Monette Manor, Llc

Based on record review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure fall interventions were placed in a person-centered care plan following falls for five (Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9) of seven residents reviewed for fall interventions in a person-centered care plan.
The findings include:
Resident #4:
A review of Resident #4's admission Record indicated the facility admitted the resident on 02/13/2024 with diagnoses which included a nondisplaced fracture of coracoid process, right shoulder (broken part of the shoulder blade), multiple rib fractures to the right side, and a wedge compression fracture of the T7-T8 vertebra (fracture to the middle of the spine).
A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/2025, revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. Resident #4's MDS also revealed the resident required partial/moderate assistance with transfers and was dependent when using a wheelchair.
A review of a facility, Incident by Incident Type, with a date range of 10/01/2024 to 10/31/2024, revealed Resident #4 had a witnessed fall on 10/29/2024.
A review of Resident #4's Care Plan, revised on 02/14/2024, revealed the resident had an actual fall and was a high risk for falls, related to a history of falls. Resident #4 did not have an intervention for the fall that occurred on 10/29/2024.
Resident #5
A review of Resident #5's admission Record indicated the facility admitted the resident on 08/14/2023, with diagnoses which included muscle wasting and atrophy, lack of coordination, difficulty walking, hemiplegia and hemiparesis following Cerebral Infarction affecting left non-dominant side (weakness and paralysis following a stroke), a personal history of Transient Ischemic Attack (TIA), and Cerebral Infarction without residual deficits (mini stroke).
A review of Resident #5's significant change MDS, with an ARD of 11/28/2025, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #5's MDS also revealed the resident required substantial/maximal assistance with transfers and was dependent when using a wheelchair.
A review of a facility, Incident by Incident Type, with a date range of 10/01/2024 to 10/31/2024, revealed Resident #5 had an unwitnessed fall on 10/05/2024.
A review of Resident #5's Care Plan, revised on 12/09/2024, revealed the resident had a history of frequent falls. Resident #5 did not have an intervention for the fall that occurred on 10/05/2024.
Resident #7
A review of Resident #7's admission Record indicated the facility admitted the resident on 10/18/2024, with diagnoses which included systolic congestive heart failure (CHF) (heart cannot pump oxygenated blood out to the body) and muscle weakness.
A review of Resident #7's admission MDS, with an ARD of 11/28/2024, revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #7's MDS also revealed the resident required partial/moderate assistance with transfers and required substantial/maximum assist while using a wheelchair.
A review of a facility, Incident by Incident Type, with a date range of 10/01/2024 to 10/31/2024, revealed Resident #7 had unwitnessed falls on 10/20/2024 and 10/24/2024.
A review of Resident #7's Fall Log revealed on 10/20/2024, Resident #7 received a skin tear approximately three centimeters in length on the left elbow.
A review of Resident #7's Care Plan revised on 12/18/2024, revealed the resident was at risk for falls related to gait and balance problems. Resident #7 did not have an intervention for the falls that occurred on 10/20/2024 and 10/24/2024.
Resident #8
A review of Resident #8's admission Record indicated the facility admitted the resident on 09/17/2024, with diagnoses which included acute on chronic diastolic CHF (heart becomes stiff preventing it from relaxing and filling properly with blood between beats), weakness, and intervertebral disc degeneration in lumbar region (age-related breakdown of the spinal discs in the lower section of the spine.)
A review of Resident #8's admission MDS, with an ARD of 11/17/2024, revealed a BIMS score of 14, which indicated the resident was cognitively intact. Resident #8's MDS also revealed the resident required partial/moderate assistance with transfers.
A review of a facility, Incident by Incident Type, with a date range of 10/01/2024 to 10/31/2024, revealed Resident #8 had an unwitnessed fall on 10/29/2024.
A review of Resident #8's Care Plan, revised on 12/11/2024, revealed the resident was at risk for falls, related to gait and balance problems. Resident #8 did not have an intervention for the fall that occurred on 10/29/2024.
Resident #9
A review of Resident #9's admission Record indicated the facility admitted the resident on 07/23/2024, with diagnoses which included encephalopathy (disease that changes brain function or structure), falls, abnormalities of gait and mobility, muscle wasting and atrophy, difficulty walking, tremors (involuntary movement), and a personal history of TIA.
A review of Resident #9's significant change MDS, with an ARD of 11/17/2025, revealed a BIMS score of 06, which indicated the resident had severe cognitive impairment. Resident #9's MDS also revealed the resident was dependent with all transfers and with utilizing a wheelchair.
A review of a facility, Incident by Incident Type, with a date range of 10/01/2024 to 10/31/2024, revealed Resident #9 had an unwitnessed fall on 10/28/2024.
A review of Resident #9's Care Plan, revised on 01/20/2025, revealed the resident was at a high risk for falls. Resident #9 did not have an intervention for the fall that occurred on 10/28/2024.
During an interview on 12/30/2025 at 2:40 PM, the Registered Nurse (RN) Supervisor explained the process of Care Planning interventions for falls was that the Director of Nursing (DON) and the Restorative Certified Nurse Assistant (CNA) would determine the intervention that was placed upon the Care Plan. She confirmed that Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9's interventions for the falls that occurred for the month of October 2024 were on the Care Planned. She stated, If you didn't see them then they are not there. I was not trained and thrown in to figure it out. She explained the importance of Care Planning falls was to inform the staff if the resident had a fall and what interventions to take. She confirmed that falls were to be Care Planned when they happened. She verbalized that she was doing Care Plans prior to the current MDS Coordinator in the building. The RN Supervisor explained that the expectation of falls being Care Planned was to make sure fall care plans were up to date and had accurate interventions. She then confirmed that the MDS Coordinator was responsible for Care Planning falls and that she was the MDS Coordinator. The RN Supervisor expressed that Care Planning falls was essential for each resident for everyday life to make sure that the resident stayed safe and that the Care Plan was person specific.
