Every finding on record at The Heritage Nursing and Rehabilitation Facility

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan for one (Resident (R) 18) of 23 sampled residents. R18's comprehensive care plan called for the use of a call light as an approach to deal with care problems including falls and incontinence. Once R18 was no longer able to use a call light, the facility failed to revise the care plan to ensure the resident was able to summon help if needed. The findings include: Review of the facility's policy Care Plans-Comprehensive H5MAPL0110, revised 09/2022, revealed that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of R18's record revealed the facility admitted R18 on 07/13/2022, with diagnoses which included unspecified dementia. Review of R18's record revealed the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2022, documented that the resident had a Brief Interview for Mental Status (BIMS) score of 4/15, indicating severe cognitive impairment. In addition, the MDS noted that the resident had a cognitive communication deficit. Review of additional MDS assessments (annual MDS of 05/3/2024 and annual MDS of 03/30/2025) revealed the resident continued to be severely cognitively impaired, based on a BIMS score of 3/15. Review of R18's Comprehensive Care Plan (CCP), initiated on 10/11/2022 and with a current target date of 05/06/2025, revealed the resident was assessed to have impaired cognitive thought process related to dementia, with short-and long-term memory loss deficits. Further review of R18's CCP revealed that, in response to the risk for falls, the resident was care planned to keep call light in reach- encourage use of call light (07/20/2022). In addition, review of the care plan revealed that in response to the problem of bowel and bladder incontinence, staff were to Keep call light in reach. (02/07/2024). Observation on 04/27/2025 revealed that R18's call light was repeatedly out of reach. At 2:17 PM, R18's call light was observed on the floor. At 3:10 PM, R18's call light was again observed to be on the floor, to the right of the trash can on the floor. At this time, two staff members (Certified Nurse Aide (CNA) 2 and Registered Nurse (RN)1) were observed in the resident's room. Staff changed R18's trash bag in the trash can, then the two staff members exited the room, leaving the call light on the floor. At 3:47 PM, R18's call light was observed to still be on the floor, while R18 was sleeping. At 4:02 PM, R18 was awake, and the call light was observed to still be on the floor. An attempt to interview the resident at this time was unsuccessful, as she was nonresponsive to questions. During an interview with CNA2 on 04/27/2025 at 3:22 PM concerning R18's call light being on the floor for almost two hours, CNA2 stated, Well, she doesn't use it anyways [sic]. Additional interviews with CNA7 on 04/30/2025 at 9:50 AM, Licensed Practical Nurse (LPN) 4 on 04/30/2025 at 9:56 AM, and the Unit Coordinator on 04/30/2025 at 10:02 AM, all confirmed that R18 can no longer use the call light. Interview with Family Member (FM) 18 on 04/30/2025 at 10:50 AM, revealed that she has not paid attention to whether R18's call light was on the floor because the resident cannot understand how to use it. Interview with the MDS Coordinator on 04/30/2025 at 2:10 PM revealed that she is responsible for revising care plans when a resident's condition/abilities changed. The MDS Coordinator stated that the Social Worker is responsible for assessing the resident's communication ability. The MDS Coordinator then care plans for residents with communication deficits to have more frequent rounds, basing the need for care plan revision on what she sees in progress notes and what is reported to her by staff members. The MDS Coordinator also noted that she gets information from morning meeting and conversations with direct staff and will revise the care plan if staff notify her of the need for a change. Further interview with the MDS Coordinator revealed she was not aware that R18 could no longer use the call light. Interview on 04/30/2025 at 2:20 PM with the Social Services staff revealed that she was aware that R18 no longer used a call light; however, she had not informed the MDS Coordinator so that the care plan could be revised to meet the resident's current abilities. Interview with the Administrator on 04/30/2025 at 2:15 PM revealed that she expects staff to provide personalized care for each resident, adding that care for residents is not a one size fits all. The Administrator stated that they revise and change care plans quarterly as well as with any change in the resident's care.

Based on observation, interview, record review, and facility policy review, the facility failed to take action to help prevent the development and transmission of communicable diseases and infections for one (Resident (R) 49) of three sampled residents reviewed during medication administration. Licensed Practical Nurse (LPN) 3) was observed to drop three of R49's medication tablets/capsules onto the top of the medication cart while pressing medications out of blister packets. LPN3, who was bare-handed, picked up each of the medications that were dropped onto the cart without wearing gloves, then placed the medications in a plastic cup with the rest of R49's medications, and administered the medications to the resident. The findings include: Review of the facility's undated policy, titled, Infection Control revealed the prevention of spread of infections is accomplished by use of hand hygiene, standard precautions and other barriers. Review of the facility's policy titled, Medication Administration General Guidelines, dated 11/2021, revealed the procedures included: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass, prior to handling any medication (gloves are to be worn if direct contact). Record review revealed the facility admitted R49 on 07/16/2021 with diagnoses of chronic obstructive pulmonary disease (COPD), malignant neoplasm of upper lobe, left bronchus or lung, and solitary pulmonary nodule. Record review of current physician orders revealed R49's medication orders included: a. hydrochlorothiazide oral tablet 12.5 milligrams (mg), give one tablet by mouth one time a day for COPD, b. Tessalon [NAME] Oral capsule 100mg (Benzonatate), give two capsules by mouth three times a day for cough, and c. Probiotic oral capsule (Saccharomyces boulardii), give one capsule by mouth two times a day for lung cancer. Observation, on 04/29/2025 at 8:40 AM, revealed that, in preparation for medication administration, LPN3, who was not wearing gloves, pulled R49's pharmacy blister packets, and punctured the packets to drop eight tablets and capsules into a plastic 30 milliliter (ml) cup. During the observation, LPN3 dropped one Probiotic capsule onto the top of the medication cart, which was not covered with a barrier so as to prevent contamination with the surface. LPN3 failed to don gloves before she picked up the capsule with her bare fingers, and then placed the capsule into the plastic cup. LPN3 also dropped the hydrochlorothiazide tablet onto the medication cart and again picked up the tablet with her bare fingers and placed the tablet into the plastic cup. In addition, LPN3 dropped one Tessalon [NAME] capsule onto the medication cart then picked up the capsule with her bare fingers and placed it into the plastic medication cup. After failing to don gloves prior to picking up and touching these three medications with her bare hand, LPN3 then administered the medications to R49. On 04/29/2025 at 8:56 AM, interview with LPN3 confirmed that she had dropped the one tablet and two capsules onto the cart and that she had picked them up with her bare hands without donning gloves. LPN3 indicated that she should have donned gloves prior to touching the various medications, as it was important to don gloves because of infection control. During an interview, with the Director of Nursing (DON), on 04/30/2025 at 3:56 PM, she stated it was her expectation staff would don gloves before touching a resident's medications. The DON stated LPN3 should have wasted (discarded) the medications that she dropped on the cart and pulled new ones from the blister packs to administer to the resident. The DON further stated that LPN3 was new to the facility, indicating that the LPN3 needed additional training.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure residents were treated with dignity and respect for three (3) of twenty-seven sampled residents (Resident #10, #24 and #30). Observation on 10/26/2021 at 12:13 PM on the 200 hall revealed three (3) aides who were delivering resident lunch trays failed to knock on the resident's door before entering three (3) different resident rooms. The findings include: Review of the facility policy titled, Resident Rights undated, revealed employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. This included the right to privacy and confidentiality. The policy also revealed residents are entitled to exercise their rights and privileges to the fullest extent possible. The facility would always make every effort to assist each resident in the implementation of those rights to assure the residents were always treated with respect, kindness and dignity. Observation on 10/26/2021 at 12:00 PM, revealed State Registered Nurse Aide (SRNA) #5, SRNA #6, and Nurse Aide (NA) #1 entered resident rooms (Resident #10, #24 and #30) to delivery lunch trays and did not knock before they entered the resident's room. Review of Resident #10's clinical records revealed the facility admitted the resident on 02/12/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) report dated 10/20/2021, revealed Resident #10 scored a fourteen (14) out of fifteen (15) the resident which indicated the resident was cognitively intact. Interview with Resident #10 on 10/29/2021 at 9:29 AM, revealed staff usually knocked on the door before they entered the room. The resident also stated he/she wanted staff to knock before they came in his/her room. Review of Resident #24's clinical records revealed the facility admitted resident on 04/17/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS report dated 08/09/2021, revealed Resident #24 scored an eight (8) out of fifteen (15) which indicated the resident moderately impaired cognition. Interview with Resident #24 on 10/29/2021 at 9:35 AM, revealed staff usually knocked before they entered his/her room. The resident stated he/she expected staff to knock before they came into his/her room. Review of Resident #30's clinical records revealed the facility admitted resident on 09/11/2019 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS report dated 08/13/2021, revealed Resident #30 was non-interviewable with a BIM's of three (3) out of fifteen (3) which indicated severe cognitive impairment. Interview with State Registered Nursing Assistant (SRNA) #5 and #6 on 10/26/2021 at 1:59 PM, revealed they both had worked at the facility for about two months. They revealed they were trained on Resident Rights during orientation. Both explained resident had the right to privacy, to be social, to choose what they wanted to wear, to dignity and respect. They revealed ways to honor resident's privacy was to close the resident's door, pull the curtain closed and knock on the door before they entered. SRNA #5 and SRNA #6 also stated it was important to knock so the resident did not get scared when a staff member walked in. They admitted they usually knocked on the door but were just scattered today when passing meal trays at lunch. Interview with Nurse Assistant (NA) #1 on 10/26/2021 at 2:21 PM, revealed she was a NA student and had been at the facility since March of 2021. She revealed she worked on the floor for a couple of months. NA #1 also revealed she was trained on Resident Rights at new employee orientation. She explained residents have the right to privacy and that was provided when staff shut the resident's door, pulled their curtain, closed the blinds, knock on the door and introduce yourself. She also stated it was important to inform residents what would be done while in their room. She revealed she normally knocked on the door before she entered but did not today because staff were in a hurry to get the lunch trays out. Interview with SRNA #11 and SRNA #12 on 10/29/2021 at 11:00 AM, revealed she had been at the facility for five (5) months and SRNA #12 revealed she had been at the facility for five (5) years. Both SRNA stated they were trained at orientation and received in-services on Resident Rights. Additionally, the facility had posters throughout that explaining Resident Rights. They revealed residents have the right to make choices. Per the SRNAs, residents were allowed privacy and that was provided when staff knocked on the door before they enter. SRNA #11 and SRNA #12 also revealed other forms of privacy were to ensure resident's curtains were pulled closed, bathroom door was closed while resident used it and to ensure resident was covered up. Both stated those services helped to provide residents with dignity and respect. Interview with Licensed Practical Nurse (LPN) #2 on 10/29/2021 at 10:28 AM, revealed she had been at the facility for eleven (11) years. She revealed she was trained she on Resident Rights. and all staff should knock on the resident's doors before they enter the room because the room was the resident's home. She stated it was all about respect and privacy. Interview with the Director of Nursing (DON) on 10/29/2021 at 3:00 PM, revealed residents had multiple rights and it was important that they were able to have and do what they wanted. The DON also stated, The facility is the resident's home. She further revealed all new hires were informed of Resident Rights at orientation and explained the importance to help and advocate for the residents. She stated that the facility did in-services every April and November. She stated the facility expected all staff to follow procedures and policies. Interview with facility Administrator on 10/29/2021 at 3:33 PM, revealed the facility covered Resident Rights annually with residents and twice yearly with staff members. Resident Rights were discussed in Resident Council. She further revealed the Ombudsman was recently at the facility and an informative packet on Resident Rights was provided to residents. The Administrator revealed the expectation was that all staff members would knock on the door before they entered the resident's room, she stated, This is their home, we should always knock and introduce ourselves when we go in. Staff were expected to knock when they delivered trays too, the only time staff were not required to knock was in an emergency.

