Every finding on record at Ormond Nursing and Care Center

Based on observation, interviews, and record reviews, the facility failed to ensure a resident with an increased risk for multidrug-resistant organisms (MDRO's) had Enhanced Barrier Precautions (EBP) implemented for 1(Resident #8) of 2 residents observed for wound care.Review of the facility's EBP policy and procedure, dated 01/2023 and revised 03/2024 revealed, in part, EBP are an infection control intervention designed to reduce transmission of MDRO's in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents at increased risk of MDRO acquisition (e.g., residents with wounds). EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposure. EBP focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDRO's to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Review of Resident #8's medical record revealed, in part, Resident #8 had a diagnosis of a stage 4 pressure ulcer to the left heel. Review of Resident #8's July 2026 physician orders revealed, in part, cleanse Resident #8's left heel stage 4 pressure ulcer with normal saline, pat dry, apply collagen to wound bed, and cover with a Mediplex dressing three times per week and prn (as needed) every day shift every Monday, Wednesday, and Friday until resolved related to pressure induced deep tissue damage to the left heel. Observation on 07/21/2026 10:39AM revealed S7Treatment Nurse performed wound care to Resident #8's left heel stage 4 pressure ulcer without wearing a gown. Further observation revealed there was no signage on or near Resident #8's room door indicating she required EBP. In an interview on 07/21/2026 at 1:41PM, S7Treatment Nurse indicated she did not wear a gown when she performed Resident #8's wound care because EBP were not implemented for Resident #8. In an interview on 07/21/2026 at 1:58PM, S6Infection Control Nurse confirmed that EBP had not been implemented for Resident #8 and should have been for Resident #8's left heel pressure ulcer. In an interview on 07/21/2026 at 1:59PM, S2Director of Nursing confirmed that EBP had not been implemented for Resident #8 and should have been as required.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident that had a risk of aspiration was supervised during meals for 1(Resident #31) of 1 sampled residents investigated for accidents hazards. Findings:Review of Resident #31's clinical record revealed, in part, Resident #31 was admitted to the facility on [DATE]. Further review revealed Resident #31's diagnoses included, myasthenia gravis (chronic autoimmune disease that causes weakness in the muscles you control voluntarily) generalized muscle weakness, gait impairment (difficulty walking), reduce mobility, and cognitive communication deficit (inability to focus, remember, organize thoughts, or follow conversations). Review of Resident #31's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2026 revealed, in part, Resident #31 had a Brief Interview for Mental Status (BIMS) of 11, which indicated he was moderately impaired but is able to express wants and understands clearly. Further review revealed Resident #31 required supervision or assistance during eating, and was dependent upon staff for chair/bed transfers. Review of Resident #31's speech therapy treatment plan dated 06/08/2026 revealed, in part, Resident #31's treatment diagnoses included, aphasia (neurological language disorder that impairs a person's ability to communicate); and dysphagia (difficulty swallowing). Review of Resident #31's physician orders dated 06/08/2026 revealed, in part, an order for speech therapy to evaluate and treat Resident #31 three times per week for dysphagia. In an interview on 07/20/2026 at 8:20AM, Resident #31 indicated he should be placed upright in a chair for every meal to keep him from choking. Observation on 07/20/2026 at 8:22AM revealed Resident #31 was sitting in bed eating breakfast, unsupervised by staff. Further observation revealed signage posted above Resident #31's bed indicated Resident #31 was to be in a chair for meals due to the risk of aspiration. In an interview on 07/21/2026 at 8:33AM, S10Certified Nursing Assistance (CNA) indicated staff is required to assist Resident #31 out of bed, into a chair for meals. S10CNA further indicated Resident #31 was not out of bed for breakfast and should have been. In an interview on 07/21/2026 at 8:36AM, S9Licensed Practical Nurse (LPN) indicated she was unaware of whether staff was required to assist Resident #31 to a chair in an upright position for all meals. S9LPN then indicated after she reviewed Resident #31's medical records and observed the signage posted on Resident #31's wall. S9LPN acknowledged Resident #31 was at risk for aspiration, and staff should have assisted him to an upright position in a chair for meals. In an interview on 07/21/2026 at 8:40AM, Resident #31 indicated he should be placed upright in a chair for every meal but no one ever gets him up for breakfast. Observation on 07/21/2026 at 8:45AM revealed Resident #31 was coughing while eating breakfast in bed, and there was no staff supervision. In an interview on 07/21/2026 at 9:09AM, S4Speech Therapist (ST) indicated signage was posted by the therapy department to inform staff that during Resident #31's meals he required supervision from staff and he should be assisted to an upright position in a chair. In an interview on 07/21/2026 at 2:09PM, S2Director of Nursing (DON) indicated she was unaware of the above mentioned requirements for Resident #31's meals by speech therapy. S2DON further indicated Resident #31 should have been receiving meals in the dining room under staff supervision. In an interview on 07/21/2026 at 2:10PM, S3Assistant Director of Nursing (ADON) indicated she was unaware of the above mentioned requirements for Resident #31's meals by speech therapy. S3ADON further indicated Resident #31 should have been receiving meals in the dining room under staff supervision. In an interview on 07/22/2026 at 1:20PM, S8Corporate Nurse indicated she was unaware of the above mentioned requirements for Resident #31's meals by speech therapy. S8Corporate Nurse confirmed Resident #31 should have been receiving meals in the dining room under staff supervision.

Based on interviews and record reviews, the facility failed to ensure a care plan was developed for a resident with exit seeking behaviors to decrease the risk of elopement (an individual who was incapable of adequately protecting themselves who left a health care facility undetected and unsupervised) for 1 (Resident #12) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, and Resident #90) sampled residents reviewed for accidents hazards.Findings: Review of the facility's Care Plan Process policy and procedure, dated 06/2015 and revised on 12/2024, revealed, in part, the care plan was driven by a resident's unique needs. Further review revealed a well-developed and executed care plan would provide information regarding how the causes and risks associated with issues and/or conditions were addressed to provide for a resident's highest practicable level of well-being. Further review revealed the facility would re-evaluate the resident's status annually and then modify the individualized care plan as appropriate and necessary. Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/06/2025 revealed, in part, Resident #12 had a Brief Interview of Mental Status score of 10 which indicated Resident #12 had moderate cognitive impairment. Further review revealed Resident #12 had a diagnosis of dementia and used a security bracelet/elopement alarm. Review of Resident #12's Nursing Data Collection and Screening dated 05/06/2025 revealed, in part, Resident #12 was at risk for elopement and a security bracelet/elopement alarm was in place. In an interview on 07/23/2025 at 2:12PM, S5Licensed Practical Nurse indicated Resident #12 was at risk for elopement and had a history of asking for his truck keys so he could leave the facility. In an interview on 07/23/2025 at 2:23PM, S6Certified Nursing Assistant indicated Resident #12 would ask for his keys to go home once or twice a week, and would ask which door he could get out of. Review of Resident #12's Care Plan revealed no evidence, and the facility did not present any evidence a care plan was developed to include measurable objectives and timeframes when Resident #12's security bracelet/elopement alarm was initiated on 10/08/2024 and/or when it was documented on his Annual MDS dated [DATE]. In an interview on 07/23/2025 at 2:33PM, S4Registered Nurse indicated Resident #12 was at risk for elopement and he did not have a care plan developed that addressed Resident #12's risk for elopement implemented into his care plan until today (07/23/2025). In an interview on 07/23/2025 at 2:53PM, S2Director of Nursing confirmed Resident #12 was at risk for elopement and a care plan was not developed to address this risk until today (07/23/2025), and should have been developed when the risk for elopement was initially identified.

Based on observation, interviews, and record reviews, the facility failed to ensure residents did not have cigarette lighters in their possession per facility policy for 1 (Resident #90) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, Resident #90) sampled residents investigated for accident hazards.Findings:Review of the facility's Smoking Policy and regulations, dated 04/2006 and revised on 10/2024, revealed, in part, cigarette lighters and matches were not permitted in a resident's room and would be kept at the nursing station. Visitors were not permitted to smoke in the facility, nor were they permitted to give or leave matches or lighters with any resident.Review of Resident #90's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/2025 revealed, in part, Resident #90 was a current tobacco user. Review of Resident #90's Care Plan initiated on 05/28/2025, with a goal date of 09/05/2025, revealed, in part, residents smoking supplies were stored per the facility policy. Observation on 07/22/2025 at 10:12AM, of the smoker's patio, revealed Resident #90 removed a lighter from his front left pants pocket and lit a cigarette.In an interview on 07/22/2025 at 12:20PM, S3Licensed Practical Nurse (LPN) indicated she was not aware Resident #90 had a cigarette lighter. In an interview on 07/22/2025 at 1:00PM, S9Regional Administrator confirmed residents should not have cigarette lighters in their possession.

Based on Interviews and record reviews the facility failed to administer a medication as ordered for 1 (Resident#1) of 3 (Resident#1, Resident#2, Resident #3) sampled residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #1's medical record revealed, in part, an admission date of 11/18/2024. Further review revealed Resident #1 had the following diagnoses, in part, chronic obstructive pulmonary disease (COPD) gastric esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #1's physician orders revealed, in part, an order dated 01/31/2025 for Ondansetron 4 milligrams (mg) by mouth p.o. every 6 hours for 3 days. In an interview on 05/22/2025 at 10:00 a.m., S1 Director of Nursing (DON) and S2 Assistant Director of Nursing (ADON) both acknowledged Resident #1 did not receive Ondansetron as ordered by her physician, and she should have.

Based on record review and interview the facility failed to ensure a resident and the resident's representative was issued a written notice of discharge prior to discharging a resident. This deficient practice was identified for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for discharge requirements. Findings: Review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE]. Further review revealed Resident #1 was discharged from the facility on 05/27/2024 because Resident #1's representative was unable to make the bed hold payments. In an interview on 07/31/2024 at 10:30 a.m., S2Assistant Director of Nursing (ADON) indicated the cost of the facility's bed hold price and amount was given and explained at length to Resident #1's representative. S2ADON further indicated Resident #1's representative knew the cost to hold Resident #1's bed, and Resident #1's representative did not make payments to the facility. There was no documented evidence and the facility did not present any documented evidence that Resident #1 and/or Resident #1's representative was issued a written notice of discharge prior to discharging Resident #1. In an interview on 07/31/2024 at 10:35 a.m., S1Administrator offered no explanation as to why Resident #1 and/or Resident #1's representative was not issued a written notice of discharge prior to Resident #1's 05/27/2024's discharge as required.

Based on record review and interviews, the facility failed to ensure a resident with a mental illness had an accurate PASARR (Preadmission Screening and Resident Review) for 1 (Resident #67) of 2 (Resident #17, Resident #67) residents reviewed for PASARR. Findings: Review of Resident #67's Medical Record review revealed, in part, Resident #67 was admitted to the facility on [DATE] with a diagnosis of PTSD (Post-Traumatic Stress Disorder). Review of Resident #67's Quarterly MDS (Minimum Data Set) dated 05/30/2024 revealed, in part, Resident #67 had a diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of Resident #67's Level I PASARR dated 10/07/2020 revealed, in part, Resident #67's diagnosis of PTSD was not selected on Section III as a mental illness. In an interview on 07/17/2024 at 10:03 a.m., S3Social Service Director indicated Resident #67 did not have a Level II PASARR, and the facility could not produce any documented evidence that a Level II PASARR for a diagnosis of PTSD was completed and submitted to the required agency for resident review. In an interview on 07/17/2024 at 10:007 a.m., S2Assistant Director of Nursing (ADON) indicated a Level II PASARR was not completed, and the facility could not produce any documented evidence that a Level II PASARR for a diagnosis of PTSD was completed and submitted to OBH for resident review.

Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 2 (Resident #22 and Resident #97) of 20 (Resident #2, Resident #13, Resident #16, Resident #17, Resident #22, Resident #25, Resident #26, Resident #39, Resident #44, Resident #61, Resident #64, Resident #67, Resident #69, Resident #70, Resident #79, Resident #77, Resident #80, Resident #88, Resident #95, and Resident #97) sampled residents reviewed. Findings: Review of the facility's Self-Administration of Medications policy with a revision date of 11/2017 revealed, in part, residents would be allowed to self-administer medications only if a physician order was obtained allowing residents to keep a medication at bedside for the purpose of self-administration, and the interdisciplinary team deemed resident to be clinically appropriate to self-administer medications. Review of the facility's Drug Administration and Documentation policy with a revision date of 12/2023 revealed, in part, under no circumstances is medication to be left at the bedside or given to the resident without him/her swallowing it in the nurses presence unless a physician had written an order to, and the facility had determined the resident is mentally and physically capable of self-administration. Resident #22 Review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2024 revealed, in part, Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #22 was cognitively intact. Observation on 07/15/2024 at 9:13 a.m. revealed a disposable medication cup with 7 tablets and/or capsules on Resident #22's bedside table. In an interview on 07/15/2024 at 9:13 a.m., Resident #22 indicated the nurse left her medications at her bedside for her to self-administer when she was feeling better. In an interview on 07/15/2024 at 9:15 a.m., S5Licensed Practical Nurse (LPN) confirmed the disposable medication cup on Resident #22's beside table contained 7 tablets and/or capsules. S5LPN indicated she did not ensure Resident #22 swallowed her medications during medication administration, and should have. In an interview on 07/17/2024 at 11:35 a.m., S6Certified Nursing Assistant indicated she had occasionally noticed medication cups containing medications left at resident's bedsides. Review of Resident #22's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #22 had physician orders to self-administer medications and/or allowed to keep medications at the bedside. In an interview on 07/17/2024 at 12:00 p.m., S1Director of Nursing (DON) indicated Resident #22 did not have a physician's order to self-administer medications and S5LPN should not have left Resident #22's medications at the bedside to self-administer. Resident #97 Review of Resident #97's MDS with an ARD of 05/09/2024 revealed, in part, Resident #97 had a BIMS score of 15 which indicated Resident #97 was cognitively intact. Observation on 07/17/2024 at 10:35 a.m. revealed a clear plastic container on Resident #97's bed which contained a box of medication labeled Betamethasone Valerate 0.1% ointment (a medication used to relieve redness, itching, or swelling caused by skin conditions) apply to affected area twice daily. In an interview on 07/17/2024 at 10:35 a.m., Resident #97 stated she previously used the above mentioned ointment for a fungal infection on her ear and she kept the ointment in case she needed it again. Review of Resident #97's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #97 had a physician's order to self-administer medications and/or allowed to keep medications at the bedside. In an interview on 07/17/2024 at 12:00 p.m., S1DON confirmed Resident #97 did not have a physician's order to self-administer medications and/or allowed to keep medications at the bedside.

Based on observation, interview, and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Elder Justice Act policy with a revision date of 04/2022 revealed, in part, it is the facility's policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime, under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act. Further review revealed staff must report the suspicion of an incident to the administrator. Resident #2 Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/2023 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. In an interview on 11/06/2023 at 9:08 a.m., S2Housekeeper asked the state surveyor to talk Resident #2 stating the resident wanted to report something. In an interview on 11/06/2023 at 9:09 a.m., Resident #2 stated S3Certified Nursing Assistant (CNA) screamed at her earlier in the morning which upset her. Resident #2 further stated she told S2Housekeeper that S3Certified Nursing Assistant (CNA) screamed at her and upset her. In an interview on 11/06/2023 at 9:10 a.m., S2Housekeeper acknowledged that Resident #2 reported to her that S3Certified Nursing Assistant had hollered at her and she was insulted. S2Housekeeper further stated she just tried to console Resident #2 from crying but did not report the incident to anyone. S2Housekeeper stated she should have reported to the nurse or administrator immediately that Resident #2 alleged S3CNA had hollered at her and insulted her. S2Housekeeper further stated Resident #2 had reported the above mentioned verbal abuse to her before breakfast on 11/06/2023. S2Housekeeper stated breakfast is at approximately 7:30 a.m. daily. In an interview on 11/06/2023 at 9:31 a.m., S1Administrator acknowledged he was not aware that Resident #2 had alleged that S3CNA screamed at her and insulted her. S1Administrator further acknowledged S2Housekeeper did not immediately report Resident #2's allegation of verbal abuse as required.

Based on observation, interviews and record review, the facility failed to monitor the oral intake of 2 (Resident #63 and Resident #106) of 2 residents investigated for nutrition. Findings: Review of the facility's Food Intake Records policy revealed, in part, the intake of each resident should be documented at each meal. Resident #63 Review of Resident #63's Registered Dietician (RD) Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #63's oral intake. Review of Resident #63's log of percentage of meals eaten revealed, in part, no documentation of the percentage of breakfast eaten 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, 08/26/2023, and 08/27/2023, no documentation of the percentage of lunch eaten on 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, and 08/27/2023 and no documentation of the percentage of dinner eaten on 08/15/2023, 08/17/2023, 08/19/2023, 08/21/2023, 08/22/2023, 08/24/2023, 08/25/2023, 08/26/2023, 08/27/2023, and 08/29/2023. In an interview on 08/31/2023 at 10:13 a.m., S11Liscensed Practical Nurse (LPN) stated Certified Nursing Assistants (CNA) were to document a resident's meal intake after every meal. In an interview on 08/31/2023 at 10:48 p.m. S15CNA stated the residents' oral intakes should be checked after every meal. In an interview on 08/31/2023 at 11:13 a.m., S4Registered Dietician (RD) stated staff were supposed to document Resident #63's meal intake for every meal. S4RD further stated a resident's meal intake should be documented accurately because it was part of what she used to make decisions regarding RD recommendations. In an interview on 08/31/2023 at 12:50 p.m., S2Director of Nursing (DON) stated Resident #63's meal intake should have been assessed and documented after breakfast, lunch, and dinner, and it was not. Resident #106 Review of Resident #106's RD Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #106's oral intake. Review of Resident #106's RD Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #106's oral intake. Review of Resident #106's log of percentage of meals eaten revealed, in part, no documentation of the percentage of breakfast eaten on 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/29/2023, 08/02/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/16/2023, 08/19/2023, 08/26/2023, 08/29/2023, and 08/30/2023, no documentation of the percentage of lunch eaten on 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/29/2023, 08/02/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/16/2023, 08/17/2023, 08/19/2023, 08/26/2023, and 08/29/2023, and no documentation of the percentage of dinner eaten on 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/28/2023, 07/29/2023, 08/01/2023, 08/04/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/13/2023, 08/14/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/27/203, and 08/28/2023. Further review revealed documentation that Resident #106 ate 75% of her lunch on 08/30/2023. Observation on 08/30/2023 at 12:05 p.m. revealed Resident #106 being fed by S2DON and another aide. Further observation of resident's lunch tray revealed that she ate less than 10% of her lunch. In an interview on 08/30/2023 at 4:35 p.m., S2DON stated Resident #106 only ate less than 10% of her lunch, and Resident #106's percentage of lunch eaten was inaccurately documented on 08/30/2023. In an interview on 08/31/2023 at 10:05 a.m., S13CNA stated the residents' meal intakes needed to be documented after every meal. In an interview on 08/31/202 at 10:13 a.m., S11LPN stated Certified Nursing Assistants (CNA) were supposed to be monitoring Resident #106 oral intake after every meal. In an interview on 08/31/2023 at 11:13 a.m., S4Registered Dietician (RD) stated staff were supposed to document Resident #106's meal intake for every meal. S4RD further stated a resident's meal intake should be documented accurately because it was part of what she used to make decisions regarding RD recommendations. In an interview on 08/31/2023 at 12:50 p.m., S2DON stated Resident #106's meal intake should have been assessed and documented after breakfast, lunch, and dinner, and it was not.

Based on observations, interviews, and record reviews the facility failed to: 1.) Ensure resident's interventions were updated after a fall for 1 (Resident #44) of 3 (Resident #19, Resident #44, and Resident #78); and, 2.) Ensure a resident's intervention listed in the Comprehensive Care Plan was implemented for 1 (Resident #78) of 3 (Resident #19, Resident #44, and Resident #78) sampled residents reviewed for falls. Findings: 1. Resident #44 Review of Resident #44's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) revealed, in part, Resident #44 had a Brief Interview of Mental Status (BIMS) of 8 (a score of 8-12 indicated a resident had moderately impaired cognition). Review of Resident #44's care plan with a target date of 09/30/2023 revealed Resident #44 was at risk for falls with a fall on 06/02/2023. Review revealed a new intervention for the fall on 06/02/2023 was not initiated. In an interview on 08/29/2023 at 3:04 p.m., S8Liscensed Practical Nurse (LPN) stated Resident #44 had a fall last week. S8LPN stated Resident #44 was recently moved to this room and was unaware of any previous falls. S8LPN further stated she was unaware of any interventions that were in place prior to the fall. In an interview on 08/30/2023 at 4:03 p.m., S2Director of Nursing (DON) stated Resident #44 had a fall on 06/02/2023. S2DON further stated the intervention for Resident #44's fall on 06/02/2023 was initiated on 06/05/2023 by transferring Resident #44 to the hospital. 2. Resident #78 Review of Resident #78's MDS with an ARD of 07/04/2023 revealed, in part, Resident #78 had a BIMS of 5 which indicated severely impaired cognition. Further review of Resident #78's MDS revealed Resident #78 had 2 or more falls with injury since admission. Review of Resident #78's Comprehensive Care Plan revealed Resident #78 was at risk falls. Further review of Resident #78's approaches revealed, in part, a full size mattress next to bed when in bed at all times. Observation on 08/28/2023 at 10:00 a.m. revealed Resident #78 lying in bed with fall mattress propped up against Resident #76's bed. Observation on 08/29/2023 at 3:04 p.m. revealed Resident #78 lying in bed asleep with a fall mattress propped up against Resident #76's bed. In an interview on 08/29/2023 at 3:18 p.m., S9LPN stated Resident #78 has had falls. S9LPN stated the interventions for Resident #78 included placing a fall mattress next to the bed when Resident #78 was in bed. Observation on 08/30/2023 at 1:52 p.m. revealed Resident #78 lying in bed with fall mattress leaning on the bed held in place by the nightstand. Observation on 08/31/2023 at 12:30 p.m. revealed Resident #78 lying in bed with fall mattress propped against the wall. In an interview on 08/31/2023 at 12:36 p.m., S2DON stated Resident #78 should have a fall mattress on the floor next to the bed at all times when he was in the bed. S2DON confirmed Resident #78 was lying in the bed and the fall mattress was propped against the wall. S2DON further stated the fall mattress should have been on the floor next to Resident #78's bed.

