 1:00 p.m. Review of Resident #71's physician orders revealed an order dated 10/29/2025 for Lacosamide oral tablet 100 mg, give 1 tablet by mouth two times a day related to epilepsy, unspecified, not intractable, without status epilepticus. Review or Resident #71's MAR (Medication Administration Record) for May 2026 revealed that Lacosamide 100 mg, 1 tab was administered at on 05/13/2026 at 8:00 a.m. Review of Resident #76's physician orders revealed an order dated 08/27/2024 for Xanax oral tablet 0.25 mg, give 1 tablet by mouth four times a day related to generalized anxiety disorder. Review or Resident #76's MAR (Medication Administration Record) for May 2026 revealed that Xanax 0.25mg (Alprazolam), 1 tab was administered on 05/13/2026 at 8:00 a.m. and at 12:00 p.m. Review of Resident #77's physician orders revealed an order dated 09/24/2025 for Xanax oral tablet 0.25mg (Alprazolam), give 1 tab by mouth two times a day for anxiety. Review or Resident #77's MAR (Medication Administration Record) for May 2026 revealed that Xanax 0.25mg (Alprazolam), 1 tab was administered on 05/13/2026 at 2:00 p.m. On 05/13/2026 at 1:13 p.m., S11LPN was approached to conduct a narcotic reconciliation of MC1. S11LPN offered that she had not signed out any of the narcotics that she had administered on the Individual Resident Narcotics Record yet. She stated that per facility policy, she should have signed out those narcotics on the Individual Resident Narcotics Record at the time the medications were administered. S1DON was requested to perform the narcotic reconciliation. On 05/13/2026 at 1:45 p.m., an interview was conducted with S1DON and S3RNS. Both confirmed that S11LPN should have signed out on the Individual Resident Narcotic Record any controlled medications she had administered at the time of administration. On 05/13/2026 at 1:47 p.m., a complete narcotic count was performed on MC1 with S3RNS which revealed the following inaccurate narcotic counts: Resident #23's Individual Resident Narcotics Record revealed a count of 42 tablets with the last dose documented on 05/12/2026 at 8:00 p.m. The current count of tablets observed was 41. Review of Resident #29's Individual Resident Narcotics Record revealed a count of 46 tablets with the last dose documented on 5/12/26 at 9:00 p.m. The current count of tablets observed was 44. Review of Resident #71's Individual Resident Narcotics Record revealed a count of 44 tablets for this medication with the last dose documented on 5/12/26 at 8:00 p.m. The current count of tablets observed was 43. Review of Resident #76's Individual Resident Narcotics Record revealed a count of 68 tablets for this medication with the last dose documented on 5/12/26 at 8:00 p.m. The current count of tablets observed was 66. Review of Resident #77's Individual Resident Narcotics Record revealed a count of 19 tablets for this medication with the last dose documented on 05/12/2026 at 8:00 p.m. The count of tablets observed was 18. On 05/13/2026 at 2:00 p.m, S3RNS confirmed that S11LPN had not signed out the controlled medications that she had administered on the day shift of 05/13/2026 on the designated Individual Resident Narcotics Record form and this caused the narcotic count to not be accurate.

Based on observations, record review, and interview, the facility failed to accurately assess 1 (#27) of 3 residents investigated for dental out of 55 sampled residents.Findings:Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophrenia, depression, bipolar, type 2 diabetes, chronic obstructive pulmonary disease, and obesity. Her Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact.On 05/11/2026 at 1:03 p.m., an observation of Resident#27's oral cavity revealed she had one decayed tooth on the top front and one decayed tooth on the bottom front. The rest of her teeth were broken and decayed at the gums. At this time, the resident stated her teeth were in this condition when she was admitted on [DATE].Record review of section L. Dental Status of Resident #27's admission MDS (Minimum Data Set) assessment dated [DATE] read in part:D. Obvious or likely cavity or broken natural teeth was not checked.E. Inflamed or bleeding gums or loose natural teeth was not checked.F. Mouth or facial Pain, Discomfort or difficulty with chewing was not checked.Z. None of the above were present was checked indicating none of the above was present. Record review of Resident #27's Dental Evaluation conducted by a dentist dated 01/22/2026 read in part: D. Obvious or likely cavity or broken natural teeth, E. Inflamed or bleeding gums or loose natural teeth. These boxes were checked, indicating the resident's dental status. On 05/12/2026 at 2:37 p.m., as assessment of Resident #27's oral cavity was conducted with S5LPN. S5LPN assessed Resident#27's oral cavity and confirmed the resident had one decayed tooth on the top front and one decayed tooth on the bottom front, and the rest of her teeth were broken off and decayed at the gums.On 05/12/2026 at 2:43p.m., review of Resident #27's dental evaluation dated 01/22/2026 and admission MDS assessment dated [DATE] was conducted with S4RN/AN who was responsible for completing MDS assessments. She confirmed she inaccurately assessed Resident #27 on her admission assessment dated [DATE]. S4RN/AS confirmed the resident had broken and decayed natural teeth on admission.

Based on observations, record reviews, and interviews, the facility failed to implement a person-centered care plan for 1 (#6) of 55 sampled residents.Findings:Record review of Resident #6's electronic record revealed she was admitted on [DATE] with diagnosis not limited to dementia, traumatic subdural hemorrhage, encephalopathy, chronic kidney disease-Stage 3, dysphagia, and depression, and bowel and bladder incontinence. Her brief interview of mental status score was 5, indicating severely impaired cognition. The resident's responsible party was identified as her daughter.Record review Resident #6's care plan dated 08/01/2024 read in part, The resident has bladder incontinence. Under task description read in part, Staff do not use perineal-wash on this resident due to sensitivity.On 05/11/2026 at 10:00 a.m. an observation revealed Resident #6 was lying in bed grimacing and holding her perineal area. The resident stated her private area was irritated and was aggravated to the point she could not tolerate it. Further observation revealed signs posted above her headboard, on the closet, and on the wall next to the door that read, Do not use perineal wash on this resident.On 05/11/2026 at 10:05 a.m., Resident #6's daughter entered the room and stated her mother's perineal area was severely irritated and was causing discomfort. She stated she had posted signs throughout the room when she realized the perineal wash irritated her mother, instructing the staff not to use perineal wash on her mother because she was extremely sensitive to the cleanser. She further stated her mother's perineal area would become irritated approximately every three months, and usually occurred when agency Certified Nursing Assistants (CNA) were utilized on the night shift.On 05/11/2026 at 10:21 a.m., an observation of Resident #6's perineal area was conducted with S9TN and S10CNA present. S9TN confirmed the resident's left groin and inner thigh was red, irritated, and raised. S10CNA confirmed she removed a bottle of perineal-wash from the resident's nightstand today when she came on her shift. She stated an agency CNA had left the perineal wash in the resident room after providing care. S10CNA further confirmed staff were not to use perineal wash on the resident due to the resident's sensitivity to the product and the resulting skin irritation.On 05/12/2026 at 9:36 a.m., an interview with S2ADON revealed CNA's were instructed to use a cleanser provided by the family and not to use perineal wash on Resident #6. S2ADON confirmed Resident #6's CNA that cared for the resident the previous night was an agency CNA.On 05/12/2026 at 9:42 a.m., an interview with S6LPN revealed she was Resident #6's assigned nurse. She confirmed the resident was allergic to perineal wash and developed a bright red rash to the groin and inner thigh areas when the product was used. On 05/12/2026 at 2:55 p.m., an interview with S1DON confirmed the C.N.A.'s were to follow the resident's plan of care and not use perineal wash on Resident #6 due to the resident's sensitivity to the product.

Based on record review, observations, and interviews, the facility failed to ensure a resident who was assessed as an unsafe smoker received adequate supervision while smoking for 1 (#24) out of 3 (#2, #11, #24) residents investigated for accidents. Findings:Review of the policy with a review date of 01/29/2026, titled Smoking Policies and Regulations read in part, residents identified as needing supervision shall have designated staff or approved visitors assist them while smoking.Review of Resident #24's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side, alcohol abuse with unspecified alcohol induced disorder, other psychoactive substance abuse with psychoactive substance induced psychotic disorder with delusions, and cognitive communication deficit.Review of Resident #24's modified significant change MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 04/17/2026 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating his cognition was severely impaired. Further review of Resident #24's MDS assessment revealed the resident was coded for current tobacco use. Review of Resident #24's care plan revealed a focus with an initiation date of 01/12/2026 which read in part: The resident is a smoker - (Supervised x (times) 1 staff member at all times). Interventions in part: The resident requires SUPERVISION while smoking. Review of Resident #24's smoking screening dated 01/26/2026 revealed he was a smoker and smoked cigarettes. Further review revealed the resident could not get to the designated smoking areas independently and was not able to follow smoking policies. Continued review revealed smoking recommendations that Resident #24 required 1:1 supervision while smoking. On 05/12/2026 at 11:45 a.m., S3RNS was observed wheeling Resident #24 in his wheelchair from the dining room to the smoking patio. S3RNS left Resident #24 on the smoking patio and re-entered the dining room. There was no staff or visitors observed on the smoking patio. On 05/12/2026 at 11:58 a.m., Resident #24 was observed on the smoking patio with a lit cigarette in his left hand. There were no staff or visitors present on the smoking patio. On 05/12/2026 at 12:01 p.m., S2ADON was summoned to the smoking patio. She removed the cigarette from Resident #24's left hand and informed him that he should not be smoking without supervision. S2ADON confirmed that Resident #24 was on the smoking patio unsupervised and should have been supervised by staff while smoking. On 05/12/2026 at 12:35 p.m., an interview was conducted with S3RNS. He confirmed that he had wheeled Resident #24 out onto the smoking patio and left him unsupervised while other residents smoked. S3RNS stated that he was aware that Resident #24 required supervision.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 25 opportunities were observed with 2 medication errors which resulted in a medication error rate of 8.00%. The facility failed to: 1. Administer Resident #38's Budesonide per manufacturer's instructions. 2. Administer Resident #98's Cholecalciferol per physician's ordersFindings:A review of the facility's policy titled Administration of Medications which was last reviewed on 01/29/2026, read in part, Purpose: To administer medications in accordance with best practice; Oral Medication Administration Procedure: 3. Verify the physician order, comparing the medication label to the MAR (Medication Administration Record) to verify the following: a. Right Medication, b. Right dosage, c. Right route, d. Right time, e. Right resident.Resident #38Review of Resident #38's health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to chronic obstructive pulmonary disease and bipolar disorder.Review of Resident #38's physician orders revealed an order dated 03/24/2026 for Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG (micrograms)/ACT (actuation) (Budesonide-Formoterol Fumarate Didydrate) 2 puff inhale orally in the morning related to chronic obstructive pulmonary disease. Review of manufacturer instructions included in the inhaler box for Resident #38, read in part, Instructions for Use, Using your Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler: 7. Breathe out fully (exhale). Hold the Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler up to your mouth. Place the white mouthpiece fully into your mouth and close your lips around it. Make sure that Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler is upright and that the opening of the mouthpiece is pointing towards that back of your throat. 8. Breathe in (inhale) deeply and slowly through your mouth. Press down firmly and fully on the top of the counter on the Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler to release the medicine. 9. Continue to breathe in (inhale) and hold your breath for about 10 seconds, or for as long as is comfortable. Before you breathe out (exhale), release your finger from the top of the counter. Keep the Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler upright and remove from your mouth. 10. Shake the Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler again for 5 seconds and repeat steps 7 to 9. On 05/12/2026 at 8:19 a.m., and observation was made of S6LPN administering medication to Resident #38. S6LPN was observed handing Resident #38's Budesonide inhaler to her. Resident #38 asked the nurse Two puffs right? for which S6LPN responded yes. No other instruction was given to the resident on the administration of the inhaler. Resident #38 inhaled two puffs, one after the other, without pausing during inhalation, or shaking the inhaler between puffs. Medication fumes were noted exiting the resident's mouth after each puff. On 05/12/2026 at 8:25 a.m., an interview and review of the manufacturer's Instructions for Use for Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler for Resident #38 was conducted with S6LPN. She confirmed that she had not instructed Resident #38 on the manufacturer's instructions for use of the inhaler, and she should have per facility protocol. She further confirmed that Resident #38's Budesonide inhaler had not been administered per manufacturer's instructions. On 05/12/2026 at 1:30 p.m., a phone interview and review of the manufacturer's instruction for use of a Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler was conducted with S7PC. He confirmed that the standard practice for Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler was to follow the manufacturer's instructions. He confirmed that if the resident was not instructed to hold her breath for 10 seconds, or as long as comfortable while using the inhaler, or shake the inhaler for 5 seconds between puffs, this medication was not administered per the standard practice. Resident #98Review of Resident #98's health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified dementia and low vitamin D.Review of Resident #98's physician orders revealed an order dated 07/08/2025 for Cholecalciferol tablet 1000 unit, give 2 tablets by mouth one time a day for low vitamin D. On 05/12/2026 at 7:35 a.m., an observation was made of S8LPN administering medications to Resident #98. S8LPN was observed administering only 1 tablet of Cholecalciferol 1000 units. On 05/12/2026 at 9:47 a.m., an interview and review of Resident #98's MAR was conducted with S8LPN. She confirmed that she had only administered 1 tablet of Cholecalciferol 1000 units and she should have administered two tablets per Resident #98's physician order. On 05/12/2026 at 5:00 p.m., an interview, review of Residents #38 and #98's MAR, and review of Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler manufacturer Instructions for Use, was conducted with S1DON. S1DON confirmed that Resident #98 should have received 2 tablets of Cholecalciferol 1000 units per her physician orders. S1DON further confirmed that Resident #38 should have been instructed on the use of her Budesonide inhaler during administration per the manufacturer's instructions. She further confirmed Resident #38 having taken two puffs without inhaling for 10 seconds or as long as comfortable, and not shaking the inhaler between puffs did not follow the standard practice for administration of this medication.

