Every finding on record at Southeast Louisiana War Veterans Home

Based on observations and interview, the facility failed to ensure medication was stored in a locked compartment. Findings:Observation on 09/10/2025 at 1:57PM revealed a cart containing Resident #1's insulin aspart (a rapid acting medication used to lower a resident's blood sugar) 100 units (U)/milliliter (ml) vial was stored behind the facility's opened and unlocked nursing station and not inside the facility's locked medication room. Observation on 09/11/2025 at 8:55AM to 8:58AM revealed the above mentioned cart was stored behind the facility's opened and unlocked nursing station and not inside the facility's locked medication room. Further observation revealed no staff was present to supervise the medication. Observation on 09/11/2025 at 11:27AM revealed the above mentioned cart was stored behind the facility's opened and unlocked nursing station and not inside the facility's locked medication room. Further observation revealed no staff was present to supervise the medication. In an interview on 09/11/2025 at 11:27AM, S1Director of Nursing (DON) confirmed the above mentioned cart was in the facility's opened, unlocked, and unstaffed nursing station. S1DON further acknowledged the resident's insulin should not be accessible to unauthorized staff.

Based on record reviews and interview the facility failed to electronically submit accurate payroll information for direct care staffing as required for the 1st Quarter of 2024 Fiscal Year (October 1, 2023 through December 31, 2023). Findings: Review of the facility's Payroll Base Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year Quarter 1 2024 (October 1, 2023-December 31, 2023) revealed, in part, the facility triggered for having no Registered Nurse hours and failed to have Licensed Nursing Coverage 24 hours/day. Review of staffing patterns for the time period of October 1, 2023-December 31, 2023 revealed the facility had a Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant working on the skilled unit on all of the days triggered: 10/01/2023; 10/07/2023; 10/08/2023; 10/13/2023; 10/14/2023; 10/15/2023; 10/21/2023; 10/26/2023; 10/27/2023; 10/28/2023; 10/29/2022; 11/04/2023; 11/10/2023; 11/11/2023; 11/12/2023; 11/18/2023; 11/19/2023; 11/20/2023; 11/23/2023; 11/24/2023; 11/25/2023; 11/26/2023; 12/01/2023; 12/02/2023; 12/03/2023; 12/08/2023; 12/09/2023; 12/10/2023; 12/11/2023; 12/16/2023; 12/17/2023; 12/18/2023; 12/22/2023; 12/23/2023; 12/24/2023; and 12/30/2023. In an interview on 05/21/2024 at 2:10 p.m., S1Administrator indicated the staffing reporting program used by the facility did not accurately code the direct care staff who worked the skilled nursing unit during the 1st Quarter of 2024 and he was aware the payroll base journal staffing information was not reported accurately as required.

Based on record review and interviews the facility failed to electronically submit payroll information for direct care staffing as required. Findings : Review of the facility's Payroll Base Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year Quarter 1 2023 (October 1-December 31) revealed, in part, the facility failed to submit staffing data for the quarter. In interview on 03/07/2023 at 10:15 a.m ., S3Human Resource Director stated the Human Resource department does not submit the payroll staffing data report to the Centers for Medicare & Medicaid Services (CMS). In interview on 03/07/2023 at 10:36 a.m ., S2Director of Nurses stated the facility had not reported the payroll base journal staffing information to CMS as required. In interview on 03/07/2023 at 12:10 p.m ., S1Administrator stated he was aware the payroll base journal staffing information was not reported as required.

Based on record review and interview, the facility failed to ensure the resident, the resident's representative, and the Office of the State Ombudsman had been notified in writing of the transfer or discharge and the reasons for the move for 3 (#5, #108, and #111) of 3 (#5, #108, and #111) residents reviewed for hospitalization s out of a total of 10 (#2, 5, 7, 10, 58, 59, 108, 109, 110, and 111) sampled residents. Findings: Resident #108 Record review on 09/25/18 at 03:15 PM revealed that Resident #108 was hosptalized on [DATE] for chest pains. Record review revealed no documented evidence of a written notice of transfer submitted/mailed to Resident #108, Resident #108's representative, or to the State Ombudsman for the 09/18/2018 transfer to the hospital. During an interview with S1DON (Director of Nurses) on 09/26/2018 at 11:25 AM, she confirmed she was not aware of the regulatory components related to notice of transfer. She confirmed she did not send written notice of transfer to Resident #108, Resident #108's representative, or copy the State Ombudsman. Resident #111 Record review on 09/25/18 at 03:59 PM revealed that Resident #111 was hosptalized on [DATE] for altered level of consciousness. Record review revealed no documented evidence of a written notice of transfer submitted/mailed to Resident #111, Resident #111's representative, or to the State Ombudsman for the 09/17/2018 transfer to the hospital. During an interview with S1DON on 09/26/2018 at 11:25 AM, she confirmed she was not aware of the regulatory components related to notice of transfer. She confirmed she did not send written notice of transfer to Resident #111, Resident #111's representative, or copy the State Ombudsman. Resident #5 Review of Resident #5's medical record with S2LPN (Licensed Practical Nurse) on 9/26/18 at 11:32 AM revealed Resident #5 was transferred to the hospital on [DATE] due to vomiting in relation to a history of recurrent bowel obstruction. There was no written notice of hospital transfer on 9/8/18 given to the resident, the resident's representative or copy to the State Ombudsman's office. S2LPN stated that only the families were notified by telephone when a resident was sent out to the hospital. During interview with S4ADON (Assistant Director of Nurses) and S3MDS (Minimum Data Set) Coordinator on 9/26/18 at 11:34 AM, S4ADON and S3MDS Coordinator confirmed that the facility did not have documented evidence that a written notice of transfer was given to the resident and his representative with copy submitted to the State Ombudsman's office.