Based on observation, interview, and record review, the facility failed to notify the physician and responsible party of a resident's onset of loose stools and bilateral buttock wounds for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of Resident #79's departmental notes, revealed, in part, the following: 1. 08/19/2023 the Certified Nurse Assistant (CNA) reported one episode of loose stool; and, 2. 08/30/2023 the CNA reported loose stools this shift; and, 3. 08/31/2023 the CNA reported one episode of loose stool. Further review revealed no documented evidence the physician or responsible party was notified of Resident #79's loose stools. Review of Resident #79's August 2023 Physician's orders revealed, in part, orders dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier that protects and helps heal skin irritations) daily until resolved. Review of Resident #79's departmental notes, revealed, in part, no documented evidence the physician or responsible party was notified of Resident #79's left and right buttock moisture associated skin damage and the initiation of wound care to the left and right buttocks. Observation on 08/30/2023 at 12:45 p.m. revealed S12CNA removed Resident #79's diaper and the diaper was soiled with loose stool and the skin to Resident #79's left and right buttocks was open and bright red. Further observation revealed, Resident #79 continued to have a bowel movement with loose stool during incontinence care. In an interview on 08/30/2023 at 12:45 p.m., S12CNA stated as she cleaned Resident #79's buttocks loose stool would continuously come from Resident #79's rectum. S12CNA stated Resident #79 had loose stool since last week. In an interview on 08/31/2023 at 2:10 p.m., S9Licensed Practical Nurse (LPN) stated she was aware Resident #79 had episodes of loose stool yesterday, and was not aware Resident #79 had any episodes of loose stool today. S9LPN confirmed she did not notified the physician of Resident #79's multiple episodes of loose stool or the moisture associated skin damage to left and right buttocks. In an interview on 08/31/2023 at 2:40 p.m., S16CNA stated Resident #79 had one episode of loose stool earlier this morning on her shift and the nurse was notified. In an interview on 08/31/2023 at 3:08 p.m., Resident #79's Nurse Practitioner stated she was only made aware a few minutes ago by the facility of Resident #79's episodes of loose stools and she ordered medication for treatment. Resident #79's Nurse Practitioner stated she had no knowledge of Resident #79's moisture associated skin damage to her left and right buttocks. Resident #79's Nurse Practitioner confirmed she had not been notified by the facility of Resident #79's left and right buttock moisture associated skin damage or the initiation of treatment to the wounds. In an interview on 08/31/2023 at 3:22 p.m., Resident #79's daughter and responsible party stated she had not been notified by the facility of Resident #79's episodes of loose stool, moisture associated skin damage to her bilateral buttocks, or the initiation of treatment on 08/24/2023 to her bilateral buttock wounds. Record review revealed no evidence and the facility did not produce any evidence the physician or responsible party was notified at the onset of Resident #79's episodes of loose stool and moisture associated skin damage to left and right buttocks.

Based on observation, interview, and record review, the facility failed to: 1) Ensure a residents wounds were assessed; and, 2) Ensure a resident was provided treatment for loose stools for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of the facility's prevention and treatment of skin issues policy revealed, in part, the facility should properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity to implement preventative measures and to provide appropriate treatment. Further review revealed, for newly identified skin issues staff should implement weekly wound documentation in the Wound Assessment Manager (WAM) to include: type of wound, location, date, length, width, depth, wound base description, and wound edge description. 1. Review of Resident #79's August 2023 Physician's orders revealed, in part, an order dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier that protects and helps heal skin irritations) daily until resolved. Review of Resident #79's departmental notes revealed, in part, no documented assessments of Resident #79's left and right buttock moisture associated skin damage. Review of the facility's Wound Assessment Manager (WAM) revealed, in part, no documented assessments of Resident #79's left and right buttock moisture associated skin damage. In an interview on 08/30/2023 at 11:45 a.m., S5Treatment Nurse stated she did not complete a wound assessment on Resident #79's left and right buttock moisture associated skin damage. In an interview on 08/31/2023 at 2:58 p.m., S2DON stated they did not have documented evidence of Resident #79's wound assessments on the left and right buttock moisture associated skin damage. Record review revealed no documented evidence and the facility did not produce any documented evidence Resident #79's moisture associated skin damage to the left and right buttock was assessed. 2. Review of Resident #79's departmental notes, revealed, in part, the following: 1.) 08/19/2023 the Certified Nurse Assistant (CNA) reported one episode of loose stool, 2.) 08/30/2023 the CNA reported loose stools this shift, and 3.) 08/31/2023 the CNA reported one episode of loose stool. Review of Resident #79's August 2023 physician orders, revealed, in part, no medication ordered for treatment of Resident #79's loose stools. Observation on 08/30/2023 at 12:45 p.m. revealed S12CNA removed Resident #79's diaper and the diaper was soiled with loose stool. In an interview on 08/30/2023 at 12:45 p.m., S12CNA stated when she cleaned Resident #79's buttocks during incontinence care loose stool would continuously come from Resident #79's rectum. S12CNA stated Resident #79 had loose stool since last week. In an interview on 08/31/2023 at 2:10 p.m., S9Licensed Practical Nurse (LPN) stated she was aware Resident #79 had episodes of loose stool yesterday. S9LPN confirmed she did not notify the physician of the multiple episodes of loose stool and Resident #79 had no current orders to treat her loose stool. In an interview on 08/31/2023 at 2:40 p.m., S16CNA stated Resident #79 had one episode of loose stool earlier this morning on her shift and the nurse was notified. In an interview on 08/31/2023 at 3:08 p.m., Resident #79's Nurse Practitioner stated she was only made aware a few minutes ago by the facility of Resident #79's episodes of loose stool and she ordered medication for treatment. Record review revealed no documented evidence and the facility did not produce any documented evidence treatment was provided for Resident #79's episodes of loose stool.

Based on observations, interviews, and record review the facility failed to apply a hand splint to a resident in order to prevent a further decrease in range of motion to his right hand. This deficient practice was identified for 1 (Resident #68) of 5 sampled residents with limited range of motion in a total sample of 27 residents reviewed. Review of the Resident Census and Conditions of Residents revealed, in part, the facility documented there were 11 residents with contractures in the facility. The facility's census was 90 residents. Findings: Observation on 10/25/2021 at 1:33pm, revealed Resident #68 had a limited range of motion, contracture, to his right hand. Observation on 10/26/2021 at 4:39pm revealed a contracture to Residents #68's right hand. Observation revealed his fingers flexed down towards the palm of his hand. In an interview on 10/26/2021 at 4:40pm, Resident #68 stated that the staff do not put a splint or do anything for his right hand. Observation on 10/27/21 at 9:53am revealed Resident #68 was outside in the smoking area and had no type of splint device placed on his right hand. In an interview on 10/27/2021 at 10:05am, S3Licensed Practical Nurse (LPN) stated that they put a splint device on Resident # 68's hand or put it on a pillow but was not sure what time of the day it was done. S3LPN further stated the surveyor would have to check with S4Certified Nursing Assistant (CNA) Supervisor. In an interview on 10/27/21 at 10:32am, S4CNA Supervisor stated that Resident #68 has what she calls a contracture to his right hand because he cannot open his hand all the way and thinks the staff, CNAs, do range of motion (ROM) to his fingers but will check on computer. In an interview on 10/27/2021 at 10:39am, S4CNA Supervisor stated, after she checked her computer information about Resident #68, that she did not see any documentation about ROM or applying a splint to his hand and maybe therapy took it off the computer. In an interview on 10/27/2021 at 10:52am, S5Rehabilitation Director Occupational Therapist (OT) stated, after reading from Resident #68's discharge summary dated 06/24/2021, Resident #68 had a resting had splint and [CONDITION(S)] glove which Resident #68 was able to tolerate from 4 to 6 hours. She further stated as far as a time frame and when to apply the hand splint it would be up to the nursing department to determine this. Review of Resident #68's OT Discharge Summary dated 06/04/2021 revealed, in part, Resident #68 had made progress with being able to tolerate hand resting splint and [CONDITION(S)] glove for 4 to 6 hours. Observation on 10/27/2021 at 2:25pm revealed Resident #68 did not have a splint device applied on his right hand. In an interview on 10/28/2021 at 9:30am, S2RN Director of Nursing stated Resident #68 was not contracted and the facility does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 10/28/2021 a 9:42am, S5Rehabilitation Director OT stated that the plan of care for Resident #68 was for staff to apply and wear his splint but she did not know where in the system to document it. In an interview on 10/28/2021 at 9:55am, S2RN Director of Nursing was informed of the plan of care by 5Rehabilitation Director OT, Resident #68 was to wear a hand splint, and she acknowledged the surveyors findings.

Based on observation and interview the facility failed to ensure staff removed personal protective equipment (PPE) prior to leaving an area designated for residents on transmission based precautions. This deficient practice had the potential to affect any of the 103 residents who resided in the facility as per the facility census list. Findings: On 12/07/2020 at 10:40am this surveyor observed S2Housekeeper walk around the nurses station wearing an isolation gown. Further observation revealed S2Housekeeper turned around and entered the unit designated as the observation unit wearing the same isolation gown. The surveyor was able to observe S2 Housekeeper enter the observation unit and proceed to room a. Observation revealed at the entrance of room a S2 Housekeeper removed the isolation gown and exited the observation unit. In an interview on 12/07/2020 at 10:44am, S2Housekeeper stated she had been in room b and had trouble with the paper towel dispenser. S2Housekeeper stated she left the observation unit to look for the maintenance worker; however, she did not see the maintenance worker so she re-entered the observation unit. S2Housekeeper confirmed she left the observation area with an isolation gown and returned to the unit in the same yellow isolation gown. S2Housekeeper stated she should not have left the unit with the isolation gown. In an interview on 12/07/2020 at 11:01am, S1Director of Nursing (DON) stated no one should leave the observation unit with an isolation gown. S2DON further stated S2Housekeeper did not follow protocol for the observation unit and PPE