Based on observation, interview, and record review, the facility failed to ensure the nurse performed hand hygiene and changed gloves while administering wound care treatments for 1 resident (#17) out of 2 residents reviewed for pressure ulcer/injury out of a final sample of 55 residents.Findings:Review of the facility's policy titled Dressing Change Police and Procedure, with a last reviewed date of 01/29/2026, revealed in part: Steps in the procedure.11. Remove dressing. Pull gloves over dressing and discard.12. Perform hand hygiene. Put on disposable gloves. 13. Irrigate/cleanse the skin area as ordered.16. Perform hand hygiene. Apply disposable gloves.18. Dress the area with the prescribed dressing, date and initial the dressing.Review of Resident #17's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, Hemiplegia and hemiparesis following cerebral infarction, pressure ulcer of left buttock, stage 2, and pressure ulcer of right buttock, stage 2. Review of Resident #17's Physician's Orders revealed an order dated 04/28/2026 that read: Cleanse stage 2 pressure injury on left inner buttocks with wound cleanser, pat dry, apply collagen and dry dressing every day. Further review revealed an order dated 05/05/2026 that read: Cleanse stage 2 pressure injury to right buttocks near sacrum with wound cleanser, apply collagen, skin prep to periwound and cover with dry dressing daily and as needed until resolved. On 05/13/2026 at 1:12 p.m., an observation was conducted of S3RNS performing wound care for Resident #17. S3RNS performed hand hygiene and donned a gown and gloves prior the entering the resident's room. S3RNS sprayed wound cleanser on gauze and used the gauze to clean Resident #17's sacral wound. S3RNS did not remove his gloves or perform hand hygiene after cleansing the resident's wound. S3RNS then opened collagen from the package and placed the collagen on Resident #17's sacral wound. S3RNS did not remove his gloves or perform hand hygiene. S3RNS then opened a dressing from the package and placed the dressing over the collagen on Resident #17's sacral wound and labeled the dressing with a marker. S3RNS did not perform hand hygiene or change gloves at any time during the procedure. On 5/13/2026 at 1:19 p.m., an interview was conducted with S3RNS. S3RNS stated he did not have taken his gloves off nor sanitized his hands between cleaning Resident #17's wound and applying the dressing. S3RNS stated it is customary to remove gloves and sanitize hands and put new gloves on after cleaning a resident's wound and before applying a dressing. On 05/13/2026 at 2:40 p.m., an interview was conducted with S1DON. S1DON stated the Infection Control nurse was out of the facility today and she was the acting Infection Control nurse in her absence. S1DON stated S3RNS should have removed his gloves and performed hand hygiene after cleansing the resident's wound and he should have donned new gloves before applying the collagen and dressing.

Based on interviews and record review, the facility failed to ensure a resident's comprehensive care plan was revised for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure that the comprehensive care plan was updated to include accurate advance directive code status for Resident #2. Findings:A review of the facility's policy titled Care Plan Process with a review date of [DATE], read in part: Baseline Care Plan and Summary: The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with each resident's written plan of care. A review of the facility's policy titled Advance Directives with a review date of [DATE], read in part: Purpose: To support the implementation of the Patient Self-Determination Act within the framework of state and federal law and facility policies. All staff providing care for the resident will review the Advance Directive and clarify any discrepancies between the Directive and current treatment plan. Review of Resident #2's electronic medical record revealed an admission date of [DATE] with diagnoses that included in part, Alzheimer's disease, cerebral vascular disease, and cerebral infarction. Review of Resident #2's Order Summary Report revealed a physician order DNR (Do not Resuscitate) dated [DATE].Review of Resident #2's Advanced Directive Consent dated [DATE] revealed DNR was selected in the code status category. Review of Resident #2's Louisiana Physician Order for Scope of Treatment (LaPOST) dated [DATE] revealed that DNR/Do Not Attempt Resuscitation (Allow Natural Death) was selected under Cardiopulmonary Resuscitation (CPR). Review of Resident #2's Care Plan Report revealed Focus: Full Code, Date Initiated: [DATE], Revision on: [DATE]. On [DATE] at 12:11 p.m., an interview and review of Resident #2's electronic medical record was conducted with S2MDS (Minimum Data Set). She confirmed that Resident #2's Care Plan Report was inaccurate, stating Full Code. She further confirmed that the Care Plan Report should have been revised to reflect the resident's DNR status, as documented in the resident's physician orders and LaPost. On [DATE] at 12:34 p.m., an interview and review of Resident #2's electronic medical record was conducted with S1DON (Director of Nursing). S1DON confirmed that Resident #2's Care Plan Report was inaccurate, stating Full Code. She further confirmed that the Care Plan Report should have been revised to reflect the resident's DNR status, as documented in the resident's physician orders and LaPost.

Based on record reviews and interview, the facility failed to ensure a Minimum Data Set (MDS) assessments were completed using the Resident Assessment Instrument (RAI) process within regulatory timeframes for 17 (#3, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #61, #66, #67, #82, #89, #307) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) total residents reviewed for assessments. Findings: Review of Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual- RAI Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary revealed that Assessment Reference Date (ARD) for Resident Assessments should be completed no later than the 14th calendar day of the resident's ARD. The following Resident records were reviewed on 04/07/2025 . Review of Resident #3's Electronic Health Record (EHR) revealed a quarterly MDS assessment with an ARD of 02/14/2025 and a required completion date of 02/28/2025. Continued review of Resident #3's EHR revealed a discharge MDS assessment with an ARD of 03/05/2025 and a required completion date of 03/19/2025. Further review of Resident #3's quarterly and discharge assessments revealed they remained in progress and had not been completed within the 14 day timeframe. Review of Resident #10's EHR revealed a quarterly MDS assessment with an ARD of 02/22/2025 and a required completion date of 03/08/2025. Further review of Resident #10's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #14's EHR revealed a quarterly MDS assessment with an ARD of 02/07/2025 and a required completion date of 02/21/2025. Further review of Resident #14's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #15's EHR revealed an annual MDS assessment with an ARD of 03/05/2025 and a required completion date of 03/19/2025. Further review of Resident #15's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #18's EHR revealed a quarterly MDS assessment with an ARD of 03/01/2025 and a required completion date of 03/15/2025. Further review of Resident #18's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #20's EHR revealed a quarterly MDS assessment with an ARD of 03/20/2025 and a required completion date of 04/03/2025. Further review of Resident #20's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #27's EHR revealed a quarterly MDS assessment with an ARD of 02/20/2025 and a required completion date of 03/06/2025. Further review of Resident #27's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #28's EHR revealed a quarterly MDS assessment with an ARD of 03/14/2025 and a required completion date of 03/28/2025. Further review of Resident #28's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #36's EHR revealed a quarterly MDS assessment with an ARD of 02/13/2025 and a required completion date of 02/27/2025. Further review of Resident #36's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #37's EHR revealed a quarterly MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025. Further review of Resident #37's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #46's EHR revealed an annual MDS assessment with an ARD of 02/21/2025 and a required completion date of 03/07/2025. Further review of Resident #46's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #61's EHR revealed an annual MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025. Further review of Resident #61's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #66's EHR revealed a quarterly MDS assessment with an ARD of 02/22/2025 and a required completion date of 03/08/2025. Further review of Resident #66's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #67's EHR revealed a quarterly MDS assessment with an ARD of 03/02/2025 and a required completion date of 03/16/2025. Further review of Resident #67's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #82's EHR revealed an annual MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025. Continued review revealed a death MDS assessment with an ARD of 03/19/2025 and a required completion date of 03/26/2025. Further review of Resident #82's annual and death assessment revealed they remained in progress and had not been completed within the 14 day timeframe. Review of Resident #89's EHR revealed a quarterly MDS assessment with an ARD of 02/13/2025 and a required completion date of 02/27/2025. Further review of Resident #89's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. Review of Resident #307's EHR revealed an admission MDS assessment with an ARD of 03/04/2025 and a required completion date of 03/04/2025. Further review of Resident #307's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe. On 04/09/2025 at 1:47 p.m., an interview and records review was conducted with S5MDS who reviewed each of the Resident's records and confirmed each one was incomplete and remained open and in progress. S5MDS confirmed that each assessment should have been completed no later than the 14th calendar day of the resident's ARD and was not.

Based on interview and record review, the provider failed to transmit a completed Discharge MDS (Minimum Data Set) Assessments within 14 days after completion for 7 (#9, #52, #68, #74, #83, #90, #95) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) resident's investigated for resident assessments. Findings: Review of Resident #9's electronic clinical record revealed a quarterly MDS assessment, with an ARD (Assessment Reference Date) of 01/28/2025, was completed on 01/31/2025. Review of the facility's CMS (Center for Medicare Services) transmittal validation report indicated Resident #9's quarterly MDS assessment with the ARD of 01/28/2025 was transmitted on 04/07/2025 and was more than 14 days late. Review of Resident #52's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 01/25/2025, was completed on 01/28/2025. Review of the facility's CMS transmittal validation report indicated Resident #52's quarterly MDS assessment with the ARD of 01/25/2025 was transmitted on 04/07/2025 and was more than 14 days late. Review of Resident #68's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/05/2025, was completed on 02/19/2025. Review of the facility's CMS transmittal validation report indicated Resident #68's quarterly MDS assessment with the ARD of 2/05/2025 was transmitted on 04/09/2025 and was more than 14 days late. Review of Resident #74's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/14/2025, was completed on 02/14/2025. Review of the facility's CMS transmittal validation report indicated Resident #74's quarterly MDS assessment with the ARD of 02/14/2025 was transmitted on 04/04/2025 and was more than 14 days late. Review of Resident #83's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 01/10/2025, was completed on 01/24/2025. Review of the facility's CMS transmittal validation report indicated Resident #83's quarterly MDS assessment with the ARD of 01/10/2025 was transmitted on 04/07/2025 and was more than 14 days late. Review of Resident #90's electronic clinical record revealed a significant change MDS assessment, with an ARD of 01/29/2025, was completed on 02/03/2025. Review of the facility's CMS transmittal validation report indicated Resident #90's quarterly MDS assessment with the ARD of 01/29/2025 was transmitted on 04/07/2025 and was more than 14 days late. Review of Resident #95's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/06/2025, was completed on 02/20/2025. Review of the facility's CMS transmittal validation report indicated Resident #95's quarterly MDS assessment with the ARD of 02/06/2025 was transmitted on 04/09/2025 and was more than 14 days late. On 04/09/2025 at 1:47 p.m., a concurrent interview and records review was conducted with S5MDS (Minimum Data Set Nurse). S5MDS reviewed each of the Resident's records and compared them to the facility's transmittal validation report that was received from CMS. S5MDS confirmed each assessment had been submitted greater than 14 days after completion and should not have been.

Based on observation, interview, and record review, the facility failed to ensure residents received food in the amount required to meet nutritional needs of residents by failing to use the appropriate serving sizes as indicated by the diet spreadsheet. This deficient practice had the potential to affect the 21 residents residing on the secured unit. Findings: Review of the diet spreadsheet for 04/07/2025 revealed dietary staff was required to serve the following: 7 oz (ounces) of ham and beans and 1/2 cup of greens for residents who received regular and mechanical soft diets, and 2 #8 scoops of pureed ham and beans for residents who received pureed diets. On 04/07/2025 at 11:00 A.M., an observation was made of the kitchen staff while they served lunch. Observations were then made of dietary staff as they prepared meal trays for the secure unit. S3Dietary placed greens onto the residents' plates using a 1/3 cup sized scoop. S8Dietary proceeded to prepare meal trays using a 6 oz scoop for the regular ham and beans. S2DM confirmed the staff were using the incorrect scoop sizes for the regular ham and beans and greens. Further observation was made of the dietary staff while they prepared pureed meal trays. The staff prepared two meal trays using a 6 oz scoop for pureed ham and beans. S2DM confirmed the staff should have been using 2 #8 scoops as the spreadsheet stated. The dietary staff did not re-make residents' plates using the correct serving sizes prior to distributing them to the secured unit.