During an interview on 12/30/2025 at 3:05 PM, Restorative CNA/CNA #1 explained that CNA#1 collaborated with the DON and the floor nurses and decided upon interventions that would go into the Care Plan for every resident. CNA #1 confirmed that she did not know for sure if the fall intervention for the falls that Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9 had for October 2024 were on their Care Plans. She explained that she used the Care Plan for the care of the residents, and that the importance of Care Planning falls was so staff would know what interventions the resident would have. She verified that the purpose of interventions was to keep the resident from falling again, and that falls should be Care Planned as soon as they happened. CNA #1 confirmed the MDS Coordinator was responsible for Care Planning falls and that fall interventions were Care Planned for safety.
During an interview on 12/31/2025 at 9:00 AM, the DON explained the process of Care Planning interventions was the MDS Coordinator was to put the fall interventions in the care plans. The DON verified that Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9 did not have a fall intervention for their falls within the month of October 2024. She confirmed not having these falls Care Planned would increase the risk for future falls. She expressed that the importance of Care Planning falls was to prevent future falls for residents and protect the residents. She confirmed that falls should be placed into the Care Plan. The DON confirmed that the MDS Coordinator was responsible for Care Planning falls, and that the Administrator oversaw that the person responsible was doing their job. She explained that the CNA's would look at the Kardex, in which information was pulled from the Care Plan, to care for the residents.
During an interview on 12/31/2025 at 10:44 AM, the Administrator explained that the DON and Restorative can/CNA #1 collaborated regarding interventions for falls and then communicated the interventions to the MDS Coordinator who put the interventions into the Care Plan. The Administrator verified that he was not aware of Resident #4, Resident #5, Resident #7, Resident #8, and Resident #9 not being Care Planned on the falls that happened in October 2024. He explained that the importance of Care Planning falls was to prevent future falls from happening and to protect the residents. He confirmed that falls should be Care Planned as they happened. He explained that the expectations of falls were to make sure the residents were Care Planned and interventions were in place and well documented. He then confirmed that the RN Supervisor, who was the MDS Coordinator at that time, was responsible for Care Planning falls.
On 12/30/2025 at 4:00 PM, this surveyor requested the policy and procedure for care plans from the Administrator, not provided.

Based on facility document review and interview, it was determined the facility failed to electronically transmit encoded, accurate, and complete, Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days to provide accurate and up-to-date information for quality measures for 6 (Residents #1, #2, #26, #34, #41, and #44) sampled residents whose MDS assessments were reviewed.
The findings are:
On 09/26/2024 the following observations were made in resident health records:
Resident #1 had an admission assessment with an ARD of 11/08/2023 exported but not accepted.
Resident #2 had a Significant Change assessment with an ARD 1/28/2024 that was export ready.
Resident #26 had an admission assessment with an ARD 11/5/2023 that was exported but not accepted.
Resident #34 had an admission assessment with an ARD 11/13/2024 that was exported but not accepted.
Resident #41 had an admission assessment with an ARD 3/12/2024 that was exported but not accepted.
Resident #44 had an admission assessment with an ARD of 2/07/2024 that was exported but not accepted.
Review of a facility policy titled, Chapter 5 Submission and Correction of the MDS Assessments revised December 2002 indicated Assessment Transmission: Comprehensive assessments must be transmitted electronically within 31 days of the MDS Completion date.

Based on record review, and interview, it was determined the facility failed to ensure a baseline care plan was completed with the minimum necessary information within 48 hours after admission to promote continuity of care for 1 (Resident #120) sampled resident who was admitted within the last 30 days.
The findings are:
A review of the admission Record indicated the facility admitted Resident #120 with diagnoses that included congestive heart failure, atrial fibrillation, chronic kidney disease and repeated falls.
A review of Resident #120's electronic records did not include an admission assessment on the admission date of 9/17/2024, a Minimum Data Set (MDS), or indicate a care plan had been initiated.
During an interview on 9/26/2024 at 2:14 PM, the Director of Nursing (DON) said the nurses were responsible for the assessments upon admission or readmission to the facility and responsible for the functional and abilities assessments which must be completed within 24 hours. She does the baseline care plan within 4 hours of admission. She looked in Resident #120's record and said that there was no admission assessment or care plan had been done.
A review of a facility's undated policy titled, Policy and Procedure .Comprehensive Care Plan indicated, 1. The admitting Registered Nurse will complete baseline care plan on admission within 48 hours to address the following care areas: Resident's initial goals, skin prevention, fall prevention, pain management, Advance Directives, Psychosocial Mood state and specific care plan on the main reason for admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the residents needs and preferences for 5 residents (Resident #37, Resident #13, Resident #14, Resident #220, and Resident #120) of 19 residents reviewed for care plans. The facility failed to properly assess residents and implement care plan interventions which affect the residents' highest practicable physical, mental, and psychosocial well-being.
The findings are:
1. A review of an admission Record, indicated the facility admitted Resident #120 with diagnoses that included congestive heart failure, atrial fibrillation, chronic kidney disease and repeated falls.
