Every finding on record at Maison du Monde Living Center

Based on interviews, and record review, the facility failed to ensure a resident who required assistance, received assistance with activities of daily living (ADLs) to maintain good grooming and personal hygiene for 1 (Resident #1) of 4 sampled residents.Findings:On 05/12/2026, a review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting with a revised date of 03/2025, read in part: Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).c. elimination.Review of Resident #1's electronic health record (EHR) revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, malignant neoplasm of colon; secondary malignant neoplasm of retro peritoneum and peritoneum; bipolar disorder and pain, unspecified. Further review of Resident #1's EHR revealed the resident was blind. Review of Resident #1's discharge return not anticipated Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/28/2026, revealed in Section GG that he required set up or clean up assistance to shower/bathe self and for personal hygiene. Review of Resident #1's admission Care Plan dated 04/23/2026, revealed the following in part: -Self-care deficit r/t (related to) needs assistance with ADLs r/t blindness, multiple disease process. Goals: resident will be clean, dry, dressed neatly, odor free and well-groomed daily this quarter.Resident's needs will be met through staff intervention.Interventions in part: Assist with ADLs as needed; bathe and shampoo hair; encourage resident to change clothes as needed; and provide peri-care (cleaning of the genital and anal areas to maintain hygiene.) as needed. -Alteration in elimination r/t occasionally incontinent of bowel and bladder. Goal: Resident will be clean, dry, and odor free this quarter. Interventions in part: Assist with personal hygiene/peri-care as needed. On 05/11/2026 at 10:16 a.m., an interview was conducted with Resident #1's responsible party (RP).The RP stated she dropped Resident #1 off at the facility on 04/23/2026 for respite care (short term care). The RP further stated that when she returned to pick Resident #1 up on 04/28/2026, the resident was dirty, smelled of urine, his incontinent underwear was full of urine and had stool stains, and his pants were wet with urine. The RP stated the facility could not provide any documentation that the resident received a bath during his 5 days stay at the facility.Review of the facility's Bath/Shower Record revealed no documentation that Resident #1 received a shower/bath during the days he was admitted (04/23/2026 to 04/28/2026). On 05/11/2026 at 2:34 p.m., an interview was conducted with S5SA, who stated she was responsible for showering Resident #1 during his 5 days stay at the facility. S5SA stated she gave Resident #1 a shower on 04/24/2026 and he was scheduled to receive another shower on 04/27/2026. S5SA stated S6CNA who was assigned to care for Resident #1 did not bring him to the shower room. S5SA stated when she was getting off her shift at around 10:30 a.m. on 04/27/2026, she asked S6CNA if the resident was clean and S6CNA stated yes.On 05/11/2026 at 3:03 p.m., an interview was conducted with S6CNA. She stated she was assigned to care for Resident #1 on 04/27/2026 and was aware that he did not receive a shower on 04/27/2026. S6CNA stated that she should have offered Resident #1 a bed bath, but did not. S6CNA confirmed that she did not report to S7LPN that the resident did not receive a shower/bath.On 05/11/2026 at 3:14 p.m., an interview was conducted with Resident #R1 who was Resident #1's roommate. Resident #R1 stated Resident #1 was blind and could not see what he was doing. He further stated staff did not help the resident to the bathroom during his stay at the facility. On 05/11/2026 at 3:16 p.m., an interview was conducted with S7LPN, who stated she was assigned to care for Resident #1 on 04/27/2026. S7LPN stated she was not made aware by S5SA nor S6CNA that Resident #1 did not receive a shower/bath.On 05/12/2026 at 11:39 a.m., an interview was conducted with S8CNA/Driver, who stated she was the CNA (Certified Nursing Assistant) Supervisor during Resident #1's 5 days stay at the facility. S8CNA/Driver stated that if a resident did not get a shower/bath on their scheduled day, the assigned CNA was responsible for notifying the assigned nurse. The assigned nurse should then find out the reason for the resident not getting a shower/bath and document it. S8CNA/Driver stated S5SA worked 8 hours and S6CNA worked 12 hours and there was no reason Resident #1 should not have at least gotten a bed bath.Review of Resident #1's progress notes revealed no documentation regarding his shower/bath on 04/27/2026.On 05/12/2026 at 12:12 p.m., an interview was conducted with S1DON. She stated that she spoke to S5SA and S6CNA on 04/28/2026 after she became aware of Resident #1 not getting a shower/bath on 04/27/2026. S1DON stated S5SA reported that S6CNA did not bring Resident #1 to the shower room. S1DON stated that S5SA was responsible for ensuring Resident #1 got a shower, but S6CNA was aware and she did not give him a bath either. S1DON stated S5SA and S6CNA should have reported the missed shower/bath to S7LPN, and neither of them did.

Based on interviews and record review, the facility failed to ensure residents belongings were secured, by failing to inventory, document, and label clothing upon admission for 1(Resident #1) of 4 sampled residents.Findings: On 05/12/2026, a review of the facility's policy titled, Personal Property with a revised date of 08/2025, read in part: Policy Interpretation and Implementation.2. Resident belongings are treated with respect by facility staff, regardless of perceived value.10. The resident's belongings and clothing are inventoried and documented upon admission and updated as necessary. Review of Resident #1's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, malignant neoplasm of colon; secondary malignant neoplasm of retro peritoneum and peritoneum; bipolar disorder and pain, unspecified. On 05/11/2026 at 10:16 a.m., an interview was conducted with Resident #1's responsible party (RP).The RP stated she dropped Resident #1 off at the facility on 04/23/2026 for respite care (short term care). The RP further stated that when she returned to pick Resident #1 up on 04/28/2026, he was missing 3 pairs of pajamas, 4 t-shirts, and 3 pairs of socks. On 05/12/2026 at 8:46 a.m., an interview was conducted with S3SSD. She stated that on 04/28/2026, Resident #1's RP reported to her that the resident was missing some clothes. S3SSD stated that on admission, S4AD was responsible for inventorying and labeling Resident #1's clothing and she did not. On 05/12/2026 at 10:48 a.m., an interview was conducted with S4AD. S4AD confirmed she was responsible for inventorying and labeling residents' clothing. S4AD stated it was her fault that Resident #1's clothing was lost and stated she took full responsibility because she should have gone into Resident #1's room, completed an inventory of his clothing and labeled the items.

Based on observation and interview, the facility failed to post daily nursing staffing that included the facility name, date, census, and the total number and actual hours worked by staff responsible for resident care in a prominent place readily accessible to residents and visitors. The facility census was 119.Findings: On 01/27/2026 at 8:39 a.m., an observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted.On 01/27/2026 at 10:30 a.m., a second observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted.On 01/27/2026 at 12:21 p.m., a third observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted.On 01/27/2026 at 12:30 p.m., an interview was conducted with S7BenCoor (Benefits Coordinator). S7BenCoor confirmed she is responsible for the calculation and posting of the nurse staffing hours. She confirmed it had not been done and should be done daily.

Based on interviews and record reviews, the facility failed to ensure residents received the proper treatment and assistive devices to maintain hearing abilities by failing to follow up with community resources for 1 (Resident #6) out of 44 sampled residents.Findings:Review of the facility's policy titled Social Services, with a last reviewed date of 04/09/2025, read in part: 4. The social worker/social services staff are responsible for: g. making referrals and obtaining needed services from outside entities.Review of Resident #6's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] and had diagnoses including, but not limited to, end stage renal disease and type 2 diabetes.Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 13, indicating the resident was cognitively intact. Further review revealed the resident was coded as moderate difficulty for hearing, indicating that the speaker has to increase volume and speak distinctly.Review of Resident #6's plan of care revealed the following: Alteration in communication r/t (related to) HOH (Hard of Hearing) impaction of cerumen reoccurring, does need hearing aids, sent paperwork with family who did not return because of financial issues 01/9/2024.On 01/27/2026 at 10:41 a.m., an interview was conducted with Resident #6. The surveyor had to speak very loudly for the resident to be able to hear the surveyor's questions. The resident stated that she had been waiting for hearing aids for months, and the facility told her that they were waiting on a company to get the hearing aids. On 01/28/2026 at 1:38 p.m., an interview was conducted with S3SSD (Social Services Director). S3SSD stated the resident was seen by an Ears, Nose, Throat (ENT) specialist for her hearing last year, and was recommended for a hearing program that could have provided her assistance with obtaining hearing aids. However, the resident's family had to complete paperwork that included financial information, and the family never returned the paperwork, so she could not participate in the hearing program.On 01/28/2026 at 4:13 p.m., S3SSD provided further information to the surveyor after calling a community provider, and stated that Resident #6 was seen by this community provider on 02/18/2025 to assist the resident with purchasing or obtaining hearing aids. This provider sent out a referral to a second outside provider that was also supposed to provide assistance with obtaining hearing aids for the resident.On 01/29/2026 at 8:30 a.m., a follow up interview was conducted with S3SSD who stated that a representative from the second community provider informed her that Resident #6 was supposed to have an evaluation at their location, but she was never scheduled for that evaluation and the representative was not sure why. She stated it appeared the provider was waiting on communication from another community resource. S3SSD was asked if she followed up with either community provider in February of 2025, and she stated she was not aware that the resident saw the first community provider, or that she was then referred to a second provider. S3SSD was asked who set the appointment up with the first community provider, and she stated that she believed the ENT specialist set that appointment up, but she was not sure. She was then asked how she found out that the resident had an appointment with the first community provider to call them to obtain further information, and she stated that there was another resident who was seen by them who needed hearing aids, so she called out of chance. S3SSD confirmed that after 08/13/2024 when the facility lost communication with the family, she did not try to obtain other assistance or resources for the resident to obtain hearing aids, and did not look into the situation until the surveyor began asking questions on 01/28/2026. On 01/29/2026 at 12:00 p.m., S3SSD provided a progress noted dated 03/05/2024 that was written by herself that read in part: Resident brought information to SSD on . program for hearing aids. SSD reviewed information with resident and informed her that there was a $300 application fee for the hearing aids program. Resident stated I don't have that kind of money!. You can't ask them to waive that fee? SSD spoke to . at [ENT] office and explained that resident stated she did not have the money for the application fee. stated that if resident couldn't pay the fee, she would not be able to participate in the program.also stated that resident was referred . for assistance with hearing devices. S3SSD stated that evidently she did know about the referral to the community provider to obtain hearing aids for Resident #6. S3SSD could not explain why she did not follow up with the community provider after not receiving communication from them regarding the resident's hearing aids or for an appointment from February 2025 to now. S3SSD was asked if she was responsible for providing residents with assistance or resources to obtain hearing aids or other assistive devices, and she stated Yea I guess.

Based on observation, interview and record and policy review, the facility failed to maintain an effective infection prevention and control program, by failing to ensure:Staff utilized Enhanced Barrier Precautions (EBP) by wearing a gown when providing wound care to Resident #1;Proper infection control techniques were practiced during perineal care (cleaning of the genitals and anal areas) for Resident #75; andFailing to properly store clean bed pads.The facility census was 119.Findings: 1. On 01/28/2026, a review of the facility's policy titled Enhanced Barrier Precautions with a last revised date of 08/2025 read in part: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .h. wound care (this generally includes residents with chronic wounds, and not those with only shorter lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers.). Resident #1 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to type 2 diabetes mellitus without complications, unspecified open wound left foot and chronic kidney disease, stage 3 unspecified. Review of Resident #1's 01/2026 active orders revealed in part.01/06/2026 left heel diabetic foot ulcer – cleanse with wc (wound cleanser), pat dry, apply medihoney and calcium alginate, cover with abd (abdominal) pad and wrap with kerlix (gauze) as needed for soilage or removal. Review of wound care progress note by S10WCNP (Wound Care Nurse Practitioner) dated 01/27/2026 revealed in part.L (left) heel wound with moderate serous-sanguineous exudate. On 01/28/2026 at 8:23 a.m., an observation was made of S8TXN (Treatment Nurse) performing Resident #1's wound care. She was assisted by S9CNA (Certified Nursing Assistant). No gowns were utilized throughout the procedure by either employee. During a subsequent interview with S8TXN, she confirmed that no gowns were utilized during the procedure because the resident was not on EBP. She stated S4ADON/IP (Assistant Director of Nursing/Infection Preventionist) gave her a list of residents on EBP and Resident #1 was not on the list. On 01/28/2026 at 9:08 a.m., an interview was conducted with S4ADON/IP. She confirmed Resident #1 had a diabetic foot ulcer with drainage and should have been on EBP precautions but she failed to identify that the resident required such precautions. S4ADON/IP confirmed staff should have been gowning for Resident #1's wound care. 2. Review of a facility policy titled Perineal Care, with a last reviewed date of 04/09/2025, revealed, in part, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Review of Resident #75's medical record revealed an admit date of 12/04/2023 with diagnoses that included, in part, personal history of urinary tract infections, dysuria, and chronic kidney disease. Review of Resident #75's MDS (Minimum Data Set) dated 12/19/2025 revealed, in part, Section H: Urinary continence: 1. Occasionally incontinent (less than 7 episodes of incontinence). Review of Resident #75's Care Plan revealed UTI-hx (history) of UTI with interventions that included, in part, assist with peri (perineal)-care as needed. Further review of Resident #75's Care Plan revealed alteration in elimination r/t (related to) has bladder accidents, wears pull ups with interventions included, in part, assist with personal hygiene/peri-care as needed. On 01/29/2026 at 10:00 a.m., an observation of peri-care was conducted on Resident #75 and a subsequent interview was conducted with S13CNA (Certified Nursing Assistant). S13CNA donned gloves, applied perineal cleanser to a wipe, and wiped Resident #75's perineal area from front to back. S13CNA then wiped Resident #75's perineal area from front to back a second time using the same wipe. An interview was conducted with S13CNA. S13CNA confirmed that she should have thrown away the wipe after wiping Resident #75's perineal area, and obtained a new wipe to wipe Resident #75's perineal area again. On 01/29/2026 at 11:12 a.m., an interview was conducted with S4ADON/IP (Assistant Director of Nursing/Infection Preventionist). S4ADON/IP confirmed the CNA should not have used the same wipe to wipe Resident #75's perineal area from front to back multiple times. She also confirmed that a new wipe should have been used each time her perineal area was wiped from front to back. 3. Review of the facility's policy titled Departmental (Environmental Services) – Laundry and Linen, with a last review date of 04/09/2025, read in part, General Guidelines: Standard Precautions: 1. Separate soiled and clean linens at all times. On 01/29/2026 at 12:10 p.m., an observation was made of the laundry department with S6HskSup (Housekeeping Supervisor). An observation was made of the soiled linen room of the laundry department. A clothes line made of metal was attached to two walls and sloped across the soiled linen room. There were blue multi-use and washable bed pads draped on the metal clothesline. S6HskSup stated the blue bed pads hanging on the metal clothes line were resident bed pads, and they had been washed and were hanging on the metal clothes line to dry. An observation of the blue bed pads revealed that the bed pads were hanging next to the washing machines and directly above the mop bucket, which contained dirty water in the soiled linen room. One bed pad was touching the outside of the door and the handle of the washing machine. S6HskSup stated the clean bed pads should probably not be hanging to dry in the soiled linen room. He stated that these items should be hung to dry in the clean linen room. On 01/29/206 at 12:35 p.m., an interview and observation was conducted with S4ADON/IP (Assistant Director of Nursing/ Infection Preventionist). An observation was conducted with S4ADON/IP of the soiled linen room. S4ADON/IP confirmed that the clean bed pads were hanging in the soiled linen laundry room, and they should not be there. S4ADON/IP confirmed that they should be hanging to dry in the clean linen laundry room since they are clean.