Based on record review, observations, and interviews, the facility failed to maintain an effective 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 as evidenced by failing to esnure: 1. S6TXN (Treatment Nurse) wore proper PPE (Personal Protective Equipment) while providing wound care to Resident #11, and S10CNA (Certified Nursing Assistant) wore proper PPE while providing care to Resident #83 who was on Enhanced Barrier Precautions; 2. S6TXN appropriately removed and discarded soiled PPE; after completing wound care. This deficient practice had the potential to affect a census of 96 residents. Findings: Review of facility policy and procedure titled Enhanced Barrier Precautions (EBP) with a review date of 01/29/25, read in part .enhanced barrier precautions require the use of gown and gloves only for high-contact resident care activities. The following high-contact resident care activities include but limited to: Providing hygiene, and wound care (chronic wounds include, but not limited to, diabetic foot ulcers, and venous stasis ulcers) Resident #11: Review of Resident #11 Electronic Medical Record (EMR) revealed he was admitted on [DATE] with diagnoses which included peripheral vascular disease, and diabetes mellitus. The resident also had bilateral lower extremity arterial ulcers which required wound care. On 04/08/2025 at 9:00 a.m., a wound care observation and immediate interview was conducted with S6TXN. Further observation revealed an EBP sign posted on the wall above the residents bed. S6TXN was observed cleaning the stasis ulcer on the resident's lower legs, and left heel. Further observation did not reveal that S6TXN had donned the appropriate PPE. S6TXN was asked if she should be wearing a gown while providing wound care, and she then stated that she should have donned a protective covering, which was a gown. On 04/08/2025 at 9:15 a.m., after completing wound care S6TXN was observed exiting Resident #11's room, with her soiled PPE rolled up and, placed onto a silver tray, and going into the hallway, she placed it into a clear plastic bag. S6TXN was asked if she should have removed the soiled PPE inside of the room, and she confirmed that the PPE should have remained inside the resident's room and placed into a bag. 49784 Resident #83: Review of Resident #83's electronic medical record revealed an admitted [DATE] with diagnosis that included in part, gastrostomy status and Alzheimer's disease. On 04/08/25 3:03 p.m., an assessment of Resident #83's mouth and an interview was conducted with S10CNA. A sign indicating EBP (Enhanced Barrier Precautions) was present on the outside of Resident #83's door. S10CNA was observed without a gown while placing her gloved hands in the resident's mouth to assist with an oral assessment. S10CNA stated that she is not required to wear a gown when providing any care for Resident #83. She stated that the EBP sign on Resident #83's door only indicated what PPE (Personal Protective Equipment) to wear if the resident was on special precautions, and that Resident #83 was not. 04/09/25 3:12 p.m., an interview was conducted with S11IP (Infection Preventionist). He stated that Resident #83 is on EBP, and that a gown should be worn for direct care of his mouth.

Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (#7) resident in a final sample size of 33. The deficient practice has the potential to affect a census of 96. Findings: Review of Resident #7's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, epilepsy, hemiplegia and hemiparesis, urinary tract infection, major depressive disorder, anxiety disorder, and abnormalities of gait and mobility. Review of Resident #7's nurse's notes revealed on 12/13/2024 at 1:20 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/15/2024 at 2:20 p.m., the resident returned from the hospital back to the facility. Review of Resident #7's nurse's notes revealed on 12/24/2024 at 8:15 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/24/2024 at 1:02 p.m., the resident returned from the hospital back to the facility. Review of the Emergency Transfer Log for December 2024 revealed Resident #7's transfer to the hospital on [DATE] and 12/24/2024 was not identified on the list. Review of Resident #7's nurse's notes revealed on 03/07/2025 at 6:15 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/09/2025 at 12:27 p.m., the resident returned from the hospital back to the facility. Review of Resident #7's nurse's notes revealed on 03/14/2025 at 3:14 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/14/2025 at 5:24 a.m., the resident returned from the hospital back to the facility. Review of Resident #7's nurse's notes revealed on 03/17/2025 at 7:45 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/17/2025 at 10:25 p.m., the resident returned from the hospital back to the facility. Review of the Emergency Transfer Log for March 2025 revealed Resident #7's transfer to the hospital on [DATE], 03/14/2025 and 03/17/2025 were not identified on the list. On 04/09/2025 at 12:45 p.m., an interview and record review was conducted with S8AM (Accounts Manager), who confirmed she was responsible for sending the Emergency Transfer Log to the State Long Term Care Ombudsman. S8AM reviewed Resident #7's nurse's notes and confirmed the resident was transferred to the hospital on [DATE], 12/24/2024, 03/07/2025, 03/14/2025, and 03/17/2025. She then reviewed the Emergency Transfer Log for December 2024 and March 2025 and confirmed the resident was not listed as having been transferred on the above dates. S8AM stated she had emailed the State Long Term care Ombudsman of facility-initiated transfers for the month of March 2025 on 04/07/2025. S8AM also stated she was not aware that facility initiated transfers for less than 24 hours had to be listed on the Emergency Transfer Log and sent to the State Long Term Care Ombudsman.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for restraint use for 1 (#28) of 33 sampled residents whose records were reviewed. Findings: Review of Resident #28's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diabetes mellitus, acquired absence of right leg below knee and acquired absence of other left toes. A review of Resident #28's December 2024 Physician's Orders revealed no order for a restraint. Further review of resident #28's medical record revealed an Annual MDS assessment with an ARD (Assessment Reference Date) of 12/12/2024, which read in part . Section P. Restraints and Alarms .Used in Chair or Out of Bed .Trunk restraints .were indicated. On 04/09/2025 at 4:29 p.m., an interview and record review was conducted with S5MDS who confirmed Resident #28 did not have an order for a restraint. She reviewed the referenced MDS, and confirmed the use of a restraint was indicated on the assessment and should not have been.

Based on record review and interview, the facility failed to develop a comprehensive centered care plan for a Level II PASRR (Preadmission Screening and Resident Review) for 1 (Resident #47) out of 33 sampled residents. This deficient practice had the potential to affect a census of 96. Findings: Review of Resident #47's medical record revealed she was admitted on [DATE] with a diagnosis that included, but not limited to, Schizoaffective Disorder, Depressive Type. Review of Resident #47's Notice of Medical Certification dated 08/28/2024 read in part, Section II. H. Approved for admission by Level II Authority for a temporary period effective 09/07/2024 through 09/06/2025. Review of OBH-PASRR (Office of Behavioral Health-Preadmission Screening and Resident Review) Evaluation Summary and Determination Notice Evaluation and Placement Recommendations read in part, the individual has a serious mental illness and is recommended nursing home admission. Review of Resident #47's comprehensive person-centered care plan revealed she was not care planned for a Level II PASRR. On 04/09/2025 at 3:04 p.m., an interview and record review was conducted with S5MDS (Minimum Data Set). She confirmed that Resident #47 was a Level II PASRR and this should have been included in her comprehensive care plan and it was not.

Based on interviews and record review, the facility failed to ensure that a resident was invited to the resident's care planning meetings for 1 (Resident #54) out of a sample of 33 residents. This deficient practice had the potential to affect a census of 96. Findings: A review of the facility's policy titled Care Plan Process with a review date of 01/29/2025, read in part: Baseline Care Plan and Summary: The facility must provide the resident and the resident representative, if applicable, with a written summary of the baseline care plan by completion of the comprehensive care plan. Step 3: Obtain and consider input from resident and/or family/resident's representative regarding the care area. The IDT (Interdisciplinary Team) will minimally include in part the resident and the resident's representative. If the participation of the resident and their representative is determined to be not practicable for the development of the resident's care plan, and explanation shall be included in the resident's medical record. Review of Resident #54's electronic medical record revealed an admitted [DATE] with diagnosis diagnoses that included in part, chronic kidney disease, heart failure, and major depressive disorder. A review of Resident #54's quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 02/25/2025 revealed she had a BIMS (Brief Interview for Mental Status) score of 15, suggesting the resident's cognition was intact. A review of Resident #54's electronic medical record revealed that she had a Significant Change MDS assessment on 02/25/2025 and 01/25/2025, and a Quarterly MDS assessment on 12/17/2024. On 04/07/2025 at 12:07 p.m., an interview was conducted with Resident #54. Resident #54 stated that she had never been to a care plan meeting and had never heard of a care plan meeting since she had lived in the facility. On 04/09/2025 at 10:18 a.m., an interview and record review was conducted with S5MDS (Minimum Data Set Nurse) and S7MDS. S5MDS explained one of the MDS staff provided SSD (Social Service Director) a calendar indicating who the specific residents or residents' representatives were for the SSD to invite to the care plan meetings. Both S5MDS and S7MDS stated that resident or representatives were not invited to care plan meetings when a Significant Change MDS assessment was completed. Both stated that residents and representatives were only invited to care plan meetings associated with quarterly and annual MDS assessments. S7MDS confirmed that there was no documentation that a care plan meeting was conducted for Resident #54 for the MDS assessment dated [DATE], nor that the resident or the residents' representative was present or had declined to attend. Both confirmed that they did not have knowledge of the resident attending this care plan meeting. On 04/09/2025 at 10:52 a.m., an interview was conducted with S9SSD. S9SSD stated that she had never been instructed to invite the residents to their care plan meetings and had not invited Resident #54 to past care plan meetings.

Based on record review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of improvement as evidenced by failing to have documented evidence of monitoring the effectiveness of the proposed plan of action. This deficient practice had the potential to affect a census of 98 residents. Findings: Review of the facility's form titled, Corrective Action Plan, dated 02/12/2025 revealed: 1. Problem Identified: Tasks not firing correctly due to facility changed from 12 hour shifts to 8 hour shifts. 12 hour shifts continued to fire to tasks in addition to 8 hours. Several time code discrepancies resulted in facility wide tasks audit to make corrections. 2. Plan of Action: Immediate action of Task audits of each resident correcting each task time code. Audit of Every individual task for each resident audited and corrected. Nursing staff were in-serviced on task time codes (8 hours) and correct body audit schedules must be verified on each new admit and hospital return/readmission. Projected completion date: 02/14/2025. 3. Monitoring: DON (Director of Nursing)/ designee to randomly audit 5 resident tasks 3 times weekly to ensure time codes are accurately reflecting 8 hour shifts and body audits are set up weekly per schedule. Hospital returns are to be audited within 24-72 hours of return to ensure any cancelled tasks that still apply to resident are reactivated. 4. Follow- up for Effectiveness: Section remained blank and failed to include a resolved date. On 03/12/2025 at 4:30 PM, a review of the facility's corrective action plan and an interview was conducted with S1CN (Corporate Nurse) and S2DON (Director of Nursing). There was no documented evidence that the actions implemented were measured or that performance of the action plans were tracked from 02/12/2025 through 03/10/2025. There was also no evidence of data collection and analysis. S1CN and S2DON confirmed there was no documented evidence of monitoring, or performance tracking conducted from 02/12/2025 thru 03/10/2025.