Based on observation, interview, record and facility policy review, it was determined the facility failed to prepare, distribute and serve food in accordance with the professional standards for food service safety. Observation in the facility kitchen on 10/26/2021 at 10:40 AM revealed a cook with a full beard plating food for the residents' lunch. The cook's beard was not fully covered with a beard guard to prevent resident foods from potential contamination. In addition, the facility failed to maintain accurate and complete temperature logs for the steam table on three separate occasions, 10/03/2021 at 4:00 PM, 10/14/2021 at 4:00 PM and 10/20/2021 at 4:00 PM. Findings include: Review of facility policy titled, Employee Sanitary Practice (2013) revealed this policy was to promote guidelines for employee sanitary practice and all employees should wear hairnets and all hair must be covered to include facial hair. 1. Observation on 10/26/2021 at 10:40 AM revealed the facility cook (Cook #1) did not have on a beard cover while he plated food for lunch. The cook did have on a surgical mask, which covered most of his face; however, both sides of his face had facial hair that was not covered. Interview with the Cook #1, on 10/26/2021 at 11:00 AM, revealed he did not think about the need for a beard cover because he had a surgical mask on and thought it covered his beard. He further revealed it was facility policy for kitchen staff to wear a hairnet and a beard guard if facial hair was present at all times in the kitchen. Interview with the facility Dietary Manager (DM), on 10/29/2021 at 9:20 AM, revealed she had worked as DM since July 2021. She stated she has been working to get her certification and was supervised remotely by the Registered Dietitian (RD) and the Senior Director of Nutrition (SDN). She stated it was the facility expectation all kitchen staff would have their hair and/or beard covered with a hairnet or beard guard. She also stated any staff who did not want to wear a beard guard would be expected to be clean shaven. The DM revealed staff needed to wear hair guards to prevent hair contamination in food. Interview with the facility RD, on 10/29/2021 at 9:57 AM, revealed she is a preceptor to the DM, she was available remotely if the DM had any questions. The RD revealed she was not informed of any concerns about hairnets or beard guards; however, she would expect staff to abide by the facility policy and wear hairnets/beard guards while in the kitchen. She stated this was important to ensure hair did not get into residents food. Interview with the Senior Director of Nutrition (SDN), on 10/29/2021 at 10:45 AM, she revealed she was a consultant to the DM. She worked directly with the DM to revamp the entire kitchen process. The SDN visited the facility monthly. Additionally, she was available to DM daily by phone to answer any questions she may have. The SDN stated she had not been contacted about concerns with hairnets or beard covers. She stated hairnets/beard covers were worn to prevent food contamination from hair. She revealed it was her expectation that kitchen staff would follow the facility policy and all kitchen staff should wear hairnets/beard cover while in the kitchen. Interview with the Director of Nursing (DON), on 10/29/2021 at 3:00 PM, revealed she had not been informed prior to survey there were concerns with kitchen staff in regard to hairnets and beard guards. She revealed it was important for all kitchen staff to wear hairnets and/or beard guards to ensure food did not get hair in it. Hair would contaminate resident's food. She also revealed she would expect staff to follow the facility policy. Interview with the Administrator, on 10/29/2021 at 3:33 PM, revealed hairnets and or beard guards should be worn any time staff were in the kitchen. She revealed that hairnets and or beard guards were worn to prevent hair contamination in the resident's food. She also stated she expected facility policy and procedure to be followed at all times. 2. Review of facility policy and procedure manual, titled Food Production and Food Safety, reference of Chapter 3, Food Temperatures, dated 2019, revealed the temperatures of all food items were to be taken and properly recorded prior to service of each meal. Additionally, a sample food temperature log provided in the packet revealed temperatures were to be recorded prior to service and again half way through service of the meal. Observation of the steam table logs on 10/26/2021 at 11:00 AM, revealed blank slots for 10/03/2021 for 4:00 PM, 10/14/2021 for 4:00 PM and 10/20/2021 for 4:00 PM. However, when the facility provided the document at the end of the day on 10/26/2021 at 4:00 PM, and each of blank slots had been filled in. Interview with the Dietary Manager (DM) on 10/29/2021 at 9:02 AM, revealed steam temperature logs were important to ensure the food was at the correct temperature before it was served. She also revealed if the food was not cooked to proper temperature, it could result in foodborne illnesses to the residents. The DM stated the temperature logs were to be completed by the cook and should have been filled in when the temperatures were taken. The DM revealed the facility had determined there was one staff member who had not filled out the log as he took temperatures (Cook #1). Continued interview with the DM on 10/29/2021 at 9:02 AM, further revealed Cook #1 was the person who filled in the missing dates of 10/3/2021, 10/14/2021 and 10/20/201 all at 4:00 PM, before the document was provided. She stated she was not aware of any temperature concerns brought to the facility by residents in August 2021 or September 2021. Interview with the Registered Dietitian (RD) on 10/29/2021 at 9:57 AM, revealed she was not informed of any concerns with the steam tray temperature logs prior to the survey. She revealed the importance of the temperature logs were to certify food was stored and served at the correct temperature to ensure residents did not get sick with foodborne illness. Interview with the Senior Director of Nutrition (SDN) on 10/29/2021 at 10:45 AM, revealed she had previously discussed temperature logs with the DM and the importance of them being completed at the time they were taken. She stated temperature logs were important to ensure food temperatures did not enter the danger zone to and to ensure resident did not get foodborne illnesses. Interview with the Director of Nursing (DON) on 10/29/2021 at 3:00 PM, revealed the facility had complaints about food temperatures in August 2021. She revealed in July 2021 they lost all of the kitchen staff and they had to start over with new staff. She revealed the facility did audits of trays when they were delivered at mealtime and did not find any concerns with food temperatures. Additionally, she revealed she had not heard any new concerns about food temperatures. She revealed if a resident did get a tray with cold food, a new tray would be retrieved, as reheating of trays does not comply with policy. During the interview with the DON on 10/29/2021 at 3:00 PM, the facility Corporate Nurse Consultant was present. She provided a written statement from the Facility Cook #1 which read, I keep temps on my prep chart daily. I didn't move them from prep chart to temp log until I realized I hadn't moved them. I keep the temp for the day on my prep chart. I forgot to on [DATE]th, [DATE]th and [DATE]trh, signed by the cook. However, when requested the facility failed to provide copies of the prep chart to verify the cook had documented the temperatures on the prep chart. Interview with the Administrator on 10/29/2021 at 3:33 PM, revealed temperature logs were important because they made sure food was heated to the correct temperature to be served. She revealed improper temperatures could lead to residents with foodborne illness. The Administrator further revealed in July 2021, the entire kitchen staff walked out and they had worked hard with the new staff to get them trained in such a short amount of time. She stated the management staff did audit after audit and worked with residents to insure their food was not cold and to address any other food concerns. Additionally, she revealed she would expect for her staff to always follow policy and procedures.