Based on observation and interview the facility failed to ensure sufficient nursing staffing as evidenced by failing to answer call bells timely. This failed practice was identified for 2 (Resident #29 and Resident #77) of 38 sampled residents. The total facility census was 127 as documented on the facility's Resident Census and Conditions of Residents. Findings: Resident #77 Observation on 03/07/18 at 09:28am revealed Resident #77 was wheeled into his room by S5/ CNA and then S5/CNA left his room. In an interview on 03/07/18 at 09:28am Resident #77 stated S5/CNA brought him into his room because he had to go to the bathroom. Observation on 03/07/18 at 09:40am revealed Resident #77 still did not receive assistance in going to the bathroom from S5/CNA. Observation on 03/07/18 at 09:43am, Resident #77's call bell was pushed and he stated he needed assistance. S5/CNA went into Resident #77's room to assist him with his needs at 09:44am which was 16 minutes lapse time. Observation on 03/09/18 at 11:15am, revealed Resident #77's call bell was pressed and the call bell intercom was answered and an employee asked twice, Can I help you? This surveyor did not respond. This surveyor waited 10 minutes with no response from staff. No overhead page was heard for assistance required in Resident #77's room. Resident #29 Observation on 03/07/18 at 10:40am revealed Resident #29, who was Diabetic with [MEDICAL CONDITION], and required oxygen at night, pressed her call bell. A staff member responded over the intercom and asked 4 times can I help you? Resident #29 did not respond to the intercom. No assistance to Resident #29's room request was heard on the overhead paging system. Observation further revealed 19 minutes passed with no response by any staff members to assist a resident who did not respond when she was asked if she required help. Observation continued at 10:59am, S5/CNA entered Resident #29's room and asked Resident #29 if she needed anything. S5/CNA was asked if she was responding to the call bell and she replied, no, that she was just checking on the resident. In a joint interview on 03/09/18 at 09:30am, S1/Administrator (Adm) and S3/Assistant Director of Nurses (ADON) were asked what the facility considered an acceptable wait time for call bells to be answered. S1/Adm and S3/ADON both stated it depended on the situation and needs of the residents. S3/ADON stated all staff have been trained to respond to call bells, which included housekeeping staff. S3/ADON stated any staff member could put their head in a door to ask a resident what is needed, and then deploy the appropriate staff. S1/Adm agreed with S3/ADON. S1/Adm and S3/ADON was asked what should staff do if a resident did not respond to an employee when the employee answered the intercom on the call system. S1/Adm stated they go to the room immediately to check on the resident. S1/Adm was informed that this surveyor waited 19 minutes after not responding to the intercom for the call system, and when an employee entered the room to check on the resident, she stated she was not sent into the room by anyone, she was just checking on the resident. S1/Adm and S3/ADON both confirmed the staff should have immediately gone to the room to check on a resident who did not respond to the intercom on the call system. In interview on 03/09/18 at 11:12am, S4/Ward Clerk stated if a resident does not respond to the intercom when the call bell is pressed, she will overhead page for assistance to be sent to the resident's room. If she does not see a staff member go into the resident's room, she will go check on the resident herself. In interview on 03/09/18 at 11:30am, S4/Ward Clerk confirmed she was responsible for answering call bells when at the desk and her work hours are 07:00am to 03:00pm Monday through Friday. S4/Ward Clerk was informed of both occasions as stated above regarding residents not responding to the call bell, and confirmed these wait times were too long, and someone should have responded immediately. In an interview with the Resident Council and Residents on 3/6/18 from 10:30am, concerns were voiced among resident attending the meeting regarding call bells not being answered in a timely manner. Resident #51 stated call bells have extended wait times. Resident #51 stated about 1 month ago, he fell on his bathroom floor and pulled the emergency cord and waited about 40 minutes for assistance. Resident #51 further stated about 3-4 months ago, he fell on the floor in his room and pressed the call bell and waited about 30 minutes for assistance. Resident #51 stated it is worse on the evening shift. Resident #112 stated about 2 to 3 days ago her roommate had to wait about 1.5 hours for assistance to change a dirty diaper. Resident #56 stated Resident #107 has a sitter except on Thursdays and when her sitter is not there, she (Resident #56) sits with Resident #107 and Resident #107 had to wait 30 or more minutes for assistance to the bathroom. Resident #56 further stated when she asks Certified Nursing Assistants (CNAs) for assistance, if they are not assigned to that hall, they will tell her, I'm not working this hall, and walk away without assisting the residents. Resident #56 was unable to name any of the CNAs, but further stated it was all CNAs.

Based on observation, record review, and interview the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #3 and Resident #4) as evidenced by the facility failing to: I. Ensure a resident with decreased lower extremity strength had foot pedals placed on her wheelchair prior to being pushed in the wheelchair by a staff member (Resident #3); and II. Ensure a resident who was assessed as not being able to propel himself in his wheelchair had foot pedals to his wheelchair at all times and while staffing are pushing the resident in his wheelchair (Resident #4). The provider had 111 residents which were in a wheelchair all or most of the time per the facility's Resident Census and Conditions of Residents Form (CMS-672). Findings: Resident #3 Review of Resident #3's Record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS (Minimum Data Set) ARD (Assessment Reference Date) dated 08/15/17 revealed Resident #4 required extensive assistance of one person for transfers and walking. Review of Resident #3's Care Plan revealed Resident #3 requires assist with ADL's (Activities of Daily Living) with goal date of 11/18/17. Further review revealed approaches of: therapy consult as needed, remove environmental barriers for mobility, assist to activities as needed, resident uses wheelchair for mobility, and allow rest periods as needed. Review of Resident #3's emergency room Notes dated 07/27/17 revealed in part: [DIAGNOSES REDACTED]. Review of Resident #3's physician progress notes [REDACTED].#3 was assessed as the resident's upper and lower extremities having had decreased range of motion and tone. Review of Resident #3's PT (Physical Therapy) Discharge Summary dated 08/25/17 revealed in part: Resident #3's coordination of bilateral lower extremity was assessed as fair due to demonstrated poor foot placement hindering ability to perform functional mobility and decreased ability to perform intentional movements. Review revealed Resident #3 had poor safety awareness. Further review revealed assessment of Resident #3's transfer status was impairments related to difficulty achieving full stand due to insufficient lower extremity strength. Observation on 09/18/17 at 9:40am revealed S12/CNA (Certified Nursing Assistant) pushing Resident #3 in a wheelchair from the nurse's station towards the front entrance and then loading the resident in the facility van with no footrests on the wheelchair, and Resident #3 was holding her feet up the entire time with no rest periods. Observation on 09/18/17 at 11:04am revealed S12/CNA pushing Resident #3 back into the main entrance of the building down the hall to the nurse's station with no footrest on the wheelchair and the resident was holding up her feet up with no rest periods. In interview on 09/19/17 at 10:27am S12/CNA stated if it was not required for the resident to have footrests then she (S12/CNA) does not place the footrests on the wheelchair even for appointments which she transports them in the van. S12/CNA further stated she will simply ask the resident to hold their feet up while pushing them in the wheelchair. S12/CNA stated the footrests are in the residents' rooms if they need footrests. In interview on 09/19/17 at 11:00am S8/PTA (Physical Therapist Assistant) stated Resident #3 had very weak leg strength due to Resident #3's recent pelvic fracture. S8/PTA stated Resident #3's hip muscles were weak and therapy worked on Resident #3's lower extremity strength. S8/PTA stated Resident #3 did self propels in her wheelchair. S8/PTA stated Resident #3 did have some weakness so the resident should have frequent rest periods when holding up her legs while being pushed in a wheelchair, and should have footrests in room to be placed on the wheelchair. S8/PTA further stated if the staff is going to push the resident for an extended period of time then they would need to place the foot rest onto the wheelchair for safety reasons. In interview on 09/19/17 at 12:30pm S4/DON (Director of Nursing) and S5/ADON (Assistant Director of Nursing) stated if a staff member is going to transport a resident for a long period or time or transport the resident to a physician appointment then the resident should have either have the footrests on the wheelchair or allow for extra rest breaks to rest the resident's legs. S2/CQI (Corporate Quality Improvement) Nurse stated Resident #3 should have had the footrest placed on the resident's wheelchair to go to the physician's appointment with all the changes in levels during the transport for safety reasons since the staff would probably be pushing the resident during the entire time. Resident #4 Review of Resident #4's Record revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's MDS with ARD dated 07/18/17 revealed the resident required extensive assistance of one person with dressing and toilet use. Further review revealed Resident #4 was further assessed as requiring set-up assistance of one person for locomotion off unit. Review of Resident #4's Care Plan revealed problems of: Resident #4 needs assistance with ADLs, the resident requires extensive assistance with most ADLs related to impaired ROM (Range of Motion) on right side secondary to right sided [DIAGNOSES REDACTED] and lack of coordination, and resident has a [DIAGNOSES REDACTED]. Further review revealed approaches of in part: remove environmental barriers for mobility, resident uses a wheelchair for mobility, and encourage resident to use assistive devices. Observation on 09/18/17 at 9:50am Resident #4 was observed being wheeled on the patio by S3/Administrator without the resident's left foot rest having been applied to the resident's wheelchair. In interview on 09/18/17 at 9:50am Resident #4 stated the footrest for his wheelchair had been missing for a while. Resident #4 further stated he was able to propel himself in the wheelchair by pushing the wheels with his arms. Observation on 09/18/17 at 12:25pm revealed Resident #4 was being pushed for a short distance by S1/Regional Supervisor and then S1/Regional Supervisor requested another staff member push Resident #4 down the hall. Further observation revealed Resident #4 did not have his left foot rest in place during the observation. Interview on 09/18/17 at 1:51pm Resident #4 stated his wheelchair came from ____ (name of facility) with both foot rests and he would like to have both foot rests on the wheelchair. Resident #4 further stated he had asked a supervisor for another foot rest when the foot rest was first missing. Resident #4 stated none of the staff had came back to speak to him regarding the foot rest. Interview on 09/18/17 at 2:05pm S10/CNA stated she was not sure how long Resident #4 had been missing his left foot rest, she stated maybe the foot rest was missing a couple of days. S10/CNA stated maintenance was supposed to fix it, but wasn't sure when maintenance was notified or when/who broke the chair. In interview on 09/18/17 at 2:15pm S6/Maintenance Supervisor stated he just notified regarding Resident #4's missing footrest today at noon. In interview on 09/18/17 at 2:17pm S11/CNA stated she did not know when the foot rest was removed. S11/CNA stated she showed up one morning and Resident #4 was sitting in his wheelchair with no foot rest to the left side. In interview on 09/19/17 at 11:45am S5/ADON (Assistant Director of Nursing) stated she was unaware of Resident #4 missing his footrest until yesterday at around 4pm. S5/ADON stated Resident #4 does not use his feet to scoot and pushes the wheels with his hands and therefore needs the footrests on the wheelchair when he is in the chair.

Based on observations, record reviews and interviews the facility failed to ensure it is free of medication error rates of five percent or greater for 2 (Resident#8 and Resident#141) of 6 (Resident#8, Resident#106, Resident#138, Resident#140, Resident#141 and Resident#149) sampled residents observed during the Medication Administration observations as evidenced by the facility having 2 medication errors out of 26 opportunities resulting in an 8% medication error rate. This failed practice had the potential to affect all 132 residents as listed on the facility ' s Resident Census and Condition form. Findings: Resident#8: During an observation of the medication administration process on 1/20/2016 at 11:04AM with S4LPN the following medication was administered: [MEDICATION NAME] SA capsule 25mg-200milligram one tablet PO BID (by mouth twice a day). Review of Resident#8 ' s January physician's order [REDACTED]. Review of Resident#8 ' s electronic Medication Administration Record [REDACTED]. An interview was conducted with S4LPN on 1/20/2016 at 12:00PM. During the interview S4LPN stated Resident#8 was not around. She also stated the resident was in the facility. She further stated she was late giving Resident#8 his 8:00AM medication. An interview was conducted with S2Director of Nursing (DON) on 1/21/2016 at 8:00AM. During the interview S2DON stated 8:00AM medications should be given by 9:00AM. An interview was conducted with S1Administrator on 1/22/2016 at 8:00AM. During the interview S1Administrator stated there is a system in place to flag if a medication is late. He also stated S1DON did not receive the alert indicating the medication was late on 1/20/2016. Resident #141: During an observation of the medication administration process on 1/21/2016 at 7:43AM with S5LPN the following medication was administered: Tylenol 325 milligram one tablet by mouth. Review of Resident#141 ' s electronic Medication Administration Record [REDACTED]. Review of Resident#141 ' s physician's order [REDACTED]. An interview was conducted with S5LPN on 1/21/2016 at 8:30AM. During the interview S5LPN agreed she had given Tylenol 325milligrams to Resident#141. She also agreed Tylenol 650milligram should have been given. An interview was conducted with S2DON on 1/21/2016 at 8:50AM. During the interview S2DON stated there was a discrepancy between the physician's order [REDACTED]. She also stated the process for taking orders off is as follows: The nurse who reads the order inputs the new order into the computer. The medical record nurse reviews the new orders the next day and verifies they are correct.