Based on record review, observations and interview, the facility failed to ensure that residents received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 2 residents (#2 and #3) out of a total of 6 (#1, #2, #3, #R4, #R5 and #R6) sampled residents. This deficient practice was evidenced by the facility staff failing to: 1. Conduct weekly body audits for Resident #3; 2. Identify a Stage 2 Pressure Ulcer for Resident #3; and 3. Provide ordered treatments for Resident #2. Findings: A review of the facility's policy titled, Weekly Body Audit, with a latest review date of 08/2021 revealed, in part: To be completed weekly for all residents to identify any new alterations in skin integrity. On a designated day of the week, per facility schedule as developed by the DON (Director of Nursing), a body audit will be performed. The Licensed Nurse completes a head to toe inspection of the skin with notation of no new problem or new problem noted. If a new issue is noted, additional documentation in the nurse notes is required. The Licensed Nurse proceeds forward per policy if a change in the resident's condition is noted. Communicate to Interdisciplinary Team, Physician/ NP (Nurse Practitioner) and family/designee any changes in skin integrity. 1. Resident #3 Resident #3 was admitted to the facility on [DATE] with the following pertinent diagnoses: COPD (chronic obstructive pulmonary disease), type 2 DM (diabetes mellitus) w/ diabetic neuropathy, paranoid schizophrenia, bipolar disorder, pulmonary nodule, vitamin b12 deficiency anemia, adult failure to thrive, weakness, dependence on supplemental oxygen, anxiety and major depressive disorder and protein-calorie malnutrition. Review of the Admission MDS (Minimum Data Set) assessment dated [DATE] revealed under Section M, Skin Conditions, Resident #3 was assessed at risk for developing pressure ulcers. Review of Resident #3's care plan revealed the resident had an intervention to conduct weekly body audits as scheduled. Further review of Resident #3's EHR failed to include evidence that weekly body audits were conducted the weeks of: 11/03/2024, 11/10/2024, 12/15/2024, 12/29/2024, 01/12/2025, 01/19/2025 and 01/26/2025. 2. Review of Significant Change MDS assessment dated [DATE] revealed under Section M, Skin Conditions, Resident #3 was assessed at risk for developing pressure ulcers. Further review of Resident #3's EHR revealed the last weekly body audit to identify any new skin issues was last conducted on 01/11/2025 which revealed no skin issues. There were no furher records of weekly body audits after this date. Review of Resident #3's EHR (Electronic Health Record) revealed the resident was sent to the emergency roiagnom on [DATE] and admitted inpatient from 02/05/2025 through 02/08/2025. Hospital records revealed visual evidence via photo of a Stage 2 pressure ulcer to Resident #3's sacral spine which was present on admission to the hospital measuring length (l) x width (w) x depth (d) in centimeters (cm) 1.5cm x 1.5 cm x 0.2 cm. On 03/11/2025 at 2:00 PM, an interview was conducted with S3TxLPN (Treatment Licensed Practical Nurse) who stated weekly body audits were completed by the floor nurses and any new skin conditions or skin changes identified were reported to her. On 03/12/2025 at 4:10 PM, an interview was conducted with S1CN (Corporate Nurse) and S2DON (Director of Nursing). S1CN was unable to provide documentation that weekly body audits were conducted for the weeks of 11/03/2024, 11/10/2024, 12/15/2024, 12/29/2024, 01/12/2025, 01/19/2025 and 01/26/2025. S1CN was also unable to provide documentation of Resident #3's weekly body audit being conducted prior to Resident #3 being hospitalized week of 02/02/2025. 39319 3. Resident #2 Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included the following in part, unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, protein-calorie malnutrition, cerebral infarction, atrial fibrillation, anxiety disorder, major depressive disorder, hypertension, and, muscle weakness. Further review revealed the resident had a facility acquired pressure ulcer identified on her left heel on 01/04/2025. Review of Resident #2's February 2025 TAR (Treatment Administration Record) revealed the following: An order with a start date: 01/24/2025 and stop date: 02/04/2025: Stage II to left heel apply collagen powder and cover with foam dressing daily. Further review revealed missed wound care treatments on 02/01/2025 and 02/02/2025. An order with a start date: 02/05/2025 and stop date: 02/13/2025. Stage II to left heel paint with betadine and dry dressing until resolved every day shift. Further review revealed missed wound care treatments on 02/08/2025, 02/09/2025 and 02/12/2025. An order with a start date 02/14/2025: Stage II to left heel paint with betadine, non-adherent pad and dry dressing until resolved every day shift. Further review revealed missed wound care treatments on 02/15/2025, 02/18/2025, 02/22/2025, and 02/23/2025. Review of the resident's March 2025 TAR revealed the following: An order with a start date: 02/14/2025: Stage II to left heel paint with betadine, non-adherent pad and dry dressing until resolved. Further review revealed missed wound care treatments on 03/03/2025, 03/08/2025, and 03/09/2025. On 03/12/2025 at 4:20 PM, an interview was conducted with S2DON (Director of Nursing). She stated that they were aware of the missed wound care treatments for Resident #2. She stated the treatments should have been done as ordered.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Discard expired foods from the kitchen refrigerator, freezer, and dry storage area; 2. Label opened foods with the date they were opened; 3. Remove compromised cans from the dry storage area; 4. Clean the inside of oven and outside of refrigerator and freezer; and 5. Ensure staff wore hair restraints in the kitchen. This deficient practice had the potential to affect the 92 residents who consumed food from the kitchen from a census of 93 Residents., Findings: On [DATE] at 3:00 p.m., a review was conducted of the facility's policy titled, Storage of Refrigerated Food with a revision date of [DATE]. This Policy read in part, The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure .5. All non-hazardous, opened foods are labeled with name of food, date stored .11. Food shall be stored base on use-by expiration date . On [DATE] at 3:00 p.m., a review was conducted of the facility's policy titled Storage of Frozen Food with a revision date of [DATE]. This Policy read in part, The facility ensures the quality and safety of frozen food through accepted storage practices. Procedure: Frozen foods are used or discarded on or before the use-by expiration date . On [DATE] at 3:00 p.m., a review was conducted of the facility's policy titled Storage of Canned and Dry Food with a revision date of ,d+[DATE]. The policy read in part, Procedure .8. Opened packages are stored in tightly covered containers or zipped plastic bag . If stored in a container other than how they were received, the items name and date it was received or opened must be visible or written on the new storage container. On [DATE] at 3:00 p.m., a review was conducted of the facility's policy titled Persons Allowed in The Food Service Department with a revision date of [DATE]. The policy read in part, Procedure .5.All employees and non-employees entering the food service department must wear hair restraints, including beard restraint as applicable. On [DATE] at 8:38 a.m., a tour of the facility's kitchen was conducted with S5DietarySup (Dietary Supervisor). She stated that she was responsible for the day-to-day management of the kitchen. An observation of the walk-in refrigerator with S5DietarySup revealed the following items were opened but not labeled with the date and time they were opened: 1-gallon bottle of myonnaise 1-gallon bottle of mustard 1 bag of dinner rolls 2-gallon bottles of milk 1-quart box of milk 3 bags of sliced bread S5DietarySup confirmed the items were opened, and not labeled with the date and time, and stated they should have been labeled with the date and time they were opened. The following items did not have a date they were made or a use-by date: 9 pre-made fruit cups covered with plastic. S5DietarySup confirmed that the pre-made fruit cups should have been labeled with the date and time they were made and placed in the refrigerator. The following items were observed without labeling to specify what they were and when they were prepared or when to be discarded. S5DietarySup identified the contents of the following unlabeled items as: 1 pitcher of brown liquid with tea 1 pitcher of red liquid with punch S5DietarySup confirmed the items had no label to specify the contents and when they were prepared. She further confirmed the items should have been labeled to specify the contents and when they were prepared. Further observations revealed the following items were expired: 31 loaves of sliced bread dated [DATE]; 1 dated [DATE]; 2 dated [DATE] S5DietarySup confirmed the items were expired and should have been discarded. An observation of the walk-in freezer revealed the following items were expired or opened with no date or time: Hot dog buns: 1 bag dated [DATE]; 1 bag dated [DATE]; 2 bags hot dog buns dated [DATE] 29 hamburger buns dated [DATE] An open bag of poboy buns with 6 remaining. S5DietarySup confirmed that the items were expired and should have been discarded on the date they expired. She also confirmed that the poboys buns should have the date and time the bag was opened. An observation of the dry storage room revealed the following items were expired: 1 plastic gallon-bag with rice cereal dated [DATE] 3 packs citrus gelatin dated [DATE] 1 plastic gallon bag with cheerios dated [DATE] and another dated [DATE] 1 plastic gallon - bag with Raisin Bran dated [DATE] 1 plastic gallon-bag with cornflakes dated [DATE] 1 gallon-bag with frosted flakes dated [DATE] 5 packages cornbread mix dated [DATE] 2 packs brownie mix dated [DATE] 4 packs brownie mix dated [DATE] The following items were opened but had no opened date: 1 two way white cake mix and 2 bags bacon bits. The following items were compromised: 1 can tomato soup with yellow build-up on the outside of the can, and 3 dented cans. Further observation of the dry storage room revealed the floor underneath the rolling shelfs had loose cereal on the floor and moderate dust build-up in the corners. S5DietarySup confirmed the items in the dry storage area were expired, opened, and had no date to tell when they were opened. She also confirmed the compromised can and the dirty floor. S5DietarySup stated that the items should have been discarded and the floor cleaned. An observation of the inside of the baking oven revealed a white dry build up on the bottom, and moderate amount of brown splatters on the inside of bilateral oven doors. Debris was noted underneath the oven doors when they were opened. S5DietarySup confirmed the findings and stated the oven should have been cleaned but was not. An observation of the outside of the walk-in refrigerator and walk-in freezer revealed a green moist build-up around the bottom of the doors. S5DietarySup confirmed the green moist build-up and stated that it should have been cleaned. On [DATE] at 9:54 a.m., an observation was made of S13Maint (Maintenance) walking in the kitchen as surveyor stood by the counter observing the pureed process. Further observation revealed S13Maint had a full beard which was uncovered. On [DATE] at 12:24 a.m., an interview was conducted with S13Maint. He confirmed that he walked through the kitchen with his beard uncovered and stated that he should have worn a beard covering. On [DATE] at 11:03 a.m., an observation was conducted of S11AD (Activities Director) walking into the kitchen with no hair covering. On [DATE] at 1:10 p.m., an interview was conducted with S11AD. S11AD stated that she walked into the kitchen without hair covering to check a schedule in the kitchen, and stated that she should have worn a hair net but had not.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards as evidenced by: 1.Failing to ensure oxygen equipment was stored appropriately when not in use for Resident #5 and Resident #68; 2.Failing to ensure oxygen equipment was changed for Resident #53, Resident #68, and Resident #80; 3.Failing to ensure oxygen equipment was properly dated for resident #80. Findings: On 03/19/2024, a review of the facility's policy titled Infection Control Oxygen Equipment Cleaning with a last reviewed date of 01/25/2024 read in part . 5. Pre-filled humidifiers are to be dated .6. Refillable humidifiers should be washed and refilled every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannulas should be replaced every 7 days. 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Resident #5 Review of Resident #5's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), and COVID-19. Review of Resident #5's March 2024 physician's orders revealed an order dated 03/06/2024 for O2 (oxygen) at 2 Liters per minute per Nasal Cannula as needed for SOB (shortness of breath), or decreased sats (oxygen saturation). Review of Resident #5's care plan read in part .Resident has a Dx (diagnosis) of COPD. Interventions included: Oxygen as ordered .Resident at risk for COVID-19: 02/20/2024: COVID-19 positive. On 03/18/2024 at 9:20 a.m., an observation was made of Resident #5's room. An oxygen concentrator was observed near the resident's bedside dresser while not in use. The nasal cannula tubing was draped over the oxygen concentrator open to air, with the nose piece of the tubing making contact with the machine. On 03/18/2024 at 10:42 a.m., a second observation was made of Resident #5's room. The nasal cannula tubing remained draped over the oxygen concentrator open to air with the nose piece of the tubing making contact with the machine. On 03/18/2024 at 10:53 a.m., S8LPN (Licensed Practical Nurse) was asked to enter Resident #5's room. S8LPN observed the oxygen concentrator machine and confirmed the nasal cannula tubing was open to air and not stored appropriately. S8LPN stated the nursing staff was responsible for storing nasal cannula tubing in a bag when not in use. 46149 Resident #68 Review of Resident #68's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety. Review of Resident #68's March 2024 physician's orders revealed the following order dated 03/18/2024: O2 (Oxygen) at 2L/Minute (Liters per Minute) per nasal cannula prn (As Needed) SOB (Shortness of Breath). On 03/18/2024 at 9:27 a.m., an observation was made of Resident #68's room. An oxygen concentrator was observed with the nasal cannula tubing attached to a refillable humidifier. The nasal cannula was draped over the oxygen concentrator and was not in bag. The refillable humidifier was labeled with a date of 02/18/2024. On 03/18/2024 at 9:29 a.m., an observation was made of Resident #68's oxygen concentrator, nasal cannula and refillable humidifier with S7LPN (Licensed Practical Nurse). S7LPN stated that the residents' humidifiers were supposed to be changed weekly. S7LPN confirmed the humidifier had a date of 02/18/2024 and should have been changed. S7LPN also stated that the resident uses the oxygen and nasal cannula that were in room. S7LPN confirmed that the resident's nasal cannula should have been stored in a bag since it was not in use. 47251 Resident #53 Review of Resident #53's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included Shortness of Breath and Chronic Obstructive Pulmonary Disease. Review of Resident #53's current physician's orders revealed an order dated 12/30/2022 that read, Oxygen 2L (Liters)/Minute via nasal cannula every day as needed for shortness of breath/increased respirations. Review of Resident #53's care plan with problem onset dated 08/27/2021 that read, Resident receives oxygen therapy as needed. One of the approaches read, Change tubing to oxygen every 7 days of used. On 03/18/2024 9:20 a.m., an observation was made of Resident #53's oxygen nasal cannula in a bag with a date of 2/18/2024 attached to a humidifier dated 2/18/2024. On 03/18/2024 at 10:41 a.m., an observation and interview was conducted with S2ADONIP (Assistant Director of Nursing Infection Preventionist). She confirmed that Resident #53's oxygen nasal cannula and humidifier were in the resident's room at the bedside and dated 02/18/2024. S2ADONIP confirmed that oxygen tubing and humidifier should have been changed, and had not been. Resident #80 Review of Resident #80's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Acute Respiratory Failure with Hypoxia. Review of Resident #80's current physician's orders dated 11/27/2023 that read, Oxygen 2L(Liters)/Min(Minute) per nasal cannula as needed for Shortness of Breath. Review of Resident #80's care plan revealed a problem with an onset date of 10/17/2023 that read, Resident receives oxygen therapy. The approaches for this problem read in part, administer oxygen as ordered, change tubing to oxygen every 7 days, change humidifier bottle at least every month. On 03/18/2024 at 10:25 a.m., and observation was made Resident #80's oxygen at bedside with nasal cannula in a bag with a date of 02/19/2024 attached to a humidifier that was not dated. At that time S8LPN was in the hall and an interview and observation was conducted. She confirmed that the bagged nasal cannula in Resident #80's room at his bedside had a date of 02/19/2024 and the humidifier did not have a date. S8LPN confirmed the nasal cannula should have been changed after 7 days of use, along with the humidifier.

Based on observation and interview, the facility failed to ensure that menus met the nutritional needs of residents according to established guidelines, as evidenced by the kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to decreased intake, altered nutritional needs, and weight loss for the 9 residents who consumed pureed diets. 92 residents consumed foods from the kitchen. Findings: On 03/18/2024 at 9:50 a.m., an observation of the pureed procedure was conducted. S12Diet (Dietary) scooped 5 large unmeasured cooking spoons of macaroni noodles into the food processor, and used the same spoon to scoop 2 large spoons of melted cheese. S12Diet poured water from a large pitcher into the food processor without measuring, then poured an unmeasured portion of a white powder from a cup on the counter into the food processor. She turned the food processor on, then stopped and poured more water and white powder in the food processor and blended again. On 03/18/2024 at 9:55 a.m., an interview was conducted with S12Diet. She stated that she had been working at the facility for [AGE] years. S12Diet stated that she prepared the pureed macaroni for 9 residents. She further stated that she had never used a recipe to prepare pureed foods for the residents, and was never informed that she had to use one. On 03/18/2024 at 9:56 a.m., an interview was conducted with S5DietarySup (Dietary Supervisor). S5DietarySup stated that she did not have pureed recipes for foods prepared in the kitchen for residents. S5DietarySup further stated that she had never received pureed recipes to use for pureed menus.