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care plan interventions were implemented for one (1) of three twenty-seven (27) sampled residents ( Resident #5), related to positioning/orthotic devices for contractual management. The facility failed to apply a splint to Resident #5's right hand as indicated in the care plan. The findings include: Review of the facility policy titled Care Planning dated 08/01/2013, revealed the Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. Review of the record for Resident #5 revealed the facility admitted the resident on 07/02/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment conducted on 10/08/2021 revealed the resident's Brief Interview Mental Status (BIMS) scare was 13, which indicated the resident was interviewable. The MDS also assessed Resident #5 to have one sided impairment of the (right) upper and lower extremities. Review of Resident #5's Comprehensive Care Plan dated 07/02/2020, and CNA (Certified Nurse Aide) care plan revealed an intervention for the resident to wear a tight hand palm protector with finger separations 4-6 hours per day. Per the plan of care, the staff responsible for applying the splint was nursing and the CNA. Observation of Resident #5 at 11:20 AM and 12:09 PM on 10/26/2021 and at 2:35 PM, and 3:00 PM on 10/27/2021 revealed the resident was in his/her room and was not wearing a splint on the right hand. Interview with Resident #5 on 10/28/2021 at 10:02 AM revealed he/she was supposed to use a splint on the right hand, but the staff had not put the splint on in 2-4 days. Review of the Therapy to Restorative Nursing Communication, form revealed the resident was to have passive range of motion to right upper extremity, with inclusion of right hand digits with focus on gentle flexion of all joints and emphasis of extension of fifth digit (pinky finger). The restorative aide was checked off on applying adaptive equipment on 10/05/2021 for Resident #5. However, further review of the restorative documentation revealed the splint to the right hand was not initiated until 10/28/2021. Review of Residents Splint/Brace/Prosthesis Flowsheet dated October 2021, revealed Resident #5's splint could be applied at 10:00 AM or 2:00 PM, then removed at 2:00 PM or 6:00 PM. Further review of the documentation revealed the splint was applied starting on 10/28/21, at 10:00 AM and removed at 2:00 PM. Interview on 10/29/21 at 1:08 PM with the Restorative Aide, revealed therapy staff provided training to Restorative staff. Occupational Therapy had established a functional maintenance plan on 09/30/2021 for Resident #5. The Restorative Aide stated when a restorative care plan is completed, a copy goes to the Director of Nursing (DON) and when the resident is discharged from therapy the DON makes assignments for restorative staff. The Restorative Aide stated on the days restorative staff was pulled to work the unit to fill in as needed, the SRNA's usually pick up restorative treatments, except not all were not trained on splint placement. Per the Restorative Aide, restorative staff tries to pick up those residents even when pulled to work the floor. The Restorative Aide stated although she was checked off on splint placement for resident #5 on 10/05/2021, she had to wait until assignment was by DON prior to beginning treatment. Per the Restorative Aide, application of the splint to Resident #5's hand was not initiated treatment until 10/28/2021. Interview with SRNA #3 on 10/28/21 3:30 PM revealed splints are applied by the therapist as ordered then by restorative staff when the resident is discontinued from therapy. Interview on with Director of Nursing (DON) on 10/29/21 at 3:03 PM revealed the DON expected staff to review the Kardex (Nurse Aide care plan) and to provide care per the plan of care. The DON stated Resident #5's care plan indicated an orthotic device to the resident's right hand 4-6 hours daily. The DON stated she did not know why the splint was not applied to Resident #5's hand on 10/26/2021, and 10/27/2021. Per the DON, there was no documentation the splint was applied prior to 10/28/2021. Interview with Administrator on 10/29/21 03:37 PM, revealed the Administrator expected staff to follow the plan of care and to meet resident needs.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide appropriate treatment and services to maintain/prevent decline in range of motion for one (1) of twenty-seven (27) sampled residents( Resident #5), related to positioning/orthotic devices for contractual management. The facility failed to apply a splint to Resident #5's right hand as indicated in the care plan to manage the resident's contracture. The findings include: Review of the record for Resident #5 revealed the facility admitted the resident on 07/02/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment conducted on 10/08/2021 revealed a Brief Interview Mental Status (BIMS) of 13, which indicated the resident was interviewable. Further review of the assessment revealed the facility assessed Resident #5 to have one sided impairment of the (right) upper and lower extremities. Also, that Resident #5 required extensive assistance of two (2) persons with bed mobility. Review of Resident #5's Comprehensive Care Plan dated 07/02/2020, revealed the facility had addressed the resident contratures on the plan and added an intervention for the resident to wear a tight hand palm protector with finger separations 4-6 hours per day. Per the plan, nurses and Certified Nurse aides were responsible to ensure the intervention was implemented. Observation of Resident #5 at 11:20 AM and at 12:09 PM on 10/26/2021 and at 2:35 PM and 3:00 PM on 10/27/ revealed the resident was in his/her room and was not wearing a splint on the right hand. Interview with Resident #5 on 10/28/2021 at 10:02 AM revealed he/she was supposed to use a splint on the right hand, but the staff had not put the splint on in 2-4 days. Review of the document, 'Therapy to Restorative Nursing Communication, sheet revealed the restorative aide was checked off on applying adaptive equipment on 10/05/2021 for Resident #5. However, further review of the restorative documentation revealed the splint to the right hand was not documented as initiated until 10/28/2021. Review of Residents Splint/Brace/Prosthesis Flowsheet dated October 2021 revealed the splint for Resident #5 could be applied at 10:00 AM or 2:00 PM, then removed at 2:00 PM or 6:00 PM. Per the documentation, the splint was applied starting on 10/28/21, at 10:00 AM and removed at 2:00 PM. Interview on 10/29/21 at 1:08 PM with the Restorative Aide revealed therapy staff provided training to Restorative staff to include the application of splints. Occupational Therapy staff had established a functional maintenance plan on 09/30/2021 for Resident #5. After the plan is completed a copy goes to the Director of Nursing (DON) and when therapy discharges the resident the DON makes assignments for restorative staff. Per the Restorative Aide, when restorative staff are pulled to work on the unit instead of providing restorative services, restorative staff try to pick up the resident's with splints because not all the SRNA's have been trained to apply splints. The Restorative Aide stated she had to wait until assignment was made by DON prior to beginning treatment. The Restorative Aide stated Resident #5's treatment (splint) was not initiated until 10/28/2021, on day shift. Interview with SRNA #3 on 10/28/21 3:30 PM revealed, the Kardex was reviewed, at the beginning of shift to review for any changes or new orders. The SRNA reported splints were applied by the therapist as ordered. Interview on 10/29/21 at 3:03 PM with Director of Nursing (DON) revealed that the DON expected staff to review the Kardex to determine what care to provide. Per the DON, Unit managers make rounds, the facility hold morning meetings, and nurses check to make sure SRNA's are providing care per the care plan/orders. The DON stated no concerns had been identified related to resident splints. Interview with Administrator, on 10/29/21 at 3:37 PM revealed to ensure treatments were provided as ordered nursing staff were to monitor to ensure treatments were done. The Administrator stated it was expected for staff to follow the plan of care and to meet resident's needs

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents received appropriate care and treatment of [REDACTED]. Resident #13 and Resident #14 were observed on 04/02/19 to have enteral feeding bags hanging that were not dated or timed to reflect when they were initiated. The findings include: Review of the facility policy, Tube Feedings, undated, revealed feeding could be hung for no more than twenty-four (24) to forty-eight (48) hours. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 09/12/13 with [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 01/16/19, revealed the facility had assessed the resident to have severe cognitive impairment. The MDS also revealed the resident received at a minimum fifty-one (51) percent more calories via enteral feeding. Review of physician orders for Resident #13 dated 02/08/18, revealed the resident received a continuous enteral feeding of DiabetiSource at 70 milliliters per hour. Observation of Resident #13 on 04/02/19 at 8:37 AM revealed the resident was in bed and the enteral feeding was infusing as ordered. However, the bag containing the enteral feeding was not labeled with the date or time of initiation. 2. Review of Resident #14's medical record revealed the facility admitted the resident on 11/29/17 with the [DIAGNOSES REDACTED]. Review of Resident #14's MDS, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), indicating the resident had severe cognitive impairment. The MDS also revealed the resident received at a minimum fifty-one (51) percent more calories via enteral feeding. Review of Resident #14's care plan dated 10/31/18, revealed the resident had an alteration in nutrition and was to receive DiabetiSource enteral feedings. Observation of Resident #14 on 04/02/19 at 8:37 AM revealed the resident was lying in bed with the enteral feeding infusing. However, the bag containing the enteral feeding was not labeled with the date or time of initiation. Interview with Licensed Practical Nurse (LPN) #1 on 04/04/19 at 9:39 AM, revealed a bag of enteral feeding could continue to infuse for up to forty-eight (48) hours, but in order to know when to discard the feeding it would have to be labeled with the time of initiation. Interview with Registered Nurse (RN) #1 on 04/04/19 at 9:28 AM, revealed enteral feedings should be labeled with the date and time of initiation, to ensure the feeding did not remain hanging for longer than permissible. Interview with the Director of Nursing (DON) on 04/04/19 at 1:39 PM, revealed enteral feeding bags were to be labeled when hung with the date and time of initiation. The DON stated she was not aware of any current issues with staff not labeling enteral feedings appropriately.

