Landmark of Plano Rehabilitation and Nursing Cente

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide specialized rehabilitative services for one of five residents (Resident #1) reviewed for specialized rehabilitative services. The facility failed to ensure Resident #1 received Occupational Therapy (OT), in accordance with her plan of treatment. This failure could place the residents at risk of not meeting their highest practicable well-being.Findings included: Record review of Resident #1's Face Sheet, dated 10/14/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including hypertensive heart disease with heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively), polyneuropathy (a condition where multiple peripheral nerves throughout the body are damaged or malfunctioning), and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 6 months and significantly impacts a person's life). Resident #1 was discharged to the hospital on [DATE]. Record review of Resident #1's MDS Assessment, dated 09/15/25, reflected she had a BIMS Summary Score of 12, indicating she had moderate cognitive impairment. Resident #1 was identified as using a wheelchair and was unable to walk 10 feet. Record review of Resident #1's Care Plan, dated 09/28/25, reflected she had an ADL self-care performance deficit due to her disease process and medical diagnoses. Identified goals included, .the resident will maintain or improve current level of function. Outlined interventions included encouraging Resident #1 to discuss her feelings about her self-care deficit, encouraging Resident #1 to participate to the fullest extent possible with each interaction, encouraging Resident #1 to use her call bell for assistance, etc. There were no interventions which specified the need for rehabilitation services. Record review of Resident #1's Occupational Therapy Evaluation and Plan of Treatment, dated 09/04/25, reflected her plan of treatment included occupational therapy services three times per week for 60 days, from 09/04/25 to 11/02/25. Record review of Resident #1's Occupational Therapy Discharge summary, dated [DATE] (the same day in which the Occupational Therapy Evaluation and Plan of Treatment was completed), reflected the Discharge Summary was initiated but not completed or submitted. Record review of the Provider Notice of Adverse Benefit Determination, dated 10/08/25 (provided to the surveyor following the completion of the investigation, on 10/16/25), reflected the facility requested for Resident #1 to receive Occupational Therapy Services from 09/25/25 to 11/02/25. The letter outlined, .The principal reason for the adverse determination is: The request for Therapy-OT does not meet medical necessity. and .We denied because notes should show why the skills of a therapist are needed. We are missing information about your care (a note including the onset date(s) of the condition being treated). Please send this information if care is needed. During an interview with the Director of Therapy on 10/14/25 at 1:00PM, he stated he had been the interim Director of Therapy since 10/03/25. He stated he did not provide services for Resident #1, but based on her medical records, it appeared as though she received an evaluation for Occupational Therapy the day after her admission to the facility. Resident #1 was recommended to receive Occupational Therapy, per the recommendations of the evaluation. The Director of Therapy stated Resident #1 did not receive Occupational Therapy. He stated an Occupational Therapy Discharge Summary was initiated (but not completed) on the same day as the evaluation was completed, but he did not know why this was done. He stated he did not know why Resident #1 did not receive Occupational Therapy services as recommended. The Director of Therapy stated the individual who completed the Occupational Therapy Evaluation and Plan of Treatment, as well as initiated the Occupational Therapy Discharge Summary, was currently unable to be reached due to being out of the country. The Director of Therapy stated the risk of a resident not receiving therapy services included no progression in their skills and abilities. A policy related to rehabilitation services was requested by the Administrator on 10/14/25 at 1:30PM but was not provided. Per the Administrator, the facility did not have a policy related to rehabilitation services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance.<BR/>The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care.<BR/>The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he would address the issue with showers and staffing. The Administrator stated lack of enough staff would affect the resident's quality of life. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure residents had the right to formulate an advanced directive for 3 (Resident #1, Resident #2 and Resident #3) of 8 residents reviewed for Advanced Directives.The facility failed to ensure that Resident #1, Resident #2 and Resident #3's OOH-DNR (Out of Hospital-Do Not Resuscitate) were completed correctly with both signatures of the resident/family and that it was signed by a physician making the forms invalid.This failure could affect all residents who have implemented an Advanced Directive and established their choice not to be resuscitated at the risk of receiving CPR (Cardiopulmonary Resuscitation) against their wishes.Findings included:Record review of Resident #1's face sheet dated [DATE] revealed he was admitted to the facility on [DATE] and was [AGE] years old. His diagnosis included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Side, (paralysis to one side of the body caused by a stroke), Type 2 Diabetes and Hypertension (high blood pressure). Resident #1's electronic face sheet reflected he was a Code Status: DNR.Record review of Resident #1's MDS (Minimum Data Set) dated [DATE] reflected he scored a 15 on his BIMS (Brief