Based on record review and interview the facility failed to ensure staff maintained an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease, infection, and prevent cross contamination. This deficient practice was identified when 12 (#113, #30, #129, #89, #98, #61, #166, #117, #130, #1, #88, #52, and #8) of 12 stage 2 Residents were affected by scabies. This failed practice had the potential to affect a total of 126 residents residing in the facility as documented on the facility's Census and Conditions of Residents Form. Findings: Resident#113 Resident #113 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the facility's policy titled Infection Control, Scabies Treatment Guidelines dated 10/09 revealed treatment must be done timely (begun within an hour or two) and follow doctor's orders and directions. According to the facility's policy treatment is done immediately when scabies is diagnosed . The policy stated contact isolation is done immediately after a Resident is diagnosed with [REDACTED]. In interview on 1/13/14 at 1:00pm S2, DON confirmed the facility was made aware of Resident #113's scabies by a family member. She also stated the family member informed her that the Resident needed to see a dermatologist as soon as possible. S2, DON further admitted that Resident#113 was diagnosed on [DATE] at a local hospital with scabies and needed to be isolated and to continue taking medication that was prescribed by her doctor. S2, DON admitted that Resident #113 was not isolated until 12/7/13 after the breakfast meal. Review of Centers for Disease Control and prevention (CDC) protocol recommended standard of practice revealed is a scabies infestation of the skin by human itch mite. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The itching may affect much of the body or be limited to between the fingers, nipples, waist, penis, belt-line, and the buttocks. Treatment is recommended for the all who have had prolonged skin -to-skin contact with the infested person. All persons should be treated at the same time to prevent infestation. CDC recommended [MEDICATION NAME] treatment given to reduce the risk of further of scabies transmission in the facility to all staff personnel. Review of the facility's nursing notes dated 11/17/13 for Resident#113 revealed Resident #113's son reported concerns that Resident#113 had raised areas to her abdomen and inner thigh. Further review of the nursing notes revealed the primary nurse assessed resident from head to toe in between fingers and toes for possible signs of scabies but no sign and symptoms were noted at the time. However, the nurse on duty documented that a cream was applied to areas and a follow up would be done by the treatment nurse. Further review of the nurses' notes dated 11/19/13 revealed during care plan conference the family of Resident#113 stated they observed small bumps on the resident's thigh and torso on the past weekend. Further review of the facility's notes for Resident#113 revealed the facility stripped and disinfected the resident's bed. The facility's nurses' notes had no documented evidence of Resident#113 being placed in isolation pending the possible transmission of scabies. According to the facility's nursing notes dated 12/7/13 Resident #113's room was cleansed per housekeeping and the Resident returned to her room on 12/8/13. Review of Resident #113's weekly body audit dated 11/30/13 revealed no new issue noted. Further review of the body audit notes revealed Resident #113 returned to the facility from the dermatologist office on 12/6/13 at 10:15am with a [DIAGNOSES REDACTED]. Review of the facility's notes failed to have documentation referencing signs and symptoms of scabies ever appearing on the resident's skin. Review of the doctor's Progress Notes dated 11/30/13 for Resident #113 revealed multiple papules noted on her medial aspect of bilateral thigh and prescribed [MEDICATION NAME] 5% cream to affected area. The doctor further informed the facility to consult a dermatologist to rule out possible scabies. Review of the Physician' s orders dated 11/30/13 revealed the facility obtained an appointment on 12/6/13 with the local hospital dermatologist. Review of the dermatologist progress notes dated 12/6/13 for Resident#113 revealed the chief complaint was a rash and itching on the upper thigh and all over body for several weeks. Review of the Dermatologist assessment and plan dated 12/6/13 revealed Scabies and to treat with [MEDICATION NAME] 1% cream for itching and to continued [MEDICATION NAME] cream to be applied to affected areas and under fingernails. Review of the facility's E-Medication Administration Record (EMAR) for Resident #113 revealed to apply [MEDICATION NAME] Cream to body from head to soles of feet, except eyes, ears nose and mouth. Wash off after 10 hours. Further review revealed a start date of 12/6/13 for [MEDICATION NAME] cream ([MEDICATION NAME]) and a stop date of 12/7/13 to wash off cream at 7:00am. Further review revealed the same medication was reordered on [DATE] with a stop date of 12/10/13. Review of the resident's Care Plan dated 12/07/13 and a target goal dated 3/7/14 revealed Intervention/Approaches: Needs topical treatment as ordered by the physician; Staff to evaluate Resident for source of rash and remove from environment; Weekly body audit by floor nurse; Provide Resident's progress report to family on healing status; further review revealed the resident was diagnosed with [REDACTED]. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed Resident #113 was moderately impaired in decision making. In interview on 1/14/14 at 10:30am S7, Assessment Nurse denied doing a skin assessment on Resident#113. S7, Assessment Nurse confirmed the first time she was made aware of Resident #113 having a scabies problem was at the care plan meeting dated 11/19/2013. S7, Assessment Nurse stated the daughter of Resident #113 verbalized in the care plan meeting, that Resident #113 had been itching over the weekend and was concerned that it was a problem. In interview on 1/14/14 at 12:00pm S5, Nursing Assistant confirmed that she left work and was out for 2 ? days due to itching and a rash over her elbow. S5, Nursing Assistant confirmed that she was treated with [MEDICATION NAME] 5% cream per doctor's orders due to the outbreak of scabies in the facility. In interview at 1:20pm on 1/14/14 S2, DON confirmed the facility did not put a system in place for a dermatitis problem and nothing was done to prevent the potential spread of scabies until 12/7/13 for the residents residing in the facility. In interview on 1/15/13 at 12:13pm S6, Housekeeping Supervisor confirmed the facility had an outbreak of scabies on on of the facility's halls. Resident #30 Review of Resident #30's Physician's Progress Notes dated 09/16/13 revealed the Resident with irritated rash possible scabies. Further review revealed the Physician prescribed [MEDICATION NAME] Cream. Review of Resident #30's New physician's orders [REDACTED]. Review of Resident #30's eMAR (electronic Medication Administration Record) for September 2013 revealed Resident #30 was treated with [MEDICATION NAME] on 09/26/13. Review of Resident #30's Care Plan revealed problem of resident has a rash to bilateral upper extremities, abdomen, and back with a goal date of 3/20/14. Further review revealed interventions in part: resident needs topical ointment as ordered and monitor resident for signs of infection or spreading. Review of Resident #30's Nurse's Notes dated 09/26/13 revealed Resident #30 was seen by her physician for reoccurring skin rash and the resident's physician ordered [MEDICATION NAME] Cream to entire body and leave on for 14 hours and wash all clothing and bed linen in hot water. Review of Resident #30's Nurse's Notes dated 09/27/13 revealed Resident #30 had a whirlpool bath and all clothing and bed linens were washed in hot water. In interview on 01/14/14 at 12:40pm S2/DON (Director of Nursing) and S4/QI (Quality Improvement) Nurse indicated staff was in-serviced regarding scabies after Resident #113 was diagnosed with [REDACTED].#30 was prescribed [MEDICATION NAME] on 09/26/13. In interview on 01/15/14 at 9:30am S2/DON indicated she did not put Resident #30 in isolation when the resident was prescribed [MEDICATION NAME] on 9/26/13. S2/DON further indicated to the facility's knowledge Resident #30's Physician had prescribed [MEDICATION NAME] treatment during a flare-up of Resident #30's dermatitis "just in case". S2/DON indicated Resident #30 was not diagnosed by the dermatologist with scabies during the appointment on 10/01/13. S2/DON did acknowledge the dermatologist appointment was after Resident #30 had already been treated with [MEDICATION NAME]. S2/DON further indicated she could not provide any documentation of Resident #30 not having had scabies in September 2013. Review of the facility's clinical records for Residents #129, #89, #98, #61, #166, #117, #130, #1, #88, #52, #8 revealed they all had to be treated [MEDICATION NAME] for scabies and isolated for 24 hours due to the facility not following their policy for isolation of the residents with scabies.

