Every finding on record at Maison Teche Nursing Center

Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 87.Findings:Review of the facility's survey history in the state agency's database revealed the following: Revisit Complaint Survey dated 10/30/2024;Complaint Survey dated 11/06/2024;Revisit Complaint Survey dated 11/26/2024;Recertification, Re-Licensure, State Licensure Survey dated 12/04/2024;Revisit Re-Licensure, State Licensure Survey dated 01/13/2025;Complaint Survey dated 01/28/2025;Complaint Survey dated 01/28/2025;Complaint Survey dated 02/25/2025; andComplaint Survey dated 08/26/2025.On 01/11/2026 at 1:30 p.m., an observation and interview was conducted with S1ADM (Administrator). S1ADM stated the survey results were in a binder attached to the bulletin board near the dining room. S1ADM reviewed the binder and confirmed the last survey results in the binder were dated 10/15/2024. S1ADM confirmed the most recent survey results were not in the binder and should have been posted in a place readily accessible to residents, family members and legal representatives.

Based on interviews and record review, the provider failed to revise a resident's care plan for 1 (Resident #42) out of 34 sampled residents as evidenced by the care plan failing to reflect the resident's plans for discharge out of the facility.Findings Review of Resident #42's medical record revealed he was admitted to the facility on [DATE].Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to participate in the Brief Interview for Mental Status (BIMS) with a score of 15 indicating the resident was cognitively intact.On 01/11/2026 at 9:34 a.m., an initial interview was conducted with Resident #42. Resident #42 stated he really wanted to get out of the nursing facility and move into his own place. Review of Resident #42's care plan meeting dated 03/19/2025 revealed: Resident hopeful waiver will find housing soon with S3MDS/LPN (MDS Licensed Practical Nurse) and S5SSD (Social Services Director) were present.Review of Resident #42's care plan meeting dated 06/18/2025 revealed Resident wants to discharge with waiver as soon as housing is available with S3MDS/LPN and S5SSD were present.Review of Resident #42's current care plan revealed in part, No plans for discharge: plans to remain in facility long term with interventions to hold care plan meeting quarterly and no active discharge planning at this time. On 01/13/2026 at 2:55 p.m., an interview was conducted with S5SSD who stated she was familiar with Resident #42 and verified the resident was on a waiting list for waiver services to assist him with housing. S5SSD confirmed Resident #42's current care plan had not been revised to reflect the resident's plan to discharge out of the facility.

Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 2 (#41 and #76) of 34 sampled residents by:not monitoring behaviors and side effects of medications for Resident #41, andnot completing skin checks for Resident #76 per the physician's order and care plan.Findings:Resident #41Review of Resident #41's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, major depressive disorder, other specified depressive episodes, and generalized anxiety disorder.A review of Resident #41's physician orders for January 2026 revealed the following orders:-order dated 08/01/2024 for Trazodone (an antidepressant) 50 mg (milligram), give 1 tablet by mouth at bedtime.-order dated 08/02/2024 for Zoloft (an antidepressant) 25 mg, give 1 tablet by mouth one time a day.-order dated 09/04/2025 for Clorazepate Dipotassium (an antianxiety) 3.75 mg, give 1 tablet by mouth two times a day.-order dated 10/31/2025 for Buspirone (an antianxiety) 10 mg, give 1 tablet by mouth three times a day.Further review of Resident #41's physician orders failed to reveal orders to monitor behaviors or side effects of antidepressant and antianxiety medications.A review of Resident #41's care plan revealed the following, in part .At Risk for Increased Complicated from Psych History, Anxiety, Depression, and Insomnia. Interventions included, in part .Assess for changes in mood status.Assess for increased s/sx (signs/symptoms) of Depression.Monitor for side effects and behaviors r/t psych med usage. A review of Resident #41's December 2025 and January 2026 Medication Administration Record (MAR) revealed documentation that the resident received Trazodone 50 mg, give 1 tablet by mouth at bedtime, Zoloft 25 mg, give 1 tablet by mouth one time a day, Clorazepate Dipotassium 3.75 mg, give 1 tablet by mouth two times a day and Buspirone10 mg, give 1 tablet by mouth three times a day, December 1, 2025-January 12, 2026.Further review of the MAR revealed no documentation that the resident was monitored for behaviors or side effects of antidepressant and antianxiety medications.On 01/13/2026 at 2:45 p.m., a record review and interview was conducted with S6LPN (Licensed Practical Nurse). She confirmed the resident had physician orders for Trazodone 50 mg, Zoloft 25 mg, Clorazepate Dipotassium 3.75 mg and Zoloft 25 mg. S6LPN further reviewed Resident #41's December 2025 and January 2026 MAR, and confirmed that there was no documentation that behaviors, or side effects of antidepressant and antianxiety medications were monitored each shift and they should have been.On 01/13/2026 at 2:48 p.m., an interview and record review was conducted with S2DON (Director of Nursing). She stated that residents on antidepressant and antianxiety medications should be monitored for behaviors and side effects of each medication. S2DON reviewed Resident #41's electronic medical record and confirmed that there was no documented evidence that behaviors or side effects of medications were completed every shift per the resident's care plan.Resident #76On 01/13/2026, a review of the facility's policy titled, Skin Assessment, with an unknown last reviewed date or revised date, revealed in part.Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission and weekly.Review of Resident #76's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease, dementia, cerebral infarction, moderate protein calorie malnutrition and pressure ulcer of left buttock, stage 3.A review of Resident #76's physician orders for January 2026 revealed the following order dated 01/31/2025 for head to toe skin assessment every night shift every Tuesday.A review of Resident #76's care plan revealed the following, in part .Skin Integrity aging process, decreased ROM (range of motion), joint pain or stiffness, contractures, edema, and impaired mobility. Interventions included, in part .Head to toe assessment weekly . Review of Resident #76's weekly head to toe skin checks revealed the last assessment was dated 12/30/2025. There was no documented skin check completed for the following date: 01/06/2026.On 01/13/2026 at 2:58 p.m., an interview and record review was conducted with S2DON (Director of Nursing). She stated that head to toe skin checks should be completed on all residents every week. S2DON reviewed Resident #76's electronic medical record and confirmed that there was no documented evidence that a head to toe skin check had been completed on 01/06/2026.

Based on record review, observation, and interviews, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff utilized appropriate personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) while administering a water flush via feeding tube for 1(Resident #5) sampled resident was reviewed for tube feeding. Findings:A review of the facility's policy titled, Enhanced Barrier Precautions, with a last reviewed date of 04/01/2024, read in part, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions refer to an infection control interventions designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. High-contact resident care activities include: . g. device care or use central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes.A review of Resident #5's record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction and gastrostomy status. A review of Section K: Swallowing/Nutritional Status of Resident #5's Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed that the resident was assessed as having a feeding tube.A review of Resident #5's physician orders revealed an order written on 11/25/2025 that read, every 4 hours enteral: flush feeding tube with 1100 cc (cubic centimeters) of water q 4 hours (every 4 hours).Further review of Resident #5's physician orders revealed an order dated 05/31/2024 that read, enhanced barrier precautions with direct care r/t (related to) feeding tube every day and night shift.On 01/12/2026 at 12:07 p.m., an observation was conducted of S4LPN (Licensed Practical Nurse), who administered Resident #5's water flush via feeding tube. S4LPN entered Resident #5's room, but did not wear a gown while administering Resident #5's water flush via feeding tube. An EBP precaution sign was observed in Resident #5's room, which read, wear gloves and gown for the following high-contact resident care activities: . Device care of use: central line, urinary catheter, feeding tube, tracheostomy . On 01/12/2026 at 1:20 p.m., an interview was conducted with S4LPN. She stated Resident #5 was on EBP, and she confirmed she did not wear a gown while administering Resident #5's water flush via feeding tube, but should have.On 01/12/2026 at 2:07 p.m., an interview with S2DON (Director of Nursing), she confirmed that Resident #5 was on EBP, and S4LPN should have worn a gown while administering his water flushes via feeding tube.

Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 90 residents residing in the facility. Findings: On 12/03/2024 at 2:49 p.m., during the resident council meeting, Resident #51 stated residents did not receive mail on Saturdays. On 12/04/2024 at 9:15 a.m., an interview was conducted with S12CNASUP (Certified Nursing Assistant Supervisor) and S11HR (Human Resources). S12CNASUP stated the mail was delivered to the residents on Monday through Friday, but not on Saturdays. She stated the office was closed on weekends, and staff were not available to distribute mail on Saturdays. S11HR confirmed the residents received mail Monday through Friday but the mail carrier holds the mail on the weekend until the following Monday. S11HR stated that the facility does not have staff in the office to deliver the mail to the residents on the weekends. S11HR stated that she was not aware that it was regulatory for the residents to receive mail on the weekend. S12CNASUP confirmed she was aware residents were supposed to receive mail on the weekend, and they had not received mail on the weekend for some time now.