Interview of Mental Status) indicating no cognitive impairment. Resident #1's needed extensive assistance with bed mobility, transfers and limited assistance with eating and toileting. Record review of Resident #1's undated care plan revealed, Focus: he had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR, Date Initiated: [DATE] Record review of Resident #1's DNR dated [DATE] revealed it had been signed by the resident at the top of the form but did not have his second signature at the bottom of the form where all who signed must sign twice to make the document valid. In an interview on [DATE] at 3:10 pm. Resident # 1 stated he did not want CPR if his heart stopped and that he had a DNR in place already.Record review of the Code Status list that was generated from PCC provided by the facility revealed that Resident #1 was not listed on the document. Record review of Resident #2's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her diagnosis included Unspecified Dementia, Unspecified Atrial Fibrillation (a condition in which the heart beats irregularly and often too fast), Hypertension (high blood pressure) and Muscle Wasting. Resident #2's electronic face sheet revealed she was a Code Status: DNR.Record review of Resident #2's Quarterly MDS dated [DATE] reflected that she scored a 3 on her BIMS indicating severe cognitive impairment. Resident # 2 needed supervision with toileting and dressing, moderate assistance with bathing and set up only for eating. Record review of Resident #2's undated care plan revealed, Focus: she had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR. Date Initiated: [DATE] Record review of Resident #2's DNR dated [DATE] revealed it had been signed only once by the resident's representative at the top of the form and is missing the second signature and the physician at the bottom of the form to make it a valid document. Record review of Resident #3's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her diagnosis included Alzheimer's, Type 2 Diabetes and Hypertension (high blood pressure). Record review Resident #3's Quarterly MDS dated [DATE] reflected that she scored a 00 on her BIMS, indicating she was unable to participate. The staff interview was conducted and indicated she did not know the current season, location of her room, staff names/faces or that she was in a nursing home. Her cognitive skill for making daily decisions was severely impaired. Record review of Resident #3's undated care plan revealed, Focus: she had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR. Date Initiated: [DATE] Record review of Resident #3's DNR dated [DATE] revealed it was missing the first witness signature and it was signed by a Family Nurse Practitioner, and not the attending physician which the form indicates, to make it a valid document. Record review of the Code Status list that was generated from PCC provided by the facility revealed that Resident #1 was not listed on the document. In an interview on [DATE] at 3:35 PM, LVN A stated he has been at the facility for 2 months. When he needs to know the code status of a resident, he checks the system (PCC) to see what the code status is. He stated the risk to the residents for not following their wishes about their code status is it would affect their health.In an interview on [DATE] at 4:02 PM, ADON B stated that the social worker normally looks at the DNR's but since they don't have one at present, she does it. She stated she was unaware that 3 of the DNR's had not been filled out correctly. She stated the risk to the residents would be negligent on the part of the facility.In an interview on [DATE] at 4:25 PM, the DON stated he was not aware the DNR's had not been completed correctly and that he and the ADON check the documents for accuracy. He did not know why Resident #1's name was missing from the Code Status list since there was an order in the chart. He stated the risk to the residents was the facility would not fulfill their wishes. Record Review of the facility's Advanced Directive undated policy, Do Not Resuscitate Order revealed in part, Procedure: Texas Out of Hospital DNR Form 1. Any resident may initiate an Out of Hospital DNR Order.2. If the resident is capable of providing informed consent for the order, he/she will sign and date the DNR order on the front of the official DNR form from the state of Texas.5. In all cases the form must be signed and dated by two witnesses. Record review of the OOH DNR Order instructions for issuing and OOH-DNR Order revealed the following: Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: . In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (Resident #1) of six residents reviewed for decent living environment. 1. The facility failed to ensure Resident #1 had access to her bathroom. This failure could place residents at risk for diminished quality of life due to a lake of a well-kept environment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy level), Impulse Disorder (Inability to resist strong urges), and Cognitive Communication Deficit (Communication difficulty). Record review of Resident #1's Quarterly MDS Assessment, dated 05/01/25, reflected Resident #1 had a BIMS score of 03, which indicated Resident #1 was severely impaired. In an observation and interview on 07/18/25 at 5:18 PM, Resident #1's bathroom in her room was locked. The Maintenance Director stated the bathroom was locked, because Resident #1 put all items down the toilet like clothes and briefs. He stated her toilet caused other toilets in memory care to back up in the memory care unit. In an interview on 07/18/25 at 6:50 PM, the DON stated Resident #1's bathroom was locked, because she had a behavior of throwing things down the toilet. She stated the door was locked to prevent flooding in the memory care unit. The DON stated the staff took her to the community restroom in the memory care unit if Resident #1 needed to use the bathroom. The DON stated the memory care unit community bathroom was locked, but the staff were able to unlock the community bathroom door. The DON stated she felt there was no risk since it was for Resident #1's safety and it prevented plumbing issues. In an interview on 07/18/25 at 8:10 PM, the Corporate Nurse stated the Administrator was suspended and no longer in the building. He stated Resident #1's bathroom was unlocked and would be cleaned for use. He stated he did know about the risks, but stated Resident #1 should have had access to an unlocked bathroom. Record review of the facility's undated policy, titled, Resident Rights, reflected the following: Resident Rights A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-- A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported no later than 2 hours if the events that caused the allegation did involve abuse or serious bodily injury to HHS, for 1 of 1 resident (Resident #1) reviewed for abuse, neglect, exploitation, or mistreatment. The facility failed to report to HHS within two hours, when a staff member reported CNA A spoke rudely and pushed Resident #1 down the memory care hallway on 07/05/25. This failure could place residents at risk of abuse or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy level), Impulse Disorder (Inability to resist strong urges), and Cognitive Communication Deficit (Communication difficulty). Record review of Resident #1's Quarterly MDS Assessment, dated 05/01/25, reflected Resident #1 had a BIMS score of 03, which indicated Resident #1 was severely impaired. In an interview on 07/18/25 at 11:45 AM, the Administrator stated he was informed by a Charge Nurse who worked in memory care, that CNA A allegedly abused a resident on 07/05/25. He stated he was told that CNA A spoke rudely to the resident. He stated he suspended CNA A, who allegedly abused Resident #1, and he stated he started an investigation. The Administrator stated he did not find any evidence of abuse. He stated Resident #1 was assessed and did not have any bruises, marks, or injuries, and he stated Resident #1 did not have an outcry of abuse. The Administrator stated he did not report the allegation to HHS, because it was not an abuse issue but a customer service issue. The Administrator stated CNA A was in-serviced on customer service. The Administrator stated he felt there was no risk of not reporting the allegations, because it was a customer service issue. In a telephone interview on 07/18/25 at 1:23 PM, CNA A stated she worked the 2:00 PM to 10:00 PM shift on 07/05/25. She stated she could hear someone beat on the door while she sat at the nurse's station. CNA A stated she had worked for years at the facility and was very familiar with Resident #1, so when she saw it was Resident #1 who made the noise, she went to calm her. She stated the staff knew to take Resident #1 to the back of memory care, to the sunroom area, where she was not around other residents, and had the opportunity to calm down. CNA A stated Resident #1 stated she wanted a snack and to use the bathroom. CNA stated Resident #1 was calm after she received a snack and had a trip to the bathroom. CNA A stated she never yelled, grabbed, pushed, pulled, or harmed Resident #1. CNA A stated she walked arm in arm with Resident #1 like she did often. CNA A stated she was trained on how to redirect residents in memory care, as well as on abuse and neglect. She stated three types of abuse were verbal, physical, and sexual. She stated she had never abused a resident, never witnessed any abuse at the facility, and would tell the abuse coordinator if she witnessed any type of abuse. In a telephone interview on 07/18/25 at 1:35 PM, the CNA Trainee stated she and the Charge Nurse went to the vending machine, and when they returned CNA B told them she did not like how that girl treated Resident #1. The CNA Trainee stated CNA B told them CNA A was very stern with Resident #1. The CNA Trainee stated CNA B told them CNA A forced Resident #1 down the hallway toward the sunroom. The CNA Trainee stated Resident #1 would yell loudly at times and had psychiatric issues. The CNA Trainee stated Resident #1 had to be redirected often. The CNA Trainee stated she did not witness the incident. She stated it happened while she and the Charge Nurse left to go to the vending machine. In a telephone interview on 07/18/25 at 1:45 PM, the Charge Nurse stated she was not in memory care to witness the incident. She stated was gone to the vending machine with the CNA Trainee. The Charge Nurse stated when they returned to the memory care unit CNA B told them she did not like how CNA A talked to Resident #1. The Charge Nurse stated at the time of the complaint, CNA A was in the bathroom with Resident #1. The Charge Nurse stated once they were finished, she asked CNA A to leave for the day. She stated CNA A was suspended, but she was not sure how long it was before she returned to work. She stated CNA B called and told the Administrator about the incident. In an interview on 07/18/25 at 5:18 PM, Resident #1 stated she could not think of any staff who were rude to her, and she stated she felt safe in the facility. Resident #1 stated she could not remember any staff member by name. She stated she could not remember any incidents were someone pulled her by the arm. In an interview on 07/18/25 at 6:18 PM, the DON stated she became aware of the abuse allegations the same day it happened on 07/05/25. She stated the staff had already notified the Administrator of the allegations. She stated CNA A was suspended, and the Administrator did an investigation. She stated she was not aware he did not report the abuse allegations to HHS. The DON stated she felt there was not a risk of the Administrator not contacting HHS, because he did his own investigation and found it to be a customer service concern and not abuse. Record review of the facility's policy, dated 03/29/18, titled, Abuse/Neglect, reflected the following: A. Reporting1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused. neglected. exploited. mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours., the Abuse Preventionist and/or designee will be called.3. Facility employees must report all allegations of abuse. neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19.a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Resident #1, Resident #2 and Resident #4) of seven residents reviewed for treatment/services for pressure ulcers.