Based on record review, observation and interview, the facility failed to ensure the resident's environment was free from accident hazards and that adequate supervision and assistance was provided to prevent accidents for one (#1) of two (#1, #2) sampled residents who required the use of the facility's van lifter for transportation. This failed practice resulted in an Immediate Jeopardy on 4/27/19 at 11:45 AM when Resident #1, a [AGE] year old cognitively impaired resident was let outside of the facility's lobby by the receptionist unsupervised. The resident, who had been care planned for noncompliance in the areas of daily care, safety devices and calling for assistance, attempted to wheel himself onto the van's lifter without any staff assistance and/or present. The resident fell backwards in his wheelchair off the lifter onto the ground. The resident was found sitting on the ground by one of the nurses who assessed the resident for injuries. The resident denied hitting his head and was treated for [REDACTED]. The resident was then transported to the [MEDICAL TREATMENT] center. After two and a half hours of his [MEDICAL TREATMENT] treatment the resident started vomiting and became very week. The resident was transferred to the hospital where a CT (computerized tomography) scan of his head revealed a diffused Subarachnoid Hemorrhage with Intraparenchymal Hemorrhage and Obstructive [DIAGNOSES REDACTED]. The Administrator was notified of the Immediate Jeopardy on 5/ 6/19 at 4:10 PM. The Immediate Jeopardy was removed on 5/8/19 at 10:15 AM when the facility presented an acceptable Plan of Removal which included the following: IJ Plan of Removal Goal/Expected Outcome: To assure that all residents are free from harm secondary to the use of the van lifter as evidence by the lifter being left unattended in the down position during loading and unloading; the facility has initiated the following to assure a risk resident have been identified and appropriate monitoring systems are in place: Supervision: 1. As of 5/7/19, forty residents in wheelchairs have been identified to require the use of the van lifter and have the potential to be affected. For these residents: *the front lobby receptionist have been in-serviced by the Transportation Supervisor to supervise residents if they insist on going outside the facility before the driver is ready to load them into the van. * A Quality Assurance monitoring will be done by the Administrator and/or her designee five times a week for two weeks then randomly thereafter. *Continue Quality Assurance monitoring for transportation safety to ensure all safety requirements for resident transports are being followed properly (resident will be loaded and unloaded properly, lift will be up and properly secured when not in use, resident and wheelchairs will be secured properly). Quality Assurance will be performed by transportation supervisor and/or her designee. Quality Assurance will be don five times a week for two weeks, then randomly thereafter. If any issue are identified, immediate intervention will be implemented to include, but not limited to, in-servicing and termination of employees if necessary. *Corporate transportation policy changes are being negotiated to recommend including to encourage residents to remain in the facility until driver is ready to load them into the van, and receptionist shall supervise residents if they insist on going outside before the driver is ready to load then into the van. Training: 1. As of 5/7/18, the Administrator and/or her designee began in-service training all staff members to encourage residents with appointments to stay inside the building until the driver is ready to load then into the van. This will be completed by (MONTH) 8, 2019. 2. Drivers have been in-serviced by the Transportation Supervisor to keep the lift in the upright and stored position at all times unless the lift is actively being used to load and unload a resident. This was completed on 4/29/19. This deficient practice continued at a potential for more than minimal harm for the other forty residents identified in wheelchairs who may require the use of the facility van lifter during transportation. Findings: Review of the facility's Company Van Policy dated 12/28/05 revealed the policy did not reflect supervision of residents when loading and unloading during transport and for leaving the van lifter down while unattended. Resident #1. Review of the resident's clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS (Minimum Data Set) revealed a BIMS (Brief Interview of Mental Status) score of 8, which was moderately impaired for cognition. Review the resident's care plan dated 3/10/19 revealed that he sustained frequent falls from the wheelchair on 12/6/18, 12/18/18, 1/22/19, 1/26/19, 1/31/19, 2/21/19, 3/5/19, 3/21/19, 4/25/19, and 4/27/19 due to the resident's noncompliance with daily care, safety devices and calling for assistance. Further review of the resident's care plan revealed that the falls on 3/21, 4/25, and 4/27/19 occurred during the transportation of the resident. Review of the resident's Fall Risk assessment dated [DATE] revealed a risk score of 13, which indicated a high risk for falls. The resident sometimes had problems with memory and recall ability. The resident was confined to a chair and oriented. He was unable to independently come to a standing position, exhibited loss of balance while standing, required hands-on assistance to move from place to place. Review of the facility's investigative report dated 3/21/19 at 2:30 PM revealed that the resident sustained [REDACTED]. Upon arrival to the van, S3 Office Manager/Transportation Supervisor observed that the resident was still strapped with the seatbelt and the wheelchair harnessed appropriately, but the wheelchair had somehow tipped backward. The resident was assessed and denied hitting his head. Resident was assisted into a different wheelchair and transported back to the facility where he was reassessed for injury. Resident #1 was not sent to the hospital. Review of the facility's investigative report dated 4/25/19 at 5:10 PM revealed that the resident sustained [REDACTED]. According to the report, the fall was witnessed by S7CNA. Resident #1 was observed by the nurse in the back of the van on the lift. The resident was tipped backward on his back and he was still sitting in his wheelchair on the lift. The resident was assessed by the nurse for injury. The resident denied hitting his head. Further review revealed that the resident was being transferred out of the facility van by S7CNA and he was still in his wheelchair at the time of the incident. Resident #1 was not sent to the hospital. Review of the resident's nurse's notes dated 4/26/19 at 6:11 PM revealed, . Resident was in the back of the van on the lift, tipped backward on his back, still in his wheelchair. Resident stated that he fell backwards. A review of an in-service conducted revealed that it did not include supervision of residents while loading and unloading for transport and leaving the lift down unattended. A review of an in-service conducted on 4/26/19 revealed that it did not include supervision of residents while loading and unloading for transport and leaving the lift down unattended. On 5/3/19 at 3:20 PM, an interview was conducted with S7CNA who confirmed that she was the van driver on 4/25/19. S7CNA stated that on 4/25/19 she was returning back to the facility with Resident #1 and another resident after their [MEDICAL TREATMENT] treatment. She stated that Resident #1 was loaded first in the van and the other resident was loaded behind him. She stated that when she arrived at the nursing home, she pulled up to the front of the facility and got out of the van and positioned the lifter to unload the other resident first. She stated that the other resident was placed on the lifter and lowered to the ground and brought into the front lobby of the facility. She stated that she returned back to the van to get Resident #1. S7CNA stated that she got into the van and started to roll Resident #1 backwards onto the lifter before she realized that she had forgotten to raise the lifter back up. She stated that Resident #1 fell backwards in his wheelchair and she fell forward towards him onto the lifter on the ground. She stated that she noticed that the resident's back pack was behind his head and asked the resident if he had hit his head. She stated that the resident informed her that he did not hit his head. On 5/3/19 at 12:00 PM, an interview was conducted with S5LPN who stated that on 4/25/19 the resident was returning from [MEDICAL TREATMENT] when the fall occurred. She stated that the receptionist paged for a nurse to come to the front lobby. She stated that when she arrived to the front lobby along with other nurses, she observed the resident was in the back of the transportation van on the lift and had fallen backward. She stated that Resident #1 was still in his wheelchair. She stated the resident denied hitting his head when he fell . She stated the resident was assessed for injury and any neuro changes. She stated that the resident was treated for [REDACTED].#1 did not always do as he was instructed. S5LPN confirmed that the van drivers are supposed to stay with the resident during transporting. Review of the facility's investigative report dated 4/27/19 at 11:45 AM revealed that Resident #1 sustained another fall that was witnessed by S6LPN. According to the report, upon arrival by staff to the front outside entrance, the resident was observed sitting on the ground in a sitting position in front of transportation lift gate with his wheelchair next to him. The report indicated that the resident fell while attempting to wheel himself onto transportation lift gate, which was left unattended. The resident denied hitting his head. Resident was not sent to the hospital. Review of the hospital emergency room final report revealed that the resident was seen in the emergency roiagnom on [DATE] at 4:16PM. The chief complaint from the nursing triage note at 4:44 PM was an unwitnessed fall backward out of wheelchair. Patient began having altered mental status and vomiting during the last 45 minutes of [MEDICAL TREATMENT] treatment. Patient unable to answer questions correctly at this time. Further review of the report's physical examination of the resident's head revealed a contusion to the back of the head. A review of the CT (computerized tomography) scan dated 4/27/19 at 5:37 PM revealed that the resident had a diffuse subarachnoid hemorrhage (bleeding in the space between the brain and surrounding membrane) with intraparenchymal hemorrhage (bleeding into the tissue of the brain) and Obstructive [DIAGNOSES REDACTED]. Further review of the hospital death record dated 4/27/19 revealed that on 4/27/19 at 8:14 PM, the resident passed away. On 5/2/19 at 2:13 PM, an interview was conducted with S4LPN who stated that the CNAs on the hall will bring residents who have appointments to the front lobby to wait for the van driver to pick them up. She stated that when Resident #1 would remember, he would sometimes propel himself to the front lobby to meet the van driver. She stated that when the resident fell on ,[DATE], she was paged to the front lobby. She stated that she noticed the van driver in the lobby. She stated that she asked the driver where she was coming from and the driver told her that she was just coming up to the front. S4LPN stated that she observed the resident sitting on the ground next to the lifter gate and his wheelchair was next to him. She confirmed that the tailgate was down to the van. She stated S6LPN was already outside by the resident because she had witnessed the resident trying to get on the lift by himself. She stated that she did not observed any apparent injuries. She stated that the resident was able to move all of his extremities, answer questions appropriately, and denied he had hit his head. She stated that she checked the resident's head and didn't feel any swelling or noticed any bleeding. She stated that the resident was assisted back into the wheel chair and the resident was transported to [MEDICAL TREATMENT]. She stated that she notified the [MEDICAL TREATMENT] center of the fall. S4LPN confirmed that the resident should not have been left along without assistance because the resident was noncompliant. On 5/3/19 at 3:55 PM, an interview was conducted with S8CNA who confirmed that she was the van driver on 4/27/19. She stated that she pulled the van around to the front of the facility. She stated that she was transporting Resident #1 and another resident to the [MEDICAL TREATMENT] center on that day. She stated that she got out of the van and put the lifter in the down position before she went into the facility to get the residents. She stated that Resident #1 and the other resident was waiting in the facility lobby when she went into the facility. She stated that the receptionist opened the door and pushed Resident #1 outside in front of the facility. She stated that she was still inside of the building when the resident fell . She stated that when she was returning back to the van, she observed the resident on the ground by the lifter on the van. She stated that the receptionist asked her to help get the resident up. She stated that she told the receptionist to page for the nurse. S8CNA stated that one nurse arrived first and then other nurses and staff came. She stated that two nurses picked the resident up and put him in his chair. She stated the nurses checked him and asked the resident if he had hit his head. She stated that the resident told the nurses that he didn't hit his head. She stated that after the nurses checked Resident #1 they told her it was okay to bring the resident to the [MEDICAL TREATMENT] center. She stated the nurse's told her they would call the [MEDICAL TREATMENT] center to let them know about the fall. She stated that around 4PM the receptionist at the nursing home called her to return to the [MEDICAL TREATMENT] center to pick up the resident. She stated that when she arrived at the [MEDICAL TREATMENT] center the staff at the [MEDICAL TREATMENT] center informed her that the resident had been vomiting for 45 minutes. She stated that she waited for the resident for a while before they came back out to tell her that they couldn't get the resident in the wheelchair because he was too weak. She stated that the [MEDICAL TREATMENT] center then called the ambulance to come pick up the resident. She stated that she called to facility and informed the receptionist to let the nurse know that the resident was being transported to the hospital from the [MEDICAL TREATMENT] center. On 5/6/19 at 8:45 AM, an interview was conducted with [MEDICAL TREATMENT] Manager who stated that the nurse from the nursing home called the center and informed the [MEDICAL TREATMENT] tech that Resident #1 had fallen. She stated that the nurse informed the tech that the resident had not hit his head in the fall. She stated that [MEDICATION NAME] was held during the resident's treatment. She stated that the [MEDICATION NAME] was held just in case the resident had hit his head. She stated that this is standard center protocol. She stated that the resident had received two and half hours of his treatment when he started vomiting. She stated that the resident vomited for forty-five minutes. She stated that the resident's treatment was discontinued and by then the resident had stopped vomiting. She stated that she called the nursing home to come pick the resident up. She stated that by the time the nursing home driver arrived, the resident was too weak and could not transfer into his wheelchair. She stated that the resident was transferred to the hospital by ambulance. She stated that she called the resident's nurse at the nursing home to inform her that the resident was sent to the hospital. She stated that she asked the nurse if she was sure that the Resident #1 had not hit his head. She stated that the nurse informed her that no one witnessed him hitting his head. On 5/6/19 at 11:25AM, an interview was conducted with S7CNA who stated that when she transports residents, she brings the van to the front entrance and the first thing she does is put the lifter down before she goes into the facility to get the residents out of the lobby. She confirmed that she was trained by S3Office Manager/Transportation Supervisor to put the lifter down before going into the facility to get the residents. On 5/6/19 at 11:30 AM, an interview was conducted with S8CNA who stated the she has always put the lifter down first before she went in the facility to get the residents out of the lobby. She confirmed that she was trained by S3Office Manager/Transportation Supervisor to do it that way. On 5/6/19 at 11:35 AM, an interview was conducted with S9Receptionist who stated that on 4/27/19, S8CNA drove up to the front of the facility to pick up Resident #1 and another resident to go to the [MEDICAL TREATMENT] center. S9Receptionist stated that Resident #1 started kicking the front door and he was asking to go outside. She stated that because the resident did not have a wander guard, she could let him go outside. She stated that she turned around after letting Resident #1 out the door to help get the other resident when she heard Resident #1 yell out. She stated that when she turned around she observed the resident was at the foot of the lifter and the resident was on his left side and the wheelchair was tilted over. She confirmed that the van lifter was left down. She stated that she did not witness the fall but that Resident #1 had tried to get on the lifter without assistance. She stated that the nurses and other staff assisted Resident #1 back into his wheelchair and assessed him for injury. She stated that Resident #1 told the nurse that he did not hit his head. She stated after the nurses assessed Resident #1, he was transported to the [MEDICAL TREATMENT] center. S9Receptionist confirmed that there was no staff present outside when the resident fell . Review of the witness statement written by S6LPN dated 4/27/19 at 11:45 AM revealed that the nurse was in the dining room of the facility when she witnessed the resident trying to wheel himself onto the van lift and the resident fell backwards in his wheelchair. This surveyor was unable to interview S6LPN after several attempts. On 5/6/19 at 11:20 AM, an observation/demonstration was conducted with S7CNA and S3Office Manager/Transportation Supervisor. S3Ofice Manager/Transportation Supervisor confirmed that the van drivers were told that they could put the van lifter down before they go get a resident for transport. She indicated that there was no increased monitoring or supervision of the van drivers until after the resident's fall on 4/27/19. On 5/6/19 at 10:00AM, an interview was conducted with S2DON who stated that she was leaving the facility on 4/25/19 and she observed the resident backward in his wheelchair lying on his left side on the lift on the ground. She stated that she was informed that the resident had fallen from the van. She stated that she didn't feel that an in-service of the nursing staff was needed after the resident's fall on 4/25/19 because the fall was not related to the nurses. She stated that she was unaware of any in-services with the drivers regarding supervision. She stated that any in-services of the van drivers are done by the S3Office Manager/Transportation Supervisor or S1Administrator. On 5/7/18 at 3:15 PM, an interview was conducted with S1Administrator who stated that after Resident #1's fall on 4/25 and 4/17/19, the van drivers were in-serviced on proper use the van lift. She confirmed that the in-services did not include supervision of the residents while loading and unloading for transport.