Based on interview and record review the facility failed to ensure a resident was free from accident hazards as much as possible by failing to ensure a resident identified as being at risk for falls was monitored and received adequate supervision for the effectiveness of existing interventions and/or revised the plan of care with measurable interventions as necessary, in order to reduce future falls. This deficient practice was identified for 2 (Resident #40 and Resident #43) of 3 (Resident #24, Resident #40, and Resident #43) Stage 2 sampled residents reviewed for accidents in at total Stage 2 sample of 21, but had the potential to affect any of the 18 residents who reside at the facility and may sustain a fall as documented on the CMS Form-672 Resident Census and Conditions of Residents. Findings: Resident #40: Review of Resident #40's clinical record revealed in part, that he was identified as being severely cognitively impaired, at being at high risk for falls, and that a plan of care was developed to prevent future falls on 01/26/16. Review of Resident #40's Care Plan for falls revealed it included to encourage Resident #40 to use the call light for assistance, to provide education including safety reminders and what do if a fall occurs, and to frequently reinforce education of using his call bell before attempting to ambulate. Further review revealed on 06/06/17, a fall intervention was added to the plan of care to monitor Resident #40 closely, but this intervention was not measurable as it did not identify how often to monitor Resident #40. Review of Resident #40's Care Plan revealed that Resident #40 sustained a fall in his room on 02/06/17, a fall at bedside on 02/28/17, a fall in his room on 05/08/17, an unwitnessed fall on 06/06/17 in the day room, an unwitnessed fall in the day room on 6/15/17, and was found sitting on his floor mat next to his bed on 10/01/17 and on 10/08/17. Further review revealed the care plan was not revised to include new intervention and/or a measurable intervention to increase Resident #40's supervision for the above mentioned falls. In interview on 10/25/17 at 10:00am, S5/Licensed Practical Nurse (LPN) indicated Resident #40 was cognitively impaired and was unable to use a call button. S5/LPN further indicated Resident #40 was assisted to the dining/activity area when not in bed for constant supervision. In interview on 10/25/17 at 10:20am, S4/LPN indicated Resident #40 was severely cognitively impaired and was incapable of using call bell. S4/LPN further indicated Resident #40 was encouraged to be active and was assisted to the dining/activity area where he would have constant supervision. In interview on 10/25/17 at 12:45pm, S6/Certified Nursing Assistant (CNA) indicated Resident #40's memory was not good. S6/CNA further indicated she observed the resident at least every 2 hours and since readmission in late September, he has been encouraged to stay around dining/activity area and not in room by himself. There was no documented evidence and the facility did not present any documented evidence that new and/or individualized interventions were developed after Resident #40's above mentioned falls. There was no documented evidence and the facility did not present any documented evidence that a measurable intervention was developed and implemented which increased supervision of Resident #40 while in his room to prevent future falls. Resident #43: Review of Resident #43's clinical record revealed, in part that he was identified as being severely cognitively impaired, at being at high risk for falls with a plan of care developed to prevent future falls on 08/16/17. Review of Resident #43's Care Plan for falls revealed it included to encourage Resident #43 to use the call light for assistance. Further review revealed that Resident #43 sustained a fall on 09/04/17 at 10:00pm in the day room, and sustained another fall in the day room on 09/08/17. Further review revealed the care plan was not revised to include a new intervention after these falls. In interview on 10/25/17 at 10:24am, S4/LPN indicated Resident #43 was severely cognitively impaired and was incapable of using call button. S4/LPN further indicated Resident #43 was assisted to the dining and activity area where resident could be observed. In interview on 10/25/17 at 12:38pm, S6/CNA indicated Resident #43's memory was not good and Resident #43 was wheeled to the dining/activity area during day. There was no documented evidence and the facility did not present any documented evidence that new and/or individualized interventions were developed after Resident #43's above mentioned falls. There was no documented evidence and the facility did not present any documented evidence that a measurable intervention which increased supervision of Resident #43 to prevent future falls was developed and implemented. In Interview on 10/25/17 at 1:21pm S3/Minimum Data Set (MDS)/Care Plan Nurse reviewed Resident #40 and Resident #43's Care Plan and indicated there were no new and/or individualized interventions implemented after the above mentioned falls. S3/MDS/Care Plan Nurse further indicated that Resident #40 and Resident #43 were cognitively impaired and unable to use the call bell; therefore, the intervention of educating or reminding them to use the call bell was unrealistic. S3/MDS/Care Plan Nurse was asked about the supervision for the above mentioned residents and S3/MDS/Care Plan Nurse indicated supervision had been increased and that's why they were placed in the day room, but acknowledged that there was not an increase in supervision while they were in their rooms and acknowledged that several falls had occurred in Resident #40's room.