<BR/>1. The facility failed to ensure Resident #2, who had a pressure ulcer on his coccyx, had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/18/25. <BR/>2. The facility failed to ensure Resident #3 and Resident #4 had a functioning low air loss mattress available to use to promote healing of their sacral wounds on 06/18/25. <BR/>3. The facility failed to ensure Resident #3 wound dressing was changed daily as per orders.<BR/>These failures placed residents at risk of developing new or worsening pressure ulcers.<BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. <BR/>Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. <BR/>Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. The wound care NP's note also reflected a summary of previous visits:<BR/>- 04.11.25: Pt admitted to facility 04.08.25 under hospice services. Pressure injury to coccyx and wounds of undetermined etiology to right toes 1-5. Pt on air mattress .Continue pressure offloading and incontinence management.<BR/>-05.28.25: .Pt tolerated debridement of coccyx wound. No s/s of infection noted . Air mattress in place.<BR/>-06.06.25: Wounds stable. Tolerated debridement of coccyx wound without complications. <BR/>-06/13/2025: Coccyx pressure injury stage 4 stable. Wound debridement tolerated. Recommend continuing offloading and frequent repositioning while in bed.<BR/>Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: May have pressure relieving mattress every shift (start date 04/08/25); Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25).<BR/>Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. The nurse who initiated she checked his low air loss mattress on the morning (6AM) on 06/18/25 was charge nurse LVN D. <BR/>Record review of Resident #2's weights recorded for the past three months reflected he weighed 162.2 pounds on 06/05/25, 160.4 pounds on 05/15/25 and 161.6 pounds on 04/08/25. <BR/>Observation of Resident #2's low air loss mattress on 06/18/25 at 10:32 AM revealed the unit was set to a weight of 280 pounds and normal pressure. <BR/>An interview with Resident #2 on 06/18/25 at 10:40 AM revealed he felt the mattress was uncomfortable and lumpy. He stated he weighed somewhere between 160 to 180 pounds, but nowhere near 280.<BR/>An interview with LVN D on 06/18/25 at 10:41 AM revealed she observed Resident #2's low air loss mattress and said the charge nurses were usually responsible for setting the mattresses at the correct weight. She was not sure how much Resident #2 weighed but surmised he was not 280 pounds and would follow up on it. <BR/>2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes (disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), aphasia (a language disorder that affects the ability to communicate), stroke (occurs when blood flow to the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), anoxic brain damage (occurs when the brain is deprived of oxygen, leading to cell death and potential neurological damage) and dysphagia (difficulty swallowing). Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed.<BR/>Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. <BR/>Record review of a Weekly Skin assessment dated [DATE] by the wound care nurse WC LVN C reflected Resident #3 had redness to his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) noted under other skin findings present.<BR/>Record review of the Wound Care NP's visit dated 06/06/25 reflected in a Skin and Wound Care Note that Resident #3 was being seen for a new skin and wound consult. The NP stated, 06.06.25: Pt being seen for new consult of breakdown to sacrum. On exam, fragility noted to sacrum with small superficial openings. No s/s of infection noted. Recommendations as noted in wound plan. Recommend continuing incontinence management and repositioning interventions. The primary etiology (cause) of the wound was noted to be incontinence associated dermatitis (skin inflammation, characterized by symptoms like itchiness, redness, and dryness) that was 4.5 cm x 5 cm x 0.1 cm and a surface area of 22.5 sq cm. The wound base was 100% epithelial , 0% granulation , 0% slough , 0% eschar with exposed dermis (middle layer of skin) tissue, attached wound edges and an intact and fragile periwound (the area of skin immediately surrounding a wound, extending outward from the wound's edge). There was no exudate (a fluid that leaks out of blood vessels into surrounding tissues, often due to inflammation or injury) and no wound pain. Treatment orders reflected, Wound # 3 Sacrum Incontinence Associated Dermatitis (IAD) Treatment Recommendations: 1. Cleanse with wound cleanser; 2. apply [name] paste to base of the wound; 3. secure with Leave open to air; 4. change Daily, and PRN. Preventative measures included, Continue with turning and repositioning schedule per protocol for pressure prevention. Use pillows for positioning to prevent pressure to bony prominences. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, incontinence of urine and stool.