Based on record review, interview, and review of the facility policy, it was determined the facility failed to complete a discharge summary for one (1) of three (3) closed records (Resident #76). Review of the closed record for Resident #76 revealed the resident's discharge summary was incomplete. The findings include: Review of the facility policy, Transfer and Discharge Protocol, undated, revealed the policy did not address completing a discharge summary. Review of Resident #76's medical record revealed the facility admitted the resident on 11/28/18 for rehabilitation following a right total hip replacement. Review of Resident #76's Minimum Data Set (MDS) discharge assessment, dated 01/03/19, revealed the facility discharged Resident #76 home on 01/03/19. Review of Resident #76's Nursing and Rehabilitation Facility Discharge Checklist revealed the form included the resident's name and discharge date ; however, the other areas of the form were blank, including review of scheduled appointments, potential complications, medications, etc. Interview with the Director of Nursing on 04/04/19 at 2:51 PM, confirmed Resident #76's discharge summary was not completed upon discharge. She stated discharge charts were required to be monitored through quality assurance (QA) audits; however, she stated she did not remember the last time a discharge audit was performed. The DON stated she had not been aware that Resident #76's discharge audit was not complete until questioned by the surveyor.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that the environment remained as free of accident hazards as was possible for one (1) of three (3) sampled residents (Resident #1). Resident #1 had received a bruise to the hand on 08/15/18, due to hitting the side rail. To prevent further occurrence of injury to Resident #1, the facility determined that the resident's side rail was not to be utilized. However, the facility failed to ensure that the side rail was not raised and on 09/11/18, the resident sustained [REDACTED]. The findings include: Review of the facility's policy, Accident and Incidents-Investigating and Reporting, dated 08/01/13, revealed all accidents or incidents involving a resident would be investigated and reported to the Administrator. The policy also stated corrective action would be documented. Review of Resident #1's medical record revealed the facility admitted the resident on 02/17/14 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. Review of Resident #1's care plan dated 06/27/18 revealed the resident required total assistance from staff at all times for activities of daily living. Further review of Resident #1's care plan revealed it not address the use of side rails for Resident #1. Review of an incident report dated 08/15/18 revealed Resident #1 had a half-dollar size bruise of unknown origin to the top of the right hand. Further review of the incident report revealed the facility's investigation determined the causative factors of the bruise to be that the resident had fragile skin, received blood thinners daily, and had hit his/her hand on the side rail. The recommended action was to discontinue the use of the side rails and initiate a winged tip mattress. However, the side rails were not removed from Resident #1's bed, but were to remain lowered and not be used. However, review of an incident report dated 10/09/18 revealed Resident #1 had sustained another bruise to the top of the right hand. The facility initiated an investigation and determined the cause of the bruise to be consistent with the resident hitting the side rail. Further review of the investigation revealed the facility determined the resident's side rail had been raised at the time of the incident. The recommended action taken was to remove side rails from Resident #1's bed. Observation of Resident #1 on 10/31/18 at 9:20 AM revealed the resident was in bed, which had no side rails attached. Interview with the Director of Nursing (DON) on 10/31/18 at 3:35 PM, revealed Resident #1's side rails had been discontinued on 08/16/18. However, according to the DON an unknown staff member had apparently raised the resident's side rail by mistake, and the DON stated the bruise sustained by the resident on 10/09/18 was believed to be caused by the resident hitting his/her hand on the side rail while it was raised by mistake. Interview with the Administrator on 10/31/18 at 3:50 PM, revealed the side rails should have been removed from Resident #1's bed on 08/16/18, when the side rails were discontinued.

Based on interview, and record review, it was determined that the facility failed to provide drinks consistent with resident preferences related to coffee choices for six (6) of seven (7) residents that attended the resident council meeting. During the resident council meeting at 9:00 AM on 02/14/18, six (6) of the residents stated they preferred caffeinated coffee. However, the residents complained regular coffee was only served with breakfast, and they could only have decaffeinated coffee any other time that they wanted coffee. The findings include: Interview with the Dietary Manager (DM) at 5:45 PM on 02/14/18 revealed there was no facility policy related to the type of coffee served at the facility. During a resident council meeting on 02/14/18 at 9:00 AM, six of seven residents present stated they preferred to drink regular caffeinated coffee, but the facility only served caffeinated coffee at the breakfast meal. The residents stated they had been told decaffeinated coffee was the only type of coffee the facility served after breakfast. However, the residents stated they had never been given a choice of what kind of coffee they preferred. Interview with the DM at 5:45 PM on 02/14/18 revealed the facility only served regular coffee in the morning with the breakfast meal, and decaffeinated coffee was served to the residents any other time of the day that they wanted coffee. Review of the resident council meeting minutes revealed there was no documentation related to coffee preferences.

Based on facility policy, interview, observation, and record review, it was determined the facility failed to ensure residents were served coffee at a palatable temperature. Six (6) of seven (7) residents who attended the resident council meeting on 02/14/18 at 9:00 AM stated the facility never served coffee that was warm enough. The residents also stated the coffee was not palatable. A palatability test at 5:40 PM on 02/14/18 revealed the coffee was 105 degrees Fahrenheit, and was not served at a palatable temperature. The findings include: Review of the facility's minimum temperature at the point of service policy (no date) revealed it was the policy of the facility to have the minimum temperature at point of delivery to the client to be of an appropriate temperature. Review of a facility recommended minimum temperature at the point of service chart (dated 2013) revealed the standard serving temperature for hot beverages was 150 degrees Fahrenheit. During a resident council meeting at 9:00 AM on 02/14/18, six of seven residents present stated the coffee served at the facility was never served warm enough. The residents also stated they had told staff about the coffee being cold; however, nothing had been done to ensure their coffee was not served cold. Observation of the evening meal on 02/14/18 revealed staff delivered the coffee urns to the units for the residents at 4:00 PM on 02/14/18. A palatability test of the coffee on Park Hall at 5:40 PM on 02/14/18 conducted by the Dietary Manager revealed the temperature of the coffee was 105 degrees Fahrenheit, and the coffee did not have a palatable taste.

Based on observation, interview, and record review, the facility failed to provide services and equipment to ensure one (1) of eighteen (18) sampled residents (Resident #20) with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Observations on 02/14/18 and 02/15/18 revealed staff failed to apply rolled washcloths in the resident's hands to prevent friction and a left palm protector in the left hand as scheduled. Further observations conducted of Resident #20 on 02/13/18, 02/14/18, and 02/15/18 revealed the resident was lying in bed with no contour pillow or blanket underneath the resident's head as ordered to prevent hyperextension of the resident's neck. The findings include: According to the Director of Nursing (DON), the facility did not have a policy/procedure related to the use of hand rolls or orthotic devices. The DON stated the facility followed the physician's orders [REDACTED]. Review of the medical record revealed the facility admitted Resident #20 on 09/12/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment conducted on 12/06/17 revealed the facility assessed Resident #20 to have limitation in range of motion in both the upper and lower extremities. Review of the Comprehensive care plan and the Certified Nursing Assistant (CNA) care plan revealed interventions to apply rolled washcloths to both hands to prevent rubbing/friction to palms and other fingers, and to use a left palm protector as ordered by Restorative Nursing (two hours on and off two hours from 8:00 AM to 6:00 PM for seven days a week). Further review of the Comprehensive care plan and the CNA care plan revealed interventions to include the use of the AB contour pillow/wedge with a blanket folded into a tri-fold position to be placed underneath Resident #20's head to reduce hyperextension. Review of the (MONTH) (YEAR) physician orders [REDACTED]. In addition, rolled washcloths were to be in place in the resident's hands to prevent friction from contractures. The physician's orders [REDACTED]. Observations of Resident #20 on 02/14/18 at 9:11 AM revealed Certified Nursing Assistant (CNA) #1 was giving the resident a bed bath. Further observation at 10:30 AM revealed the hand rolls or palm protector were not in place. Continued observations on 02/14/18 at 1:15 PM revealed there were still no hand rolls in place and no palm protector in place in the left hand and the contour pillow with the blanket folded was also not in place. At 3:05 PM there was still no evidence the hand rolls, palm protector, or contour pillow with the folded blanket were in place for Resident #20. Further observations conducted on 02/15/18 at 10:50 AM revealed there were no hand rolls, palm protector, or contour pillow with folded blanket being utilized for Resident #20. Interview conducted with CNA #1 on 02/15/18 at 11:20 AM revealed she had been trained to refer to the CNA Clinical Care Flow guide for specific care needs for each resident. CNA #1 stated she was familiar with the physician's orders [REDACTED].#20 and also for the use of the contour pillow with the tri-fold blanket. The CNA stated she had been trained by the Restorative staff on applying the palm protector in the resident's hand. CNA #1 stated she had overlooked the direction to place the washcloths and palm protector in the resident's hands and placing the contour pillow with the blanket as ordered by the physician, and therefore had not done it. Interview on 02/15/18 at 11:05 AM with Registered Nurse (RN) #1 revealed the nurses use a check list that has each resident's specific care needs identified to ensure care is being provided as ordered by the physician and as directed by the plan of care. RN #1 stated the nurses are assigned a hall and make rounds every two hours to monitor the residents and no problems had been identified. Interview conducted with the DON on 02/15/18 at 1:45 PM revealed the CNAs were responsible to follow the CNA Clinical Care Flow guide record to identify resident care needs, to keep it with them, and to refer to it as often as needed. The DON added that the licensed nurses were responsible to ensure the CNA care plan and physician orders [REDACTED]. The DON further stated she was not aware of any problems related to devices not being applied as ordered.