Based on record review and interview the facility failed to notify the physician and/or family/responsible party of a significant change in condition and/or treatment by: 1) failing to notify the physician of the development of new wounds (Resident #4); 2) failing to notify the family/Responsible party (RP) of the development of new wounds (Resident #4); and 3) failing to inform the family/RP of a change in treatment of [REDACTED].#50). This deficient practice was identified for 2 (Resident #4 and Resident #50) of 3 Resident #4, Resident #44 and Resident #50) Stage 2 sampled residents reviewed for pressure ulcers in a total Stage 2 sample of 27. This had the potential to affect any of the 34 residents who may develop pressure ulcers as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. Findings: Resident #4 Review of Resident #4 ' s record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 started receiving Hospice services on 01/12/16. Review of Resident #4 ' s wound assessment report dated 10/11/16 revealed new pressure area, deep tissue injury (DTI) on lumbar back with no documentation of family/RP or physician being notified of new wound. Further review of the wound assessment report revealed a resolved date for DTI to lumbar back area on 10/26/16. On 11/17/16 at 2:30pm Resident #4 ' s wound care treatment was observed with S6/Licensed Practical Nurse (LPN). Observation revealed dressing and wounds to lumbar area and right scapula area. Lumbar wound with white colored coating on wound bed and right scapula wound with black colored coating on wound bed. Review of nurse ' s notes dated 10/26/16 through 11/16/16 revealed no documentation of Resident #4 ' s physician and family/RP being notified of new wounds to lumbar area and right scapula area that developed after DTI to lumbar area resolved on 10/26/16. In interview on 11/18/16 at 2:15pm S7/Registered Nurse (RN)/Program Coordinator stated she resolved Resident #4 ' s DTI to lumbar area on 10/26/16 and she failed to remove the orders for the DTI to lumbar area on the TAR. S7/RN/Program Coordinator stated she was not notified of a change in Resident #4 ' s skin condition and development of two new wounds to Resident #4 ' s lumbar and right scapula area until 11/17/16. S7/RN/Program Coordinator stated the staff nurses and Certified Nursing Assistant's should report any changes in a Resident ' s skin to her. Review of Resident #4's wound assessment reports from 11/1/16 through 11/16/16 revealed no documentation of the physician and family/RP being notified of new wounds to the lumbar and right scapula area. In interview on 11/18/16 at 11:30am S2/DON confirmed S7/RN/Program Coordinator was not documenting the physician and family/RP being notified with changes in Resident #4's wounds after reviewing Resident #4 ' s nurse ' s notes for November 2016. In interview on 11/18/16 at 2:40pm S2/DON stated the physician notification of pressure ulcer status and changes in skin condition to the physician and family/RP should be documented in the nurse's notes. S2/DON stated if it's not in the nurse's notes then it wasn't done. There was no documented evidence and the facility did not present any further evidence of the physician and family/RP being notified of a change in Resident's skin condition after 10/26/16. Resident #50 Review of Resident #50 ' s record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of record revealed Resident #50 was readmitted to facility on 07/01/16 with two Stage 2 sacral wounds to right and left buttocks. Documentation revealed physician was notified of sacral wounds on 07/01/16; however no documentation of the family/RP being notified of Resident #50 ' s sacral wounds. Review of record revealed Resident #50 was transferred out to a hospital on [DATE] and readmitted to facility on 7/15/16. Review of wound assessment report dated 07/15/16 revealed resident with two Stage 2 sacral wounds to right and left buttocks. Documentation revealed wound resolved to left buttocks on 07/22/16. Further review of documentation revealed physician was notified, but no documentation of family notification of pressure ulcers. Review of physician orders [REDACTED]. Review of wound assessment reports dated August 2016 through November 2016 revealed no documentation of family/RP being notified of Resident #50 ' s sacral wound status and no documentation of physician notification of sacral wound status. In interview on 11/17/16 at 3:00pm S4/Medicare Registered Nurse (RN) stated she admitted Resident #50 and remembers calling his wife about his pressure ulcer, but didn't document it. S4/Medicare RN stated S7/RN/Program Coordinator was the RN that performs the staging of wounds and S7/RN/Program Coordinator would be the person to call the family/RP to report any change in treatment. In interview on 11/18/16 at 11:45pm S7/RN/Program Coordinator stated she stages each wound weekly and she would notify the family/RP with any changes in treatment orders with wounds. S7/RN/Program Coordinator reviewed Resident #50 ' s record and documentation and stated she did not have documentation of the telephone contacts with Resident #50's wife concerning the change in treatment and status of the sacral pressure ulcer. In telephone interview on 11/18/16 at 2:15pm Resident #50's RP confirmed that the facility staff was not communicating updates on Resident #50's sacral pressure ulcer or changes in his wound care treatment.

Based on observation, interview, and record review the facility failed to ensure a resident's Care Plan was revised to meet the resident's by: 1.) failing to ensure a resident's plan of care was revised when a resident's wound was resolved (Resident #4); 2.) failing to ensure a resident's plan of care was revised after new unstageable wounds were discovered to a resident's lumbar and right scapula area (Resident #4); and 3.) failing to ensure a resident's plan of care was revised with new interventions after a resident sustained [REDACTED]. This deficient practice was identified for 2 (Resident #4 and Resident #66) of 27 (Resident #60, Resident #61, Resident #65, and Resident #66) Stage 2 sampled residents reviewed for accidents in a total Stage 2 sample of 27, but had the potential to affect any of the 34 residents who reside in the facility as documented on the facility's Resident Census and Conditions of Residents. Findings: Resident #4 Review of Resident #4's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 started receiving Hospice services on 01/12/16. Review of Resident #4's wound assessment report dated 10/11/16 revealed new pressure area, deep tissue injury (DTI) on lumbar back. Further review of the wound assessment report revealed a resolved date for DTI to lumbar back area on 10/26/16. Review of Resident #4's Treatment Administration Record (TAR) dated 10/19/16 through 11/17/16 revealed an order for [REDACTED]. Review of weekly skin assessment dated [DATE] and 11/09/16 revealed no new skin issues. Review of October 2016 and November 2016 nurse's notes revealed no documentation of new wounds to lumbar and right scapula area. In interview on 11/18/16 at 2:15pm S7/Registered Nurse (RN)/Program Coordinator stated she resolved Resident #4's DTI to lumbar area on 10/26/16 and she failed to remove the orders for the DTI to lumbar area on the October 2016 TAR. S7/RN/Program Coordinator stated she was not notified of a change in Resident #4's skin condition and development of two new wounds to Resident #4's lumbar and scapula area until 11/17/16. S7/RN/Program Coordinator stated the staff nurses and Certified Nursing Assistant's should report any changes in a Resident's skin to her. S7/RN/Program Coordinator stated she failed to revise the care plan when the DTI to lumbar area resolved on 10/26/16 and failed to revise the plan of care when Resident #4 developed two new unstageable wounds to lumbar and right scapula area. On 11/17/16 at 2:30pm Resident #4's wound care treatment was observed with S6/Licensed Practical Nurse (LPN). Pink colored dressing was intact to lumbar and right scapula area dated 11/15/16. Review of Resident #4's record revealed unsigned physician order [REDACTED]. Review of Resident #4's care plan revealed no documentation of a care plan revision when Resident #4's lumbar wound was resolved on 10/26/16 and new unstageable wounds identified to lumbar and right scapula area on 11/17/16 by S7/RN/Program Coordinator. Resident #66: Review of Resident #66's clinical record revealed in part, that he was admitted to the facility on [DATE] after a hospitalization for a fall prior to admit which resulted in a Left Subdural Hematoma. Further review revealed Resident #66 was identified as at high risk for falls with a Care Plan developed for being at high risk for falls related to a history of frequent fall, poor safety awareness secondary to cognitive deficit. Review of Resident #66's 14 day Minimum Data Set with a reference date of 10/23/16, revealed in part, that Resident #66 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2. Observation on 11/17/16 at 8:30am, revealed Resident #66 was in his room alone, lying in his bed. In interview on 11/16/16 at 2:00pm, S5/LPN indicated Resident #66 falls just about daily. S5/LPN was then asked if Resident #66 was receiving constant supervision/1:1 monitoring, and S5/LPN indicated Resident #66 was not. Review of Resident #66's Nurse's Notes revealed in part, that Resident #66 had sustained the following falls: 10/11/16 at 6:00am, revealed Resident #66 was found on the floor of his bathroom. Further review revealed a small contusion to the left side of his forehead was seen. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of reminding Resident #66 to call for help, bed alarm, mat on floor, and for staff to answer call lights, bed, and chair alarms quickly; 10/12/16 at 4:15pm, revealed that Resident #66 attempted to transfer himself from his wheelchair to use the bathroom, fell in his room, and was found lying on his side. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of increasing visual checks with no measureable times which indicated how often and who was to make visual checks on Resident #66; 10/15/16 at 1:15pm, revealed Resident #66 had a fall while attempting to get in bed without assistance while transferring himself from wheelchair to his bed. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of frequent toileting. 10/17/16 at 12:15pm, revealed Resident #66 was found on the bathroom floor. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of placing a door alarm on Resident #66's bedroom door to alert staff that Resident #66 was in his room; 10/22/16 at 4:30pm, revealed Resident #66 was found sitting on the floor next to his bed eating chips. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 10/22/16 fall; 10/24/16 at 3:45pm, revealed Resident #66 was found lying in left lateral position on the floor next to his bed which resulted in a skin tear to his left arm. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of increase supervision while awake, with no measureable times which indicated how often and who was to make visual checks on Resident #66; 10/26/16 at 4:50am, revealed Resident #66 was found on the floor outside of his room positioned on his left side and complaining of back pain. Further review revealed he also had a Hematoma to the left forehead, and a back and left arm injury. Review of Resident #66's Nurse's Notes dated 10/26/16 at 6:47am, revealed Resident #66 required 1:1 supervision to prevent falls in addition to all other preventive fall measures. There was no documented evidence and the facility did not present any documented evidence that 1:1 supervision was being done. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 10/26/16 fall; 11/05/16 at 3:15pm, revealed Resident #66 was found on the floor by another resident who then alerted staff. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/05/16 fall; 11/06/16 at 5:44pm, revealed Resident #66 was being transferred to the emergency room following an unwitnessed fall with head injury and left elbow and [MEDICAL CONDITION]. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/06/16 fall; and 11/17/16 at 9:16am, revealed Resident #66 was found on the floor in his room by the maintenance man. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/17/16 fall. There was no documented evidence and the facility did not present any documented evidence that Resident #66 had an increase in supervision which included measurable objectives and timetables. In interview on 11/18/16 at 12:35pm, S4/Medicare RN, indicated Resident #66 was identified as being at risk for falls since being admitted because during the admission process, Resident #66's family indicated he had 50+ falls prior to admit. S4/Medicare RN further indicated that new interventions were not put into place after every fall because everything that could be done was being done, that staff usually just puts him by nursing staff that was available to sit by him while they worked with no set time, but it was not one on one supervision. S4/Medicare RN also indicated that she now sees that other interventions and/or an increase in supervision which may include 1:1 supervision, if needed, could have been put in place to prevent Resident #66's falls.

