Every finding on record at Willow Wood at Woldenberg Village

Based on observations, interviews, and record reviews, the facility failed to store raw chicken in a sanitary manner for 1 (Cooler a) of 2 walk-in coolers observed in the kitchen. Findings: Review of the facility's Food Receiving and Storage policy and procedure, revised on 10/2017, revealed, in part, food services would maintain clean food storage areas at all times. Further review revealed uncooked and raw animal products would be stored separately in drip proof containers to prevent contamination. Review of the facility's June 2026 Dietary Cleaning Schedule revealed, in part, walk-in coolers should be cleaned daily. Observation of Cooler a on 06/29/2026 at 9:00AM revealed plastic bags of raw chicken lying in a shallow tray on the bottom shelf on the right side of Cooler a. Further observation revealed the plastic bags were hanging over the edge of the tray and a bloody liquid substance was dripping on to the floor of the cooler and down the wheels of the shelf. Further observation revealed the bloody liquid substance was pooled along the floor on the right side of the cooler. Observation of Cooler a on 06/29/2026 at 4:20PM revealed plastic bags of raw chicken lying in a shallow tray on the bottom shelf on the right side of Cooler a. Further observation revealed the plastic bags were hanging over the edge of the tray and a bloody liquid substance was dripping on to the floor of the cooler and down the wheels of the shelf. Further observation revealed the bloody liquid substance was pooled along the floor on the right side of the cooler. Observation of Cooler a on 06/30/2026 at 10:57AM with S13Executive Chef revealed plastic bags of raw chicken lying in a shallow tray on the bottom shelf on the right side of Cooler a. Further observation revealed the plastic bags were hanging over the edge of the tray and a bloody liquid substance was dripping on to the floor of the cooler and down the wheels of the shelf. Further observation revealed the bloody liquid substance was pooled along the floor on the right side of the cooler. In an interview on 06/30/2026 at 10:58AM, S13Executive Chef, confirmed the above mentioned bloody liquid substance was raw chicken juice and should have been contained in a leak proof container and should not have been allowed to drip on the floor of Cooler a for multiple shifts. S13Executive Chef further indicated the floors in the cooler were not kept in a sanitary manner and should have been. In an interview on 07/01/2026 at 11:42AM, S1Administrator indicated raw chicken juice should not have been allowed to drip onto the floor of the cooler. S1Administrator further indicated the cooler should have been maintained in a sanitary manner.

Based on interviews and record reviews, the facility failed to ensure a resident's medication was administered as ordered by a physician for 1 (Resident #8) of 25 sampled residents investigated for compliance with physician orders. Findings:Review of the Louisiana State Legislature- Title 37: Professions and Occupations, Revised Statute (R.S.) 37:961, last amended in 2020, revealed, in part, the practice of practical nursing means the performance for compensation of any acts, in the care, treatment, or observation of persons who are ill, injured, or infirm and for the maintenance of the health of others and the promotion of health care, including the administration of medications. Review of the facility's Licensed Staff (Registered Nurse/Licensed Practical or Vocational Nurse) job description, dated 07/01/2015 and revised on 12/03/2019, revealed, in part, an essential job duty of licensed staff included preparing and administering medications as ordered. Review of the facility's Administering Medications policy and procedure, revised on 04/2019, revealed, in part, medications were administered in accordance with prescriber orders within one hour of the prescribed time. Review of Resident #8's electronic medical record (EMR) revealed, in part, Resident #8 was admitted to the facility on [DATE] with diagnoses, which included, atrial fibrillation (an irregular heartbeat), hypertension (high blood pressure), hyperlipidemia (an excessive amount of fats in the blood), gastro-esophageal reflux disease without esophagitis ([GERD] excessive stomach acid in the throat), hypokalemia (low potassium level in the blood), right femur neck fracture (a serious break in the upper part of the thigh bone), and nonrheumatic aortic stenosis (narrowing of a heart valve). Review of Resident #8's June 2026 physician's orders revealed, in part, Resident #8 should have been administered the following medications:- one tablet of amiodarone hydrochloride (HCl) (a medication used to treat atrial fibrillation) 200 milligrams (mg) by mouth;-one tablet of amlodipine besylate (a medication used to lower high blood pressure) 10 mg by mouth; -one tablet of atorvastatin calcium (a medication used to treat hyperlipidemia) 80 mg by mouth; -one tablet of famotidine (a medication used to treat GERD) 40 mg by mouth; -one tablet of losartan potassium (a medication used to lower high blood pressure) 50 mg by mouth; -two tablets of potassium chloride (Cl) extended release (ER) (a medication used to treat hypokalemia) 10 milliequivalents (mEq) by mouth;-one tablet of apixaban (a medication used to prevent blood clots) 5 mg by mouth; and,-one tablet of ranolazine ER (a medication used to treat ongoing chest pain) 500 mg by mouth. Review of Resident #8's June 2026 Electronic Medication Administration Record (eMAR) revealed, in part, the following medications were scheduled to be administered at 8:00AM and/or 9:00AM to Resident #8 on 06/30/2026:-one tablet of amiodarone HCl 200 mg at 9:00AM; -one tablet of amlodipine besylate 10 mg at 8:00AM; -one tablet of atorvastatin calcium 80 mg at 8:00AM;-one tablet of famotidine 40 mg at 9:00AM; -one tablet of losartan potassium 50 mg at 8:00AM;-two tablets of potassium Cl 10 mEq at 8:00AM; -one tablet of apixaban 5 mg at 9:00AM; and,-one tablet of ranolazine ER 500 mg at 9:00AM.Further review of Resident #8's above-mentioned eMAR revealed no documentation the above-mentioned medications scheduled for administration at 8:00AM and/or 9:00AM on 06/30/2026 were administered. Review of Resident #8's EMR revealed, in part, no documentation of the reason Resident #8's above-mentioned medications were not administered on 06/30/2026. In an interview on 06/30/2026 at 12:29PM, Resident #8's responsible party (RP), indicated Resident #8 had not received her morning medications on 06/30/2026. Resident #8's RP further indicated Resident #8 was not administered her medications prior to leaving for her scheduled medical appointment at 9:30AM. In an interview on 06/30/2026 at 12:35PM, S11LPN indicated Resident #8 had a scheduled medical appointment on 06/30/2026 at 9:30AM. S11LPN further indicated she (S11LPN) had not administered Resident #8's medications which were scheduled to be administered at 8:00AM and 9:00AM, prior to Resident #8 leaving for her scheduled medical appointment on 06/30/2026 and should have. In an interview on 07/01/2026 at 8:05AM, S10Certified Nursing Assistant Transportation indicated Resident #8 left the faciity on [DATE] at approximately 9:00AM for Resident #8's scheduled medical appointment. In an interview on 07/01/2026 at 9:01AM, S12LPN indicated Resident #8 should have been administered Resident #8's above-mentioned medications on 06/30/2026, prior to Resident #8 leaving for her scheduled medical appointment. In an interview on 07/01/2026 at 11:41AM, S2Director of Nursing (DON) indicated resident medications should be administered one hour before to one hour after the scheduled administration time. S2DON further indicated she had nothing to present to dispute the above-mentioned deficient practice. In an interview on 07/01/2026 at 11:42AM, S1Administrator was informed of the above-mentioned findings and had nothing to present to dispute the above-mentioned deficient practice.

Based on interviews and record reviews, the facility failed to provide surveyor staff during the survey with the requested complete Quality Assurance and Performance Improvement (QAPI) documentation, including the facility's identified quality concerns necessary to evaluate the effectiveness of the facility's QAPI program as evidenced by the removal of identified quality concerns from the document produced to surveyors. Findings: Review of the facility's undated QAPI Program policy and procedure, revealed, in part, the facility shall develop, implement, and maintain an effective, comprehensive, data-driven QAPI program which identified systems and processes that may have led to avoidable negative outcomes. Further review revealed the QAPI plan and documents generated shall be presented to the state survey agency when needed to determine regulatory compliance. On 07/01/2026 at 9:15AM, S1Administrator and S2Director of Nursing (DON) were presented with a request for the facility's complete QAPI Plan. The facility provide a version of the QAPI plan that did not include identified quality concerns. Subsequent review determined the omitted quality concerns had been removed from the documents provided to the surveyors. Observation on 07/01/2026 at 10:50AM revealed S2DON was using a sharpie marker to redact the specific problems identified by the facility in their QAPI plan. In an interview on 07/01/2026 at 10:52AM, S2DON indicted the information she was redacting from the facility's QAPI plan was the specific practices the facility identified as problematic before providing the plan to the survey team. Review of the facility's QAPI plan entitled, Mock Survey, dated 05/12/2026 through 05/13/2026, revealed, in part, no documentation as to the specific practices identified by the facility which could lead to avoidable negative outcomes. Further review revealed blank spaces in areas where specific identified concerns were documented and subsequently redacted by S2DON. On 07/01/2026 at 3:00PM, S1Administrator and S2DON were presented with a request for documentation of the specific problems the facility's QAPI committee had identified during their QAPI process that showed facility QAPI compliance. In an interview on 07/01/2026 at 3:04PM, S2DON indicated that the specific problems identified by the facility during their QAPI process would not be provided to the state survey team. S2DON further indicated the problems identified by the QAPI committee could be figured out by looking at the training conducted and audit reports. S2DON further indicated she would summarize the identified problems on the QAPI plan. In an interview on 07/01/2026 at 3:15PM, S2DON indicated she handwrote a summary of the problems identified on the original QAPI plan. S2DON further indicated the handwritten summary was not part of the original QAPI plan. Review of the facility's QAPI plan entitled, Mock Survey, presented by S2DON on 07/01/2026 at 3:20PM, revealed, in part, hand written identified problems in the previously reviewed blank space which were inconsistent with the plan of corrections on the same QAPI plan. In an interview on 07/01/2026 at 4:00PM, S1Administrator was informed their QAPI plan/Mock Survey presented to the survey team was incomplete because it did not include the specific problems the facility had identified during its QAPI process, preventing the survey team from determining whether the facility's corrective actions addressed those identified problems. On 07/01/2026 at 4:17PM, S4Quality Improvement Nurse ([NAME]) was presented with a request for the facility's complete QAPI plan which included the specific problems the facility had identified during their QAPI process. In an interview on 07/01/2026 at 4:18PM, S4QIN confirmed the Mock Survey that was presented to the survey team on 07/01/2026 was what the facility had used to identify and correct problems. S4QIN further indicated the facility would not present the state survey agency with the specific problems identified. S4QIN further indicated the state survey agency could figure out what the identified problems were based on the in-service training conducted and the audits performed.