Based on record reviews, interviews, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse for 2 (Resident #2 and Resident #81) of 2 (Resident #2 and Resident #81) residents investigated for resident to resident abuse. The facility failed to protect:1. Resident #81 from physical abuse by Resident #2; and2. Resident #2 from physical abuse by Resident #81. Findings: Review of the facility's policy titled, Abuse Prevention Program with a last review date of 04/09/2025, read in part. Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents.6. Identify and assess all possible incidents of abuse.8. Protect residents during abuse investigations. Resident #81 Review of Resident #81's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder and depression with psychotic features. Review of Resident #81's Quarterly Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/29/2025 revealed she had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Review of Resident #81's progress notes revealed the following: On 12/06/2025 at 17:45 (5:45 p.m.), S11LPN (Licensed Practical Nurse) wrote: Resident (#81) was walking in hallway with walker as another resident (Resident #2) passed by this resident said to the other resident you stole my pop, the other resident (Resident #2) then took her w/c (wheelchair) and ran it into this resident's walker. The staff then took resident's (Resident #2) w/c and began to push her to her room and the resident (Resident #2) reached out and hit this resident (#81) on her leg. This resident began yelling and attempted to hit (Resident #2) back without success because staff was between them. Both residents were taken to their rooms. On 12/07/2025 at 9:44 a.m., S11LPN wrote: Resident (#2) was propelling herself in the hallway and as she passed by (Resident #81) this resident came out of her room and kicked the other resident (#2) on her leg. The resident (#2) yelled ouch she kicked me. This nurse asked this resident what happened and she replied yes I kicked her because she hit me yesterday and stole my pop and I'm not sorry. This nurse then assisted resident (#2) to her room and this resident (#81) stayed in her room and finished eating her breakfast. On 01/28/2026 at 3:14 p.m., an interview was conducted with Resident #81. The resident stated that one day she was returning from exercise class and Resident #2 was leaving her (Resident #81's) room with her pop (soda) and Resident #2 ran her wheelchair into her (Resident #81). She stated she kicked Resident #2 and she yelled. She stated that staff came when they heard the yell and she confessed to them that she kicked Resident #2. Resident #2 Review of Resident #2's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, dementia, with other behavioral disturbances, major depressive disorder, and anxiety disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/22/2025 revealed she had a Brief Interview for Mental Status (BIMS) score of 08, which indicated she was moderately cognitively impaired. A review of the facility's incident titled, Physical Aggression Received, dated 12/06/2025 at 14:35, included a note by S11LPN (Licensed Practical Nurse) that revealed in part. This resident (Resident #2) was propelling down the hallway in her w/c (wheelchair), when another resident (Resident #81) walked up and told this resident you stole my pop (soda). This resident (Resident #2) ran into the other resident's (Resident #81) walker. A CNA (certified nurse assistant) ran over and took this resident (Resident #2) and began pushing her w/c towards her room and this resident hit the other resident (Resident #81) on her leg.No injuries observed at time of incident. A review of the facility's incident titled, Physical Aggression Received, dated 12/07/2025 at 07:50, included a note by S11LPN that revealed in part.Resident (Resident #2) was propelling herself in the hallway and as she passed by, the resident (Resident #81) came out of her room and kicked this resident (Resident #2) on her leg. This resident yelled ouch she kicked me. This nurse asked the resident (Resident #81) what happened, and she replied, Yes, I kicked her because she hit me yesterday and stole my pop and I'm not sorry. This nurse then assisted this resident (Resident #2) to her room, and the other resident (Resident #81) stayed in her room and finished eating her breakfast.No injuries observed at time of incident. On 01/28/2026 at 2:14 p.m., a phone interview was conducted with S11LPN regarding the incidents on 12/06/2025 and 12/07/2025 between Resident #2 and Resident #81. S11LPN stated on 12/06/2025, Resident #2 was in the hall, and Resident #81 was walking out of her room, and saw Resident #2 in the hall. Resident #81 stated to Resident #2 something about she had stolen her pop. Resident #2 then approached Resident #81's walker with her wheelchair, and S12CNA separated the residents. When S12CNA was moving Resident #2, she hit Resident #81's leg with her hand. S11LPN stated on 12/07/2025, Resident #2 was propelling herself down the hall, and she passed by Resident #81's room. Resident #81 was coming out of her room when S11LPN stated she heard Resident #2 state, ouch, she kicked me. S11LPN stated she asked Resident #2 what had happened, and she stated that Resident #81 had kicked her in the leg. Resident #81 told S11LPN that she had kicked Resident #2 because she had hit her leg yesterday, and had stolen her pop. S11LPN stated she informed S1ADM (Administrator) of the incidents on 12/06/2025 and 12/07/2025 at the times that they occurred. On 01/28/2026 at 2:31 p.m., a phone interview was conducted with S12CNA (Certified Nursing Assistant) regarding the incident on 12/06/2025 between Resident #2 and Resident #81. S12CNA stated on 12/06/2025, Resident #2 was wheeling herself down the hall, Resident #81 walked out of her room, and both residents were in the hall at the same time. Resident #81 stated something about Resident #2 stealing her pop. S12CNA stated that when she was separating the residents and wheeling Resident #2 back to her room, she hit Resident #81 on her leg. On 01/28/2026 at 3:53 p.m., an interview and record review were conducted with S1ADM. S1ADM confirmed he was notified by S3SSD (Social Service Director) and S11LPN of the physical altercations between Resident #2 and Resident #81 at the times they occurred on 12/06/2025 and 12/07/2025. S1ADM stated the incidents resulted in no injury to both residents.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 2 (Resident #2 and Resident #81) of 2 (Resident #2 and Resident #81) residents investigated for resident to resident abuse. Findings: Review of the facility's policy titled, Abuse Investigation and Reporting with a last reviewed date of 04/09/2025, revealed the following in part. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing of facility.2. An alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Resident #2 Review of Resident #2's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, dementia, with other behavioral disturbances, major depressive disorder, and anxiety disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/22/2025 revealed she had a Brief Interview for Mental Status (BIMS) score of 08, which indicated she was moderately cognitively impaired. Resident #81 Review of Resident #81's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder and depression with psychotic features. Review of Resident #81's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/29/2025 revealed she had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. A review of the facility's incident report titled, Physical Aggression Received, dated 12/06/2025 at 14:35, included a note by S11LPN (Licensed Practical Nurse) that revealed in part. This resident (Resident #2) was propelling down the hallway in her w/c (wheelchair), when another resident (Resident #81) walked up and told this resident you stole my pop (soda). This resident (Resident #2) ran into the other resident's (Resident #81) walker. A CNA (Certified Nurse Assistant) ran over and took this resident (Resident #2) and began pushing her w/c towards her room and this resident hit the other resident (Resident #81) on her leg. A review of the facility's incident report titled, Physical Aggression Received, dated 12/07/2025 at 07:50, included a note by S11LPN that revealed in part. Resident (Resident #2) was propelling herself in the hallway and as she passed by, the resident (Resident #81) came out of her room and kicked this resident (Resident #2) on her leg. This resident yelled ouch she kicked me. This nurse asked the resident (Resident #81) what happened, and she replied, Yes, I kicked her because she hit me yesterday and stole my pop and I'm not sorry. This nurse then assisted this resident (Resident #2) to her room, and the other resident (Resident #81) stayed in her room and finished eating her breakfast. On 01/28/2026 at 2:14 p.m., a phone interview was conducted with S11LPN regarding the incidents on 12/06/2025 and 12/07/2025 between Resident #2 and Resident #81. S11LPN stated on 12/06/2025, Resident #2 was in the hall, and Resident #81 was walking out of her room, and saw Resident #2 in the hall. Resident #81 stated to Resident #2 something about she had stolen her pop. Resident #2 then approached Resident #81's walker with her wheelchair, and S12CNA separated the residents. When S12CNA was moving Resident #2, she hit Resident #81's leg with her hand. S11LPN stated on 12/07/2025, Resident #2 was propelling herself down the hall, and she passed by Resident #81's room. Resident #81 was coming out of her room when S11LPN stated she heard Resident #2 state ouch, she kicked me. S11LPN stated she asked Resident #2 what had happened, and she stated that Resident #81 had kicked her in the leg. Resident #81 told S11LPN that she had kicked Resident #2 because she had hit her leg yesterday, and had stolen her pop. S11LPN stated she informed S1ADM (Administrator) of the incidents on 12/06/2025 and 12/07/2025 at the times that they occurred. On 01/28/2026 at 2:31 p.m., a phone interview was conducted with S12CNA (Certified Nursing Assistant) regarding the incident on 12/06/2025 between Resident #2 and Resident #81. S12CNA stated on 12/06/2025, Resident #2 was wheeling herself down the hall when Resident #81 walked out of her room, and both residents were in the hall at the same time. Resident #81 stated something about Resident #2 stealing her pop. S12CNA stated that when she was separating the residents, and wheeling Resident #2 back to her room, she hit Resident #81 on her leg with her hand. On 01/28/2026 at 3:53 p.m., an interview and record review were conducted with S1ADM. S1ADM confirmed he was notified by S3SSD (Social Service Director) and S11LPN of the physical altercations between Resident #2 and Resident #81 at the times they occurred on 12/06/2025 and 12/07/2025. S1ADM stated the incidents were not reported to the state agency.

Based on record review and interview, the facility failed to complete a discharge summary for 1 (Resident #123) of 3 closed records reviewed.Findings:A review of the facility's policy titled, Discharge Summary and Plan, with a last reviewed date of 04/09/2025, read in part, When the facility anticipates a resident's discharge to private residence, another nursing care facility, a discharge summary and post discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: c. discharge summary.A review of Resident #123's record revealed she was admitted to the facility on [DATE] and discharged from the facility on 11/07/2025. Further review of the record revealed no documentation of a discharge summary completed for Resident #123.On 01/28/2026 at 2:06 p.m., a record review and interview was conducted with S3SSD (Social Services Director). S3SSD confirmed Resident #123 was discharged from the facility on 11/07/2025. S3SSD further confirmed that a discharge summary was not completed for Resident #123.

Based on observation, interview and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#9) of 2 (#9, #124) residents investigated for ADLs.Findings:On 01/28/2026, a review of the facility's policy titled Activities of Daily living (ADLs), Supporting, with a last reviewed date of 04/09/2025, read in part: Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Resident #9 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; encounter for attention to gastrostomy and anxiety disorder.Review of Resident #9's quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 01/14/2026, revealed in Section E0800 under Rejection of Care that the behavior was not exhibited. Further review revealed a code of 01 in Section GG0130 Self-Care I. Personal hygiene indicating the resident was dependent - helper does ALL of the effort. Resident does none of the effort to complete the activity.Review of Resident #9's current care plan revealed a focus area dated 06/11/2025 self-care deficit r/t (related to) needs assistance with ADLs, decreased mobility, dx (diagnosis) dementia, refuses to get up. Interventions in part: assist with ADLs as needed and Personal Hygiene (totally dependent).On 01/27/2026 at 9:23 a.m., an observation was made of Resident #9. The resident was in bed with her left hand exposed. Her fingernails of her left hand were observed to be long and dirty with a thick layer of brown substance underneath her left middle fingernail.On 01/28/2026 at 2:34 p.m., a second observation was made of Resident #9. The resident was in her bed and her left hand fingernails were still long and dirty with a thick brown substance underneath her left middle fingernail.On 01/28/2026 at 2:40 p.m., an observation of Resident #9 was conducted with S4ADON/IP (Assistant Director of Nursing/Infection Preventionist). She confirmed the above findings, and stated the CNA (Certified Nursing Assistant) should have cleaned the resident's nails. She further stated that if she was unable to do so she should have notified the treatment nurse. S8TXN (Treatment Nurse) was standing outside Resident #9's room door and stated that she was not notified by the CNA that the resident refused nail care.

Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed diets were followed. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 12 residents who received pureed meals. Findings: Review of a facility document titled Puree Recipe Liquid Addition - Quick Guide that read in part Item - vegetables, breads, desserts, pasta, sandwiches, fish, potato dishes, eggs, port, ham, chicken, steak/beef. Liquid - whole milk and margarine/butter for all listed items except steak/beef use gravy. On 12/16/2024 at 10:55 a.m., S4Cook was observed preparing pureed rice with a pan filled with water, pouring a white powdery substance from a white bag that contained instant puree rice into the water, and continuously stirring with a whisk. S4Cook was asked how much water the pan held, and she stated she did not know. S4Cook stated she just poured the pureed rice into the water and stirred until she achieved the smooth blended consistency she wanted. She stated she did not measure, but she guessed the proper amounts. On 12/16/2024 at 11:00 a.m., an observation of S5Cook was conducted while she prepared puree bread. After placing several slices of bread into the blender, she added 8 ounces of whole milk. Observations of the pureed bread after S5Cook completed the process revealed the puree bread was thin liquid. Further observations of pureed beans that were prepared by S5Cook revealed the beans were thin consistency. S5Cook was asked about the consistency of the pureed bread and pureed beans. She stated she thought puree meant not too thick and not too thin. On 12/16/2024 at 11:15 a.m., an interview was conducted with S4Cook who confirmed the consistency of S5Cook's pureed bread and pureed red beans were not consistent for a puree diet, they were thinned liquid. S4Cook stated the consistency should have been smooth and blended. On 12/16/2024 at 2:45 p.m., an interview was conducted with S6DS (Dietary Staff), S8Cook, and S9DS. S6DS stated she was not trained on how to puree using a recipe. S8Cook stated that she was not trained on puree recipes, S9DS stated she was not trained on puree recipes, but was shown how to puree foods from other staff. S6DS confirmed the puree recipe liquid addition - quick guide did not help her puree meals. She stated there were no measurements for puree desserts. On 12/17/2024 at 2:37 p.m., an interview was conducted with S7RD (Registered Dietician). She confirmed puree recipes were not located in the main kitchen, and were not available for the cooks to use while preparing puree meals.