Based on record review and interviews the facility failed to ensure each resident received necessary care and services to attain and or maintain the highest practicable physical, mental and psychosocial well-being as evidence by the facility failing to: 1) provide treatment in a timely manner for an outbreak of scabies for 2 (#113, and #30) stage 2 residents who contracted scabies, 2) isolate 2 (#113 and #30) of 2 stage 2 residents that contracted scabies upon notification, 3) ensure residents were not subjected to unnecessary treatment and isolation due to a scabies outbreak for 10 (#1, #8, #52, #129, #89, #61, #166, #117, #130, & #88) of 10 stage 2 samples residents who were reviewed for scabies. This failed practice had the potential to affect a total of 126 residents residing at the facility as documented on the facility's Census and Conditions of Residents Form. Findings: Resident#113 Resident #113 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the facility's policy titled Infection Control, Scabies Treatment Guidelines dated 10/09 revealed treatment must be done timely (begun within an hour or two) and follow doctor's orders and directions. According to the facility's policy treatment is done immediately when scabies is diagnosed . The policy stated contact isolation is done immediately after a Resident is diagnosed with [REDACTED]. In interview on 1/13/14 at 1:00pm S2, DON confirmed the facility was made aware of Resident #113's scabies by a family member. She also stated the family member informed her that the Resident needed to see a dermatologist as soon as possible. S2, DON further admitted that Resident#113 was diagnosed on [DATE] at a local hospital with scabies and needed to be isolated and to continue taking medication that was prescribed by her doctor. S2, DON admitted that Resident #113 was not isolated until 12/7/13 after the breakfast meal. Review of Centers for Disease Control and prevention (CDC) protocol recommended standard of practice revealed is a scabies infestation of the skin by human itch mite. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The itching may affect much of the body or be limited to between the fingers, nipples, waist, penis, belt-line, and the buttocks. Treatment is recommended for the all who have had prolonged skin -to-skin contact with the infested person. All persons should be treated at the same time to prevent infestation. CDC recommended [MEDICATION NAME] treatment given to reduce the risk of further of scabies transmission in the facility to all staff personnel. Review of the facility's nursing notes dated 11/17/13 for Resident#113 revealed Resident #113's son reported concerns that Resident#113 had raised areas to her abdomen and inner thigh. Further review of the nursing notes revealed the primary nurse assessed resident from head to toe in between fingers and toes for possible signs of scabies but no sign and symptoms were noted at the time. However, the nurse on duty documented that a cream was applied to areas and a follow up would be done by the treatment nurse. Further review of the nurses' notes dated 11/19/13 revealed during care plan conference the family of Resident#113 stated they observed small bumps on the resident's thigh and torso on the past weekend. Further review of the facility's notes for Resident#113 revealed the facility stripped and disinfected the resident's bed. The facility's nurses' notes had no documented evidence of Resident#113 being placed in isolation pending the possible transmission of scabies. According to the facility's nursing notes dated 12/7/13 Resident #113's room was cleansed per housekeeping and the Resident returned to her room on 12/8/13. Review of Resident #113's weekly body audit dated 11/30/13 revealed no new issue noted. Further review of the body audit notes revealed Resident #113 returned to the facility from the dermatologist office on 12/6/13 at 10:15am with a [DIAGNOSES REDACTED]. Review of the facility's notes failed to have documentation referencing signs and symptoms of scabies ever appearing on the resident's skin. Review of the doctor's Progress Notes dated 11/30/13 for Resident #113 revealed multiple papules noted on her medial aspect of bilateral thigh and prescribed [MEDICATION NAME] 5% cream to affected area. The doctor further informed the facility to consult a dermatologist to rule out possible scabies. Review of the Physician' s orders dated 11/30/13 revealed the facility obtained an appointment on 12/6/13 with the local hospital dermatologist. Review of the dermatologist progress notes dated 12/6/13 for Resident#113 revealed the chief complaint was a rash and itching on the upper thigh and all over body for several weeks. Review of the Dermatologist assessment and plan dated 12/6/13 revealed Scabies and to treat with [MEDICATION NAME] 1% cream for itching and to continued [MEDICATION NAME] cream to be applied to affected areas and under fingernails. Review of the facility's E-Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Wash off after 10 hours. Further review revealed a start date of 12/6/13 for [MEDICATION NAME] cream ([MEDICATION NAME]) and a stop date of 12/7/13 to wash off cream at 7:00am. Further review revealed the same medication was reordered on [DATE] with a stop date of 12/10/13. Review of the resident's Care Plan dated 12/07/13 and a target goal dated 3/7/14 revealed Intervention/Approaches: Needs topical treatment as ordered by the physician; Staff to evaluate Resident for source of rash and remove from environment; Weekly body audit by floor nurse; Provide Resident's progress report to family on healing status; further review revealed the resident was diagnosed with [REDACTED]. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed Resident #113 was moderately impaired in decision making. In interview on 1/14/14 at 10:30am S7, Assessment Nurse denied doing a skin assessment on Resident#113. S7, Assessment Nurse confirmed the first time she was made aware of Resident #113 having a scabies problem was at the care plan meeting dated 11/19/2013. S7, Assessment Nurse stated the daughter of Resident #113 verbalized in the care plan meeting, that Resident #113 had been itching over the weekend and was concerned that it was a problem. In interview on 1/14/14 at 12:00pm S5, Nursing Assistant confirmed that she left work and was out for 2 ? days due to itching and a rash over her elbow. S5, Nursing Assistant confirmed that she was treated with [MEDICATION NAME] 5% cream per doctor's orders due to the outbreak of scabies in the facility. In interview at 1:20pm on 1/14/14 S2, DON confirmed the facility did not put a system in place for a [MEDICAL CONDITION] problem and nothing was done to prevent the potential spread of scabies until 12/7/13 for the residents residing in the facility. In interview on 1/15/13 at 12:13pm S6, Housekeeping Supervisor confirmed the facility had an outbreak of scabies on on of the facility's halls. Resident #30 Review of Resident #30's Physician's Progress Notes dated 09/16/13 revealed the Resident with irritated rash possible scabies. Further review revealed the Physician prescribed [MEDICATION NAME] Cream. Review of Resident #30's New physician's orders [REDACTED]. Review of Resident #30's eMAR (electronic Medication Administration Record) for September 2013 revealed Resident #30 was treated with [MEDICATION NAME] on 09/26/13. Review of Resident #30's Care Plan revealed problem of resident has a rash to bilateral upper extremities, abdomen, and back with a goal date of 3/20/14. Further review revealed interventions in part: resident needs topical ointment as ordered and monitor resident for signs of infection or spreading. Review of Resident #30's Nurse's Notes dated 09/26/13 revealed Resident #30 was seen by her physician for reoccurring skin rash and the resident's physician ordered [MEDICATION NAME] Cream to entire body and leave on for 14 hours and wash all clothing and bed linen in hot water. Review of Resident #30's Nurse's Notes dated 09/27/13 revealed Resident #30 had a whirlpool bath and all clothing and bed linens were washed in hot water. In interview on 01/14/14 at 12:40pm S2/DON (Director of Nursing) and S4/QI (Quality Improvement) Nurse indicated staff was in-serviced regarding scabies after Resident #113 was diagnosed with [REDACTED].#30 was prescribed [MEDICATION NAME] on 09/26/13. In interview on 01/15/14 at 9:30am S2/DON indicated she did not put Resident #30 in isolation when the resident was prescribed [MEDICATION NAME] on 9/26/13. S2/DON further indicated to the facility's knowledge Resident #30's Physician had prescribed [MEDICATION NAME] treatment during a flare-up of Resident #30's [MEDICAL CONDITION] "just in case". S2/DON indicated Resident #30 was not diagnosed by the dermatologist with scabies during the appointment on 10/01/13. S2/DON did acknowledge the dermatologist appointment was after Resident #30 had already been treated with [MEDICATION NAME]. S2/DON further indicated she could not provide any documentation of Resident #30 not having had scabies in September 2013. Review of the facility's clinical records for Residents #129, #89, #98, #61, #166, #117, #130, #1, #88, #52, #8 revealed they all had to be treated [MEDICATION NAME] for scabies and isolated for 24 hours due to the facility not following their policy for isolation of the residents with scabies.

Based on record review and interview the facility failed to ensure services provided by the facility met professional standards by falling to: 1) assess Resident #3 after her initial fall on 2/19/13 to monitor for changes as ordered and/or as needed, 2) failed to adequately assess Resident #3 for injury and/or pain as needed and as per policy. This resulted in actual harm when Resident #3 was injured in a fall with a subsequent broken right thigh bone and was not assessed as needed to monitor for injuries related to the fall and failed to assess her as needed for pain. This was for 1 of 4 residents (#3) that had fallen in a total sample of 5 residents (#1-#5). There were 133 total residents as documented on the Resident Census and Conditions of Residents. Findings: Review of the Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3703: Revealed, in part, section a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient care problems. This assessment shall be utilized to assist in determining which task may be delegated and the amount of supervision which will be required. The patient's status is safe for the person to carry out the task. Review of the section titled Executing HealthCare Regime as Prescribed by a Licensed Physician, Dentist, or Authorized Prescriber revealed the registered nurse shall carry out the medical orders of a physician, dentist or other authorized prescriber licensed in Louisiana. Review of the section titled Managing and Supervising the Practice of Nursing revealed the registered nurse when delegating task, shall be accountable for providing information needed by personnel for the implementation of the assigned nursing care and ascertaining the assimilation of same information. Review of Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3909: Standard Number 4: Implementation of Nursing Care Plan A2 revealed the nurse must ensure the nursing care plan interventions are implemented in a safe and appropriate manner. Review of the Facility's Pain Screen and Management form revealed, in part, all residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]. A pain scale is used whereby resident describes his/pain and amount of pain relief, A plan for pain and symptom management is developed based upon collected data in collaboration with the appropriate interdisciplinary care team members, which includes the resident and family as needed. Acute onset of pain: a pain screen is developed when a resident has a new onset of pain, a new type of pain or breakthrough pain, and/or new pain medication has been added or changed, when documenting regarding pain the following elements should be assessed: Date and time of onset, location of pain, character, severity (must use pain scale) alleviation factors,(what makes it better), exacerbation factors (what makes it worse), treatments and medications, responses, documentation, using the pain scale, of a new pain, a pain medication and/or treatment change is done every shift until the pain is managed effectively. Once the pain is managed effectively, document daily using the pain scale for two days, then document medication usage as appropriate as changes occur. Documentation includes location of pain medication, medication given and its effects using the pain scale plus any concerns about side effects. Care plans are reviewed and changes are documented as appropriate. Review of the facility's Pain Screen dated 2/20/13 for Resident #3 revealed, in part, nonverbal expressions of pain were crying, facial grimacing, guarding/bracing/stiff, more leg and back pain than usual, medication for pain improves the pain, and movement makes the pain worse. Review of the hospital emergency room visit dated 2/24/13 revealed, in part, Resident #3 was a [AGE] year old female with a history of dementia and being wheel chair bound presents with acute worsening right lower extremity pain. Patient lives at a nursing home and fell this last Tuesday when an aide attempted to assist her from the wheel chair to bed. Patient fell on to her right side at that time, and there was no head trauma or loss of consciousness. The patient has an obvious deformity and had been more agitated than usual. It was not until today the nursing home obtained x-rays of her leg and found a fracture. Physical exam section revealed right leg externally rotated and shortened. The right lower extremity had ecchymosis on inside aspect of knee down to her lower extremity to her ankle area. There was skin breakdown on the right posterior calf with surrounding redness and no discharge. Review of the facility's Nurses Notes for Resident #3 revealed the following: On 2/19/13 at 7am revealed the resident was on the floor and was lying on a gray floor mat next to her roommate ' s bed. S3/C.N.A. reported to the nurse that she was transferring the resident from her bed to her wheelchair and the resident ' s legs gave out and S3/C.N.A then slid the resident to the floor. Resident #3 complained of both knees having pain. The resident was assessed. There were no new skin problems noted and active range of motion and passive range of motion noted. [MEDICATION NAME] 100mg was given as was scheduled for complaints of both knee pain, and vital signs were documented, On 2/19/13 at 8:00am, telephone call was received from the doctor and was informed of the above and to see if an x-ray can be done. The doctor stated he didn ' t want her to have an x-ray done if the resident didn ' t fall on her knees, just to monitor her and call me if she has any changes. Report was given to 7am-3pm shift nurse. On 2/19/13 at 9am while in wheel in dining room the resident continues to complain of pain to right leg, receives [MEDICATION NAME] as scheduled, without distress noted, and vital signs were taken. Review of the facility's Physician Telephone orders revealed the following: - Dated 2/20/13 revealed an order for [REDACTED]. -dated 2/24/13 at 10:00am revealed STAT (immediate) x-ray to right lower extremity and hip to foot to rule out fracture and pain and swelling. In an interview on 3/5/12 at 3:20pm, S13/Social Service Director stated that she tried to get an appointment for Resident#3 through the normal process of using the automated telephone system and was not able to get an appointment until approximately 6 weeks. She stated that she felt the situation was urgent because of the report, but she did not try again to schedule an appointment. In an interview on 3/5/13 at 2:45PM, S8/LPN stated that the resident's pain increased after the incident of the fall, and she had gotten an order to give her [MEDICATION NAME], a pain medication. She further stated as far as an orthopedic consult that would have been up to the social service. Review of the facility's Departmental Notes dated 2/26/12 at 4:51am, revealed it was a late entry dated for 2/21/13 at approximately 9:15am. Review of this note revealed it was written per S6/RN and while she was making rounds she noted Resident #3 in bed consuming breakfast in a slumped over position. The resident had a bruise to her right shoulder; bruise was purple in appearance with a yellow border. The resident was not sure how she obtained bruise. S6/RN spoke with S8/LPN who was unaware of bruise. Resident was due for a body audit the previous day and on the audit revealed there were no new skin issues. S6/LPN went to S2/DON and went further assess the resident. Noted dry patch to mid area of chest, redness to breast, discoloration to bilateral lower extremities as well as bruise to right shoulder. Resident was upright position supine in bed with right ankle crossed over left leg. Resident complained of pain during assessment in which time S8/LPN administered as needed pain medication per doctor orders. Review of Physician Medical Orders for Resident #3 dated February 2013 revealed the [MEDICATION NAME], pain medication, which was given three times a day for Generalized Pain. Review of Resident #3's Medications form revealed [MEDICATION NAME] was given 8am, 12pm, and 8pm, three times a day. Review of the facility's Weekly Skin Assessment form for Resident #3 dated 1/16/13 at 8:30am revealed no new skin problems noted. The form dated 1/23/13 at 7:30pm revealed skin intact. There were no other noted documented findings. In an interview on 3/6/13 at 11:40am, S6/RN stated that they did not assess the resident on her back side that day she just assessed the front part of the resident's body and the resident had lower discoloration to both front part of her legs and we stopped the assessment after the resident complained of pain too much. In an interview on 3/6/13 at 11:45am, S2/DON stated after reviewing the above departmental note dated 2/21/13 at approximately 9:15am; she stated she did not do an assessment of the residents back sides of her body and/or legs. Review of the facility's Nurses Notes revealed, in part, the following: -dated 2/24/13 at 11:00am revealed family concerned regarding Resident #3's continued complaint of pain to right lower extremity. The nurse observed swelling to area. The doctor ' s nurse requested stat (immediate) x-ray to right lower extremity for pain and swelling and to rule out fracture. The call was placed to the x-ray company, -dated 2/24/13 at 1:40pm revealed the resident's x-ray to her right lower extremity was done. The findings were acute minimally commuted [MEDICAL CONDITION] femur just above the total knee prosthesis well -seated in the proximal tibia (broken thigh bone above the resident ' s prosthetic knee). -dated 2/24/13 at 2:05pm revealed the doctor returned call and was made aware of x-ray results and the doctor ordered to send the resident to the hospital, -dated 2/24/13 at 2:51pm revealed the resident was sent to hospital by ambulance. Review of Facility's Medications Record for March 2013 revealed [MEDICATION NAME] 5/325mg by mouth every 6 hours as needed for pain with a start date of 2/20/13. Further review revealed on 2/22/13 there were 2 initials documented for giving the pain medication. There was no time documented for when one pain medication was given on 2/22/13 and the other time located on the back of the form dated 2/22/13 revealed it was given at 6pm and 2 hours later at 8:00pm revealed the nurse assessed the residents pain as sleeping. On 2/24/13 at 9am revealed the medication was given for facial grimacing and the pain medication was assessed as not effective. Review of the record revealed there was no other documentation to show the resident had been assessed for pains every shift as per policy. There was no documentation that after Resident #3 was confirmed as having a fractured thigh bone that pain medication was given as needed. In an interview on 3/6/13 at 10:50am, S2/DON stated that there was no type of an assessment of Resident #3 related to her fall after 2/19/13 through 2/24/13. S2/DON stated she went and looked back through the record but could not find any more information. In an interview on 3/7/13 at 1:40pm, S2/DON stated that Resident #3 would not be able to use the call bell for help, but she could answer yes or no questions. The resident could also tell one if she was hurting more than her normal generalized pains. In an interview on 3/6/13 at 11:15am, with S2/DON and S1/Administrator present, S2/DON stated that the Resident's fractures were determined to be a result of the fall on 2/19/13. S1/Administrator stated that the result of the fracture was the result of the fall and per the emergency room doctor's stated the fracture was the result of the resident ' s fall.