Based on interview, and record review, the facility failed to develop and implement a comprehensive plan of care for 3 (#15, #39, #76) residents out of a total sample of 36 residents as evidenced by failing to: 1. Administer Resident #15's medications before meals; 2. apply compression stockings daily for Resident #39; and 3. monitor behaviors and side effects of anticoagulant, antidepressant and antipsychotic medications for Resident #76. Findings: Resident #15 On 12/04/2024, a review of the facility's policy titled Medication Administration with a revision date of 06/01/2024, read in part, Medications are administered by licensed nurses, or other staff .Policy Explanation and Compliance Guidelines: 12. Compare medication source (bubble pack, vial etc.) with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . A review of Resident #15's EHR (Electronic Health Record) revealed an admitted [DATE] and Diagnoses which included, but were not limited to Gastro-Esophageal Reflux Disease without Esophagitis and Iron Deficiency Anemia. Further review of Resident #15's EHR revealed Physician Orders, for the month of December 2024, which included the following orders dated 11/19/2024: 1. Carafate Oral Tablet 1 GM (gram) (Sucralfate). Give 1 tablet by mouth before meals . 2. Ferrous Sulfate Oral Tablet 325 (65 Fe) MG (milligram) (Ferrous Sulfate) Give 1 tablet by mouth before meals . During an observation of morning medication pass on 12/03/2024 at 7:50 a.m., S6LPN (Licensed Practical Nurse) administered medications to Resident #15 after the resident returned from having breakfast in the dining room. S6LPN scanned the single dose medication blister packets which included the medications above, and administered them to the resident. During an interview on 12/03/2024 at 9:03 a.m., S6LPN stated that the resident had eaten breakfast in the dining room then came back to Hall W for medications. S6LPN checked the orders for Ferrous Sulfate and Sucralfate and confirmed that the orders were written to be given before meals for GERD and were not offered before the resident ate breakfast. S6LPN stated the blister packets should have been compared with the physician orders and were not. 41419 Resident #39 Review of Resident #39's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Heart Failure, Peripheral Vascular Disease, and Overactive Bladder. Review of Resident #39's Brief Interview Mental Status revealed a score of 12, indicating moderately intact cognition. Review of Physician Orders dated 08/01/2024, read in part .compression stocking on daily, remove at night. On 12/02/2024 at 10:12 a.m., an observation of Resident #39 was conducted. The resident was observed sitting in her wheelchair with Christmas socks on bilateral feet, no compression stockings were noted. On 12/02/2024 at 3:00 p.m., a follow up observation and interview was conducted with Resident #39 who stated that staff had not applied her compression stockings that morning. On 12/03/2024 at 1:00 p.m., another observation and interview was conducted with Resident #39 who was observed without compression stockings on. The resident stated that staff had not applied her compression stockings, and she had not refused to have them applied. On 12/04/0224 at 1:00 p.m., an interview was conducted with S10CNA (Certified Nursing Assistant) who stated she was not aware Resident #39 was to have compression stockings applied daily. On 12/04/2024 at 1:05 p.m., an interview was conducted with S9CNA who confirmed the resident was to have compression stockings applied daily by staff. She stated they should have been applied. 49176 Resident #76 Review of Resident #76's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Atrial Fibrillation, Dementia, Psychotic Disturbance and Anxiety. A review of Resident #76's physician orders for December 2024 revealed the following orders dated 08/26/2024: Eliquis (an anticoagulant) 2.5 mg (milligram), give 1 tablet by mouth two times a day; Trazodone (an antidepressant) 50 mg, give 1 tablet by mouth at bedtime; and Zyprexa (an antipsychotic) 2.5 mg, give 1 tablet by mouth one time a day. A further review of Resident #76's physician orders failed to reveal orders to monitor behaviors or side effects of anticoagulant, antidepressant and antipsychotic medications. A review of Resident #76's care plan revealed the following, in part .Potential for Bruising and Bleeding r/t (related to) Anticoagulant Use. Interventions included, in part .Monitor for bleeding/DVT (Deep Vein Thrombosis) Blood Clot q (every) shift .Report any increased s/sx (sign and symptom) of bleeding: Bruising, Hematuria, Melana, Coughing or Spitting up blood, Coffee ground emesis, Headache, Pale appearance. Further review of the care plan revealed the following, in part .At Risk for Increased Complications from Psych History, Anxiety, and Insomnia. Interventions included, in part .Assess for changes in mood status .Assess for increased s/sx of Depression .Monitor for side effects and behaviors r/t psych med usage. A review of Resident #76's November 2024 and December 2024 Medication Administration Record (MAR) revealed documentation that the resident received Eliquis 2.5 mg (milligram), give 1 tablet by mouth two times a day, Trazodone 50 mg, give 1 tablet by mouth at bedtime, and Zyprexa 2.5 mg, give 1 tablet by mouth one time a day, November 1, 2024-December 3, 2024. Further review of the MAR revealed no documentation that the resident was monitored for behaviors or side effects of anticoagulant, antidepressant and antipsychotic medications. On 12/04/2024 at 2:22 p.m., a record review and interview was conducted with Sl4LPN (Licensed Practical Nurse). She confirmed the resident had physician orders dated 08/26/2024 for Eliquis 2.5 mg, Trazodone 50 mg, and Zyprexa 2.5 mg. S14LPN further reviewed Resident #76's November 2024 and December 2024 MAR and confirmed that there was no documentation that behaviors, or side effects of anticoagulant, antidepressant and antipsychotic medications were monitored each shift and they should have been. On 12/04/2024 at 2:28 p.m., an interview and record review was conducted with S3DON (Director of Nursing). She stated that residents on anticoagulant, antidepressant and antipsychotic medications are monitored for behaviors and side effects of each medication. S3DON reviewed Resident #76's electronic medical record and confirmed that there was no documented evidence that behaviors or side effects of medications were monitored every shift.

Based on observation and interview, the facility failed to provide a homelike environment for 1 (#35) out of 5 (#18, #35, #36, #46 and #60) residents investigated for environment, out of a total sample of 36 residents. Findings: Review of a facility policy titled, Safe and Homelike Environment, reviewed 01/2024, indicated Policy: In accordance with the residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Resident #35 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism and End Stage Renal Disease. Review of Resident #35's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/17/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 15, indicating his cognition was intact. During an observation and interview on 12/02/2024 at 9:36 a.m., a hole the size of the door knob was observed in the sheetrock on the right wall immediately after entering Resident #35's room. The resident stated it had been there about a month and the nurses and maintenance had been notified. Further observation revealed there was no door stopper to prevent the door knob from slamming into the wall. During an interview on 12/03/2024 at 12:54 p.m., S4Maint (Maintenance Director) stated that he was not aware of the hole in Resident #35's wall. During an interview on 12/03/2024 at 2:25 p.m., S1ADM (Administrator) stated that all staff members were responsible for checking the residents' rooms and notifying maintenance of identified problems so they can be addressed.

Based on observations, interviews and record reviews, the facility failed to ensure their medication error rate was less than five percent. Findings: Observations of morning med pass were conducted on 12/03/2024. S6LPN (Licensed Practical Nurse) administered Carafate Oral Tablet 1 GM (gram) and Ferrous Sulfate Oral Tablet 325 MG (milligram) to Resident #15 after the resident ate breakfast. Review of Resident #15's EHR (Electronic Health Record) revealed Physician Orders, for the month of December 2024, including the following orders dated 11/19/2024: 1. Carafate Oral Tablet 1 GM (gram) (Sucralfate). Give 1 tablet by mouth before meals . 2. Ferrous Sulfate Oral Tablet 325 (65 Fe) MG (milligram) (Ferrous Sulfate) Give 1 tablet by mouth before meals . During an interview on 12/03/2024 at 9:03 a.m., S6LPN stated that the resident had eaten breakfast in the dining room then came back to Hall W for medication administration. S6LPN checked the orders for Ferrous Sulfate and Sucralfate in the resident's EHR and confirmed that the orders were written to be given before meals and were not administered before the resident ate breakfast. A total of 30 opportunities for medication pass were conducted during the survey with two errors observed. The facility's calculated medication error rate was 6.67%).

Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (#42) out of 2 (#8 and #42) residents investigated for respiratory care, by failing to label and properly store Oxygen tubing, and safely store Oxygen tanks. The total sample size was 36 residents. Findings: On 12/04/2024, a review of the facility's policy titled Oxygen Administration with a revision date of 06/01/2024, indicated Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice .5. e. Keep delivery devices covered in a black IFP (infection prevention) bag when not in use. On 12/04/2024, a review of the facility's policy titled Oxygen Safety with a revision date of 06/01/2024, indicated Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public .Policy Explanation and Compliance guidelines: 4. Oxygen storage - a. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. Resident #42 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. During an observation on 12/02/2024 at 10:44 a.m., Two Oxygen tanks were observed on a rack by the door in Resident #42's room. Another Oxygen tank was in a hanger on the back of the resident's wheelchair with a nasal cannula tubing attached and wrapped around the back of the wheelchair. The tubing was not dated and/or stored in a bag. During an interview on 12/02/2024 at 10:52 a.m., S7LPN (Licensed Practical Nurse) stated that as long as the oxygen tanks are on a rack they can be stored in the resident's room. S7LPN confirmed the O2 tubing was undated and opened to air on the back of the resident's chair and stated it should have been labeled and in a bag. During an interview on 12/03/2024 at 10:51 a.m., S3DON (Director of Nursing) stated that the Oxygen tanks should not have been stored in the resident's room. She stated that they should have been placed on a rack in a separate room.