Based on observation, interview, and record review the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care by failing to provide daily wound care treatment as ordered (Resident #4). This deficient practice was identified for 1 (Resident #4) of 3 (Resident #4, Resident #44 and Resident #50) Stage 2 sampled residents reviewed for pressure ulcers in a total Stage 2 sample of 27. This had the potential to affect any of the 34 residents who may develop pressure ulcers as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. Findings: Review of Resident #4's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 started receiving Hospice services on 01/12/16. Review of Resident #4's wound assessment report dated 10/11/16 revealed new pressure area, deep tissue injury (DTI) on lumbar back. Further review of the wound assessment report revealed a resolved date for DTI to lumbar back area on 10/26/16. Review of Resident #4's Treatment Administration Record (TAR) dated 10/19/16 through 11/17/16 revealed order for DTI lumbar back: paint daily with [MEDICATION NAME], leave open to air, until healed. Further review of documentation revealed wound care to DTI lumbar back performed daily from 10/19/16 through 11/16/16. In interview on 11/18/16 at 2:15pm S7/Registered Nurse (RN)/Program Coordinator stated she resolved Resident #4's DTI to lumbar area on 10/26/16 and she failed to remove the orders for the DTI to lumbar area on the October 2016 TAR. S7/RN/Program Coordinator stated she was not notified of a change in Resident #4's skin condition and development of two new wounds to Resident #4's lumbar and scapula area until 11/17/16. S7/RN/Program Coordinator stated the staff nurses and Certified Nursing Assistant's should report any changes in a Resident's skin to her. S7/RN/Program Coordinator stated the pressure ulcer dressing changes should be done daily; except for the sacral wound dressing with the [MEDICATION NAME] dressing, which was ordered to be done every two days. Review of November 2016 physician orders revealed daily wound care orders to DTI to right lateral foot, Stage 2 pressure ulcer to right lateral heel and DTI lumbar back until healed. Review of sacral wound care orders dated 10/20/16 revealed order to cleanse area with cotton tip swab and wound cleanser and pack lightly with maxisorb, cover with clean [MEDICATION NAME] dressing every two days until healed, prn for loose, soiled and drainage. Review of record on 11/17/16 at 3:00pm revealed no physician orders for the lumbar and right scapula wounds. Review of October 2016 TAR revealed no documentation of wound care treatments on the following dates: 10/07/16 and 10/11/16 -DTI to right lateral foot; 10/11/16- sacral wound Review of November 2016 TAR revealed documentation of wound care completed on 11/16/16 for all Resident #4's wounds. On 11/17/16 at 2:30pm Resident #4's wound care treatment was observed with S6/Licensed Practical Nurse (LPN). All dressings on each wound were pinkish in color and all dressings were dated 11/15/16. In interview on 11/17/16 at 2:45pm S6/LPN confirmed all wound dressings were dated 11/15/16 prior to wound care on 11/17/16. S6/LPN confirmed wound care treatment orders were daily and all wounds covered with border gauze except for the lumbar and right scapula wounds were left open to air during wound care on 11/17/16. S6/LPN stated she was not aware of the treatment order change for Resident's sacral wound on 10/20/16 to apply a [MEDICATION NAME] dressing and confirmed the sacral wound was covered with border gauze. In interview on 11/17/16 at 2:55pm S5/LPN stated she performed wound care on Resident #4 on 11/15/16 and used the [MEDICATION NAME] dressings on all her wounds. S5/LPN stated the [MEDICATION NAME] dressings can remain on for two days, but confirmed there was no change in orders to apply the [MEDICATION NAME] dressing to all wounds. S5/LPN stated she applied the [MEDICATION NAME] dressing to the lumbar and scapula wounds because they were draining and she didn't want to leave them open to air as ordered. In interview on 11/18/16 at 1:15pm S6/LPN stated she doesn't recall Resident #4's lumbar wounds ever resolving. S6/LPN stated if a wound resolves then S7/RN/Program Coordinator goes to the TAR and resolves the wound so the treatment was no longer performed. Review of Resident #4's care plan revealed problem addressed for actual skin impairment with deep tissue injury and sacral wound with approaches in part to perform wound care treatment as ordered by physician.

