Every finding on record at The Lodge at Tangi Pines

Based on record reviews and interviews, the provider failed to develop a comprehensive person-centered care plan for each resident in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (#1, #2, and #4) of 4 sampled residents reviewed. Findings: Resident #1Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses which included Dementia and Bipolar Disorder. Review of Resident #1's MDS with an ARD of 07/14/2026 revealed the resident had a BIMS of 8, which indicated she was moderately cognitively impaired. Review of Resident #1's current Care Plan revealed the following, in part: Problem: alteration in behavior related to delusions, hallucinations. 07/11/2026-hit staff with clothes hanger.Goal: will have no complications or injuries from behaviors this quarter.Interventions: consult doctor as needed; encourage socialization and participation in activities; medications as ordered; redirect as needed; resides on memory care unit.Further review revealed no documented evidence of any additional behaviors. Review of Resident #1's Nurse's Notes, dated 07/11/2026, revealed Resident #1 hit a CNA in the stomach with a clothes hanger. Further review revealed no documented evidence of any additional behaviors. On 08/10/2026 at 1:35 p.m., an interview was conducted with S6CNA. She stated Resident #1 frequently flooded her bathroom at night by cutting the water on and stuffing the toilet with clothes. She stated night shift staff started shutting the water valve off in Resident #1's restroom whenever her water was not in use to prevent flooding. On 08/11/2026 at 8:10 a.m., an interview was conducted S7LPN. She stated Resident #1 frequently flooded her bathroom at night by cutting the water on and stuffing the toilet with clothes. She stated night shift staff started shutting the water valve off in Resident #1's restroom whenever her water was not in use to prevent flooding. On 08/12/2026 at 9:13 a.m., an interview was conducted with S8MS. He stated he was familiar with Resident #1. He stated Resident #1 frequently flooded her bathroom by leaving the water on and stuffing the toilet with clothes. He stated night shift staff started shutting the water off via water valve in her bathroom at night to prevent her from flooding it. On 08/11/2026 at 12:07 p.m., an interview was conducted with S3MDS. She stated was responsible for the resident's care plans. She stated she reviewed progress notes daily, which was how she knew what to care plan each resident for. She reviewed Resident #1's care plan and verified Resident #1 had a behavior on 07/11/2026 where she hit staff with a clothes hanger. S3MDS confirmed no intervention was put in place after this behavior and should have been. She further confirmed Resident #1 had no progress notes related to her flooding her bathroom, which would be considered a behavior. She confirmed Resident #1 should have been care planned for all her behaviors and was not. On 08/11/2026 at 1:21 p.m., an interview was conducted with S4MDS. She stated she was responsible for the resident's care plans. She stated she could only care plan residents for what was documented in their charts. She stated if a resident had a behavior and it was not documented, she would not know to develop a care plan for it. She reviewed Resident #1's care plan and confirmed she had a behavior on 07/11/2026 of hitting staff with a clothes hanger. She stated no new behavioral intervention was put into place for Resident #1 following this behavior. She further stated she was not aware Resident #1 had been flooding her bathroom, which would be considered a behavior. She confirmed Resident #1 should have been care planned for all her behaviors and was not. On 08/12/2026 at 10:25 a.m., an interview was conducted with S2DON. He stated Resident #1 flooded her restroom frequently, which would be considered a recurring behavior. He reviewed Resident #2's nurse's notes and confirmed there was no documentation to indicate she frequently flooded her own bathroom at night. He reviewed Resident #1's care plan and confirmed she was not care planned for this behavior and further confirmed an intervention was not put into place after her behavior on 07/11/2026 when she hit staff with a clothes hanger. He confirmed a resident's behaviors should be documented in a nurse's note so they could be care planned appropriately. Resident #2Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, Unspecified Mental Disorder, and Unspecified Psychosis. Review of Resident #2's Quarterly MDS, with an ARD of 05/19/2026, revealed he had a BIMS of 10, which indicated he was moderately cognitively impaired. Review of Resident #2's current Care Plan revealed no documented evidence of any behaviors. Review of Resident #2's Nurse's Notes dated 07/01/2026-08/11/2026 revealed no documented evidence of any behaviors. On 08/10/2026 at 9:03 a.m., an interview was conducted with Resident #2. He stated a couple weeks ago, he saw another resident beating up S6CNA. He stated he intervened and punched the resident so he would stop hitting the CNA. On 08/10/2026 at 1:48 p.m., an interview was conducted with S6CNA. S6CNA stated on 08/01/2026, while trying to redirect Resident #4 from entering another resident's room, he became angry then kicked her and attempted to hit her. S6CNA stated Resident #2 saw what was happening and came over to where she and Resident #4 were. S6CNA stated Resident #4 turned around and hit Resident #2 in the face then Resident #2 hit Resident #4 back. S6CNA confirmed this incident was resident to resident abuse and she reported it to S7LPN immediately after it occurred. On 08/11/2026 at 8:19 a.m., an interview was conducted with S7LPN. She stated on the evening of 08/01/2026, S6CNA informed her Resident #2 and #4 got into a fight after Resident #2 witnessed Resident #4 kick her. S7LPN stated S6CNA stated when Resident #2 came over, he and Resident #4 started hitting each other. S6CNA stated after she became aware of the incident, she immediately reported it to S2DON. She confirmed she did not document the altercation between Resident #2 and Resident #4 in Resident #2's nurse's notes. On 08/11/2026 at 12:16 p.m., an interview was conducted with S3MDS. She stated she reviewed resident charts daily and Resident #2's chart did not contain any documentation to indicate he and Resident #4 had a physical altercation. She stated resident behaviors should be documented in their nurse's notes so they could be care planned appropriately. On 08/12/2026 at 10:25 a.m., an interview was conducted with S2DON. He stated he was aware of the incident between Resident #2 and Resident #4. He confirmed the incident should have been documented in Resident #2's nurse's notes so it could be care planned appropriately, and was not. Resident #4Review of Resident #4's clinical record revealed he was admitted to the facility on [DATE], with diagnoses which included Bipolar Disorder, Psychotic Disorder, and Dementia. Review of Resident #4's Quarterly MDS with an ARD of 07/14/2026 revealed he had a BIMS of 2, which indicated he was severely cognitively impaired. Review of Resident #4's current Care Plan revealed the following, in part:Problem: alteration in behavior related to history refusing care/medications, wanders, combative, diagnosis bipolar, diagnosis anxiety, diagnosis psychosis, history of attempted risk for elopement. 02/22/2026 - behavior noted.02/25/2026 - aggressive combative behavior toward staff noted.03/17/2026 - aggressive combative behavior toward staff noted.06/11/2026 - climbing over furniture to get out back of unit; swinging at staff who attempted to redirect.Goal: will have no complications or injuries from behaviors this quarterInterventions: consult MD as needed; encourage socialization and participation in activities; medications as ordered; pharmacy drug regimen review as scheduled; redirect as needed; 03/18/2026-increase to Seroquel.Further review revealed no documented evidence of Resident #4's behaviors on 08/01/2026. Review of Resident #4's Nurse's Notes, dated 07/01/2026-08/11/2026, revealed no documented evidence of any behaviors. On 08/11/2026 at 8:19 a.m., an interview was conducted with S7LPN. She confirmed she did not document the aforementioned altercation between Resident #4 and Resident #2 in Resident #4's nurse's notes. On 08/11/2026 at 12:16 p.m., an interview was conducted with S3MDS. She stated Resident #4 had known behaviors. She reviewed Resident #4's chart and confirmed his last documented behavior was on 06/11/2026. She confirmed a new intervention was not added to his care plan following each of his behaviors. She confirmed Resident #4's chart did not contain any documentation to indicate he and Resident #2 had a physical altercation on 08/01/2026. She confirmed all of Resident #4's behaviors should be documented within his nurse's notes so they could be care planned appropriately On 08/11/2026 at 1:30 p.m., an interview was conducted with S4MDS. She reviewed Resident #4's care plan and verified he had a list of behaviors, but no interventions were added after each of them. On 08/12/2026 at 10:25 a.m., an interview was conducted with S2DON. He confirmed the aforementioned incident between Resident #4 and Resident #2 should have been documented in Resident #4's nurse's notes so his care plan could have been updated, and was not. S2DON further confirmed Resident #4's care plan did not have interventions added for each of the behaviors listed.

Based on interviews and record reviews, the facility failed to ensure alleged incidents of resident to resident physical abuse were reported to the administrator immediately and to the state agency within two hours after the allegation was made for 2 (#2 and #4) of 4 sampled residents.Findings: Review of the facility's Abuse, Neglect and Exploitation policy, revised 2025, revealed the following, in part: IV. Reporting/Response1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Resident #2Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #2's Quarterly MDS, with an ARD of 05/19/2026, revealed he had a BIMS of 10, which indicated he was moderately cognitively impaired. Resident #4Review of Resident #4's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's Quarterly MDS, with an ARD of 07/14/2026, revealed he had a BIMS of 2, which indicated he was severely cognitively impaired. On 08/10/2026 at 9:03 a.m., an interview was conducted with Resident #2. He stated a couple weeks ago, he saw another resident beating up S6CNA. He stated he intervened and punched the resident so he would stop hitting the CNA. He stated he did not know the resident's name. On 08/10/2026 at 11:35 a.m., an interview was conducted with Resident #2's family member. She stated on 08/01/2026, facility staff informed their family Resident #2 got into a fight and punched another resident after he saw him hitting a CNA. She stated as a result of the altercation, both of Resident #2's hands had abrasions and she was unaware of any injuries to the other resident. On 08/10/2026 at 1:48 p.m., an interview was conducted with S6CNA. S6CNA stated on 08/01/2026, while trying to redirect Resident #4 from entering another resident's room, he became angry then kicked her and attempted to hit her. S6CNA stated Resident #2 saw what was happening and came over to where she and Resident #4 were. S6CNA stated Resident #4 turned around and hit Resident #2 in the face then Resident #2 hit Resident #4 back. S6CNA confirmed this incident was resident to resident abuse and she reported it to S7LPN immediately after it occurred. On 08/10/2026 at 2:52 p.m., an interview was attempted with Resident #4 but was not completed due to his impaired cognition. On 08/11/2026 at 8:19 a.m., an interview was conducted with S7LPN. She stated on the evening of 08/01/2026, S6CNA reported to her Resident #2 and #4 got into a fight after Resident #2 witnessed Resident #4 kick her. S7LPN stated S6CNA stated when Resident #2 came over, he and Resident #4 started hitting each other. S7LPN stated after she became aware of the incident, she immediately reported it to S2DON. On 08/11/2026 at 9:56 a.m., an interview was conducted with S2DON. S2DON stated S7LPN called him on 08/01/2026 and informed him Resident #2 witnessed Resident #4 kicking S6CNA so he attempted to intervene by getting in between Resident #4 and S6CNA. S2DON stated S7LPN informed him Resident #2 sustained some abrasions to both of his hands as a result of the incident but he was not informed the residents hit each other. S2DON confirmed he made S1ADM aware of Resident #4's behaviors. S2DON confirmed the facility's policy stated staff should report abuse allegations to either himself or S1ADM immediately and hitting would be considered abuse. On 08/11/2026 at 10:43 a.m., an interview was conducted with S1ADM. He stated on 08/01/2026, S2DON contacted him and reported S7LPN told him Resident #2 and #4 almost got into a physical altercation and during the interaction, Resident #2 sustained some abrasion to his hands. He confirmed he was not aware the residents hit or punched each other. He stated the facility's process was for staff to report allegations of abuse to their supervisor or to himself. He stated if S6CNA saw the residents hitting each other, and reported it to S7LPN, S7LPN should have reported the hitting and punching to S2DON or himself. He confirmed he was required to report allegations of abuse to the state agency and he would have reported this incident if he would have been made aware.

Based on record review and interviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a PASRR Level II evaluation as required for 1 (#4) of 4 sampled residents records reviewed.Findings: Review of Resident #4's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Major Depressive Disorder. Further review revealed additional medical diagnoses of Paranoid Personality Disorder (onset date 07/23/2021); Psychotic Disorder (onset date 12/22/2021); Anxiety Disorder (onset date 12/22/2021); Bipolar Disorder (onset date 11/09/2022). Review of Resident #4's OBH-PASRR Level II Summary & Determination Notice dated 09/14/2020 revealed the following, in part: The individual does not have a serious mental illness and a level II is not required. Review of Resident #4's clinical record, as of 08/11/2026 at 9:00 a.m., revealed no PASRR Level II Evaluation Summary & Determination documented in Resident #4's medical record after 2020. On 08/11/2026 at 3:23 p.m., an interview was conducted with S5SS. She reviewed Resident #4's PASRR Level II Summary & Determination dated 2020. She confirmed Resident #4 acquired the above listed diagnoses since the last Resident Review submission. She confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not. On 08/12/2026 at 10:58 a.m., an interview was conducted with S1ADM. He reviewed Resident #4's diagnoses list and PASRR Level II Summary & Determination dated 2020. He confirmed Resident #4 acquired the above listed diagnoses since the last Resident Review submission. He confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not.

Based on observations, interviews, and record review, the facility failed to store foods under sanitary conditions. The facility failed to ensure:1. Food requiring refrigeration after opening was refrigerated, and2. Food items were dated after opening. This deficient practice had the potential to affect 92 residents who were provided meals from the facility's kitchen.Review of the facility's policy titled Date Marking for Food Safety dated 2026 revealed in part, the following:2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or prepared.During the initial tour of the facility's kitchen on 04/13/2026 at 8:12 a.m. with S5DM, the following observations were made:Snack/Nourishment Refrigerator:27-uncovered, undated serving cups of ranch dressing.1-uncovered, undated large cup filled with a dark brown substance.Pantry:1-opened, partially used gallon container of teriyaki sauce, no open date, with a label which read Refrigerate after opening.An interview was conducted on 04/13/2026 at 8:16 a.m. with S5DM. She confirmed the above findings. She confirmed all opened food items should be covered and labeled with an open date. She confirmed food items requiring refrigeration after opening should be refrigerated.An interview was conducted on 04/15/2026 at 12:05 p.m. with S1ADM. He confirmed all opened food items should be covered and labeled with an open date. He confirmed food items requiring refrigeration after opening should be refrigerated.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin vial stoppers prior to extracting insulin for 3 (#3, #7, and #97) of 4 residents observed for insulin administration.Review of the facility's policy titled Medication Administration dated 2025, revealed in part, the following:Policy: Medications are administered by licensed nurses in a manner to prevent contamination or infection. Review of Insulin Manufacturer's Insert revealed in part, the following:For insulin vials (and other multi dose vials), the rubber stopper is not sterile and can harbor microorganisms. Therefore, cleaning before use is essential to reduce contamination risk. Resident #3 Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE].Further review revealed an active Physician's Order for Humalog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. An observation was made of S4LPN administering Humalog Insulin 100 unit/mL to Resident #3 on 04/13/2026 at 3:25 p.m. S4LPN extracted insulin from the insulin vial without sanitizing the insulin vial stopper. S4LPN administered the insulin. Resident #7Review of Resident #7's Clinical Record revealed the resident was admitted to the facility on [DATE].Further review revealed an active Physician's Order for Humalog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. An observation was made of S4LPN administering Humalog Insulin 100 unit/mL to Resident #7 on 04/13/2026 at 3:17 p.m. S4LPN extracted insulin from the insulin vial without sanitizing the insulin vial stopper. S4LPN administered the insulin.Resident #97Review of Resident #97's Clinical Record revealed the resident was admitted to the facility on [DATE].Further review revealed an active Physician's Order for Humalog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. An observation was made of S4LPN administering Humalog Insulin 100 unit/mL to Resident #97 on 04/13/2026 at 3:42 p.m. S4LPN extracted insulin from the insulin vial without sanitizing the insulin vial stopper. S4LPN administered the insulin. An interview was conducted on 04/13/2026 at 3:45 p.m. with S4LPN. She confirmed she did not sanitize the insulin vial stopper prior to extracting the insulin for Residents #3, #7, and #97. An interview was conducted with on 04/14/2026 at 9:28 a.m. S2DON. He stated insulin vial stoppers should always be sanitized prior to extracting insulin.

Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (#68) of 3 residents reviewed for falls. The facility failed to ensure Resident #68's care plan was implemented for transfers with a mechanical lift.Review of Resident #68's Clinical Record revealed an admission date of 06/29/2017. Further review revealed Resident #68 had diagnoses which included a fracture of an unspecified part of neck of right femur, generalized muscle weakness, and Alzheimer's Disease. Review of Resident #68's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2026, revealed Resident #68 was dependent on staff for chair/bed-to-chair transfers. Further review revealed a Brief Interview for Mental Status (BIMS) of 03, indicating severe cognitive impairment. Review of Resident #68's current Care Plan revealed the following:Self-care deficit related to needing assistance with activities of daily living (ADLs), decreased mobility, dementia diagnosis, and non-ambulatory status. Uses a mechanical lift for all transfers with 2 staff. Review of the Facility's Incident Log from 12/01/2025 to 04/13/2026 revealed Resident #68 had a witnessed fall on 03/24/2026. Review of Resident #68's Incident Report, dated 03/24/2026, revealed a witness statement from unnamed staff, dated 03/24/2026, indicating Resident #68 rolled out of bed with the staff member present and was transferred back to bed by the staff member prior to nurse notification or assessment. An interview was conducted on 04/14/2026 at 11:39 a.m. with S6CNA. S6CNA stated Resident #68 required a two-person mechanical lift for transfers. S6CNA confirmed use of the mechanical lift required two staff members. S6CNA stated he worked on 03/24/2026 and wrote the witness statement regarding Resident #68's fall. S6CNA stated he witnessed the fall and was the only staff member present. S6CNA confirmed, after the fall, he did not use the mechanical lift to transfer Resident #68 from the floor to the bed. S6CNA confirmed he manually transferred Resident #68 to the bed by himself and should not have. An interview was conducted on 04/15/2026 at 9:40 a.m. with S10LPN. S10LPN stated she responded to Resident #68's fall on 03/24/2026. S10LPN stated S6CNA transferred Resident #68 from the floor to the bed before she assessed the resident. S10LPN stated she did not assist S6CNA with Resident #68's transfer. An interview was conducted on 04/14/2026 at 3:00 p.m. with S3ADON. S3ADON stated she supervised the CNA staff. S3ADON confirmed Resident #68 required the mechanical lift for all transfers and 2 staff members needed to be present for the operation of the mechanical lift. S3ADON confirmed S6CNA transferred Resident #68 by himself and should not have.

Based on interviews and record review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for 1 (#68) of 3 residents reviewed for falls. Review of Resident #68's Clinical Record revealed an admission date of 06/29/2017 with diagnoses including fracture of unspecified part of neck of right femur dated 03/25/2026. Review of Facility's Incident Log, dated December 2025 to present, revealed in part, the following:Witnessed Fall Incident:Resident #68, 03/24/2026 at 6:15 a.m.Incident Location: Resident RoomPerson Preparing Report: S10LPN Review of Resident #68's Nurse Progress Notes, dated 03/25/2026, revealed, in part, the following:03/25/2026, 4:30 p.m., signed S11LPN: Resident noted to be screaming from bed. Upon entry into resident room, swelling was noted to Resident Right upper thigh area. Resident guarded area from touch, stating that it hurt. Resident was unable to answer simple questions regarding possible injury due to cognitive impairment. MD notified of finding. New order for x-ray of right thigh/pelvis and knee. Order noted and Express Ray notified of new order. Responsible Party notified of resident change in status. 03/25/2026, 6:43 p.m., signed S11LPN: Express Ray x-ray of right hip and knee completed, with fracture noted. MD notified at 6:50 p.m. New order to send to ER for evaluation and treatment. Responsible Party notified of new order to send to ER and stated understanding. Acadian Ambulance notified of transport. Review of Resident #68's Physician's Progress Notes, dated 03/25/2026, revealed, in part, the following:Diagnostic Studies/Radiology:XR Femur Right 2+ ViewsResult Date: 03/25/2026Findings: Oblique fracture through the proximal femoral diaphysis just below the femoral neck. Review of Resident #68's Care Plan, dated 04/16/2026, revealed, in part, the following:Focus: Potential for falls related to history of falls05/29/2025 - Fell after rolling out of bed while being assisted03/24/2026 - Rolled out of bed to floor; injuries notedInterventions:05/29/2025 - Will use 2 certified nursing assistants (CNAs) for all care.03/24/2026 - Bed placed against wall, feet to door. Review of facility's Quality Improvement Corrective Action Plan, dated 02/15/2026, revealed, in part, the following: Problem Area Identified: Care plans: Interventions not being entered by MDS nurse for falls, care plans not being updated in general. Information is not being communicated to CNA staff about care plan changes concerning resident care.Recommended Plan of Action:1. Started entering CNA tasks in point-of-care (POC) so CNAs could sign off on them each day.Date of Follow-up: 03/15/2026CNAs can now sign off on resident care for falls in POC, and it is being done. S3ADON checks random ADL charting.Recurring Problems:Some resident care not updated, but it is being worked on.Date of Follow-up: 04/15/2026All April 2026 ADL charting (with POC sign-offs) is being done 100% per staff. Review of the facility report, dated 04/15/2026, titled Documentation Survey Report v2 Apr-26, revealed, in part, the following: Resident: Resident #68Intervention/Task: 05/29/2025 - Will use 2 CNAs for all care04/01/2026 through 04/13/2026 revealed X for both 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. shifts on all dates.04/14/2026, shift 6:00 a.m. to 6:00 p.m. - blank04/14/2026, shift 6:00 p.m. to 6:00 a.m. - 30, S8CNA, 8:13 p.m.Was task performed? 30 - Yes, 31 - No An interview was conducted on 04/14/2026 at 11:39 a.m. with S6CNA. S6CNA stated he was assigned to Resident #68. S6CNA stated he did not know two-person care was a fall intervention for Resident #68. S6CNA further reviewed Resident #68's chart on the facility's tablet and was unable to locate information indicating Resident #68 required two-person care as a fall intervention. An interview was conducted on 04/15/2026 at 11:00 a.m. with S7MDS. S7MDS stated the intervention/task, dated 05/29/2025, will use 2 CNAs for all Resident #68's care, was not placed into the CNA POC until 04/14/2026. S7MDS stated it should have been loaded into the CNA POC on 01/08/2026 and was not. S7MDS stated the error was not identified in the above referenced care plan quality assurance (QA). S7MDS confirmed she had no record, log, or monitoring documentation of which resident care plans or interventions had been reviewed during the QA or still need to be reviewed. S7MDS stated she was not aware any such documentation should have been kept. An interview was conducted on 04/15/2026 at 2:35 p.m. with S1ADM. S1ADM stated all documents related to the above-mentioned QA had been provided and confirmed there was no documentation where they had been monitoring their QA.

Based on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions for each fall for 3 (#1, #2 and #3) of 3 residents reviewed for falls. Findings: Resident #1Review of the Clinical Record for Resident #1 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Repeated Falls, Progressive Neurological Condition and Parkinson's Disease with Dyskinesia. Review of the most recent MDS with an ARD of 10/07/2025 revealed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment.Review of the facility's Incident Reports revealed Resident #1 had witnessed falls on 09/30/2025, 10/27/2025 and 11/11/2025. Review of Resident #1's Nurse's Notes revealed the following:09/30/2025 at 8:14 p.m. - The nurse entered the resident's room to offer her a snack. When she got out of bed she lost her balance and hit her head on the floor.10/27/2025 at 4:30 a.m. - Resident's daughter called and stated that resident was on the floor as she had seen on resident's camera in her room. She stated the resident was trying to get out of bed and got tangled in her blankets and rolled out of bed and bumped her head on the floor. The nurse entered the room and resident was observed served sitting on the floor.11/11/2025 at 12:05 a.m. -CNA reported to nurse that resident was on the floor. The nurse entered the resident's room and she was sitting on the floor away from her bed. Review of Resident #1's Care Plan revealed it was not revised to include interventions to address Resident #1's fall on 09/30/2025, 10/27/2025 and 11/11/2025. On 12/19/2025 at 10:35 a.m., an interview was conducted with S4STAFF. She reviewed and confirmed Resident #1 had a fall on 09/30/2025, 10/27/2025 and 11/11/2025. S4STAFF reviewed Resident #1's care plan and confirmed it was not revised to reflect Resident #1 falls which occurred on 09/30/2025, 10/27/2025 and 11/11/2025 prior to the survey team entry on 12/17/2025 and should have been. On12/17/2025 at 2:11 p.m., an interview was conducted with S5MDS. She reviewed and confirmed Resident #1 had a fall on 10/27/2025. S5MDS reviewed Resident #1's care plan and confirmed it was not revised to reflect Resident #1 fall which occurred on 10/27/2025 prior to the survey team entry on 12/17/2025 and should have been. On 12/19/2025 at 11:37 a.m., an interview was conducted with S1DON. He reviewed Resident #1's care plan and confirmed it was not revised to reflect Resident #1's falls on 09/30/2025, 10/27/2025 and 11/11/2025 prior to the survey team entry and should have been. Resident #2Review of the Clinical Record for Resident #2 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses which included Alzheimer's Disease, Malignant Neoplasm of Pelvic Bones, Sacrum, and Coccyx. Review of the most recent MDS with an ARD of 10/28/2025 revealed Resident #2 had a BIMS of 3, which indicated severe cognitive impairment. Review of the facility's Incident Reports revealed Resident #2 had a witnessed fall on 11/26/2025. Review of Resident #2's Nurse's Notes revealed the following:11/26/2025 at 11:56 a.m.- the CNA called me to the memory care unit, upon entry resident was lying on her left side on floor. The CNA stated that the resident was in her wheelchair when she started to fall asleep and fell forward out of wheelchair. Review of Resident #2's Care Plan revealed it was not revised to include interventions to address Resident #2's fall on 11/26/2025. On 12/19/2025 at 10:35 a.m., an interview was conducted with S4STAFF. She reviewed and confirmed Resident #2 had a fall on 11/26/2025. S4STAFF reviewed Resident #2's care plan and confirmed it was not revised to reflect Resident #2 fall which occurred on 11/26/2025 prior to the survey team entry on 12/17/2025 and should have been. On 12/19/2025 at 11:37 a.m., an interview was conducted with S1DON. He reviewed Resident #2's care plan and confirmed it was not revised to reflect Resident #2's falls on 11/26/2025 prior to the survey team entry and should have been. Resident #3Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractures and Other Multiple Fractures, Right Foot Fracture, History of Falling, Hereditary and Idiopathic Neuropathy, Displaced Fracture of 2nd Metatarsal Bone, Right Foot and Displaced Fracture of 3rd Metatarsal Bone, Right Foot. Review of the facility's Incident Report revealed Resident #3 had an unwitnessed falls on the 09/14/2025, 09/17/2025, 10/13/2025, and 11/13/2025.Review of Resident #3's Nurse's Note revealed the following:09/14/2025 at 3:21 p.m. -The CNA called me, the nurse, to resident's room because resident was on the floor in bathroom. Upon entering the room resident noted to be in the bathroom on the floor next to the toilet. Resident reports she needed to use the toilet and did not call for assistance. When transferring from wheelchair to toilet she started to wet herself causing her feet to become slippery. 09/17/2025 at 12:55 a.m.-Upon entering the room at approximately 00:30, resident was seen sitting on the floor beside her bed. Resident has noticeable swelling & bruising to the left cheek bone area. PRN Tylenol 650 MG administered for pain rated 6/10 by resident. Resident denies any other pain or discomfort.10/13/2025 at 6:47 p.m.- The nurse was called to the resident room. CNA was entering room to deliver supper tray and found resident on floor. Resident states she was sitting on bed and attempted to get up to wheelchair and move cords out of her way and fell. She denies hitting her head or any injuries. 11/13/2025 at 1:30 p.m.- The nurse was called to resident's bathroom and upon entering resident was noted to be laying on the floor in front of the toilet. Resident #3 reports going to the restroom unassisted and when resident stood to pull pants up she lost her balance and fell. Review of Resident #3's Care Plan revealed it was not revised to include interventions to address Resident #3's fall on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025. On 12/19/2025 at 10:35 a.m., an interview was conducted with S4STAFF. She reviewed and confirmed Resident #3 had a fall on 09/14/2025, 09/17/2025, 10/13/2025 and11/13/2025. S4STAFF reviewed Resident #3's care plan and confirmed it was not revised to reflect Resident #3's fall which occurred on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025 prior to the survey team entry on 12/17/2025 and should have been. On 12/19/2025 at 11:37 a.m., an interview was conducted with S1DON. He reviewed Resident #3's care plan and confirmed it was not revised to reflect Resident #3's falls which occurred on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025 prior to the survey team entry and should have been.

Based on observations, interviews, and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1( #1) of 3 residents reviewed for falls. Findings: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Repeated Falls, Progressive Neurological Condition, and Parkinson's Disease with Dyskinesia. Review of the most recent MDS with an ARD of 10/07/2025 revealed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment. Review of the most current Care Plan revealed the following:Problem: Potential for falls related to history of falls, decreased mobility, medication effects, confusion, poor safety awareness and impaired mobility. On 05/22/2024 Resident #1 slid off her bed and had a fall.Intervention: 05/22/2024: Resident given non-skid socks instead of wearing regular socks. On 12/17/2025 at 11:10 a.m., an observation was made of Resident #1 awake, sitting up in a wheelchair. An observation was made of white socks on Resident #1's feet without non-skid bottoms. On 12/17/2025 at 11:11 a.m., an interview was conducted with S2STAFF. She stated Resident #1 was a fall risk. She observed and confirmed Resident #1 was not wearing non-skid socks. On 12/17/2025 at 11:25 a.m., an interview was conducted with S3STAFF. She stated Resident #1 was a fall risk. She stated an intervention used to prevent falls for Resident #1 was to place non-skid socks on the resident. On 12/17/2025 at 11:29 a.m., an observation and interview was conducted with S3STAFF. She observed and confirmed Resident #1 was not wearing non-skid socks and should have been. On 12/17/2025 at 12:00 p.m., an interview was conducted with Resident #1's Representative. She stated she visited Resident #1 once or twice a week. She Resident #1 had a history of falls. She stated Resident #1 does not wear non-skid socks. On 12/17/2025 at 2:50 p.m., an interview was conducted with S1DON. He stated he expected all staff to follow a resident's care plan and implement fall interventions to prevent further falls. He reviewed Resident #1's care plan and confirmed Resident #1 had a fall intervention to place non-skid socks.