<BR/>Record review of Resident #3's physician order summary reflected, May have pressure relieving mattress every shift (start dated 10/17/24); Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). <BR/>Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. <BR/>An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25. <BR/>An interview with LVN E on 06/18/25 at 10:08 AM occurred where she was asked about the low air loss mattress not being in place for Resident #3, to which she replied, We don't leave him in bed all day, we like to keep him in his wheelchair until after lunch. LVN E did affirm that Resident #3 had a wound on his sacrum. <BR/>3. Record review of Resident #4's Face Sheet dated 06/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and had active diagnosis of lupus erythematosus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissues and organs), adult failure to thrive (a decline in physical and cognitive function, accompanied by weight loss, decreased appetite, and reduced activity levels), vascular dementia (a condition where damage to blood vessels in the brain impairs blood flow, leading to cognitive decline), diabetes (a disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), psoriasis (a chronic, immune-mediated skin disease that causes red, scaly patches on the skin) and dysphagia (difficulty swallowing). <BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she had long and short-term memory problems and severely impaired cognitive skills for decision making. Resident #4 did not have any behavioral symptoms or rejection of care issues. Resident #4 was totally dependent on staff for all ADLs, movement and bed mobility. She had no range of motion issues and used a wheelchair for ambulation. Resident #4 was always incontinent of bowel and bladder, weighed 127 pounds and was at risk of developing pressure ulcers/injuries. She did not have any identified wounds, ulcers or skin issues during the look back period but under the Skin and Ulcer/Injury Treatments, the box was checked that she had a pressure reducing device for her bed and applications of ointments and medications to areas other than feet. Resident #4 was also receiving hospice services and had a life expectancy of less than six months. <BR/>Record review of Resident #4's care plan initiated 12/08/22 and last updated related to wounds on 01/23/24 reflected, Goal: [Resident #4] has a potential for skin breakdown r/t lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue, causing inflammation and damage to various organs) and psoriasis (a chronic, immune-mediated skin condition that causes red, scaly patches on the skin); Interventions: .Provide pressure reducing mattress on bed, Weekly skin assessment to be completed. The care plan did not reflect she had a new skin alteration on her bottom. <BR/>Record review of Resident #4's physician order summary reflected, Left buttock: Cleanse with wound cleanser pat dry, apply honey and calcium alginate. Cover, secure with border foam dressing. every day shift every Mon, Wed, Fri for wound management Hospice nurse will assess once a week (start date 06/18/25) . Right buttock: Cleanse with wound cleanser pat dry, apply xeroform and cover with border foam dressing every day shift every Mon, Wed, Fri for wound management (written 06/19/25 with a start date of 06/20/25). Resident #4 did not have an order for a pressure reducing mattress.<BR/>An observation of Resident #4 on 06/18/25 at 10:25 AM revealed she was in bed, was not able to be interviewed as she was no responsive to questions. Resident #4 was observed to not have a low air loss mattress in place. She had a pillow minimally offloading her right butt cheek and another pillow under her thighs. The wound dressing was observed to be intact and on her left butt cheek and was dated 06/18/25 by WC LVN C.<BR/>An interview with LVN D on 06/18/25 at 10:25 AM revealed Resident #4 had a blister on her bottom that had popped and was currently receiving treatment for it. <BR/>4. An interview with ADON A on 06/18/25 at 3:16 PM revealed the purpose of an air loss mattress was for when a resident had compromised skin or to prevent skin breakdown from happening or getting worse, to promote healing and to make the resident feel comfortable. He stated the setting for the pump should go by the weight of the resident according to what the rental company staff for the mattress have told him, But I am not exactly sure, mostly when they [DME rental company] comes, they set it up for us. Then the nurses check it to make sure it is running with that parameter. ADON A stated the charge nurse was supposed to be checking the low air loss mattress and pump settings during a daily routine check. ADON A said in order to prevent pressure ulcers from getting worse, as a unit manager, he assesses residents with wounds and made sure there was a low air loss mattress in place for a new or reopened wound. ADON A stated using pillows versus a low air loss mattress would depend on the physician's order. He stated, Mostly from my experience, I don't know if a pillow is enough for a pressure ulcer, we need a low air loss mattress. I don't know if you can replace that with a pillow. But to prevent a wound, you can reposition, use pillows but once the wound starts forming, we need a low air loss mattress. <BR/>An interview with ADON B on 06/19/25 at 10:45 AM revealed the purpose of a low air loss mattress was to prevent pressure ulcers or other wounds and the setting should go by the resident's weight. She said the setting should be monitored daily by the ADONs, treatment (wound care) nurse and the DON. <BR/>An interview with WC LVN C on 06/19/25 at 11:15 AM revealed the purpose of a low air loss mattress was to prevent wounds and the setting should go by the weight of the resident. She did not know who was responsible for setting the pump to the correct setting. WC LVN C stated, I probably should check the setting on the mattress, I should know how it is being effective with the wound, but I don't do it with every wound. <BR/>An interview with the ADM on 06/19/25 at 11:45 AM revealed after investigator intervention, Residents #3 and #4 were ordered and provided a low air loss