Based on observation, interview, and record review the facility failed to ensure a resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing by: 1.) failing to ensure a resident's development of a pressure sore was accurately assessed (Resident #4); 2.) failing to ensure a resident received daily wound care treatment as ordered (Resident #4); 3.) failing to ensure a Registered Dietician's recommendation was acted upon for a Resident with pressure sores (Resident #4); 4.) failing to ensure a plan of care was revised for a resident with a pressure ulcer (Resident #4); and 5) failing to ensure the physician was notified of a residents' change in wound status (Resident #4). This deficient practice was identified for 1 (Resident #4) of 3 (Resident #4, Resident #44 and Resident #50) Stage 2 sampled residents reviewed for pressure ulcers in a total Stage 2 sample of 27. This had the potential to affect any of the 34 residents who may develop pressure ulcers as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. Findings: Review of Resident #4's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 started receiving Hospice services on 01/12/16. Review of Resident #4's annual Minimum Data Sheet with an Assessment Reference Date of 09/19/16 revealed Resident #4 was at risk for pressure ulcers with one Stage 2 pressure ulcer with the oldest Stage 2 pressure ulcer since 09/28/15 and one unstageable Deep Tissue Injury. Treatments included pressure reducing device for chair and bed, turning/repositioning, nutrition/hydration, pressure ulcer care, application of nonsurgical dressing and applications of ointments/medications. Review of Resident #4's Braden scale dated 08/12/16 revealed a score of 13 (0-13 was high risk) Review of Resident #4's wound assessment report dated 10/11/16 revealed new pressure area, deep tissue injury (DTI) on lumbar back. Resident receiving Hospice services, poor oral intake, alternating air mattress on bed, foam heel protectors also in place, turning, status declining. Further review of the wound assessment report revealed a resolved date for DTI to lumbar back area on 10/26/16. Review of Resident #4's Treatment Administration Record (TAR) dated 10/19/16 through 11/17/16 revealed order for DTI lumbar back: paint daily with [MEDICATION NAME], leave open to air, until healed. Further review of documentation revealed wound care to DTI lumbar back performed daily from 10/19/16 through 11/16/16. Review of weekly skin assessment dated [DATE] and 11/09/16 revealed no new skin issues. Review of October 2016 and November 2016 nurse's notes revealed no documentation of DTI to lumbar back resolving and no documentation of new wounds to upper and lower lumbar back area. In interview on 11/18/16 at 2:15pm S7/Registered Nurse (RN)/Program Coordinator stated she resolved Resident #4's DTI to lumbar area on 10/26/16 and she failed to remove the orders for the DTI to lumbar area on the October 2016 TAR. S7/RN/Program Coordinator stated she was not notified of a change in Resident #4's skin condition and development of two new wounds to Resident #4's lumbar and scapula area until 11/17/16. S7/RN/Program Coordinator stated the staff nurses and Certified Nursing Assistant's should report any changes in a Resident's skin to her. S7/RN/Program Coordinator stated the pressure ulcer dressing changes should be done daily; except for the sacral wound dressing with the [MEDICATION NAME] dressing, which was ordered to be done every two days. S7/RN/Program Coordinator stated she failed to revise the care plan when the DTI to lumbar area resolved on 10/26/16. On 11/17/16 at 2:30pm Resident #4's wound care treatment was observed with S6/Licensed Practical Nurse (LPN). All dressings on each wound were pinkish in color and all dressings were dated 11/15/16. Review of November 2016 physician orders [REDACTED]. Review of sacral wound care orders dated 10/20/16 revealed order to cleanse area with cotton tip swab and wound cleanser and pack lightly with maxisorb, cover with clean [MEDICATION NAME] dressing every two days until healed, prn for loose, soiled and drainage. Review of October 2016 TAR revealed no documentation of wound care treatments on the following dates: 10/07/16 and 10/11/16 -DTI to right lateral foot; 10/11/16- sacral wound Review of November 2016 TAR revealed documentation of wound care completed on 11/16/16 for all Resident #4's wounds. In interview on 11/17/16 at 2:30pm S6/LPN confirmed all wound dressings were dated 11/15/16 prior to wound care on 11/17/16. S6/LPN confirmed wound care treatment orders were daily and all dressings used during wound care on 11/17/16 were border gauze. S6/LPN stated she was not aware of the treatment order change for Resident's sacral wound on 10/20/16 to apply a [MEDICATION NAME] dressing. In interview on 11/17/16 at 2:35pm S5/LPN stated she performed wound care on Resident #4 on 11/15/16 and used the [MEDICATION NAME] dressings on all her wounds. S5/LPN stated the [MEDICATION NAME] dressings can remain on for two days, but confirmed there was no change in orders to apply the [MEDICATION NAME] dressing to all wounds. S5/LPN stated she applied the [MEDICATION NAME] dressing to the lumbar and scapula wounds because they were draining and she didn't want to leave them open to air. In interview on 11/18/16 at 1:15pm S6/LPN stated she doesn't recall Resident #4's lumbar wounds ever resolving. S6/LPN stated if a wound resolves then S7/RN/Program Coordinator goes to the TAR and resolves the wound so the treatment was no longer performed. S6/LPN stated Resident #4's skin was declining due to her medical status. Review of Resident #4's record revealed unsigned physician order [REDACTED]. Review of Resident #4's care plan revealed problem addressed for actual skin impairment with no documentation of a care plan revision when Resident #4's lumbar wound was resolved on 10/26/16 and new unstageable wounds identified to lumbar and right scapula area on 11/17/16 by S7/RN/Program Coordinator. Review of the Registered Dietician (RD) assessment dated [DATE] revealed a recommendation to add appetite stimulant daily. Review of Resident #4's physician orders [REDACTED].>Review of Hospice routine visit notes dated September through November 2016 revealed no documentation of the RD recommendation for an appetite stimulant on 09/14/16. In interview on 11/18/16 at 9:00am S2/Director of Nursing (DON) stated the Hospice RN receives recommendations from the RD and the Hospice nurse would write the order for the physician to sign. S2/DON reviewed the physician orders [REDACTED]. In interview on 11/18/16 at 11:45am S7/RN/Program Coordinator stated when the RD makes a recommendation they notify the physician and the physician would write an order. When questioned if there was documentation of the communication to the physician concerning the appetite stimulant recommendation for Resident #4, S7/RN/Program Coordinator stated they normally don't document that. Review of Resident #4's wound assessment reports dated November 2016 revealed no documentation of the physician being notified of Resident #4's new unstageable wounds to the lumbar and right scapula area. Review of Resident #4's nurse's notes dated October and November 2016 revealed no documentation of the physician being notified of Resident #4's new unstageable wounds to lumbar and right scapula area. In interview on 11/18/16 at 11:30am S2/DON confirmed S7/RN/Program Coordinator was not documenting the physician being notified with changes in Resident #4's wounds. In interview on 11/18/16 at 2:40pm S2/DON stated the physician notification of pressure ulcer status and changes in skin condition to the physician should be documented in the nurse's notes. S2/DON stated if it's not in the nurse's notes then it wasn't done. There was no documented evidence and the facility did not present any further evidence of the physician being notified of a change in Resident's skin condition after 10/26/16.