A review of Resident #120's electronic records revealed on 9/17/2024, an admission MDS had not been completed and a Baseline Care Plan had not been initiated. There was not a Plan of Care to document Resident #120's cognitive function, fall risk or the administration of Oxygen (O2), an anxiety medication, pain medication, a diuretic, nor the care and monitoring required related to use and potential side effects of these medications.
A review of Resident #120's Order Summary Report revealed an order dated 9/17/2024 for O2 [oxygen] at 2L (liters) per nasal cannula PRN (as needed) for SOB (shortness of breath), CP (chest pain) O2 saturation < [less than] 92% or maintenance of medical condition as needed, for SOB.
A review of Resident #120's Order Summary Report revealed an order dated 9/17/2024 for Alprazolam Oral Tablet 0.5mg (milligram), give 1 tablet by mouth every 8 hours as needed for anxiety.
A review of Resident #120's Order Summary Report revealed an order dated 9/17/2024 for Hydrocodone Oral Tabel 7.5-325mg, give 1 tablet by mouth every 8 hours as needed for pain.
A review of Resident #120's Order Summary Report revealed an order dated 9/17/2024 for Furosemide 40mg, give 1 tablet by mouth once daily related/to Congestive Heart Failure.
During an interview on 9/26/2024 at 2:14 PM, the Director of Nursing (DON) said she tries to complete- the baseline care plans within 4 hours after an admission. Currently she is responsible for ensuring the MDS is completed, and the care plans are updated since the facility does not have an MDS Coordinator. She looked in Resident #120's record and said there was no admission assessment or care plan and that needed to be corrected. The care plan should be updated with relevant interventions.
A review of a facility's undated policy titled, Policy and Procedure Topic: Comprehensive Care Plan indicated, .1. The admitting Registered Nurse will complete baseline care plan on admission within 48 hours to address the following care areas: Resident's initial goals, skin prevention, fall prevention, pain management, Advance Directives, Psychosocial Mood state and specific care plan on the main reason for admission . 2. Resident #220 had a diagnosis of osteoarthritis and [NAME] Nephropathy (kidney disease).
The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2024 indicated the resident received a score of 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and that the resident received pain medication.
Review of the Order Summary Report revealed an order dated 04/11/2024 indicated to administer Oxycodone with Acetaminophen 10-325 milligrams (mg) 1 tablet every 12 hours as needed for pain.
Review of the Order Summary Report revealed an order dated 04/11/2024 indicated to administer, Morphine Sulfate Extended Release (ER) 15 MG, 1 tablet two times a day as needed for pain.
Review of the resident's care plan with a revision date of 04/03/2024 did not address the use of the pain medication. 3. Upon review of the admission Record, Resident #37 was admitted on [DATE], with a diagnosis of altered mental status.
Upon review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 6/23/2024 revealed Resident # 37 had a Brief Interview for Mental Status (BIMS) score of 00 (0-7 suggest severe cognitive impairment). Has both verbal and physical behavioral symptoms directed toward others, and behaviors were present one to three days and ambulates per self with supervision.
Upon review of the Progress Notes, Resident #37 had multiple documented physical altercations with staff such as resident hitting, scratching, and kicking staff, the most recent on 09/22/24 where Resident #37 was urinating in a hallway, then became angry during redirection to the bathroom by staff. Resident #37 is known to have many triggers such as staff attempting to offer medications, showers, meals, redirection, or other assistance in daily care.
During an interview on 09/23/24 at 10:42 AM, Resident #67 and Resident #71 both complained about Resident #37 coming into their room often and stated they are fearful. Both residents stated they have woken up to Resident #37 in their room at night. Resident #71 stated, Resident #37 will get mad or angry when asked to leave their room.
On 09/23/24 at 10:55 AM, observed Resident #37 walking into Resident's #67's and Resident #71's room, then quickly exiting the room.
On 09/23/24 at 11:50 AM, the surveyor notified the Administrator of Resident #67 and Resident #71 complaining about Resident #37 coming into their room often, stating they don't feel safe.
Upon review of Resident #37's care plan, last revised 06/26/2024, interventions regarding the behaviors during mealtime stated resident refuses to eat, and when staff encourages, the resident becomes upset, yells and raises fist to staff, but no interventions were noted regarding monitoring for behaviors, aggression, wandering into resident rooms, hitting, anger, or irritability outside of the dining episodes. Wandering and aggressive behaviors had been present per staff interviews and documentation since admission [DATE] for Resident #37. The physical aggression towards staff continued with the resident striking staff repeatedly. Per documentation, no physical altercation had occurred with another resident at this time, but on 1/30/2024 at 4:55 PM, Resident #37 was repeatedly hitting the dining table with their fist. Another resident at the table asked him to stop leading to a verbal argument between the residents. Per documentation, staff had to intervene to prevent a physical altercation.
Per the facility's undated policy titled, Behavioral Health Services, number 2 referenced the resident's individualized behavioral health needs are met through the Resident Assessment Instrument (RAI) process. This process includes the Minimum Data Set (MDS), Care Area Assessment (CAA) process, Care plan development and implementation, and Evaluation of care plan. The facility did not meet this resident's individualized needs due to not completing assessments and the MDS in a timely manner, and not updating care plans as care areas and needs changed. In addition to not meeting the needs of the residents, and potentially putting other residents at risk due to the continued aggressive behaviors.
On 09/24/24 at 8:40 AM, during an interview- the (Interim) Director of Nursing (DON) confirmed the facility had lost the MDS Coordinator and the Director of Nursing recently which had delayed the completion of assessments and updates to the care plans. She continued to explain they do have someone hired for both positions. During the interview, the DON reviewed the care plan for Resident #37, the DON confirmed the care plan did not adequately address -Resident #37's wandering or aggressive behaviors, nor did it mention monitoring behaviors.