mattress. He stated central supply was present during the stand-up meetings and when she was made aware of the need for a low air loss mattress, she ordered it and it would usually come within the same day or within 24-48 hours. He stated hospice delivered Resident #4's and Resident #3's came in on 06/19/25. The ADM stated he was not sure why there was a delay in getting them. <BR/>An interview with LVN F on 06/19/25 at 12:58 PM revealed the purpose of a low air loss mattress was to help with pressure sores and positioning. LVN F stated she would know if the mattress was not set correctly because an alarm would go off and give an alert on the pump unit. She said when the dial was turned on, It goes to 250 and that is where it should be put, it is the amount of air going into the mattress. LVN F stated the low air loss mattresses were usually for residents who might be at risk for pressure ulcers as well as for those residents who could not reposition themselves in bed. She stated the setting for the pump to ensure accuracy was usually monitored by the charge nurses and CNAs. <BR/>5. Review of the facility's policy titled, Skin Integrity Management revised October 16, 2016, reflected, .14. Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one medication carts (700/500 hall nurses' medication cart) of two medication carts reviewed for pharmacy services in that:<BR/>The 500/700 hall medication cart had expired medications.<BR/>The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status.<BR/>Findings included:<BR/>1. Review on 05/16/2023 at 10:00 AM of nurse medication cart (Hall 700/500) reflected Hydrocodone/Acetaminophen 5-325 mg medications strip packaging with expiration date of 03/07/2023, 22 tablets left in the medication strip packaging of 60 tablets.<BR/>Review of Resident #7's face sheet, dated 05/17/2023, reflected he was a [AGE] year-old male admitted originally to the facility on [DATE], and readmitted on [DATE]. His diagnosis included sacral spina bifida, end stage renal disease on hemodialysis, type 2 diabetes Mellitus, hypertension, chronic pain syndrome. <BR/>Review of Resident #7's most recent Quarterly MDS Assessment, dated 03/01/2023, reflected he had a BIMS score of 15 indicating intact cognition, the pain assessment suction on the MDS was not complete. <BR/>Review of Resident #7's Care Plan dated 07/08/2021 reflected the following: Focus- (Resident#7) has a diagnosis of spina bifida, chronic pain and osteomyelitis which can cause episode of pain/discomfort. Goal-(Resident#7) will have pain managed with interventions through the next quarterly review. Interventions- give scheduled pain medications as ordered, observe, and assess for the effectiveness of as needed pain medication and document.<BR/>Record review reflected the last time the (resident#7) received the medication according to the narcotic count binder, and the e-MAR (electronic medications administration record) was on 05/11/2023.<BR/>In an interview on 05/17/23 at 12:01 PM with LVN P stated she did give the expired hydrocodone/ acetaminophen 5-325 mg tablet per mouth to (Resident #7), she did not notice any side effect on the (Resident#7), and that she should check the medication expiration date before she gives it to resident to prevent harming residents, and the risk to resident, the resident may get sick. LVN P further stated the facility wants the nurses to check the expiration dates of the medications in the carts, and before given it to residents.<BR/>Interview on 05/17/23 02:00 PM with ADON stated the nurses and medication aides were supposed to check the medications expiration date before given it to residents, according to medications administrations five rights. The ADON further stated she checked some medications last Monday (05/15/2023), but she was busy taking care of the residents in the hall she was assigned to. The ADON stated we check the medication's carts randomly, and she was going to put in place a system to start checking the medications carts, and medications storge room on scheduled time. <BR/>Record review of the facility policy, revised October 2010, titled Administering Oral Medications reflected, .5. Select the drug from the unit dose drawer or the stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration on the medication. Return any expired medications to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents right to retain their personal clothing for one of one resident, (Resident #4) reviewed for resident's rights. <BR/>The facility failed to allow Resident #4 to exercise the right to retain and use personal possessions, including clothing.<BR/>This failure placed residents at risk of for anxiety, frustration, and decreased quality of life who retain their personal clothing in their room. <BR/>The Findings: <BR/>Record review of Resident #4's admission Record dated 5/28/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 2 indicating severely impaired cognition. Her diagnoses included unspecified dementia, and anxiety disorder. <BR/>Record review of Resident #4's Care Plan Report reflected impaired cognitive function/dementia or impaired thought processes- Dementia. <BR/>Record review of Resident #4's progress notes dated 2/11/25 at 18:54 AM revealed RN F, pronounced Resident#4 dead at 18:34 at the facility.