Based on interviews and record reviews, the facility failed to ensure a resident's personal funds were not susceptible to misappropriation by an employee of the facility for 1 (#46) of 21 residents reviewed in the initial pool. The facility failed to protect Resident #46 from misappropriation of funds by S9CNA which lead to Resident #46 experiencing psychosocial harm. This deficient practice resulted in physical and emotional harm on 03/28/2025, when Resident #46 experienced vomiting, depression, shame and embarrassment due to financial manipulation by S9CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled Abuse Program, with no revision date, revealed the following, in part: Intent: This protocol was intended to assist the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from financial abuse. Definitions: Misappropriation of property/financial abuse is defined as the deliberate misplacement, exploitation or wrongful temporary or permanent, use of a resident's belongings or money without the resident's consent. A review of Resident #46's medical record revealed an admitted [DATE] with a BIMS of 15, which indicated the resident was cognitively intact. A review of Resident #46's Incident Report dated 04/02/2025 at 5:04 p.m., revealed Resident #46 reported to S1ADM she had been giving money to S9CNA since October 2024. Resident #46 stated she gave S9CNA approximately $7530.00. On 04/29/2025 at 10:45 a.m., an interview was conducted with Resident # 46. She stated S9CNA manipulated her into giving the money beginning in October 2024. She stated S9CNA set up a money transferring account on her phone using a fake name so no one would find out the about the money exchange. Resident #46 stated she started giving S9CNA money because she was hungry and had no money for lunch. Resident #46 stated she felt sorry for S9CNA and wanted to help her. She stated S9CNA would ask for lunch money two and three times a week. Resident #46 stated S9CNA began telling her she needed money to repair her car or money to buy parts to repair her car. She stated S9CNA would tell her the car parts were wrong and additional parts were needed. Resident #46 stated she gave S9CNA money to repair pipes in her home she claimed has frozen during the freeze. She stated she gave S9CNA money for her children's birthday after S9CNA told her she had no money for their birthdays. She stated she started noticing that the CNA was coming into her room talking on her cell phone saying things like I know, I will figure it out and I'll get the money and then S9CNA would ask for money. Resident #46 stated she told S8CNA on a Friday evening, unable to recall date, about giving S9CNA money. Resident #46 stated on 04/02/2024 she reported the issue to S1ADM. Resident #46 stated the facility contacted the local police, but she did not want to press charges at that time. She stated she felt ashamed, embarrassed, and taken advantage of. On 04/29/2025 at 10:45 a.m., an interview was conducted with Resident # 46. She stated beginning in October 2024, S9CNA would come into her room and tell her she was hungry and did not have money for food. She said she felt sorry for the CNA and wanted to help. She stated S9CNA set up a money transferring account on her phone using a fake name so no one would find out the about the money exchange. Resident #46 explained S9CNA would ask her for lunch money 2 to 3 times a week. S9CNA asked her for money to repair her car, repair the pipes in her home, and for her children's birthday. She said towards the end of March, she realized how much money she had given to the CNA and got scared. She said S9CNA manipulated her. Resident #46 stated she was not feeling well because of the situation and told S8CNA on a Friday evening, unable to recall date, about giving S9CNA money. Resident #46 stated on 04/02/2024 she reported the issue to S1ADM. Resident #46 stated the facility contacted the local police and the police talked to her. She stated she felt ashamed, embarrassed, and taken advantage of. She said she started taking medicine after she reported the incident to help her sleep. On 04/29/2025 at 6:00 p.m., a telephone interview was conducted with S8CNA. S8CNA stated on 03/28/2025, she noticed Resident #46 was vomiting, not eating, did not want to get out of bed, and was not her normal self. S8CNA asked Resident #46 what was wrong, and the resident told her about the money she had been giving to S9CNA. S8CNA stated she spoke with S7ADON on 03/29/2025 and reported the incident. On 04/29/2025 at 1:36 p.m., an interview was conducted with S7ADON. S7ADON stated S8CNA informed her on 03/29/2025 that Resident #46 had been giving S9CNA money. S7ADON stated she notified S2DON on 03/31/2025 of the incident. On 04/30/2025 at 1:30 p.m., an interview was conducted with S2DON. S2DON stated he was notified by S7ADON on 03/31/2025 of the incident involving Resident #46 giving money to S9CNA. S2DON stated he notified S1ADM by phone on 04/01/2025. On 04/30/2025 at 09:30 a.m., an interview was conducted with S1ADM. S1ADM stated on 04/01/2025 he received a phone call from the S2DON informing him that Resident #46 had given a staff member money. He stated on 04/02/2025 when he arrived at the facility, he met with Resident #46. Resident #46 told him she had given S9CNA money multiple times beginning in October 2024. Resident #46 stated that she was giving S9CNA money to help her but it had gotten out of hand. S1ADM stated Resident #46 told him she had given S9CNA approximately $8,600.00 in total since October 2024. S1ADM stated he, S2DON, and S7ADON called S9CNA in to his office on the morning of 04/02/2025 and asked her if she had taken money form Resident #46. S1ADM stated S9CNA confessed she had taken the money. S1ADM stated after S9CNA's admission of guilt she was terminated on 04/02/2025. S1ADM stated he notified the local police on 04/02/2025. S1ADM stated the local police deputy came to the facility and spoke with Resident #46 on 04/02/2025. S1ADM stated at this time he opened a SIMs report. He confirmed S9CNA misappropriated Resident #46's funds, and should not have. S1ADM stated on 04/02/2025 all residents were interviewed asking each one if they had ever been ask to or given staff money. S1ADM stated on 04/02/2025-04/09/2025 all staff were in-serviced on misappropriation of funds. S1ADM stated the Ombudsman was notified. He stated Resident #46's physician was notified along with the Facility's psychiatrist mental health nurse practitioner and both evaluated the resident. S1ADM stated he notified the CNA registry and reported the incident. He stated since the incident, Social services here at the facility has been communicating with the resident to make sure she was okay emotionally and mentally. He stated resident council meeting was also held and led by S1ADM. S1ADM stated he went over the facility policy on abuse and specified, especially financial abuse. From 04/28/2025-04/30/2025 multiple attempts were made to contact S9CNA. The attempts were unsuccessful. On 04/30/2025 at 11:05 a.m., an interview was conducted with S11LPN. She stated she attended in-services regarding reporting of abuse, neglect and misappropriation of funds to administration immediately after the incident with Resident #46 on 04/02/2025. She stated taking money for any reason from a resident is a reportable offense and she would report to the DON or the Administrator immediately. On 04/30/2025 at 11:30 a.m., an interview was conducted with S10CNA. He stated he had attended in-services on misappropriation of funds after the incident involving Resident #46 on 04/02/2025. He stated the in-service covered not accepting money from residents for any reason and to report an allegation immediately. Throughout the survey from 04/28/2025 to 04/30/2025, observations, record review, and staff interviews revealed staff received training on misappropriation of funds and reporting policies and procedures. Interviews revealed staff were knowledgeable of the types of exploitation, and were aware to report these incidents to administration immediately. The facility had implemented the following actions to correct the deficient practice: One resident was affected by this practice. There is no evidence through our interviews and investigation that this occurred to any other resident. Corrective actions and measures that have been put into place. 1. Our immediate actions were that law-enforcement was contacted, all residents were interviewed to make sure that this has not happened to anyone else in parentheses it has not parentheses. All staff was in serviced on this issue. Ombudsman was notified. Resident physician was notified. Facilities psychiatrist mental health nurse practitioner was notified and has seen the resident. The CNA registry has been notified. Social services here at the facility has been communicating with the resident to make sure she was okay emotionally and mentally. A resident council meeting was held and led by S1ADM. We went over our policy on abuse and specified, especially financial abuse. 2. Our plan of correction started on 04/02/2025 with contacting law-enforcement, opening a facility self-reported incident report, interview, interviews, and in servicing. All staff have been in-serviced on misappropriation of funds/exploitation. All residents have been interviewed and our plan of correction stop date was 04/09/2025 once we completed our corrective action plans. Sims report was closed on 04/09/2025. 3. The end date for our plan of correction was 04/09/2025. We will continue to in-service, education, train and evaluate during our QA process moving forward. A part of our QA process we will be for four consecutive weeks starting Monday 04/14/2025, we will do three random interviews a week to make sure no other resident have been exploited financially. We will also do three random tests a week for four consecutive weeks on staff regarding reporting any potential abuse. The facility will view these interviews and test in our next QA meeting.

Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly labeled, sealed, and dated in the refrigerator and dry storage area of the facility's kitchen. This deficient practice had the potential to affect the 90 residents who were served food from the kitchen. Findings: Review of the facility's undated policy titled, Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: All foods stored in the refrigerator or freezer will be covered, labeled, and dated. On 04/28/2025 at 8:10 a.m., an initial tour was made of the kitchen with S3DS. The observations were made of the following items: Refrigerator: 1 one gallon clear bag containing three pieces of cornbread unsealed, 1 medium turkey breast wrapped in clear wrapping with no label or date, 1 clear plastic bag containing diced turkey pieces, half full, with no label or date; and 1 clear plastic bag containing churros, half full, with no label or date. Dry Storage: 1 party sized bag of buttermilk pancake mix, which had been opened, with no label or date. On 04/28/2025 at 8:15 a.m., an interview was conducted with S3DS. She confirmed the above items were not labeled or dated and should have been. She confirmed the bag of cornbread was not sealed and should have been. On 04/28/2025 at 3:35 p.m., an interview was conducted with S1ADM. He was made aware of the above findings in the kitchen. He confirmed food should be sealed, dated, and labeled. 52121

Based on interviews and record reviews, the facility failed to ensure alleged violations involving misappropriated funds were reported to the administrator immediately and to the state agency within twenty four hours after the allegations were made for 1 (#46) of 21 residents reviewed in the initial pool. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled, Abuse Program, with no revision date, revealed the following, in part: Intent: This protocol was intended to assist the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from financial abuse. Definitions: Misappropriation of property/financial abuse is defined as the deliberated misplacement, exploitation or wrongful temporary or permanent, use of a resident belongings or money without the resident's consent. A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. A review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/20/2024 revealed Resident #46 had a BIMS (Brief Interview for Mental Status) of 15 indicating she was cognitively intact. A review of the facility's self-reported incident dated 04/02/2025 revealed, in part: Entered: 04/02/2025 at 05:04 p.m. Discovered: 04/02/2025 at 11:00 a.m. Victim Name: Resident #46 Accused Name: S9CNA Accused Allegations Misappropriation of Funds/Exploitation On 04/29/2025 at 10:45 a.m., an interview was conducted with Resident # 46. Resident #46 stated she started giving S9CNA money in October 2024. Resident #46 stated one Friday evening, she could not recall the date, she told S8CNA that S9CNA was asking for money. Resident #46 stated on 04/02/2024 she also reported the issue to S1ADM. On 04/29/2025 at 6:00 p.m., a telephone interview was conducted with S8CNA. S8CNA stated on 03/28/2025 at 10:00 p.m. Resident #46 old her she had given money to S9CNA. S8CNA stated she reported the incident to S7ADON, her supervisor, on 03/29/2025. She stated she attended an in-service on missappropations of funds and now understands all allegation of missappropations of funds must be reported to administration immediately after discovery. On 04/29/2025 at 1:36 p.m., an interview was conducted with S7ADON. S7ADON confirmed S8CNA reported the aforementioned incident to her on 03/29/2025. S7ADON stated she notified S2DON on 03/31/2025 of the incident. She stated she was unaware she should have reported the incident immediately. S7ADON stated she attended an in-service related to reporting any allegations of missappropations of funds and now understands all allegations should be reported to administration immediately after discovery. On 04/30/2025 at 1:30 p.m., an interview was conducted with S2DON. S2DON stated he was notified by the S7ADON on 03/31/2025 of the incident involving Resident #46 giving money to S9CNA. He stated he notified S1ADM by phone on 04/01/2025. S2DON stated all allegations of missappropations of funds should be reported to administration immediately after discovery. On 04/30/2025 at 1:55 p.m., an interview was conducted with S1ADM. S1ADM confirmed the misappropriation funds was discovered on 03/28/2025 by S8CNA. S1ADM confirmed he was not notified of the incident until 04/01/2025. S1ADM confirmed S7ADON should have notified him immediately when she was made aware on 03/29/2025 and did not. S1ADM stated he was responsible for filing facility self-reported incident reports with the stated agency. He further confirmed a facility self-reported incident report should have been filed when the incident was discovered and was not. S1ADM stated all staff have been in-serviced on reporting incidents of missappropations of funds immediately to their supervisors and or to himself. Throughout the survey from 04/28/2025 to 04/30/2025, observations, record review, and staff interviews revealed staff received training on the facility's misappropriation of funds and reporting policies and procedures. Interviews revealed staff were knowledgeable of the types of exploitation, and were aware to report these incidents to administration immediately. The facility had implemented the following actions to correct the deficient practice: One resident was affected by this practice. There is no evidence through our investment through our interviews and investigation that this occurred to any other resident. Corrective actions and measures that have been put into place. 1. Our immediate actions were that law-enforcement was contacted, all residents were interviewed to make sure that this has not happened to anyone else in parentheses it has not parentheses. All staff was in serviced on this issue. Ombudsman was notified. Resident physician was notified. Facilities psychiatrist mental health nurse practitioner was notified and has seen the resident. The CNA registry has been notified. Social services here at the facility has been communicating with the resident to make sure she was okay emotionally and mentally. A resident council meeting was held and led by S1ADM. We went over our policy on abuse and specified, especially financial abuse. 2. Our plan of correction started on 04/02/2025 with contacting law-enforcement, opening a facility self-reported incident report, interview, interviews, and in servicing. All staff have been in-serviced on misappropriation of funds/exploitation. All residents have been interviewed and our plan of correction stop date was 04/09/2025 once we completed our corrective action plans. The facility's self-reported incident report was closed on 04/09/2025. 3. The end date for our plan of correction was 04/09/2025. We will continue to in-service, education, train and evaluate during our QA process moving forward. A part of our QA process will be for four consecutive weeks starting Monday 04/14/2025, we will do three random interviews a week to make sure no other resident have been exploited financially. We will also do three random tests a week for four consecutive weeks on staff regarding reporting any potential abuse. The facility will review these interviews and test in our next QA meeting.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#39) of 3 (#39, #54, and #71) residents reviewed for hospice care. The facility failed to ensure Resident #39 was coded correctly for hospice care. Findings: Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. Review of Resident #39's Physician Orders revealed in part, the following: Admit to Hospice, active 12/19/2024. Review of Resident #39's quarterly MDS assessment with ARD of 03/25/2025 revealed in Section O0110.K1. Hospice care: While a resident: Blank. An interview was conducted on 04/30/2025 at 9:45 a.m. with S4MDS. She reviewed Resident #39's MDS assessment dated [DATE]. She confirmed the quarterly MDS assessment was not coded correctly for Hospice and should have been. An interview was conducted on 04/30/2025 at 9:55 a.m. with S2DON. He reviewed Resident #39's MDS assessment dated [DATE]. He confirmed the quarterly MDS assessment was not coded correctly for Hospice and should have been.

Based on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update advance directive code status for 1 (#71) of 24 residents reviewed for code status in the initial sample. Findings: Review of the facility's undated policy titled, Resident Rights Regarding Treatment and Advance Directives, revealed in part, the following: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. Review of Resident #71's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Dementia, Metabolic Encephalopathy and Acute Respiratory Failure with Hypoxia. Review of Resident #71's Physician Order's revealed he was admitted to Hospice services on 01/28/2025 with a change in advance directive on 03/06/2025 to reflect Do Not Resuscitate (DNR) code status. Review of Resident #71's clinical record documentation titled Louisiana Physician Order for Scope of Treatment, revealed a DNR code status was initiated on 01/28/2025. Review of Resident #71's Care Plan revealed it was not revised to reflect the change in code status and revealed a code status of Full Code. On 04/30/2025 at 12:40 p.m., an interview was conducted with S4CUC. She confirmed Resident #71 was a DNR Code status in the event of an emergency. S4CUC reviewed Resident #71's care plan and confirmed it was not revised to reflect Resident #71 end of life wishes prior to the survey team entry and should have been. On 04/30/2025 at 12:50 p.m., an interview was conducted with S2DON. He reviewed Resident #71's care plan and confirmed it was not revised to reflect Resident #71 end of life wishes prior to the survey team entry and should have been.

Based on interviews, record reviews, and observations, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection for 2 (#17 and #52) of 3 (#17, #52, and #71) residents observed for wound care. Findings: Review of the facility's policy with revision date of 2010 and titled: Clean Dressing Change Policy and Guidelines revealed the following, in part: Policy: It is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross-contamination. Policy Explanation and Compliance Guidelines: 11. Wash hand and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of wound. Pat dry with gauze. 13. Remove gloves and wash hands. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Resident #17 Review of Resident #17's clinical record revealed she was admitted to the facility on [DATE]. The resident's diagnoses included the following: Pressure Ulcer of Sacral Region, Stage 2 On 04/29/2025 at 2:12 p.m. an observation was made of S5RN with the assistance of S6RN preforming wound care to Resident #17's sacrum. S5RN performed hand hygiene and donned gloves. S5RN removed the dirty dressing and took pictures of the wounds. S5RN then removed her gloves placed them in a red bag, applied a clean pair of gloves, without preforming hand hygiene. Then, S5RN cleaned the wounds with wound cleanser and without removing the soiled gloves, she applied collagen and a clean foam dressing. Resident #52 Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE]. Resident #52's diagnoses included the following: Pressure Ulcer of Left Ankle, Stage 3, Pressure Ulcer of Other Site Stage 3. On 04/29/25 02:26 p.m., an observation was made of S5RN with the assistance of S6RN performing wound care for Resident #52. S5RN preformed hand hygiene and donned gloves. S5RN removed the dirty dressing and placed in a red bag. S5RN took pictures of the wound, removed her gloves and placed the soiled gloves in a red bag. S5RN then donned a clean pair of gloves without preforming hand hygiene, cleaned the wound with wound cleanser, without removing her soiled gloves or preforming hand hygiene, she applied ointment and a clean dressing. On 04/29/2025 at 2:52 p.m., an interview was a conducted with S5RN. S5RN confirmed after she removed Resident # 17's and Resident #52's soiled wound dressings, she did not perform hand hygiene prior to applying clean gloves and cleansing their wounds. S5RN further confirmed she did not change gloves or preform hand hygiene prior to applying medications and bandages to the cleaned wounds. On 04/30/2025 at 10:00 a.m. an interview was conducted with S2DON. S2DON stated the process for wound care was to change gloves and perform hand hygiene after removing a soiled dressing, after cleaning a wound and prior to applying medications and a clean dressing to the wound. S2DON confirmed S5RN should have followed this process and did not.

Based on interviews and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#4) of 2 (#4 and #51) residents reviewed for wound care. Findings: Review of the facility's policy titled, Documentation in Medical Record, with a Copyright date of 2024, revealed the following, in part: Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. c. Documentation shall be timely and in chronological order. Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer of Other Site, Stage 3 and Functional Quadriplegia. Review of Resident #4's current Physician Orders revealed in part, the following: 01/13/2022-Cleanse suprapubic cath site with wound cleanser, pat dry, apply Calcium Alginate and foam over reddened area and apply foam adhesive dressing over both, daily and as needed for soiling. 02/17/2022-Suprapubic catheter care every day. 03/06/2022-Irrigate Foley daily with 120 mLs of sterile water. 07/01/2022-Ampicillin 500 mg mix with 1liter of normal saline. Drain bladder. Instill 60 mL into bladder, plug catheter for 30 minutes. Drain bladder. Perform 3 times a week, one time a day every Mon, Wed, Fri. Review of Resident #4's March 2024-April 2024 TARs revealed wound care, catheter care, and irrigation of Foley was not documented on the following days: 03/05/2024, 03/20/2024, 03/30/2024, 04/22/2024, 04/24/2024, 04/27/2024, and 04/30/2024. Review of Resident #4's March 2024-April 2024 TARs revealed Ampicillin administration was not documented on 03/20/2024, 04/22/2024, and 04/24/2024. An interview was conducted on 05/22/2024 at 10:13 a.m. with S5WCN. S5WCN reviewed Resident #4's March 2024-April 2024 TARs. S5WCN confirmed there was no documentation of wound care, catheter care, and irrigation of Foley on the following days: 03/05/2024, 03/20/2024, 03/30/2024, 04/22/2024, 04/24/2024, 04/27/2024 and 04/30/2024. S5WCN confirmed there was no documentation of Ampicillin administration on 03/20/2024, 04/22/2024, and 04/24/2024. S5WCN stated these tasks were performed as ordered for Resident #4, however were not documented and should have been. An interview was conducted on 05/22/2024 at 1:45 p.m. with S2DON. S2DON reviewed Resident #4's March 2024-April 2024 TARs S2DON confirmed Resident #4 did not have accurate and complete documentation for wound care, Foley catheter irrigation, suprapubic catheter care, and Ampicillin administration and should have.