On 09/24/24 at 9:50 AM, during an interview with the Administrator, when asked if Resident #37 had been sent to any in-patient behavioral health facilities for stabilization, evaluation and treatment, the Administrator stated, The resident hasn't been aggressive with other residents, just staff to my knowledge, so not since they've been here. When asked if the administrator thought it was possible for Resident #37 to be physically aggressive with other residents, he stated, Yes, it's possible. During the interview, the Administrator was asked to review the current care plan (updated 6/26/2024) and particularly the area that addresses aggressive behaviors for Resident #37. As he scanned, he stated, I don't see an area where we are addressing the behaviors with interventions.
On 09/25/24 at 11:36 AM, during an interview Licensed Practical Nurse (LPN) #7 confirmed Resident #37 displays anger and irritability often, triggered by various things such as administering medications, checking his wander guard, encouraging him to eat, redirecting him from an exit, or encouraging showers. She confirmed there have been several incidents of verbal and physical aggressions she is aware of with Resident #37. LPN #7 stated, When the resident follows me for med [medication] pass, I make sure I've got eyes on him all the time because of his behaviors.
On 09/25/24 at 1:42 PM, during an interview Certified Nursing Assistant (CNA) #8 stated, This particular resident does get angry very easy, and we have to watch how we offer him care because he will hit and grab us [staff]. When asked if there are concerns of aggression with other residents and Resident #37, CNA #8 confirmed there haven't been any resident-to-resident physical altercations, but several verbal arguments where staff quickly intervened.4. A review of the Order Summary Report revealed Resident #13 had diagnoses of chronic kidney disease stage 3, retention of urine, and need for assistance with personal care.
A review of the Order Summary Report revealed an active order for a suprapubic catheter was received on 08/24/2024.
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/2024 revealed Resident #13 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
A review of the care plan initiated on 4/10/2024 revealed interventions had not been implemented for the suprapubic catheter or enhanced barrier precautions. The feeding tube interventions are missing the treatment orders and the head of the bed elevation interventions.
On 09/25/2024 at11:30 AM, observed with Licensed Practical Nurse (LPN) #5 that Resident #13 had stat lock (stabilization device for catheters) to right thigh.
On 09/26/2024 at 2:30 PM, during an interview the Director of Nursing (DON) confirmed that treatment orders and the head of the bed elevations were not implemented in the care plan. The DON then confirmed that the suprapubic catheter and interventions including treatment, size, enhanced barrier precautions, a securement device, and others were not implemented in the care plan.
A review of the Order Summary Report revealed Resident #14 had diagnoses of edema, congestive heart failure, type 2 diabetes, and blood clot of right lower extremity.
A review of the MDS with an ARD of 06/12/2024 revealed that Resident #14 scored a 13 (cognitively intact) on the BIMS.
A review of the emergency room Transfer Sheets revealed Resident #14 had been transferred to the emergency room on [DATE] to 06/12/2024, and 06/22/2024 to 07/02/2024 for the diagnosis of edema.
A review of the Order Summary Report revealed an active order as of 08/20/2024, to apply two-layer lite compression system to bilateral lower extremities every three days.
A review of the Order Summary Report revealed an active order as of 09/03/2024 to cleanse wound to right dorsal foot with normal saline. Pat dry. Use (a no-sting skin protection wipe) to peri wound. Apply nickel thick Santyl (used to help with healing skin ulcers) to wound bed then cover with calcium alginate. Cover with supra-absorbent dressing and roll gauze every day on dayshift.
A review of the Order Summary Report revealed an active order as of 06/12/2024 for Eliquis Oral Tablet (Apixaban) by mouth two times a day for blood clots.
A review of the care plan initiated on 05/30/2024 revealed that Resident #14 did not have interventions implemented for anticoagulant with blood clot interventions and wound care in the care plan. Further review revealed that the care plan was to be reviewed on 09/12/2024 but was not completed.
On 09/26/2024 at 2:30 PM, during an interview the DON confirmed that wound care interventions, and the anticoagulant with blood clot interventions were not implemented into the care plan.

Based on record review and interview, the facility failed to complete clinical assessments to accurately portray the resident's care for the Minimum Data Set (MDS) and care plan intervention implementation for 6 (Residents #2, #14, #37, #48, #70, and #220) residents of 19 sampled residents affecting their quality of care.
These are our findings:
A review of the electronic health record revealed that Resident #2 had the following overdue assessments: wandering risk assessment due on 05/02/2024, side rail assessment due on 05/02/2024, fall scale due on 05/29/2024, pain interview due on 05/29/2024, neurological check list due on 05/30/2024 at the following times 1:15 AM, 1:30 AM, 2:00 AM, and 9:00 AM, pain interview due on 07/09/2024, fall scale due on 07/09/2024, skin observation tool on 08/16/2024, and skilled charting on 09/08/2024 at 8:49 AM.
A review of the Clinical - Assessment revealed Resident #14 had the following overdue assessments: side rail assessment due on 05/30/2024, functional abilities and goals-admission due on 05/31/2024, skin observation tool due on 08/16/2024, wandering risk assessment due on 08/30/2024, pain interview due on 08/30/2024, fall scale due on 08/30/2024, Patient Health Questionnaire (PHQ)-9 due on 09/01/2024, and Brief Interview for Mental Status (BIMS) Assessment due on 09/04/2024.