Based on record review and interview the facility failed to notify Resident #3's physicain as ordered to monitor her after she substanied a fall which subsequently resulted in a right thigh bone fracture, and failed to notify the physician that Resident #3's pain medication was not effective. This failed action resulted in an actual harm to Resident#3 by her remaining in pain from a fall on 2/19/13 untill 2/24/13 when she was transported to an emergency room for treatment. This was for 1 of 4 residents that had fallen (#3) in a total sample of 5 residents (#1-#5). There were 133 total residents as documented on the Resident Census and Conditions of Residents. Findings: Based on record review and interview the facility failed to ensure services provided by the facility met professional standards by falling to: 1) assess Resident #3 after her initial fall on 2/19/13 to monitor for changes as ordered and/or as needed, 2) failed to adequately assess Resident #3 for injury and/or pain as needed and as per policy. This resulted in actual harm when Resident #3 was injured in a fall with a subsequent broken right thigh bone and was not assessed as needed to monitor for injuries related to the fall and failed to assess her as needed for pain. This was for 1 of 4 residents (#3) that had fallen in a total sample of 5 residents (#1-#5). There were 133 total residents as documented on the Resident Census and Conditions of Residents. Findings: Review of the Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3703: Revealed, in part, section a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient care problems. This assessment shall be utilized to assist in determining which task may be delegated and the amount of supervision which will be required. The patient's status is safe for the person to carry out the task. Review of the section titled Executing HealthCare Regime as Prescribed by a Licensed Physician, Dentist, or Authorized Prescriber revealed the registered nurse shall carry out the medical orders of a physician, dentist or other authorized prescriber licensed in Louisiana. Review of the section titled Managing and Supervising the Practice of Nursing revealed the registered nurse when delegating task, shall be accountable for providing information needed by personnel for the implementation of the assigned nursing care and ascertaining the assimilation of same information. Review of Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3909: Standard Number 4: Implementation of Nursing Care Plan A2 revealed the nurse must ensure the nursing care plan interventions are implemented in a safe and appropriate manner. Review of the Facility's Pain Screen and Management form revealed, in part, all residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]. A pain scale is used whereby resident describes his/pain and amount of pain relief, A plan for pain and symptom management is developed based upon collected data in collaboration with the appropriate interdisciplinary care team members, which includes the resident and family as needed. Acute onset of pain: a pain screen is developed when a resident has a new onset of pain, a new type of pain or breakthrough pain, and/or new pain medication has been added or changed, when documenting regarding pain the following elements should be assessed: Date and time of onset, location of pain, character, severity (must use pain scale) alleviation factors,(what makes it better), exacerbation factors (what makes it worse), treatments and medications, responses, documentation, using the pain scale, of a new pain, a pain medication and/or treatment change is done every shift until the pain is managed effectively. Once the pain is managed effectively, document daily using the pain scale for two days, then document medication usage as appropriate as changes occur. Documentation includes location of pain medication, medication given and its effects using the pain scale plus any concerns about side effects. Care plans are reviewed and changes are documented as appropriate. Review of the facility's Pain Screen dated 2/20/13 for Resident #3 revealed, in part, nonverbal expressions of pain were crying, facial grimacing, guarding/bracing/stiff, more leg and back pain than usual, medication for pain improves the pain, and movement makes the pain worse. Review of the hospital emergency room visit dated 2/24/13 revealed, in part, Resident #3 was a [AGE] year old female with a history of dementia and being wheel chair bound presents with acute worsening right lower extremity pain. Patient lives at a nursing home and fell this last Tuesday when an aide attempted to assist her from the wheel chair to bed. Patient fell on to her right side at that time, and there was no head trauma or loss of consciousness. The patient has an obvious deformity and had been more agitated than usual. It was not until today the nursing home obtained x-rays of her leg and found a fracture. Physical exam section revealed right leg externally rotated and shortened. The right lower extremity had ecchymosis on inside aspect of knee down to her lower extremity to her ankle area. There was skin breakdown on the right posterior calf with surrounding redness and no discharge. Review of the facility's Nurses Notes for Resident #3 revealed the following: On 2/19/13 at 7am revealed the resident was on the floor and was lying on a gray floor mat next to her roommate ' s bed. S3/C.N.A. reported to the nurse that she was transferring the resident from her bed to her wheelchair and the resident ' s legs gave out and S3/C.N.A then slid the resident to the floor. Resident #3 complained of both knees having pain. The resident was assessed. There were no new skin problems noted and active range of motion and passive range of motion noted. [MEDICATION NAME] 100mg was given as was scheduled for complaints of both knee pain, and vital signs were documented, On 2/19/13 at 8:00am, telephone call was received from the doctor and was informed of the above and to see if an x-ray can be done. The doctor stated he didn ' t want her to have an x-ray done if the resident didn ' t fall on her knees, just to monitor her and call me if she has any changes. Report was given to 7am-3pm shift nurse. On 2/19/13 at 9am while in wheel in dining room the resident continues to complain of pain to right leg, receives [MEDICATION NAME] as scheduled, without distress noted, and vital signs were taken. Review of the facility's Physician Telephone orders revealed the following: - Dated 2/20/13 revealed an order for [REDACTED]. -dated 2/24/13 at 10:00am revealed STAT (immediate) x-ray to right lower extremity and hip to foot to rule out fracture and pain and swelling. In an interview on 3/5/12 at 3:20pm, S13/Social Service Director stated that she tried to get an appointment for Resident#3 through the normal process of using the automated telephone system and was not able to get an appointment until approximately 6 weeks. She stated that she felt the situation was urgent because of the report, but she did not try again to schedule an appointment. In an interview on 3/5/13 at 2:45PM, S8/LPN stated that the resident's pain increased after the incident of the fall, and she had gotten an order to give her [MEDICATION NAME], a pain medication. She further stated as far as an orthopedic consult that would have been up to the social service. Review of the facility's Departmental Notes dated 2/26/12 at 4:51am, revealed it was a late entry dated for 2/21/13 at approximately 9:15am. Review of this note revealed it was written per S6/RN and while she was making rounds she noted Resident #3 in bed consuming breakfast in a slumped over position. The resident had a bruise to her right shoulder; bruise was purple in appearance with a yellow border. The resident was not sure how she obtained bruise. S6/RN spoke with S8/LPN who was unaware of bruise. Resident was due for a body audit the previous day and on the audit revealed there were no new skin issues. S6/LPN went to S2/DON and went further assess the resident. Noted dry patch to mid area of chest, redness to breast, discoloration to bilateral lower extremities as well as bruise to right shoulder. Resident was upright position supine in bed with right ankle crossed over left leg. Resident complained of pain during assessment in which time S8/LPN administered as needed pain medication per doctor orders. Review of Physician Medical Orders for Resident #3 dated February 2013 revealed the [MEDICATION NAME], pain medication, which was given three times a day for Generalized Pain. Review of Resident #3's Medications form revealed [MEDICATION NAME] was given 8am, 12pm, and 8pm, three times a day. Review of the facility's Weekly Skin Assessment form for Resident #3 dated 1/16/13 at 8:30am revealed no new skin problems noted. The form dated 1/23/13 at 7:30pm revealed skin intact. There were no other noted documented findings. In an interview on 3/6/13 at 11:40am, S6/RN stated that they did not assess the resident on her back side that day she just assessed the front part of the resident's body and the resident had lower discoloration to both front part of her legs and we stopped the assessment after the resident complained of pain too much. In an interview on 3/6/13 at 11:45am, S2/DON stated after reviewing the above departmental note dated 2/21/13 at approximately 9:15am; she stated she did not do an assessment of the residents back sides of her body and/or legs. Review of the facility's Nurses Notes revealed, in part, the following: -dated 2/24/13 at 11:00am revealed family concerned regarding Resident #3's continued complaint of pain to right lower extremity. The nurse observed swelling to area. The doctor ' s nurse requested stat (immediate) x-ray to right lower extremity for pain and swelling and to rule out fracture. The call was placed to the x-ray company, -dated 2/24/13 at 1:40pm revealed the resident's x-ray to her right lower extremity was done. The findings were acute minimally commuted [MEDICAL CONDITION] femur just above the total knee prosthesis well -seated in the proximal tibia (broken thigh bone above the resident ' s prosthetic knee). -dated 2/24/13 at 2:05pm revealed the doctor returned call and was made aware of x-ray results and the doctor ordered to send the resident to the hospital, -dated 2/24/13 at 2:51pm revealed the resident was sent to hospital by ambulance. Review of Facility's Medications Record for March 2013 revealed [MEDICATION NAME] 5/325mg by mouth every 6 hours as needed for pain with a start date of 2/20/13. Further review revealed on 2/22/13 there were 2 initials documented for giving the pain medication. There was no time documented for when one pain medication was given on 2/22/13 and the other time located on the back of the form dated 2/22/13 revealed it was given at 6pm and 2 hours later at 8:00pm revealed the nurse assessed the residents pain as sleeping. On 2/24/13 at 9am revealed the medication was given for facial grimacing and the pain medication was assessed as not effective. Review of the record revealed there was no other documentation to show the resident had been assessed for pains every shift as per policy. There was no documentation that after Resident #3 was confirmed as having a fractured thigh bone that pain medication was given as needed. In an interview on 3/6/13 at 10:50am, S2/DON stated that there was no type of an assessment of Resident #3 related to her fall after 2/19/13 through 2/24/13. S2/DON stated she went and looked back through the record but could not find any more information. In an interview on 3/7/13 at 1:40pm, S2/DON stated that Resident #3 would not be able to use the call bell for help, but she could answer yes or no questions. The resident could also tell one if she was hurting more than her normal generalized pains. In an interview on 3/6/13 at 11:15am, with S2/DON and S1/Administrator present, S2/DON stated that the Resident's fractures were determined to be a result of the fall on 2/19/13. S1/Administrator stated that the result of the fracture was the result of the fall and per the emergency room doctor's stated the fracture was the result of the resident ' s fall.