Based on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 1 (#13) of 3 (#13, #71, and #90) residents reviewed for incontinent care. Finding: Review of the facility's policy labeled, Perineal Care with no revision date, reviewed on 05/22/2024 revealed the following: Policy Explanation and Compliance Guidelines: 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. a. Cleanse buttocks and anus, front to back, vagina to anus in female, then using a separate washcloth or wipes. b. Thoroughly dry. 10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. 16. Remove gloves and discard. Perform hand hygiene. Review of the facility's policy labeled, Hand Hygiene with no revision date, reviewed on 05/22/2024 revealed the following: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Review of Resident #13's Clinical Record revealed she was admitted to the facility on [DATE]. On 05/21/2024 at 12:50 p.m., an observation was made of S3CNA and S4CNA performing peri-care on Resident #13. With clean gloves, S3CNA unfastened Resident #13's stool soiled brief, turned the resident to her right side, and wiped the resident's sacrum removing the stool. Then without removing soiled gloves or performing hand hygiene, S3CNA grabbed the new clean brief and assisted the resident to turn on her left side. S4CNA then removed the stool soiled brief, and wiped Resident #13's peri-area clean. Then without removing soiled gloves or performing hand hygiene, S4CNA secured the new brief on Resident #13. S3CNA touched resident to reposition her, applied covers to resident, and adjusted Resident #13's pillow. S4CNA used Resident #13's remote to adjust her head of bed with the same soiled gloves used during peri-care. S3CNA and S4CNA then removed their gloves, preformed hand hygiene, and exited the room. On 05/21/2024 at 12:56 p.m., an interview was conducted with S3CNA. S3CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief, cleaning the stool from Resident #13's sacrum, and before touching the resident or his/her belongings. On 05/21/2024 at 12:59 p.m., an interview was conducted with S4CNA. S4CNA confirmed she did not remove her soiled gloves or perform hand hygiene during the above observation. She stated she should have removed her gloves and performed hand hygiene after removing the soiled brief and before applying the new one. She stated she should not have touched the resident's remote to adjust the head of the bed with the soiled gloves. On 05/21/2024 at 3:55 p.m., an interview was conducted with S2DON. He stated staff should perform hang hygiene and apply clean gloves upon entering a resident's room, when going from soiled to clean during incontinence care, after completing incontinence care, and prior to exiting the resident's room. S2DON confirmed staff were trained to perform hand hygiene correctly and should have done so during peri-care.

Based on observation, record review, and interview, the facility failed to ensure all complaint surveys since the last annual survey were available for resident review. Findings: An observation was made on 05/20/2024 at 9:07 a.m. of the facility's binder Survey results located near the entrance of the facility. Review of the survey results binder revealed the last survey posted in the binder was dated 05/05/2023. Further review revealed no documented evidence of the survey results from complaint surveys dated 07/12/2023, 03/20/2024, and 05/13/2024 having been available for review. An interview was conducted on 05/20/2024 at 9:40 a.m. with S1ADM. He reviewed the facility's binder Survey results. He confirmed the only survey results located in the binder was the survey dated 05/05/2023. He confirmed the complaint surveys since the annual recertification survey should have been in the binder. 46981

Based on observations, interviews and record reviews, the facility failed to protect the residents' right to be free from psychosocial harm by Resident #3 for 4 (#1, #R4, #R5, and #R7) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents reviewed for abuse. This deficient practice resulted in an actual psychosocial harm on the morning of 02/24/2024 when Resident #3, a cognitively intact resident, was observed kissing Resident #1, a severely cognitively impaired resident, on the cheek. Resident #3's nonconsensual inappropriate sexual advances and psychosocial harm continued for Resident #1. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #1, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. Interviews with Random Resident #4, Random Resident #5, and Random Resident #7 revealed they were afraid of residing in the facility with Resident #3 due to his inappropriate sexual behaviors. Further interview with Random Resident #7 revealed she was sleeping with a walking stick at night in case she needed to defend herself from Resident #3. Findings: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation revealed the following in part: 1. The facility will . : a. Prohibit and prevent abuse .of residents. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Major Depressive Disorder, Expressive Language Disorder, and Altered Mental Status. Review of Resident #1's MDS with an ARD of 02/20/2024 revealed a BIMS of 4, which indicated she was severely cognitively impaired. Resident #3 Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Depression. Review of Resident #3's MDS with an ARD of 02/20/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #3's current Care Plan undated revealed the following in part Focus: Potential for Altered Mood Behaviors r/t Depression. Focus: Exhibits Inappropriate Behaviors at times. Review of #R5's Annual MDS with an ARD of 02/29/2024 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. On 03/14/2024 at 4:14 p.m., an interview was conducted with #R5. She stated Resident #1 was being sexually harassed by Resident #3. She stated Resident #1 had a childlike mentality, and could not speak. She stated on 02/23/2024 she saw Resident #3 leading Resident #1 down Hall A in the direction of Resident #3's room, arm in arm. She stated Resident #1 did not reside on Hall A. She stated she alerted S10LPN, who then brought Resident #1 to the dining area. She stated on 02/24/2024 Resident #3 put his arm around Resident #1 and kissed her on the cheek. She stated S2DON was present and saw what happened. She stated S2DON escorted Resident #3 back to his room. She stated on 02/25/2024 Resident #3 put his arm around Resident #1 and tried to kiss her. She stated a CNA, who she couldn't identify stopped him and brought Resident #3 to his room. She further stated on 02/28/2024 during activities, Resident #3 began calling Resident #1's name over and over again loudly. She stated when the activities director asked if everyone wanted to watch a movie, Resident #3 asked, Do you have any porn? She stated she did not feel safe living in the facility with Resident #3. She stated she was afraid to have her grandchildren visit because of his sexually inappropriate behaviors. She stated she kept a notebook with documentation of the incidents that happened involving Resident #1. She stated she did not feel safe living in the facility with Resident #3. On 03/19//2024 at 10:50 a.m. an interview was conducted with S8LPN. She stated on 03/01/2024, she witnessed Resident #3 blow kisses to Resident #1 and rub Resident #1's back. She stated on that same date, she witnessed Resident #3 approach Resident #1 and he was staring at her. She stated she asked Resident #3 to leave. She stated this incident made her feel very uncomfortable, so she notified the S2DON. She stated S2DON assured her the Administrator was aware of the situation. On 03/18/2024 at 1:01 p.m., an interview was conducted with Resident #3's Responsible Party. He stated S1ADM informed him Resident #3 kissed Resident #1 on the forehead, but he could not recall the date. He stated S1ADM stated Resident #3 was told he could not kiss women in the facility. He stated he spoke to Resident #3 about kissing Resident #1, and Resident #3 didn't think it was wrong. He stated Resident #3 was aware of right and wrong, and confirmed he was cognitively intact. On 03/18/2024 at 1:36 p.m., an interview was conducted with Resident #3. He stated he kissed female residents on the hand, and he kissed a lot of them. He stated now he only kisses Resident #1 because she was the prettiest and she liked it. He stated he knew she liked him, because he sat in the dining room and stared at Resident #1 for 6 hours and she only smiled at him, and no one else. He stated he kissed Resident #1 on the forehead. He stated S1ADM told him he could not kiss Resident #1. He stated he kissed Resident #1 and was going to continue to kiss her, even though S1ADM asked him not to. On 03/18/2024 at 1:56 p.m., an interview was conducted with S1ADM. He said Resident #1 was severely cognitively impaired and resident #3 was cognitively intact. He confirmed knowing some resident's in the facility had complained to staff about Resident #3 exhibiting sexually inappropriate behaviors. He stated he was aware Resident #3 allegedly kissed Resident #1. He confirmed being told Resident #3 made a joke to another female resident in reference to Resident #1 stating, You should have seen what we did last night. He stated other residents were exaggerating Resident #3's behaviors, and he did not believe Resident #3 kissed Resident #1. On 03/18/2024 at 2:27 p.m., an interview was conducted with S3MDS. She stated staff were asked to keep Resident #3 away from Resident #1 because he was kissing Resident #1. She confirmed Resident #3 was cognitively intact and Resident #1 was severely cognitively impaired. On 03/19/2024 at 9:15 a.m., an interview was conducted with S5RN. She stated the last meeting she attended was 03/06/2024. She stated staff discussed inappropriate verbal behaviors regarding Resident #3. She stated she was aware Resident #3 had kissed Resident #1 on the forehead. She stated Resident #3 had asked her once to call a prostitute for him. She stated Resident #3 had requested multiple times to only have a female staff to shower him. She stated Resident #3 was aware that Resident #1 had a childlike mind. She stated the Administrator talked to him about this with Resident #3 and she witnessed the conversation. She stated Resident #3 continued with inappropriate comments. She stated because of his comments there was a group of ladies in the dining area who were uncomfortable with him around them. On 03/19/2024 at 9:47 a.m., an interview was conducted with S9A. She stated staff had to watch Resident #1 constantly to assure she was safe from Resident #3. S9A stated Resident #3 walked up quietly behind her and startled her. She stated Resident #3 made her (S9A) feel uncomfortable and uneasy and she did not feel safe with him here at the facility. She stated she attended weekly meetings on Wednesdays with all department heads. She stated in the meetings Resident #3's sexually inappropriate behaviors, were discussed with staff. She stated staff had increased supervision on Resident #3. She stated Resident #1 had a childlike mind. On 03/19/2024 at 10:10 a.m., an interview was conducted with S2DON. S2DON stated, on 02/24/2024, #R5 and other female residents told him Resident #3 kissed Resident #1. He stated he did not witness the kiss, so he didn't think it happened. He confirmed Resident #1 was severely cognitively impaired and nonverbal. He confirmed Resident #3 was cognitively intact. Review of #R4's Significant Change MDS with an ARD of 01/05/2024 revealed, in part, a BIMS of 10, which indicated she was moderately cognitively impaired. On 03/19/2024 at 11:16 a.m. an interview was conducted with #R4. She stated she witnessed Resident #3 kiss Resident #1 three times on the head. She stated she said to him, You know you are not supposed to be anywhere near her! She stated Resident #3 told her, in reference to Resident #1, You should have seen what we done last night. She stated Resident #3 made hip gestures in a sexual manner, and said, Making hot love. She stated she was concerned about his inappropriate behavior. She stated a staff member took her to see the Administrator and they told him. She stated this occurred about 3 weeks ago. She stated she was afraid to live in the facility with Resident #3 there. On 03/19/2024 at 1:40 p.m., an interview was conducted with S10LPN. She stated on 02/23/2024, residents seated in the dining room were tapping on the window and pointing toward Resident #1 and Resident #3 walking together. She stated she walked down Hall A, and saw Resident #1 and Resident #3 walking towards Resident #3's room with their arms locked together. She stated she redirected Resident #1 and separated the residents. She stated she told Resident #3, You know you can't take her walking anywhere. She doesn't know what she is doing. She confirmed Resident #3 was oriented and knew right from wrong. She confirmed reporting the incident to S2DON. She stated since the incident on 02/23/2024, staff increased supervision of Resident #1 and Resident #3. She stated supervision was not 1:1, but staff monitored both residents more closely. On 03/20/2024 at 9:17 a.m., an interview was conducted with Resident #1's RP. The RP said Resident #1 was not capable of knowing if she was being sexually abused. Resident #1's RP stated Resident #1 would not want a male she did not know holding arms with her or kissing her anywhere. She confirmed Resident #1 had the mind of a child and can't speak up for herself. Review of #R7's Quarterly MDS with an ARD of 02/06/2024 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. On 03/20/2024 at 12:50 p.m. an interview was conducted with #R7. She stated Resident #3 snuck up behind her and startled her. She stated his face was almost touching hers and he whispered in her ear, Hello sweetheart. She stated she told him to stay away from her, and she put up her hand up by his face. She stated she saw Resident #3 petting Resident #1's hand and then he kissed Resident #1 on the face, and she told Resident #3 to stay away from her. She stated he replied, Shut up you old mean B****! She stated she kept a walking stick by her bedside at night to defend herself from Resident #3. She stated she was afraid living in the facility while he is there. She stated S1ADM talked with her about the incident. She stated S1ADM told her Resident was a nice man who lost his wife and son, and he didn't mean what he said.

Based on interviews and record reviews, the facility failed to ensure an allegation of sexual abuse was reported immediately, to the facility Administrator and to the State Survey Agency for 1 (#1) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) residents sampled for abuse. Findings: Review of the Policy titled Abuse, Neglect and Exploitation undated, revealed the following in part: VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of abuse to the Administrator, state agency, adult protective services and to all other required agencies . a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of the facility's self-reported incidents from February 2024 through 03/18/2024 revealed: No reports completed for Resident #3. Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Expressive Language Disorder, Vascular Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder. Resident #1's MDS with an ARD of 01/23/2024 revealed she had a BIMS of 4, which indicated she was severely cognitively impaired. Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Depression. Further review of Resident #3's MDS with an ARD of 02/20/2024 revealed he had a BIMS of 15, which indicated he was cognitively intact. On 03/19/2024 at 11:16 a.m. an interview was conducted with #R4. She stated Resident #3 told her, in reference to Resident #1, You should have seen what we done last night. She stated Resident #3 made hip gestures in a sexual manner, and said, Making hot love. She stated a staff member took her to see the Administrator and they told him. She stated this occurred about 3 weeks ago. On 03/19/2024 at 10:10 a.m., an interview was conducted with S2DON. He stated on 02/24/2024, another resident informed him Resident #3 kissed Resident #1. He confirmed he did not report the incident because he did not witness the incident. On 03/18/2024 at 1:56 p.m., an interview was conducted with S1ADM. He confirmed he was responsible for reporting alleged abuse to the state agency. He confirmed is was aware Resident #3 allegedly kissed Resident #1, who had a childlike mentality and was nonverbal. He confirmed he was aware of Resident #3's statements regarding Resident #1 You should have seen what we did last night. He confirmed he had not reported the allegations of sexual abuse.