A review of the electronic health record revealed Resident #37 had the following overdue assessments: pain interview due on 06/13/2024, fall scale due on 06/19/2024, scale for predicting pressure sores risk assessment due on 06/19/2024, side rail assessment due on 06/19/2024, skin observation tool due on 08/16/2024, Brief Interview for Mental Status (BIMS) assessment due on 09/13/2024, Patient Health Questionnaire (PHQ)-9 due on 09/13/2024.
A review of the electronic health record revealed Resident #48 had the following overdue assessments: side rail assessment due on 05/06/2024, interim care plan due on 05/06/2024, admit/readmit screener due 05/07/2024, functional abilities and goals assessments due on 05/07/2024, wandering risk assessment due on 08/07/2024, skin observation tool due on 08/16/2024, pain interview due on 09/05/2024, fall scale due on 09/05/2024, MORSE fall scale due on 09/09/2024, pain interview due on 09/09/2024.
A review of the Clinical - Assessment revealed that Resident #70 had the following overdue assessments: admit/readmit screener due on 03/20/2024, scale for predicting pressure sore risk assessments due on 06/19/2024, wandering risk assessment due on 06/19/2024, side rail assessment due on 06/19/2024, Brief Interview for Mental Status (BIMS) Assessment due on 09/02/2024.
A review of the Clinical - Assessment revealed that Resident #220 had the following overdue assessments: fall scale due on 04/17/2024, side rail assessment due on 04/27/2024, pain interview due on 07/16/2024, wandering risk assessment due 07/17/2024, skin observation tool on 08/16/2024.
On 09/24/2024 at 10:09 AM, during an interview the Director of Nursing (DON) stated she had worked here for seven years and came back after the tornado and rebuild, about 22 months ago and was named the Assistant Director of Nursing (ADON). The DON stated that she completes admissions, does Infection Preventionist duties including rounding with wound Advanced Practice Registered Nurse (APRN). The DON stated she is helping to complete the Minimum Data Sets (MDS) and care plans since the MDS nurse left 8/14/2024. The MDS Consultant assists with advising her of the MDS tasks to complete because she isn't familiar with MDS and completely how it works. When asked who was responsible for completing the resident assessments, the DON stated, The nurses on the floor complete them as they can complete them.
On 09/26/2024 at 9:30 AM, during an interview the Social Director stated that the MDS does assessments, I do quarterly, annual, and discharges and social history. She was not sure who did the assessments that are currently overdue.
On 09/26/2024 at 2:30 PM, during an interview the DON stated that she was responsible until there was an MDS Coordinator for section C and the BIMS and that the Social Director is responsible for section D and the PHQ9 for the assessments.

Based on observations, interviews, and record review, the facility failed to follow the menu for pureed diets for the lunch service.
The findings are:
On 09/26/2024 at 11:50 AM, Dietary Aide #2 was overheard stating they did not puree white beans.
On 09/26/2024 at 12:10 PM, the Surveyor observed that while plating the pureed trays during lunch that the resident's received pureed pork chop, pureed turnip greens, puree cornbread, and pureed banana crème pie for dessert, an alternate was not observed for the white beans.
On 09/26/2024 at 2:11 PM, during an interview the Assistant Dietary Manager stated that yesterday for lunch the puree diets should have got pork chops, turnip greens, white beans, cornbread, and banana crème pie. The Assistant Dietary Manager continued stating that they were not aware until later that the pureed white beans were not served with the lunch meal. The Assistant Dietary Manager stated that Dietary Aide #2 had come to them and explained that she had forgotten to puree the white beans for lunch service. The Assistant Dietary Manager then stated that it was important to follow the menus to ensure residents are getting proper nutrition.
On 09/26/2024 at 2:31 PM, during an interview the Director of Nursing (DON) stated following a menu is important with some residents who have swallowing issues, diabetic or other diets that need to follow.
A review of the menu revealed for puree diets the following should have been received during the lunch service on 09/25/2024: pureed pork chop, pureed white beans, pureed turnip greens, pureed cornbread, and pureed banana creme pie.
On 9/27/2024 at 3:00 PM, the Assistant Dietary Manager stated the facility did not have policy for Menus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, the facility failed to report 3 of 3 incidents of resident-to-resident abuse reviewed, failed to report an unwitnessed fall with serious injury, and failed to complete a thorough investigation of the incidents.
The findings are:
1. A review of an admission Record indicated the facility admitted Resident # 46 with diagnosis Dementia, Severe with other Behavioral disturbance.
The quarterly Minimum Data Set with an Assessment Reference Date 6/27/2024 revealed Resident # 46 had a Brief Interview for Mental Status (BIMS) score of 01 (0-7 suggest severe cognitive impairment). In Section E0200. Behavioral Symptoms revealed Physical behavioral symptoms directed towards others and B. Verbal behavioral symptoms directed towards others.
A review of nursing Health Status Note dated 8/16/2024 at 8:04 revealed Resident was aggressive and combative toward another resident. Resident being sent to ER (Emergency Room) for evaluation. (family member) notified and report called to (Name of hospital) ER.
During an interview on 9/25/2024 at 10:54 AM Certified Nurse Aid (CNA) # 1 said she was in the dining room when Resident # 46 hit another resident. She said it happened very fast and resident was immediately separated from the other resident. The Director of Nurses (DON) came into the dining room and quickly assessed both residents.