Based on observations and interviews, the facility failed to ensure a resident shower room and resident shower equipment were maintained in a sanitary manner for 3 (Shower Room X, Shower Room Y, Shower Room Z) of 6 shower rooms observed for environment requirements. Findings:Observation on 06/29/2026 at 8:45AM of Shower Room c revealed a shower chair had an unknown tan substance on the shower chair's seat support bar. Observation on 06/29/2026 at 8:56AM of Shower Room b revealed the shower-tub had an unknown pink substance in the inner bowl of the shower-tub. Observation on 06/29/2026 at 9:53AM of Shower Room d revealed a shower chair had an unknown pink substance on the shower chair's seat support bar and to the legs of the shower chair. Observation on 06/30/2026 at 9:59AM of Shower Room c revealed a shower chair had an unknown tan substance on the shower chair's seat support bar. Further observation revealed an unknown brown substance was dried on the surface of the shower wall behind the shower chair. Observation on 06/30/2026 at 10:28AM of Shower Room b revealed the shower-tub had an unknown pink substance in the inner bowl of the shower-tub. Observation on 06/30/2026 at 10:36AM of Shower Room d revealed a shower chair had an unknown pink substance on the shower chair's seat support bar and to the legs of the shower chair. In an interview on 06/30/2026 at 9:53AM, S8Certified Nursing Assistant (CNA) indicated the CNAs were supposed to clean the shower chairs after each use. In an interview on 06/30/2026 at 10:53AM, S9CNA indicated it was her responsibility to clean the shower rooms and shower chairs between giving residents baths. In an interview on 06/30/2026 at 12:29PM, S3Assistant Director of Nursing (ADON) indicated it was the facility's policy to clean the shower rooms and the shower room equipment before and after each resident's use. S3ADON further indicated the above mentioned unknown substances in Shower Room X, Shower Room Y, and Shower Room Z should not have been present on the residents' shower equipment, the residents' shower wall, or the residents' shower-tub. In an interview on 06/30/2026 at 12:30PM, S1Administrator indicated the above mentioned unknown substances in Shower Room X, Shower Room Y, and Shower Room Z should not have been present on the residents' shower equipment, the residents' shower wall, and/or the residents' shower-tub.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with diabetes (a chronic condition where your blood sugar is too high) and peripheral vascular disease (a slow circulation disorder where the blood vessels outside your heart and brain become narrow or blocked) received needed foot care for 1 (Resident #9) of 2 sampled residents investigated for foot care. Findings:Review of Resident #9's medical record revealed, in part, a diagnosis of diabetes mellitus and peripheral vascular disease. Review of Resident #9's Significant Change Minimum Data Set with an Assessment Reference Date of 06/03/2026 revealed Resident #9 had a Brief Interview Mental Status Score of 6, which indicated severe cognitive impairment. Further review revealed Resident #9 was dependent on staff for personal hygiene. Review of Resident #9's care plan, dated 11/02/2025, with a goal date of 09/20/2026, revealed in part, Resident #9 required extensive assistance from staff for personal hygiene. Review of Resident #9's progress note dated 06/30/2026 at 9:02PM revealed, in part, S6Licensed Practical Nurse documented Resident #9's toenails were overgrown, approximately a 1/2 inch long, and extended over the nail beds. Review of the facility's podiatry lists revealed Resident #9 was not evaluated by the podiatrist when the podiatrist came to the facility on [DATE], 03/26/2026, 04/16/2026, and 06/25/2026. Observation on 06/30/2026 at 3:41PM revealed Resident #9's bilateral 2nd and 3rd toenails were approximately a 1/2 inch long and curled over the nail bed. Further observation revealed Resident #9's left first/great toenail was approximately 1/2 inch thick and black and brown in color. Further observation revealed Resident #9's right first toe/great toenail was approximately a 1/4 inch thick and yellow/brown in color. Further observation revealed Resident #9's bilateral 4th and 5th toenails extended about a 1/4 inch past the nail bed. Observation on 06/30/2026 at 3:49PM with S6Licensed Practical Nurse revealed Resident #9's bilateral 2nd and 3rd toenails were approximately a 1/2 inch long and curled over the nail bed. Further observation revealed Resident #9's left first/great toenail was approximately 1/2 inch thick and black and brown in color. Further observation revealed Resident #9's right first/great toenail was approximately a 1/4 inch thick and yellow/brown in color. Further observation revealed Resident #9's bilateral 4th and 5th toenails extended about a 1/4 inch past the nail bed. In an interview on 06/30/2026 at 3:52PM, S6Licensed Practical Nurse indicated Resident #9's toenails were thick and curled over the nail bed. S6Licesned Practical Nurse further indicated Resident #9 needed to be evaluated by a podiatrist. Observation on 06/30/2026 4:16PM with S5Clinical Coordinator/Minimum Data Set Licensed Practical Nurse and S2Director of Nursing revealed Resident #9's bilateral 2nd and 3rd toenails were approximately a 1/2 inch long and curled over the nail bed. Further observation revealed Resident #9's left first/great toenail was approximately 1/2 inch thick and black and brown in color. Further observation revealed Resident #9's right first/great toenail was approximately a 1/4 inch thick and yellow/brown in color. Further observation revealed Resident #9's bilateral 4th and 5th toenails extended about a 1/4 inch past the nail bed. Observation 07/01/2026 at 11:43AM with Resident #9's Hospice Nurse revealed Resident #9's bilateral 2nd and 3rd toenails were approximately a 1/2 inch long and curled over the nail bed. Further observation revealed Resident #9's left first toe/great toenail was approximately 1/2 inch thick and black and brown in color. Further observation revealed Resident #9's right first/great toenail was approximately a 1/4 inch thick and yellow/brown in color. Further observation revealed Resident #9's bilateral 4th and 5th toenails extended about a 1/4 inch past the nail bed. In an interview on 07/01/2026 at 11:44AM, Resident #9's hospice nurse indicated Resident #9 needed to be evaluated by a podiatrist and have her toenails cut. In an interview on 07/01/2026 at 3:30PM, S7Licensed Practical Nurse indicated Resident #9 needed to be evaluated by a podiatrist. In an interview on 07/01/2026 at 1:20PM, S2Director of Nursing indicated she did not have any additional evidence to dispute the above-mentioned deficient practice for Resident #9.

Based on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Nebulizer Machine (a machine that turns liquid medicine into a mist, allowing it to be inhaled directly into the lungs) Cleaning policy and procedure, dated 11/04/2014 revealed, in part, nebulizer machines and equipment should be kept clean and the nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. Further review revealed the tubing, mouthpiece and mask should be changed weekly and as needed. Resident #51 Review of Resident #51's June 2025 Physician orders revealed, in part, Ipratropium-Albuterol nebulizer solution (a medication primarily used to treat respiratory conditions) 0.5milligram (mg) per 2.5millitleter (ml) inhale orally via nebulizer every 8 hours as needed for wheezing. Review of Resident #51's Care Plan revealed, in part, Resident #51 had shortness of breath with a documented intervention to change all respiratory tubing and equipment per facility policy. Observation on 06/30/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag was dated of 05/25/2025. Observation on 07/01/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag had a date of 05/25/2025. Review of Resident #51's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 06/01/2025, 06/03/2025, 06/07/2025 and 06/12/2025 per nebulizer. In an interview on 07/01/2025, S6Licensed Practical Nurse (LPN) confirmed Resident #51's nebulizer was stored in a plastic bag and the plastic bag had a date of 05/25/2025. In an interview on 07/02/2025 at 9:47AM, S4LPN Supervisor indicated Resident #51's nebulizer tubing and mouthpieces should be changed weekly and should be stored in a plastic bag. S4LPN further indicated staff should document the date it was changed on the eMAR. Review of Resident #51's June 2025 and July 2025 eMAR revealed no documented evidence, and the provider did not present any documented evidence, Resident #51's nebulizer tubing and mouthpiece had been changed since 05/25/2025. In an interview on 07/02/2025 at 10:10AM, S3Registered Nurse/Infection Preventionist (RN/IP) indicated nebulizer tubing and mouthpieces should be changed per the facility policy. S3RN/IP further indicated there was no documented evidence Resident #51's nebulizer tubing and mouthpiece had been changed since the date of 05/25/2025. Resident #79 Review of Resident #79's Physician's orders dated 06/26/2025 revealed, in part, Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ml 1 vial inhale orally every 6 hours as needed for wheezing. Observation on 06/30/25 at 11:19AM revealed, Resident #79 had an uncontained nebulizer mask lying on Resident #79's lap. Observation on 07/01/2025 at 10:49AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Observation on 07/02/2025 at 8:48AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Review of Resident #79's July 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #79 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 07/01/2025 and 07/02/2025 per the nebulizer. In an interview on 07/02/2025 at 9:10AM S10Licensed Practical Nurse confirmed Resident #79's nebulizer mask should been stored in a plastic bag when not in use. In an interview on 07/02/2025 at 9:15AM S2Registered Nurse/Assistant Director of Nursing confirmed nebulizer masks should been stored in a plastic bag when not in use. Based on observations, interviews, and record reviews, the facility failed to: 1. Change nebulizer supplies per facility policy (Resident #51); and, 2. Store nebulizer mouthpiece per facility policy (Resident #79). This deficient practice was identified for 2 (Resident #51, Resident #79) of 3 (Resident #23, Resident #51, Resident #79) sampled residents reviewed for respiratory care requirements. Findings: Review of the facility's Nebulizer Machine (a machine that turns liquid medicine into a mist, allowing it to be inhaled directly into the lungs) Cleaning policy and procedure, dated 11/04/2014 revealed, in part, nebulizer machines and equipment should be kept clean and the nebulizer tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. Further review revealed the tubing, mouthpiece and mask should be changed weekly and as needed. Resident #51 Review of Resident #51's June 2025 Physician orders revealed, in part, Ipratropium-Albuterol nebulizer solution (a medication primarily used to treat respiratory conditions) 0.5milligram (mg) per 2.5millitleter (ml) inhale orally via nebulizer every 8 hours as needed for wheezing. Review of Resident #51's Care Plan revealed, in part, Resident #51 had shortness of breath with a documented intervention to change all respiratory tubing and equipment per facility policy. Observation on 06/30/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag was dated of 05/25/2025. Observation on 07/01/2025 at 10:47AM revealed Resident #51's nebulizer mask was stored in a plastic bag on the bedside table and the plastic bag had a date of 05/25/2025. Review of Resident #51's June 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 06/01/2025, 06/03/2025, 06/07/2025 and 06/12/2025 per nebulizer. In an interview on 07/01/2025, S6Licensed Practical Nurse (LPN) confirmed Resident #51's nebulizer was stored in a plastic bag and the plastic bag had a date of 05/25/2025. In an interview on 07/02/2025 at 9:47AM, S4LPN Supervisor indicated Resident #51's nebulizer tubing and mouthpieces should be changed weekly and should be stored in a plastic bag. S4LPN further indicated staff should document the date it was changed on the eMAR. Review of Resident #51's June 2025 and July 2025 eMAR revealed no documented evidence, and the provider did not present any documented evidence, Resident #51's nebulizer tubing and mouthpiece had been changed since 05/25/2025. In an interview on 07/02/2025 at 10:10AM, S3Registered Nurse/Infection Preventionist (RN/IP) indicated nebulizer tubing and mouthpieces should be changed per the facility policy. S3RN/IP further indicated there was no documented evidence Resident #51's nebulizer tubing and mouthpiece had been changed since the date of 05/25/2025. Resident #79 Review of Resident #79's Physician's orders dated 06/26/2025 revealed, in part, Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ml 1 vial inhale orally every 6 hours as needed for wheezing. Observation on 06/30/25 at 11:19AM revealed, Resident #79 had an uncontained nebulizer mask lying on Resident #79's lap. Observation on 07/01/2025 at 10:49AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Observation on 07/02/2025 at 8:48AM revealed, in part, Resident #79's nebulizer mask was stored uncontained on the bedside table. Review of Resident #79's July 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #79 received Ipratropium-Albuterol nebulizer solution 0.5mg per 2.5ml on 07/01/2025 and 07/02/2025 per the nebulizer. In an interview on 07/02/2025 at 9:10AM S10Licensed Practical Nurse confirmed Resident #79's nebulizer mask should been stored in a plastic bag when not in use. In an interview on 07/02/2025 at 9:15AM S2Registered Nurse/Assistant Director of Nursing confirmed nebulizer masks should been stored in a plastic bag when not in use.

Based on observations, interviews, and record reviews, the facility failed to: 1. ensure the facility completed evaluations after a resident sustained a fall per policy (Resident #17 and Resident #75); 2. ensure a resident's care plan was revised with new individualized interventions after a resident sustained a fall (Resident #17 and Resident #75); 3. ensure oxygen tanks were secured and not free standing (Resident #102). This deficient practice was identified for 3 (Resident #17, Resident #75, Resident #102) of 5 (Resident #6, Resident #17, Resident #31, Resident #75, Resident #102) sampled residents reviewed for accident hazards. Findings: Resident #17 Review of facility's policy titled Falls - Clinical Protocol revised October 2010 revealed, in part, Residents should be evaluated for a risk of falling, the staff and physicians would identify pertinent interventions, if the cause was not identified staff would try relevant interventions, based on assessments and the nature or category of falling. For any resident who had fallen, staff would attempt to define possible causes within 24 hours of the fall, based on preceding assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff would monitor and document the individual's response to the fall interventions intended to reduce falling. Review of Resident #17's record revealed, in part, a Fall Risk assessment dated [DATE] with a score of 17, which indicated at risk for falls. Review of Resident #17's care plan revealed, in part, Resident #17's was high risk for falls related to confusion, incontinence, medication effects, cognition, and impulsive behaviors. Review of Resident #17's record revealed, in part, Resident #17 sustained a fall on 02/09/2025, 02/20/2025 and 05/27/2025. Review of Resident #17's record revealed, in part, there was no documented evidence and the facility did not present any documented evidence an evaluation was completed on the above mentioned falls per facility policy. Review of Resident #17's care plan revealed, in part, there was no documented evidence and the facility did not present any documented evidence that Resident #17's care plan was revised to include new individualized interventions after the above mentioned falls. In an interview on 07/02/2025 at 2:15PM, S2Registered Nurse/Assistant Director of Nursing confirmed there were no documented evidence and the facility could not provide documented evidence of fall evaluations being completed, and Resident #17's care plan revised with new interventions after Resident #17 sustained falls on 02/09/2025, 02/20/2025, and 05/27/2025, and this should have been done. Resident #75 Review of Resident #75's Fall Risk Evaluation dated 04/29/2025 revealed, in part, Resident #75 was high risk for falls. Review of Resident #75's progress notes revealed, in part, Resident #75 had falls on 01/20/2025, 03/30/2025, 04/20/2025, and 05/05/2025. Review of Resident #75's fall care plan revealed, in part, there was no documented evidence and the facility did not present any documented evidence that Resident #75's care plan was revised to include new individualized interventions after Resident #75 fell on [DATE], 03/30/2025, and 05/05/2025. Review of Resident #75's record revealed, in part, there was no documented evidence and the facility did not present any documented evidence an evaluation was completed on Resident #75's falls on 03/30/2025, and, or 04/20/2025. In an interview on 07/01/2025 at 2:20PM S2Registered Nurse/Assistant Director of Nursing (RN/ADON) indicated all interventions for Resident #75 would have been in Resident #75's care plan. In an interview on 07/02/2025 at 12:32PM, S2RN/ADON confirmed the facility has no documented evidence that Resident #75's fall on 03/30/2025 and 04/20/2025 were investigated and evaluated for the root cause after the above mentioned falls. S2RN/ADON further confirmed that Resident #75's falls which occurred on 01/20/2025, 03/30/2025, and 05/05/2025 did not have a new interventions in the care plan to prevent further falls. Resident #102 Review of the facility's Oxygen Administration policy and procedure, revised October 2010, revealed, in part, portable oxygen cylinders are to be strapped to the oxygen cylinder stands. Observation on 07/01/2025 at 10:58AM revealed, in part, a free standing oxygen tank located in the corner of Resident #102's room, sitting on the floor, and not strapped to an oxygen cylinder stand. Observation on 07/02/2025 at 9:10AM revealed, in part, a free standing oxygen tank located in the corner of Resident #102's room, sitting on the floor, and not strapped in an oxygen cylinder stand. In an interview on 07/02/2025 at 9:13AM, S11Licensed Practical Nurse indicated oxygen tanks should be strapped in an oxygen cylinder stand or in the cage located in the medication storage room off of the floor when not in use. In an interview on 07/02/2025 at 9:15AM, S2Registered Nurse/Assistant Director of Nursing confirmed that oxygen tanks should be strapped in a oxygen cylinder stand or in the cage located in the medication storage room when not in use.

Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #6) of 1 (Resident #6) sampled resident investigated for the self-administration of medications. Findings: Review of the facility's Right to Self-Administration Medications policy, dated 12/05/2014 revealed, in part, residents would be assessed on admission, quarterly, annual, and any significant change in condition and as needed for self-administration of medication, if applicable. Review of Resident #6's Quarterly Minimum Data Set with an Assessment Reference Date of 05/06/2025 revealed, in part, Resident #6 had a Brief Interview for Mental Status score of 11, which indicated Resident #6 had moderate cognitive impairment. Review of Resident #6's record revealed, in part, no documented evidence and the facility was unable to present any documented evidence Resident #6 was assessed for the self-administration of medications. Observation on 06/30/2025 at 10:25AM revealed on Resident #6's bathroom counter a gray tray with 1 opened 45 gram tube of Cloderm 0.1% cream, (a cream used to treat topical skin irritation). In an interview on 06/30/2025 at 10:30AM, Resident #6 confirmed she had applied the Cloderm 0.1% cream to her hands several times. Observation on 07/01/2025 at 9:48AM revealed on Resident #6's bathroom counter a gray tray with 1 opened 45 gram tube of Cloderm 0.1% cream. Further observation revealed on Resident #6's bedside table 2 medication cups. One cup had 1 yellow and 1 light green approximately 1 half inch tablet, and the second cup had 5 tablets yellow, green and orange in color. Further observation revealed 1 bottle of pain relief roll on, 2.5 ounces, with the active ingredient lidocaine hydrochloride 4% (topical medication used for pain relief). In an interview on 07/01/2025 at 11:00AM, S7Licensed Practical Nurse confirmed Resident #6 was not assessed to self-administer medications. She further confirmed Resident #6 should not have medications left at her bedside or in her bathroom. In an interview on 07/01/2025 at 11:50AM, S2Registered Nurse/Assistant Director of Nursing confirmed Resident #6 was not assessed to self-administer medications and should not have medications left at the bedside and or the bathroom. In an interview on 07/01/2025 at 12:00PM, S1Administer confirmed Resident #6 should not have medications left at the bedside and/or bathroom.

Based on observation, interviews, and record review, the facility failed to serve food in a sanitary manner for 1 (Resident #51) of 10 (Resident #10, Resident #26, Resident #41, Resident #50, Resident #51, Resident #54, Resident #74, Resident #83, Resident #88, Resident #92) sampled residents investigated for dining observation. Findings: Review of the 2022 Food Code U.S. Food and Drug Administration revealed, in part, employees were to prevent cross-contamination of ready-to-eat food with bare hands, and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Observation on 07/01/2025 at 12:01PM revealed S5Certified Nursing Assistant (CNA) served Resident #51 her lunch tray. S5CNA brought Resident #51's lunch tray to her room. S5CNA, with bare hands, removed Resident #51's insulated cover off of her plate and revealed a lunch which consisted of chicken tenders, french fries, and a can of soda. S5CNA placed Resident #51's lunch tray on Resident #51's bedside table. S5CNA then repositioned Resident #51's feet with bare hands. S5CNA, with bare hands, picked up a chicken tender off of Resident #51's plate and placed it in Resident #51's hand. S5CNA then opened Resident #51's soft drink and 2 packets of ketchup. Observation then revealed Resident #51 dropped the chicken tender on her bedside table and S5CNA, with bare hands, picked up the chicken tender and placed it on Resident #51's plate. S5CNA did not perform hand hygiene during the above documented observation. At no time during the above documented observation did S5CNA perform hand hygiene. In an interview on 07/01/2025 at 12:07PM, S5CNA confirmed she touched Resident #51's food with bare hands and she should not have. In an interview on 07/02/2025 at 9:47AM, S4Licensed Practical Nurse (LPN) Supervisor indicated staff should not touch a resident's food with bare hands during meal service. In an interview on 07/02/2025 at 10:06AM, S3Registered Nurse / Infection Preventionist (RN/IP) indicated it was not appropriate for a staff member to touch a resident's food with bare hands. In an interview on 07/02/2025 at 11:06AM,S2RN /Assistant Director of Nursing indicated S5CNA should not have touched Resident #51's food with bare hands.

Based on observation, interviews and record reviews, the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into the stomach) as ordered for 1 (Resident #46) of 1 (Resident #46) sampled resident investigated for enteral nutrition requirements. Findings: Review of the facility's Enteral Nutrition policy with a revision date of 11/2018, revealed, in part, the nurse confirms the administration method and the volume/rate of administrations. Review of Resident #46's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/08/2025 revealed, in part, Resident #46 was indicated for a feeding tube. Review of Resident #46's July 2025 order summary report revealed, in part, an order with a date of 04/17/2025 for Glucerna 1.2 Cal (a tube feeding formula used to provide nutrition) 50 milliliters per hour (mL/hour ) via percutaneous feeding tube (PEG tube) over 22 hours. Observation on 07/01/2025 at 3:00PM revealed Resident #46's continuous tube feeding pump was set at 60 ml/hr. In an interview on 07/01/2025 at 3:33PM, S7License Practical Nurse (LPN) confirmed Resident #46's feeding infusion pump was infusing at 60ml/hr., and should be infusing at 50ml/hr. In an interview on 07/02/2025 at 11:10AM, S2Registered Nurse/Assistant Director of Nursing confirmed Resident #46's enteral feeding infusion pump should have been infusing at 50 ml/hr, as ordered.

Based on observations, interviews, and record reviews, the facility failed to ensure a pressure reducing mattress was inflated for a resident who was identified as at risk for skin breakdown for 1 (Resident #75) of 3 (Resident #51, Resident #75, Resident #80) sampled residents investigated Per the Surveyor Workload Report by Investigation they were investigated for Pressure Ulcer/ Injury. Findings: Review of the facility's policy, Prevention of Pressure Ulcers, revised [DATE], revealed, in part, Pressure Ulcers are usually formed when a resident remains in the same position for extended periods, causing increased pressure or decreased circulation (blood flow) to that area. Further review of the policy revealed preventative measures should include: a change in bed position every 2 hours or more, determining if the resident needs a specialized mattress, if a specialized mattress is needed, use one that contains foam, air, gel, or water, as indicated. Review of Resident #75's Electronic Medical Record revealed, in part, Resident #75 had diagnoses which included: Hemiplegia. Review of Resident #75's Minimum Data Set with an Assessment Reference Date of [DATE] revealed, in part, Resident #75 had a Brief Interview for Mental Status score of 10, which indicated Resident #75's cognition was moderately impaired. Review of Resident #75's Comprehensive Care Plan, revised [DATE], revealed, in part, Resident #75 had the potential for development of a pressure ulcer related to (r/t) incontinence, debility, and health comorbidities with an intervention for a pressure reduction mattress. Observation on [DATE] at 10:28AM revealed Resident #75's air-loss mattress had a low air pressure warning light was activated, which indicated the air-loss mattress was not inflated completely, and the bed frame was palpable when the surveyor applied pressure to the mattress. Observation on [DATE] at 4:30PM revealed Resident #75's air-loss mattress had a low air pressure warning light was activated, which indicated the air-loss mattress was not inflated completely, and the bed frame was palpable when the surveyor applied pressure to the mattress. In an interview on [DATE] at 4:30PM, Resident #75 indicated she had reported to staff she heard the air coming out of the mattress, and the staff informed Resident #75 that the air-loss mattress was plugged in. Resident #75 further indicated staff did not attempt to apply pressure to the mattress to check the inflation of the mattress. In an interview on [DATE] at 7:08AM, S8Licensed Practical Nurse (LPN) indicated Resident #75's nurse on the night shift on [DATE] and observed Resident #75's air-loss mattress had a low air pressure warning light activated. S8LPN further indicated she assessed the problem and identified that the CPR function on Resident #75's air-loss mattress was initiated, which deflated the bed. In an interview on [DATE] at 11:08AM, S2Registered Nurse/Assistant Director of Nurses (RN/ADON) confirmed Resident #75 was left lying on a deflated air mattress for over 8 hours on [DATE], and should not have been.

Based on interview and record review the facility failed to ensure a resident with a new diagnosis of schizophrenia was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for PASARR requirements. Findings: Review of Resident #19's clinical record revealed an admit date of 09/03/2010. Further record review revealed on 02/27/2018, Resident #19 was diagnosed with schizophrenia. Review of Resident #19's annual Minimal Data Set with an Assessment Reference Date of 04/08/2025 revealed, in part, Resident #19 was assessed to have a Brief Interview for Mental Status score of 2 which indicated severe cognitive impairment, and had an active diagnoses of Schizophrenia without a diagnosis of Dementia. Review of Resident #19's medical record revealed, in part, a care plan was developed for alteration in behavior related to psychosis. Further review revealed an approach to place on the Memory Care Unit for consistent ongoing supervision. Review of Resident #19's record revealed, in part, no documented evidence, and the facility could not provide documented evidence a Level II PASARR was completed after Resident #19 was diagnosed with schizophrenia on 02/27/2018. In an interview on 07/02/2025 at 10:15AM, S9Social Service Director indicated Resident #19 should did not have a Level II PASARR evaluation completed after a new diagnosis of schizophrenia on 02/27/2018 and should have.

Based on interviews and record reviews, the facility failed to notify a resident's representative and the State's Long-Term Care Ombudsman in writing of a resident transfer for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for transfer and discharge requirements. Findings: Review of Resident #2's electronic medical record (EMR) revealed, in part, Resident #2 was admitted to the facility on [DATE] and was discharged from the facility on 04/08/2025. Review of Resident #2's nurse's note dated 04/08/2025 at 5:06PM revealed, in part, Resident #2 was transferred on 04/08/2025 at 2:30PM to a behavioral health hospital for treatment. Review of Resident #2's clinical record revealed no documented evidence, and the facility did not present any documented evidence, Resident #2's representative and the State's Long-Term Care Ombudsman were notified in writing of Resident # 2's transfer to a behavioral health hospital on [DATE], as required. In an interview on 05/06/2025 at 10:35AM, the facility's assigned Ombudsman indicated she had not received a written transfer notice from the facility when Resident #2 was transferred from the facility to a behavioral health hospital on [DATE]. In an interview on 05/06/2025 at 11:48AM, Resident #2's daughter/Resident Representative indicated she had not received a written transfer notice from the facility when Resident #2 was transferred from the facility to a behavioral health hospital on [DATE]. In an interview on 05/06/2025 at 2:48PM, S1Administrator indicated the facility had not issued a written notice to Resident's #2's representative or the facility's assigned Ombudsman when Resident #2 transferred to a local behavioral health hospital on [DATE], as required.