Based on observations, interviews, and record review, the facility failed to ensure the nurses consult the physician regarding the resident's complaints of pain for 1 (#3) of 2 (#3, #4) residents reviewed that sustained fractures after falling from a total of 5 sampled residents. The deficient practice resulted in actual harm for Resident #3 when the facility failed to provide adequate supervision in order to prevent the resident from experiencing an unwitnessed fall by slipping in his own urine. The fall resulted in an left [MEDICAL CONDITION] in which the resident was hospitalized from [DATE] - 6/26/13. During the hospitalization , the resident underwent [REDACTED]. The resident returned to the facility with staples to the incision site of the left hip. The resident was discharged from the hospital without orders for routine or as needed pain medication. The licensed nurses failed to notify the physician of the resident's complaints of pain and failed to conduct ongoing assessments to ensure the resident was free of pain. Once the physician ordered pain medication as needed for the resident, the licensed nurses failed to transcribe the order as to ensure the resident received the medication when he complained of pain. The facility failed to implement interventions to ensure the resident maintained his level of functioning prior to the fall and left [MEDICAL CONDITION]. The resident was discharged from therapy services on 8/29/13. Through observations and interviews, it was determined that the resident had declined in his level of functioning. He declined from being ambulatory without assistance, continent of bowel with minimal episodes of urinary incontinence and requiring no to limited staff assistance to being wheelchair dependent for mobility, incontinent of bowel and bladder, and requiring extensive to total staff assistance. Findings: Resident #3 Review of the clinical record revealed Resident #3 was a [AGE] year old male that had resided in the facility since January 2013. Further review of the record revealed the resident had [DIAGNOSES REDACTED]. Review of the Nursing Departmental Notes revealed in part: 6/13/13 at 11:01 a.m.: Notified per CNA, resident lying on the floor in room. Resident awake and alert. Resident stated "I was going to bathroom and couldn't make it and peed on the floor, slipped and fell on my butt." Resident complained of left leg pain. Full ROM (range of motion) to upper and lower extremities. 6/13/13 at 12:15 p.m. New order to send resident to ER for treatment and evaluation. Resident left facility at 12:30 p.m. Review of the hospital records revealed revealed in part the following: Admission Diagnoses: [REDACTED]. Brief History: ... presented to ER after a fall while in the nursing home. He noted immediate pain in the left hip and inability to ambulate. On x-rays he had a displaced intratrochanteric femur fracture. On physical exam, he had point tenderness in the groin, with no range of motion secondary to pain. Review of the clinical record revealed Resident #3 returned to the facility on [DATE] at 8 a.m. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Nursing Departmental Notes included: 6/26/13 at 8 a.m.: Returned to secure unit per ambulance service. Alert, verbal, and oriented. Dressing clean, dry and intact to left hip. Further review of the Nursing Departmental Notes revealed no evidence of a nursing assessments for the following dates and/or times: 6/26/13 at 8 a.m. - 6/29/13 at 9:43 a.m. 6/29/13 at 2:16 p.m. - 6/30/13 at 2:47 p.m. 6/30/13 at 2:47 p.m. - 7/3/13 at 12:25 p.m. 7/3/13 at 12:25 p.m. - 7/10/13 at 12:43 p.m. 7/10/13 at 12:43 p.m. - 7/17/13 at 11:52 a.m. Included in the Nursing Departmental Notes was the following: PRIOR TO INJURY: 6/5/13 at 1:39 p.m.: Ambulation at lib. Steady gait. Incontinent episodes. 6/12/13 at 11:46 a.m.: Ambulating up the hallways with a slow but steady gait. Requires assistance x 1 with ADLs. Incontinent episodes of bladder. Requires staff assist with changing clothes. Encouraged resident to go to the restroom more often. AFTER INJURY: 6/29/13 at 9:43 a.m.: Resident lying in bed. Assist provided with ADLs. 6/29/13 at 2:16 p.m.: Resident's niece stated resident complained of pain. Asked resident if he was in pain and he stated, "No but I can't walk. They told me I can't walk." Informed resident that therapy would work with him to walk. He stated "ok then". 7/3/13 at 12:25 p.m.: Lying in bed. Increased agitation noted daily. 7/10/13 at 12:43 p.m.: Up in w/c (wheelchair). Incontinent episodes of bowel and bladder. Increased agitation noted daily. 7/10/13 at 3:31 p.m.: Order received for treatment nurse to remove staples from left hip. 8/28/13 at 10:13 a.m.: Up in w/c. Propels self. 9/11/13 at 3:08 p.m.: Resident yelled out for help. CNA entered room to find resident sitting upright on floor. Resident stated he was trying to get into his w/c and when he sat down, he was on the edge of the chair and slide off the seat to the floor. Assisted to w/c. 9/25/13 at 11:43 a.m.: Lying in bed. Up in w/c when out of bed. Assistance provided with ADLs. Incontinent episodes of bowel and bladder. 10/2/13 at 12:02 p.m.: Lying in bed awake and alert. Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. 10/9/13 at 12:46 p.m.: Assistance provided with ADLs. Incontinent episodes of bladder. "Encouraged to attend commode." 10/16/13 at 1:04 p.m.: Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. Review of the Care Plan included: Pain. Onset 10/8/13 Goal & Target Date: Pain will be effectively managed x 90 days. 1/7/14 Approaches: * Administer medications as ordered to address pain or discomfort * Monitor for pain or discomfort Review of the Physical Therapy (PT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: To be able to walk Underlying Impairments: Pain with movement. Intensity = 7/10. Frequency/Duration = Intermittent; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with decreased bed mobility, transfers, balance and gait from weakness following left [MEDICAL CONDITION]. Review of the Physical Therapy Discharge Summary revealed the last date of service was on 8/28/13. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: Pt will increase BUE (bilateral upper extremity) strength Underlying Impairments: Pain with movement. Intensity = 8/10. Frequency/Duration = Constant; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with the following deficit areas: decreased ADL ability, decreased strength/endurance, decreased balance, decreased functional mobility, and decreased safety awareness. Review of the Occupational Therapy Discharge Summary revealed the last date of service was on 8/28/13. On 10/29/13 at 10:15 a.m., an observation was made of Resident #3. The resident was lying in bed. He was awake but drowsy. He was oriented to person only. He was in a curled position on his left side. An observation was made of Resident #3 receiving a shower on 10/29/13 at 10:30 a.m. S24CNA was providing the shower. The resident received extensive to total assistance from S24CNA during the shower. The resident followed directions but required encouragement and repetition of directions. He moved his upper and lower extremities with slow purposeful movement. On 10/29/13 at 10:50 a.m., an observation was made of S24CNA assisting Resident #3 back to bed. He required extensive assistance during the transfer. He was observed to be very weak and unsteady during the transfer. The resident wore incontinent briefs. On 10/29/13 at 11 a.m., an interview was held with S24CNA. She recalled Resident #3's level of functioning prior to the fall that occurred in June 2013 where he sustained a left [MEDICAL CONDITION] as being "independent". She stated the resident was ambulatory without staff assistance, required minimal assistance with ADLs, and was continent of bowel and bladder. She said the resident wore underwear. She stated he did have occasional bladder incontinence, but it wasn't often. She said he "never" had bowel incontinence. She described Resident #3 after the fall as being "completely different". She said he now relied on staff for all care, did not walk at all anymore, used a wheelchair for mobility, and was incontinent of bowel and bladder. She recalled the resident returned to the facility after being hospitalized for [REDACTED]. S24CNA said the resident did complain of left hip pain. She said she thought the nurses were giving him medication for pain. An interview was held with S13CNA on 10/29/13 at 1:45 p.m. She stated she routinely cared for Resident #3. She recalled the incident on 6/13/13. She said the resident was trying to use his bathroom but he didn't make it in time and urinated on himself. She stated the resident slipped in the urine and fell down. She said another staff member was passing the resident's room, observed him lying on the floor and notified her. She stated the resident's fall was unwitnessed, but he told the staff what occurred and there was urine on the floor supporting his description of the incident. She stated the resident immediately complained of pain to his left hip. She said he was sent out to the hospital where he was found to have a fractured left hip. She said the resident returned to the facility a week or so later with staples to his left hip. She said the resident did complain of pain to his left hip when he initially returned to the facility. When asked if she reported this to the nurse, she stated the nurse was aware and gave him medication for the pain. She said when he returned, he was going to therapy, but that had stopped a month or so ago and she did not know why. She recalled the resident walking with the therapy staff. She said she made rounds to check on each of the residents every two hours. She said during rounds, she provided incontinent care to the residents that needed it. S13CNA said that prior to the fall, Resident #3 ambulated independently and was continent of bowel and bladder. She said she did not offer the bathroom to the resident because he could go without assistance and knew when he needed to go. She stated the resident did have occasional episodes of urinary incontinence but she felt that was because he had waited too long to go to the bathroom and could not make it in time. She said the resident used to wear underwear, not incontinent briefs. She said the resident was more social also. She explained that the resident would come watch television in the day room and interact more with staff and other residents. She said after the fall, the resident wanted to stay in bed or in his room and required extensive to total assistance from staff for all care. She said the resident was now incontinent of both bowel and bladder. She said the staff had not tried a scheduled toileting program because the resident would not tell the staff when he needed to use the toilet. She stated the resident was now totally dependent on a wheelchair for mobility. She stated the staff provided range of motion to the resident when they provided care such as a bathing. She said the facility did not have a restorative program. She said all restorative nursing care was done by either therapy or the nurses. On 10/29/13 at 3:05 p.m., an interview was held with S20LPN. She stated she had cared for Resident #3 since his admission to the facility. She described Resident #3 prior to falling and sustaining the left [MEDICAL CONDITION] as being independent with ambulation, requiring limited assistance from staff with ADLs and continent of bowel and bladder. She said that since the incident, the resident required extensive assistance from staff and was incontinent of bowel and bladder. She said he used a wheelchair for mobility but the therapy staff were walking the resident five days a week. She recalled the resident being hospitalized for [REDACTED]. S20LPN stated that upon Resident #3's hospital return following the left [MEDICAL CONDITION], he did have occasional complaints of pain. She said he received Tylenol as needed for pain. She stated the nurses must call the physician to obtain an order for [REDACTED]. She reiterated that the nurses called the physician to obtain orders for any medications. S20LPN reviewed Resident #3's clinical record. She verified the resident returned to the facility on [DATE] without pain medication ordered. She further verified the resident had not received any Tylenol for pain. She then stated she thought the resident was ordered Tylenol when he returned from the hospital. When asked about the resident's socialization since the incident, S20LPN stated that he preferred to stay in the bed. She said the resident had always been "more to himself" but prior to the fall, she stated the resident would walk around the unit and interact with staff and residents. She said he doesn't do that as much because he used the wheelchair and preferred to stay in his bed. S20LPN further stated the resident had behaviors of "constantly complaining about something being wrong with him". She said the resident usually stated that he could not breath but when his oxygen saturations were checked and within normal range, she felt it was his mental disorder. She stated he had "always been like that". Further observations were made of Resident #3 during the onsite investigation on 10/29/13. The resident was observed to be in bed and asleep during every observation. On 10/30/13 at 8:30 a.m., an observation was made of Resident #3. He was asleep lying on his back in bed. An interview was held with S21CNA on 10/30/13 at 9 a.m. She stated she had cared for Resident #3 and was familiar with his care. She recalled the resident having a [MEDICAL CONDITION] after falling. She stated prior to the fall, Resident #3 walked independently, only required minimal staff assistance with ADLs and was continent of bowel and bladder. She said the resident would socialize with others as he walked throughout the secure unit. She said after hospitalization following the fall, Resident #3 complained of pain to his leg. She stated the resident complained of pain to the nurses as well. She described the resident's current status as being wheelchair dependent, requiring total care from staff and incontinent of bowel and bladder. On 10/30/13 at 9:05 a.m., an interview was held with S22LPN. She recalled the incident with Resident #3 on 6/13/13. She stated S13CNA called her to the secure unit because Resident #3 had fallen. She said the resident was found in his room on the floor. She said he had slipped in urine while trying to go to the bathroom. She said he did not appear to have any injuries and therefore the staff assisted him to the bed. She said he began complaining of pain to his left leg when he moved to the bed. She said she notified the physician, S19MD, and was given a order for an x-ray of the left hip. She said the x-rays were obtained and indicated the resident had a left [MEDICAL CONDITION]. She said she called S19MD again and received an order to transfer the resident to the hospital. She stated the resident was hospitalized for [REDACTED]. She stated that when she had cared for Resident #3, he had not complained of pain following the fall. She said when the incident occurred, Resident #3 was able to walk independently, required minimal assistance with ADLs and was continent of bowel and bladder. She stated the resident had urinary incontinence episodes but they were infrequent. She stated that currently the resident used a wheelchair for mobility, required total assistance from staff for ADLs, and was incontinent of bowel and bladder. She stated range of motion was provided by therapy staff. She said the resident attended therapy but she was not sure what services he was currently receiving. She stated the resident's range of motion was provided during therapy and when the CNAs provided ADLs. Upon review of the clinical record, S22LPN verified there were no orders written for Resident #3 to receive an x-ray of the left hip. She then recalled the resident was sent to the hospital instead of the facility obtaining an x-ray. An interview was held on 10/30/13 at 9:15 a.m. with S7CNA. She stated she had cared for Resident #3 prior to and since he fell sustaining a left [MEDICAL CONDITION]. She said prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said the resident wore underwear and did have occasional urinary incontinence. She stated since the fall, the resident required total care from staff with ADLs, used a wheelchair for mobility, and was incontinent of bowel and bladder. She stated that currently the resident spent most of his time in bed or in his room. She said prior to the fall, the resident walked along the secure unit. She said although he usually kept to himself, he used to interact more others. She said the CNAs encourage him to get out of bed but he immediately wanted to return to bed after only being up a short amount of time. She stated the resident received therapy and walked daily with the therapy staff. She recalled that the resident had complained of pain when he had first returned from the hospital in June 2013. She said any complaints made by the resident were reported to the nurse. On 10/30/13 at 10:15 a.m., an interview was held with S11CNA. She stated she had cared for Resident #3 prior to and since he had fell and broke his left hip. She stated prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said since the fall, the resident was unable to walk, required total assistance with ADLs and was incontinent of bowel and bladder. She stated when the resident returned from the hospital after the fall, he did complain of pain to his left leg. She said the nurses were aware of it. She further stated the resident was encouraged to move his extremities during ADLs. An interview was held with S17COTA on 10/30/13 at 10:35 a.m. She stated when Resident #3 returned from the hospital in June 2013, he began receiving OT. She stated the resident complained of pain to the affected leg "every once in a while". She said the therapy department verbally communicated the resident's complaints of pain to the resident's assigned nurse. She stated she could not recall any specific nurses that she had spoken with regarding the resident's complaints of pain. S17COTA further stated the resident did well while receiving therapy. She said he required encouragement from the staff for participation, but he would participate. She said he was discharged from OT in August 2013. She said at the time of discharge, the resident was able to walk with supervision. On 10/30/13 at 10:40 a.m., an interview was held with S12PTA. She stated Resident #3 received PT when he returned from the hospital after a fall where he injured his hip. She said the resident complained of pain "every now and then" to his left leg. She stated the pain was usually caused by movement of the leg during PT. She stated the resident participated well in PT but did require encouragement to do so. She said the resident was discharged from PT in August 2013. S12PTA stated upon discharge from PT the resident was able to walk with staff supervision. An observation was made of Resident #3 on 10/30/13 at 10:50 a.m. The resident was sitting upright in a wheelchair in the day room. An interview was held at this time with Resident #3. He was oriented to his name and place. He recalled falling in his room but could not recall how he had fallen. He said he went to the hospital where his hip (pointing to his left hip) was operated on. He stated "they put screws in my hip". He said when he returned to the facility, he went to therapy nearly every day. He said he was doing good with getting his strength back and being able to walk again, but then therapy stopped. He stated he didn't know why he had quit going to therapy. He said that was a month or so ago. He said since then, he had gotten "weaker and weaker". He stated he could barely stand anymore and he could not walk. He said he used the wheelchair to get around and he didn't like it. He stated he wanted to walk again. He said he experienced pain from his left hip when he returned from the hospital. He said he told the nurses but they didn't listen. He stated his knees hurt him currently not his hip. He said when he tried to stand and transfer to the wheelchair, he experienced pain in his knees. He stated the pain was why he preferred to stay in bed. An interview was held with S2DON and S3ADON on 10/30/13 at 12:05 p.m. They verified Resident #3 had fallen in June 2013, sustained a left [MEDICAL CONDITION], transferred to the hospital and underwent surgical repair of the left hip. They said that prior to the fall the resident ambulated without assistance, required some staff assistance with ADLs and was continent of bowel and bladder. They said after the fall, the resident used a wheelchair for mobility, but his ADL, bowel, and bladder needs had not changed. They verified the resident returned to the facility with staples to his left hip and no medications ordered for pain management. They said that S19MD did not have standing orders for any medications therefore when a nurse needed an order, she called S19MD to obtain an order. They stated Resident #3 had not experienced any pain when he returned from the hospital following the fall. They said the resident would have told the nurse if he was experiencing pain. They stated the nurses assessed a resident for pain each time he/she went into the resident's room. They stated results of the assessments should be within the nursing notes. They said when the resident returned from the hospital, he was receiving "skilled services" and therefore the nurses would have documented their assessments on the "skilled nursing notes". At this time, requested all skilled documentation related to Resident #3 since June 2013. An observation was made of Resident #3 on 10/30/13 at 12:25 p.m. He was asleep in bed. He was lying on his left side with his legs curled next to him. A telephone interview was held with Resident #3's responsible party on 10/30/13 at 12:30 p.m. She stated Resident #3 returned to the facility after being hospitalized for [REDACTED]. She said the resident did experience and complain of pain to the left hip when he returned to the facility. She further stated the resident had medication ordered for pain and to her knowledge was administered the medication when he complained of pain. She stated before the fall, Resident #3 walked and was much more interactive with others. She said since the fall, he used the wheelchair for mobility and preferred to stay in bed. On 10/30/13 at 1:25 p.m., continued the interview with S2DON and S3ADON. S2 and S3 stated they were unable to locate skilled nursing documentation on Resident #3. Both, S2 and S3, confirmed the resident was not receiving skilled nursing following the left [MEDICAL CONDITION] hospitalization in June 2013. They said the resident was receiving therapy services following the hospitalization . Each said he did well with therapy. They stated the facility did not have a restorative program. Both said they would have to review the resident's ADL sheets to see if he was receiving restorative nursing. They stated restorative nursing was provided by the CNAs. Review of the documentation presented by S2DON and S3ADON on 10/30/13 at 2:30 p.m. included a Restorative Roster. Review of the Restorative Roster revealed 15 minutes of walking was provided to Resident #3, however, this was not done on a routine basis. In comparing the resident's therapy discharge date of [DATE] to the Restorative Roster, the resident was not provided restorative nursing care on the following dates: 8/29/13, 8/30/13, 8/31/13, 9/1/13, 9/2/13, 9/8/13, 9/14/13, 9/15/13, 9/22/13, 9/29/13, 10/5/13, 10/13/13, 10/16/13, 10/17/13, 10/20/13, 10/21/13, 10/26/13, 10/27/13, 10/29/13, and 10/30/13. A telephone interview was held with S19MD on 10/30/13 at 2:10 p.m. He recalled Resident #3 and the resident being hospitalized in June 2013 for a [MEDICAL CONDITION]. He stated he did not receive any calls from the nursing staff in regards to Resident #3 having pain upon his return to the facility in June 2013. He said had he been notified the resident was experiencing pain, he was have given an order for [REDACTED]. On 10/30/13 at 2:15 p.m., an interview was held with S25SW. She said prior to Resident #3 having the left [MEDICAL CONDITION], he walked independently around the secure unit. She stated since the [MEDICAL CONDITION], he used a wheelchair. An interview was held with S28AD on 10/30/13 at 2:20 p.m. She stated prior to the resident's left [MEDICAL CONDITION], he walked without assistance and was out of his room more. She stated since the fracture, the resident used a wheelchair for mobility and preferred to stay in his room. An observation was made of Resident #3 on 10/31/13 at 8:25 a.m. He was asleep and lying on his right side with his legs curled next to him on a sofa in the secure unit's day room. An observation was made of Resident #3 on 10/31/13 at 10:00 a.m. He was watching television while sitting on the sofa in the secure unit's day room. At this time an interview was held with Resident #3. He was alert and oriented to self and place. He recalled being seen by S19MD on the afternoon of 10/30/13. He said he told S19MD that his knees were hurting. When asked what the physician had done to help with his knee pain, Resident #13 responded, "nothing". The resident further stated he hadn't been given anything by the nurse to help ease the knee pain. An interview was held with S13CNA on 10/31/13 at 10:05 a.m. She stated she had tried to walk Resident #3 that morning, but he could not hardly walk. She said he complained about his knees hurting him when he stood up. At this time an observation was made of S13CNA assisting Resident #3 to a standing position. The CNA held the resident in the standing position due to the resident's inability to do so on his own. The resident required total assistance from the CNA. He maintained a slight bend at the waist and his knees stayed flexed (bent). He was unable to stretch out his legs or his upper body completely. He complained of pain to his knees the entire time. S13CNA was asked if the resident was always like that, she responded yes. She was then asked how he was able to walk for 15 minutes when he could not stand, she stated she just held him in a standing position. Review of the hand-written order by S19MD and dated 10/30/13 revealed: Tylenol 650mg (milligrams) PO (by mouth) Q (every) 4 hr (hours) PRN (as needed) pain Review of the Physician's Progress Notes dated 10/30/13 included: C/O (complained of) mild bilateral knee pain. Plan: Tylenol Review of the October 2013 electronic MARs did not include the order for Tylenol. Review of the Nursing Departmental Notes for October 2013 revealed no documentation of the resident's complaints of knee pain. An interview was held with S22LPN on 10/31/13 at 10:15 a.m. S22LPN stated that on 10/30/13, she made rounds with S19MD. She said she was present when S19MD seen Resident #3. S22LPN said she did hear the resident inform the physician of his knee pain. She stated S19MD did not tell her he had written an order for [REDACTED]. On 10/31/13 at 11:15 a.m., an interview was held with S2DON and S3ADON. Both stated they had provided all available documentation and/or evidence related to Resident #3. They verified the physician had written an order for [REDACTED]. An interview was held with S1Administrator, S2DON, S3ADON, and S4MDS on 10/31/13 at 1:45 p.m. S1Administrator stated S2DON and S3ADON had communicated all nursing concerns with her throughout the survey. S1Administrator stated prior to Resident #3 falling and sustaining the left [MEDICAL CONDITION], he was using a wheelchair for mobility and had incontinent episodes of urine at times. She said his level of functioning had not changed or declined since the fall. She said when the resident returned from the hospital, he did not experience any pain. She stated Resident #3 had a history of [REDACTED]. She stated prior to the fall he was saying he could not walk and used a wheelchair. She said she seen him walking around the secure unit each day and she felt he was choosing not to walk at this time. S1Administrator said the resident had also had continuous health complaints that he could not breath, but the nurses never found his oxygen saturations to be low. She again said she felt the resident's physical status was due to his mental disorders. She verified she had been notified of the order that was written on 10/30/13 and was not taken off by the nurse. She stated the nursing assistants check the residents for pain and report it to the nurses. She was informed the facility was unable to provide ongoing nursing assessments of the resident's pain levels related to his left hip surgical site or that the resident received ongoing restorative nursing care to prevent a decline in physical functioning.