During an interview on 9/26/2024 at 4:30 PM, The Administrator said he didn ' t file a report to the State Office of Long-Term Care because the incident lasted a few seconds and neither resident was hurt. A video of the incident was shown to the surveyor by the Administrator. Resident # 46 was observed seated in adjustable chair at the assisted table, when Resident # 120 scooted the adjustable chair over to another resident, pulled the hair of that resident and slapped at the top of the resident ' s head twice before the Dietary Manager could separate them. CNA # 1 was observed removing resident was removed.
The Dietary Manager was unavailable for interview.
2. Upon review of the admission record, Resident #48 was admitted on [DATE] with diagnoses of dementia and generalized weakness due to previous stroke.
The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 6/24/2024 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 02 (0-7 suggest severe cognitive impairment). Resident #48 required set up assistance for meals, and 1to 2 staff assistance for transfers. used a manual wheelchair for mobility.
No Incident & Accident (I&A) reports were provided. Upon review of an I&A progress note dated 07/10/2024 at 11:32 PM, revealed the resident had an unwitnessed fall from a wheelchair in the hall. The facility's nursing staff assessed Resident #48. Resident #48 had a skin tear to the right elbow and complained of right hip pain. The Director of Nursing (DON), provider, and family were notified per documentation. Resident #48 was transported via ambulance to a local hospital for evaluation and treatment. Upon review of the hospital records, it was determined Resident #48 sustained a fracture to the right hip which required surgical repair.
During an interview on 09/24/24 at 03:28 PM, the Administrator stated he didn't file a report to the State Office of Long-Term Care because the incident was originally reviewed via video and staff responded quickly to assist the resident after the fall. Since a video was reviewed, the Administrator didn't view it as an unwitnessed fall. There were no witness statements available or documentation of an investigation determining the cause of the fall with major injury. The video was unavailable for review when requested due to the incident being over 60 days ago.
3. Upon review of the admission Record, Resident #71 was admitted on [DATE] for a diagnosis of left hip pain and initially for rehabilitation, and assistance with abnormal gait.
The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date 8/04/2024 revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggests that cognition is intact). Resident #71 requires set up assistance for meals and was independent with transfers. The MDS reflects Resident #48 used a walker to assist with mobility.
Upon review of a progress note dated 01/14/2024 at 5:15 PM, Resident #71 was involved in a resident-to-resident altercation with the roommate at that time.
During an interview on 09/26/24 at 10:42 AM, Resident #71, and was notified of an incident that was not reported during our initial encounter on 09/23/2024. Resident #71 reported physical altercation where the roommate choked, scratched, and hit Resident #71 due to an argument about a light being turned on. Resident #71 stated, I took a video of the attack because this other roommate was always threatening me. The staff intervened and moved me to a different room afterwards. I showed the video to the girls (staff) that helped me.
During an interview with Certified Nursing Assistant (CNA) #8 on 09/26/24 at 1:42 PM, she stated she was one of the staff that assisted with this incident, and stated, she was on the north front of the hall and heard screaming and yelling. She, the nurse, and another aide ran to the back hall. We saw [Resident #71] hurrying out of the room with the roommate following close behind, cursing and hitting. (Resident #71) explained the resident turned on the light and the roommate started yelling and threatening the resident. Resident #71 showed us the video Resident #71 took on the phone of the roommate attacking Resident #71, and also the marks on (Resident #71's) neck and chest. We reported it to the DON at the time. We moved (Resident #71) into a different room.
During an interview on 09/26/24 at 2:15 PM, the Administrator stated he didn't file a report to the State Office of Long-Term Care regarding this resident-to-resident altercation because he was unaware of any injuries and was advised it was just a [NAME] between the residents. There were no I&A reports or witness statements provided. Resident #71 did not have a body audit or documentation related to any injuries or marks seen per CNA #8 interview and reported by Resident #71. No documentation was provided by the facility showing an investigation regarding the altercation.

Based on record review, and interviews, the facility failed to have an effective governing body in place to ensure proper management and operation of the facility's: Quality Assurance and Performance Improvement Plan (QAPI) feedback system to ensure resident care areas were addressed, for baseline, implementation, and revision of care plans and for timing and transmitting the Minimum Data Sets (MDS).
The findings include:
On 09/23/2024 at 11:30 AM, the survey team confirmed with the Administrator that there had not been a Minimum Data Set (MDS) Coordinator at the facility. That the previous MDS Coordinator put in her two weeks and her last day was 08/14/2024.
On 09/23/2024 at 4:00 PM, the survey team confirmed during record review for initial pool that there was a widespread issue with MDS timing and transmitting, and care plan implementation.
On 09/24/2024 at 3:00 PM, during an interview the Administrator stated, We do have the Director of Nursing (DON) and the MDS new hires starting in the next week or so and that should help us get caught up on anything we are behind on completing. He stated the previous MDS nurse that left 8/14/2024, was still learning MDS and the MDS Consultant was assisting her as needed via contract work. At this time the Assistant Director of Nursing (ADON) is assigned those duties. When asked what other duties is the ADON assigned, he responded, admissions, Infection Preventionist, assessments, ADON/DON duties, and MDS/care plans.
On 09/26/2024 at 2:30 PM, during an interview the Administrator stated that feedback systems were usually done by doing routine meetings. The Administrators stated, The current feedback system is not working, I have noticed this with the concerns that are being brought to me this week. The Administrator then stated, For the last year we have been in admissions mode with our QAPI we need to make the switch to involve more resident concerns. The Administrator then stated that their governing body duties were up to him to make sure we have staff, the supplies needed, and he takes personal responsibility for interviews and CNA scheduling. He tries to make sure each department lead has what they need to adequately perform their jobs and for each department he helps out with areas that may need assistance.