Based on record review and interview, the facility failed to ensure that each resident was provided with sufficient fluid intake to maintain proper hydration as evidenced by the facility documenting that resident #30's peg tube was draining and leaking for several days. As a result, the resident was transferred to the hospital and admitted with dehydration for 1 out of 2 residents reviewed for hydration (#30 and #122) out of a total sample of 26 residents. Findings: 1. Resident #30. Review of resident #30's physician's orders [REDACTED]. Review of the resident's dietary assessment note dated 1/13/13 revealed documentation that the registered dietician assessed the resident to need 2864cc of fluid a day. Review of the resident's health status nursing progress note dated 2/20/13 at 10:29 revealed, "Paged to resident's room by S23LPN. Observed that peg tube was out; nurse could not confirm if resident had pulled it out or otherwise. Inserted 24F/15ml [DEVICE] without incident or resistance. Bulb inflated; placement confirmed. Resident tolerated well. Tube feeding resumed at prescribed rate." Review of the resident's health status nursing progress note dated 2/24/13 03:30 revealed, "Res lying in bed with HOB elevated. Peg feeding changed. Residual at <60. No regurgitation upon auscultation. Feeding contents protruding at site of peg to skin entry......... Dr. ____ on call for Dr. _____ notified and NON to transfer to (hospital) for evaluation. Family notified. Transferred per (ambulance) via stretcher." Review of the resident's health status nursing progress note dated 2/24/13 at 04:30 revealed, "(hospital) called this nurse informing that res tube is inflated and is tolerating 70cc of H20 and is to return per ER Dr. _____ noted." Review of the resident's health status nursing progress note dated 2/24/13 at 05:00 revealed, "Res returned from (hospital per ambulance). HOB elevated. Regurgitation heard upon auscultation & 10cc air [MEDICATION NAME] with air bubbles to peg site to skin. Flushed with 30cc H20 and leakage noted to site & skin and _____ RN observed. On call Dr. _____ notified & states need to see original GI noted. Will continue to monitor." Review of the resident's health status nursing progress note dated 2/24/13 at 21:00 revealed, "Res lying in bed with HOB elevated. Peritive infusing via peg at 90cc/hr. Large amts of liquid contents are pouring from insertion site. Placement checked & residual @ 20cc noted........" Review of the resident's health status nursing progress note dated 2/25/13 at 01:33 revealed, "Res lying in bed with HOB elevated with Peritive infusing @ 90cc/hr. Formula is pouring out from insertion site. 20cc residual noted. Placement checked. Will continue to monitor." There is no documentation noted that the resident's physician was notified that the resident's peg tube continues to drain from the insertion site. Also, there is no documentation noted concerning the formula pouring out from the insertion site until 2/27/13, which is 2 days later. Review of the resident's eMAR Hour of Administration Level nursing progress note dated 2/27/13 at 07:48 revealed, "I was called to resident room by the CNA to disconnect resident peg tube. Upon arrival to resident room (ambulance) personal was in res room to transfer him to an appt with wound care. Observed resident gown and peg dressing saturated with drainage. Once removed res was observed with a moderate amt of tan colored drainage coming from his stoma site with clumps of particles resembling cottage cheese. On further assessment I observed resident to have what looks like clabbered milk (clumps of particles mentioned above, but smaller in appearance) to the inside of his peg tube........" There is was no documentation noted concerning the tube feeding until 3/6/13, which is 7 days later. Review of the resident's Daily Skin Assessment for February 2013 revealed documentation that the resident's peg tube site dressing was saturated with drainage on 2/27/13. Also, there was documentation that the peg tube continued to have drainage at the insertion site and that the drainage was not a new problem and that the drainage continued on 2/28/13. Further review of the resident's Daily Skin Assessment for March 2013 revealed documentation on 3/1/13 through 3/4/13 that there was no new problems. There was no documentation that the drainage at the resident's peg tube insertion site had resolved. Review of the resident's health status nursing progress note dated 3/7/13 at 13:09 revealed that res returned from appt with Dr. _____ no new orders noted unable to see MD today has f/u appt on 3/14/13 @ 1 p. m......." Review of the resident's health status nursing progress note dated 3/7/13 at 23:12 revealed, ".............foley patent and draining moderate amount of dark urine......." There was no documentation noted that the physician was notified concerning the dark urine. Review of the resident's health status nursing progress note dated 3/8/13 at 09:27 revealed, "......res continuous feed [MEDICATION NAME] @ 94cc/hr; no residual noted and tol well......noted foley cath in place with yellow, cloudy, adequate amount drainage....." There was no documentation that the physician was notified that the resident's urine was cloudy. Review of the resident's health status nursing progress note dated 3/10/13 revealed, "Res lying in bed with HOB elevated. Peritive formula infusing @ 94cc/hr per PEG. 0 residual noted and placement checked. Res sweating profusely. Gurgling heard at BS. Suctioned per [MEDICATION NAME] and lg amts of cloudy liquid collected to canister with lg scant amts of blood noted. VS are as follows B/P 156/68, pulse 98, Temp 102(ax), Resp 24. Dr. _____ on call for Dr. _____ notified. NON to transfer res to (hospital) noted. Flushed PEG with 60cc H20. (........ambulance) transferred. Res per stretcher to (hospital). Family notified." Review of the resident's health status nursing progress note dated 3/12/13 at 10:19 revealed that the resident was currently being hospitalized for [REDACTED]. Review of the facility's appointment book revealed that resident #30 was scheduled for a wound care appointment on 2/27/13. There was no appointment documented for the resident to see the surgeon on 2/28/13, which was a Thursday. Review of the facility's appointment book revealed documentation that the resident had an appointment to see the surgeon on 3/7/13. Further review of the appointment book revealed documentation that the resident had an appointment for a follow-up appointment for the surgeon on 3/14/13. On 3/21/13 at 11:15 am, S34Receptionist, stated that the nurses tell her when the residents need to have appointments scheduled and that is when she documents the appointments in the appointment book. On 3/21/13 at 10:15 am, S22LPN stated that when she started working with the resident in February the resident was being flushed with 200cc of fluid every 4 hours and then it changed to 300cc of fluid every 4 hours on 3/12/13 because of the resident being diagnosed with [REDACTED]. S22LPN stated that on 3/10/13 that the resident was sent to the hospital because he might have aspirated and not because he had signs and symptoms of dehydration. S22LPN stated that the resident had problems with the peg site leaking and that he was sent to the emergency room several times concerning the leakage and each time he was sent back from the hospital because the emergency room doctor found no problems with the peg tube site. S22LPN stated that on 2/24/13 and 2/25/13, she confirmed that the night nurse documented that the tube feeding was pouring out from the insertion site and that there was no documentation that the nurse informed anyone concerning that. S22LPN stated that because the resident was having so much problems with leaking from the peg tube site, the primary physician gave an order to send the resident to the surgeon. S22LPN stated that the resident's appt was for 3/7/13 and that it had to be rescheduled because the surgeon did not see the resident on 3/7/13. S22LPN stated that the doctor was in surgery on 3/7/13. On 3/21/13, S8ADON stated that the resident had problems with leaking at the site and was sent to to the emergency room several times. She stated that the resident saw the physician on 2/18/13 and that he saw the surgeon on 3/7/13. On 3/21/13 at 1:00 p. m., S33RD stated that the resident needed 2864cc of fluid a day. S33RD stated that if the resident's tube feeding was leaking a lot from the peg tube site, that the resident probably was not meeting his daily fluid intake needs. S33RD stated that she was not notified that the resident's peg tube feeding was leaking. S33RD stated that if she knew the resident's peg tube site was leaking that she would have readjusted the resident's fluid intake needs. On 3/21/13 at 1:15 p. m., S2DON stated that she was aware that the resident had problems with the peg tube feeding leaking around the insertion site. On 3/22/13 at 8:05 a. m., S2DON confirmed that there was no documentation concerning the peg tube insertion site and the peg tube feeding between 2/27/13 and 3/6/13. S2DON confirmed that the primary physician gave an order for [REDACTED]. that the appointment was made for 3/7/13. S2DON stated that the surgeon was in his office in town only on Thursdays and every other Friday. The order was noted on 2/25/13, which was a Monday, and the Thursday of that week was 2/28/13. S2DON confirmed that S34Receptionist that makes all the appointments, was out on leave during that time period on 2/25/13 when the primary physician gave the order. On 3/22/13 at 8:30 am, S32LPN treatment nurse, stated that she did not document daily concerning the resident's peg tube site dressing changes. On 3/22/13 at 8:50 am, S32LPN treatment nurse, confirmed that the resident had drainage at his peg tube feeding site. S32LPN treatment nurse confirmed that she documented the resident's peg tube site dressing was saturated with drainage on 2/27/13 and documented that it continued to have drainage on 2/28/13. S32LPN treatment nurse confirmed that there was no documentation concerning the resident's peg tube site between 2/28/13 and 3/6/13. S32LPN treatment nurse confirmed that the resident was admitted to the hospital on [DATE] and was diagnosed with [REDACTED].