Based on interviews and record reviews, the facility failed to provide services that met professional standards for 2(#17 and #21) of 2 (#17 and #21) residents investigated for hospice services, by failing to: 1. Collaborate with the hospice agency to ensure the hospice nurse's visit notes and certification were up-to-date in Resident #21's hospice binder; and 2. Communicate with the hospice agency of Resident #17's high blood sugars. Findings: 1. A review of a document titled Nursing Facility Agreement indicated This Agreement is made and entered into this 23rd day of April 2018 by and between the facility and hospice .4.1 Compilation of Records. Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving nursing facility services and hospice services under this agreement in accordance with prudent record keeping procedures and as required by applicable Federal and state law and regulations and applicable Medicare and/or Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning each resident hospice patient including evaluations, treatments, program notes, authorizations for admissions to hospice and/or nursing facility . Each such record shall be readily accessible and systematically organized to facilitate retrieval by either party. A review of Resident #21's electronic health record (EHR) revealed an admitted [DATE], with diagnoses which included, but were not limited to heart failure and age related Osteoporosis. A review of Resident #21's physician orders revealed an order written on 03/20/2024 to admit to hospice. A review of resident #21's hospice binder revealed the last certification period was 03/20/2024 to 06/17/2024. Further review revealed the last hospice nurse visit notes were on 11/21/2024. During an interview and review of Resident #21's hospice binder with S11LPNDA (Licensed Practical Nurse/Data analyst) on 12/17/2024 at 1:35 p.m., she confirmed the last certification period was 03/20/2024 to 6/17/2024 and the last hospice nurse visit notes were dated 11/21/2024. During an interview with S2DON (Director of Nursing) on 12/17/24 at 3:25 p.m., she stated she did not know who was responsible for ensuring the hospice agency updated the resident's binder, and would find out. During a follow-up interview with S2DON at 3:35 p.m., she stated that she called her corporate office and it was the hospice agency's responsibility to ensure the hospice binder at the facility was updated with the current certification and visit notes. She stated hospice was responsible and the facility was not responsible for ensuring hospice update the binder. 49784 2. A review of a document titled Hospice and Facility Agreement indicated This Hospice and nursing facility residential agreement is made and entered into this 21st day of January, 2015, by and between Hospice Agency and Facility .4.4 Coordination with Hospice Regarding Plan of Care, c. Monitoring of Residential Hospice Patient. Nursing Facility shall immediately inform Hospice of any change in the condition of a Residential Hospice Patient. A review of Resident #17's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage heart failure, unspecified dementia, and type 2 diabetes mellitus. A review of Resident #17's Order Summary Report, for the month of 02/2024, revealed an order dated 02/12/2024, admit to hospice agency effective 02/12/2024 with a diagnosis of end stage heart failure. A review of Resident #17's Order Summary Report, for the month of 08/2024, revealed an order, dated 08/01/2024, Novolin R Injection Solution (Insulin Regular (Human)) Inject as per sliding scale: if 0-150=0 units if <50, administer orange juice; 151-200=2 units; 201-250=4 units; 251-300 = 6 units; 301-350= 8 units; 351-400=10 units; 401-999= 10 units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus). Review of Resident #17's MAR (Medication Administration Record), for the month of 09/2024, 10/2024, 11/2024, and 12/2025, revealed abnormal CBG levels above 401 for the following dates: this format is not easy to follow. spell out months and list. a. September 2024: 09/06/2024 at 2000 = 505, 09/21/2024 at 2000 = 467, 09/22/2024 at 2000 = 457, 09/25/2024 at 2000 = 472, 09/27/2024 at 1600 = 439; b. October 2024: 10/06/2024 at 1100 = 448, 10/09/2024 at 2000 = 579, 10/12/2024 at 1100 = 403, 10/14/2024 at 2000 = 541, 10/22/2024 at 1600 = 474, 10/23/2024 at 2000 = 459, 10/24/2024 at 2000 = 527, c. November 2024: 11/03/2024 at 2000=558, 11/06/2024 at 2000= 512, 11/12/2024 at 2000 = 426, 11/29/2024 at 2000 = 421, 11/30/2024 at 2000 = 472; d. December 2024: 12/03/2024 at 2000 = 419 12/15/2024 at 2000 = 521. On 12/18/2024 at 4:40 p.m., an interview and record review was conducted with S16CN (Corporate Nurse). A review of Resident #17's Order Summary Report and MARs for the month of 09/2024, 10/2024, 11/2024, and 12/2024 revealed a total of 19 occurrences where Resident #17's CBG levels were greater than 401. She confirmed that there was no documentation in Resident #17's Hospice Binder or the resident's medical record that revealed the Hospice agency was notified of the abnormal CBG levels. On 12/18/2024 at 4:52 p.m., a phone interview was conducted with S17HADON (Hospice Agency Director of Nursing). She stated that the Hospice agency should be notified of significantly high CBG levels for Resident #17 as collaboration between the facility and the Hospice agency.

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered careplan for 2 (#17 and #53) residents in a final sample of 35 residents as evidenced by failing to: 1. notify the physician of Resident #17's abnormal CBG (Capillary Blood Glucose) levels as ordered; and 2. develop a focus area and interventions related to a choking incident for Resident #53. Findings: 1. Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level last reviewed on 10/09/2024, revealed in part, Report abnormal results promptly to the supervisor or Attending Physician. Review of Resident #17's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage heart failure, unspecified dementia, and type 2 diabetes mellitus. A review of Resident #17's Order Summary Report, for the month of 08/2024, revealed an order, dated 08/01/2024, Novolin R Injection Solution (Insulin Regular (Human)) Inject as per sliding scale: if 0-150=0 units if <50, administer orange juice; 151-200=2 units; 201-250=4 units; 251-300 = 6 units; 301-350= 8 units; 351-400=10 units; 401-999= 10 units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus). Review of Resident #17's MAR (Medication Administration Record), for the month of 09/2024, 10/2024, 11/2024, and 12/2025, revealed abnormal CBG levels above 401 for the following dates: a. September 2024: 09/06/2024 at 2000 = 505, 09/21/2024 at 2000 = 467, 09/22/2024 at 2000 = 457, 09/25/2024 at 2000 = 472, 09/27/2024 at 1600 = 439; b. October 2024: 10/06/2024 at 1100 = 448, 10/09/2024 at 2000 = 579, 10/12/2024 at 1100 = 403, 10/14/2024 at 2000 = 541, 10/22/2024 at 1600 = 474, 10/23/2024 at 2000 = 459, 10/24/2024 at 2000 = 527, c. November 2024: 11/03/2024 at 2000=558, 11/06/2024 at 2000= 512, 11/12/2024 at 2000 = 426, 11/29/2024 at 2000 = 421, 11/30/2024 at 2000 = 472; d. Deceber 2024: 12/03/2024 at 2000 = 419 12/15/2024 at 2000 = 521. . A review of Resident #17's medical record failed to reveal documentation regarding nurses notifying Resident #17's MD of the abnormal CBG results that were listed. On 12/18/2024 at 3:24 p.m., an interview and record review was conducted with S16CN (Corporate Nurse). A review of Resident #17's Order Summary Report and MARs for the month of 09/2024, 10/2024, 11/2024, and 12/2024 revealed a total of 19 occurrences where Resident #17's CBG levels were greater than 401. S16CN confirmed the physician's orders revealed for a CBG result of 401 and above, to call the MD. She confirmed the resident's physician was not notified for each of the occurrences and should have been. 47540 2. On 12/19/2024, a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered with a last revision date of 10/09/2024, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated that the following information is to be documented in the resident care plan: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporate identified problem area. Care plan interventions are chosen after careful data gathering and consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Resident #53 Review of Resident #53's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, paraplegia, dry mouth, ileus, and gastroesophageal reflux disease. Review of Resident #53's most recent annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. Review of Resident #53's progress notes revealed a note dated 09/06/2024 by S14LPN (Licensed Practical Nurse) read in part, resident said . he was choking on brisket and coleslaw he had for lunch that was caught in his throat and was short of breath. Resident #53 requested to go to the emergency room . Review of Resident #53's CT (Computed Tomography) of the chest w/o (without) contrast dated 09/06/2024 read in part, food in the distal esophagus with fluid present proximally, findings concerning for residual food with impaction . Further review of Resident #53's progress notes revealed a note dated 09/07/2024 by S14LPN read in part, Resident #53 was admitted with esophageal obstruction and will see GI (Gastrointestinal). Review of Resident #53's comprehensive care plan failed to reveal a focus area or interventions related to Resident #53's choking incident on 09/06/2024. On 12/18/2024 at 9:50 a.m. A record review and interview was conducted with S10MDS/LPN (Minimum Data Set Coordinator/Licensed Practical Nurse). S10MDS/LPN confirmed Resident #53 had a choking incident on 09/06/2024 and was transferred to the emergency room for evaluation. She also confirmed the incident on 09/06/2024 should have been in the care plan with interventions, but it was not. On 12/18/2024 at 10:13 a.m., an interview was conducted with S2DON (Director of Nursing) who confirmed Resident #53 had a choking incident on 09/06/2024 and was sent to the emergency room for evaluation. She confirmed this incident should have been developed in the care plan with interventions, but it was not.

Based on record review and interview, the provider failed to document, investigate, and maintain documentation of complaints voiced during the facility's resident council meetings that were conducted on 07/09/2024 and 10/08/2024. This had the potential to effect a census of 112 residents in the facility. Findings: Review of the facility's policy titled Grievance/ Complaint Filing, with a last review date of 10/09/2024 revealed in part . 8. Upon receipt of a grievance or complaint, the designee will review and investigate the allegations and submit a written report of the findings to the administrator within 5 working days of receiving the complaint or grievance. 12. The person filing the complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator or his designee will make a report within 5 working days of the filing of the grievance with the facility. b. A written summary will be provided to the resident upon request regarding any corrective action taken by the facility. On 12/16/2024 11:19 a.m., during meeting conducted with members of the resident council, Resident # 82 expressed the complaints that the residents voiced during the July and October 2024 meetings about the facility not passing of ice that was not totally resolved. He stated, they do pass ice sometimes, but not consistently. They will correct the issue for a couple weeks but fail to keep it up. After we report it again it gets resolved for a few days then falls back to not being passed for days. Resident # 55 confirmed the inconsistency of passing the ice. On 12/17/2024 at 10:00 a.m., an interview was conducted with Resident #15 who stated the facility's staff were inconsistent with passing ice. She further stated it would be much better if they would pass ice and water on a schedule so the residents wouldn't feel like they were bothering someone by asking them to go get ice. On 12/17/2024 at 2:40 p.m., during an interview and review of the Resident Council meeting minutes from 07/09/2024 and 10/08/2024, S12AD (Activity Director) revealed she did not write up the complaints about no ice being passed as a grievance because it was just one resident in each meeting that complained. S12AD stated she provided the resident with ice and water then informed the CNA (Certified Nurse Assistant) supervisor. On 12/17/2024 at 2:50 p.m., an interview was conducted with S13CNASup (Certified Nurse Assistant Supervisor) who failed to remember if she ever heard the complaint about no ice being passed in the facility. S13CNASup confirmed she had no documentation of any complaints expressed about residents not receiving ice.

Based on record review and interviews, the facility failed to ensure an alleged injury of unknown source was reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 2 (#84, #113) out of 3 (#7, #84, #113) sampled residents investigated for falls. The deficient practice had the potential to affect a total census of 112 residents. Findings: On 12/17/2024, a review of the facility's policy titled, Abuse Investigation and Reporting with a last reviewed date of 10/09/2024 revealed the following in part .Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing of facility .2. All alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury Resident #84 Review of Resident #84's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle wasting and atrophy. Review of Resident #84's Quarterly Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/11/2024 revealed she had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Review of Resident #84's electronic health record revealed a nurse note dated 10/15/2024 at 5:44 a.m., that read in part .resident found outside of room door in hallway on the floor. Urine and feces noted on the floor. Barefoot, without a brief on. Resident c/o (complained of) pain to left arm and sob (shortness of breath) . Review of Resident #84's Fall Report revealed the incident occurred 10/15/2024 at 5:00 a.m., that read in part .resident was found outside of room door in hallway on the floor. Urine and feces noted on the floor. Barefoot, without a brief on. Resident c/o pain to left arm and sob. Scheduled transfer to ER (emergency room ) . Review of Resident #84's Radiology Interpretation for XR (x-ray) Forearm 2 views left on 10/15/2024 read in part: impacted non-displaced fracture of the distal radius with minimal cortical deformity. Further review of Resident #84's electronic health record revealed a nurse note dated 10/15/2024 at 10:46 a.m., that read in part .Resident returned from ER via van. DX (diagnosis) UTI (urinary tract infection and left radial fracture . On 12/17/2024 at 11:36 a.m., attempted interview with Resident #84 regarding incident on 10/15/24. Resident unable to recall events of incident. Resident #113 Review of Resident #113's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, depression, anxiety disorder, unspecified psychosis, and muscle wasting and atrophy. Review of Resident #113's Significant Change Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/25/2024 revealed he had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Review of Resident #113's electronic health record revealed a nurse note dated 10/12/2024 at 6:01 a.m., that read in part .staff came out of MCU (memory care unit) while nurses were giving report and stated that resident was sitting on the floor. Resident stated that his feet just left from under him. ROM (range of motion) done. Resident stated that he hit his head. Small bruises noted to top of head. Resident complains of left wrist pain . Review of Resident #113's Fall Report revealed the incident occurred 10/12/2024 at 6:00 a.m., that read in part . staff came out of MCU (memory care unit) while nurses were giving report and stated that resident was sitting on the floor. Resident stated that his feet just left from under him. ROM (range of motion) done. Resident stated that he hit his head. Small bruises noted to top of head. Resident complains of left wrist pain. Notified NP. Will call son. Sending to ER for eval (evaluation). Neuros initiated . Review of Resident #113's Radiology Interpretation for XR Wrist 3 views Lt (left) on 10/12/2024 read in part: acute fracture of the ulnar styloid and distal radial metaphysis. Review of Resident #113's electronic health record revealed a nurse note dated 10/12/2024 at 10:50 a.m., that read in part .Resident returned to facility with transport. Resident in stable condition. Resident has colles splint to left hand, wrist, and forearm. Resident has an acute minimally displaced fracture to left ulnar styloid. On 12/17/2024 at 11:24 a.m., attempted interview with Resident #113 regarding incident on 10/12/24. Resident unable to recall events of incident. On 12/18/2024 at 10:27 a.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed Resident #84 had an unwitnessed fall with a fracture on 10/15/2024 and the resident had severe cognitive impairement and unable to state how the incident occured . S2DON also confirmed the incident was not reported to the state agency and should have been. S2DON also confirmed Resident #113 had an unwitnessed fall with a fracture on 10/12/2024 and the resident had severe cognitive impairement and uable to state how the incident occured. S2DON also confirmed the incident was not reported to the state agency and should have been.

Based on observation, interviews, and record review, the facility failed to ensure 1 (#49) of 35 sampled residents was safe to perform self-administration of medication. Findings: On 12/18/2024, a review of the facility's policy titled Self- Administration of Medications which was last reviewed on 10/09/2024, read in part, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; Policy Interpretation and Implementation: 1. As part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical, abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and/or practitioner will perform a more specific skill assessment, 3. If the team determines that a resident cannot safely self-administer, the nursing staff will administer the resident's medications. 4. The staff will document their findings and the choices of residents who are able to self-administer medications. Review of Resident #49's health record revealed she was admitted to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease. Review of Resident #49's physician orders revealed an order dated 11/17/2023, Aluminum-Magnesium-Simethicone Oral Suspension 200-200-20 mg(milligrams)/5ml(milliliters) (Alum (Aluminum) & Mag (Magnesium) Hydrox(Hydroxide)-Simethicone). Give 30ml by mouth with meals related to Gastro-Esophageal Reflux Disease without Esophagitis. Review of Resident #49's Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/17/2024, revealed she had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. Review of Resident #49's record revealed no assessment, physician's orders, or careplan for self-administration of medication. On 12/16/2024 at 9:40 a.m., an observation and interview was conducted with Resident #49. A medicine cup containing a thick, white substance was observed on the bedside table. Resident #49 stated that she had not taken her Maalox yet, but intended to take it, referring to the medicine cup with the thick liquid. During an observation and interview on 12/16/2024 at 9:51 a.m. with S18LPN (Licensed Practical Nurse), she confirmed she had left the medicine cup on the resident's bedside table. She stated the medication was Mylanta, and the resident preferred to drink it in intervals. She further stated that she should not have left the resident's medication at her bedside. During an interview and record review on 12/18/2024 at 9:03 a.m. with S2DON (Director of nursing), she confirmed that Resident #49's record did not contain an assessment or a physician's order for Resident #49 to self- administer her own medications. She also confirmed that self- administration of medication was not included in her the resident's plan of care. S2DON also confirmed Resident #49 did not have the appropriate documentation to prove the resident could safely self-administer her medications and the nurse should not have been left Mylanta at the resident's bedside.