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the person-centered care plan interventions for one (1) of eighteen (18) sampled residents (Resident #20) was implemented related to positioning devices and orthotic devices for contractural management. Observations revealed a contour pillow/wedge with a blanket folded into a tri-fold position was not utilized as ordered under Resident #20's head to prevent hyperextension. Observations further revealed that an orthotic and hand rolls were not utilized as ordered and in accordance with the plan of care. The findings include: Review of the facility Care Plan policy dated 08/01/13 revealed the interdisciplinary team would be responsible for the development of an individualized comprehensive care plan for each resident. However, the policy did not include measures to identify how the facility would ensure interventions would be implemented. Review of the medical record revealed the facility admitted Resident #20 on 09/12/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment conducted on 12/06/17 revealed the facility assessed Resident #20 to have limitation in range of motion in both the upper and lower extremities. Review of the Comprehensive care plan and the Certified Nursing Assistant (CNA) care plan revealed interventions to include the use of the AB contour pillow/wedge with a blanket folded into a tri-fold position to be placed underneath Resident #20's head to reduce hyperextension. In addition, the care plan included interventions to apply rolled washcloths to both hands to prevent rubbing/friction to palms and other fingers, and to use a left palm protector as ordered by Restorative Nursing (two hours on and off two hours from 8:00 AM to 6:00 PM for seven days a week). Observations on 02/13/18 at 6:23 PM revealed Resident #20 was lying in bed with no contour pillow or blanket underneath the resident's head. In addition, there were no washcloths observed to be rolled and placed in the resident's hands and no palm protector in the resident's left hand. Further observations conducted on 02/14/18 at 9:11 AM, 1:15 PM, and 3:05 PM and on 02/15/18 at 10:50 AM, revealed there was no evidence the contour pillow or blanket, washcloth/hand roll, palm protector was being utilized for Resident #20 as directed by the plan of care. Interview conducted with CNA #1 on 02/15/18 at 11:20 AM revealed she had been trained to refer to the CNA Clinical Care Flow guide for specific care needs for each resident. CNA #1 stated she was familiar with the directions to use the contour pillow and tri-fold blanket, washcloths/hand rolls, and palm protector for Resident #20. The CNA stated she overlooked these items/devices on 02/14/18 and 02/15/18 and did not place them under the resident's head or hands as directed by the plan of care. Interview on 02/15/18 at 11:05 AM with Registered Nurse (RN) #1 revealed the nurses use a check list that has each resident's specific care needs identified to ensure care is being provided as directed by the resident's individual plan of care. RN #1 stated the nurses are assigned a hall and make rounds every two hours to monitor the residents and no problems had been identified. Interview conducted with the DON on 02/15/18 at 1:45 PM revealed the CNAs were responsible to follow the CNA Clinical Care Flow guide record to identify resident care needs, to keep it with them, and to refer to it as often as needed. The DON added that the licensed nurses were responsible to ensure the CNA care plan interventions were implemented when the nurse does the medication pass or whenever making rounds up/down the halls. The DON further stated she was not aware of any problems related to devices not being applied as ordered.

Based on observation, interviews, and review of facility policies, it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions for all residents of the facility who received nutrition from the kitchen. Observations in the kitchen on 11/21/16 revealed two (2) male staff members with facial hair were in the kitchen without having their facial hair covered. The findings include: Review of the facility policy for Employee Sanitary Practices, dated 2013, revealed any employee in the kitchen must have their hair covered, including facial hair. Observations on 11/21/16 at 1:41 PM during the initial tour of the kitchen revealed the two male staff members were observed in the kitchen without having their facial hair covered. Observations in the kitchen on 11/21/16 from 3:54 PM through 5:08 PM during tray line revealed two male staff members and the Dietary Manager were observed to be in the kitchen in close proximity to the food, and did not have their facial hair covered. Interview with the Dietary Manager on 11/22/16 at 3:14 PM revealed he was not aware that facial hair coverings were required to be utilized in the kitchen when preparing or serving food. Interview with the Registered Dietitian (RD) on 11/22/16 at 3:29 PM revealed anyone that enters the kitchen should ensure their hair, including facial hair, is covered.

Based on observation, interview, review of manufacturer's guidelines, and facility policy review, it was determined the facility failed to establish and maintain an effective infection control program designed to provide a safe and sanitary environment to prevent the transmission of disease and infection for two (2) of fifteen (15) sampled residents (Resident #2 and Resident #9) and two (2) unsampled residents (Resident A and Resident B). Observation during medication administration on 11/21/16, revealed staff failed to wash/sanitize their hands after performing blood glucose monitoring for Resident A and prior to cleaning the glucose monitoring device and administration of insulin. In addition, observation of blood glucose monitoring for Resident B on 11/21/16, revealed staff failed to wash/sanitize their hands after performing blood glucose monitoring and prior to cleaning the blood glucose monitoring device. Observation of a skin assessment on Resident #2 on 11/22/16 revealed Licensed Practical Nurse #1 assessed the resident's buttocks and then with the same gloved hands held the resident's hands to help him/her put his/her shirt on. Observation of incontinence care for Resident #9 on 11/22/16 revealed after performing incontinence care staff dressed the resident, transferred the resident from his/her bed to his/her wheelchair, touched the resident's face, and then opened the resident's dresser drawer to place items back into the drawer with the same gloved hands that were used to provide the incontinence care. The findings include: Review of the facility's policy titled, Glucometer Decontamination, not dated, revealed after performing blood glucose monitoring, staff was required to perform hand hygiene, and put on disposable gloves prior to performing blood glucose monitor cleaning. The policy further stated after performing blood glucose monitor cleaning, staff was required to remove their gloves and perform hand hygiene. 1. Observation of blood glucose monitoring for Resident A on 11/21/16, at 4:35 PM, revealed Registered Nurse (RN) #1 performed the test without performing hand hygiene prior to administration of insulin to the resident, and prior to cleaning the glucometer. Observation of blood glucose monitoring for Resident B on 11/21/16, at 4:40 PM, revealed RN #1 wore gloves to perform a blood glucose test and to clean the blood glucose monitoring device. However, although the RN wore gloves to test the resident's blood sugar and to clean the device, she failed to wash/sanitize her hands after she removed the soiled gloves prior to putting on clean gloves to cleanse the blood glucose monitoring device. Interview conducted with RN #1 on 11/23/16, at 2:30 PM, revealed she was aware she had failed to perform hand hygiene while performing the blood glucose monitoring for Resident A and Resident B and should have washed/sanitized her hands after performing blood glucose monitoring, and after cleaning the blood glucose monitoring device prior to administering insulin to Resident A. Interview conducted with the Director of Nursing (DON) on 11/23/16, at 3:10 PM revealed staff was required to perform hand hygiene when they conducted a test of the residents' blood glucose levels. In addition, the DON stated staff was required to wash/sanitize their hands after cleaning a blood glucose monitoring device and before administering insulin. The DON stated all nurses were required to do a competency skills check upon hire and annually. During further interview with the DON, she stated RN #1 had completed a skills check and no concerns had been identified regarding her performing blood glucose monitoring. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 01/28/11 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Observation of a skin assessment for Resident #2 on 11/22/16 at 2:16 PM revealed Licensed Practical Nurse (LPN) #1 assessed the resident's buttocks and then with the same gloved hands, held the resident's hands while assisting the resident to dress. Interview with LPN #1 on 11/23/16 at 2:39 PM was attempted but the LPN was unable to be reached. 3. Review of Resident #9's medical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of Resident #9's annual MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident to be frequently incontinent of urine and require extensive assistance of two (2) staff persons for toileting. Observation of incontinence care for Resident #9 on 11/22/16 at 2:01 PM revealed staff dressed the resident, transferred the resident from the bed to the wheelchair, touched the resident's face, and then opened the resident's dresser drawer to place items back into the drawer with the same gloved hands that had been used while performing incontinence care. Interview with Certified Nursing Assistant (CNA) #4 on 11/23/16 at 2:13 PM revealed she was trained to change gloves and wash her hands after providing incontinence care. She stated she should have removed her gloves and washed her hands after providing incontinence care. She further stated that by not removing her gloves and washing her hands it could cause the resident to get an infection. Interview with the Unit Coordinator (UC) on 11/23/16 at 2:18 PM revealed that staff was trained to remove their gloves and wash their hands after providing incontinence care and when going from a dirty area of the body to a clean area of the body. She stated CNA #4 should not have touched the resident with the same gloves that she used to provide incontinence care. The UC also stated LPN #1 should not have touched the resident's hands after she assessed the resident's buttocks. Further interview revealed the CNAs and nurses complete competencies annually for handwashing. She stated she had not identified any concerns with staff not changing gloves or washing their hands when providing care. Interview with the Director of Nursing (DON) on 11/23/16 at 4:08 PM revealed the CNA should not have touched the resident with the same gloves she used to provide incontinence care and that LPN #1 should not have touched the resident's hands after she assessed the resident's buttocks. She stated that staff was trained annually to change their gloves and wash their hands after providing incontinence care, and if they identify concerns. She further stated she had not identified any concerns with staff not changing their gloves or washing their hands when indicated.