Based on interview and record review, the facility failed to ensure a resident was not required to supply a personal sitter (a caregiver who provides bedside assistance and supervision for safety) as a condition of continued stay for 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for resident rights. Findings: Review of the facility's Resident Rights policy statement, amended on 09/2016, revealed, in part, non-covered special care services such as privately hired nurses or aides may be charged to residents' funds if the services are requested by a resident. Further review revealed the facility must not require a resident to request services as a condition of admission or continued stay. Review of Resident #2's clinical record revealed, in part, Resident #2 was admitted to the facility's dementia unit on 04/07/2025 and was discharged from the facility on 04/08/2024. Further review revealed Resident #2 had a diagnosis of unspecified dementia. Review of Resident #2's progress notes dated 04/07/2025 revealed, in part, Resident #2 became verbally and physically aggressive towards staff. Review of Resident #2's progress notes dated 04/08/2025 revealed, in part, Resident #2 continued to be verbally and physically aggressive towards staff. Further review revealed Resident #2 was issued a Psychiatric Emergency Certificate (a legal document that authorizes a healthcare professional to detain and treat a patient in a psychiatric emergency) and was transferred to a behavioral health hospital for treatment. In an interview on 04/30/2025 at 2:28PM, Resident #2's daughter/Resident Representative (RR) indicated she was contacted by the facility on 04/08/2025 and notified Resident #2 had been combative with the staff and was transferred to a behavioral health hospital. Resident #2's daughter/RR further indicated she was informed by a nurse, who she could not name, that Resident #2 could not return to the facility without a personal sitter supplied by Resident #2. Resident #2's daughter/RR further indicated she had to bring Resident #2 home because she could not afford to pay for a personal sitter. In an interview on 05/01/2025 at 11:15AM, S4Social Worker indicated she was responsible to coordinate all planned resident transfers and discharges from the facility. S4Social Worker indicated S3Assistant Director of Nursing (ADON) emailed her and requested S4Social Worker reach out to Resident #2's daughter/RR to inform her Resident #2 required a personal sitter when Resident #2 returned to the facility from the behavioral health hospital. Review of S4Social Worker's email correspondence with S3ADON dated 04/09/2025 revealed, in part, S3ADON indicated she spoke to Resident #2's daughter/RR regarding Resident #2's daughter/RR having to obtain a personal sitter for Resident #2 when Resident #2 returned to the facility from the behavioral health hospital. Further review revealed S3ADON indicated she was not sure if Resident #2's daughter/RR would be able to afford the personal sitter services. Review of Resident #2's behavioral health hospital's multidisciplinary note dated 04/09/2025 revealed, in part, the facility would allow Resident #2 to return to the facility provided Resident #2's family supplied a personal sitter. In an interview on 05/05/2025 at 11:23AM, the behavioral healthcare hospital Clinical Director indicated the behavior health hospital nurse who made rounds at the facility told her Resident #2's family would have to supply a personal sitter if Resident #2 returned to the facility. The behavioral health hospital Clinical Director further indicated Resident #2 discharged to home from the behavioral health hospital on [DATE] with Resident #2's daughter/RR. In an interview on 05/05/2025 at 11:48AM, the behavioral health hospital nurse indicated S2Director of Nursing informed her that she contacted Resident #2's daughter/RR and informed her Resident #2 could return to the facility, but Resident #2's family would have to supply a personal sitter until Resident #2 adjusted to the nursing home setting. In an interview on 05/05/2025 at 12:04PM, S2DON indicated she spoke to Resident #2's daughter/RR days after Resident #2 transferred to the behavioral health hospital to inform Resident #2's daughter/RR that Resident #2 required a personal sitter when she returned to the facility to monitor Resident #2's behaviors until she adjusted. In an interview on 05/06/2025 at 1:23PM, S1Administrator confirmed the facility had notified Resident #2's daughter/RR Resident #2 required a personal sitter if Resident #2 returned to the facility to monitor Resident #2's behaviors. In an interview on 05/06/2025 at 2:57PM, S5Admissions Coordinator indicated on 04/16/2025 Resident #2's daughter/RR had informed her she was in the facility to pick up Resident #2's belongings and indicated she could not afford to pay for a personal sitter for Resident #2. S5Admissions Coordinator further indicated she then notified S2DON that Resident #2's daughter/RR was taking Resident #2 home because Resident #2's daughter/RR could not afford to pay for a personal sitter. S5Admissions Coordinator indicated S2DON responded that it was Resident #2's daughter/RR's, right to do so.

Based on observations and interviews, the facility failed to ensure the daily nurse staffing information was posted daily in a prominent place readily accessible as required. Findings: Observations on 04/30/2025 at 12:00PM of the facility hallways and public areas revealed the facility's daily nurse staffing information was not posted in a prominent place and readily accessible. There was no documented evidence, and the facility was unable to provide any documented evidence, the daily nurse staffing information was posted daily in a prominent place readily accessible as required. In an interview on 04/30/2025 at 12:00PM, S1Administrator indicated he had no knowledge the daily nurse staffing information was to be posted daily and available to the public for review. In an interview on 05/01/2025 at 7:55AM, S2Director of Nursing indicated the facility had not posted the daily nurse staffing information because the administrative staff was not aware of the above requirement.

Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure raw chicken was thawed in a sanitary manner; 2. Ensure the walk in cooler was kept clean and sanitary; 3. Ensure the walk in freezer was free of excessive ice accumulation; and, 4. Ensure water temperature and the concentration level of the sanitizing solution in the facility's 3 compartment sink and dishwasher were monitored and at the level required per the manufacture's guidelines. Findings: 1. Observation of the facility's kitchen on 07/08/2024 at 8:33 a.m. revealed a metal container which contained raw chicken submerged in water. In an interview on 07/08/2024 at 8:40 a.m., S3Chef confirmed the above mentioned raw chicken was submerged in water to thaw and should not have been. In an interview on 07/08/2024 at 8:42 a.m., S5Cook indicated she placed the raw frozen chicken in warm water to thaw. S5Cook further indicated the chicken should have been thawed under running water. 2. Observation of the facility's walk in cooler on 07/09/2024 at 12:04 p.m. revealed a foul odor inside. Further observation of the right side of the walk in cooler revealed a brown colored unknown liquid pooled on the floor below a shelf of produce, an unknown clear wet gelatinous (the consistency of jelly) substance along the top of the baseboard tiles, and a buildup of an unknown black, brown, and/or white substance along the wall where the wall and the baseboard tiles met. In an interview on 07/09/2024 at 12:07 p.m., S3Chef confirmed the walk in cooler had a foul odor, was unsanitary, and needed to be cleaned. 3. Observation of the facility's walk in freezer on 07/08/2024 at 8:30 a.m. revealed a thick layer of ice was built up on the freezer's floor, walls, shelves, ceiling, and the freezer's fan. In an interview on 07/08/2024 at 9:05 a.m., S3Chef confirmed there was a thick layer of ice on the freezer's floor, walls, shelves, ceiling, and the freezer's fan, and that there should have not been. 4. Review of the facility's policy titled, Machine Warewashing, dated 09/2012, revealed, in part, dishes should be washed according to the manufacturer's directions. Further review revealed the dishwasher machine operator should document the machine temperature and concentration of sanitizing solution for ware washing for each meal on the sanitizer solution log. Review of National Sanitization Foundation (NSF) Data plate attached to dishwasher machine revealed, in part, NSF operational requirements for the dishwasher machine using chemical sanitizing are as follows: wash minimal temperature is 140 F, final rinse minimal temperature of 120 F and sanitizer minimum 50 parts per million (ppm) available chlorine. Review of the facility's May, June, and July 2024's Sanitizer Solution Logs, revealed in part, no documented evidence, and the provider did not present any documented evidence that the sanitization level and/or the water temperature of the facility's 3 compartment sink and dishwasher were checked for each meal as required. Observation on 07/10/2024 at 12:25 p.m. revealed S3Chef tested the sanitization level of the dishwasher rinse cycle and the chlorine concentration read less than 50 ppm. In an interview on 07/10/2024 at 12:30 p.m., S3Chef confirmed the chlorine concentration level during the dishwasher rinse cycle was less than 50 ppm and should not have been.

Based on observations and interviews, the facility failed to ensure insulin (a medication used to lower blood sugar) was discarded within 28 days of the date it was opened on 1 (Cart a) of 3 (Cart a, Cart b, and Cart c) medication carts observed for medication storage. Findings: Observation on [DATE] at 10:30 a.m. of medication cart a, Resident #42's Insulin Aspart Pen 100 unit/1millimeter had an open date of [DATE] and was available for use. Further observation revealed Resident #97's Lantus Solostar (Insulin Glargine) Pen 100unit/1millimeter had an open date of [DATE] and was available for use. In an interview on [DATE] at 10:29 a.m., S2Licensed Practical Nursing (LPN) confirmed the dates written on Resident #42 and Resident #97's insulin pens as [DATE]. S2LPN further indicated Resident #42 and Resident #97's insulin pens should have been discarded, not used and switched out with new pens because they were expired. In an interview on [DATE] at 3:10 p.m., S1Director of Nursing (DON) indicated Resident #42 and Resident #97's insulin pens should have been discarded within 28 days after the date it was opened. S1DON further indicated Resident #42 and Resident #97's insulin pens should not have been available for use.

Based on observation, record review, and interview, the facility failed to ensure a resident's medication was available to be administered for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for pharmaceutical services. Findings: Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 10/24/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status of 14 which indicated Resident #1 was cognitively intact. Review of Resident #1's January 2024 Physician's Orders revealed, in part, an order for Bisacodyl (a laxative used to treat constipation) 10 milligrams (mg) suppository, insert 1 per rectum each night dated 10/11/2023. In an interview on 01/17/2024 at 2:38 p.m., Resident #1 stated she had not been receiving a Bisacodyl suppository as ordered. Review of Resident #1's January 2024 electronic Medication Administration Record (eMAR) revealed, in part, Resident #1's Bisacodyl 10mg suppository was not administered on 01/06/2024, 01/07/2024, 01/08/2024, 01/13/2024, 01/14/2024, and 01/15/2024 because the medication was reordered and awaiting arrival. In an interview on 01/18/2024 at 9:59 a.m., S3Licensed Practical Nurse stated there was no Biscodyl 10mg suppository available on the medication cart. S3Licensed Practical Nurse confirmed Resident #1 had an order to receive a Biscodyl 10mg suppository nightly. In an interview on 01/18/2024 at 10:05 a.m., Resident #1 stated she did not receive a Biscodyl suppository on the night of 01/17/2024 because the medication was not available. Observation on 01/18/2024 at 10:23 a.m., revealed there was no Biscodyl 10mg suppositories available in the facility's stock medication room. In an interview on 01/18/2024 at 10:25 a.m., S2Medical Records Coordinator stated the Biscodyl 10mg suppositories were on back order. S2Medical Records Coordinator confirmed the Bisacodyl 10mg suppositories were not available for administration to residents. In an interview on 01/18/2024 at 2:10 p.m., S1Director of Nursing confirmed the facility did not have Biscodyl 10mg suppositories available for administration. S1Director of Nursing further stated Resident #1's Biscodyl 10mg suppositories should have been available for administration. S1Director of Nursing confirmed Resident #1 did not receive Biscodyl 10mg suppository nightly as ordered on 01/06/2024, 01/07/2024, 01/08/2024, 01/13/2024, 01/14/2024, 01/15/2024, and 01/17/2024.