Based on observations, record review and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff used personal protective equipment according to accepted standards of practice during biohazard trash removal. Findings: Review of a facility policy and procedure titled Personal Protective Equipment - Using Gloves, with revised date of 10/09/2024, read in part, .purpose to guide the use of gloves. Objectives - 1. To prevent the spread of infection. 3. To protect hand from potentially infectious material. When to use gloves: 4. When cleaning potentially contaminated items; and 5. Whenever in doubt. On 12/17/2024 at 10:58 a.m., an observation of Hall A revealed a treatment cart positioned against the wall. The treatment cart had a trash can attached with the lid of the trash can opened. A red biohazard trash bag was observed lining the trash can. A partially discarded blue glove was observed hanging half way outside of the red trash bag along with other discarded materials. On 12/17/2024 at 10:59 a.m., an observation and interview was conducted with S3TXN (Treatment Nurse) who stated she had completed her treatments for the day. S3TXN stated that she should have emptied her trash when she completed her treatments. Further observation revealed S3TXN removed the partially discarded blue glove from the trash can, and placed it inside the biohazard trash bag without gloves. She then proceeded to remove the biohazard trash bag from the trash can, and placed the biohazard bag on top of the treatment cart. S3TXN confirmed she should have donned gloves prior to touching the soiled blue glove, and removing the biohazard trash bag. She also confiirmed she should not have placed the biohazard bag on top of her treatment cart. On 12/17/2024 at 4:07 p.m., an interview was conducted with S2DON (Director of Nursing) who was also the facility's Infection Preventionist. She confirmed S3TXN should have put on personal protective equipment before she handled soiled and biohazard materials. She also confirmed the nurse should not have placed the biohazard bag on top of her treatment cart.

Based on policy review, observations and interviews, the facility failed to ensure that the enteral feeding infused at the ordered rate for one (Resident #63) out of 2 Residents (Resident #63 and Resident #66) investigated for tube feeding. This had the potential to effect 3 residents in the facility who had tube feedings. Findings: Review of the facility's policy titled, Enteral Feedings-Safety Precautions last reviewed on 10/09/2024 revealed in part, the following Preventing errors in administration, 1. Check the enteral nutrition label against the order before administration. Check the following information: g. Rate of administration (ml (milliliters)/hr (hour)). Review of Resident #63's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, unspecified dementia, dysphagia, chronic systolic (congestive) heart failure, and encounter for attention to gastrostomy. Review of Resident #63's physician orders revealed an order dated 10/25/2024 Enteral Feed Order every shift Isosource 1.5 @ 44ml (milliliters)/hr (hour) to provide 1584 total calories every 24 hours, 71g Protein, 1641 ml Free Water & 1896 ml Total fluid volume in 24 hours. On 12/17/2024 at 11:41 a.m., an observation of Resident #63's enteral feeding pump and interview was conducted with S18LPN. S18LPN confirmed that the resident's enteral feeding was running at a rate of 45ml/hour. She confirmed that the enteral feeding rate was ordered to run at 45ml/hour and was not running at the rate ordered.

Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure the comprehensive care plan was accurately documented for 1 (#53) resident. The deficient practice has the potential to affect a census of 112. On 12/19/2024, a review of the facility's policy titled, Charting and Documentation with a last review date of 10/09/2024, read in part, All services provided to the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated that the following information is to be documented in the resident medical record: Progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #53 Review of Resident #53's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, paraplegia, spinal stenosis, muscle wasting and atrophy, and ileus. Review of Resident #53's progress notes revealed a note dated 11/11/2024 by S7RD (Registered Dietician) that read in part, Current weight is 121.2 from 11/11/2024. Resident is 68 tall with BMI (body mass index) = 18.4 (underweight). Weight loss triggers: -5.0% change [Comparison Weight 10/16/2024, 137.0 Lbs (pounds), -11.5%, -15.8 Lbs], -7.5% change [Comparison Weight 9/10/2024, 141.4 Lbs, -14.3%, -20.2 Lbs], and -10.0% change [Comparison Weight 6/5/2024, 140.2 Lbs, -13.6%, -19.0 Lbs]. Weekly weights until stable . Review of Resident #53's Comprehensive Care Plan revealed the resident had an alteration in nutrition r/t (related to) refuses meals at times and 11/12/2024 weight loss. Interventions included weigh monthly. On 12/18/2024 at 9:50 a.m., a record review and interview was conducted with S10MDS/LPN (Minimum Data Set Coordinator/Licensed Practical Nurse). S10MDS/LPN reviewed Resident #53's progress notes and comprehensive care plan. She confirmed Resident #53 was to be weighed weekly and this was not accurately documented in the comprehensive care plan.

Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 2 (#84, #113) out of 2 (#84, #113) residents in a final sample size of 35. The deficient practice has the potential to affect a census of 112. Findings: Review of Resident #84's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle wasting and atrophy. Review of Resident #84's nurse's notes revealed on 10/15/2024 at 6:00 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 10/15/2024 at 10:46 a.m., the resident returned from the hospital back to the facility. Further review of the facility's document titled Census List revealed Resident #84 was transferred to the hospital on 10/15/2024, 11/08/2024 and 11/17/2024. Review of the Emergency Transfer Log for October 2024 revealed Resident #84's transfer to the hospital on 10/15/2024 was not identified on the list. Further review of the Emergency Transfer Log for November 2024 revealed Resident #84's transfer to the hospital on 11/08/2024 was not identified on the list. Review of Resident #113's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, depression, anxiety disorder, unspecified psychosis, and muscle wasting and atrophy, and repeated falls. Review of Resident #113's nurses' notes revealed on 10/12/2024 at 7:09 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 10/12/2024 at 10:50 a.m., the resident returned from the hospital back to the facility. Further review of the facility's document titled Census List revealed Resident #113 was transferred to the hospital on 08/19/2024, 10/10/2024, 10/12/2024, 10/17/2024, 11/28/2024 and 12/02/2024. Review of the Emergency Transfer Log for August 2024 revealed Resident #113's transfer to the hospital on 08/19/2024 was not identified on the list. Further review of the Emergency Transfer Log for October 2024 revealed Resident #113's transfer to the hospital on 10/10/2024 and 10/12/2024 was not identified on the list. Further review of the Emergency Transfer Log for November 2024 revealed Resident #113's transfer to the hospital on 11/28/2024 was not identified on the list. Further review of the Emergency Transfer Log for December 2024 revealed Resident #113's transfer to the hospital on 12/02/2024 was not identified on the list. On 12/18/2024 at 2:22 p.m., an interview and record review was conducted with S15BOM (Business Office Manager). She confirmed she was responsible for the Emergency Transfer Log and to send it to the State Long Term Care Ombudsman. S3BOM reviewed Resident #84's facility document titled Census List and confirmed the resident was transferred to the hospital on 10/15/2024, 11/08/2024 and 11/17/2024. She then reviewed the Emergency Transfer Log for October 2024 and November 2024 and confirmed the resident was not listed as having been transferred on 10/15/2024 and 11/08/2024. S3BOM reviewed Resident #113's facility document titled Census List and confirmed the resident was transferred to the hospital on 08/19/2024, 10/10/2024, 10/12/2024, 10/17/2024, 11/28/2024 and 12/02/2024. She then reviewed the Emergency Transfer Log for August 2024, October 2024, November 2024 and December 2024 and confirmed resident was not listed as having been transferred on 08/19/2024, 10/10/2024, 10/12/2024, 11/28/2024 and 12/02/2024. S15BOM stated she was not aware that facility initiated transfers for less than 24 hours had to be listed on the Emergency Transfer Log sent to the State Long Term Care Ombudsman.

Based on record review and interviews, the facility failed to notify the resident's responsible party (RP), the nurse practitioner, and physician of a deteriorating right foot wound for 1 (#2) out of 3 (#1, #2, #3) sampled residents by failing to contact the responsible party (RP), nurse practitioner, and physician in a timely manner. Findings: On 05/07/2024, a review of the facility's policy titled, Wound Prevention with a last revised date of 06/14/2023 revealed in part the following: Policy: The purpose of this policy is to provide information regarding identification of wound/pressure ulcer/injury risk factors and interventions for specific risk factors for prevention of pressure ulcers/wounds. Monitoring: 1. Evaluate, report and document potential changes in the skin including new wounds/pressure ulcers. No mention of which professional discipline could perform the assessments or to who to report changes noted in the policy. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Schizoaffective Disorder, Atherosclerosis of Native Arteries of Right Leg with Ulceration of Heel and Midfoot, Peripheral Vascular Disease, Contracture Right Elbow, Hypertension, Edema, Dysphagia, Aphasia Following Cerebral Infarction, Type 2 Diabetes Mellitus with other Circulatory Complications, and Chronic Ischemic Heart Disease. Review of Resident #2's wound evaluations revealed in part: Initial Wound Evaluation dated 03/19/2024 body location: right dorsum foot, dimensions- area: 35.9 centimeters (cm), length: 9.09cm, width: 6.58cm. Wound Evaluation dated 03/26/2024: right dorsum foot, dimensions- area: 0.87cm (-98%), length: 1.85cm (-80%), width: 0.63cm (-90%). Wound Evaluation dated 04/02/2024: right dorsum foot, dimensions- area: 28.69cm (+3184%), length: 7.1cm (+283%), width: 6.51cm (+926%). Positive percentage indicated the wound increased in size. There was no documentation of notification to Resident #2's responsible party or nurse practitioner or physician. Wound Evaluation dated 04/17/2024: right dorsum foot, there was no documentation of the dimensions of the right dorsum foot. Wound Evaluation dated 04/24/2024 dorsum foot, dimensions- area: 37.85cm (+183%), length: 9.09cm (+36%), width: 6.58cm (+135%). There was no documentation of notification to Resident #2's responsible party or nurse practitioner or physician. On 05/06/2024 at 9:00 a.m., a phone interview was conducted with Resident #2's RP. She stated she was never notified by the facility that the resident's right foot wound was getting worse. On 05/06/2024 at 3:32 p.m., an interview was conducted with S3WCN (Wound Care Nurse). S3WCN was asked to compare the wound evaluation from 03/19/2024 to 04/24/2024. She stated the right foot wound did not look bad in March, however every week the right foot wound looked more macerated with increase drainage noted to the wound. S3WCN stated no notification was made to the residents RP. On 05/07/2024 at 10:41 a.m., a phone interview was conducted with S5NP (Nurse Practitioner). S5NP stated she was aware of Resident #2's right foot wound, but was not notified of the wounds worsening condition.

Based on record review and interview, the facility failed to assure that services were provided in accordance with each resident ' s written plan of care by not following physician orders [REDACTED].#8, #89, #113) out of 48 residents. The facility failed to ensure that staff carries out physician's order [REDACTED]. 1. Place bed alarms on resident beds as ordered (#8, #113), 2. Administer [MEDICATION NAME] as ordered (#7), and 3. Obtain laboratory test as ordered (#89) This failed practice resulted in an actual harm for resident #113 on 3/11/15 when the staff failed to place the bed alarm on the resident ' s bed. The resident got out of bed unassisted, sustained a fall resulting in a [MEDICAL CONDITION] humerus. FINDINGS: 1. Resident #113. A review of the clinical record revealed that Resident #113 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Continued review of the clinical record revealed that the resident was transferred from the Memory Care Unit to the general population on 2-10-14 after determining resident no longer meets the requirement for housing in this specialty unit. A review of the Physician order [REDACTED]. A review of the Nurses Notes dated 3-11-15 at 1:30pm revealed an entry which read: called to room by CNA; Resident observed lying supine on floor, head towards bathroom and feet toward bed; wearing only socks;...complaining of left shoulder pain...states was going to the bathroom...MD and RP notified...the hospital via ambulance for evaluation. 3-11-15 at 1730 admitted to ___(Local Hospital) c (with) Humoral Head Fx. Notified ____. A review of the incident report dated 3-11-15 at 1:30pm revealed the following: Description of situation: summoned to room per CNA, resident observed laying on back on floor wearing socks only; stated "I am going to the bathroom" c/o of shoulder pain left. Summary of Investigation: Resident got out of bed without assistance and attempted to ambulate. Bed alarm was not on bed. Resident fell . Recommendations/New Interventions: CNA given written disciplinary form related to not following the plan of care and not transferring pressure pad alarm from wheelchair to bed. An interview with S18CNA was conducted on 3-13-15 at 8:15am. S18CNA stated that when she was coming from lunch break, daughter of the resident was standing in the doorway waiting for assistance with the resident for toileting. S18CNA stated that after assisting the resident in the bathroom, she placed the resident in bed for a nap. S18CNA stated that she placed the alarm on the bed before leaving the room. An interview was conducted with S7 RN, ADON on 3-12-15 at 3:35pm. After reviewing the incident report, S7RN, ADON confirmed that she personally made a room observation within minutes of the incident, there was no alarm sounding upon her entering the resident's room and the bed alarm was not on the bed but located in the seat of the wheelchair. 2. Resident #8: Resident #8 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's care plan revealed that she was care planned to be at risk for falls related to unsteady gait, [MEDICAL CONDITION] medication use, confused, Alzheimer ' s, non-compliant with using call bell and decreased cognition status. Further review of the care plan for the resident ' s risk for falls revealed an approach of bed/chair alarm dated 1/16/15. A review of Resident #8 ' s physician's order [REDACTED]. Monitor q shift " . A review of Resident #8 ' s Incident and Accident form revealed the following: Date of Incident/accident: 2/15/15 Describe exactly what happened: Called to resident room per CNA. Resident noted lying on floor on right side. No injury noted. +ROM. MAE without discomfort. Res unable to to tell exactly what caused fall. Keep say " I ' m OK, I ' m OK " . Assisted to stand x 2 & place in w/c. V/S taken & neuro ¿ initiated. Type of injury: none apparent is checked Summary of Investigation: Res unable to verbalize what led to fall. But res got out of bed without assistance and fell on floor. Alarm was on and sounded Recommendations: Inservice to make sure the chair alarm is transferred from w/c to bed and on. On 3/12/15 at 1:06 pm, an interview was conducted with S7RN,ADON during which she stated that she completed the fall investigation for Resident #89. During the interview, S7RN,ADON was asked why the recommendation was to inservice on transferring the chair alarm from the wheel chair and bed alarm when the investigation revealed that the alarm was on and sounded. Her response was that at the time of the fall on 2/15/15, the nurse on duty stated that the bed alarm was on and sounding when they found her. However, upon further investigation, it was determined that the alarm was not on and was left on the wheel chair. An additional interview was conducted on 3/12/15 at 2:15 pm with S7RN,ADON and she clarified that the CNA who found Resident #8 on the floor was not assigned to her. She continued to say that the CNA happened to be walking down the hall and saw Resident #8 was on the floor. She confirmed that there was no alarm sounding at the time Resident #8 was found on the floor on 2/15/15. 3. Resident #7. Record review revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Record review of Resident #7 ' s February 2015 physician's order [REDACTED]. [MEDICATION NAME] (antidepressant) 30mg 1 PO Q DAY was started on 2/3/15. On 2/27/15, [MEDICATION NAME] 30mg 1 PO Q DAY was discontinued and [MEDICATION NAME] 20mg 1 PO Q DAY was started. Record review of Resident #7 ' s March 2015 physician's order [REDACTED]. During an interview with S16LPN on 3/11/15 at 10:33 AM, she stated [MEDICATION NAME] was discontinued and changed to [MEDICATION NAME] on February 27, 2015. Record review of the March,2015 MAR (Medication Administration Record) revealed [MEDICATION NAME] 20 mg 1 PO Q DAY with a start date of 2/27/15. Further review of the March, 2015 MAR failed to reveal that the prescribed [MEDICATION NAME] doses were administered on 3/1/15, 3/2/15, 3/3/15, or 3/4/15 as there were no nurse ' s initials for these doses on the MAR indicated [REDACTED]. During an interview and review of the March 2015 MAR indicated [REDACTED]. During an interview and review of the February and March 2015 MARs with S2DON on 3/11/15 at 2:30 PM, she confirmed [MEDICATION NAME] 20mg 1 PO Q DAY was ordered on [DATE], and she confirmed that the [MEDICATION NAME] doses were not initialed by the nurses on 3/1/15, 3/2/15, 3/3/15 and 3/4/15 and could not prove that these doses were administered according to the physician's order [REDACTED]. 4. Resident #89: Resident #89 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/13/15, a review of Resident #89's Physician orders [REDACTED].#89 in February 2015 as ordered by the physician. An interview was conducted on 3/13/15 at 11:40 am with S3CNA during which she stated that she is responsible for ordering labs and that routine labs are ordered within the first few days of the month that it is due. Both S3CNA and S7RN,ADON, who was present during the interview, reviewed Resident #89 ' s clinical record and they confirmed the HGBA1C had not been completed as per the physician's order [REDACTED].