Based on interview, observation and record review, the facility failed to provide treatment/services to prevent further avoidable reduction of Range of Motion (ROM) and mobility as evidenced by a resident being unable to use his left leg prosthetic limiting his ability to walk for 1 (Resident #60) of 2 (#36 and #60) residents investigated for positioning and mobility in a final sample of 36 residents. Findings: Review of Resident #60's Admission Record indicated the facility admitted the resident on 02/16/2023 with diagnoses that included acquired absence of left leg below the knee with an onset date of 07/23/2019, other specified Depressive episodes and Generalized Anxiety disorder. Review of the list of residents with current wounds in the facility provided by S3DON (Director of Nursing) on 12/02/2024 at approximately 10:00 a.m. indicated Resident #60 had a facility acquired non pressure ulcer to his left stump that was acquired on 05/14/2024. Review of Resident #60's current physician's orders as of 05/31/2024 revealed the following orders dated: 11/20/2023 FYI (For Your Information) steps to put prosthetic leg on: 1st tangel (rubber) on skin, 2nd 3 ply or 5 ply sock, 3rd prosthetic leg and roll brown sleeve all the way up onto thigh; 05/23/2024 for open area to left stump: cleanse with wc (wound cleanser), apply ca (Calcium) alg (Alginate), cover with clean/dry dressing daily and PRN (as needed) soiling/peeling. On 12/04/2024 at 8:12 a.m., an interview was conducted with S13TxRN (Treatment Registered Nurse) who explained that Resident #60 had a wound to his left BKA that started out as an intact blister on 05/14/2024 which has deteriorated to 100% slough with bone exposure that was last assessed on 11/28/2024. S13TxRN further explained the facility participated in a special event offsite and Resident #60 was a participant in a dance contest. One of the therapy aides had assisted Resident #60 in the bathroom and noticed that the resident's left leg prosthetic sleeve/stocking was applied in the wrong order causing friction during the time that the resident was wearing his prosthesis. S13TxRN stated Resident #60 had not been able to wear his prosthetic leg currently due to the presence of an unhealed wound that subsequently developed. Review of Physical Therapy (PT) Discharge Summary dated 07/31/2023 revealed the resident was seen for 2 days during the 07/25/2023- 07/27/2023 progress period. PT's discharge recommendations included an exercise program and prosthesis. PT established an ambulation program and evaluated the resident as currently able to walk to the dining room, walk in corridor and negotiate steps and balance is steady. Review of PT Evaluation and Plan of Treatment dated 06/03/2024 revealed reason for therapy indicated recurrent falls with pressure ulcer noted to L (left) residual limb with L BK (below knee) prosthesis not being worn, negatively impacting functional mobility tasks as he is requiring increased assistance. Resident presents with generalized weakness/fatigue, decreased balance, decreased standing tolerance and decreased endurance/activity tolerance. Review of Resident #60's quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date), of 03/26/2024 revealed the resident's functional abilities and goals were assessed as the resident requiring max assistance putting on/taking off footwear and getting in and out of a tub/shower. The resident required partial/moderate assistance to shower/bathe self and with upper body dressing. The resident required supervision or touching assistance with toileting hygiene, lower body dressing and transferring to and from a bed to a chair (or wheelchair).The resident required set up assistance when transferring from sitting to standing and maintaining his personal hygiene The resident was able to independently roll from left and right, sit to lying, lying to sitting on side of bed, and get on and off a toilet or commode. Review of Resident #60's quarterly MDS, with an ARD of 06/18/2024, revealed the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident's functional abilities and goals revealed the resident now required partial/moderate assistance with showering/bathing self, upper and lower body dressing, personal hygiene, putting on/taking off footwear. The resident was also coded as needing partial/moderate assistance for mobility moving from sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. On 12/04/2024 at 2:10 p.m., an interview was conducted with S5PT (Physical Therapist). S5PT explained Resident #60 was present at the offsite special event and recalled the resident was complaining of pain during his dancing contest. One of the former therapy aides assisted the resident in the bathroom and observed the resident's prosthetic leg was incorrectly applied and observed he had breakdown on his left knee stump. S5PT evaluated Resident #60 on 06/03/2024 because the resident was experiencing a functional decline since he could no longer wear his leg prosthetic. S5PT explained the resident was mobile, able to walk without assistance using is prosthesis, and did not use his wheelchair prior to 05/14/2024. On 12/04/2024 at 2:45 p.m., an interview was conducted with Resident #60 who was observed in his bed, and stated he was able to put on and wear his leg prosthetic prior to the event on 05/14/2024. Resident #60 was unable to recall which therapy staff assisted him the morning of 05/14/2024 with putting on his prosthetic leg. Resident #60 confirmed he went to the event offsite and participated in a dancing contest. He stated while he was at the event, he began to feel pain to his in his left leg. One of the therapy aides helped him get out of his costume which is when the therapy aide saw that his left thigh stocking and sleeve were put on incorrectly. Resident #60 expressed feeling sad about not being able to walk anymore and could not wear his leg prosthesis until the wound healed.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#31) of 3 (#3, #31, #54) residents investigated for PASARR in a final sample of 36 residents. Findings: A review of Resident #31's medical record revealed she was admitted to the facility on [DATE]. Further review revealed she was diagnosed with Schizoaffective Disorder on 12/14/2022. A review of the Resident #31's physician's orders for December 2024 revealed resident had been prescribed the antipsychotic medication Aripiprazole 2mg (milligrams) related to the diagnosis of Schizoaffective Disorder. Further review of Resident #31's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 07/21/2022. There was no evidence that a new review or a Level II PASARR had been submitted to the appropriate state-designated authority after the new diagnosis of Schizoaffective Disorder on 12/14/2022. On 12/04/2024 at 4:13 p.m., an interview and review of Resident #31's diagnosis list was conducted with S2SSD (Social Service Director). She confirmed that Resident #31 received a new diagnosis of Schizoaffective Disorder on 12/14/2022 and that a Level II PASARR had not been submitted for this new diagnosis and should have been.

Based on record review, interviews, and observations, the facility failed to ensure a resident's rights to personal privacy for 2 (#2, #39) of 2 (#2, #39) residents out of a total sample of 36 residents investigated for Activities of Daily Living by failing to ensure: 1. Resident #2 had privacy while in the bathroom; and 2. Resident #39 had the room door and bathroom door closed prior to staff providing personal care. Findings: 1. Resident #2 Review of Resident #2's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of Dementia, Paranoid Schizophrenia, and Anxiety. Review of Resident #2's Brief Interview for Mental Status (BIMS) revealed a score of 15, which indicated normal cognition. On 12/02/2024 at 9:15 a.m., Resident #2 stated Resident #54, who resided in the next room, made comments to her when she was in the bathroom. She stated if she passed gas in the bathroom, Resident #54 would state he heard that and laugh at her. She added that Resident #54 also would say he heard her diarrhea, or stated she was constipated. She stated she told S8LPN (Licensed Practical Nurse) about what Resident #54 was doing when she used the bathroom, but nothing was done about it. She stated it made her feel bad, but she had to learn to ignore Resident #54. On 12/02/2024 at 9:25 a.m., an interview was conducted with S8LPN. S8LPN stated she did not recall Resident #2 complaining about Resident #54 making comments about her while she was in the bathroom. On 12/02/2024 at 9:43 a.m., an interview was conducted with Resident #54 who stated he hears Resident #2 while she is in the bathroom farting and it's pretty funny. He stated it's funny to hear someone farting in the bathroom. He confirmed that he did make comments to Resident #2 while she used the bathroom. He added that Resident #2 did not say anything to him, but it's pretty funny to him. 2. Resident #39 Review of Resident #39's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Heart Failure, and Overactive Bladder. Review of Resident #39's Brief Interview Mental Status revealed a score of 12, indicating moderate cognitive impairment. On 12/02/2024 at 10:00 a.m., upon entrance to Resident #39's room, it was observed the room door was opened and the bathroom door was opened. When the surveyor knocked on the room door prior to entrance, S9CNA (Certified Nursing Assistant) stated patient care. S9CNA was observed standing in the bathroom, and Resident #39 was observed pulling up her pants. Further observation revealed Resident #39's roommate who was seated in her wheelchair was in line of site of the bathroom. On 12/02/2024 at 10:03 a.m., an interview was conducted with S9CNA confirmed she should have closed the room door and bathroom door prior to assisting Resident #39 with personal care. On 12/03/02024 at 9:14 a.m., a follow up observation was conducted which revealed the resident's door was closed. Upon knocking prior to entering, the bathroom door was opened, the resident's roommate was seated in her wheelchair in the line of site of the bathroom. S10CNA was observed standing in the bathroom with Resident #39 who was observed pulling up her adult brief and pants. On 12/03/2024 at 9:17 a.m., an interview was conducted with S10CNA who confirmed she was supposed to protect the resident's privacy at all times and she should have closed the bathroom door prior to assisting Resident #39 with personal care. On 12/03/2024 at 12:50 p.m., an interview was conducted with Resident #39 who stated she was not comfortable when staff left the bathroom door opened while she was using the bathroom.