Based on observation, interviews and record reviews the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #1) of 3 (Resident #1 Resident #2, and Resident #3) sampled residents investigated for abuse. The facility's noncompliance resulted in actual harm on 11/03/2023 when Resident #2 bit Resident #1 on the right arm area above the wrist resulting in the resident screaming in pain with a visible bite and teeth marks on the skin requiring first aid treatment. Findings: Review of the facility's Abuse and Neglect Policy revealed, in part, residents must not be subjected to abuse including abuse from other residents. Further review revealed, physical abuse included hitting. Resident #1 Review of Resident #1's admission record revealed, in part, Resident #1 was admitted to the facility on [DATE] with a diagnoses in part, of Dementia with behavioral disturbances, Alzheimer's disease, Major Depressive Disorder, Hard of Hearing. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #1 was severely cognitively impaired. Review of the facility's incident log revealed, on 11/03/2023 that Resident #1 and Resident #2 had a physical contact incident and Resident #1 had a skin injury. Review of the facility's incident investigation dated 11/03/2023 revealed, in part, Resident #2 bit another resident (Resident #1) on her right arm. Interview on 11/17/2023 was attempted with Resident #1 and was unsuccessful due to the resident's severe cognitive impairment. Resident #1 was not interviewable. Resident #2 Review of Resident #2's admission record revealed, in part, Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia and Depression. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2023 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #2 was severely cognitively impaired. Review of Resident #2's care plan dated 11/02/2023 revealed in part, Resident #2 wanders into others room and is combative towards staff. Further review revealed on 11/03/2023 Resident #2 bit another resident (Resident #1). Review of Resident #2's nurse's notes dated 11/01/2023 revealed the following, in part: At 2:57 p.m. Resident #2 was wandering and banging on windows and the front door. She was aggressive with staff and attempted to slap the nurse. At 9:04 p.m. Resident #2 interrupted med pass and pushed the cart attempting to hit the staff with the cart. She walked up close to staff with fists balled and cursed staff. At 9:20 p.m. a noise was heard multiple times of opening and closing dining room doors. Upon nurse arrival, Resident #2 had her hands around the CNA's neck and attempted to bite the CNA on her shoulder. Review of Resident #2's nurse's note on 11/02/2023 revealed the following, in part: At 11:22 a.m. S2DON (Director of Nursing) spoke with the medical doctor regarding Resident #2 choking staff, aggression and exit seeking behaviors. New order for Seroquel to be increased to 50mg three times a day. An entry was made at 5:51 p.m. that revealed at 1:30 p.m. Resident #2 began fighting, kicking, scratching, and attempting to bite the CNA supervisor. The CNA supervisor informed S2DirectorOf Nursing (S2DON) of the incident. Review of Resident #2's nurse's notes dated 11/03/2023 revealed, in part: At 10:03 a.m. Resident #1 was seen being forced from Resident #2's room after hearing Resident #2 yell Get Out. Resident #1 was heard by staff as she screamed in pain grabbing all staff attention. Visible bite with teeth marks was noted to Resident #1's right arm above her hand. Further review revealed Resident #1 was assessed at the facility for the bite, the wound site was cleansed with normal saline and a bandage was applied. Review of S4CNA (Certified Nursing Assistant) written statement dated 11/03/2023 revealed a loud scream was heard from the dining room. Upon Arrival to Resident #2's room Resident #1 was noted trying to push the door to Resident #2's room as Resident #2 was pushing the door to avoid Resident #1 from entering her room. Resident #1 stated her arm was hurting and a visible bite mark was noted to Resident #1's arm. Review of S3LPN (Licensed Practical Nurse) written statement dated 11/03/2023 revealed Resident #1 was seen being forced from Resident #2's room as Resident #2 yelled Get out Resident #2 yells in pain getting all staff attention. Resident #2 was immediately assessed with teeth marks noted from a bite to her right hand. Interview on 11/17/2023 was attempted with Resident #2 and was unsuccessful due to the resident's severe cognitive impairment. Resident #2 was not interviewable. In an interview on 11/21/2023 at 11:00 a.m., S5CNA stated she was in the dining area when she heard the loud screams, staff went to Resident #2's room to check on Resident #2. S5CNA stated Resident #2 can be aggressive at times with the staff and is very hard to redirect when she has tantrums. Record review of the facility's investigation report revealed, in part, S1Administrator reviewed the facility's surveillance footage from 11/03/2023 which revealed Resident #1 went into Resident #2's room around 9:05 a.m., Resident #2 became agitated made contact and bit Resident #1 on right arm/wrist. In an interview on 11/20/2023 at 2:30 p.m., S2DON stated she was made aware of the incident between Resident #1 and Resident #2 on 11/03/2023. She stated Resident #2 had aggressive behaviors resulting in close monitoring, medication changes and labs. S2DON stated when the staff noticed Resident #1 was walking towards entering Resident #2's room the staff yelled out to Resident #1 to redirect her but was unsuccessful due to Resident #1 being hard of hearing. S2DON stated by the time staff arrived to the redirect Resident #1, she had already entered Resident #2's room and bit her on the wrist. S2DON stated Resident #2 was sent out to a local hospital for a geriatric psychiatric evaluation related to aggression and harm to others.

Based on observations, record reviews, and interview, the facility failed to store and distribute food in a manner to prevent the possibility of food contamination. Findings: Observation of the facility's cooler on 08/21/2023 at 9:32 a.m. revealed, in part, 1 bag of shredded cheese not dated, 6 breaded cutlets in a pan covered with clear wrap not dated, 6 packages of tortillas not dated, a bag of shredded lettuce not dated, 6 containers of strawberries with a buildup of a grayish color substance and 5 cucumbers with soft spots. Observation of the automated dishwasher on 08/21/2023 at 9:43 a.m. revealed the temperature gauges did not work when the wash cycle was initiated. Observation of the facility's walk in freezer on 08/21/2023 at 9:50 a.m. revealed an accumulation of ice on the freezer floor. S4Executive Chef was observed with a long handled tool with a straight edge as he attempted to break up the ice with the straight edge. In an interview on 08/22/2023 at 11:24 a.m., S4Executive Chef stated the freezer had not functioned properly and had maintained a buildup of ice for a long time. In an interview on 08/21/2023 at 9:45 a.m., S7Diet Aide stated the porters were responsible to monitor the dishwasher temperatures and sanitizer levels of the three compartment sink and document the results on a log which was maintained in a binder. S7Diet Aide presented the surveyor with the binders and acknowledged the last documented dishwasher temperatures and sanitizer levels of the three compartment sink was on 06/30/2023. In an interview on 08/24/2023 at 10:28 a.m. S4Executive Chef confirmed the dishwasher temperatures and sanitizer levels of the three compartment sink logs were not documented since 06/30/2023 and stated he did not know the temperature gauge of the dishwasher did not work. S4Executive Chef stated food in the refrigerator should be dated and discarded when not appropriate for resident use. S4Executive Chef confirmed the strawberries and the cucumbers were not appropriate for resident use.

Based on record review and interview the facility failed to ensure services provided by the facility meet professional standards of practice for 1 of 5 (resident #5) sampled residents. The nurse (S9LPN) failed to assess resident #5when she was found on the ground outside of the facility by staff and the aide reported swelling and redness to the resident's ankle. The nurse indicated verbally and through a written report that the resident sustained [REDACTED]. This failed practice resulted in an actual harm. It was later found the resident's fall on 9/27/14 had caused a subdural hematoma and a fracture to the left ankle This failed practice had the potential to affect all eight wanders in the facility as listed on the facility's Residents Identified as Elopement/Wanders Risk Sheet.. Findings: Review of the National Federation Nursing Practice Standards for the Licensed Practical /Vocational Nurse, Section, Standards, Subsection Legal/Ethical Status reads in part as follows: The Licensed Practical/Vocational Nurse shall recognize and have a commitment to meet the ethical and moral obligations of the practice of nursing. Further Review of the National Federation Nursing Practice Standards for the Licensed Practical /Vocational Nurse, Section Standards, Subsection Practice reads in part as follows: The Licensed Practical/Vocational Nurse shall know and utilize the nursing process in planning, implementing and evaluating health services and nursing care for individual patients. Planning: The planning of nursing includes assessment /data collection of health status of the individual patient and reporting information gained from assessment. Implementation: The plan for nursing care is put into practice to achieve the stated goals and includes: observing, recording and reporting significant changes which require interventions or different goals. Review of facility ' s accident/ incident reports revealed a resident incident report for Resident#5 dated 9/27/14. The descriptive narrative section of the report reads in part as follows: Alerted to the room by CNA. The resident was not in her bed. We searched the facility and the resident was found sitting in the courtyard. She was escorted back to her room and placed in bed. No injuries noted Review of the facility's fall prevention protocol indicated all falls resulting in head injuries must have a neurological assessment form completed on each shift.. A review of (S9LPN) unit nurse's statement dated 9/28/14 reads in part as follows: At approximately 5AM, I (S9LPN) was alerted to the resident ' s room by the CNA. She had discovered that the resident wasn ' t in her room. We began to search the premises for her by checking each of the residents ' rooms on the hall. We continued the search onto the halls where the other CNAs joined in on the search. At that time, I (S9LPN) decided to go look outside, in the parking lot in search of the resident. There wasn ' t any movement outside, so I (S9LPN) reverted back into the building. While walking back towards the facility I (S(LPN) discovered the resident sitting in the courtyard. She was escorted back into her room. She hadn ' t sustained any notable injuries. After we finished getting the resident situated, the Nursing Supervisor was notified of the incident. A message was left with the MD answering service. I (S9LPN) also left messages on the resident ' s son and daughter cell phone in reference to the incident. An interview was conducted with S5CNA on 10/15/14 at 10:15AM. During the interview S5CNA said she made her rounds and was in Resident#5 ' s room at 3:30AM. She stated she checked on both residents and they were both in bed. S5CNA said they make rounds every two hours and as needed. S5CNA said she was back in Resident#5 ' s room between 4:45AM and 5:00AM because Resident #5 ' s roommate needed to have a bowel movement. S5CNA said after Resident #5 ' s roommate was clean she checked on Resident#5. The curtains were pulled and when she pulled the curtains back she noticed the resident was not in bed. S5CNA said she started looking in all the rooms on the hall. She said she met the unit nurse (S9LPN) on the hall and told her the resident was not in her room. She also said S9LPN had been on the hall passing medications and she had recently left the resident ' s room giving medication to the roommate. S5CNA said she went down to the other end of the hall looking for the resident. She stated she met S3CNA and S6CNA and asked them had they seen Resident #5. They said no, but began assisting her in looking for the resident. S5CNA said she did not see the resident when they found her; she did not go outside, because if she went outside the door would lock and they would be locked outside. S5CNA said she went to get a wheel chair. She also stated when she returned with the wheelchair they had picked the resident up and taken her to her room. She stated she went to the resident ' s room and cleaned the resident up because the resident had had a bowel movement and her gown had grass and leaves on it. Review of S5CNA ' s written statement dated 10/2/14 essentially imparted the same information as the above interview except the sequences of events that took place after the resident was noted to be missing and was more detailed in the oral interview. An interview was conducted with S6CNA on 10/15/14 at 10:29AM. During the interview S6CNA said S5CNA came running down the hall looking for Resident#5. She also stated she and S3CNA assisted S5CNA in looking for the resident. S6CNA further said the unit nurse (S9LPN) was the individual who initially found the resident. She said when she saw the resident; the resident was lying on the ground in the bushes. She also stated the resident ' s gown was askew and open and she noticed her ankle was red and swollen. She further stated she told the nurse the resident ' s ankle was swollen and red, but the nurse said nothing and made a motion at her with her hand. She also said S3CNA and the S9LPN picked the resident up off the ground and when they attempted to walk with the resident the resident had a limp. She also said S9LPN asked S3CNA to carry the resident to her room. S6CNA was asked did she tell anyone else about the resident ' s ankle being red and swollen. S6CNA said she told S4LPN a few days later when they called her in to write a statement. Review of S6CNA written statement dated 10/2/14 essentially reads the same as the above interview except the written statement indicated the resident was found in an awkward position, like sitting and lying back at the same time. The written report also indicated the resident ankle was swollen. Review of a Nurse Practitioner's note in resident chart dated 9/29/14 reads in part as follows: Long discussion with the family. They reported resident has had periods of lethargy in the past and was previously seen in the emergency room with negative workups. Am going to err on side of caution and send resident to emergency room in light of the lethargy and inability to take p.o. fluids/ foods/medications. The family is in agreement. Review of Chief Complaint note in local hospital dated 9/30/14 reads in part as follows. The daughter in law reports the resident fell at the nursing home on Saturday and now complains of left sided head pain, arm pain, and left foot pain. The daughter in law states that this is not the resident's baseline mental status; prior to hip surgery she was ambulatory, able to dress herself, non lethargic and had no difficulty swallowing . Review of nurses ' notes dated 9/30/14 reads in part as follows: Conference with daughter and daughter in law. I (DON) explained to her that the incident was under investigation, and that as soon as we had the details we would follow up with the family. The daughter went on to say that the mother had sustained a subdural hematoma and a fractured ankle and asked if we were aware of her injuries. I (DON) informed her that based on the initial documentation reviewed there was no indication of injuries being assessed or reported but that an investigation was still ongoing. An interview was conducted with S2DON on 10/14/14 at 2PM. During the interview S2DON stated she was initially informed about the incident from the day shift supervisor on 9/28/14. She stated she was informed that the resident was found sitting in the courtyard on a bench and there were no injuries involved. She also stated she did not become aware of the severity of the resident ' s injuries until 9/30/14 when she had a conference with the resident ' s daughter and daughter in law. She further stated when the resident was admitted to the hospital on the morning of 9/29/14 for a possible Urinary Tract Infection [MEDICAL CONDITION], which proved to be accurate, the family members said other x-rays and testes were done on the resident. S2DON said she was informed by the resident ' s daughter and daughter in law that the resident had a subdural hematoma and a fractured ankle. S2DON also said she told the family members that based on the initial documentation reviewed there was no indication of injuries being assessed or reported but that an investigation was on going. S2DON said she knew something was wrong because those injuries aren ' t obtained from sitting on a bench. S2DON said she talked with the aides involved in the incident and was informed that the resident was found on the ground. S2DON stated on 10/2/14 she talked with S9LPN unit nurse and asked her to tell her what happened with Resident#5 on the morning of 9/27/14. S2DON said S9LPN unit nurse reiterated the story as before saying the resident was found in the courtyard sitting on a bench. S2DON stated she asked S9LPN unit nurse specifically where the resident was sitting. S2DON said S9LPN unit nurse pointed to a bench outside. She also said she asked S9LPN to read her incident report and asked was it accurate. S2DON said S9LPN said it was accurate. S2DON stated she then told S9LPN she had spoken with the aides who were on duty that night and they said the resident was found on the ground. S2DON further stated she asked S9LPN why didn ' t she report what actually happened. S2DON said S9LPN did not respond. S2DON also said the resident was only a few days post-operative for hip surgery and should have been sent to the emergency room . Review of S2DON written statement dated 10/1/14 states essentially the same information as the above interview.