Based on observation, record review and interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; by failing to provide adequate supervision and assistance devices to prevent a fall for resident #113 and #8. This failed practice resulted in an actual harm for resident #113 on 3/11/15 when the staff failed to place the bed/chair alarm on the resident ' s bed. The resident got out of bed unassisted, sustained a fall resulting in a fracture of the left humerus. FINDINGS: 1. RESIDENT #113. A review of the clinical record revealed that Resident #113 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Continued review of the clinical record revealed that the resident was transferred from the Memory Care Unit to the general population on 2-10-14 after determining resident no longer meets the requirement for housing in this specialty unit. A review of the Physician order [REDACTED]. A review of the Nurses Notes dated 3-11-15 at 1:30pm revealed an entry which read: called to room by CNA; Resident observed lying supine on floor, head towards bathroom and feet toward bed; wearing only socks;...complaining of left shoulder pain...states was going to the bathroom...MD and RP notified...to hospital via ambulance for evaluation. admitted to hospital with [DIAGNOSES REDACTED]. A review of the incident/accident report dated 3-11-15 at 1:30pm revealed the following: Description of situation: summoned to room per CNA, resident observed laying on back on floor wearing socks only; stated "I am going to the bathroom" c/o of shoulder pain left. Summary of Investigation: Resident got out of bed without assistance and attempted to ambulate. Bed alarm was not on bed. Resident fell . Recommendations/New Interventions: CNA given written disciplinary form related to not following the plan of care and not transferring pressure pad alarm from wheelchair to bed. An interview with S8CNA was conducted on 3-13-15 at 8:15am. S8CNA stated that when she was coming from lunch break, daughter of the resident was standing in the doorway waiting for assistance with the resident for toileting. S8CNA stated that after assisting the resident in the bathroom, she placed the resident in bed for a nap. S18CNA stated that she placed the alarm on the bed before leaving the room. A phone interview with the daughter of Resident #113 was conducted by phone on 3-12-15 at 3:45 pm. During this interview, the daughter confirmed that she was present with the resident prior to the occurrence of the resident's fall. Resident #113's daughter stated she called for assistance to help her mother to the bathroom. A CNA came in the room and assisted her mother to the bathroom and then assisted her from the wheelchair to the bed to take a nap. The daughter of the resident stated she did not recall seeing the bed/chair alarm nor did she see the CNA placing one on the bed. Resident #113's daughter confirmed that she did see an alarm on the wheelchair and the dresser located in the resident's room. An interview was conducted with S7 RN, ADON on 3-12-15 at 3:35pm. After reviewing the incident report, S7RN, ADON confirmed that she personally made a room observation within minutes of the incident. S7RN, ADON confirmed that there was no alarm sounding upon her entering the resident's room and the bed alarm was not on the bed but located in the seat of the wheelchair. 2. RESIDENT #8: Resident #8 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's care plan revealed that she was care planned to be at risk for falls related to unsteady gait, psychotropic medication use, confused, Alzheimer ' s, non-compliant with using call bell and decreased cognition status. Further review of the care plan for the resident ' s risk for falls revealed an approach of bed/chair alarm dated 1/16/15. A review of Resident #8 ' s physician's order [REDACTED]. Monitor q shift " . A review of Resident #8 ' s Incident and Accident form revealed the following. Date of Incident/accident: 2/15/15 Describe exactly what happened: Called to resident room per CNA. Resident noted lying on floor on right side. No injury noted. +ROM. MAE without discomfort. Res unable to to tell exactly what caused fall. Keep say " I ' m OK, I ' m OK " . Assisted to stand x 2 & place in w/c and into wheel chair. V/S taken & neuro ¿ initiated. Type of injury: none apparent is checked Summary of Investigation: Res unable to verbalize what led to fall. But res got out of bed without assistance and fell on floor. Alarm was on and sounded. Recommendations: Inservice to make sure the chair alarm is transferred from w/c to bed and on. On 3/12/15 at 1:06 pm, an interview was conducted with S7ADON during which she stated that she completed the fall investigation for Resident #89. S7ADON said during investigation, it was determined that the alarm was not on and was left on the wheel chair. An additional interview was conducted on 3/12/15 at 2:15 pm with S7ADON and she clarified that the CNA who found Resident #8 on the floor was not assigned to her. She continued to say that the CNA happened to be walking down the hall and saw Resident #8 was on the floor. She confirmed that there was no alarm sounding at the time Resident #8 was found on the floor on 2/15/15.

Based on record reviews and interviews, the facility failed to ensure that the licensed nurse conducted a periodic comprehensive assessment of resident #1 when a change of condition was reported by the CNA as evidenced by the licensed nurses failling to: 1. assess a resident's right leg pain when the CNA reported the pain to the nurse on 6/8/14 (#1); 2. assess the resident when the CNA requested after reporting the resident was not herself and had a concern if the resident could be transferred out of bed (#1). This deficient practice resulted in an actual harm for resident #2 who experienced pain from 6/8/14 at 1:30 a.m. until 6/9/14 at 6:30 a.m. when the nurse assessed the resident and the resident was discovered to have a fracture to the right hip. The resident was not administered medications for pain until 6/9/14 at 6:45 a.m. The deficient practice affected 1 (#1) of 5 (#2, #3, #4, and #5) sample residents with the potential to affect 126 according to the facility ' s census. Findings: Review of resident #1's clinical record revealed the following Diagnosis: [REDACTED]. Review of resident #1's MDS Assessment of the Cognitive Pattern dated 4/16/14 revealed the BIMS summary score for the resident was a zero. Review of Radiology Report of resident #1's right hip/femur dated 6/9/14 revealed the following results: Reason - Pain; Impression - There is acute minimally displaced intertrochanteric [MEDICAL CONDITION] proximal femur. No other fracture or dislocation. No lytic or biastic [MEDICAL CONDITION]. The bones are osteopenic with moderate arthritic changes. Right hip Acute minimal displaced intertrochanteric fracture. Review of the Witness Statement dated 6/10/14 and signed by S15CNA, revealed the following documentation: I started my rounds when I got to resident #1 she was sleeping and dry so I left her alone. On my second round about 1:30 a.m. when I checked on her she was wet, so I woke her up to change her and she starts yelling and talking very loud. I changed her and when I went to float her heels on the pillow, she started screaming and picking her head off the pillow and turning red in the face like she was in pain, so I went to get the nurse S12LPN to come see about her. I also told the other 10-6 aide S11CNA and she went down to the room. I also told the bather S17CNA and the oncoming aide S8CNA. Resident #1 always yells and screams when you change her but not like that. Review of the Witness Statement dated 6/9/14 and signed by S8CNA, revealed the following documentation: I S8CNA was off Friday and Saturday returning back to work on Sunday morning. The night CNA, S15 stopped me outside and informed me not to get up resident #1 because she's complaining of right leg so I asked S3LPN and S12 LPN about getting resident #1 up for breakfast. I told them what S15CNA told me but they both said, she was fine to get her up. So, I, S7CNA and S13CNA went inside room. S7CNA help me assisted resident #1 transferred her with lifter and we noticed that she was in pain. So I reported to the 6-2 nurse. I notice resident #1 was in pain Monday morning and reported to the 6-2 nurse. Review of the Witness Statement dated 6/9/14 and signed by S13CNA, revealed the following documentation: I, S13CNA went along on Sunday morning along with S7CNA and S8CNA to assist before entering S8CNA was telling S7CNA that the 10-6 CNA, S15 said not to get resident #1 up because something is going on with her leg (she was in pain). I said before we touch her send for S3LPN to come take a look. S3LPN hadn't come but said she can be gotten up since she was up yesterday. So with the lifter S7 and S8 got her up but we felt we should have let her stay in bed we again expressed for her to take a look. Review of the Witness Statement dated 6/9/14 and signed by S3LPN revealed the following documentation: I was never told resident #1 was in pain only asked if she could get up. No one ever expressed that she was in pain and resident #1 never complained while she was up either in kitchen or dayroom. Review of the Care Plan revealed the following: Problem/Need - At risk for pain or discomfort r/t (related to) closed [MEDICAL CONDITION] right hip. Goal - Pain or discomfort will be minimal or none thru this quarter 6/14/14. Approaches - Administer meds as ordered; Observe for pain or facial grimaces Make sure resident is positioned for comfort; Notify MD prn (as needed). Record review of the MAR indicated [REDACTED].o. on the following dates: 6/9/14 at 0645; 6/14/14 at 09:30; 6/15/14 at 2300; 6/16/14 at 2230; 6/19/14 at 1300; 6/21/14 at 09:00; 6/22/14 at 1115. Record review of the MAR indicated [REDACTED].o. q 4 hours on the following dates: 6/14/14 at 09:30; 6/15/14 at 09:10; 6/15/14 at 3:40 p.m.; 6/16/14 at 7:00 p.m. In an interview on 6/24/14 at 10:03 a.m. with S3LPN, she revealed that there was nothing going on with resident #1. She confirmed that the night nurse was S12LPN and she did not report to her that there was anything happening with resident #1. She revealed that she did not do an assessment on resident #1 and chart because there was no need to. She stated that it was not reported to her by S12LPN that there was a problem with resident #1. S3LPN indicated that she did a body audit which is an assessment on resident #1 on Sunday 6/8/14. She revealed that the resident did not have any complaints of pain. She indicated that what was asked of her by S8CNA, was if resident #1 could be taken out of bed. She stated that she informed the CNA that resident #1 could be taken out of bed. S3LPN revealed that there was no concern in what was asked because she did not get any report or indication that the resident could not be taken out of bed. She indicated that when she saw the resident at the nurse 's desk, the resident did not appear to be in pain. She was asked by this surveyor if she would have done anything different. S3LPN responded that she would have gone to the resident 's room to see what was going on at that time. In an interview on 6/24/14 at 11:05 a.m. with S7CNA she confirmed that she did provide care to resident #1. She indicated that she assisted another CNA on Sunday 6/8/14 and when she went into resident #1 's room she notice that resident #1 was not herself. She revealed that the resident appeared to be in pain. She stated that she and S8CNA went to the desk and the nurse S3LPN was getting report from the night nurse S12LPN and S8CNA informed her that resident #1 was not herself and asked if she could be taken out of bed. S7CNA indicated that S3LPN stated that the resident was taken out of bed on the day before and she could be taken out of bed. She stated that it was not reported at that time to S3LPN that resident #1 was having pain. She indicated that S8CNA told the nurse that the resident was not herself. She revealed that she stood behind S8CNA when she asked the nurse if resident #1 could be taken out of bed. In an interview on 6/24/14 at 12:24 p.m. with S8CNA, she confirmed that she worked with resident #1 on Sunday 6/8/14 and Monday 6/9/14. She revealed that she worked on Sunday 6/8/14 and was informed by S15CNA, not to get resident #1 out of bed because she was complaining of pain to her right leg. She stated that she went to the nurses S3LPN and S12LPN who were at the desk counting and informed them what S15CNA, told her about resident #1 having pain in her right leg and if she could get the resident up out of bed. She indicated that they both stated that they did not know anything about that and that she could get resident #1 out of bed. S8CNA stated that she, S7CNA, and S13CNA went on and got resident #1 clean and got her up. She revealed that the resident did complain some, but she always complained by hollering. She added that resident #1 always hollers out. She indicated that on Monday 6/9/14 she notice a change in the resident and she was complaining of pain to her leg and she informed the nurse S14LPN what was going on with resident #1. In an interview on 6/25/14 at 9:02 a.m. with S15CNA, she confirmed that she wrote the written statement because it was reported to her by the DON that resident #1 had a [MEDICAL CONDITION]. She stated that she worked with resident #1 on Wednesday, Thursday, Friday and Saturday nights and worked with S12LPN on Friday and Saturday night. She revealed that she made her first round to check on resident #1 at approximately 11:30 p.m. and the resident was not wet. S15CNA indicated that she went on her second round approximately at 1:30 a.m. and the resident was wet. She stated that she woke the resident and she told the resident that she was going to change her diaper and the resident yelled, " leave me alone " . She revealed that she proceeded to change the resident and after changing her she went to float the heels. S15CNA indicated that she put the heel protector on the left heel and the resident did not yell, but after she picked up the right heel, resident #1 starting screaming and raised her head off the bed and turned red. She stated that the resident was in pain and after noticing this she went to the nurse 's desk and reported this to S12 LPN the nurse that when she picked resident #1's right heel up, the resident became unglued and appear to be in pain. They went back to resident #1's room and S3LPN raised resident #1's left leg by grabbing by the resident ' s calf area and the resident did not have any response. S15CNA indicated that S12LPN grabbed the resident 's right leg around the calf and begin to raise it and the resident immediately started to scream in pain. It was at this time that S12LPN told her that she was going to text the doctor and give resident #1 some Tylenol. She stated that she did not know if the nurse called the doctor or gave the resident some Tylenol for pain. She stated that she ran into S11CNA at approximately 2:00 a.m. and told her that resident #1 appeared to be having leg pain. S15CNA stated that they went to the resident 's room and noticed that she had gone back to sleep. She states that when there is a change in the resident 's condition that she reports it to the nurse and the oncoming CNA. She stated that when she was leaving the building, she saw S8CNA and told her that there was something wrong with resident #1's leg that she was having pain and S3LPN stated she was going to get x-rays on the resident. She added that she told the other bather S17CNA who came on at 4:30 a.m. about not getting the resident up out of bed because she was having pain in her leg. In an interview on 6/25/14 at 10:19 a.m. with S13CNA, she confirmed that she worked the Sunday 6/8/14 the 6-2 shift and went to assist with resident #1. She stated that she was with S8CNA when the 10-6 CNA, S15 came to her and told her not to get resident #1 out of bed because she was in pain and something was wrong with her leg. She revealed that she was at the desk and overheard S8CNA tell S3LPN and S12LPN what S15 the 10-6 CNA reported to her about resident #1 having pain in her right leg and that she should not be taken out of bed. S13CNA revealed that S3LPN responded that nothing was reported to her so resident #1 should be ok to get up. She indicated that she, S8CNA and S7CNA went to the resident 's room. They went to resident #1's room and uncovered her and noticed that there was something wrong with her leg and it looked different. S13CNA saied that she suggested to S8CNA and S7CNA to go to the nurse and find out what was going on with the resident and get the nurse to come before they move her. She, S8CNA and S7CNA went back to the nurse 's desk and S3LPN and S12LPN were still in report. 8CNA asked S3LPN again could she come and take a look at resident #1 because the resident did not look right and could the resident be taken out of bed. S13CNA stated that S3LPN informed S8CNA that nothing was reported to her so it was ok to get resident #1 up. She revealed that S12LPN was present both times that S3LPN was questioned about resident #1's condition, and did not report anything about the resident to her from the night shift. S8CNA asked S3LPN to come to the room to see resident #1 because of the report she got from S15CNA that she shouldn't get resident #1 out of bed. She said that S8CNA and S7CNA did the actual transfer of resident #1 from the bed to the wheelchair and she was present. S13CNA stated that the transfer went well and the resident did holler, but no more than usual. She transported resident #1 in the wheelchair to the nurse's desk. She indicated that she notice that only S3LPN was at the desk. She stated that she did not see S12LPN anymore and resident #1 was in view of S3LPN. In an interview on 6/25/14 at 12:14 p.m. with S2RN/DON she revealed that they were notified on Monday 6/9/14 that resident #1 had a [MEDICAL CONDITION]. She confirmed that it was the same day that the resident was sent out to the hospital. She stated that they were not able to obtain a witness statement from S12LPN. They made several attempts to contact S12LPN to obtain a statement from her. S2RN/DON indicated that S12LPN refused to give a written statement and quit by texting her to notify her. She confirmed that S15CNA told her that she went and got S12LPN to assess resident #1. The DON revealed that S15CNA stated that S12LPN told her that she was going to call the doctor and give resident #1 something for pain. S2RN/DON confirmed that there was no documentation in the nurse ' s notes of the assessment of resident #1 or notification to the doctor or the RP (responsible party) of the resident 's condition. She indicated that the nurse should have documented the condition of the resident. S2RN/DON revealed that when she called S12LPN and questioned her about resident #1, she stated that S12LPN told her that when she went back into resident #1's room, the resident did not complain of pain and the resident did not complain after she went in the room with the CNA. She indicated that the video surveillance revealed that S12LPN went down the hallway at approximately 4:01 a.m. and back up the hall at 4:07 a.m. She stated that there was no assessment in the Nurse 's Notes. S2RN/DON confirmed again that the assessment of the resident should have been written in the Nurse ' s Notes. She stated that there was no documentation that the physician was notified or that the resident was administered medication for pain. She confirmed that the video surveillance confirmed that S8CNA and S13CNA were at the desk with S3LPN and S12LPN between 6:01 a.m. and 6:15 a.m. S2RN/DON confirmed that S7CNA clocked in late at 6:10 a.m. She confirmed that S3LPN should have gone to assess the condition of resident #1 and document in the Nurse ' s Notes of the assessment she would have expected her to assess the resident. In an interview on 6/26/14 at 12:00 p.m. with S14LPN revealed that she did not get a report from the night nurse that resident #1 was having pain.