Based on record review and interviews, the facility failed to ensure as needed narcotic pain medication was documented as administered on the Medication Administration Record (MAR) for 1 (#1) of 3 (#1, #2, #3) residents reviewed for pain management. Findings: Review of facility policy and procedure with no revision date for Controlled Substance Administration and Accountability read in part .Policy Explanation and Compliance Guidelines: 1. General Protocols: g. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration record (MAR). H. The controlled drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. I. The controlled drug record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy. Review of Resident #1's Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses, which included Malignant Neoplasm of colon, Hemiplegia affecting right dominant side, Type 2 diabetes mellitus with diabetic nephropathy, Paraplegia, and Physical debility. Review of Resident #1's Physician Orders dated 08/2024, read in part: Start: 08/13/2024, Alprazolam 0.25 mg (Milligrams) 1 tab via PEG Tube every 8 hours as needed for pain. Start: 08/13/2024 Oxycodone 5 mg 1 tab via PEG-Tube every 4 hours as needed for pain. Review of Resident #1's Individual Narcotic Record for Alprazolam 0.25 mg revealed the following, in part: 08/15/2024 at 5:50 p.m. - 1 tab given. 08/17/2024 at 00:09 a.m. - 1tab given and at 23:00 1 tab given. 08/19/2024 at 23:54 p.m. - 1 tab given. 08/20/2024 at non-legible time - 1tab given and 23:00 1 tab given. 08/21/2024 at 17:30 p.m. - 1 tab given. Review of Resident #1's MAR dated 08/2024 revealed documentation Resident #1 received Alprazolam 0.25 mg on the following dates and times: 08/18/2024 at 23:54 p.m. 08/20/2024 at 23:00 p.m. Only one dose that day was documented on the MAR. Review of Resident #1's Individual Narcotic Record for Oxycodone 5 mg revealed the following, in part: 08/15/2024 at 5:50 p.m. - 1 tab given 08/20/2024 time was not legible - 1 tab given and at 23:00 1 tab given 08/21/2024 at 17:30 p.m. - 1 tab given 08/22/2024 at 23:15 p.m. - 1 given 08/24/2024 at 15:35 - 1 tab given Review of Resident #1's MAR dated 08/2024 revealed documentation Resident #1 received Oxycodone 5 mg on the following dates and times: 08/20/2024 at 04:32 p.m. No dose was documented on MAR for the 23:00 dose. There was no evidence on the MAR that the resident recieved the doses of these medications as documented on the resident's narcotic record. On 11/06/2024 at 1:06 p.m., an interview was conducted with S3LPN (Licensed Practical Nursing) who stated that when a narcotic is administered to a resident, the nurse signs the medication out in the narcotic book, and then administers the medication to the resident . She added the last step is to scan the medication in the computer to document the administration on the MAR. She stated that the narcotic count book and the MAR should match one another, but stated they did not match in Resident #1's records. On 11/06/2024 at 2:37 p.m., a review of Resident #1's narcotic count sheet and 08/2024 MAR was conducted with S2DON (Director of Nursing). S2DON stated the MAR and resident's narcotic count sheet should match one another. She stated that some time entries on the narcotic count sheets were not legible. She confirmed nursing staff did not scan the medication after it was administered into the computer as per facility policy and procedure.

Based on record review and interviews, the facility failed to initiate a grievance for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility policy and procedure titled, Resident and Family Grievances read in part .it is the policy of the facility to support each resident's family members right to voice grievances without discrimination reprisal or fear of discrimination or reprisal .Policy Explanation and Compliance Guidelines: 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concern regarding their facility stay. Review of Resident #1's Electronic Medical Record (EMR) record revealed an admitted [DATE] with diagnoses that included but not limited to Malignant neoplasm of colon, Hemiplegia affecting right dominant side, Type 2 diabetes mellitus with diabetic nephropathy, Paraplegia, Moderate protein calorie malnutrition, Pressure Ulcer Stage 2, and Physical debility. Review of Resident #1's Admission MDS (Minimum Data Set) dated 08/23/2024 revealed Resident #1 had a BIMS (Brief Interview of Mental Status) score of 06 indicating severely impaired cognition. Review of nurse's notes dated 08/24/2024 at 16:25 p.m., read in part family called ambulance to pick up resident and take to a local hospital. Family stated they felt resident was not being taken care of. Review of Care Plan dated 08/24/2024 read in part family visiting and upset, yelling at staff. Review of facility Grievance Log for 08/2024 did not reveal a filed grievance for Resident #1. Multiple attempts were made to interview the family, but calls went unanswered. On 11/06/2024 at 2:27 p.m., an interview was conducted with S1ADM (Administrator) who stated that she tried to communicate with the family about their concerns, but did not receive a call back from the family. She stated that she took no further steps to resolve the grievance or find out why the family of Resident #1 was upset. S1ADM was not able to provide any documented evidence that she took steps to resolve the issue. S1ADM stated there was no documented evidence of her attempts to call the resident's family. On 11/06/2024 at 2:45 p.m., during exit conference S1ADM and S2DON (Director of Nursing) stated they did not complete a grievance report, because they did not know what the grievance was about. S1ADM stated the family stated they were not satisfied with the care. S2DON added the facility did not know what the family meant by not being satisfied with the care. They didn't know what care the family was talking about nor did they make an attempt to find out why to resolve the matter.

Based on record review and interview, the facility failed to implement the comprehensive person-centered care plan for 1 (#1) of 3 ( #1, #2, #3) sampled residents as evidenced by staff failing to ensure a third person was available to observe a resident that was transferred back to the bed using a mechanical lift. The facility has a census of 92 residents. Findings: Resident #1: A review of Resident #1's record revealed an admitted [DATE] with diagnoses including but not limited to Metabolic encephalopathy, Muscle wasting, Peripheral vascular disease, Cognitive communication deficit, Dysphagia, Alzheimer's disease. and Aphasia. A review of her care plan revealed a problem: Self-care deficit, needs assistance with ADLs (Activities of Daily Living) r/t (related to), decreased mobility, lack of coordination, and muscle weakness. An intervention dated 09/3/2023 read .Transfer assistance: Resident is a 3 person assist using mechanical lift, (Third Person for Observation). A review of a facility incident report dated 10/10/2024 revealed Resident #3 was observed to have a bruise under her left eye which was discovered at 2:18 p.m. Review of the investigation data collected and the video surveillance captured during the time the mechanical lift was used to transfer the resident back into her bed on 10/10/2024 at 12:43 p.m., revealed several staff were in the line of site at the door but denied witnessing the transfer. The CNAs (Certified Nursing Assistants) that performed the transfer denied noticing any hazard that may have caused the bruise. On 10/15/24 at 2:30 p.m., during an interview, S3CNA stated she was asked to assist in the transfer of resident #1, but the third CNA stepped out to get supplies and denied she witnessed or observed the transfer of Resident #1. On 10/15/24 at 3:55 p.m., during an interview S1 Administrator (Adm) and S2 Director of Nursing (DON) both confirmed that according to the interviews collected during the investigation the intervention for a third person assist for observation in the transfer of Resident #1 was not implemented.

Based on observations, interviews and record reviews, the facility failed to ensure that nursing aides possessed the competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and attain or maintain the highest practicable physical well-being as evidenced by S3Transportation failing to demonstrate the correct procedure for securing a resident in the facility's transportation van. Findings: Review of facility training and in-service records revealed an attestation signed by S3Transportation on 03/17/2023, attesting that she had watched the training videos for the use of the Q-straint Restraint System and [NAME] Wheelchair Lifts. Further review of facility training and in-service records revealed a van wheelchair in-service was conducted with all transportation drivers on 04/10/2024. S3Transportation's signature was on the sign-in sheet. Review of the van wheelchair in-service read in part: When transporting resident via wheelchair/power chair in transport van, ensure all straps are secured on an immobile part of the wheelchair/power chair. All 4 straps should be in place and secured on the chair, wheelchair must be locked, and seatbelt must be placed across lap and chest, then secured. Review of the Braunability Rear entry Manual Foldout built on the [NAME] Voyager operator's manual revealed the following instructions for wheelchair and occupant restraint in part: QRT Retractor Strap Attachments: 3. Attach the four tiedown hooks to solid frame members or weldments, near the seat level. Ensure tiedowns are fixed at approximately 45 degrees, and are within angles shown in Figure 2 on page 34. Do not attach hooks to wheels, plastic or removable parts of wheelchair. On 05/02/2024 at 10:30 a.m., an interview was conducted with S1ADM (Administrator) who stated that an in-service with return demonstration for competency was conducted with all van drivers on 04/10/2024. On 05/02/2024 at 11:30 a.m., a mock observation was conducted of S3Transportation secure S2DON (Director of Nursing) in the facility's small transportation van. S3Transportation wheeled S2DON into the back of the van, locked the wheelchair, and secured the tiedown hooks to the back of the wheelchair. S3Transportation proceeded to secure the front tiedown straps and hooked the tiedown hooks on the lower portion of the wheelchair, above the wheels, but not closest to the seat cushion. The tiedowns were at approximately 90 degrees and not at a 45-degree angle per the instruction manual. S2DON confirmed that the straps were not at a 45- degree angle. On 05/02/2024 at 11:52 a.m. during a second mock observation with S1ADM, it was revealed that S3Transportation had not hooked the tiedown hooks in the correct position so that the tiedown straps could be at a 45-degree angle. S3Transportation confirmed she had not hooked the tiedown hooks closest to the seat cushion and had them hooked lower on the wheelchair.