Based on interview, record review, and review of facility policy it was determined the facility failed to ensure the resident environment remained as free from accident hazards as possible for five (5) of fifteen (15) sampled residents (Residents #2, #3, #8, #9, and #10). Resident #2 had a physician's orders [REDACTED]. However, observations revealed the seatbelt was not provided. Resident #3 had physician orders [REDACTED]. Resident #8 had care plan interventions to have dycem in his/her wheelchair. However, observations revealed the dycem mat was not in the chair. Resident #9 had a physician's orders [REDACTED]. Resident #10 was assessed to require two staff members for transferring. However on 05/29/16 and 09/08/16 the resident was transferred by one staff member. In addition, observations during the environmental tour on 11/23/16 revealed three (3) storage areas unlocked that contained medical supplies that could be hazardous to residents if ingested. The findings include: Review of the facility's policy titled Accidents/Incidents, dated 08/01/13, revealed the facility would provide a safe and healthful environment. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 01/28/11 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment for Resident #2 dated 09/28/16 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Review of the November 2016 Physician order [REDACTED]. Observations of Resident #2 on 11/22/16 and 11/23/16 revealed the resident sitting in his/her electric wheelchair without the self-releasing seatbelt in place. Interview with Resident #2 on 11/22/16 at 2:16 PM revealed that staff at times does not remember to apply the seatbelt when the resident is assisted up in the chair. Interview with CNA #2 on 11/23/16 at 1:50 PM revealed she was aware that Resident #2 was at an increased risk for falls, but was not aware the resident was to have a self-releasing seatbelt when up in the wheelchair. 2. Review of the medical record for Resident #3 revealed the facility readmitted the resident on 03/05/16, with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident to have a BIMS score of three (3) which indicated the resident was severely cognitively impaired and therefore not interviewable. Further review of the MDS revealed Resident #3 required extensive assistance with transfers. Review of a Fall Risk assessment dated [DATE] revealed the facility assessed Resident #3 to be at high risk for falls. Review of Resident #3's Comprehensive Care Plan dated 07/19/16 revealed a fall mat would be placed on the floor at Resident #3's bedside. Observations of Resident #3 on 11/21/16 at 1:37 PM, 3:20 PM, and 4:15 PM, revealed the resident was observed to be in bed with the fall mat observed leaning against the wall and not in place on the bedside floor. Interview conducted with SRNA #3 on 11/23/16, at 2:00 PM, revealed she was responsible to ensure the fall mat was placed at Resident #3's bedside. She further revealed there have been times when Housekeeping moves the fall mats to clean the rooms and forgets to place the fall mats back by the bedside. 3. Review of the medical record for Resident #8 revealed the facility admitted the resident on 11/15/13, with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment completed by the facility for Resident #8 dated 10/19/16, revealed the facility had assessed the resident to have a BIMS score of five (5) which indicated the resident was severely cognitively impaired. Review of the Fall Risk assessment dated [DATE] revealed the facility assessed Resident #8 to be at high risk for falls. Review of Resident #8's Comprehensive Care Plan dated 01/21/16 revealed an intervention for a dycem mat to be placed in Resident #8's wheelchair for the prevention of falls. Observations of Resident #8 on 11/21/16 at 4:42 PM and 4:55 PM, and on 11/22/16 at 9:45 AM, 10:58 AM, and 12:00 PM, revealed the resident was observed to be sitting in his/her wheelchair without the dycem mat in the wheelchair. Interview with SRNA #2 on 11/23/16 at 1:50 PM revealed she was not aware that Resident #8 was supposed to have the dycem mat in his/her wheelchair. Interview conducted with the Unit Manager on 11/23/16 at 2:20 PM revealed she conducted rounds every two (2) hours to ensure falls interventions were in place for the residents, but had not identified that Resident #8's interventions were not in place. Interview with the DON on 11/23/16 at 4:10 PM revealed the SRNAs were responsible for providing the care and ensuring that the residents had the assistive devices in place that they had been assessed to require. The DON stated she had not identified any concerns with residents not having fall interventions in place. 4. Review of Resident #9's medical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of Resident #9's annual MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) indicating the resident was cognitively intact. Review of the Hot Beverage Safety Assessment for Resident #9 dated 09/07/16 revealed the facility had identified that the resident required a cup with a lid when holding hot beverages due to the resident experiencing tremors. Review of Resident #9's November 2016 Physician order [REDACTED]. Interview with Resident #9 on 11/22/16 at 1:58 PM revealed the CNAs take the lid off of his/her coffee cup when they deliver the meal tray. Interview with CNA #1 on 11/22/16 at 4:01 PM revealed she delivered Resident #9's meal to him/her on 11/22/16. She stated she looked at the resident's meal card when she delivered the tray to ensure the resident was receiving the correct diet and utensils. She stated she was aware the resident had an order for [REDACTED]. However, CNA #1 stated the resident does not like to have a lid on his/her coffee so she takes it off for the resident. 5. Review of the medical record revealed the facility readmitted Resident #10 on 04/03/16, with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed that Resident #10 required two (2) person assistance for transfer. Review of the facility's falls investigation report dated 05/29/16, at 12:20 PM, revealed Resident #10 was lowered to the floor by SRNA #9 while attempting to transfer Resident #10 to the wheelchair from the toilet unassisted. Resident #9 became weak and sat on the floor. No injuries were reported. Review of the facility's falls investigation report dated 09/08/16 at 10:35 AM, revealed Resident #10 was found sitting on the floor in front of the commode. Resident #10 had been assisted with a transfer to the toilet by SRNA #10 unassisted. No injuries were reported. Interview conducted with SRNA #9 on 11/23/16, at 2:27 PM, revealed she had provided care for Resident #10 on 05/29/16. SRNA #9 stated she was transferring the resident alone when the resident became weak and was lowered to the floor. The SRNA stated she was unaware that Resident #10 was a two (2) person assist with transfer. Interview conducted with SRNA #10 on 11/23/16 at 2:50 PM, revealed she had provided care for Resident #10 on 09/08/16. SRNA #10 stated she had assisted the resident with transferring to the toilet unassisted, when the resident became weak and had to sit down on the floor. No injuries were reported. Interview with the Unit Coordinator on 11/23/16 at 2:18 PM revealed the CNAs are expected to ensure residents are provided with supervision and assistive devices that they require. She further stated she does rounds every two (2) hours to ensure appropriate interventions are in place. Interview with the Director of Nursing (DON) on 11/23/16 at 4:08 PM revealed she does audits often to ensure staff is providing residents with the appropriate supervision and assistive devices to prevent accidents. Further interview with the DON revealed the CNAs, nurses, and any other staff makes daily rounds to ensure residents are being provided the care and services they are assessed to need. 6. Observations during the environmental tour on 11/23/16 at 3:10 PM on the 300 Hall revealed the Clean Utility Room door to be unlocked and the following supplies to be present and accessible to residents: Med Spa Shaving Cream - five (5) cans, Soothe and Cool Moisturizing Body Lotion - seven (7) tubes, Med SPA Roll On Antiperspirant - ten (10) bottles, Mouthwash Rinse - ten (10) bottles, Dawn Mist Anticavity Fluoride Toothpaste - twelve (12) tubes, Denture Cleanser - ninety-six (96) tablets, Microdot Bleach Wipes - eleven (11) bottles, and DermaSyn Spray Gel Wound Dressing - four (4) bottles. Observations of the 100 Hall Clean Linen Room on 11/23/16 at 3:40 PM revealed the room to be unlocked and the following supplies to be present and accessible to residents: Mouthwash Rinse - four (4) bottles, Med Spa Shaving Cream - twelve (12) cans, and Denture Cleanser - eighty-eight (88) tablets. Observations of the Clean Utility Room on 100 Hall at 3:50 PM revealed the door to be unlocked and the following supplies to be present and accessible to residents: Microdot Bleach Wipes - five (5) bottles, DermaSyn Spray Gel Wound Dressing - three (3) bottles, and Whirl Bath Lemon Kleen - two (2) bottles. Review of the Material Safety Data Sheets (MSDS) on all items, except the Med Spa Shaving Cream and the DermaSyn Spray Gel Wound Dressing, revealed if swallowed get medical help or contact a Poison Control Center. Interview with the Maintenance Supervisor on 11/23/16 at 3:55 PM revealed the maintenance crew is in and out of the storage rooms several times a week and had not identified any concerns with the doors being unlocked. Further interview revealed staff used a maintenance requisition book to write in any concerns and he checks the book twice a day and no concerns had been identified by staff concerning the locks on the storage room doors. Interview with the Vice President of Clinical Services on 11/23/16 at 4:00 PM revealed the facility had twenty (20) wandering residents and no residents had entered the storage rooms and no accidents had been reported.