Based on record reviews and interviews, the facility failed to ensure that the necessary care and services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for a resident as evidence by failing to ensure the licensed nurses: 1. assessed the resident for reported complaints of pain; 2. notified the physician of the change in the medical condition of the resident in a timely manner causing delayed treatment and pain management; This deficient practice resulted in an actual harm for resident #1 who had a change in her medical condition that was not reported to the physician in a timely manner, and the resident having to experience pain from 6/8/14 at 1:30 a.m. until 6/9/14 at 6:30 a.m. when the nurse assessed resident #1 and the resident was discovered to have a fracture to the right hip that required surgical intervention; had to be administered pain medications; and there was a change in the resident 's bed mobility. The deficient practice affected 1 (#1) of 5 (#2, #3, #4, and #5) sample residents with the potential to affect 126 according to the facility's census. Findings: Review of resident #1's clinical record revealed the following Diagnosis: [REDACTED]. Review of resident #1's MDS Assessment of the Cognitive Pattern dated 4/16/14 revealed the summary score for the resident was 0. Review of Radiology Report of resident #1's right hip/femur dated 6/9/14 revealed the following results: Reason - Pain; Impression - There is acute minimally displaced intertrochanteric [MEDICAL CONDITION] proximal femur. No other fracture or dislocation. No lytic or biastic [MEDICAL CONDITION]. The bones are osteopenic with moderate arthritic changes. Right hip Acute minimal displaced intertrochanteric fracture. Review of the Witness Statement dated 6/10/14 and signed by S15CNA, revealed the following documentation: I started my rounds when I got to resident #1 she was sleeping and dry so I left her alone. On my second round about 1:30 a.m. when I checked on her she was wet, so I woke her up to change her and she starts yelling and talking very loud. I changed her and when I went to float her heels on the pillow, she started screaming and picking her head off the pillow and turning red in the face like she was in pain, so I went to get the nurse S12LPN to come see about her. Review of the Witness Statement dated 6/9/14 and signed by S8CNA, revealed the following documentation: I S8CNA was off Friday and Saturday returning back to work on Sunday morning. The night CNA, S 15 stopped me outside and informed me not to get up resident #1 because she ' s complaining of right leg so I asked S3LPN and S12LPN about getting resident #1 up for breakfast. I told them what S15CNA told me but they both said, she was fine to get her up. So, I, S7CNA and S13CNA went inside room. S7CNA help me assisted resident #1 transferred her with lifter and we noticed that she was in pain. So I reported to the 6-2 nurse. I notice resident #1 was in pain on Monday morning and reported to the 6-2 nurse. Review of the Witness Statement dated 6/9/14 and signed by S13CNA, revealed the following documentation: I, S13CNA went along on Sunday morning along with S7CNA and S8CNA to assist before entering S8CNA was telling S7CNA that the 10-6 CNA, S15 said not to get resident #1 up because something is going on with her leg (she was in pain). I said before we touch her send for S3LPN to come take a look. S3LPN hadn't come but said she can be gotten up since she was up yesterday. So with the lifter S7 and S8 got her up but we felt we should have let her stay in bed we again expressed for her to take a look. Review of the Witness Statement dated 6/9/14 and signed by S3LPN revealed the following documentation: I was never told resident #1 was in pain only asked if she could get up. No one ever expressed that she was in pain and resident #1 never complained while she was up either in kitchen or dayroom. Review of the Care Plan revealed the following: Problem/Need - At risk for pain or discomfort r/t (related to) closed [MEDICAL CONDITION] right hip. Goal - Pain or discomfort will be minimal or none thru this quarter 6/14/14. Approaches - Administer meds as ordered; Observe for pain or facial grimaces Make sure resident is positioned for comfort; Notify MD prn (as needed). Record review of the MAR indicated [REDACTED].o. on the following dates: 6/9/14 at 0645; 6/14/14 at 09:30; 6/15/14 at 2300; 6/16/14 at 2230; 6/19/14 at 1300; 6/21/14 at 09:00; 6/22/14 at 1115. Record review of the June 2014 MAR indicated [REDACTED].o. q 4 hours on the following dates: 6/14/14 at 09:30; 6/15/14 at 09:10; 6/15/14 at 3:40 p.m.; 6/16/14 at 7:00 p.m. Review of the Care Plan revealed the following: Problem/Need - At risk for fractures r/t [MEDICAL CONDITION]/osteopenia. Goal -Resident will remain free of any fractures by 8/4/14. Approaches -6/14/14 Closed [MEDICAL CONDITION] with rodding; Treat as ordered; Ted hose as ordered; Bed rest (D/C 6/18/14); PT/OT to evaluate treat if indicated. Review of the Professional Conduct for the Licensed Practical Nurse revealed the following: Standards of practice also require that LPN follow professional conduct guidelines at all times, LPNs are expected to treat patients with respect and [MEDICATION NAME], maintain confidentiality regarding patients medical care, collaborate and cooperate with physician and fell ow nursing staff, perform procedures only as outlined within their scope of practice, and adhere to Nursing Code of ethics. Record review of the facility's Policy and Procedure on Change in a Resident 's Condition or Status revealed the following: Policy Statement - Our facility shall promptly notify the resident, this or her Attending Physician, and representative (sponsor) of changes in the resident 's medical condition and or status (e.g. changes in level of care, billing payments, resident rights, etc.). Protocol for Notifying Attending Physician of Changes in Resident 's Medical Mental Condition: 1. The Nurse Supervisor Charge Nurse will notify the resident 's Attending Physician or On-Call Physician when there has been. a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; Review of the facility ' s Policy and Procedure on Charting and Documentation revealed the following: Policy Statement - All services provided to the resident, or any changes in the resident ' s medical or mental condition, shall be documented in the resident ' s medical record. Documentation Requirements - All observations, medications administered, services performed, etc. must be documented in the resident ' s clinical records. In an interview on 6/23/14 at 3:39 p.m. with S2RN/DON she revealed that when resident #1 complained of pain on 6/8/14 and the CNA reported it to the nurse, that it was a change in the resident 's condition and the nurse should have documented it and the MD and RP should have been notified. She added that when the CNAs reported to the nurses that resident #1 was in pain, it was expected that the nurses would assess the resident and document the assessment in the Nurse 's Notes. She confirmed that there was no documentation on 6/8/14 that resident #1 was assessed for pain. In an interview on 6/24/14 at 10:03 a.m. with S3LPN, she revealed that there was nothing going on with resident #1. She confirmed that the night nurse was S12LPN and she did not report to her that there was anything happening with resident #1. She revealed that she did not do an assessment on resident #1 and chart because there was no need to. She stated that it was not reported to her by S12LPN that there was a problem with resident #1. S3LPN indicated that she did a body audit which is an assessment on resident #1 on Sunday 6/8/14. She revealed that the resident did not have any complaints of pain. She indicated that what was asked of her by S8CNA, was if resident #1 could be taken out of bed. She stated that she informed the CNA that resident #1 could be taken out of bed. S3LPN revealed that there was no concern in what was asked because she did not get any report or indication that the resident could not be taken out of bed. She indicated that when she saw the resident at the nurse ' s desk, the resident did not appear to be in pain. She was asked by this surveyor if she would have done anything different. S3LPN responded that she would have gone to the resident ' s room to see what was going on at that time. In an interview on 6/24/14 at 11:05 a.m. with S7CNA she confirmed that she did provide care to resident #1. She indicated that she assisted another CNA on Sunday 6/8/14 and when she went into resident #1 ' s room she notice that resident #1 was not herself. She revealed that the resident appeared to be in pain. She stated that she and S8CNA went to the desk and the nurse S3LPN was getting report from the night nurse S12LPN and S8CNA informed her that resident #1 was not herself and asked if she could be taken out of bed. S7CNA indicated that S3LPN stated that the resident was taken out of bed on the day before and she could be taken out of bed. She stated that it was not reported at that time to S3LPN that resident #1 was having pain. She indicated that S8CNA told the nurse that the resident was not herself. She revealed that she stood behind S8CNA when she asked the nurse if resident #1 could be taken out of bed. In an interview on 6/24/14 at 12:24 p.m. with S8CNA, she confirmed that she worked with resident #1 on Sunday 6/8/14 and Monday 6/9/14. She revealed that she worked on Sunday 6/8/14 and was informed by S15CNA, not to get resident #1 out of bed because she was complaining of pain to her right leg. She stated that she went to the nurses S3LPN and S12LPN who were at the desk counting and informed them what S15CNA, told her about resident #1 having pain in her right leg and if she could get the resident up out of bed. She indicated that they both stated that they did not know anything about that and that she could get resident #1 out of bed. S8CNA stated that she, S7CNA, and S13CNA went on and got resident #1 clean and got her up. She revealed that the resident did complain some, but she always complained by hollering. She added that resident #1 always hollers out. She indicated that on Monday 6/9/14 she notice a change in the resident and she was complaining of pain to her leg and she informed the nurse S14LPN what was going on with resident #1. In an interview on 6/25/14 at 9:02 a.m. with S15CNA, she confirmed that she wrote the written statement because it was reported to her by the DON that resident #1 had a [MEDICAL CONDITION]. She stated that she worked with resident #1 on Wednesday, Thursday, Friday and Saturday nights and worked with S12LPN on Friday and Saturday night. She revealed that she made her first round to check on resident #1 at approximately 11:30 p.m. and the resident was not wet. S15CNA indicated that she went on her second round approximately at 1:30 a.m. and the resident was wet. She stated that she woke the resident and she told the resident that she was going to change her diaper and the resident yelled, " leave me alone " . She revealed that she proceeded to change the resident and after changing her she went to float the heels. S15CNA indicated that she put the heel protector on the left heel and the resident did not yell, but after she picked up the right heel, resident #1 starting screaming and raised her head off the bed and turned red. She stated that the resident was in pain and after noticing this she went to the nurse 's desk and reported this to S12 LPN the nurse that when she picked resident #1's right heel up, the resident became unglued and appear to be in pain. They went back to resident #1's room and S3LPN raised resident #1's left leg by grabbing by the resident ' s calf area and the resident did not have any response. S15CNA indicated that S12LPN grabbed the resident 's right leg around the calf and begin to raise it and the resident immediately started to scream in pain. It was at this time that S12LPN told her that she was going to text the doctor and give resident #1 some Tylenol. She stated that she did not know if the nurse called the doctor or gave the resident some Tylenol for pain. She stated that she ran into S11CNA at approximately 2:00 a.m. and told her that resident #1 appeared to be having leg pain. S15CNA stated that they went to the resident 's room and noticed that she had gone back to sleep. She states that when there is a change in the resident 's condition that she reports it to the nurse and the oncoming CNA. She stated that when she was leaving the building, she saw S8CNA and told her that there was something wrong with resident #1's leg that she was having pain and S3LPN stated she was going to get x-rays on the resident. She added that she told the other bather S17CNA who came on at 4:30 a.m. about not getting the resident up out of bed because she was having pain in her leg. In an interview on 6/25/14 at 10:19 a.m. with S13CNA, she confirmed that she worked the Sunday 6/8/14 the 6-2 shift and went to assist with resident #1. She stated that she was with S8CNA when the 10-6 CNA, S15 came to her and told her not to get resident #1 out of bed because she was in pain and something was wrong with her leg. She revealed that she was at the desk and overheard S8CNA tell S3LPN and S12LPN what S15 the 10-6 CNA reported to her about resident #1 having pain in her right leg and that she should not be taken out of bed. S13CNA revealed that S3LPN responded that nothing was reported to her so resident #1 should be ok to get up. She indicated that she, S8CNA and S7CNA went to the resident 's room. They went to resident #1's room and uncovered her and noticed that there was something wrong with her leg and it looked different. S13CNA said that she suggested to S8CNA and S7CNA to go to the nurse and find out what was going on with the resident and get the nurse to come before they move her. She, S8CNA and S7CNA went back to the nurse 's desk and S3LPN and S12LPN were still in report. S8CNA asked S3LPN again could she come and take a look at resident #1 because the resident did not look right and could the resident be taken out of bed. S13CNA stated that S3LPN informed S8CNA that nothing was reported to her so it was ok to get resident #1 up. She revealed that S12LPN was present both times that S3LPN was questioned about resident #1's condition, and did not report anything about the resident to her from the night shift. S8CNA asked S3LPN to come to the room to see resident #1 because of the report she got from S15CNA that she shouldn't get resident #1 out of bed. She said that S8CNA and S7CNA did the actual transfer of resident #1 from the bed to the wheelchair and she was present. S13CNA stated that the transfer went well and the resident did holler, but no more than usual. She transported resident #1 in the wheelchair to the nurse's desk. She indicated that she notice that only S3LPN was at the desk. She stated that she did not see S12LPN anymore and resident #1 was in view of S3LPN. In an interview on 6/25/14 at 12:14 p.m. with S2RN/DON she revealed that they were notified on Monday 6/9/14 that resident #1 had a [MEDICAL CONDITION]. She confirmed that it was the same day that the resident was sent out to the hospital. She stated that they were not able to obtain a witness statement from S12LPN. They made several attempts to contact S12LPN to obtain a statement from her. S2RN/DON indicated that S12LPN refused to give a written statement and quit by texting her to notify her. She confirmed that S15CNA told her that she went and got S12LPN to assess resident #1. The DON revealed that S15CNA stated that S12LPN told her that she was going to call the doctor and give resident #1 something for pain. S2RN/DON confirmed that there was no documentation in the nurse ' s notes of the assessment of resident #1 or notification to the doctor or the RP (responsible party) of the resident 's condition. She indicated that the nurse should have documented the condition of the resident. S2RN/DON revealed that when she called S12LPN and questioned her about resident #1, she stated that S12LPN told her that when she went back into resident #1's room, the resident did not complain of pain and the resident did not complain after she went in the room with the CNA. She indicated that the video surveillance revealed that S12LPN went down the hallway at approximately 4:01 a.m. and back up the hall at 4:07 a.m. She stated that there was no assessment in the Nurse 's Notes. S2RN/DON confirmed again that the assessment of the resident should have been written in the Nurse ' s Notes. She stated that there was no documentation that the physician was notified or that the resident was administered medication for pain. She confirmed that the video surveillance confirmed that S8CNA and S13CNA were at the desk with S3LPN and S12LPN between 6:01 a.m. and 6:15 a.m. S2RN/DON confirmed that S7CNA clocked in late at 6:10 a.m. She confirmed that S3LPN should have gone to assess the condition of resident #1 and document in the Nurse ' s Notes of the assessment she would have expected her to assess the resident.