Based on observation, record review and interview, the facility failed to ensure the smoking policy included the use of e (electronic)-cigarettes for 1 (#44) out of a total of 11 smokers who resided in the facility. Findings: Review of the facility's policy and procedure titled Smoking Policy-Residents failed to include e-cigarettes. On 11/01/2023 at 3:05 p.m., Resident #44 was observed sitting in his wheelchair, outside in the designated smoking area, smoking his personal e-cigarette. On 11/01/2023 at 3:09 p.m., an interview was conducted with S2DON (Director of Nursing) who stated she was unsure if the facility had a policy on e-cigarettes. On 11/01/2023 at 5:00 p.m., S1ADM (Administrator) confirmed the facility failed to include the use of e-cigarettes in the smoking policy.

Based on observations and interviews, the facility failed to provide a sanitary environment during a meal observation. This deficient practice was evident when the CNA (Certified Nurse Assistant) failed to perform appropriate hand hygiene while feeding residents. This deficient practice had the potential to affect the 10 residents who eat in the dining room that required assistance with feeding. Findings: On 10/30/2023 at 11:27 a.m. to 11:40 a.m., a meal observation was conducted. A hand sanitizer dispenser was noted on the wall next to the feeder table. S7CNA was observed at a feeder table in the dining room feeding four residents. During the observation, she cleaned one of the resident's mouth with his bib after he coughed then picked up a different resident's serving utensil without applying hand sanitizer. She was observed wiping another resident's mouth with his bib after the resident stated he was finished with his meal. Then she placed the resident's face mask on his face. She unlocked his wheelchair, grabbed the wheelchair handle, and pulled the resident's wheelchair away from the feeder table. 7CNA sat back down at the feeder table to resume feeding the other three resident without performing hand hygiene. S7CNA was stopped immediately. At 11:40 a.m., an interview was conducted with S7CNA who was asked if she should have used hand sanitizer between feeding residents; when she touched one of the resident's bib to wipe his mouth after he coughed; when she wiped the another resident's mouth and picked up his used mask to place on his face, placed his helmet on his head, then touched his wheel chair. She stated that she should have used hand sanitizer each time she needed to pick up a different resident's feeding utensil. S7CNA stated that she should have also used hand sanitized after she touched the resident's mask, his helmet, and wheelchair before she attempted to resume feeding the other residents at the table. S7CNA stated she did not have hand sanitizer in her pocket. She confirmed that there was a sanitizer dispenser mounted on the wall next to the feeder table where she was feeding the residents, but she did not get up to use it. S7CNA stated a bottle of hand sanitizer was placed on each feeder table, but they are just props because no one really used them like they supposed to. On 10/30/2023 at 12:22 p.m., an interview was conducted with S5CNASupervisor. She stated that bottles of hand sanitizers are handed out each morning. S5CNA Supervisor stated that she personally walked around the building each morning and handed out hand sanitizer to the CNA staff. She stated that if a CNA did not get a bottle of hand sanitizer when she give them out, it was that CNA's responsibility to come to her and let her know. She stated when a CNA is assigned to assist with feeding at a feeder table, which requires to feed multiple residents, the CNA should sanitizer her hands before she picks up a different resident's spoon and if they have to touch anything while feeding. 49176

Based on record review and interview, the facility failed to maintain a system of accounting of each resident's personal funds entrusted to the facility on the resident's behalf by failing to provide quarterly statements for 1 (# 2) of 1 resident investigated for personal funds. The facility was entrusted with personal funds for 75 residents. Findings: A review of the facility's policy titled Resident's Account, read in part: Residents shall have the right to the following options regarding their personal financial affairs. 1. They shall be allowed to manage their personal financial affairs or to designate someone to assume this responsibility for them .3. The resident or his/her legal representative shall have access through quarterly statements . Resident #2 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview of Mental Status) of 15, indicating that her cognition was intact. On 10/30/2023 at 09:38 a.m., an interview was conducted with Resident #2. The resident stated she had been living at the facility for [AGE] years and the facility kept her funds. She further stated that she had never received a statement of her account from the facility. On 10/31/2023 at 11:05 a.m., an interview was conducted with S5BOM (Business Office Manager). S5BOM stated the reason the resident doesn't receive a statement is because it is sent to her RP (Responsible Party). On 10/31/2023 at 11:22 a.m., a phone interview was conducted with Resident #2's RP. She stated that she had received account statements from the facility but hasn't received one since the pandemic two years ago. On 10/31/2023 at 11:36 a.m., a follow up interview was conducted with S5BOM. She confirmed that she had not sent a statement of account to Resident #2 or her RP in two years and should have. She also confirmed that she had not sent quarterly statements to any of the residents or their RPs in two years and should have.

Based on interviews and observations, the facility failed to maintain a homelike environment for 2 (#8 and #58) out of 4 (#8, #37, #43, and #58) residents investigated for a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 83. Findings: Review of the facility's policy, Safe and Homelike Environment revealed, in part, the following: Policy Statement: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes the resident independence and does not pose a safety risk . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Resident #58: Review of Resident #58's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Vascular Dementia, Cerebral Infarction, and Cognitive Social or Emotional Deficit. Review of Resident #58's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 indicating his cognition was severely impaired. Observation on 10/30/2023 at 11:06 a.m., revealed baseboards were missing from the wall and a hole noted in the wall where the baseboards were missing from Resident #58's room. A follow up observation on 10/31/2023 at 11:10 a.m., revealed baseboards were missing from the wall and a hole noted in the wall where the baseboards were missing from Resident #58's room. On 10/31/2023 at 3:30 p.m., an interview and observation was conducted with S9MaintSupervisor (Maintenance Supervisor). S9MaintSupervisor stated that his responsibility is to maintain the building for the facility and fix any issues for the residents. S9MaintSupervisor denied having a maintenance log. S9MaintSupervisor stated that nursing or administration staff will tell him verbally if something is wrong with the condition of resident's room. S9MaintSupervisor stated I pop my head into resident's rooms randomly to see if anything needs to be fixed. Observation of Resident #58's room conducted with S9MaintSupervisor who confirmed the baseboards missing from the wall and the hole in the wall needed to be repaired, and these issues did not provide a homelike environment for Resident #58. 47965 Resident #8: Resident # 8 was admitted to the facility on [DATE] with diagnoses in part: Functional Quadriplegia, Spastic Hemiplegia Affecting Right Dominant Side, Muscle Wasting and Atrophy, Hx (History of) of Traumatic Brain Injury, Lack of Coordination, and Stiffness of right knee. On 10/30/2023 at 10:10 a.m., an observation was conducted of Resident #8's room. The resident's door was closed. There was a strong smell of urine as the door was opened. The resident was in his bed. The floor was dirty, littered with cereal flakes, and was cluttered. A Styrofoam bowl and a paper cup were on the floor beside his bed. Two empty urinals were hanging on his trash can at his bedside. His over bed table was full of assorted items including cola bottles with water, straws, and Styrofoam bowls. The resident stated he could not remember the last time his room was cleaned. On 10/31/2023 at 9:23 a.m., an observation was conducted Resident #8's room. The resident's room door was closed. There is a strong smell of urine as the door was opened. The resident was in his bed. Two urinals, one full and the other half full were hanging on the resident's garbage can. The resident was asked how often the urinals are emptied and he stated if he barks loud enough someone will come in to empty them. A Styrofoam bowl and three paper cups were on the floor beside the resident's bed. The floor was littered with cereal flakes and the floor was dirty and cluttered. The resident's over bed table was cluttered with straws, three coke bottles with water, an empty frosted flake box, two styrofoam bowls and other items. His blanket had brown stains in multiple areas. Resident stated that it's been a long time since they changed his sheets. On 10/31/2023 at 9:48 a.m., an observation of Resident #8's room and interview were conducted with S8HSKPSup (Housekeeping Supervisor). S8HSKPSup confirmed that the resident's room was dirty and in an unacceptable condition. She stated that resident's rooms are supposed to be cleaned daily. On 10/31/2023 at 9:53 a.m., an interview was conducted with S10HSKP (Housekeeper) with S8HSKPSup present. S10HSKP confirmed that she did not clean the resident's room the previous day and should have.