I. Based on observations, record review and interviews the facility failed to conduct a complete, and accurate comprehensive assessment of each resident's functional capacity, and reassess on an ongoing basis to meet the resident's needs by failing to 1. conduct an assessment prior to resident #15 being moved from the floor to the bed following a fall; and 2. conduct a complete, accurate, comprehensive and ongoing assessment of injuries following a fall, for 1 resident (#15) out of 4 sampled residents reviewed for accidents, out of a total of 37 sampled residents. This deficient practice has the potential to affect a total of 123 residents living in the facility. An Immediate Jeopardy situation for the resident began on 7/9/11 at 5:45 a.m., when Resident #15 fell from her bed to the floor. The resident was then picked up by S15 and S16 (CNAs), and placed back into bed, prior to an assessment from a licensed person. Following the resident being put back in bed, S14LPN then assessed the resident's head injury, but failed do a comprehensive, complete assessment of the resident's body, to fully assess for other injuries. The resident obtained a bruise to her right eye and forehead, and also a fracture of her left lower leg. The fracture of her lower leg went undetected, until an assessment of the resident ' s lower leg was completed at 11:45 a.m., when S30CNA reported to S17LPN the resident was screaming in pain when she attempted to move the resident into a geri chair. At that time, S17LPN assessed the resident's leg and discovered a bump on the resident's lower leg with swelling to the area. The resident was sent to a local emergency room at 12:50 p.m. on 7/9/11, where it was discovered the resident had a fractured lower left leg, along with the head injury. The Administrator and the DON were notified of the Immediate Jeopardy Situation on 7/15/11 at 1:30 p.m. for resident #15. The Immediate Jeopardy continued until a plan of removal was accepted by the survey team on 7/15/11 at 3:25 p.m. which indicated the facility would in service all staff regarding assessing residents following accidents; and instruct staff to not move resident until assessed by licensed personnel. The Immediate Jeopardy was removed on 7/18/11 at 6:00 p.m., when the facility was deemed to have completed the requirements of the plan of removal, and all interventions were in place. Findings: A review of the resident's Fall Risk assessment dated [DATE] revealed the resident had 1 to 2 falls over the past 6 months checked off. During an interview with S8RSD on 7/15/11 at 8:20 a.m., she verified this was not accurate; the resident's last fall was in July of 2010. This Risk Assessment indicated the resident was a Moderate risk for falls with a score of 14. A Fall Risk assessment dated [DATE], the date of resident #15's fall, also indicated the resident had 1 - 2 falls within the last six months, with the overall score remaining the same, at 14, as a Moderate risk for falls. During an observation of the resident on 7/11/11 at 11:45 a.m., the resident was noted to be in bed being fed by S31CNA. The resident was noted to have a dark red/purple bruise encircling her right eye. When questioned, S31CNA stated the resident had fallen out of bed earlier during the week. Observation of the resident's bed revealed padded side rails up at the head of the bed, on both sides, and supports to the resident's lower extremities. There was also an air mattress noted on the bed, and a bed alarm. During an observation of the resident on 7/13/11 at 1:45 p.m. the resident was in bed, padded side rails up on both sides up on the upper bed. The bed was not in the lowest position. The head of the bed was slightly raised with the resident's head slightly bent forward. During an interview with S17LPN on 7/14/11 at 3:15 p.m., S17 verified she had started her shift on 7/9/11 at 6:00 a.m., shortly after resident #15 had fallen. She stated the resident was already in the bed when she came on duty. S17 revealed the resident does not understand, responds slowly to any communication, and the resident is non verbal. She stated she went to the resident's room shortly after she was given report and found the resident to have a bruised right eye, indicating she was concerned about the resident ' s head injury, especially because she has two shunts, one of which was the area of the head injury. S17 indicated staff has to pull the resident up in bed because she slides down. S17 revealed that the CNA called her to the resident ' s room about lunch time, and reported the resident was screaming in pain when her left leg was touched. S17 verbalized, at that time, she assessed the resident ' s lower left leg and found the lower leg with [MEDICAL CONDITION] and an elevated area on the shin. Review of an Incident and Accident report dated 7/9/11 and timed 05:40 a.m., revealed the CNAs were called to resident's room. The resident was on the floor beside the bed, per CNAs. CNAs had already place the resident back into the bed before S14LPN arrived to the room. LPN did an assessment and did not note any other injuries. S14LPN explained to the CNAs that the resident is supposed to be pulled up to the head of the bed or she'll fall out. Injuries noted on the report were Hematoma to the face. The resident's level of pain was checked off as "Hurts a Little More". The report also revealed the side rails were up and under "Other Info" another notation indicating the resident has to be pulled up to the head of the bed or she'll fall out even with the side rails up X 2 (up on both sides). A Progress Note dated 7/9/11 read: "Details: Resident was found by the CNAs on the floor beside the bed. Side rails up x 2. CNAs placed the resident onto the bed without letting me (S14LPN) check her first. Did a skin assessment and noted a large hematoma on the R side of her forehead. Started neuro checks and called Dr. ___. Factors/causes: Not pulled up to the head of the bed. Treatment: Neuro checks and monitor for neurological problems." The noted was electronically signed by S14LPN. A Progress Note dated 7/9/11 at 11:45 a.m., indicated S17LPN was call to the resident's room per the CNA. The CNA reported resident yelled out when the resident's left leg was touched. On assessment, area to the left lower anterior leg with [MEDICAL CONDITION] circumferential with elevated area ... possibly a bony deformity. During an interview on 7/14/11 with S19CNA at 2:35 p.m., S19 verified she was caring for the resident on this day (7/14/11), and had heard that the resident had fallen out of her bed earlier during the week. She stated she had noted the resident had been found with her legs hanging off the bed at times. . During an interview with S14LPN on 7/14/11 at 5:45 p.m., she verified she was the nurse working with resident #15 on 7/9/11 at the time of the fall. She verbalized S16CNA called to the resident's room about 5:45 a.m. because resident #15 was on the floor. When she arrived at the doorway of the resident's room, the resident had already been put into the bed by the CNAs. S14 indicated she told S15 and S16CNAs, they should not have moved the resident back into bed until she had assessed the resident. She stated S17LPN came on duty about 6:00 a.m., went to assess the resident and told her the resident's shoulder looked red. She also stated resident #15 has a history of sliding down the bed, and has to be pulled up to the head of bed. When questioned what she did when she found the resident in bed following the fall, S14 stated she held the resident's head in her hands, looked in face, head, and hands, briefly looked at her body, and ran to call the resident's doctor. She stated she did not feel or spend time assessing the resident's lower body because she was more concerned with the resident's head injury. During a phone interview with S15CNA on 7/14/11 at 6:15 p.m. she verified she was working the shift when resident #15 fell out of bed. She stated S16CNA called her to the resident's room, and requested help to put resident #15 back to bed. During a phone interview with S16CNA on 7/15/11 at 8:30 a.m., she verified she was the CNA who had found resident #15 on the floor on 7/9/11. She indicated around 5:45 a.m. upon entering the resident's room, she saw resident #15 lying on her left side on the floor with the resident's head towards the door. S15CNA to help put the resident in the bed. She verbalized, she then called S14LPN, after they had put the resident back in the bed. S16 indicated when S14LPN arrived in the room, she checked the resident's knot on her head, took the resident's blood pressure, and temperature and left out of the room. A physician progress notes [REDACTED]. Nurse states pt was returned to bed before her assessment. R forehead puffy. Neruo checks (sign) began. Later in day L ankle noted swollen. Sent to ER. Dx with (sign) tib/fib fracture". II. Based on observations, record review, and interviews, the facility failed to accurately assess 1 of 2 residents reviewed for range of motion (#85) and 1 of 3 residents reviewed (#85) for pressure ulcers out of a total of 37 sampled residents. Resident #85 was assessed with [REDACTED]. On 3/22/11, the ' shear ' type area was documented as an ' unstageable ' pressure ulcer with 100 % eschar at the sacrum. Resident #85 was admitted to the hospital on [DATE] with a temperature of 102 degrees and approximately 7 cm, foul smelling sacral decubitus ulcer, Stage III, possibly Stage IV wound. In addition, Resident #85 was not assessed for limitations in her ROM functions. According to the Resident Census and Conditions of Residents, dated 7/14/11, there were 19 residents with contractures and 6 residents with pressure sores. Also, there were 8 residents that had contractures on admission and 4 residents had pressure sores on admission out of a total of 123 residents that reside in the facility. Findings: On 7/11/11 at 2:30 p.m., S3DON was observed exiting Resident's #85 room. S3 revealed Resident #85 had a pressure area on her bottom and she stated S18LPN/Treatment Nurse wanted her to see Resident's right ear. S3 further stated the scab probably came off of the Resident's ear, while being bathed and she would call the area a pressure area because the Resident had came from the hospital with this pressure area. On 7/13/11 at 10:25 a.m., Resident #85 was observed lying on her left side. S18LPN/Treatment Nurse revealed she had already done the wound care for this Resident on 7/13/11 at 10:45 a.m. On 7/14/11 at 8:50 a.m., Resident #85 was lying on her right side. During the wound care observation, with S18LPN/Treatment Nurse and S24CNA, S18 was asked what medicine was used for the Resident's wound and she stated they clean it with NS and pack with Calcium Alginate and then a dry dressing. Then, S18 was asked if Resident #85 was admitted with the sacral wound and S18 stated " it started out as excoriation and it got worse. " S18 revealed that the wound started out here in the facility and when the Resident was sent out, the wound was debrided, which made it worse; and then the Resident was in and out of the hospital. The sacral wound was a beefy red in color and white around the edges; the wound was deep. There was drainage as evident by the old dressing that was removed. The size of the sacral wound was slightly larger than a half a dollar and there was about ? inch to an inch in depth. The wound on the Resident's right lateral and outer ear, there was a dried gauze (with old reddish-brownish drainage) stuck to the Resident's ear. As S18 was trying to remove the gauze, the Resident would flinch, making facial expressions to possibly represent pain. S18 got some normal saline to ease the gauze off of the Resident's ear. The blacken scab had partially came off, it bled; and part of the wound remained red were the skin was completely off of the ear. S18 said the band aid must have come off and S24 stated she did not remove a band aid this morning during the Resident's am care. There was no hand rolls observed in the Resident's hands. S24 stated she did not see any hand rolls this morning when she provided am care and S18 told S24 that she would replace the hand rolls for the Resident. On 7/14/11 at 10:20 a.m., an interview with S8RSD was held with S9 and S10RSDs present in their office. S8 was asked where were the Stage II and Stage III pressure ulcers located on Resident #85 according to the quarterly MDS assessment dated [DATE]. At this time, S8 informed the Surveyor the section read healed pressure ulcers, one Stage II and one Staged III. S8 was asked where the healed Stage II and Stage III's pressure ulcers located was. S8 started reviewing the assessments on the computer, and S8 stated the Stage III was on her sacrum. S10 interjected and she said she was trying to locate the information of when all of the pressure ulcers began. S8 read that there was a change on 4/13/11 and when asked what kind of change, did the wound improve? S8 did not answer and S10 said, " it kind of looks like it got worse." When asked if the sacral wound had ever healed, there was no verbal response to the question asked. The skin assessment notes, dated 2/24/11, after the Resident's returned from a hospital revealed the Resident's had dry skin to her bilateral feet and [MEDICAL CONDITION] to both of her lower extremities. There was no evidence of shearing and/or wounds documented at this time. On 3/2/11, the skin assessment notes stated in the comments section that shearing present. Part of the skin is slightly rolled back. Attempted to replace in position, however a small portion remains off. Wound bed is pinkish/red in color. Small amount of serosanguinous drainage is present... Utilized standing orders with [MEDICATION NAME] for the Resident's treatment. Area was assessed by the DON. Physician was faxed and reply pending ... The site was documented as the sacral crevice measuring 2.3 length x 0.6 width x <0.1 depth and underneath the Stage section stated N/A. The skin assessments notes on 3/9/11 revealed that the sacral crevice had decreased in size (2.1 x 0.4 x <0.1) and under the comments section read that the wound bed remains pinkish/red in color. Small amt. of serosanguinous drainage present... On 3/15/11 the skin assessments notes stated the wound was unchanged for this shearing type wound. The wound assessment profile, dated 3/22/11, stated a pressure ulcer was located on the sacrum, with the date of onset of 3/19/11. The wound stage was unstageable with the size of 3.9 x 2.2 x intact slough. 100% eschar was documented. Under the comments section stated the wound bed was yellow/brown tinge non-viable tissue (slough) covering 100 % of the wound bed... S18LPN/Treatment Nurse was interviewed on 7/14/11 at 2:00 p.m. She stated Resident #85 was observed to have shearing to her sacrum. S18 also stated the shearing started to get better until 3/22/11 when it was noticed to have an odor. At that time, it was listed as an unstageable wound. The Physician was called that day to change the order to Mesalt and add Santyl. These medications had [MEDICATION NAME] properties. S18 revealed Resident #85 went to the hospital on [DATE] with a temperature, and during the hospital stay the Resident had the sacral wound debrided and a [DEVICE] was placed in the Resident. The MDS assessment for April 2011 stated Resident #85 had no impairments under the functional limitation in range of motion section for upper and lower extremities. On 7/14/11 at 3:30 p.m., S25CNA, S26CNA, and S6CNA Coordinator were present for turning Resident #85. The Resident's legs were lifted and when S6CNA tried to straighten the right leg out for the Resident, Resident #85 would flinch or make facial expression as if it hurt her. S6 confirmed that the Resident #85 needed assistance to open her hands or straighten her legs out, the Resident could not perform these tasks by herself when asked if the Resident #85 could open her hands or straighten out her legs without assistance. S26CNA agreed with S6. There was no hand roll in the Resident's right hand and S26 stated she did not know what happen to the hand roll. On 7/14/11 at 3:45 p.m., S8RSD confirmed the range of motion of the extremities was not care planned and she would have to get with the staff to let her know when they are doing morning care to assess the resident. During another interview, with S18LPN/Treatment Nurse on 7/14/11 at 4:05 p.m., she revealed Resident #85 had contractures of the lower knees and that the facility was using hand rolls in the Resident's hands because the Resident's arms and hands were pulling upwards. S18 stated Resident #85 had shearing to her sacrum then it turned into unstageable, that was tan in color. The facility sent the Resident to a wound care clinic and they recommended debridement. The hospital debrided the wound because the wound had an odor to it; and also because the Resident had a temperature. S18 revealed the facility was doing daily skin assessments on the Resident and now the sacral wound appeared to be a Stage III. Resident has small or moderate amount of drainage. S18 state the wound initiated here in the facility, and later, it became tan and that was when the facility considered it a pressure ulcer. She went on to say Resident #85 went to the hospital and the resident developed multiple pressure ulcers around her coccyx and sacral, ears, foot... it was worst when she got back from the hospital. She indicated the Physician had a problem with healing the wounds at the hospital, and that was when they put Resident #85 on hospice. S18 further stated the Physician did not think the Resident was going to make it out of the hospital with the wounds ... A skin shear is like an abrasion S18 stated. According to the MDS 2.0 version, an abrasion was considered a Stage II pressure ulcer. On 7/14/11 at 4:55 p.m., S3DON presented a definition of 'shear' which read a frictional force per unit of surface area applied parallel to the planes of any object. In addition, S3 presented a 'General Guidelines for Positioning Residents' stated draw sheets, lifting sheets, and similar devices should be used whenever possible to avoid friction, shearing, and pulling on the resident's skin... Pad bony areas, such as between the knees and ankles, to prevent discomfort and skin breakdown caused by the skin surfaces rubbing together ... S3 also verbalized an RN will stage the wounds, and S3 confirmed the wound to the sacral area was unstageable on 3/22/11, and she had signed behind S18LPN/Treatment Nurse, to indicate the assessment was correct, on 7/15/11 at 10:55 a.m.