Based on observations, interviews, and record review, the facility failed to ensure services were provided in accordance with professional standards of quality for 1 (#3) of 5 sampled residents. The facility failed to ensure: 1. Supervision of a resident that resided on a secure unit was provided to prevent the resident from slipping in his own urine and falling which resulted in a left [MEDICAL CONDITION] 2. A licensed nurse notified the physician of the resident's complaints of pain and assessed the resident on an ongoing basis for pain after returning to the facility following hospitalization that included surgical repair of the left [MEDICAL CONDITION]; 3. The plan of care was revised to include interventions to prevent the resident's level of functioning from declining once the resident was discharged from therapy services and 4. Medications was administered to the resident as needed for pain once ordered by the physician. The deficient practice resulted in actual harm for Resident #3 when the facility failed to provide adequate supervision in order to prevent the resident from experiencing an unwitnessed fall by slipping in his own urine. The fall resulted in an left [MEDICAL CONDITION] in which the resident was hospitalized from [DATE] - 6/26/13. During the hospitalization , the resident underwent [REDACTED]. The resident returned to the facility with staples to the incision site of the left hip. The resident was discharged from the hospital without orders for routine or as needed pain medication. The licensed nurses failed to notify the physician of the resident's complaints of pain and failed to conduct ongoing assessments to ensure the resident was free of pain. Once the physician ordered pain medication as needed for the resident, the licensed nurses failed to transcribe the order as to ensure the resident received the medication when he complained of pain. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E.Curriculum Requirements revealed in part: 3. ...development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgement, prudence, ethical thing and behaviors, problem solving and critical thinking abilities... 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to: the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team... Review of the clinical record revealed Resident #3 was a [AGE] year old male that had resided in the facility since January 2013. Further review of the record revealed the resident had [DIAGNOSES REDACTED]. Review of the Nursing Departmental Notes revealed in part: 6/13/13 at 11:01 a.m.: Notified per CNA, resident lying on the floor in room. Resident awake and alert. Resident stated "I was going to bathroom and couldn't make it and peed on the floor, slipped and fell on my butt." Resident complained of left leg pain. Full ROM (range of motion) to upper and lower extremities. 6/13/13 at 12:15 p.m. New order to send resident to ER for treatment and evaluation. Resident left facility at 12:30 p.m. Review of the hospital records revealed revealed in part the following: Admission Diagnoses: [REDACTED]. Brief History: ... presented to ER after a fall while in the nursing home. He noted immediate pain in the left hip and inability to ambulate. On x-rays he had a displaced intratrochanteric femur fracture. On physical exam, he had point tenderness in the groin, with no range of motion secondary to pain. Review of the clinical record revealed Resident #3 returned to the facility on [DATE] at 8 a.m. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Nursing Departmental Notes included: 6/26/13 at 8 a.m.: Returned to secure unit per ambulance service. Alert, verbal, and oriented. Dressing clean, dry and intact to left hip. Further review of the Nursing Departmental Notes revealed no evidence of a nursing assessments for the following dates and/or times: 6/26/13 at 8 a.m. - 6/29/13 at 9:43 a.m. 6/29/13 at 2:16 p.m. - 6/30/13 at 2:47 p.m. 6/30/13 at 2:47 p.m. - 7/3/13 at 12:25 p.m. 7/3/13 at 12:25 p.m. - 7/10/13 at 12:43 p.m. 7/10/13 at 12:43 p.m. - 7/17/13 at 11:52 a.m. Included in the Nursing Departmental Notes was the following: PRIOR TO INJURY: 6/5/13 at 1:39 p.m.: Ambulation at lib. Steady gait. Incontinent episodes. 6/12/13 at 11:46 a.m.: Ambulating up the hallways with a slow but steady gait. Requires assistance x 1 with ADLs. Incontinent episodes of bladder. Requires staff assist with changing clothes. Encouraged resident to go to the restroom more often. AFTER INJURY: 6/29/13 at 9:43 a.m.: Resident lying in bed. Assist provided with ADLs. 6/29/13 at 2:16 p.m.: Resident's niece stated resident complained of pain. Asked resident if he was in pain and he stated, "No but I can't walk. They told me I can't walk." Informed resident that therapy would work with him to walk. He stated "ok then". 7/3/13 at 12:25 p.m.: Lying in bed. Increased agitation noted daily. 7/10/13 at 12:43 p.m.: Up in w/c (wheelchair). Incontinent episodes of bowel and bladder. Increased agitation noted daily. 7/10/13 at 3:31 p.m.: Order received for treatment nurse to remove staples from left hip. 8/28/13 at 10:13 a.m.: Up in w/c. Propels self. 9/11/13 at 3:08 p.m.: Resident yelled out for help. CNA entered room to find resident sitting upright on floor. Resident stated he was trying to get into his w/c and when he sat down, he was on the edge of the chair and slide off the seat to the floor. Assisted to w/c. 9/25/13 at 11:43 a.m.: Lying in bed. Up in w/c when out of bed. Assistance provided with ADLs. Incontinent episodes of bowel and bladder. 10/2/13 at 12:02 p.m.: Lying in bed awake and alert. Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. 10/9/13 at 12:46 p.m.: Assistance provided with ADLs. Incontinent episodes of bladder. "Encouraged to attend commode." 10/16/13 at 1:04 p.m.: Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. Review of the Minimum Data Set (MDS) completed prior to the resident's injury had an Assessment Reference Date (ARD) of 4/10/13. The MDS included the resident was unable to complete the interview to determine his cognition and that he had no impairment of his range of motion. According to the MDS, the resident required limited one person assistance with bed mobility, transfers and walking. The resident's balance was not steady. Review of the most recent MDS with ARD of 10/8/13 revealed the resident was unable to complete the interview to determine his cognition. Further review of the MDS revealed the resident required one person, extensive assistance with transfers, bed mobility, and personal hygiene. The MDS indicated the resident had impaired ROM to one side of the lower extremities and used a wheelchair for mobility. The resident was always incontinent of urine and always continent of bowel. Review of the Care Plan included: At risk for fall. Onset 10/8/13 Goal & Target Date: Will remain free from injury related to falls x 90 days. 1/7/14 - 6/13/13: urinated on floor, slipped and fell . C/O left leg pain. Resident sent to hospital - incontinent briefs to be offered, therapy to be consulted. Approaches: * Maintain well light environment free of clutter * Maintain bed in low position with wheels locked * Assure visual cues in place * Reassess fall risk quarterly unless otherwise indicated. Pain. Onset 10/8/13 Goal & Target Date: Pain will be effectively managed x 90 days. 1/7/14 Approaches: * Administer medications as ordered to address pain or discomfort * Monitor for pain or discomfort Review of the Physical Therapy (PT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: To be able to walk Underlying Impairments: Pain with movement. Intensity = 7/10. Frequency/Duration = Intermittent; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with decreased bed mobility, transfers, balance and gait from weakness following left [MEDICAL CONDITION]. Review of the Physical Therapy Discharge Summary revealed the last date of service was on 8/28/13. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: Pt will increase BUE (bilateral upper extremity) strength Underlying Impairments: Pain with movement. Intensity = 8/10. Frequency/Duration = Constant; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with the following deficit areas: decreased ADL ability, decreased strength/endurance, decreased balance, decreased functional mobility, and decreased safety awareness. Review of the Occupational Therapy Discharge Summary revealed the last date of service was on 8/28/13. On 10/29/13 at 10:15 a.m., an observation was made of Resident #3. The resident was lying in bed. He was awake but drowsy. He was oriented to person only. He was in a curled position on his left side. An observation was made of Resident #3 receiving a shower on 10/29/13 at 10:30 a.m. S24CNA was providing the shower. The resident received extensive to total assistance from S24CNA during the shower. The resident followed directions but required encouragement and repetition of directions. He moved his upper and lower extremities with slow purposeful movement. On 10/29/13 at 10:50 a.m., an observation was made of S24CNA assisting Resident #3 back to bed. He required extensive assistance during the transfer. He was observed to be very weak and unsteady during the transfer. The resident wore incontinent briefs. On 10/29/13 at 11 a.m., an interview was held with S24CNA. She recalled Resident #3's level of functioning prior to the fall that occurred in June 2013 where he sustained a left [MEDICAL CONDITION] as being "independent". She described Resident #3 after the fall as being "completely different". She said he now relied on staff for all care, did not walk at all anymore, used a wheelchair for mobility, and was incontinent of bowel and bladder. She recalled the resident returned to the facility after being hospitalized for [REDACTED]. S24CNA said the resident did complain of left hip pain. She said she thought the nurses were giving him medication for pain. An interview was held with S13CNA on 10/29/13 at 1:45 p.m. She stated she routinely cared for Resident #3. She recalled the incident on 6/13/13. She said the resident was trying to use his bathroom but he didn't make it in time and urinated on himself. She stated the resident slipped in the urine and fell down. She said another staff member was passing the resident's room, observed him lying on the floor and notified her. She stated the resident's fall was unwitnessed, but he told the staff what occurred and there was urine on the floor supporting his description of the incident. She stated the resident immediately complained of pain to his left hip. She said he was sent out to the hospital where he was found to have a fractured left hip. She said the resident returned to the facility a week or so later with staples to his left hip. She said the resident did complain of pain to his left hip when he initially returned to the facility. When asked if she reported this to the nurse, she stated the nurse was aware. S13CNA said that prior to the fall, Resident #3 ambulated independently and was continent of bowel and bladder. She stated the resident did have occasional episodes of urinary incontinence but she felt that was because he had waited too long to go to the bathroom and could not make it in time. She said the resident used to wear underwear, not incontinent briefs. She said the resident was more social also. She explained that the resident would come watch television in the day room and interact more with staff and other residents. She said after the fall, the resident wanted to stay in bed or in his room and required extensive to total assistance from staff for all care. She said the resident was now incontinent of both bowel and bladder. She stated the resident was now totally dependent on a wheelchair for mobility. On 10/29/13 at 3:05 p.m., an interview was held with S20LPN. She stated she had cared for Resident #3 since his admission to the facility. She described Resident #3 prior to falling and sustaining the left [MEDICAL CONDITION] as being independent with ambulation, requiring limited assistance from staff with ADLs and continent of bowel and bladder. She said that since the incident, the resident required extensive assistance from staff and was incontinent of bowel and bladder. She said he used a wheelchair for mobility but the therapy staff were walking the resident five days a week. She recalled the resident being hospitalized for [REDACTED]. S20LPN stated that upon Resident #3's hospital return following the left [MEDICAL CONDITION], he did have occasional complaints of pain. She said he received Tylenol as needed for pain. She stated the nurses must call the physician to obtain an order for [REDACTED]. She reiterated that the nurses called the physician to obtain orders for any medications. S20LPN reviewed Resident #3's clinical record. She verified the resident returned to the facility on [DATE] without pain medication ordered. She further verified the resident had not received any Tylenol for pain. She then stated she thought the resident was ordered Tylenol when he returned from the hospital. When asked about the resident's socialization since the incident, S20LPN stated that he preferred to stay in the bed. She said the resident had always been "more to himself" but prior to the fall, she stated the resident would walk around the unit and interact with staff and residents. She said he doesn't do that as much because he used the wheelchair and preferred to stay in his bed. S20LPN further stated the resident had behaviors of "constantly complaining about something being wrong with him". She said the resident usually stated that he could not breath but when his oxygen saturations were checked and within normal range, she felt it was his mental disorder. She stated he had "always been like that". Further observations were made of Resident #3 during the onsite investigation on 10/29/13. The resident was observed to be in bed and asleep during every observation. On 10/30/13 at 8:30 a.m., an observation was made of Resident #3. He was asleep lying on his back in bed. An interview was held with S21CNA on 10/30/13 at 9 a.m. She stated she had cared for Resident #3 and was familiar with his care. She recalled the resident having a [MEDICAL CONDITION] after falling. She stated prior to the fall, Resident #3 walked independently, only required minimal staff assistance with ADLs and was continent of bowel and bladder. She said the resident would socialize with others as he walked throughout the secure unit. She said after hospitalization following the fall, Resident #3 complained of pain to his leg. She stated the resident complained of pain to the nurses as well. She described the resident's current status as being wheelchair dependent, requiring total care from staff and incontinent of bowel and bladder. On 10/30/13 at 9:05 a.m., an interview was held with S22LPN. She recalled the incident with Resident #3 on 6/13/13. She stated S13CNA called her to the secure unit because Resident #3 had fallen. She said the resident was found in his room on the floor. She said he had slipped in urine while trying to go to the bathroom. She said he did not appear to have any injuries and therefore the staff assisted him to the bed. She said he began complaining of pain to his left leg when he moved to the bed. She said she notified the physician, S19MD, and was given a order for an x-ray of the left hip. She said the x-rays were obtained and indicated the resident had a left [MEDICAL CONDITION]. She said she called S19MD again and received an order to transfer the resident to the hospital. She stated the resident was hospitalized for [REDACTED]. She stated that when she had cared for Resident #3, he had not complained of pain following the fall. She said when the incident occurred, Resident #3 was able to walk independently, required minimal assistance with ADLs and was continent of bowel and bladder. She stated the resident had urinary incontinence episodes but they were infrequent. She stated that currently the resident used a wheelchair for mobility, required total assistance from staff for ADLs, and was incontinent of bowel and bladder. Upon review of the clinical record, S22LPN verified there were no orders written for Resident #3 to receive an x-ray of the left hip. She then recalled the resident was sent to the hospital instead of the facility obtaining an x-ray. An interview was held on 10/30/13 at 9:15 a.m. with S7CNA. She stated she had cared for Resident #3 prior to and since he fell sustaining a left [MEDICAL CONDITION]. She said prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said the resident wore underwear and did have occasional urinary incontinence. She stated since the fall, the resident required total care from staff with ADLs, used a wheelchair for mobility, and was incontinent of bowel and bladder. She stated that currently the resident spent most of his time in bed or in his room. She said prior to the fall, the resident walked along the secure unit. She said although he usually kept to himself, he used to interact more others. She said the CNAs encourage him to get out of bed but he immediately wanted to return to bed after only being up a short amount of time. She stated the resident received therapy and walked daily with the therapy staff. She recalled that the resident had complained of pain when he had first returned from the hospital in June 2013. She said any complaints made by the resident were reported to the nurse. On 10/30/13 at 10:15 a.m., an interview was held with S11CNA. She stated she had cared for Resident #3 prior to and since he had fell and broke his left hip. She stated prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said since the fall, the resident was unable to walk, required total assistance with ADLs and was incontinent of bowel and bladder. She stated when the resident returned from the hospital after the fall, he did complain of pain to his left leg. She said the nurses were aware of it. She further stated the resident was encouraged to move his extremities during ADLs. An interview was held with S17COTA on 10/30/13 at 10:35 a.m. She stated when Resident #3 returned from the hospital in June 2013, he began receiving OT. She stated the resident complained of pain to the affected leg "every once in a while". She said the therapy department verbally communicated the resident's complaints of pain to the resident's assigned nurse. She stated she could not recall any specific nurses that she had spoken with regarding the resident's complaints of pain. S17COTA further stated the resident did well while receiving therapy. She said he required encouragement from the staff for participation, but he would participate. She said he was discharged from OT in August 2013. She said at the time of discharge, the resident was able to walk with supervision. On 10/30/13 at 10:40 a.m., an interview was held with S12PTA. She stated Resident #3 received PT when he returned from the hospital after a fall where he injured his hip. She said the resident complained of pain "every now and then" to his left leg. She stated the pain was usually caused by movement of the leg during PT. She stated the resident participated well in PT but did require encouragement to do so. She said the resident was discharged from PT in August 2013. S12PTA stated upon discharge from PT the resident was able to walk with staff supervision. An observation was made of Resident #3 on 10/30/13 at 10:50 a.m. The resident was sitting upright in a wheelchair in the day room. An interview was held at this time with Resident #3. He was oriented to his name and place. He recalled falling in his room but could not recall how he had fallen. He said he went to the hospital where his hip (pointing to his left hip) was operated on. He stated "they put screws in my hip". He said when he returned to the facility, he went to therapy nearly every day. He said he was doing good with getting his strength back and being able to walk again, but then therapy stopped. He stated he didn't know why he had quit going to therapy. He said that was a month or so ago. He said since then, he had gotten "weaker and weaker". He stated he could barely stand anymore and he could not walk. He said he used the wheelchair to get around and he didn't like it. He stated he wanted to walk again. He said he experienced pain from his left hip when he returned from the hospital. He said he told the nurses but they didn't listen. He stated his knees hurt him currently not his hip. He said when he tried to stand and transfer to the wheelchair, he experienced pain in his knees. He stated the pain was why he preferred to stay in bed. An interview was held with S2DON and S3ADON on 10/30/13 at 12:05 p.m. They verified Resident #3 had fallen in June 2013, sustained a left [MEDICAL CONDITION], transferred to the hospital and underwent surgical repair of the left hip. They said that prior to the fall the resident ambulated without assistance, required some staff assistance with ADLs and was continent of bowel and bladder. They said after the fall, the resident used a wheelchair for mobility, but his ADL, bowel, and bladder needs had not changed. They verified the resident returned to the facility with staples to his left hip and no medications ordered for pain management. They said that S19MD did not have standing orders for any medications therefore when a nurse needed an order, she called S19MD to obtain an order. They stated Resident #3 had not experienced any pain when he returned from the hospital following the fall. They said the resident would have told the nurse if he was experiencing pain. They stated the nurses assessed a resident for pain each time he/she went into the resident's room. They stated results of the assessments should be within the nursing notes. They said when the resident returned from the hospital, he was receiving "skilled services" and therefore the nurses would have documented their assessments on the "skilled nursing notes". At this time, requested all skilled documentation related to Resident #3 since June 2013. An observation was made of Resident #3 on 10/30/13 at 12:25 p.m. He was asleep in bed. He was lying on his left side with his legs curled next to him. A telephone interview was held with Resident #3's responsible party on 10/30/13 at 12:30 p.m. She stated Resident #3 returned to the facility after being hospitalized for [REDACTED]. She said the resident did experience and complain of pain to the left hip when he returned to the facility. She further stated the resident had medication ordered for pain and to her knowledge was administered the medication when he complained of pain. She stated before the fall, Resident #3 walked and was much more interactive with others. She said since the fall, he used the wheelchair for mobility and preferred to stay in bed. On 10/30/13 at 12:50 p.m., an interview was held with S4MDS. She recalled Resident #3 sustaining a fall in June 2013 that resulted in a left [MEDICAL CONDITION]. She stated the resident was hospitalized and upon return was seen in therapy. She stated during the morning meetings interventions were discussed for residents that had falls and then the plan of care was updated accordingly. She reviewed the resident's plan of care and stated he was supposed to receive therapy, once discharged start restorative, and pain management. She verified the resident currently used a wheelchair for mobility but further stated she felt most of the resident's decline was related to his psychological disorders. She explained the resident had a history of [REDACTED]. On 10/30/13 at 1:25 p.m., continued the interview with S2DON and S3ADON. S2 and S3 stated they were unable to locate skilled nursing documentation on Resident #3. A telephone interview was held with S19MD on 10/30/13 at 2:10 p.m. He recalled Resident #3 and the resident being hospitalized in June 2013 for a [MEDICAL CONDITION]. He stated he did not receive any calls from the nursing staff in regards to Resident #3 having pain upon his return to the facility in June 2013. He said had he been notified the resident was experiencing pain, he was have given an order for [REDACTED]. On 10/30/13 at 2:15 p.m., an interview was held with S25SW. She said prior to Resident #3 having the left [MEDICAL CONDITION], he walked independently around the secure unit. She stated since the [MEDICAL CONDITION], he used a wheelchair. An interview was held with S28AD on 10/30/13 at 2:20 p.m. She stated prior to the resident's left [MEDICAL CONDITION], he walked without assistance and was out of his room more. She stated since the fracture, the resident used a wheelchair for mobility and preferred to stay in his room. An observation was made of Resident #3 on 10/31/13 at 8:25 a.m. He was asleep and lying on his right side with his legs curled next to him on a sofa in the secure unit's day room. An observation was made of Resident #3 on 10/31/13 at 10:00 a.m. He was watching television while sitting on the sofa in the secure unit's day room. At this time an interview was held with Resident #3. He was alert and oriented to self and place. He recalled being seen by S19MD on the afternoon of 10/30/13. He said he told S19MD that his knees were hurting. When asked what the physician had done to help with his knee pain, Resident #13 responded, "nothing". The resident further stated he hadn't been given anything by the nurse to help ease the knee pain. An interview was held with S13CNA on 10/31/13 at 10:05 a.m. She stated she had tried to walk Resident #3 that morning, but he could not hardly walk. She said he complained about his knees hurting him when he stood up. At this time an observation was made of S13CNA assisting Resident #3 to a standing position. The CNA held the resident in the standing position due to the resident's inability to do so on his own. The resident required total assistance from the CNA. He maintained a slight bend at the waist and his knees stayed flexed (bent). He was unable to stretch out his legs or his upper body completely. He complained of pain to his knees the entire time. S13CNA was asked if the resident was always like that, she responded yes. She was then asked how he was able to walk for 15 minutes when he could not stand, she stated she just held him in a standing position. Review of the hand-written order by S19MD and dated 10/30/13 revealed: Tylenol 650mg (milligrams) PO (by mouth) Q (every) 4 hr (hours) PRN (as needed) pain Review of the Physician's Progress Notes dated 10/30/13 included: C/O (complained of) mild bilateral knee pain. Plan: Tylenol Review of the October 2013 electronic MARs did not include the order for Tylenol. Review of the Nursing Departmental Notes for October 2013 revealed no documentation of the resident's complaints of knee pain. An interview was held with S22LPN on 10/31/13 at 10:15 a.m. S22LPN stated that on 10/30/13, she made rounds with S19MD. She said she was present when S19MD seen Resident #3. S22LPN said she did hear the resident inform the physician of his knee pain. She stated S19MD did not tell her he had written an order for [REDACTED]. On 10/31/13 at 11:15 a.m., an interview was held with S2DON and S3ADON. Both stated they had provided all available documentation and/or evidence related to Resident #3. They verified the physician had written an order for [REDACTED]. An interview was held with S1Administrator, S2DON, S3ADON, and S4MDS on 10/31/13 at 1:45 p.m. S1Administrator stated S2DON and S3ADON had communicated all nursing concerns with her throughout the survey. S1Administrator stated prior to Resident #3 falling and sustaining the left [MEDICAL CONDITION], he was using a wheelchair for mobility and had incontinent episodes of urine at times. She said his level of functioning had not changed or declined since the fall. She said when the resident returned from the hospital, he did not experience any pain. She stated Resident #3 had a history of [REDACTED]. She stated prior to the fall he was saying he could not walk and used a wheelchair. She said she seen him walking around the secure unit each day and she felt he was choosing not to walk at this time. S1Administrator said the resident had also had continuous health complaints that he could not breath, but the nurses never found his oxygen saturations to be low. She again said she felt the resident's physical status was due to his mental disorders. She verified she had been notified of the order that was written on 10/30/13 and was not taken off by the nurse. She stated the nursing assistants check the residents for pain and report it to the nurses. She was informed the facility was unable to provide ongoing nursing assessments of the resident's pain levels related to his left hip surgical site or that the resident received ongoing restorative nursing care to prevent a decline in physical functioning.