Based on observation, record review and interview, the facility failed to accurately assess Residents #19 and #58 in order to identify and avoid the development of pressure sores as evidenced by: 1. a. Resident #19 developed an avoidable unstageable pressure ulcer to her right heel which was found by the facility on 1/14/13 and was staged on 3/7/13 as a stage III pressure ulcer and b. inaccurate assessment of the resident on the Braden Scale For Predicting Pressure Score Risk, 2. Resident #58 developed an avoidable unstageable pressure ulcer to his left heel which was found by the facility on 2/18/13. The facility's Resident Census and Conditions of Residents form was reviewed and revealed that there were 6 residents currently residing in the facility with pressure ulcers but that 1 resident was admitted with pressure ulcers. This deficient practice affected 2 out of 2 reviewed for pressure ulcer out of a total of 6 residents identified by the facility as having pressure ulcers and 70 residents that were listed by the facility on the Resident Census and Conditions of Residents form as bedfast or being in the chair most of the time in the facility. (#19, #58) Findings: 1. a. Resident #19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's Activities of Daily Living (ADL) Tracking Tool reviewed for the month of January and February 2013 and the resident coded as 4/2 ( Total Dependence/One person physical assist) for bed mobility and for transfer, toileting and eating. The resident's Minimum Data Set ((MDS) dated [DATE] was reviewed and under cognition, the resident was listed as 0 for No- Resident is rarely /never understood. She was also listed as a 3- Moderately impaired for her cognition. The resident's Braden Scale For Predicting Pressure Sore Risk was reviewed and revealed that the resident was a 18. (15-18 was risk) The resident's Wound Assessment sheet was reviewed and revealed that on 1/14/13 the resident acquired an unstageable pressure ulcer to her right heel. The treatment nurses notes dated 1/14/2013 revealed the following: This nurse along with S7ADON summoned to resident's room to assess right heel. Upon assessment the following was noted, a suspected DTI (deep tissue injury) reddish -purple in color, painful to touch. Wound measures @ 3.1x 3.5cm, depth <.01. No exudate/odor, treatment initiated immediately. New order: clean wound to right heel with WC (wound care), pat dry, apply [MEDICATION NAME] then wrap Kerlix every day until healed. Tolerated treatment well. Notified physician and responsible party. The Wound Assessment form was reviewed and revealed that on 1/14/13 the resident's wound bed to her right heel was black with 100% necrosis and the necrosis type was listed as eschar. The Wound Assessment measurements are as follows: 1/14/13 Measurements L-3.1, W-3.5, D -<.1 cm 1/23/13 Measurements L- 3.1, W- 3.4, D-<.1cm 1/30 12 Measurements L- 3.0, W- 4.0, D-<.1cm 2/06/13 Measurements L- 1.5, W- 1.6, D, -<.1cm 2/13/13 Measurements L- 1.5, W-1.5, and D-<.1cm 2/21/13 Measurements L-1.5, W-1.5, and D-<.1cm 2/28/13 Measurements L- 1.5, W -1.5, and D-<.1cm 3/07/13 Measurements L- 1.0 W- .8, and D-<.1 cm Stage III 3/13/13 Measurements L- .9 W-.6 and D-<.1cm The resident's care plan was reviewed and revealed documentation that the resident was at risk for impaired skin integrity, pressure ulcer related to incontinent of bowel and bladder, dry fragile skin, needs total assistance with bed mobility. One of the approaches was to be repositioned every 2 hours and as indicated. On 3/14/13 at 10:15 am, an observation of the S4LPN/ Treatment Nurse changing the resident's dressing to her right heel was made. The site to right heel was pink in color about the size of a quarter with darker pink area noted to center of heel. No opened area viewed. Site was cleansed with wound cleanser and patted dry with 4x4 gauze. Zinc Oxide was then applied to the site using a Q-tip. Border dressing was applied over site which was labeled with date of dressing change. The resident's medical record was reviewed and there was no documentation found that the resident was being monitored by the Certified Nursing Assistants (CNAs) and Licensed Practical Nurses that ensured the resident was turned every 2 hours and assessed for the development of an avoidable pressure ulcer. On 3/14/13 1:18 pm, an interview was conducted with S1DON. A review of the wound assessment sheets dated from 1/14/13 to 3/13/13, on 3/7/13, 75% of the wound was yellow slough and not eschar and 25% of the site was pink. S1DON stated that the resident was in a wheelchair and she remembered having a conversation with her daughter about her heel rubbing on her foot pedal. S1DON stated, " I don't know if this caused the area on her heel". S1DON confirmed that the resident was to be turned and repositioned every 2 hours. When asked for the documentation that this resident was being turned and monitored by the CNAs or LPNs, S1DON stated that there was no documentation. S1DON further stated that the facility did not use an ADL flow sheet for documentation by the CNAs. When asked if the LPNs were documenting the resident being turned as written in the plan of care she stated that there was no documentation by the LPNs on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. S1DON stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on her heel prior to it becoming an unstageable or a stage III pressure ulcer. b. During the survey, Resident #19's Braden Scale for Predicting Pressure Sore Risk was reviewed and revealed that the resident was coded under the section activity - as a 4 -Walks Frequently: walks outside room at least twice a day and inside room at least once every 2 hours during waking hours. Under the section Friction and Shear she was coded a 3- No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. The facility's ADL tracking sheet was reviewed and revealed that the resident in the areas of Bed Mobility she was a 4/2 ( total dependence/one person physical assist) , Transfer she was a 4/3 ( total dependence/two person physical assist) , Toileting she was a 4/2 (total dependence/one person physical assist). On 3/15/13 at 1:15 pm, an interview with S6LPN/MDS was conducted and she stated after a review of the assessment of the Braden Scale For Predicting Pressure Sore Risk that she had incorrectly assessed the resident. She stated that the resident was not able to freely move her extremities and required maximum assistance from the CNAs for all of her ADL care. She stated under the area of Friction and Shear, the resident should have been coded as a 1 - requires moderate to maximum assistance in moving and was not a 3. She then changed the assessment to a 1 to reflect what she stated the resident should have been coded. 2. Resident #58. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE] revealed under the Activities Of Daily Living (ADL) section that the resident under the G section- Functional Status under A. Bed Mobility as a 4/2 ( Total Dependence/One person physical assist) The resident's Braden Scale for Predicting Pressure Sore Risk dated 1/12/13 revealed that the resident's score was a 16 (At Risk). Weekly skin audit dated 1/24/13, 1/31/13, 2/7/13, 2/14/13, completed and reviewed with no documenation of pressure ulcer to left heel. The Wound assessment dated [DATE] revealed an acquired unstageable pressure ulcer. The documentation on the form identified the tissue to the resident's left heel as dark purple. The unstageable pressure ulcer was surrounded by a fluid blister with underlying pink granulating tissue. Measurements - L 3.5 cm, W 4.5 cm, D <.1cm. The Measurement of the unstageable pressure ulcer to the left heel are as follows: 2/21/13 - the resident was in the hospital. 3/1/13 Unstageable left heel. Measurements L- 3x3 W- 4.5, D-<.6 cm 3/7/13 Measurements L-3.3, W-4.5, D-<.6cm 3/13/13 measurements L- 3.0, W- 3.8, D-<.1cm Current Treatment [MEDICATION NAME]- remains unstageable. Treatment Nurse Notes revealed on 2/18/13- Summoned to the room per CNA along with DON to assess resident's left heel which was blister -like DTI- unstageable dark purple fluid filled with underlying pink granulating tissue. ( [MEDICAL CONDITION] cm depth). Treatment initiated immediately, resident tolerated well. Notified physician and responsible party. On 3/14/13 at 10:00 am, an observation of the pressure ulcer to the resident's left heel was made with S4LPN/Treatment Nurse. The resident was sitting in his wheelchair while the dressing to his left foot was changed. The dressing was removed by S4LPN and the site to left heel noted with black eschar the size of a quarter. The site was cleaned with wound cleanser and 4x4 then [MEDICATION NAME] was sprayed on 4x4 and placed over the site. The site was then covered with Kerlix and taped in place. His boot was reapplied. The resident complained of pain during the dressing change. S4LPN stated she would tell the nurse about the resident's complaint of pain to get pain medication for the resident. About 5 minutes after exiting the room the nurse was observed going into the resident's room and when questioned she stated it was to give the resident his pain medications. On 3/14/13 at 12:20 pm, an interview was conducted with S1DON and she stated, "The resident's pressure ulcer started as a blister with fluid around the area but the middle was a dark purple spot." S1DON stated, "I called it DTI (Deep Tissue Injury) and labeled it as being unstageable. I was not sure what was under the blister. We put [MEDICATION NAME] on it and it developed the eschar. We even had the physician to look at it on yesterday and he said to keep using the [MEDICATION NAME] and the other part would come off." The care plan reviewed and this resident was care planned for impaired skin integrity, pressure ulcers related to fragile skin, needs total assistance with toileting and bed mobility, is incontinent of bowel. One of the approaches included offer toileting every 2 hours and as indicated. The resident's functional status was total dependency on the staff and there was no documentation listed for turning the resident every two hours. On 3/14/13 at 1:00 pm an interview with the S1DON was conducted and she stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on his heel prior to it becoming an unstageable pressure ulcer.

Based on observation, record review and interview, the facility failed to prevent: 1. Resident #19 from developing an avoidable unstageable pressure ulcer to her right heel which was found by the facility on 1/14/13 and was staged on 3/7/13 as a stage III pressure ulcer and 2. Resident #58 from developing an avoidable unstageable pressure ulcer to his left heel which was found by the facility on 2/18/13. The facility failed to have a system in place for the monitoring of the residents to accurately assess the residents in order to identify and avoid the development of the unstageable pressure ulcers and failed to follow the plan of care for these residents which resulted in the facility finding the unstageable pressure ulcers after the residents were admitted to the facility. The facility's Resident Census and Conditions of Residents form was reviewed and revealed that there were 6 residents currently residing in the facility with pressure ulcers but that 1 resident was admitted with pressure ulcers. This deficient practice affected 2 out of 2 reviewed for pressure ulcer out of a total of 6 residents identified by the facility as having pressure ulcers and 70 residents that were listed by the facility on the Resident Census and Conditions of Residents form as bedfast or being in the chair most of the time in the facility. (#19, #58) Findings: 1. Resident #19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's Activities of Daily Living (ADL) Tracking Tool reviewed for the month of January and February 2013 and the resident was coded as 4/2 ( Total Dependence/One person physical assist) for bed mobility and for transfer, toileting and eating. The resident's Minimum Data Set ((MDS) dated [DATE] was reviewed and under cognition, the resident was listed as 0 for No- Resident is rarely /never understood. She was also listed as a 3- Moderately impaired for her cognition. The resident's Braden Scale For Predicting Pressure Sore Risk was reviewed and revealed that the resident was a 18. (15-18 was risk) The resident's Wound Assessment sheet was reviewed and revealed that on 1/14/13 the resident acquired an unstageable pressure ulcer to her right heel. The Treatment Nurses Notes dated 1/14/2013 revealed the following: This nurse along with S7ADON summoned to resident's room to assess right heel. Upon assessment the following was noted, a suspected DTI (deep tissue injury) reddish -purple in color, painful to touch. Wound measures @ 3.1x 3.5cm, depth <.01. No exudate/odor, treatment initiated immediately. New order: clean wound to right heel with WC (wound care), pat dry, apply [MEDICATION NAME] then wrap Kerlix every day until healed. Tolerated treatment well. Notified physician and responsible party. The Wound Assessment form was reviewed and revealed that on 1/14/13 the resident's wound bed to her right heel was black with 100% necrosis and the necrosis type was listed as eschar. The Wound Assessment measurements are as follows: 1/14/13 Measurements L-3.1, W-3.5, D -<.1 cm 1/23/13 Measurements L- 3.1, W- 3.4, D-<.1cm 1/30 12 Measurements L- 3.0, W- 4.0, D-<.1cm 2/06/13 Measurements L- 1.5, W- 1.6, D, -<.1cm 2/13/13 Measurements L- 1.5, W-1.5, and D-<.1cm 2/21/13 Measurements L-1.5, W-1.5, and D-<.1cm 2/28/13 Measurements L- 1.5, W -1.5, and D-<.1cm 3/07/13 Measurements L- 1.0 W- .8, and D-<.1 cm Stage III 3/13/13 Measurements L- .9 W-.6 and D-<.1cm physician's orders [REDACTED]. Orders revealed order to monitor pressure relieving mattress, monitor off loading device for wheelchair while up. The resident's care plan was reviewed and revealed documentation that the resident was at risk for impaired skin integrity, pressure ulcer related to incontinent of bowel and bladder, dry fragile skin, needs total assistance with bed mobility with approaches listed to assure pressure relieving mattress, perform weekly skin assessments, turn and reposition every 2 hours and as indicated and monitor off loading device for geri-chair while up. The resident was observed lying in her bed in her room on 3/11/13 at 2:05 pm when the surveyor attempted to interview the resident and was unsuccessful due to her cognition. The resident was also observed on 3/14/13 at 10:15 am for an observation of the dressing change while she was lying in her bed. On 3/14/13 at 10:15 am, an observation of the S4LPN/ Treatment Nurse changing the resident's dressing to her right heel was made. The site to right heel was pink in color about the size of a quarter with darker pink area noted to center of heel. No opened area viewed. Site was cleansed with wound cleanser and patted dry with 4x4 gauze. Zinc Oxide was then applied to the site using a Q-tip. Border dressing was applied over site which was labeled with date of dressing change. The resident's medical record was reviewed and there was no documentation found that the resident was being monitored by the Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPN) that ensured the resident was turned every 2 hours and assessed for the development of an avoidable pressure ulcer. On 3/14/13 1:18 pm, an interview was conducted with S1DON. A review of the wound assessment sheets dated from 1/14/13 to 3/13/13 revealed the resident was having her right heel painted with [MEDICATION NAME] and it dried the site. On 2/28/13 the dressing was changed to [MEDICATION NAME] and the [MEDICATION NAME] dried off the area and the slough fell off. On 3/7/13, 75% of the wound was yellow slough and not eschar and 25% of the site was pink. S1DON stated that the resident was in a wheelchair and she remembered having a conversation with her daughter about her heel rubbing on her foot pedal. S1DON stated, " I don't know if this caused the area on her heel". S1DON confirmed that the resident was to be turned and repositioned every 2 hours. When asked for the documentation that this resident was being turned and monitored by the CNAs or LPNs, S1DON stated that there was no documentation. S1DON further stated that the facility did not use an ADL flow sheet for documentation by the CNAs. When asked if the LPNs were documenting the resident being turned as written in the plan of care she stated that there was no documentation by the LPNs on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. S1DON stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on her heel prior to it becoming an unstageable or a stage III pressure ulcer. 2. Resident #58. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Th resident's Minimum Data Set ((MDS) dated [DATE] revealed under the Activities Of Daily Living (ADL) section that the resident under the G section- Functional Status under A. Bed Mobility as a 4/2 ( Total Dependence/One person physical assist) The resident's Braden Scale for Predicting Pressure Sore Risk dated 1/12/13 revealed that the resident's score was a 16 (At Risk). Upon admit to facility, the resident's January's MAR indicated [REDACTED]. Weekly skin audit dated 1/24/13, 1/31/13, 2/7/13, 2/14/13, completed and reviewed with no documenation of pressure ulcer to left heel. The Wound assessment dated [DATE] revealed an acquired unstageable pressure ulcer. The documentation on the form identified the tissue to the resident's left heel as dark purple. The unstageable pressure ulcer was surrounded by a fluid blister with underlying pink granulating tissue. Measurements - L 3.5 cm, W 4.5 cm, D <.1cm. Preventive Measures documented on form- Heel protectors while in bed- Monitor Q shift, Float heels while in bed- Monitor Q shift. The Measurement of the unstageable pressure ulcer to the left heel are as follows: 2/21/13 - the resident was in the hospital. 3/1/13 Unstageable left heel. Measurements L- 3x3 W- 4.5, D-<.6 cm 3/7/13 Measurements L-3.3, W-4.5, D-<.6cm 3/13/13 measurements L- 3.0, W- 3.8, D-<.1cm Current Treatment [MEDICATION NAME]- remains unstageable. Treatment Nurse Notes revealed on 2/18/13 - Summoned to the room per CNA along with DON to assess resident's left heel which was blister -like DTI- unstageable dark purple fluid filled with underlying pink granulating tissue. ( 3.1x cm depth). Treatment initiated immediately, resident tolerated well. Notified physician and responsible party. On 3/14/13 at 10:00 am, an observation of the pressure ulcer to the resident's left heel was made with S4LPN/Treatment Nurse. The resident was sitting in his wheelchair while the dressing to his left foot was changed. The dressing was removed by S4LPN and the site to the left heel was noted with black eschar the size of a quarter. The site was cleaned with wound cleanser and 4x4 then [MEDICATION NAME] sprayed on 4x4 and placed over site. The site was then covered with Kerlix and taped in place. His boot was reapplied. The resident complained of pain during the dressing change. S4LPN stated she would tell the nurse about the resident's complaint of pain to get pain medication for the resident. About 5 minutes after exiting the room the nurse was observed going into the resident's room and when questioned she stated it was to give the resident his pain medications. Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation revealed the resident received the Tylenol on 3/9, 3/13 and 3/14 for complaint of pain. On 3/14/13 at 12:20 pm, an interview was conducted with S1DON and she stated, "The resident's pressure ulcer started as a blister with fluid around the area but the middle was a dark purple spot. I called it DTI (Deep Tissue Injury) and labeled it as being unstageable. I was not sure what was under the blister. We put [MEDICATION NAME] on it and it developed the eschar. We even had the physician look at it on yesterday and he said to keep using the [MEDICATION NAME] and the other part would come off." The care plan was reviewed and this resident is care planned for impaired skin integrity, pressure ulcers related to fragile skin, needs total assistance with toileting and bed mobility, is incontinent of bowel. The approaches included perform weekly skin assessments, offer toileting every 2 hours and as indicated, pressure relieving mattress, and keep skin moisturized. The resident's functional status was total dependency on the staff and there was no documentation listed for turning the resident every two hours. On 3/14/13 at 1:00 pm an interview with the DON was conducted. Upon a review of the resident's care plan, she confirmed that the resident was to be toileted every 2 hours as indicated. When asked for the documentation by the CNAs that the resident was brought to the bathroom, she confirmed that there was no documentation by the CNAs charting that the resident was being taken to the bathroom every 2 hours. When asked for the documentation that this resident was being monitoring by the CNAs or LPNs, S1DON stated that there was no documentation. S1DON further stated that the facility did not use an ADL flow sheet for documentation by the CNAs. When asked how she was monitoring the staff to ensure the resident's plan of care was followed, S1DON stated she did not have any measures in place for the monitoring of CNAs to ensure that they were toileting the resident every two hours and as needed. S1DON stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on his heel prior to it becoming an unstageable pressure ulcer.