Based on observation, interview, record review, facility policy review, and review of a facility investigation, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for six (6) of fifteen (15) sampled residents (Residents #2, #3, #8, #9, #10, and #13). Resident #2 had interventions for a self-releasing seatbelt and hip/knee wedges to be in place while the resident was up in his/her electric wheelchair. However, observations revealed the resident did not have a self-releasing seatbelt or hip/knee wedges in place while up in the electric wheelchair. Resident #3 had interventions for a fall mat to be placed at bedside and to wear sleeve protectors on arms bilaterally. However, observations revealed a fall mat was not in place at the resident's bedside and the resident did not have sleeve protectors in place. Resident #8 had interventions for a dycem mat to be placed in his/her wheelchair. However, observations revealed Resident #8 did not have a dycem mat in place in the wheelchair. Resident #9 had interventions in place to utilize a cup with a lid for hot liquids. However, the resident was observed with a cup of coffee without a lid in place. A review of Resident #10's care plan revealed the facility had assessed Resident #10 to require the assistance of two staff persons for transfer. However, on 5/29/16, State Registered Nursing Assistant (SRNA) #9 transferred Resident #10 from the toilet to the wheelchair unassisted and the resident slid to the floor. In addition on 09/08/16, SRNA #10 transferred Resident #10 to the toilet from a wheelchair unassisted and the resident sat down in on the floor. Resident #13 had interventions for a dycem mat to be in place on top of his/her wheelchair cushion. However, observations revealed the resident did not have a dycem mat in place on top of his/her wheelchair cushion. Further review of Resident #13's care plan revealed an Ankle Foot Orthotic (AFO) brace was to be applied to the resident's right ankle. However, observation revealed the resident was not wearing the AFO brace as required. The findings include: Review of the Using the Care Plan policy, dated 08/01/13, revealed the care plan would be used in developing each resident's daily care routines and would be available to staff personnel who were responsible for providing care or services to the resident. Further review revealed the resident's daily care would be consistent with the resident's care plan. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 01/28/11 with [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Review of Resident #2's Comprehensive Care Plan dated 09/29/16 revealed an intervention for a seatbelt to be utilized when the resident was up in an electric wheelchair, to prevent the resident from sliding in the chair. The Care Plan also included an intervention for the resident to utilize hip/knee wedges to limit the resident's lower extremity abduction when out of bed. Review of the Certified Nursing Assistant (CNA) Clinical Flow Sheet for resident #2 dated November 2016 revealed the interventions for the seatbelt and hip/knee wedges were listed on the flow sheet. Observations of Resident #2 on 11/22/16 at 2:16 PM and on 11/23/16 at 9:15 AM revealed the resident was sitting in his/her electric wheelchair without the self-releasing seatbelt or hip/knee wedges in place. Interview with Resident #2 on 11/22/16 at 2:16 PM revealed he/she does not always use the self-releasing seatbelt or the hip/knee wedges when up in the electric wheelchair, because staff does not always remember to apply them when he/she is assisted up to the wheelchair. Interview with CNA #2 on 11/23/16 at 1:50 PM revealed CNAs would be responsible for ensuring that Resident #2's seatbelt and hip/knee braces were in place as directed by the resident's plan of care. However, the CNA stated she was not aware the resident was required to have a hip/knee brace or seatbelt in place when in the wheelchair. The CNA also stated she was required to review the CNA flowsheets daily for the residents she was providing care to, and that nurses made the CNAs aware of any changes to a resident's plan of care throughout the day. 2. Review of the medical record for Resident #3 revealed the facility readmitted the resident on 03/05/16, with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS)assessment completed by the facility on 10/19/16, revealed the facility had assessed the resident to have a BIMS score of three (3) which indicated the resident was severely cognitively impaired and therefore not interviewable. Review of Resident #3's Comprehensive Care Plan dated 07/19/16 revealed a fall mat would be placed at the bedside on the floor of the resident's room. Further review of the care plan revealed an intervention originally dated 05/31/16, for sleeve protectors to be worn by Resident #3 at all times. Observations of Resident #3 on 11/21/16 at 1:37 PM, 3:20 PM, and 4:15 PM revealed the resident was observed to be in bed without sleeve protectors on and the fall mat was leaning against the wall, and not in place at the bedside as required. Further observation on 11/21/16 at 4:48 PM, and on 11/22/16 at 9:40 AM, 10:55 AM, and 11:50 AM revealed Resident #3 was in bed without sleeve protectors on. Interview conducted with SRNA #3 on 11/23/16, at 2:00 PM, revealed she reviews resident care plans every morning for the residents she is assigned to provide care to. She further revealed she had overlooked the fall mat leaning against the wall when she was in Resident #3's room. Further interview revealed she just forgot to place the sleeve protectors on Resident #3. 3. Review of the medical record for Resident #8 revealed the facility admitted the resident on 11/15/13, with [DIAGNOSES REDACTED]. Review of a quarterly (MDS) assessment completed by the facility for Resident #8 dated 10/19/16, revealed the facility had assessed the resident to have a BIMS score of five (5) which indicated the resident was severely cognitively impaired. Review of Resident #8's Comprehensive Care Plan dated 01/21/16 revealed an intervention for dycem to be placed in Resident #8's wheelchair. Review of the nurse aide care plan dated 11/2016, revealed the intervention for the dycem pad to be in place to the resident's wheelchair was listed. Observations of Resident #8 on 11/21/16 at 4:42 PM and 4:55 PM, and on 11/22/16 at 9:45 AM, 10:58 AM, and 12:00 PM, revealed the resident was observed to be sitting in his/her wheelchair without a dycem mat in place. Interview with SRNA #2 on 11/23/16 at 1:50 PM revealed she reviews the care plans for her residents two (2) times a day. However, she stated she was not aware that Resident #8 was required to have the dycem mat in his/her wheelchair. 4. Review of Resident #9's medical record revealed the facility admitted the resident on 10/30/14 with [DIAGNOSES REDACTED]. Review of the annual MDS assessment for Resident #9 dated 09/07/16 revealed the facility assessed the resident to have a BIMS score of fifteen (15) indicating the resident was cognitively intact. Review of Resident #9's comprehensive care plan dated 09/08/16 revealed an intervention for the resident to utilize a cup with a lid for hot liquids. Observation of the evening meal on 11/22/16 revealed the resident had a cup of coffee on his/her tray. However, the cup of coffee was observed to be uncovered with the lid lying on the resident's overbed table. Interview with Resident #9 on 11/22/16 at 1:58 PM revealed that the CNAs take the lid off of his/her coffee when they deliver the resident's meal tray. Interview with CNA #1 on 11/22/16 at 4:01 PM revealed she delivered Resident #9's meal tray on 11/22/16. The CNA stated she looked at the resident's meal card when she delivered the tray to ensure the resident received the correct diet and utensils. The CNA stated she should not have removed the lid from the resident's coffee cup. 5. Review of the medical record for Resident #10 revealed the facility readmitted the resident on 4/03/16, with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 05/18/16 and review of an annual MDS for Resident #10 dated 08/18/16, revealed the resident had been assessed by the facility to require the extensive assistance of two persons to transfer the resident. The MDS also revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15). A review of Resident #10's care plan dated 08/22/16 revealed the facility had assessed Resident #10 to require the assistance of two staff persons for transfer. Review of the Clinical Flow Sheet dated May 2016 and September 2016 for Resident #10 revealed the facility had assessed the resident to require two (2) persons to transfer the resident. Review of the facility's investigation of a fall sustained by Resident #10 on 05/29/16, at 12:20 PM, revealed SRNA #9 attempted to transfer Resident #10 unassisted resulting in the resident sliding to the floor. Documentation revealed the resident sustained [REDACTED]. Review of the facility's investigation of a fall sustained by Resident #10 on 09/08/16 at 10:35 AM, revealed SRNA #10 attempted to transfer Resident #10 unassisted from the wheelchair to the toilet. The investigation revealed Resident #10 began to feel weak and had to sit down on the floor with SRNA #10. Interview conducted with SRNA #9 on 11/23/16, at 2:27 PM, revealed she had provided care to Resident #10 unassisted and had assisted Resident #10 from the toilet to the wheelchair unassisted. SRNA #9 stated she was not aware that Resident #10 was required to have a two (2) person assist for transfer. Interview conducted with SRNA #10 on 11/23/16 at 2:50 PM, revealed she had provided direct care to Resident #10 by herself and had assisted Resident #10 to the toilet from the wheelchair unassisted when the resident slid off the toilet and sat on the floor. SRNA #10 stated she was required to read Resident Flow Sheets daily and was unaware that Resident #10 was a two (2) person assist. Interview with Licensed Practical Nurse (LPN) #1 on 11/23/16 at 2:00 PM, revealed SRNAs were required to review Resident Flow Sheets daily, which was where information regarding the care needs of a resident were kept, and stated the SRNAs were required to keep the sheets with them while on duty. Interview conducted with the Director of Nursing (DON) on 11/23/16, at 4:08 PM, revealed SRNAs were required to keep the Resident Flow Sheets with them during their shift. The DON stated SRNAs should not have been alone when assisting Resident #10. The DON stated she monitored residents to ensure they received appropriate care by making rounds daily and also attended clinical team meetings. The DON stated she had not identified any problems with staff not following resident care plans. 