Based on observation, interview, and record review the facility failed to ensure a resident remains free of accident hazards as is possible and/or that each resident received adequate supervision and assistive devices to prevent accidents by: 1.) failing to ensure a resident's plan of care was revised with new interventions after a resident sustained [REDACTED]. 2.) failing to ensure a resident received adequate supervision to prevent falls (Resident #66); and 3.) failing to ensure a resident with a history of multiple falls was monitored for the effectiveness of his plan of care with modified interventions when necessary (Resident #66). This deficient practice was identified for 1 (Resident #66) of 4 (Resident #60, Resident #61, Resident #65, and Resident #66) Stage 2 sampled residents reviewed for accidents in a total Stage 2 sample of 27, but had the potential to affect any of the 34 residents who reside in the facility as documented on the facility's Resident Census and Conditions of Residents. Findings: Review of Resident #66's clinical record revealed in part, that he was admitted to the facility on [DATE] after a hospitalization for a fall prior to admit which resulted in a Left Subdural Hematoma. Further review revealed Resident #66 was identified as at high risk for falls with a Care Plan developed for being at high risk for falls related to a history of frequent fall, poor safety awareness secondary to cognitive deficit. Review of Resident #66's 14 day Minimum Data Set with a reference date of 10/23/16, revealed in part, that Resident #66 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2. Observation on 11/17/16 at 8:30am, revealed Resident #66 was in his room alone, lying in his bed. In interview on 11/16/16 at 2:00pm, S5/LPN indicated Resident #66 falls just about daily. S5/LPN was then asked if Resident #66 was receiving constant supervision/1:1 monitoring, and S5/LPN indicated Resident #66 was not. Review of Resident #66's Nurse's Notes revealed in part, that Resident #66 had sustained the following falls: 10/11/16 at 6:00am, revealed Resident #66 was found on the floor of his bathroom. Further review revealed a small contusion to the left side of his forehead was seen. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of reminding Resident #66 to call for help, bed alarm, mat on floor, and for staff to answer call lights, bed, and chair alarms quickly; 10/12/16 at 4:15pm, revealed that Resident #66 attempted to transfer himself from his wheelchair to use the bathroom, fell in his room, and was found lying on his side. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of increasing visual checks with no measureable times which indicated how often and who was to make visual checks on Resident #66; 10/15/16 at 1:15pm, revealed Resident #66 had a fall while attempting to get in bed without assistance while transferring himself from wheelchair to his bed. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of frequent toileting. 10/17/16 at 12:15pm, revealed Resident #66 was found on the bathroom floor. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of placing a door alarm on Resident #66's bedroom door to alert staff that Resident #66 was in his room; 10/22/16 at 4:30pm, revealed Resident #66 was found sitting on the floor next to his bed eating chips. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 10/22/16 fall; 10/24/16 at 3:45pm, revealed Resident #66 was found lying in left lateral position on the floor next to his bed which resulted in a skin tear to his left arm. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated the new intervention consisted of increase supervision while awake, with no measureable times which indicated how often and who was to make visual checks on Resident #66; 10/26/16 at 4:50am, revealed Resident #66 was found on the floor outside of his room positioned on his left side and complaining of back pain. Further review revealed he also had a Hematoma to the left forehead, and a back and left arm injury. Review of Resident #66's Nurse's Notes dated 10/26/16 at 6:47am, revealed Resident #66 required 1:1 supervision to prevent falls in addition to all other preventive fall measures. There was no documented evidence and the facility did not present any documented evidence that 1:1 supervision was being done. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 10/26/16 fall; 11/05/16 at 3:15pm, revealed Resident #66 was found on the floor by another resident who then alerted staff. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/05/16 fall; 11/06/16 at 5:44pm, revealed Resident #66 was being transferred to the emergency room following an unwitnessed fall with head injury and left elbow and head laceration. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/06/16 fall; and 11/17/16 at 9:16am, revealed Resident #66 was found on the floor in his room by the maintenance man. In interview on 11/18/16 at 12:35pm, S4/Medicare Nurse reviewed the record and Care Plan with the surveyor and indicated Resident #66's plan of care was not revised with a new intervention to prevent future falls after his 11/17/16 fall. There was no documented evidence and the facility did not present any documented evidence that Resident #66 had an increase in supervision which included measurable objectives and timetables. In interview on 11/18/16 at 12:35pm, S4/Medicare RN, indicated Resident #66 was identified as being at risk for falls since being admitted because during the admission process, Resident #66's family indicated he had 50+ falls prior to admit. S4/Medicare RN further indicated that new interventions were not put into place after every fall because everything that could be done was being done, that staff usually just puts him by nursing staff that was available to sit by him while they worked with no set time, but it was not one on one supervision. S4/Medicare RN also indicated that she now sees that other interventions and/or an increase in supervision which may include 1:1 supervision, if needed, could have been put in place to prevent Resident #66's falls.