Based on observation, interview, and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores for 1 (Resident #2) of 3 residents (#1, #2, #3) investigated for pressure ulcers out of five sampled residents (#1-#5). This deficient practice resulted in acutal harm when Resident #2 entered the facility on 8/25/15 with no pressure sores idenitied in between the resident's fingers on the initial nursing assessment and developed a Stage 3 pressure sore to the resident's right middle finger measuring 1.10 X 0.80 X 0.20 centimeters with a serosanguineous (bloody, serous fluid) drainage. The resident grimaced, moaned, reported pain, and directed staff to avoid his right hand fingers. This deficient practice had the potential to affect a total census of 79 residents reported by S10ADM on 9/12/16. Findings: Resident #2 was a [AGE] year old male with the following Diagnoses: [REDACTED]., and Pain. Record review of Resident #2's Quarterly 7/5/16 Braden Risk Assessment revealed the resident was at high risk for pressure ulcer development due to the following factors: Sensory Perception-Very limited-Responds only to painful stimuli-Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over half of body; Moisture-Skin is often, but not always, moist-Linens must be changed at least once a shift; Activity-Chair Fast-Ability to walk severely limited or non-existent-cannot bear weight and/or must be assisted into chair or wheelchair; Mobility-Makes occasional slight changes in body extremity position but unable to make frequent or significant changes independently; Friction and Shear-Problem-Requires moderate to maximum assistance in moving-Complete lifting without sliding against sheets is impossible-Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance-[DIAGNOSES REDACTED], contractures or agitation lead to almost constant friction. Record review of Skin Inspection Reports dated 8/2/16, 8/9/16, 8/16/16, 8/23/16, 8/30/16, 9/6/16 and 9/13/16 revealed staff LPN's (Licensed Practical Nurses) performed skin assessments on Resident #2 and documented on each report that the resident's skin was intact. Record review of Wound Assessment Reports from 12/2015 through 6/2016 revealed Resident #2 had pressure ulcers. The last of these pressure ulcers resolved on 7/7/16. These wound assessment reports did not indicate the resident had a Stage 3 pressure ulcer to his right middle finger. Further record review revealed that from 7/7/16 to 9/11/16 there was no wound assessment report documentation. Record review of a Wound Assessment Report dated 9/12/16 revealed Resident #2 had a Stage 3 pressure ulcer to his right middle finger. The report indicated that the pressure ulcer was a new wound and was identified on 9/11/16. Review of Resident #2's record revealed the resident had physical exams performed by S16FNP's on the following dates: 12/17/15, 1/12/16, 1/28/16, 2/4/16, 2/11/16, 3/24/16, 3/29/16, 4/5/16, 5/12/16, 5/19/16, 6/7/16, 6/14/16, 6/23/16, 6/30/16, 7/7/16, 7/12/16, 7/14/16, 7/19/16, 7/26/16, 8/25/16, and 9/1/16. S16FNP documented on each of these physical exams that the resident's skin was warm and dry, and her documentation did not reveal the resident had a Stage 3 pressure ulcer to his right middle finger. Record review of Resident #2's nurse's notes from 7/8/16 through 7/31/16 revealed the nurses' skin assessments indicated the resident had no skin issues. Record review of Resident #2's August and September 2016 nurse's notes revealed: 8/7/16 Assessment complete no new skin issues noted @ this time . 8/8/16 No new skin issues notes at this time . 8/12/16 Assessment complete no new skin issues noted . 8/14/16 No new skin issues noted . 8/15/16 No new skin issues noted . 8/17/16 .No new skin issues noted . 8/18/16 Assessment complete no new skin issues noted . 8/19/16 .No new skin issues 8/23/16 .No new skin issues noted . 8/24/16 .Assessment done no new skin issues noted . 8/25/16 .Assessment done no new skin issues noted at this time . 8/26/16 Skin assessment complete no skin issues noted . 8/27/16 Assessment done no new skin issues noted . 8/28/16 No new skin issues noted . 8/29/16 Assessment complete no new skin issues noted . 8/30/16 .No new skin issues . 9/2/16 .No new skin issues 9/6/16 No new skin issues noted at this time . 9/7/16 .Skin assessment done no new issues noted . 9/8/16 No new skin issues . 9/9/16 No new skin issues . 9/10/16 at 3:07 PM Skin assessment done no new skin issues . Signed by: S18LPN. 9/11/16 at 2:01 PM Daughter present c/o (complaints of) right hand middle finger swollen. Finger noted swollen and red. Resident fingers contracted. When hand moved open area noted by this nurse. RN (Registered Nurse) assessed Stage 3 pressure ulcer noted. VPO (Verbal phone order) noted per ____ (resident's physician) (1) pressure ulcer to right hand middle finger, clean with wound cleaner, pat dry, apply Mesalt, cover with bordered foam. Change daily and prn (as needed). RP (responsible party) present and aware. Signed by: S7LPN 9/12/16 at 8:30 AM Assessed right hand middle finger, Stage 3 pressure ulceration noticed in hand, hand moist, cleaned, dried and dressed wound, see wound assessment manager for details. Signed by: S1DON. Record review of a Wound Assessment Report dated 9/12/16 revealed that on 9/11/16 a Stage 3 pressure ulcer to the resident's right middle finger was identified. The pressure ulcer measured 1.10 X 0.80 X 0.20 centimeters with serosanguineous (containing both blood and serous fluid) drainage. An observation was made of Resident #2 on 9/13/16 at 2:40 PM. The resident was noted to have contractures to his 2nd through 5th right hand fingers. The resident's right middle finger was observed to be beefy red and swollen. A pressure ulcer was noted to the lateral aspect of his right middle finger just distal to the second joint. An observation was conducted on 9/13/16 at 2:40 PM while S20LPN/Tx Nurse performed treatment to Resident #2's right middle finger. Before and during the observation of the pressure ulcer treatment, the resident was noted with facial grimacing, flinching, moaning and repeatedly stating, Stop. My fingers are all messed up. Don't touch my fingers. Leave them. Ouch. They have problems. During an interview on 9/13/16 at 2:12 PM with S18LPN, she stated she had been caring for the resident since he was admitted to the facility. She stated that she performed ongoing skin assessments on the resident, which included an assessment of the resident's hands. She confirmed that her documentation revealed Resident #2 had no skin issues for the past several months, including her last skin assessment of the resident on 9/10/16. She confirmed that she should have noted skin breakdown to the Resident's right middle finger before a Stage 3 pressure ulcer was discovered by Resident #2's daughter on 9/11/16. During an interview on 9/13/16 at 1:05 PM S1DON, she stated that the nurses should have known to pay close attention to the resident's hands for skin breakdown because of the resident's right hand contractures. She stated that the resident's contractures put the resident at an increased risk for skin breakdown because the fixed fingers held moisture in between them. She confirmed that since the nurses performed daily skin assessments, the nurses should have noted skin breakdown to his right middle finger before a Stage 3 pressure ulcer developed. S1DON confirmed that the nurses did not accurately assess Resident #2's skin to prevent the development of a Stage 3 pressure ulcer. She stated that the contracture was increased risk for skin breakdown due to fixed finger holding moisture.