6. Review of Resident #13's medical record revealed the facility admitted the resident on 04/24/16 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of fifteen (15) indicating the resident was cognitively intact. Review of Resident #13's comprehensive care plan revealed an intervention dated 05/03/16 for a dycem mat to be placed on top of the wheelchair cushion. In addition an intervention was listed for the resident to wear an Ankle Foot Orthotic (AFO) brace, dated 05/05/16. Review of the CNA Clinical Flow Sheet dated November 2016 revealed interventions were listed for an AFO brace to the resident's right ankle and the dycem on top of the resident's cushion on his/her wheelchair. Observations of Resident #13 on 11/23/16 revealed the resident did not have dycem to the cushion of the resident's wheelchair and the resident was not wearing the AFO brace to his/her right ankle. Interview with Resident #13 on 11/23/16 at 12:57 PM revealed staff usually helped him/her put on the AFO brace. However, the resident stated staff had failed to put the brace on him/her on 11/23/16. Further interview revealed the resident was not sure if he/she had dycem to his/her wheelchair. Interview with CNA #3 on 11/23/16 at 2:00 PM revealed the resident is independent with putting the brace on and putting the dycem on his/her wheelchair cushion. The CNA further stated that it was ultimately her responsibility to ensure care plan interventions were in place and that she should not depend on the resident to put on the brace or place the dycem mat in the chair. She further stated that she gets information related to resident care from the resident's CNA Clinical Flow Sheet and that she looked at it daily. Interview with the Unit Coordinator on 11/23/16 at 2:18 PM revealed the CNAs are expected to look at the CNA Flow Sheet daily and that she conducts rounds every two (2) hours to ensure the residents' care plans are followed. She stated she had not identified any concerns with staff not following the residents' care plans. Interview with the DON on 11/23/16 at 4:10 PM revealed the SRNAs were responsible for providing the care for the residents that is outlined on their care plans. She further revealed the nurses were to check on the residents, while doing their rounds, to ensure the care plans were being followed. She had not identified any concerns with staff not following the care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to administer oxygen in accordance with the physician's orders [REDACTED].#11). Resident #11 had a physician's orders [REDACTED]. However, observation on 11/23/16 revealed the facility failed to ensure that oxygen was administered to Resident #11 as ordered by the physician. The findings include: Interview with the Vice President of Clinical Services on 11/23/16 at 1:23 PM revealed the facility did not have a policy to address oxygen administration. Review of Resident #11's medical record revealed the facility admitted the resident on 10/10/16 with [DIAGNOSES REDACTED]. Review of the Manual Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident's cognition was intact. The MDS also revealed the resident received oxygen treatment. Review of the Comprehensive Care Plan for Resident #11 dated 10/23/16 revealed the facility would provide the resident with oxygen per nasal cannula as ordered by the physician. Review of Physician orders [REDACTED].#11 and the Clinical Flow Sheet for the resident dated November 2016, revealed the resident was to be administered oxygen at two (2) liters per minute. Observation of Resident #11 on 11/23/16 at 10:56 AM, 11:07 AM, 11:31 AM, 1:00 PM, and 1:36 PM revealed Resident #11 to be lying in bed, but did not have oxygen applied. Interview with State Registered Nurse Aide (SRNA) #8 on 11/23/16 at 11:00 AM revealed Resident #11 was required to have oxygen in place at two (2) liters per minute, as stated on the resident's Clinical Flow Sheet. Interview with Registered Nurse (RN) #6 on 11/23/16 at 2:43 PM revealed Resident #11 should have been wearing oxygen as ordered. Additional interview revealed she conducted rounds every two (2) hours per shift and had not identified any problems. Interview with the Director of Nursing (DON) on 11/23/16 at 4:10 PM revealed nurses were required to review resident physician orders [REDACTED].#11 had not been wearing his/her oxygen as required. Additional interview revealed the facility used audit tools to ensure care and services were provided. Further interview revealed she had not identified any concerns.

Based on observation, interview, and record review it was determined the facility failed to ensure one (1) of fifteen (15) sampled residents (Resident #13) who had limited range of motion received appropriate treatment and services to prevent further risk of injury due to contractures. The facility had assessed Resident #13 to have a decrease in range of motion to one of his/her lower extremities and had a care plan intervention for an Ankle Foot Orthotic (AFO) brace. However, observations of Resident #13 on 11/23/16 revealed Resident #13 did not have the AFO brace on his/her right ankle. The findings include: Review of the Restorative Nursing Care Protocol, not dated, revealed Restorative Nursing Care Programs consisted of, but were not limited to, prosthesis care. The protocol also stated Restorative Nursing Care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible with a goal to restore or to prevent further impairments in a specific area. Review of Resident #13's medical record revealed the facility admitted the resident on 04/24/15 with [DIAGNOSES REDACTED]. Review of Resident #13's minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #13 to have a functional limitation in range of motion and to have impairment to the resident's right lower extremity. Further review revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Review of Resident #13's Clinical Flow Sheet, Certified Nurse Aide (CNA) care plan, dated 05/05/16 revealed an intervention for Resident #13 to have an AFO brace to his/her right ankle when out of bed. Observation of Resident #13 on 11/23/16 revealed Resident #13 did not have the ordered AFO brace on his/her right ankle. Interview with Resident #13 on 11/23/16 at 12:57 PM revealed staff usually helped him/her apply the AFO brace. However, the resident stated staff had not assisted him/her that morning with putting the brace on. Interview with CNA #3 on 11/23/16 at 2:00 PM revealed the resident was independent with applying the AFO brace. However, the CNA further stated that it was ultimately her responsibility to ensure residents were provided with the care devices they were assessed to require. Interview with the Unit Coordinator on 11/23/16 at 2:18 PM revealed CNAs were responsible for ensuring residents had the required care equipment, including Resident #13's AFO brace. She stated she does rounds daily to ensure residents are receiving ordered care. She further stated she had not identified any concerns with residents not wearing their ordered braces. Interview with the Director of Nursing (DON) on 11/23/16 at 4:08 PM revealed she does audits often to ensure staff followed the resident's care plan. She stated she and the Unit Coordinators make rounds daily and no concerns had been identified with staff not following the resident's care plan.

Based on observation, interview, resident record review, and facility policy review it was determined that the facility failed to provide appropriate interventions to prevent skin breakdown for one (1) of fifteen (15) sampled residents (Resident #5). Review of Resident #5's comprehensive care plan revealed Resident #5 was to have a right heel protector in place at all times and was to elevate his/her ankles while in bed to prevent skin breakdown. However, observations of Resident #5 on 11/21/16 and 11/22/16 revealed Resident #5 did not have a heel protector present and his/her ankles were not elevated while in bed. The findings include: Review of the facility policy titled Skin Wound Protocol, with a revision date of 01/01/16, revealed the facility would implement early interventions to prevent skin breakdown. Review of Resident #5's medical record revealed the facility readmitted the resident on 02/04/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident's cognition was impaired. Review of the Comprehensive Care Plan for Resident #5 dated 04/28/16 revealed the facility would keep the resident's ankles off the bed. Review of the Clinical Flow sheet used by State Registered Nurse Aides (SRNAs) for Resident #5 dated November 2016 revealed a heel protector to the resident's right lower extremity (RLE) was to be used at all times, and the resident's ankles would be kept off the bed utilizing pillows. Review of physician's orders for Resident #5 dated November 2016, revealed a heel protector to the RLE was to be utilized at all times, and staff was to off load the resident's ankles from the bed by using pillows. Observation of Resident #5 on 11/21/16 at 2:49 PM revealed Resident #5 was lying in bed; however, his/her ankles were not elevated and a heel protector was not applied to the resident's RLE. Further observation of Resident #5 at 3:21 PM revealed the resident was sitting on the side of the bed with no heel protector in place. Observation of Resident #5 on 11/22/16 at 9:34 AM revealed Resident #5 was lying in bed, however, his/her ankles were not elevated and the resident did not have a heel protector applied to the RLE. Further observation of Resident #5 at 10:19 AM revealed the resident sitting up on the side of the bed without a heel protector present to the RLE. Interviews with SRNA #6 on 11/21/16 at 3:22 PM and SRNA #7 on 11/22/16 at 9:35 AM revealed they were not aware that Resident #5's ankles were to be off the bed utilizing pillows, or that a heel protector was to be applied to the resident's RLE. Interview with Registered Nurse (RN) #6 on 11/23/16 at 2:43 PM revealed Resident #5 should have a heel protector on at all times to the RLE and his/her ankles should have been elevated while in bed. RN #6 also stated she conducted daily rounds every two (2) hours per shift and had not identified any problems. Interview with the Director of Nursing (DON) on 11/23/16 at 4:10 PM revealed a heel protector should have been applied to Resident #5's RLE and his/her ankles should have been elevated while in bed. Additional interview revealed the facility used audit tools to ensure care and services were provided. The DON also stated random skin assessments were conducted, but she had not identified any concerns.