Based on observations, interviews, and record review, the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical and psychosocial well-being for 1 (#3) of 5 sampled residents. The facility failed to ensure: 1. Supervision of a resident with unsteady balance and urinary incontinence was provided to prevent the resident from sustaining a fall that resulted in a left [MEDICAL CONDITION] (#3); 2. A licensed nurse notified the physician of the resident's complaints of pain and assessed the resident on an ongoing basis for pain after returning to the facility following hospitalization that included surgical repair of the left [MEDICAL CONDITION] (#3); 3. The plan of care was revised to include interventions to prevent the resident's level of functioning from declining once the resident was discharged from therapy services (#3); 4. Medications was administered to the resident as needed for pain (#3); and 5. A resident did not have a decline in their ADLs and level of functioning once discharged from therapy services (#3). The deficient practice resulted in actual harm for Resident #3 when the facility failed to provide adequate supervision in order to prevent the resident from experiencing an unwitnessed fall by slipping in his own urine. The fall resulted in an left [MEDICAL CONDITION] in which the resident was hospitalized from [DATE] - 6/26/13. During the hospitalization , the resident underwent [REDACTED]. The resident returned to the facility with staples to the incision site of the left hip. The resident was discharged from the hospital without orders for routine or as needed pain medication. The licensed nurses failed to notify the physician of the resident's complaints of pain and failed to conduct ongoing assessments to ensure the resident was free of pain. Once the physician ordered pain medication as needed for the resident, the licensed nurses failed to transcribe the order as to ensure the resident received the medication when he complained of pain. The facility failed to implement interventions to ensure the resident maintained his level of functioning prior to the fall and left [MEDICAL CONDITION]. The resident was discharged from therapy services on 8/29/13. Resident #3 declined from being ambulatory without assistance, continent of bowel with minimal episodes of urinary incontinence and requiring no to limited staff assistance to being wheelchair dependent for mobility, incontinent of bowel and bladder, and requiring extensive to total staff assistance. Findings: Resident #3 Review of the clinical record revealed Resident #3 was a [AGE] year old male that had resided in the facility since January 2013. Further review of the record revealed the resident had [DIAGNOSES REDACTED]. Review of the Nursing Departmental Notes revealed in part: 6/13/13 at 11:01 a.m.: Notified per CNA, resident lying on the floor in room. Resident awake and alert. Resident stated "I was going to bathroom and couldn't make it and peed on the floor, slipped and fell on my butt." Resident complained of left leg pain. Full ROM (range of motion) to upper and lower extremities. 6/13/13 at 12:15 p.m. New order to send resident to ER for treatment and evaluation. Resident left facility at 12:30 p.m. Review of the hospital records revealed revealed in part the following: Admission Diagnoses: [REDACTED]. Brief History: ... presented to ER after a fall while in the nursing home. He noted immediate pain in the left hip and inability to ambulate. On x-rays he had a displaced intratrochanteric femur fracture. On physical exam, he had point tenderness in the groin, with no range of motion secondary to pain. Review of the clinical record revealed Resident #3 returned to the facility on [DATE] at 8 a.m. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Nursing Departmental Notes included: 6/26/13 at 8 a.m.: Returned to secure unit per ambulance service. Alert, verbal, and oriented. Dressing clean, dry and intact to left hip. Further review of the Nursing Departmental Notes revealed no evidence of a nursing assessments for the following dates and/or times: 6/26/13 at 8 a.m. - 6/29/13 at 9:43 a.m. 6/29/13 at 2:16 p.m. - 6/30/13 at 2:47 p.m. 6/30/13 at 2:47 p.m. - 7/3/13 at 12:25 p.m. 7/3/13 at 12:25 p.m. - 7/10/13 at 12:43 p.m. 7/10/13 at 12:43 p.m. - 7/17/13 at 11:52 a.m. Included in the Nursing Departmental Notes was the following: PRIOR TO INJURY: 6/5/13 at 1:39 p.m.: Ambulation at lib. Steady gait. Incontinent episodes. 6/12/13 at 11:46 a.m.: Ambulating up the hallways with a slow but steady gait. Requires assistance x 1 with ADLs. Incontinent episodes of bladder. Requires staff assist with changing clothes. Encouraged resident to go to the restroom more often. AFTER INJURY: 6/29/13 at 9:43 a.m.: Resident lying in bed. Assist provided with ADLs. 6/29/13 at 2:16 p.m.: Resident's niece stated resident complained of pain. Asked resident if he was in pain and he stated, "No but I can't walk. They told me I can't walk." Informed resident that therapy would work with him to walk. He stated "ok then". 7/3/13 at 12:25 p.m.: Lying in bed. Increased agitation noted daily. 7/10/13 at 12:43 p.m.: Up in w/c (wheelchair). Incontinent episodes of bowel and bladder. Increased agitation noted daily. 7/10/13 at 3:31 p.m.: Order received for treatment nurse to remove staples from left hip. 8/28/13 at 10:13 a.m.: Up in w/c. Propels self. 9/11/13 at 3:08 p.m.: Resident yelled out for help. CNA entered room to find resident sitting upright on floor. Resident stated he was trying to get into his w/c and when he sat down, he was on the edge of the chair and slide off the seat to the floor. Assisted to w/c. 9/25/13 at 11:43 a.m.: Lying in bed. Up in w/c when out of bed. Assistance provided with ADLs. Incontinent episodes of bowel and bladder. 10/2/13 at 12:02 p.m.: Lying in bed awake and alert. Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. 10/9/13 at 12:46 p.m.: Assistance provided with ADLs. Incontinent episodes of bladder. "Encouraged to attend commode." 10/16/13 at 1:04 p.m.: Mobil via wheelchair. Incontinent of bowel and bladder, briefs worn at all times. Review of the Minimum Data Set (MDS) completed prior to the resident's injury had an Assessment Reference Date (ARD) of 4/10/13. The MDS included the resident was unable to complete the interview to determine his cognition and that he had no impairment of his range of motion. According to the MDS, the resident required limited one person assistance with bed mobility, transfers and walking. The resident's balance was not steady. Review of the most recent MDS with ARD of 10/8/13 revealed the resident was unable to complete the interview to determine his cognition. Further review of the MDS revealed the resident required one person, extensive assistance with transfers, bed mobility, and personal hygiene. The MDS indicated the resident had impaired ROM to one side of the lower extremities and used a wheelchair for mobility. The resident was always incontinent of urine and always continent of bowel. Review of the Care Plan included: At risk for fall. Onset 10/8/13 Goal & Target Date: Will remain free from injury related to falls x 90 days. 1/7/14 - 6/13/13: urinated on floor, slipped and fell . C/O left leg pain. Resident sent to hospital - incontinent briefs to be offered, therapy to be consulted. Approaches: * Maintain well light environment free of clutter * Maintain bed in low position with wheels locked * Assure visual cues in place * Reassess fall risk quarterly unless otherwise indicated. Pain. Onset 10/8/13 Goal & Target Date: Pain will be effectively managed x 90 days. 1/7/14 Approaches: * Administer medications as ordered to address pain or discomfort * Monitor for pain or discomfort Review of the Physical Therapy (PT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: To be able to walk Underlying Impairments: Pain with movement. Intensity = 7/10. Frequency/Duration = Intermittent; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with decreased bed mobility, transfers, balance and gait from weakness following left [MEDICAL CONDITION]. Review of the Physical Therapy Discharge Summary revealed the last date of service was on 8/28/13. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment revealed a start of care as 6/28/13. The Plan included: Long-Term Goals: Pt will increase BUE (bilateral upper extremity) strength Underlying Impairments: Pain with movement. Intensity = 8/10. Frequency/Duration = Constant; Location: left hip; Pain Description: Sharp Pain Assessment: Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; IDT (Interdisciplinary Team) Pain Interventions = Patient receives meds on scheduled program. Impressions: Patient presents with the following deficit areas: decreased ADL ability, decreased strength/endurance, decreased balance, decreased functional mobility, and decreased safety awareness. Review of the Occupational Therapy Discharge Summary revealed the last date of service was on 8/28/13. On 10/29/13 at 10:15 a.m., an observation was made of Resident #3. The resident was lying in bed. He was awake but drowsy. He was oriented to person only. He was in a curled position on his left side. An observation was made of Resident #3 receiving a shower on 10/29/13 at 10:30 a.m. S24CNA was providing the shower. The resident received extensive to total assistance from S24CNA during the shower. The resident followed directions but required encouragement and repetition of directions. He moved his upper and lower extremities with slow purposeful movement. On 10/29/13 at 10:50 a.m., an observation was made of S24CNA assisting Resident #3 back to bed. He required extensive assistance during the transfer. He was observed to be very weak and unsteady during the transfer. The resident wore incontinent briefs. On 10/29/13 at 11 a.m., an interview was held with S24CNA. She recalled Resident #3's level of functioning prior to the fall that occurred in June 2013 where he sustained a left [MEDICAL CONDITION] as being "independent". She stated the resident was ambulatory without staff assistance, required minimal assistance with ADLs, and was continent of bowel and bladder. She said the resident wore underwear. She stated he did have occasional bladder incontinence, but it wasn't often. She said he "never" had bowel incontinence. She described Resident #3 after the fall as being "completely different". She said he now relied on staff for all care, did not walk at all anymore, used a wheelchair for mobility, and was incontinent of bowel and bladder. She recalled the resident returned to the facility after being hospitalized for [REDACTED]. S24CNA said the resident did complain of left hip pain. She said she thought the nurses were giving him medication for pain. An interview was held with S13CNA on 10/29/13 at 1:45 p.m. She stated she routinely cared for Resident #3. She recalled the incident on 6/13/13. She said the resident was trying to use his bathroom but he didn't make it in time and urinated on himself. She stated the resident slipped in the urine and fell down. She said another staff member was passing the resident's room, observed him lying on the floor and notified her. She stated the resident's fall was unwitnessed, but he told the staff what occurred and there was urine on the floor supporting his description of the incident. She stated the resident immediately complained of pain to his left hip. She said he was sent out to the hospital where he was found to have a fractured left hip. She said the resident returned to the facility a week or so later with staples to his left hip. She said the resident did complain of pain to his left hip when he initially returned to the facility. When asked if she reported this to the nurse, she stated the nurse was aware and gave him medication for the pain. She said when he returned, he was going to therapy, but that had stopped a month or so ago and she did not know why. She recalled the resident walking with the therapy staff. She said she made rounds to check on each of the residents every two hours. She said during rounds, she provided incontinent care to the residents that needed it. S13CNA said that prior to the fall, Resident #3 ambulated independently and was continent of bowel and bladder. She said she did not offer the bathroom to the resident because he could go without assistance and knew when he needed to go. She stated the resident did have occasional episodes of urinary incontinence but she felt that was because he had waited too long to go to the bathroom and could not make it in time. She said the resident used to wear underwear, not incontinent briefs. She said the resident was more social also. She explained that the resident would come watch television in the day room and interact more with staff and other residents. She said after the fall, the resident wanted to stay in bed or in his room and required extensive to total assistance from staff for all care. She said the resident was now incontinent of both bowel and bladder. She said the staff had not tried a scheduled toileting program because the resident would not tell the staff when he needed to use the toilet. She stated the resident was now totally dependent on a wheelchair for mobility. She stated the staff provided range of motion to the resident when they provided care such as a bathing. She said the facility did not have a restorative program. She said all restorative nursing care was done by either therapy or the nurses. On 10/29/13 at 3:05 p.m., an interview was held with S20LPN. She stated she had cared for Resident #3 since his admission to the facility. She described Resident #3 prior to falling and sustaining the left [MEDICAL CONDITION] as being independent with ambulation, requiring limited assistance from staff with ADLs and continent of bowel and bladder. She said that since the incident, the resident required extensive assistance from staff and was incontinent of bowel and bladder. She said he used a wheelchair for mobility but the therapy staff were walking the resident five days a week. She recalled the resident being hospitalized for [REDACTED]. S20LPN stated that upon Resident #3's hospital return following the left [MEDICAL CONDITION], he did have occasional complaints of pain. She said he received Tylenol as needed for pain. She stated the nurses must call the physician to obtain an order for [REDACTED]. She reiterated that the nurses called the physician to obtain orders for any medications. S20LPN reviewed Resident #3's clinical record. She verified the resident returned to the facility on [DATE] without pain medication ordered. She further verified the resident had not received any Tylenol for pain. She then stated she thought the resident was ordered Tylenol when he returned from the hospital. When asked about the resident's socialization since the incident, S20LPN stated that he preferred to stay in the bed. She said the resident had always been "more to himself" but prior to the fall, she stated the resident would walk around the unit and interact with staff and residents. She said he doesn't do that as much because he used the wheelchair and preferred to stay in his bed. S20LPN further stated the resident had behaviors of "constantly complaining about something being wrong with him". She said the resident usually