Based on record review and interview, the facility failed to ensure that each resident was provided the necessary care and services to attain or maintain the highest practicable physical well being by failing to assess and identify an infected wound for a resident that is a diabetic and has a history of ulcers, osteo[DIAGNOSES REDACTED], and amputations of toes to her feet. By failing to conduct skin assessments and identify an infected wound, this delayed the resident receiving treatment which resulted in resident #5 being hospitalized for [REDACTED]. Resident #5 was admitted to the hospital on [DATE] and currently remains hospitalized for [REDACTED].#2, #3, #4, #5) out of a total sample of 9 residents (#6, #7,#8,#9). Findings: 1. Resident #5. Review of resident #5's clinical record revealed that the resident had [DIAGNOSES REDACTED]. Review of resident #5's Braden Scale For Predicting Pressure Sore Risk form dated 8/7/12 revealed that the resident was assessed to be a moderate risk for developing a pressure sore. Review of resident #5's care plan dated 8/1/12 and updated to 10/25/12 revealed that the nursing staff was to report any red or open areas, that the nursing assistants were to assess right and left foot for signs and symptoms of ulcers, and that the licensed nursing staff were to conduct weekly skin checks to feet. Review of resident #5's Weekly Skin Assessment Form for October 2012 revealed that the last documented weekly skin assessment conducted by the nurse was on 10/19/12. Further review of the Weekly Skin Assessment Form for October 2012 revealed that there was documentation that the skin assessments were being documented twice a week. There was no documentation that there were any problems noted with the resident's feet. There was no other documentation noted that there was a skin assessment conducted by the nurse after 10/19/12 in the resident's clinical records. Review of resident #5's nurses' notes dated 10/19/12 at 0900 revealed, "Noted order c regards to Res eye & H. [MEDICATION NAME] flare up................" There was no other documenation noted in the nurses' notes until 10/23/12. Review of resident #5's physician's office visit note dated 10/23/12 revealed, "Pt seen in office in w/c c family member. (1) c/o pt sleeping a lot (2) eyes draining (3) Lt foot red ... ... ...EX: Lt foot [DIAGNOSES REDACTED] 2nd toe ... ... 3rd toe c ulcer dorsally ... ....Foot-[MEDICAL CONDITION], ulcer" Review of resident #5's physician's progress notes dated 10/23/12 revealed, " ... .....(6)Bring pt to Dr. _____ office for 3:00 pm appt. I called and made appt." Review of resident #5's nurses' notes dated 10/23/12 at 1200 revealed, "Returned from appt............. c the following orders ... ... .... (6) Bring pt to Dr. ______ office this pm for 3 pm appt was called and made by MD." Review of resident #5's nurses' notes dated 10/23/12 at 1340 revealed, "(L) foot middle toe assessed per (S2DON). Measurements noted. 0.3 x 1.0 cm depth of 0.2 ... ...Res is to consult c (Dr.) @ 3pm." Review of resident #5's consulting physician's progress notes dated 10/23/12 revealed, Pt c [DIAGNOSES REDACTED], ... .... (L) FOOT c ulcer (L) toe >/ osteo Admit" Review of resident #5's physician's observations and orders form dated 10/23/12 revealed, "Admit pt (hospital)" Review of resident #5's nurses' notes dated 10/24/12 at 0100 revealed, "Noted @ this time Resident left nursing home at 1435 to go to appt. c Dr. _____ on 10/23/12. Dr. ____ admitted pt to (hospital) on 10/23/12 ... ..." Review of resident #5's (nursing home) physician's contact form dated 10/24/12 revealed, "FYI: Res admit to (hospital) c regards to (L) foot ulcer infection." There was no documentation noted in resident #5's clinical records that the nursing home staff had assessed or identified that the resident had any skin problems with her feet prior to being seen by her physician. The physician assessed and identified that the resident had an ulcer on her left foot. Review of resident #5's hospital physician's orders [REDACTED]. Review of resident #5's Hospital History and Physical note dated 10/23/12 revealed, "Chief Complaint: Painful left foot. History of Present Illness: An [AGE] year-old white female well known to me with a long history of deformities in her feet and multiple decubitus ulcers. She had osteo[DIAGNOSES REDACTED] on her feet before with previous toe amputations. She now presents with marked [DIAGNOSES REDACTED], pain, and [MEDICAL CONDITION], left foot, with an ulcer on the dorsal aspect of the left fourth toe, which appears to have some bone in the base of this ulcer. It looks like she has some [MEDICAL CONDITION] with some osteo[DIAGNOSES REDACTED] ... ... .....Extremities: She has a viable left foot and right foot, but the left foot has marked [DIAGNOSES REDACTED] and [MEDICAL CONDITION] on the entire surface of the foot and on the fourth toe, she has about a 1 centimeter purulent foul ulcer with what appears to be some bone in the base of this ulcer of the left fourth toe. IMPRESSION: [MEDICAL CONDITION], left foot, with possible osteo[DIAGNOSES REDACTED], left fourth toe. PLAN: IV antibiotics, local care, and may come to amputation of this toe." Review of resident #5's Hospital Consultation note dated 10/24/12 revealed, "Chief Complaint: Left foot pain. History of Present Illness: An [AGE] year-old Caucasian female from nursing home presented as a direct admit to Dr. _____ for left foot pain. The patient is nonverbal and very difficult to arouse during examination, so the information taken in this history and physical obtained from both Dr. ______'s notes and nursing charting records. According to them, the patient is an [AGE] year-old Caucasian female who has a history of osteo[DIAGNOSES REDACTED] to her left foot which required previous toe amputation. She presented as a direct admit for [DIAGNOSES REDACTED], pain and [MEDICAL CONDITION] to the left foot with ulceration on the dorsal aspect of the left fourth toe. On examination ulceration shows what appears to be evidence of bone showing through................ She does show evidence of [MEDICAL CONDITION]. ... ... ... ... ....Skin: Shows multiple contusions to the extremities........... The patient has 3 toes missing on her left foot, 1 toe missing on the right foot. She also shows an ulceration to the fourth digit on her left foot, which appears to have some protusion in the bones ulceration also have a foul odor as well as purulent discharge. IMPRESSION AND PLAN: ... ... ... ...1. Left foot [MEDICAL CONDITION] with possible osteo[DIAGNOSES REDACTED] of left fourth metatarsal patient was originally placed on IV antibiotics [MEDICATION NAME]. However, we are going to discontinue this and instead she tried the antibioctics of [MEDICATION NAME] and [MEDICATION NAME]. Blood cultures x2 have been ordered. The patient is also on IV fluids of [MEDICATION NAME]. Wound cultures are also currently pending, and laboratories have been ordered for the morning ... ... ..." Review of resident #5's Patient Transfer Form from the hospital dated 10/24/12 revealed that the resident's diagnois was [MEDICAL CONDITION] left foot with ulcer. Also, the form revealed that the resident was being transferred because the services that the resident needed were not available at the current hospital. Review of resident #5's Client Incident Report dated 10/23/12 revealed, "Description: On the morning of Tuesday, October 23, at approximately 9:30 am, (resident #5) had a doctor visit with Dr. ______. At that visit, a wound to her L foot was found, which no one knew about, neither her family, the nursing home nor the physician. When resident returned to the facility, (S2DON) and I, (S1administrator), looked at her foot. (S2DON) stated that it appeared to be a diabetic ulcer that had gotten infected. We started the investigation, which at the time looked like an oversight. During the course of the investigation, it became apparent that this was indeed an issue of neglect by the staff, so the OTIS report was opened. Summary: The allegation of neglect is substantiated............... (Resident #5's) foot was looked at during a skin assessment on October 19th on the 7p-7a shift _____LPN on duty. She had a whirlpool on Saturday morning and staff states nothing wrong with the foot at the time. On Saturday the 20th, (S3LPN) on the 7a-7p, saw her foot during the morning med pass. She had her socks off, so (S3LPN) put them back on. From that time on Saturday morning, none of the staff is acknowledging seeing her foot or seeing anything wrong with the foot. Yet from that time on, either the foot may have been injured (resident #5 was prone to removing her socks and slippers and dragging her feet, even rolling over them with her chair.) At the time the doctor saw the foot, it was severely infected and no one can state how this happened. It was a diabetic ulcer that had become infected. (Resident #5) was on skin assessments twice weekly. A skin assessment was not performed on Monday, Oct. 22nd by the nurse on duty, (S4LPN)................ This would not have prevented the injury, but at least we would have had foreknowledge of the injury and could have had the foot tended too sooner......................." Review of the facility's Counseling Statement Form for S5CNA dated 10/25/12 revealed that when the CNA(certified nursing assistant) was whirlpooling the resident that the CNA noted redness to resident's left foot and did not report it to the LPN (licensed practical nurse). Review of the facility's Counseling Statement Form for S4LPN dated 10/25/12 revealed that the LPN did not do the skin assessment as scheduled for the resident. Further review of the form revealed that the resident was a diabetic and due to the skin check not being done, the resident proceeded to go to doctor's appt and the doctor noted redness to foot and then sent resident to the surgeon who directly admitted the resident to the hospital. On 11/20/12 at 9:15 am, S2DON(director of nurses) stated that it was unknown how resident #5 developed an ulcer to her left foot. S2DON stated that an investigation was conducted and that an OTIS report was done concerning the ulcer on resident #5's left foot. S2DON stated that the administrator had all the information regarding the investigation concerning the ulcer. On 11/20/12 at 10:10 am, S1Administrator stated that the facility came to conclusion that neglect occurred as a result of resident #5 developing an ulcer to her left foot. S1administrator stated that it was neglect because the nurse, S4LPN (licensed practical nurse) had not done the resident's skin assessment as scheduled on 10/20/12. Also, S1administrator stated that S5CNA (certified nursing assistant) had admitted to noticing the redness and swelling to resident #5's left foot when the resident was being whirpooled, but she did not report what she saw to the nurse because she thought that it was nothing new for the resident so she did not report it. Also, S1administrator stated that she did not believe that S6CNA had actually taken off the resident's socks and looked at her feet to notice if there was anything wrong with her feet. S1administrator stated that if the skin assessment was conducted as scheduled and if the changes in the resident's foot was reported then treatments to the resident's left foot could have been started sooner.