Based on record review and interview the facility failed to ensure adequate measures were implemented and maintained to ensure each resident received adequate supervision to prevent accidents for 1of 5 (resident #5) sampled residents. An actual harm occured when Resident#5 was found on the ground on 9/27/14 at 5AM. The resident was hosptalized on [DATE] for a possible UTI and testing revealed resident#5 was found to have sustained a subdural hematoma and a fracture left ankle. This failed practice had the potential to affect all eight wanders in the facility as listed on the facility's Residents Identified as Elopment /Wanders Risk Sheet. Findings: Review of facility ' s accident/ incident reports revealed a resident incident report for Resident#5 dated 9/27/14. The descriptive narrative section of the report reads in part as follows: Alerted to the room by CNA. The resident was not in her bed. We searched the facility and the resident was found sitting in the courtyard. She was escorted back to her room and placed in bed. No injuries noted. A review of (S9LPN) unit nurse statement dated 9/28/14 reads in part as follows: At approximately 5AM, I (S9LPN) was alerted to the resident ' s room by the CNA. She had discovered that the resident wasn ' t in her room. We began to search the premises for her by checking each of the residents ' rooms on the hall. We continued the search onto the halls where the other CNAs joined in on the search. At that time, I (S9LPN) decided to go look outside, in the parking lot in search of the resident. There wasn ' t any movement outside, so I (S9LPN) reverted back into the building. While walking back towards the facility I (S9LPN) discovered the resident sitting in the courtyard. She was escorted back into her room. She hadn ' t sustained any notable injuries. After we finished getting the resident situated, the Nursing Supervisor was notified of the incident. A message was left with the MD answering service. I (S9LPN) also left messages on the resident ' s son and daughter cell phone in reference to the incident. An interview was conducted with S5CNA on 10/15/14 at 10:15AM. During the interview S5CNA said she made her rounds and was in Resident#5 ' s room at 3:30AM. She stated she checked on both residents and they were both in bed. S5CNA said they make rounds every two hours and as needed. S5CNA said she was back in Resident#5 ' s room between 4:45AM and 5:00AM because Resident #5 ' s roommate needed to have a bowel movement. S5CNA said after Resident #5 ' s roommate was clean she checked on Resident#5. The curtains were pulled and when she pulled the curtains back she noticed the resident was not in bed. S5CNA said she started looking in all the rooms on the hall. She said she met the unit nurse (S9LPN) on the hall and told her the resident was not in her room. She also said S9LPN had been on the hall passing medications and she had recently left the resident ' s room giving medication to the roommate. S5CNA said she went down to the other end of the hall looking for the resident. She stated she met S3CNA and S6CNA and asked them had they seen Resident #5. They said no, but began assisting her in looking for the resident. S5CNA said she did not see the resident when they found her; she did not go outside, because if she went outside the door would lock and they would be locked outside. S5CNA said she went to get a wheel chair. She also stated when she returned with the wheelchair they had picked the resident up and taken her to her room. She stated she went to the resident ' s room and cleaned the resident up because the resident had had a bowel movement and her gown had grass and leaves on it. Review of S5CNA ' s written statement dated 10/2/14 essentially imparted the same information as the above interview except the sequences of events that took place after the resident was noted to be missing and was more detailed in the oral interview. An interview was conducted with S6CNA on 10/15/14 at 10:29AM. During the interview S6CNA said S5CNA came running down the hall looking for Resident#5. She also stated she and S3CNA assisted S5CNA in looking for the resident. S6CNA further said the unit nurse (S9LPN) was the individual who initially found the resident. She said when she saw the resident; the resident was lying on the ground in the bushes. She also stated the resident ' s gown was askew and open and she noticed her ankle was red and swollen. She further stated she told the nurse the resident ' s ankle was swollen and red, but the nurse said nothing and made a motion at her with her hand. Surveyor stated " you told the unit nurse the resident ankle was red and swollen " . S6CNA said yes she told S9LPN and S6CNA demonstrated with her hands the hand motion S9LPN made at her. She also said S3CNA and S9LPN picked the resident up off the ground and when they attempted to walk with the resident the resident had a limp. She also said S9LPN asked S3CNA to carry the resident to her room. S6CNA was asked did she tell anyone else about the resident ' s ankle being red and swollen. S6CNA said she told S4LPN a few days later when they called her in to write a statement. Review of S6CNA written statement dated 10/2/14 essentially reads the same as the above interview except the written statement indicated the resident was found in an awkward position, like sitting and lying back at the same time. The written report also indicated the resident ankle was swollen. An interview was conducted with S3CNA on 10/15/14 at 9:50AM. During the interview S3CNA stated between 4:30AM and 5:00AM S5CNA came on the hall where he was working looking for Resident#5. S3CNA also said S5CNA asked him had he seen Resident#5 and he told her no. S3CNA further stated he and S6CNA stopped what they were doing and assisted S5CNA in looking for the resident. S3CNA said he looked through the glass doors (patio) and saw the resident sitting/lying in the courtyard on the ground near the bushes. He said the resident was sitting /lying (like she had fallen) on the pavement, leaning against the bushes. S3CNA also said he, S5CNA, S6CNA, went outside and the unit nurse (S9LPN) followed them. S3CNA further said the unit nurse asked Resident#5 was she alright and was she having any pain. S3CNA said the resident did not respond. S3CNA also said (S9LPN) ask the resident could she stand, but at the same time she ask the resident could she stand they assisted the resident to the standing position. S3CNA said the resident took two steps and he noticed she was limping and she could not put any weight on her leg. S3CNA was asked did he notice the resident ' s ankle and what leg was the resident favoring when she limped. S3CNA said he did not look at the resident ' s ankle and he did not remember which leg caused the limp, because she only took a few steps before they noticed the limp and stopped attempting to walk with her. S3CNA also stated S5CNA went to get a wheel chair but in the meantime (S9LPN) asked him could he carry the resident. S3CNA said he told her yes, and he carried the resident to her room. S3CNA also said S6CNA held the door open while he carried the resident through the door. S3CNA said he carried the resident to her room, put her in the bed and went back to his unit. Review of S3CNA ' s written statement (no date noted on statement) imparted the same information as S3CNA ' s interview. Review of nurses ' notes dated 9/30/14 reads in part as follows: Conference with daughter and daughter in law. I (DON) explained to her that the incident was under investigation, and that as soon as we had the details we would follow up with the family. The daughter went on to say that the mother had sustained a subdural hematoma and a fractured ankle and asked if we were aware of her injuries. I (DON) informed her that based on the initial documentation reviewed there was no indication of injuries being assessed or reported but that an investigation was still ongoing. An interview was conducted with S2DON on 10/14/14 at 2PM. During the interview S2DON stated she was initially informed about the incident from the day shift supervisor on 9/28/14. She stated she was informed that the resident was found sitting in the courtyard on a bench and there were no injuries involved. She also stated she did not become aware of the severity of the resident ' s injuries until 9/30/14 when she had a conference with the resident ' s daughter and daughter in law. She further stated when the resident was admitted to the hospital on the morning of 9/29/14 for a possible Urinary Tract Infection (UTI), which proved to be accurate, the family members said other x-rays and testes were done on the resident. S2DON said she was informed by the resident ' s daughter and daughter in law that the resident had a subdural hematoma and a fractured ankle. S2DON also said she told the family members that based on the initial documentation reviewed there was no indication of injuries being assessed or reported but that an investigation was on going. S2DON said she knew something was wrong because those injuries aren ' t obtained from sitting on a bench. S2DON said she talked with the aides involved in the incident and was informed that the resident was found on the ground. S2DON stated on 10/2/14 she talked with S9LPN unit nurse and asked her to tell her what happened with Resident#5 on the morning of 9/27/14. S2DON said S9LPN unit nurse reiterated the story as before saying the resident was found in the courtyard sitting on a bench. S2DON stated she asked S9LPN unit nurse specifically where the resident was sitting. S2DON said S9LPN unit nurse pointed to a bench outside. She also said she asked S9LPN to read her incident report and asked was it accurate. S2DON said S9LPN said it was accurate. S2DON stated she then told S9LPN she had spoken with the aides who were on duty that night and they said the resident was found on the ground. S2DON further stated she asked S9LPN why didn ' t she report what actually happened. S2DON said S9LPN did not respond. S2DON also said the resident was only a few days post-operative for hip surgery and should have been sent to the emergency room . S2DON was asked by the surveyor how did an eighty eight year old woman S/P ORIF (Open Reduction Internal Fixation) ambulates down a hall go through two sets of double doors and make it outside. S2DON said she didn ' t know. She also said the video camera wasn ' t working on that hall and she has asked everyone she could think of to ask and no one saw her. Review of S2DON written statement dated 10/1/14 states essentially the same information as the above interview. An interview was conducted with S10PT (current facility) on 10/14/14 at 9:25AM. During the interview S10PT said the resident was moderate assist with transfer and ambulation. She also stated the resident needs a lot of stimulation and cueing with everything. She further stated the resident is very weak and cannot walk on her own. S10PT said the resident needs physical assistance and the use of a walker to ambulate. An interview was conducted with S8PT (physical therapy) on 10/14/14 at 1:30PM. During the interview S8PT said the resident was not able to walk without assistant. He also stated the resident was 25% assist which meant they (PT) are the 25% that help. He further stated the resident walked when they used the gait belt. S8PT was asked was the resident physically capable of getting out of bed and walking. S8PT said no way. Review of Resident#5 ' s initial dated Minimum Data Set ((MDS) dated [DATE] Section G, Functional Status revealed a score of 3(extensive assistant) for bed mobility, transfer, dressing, and walk in room. A score of 8 (activity did not occur) was given for walk in corridor. A score of 4 (total dependence) was given for locomotion on unit and locomotion off unit.