Based on record review and interview the facility failed to maintain clinical records on a resident that was complete, accurately documented, and contained sufficient information to identify resident assessments and services provided as evidenced by: 1) failing to accurately document that a treatment was performed; 2) failing to document performance of wound care treatment as ordered by the physician; and 3) documentating that a treatment was done on a healed pressure ulcer (Resident #4). This deficient practice was identified for 1 (Resident #4) of 3 (Resident #4, Resident #44 and Resident #50) Stage 2 sampled residents reviewed for pressure ulcers in a total Stage 2 sample of 27. This had the potential to affect any of the 34 residents who may develop pressure ulcers as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. Findings Review of Resident #4's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 started receiving Hospice services on 01/12/16. Review of Resident #4's wound assessment report dated 10/11/16 revealed new pressure area, deep tissue injury (DTI) on lumbar back. Further review of the wound assessment report revealed a resolved date for DTI to lumbar back area on 10/26/16. Review of Resident #4's Treatment Administration Record (TAR) dated 10/19/16 through 11/17/16 revealed order for DTI lumbar back: paint daily with [MEDICATION NAME], leave open to air, until healed. Further review of documentation on the TAR revealed wound care to DTI lumbar back performed daily from 10/19/16 through 11/16/16. In interview on 11/18/16 at 2:15pm S7/Registered Nurse (RN)/Program Coordinator stated she resolved Resident #4's DTI to lumbar area on 10/26/16 and she failed to remove the orders for the DTI to lumbar area on the October 2016 TAR. S7/RN/Program Coordinator stated she was not notified of a change in Resident #4's skin condition and development of two new wounds to Resident #4's lumbar and scapula area until 11/17/16. S7/RN/Program Coordinator stated the pressure ulcer dressing changes should be done daily; except for the sacral wound dressing with a [MEDICATION NAME] dressing (pink colored dressing), which was ordered to be done every two days. Review of November 2016 physician orders revealed daily wound care orders to DTI to right lateral foot, Stage 2 pressure ulcer to right lateral heel and DTI lumbar back until healed. Review of sacral wound care orders dated 10/20/16 revealed order to cleanse area with cotton tip swab and wound cleanser and pack lightly with maxisorb, cover with clean [MEDICATION NAME] dressing every two days until healed, prn for loose, soiled and drainage. Review of record on 11/17/16 at 3:00pm revealed no physician orders for the lumbar and right scapula wounds. Review of October 2016 TAR revealed no documentation of wound care treatments on the following dates: 10/07/16 and 10/11/16 -DTI to right lateral foot; 10/11/16- sacral wound Review of November 2016 TAR revealed documentation of wound care completed on 11/16/16 for all Resident #4's wounds. On 11/17/16 at 2:30pm Resident #4's wound care treatment was observed with S6/Licensed Practical Nurse (LPN). All dressings on each wound were pinkish in color and all dressings were dated 11/15/16 prior to the start of wound care. In interview on 11/17/16 at 2:45pm S6/LPN confirmed all wound dressings were dated 11/15/16 prior to wound care on 11/17/16. S6/LPN confirmed wound care treatment orders were daily and all wounds covered with border gauze except for the lumbar and right scapula wounds were left open to air during wound care on 11/17/16. S6/LPN stated she was not aware of the treatment order change for Resident's sacral wound on 10/20/16 to apply a [MEDICATION NAME] dressing and confirmed the sacral wound was covered with border gauze. In interview on 11/17/16 at 2:55pm S5/LPN stated she performed wound care on Resident #4 on 11/15/16 and used the [MEDICATION NAME] dressings on all her wounds. S5/LPN stated the [MEDICATION NAME] dressings can remain on for two days, but confirmed there was no change in orders to apply the [MEDICATION NAME] dressing to all wounds. S5/LPN stated she applied the [MEDICATION NAME] dressing to the lumbar and scapula wounds because they were draining and she didn't want to leave them open to air as ordered. In interview on 11/18/16 at 1:15pm S6/LPN stated she doesn't recall Resident #4's lumbar wounds ever resolving. S6/LPN stated if a wound resolves then S7/RN/Program Coordinator goes to the TAR and resolves the wound so the treatment was no longer performed.

Based on observation, interview, and record review, the facility failed to ensure each resident receives and the facility provides food at the proper temperature for 1 (Resident # 19) of 4 (Resident # 19, Resident # 22, Resident #23, and Resident # 39) Stage 1 interviewable sampled residents out of a total of 7 sampled residents as evidenced by failing to serve food at the proper temperature. The facility had 36 residents residing in the skilled nursing unit of the facility as documented on the Resident's Census and Conditions of Residents Form. Findings: In interview on 10/05/15 at 11:05am Resident #19 stated his food is usually cold by the time he eats. Resident #19 further stated he eats in his room with the full assistance of staff due to he has [MEDICAL CONDITION]. Observation on 10/07/15 at 11:55am revealed hall trays were being delivered to rooms near Resident #19's room. Surveyor requested a test tray from the trays being delivered and food temperatures were obtained in the presence of staff with the temperature of the entree (spaghetti and meatballs) and the vegetable (broccoli) of 90 degrees Fahrenheit. Review of the facility's Test Tray Evaluation form revealed the proper temperature range was between 120 degrees Fahrenheit and 140 degrees Fahrenheit for any type of meat, entree, starch, vegetable, and soup. In interview on 10/07/15 at 1:45pm S1/ Dietary Manager indicated and confirmed the proper temperature range should be between 120 degree and 140 degree Fahrenheit according to the facility's Test Tray Evaluation form for meals being delivered to a resident 's room for consumption.

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly by having cups, dirty gloves, paper trash and cigarette butts around and under the garbage dumpster. This failed practice had the potential to affect everyone in the facility. Findings: An observation of the garbage dumpster was conducted with S1, Dietary Manager on 12/18/12 at 4:15PM. During the observation various sizes of cups were noted under the dumpster. Paper trash, dirty gloves and a large number of cigarette butts were note on the ground around the dumpster. An interview was conducted with S1, Dietary Manager on 12/18/12 at 4:15PM. During the interview S1, Dietary Manager stated she told housekeeping and nursing that they must keep the area around the dumpster clean.

Based on observation and interview the facility failed to ensure meals are prepared under sanitary conditions. This was evidenced by a staff member walking through the facility 's kitchen during preparation of the dinner meal with no head covering. This failed practice had the potential to affect everyone who eats meals prepared in the facility 's kitchen. Findings: An observation was made of the facility 's kitchen during the preparation of dinner meal on 12/18/12 at 4:30PM. During the observation, one of the facility 's staff members was noted walking through the kitchen with no head covering. The staff member approached S1, Dietary Manager, who was talking to the surveyor, and engaged her in a conversation. S1, Dietary Manager informed the staff member that he is to wear some type of head covering when entering the kitchen. The staff member did not leave the kitchen immediately, but finished what he was saying then left the kitchen.