Based on observation, record review and interview, the facility failed to have a system in place for the monitoring of the facility's staff to provide services to Resident #19 and #58 to meet professional standards of quality to avoid the development of pressure sores as evidenced by: 1. a. Resident #19 developed an avoidable unstageable pressure ulcer to her right heel which was found by the facility on 1/14/13 and was staged on 3/7/13 as a stage III pressure ulcer and b. inaccurate assessment of the resident on the Braden Scale For Predicting Pressure Score Risk, 2. Resident #58 developed an avoidable unstageable pressure ulcer to his left heel which was found by the facility on 2/18/13. The facility's Resident Census and Conditions of Residents form was reviewed and revealed that there were 6 residents currently residing in the facility with pressure ulcers but that 1 resident was admitted with pressure ulcers. This deficient practice affected 2 out of 2 reviewed for pressure ulcer out of a total of 6 residents identified by the facility as having pressure ulcers and 70 residents that were listed by the facility on the Resident Census and Conditions of Residents form as bedfast or being in the chair most of the time in the facility. (#19, #58) Findings: 1. a. Resident #19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's Activities of Daily Living (ADL) Tracking Tool reviewed for the month of January and February 2013 and the resident was coded as 4/2 ( Total Dependence/One person physical assist) for bed mobility and for transfer, toileting and eating. The resident's Minimum Data Set ((MDS) dated [DATE] was reviewed and under cognition, the resident was listed as 0 for No- Resident is rarely /never understood. She was also listed as a 3- Moderately impaired for her cognition. The resident's Braden Scale For Predicting Pressure Sore Risk was reviewed and revealed that the resident was a 18. (15-18 was risk) The resident's Wound Assessment sheet was reviewed and revealed that on 1/14/13 the resident acquired an unstageable pressure ulcer to her right heel. The Treatment Nurses Notes dated 1/14/2013 revealed the following: This nurse along with ________ (ADON) summoned to resident's room to assess right heel. Upon assessment the following was noted, a suspected DTI (deep tissue injury) reddish -purple in color, painful to touch. Wound measures @ 3.1 x 3.5 cm, depth <.01. No exudate/odor, treatment initiated immediately. New order: clean wound to right heel with WC (wound care), pat dry, apply [MEDICATION NAME] then wrap Kerlix every day until healed. Tolerated treatment well. Notified physician and responsible party. The Wound Assessment form was reviewed and revealed that on 1/14/13 the resident's wound bed to her right heel was black with 100% necrosis and the necrosis type was listed as eschar. The Wound Assessment measurements are as follows: 1/14/13 Measurements L-3.1, W-3.5, D -<.1 cm 1/23/13 Measurements L- 3.1, W- 3.4, D-<.1cm 1/30 12 Measurements L- 3.0, W- 4.0, D-<.1cm 2/06/13 Measurements L- 1.5, W- 1.6, D, -<.1cm 2/13/13 Measurements L- 1.5, W-1.5, and D-<.1cm 2/21/13 Measurements L-1.5, W-1.5, and D-<.1cm 2/28/13 Measurements L- 1.5, W -1.5, and D-<.1cm 3/07/13 Measurements L- 1.0 W- .8, and D-<.1 cm Stage III 3/13/13 Measurements L- .9 W-.6 and D-<.1cm physician's orders [REDACTED]. The resident's care plan was reviewed and revealed documentation that the resident was at risk for impaired skin integrity, pressure ulcer related to incontinent of bowel and bladder, dry fragile skin, needs total assistance with bed mobility with approaches listed to assure pressure relieving mattress, perform weekly skin assessments, turn and reposition every 2 hours and as indicated and monitor off loading device for geri-chair while up. The resident was observed lying in her bed in her room on 3/11/13 at 2:05 pm when the surveyor attempted to interview the resident and was unsuccessful due to her cognition. The resident was also observed on 3/14/13 at 10:15 am for an observation of the dressing change while she was lying in her bed. On 3/14/13 at 10:15 am, an observation of the S4LPN/ Treatment Nurse changing the resident's dressing to her right heel was made. The site to right heel was pink in color about the size of a quarter with darker pink area noted to center of heel. No opened area viewed. Site was cleansed with wound cleanser and patted dry with 44 gauze. Zinc Oxide was then applied to the site using a Q-tip. Border dressing was applied over the site which was labeled with the date of the dressing change. The resident's medical record was reviewed and there was no documentation found that the resident was being monitored by the Certified Nursing Assistants (CNAs) and Licensed Practical Nurses that ensured the resident was turned every 2 hours and assessed for the development of an avoidable pressure ulcer. On 3/14/13 1:18 pm, an interview was conducted with S1DON. After a review of the wound assessment sheets dated from 1/14/13 to 3/13/13 revealed the resident was having her right heel painted with [MEDICATION NAME] and it dried the site. On 2/28/13 the dressing was changed to [MEDICATION NAME] and the [MEDICATION NAME] dried off the area and the slough fell off. On 3/7/13 75% of the wound was yellow slough and not eschar and 25% of the site was pink. The dressing was changed to Santel. S1DON stated that on 3/13/13 they again changed the wound care to Zinc. S1DON stated that the resident was in a wheelchair and she remembered having a conversation with her daughter about her heel rubbing on her foot pedal. S1DON stated, " I don't know if this caused the area on her heel". S1DON confirmed that the resident was to be turned and repositioned every 2 hours. When asked for the documentation that this resident was being turned and monitored by the CNAs or LPNs, S1DON stated that there was no documentation. S1DON further stated that the facility did not use an ADL flow sheet for documentation by the CNAs. When asked if the LPNs were documenting the resident being turned as written in the plan of care she stated that there was no documentation by the LPNs on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. S1DON stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on her heel prior to it becoming an unstageable or a stage III pressure ulcer. b. During the survey, Resident #19's Braden Scale for Predicting Pressure Sore Risk was reviewed and revealed that the resident was coded under the section activity - as a 4 Walks Frequently: walks outside room at least twice a day and inside room at least once every 2 hours during waking hours. Under the section Friction and Shear she was coded a 3- No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. The facility's ADL tracking sheet was reviewed and revealed that the resident in the areas of Bed Mobility she was a 4/2 ( total dependence/one person physical assist) , Transfer she was a 4/3 ( total dependence/two person physical assist) , Toileting she was a 4/2 (total dependence/one person physical assist) and in the area of Eating she was a 4/2 (total dependence/one person physical assist). On 3/15/13 at 1:15 pm, an interview with S6LPN/MDS was conducted and she stated after a review of the assessment of the Braden Scale For Predicting Pressure Sore Risk that she had incorrectly assessed the resident. She stated that the resident was not able to freely move her extremities and required maximum assistance from the CNAs for all of her ADL care. She stated under the area of Friction and Shear, the resident should have been coded as a 1 - requires moderate to maximum assistance in moving and was not a 3. She then changed the assessment to reflect what she stated the resident should have been coded. 2. Resident #58. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Th resident's Minimum Data Set ((MDS) dated [DATE] revealed under the Activities Of Daily Living (ADL) section that the resident under the G section- Functional Status under A. Bed Mobility as a 4/2 ( Total Dependence/One person physical assist) The resident's Braden Scale for Predicting Pressure Sore Risk dated 1/12/13 revealed that the resident's score was a 16 (At Risk). Upon admit to facility, the resident's January's MAR indicated [REDACTED]. Weekly skin audit dated 1/24/13, 1/31/13, 2/7/13, 2/14/13, completed and reviewed with no documenation of pressure ulcer to left heel. The Wound assessment dated [DATE] revealed an acquired unstageable pressure ulcer. The documentation on the form identified the tissue to the resident's left heel as dark purple. The unstageable pressure ulcer was surrounded by a fluid blister with underlying pink granulating tissue. Measurements - L 3.5 cm, W 4.5 cm, D <.1cm. Preventive Measures documented on form- Heel protectors while in bed- Monitor Q shift, Float heels while in bed- Monitor Q shift. The Measurement of the unstageable pressure ulcer to the left heel are as follows: 2/21/13 - the resident was in the hospital. 3/1/13 Unstageable left heel. Measurements L- 3x3 W- 4.5, D-<.6 cm 3/7/13 Measurements L-3.3, W-4.5, D-<.6cm 3/13/13 measurements L- 3.0, W- 3.8, D-<.1cm Current Treatment [MEDICATION NAME]- remains unstageable. Treatment Nurse Notes revealed on 2/18/13- Summoned to the room per CNA along with DON to assess resident's left heel which was blister -like DTI- unstageable dark purple fluid filled with underlying pink granulating tissue. ( 3.5 x 4.5 [MEDICAL CONDITION] cm depth). Treatment initiated immediately, resident tolerated well. Notified physician and responsible party. On 3/14/13 at 10:00 am, an observation of the pressure ulcer to the resident's left heel was made with S4LPN/Treatment Nurse. The resident was sitting in his wheelchair while the dressing to his left foot was changed. The dressing was removed by S4LPN and the site to the left heel was noted with black eschar the size of a quarter. The site was cleaned with wound cleanser and 4x4 then [MEDICATION NAME] was sprayed on a 4x4 and placed over the site. The site was then covered with Kerlix and taped in place. His boot was reapplied. The resident complained of pain during the dressing change. S4LPN stated she would tell the nurse about the resident's complaint of pain to get pain medication for the resident. About 5 minutes after exiting the room the nurse was observed going into the resident's room and when questioned she stated it was to give the resident his pain medications. Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation revealed the resident received the Tylenol on 3/9, 3/13 and 3/14 for complaint of pain. On 3/14/13 at 12:20 pm, an interview was conducted with S1DON and she stated, "The resident's pressure ulcer started as a blister with fluid around the area but the middle was a dark purple spot. I called it DTI (Deep Tissue Injury) and labeled it as being unstageable. I was not sure what was under the blister. We put [MEDICATION NAME] on it and it developed the eschar. We even had the physician look at it on yesterday and he said to keep using the [MEDICATION NAME] and the other part would come off." The care plan was reviewed and this resident is care planned for impaired skin integrity, pressure ulcers related to fragile skin, needs total assistance with toileting and bed mobility, is incontinent of bowel. The approaches included perform weekly skin assessments, offer toileting every 2 hours and as indicated, pressure relieving mattress, and keep skin moisturized. The resident's functional status was total dependency on the staff and there was no documentation listed for turning the resident every two hours. On 3/14/13 at 1:00 pm an interview with the DON was conducted. Upon a review of the resident's care plan, she confirmed that the resident was to be toileted every 2 hours as indicated. When asked for the documentation by the CNAs that the resident was brought to the bathroom, she confirmed that there was no documentation by the CNAs charting that the resident was being taken to the bathroom every 2 hours. When asked for the documentation that this resident was being monitored by the CNAs or LPNs, S1DON stated that there was no documentation. S1DON further stated that the facility did not use an ADL flow sheet for documentation by the CNAs. When asked how she was monitoring the staff to ensure the resident's plan of care was followed, S1DON stated she did not have any measures in place for the monitoring of CNAs to ensure that they were toileting the resident every two hours and as needed. S1DON stated that the staff of the facility did not do an accurate assessment on the resident's skin and should have found the area on his heel prior to it becoming an unstageable pressure ulcer. In the Rules and Regulations of the Professional and Occupational Standards in Chapter 39. Legal Standards of Nursing Practice under section 3909 Standard Number 4: Implementation of Nursing Plan under A 1. Nursing actions are consistent with the plan for nursing care and B. Documentation includes, but is not limited to, written records that attest to the care provided to patients based on assessment data and the patient's response to the intervention.