<BR/>Interview on 5/28/25 at 12:48pm the family member revealed three weeks of clothing including pajamas were brought to the facility at admission. Revealed all clothes had Resident #4's name on clothing which disappeared by January. While visiting one day family found Resident #4 dressed in a hospital gown. On 1/27/25 Resident #4 had an appointment but had no clothing to wear to the appointment. Family revealed before going to the appointment they had to purchase clothing. Family revealed the newly purchased clothing cost $150.00. The family revealed they did not have a receipt for the clothing. The Family member revealed Resident #4's name and room number was put on the new clothing. The Family member revealed by the time Resident #4 passed she only had 1-2 pair of pajamas. Family did not write grievances. <BR/>Interview on 5/28/25 at 3:12pm with RN G, revealed no family complained about missing clothes. Does inventory of clothing in electronic health records not sure where in electronic health records but does it upon admission. No Inventory Record of Resident # 4's clothing. Staff revealed they need help with inventory for clothing added or removed and have asked mgt for label maker. <BR/>Interview on 5/28/25 at 3:38pm CNA H, revealed never knew of Resident #4 had missing clothing. Residents kept their clothing in their rooms. kept in Resident #4's room. CNAH revealed no knowledge of clothes going missing or that Resident #4 had a large amount of clothes. <BR/>Interview on 5/28/25 at 4:10pm CNA I, worked here almost 3yrs. CNA I revealed at admission the resident clothes were put in a trash bag and given to laundry to label each item. CNA, I revealed it took days to get clothes back. If aide had a permanent marker and time, CNA I would label the clothes. CNAI revealed if the clothing came labeled, they put the clothing in the resident's room. CNA I revealed ADON C was supposed to do the inventory sheet. <BR/>Interview on 5/28/25 at 4:18pm with ADON C who revealed knowledge of Resident #4 for missing clothes but revealed no knowledge of Resident #4 having multiple bags of clothes . ADON C reveled if clothing was missing, they looked in the laundry area. ADON C revealed the aides took laundry to the laundry area with an unknown period for when the laundry was returned to the resident. ADON C revealed when resident admitted then the inventory was done by medical records and had family and staff signed the inventory form, and it uploaded into the electronic health records. ADON C revealed the facility did not have a system for documenting removed clothing during the stay, such as if family swapped out seasonal clothes. <BR/>Interview on 5/28/25 at 7:15pm with the Administrator revealed nursing usually did resident inventory at admission and if family brought additional things throughout the stay. The Administrator revealed residents kept their clothing in their rooms. The Administrator revealed at discharge the staff went through clothing and items that went home with the resident. The Administrator revealed after the passing of Resident #4 the family revealed they wanted to donate all remaining items including the television, clothing, and any other items the resident had in left in the room. The Administrator revealed Resident #4's family came back at some point to request a refund for Resident #4's missing clothing. The Administrator revealed he informed Resident #4's family would need to provide a receipt for him to consider a refund. The Administrator revealed the facility did not have a missing items policy. <BR/>Review of records revealed facility policy titled: Abuse/Neglect Nursing Policy and Procedure Manual 2003 Rev: 5/9/2017 TG 03-1.0 The policy reveals: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. <BR/>9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance.<BR/>The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care.<BR/>The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he would address the issue with showers and staffing. The Administrator stated lack of enough staff would affect the resident's quality of life. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 received treatment immediately after she complained of having symptoms of a urinary tract infection. <BR/>This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 5/28/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating no impaired cognition. Her diagnoses included hypertension (high blood pressure); type 2 diabetes, stroke, amputation, and progressive neurological conditions. <BR/>Record review of Resident #1's Care Plan Report dated 5/28/25 reflected no indication of the resident with urinary tract infection. <BR/>Review of Resident #1's Physician Order as of 5/28/25 reflected there were no orders for urinalysis, antibiotics, or medications to treat a urinary tract infection. <BR/>Review of the facility 24-report for 5/28/25 reflected there was no information documented about Resident #1.<BR/>Review of Resident #1's progress notes from 5/23/25 through 5/28/25 reflected no progress notes regarding Resident #1's complaint of a urinary tract infection.<BR/>Observation and interview on 5/28/25 at 10:40 AM revealed Resident #1 was in her room, resting in bed. She appeared well-dressed and groomed. Resident #1 stated she was having signs and symptoms of urinary tract infection, voiding frequently and burning when voiding. The resident stated she informed the charge nurse in the morning of Friday, but she did not remember the name of the charge nurse. She stated she was still having the signs and symptoms of urinary tract infection, and nothing had been done yet. <BR/>In an interview on 5/28/25 at 2:30 PM with RN B she stated she was the charge nurse for Resident #1 for the 2-10 shift. She stated the resident had not reported having any signs or symptoms of infection. She also stated LVN E did not inform her of the resident's change of condition or obtaining the urine specimen. She stated if the resident had a change of condition the resident's primary care provider was to be notified and follow the doctor's orders. If laboratory test was required, the staff was expected to fill the laboratory request online and document in the 24-hours report and progress notes. RN B stated urinalysis was to be completed timely to prevent the symptoms from getting worse. <BR/>In an interview on 5/28/25 at 2:34 PM with LVN D she stated while completing the resident's wound assessment with the wound doctor on 5/27/25, the