On 09/26/2024 at 2:40 PM, during an interview the Director of Nursing (DON) stated that for the governing body involves the interdisciplinary team, me, administrator, business office manager, medical director and therapy.
A review of the facility policy titled, Governing Body stated, .2. The governing body appoints the Administrator who is licensed by the State and is responsible for the management of this facility. The Administrator reports to and is accountable to the governing body. The governing body determines the process and frequency for communications and reports between itself and the Administrator. 3. The governing body is responsible and accountable for this facility's Quality Assurance and Performance improvement (QAPI) program.
A review of the MDS [Minimum Data Set] Coordinator - Job Description revealed that the staff member was in charge of completing all MDSs and Care Area Assessments (CAAs), schedules and leads the Care Plan Conferences, transmit completed MDS assessments to the state in compliance with federal regulation, completes, or ensures that the Unit Nurses can complete special quarterly assessments, and writes all chronic nursing care plans for all residents in the facility and monitors acute nursing care plans.
A review of the document titled, Job Description - Administrator revealed the Nursing Home Administrator Duties are planning, organizing, directing, and evaluating the overall operation of a nursing home facility. Developing and implementing policies and procedures. Ensuring compliance with state and federal regulations.

Based on record review, and interviews, the facility failed to ensure qualified staff was hired in a position to accurately encode, transmit, and implement assessments and care plans.
The findings are:
A facility review of the job description for Minimum Data Set Coordinator (MDS) revealed the staff member was in charge of completing all MDS and Care Area Assessments (CAAs), schedules, and leads the Care Plan Conferences, transmits completed MDS assessments to the state in compliance with federal regulations, completes, or ensures that the Unit Nurses can complete special quarterly assessments, and writes all chronic nursing care plans for all residents in the facility and monitors acute nursing care plans.
On 09/23/2024 at 11:30 AM, the survey team confirmed with the Administrator that there had not been an MDS Coordinator at the facility. That the previous MDS Coordinator put in their two weeks and that their last day was 08/14/2024.
On 09/24/24 at 10:09 AM, during an interview the Director of Nursing (DON) stated she had worked here for seven years and came back after the tornado and rebuild. About one year and ten months ago she was named the Assistant Director of Nursing (ADON). She stated she completes admissions, is the Infection Preventionist including rounding with wound Advanced Practice Registered Nurse (APRN). The DON stated she is helping complete the MDS and care plans since the MDS nurse left 8/14/2024. The MDS Consultant assists with advising her of the MDS tasks to complete because she isn't familiar with the MDS and completely how it works. When asked who was responsible for completing the resident assessments, the DON stated, The nurses on the floor complete them as they can complete them.
On 09/24/2024 at 3:00 PM, during an interview the Administrator stated, We do have the DON and the MDS new hires starting in the next week or so and that should help us get caught up on anything we are behind on completing. He stated the previous MDS nurse that left 8/14/2024 was still learning MDS and the MDS Consultant was assisting her as needed via contract work. At this time the ADON is assigned those duties. When asked what other duties the ADON was assigned, he responded, Admissions, Infection Preventionist, assessments, ADON/DON duties, and MDS/care plans. When asked if he thought the workload was realistic for the ADON to be successful, he responded, Probably not something she could keep up for long term.
On 09/26/2024 at 2:14 PM, during an interview the DON stated that she has had no training in MDS, and that normally a DON would be providing oversight but right now it is the MDS Consultant or the Administrator.
On 09/27/2024 at 8:36 AM, a telephone interview was attempted by the state surveyor with the MDS Consultant with no response.
On 09/27/2024 at 12:07 PM, a telephone interview was attempted by the state surveyor with the MDS Consultant with no response.

Based on record review and interview, the facility failed to ensure an effective feedback system was in place for the Quality Assurance and Performance Improvement Plan (QAPI).
The findings are:
A review of the Quarterly QAPI Minutes revealed that admissions, staffing issues, facility issues (such as the Certified Nursing Assistants (CNAs) needing smaller linen carts), ongoing staff education, shower scheduling, improving transport, and staff scheduling had been discussed. The was no mention of falls, behaviors, Minimum Data Sets (MDS), care plans or other resident concerns identified during the survey had been discussed.
A review of the Quality Assurance and Performance Improvement Plan (QAPI) Program stated, .1. Systems and reports demonstrating systematic identification, reporting investigation, analysis, and prevention of adverse events .
A review of the QAPI Committee stated, Purpose: Review all facets of the facility's operations to ensure that care and services promote the environment needed to identify issues that may impede quality of life for the residents. Implement the plan of correction to rectify these areas of concern .
A review of the Administrator Job Descriptions revealed the Nursing Home Administrator duties were planning, organizing, directing, and evaluating the overall operation of a nursing home facility. Developing and implementing policies and procedures. Ensuring compliance with state and federal regulations.
On 09/26/2024 at 2:30 PM, during an interview, the Administrator stated that when an issue arises it is usually brought to my attention from observation, staff, family or resident concerns. Then stated that when a negative trend occurs usually it is known by communication or observation. The Administrator then stated that they try to work on all the issues that they can in the building. The Administrator stated that an issue is monitored for a week to a month. The Administrator stated that in the morning stand up resident concern issues such as falls are brought up. The Administrator stated that they have not reviewed behaviors or abuse/neglect issues during QAPI. The Administrator stated that feedback systems were usually done by doing routine meetings. Administrators stated that the current feedback system is not working, I have noticed with the concerns that are being brought to me this week. The Administrator then stated that for the last year we have been in admissions mode with our QAPI we need to make the switch to involve more resident concerns.