Based on record review and interview the Provider failed to ensure implementation of the facility's Abuse Policy and Procedure by failing to ensure supervision of staff implementation of the protocol for reporting witnessed verbal abuse in a timely matter which would have avoided the resident from being physically abused for 1 of 3 Stage 2 sampled residents reviewed in a total of 3 residents who had allegations of abuse at the facility (#19) . After discovery, the facility failed to ensure the resident's safety by allowing the accused to sit with resident for an hour and one-half, while completing the investigation. The facility did not report the incident to the proper authorities as mandated by State Law. This failed practice caused an Immediate Jeopardy situation for Resident #19. The Immediate Jeopardy began for Resident #19 on 4/27/11 at 10:00am when a CNA witnessed the resident's private sitter being verbally abusive during the resident's morning care and later during the day the same CNA witnessed the private sitter being physically and verbally abusive to the resident during transfer to bed. The incidents of abuse were not reported until the next day, 4/28/11 at 8:15am. The immediate jeopardy ended for Resident #19 on 4/28/11 at 10:00am when the sitter was removed from the facility. The deficient practice continues at the level of actual harm. Findings: An interview on 5/23/2011 at 10:45am with resident #19 revealed that the resident did not want to talk about the incident with the sitter, because she did not want to get anyone in trouble. She further indicated that she no longer has a sitter. An interview on 5/23/11 at 11:05am with S10 CNA (Certified Nursing Assistant) revealed that she has worked at the facility for about 7 months. S10 CNA indicated that she was assigned to work with resident #19. On that day of the incident, she was asked by the resident's sitter to assist her with the resident's whirlpool bath. She indicated this was around 10am. During the bath, the sitter was verbally abusive to the resident. S10 CNA indicated that she witnessed the sitter telling resident #19 that she knows that she(resident) did not like black people and that she (sitter) don't like white people either. The sitter told resident #19 things like: all you do is complain, but you can't wipe your own ass, you make me sick, you disgust me, you don't see black women in the bed helpless, they know how to take care of themselves, you're lazy and helpless, a spoiled brat, I can't stand this f-----(vulgar word) woman. S10 CNA indicated that later that day she witnessed the sitter physically and verbally abusing resident #19. S10 CNA further indicated that the sitter asked her to assist with transferring the resident to bed. S10 CNA told the sitter that the resident had a bowel movement. The sitter rushed to the bed and looked in the resident ' s diaper. The sitter was very rough with the resident and told the resident that she would beat her ass for[***]ing on herself. The sitter told the resident why the f-----(vulgar word) didn't you tell me you had to go to the bathroom. The sitter grabbed resident #19 by the arms and started shaking the resident. Then the sitter threw resident #19 to the top of the bed and the resident hit her head against the head board and the resident screamed, when she hit her head. S10 CNA indicated that she did not tell anyone about these incidents. She indicated that she was afraid to say anything. S10 CNA indicated that the next day she went to the Unit Manager and told him what she had witnessed. S10 CNA indicated that she had been in-serviced on abuse during her orientation. An interview on 5/ 23/11 at 2:45pm with S2 DON(Director of Nursing) revealed that the verbal and physical abuse was reported to the State and the family did not want the incident reported to the local authorities or Elderly Protective Services (EPS). The facility did not report the incident to the police or EPS and the sitter was removed from the facility by the facility security. S2 DON further indicated that the CNA should have reported the first incident immediately, and then they would not have been a second incident. Review of the facility investigation of the incident dated 4/28/11 revealed that the incident occurred on 4/27/11 at 10:00am and 1:00pm and not reported by the CNA until 4/28/11 at 08:15am. Further review revealed that the sitter was not removed from the resident ' s room until 10:00am (1 ? hours after the incident was reported to the facility). There was no mention that the incident was reported to the local police or Elderly Protective Services.

Based on observation, record review and interview the facility failed to ensure a CNA immediately reported to administration witnessed verbal abuse of a resident by private sitters for 1 of 3 (#19) Stage 2 sampled residents reviewed in a total of 3 residents who had allegations of abuse at the facility. On 4/27/11 at 10:00am, a CNA witnessed resident #19 ' s private sitter verbally abusing the resident during morning care. Resident #19 was placed in Immediate Jeopardy situation when the CNA failed to report this verbal abuse to the administrator. Later during the day the same CNA witnessed the private sitter being physically and verbally abusive to the resident during transfer from chair to bed. The CNA did not report the incidents of abuse until the next day, 4/28/11 at 8:15am. The sitter was not removed from the resident ' s room until 10:00am on 04/28/11. The Immediate Jeopardy ended for Resident #19 on 4/28/11 at 10:00am when the sitter was removed from the facility. The deficient practice remains at a potential for more than minimal harm for any resident abused and the abuse is not reported by the observing CNA. Findings: An observation on 5/23/2011 at 10:45am with resident #19 revealed the resident in bed, clean and well groomed. The resident was interviewed and indicated that she did not want to talk about the incident with the sitter, because she did not want to get anyone in trouble. She further indicated that she no longer had a sitter. An interview on 5/23/11 at 11:05am with S10 CNA (Certified Nursing Assistant) revealed that she has worked at the facility for about 7 months. S10 CNA indicated that she was assigned to work with resident #19. On that day of the incident, she was asked by the resident's sitter to assist her with the resident's whirlpool bath. She indicated this was around 10am. During the bath, the sitter was verbally abusive to the resident. S10 CNA indicated that she witnessed the sitter telling resident #19 that she knows that she(resident) did not like black people and that she (sitter) don't like white people either. The sitter told resident #19 things like: all you do is complain, but you can't wipe your own ass, you make me sick, you disgust me, you don't see black women in the bed helpless, they know how to take care of themselves, you're lazy and helpless, a spoiled brat, I can't stand this f-----(vulgar word) woman. S10 CNA indicated that later that day she witnessed the sitter physically and verbally abusing resident #19. S10 CNA further indicated that the sitter asked her to assist with transferring the resident to bed. S10 CNA told the sitter that the resident had a bowel movement. The sitter rushed to the bed and looked in the resident ' s diaper. The sitter was very rough with the resident and told the resident that she would beat her ass for[***]ing on herself. The sitter told the resident why the f-----(vulgar word) didn't you tell me you had to go to the bathroom. The sitter grabbed resident #19 by the arms and started shaking the resident. Then the sitter threw resident #19 to the top of the bed and the resident hit her head against the head board and the resident screamed, when she hit her head. S10 CNA indicated that she did not tell anyone about these incidents. She indicated that she was afraid to say anything. S10 CNA indicated that the next day she went to the Unit Manager and told him what she had witnessed. S10 CNA indicated that she had been in-serviced on abuse during her orientation. An interview on 5/ 23/11 at 2:45pm with S2 DON revealed that the incident was reported to the State and the family did not want the incident reported to the local authorities or Elderly Protective Services (EPS). The facility did not report the incident to the police or EPS and the sitter was removed from the facility by the facility's security. S2 DON further indicated that the CNA should have reported the first incident immediately, and then there would not have been a second incident. S10 CNA had been in-serviced on abuse reporting. S10 CNA was verbally reprimanded. Review of the facility investigation of the incident dated 4/28/11 revealed the reported incident occurred on 4/27/11 at 10:00am and 1:00pm and was not reported by the CNA until 4/28/11 at 08:15am. Further review revealed that the sitter was not removed from the resident's room until 10:00am (1 hour and 45 minutes from 8:15am to 10:00am after the CNA reported the incident up till the removal of the sitter, the resident was not protected). On physical inspection- resident found to have a purple bruise to her posterior right scalp approximately 3 inches round. Upon palpation, the resident validated that it was the location that had been hit and was hurting. No other physical injury noted. The resident had multiple bruises to both upper extremities. The resident could not validate if the locations coincided with where she had been grabbed and shaken. The physician was notified and orders given for the resident to be evaluated in the emergency room . Review of the provider's Policy Abuse Investigations effective 1/1/09 under #8 reads: While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents ...