Based on record review and interview, the facility failed to assess and identify an infected wound for a resident that is a diabetic and has a history of ulcers, osteo[DIAGNOSES REDACTED], and amputations of toes to her feet. By failing to conduct skin assessments and identify an infected wound, this resulted in resident #5 being hospitalized for [REDACTED]. Resident #5 was admitted to the hospital on [DATE] and currently remains hospitalized . This effects 1 out of 5 sampled residents with ulcers (#1, #2, #3, #4, #5) out of a total sample of 9 residents (#6, #7,#8,#9). Findings: 1. Resident #5. Review of resident #5's clinical record revealed that the resident had [DIAGNOSES REDACTED]. Review of resident #5's Braden Scale For Predicting Pressure Sore Risk form dated 8/7/12 revealed that the resident was assessed to be a moderate risk for developing a pressure sore. Review of resident #5's care plan dated 8/1/12 and updated to 10/25/12 revealed that the nursing staff was to report any red or open areas, that the nursing assistants were to assess right and left foot for signs and symptoms of ulcers, and that the licensed nursing staff were to conduct weekly skin checks to feet. Review of resident #5's Weekly Skin Assessment Form for October 2012 revealed that the last documented weekly skin assessment conducted by the nurse was on 10/19/12. Further review of the Weekly Skin Assessment Form for October 2012 revealed documentation that skin assessments were being done twice a week. There was no documentation that there were any problems noted with the resident's feet. There was no other documentation noted that there was a skin assessment conducted by the nurse after 10/19/12 in the resident's clinical records. Review of resident #5's nurses' notes dated 10/19/12 at 0900 revealed, "Noted order c regards to Res eye & H. [MEDICATION NAME] flare up................" There was no other documenation noted in the nurses' notes until 10/23/12. Review of resident #5's physician's office visit note dated 10/23/12 revealed, "Pt seen in office in w/c c family member. (1) c/o pt sleeping a lot (2) eyes draining (3) Lt foot red ... ... ...EX: Lt foot [DIAGNOSES REDACTED] 2nd toe ... ... 3rd toe c ulcer dorsally ... ....Foot-[MEDICAL CONDITION], ulcer" Review of resident #5's physician's progress notes dated 10/23/12 revealed, " ... .....(6)Bring pt to Dr. _____ office for 3:00 pm appt. I called and made appt." Review of resident #5's nurses' notes dated 10/23/12 at 1200 revealed, "Returned from appt............. c the following orders ... ... .... (6) Bring pt to Dr. ______ office this pm for 3 pm appt was called and made by MD." Review of resident #5's nurses' notes dated 10/23/12 at 1340 revealed, "(L) foot middle toe assessed per (S2DON). Measurements noted. 0.3 x 1.0 cm depth of 0.2 ... ...Res is to consult c (Dr.) @ 3pm." Review of resident #5's consulting physician's progress notes dated 10/23/12 revealed, Pt c [DIAGNOSES REDACTED], ... .... (L) FOOT c ulcer (L) toe >/ osteo Admit" Review of resident #5's physician's observations and orders form dated 10/23/12 revealed, "Admit pt (hospital)" Review of resident #5's nurses' notes dated 10/24/12 at 0100 revealed, "Noted @ this time Resident left nursing home at 1435 to go to appt. c Dr. _____ on 10/23/12. Dr. ____ admitted pt to (hospital) on 10/23/12 ... ..." Review of resident #5's (nursing home) physician's contact form dated 10/24/12 revealed, "FYI: Res admit to (hospital) c regards to (L) foot ulcer infection." There was no documentation noted in resident #5's clinical records that the nursing home staff had assessed or identified that the resident had any skin problems with her feet prior to being seen by her physician. The physician assessed and identified that the resident had an ulcer on her left foot. Review of resident #5's hospital physician's orders [REDACTED]. Review of resident #5's Hospital History and Physical note dated 10/23/12 revealed, "Chief Complaint: Painful left foot. History of Present Illness: An [AGE] year-old white female well known to me with a long history of deformities in her feet and multiple decubitus ulcers. She had osteo[DIAGNOSES REDACTED] on her feet before with previous toe amputations. She now presents with marked [DIAGNOSES REDACTED], pain, and [MEDICAL CONDITION], left foot, with an ulcer on the dorsal aspect of the left fourth toe, which appears to have some bone in the base of this ulcer. It looks like she has some [MEDICAL CONDITION] with some osteo[DIAGNOSES REDACTED] ... ... .....Extremities: She has a viable left foot and right foot, but the left foot has marked [DIAGNOSES REDACTED] and [MEDICAL CONDITION] on the entire surface of the foot and on the fourth toe, she has about a 1 centimeter purulent foul ulcer with what appears to be some bone in the base of this ulcer of the left fourth toe. IMPRESSION: [MEDICAL CONDITION], left foot, with possible osteo[DIAGNOSES REDACTED], left fourth toe. PLAN: IV antibiotics, local care, and may come to amputation of this toe." Review of resident #5's Hospital Consultation note dated 10/24/12 revealed, "Chief Complaint: Left foot pain. History of Present Illness: An [AGE] year-old Caucasian female from nursing home presented as a direct admit to Dr. _____ for left foot pain. The patient is nonverbal and very difficult to arouse during examination, so the information taken in this history and physical obtained from both Dr. ______'s notes and nursing charting records. According to them, the patient is an [AGE] year-old Caucasian female who has a history of osteo[DIAGNOSES REDACTED] to her left foot which required previous toe amputation. She presented as a direct admit for [DIAGNOSES REDACTED], pain and [MEDICAL CONDITION] to the left foot with ulceration on the dorsal aspect of the left fourth toe. On examination ulceration shows what appears to be evidence of bone showing through................ She does show evidence of [MEDICAL CONDITION]. ... ... ... ... ....Skin: Shows multiple contusions to the extremities........... The patient has 3 toes missing on her left foot, 1 toe missing on the right foot. She also shows an ulceration to the fourth digit on her left foot, which appears to have some protusion in the bones ulceration also have a foul odor as well as purulent discharge. IMPRESSION AND PLAN: ... ... ... ...1. Left foot [MEDICAL CONDITION] with possible osteo[DIAGNOSES REDACTED] of left fourth metatarsal patient was originally placed on IV antibiotics [MEDICATION NAME]. However, we are going to discontinue this and instead she tried the antibioctics of [MEDICATION NAME] and [MEDICATION NAME]. Blood cultures x2 have been ordered. The patient is also on IV fluids of [MEDICATION NAME]. Wound cultures are also currently pending, and laboratories have been ordered for the morning ... ... ..." Review of resident #5's Patient Transfer Form from the hospital dated 10/24/12 revealed that the resident's diagnois was [MEDICAL CONDITION] left foot with ulcer. Also, the form revealed that the resident was being transferred because the services that the resident needed were not available at the current hospital. Review of resident #5's Client Incident Report dated 10/23/12 revealed, "Description: On the morning of Tuesday, October 23, at approximately 9:30 am, (resident #5) had a doctor visit with Dr. ______. At that visit, a wound to her L foot was found, which no one knew about, neither her family, the nursing home nor the physician. When resident returned to the facility, (S2DON) and I, (S1administrator), looked at her foot. (S2DON) stated that it appeared to be a diabetic ulcer that had gotten infected. We started the investigation, which at the time looked like an oversight. During the course of the investigation, it became apparent that this was indeed an issue of neglect by the staff, so the OTIS report was opened. Summary: The allegation of neglect is substantiated............... (Resident #5's) foot was looked at during a skin assessment on October 19th on the 7p-7a shift _____LPN on duty. She had a whirlpool on Saturday morning and staff states nothing wrong with the foot at the time. On Saturday the 20th, (S3LPN) on the 7a-7p, saw her foot during the morning med pass. She had her socks off, so (S3LPN) put them back on. From that time on Saturday morning, none of the staff is acknowledging seeing her foot or seeing anything wrong with the foot. Yet from that time on, either the foot may have been injured (resident #5 was prone to removing her socks and slippers and dragging her feet, even rolling over them with her chair.) At the time the doctor saw the foot, it was severely infected and no one can state how this happened. It was a diabetic ulcer that had become infected. (Resident #5) was on skin assessments twice weekly. A skin assessment was not performed on Monday, Oct. 22nd by the nurse on duty, (S4LPN)................ This would not have prevented the injury, but at least we would have had foreknowledge of the injury and could have had the foot tended to sooner......................." Review of the facility's Counseling Statement Form for S5CNA dated 10/25/12 revealed that when the CNA(certified nursing assistant) was whirlpooling the resident that the CNA noted redness to resident's left foot and did not report it to the LPN (licensed practical nurse). Review of the facility's Counseling Statement Form for S4LPN dated 10/25/12 revealed that the LPN did not do the skin assessment as scheduled for the resident. Further review of the form revealed that the resident was a diabetic and due to the skin check not being done, the resident proceeded to go to doctor's appt and the doctor noted redness to foot and then sent resident to the surgeon who directly admitted the resident to the hospital. On 11/20/12 at 9:15 am, S2DON(director of nurses) stated that it was unknown how resident #5 developed an ulcer to her left foot. S2DON stated that an investigation was conducted and that an OTIS report was done concerning the ulcer on resident #5's left foot. S2DON stated that the administrator had all the information regarding the investigation concerning the ulcer. On 11/20/12 at 10:10 am, S1Administrator stated that the facility came to conclusion that neglect occurred as a result of resident #5 developing an ulcer to her left foot. S1administrator stated that it was neglect because the nurse, S4LPN (licensed practical nurse) had not done the resident's skin assessment as scheduled on 10/22/12. Also, S1administrator stated that S5CNA (certified nursing assistant) had admitted to noticing the redness and swelling to resident #5's left foot when the resident was being whirpooled, but she did not report what she saw to the nurse because she thought that it was nothing new for the resident so she did not report it. Also, S1administrator stated that she did not believe that S6CNA had actually taken off the resident's socks and looked at her feet to notice if there was anything wrong with her feet. S1administrator stated that if the skin assessment was conducted as scheduled and if the changes in the resident's foot was reported then treatments to the resident's left foot could have been started sooner.