Based on observation, record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care by failing to identify, and act upon, 1 resident's (#15) pain following a fall. The resident has [DIAGNOSES REDACTED]. Resident #15 fell from her bed on 7/9/11 at 5:45 a.m., and was sent to the hospital later that day, at 12:50 p.m, The resident obtained a bruise to her right eye and forehead area, and it was also discovered, seven hours later when the resident was sent to the emergency room , that she had a left lower leg fracture.. Although the resident had been showing signs of pain, the facility failed to attempt to obtain orders for pain medication or to take appropriate actions to relieve the resident's pain. The facility did not intervene when the resident experienced pain following a fall from the resident's bed to the floor on 7/9/11. Findings: Review of the resident's current quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident is rarely/never understood; rarely/never understands others; cognitive skills for daily living are severely impaired. The resident is totally dependent on staff for bed mobility, transfers, hygiene, toileting, She has [DIAGNOSES REDACTED]. This MDS also indicated the resident is unable to answer when questioned if she is in pain. Review of a fall report dated 7/9/11 at 5:40 a.m., the scale was checked to indicate the resident "hurts a little more". Review of a witness statement dated 7/9/11 at 9:00 a.m., indicated S28CNA noted when she attempted to give resident #15 a bath, the resident screamed and had increased facial grimacing. She indicated the resident's vitals were being monitored because of the fall, so she thought the pain was from bruises to the resident's head. Review of a statement made by S30CNA on 7/9/11 at 12:00 p.m. revealed she had been in the resident's room, and as she attempted to move the resident's leg down from the footrest, the resident screamed. The statement indicated S30 and S28 then moved the resident to the bed and notified the nurse. Review of a statement from S29LPN dated 7/9/11 at 11:40 a.m., she was called to the resident's room to assist with an assessment of the resident following the resident falling that morning. She indicated upon assessment, the resident left mid shin was noted to have redness and swelling. Upon palpation of the area, the resident was noted to have facial grimacing and moaning... the area appeared to have abnormalities. During an interview with S14LPN on 7/14/11 at 5:45 p.m., S14 stated she did not give the resident any pain medications following the fall, and the resident had not been on any prn or scheduled pain medications. She verbalized, she called the resident's physician to inform him of the accident. The resident's physician gave orders to keep the resident at the facility and monitor for change in status. S14 did not inform the physician of any pain the resident was, or might be experiencing. During an interview with S17LPN on 7/14/11 at 3:00 p.m., she stated she had not given the resident any pain medication the day of the fall. S17 checked the physician's orders [REDACTED]. Review of the resident's July MAR indicated [REDACTED]' notes, the resident was sent to the emergency roiagnom on [DATE] at 12:50 p.m., noted to be in severe pain. While at the emergency room , the resident was diagnosed with [REDACTED].

Based on observations, record review, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and/or assistance devices to prevent accidents, by failing to ensure measures were in place to prevent 1 resident (#15) from falling out of bed by: 1. Placing resident #15 back into the same bed the resident had fallen from without assessing and taking immediate interventions to prevent her from falling out of the bed again; and An Immediate Jeopardy situation for the resident began on 7/9/11 at 5:45 a.m., when Resident #15 fell from the bed onto the floor. The resident was then picked up by S15CNA and S16CNA, and was placed back into her bed. The facility did not assess the Resident ' s environmental area because the Resident was placed back in the same bed that the resident fell from. Resident #15 had experienced a bruise to her right eye and forehead, and a tibula/fibula fracture of her left lower leg. This was not discovered until S30CNA reported that the Resident was screaming in pain, and the LPN completed an assessment of the Resident ' s lower extremities on 7/9/11 at 11:45 a.m. The resident was then sent to the emergency room , where it was discovered the resident ' s lower left leg was fractured. The Administrator and the DON were notified of the Immediate Jeopardy Situation on 7/15/11 at 1:30 p.m. for Resident #15. A plan of removal was presented on 7/15/11 at 3:25 p.m. The Immediate Jeopardy situation was removed on 7/18/11 at 6:00 p.m., when the facility was deemed to have completed all interventions presented in the plan of removal. The deficient practice continues at a "G", as resident #15 experienced actual harm. This deficient practice also has the potential to affect all residents who are at risk for falls, all resident's using side rails. According to the Resident Census and Condition of Resident's, there are a total of 123 residents residing at the facility. Findings: Review of resident #15's care plan dated 5/11/11 indicated the resident would remain oriented to family members ... alteration in communication ... does not understand, mumbles , cues and reorient as needed. Review of care plan for Potential for Falls (revised on 7/11/11 according to the computer generated sheet) indicated padded top half rails (initiated 7/12/10); total assistance with all transfers--(lifter) w/ two people (initiated 7/12/10); fall risk assessment (initated 7/12/10); keep bed in lowest position (initiated 8/17/10); bed alarm (initiated 7/11/11); wedges to bilateral extremities in place (initiated 7/13/11); and turn and reposition every 2 hours from left to right (initiated 7/13/11). This care plan also included resident to have air mattress as ordered, and monitor every shift and as needed (initiated 8/17/10); Alteration in communication: Does not understand/mumble speech.. talks to no one present (initiated 8/16/10) with interventions to cue an reorient as needed. Review of the resident's fall risk assessment dated [DATE] indicated the resident had 1 to 2 falls over the past 6 months. During an interview with S8RSD on 5/17/11 at 8:20 a.m., she verified this was not accurate, the resident ' s last fall was in July of 2010. This risk assessment indicated the resident was a Moderate risk for falls with the score of 14. A Fall Risk assessment dated [DATE], the date of the resident's fall, also indicated the resident had 1 - 2 falls within the last six months, and the score remained the same, at 14, as a Moderate risk for falls. Review of an Incident and Accident report dated 7/9/11 and timed 05:40 a.m., indicated the resident was found on the floor beside the bed, per CNAs. CNAs had transferred the resident from the floor, back into the bed before S14LPN arrived to the room. S14LPN explained to the CNAs that the resident is supposed to be pulled up to the head of the bed, or she'll fall out. Injuries noted on the report were Hematoma to the face. The report also revealed the side rails were up and under "Other Info" another notation indicated the resident has to be pulled up to the head of the bed or she'll fall out even with half side rails up on each upper side of the bed. During an observation of the resident on 7/11/11 at 11:45 a.m., she was noted to be in bed being fed by S31CNA. The resident was noted to have a dark red/purple bruise encircling her right eye. When questioned at this time, S31 stated the resident had fallen out of bed earlier during the week. Observation of the resident's bed at that time revealed side rails on each upper side of the upper bed with attached pads, and pillow supports to her lower extremities. There was also an air mattress noted to the bed, and a bed alarm. During an observation of the resident on 7/13/11 at 1:45 p.m. the resident was in bed, half side rails up on each side of the upper bed. The bed was noted to not be in the lowest position. The head of the bed was slightly raised with the residents head slightly bent forward. During an observation of the resident with S17LPN present, on 7/14/11 at 3:50 p.m., the resident was in bed, half side rails up on each side of the upper bed, and floor mats on each side of the bed. The resident had a pillow between her lower legs for positioning, and a posterior splint to her left lower extremity. Her legs were noted to be slightly pulled up towards her chest. Wedges were also noted on each side of the resident on the lower bed sides. The resident is able to grasp with her thumb and index fingers. The resident was noted to be unable to straighten out her arms fully. The resident could not verbally communicate, although the resident did make contact with S17 ' s eyes. There was a large bruise to the resident ' s right eye, with yellowish bruising to her right forehead, and shunt tubing was noted directly under the resident ' s skin on her forehead in the area of the bruise. A progress note dated 7/9/11 read: "Details: Resident was found by the CNAs on the floor beside the bed. Side rails up x 2. CNAs placed the resident onto the bed without letting me (S14LPN) check her fires. Did a skin assessment and noted a large hematoma on the R side of her forehead. Started neuro checks and called Dr. ___. Factors/causes: Not pulled up to the head of the bed. Treatment: Neuro checks and monitor for neurological problems." The noted was electronically signed by S14LPN. During an interview on 7/14/11 with S19CNA at 2:35 p.m., she stated she had heard that the resident had fallen out of her bed earlier during the week. She stated she had noted the resident would be found with her legs hanging off the bed at times, and had to be pulled up to the top of the bed. When questioned about the resident's bed, she verified the resident's bed was not a low bed, but was kept in a lower position, although not always the lowest position. During an interview with S14LPN on 7/14/11 at 5:45 p.m., she verified she was the nurse working with resident #15 on 7/9/11 at the time of the fall. She verbalized she was called to the resident's room around 5:45 a.m. by S16CNA because resident #15 was on the floor. She also stated resident #15 has a history of sliding down the bed and has to be pulled up to the head of bed. She also verbalized the resident can cross one leg over the other, and can slide out of the bed by doing this. S14 stated the resident has some bed mobility. She indicated the side rails were up when the resident fell , and the side rail pads were in place. S14 verified the resident was not in a low bed, although her bed should be kept in the lowest position. During a phone interview with S15CNA on 7/14/11 at 6:15 p.m. she verified she was working the shift when resident #15 fell out of bed. She stated that S16CNA had called her to help put the resident back in the bed. When she went in the room the resident was on the floor, on the left side with head towards the doorway, and feet a few inches away from the underside of the bed. S15 stated the side rails were up and there was padding to only one side of the bed, the right side. S15 stated she did not remember the left side rail having a pad on it. She stated she had taken care of the resident a couple of times before, and the resident had not slid out or down the bed, but other CNAs had reported to her that the resident would slide down and her feet would dangle off of the bed. During a phone interview with S16CNA on 7/15/11 at 8:30 a.m., she verified she was the CNA who found resident #15 on the floor on 7/9/11. She stated about 5:45 a.m., she was following another resident, who was wandering around the unit, and into resident #15's room, when she saw resident #15 lying on the floor on the left side of body, with head towards the door. She stated she covered the resident and went to get S15CNA to help put the resident in the bed. S16 stated she called S14LPN, after they had transferred resident #15 back into the bed. S16 stated the resident frequently slid down in bed and had to be pulled back up in bed. She verbalized staff were aware of the resident doing this, and aware that the resident's legs were sometimes found hanging over the side of the bed. She indicated when she found the resident on the floor, the side rails were up at and the pads were on both sides of the side rails. S16 stated S15 helped to put the resident back in bed by putting their arms under the resident's arms, and lifted the resident to the bed. She also stated, that the night the resident fell was the first night the resident had slept on the new air mattress, stating the previous mattress was not inflating the right way, so the facility changed the mattress. She indicated during the night shift of the resident ' s fall, she had to pull the resident up more frequently than she usually did, and indicated she thought the new mattress may have had something to do with having to reposition the resident so frequently. Review of a written statement from S16CNA of 7/9/11 at 5:45 a.m., indicated the resident was sometimes noted to be on the rail, and sometimes her feet were hanging out the bed, and she would sometimes also be low in the bed or sideways. During an interview with S17LPN on 7/14/11 at 3:15 p.m., she revealed the resident does not understand what is said to her, responds slowly to any communication, and the resident is non verbal. She stated she went to the resident ' s room shortly after she was given report and found the resident to have a bruised right eye, saying she was concerned about the resident ' s head injury, especially because the resident has two shunts, one of which was under the area of the head injury. She stated the resident still tries to cross one leg over the other one, as the resident did before the accident. S17 indicated staff still have to pull the resident up in bed because of sliding down. She also indicated the head of the resident ' s bed was kept raised up about 30 degrees. S17 verified a new air mattress had been put on the resident ' s bed recently, because the air mattress the resident had been sleeping on, was not inflating correctly. She verbalized the bed that the resident was in prior to the accident, is the same bed the resident was put back into following the accident. The resident now has floor mats to either side of the bed, and a bed alarm. She indicated, to her knowledge, S11Maintenance had replaced the mattress and adjusted the settings, but she was not sure. She verified she had not adjusted the new mattress A Physician's Progress Note dated 7/10/11 indicated the resident was sent to the emergency room at 12:50 p.m. on 7/9/11. A physician progress notes [REDACTED]. diagnosed with [REDACTED].