Based on interviews and record reviews the facility failed to ensure care plans are revised and updated after a resident experienced a fall for 1 of 1 Stage 2 residents reviewed for falls in a total Stage 2 sample of 18 (resident #58). This failed practice had the potential to affect all residents in the facility that may experience a fall. Findings: During stage 1, staff interview of the QIS process on 12/17/12 at 11:20AM, resident#58 's nurse stated he had experienced a fall on 12/2/12. A review of resident #58 's medical record was conducted on 12/18/12 at 3:45PM A review of the resident 's fall investigation report reads in part as follows: Incident date: 12/2/2012. Time: 23:45:00. Veteran found on the floor by his roommate. Unwitnessed fall. Small skin tear noted to left index finger. Skin tear protocol followed wound cleaned with cleanser. A review of resident #58 's fall care plan dated 11/14/2012(admitted ) revealed that the care plan was not revised or updated after the resident had fallen. An interview was conducted on 12/18/12 at 3:50PM with S2 (acting care plan nurse), Assistant Director of Nursing (ADON). During the interview S2, ADON was shown the resident 's care plan and asked was it revised after the resident had fallen on 12/2/12. S2, ADON reviewed resident #58 's paper chart and documentation on the computer and stated the care plan was not revised after the resident 's fall.

Based on record review and staff interview, the facility failed to ensure residents received notice before the residents' roommate was changed for 2 of 28 Stage 2 sampled residents (#23 and #63). This deficient practice had the potential to negatively impact the 32 residents on census as documented on the facility's Resident Census and Conditions of Residents form. Findings: Resident #23: An interview was conducted with the resident on 10/25/11 at 9:40 am. When the resident was asked if he had a roommate change in the last nine months the resident indicated he had several roommate changes. When the resident was asked if he was given notice before the change in roommates he indicated he did not. Review of the medical record revealed the resident was admitted to the facility on [DATE]. Review of the Social Service section of the medical record revealed no documented evidence the resident was notified of roommate changes. Resident #63: An interview was conducted with the resident on 10/25/11 at 10:41 am. When the resident was asked if he had a roommate change in the last nine months the resident indicated he did. When the resident was asked if he was given notice before the change in roommate he indicated he did not. Review of the medical record revealed the resident was admitted to the facility on [DATE]. Review of the Social Service section of the medical record revealed no documented evidence the resident was notified of roommate changes. In interview on 10/26/11 at 1:48 pm, S3/Social Services Director indicated resident #23 and resident #63 have had roommate changes and there was no evidence they were notified of the roommate changes.

Based on observation, record review, and interview, the facility failed to care plan the use of an indwelling urinary catheter for 1 of 3 Stage 2 sampled residents with catheters (#51) and failed to care plan range of motion for 1 of 28 Stage 2 sampled residents (#62). This deficient practice of failing to care plan residents care needs had the potential to negatively impact the 32 residents on census as documented on the facility's Resident Census and Conditions of Residents form. Findings: Resident #51: An observation of resident #51 was made on 10/24/11. During the observation the resident was lying in bed with the head of bed elevated. An indwelling catheter was noted hanging on the side rail. A record review of resident #51's chart was conducted on 10/26/11 at 10:15 am. The record reviewed revealed there was no care plan addressing the resident's indwelling catheter. An interview was conducted with S1, DON on 10/26/11 at 10:15 am. During the interview S1, DON reviewed resident #51's chart and acknowledged that there was no care plan addressing the resident's indwelling catheter. Resident #62: Observation on 10/24/11 at 1:22 pm revealed the resident was sitting in a wheelchair with his left arm and hand drawn up to his chest. In interview at this time the resident indicated he had a stroke and did not have use of his left side. Record review revealed the resident was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. Review of the resident's Minimum (MDS) data set [DATE] revealed under Section G - Functional Limitation in Range of Motion the resident had upper extremity (shoulder, elbow, wrist, and hand) impairment on one side and lower extremity (hip, knee, ankle, and foot) impairment on both sides. Review of the resident's Comprehensive Care Plan updated on 09/15/11 revealed no evidence the facility care planned the resident's functional limitation in range of motion. In interview on 10/26/11 at 10:26 am S4, Restorative Certified Nursing Assistant indicated resident #62 was not on the facility's restorative program. In interview on 10/26/11 at 11:28 am S1, DON reviewed resident #62's medical record and acknowledged that there was no care plan to address the resident's functional limitation in range of motion.

Based on interview and record review the facility failed to ensure that the resident's plan of care was implemented as evidenced by the resident not receiving showers on his scheduled days. This failed practice was identified in 1 of 3 Stage 2 residents reviewed in a total of 28 staged 2 sampled residents (#38). This failed practice had the potential to affect all of the residents. Finding: An interview was conducted with resident#38 on 10/24/11 at 2:30PM. During the interview the resident stated his shower days are Monday, Wednesday and Friday, but sometime the CNAs forget to give him a shower on his shower days. A review of the unit ' s daily shower sheet for the months of September and October was conducted on 10/26/11. The shower sheets revealed that the resident had not received a shower on 9/5/11, 9/9/11, 9/16/11, 9/23/11, 9/28/11, 10/7/11, 10/10/11, 10/17/11, 10/19/11, and 10/22/11. Review of the resident ' s care plan revealed that the resident should receive a shower three times a week. An interview was conducted with S2, CNA Supervisor, on 10/26/11 at 2:30PM. During the interview S2, CNA Supervisor reviewed the shower sheets and stated that she will talk with the CNAs.

Based on observation, record review, and interview the facility failed to have a valid medical justification for the continued use of an indwelling catheter for 1 of 3 stage II residents reviewed for catheter use out of a total of 28 Stage 2 sampled resident. (#51) Findings: An observation of resident#51 was conducted on 10/24/11. During the observation the resident was lying in bed with the HOB elevated. An indwelling catheter was noted hanging on the side rail. A record review of resident#51 ' s chart was conducted on 10/26/11. The record review revealed an order dated 4/3/11 which read as follows: Foley catheter secondary to stage III sacral decubitus. Review of the wound/ skin management sheet revealed that the decubitus was healed on 10/6/11. An interview was conducted with S1, DON on 10/26/11 at 10:15AM. During the interview S1, DON reviewed resident#51 ' s chart and acknowledged that there was no justification for the indwelling catheter.