A. Based on observation, interview, and record review, the facility failed to ensure that residents received the appropriate care and services by failing to obtain treatment for two areas of skin breakdown (#271) and by failing to provide treatment for pressure ulcers and by failing to follow physician orders in order to promote healing and comfort (#188) for 2 of 7 Stage 2 sampled residents reviewed out of 9 total residents, who had pressure ulcers in the facility. This failed practice resulted in actual harm for Resident #271 when the facility failed to identify the resident's heel ulcer on admission which resulted in delay of care and treatment for 6 days and when the facility identify on admission an area of skin redness and the resident did not receiving continually monitor of the resident's skin condition or the appropriate interventions or treatment which resulted in the development of 2 Stage 2 pressure ulcers. Review of the Resident Census and Condition of Residents dated 05/18/11 revealed the facility had 9 in the facility with pressure sores and 1 of the 9 residents was admitted with the pressure sore. B. Based on interview and record review the facility failed to have a system in place to ensure pressure sore assessments were completed timely for 1 of 7 (#274) Stage 2 sampled residents reviewed and out of 9 total residents, who had pressure ulcers in the facility and failed to provide the necessary treatment of accurately and ongoing assessments by a Registered Nurse of a resident ' s skin integrity by failing to stage and measure the pressure ulcer for 1of 7 (#246) Stage 2 sampled residents reviewed out of 9 total residents, who had pressure ulcers in the facility. The facility failed to have a monitoring system in place which would ensure all residents receive care and services for pressure sores. Findings: RESIDENT #271 Review of local hospital Discharge Summary and Physician Transfer Orders dated 5/10/2011 revealed several notations of the resident having a left heel ulcer, there was no mention of redness to the buttock. Review of the resident's Initial Nursing History and assessment dated [DATE] under skin condition revealed no mention of a left heel impairment or redness on buttocks. Further review of the Interim Care Plan dated 5/11/11, revealed a notation of tissue impairment on left heel and red buttocks. Review of the Physician Orders dated May 11, 2011 revealed an order to consult wound care nurse for standing orders. An interview on 05/20/11 at 9:45am with S5RN Unit Manager stated that when the admitting nurse tried to assess the resident, the resident refused to take off his heel protector. She further stated that his family left a note on her door indicating that resident # 271 has a pressure ulcer to the left heel and that he did not want any nurse to change his dressing. She further stated that on 05/17/11, she decided to call the doctor and tried to make an appointment with the resident's Podiatrist, who treated the resident's left foot. She further indicated that the resident received treatment yesterday (05/19/11) at the doctor's office. S5 RN acknowledged that she reviewed the note from the weekend nurse on 5/17/11. Review of a note written to the Unit Manager (S5RN) by the weekend floor nurse dated 5/15/11 revealed that the resident had a left heel ulcer and needs a doctor's appointment with his podiatrist. The note includes information from the resident that he goes once a week and it had been a week and half since he saw the doctor. There is an entry that mentions several open areas on the buttocks and that Medsiptic was applied and may need further treatment. Further review revealed no descriptions of the open areas to the buttocks or the heel ulcer. An interview on 05/20/11 at 10:10am with the resident's family member, who is a nurse, revealed that she left a note for the unit manager because she did not think that the facility knew that the resident had a foot ulcer. She further indicated that she was informed on Monday (05/16/11) or Tuesday (05/17/2011) (she could not remember the exact date) by the evening nurse that the resident had an ulcer to his sacral area. The resident's family member recalled that the area (sacral) was red but was not open. An observation on 05/20/11 at 11:20am was made with S12LPN Treatment Nurse, who measured the pressure ulcer to the left heel. The appearance of the outer skin was intact, wound bed yellow, with no drainage noted, and measured 1.4 cm x 1.5cm x 0. The wound was characterized as a stage 3. Two open areas to sacrum measured 0.5cm x 0.5 Stage 2 and a left inner buttock Stage 2 measured 0.4cm x 0.6cm. The measurements and staging of these pressure ulcer where done by the LPN. On 05/20/2011 at 12:00 noon, an interview was conducted with S22 LPN, who was the nurse for the resident on 05/12/2011 during the 7:00am through 3:00pm shift and the nurse working with the resident today (05/20/2011). She indicated that she thought the resident had on boots for the prevention of pressure ulcers. She stated that she was not aware that the resident has a pressure ulcer. On 05/20/2011 at 1:05pm, Interview with S23 Physical Therapist (PT), indicated that during therapy on 5/12/11, he took off the resident's boots and noticed a dressing on the left foot but he did not know the resident had a pressure ulcer. An interview on 5/20/11 at 2:45pm with S12LPN Treatment Nurse revealed that she started as the Treatment Nurse 4/4/11. S12 further indicated that the procedure for wound consultation on admission is that the Unit Manager notifies the TX Nurse, they keep a binder on the floor. The initial assessment are done by the ADON and staged and measure weekly by the ADON. An interview on 5/23/11 at 5:15pm with S13LPN revealed that she was a new nurse and graduated 3 months ago. S13 LPN reviewed the resident's medical record and acknowledged the resident's admit assessment was inaccurate. S13LPN indicated that she noted the heel protector on the left foot and a vascular boot on the right foot. She indicated that she did not notice that the resident had a dressing on the left foot. S13LPN further indicated that the order for wound consultation was not followed and the resident was not referred for the wound care consultation. She indicated that the Unit Manager is working with her to increase her skill level. Record review revealed that the resident was admitted on [DATE] with a left heal ulcer and a red buttock. The resident was not assessed and treated for the heel ulcer until 5/17/11 and the sacral ulcers were treated at that time with standing orders. There is no description of the ulcers until Friday 5/20/11, which were measured and staged by the LPN. Review of the daily Nurses' Note from 5/11/2011-5/20/11 revealed no mention of the resident's skin impairment. An interview on 5/24/11 10:50am with the S3ADON revealed that she could not answer as to why the admit nurse did not order wound care on admission. Resident #274: In interview on 05/16/11 at 1:19pm, S20/LPN indicated resident #274 was admitted with a stage 1 pressure sore to the right heel. Review of the medical record revealed the resident was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. Review of the resident ' s Initial Nursing History and assessment dated [DATE] revealed the form had a diagram of a person with instructions to indicate on the diagram all body marks such as pressure sores and other ulcerations or questionable markings considered other than normal. Indicate the size and depth in centimeters. Further review revealed no evidence staff identified that the resident had a right heel pressure sore. Review of the resident ' s Skilled Nursing Note dated 05/10/11 at 8:30pm revealed S21/LPN documented skin was intact and no breakdowns. Review of the resident ' s Nurse ' s Notes dated 05/11/11 at 10:00am revealed S17/RN Second Floor Unit Manager documented an assessment of the resident. Review of the assessment documentation revealed no evidence the resident had a right heel pressure sore. Review of Physician's Orders revealed wound care orders dated 05/11/11 for the right heel that were written by S12/LPN Treatment Nurse. Review of the resident ' s Skilled Nursing Notes dated 05/11/11 and 05/12/11 revealed no documentation the resident had a right heel pressure sore. Review of the resident ' s Nurse ' s Notes dated 05/13/11, 05/15/11, 05/16/11, 05/19/11, 05/21/11, and 05/22/11 revealed no documentation the resident had a right heel pressure sore. Review of the Skin Care section of the medical record revealed a Wound Assessment entered by S12/LPN Treatment Nurse on 05/13/11. Review of this assessment revealed, in part: Wound Location: Right Heel; Wound Measurements: (no measurements documented); Wound Progress: Initial Exam; Assessment Notes: noted blister to heel flat and intact. Review of the Skin Care section of the medical record revealed a Wound Assessment entered by S12/LPN Treatment Nurse on 05/20/11. Review of this assessment revealed, in part: Wound Location: Right heel; Wound Status: not healed; Wound Measurements: (no measurements documented); Wound Progress: No change. In interview on 05/23/11 at 11:06am, S12/LPN Treatment Nurse indicated another staff member told her about the resident ' s right heel pressure sore and she started treating the sore on 05/11/11. S12/LPN Treatment Nurse indicated the facility ' s procedure for skin assessments on newly admitted residents was that the floor nurse did the initial skin assessment and notified the RN Unit Manager of any pressure sores. S12/LPN Treatment Nurse indicated the RN Unit Manager would assess all pressure sores within 24 hours of admit. S12/LPN Treatment Nurse indicated she started treatment of the right heel pressure sore on 05/11/11 and documented an assessment on 05/13/11 and 05/20/11. S12/LPN Treatment Nurse indicated the right heel pressure sore had a blister and it was not measured. In interview on 05/23/11 at 11:14am, S21/LPN indicated she completed the initial nursing history and assessment on 05/10/11 and did not remember the resident having a pressure sore to the right heel. In interview on 05/23/11 at 12:26pm, S2/DON indicated an assessment of the resident ' s right heel pressure sore should have been performed and documented by a registered nurse within 24 hour of admission to the facility. In interview on 05/23/11 at 12:51pm, S17/RN, Second Floor Unit Manager indicated he assessed the resident's right heel pressure sore on 05/11/11, but did not document the assessment. In interview on 05/23/11 at 2:13pm, S2/DON indicated that residents with pressure sores should have weekly skin assessments documented and she was not able to find a weekly skin assessment for resident #274. S2/DON indicated there was no documented evidence a registered nurse had assessed the resident ' s right heel pressure sore since being admitted to the facility. Resident #188 Documentation on the Multi Wound Chart dated 04/19/2011 (obtained from the hospital) revealed Resident #188 was transferred back to the nursing facility on 04/22/2011 with an unstageable Pressure Ulcer to the right buttock , measurements 02x1 centimeters 1.57 necrotic tissue, left foot great toe metarsal head, diabetic ulcer 4.5 x4.5, centimeters 15.9 deteriorating eschar. Review of Resident #188 ' s Admit Orders dated 04/22/11 and Initial Nursing History assessment dated [DATE] revealed the following diagnosis ; [MEDICAL CONDITION], Right Below Knee Amputation, and Diabetic Mellitus. The Admit note dated 04/22/11 revealed Resident #188 stump was wrapped in an ace bandage, Stage 11 decubitus to the right cheek, and stage 111 decubitus ulcer on the left cheek, treatment Xenederm. Resident #188's Initial Skilled Nursing Notes dated 04/22/2011 revealed dime size decubitus bilateral top of butt checks. Left great toe gone, left great toe amputated, necrotic tissue, 2nd left toe, top of third toe necrotic midway. Have contractures, receiving preventative skin care. Review of Resident #188 ' s Initial Plan of Care dated 04/22/11 revealed tissue impairment Sacral Decubitus right and left buttocks. Review of Resident #188 ' s Braden Scale for Predicting Pressure Sore Risk dated 04/22/11 revealed a score of 11 (eleven) indicating Resident #188 was a high risk for developing pressure ulcers. Record review revealed the initial Wound Assessment of Resident #188's right below knee surgical wounds was not done timely. Review of the Initial Wound Assessment Detail Report revealed the Assessment was done by the LPN on 04/25/11 (3 days after the resident was readmitted back to the facility). The facility failed to have documented evidence indicating staff assessed and monitored Resident surgical wounds (BKA) and pressure Ulcers (Sacral area) as indicated per physician orders. In review of the facility ' s policy and procedure for Wound Prevention protocol (dated 12/13/10) revealed residents will be assessed daily for reddened areas or any alteration in skin, feet, heels, between skin folds and contracted extremities daily by the Charge Nurse and Certified Nurse ' s Aides. Resident #188's Physician Orders for readmitted d 04/22/11 revealed the following orders : [MEDICAL TREATMENT] MWF, wound care evaluation to the right foot left foot and sacral decubitus, low air mattress, change position every 2 hours, apply Xenoderm dressing twice a day to Sacral Area andas needed for contamination. Physician Orders dated 04/25/2011 at 1213 revealed left foot medial great toe and heel apply [MEDICATION NAME] soaked gauze, wrap with kerlix every other day. Review of Resident #188 ' s History and Physical dated 3/29/11 revealed Resident #188 was allergic to iodine and [MEDICATION NAME]. Further review of Resident #188 ' s initial nurses ' assessment dated [DATE] revealed the resident was allergic to [MEDICATION NAME] and iodine. Record review revealed the facility had documented evidence indicating [MEDICATION NAME] soaked gauze was applied to Resident #188; s left heel and toe twice a day from 04/25/11 through 04/26/11. The facility had no documented evidence indicating Resident #188 ' s physician was notified and clarification obtained from the physician concerning the use of [MEDICATION NAME] for a resident who is allergic to iodine and [MEDICATION NAME]. he facility had no documented evidence indicating the air mattress was obtained and placed on the resident ' s bed as ordered by the physician. In interview on 05/19/2011 at 4:30pm S7 (LPN) indicated she admitted Resident #188 on 04/22/11. The LPN (S7) indicated she was not sure if the air mattress was obtained because the resident was admitted on a Friday afternoon and central supply staff was not present. In addition the treatment Nurse indicated the treatments are done by the treatment nurses. After reviewing Resident #188 ' s medical record the LPN (S7) indicated she did not know why air mattress were not documented. In interview on 05/23/2011 at 10:30am the Administrator (S1) indicated the facility did not have a specific policy for wound assessments. The facility had no documented evidence indicating Xenoderm dressing was applied twice a day to Resident #188 ' s Sacral area as ordered by the physician.. In interview on 05/19/11 at 10:00am the S12 (LPN) indicated Resident #188 was admitted to the facility on a Friday (04/22/11) and she was not informed the resident had a pressure ulcer. In addition S12 (LPN) indicated the treatments appearing on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The LPN (S12) indicated she did not know Resident #188 had a pressure Ulcer on the sacral area and she could not locate documentation indicating the physician orders for wound care with Xenoderm was followed. Review of the Nurses Notes obtained from the hospital and dated 04/26/11 revealed patient uncomfortable complain of pain in left foot and right leg. Patient has left foot ulcer with gangrene and multiple decubitus on hips and sacrum. Resident # 246 Record review of the admit orders revealed resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the admit orders revealed [MEDICATION NAME] was order to be place on the sacrum two times a day and prn (as needed). Record review of the Initial Nursing History & assessment dated [DATE] revealed a stage 2 decubitus to the sacral area, but there was no documentation that the staging was done by a Registered Nurse (RN). Record review of the Wound Assessment Form dated 4/22/2011 revealed the first staging of the pressure ulcer by a Registered Nurse. (2 days later after admission). Record review of the Wound Assessment Form dated 4/29/2011 and 5/20/2011 revealed the staging of the pressure ulcer was performed by a Licensed Practical Nurse (LPN). (not by a Registered Nurse) Record review of the Wound Assessment Form dated 5/6/2011 and 5/13/2011 revealed no documented evidence the resident ' s pressure ulcer was stage and measured by a Registered Nurse. During an interview on 5/23/2011 at 12:15pm with S2, Director of Nursing (DON), she indicated that the Registered Nurse should stage and assess the pressure ulcer within 24 hours of admit. The surveyor asked for the facility ' s policy on pressure ulcer to review. An interview on 5/23/2011 at 1:35pm with S2, Director of Nursing (DON) indicated she did not have a policy on the process that included who should stage and measure the pressure ulcer.

Based on observation, record review, and interview facility failed to ensure a resident received an accurate, complete and on-going assessment of the resident ' s skin by: 1) failing to conduct a complete and accurate initial assessment on a resident high risk for skin breakdown, and 2) failing to conduct an accurate and complete body audit, and on-going skin assessments which includes monitoring for changes in skin condition during routine care, was identified in 1 of 7 (#271) Stage 2 sampled residents reviewed out of 9 total residents, who had pressure ulcers in the facility. The deficient practice resulted in actual harm when the facility failed to initially assess and discover a Stage 3 pressure ulcer to the resident ' s left heel and monitor the resident ' s skin condition after staff noted skin impairment on admission which lead to 2 Stage 2 pressure ulcers on the resident ' s sacrum, which resulted in the resident ' s not receiving the appropriate interventions, treatment or progress towards healing for 5 days past admission to the facility. The facility failed to have a monitoring system in place which would ensure all residents receive accurate assessments. Findings: Resident #271 Review of local hospital Discharge Summary and Physician Transfer Orders dated 5/10/2011 revealed several notation of the resident having a left heel ulcer, there was no mention of redness to the buttock. Review of the resident's Initial Nursing History and assessment dated [DATE] under skin condition revealed no mention of a left heel impairment or redness on buttocks. Further review of the Interim Care Plan dated 5/11/11, revealed a notation of tissue impairment on left heel and red buttocks. Review of the Physician order [REDACTED]. An interview on 05/20/11 at 9:45am with S5RN Unit Manager stated that when the admitting nurse tried to assess the resident, the resident refused to take off his heel protector. She further stated that his family left a note on her door indicating that resident # 271 has a pressure ulcer to the left heel and that he did not want any nurse to change his dressing. She further stated that on 05/17/11, she decided to call the doctor and tried to make an appointment with the resident's Podiatrist, who treated the resident's left foot. She further indicated that the resident received treatment yesterday (05/19/11) at the doctor ' s office. S5 RN acknowledged that she reviewed the note from the weekend nurse on 5/17/11. An interview on 05/20/11 at 10:10am with the resident's family member, who is a nurse, revealed that she left a note for the unit manager because she did not think that the facility knew that the resident had a foot ulcer. She further indicated that she was informed on Monday (05/16/11) or Tuesday (05/17/2011) (she could not remember the exact date) by the evening nurse that the resident had an ulcer to his sacral area. The resident ' s family member recalled that the area (sacral) was red but was not open. An observation on 05/20/11 at 11:20am was conducted with S12LPN Treatment Nurse, who measured the pressure ulcer to the left heel. The appearance of the outer skin was intact, wound bed yellow, with no drainage, and measured 1.4 cm x 1.5cm x 0. The wound was characterized as a stage 3. Two open areas to sacrum measured 0.5cm x 0.5 stage 2 and a left inner buttock stage 2 measured 0.4cm x 0.6cm. The measurements and staging of these pressure ulcers where done by the LPN. On 05/20/2011 at 12:00 noon, an interview was conducted with S22 LPN, who was the nurse for the resident on 05/12/2011 during the 7:00am through 3:00pm shift and the working today (05/20/2011). She indicated that she though the resident had boots on for the prevention of pressure ulcers. She stated that she was not aware that the resident has a pressure ulcer. An interview on 5/23/11 at 5:15pm with S13LPN revealed that she was a new nurse and graduated 3 months ago. S13 LPN reviewed the resident's medical record and acknowledged the resident's admit assessment was inaccurate. S13LPN indicated that she noted the heel protector on the left foot and a vascular boot on the right foot. She indicated that she did not notice that the resident had a dressing on the left foot. S13LPN further indicated that the order for wound consult was not followed and the resident was not referred for wound care consultation. Record review revealed that the resident was admitted on [DATE] with Left heel ulcer and red buttock. The resident was not assessed and treated for [REDACTED]. The there is no description of the ulcers until Friday 5/20/11, which were measured and staged by the LPN. Review of the daily Nurses' Note from 5/11/2011-5/20/11 revealed no mention of the resident's skin impairment.