Based on record review and interview the facility failed to provide the necessary care and services by not monitoring and assessing for pain for Resident #3 who fell on [DATE] and subsequently had a broken right thigh bone when she was sent to the hospital on [DATE]. This failure resulted in actual harm when the facilty failed to monitor Resident #3 by not assessing her after the initail fall and failure to advocate for her by assessing her for pain as per facility policy. This was for 1 of 4 residents that had fallen (#3) in a total sample of 5 residents (#1-#5). There were 133 total residents as listed on the facility's Resident Census and Conditions of Residents. Findings: Based on record review and interview the facility failed to ensure services provided by the facility met professional standards by falling to: 1) assess Resident #3 after her initial fall on 2/19/13 to monitor for changes as ordered and/or as needed, 2) failed to adequately assess Resident #3 for injury and/or pain as needed and as per policy. This resulted in actual harm when Resident #3 was injured in a fall with a subsequent broken right thigh bone and was not assessed as needed to monitor for injuries related to the fall and failed to assess her as needed for pain. This was for 1 of 4 residents (#3) that had fallen in a total sample of 5 residents (#1-#5). There were 133 total residents as documented on the Resident Census and Conditions of Residents. Findings: Review of the Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3703: Revealed, in part, section a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient care problems. This assessment shall be utilized to assist in determining which task may be delegated and the amount of supervision which will be required. The patient's status is safe for the person to carry out the task. Review of the section titled Executing HealthCare Regime as Prescribed by a Licensed Physician, Dentist, or Authorized Prescriber revealed the registered nurse shall carry out the medical orders of a physician, dentist or other authorized prescriber licensed in Louisiana. Review of the section titled Managing and Supervising the Practice of Nursing revealed the registered nurse when delegating task, shall be accountable for providing information needed by personnel for the implementation of the assigned nursing care and ascertaining the assimilation of same information. Review of Louisiana Administrative Code, Professional Occupational Standards, Title 46, Part XLVII, 3909: Standard Number 4: Implementation of Nursing Care Plan A2 revealed the nurse must ensure the nursing care plan interventions are implemented in a safe and appropriate manner. Review of the Facility's Pain Screen and Management form revealed, in part, all residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]. A pain scale is used whereby resident describes his/pain and amount of pain relief, A plan for pain and symptom management is developed based upon collected data in collaboration with the appropriate interdisciplinary care team members, which includes the resident and family as needed. Acute onset of pain: a pain screen is developed when a resident has a new onset of pain, a new type of pain or breakthrough pain, and/or new pain medication has been added or changed, when documenting regarding pain the following elements should be assessed: Date and time of onset, location of pain, character, severity (must use pain scale) alleviation factors,(what makes it better), exacerbation factors (what makes it worse), treatments and medications, responses, documentation, using the pain scale, of a new pain, a pain medication and/or treatment change is done every shift until the pain is managed effectively. Once the pain is managed effectively, document daily using the pain scale for two days, then document medication usage as appropriate as changes occur. Documentation includes location of pain medication, medication given and its effects using the pain scale plus any concerns about side effects. Care plans are reviewed and changes are documented as appropriate. Review of the facility's Pain Screen dated 2/20/13 for Resident #3 revealed, in part, nonverbal expressions of pain were crying, facial grimacing, guarding/bracing/stiff, more leg and back pain than usual, medication for pain improves the pain, and movement makes the pain worse. Review of the hospital emergency room visit dated 2/24/13 revealed, in part, Resident #3 was a [AGE] year old female with a history of dementia and being wheel chair bound presents with acute worsening right lower extremity pain. Patient lives at a nursing home and fell this last Tuesday when an aide attempted to assist her from the wheel chair to bed. Patient fell on to her right side at that time, and there was no head trauma or loss of consciousness. The patient has an obvious deformity and had been more agitated than usual. It was not until today the nursing home obtained x-rays of her leg and found a fracture. Physical exam section revealed right leg externally rotated and shortened. The right lower extremity had ecchymosis on inside aspect of knee down to her lower extremity to her ankle area. There was skin breakdown on the right posterior calf with surrounding redness and no discharge. Review of the facility's Nurses Notes for Resident #3 revealed the following: On 2/19/13 at 7am revealed the resident was on the floor and was lying on a gray floor mat next to her roommate ' s bed. S3/C.N.A. reported to the nurse that she was transferring the resident from her bed to her wheelchair and the resident ' s legs gave out and S3/C.N.A then slid the resident to the floor. Resident #3 complained of both knees having pain. The resident was assessed. There were no new skin problems noted and active range of motion and passive range of motion noted. [MEDICATION NAME] 100mg was given as was scheduled for complaints of both knee pain, and vital signs were documented, On 2/19/13 at 8:00am, telephone call was received from the doctor and was informed of the above and to see if an x-ray can be done. The doctor stated he didn ' t want her to have an x-ray done if the resident didn ' t fall on her knees, just to monitor her and call me if she has any changes. Report was given to 7am-3pm shift nurse. On 2/19/13 at 9am while in wheel in dining room the resident continues to complain of pain to right leg, receives [MEDICATION NAME] as scheduled, without distress noted, and vital signs were taken. Review of the facility's Physician Telephone orders revealed the following: - Dated 2/20/13 revealed an order for [REDACTED]. -dated 2/24/13 at 10:00am revealed STAT (immediate) x-ray to right lower extremity and hip to foot to rule out fracture and pain and swelling. In an interview on 3/5/12 at 3:20pm, S13/Social Service Director stated that she tried to get an appointment for Resident#3 through the normal process of using the automated telephone system and was not able to get an appointment until approximately 6 weeks. She stated that she felt the situation was urgent because of the report, but she did not try again to schedule an appointment. In an interview on 3/5/13 at 2:45PM, S8/LPN stated that the resident's pain increased after the incident of the fall, and she had gotten an order to give her [MEDICATION NAME], a pain medication. She further stated as far as an orthopedic consult that would have been up to the social service. Review of the facility's Departmental Notes dated 2/26/12 at 4:51am, revealed it was a late entry dated for 2/21/13 at approximately 9:15am. Review of this note revealed it was written per S6/RN and while she was making rounds she noted Resident #3 in bed consuming breakfast in a slumped over position. The resident had a bruise to her right shoulder; bruise was purple in appearance with a yellow border. The resident was not sure how she obtained bruise. S6/RN spoke with S8/LPN who was unaware of bruise. Resident was due for a body audit the previous day and on the audit revealed there were no new skin issues. S6/LPN went to S2/DON and went further assess the resident. Noted dry patch to mid area of chest, redness to breast, discoloration to bilateral lower extremities as well as bruise to right shoulder. Resident was upright position supine in bed with right ankle crossed over left leg. Resident complained of pain during assessment in which time S8/LPN administered as needed pain medication per doctor orders. Review of Physician Medical Orders for Resident #3 dated February 2013 revealed the [MEDICATION NAME], pain medication, which was given three times a day for Generalized Pain. Review of Resident #3's Medications form revealed [MEDICATION NAME] was given 8am, 12pm, and 8pm, three times a day. Review of the facility's Weekly Skin Assessment form for Resident #3 dated 1/16/13 at 8:30am revealed no new skin problems noted. The form dated 1/23/13 at 7:30pm revealed skin intact. There were no other noted documented findings. In an interview on 3/6/13 at 11:40am, S6/RN stated that they did not assess the resident on her back side that day she just assessed the front part of the resident's body and the resident had lower discoloration to both front part of her legs and we stopped the assessment after the resident complained of pain too much. In an interview on 3/6/13 at 11:45am, S2/DON stated after reviewing the above departmental note dated 2/21/13 at approximately 9:15am; she stated she did not do an assessment of the residents back sides of her body and/or legs. Review of the facility's Nurses Notes revealed, in part, the following: -dated 2/24/13 at 11:00am revealed family concerned regarding Resident #3's continued complaint of pain to right lower extremity. The nurse observed swelling to area. The doctor ' s nurse requested stat (immediate) x-ray to right lower extremity for pain and swelling and to rule out fracture. The call was placed to the x-ray company, -dated 2/24/13 at 1:40pm revealed the resident's x-ray to her right lower extremity was done. The findings were acute minimally commuted [MEDICAL CONDITION] femur just above the total knee prosthesis well -seated in the proximal tibia (broken thigh bone above the resident ' s prosthetic knee). -dated 2/24/13 at 2:05pm revealed the doctor returned call and was made aware of x-ray results and the doctor ordered to send the resident to the hospital, -dated 2/24/13 at 2:51pm revealed the resident was sent to hospital by ambulance. Review of Facility's Medications Record for March 2013 revealed [MEDICATION NAME] 5/325mg by mouth every 6 hours as needed for pain with a start date of 2/20/13. Further review revealed on 2/22/13 there were 2 initials documented for giving the pain medication. There was no time documented for when one pain medication was given on 2/22/13 and the other time located on the back of the form dated 2/22/13 revealed it was given at 6pm and 2 hours later at 8:00pm revealed the nurse assessed the residents pain as sleeping. On 2/24/13 at 9am revealed the medication was given for facial grimacing and the pain medication was assessed as not effective. Review of the record revealed there was no other documentation to show the resident had been assessed for pains every shift as per policy. There was no documentation that after Resident #3 was confirmed as having a fractured thigh bone that pain medication was given as needed. In an interview on 3/6/13 at 10:50am, S2/DON stated that there was no type of an assessment of Resident #3 related to her fall after 2/19/13 through 2/24/13. S2/DON stated she went and looked back through the record but could not find any more information. In an interview on 3/7/13 at 1:40pm, S2/DON stated that Resident #3 would not be able to use the call bell for help, but she could answer yes or no questions. The resident could also tell one if she was hurting more than her normal generalized pains. In an interview on 3/6/13 at 11:15am, with S2/DON and S1/Administrator present, S2/DON stated that the Resident's fractures were determined to be a result of the fall on 2/19/13. S1/Administrator stated that the result of the fracture was the result of the fall and per the emergency room doctor's stated the fracture was the result of the resident ' s fall.