stated that he could not breath but when his oxygen saturations were checked and within normal range, she felt it was his mental disorder. She stated he had "always been like that". Further observations were made of Resident #3 during the onsite investigation on 10/29/13. The resident was observed to be in bed and asleep during every observation. On 10/30/13 at 8:30 a.m., an observation was made of Resident #3. He was asleep lying on his back in bed. An interview was held with S21CNA on 10/30/13 at 9 a.m. She stated she had cared for Resident #3 and was familiar with his care. She recalled the resident having a [MEDICAL CONDITION] after falling. She stated prior to the fall, Resident #3 walked independently, only required minimal staff assistance with ADLs and was continent of bowel and bladder. She said the resident would socialize with others as he walked throughout the secure unit. She said after hospitalization following the fall, Resident #3 complained of pain to his leg. She stated the resident complained of pain to the nurses as well. She described the resident's current status as being wheelchair dependent, requiring total care from staff and incontinent of bowel and bladder. On 10/30/13 at 9:05 a.m., an interview was held with S22LPN. She recalled the incident with Resident #3 on 6/13/13. She stated S13CNA called her to the secure unit because Resident #3 had fallen. She said the resident was found in his room on the floor. She said he had slipped in urine while trying to go to the bathroom. She said he did not appear to have any injuries and therefore the staff assisted him to the bed. She said he began complaining of pain to his left leg when he moved to the bed. She said she notified the physician, S19MD, and was given a order for an x-ray of the left hip. She said the x-rays were obtained and indicated the resident had a left [MEDICAL CONDITION]. She said she called S19MD again and received an order to transfer the resident to the hospital. She stated the resident was hospitalized for [REDACTED]. She stated that when she had cared for Resident #3, he had not complained of pain following the fall. She said when the incident occurred, Resident #3 was able to walk independently, required minimal assistance with ADLs and was continent of bowel and bladder. She stated the resident had urinary incontinence episodes but they were infrequent. She stated that currently the resident used a wheelchair for mobility, required total assistance from staff for ADLs, and was incontinent of bowel and bladder. She stated range of motion was provided by therapy staff. She said the resident attended therapy but she was not sure what services he was currently receiving. She stated the resident's range of motion was provided during therapy and when the CNAs provided ADLs. Upon review of the clinical record, S22LPN verified there were no orders written for Resident #3 to receive an x-ray of the left hip. She then recalled the resident was sent to the hospital instead of the facility obtaining an x-ray. An interview was held on 10/30/13 at 9:15 a.m. with S7CNA. She stated she had cared for Resident #3 prior to and since he fell sustaining a left [MEDICAL CONDITION]. She said prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said the resident wore underwear and did have occasional urinary incontinence. She stated since the fall, the resident required total care from staff with ADLs, used a wheelchair for mobility, and was incontinent of bowel and bladder. She stated that currently the resident spent most of his time in bed or in his room. She said prior to the fall, the resident walked along the secure unit. She said although he usually kept to himself, he used to interact more others. She said the CNAs encourage him to get out of bed but he immediately wanted to return to bed after only being up a short amount of time. She stated the resident received therapy and walked daily with the therapy staff. She recalled that the resident had complained of pain when he had first returned from the hospital in June 2013. She said any complaints made by the resident were reported to the nurse. On 10/30/13 at 10:15 a.m., an interview was held with S11CNA. She stated she had cared for Resident #3 prior to and since he had fell and broke his left hip. She stated prior to the fall, Resident #3 walked without assistance, required minimum assistance with ADLs and was continent of bowel and bladder. She said since the fall, the resident was unable to walk, required total assistance with ADLs and was incontinent of bowel and bladder. She stated when the resident returned from the hospital after the fall, he did complain of pain to his left leg. She said the nurses were aware of it. She further stated the resident was encouraged to move his extremities during ADLs. An interview was held with S17COTA on 10/30/13 at 10:35 a.m. She stated when Resident #3 returned from the hospital in June 2013, he began receiving OT. She stated the resident complained of pain to the affected leg "every once in a while". She said the therapy department verbally communicated the resident's complaints of pain to the resident's assigned nurse. She stated she could not recall any specific nurses that she had spoken with regarding the resident's complaints of pain. S17COTA further stated the resident did well while receiving therapy. She said he required encouragement from the staff for participation, but he would participate. She said he was discharged from OT in August 2013. She said at the time of discharge, the resident was able to walk with supervision. On 10/30/13 at 10:40 a.m., an interview was held with S12PTA. She stated Resident #3 received PT when he returned from the hospital after a fall where he injured his hip. She said the resident complained of pain "every now and then" to his left leg. She stated the pain was usually caused by movement of the leg during PT. She stated the resident participated well in PT but did require encouragement to do so. She said the resident was discharged from PT in August 2013. S12PTA stated upon discharge from PT the resident was able to walk with staff supervision. An observation was made of Resident #3 on 10/30/13 at 10:50 a.m. The resident was sitting upright in a wheelchair in the day room. An interview was held at this time with Resident #3. He was oriented to his name and place. He recalled falling in his room but could not recall how he had fallen. He said he went to the hospital where his hip (pointing to his left hip) was operated on. He stated "they put screws in my hip". He said when he returned to the facility, he went to therapy nearly every day. He said he was doing good with getting his strength back and being able to walk again, but then therapy stopped. He stated he didn't know why he had quit going to therapy. He said that was a month or so ago. He said since then, he had gotten "weaker and weaker". He stated he could barely stand anymore and he could not walk. He said he used the wheelchair to get around and he didn't like it. He stated he wanted to walk again. He said he experienced pain from his left hip when he returned from the hospital. He said he told the nurses but they didn't listen. He stated his knees hurt him currently not his hip. He said when he tried to stand and transfer to the wheelchair, he experienced pain in his knees. He stated the pain was why he preferred to stay in bed. An interview was held with S2DON and S3ADON on 10/30/13 at 12:05 p.m. They verified Resident #3 had fallen in June 2013, sustained a left [MEDICAL CONDITION], transferred to the hospital and underwent surgical repair of the left hip. They said that prior to the fall the resident ambulated without assistance, required some staff assistance with ADLs and was continent of bowel and bladder. They said after the fall, the resident used a wheelchair for mobility, but his ADL, bowel, and bladder needs had not changed. They verified the resident returned to the facility with staples to his left hip and no medications ordered for pain management. They said that S19MD did not have standing orders for any medications therefore when a nurse needed an order, she called S19MD to obtain an order. They stated Resident #3 had not experienced any pain when he returned from the hospital following the fall. They said the resident would have told the nurse if he was experiencing pain. They stated the nurses assessed a resident for pain each time he/she went into the resident's room. They stated results of the assessments should be within the nursing notes. They said when the resident returned from the hospital, he was receiving "skilled services" and therefore the nurses would have documented their assessments on the "skilled nursing notes". At this time, requested all skilled documentation related to Resident #3 since June 2013. An observation was made of Resident #3 on 10/30/13 at 12:25 p.m. He was asleep in bed. He was lying on his left side with his legs curled next to him. A telephone interview was held with Resident #3's responsible party on 10/30/13 at 12:30 p.m. She stated Resident #3 returned to the facility after being hospitalized for [REDACTED]. She said the resident did experience and complain of pain to the left hip when he returned to the facility. She further stated the resident had medication ordered for pain and to her knowledge was administered the medication when he complained of pain. She stated before the fall, Resident #3 walked and was much more interactive with others. She said since the fall, he used the wheelchair for mobility and preferred to stay in bed. On 10/30/13 at 1:25 p.m., continued the interview with S2DON and S3ADON. S2 and S3 stated they were unable to locate skilled nursing documentation on Resident #3. Both, S2 and S3, confirmed the resident was not receiving skilled nursing following the left [MEDICAL CONDITION] hospitalization in June 2013. They said the resident was receiving therapy services following the hospitalization . Each said he did well with therapy. They stated the facility did not have a restorative program. Both said they would have to review the resident's ADL sheets to see if he was receiving restorative nursing. They stated restorative nursing was provided by the CNAs. Review of the documentation presented by S2DON and S3ADON on 10/30/13 at 2:30 p.m. included a Restorative Roster. Review of the Restorative Roster revealed 15 minutes of walking was provided to Resident #3, however, this was not done on a routine basis. In comparing the resident's therapy discharge date of [DATE] to the Restorative Roster, the resident was not provided restorative nursing care on the following dates: 8/29/13, 8/30/13, 8/31/13, 9/1/13, 9/2/13, 9/8/13, 9/14/13, 9/15/13, 9/22/13, 9/29/13, 10/5/13, 10/13/13, 10/16/13, 10/17/13, 10/20/13, 10/21/13, 10/26/13, 10/27/13, 10/29/13, and 10/30/13. A telephone interview was held with S19MD on 10/30/13 at 2:10 p.m. He recalled Resident #3 and the resident being hospitalized in June 2013 for a [MEDICAL CONDITION]. He stated he did not receive any calls from the nursing staff in regards to Resident #3 having pain upon his return to the facility in June 2013. He said had he been notified the resident was experiencing pain, he was have given an order for [REDACTED]. On 10/30/13 at 2:15 p.m., an interview was held with S25SW. She said prior to Resident #3 having the left [MEDICAL CONDITION], he walked independently around the secure unit. She stated since the [MEDICAL CONDITION], he used a wheelchair. An interview was held with S28AD on 10/30/13 at 2:20 p.m. She stated prior to the resident's left [MEDICAL CONDITION], he walked without assistance and was out of his room more. She stated since the fracture, the resident used a wheelchair for mobility and preferred to stay in his room. An observation was made of Resident #3 on 10/31/13 at 8:25 a.m. He was asleep and lying on his right side with his legs curled next to him on a sofa in the secure unit's day room. An observation was made of Resident #3 on 10/31/13 at 10:00 a.m. He was watching television while sitting on the sofa in the secure unit's day room. At this time an interview was held with Resident #3. He was alert and oriented to self and place. He recalled being seen by S19MD on the afternoon of 10/30/13. He said he told S19MD that his knees were hurting. When asked what the physician had done to help with his knee pain, Resident #13 responded, "nothing". The resident further stated he hadn't been given anything by the nurse to help ease the knee pain. An interview was held with S13CNA on 10/31/13 at 10:05 a.m. She stated she had tried to walk Resident #3 that morning, but he could not hardly walk. She said he complained about his knees hurting him when he stood up. At this time an observation was made of S13CNA assisting Resident #3 to a standing position. The CNA held the resident in the standing position due to the resident's inability to do so on his own. The resident required total assistance from the CNA. He maintained a slight bend at the waist and his knees stayed flexed (bent). He was unable to stretch out his legs or his upper body completely. He complained of pain to his knees the entire time. S13CNA was asked if the resident was always like that, she responded yes. She was then asked how he was able to walk for 15 minutes when he could not stand, she stated she just held him in a standing position. Review of the hand-written order by S19MD and dated 10/30/13 revealed: Tylenol 650mg (milligrams) PO (by mouth) Q (every) 4 hr (hours) PRN (as needed) pain Review of the Physician's Progress Notes dated 10/30/13 included: C/O (complained of) mild bilateral knee pain. Plan: Tylenol Review of the October 2013 electronic MARs did not include the order for Tylenol. Review of the Nursing Departmental Notes for October 2013 revealed no documentation of the resident's complaints of knee pain. An interview was held with S22LPN on 10/31/13 at 10:15 a.m. S22LPN stated that on 10/30/13, she made rounds with S19MD. She said she was present when S19MD seen Resident #3. S22LPN said she did hear the resident inform the physician of his knee pain. She stated S19MD did not tell her he had written an order for [REDACTED]. On 10/31/13 at 11:15 a.m., an interview was held with S2DON and S3ADON. Both stated they had provided all available documentation and/or evidence related to Resident #3. They verified the physician had written an order for [REDACTED]. An interview was held with S1Administrator, S2DON, S3ADON, and S4MDS on 10/31/13 at 1:45 p.m. S1Administrator stated S2DON and S3ADON had communicated all nursing concerns with her throughout the survey. S1Administrator stated prior to Resident #3 falling and sustaining the left [MEDICAL CONDITION], he was using a wheelchair for mobility and had incontinent episodes of urine at times. She said his level of functioning had not changed or declined since the fall. She said when the resident returned from the hospital, he did not experience any pain. She stated Resident #3 had a history of [REDACTED]. She stated prior to the fall he was saying he could not walk and used a wheelchair. She said she seen him walking around the secure unit each day and she felt he was choosing not to walk at this time. S1Administrator said the resident had also had