During an observation on 09/23/2024 at 12:26 PM, CNA #1 was observed seated between 2 residents at the assisted dining table (for residents needing help with eating) in the dining room. The resident seated on the right side of CNA #1 was being fed by the CNA and the resident seated on the left side was being encouraged to eat by CNA #1.
During the observation at 12:41 PM, CNA #1 was observed feeding the resident on the right, she then picked up the spoon for the resident on the left and assisted the resident's with taking the spoon the resident's mouth, then she touched the straw and assisted the second resident with drinking, before turning back to the first resident. Hand hygiene was not performed between residents.
During an interview on 09/23/2024 at 12:45 PM, CNA #1 said she had been a CNA for 4 months and should have performed hand hygiene between residents to prevent spread of infection between residents.
An in-service for the nurses and CNAs titled, Hand Hygiene instructed by the previous DON on 09/28/23 indicated, Wash your hands or use alcohol-based hand rub before and after each resident contact to prevent infections.
A review of facility undated policy titled Infection Prevention and Control Program (IPCP) indicated that hand hygiene procedures were to be followed by staff involved in direct resident contact.
Based on observations, record review, and interview, the facility failed to ensure infection control procedures were followed by not performing hand hygiene between residents while assisting at the assisted diner table in the dining room to prevent the potential spread of infection for 2 residents observed during a lunch meal, and failed to ensure infection control procedures were followed in the areas of perineal care, catheter care, and enhanced barrier precautions to prevent the spread of infections for 1 of 1 sampled resident (Resident #13).
The findings are:
A review of the Order Summary Report revealed Resident #13 had diagnoses of chronic kidney disease stage 3, retention of urine, and need for assistance with personal care.
A review of the Order Summary Report revealed Resident #13 had an order for Enhanced Barrier Precautions active as of 08/23/2024, related to the resident having a percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that's inserted through the abdominal wall and into the stomach) and a suprapubic catheter placement (a tube that drains urine from the bladder through a small incision in the lower abdomen).
A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #13 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS).
A review of the care plan initiated on 04/10/2024 revealed interventions had not been implemented for the suprapubic catheter or enhanced barrier precautions.
On 09/25/2024 at 10:30 AM, the Surveyor observed Certified Nursing Assistant (CNA) #3 and CNA #4 enter Resident #13's room. CNA #3 and CNA #4 did not put on personal protective equipment to perform high contact care, perineal care, as stated by CNA #3.
On 09/26/2024 at 11:10 AM, the Surveyor observed perineal care with CNA #6 and the Director of Nursing (DON). The DON and CNA #6 cleaned the bowel movement first before cleaning the front half. The DON then performed wound care after changing gloves and washing hands. CNA #6 then performed perineal care for the front half, and catheter care by starting at the end of the catheter and working towards where it was inserted. The Surveyor observed debris around the insertion site after catheter care was performed and that the perineal area was covered in several red open areas. The DON stated, It was the first time she had seen the open areas. Resident #13 stated, It has been like this for a couple days and I have told staff.
On 09/25/2024 at 10:40 AM, during an interview CNA #3 confirmed that she had performed perineal care without personal protective equipment. CNA #3 stated, I know we are supposed to do that in Resident #13's room. CNA #3 then stated that they are to wear a gown and gloves in an Enhanced Barrier room to protect the staff and the residents.
On 09/25/2024 at 10:45 AM, during an interview CNA #4 confirmed that she had performed perineal care without personal protective equipment. CNA #4 then stated that she knows that they are to wear gowns and gloves in an Enhanced Barrier room to protect the staff and resident.
On 09/26/2024 at 12:15 PM, during - an interview with the DON and CNA #6. The DON stated she had performed perineal care back to front first, to be able to perform wound care for Resident #13. The DON stated that it is proper to work from front to back when performing perineal care to prevent infection to the resident. CNA #6 then stated catheter care should be performed from the top down to keep debris out of the insertion area.
A review of a facility training titled, Catheter Care, Indwelling Catheter, stated, .7. All debris must be removed from the catheter insertion site .
A review of a facility training titled, Perineal Care, indicated, 8. a. If a resident is soiled with feces, place the resident on their side and clean the perineum and rectal area.
A review of the facility policy titled, Enhanced Barrier Precautions, stated, .These precautions refer to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDROs) to staff hands .

Based on observation, interviews, and record review, the facility's administration failed to ensure the administrator was knowledgeable regarding reporting requirements, which resulted in failure to immediately report a resident to resident altercations, and an unwitnessed fall with major injury, to the State Survey Agency (SSA).
The findings are:
a. On 01/14/2024, a resident to resident altercation involving Resident #71 was not reported to the SSA.
b. On 07/10/2024, Resident #48's unwitnessed fall with major injury was not reported to the SSA.
c. On 08/16/2024, a resident to resident altercation involving Resident #46 was not reported to the SSA.
Review of the Administrator's job description provided by Business Office Manager (BOM) on 09/25/2024 indicated the nursing home administrators are responsible for managing the daily operations of long-term care facilities, including hiring personnel, developing budgets, and ensuring that the facility meets all local, state, and federal regulations.
During an interview on 09/25/2025, the Administrator was asked who was responsible for reporting verbal and physical resident to resident altercations and unwitnessed fall with a major injury to the SSA. He stated the administrator was responsible for reporting to the SSA.