resident stated she was having signs and symptoms of urinary tract infection. The resident stated she had already notified the nurse assigned to her, so she did not follow up with the charge nurse on the hall. <BR/>In an interview on 5/28/25 at 3:40 PM with ADON C she stated she was not aware of the resident having a change of condition. She stated the resident had not reported having signs and symptoms of infection to her. She stated early today (5/28/25) a laboratory personnel had come to the facility and asked for Resident #1 urine specimen, ADON C checked in the specimen fridge and there was no urine specimen for Resident #1. ADON C stated she failed to do a follow up and find out why the urine specimen was required for the resident. ADON C stated if there was a change of condition the charge nurse was expected to assess the resident and notify the resident's primary care provider and follow the orders. The charge nurse was expected to document the orders in the physician orders and document in the progress notes and in the 24-hour report, and if a laboratory test was required the charge nurse was to fill out the laboratory request online. When ADON C reviewed the laboratory request she saw a urinalysis laboratory request that was completed on 5/26/25 but was unable to tell who completed the request because the system does not a section to fill the nurse who filled the request. ADON C stated laboratory tests was to be completed timely to prevent the symptoms getting worse, and if the resident was having signs and symptoms of infection to prevent the resident being septic. <BR/>In an interview on 5/28/25 at 6:27 PM with LVN E she initially stated the resident reported to her on Friday (5/23/25) she was having signs and symptoms of urinary tract an infection. LVN E contacted the resident's primary care provider and was given and order for urinalysis for the resident. LVN E then stated it was not on Friday when the resident informed her it was on Tuesday (5/27/28). LVN E stated she did not document in the progress notes or in the 24 hours reports and did not write the order. LVN E stated she was supposed to follow the primary care providers orders and obtain the specimen and if she was not able to, she was supposed to inform the oncoming charge nurse. The nurse was not able to give a reason why she did not document or write the order. LVN E stated not completing the orders could worsen the resident's symptoms and could be septic if the resident had an infection. LVN E also stated she was expected to document in the 24 hours report and progress notes and inform the ADON of the resident's change of condition. <BR/>Contacted the resident's primary care provider on 5/28/25 at 6:38pm and was unable to reach the primary care provider. <BR/>Review of the facility policy revised 3/11/13 and dated Notifying the Physician of Change in Status reflected, . 1. <BR/>The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.

Based on interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of three residents reviewed for abuse.<BR/>The facility failed to ensure CNA A did not abuse Resident #1 on 03/14/25 by taking a private photo of her. This was determined to be past non-compliance. <BR/>The noncompliance was identified as PNC. The noncompliance began on 03/14/25 and ended on 03/16/25. The facility had corrected the noncompliance before the survey began.<BR/>This failure placed residents at risk of being abused by having their photo taken. <BR/>Findings included: <BR/>Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMS score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting.<BR/>Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed. <BR/>An interview on 03/18/25 at 10:55 am with Resident #1 revealed on 03/14/25, evening shift CNA A entered her room and was cursing. The resident said she turned her light on at 1:30 PM to be changed because she had a blow-out. CNA A entered the room and the resident said CNA A was mad because she had to perform incontinence care for the resident. The resident said CNA A told her that the day shift CNA should have changed Resident #1. The resident said CNA A took a phone out of her pocket, told the resident to turn her face to the side, and took a picture of the resident's private area. The resident said CNA A told her that she was going to send the picture to the DON because day shift should have changed the resident. Resident #1 said it really bothered her that CNA A would take such a private and embarrassing photo of her. Resident #1 said she was crying and called her family member on 03/15/25 about the incident. The resident said the did not tell anyone at the facility about the incident. The police were called on 03/15/25. Resident #1 said the DON came and spoke to her and said the incident was being addressed and CNA A was suspended. Resident #1 said the Administrator spoke to her and made sure the photo was deleted. <BR/>An interview on 03/18/25 at 1:00 PM with the DON revealed she had been employed at the facility for a month. The DON said on 03/15/25 she received a call that the police were at the facility because CNA A took a photo of Resident #1. The DON said she never received a picture from CNA A and she never saw the photo. The DON said she spoke to the resident and told her the facility was investigating the incident. The DON said CNA A deleted the photo and did not share it with anyone. The DON said she had been monitoring the resident to ensure the resident did not have any on-going issues. <BR/>An interview on 03/18/25 at 3:00 PM with the Administrator revealed CNA A admitted to him that she took the photo of the resident and deleted it. The Administrator said the facility was still investigating and CNA A was suspended and being terminated pending the investigation findings. <BR/>An interview was attempted with CNA A on 03/18/25 at 12:20 PM. CNA A did not return the call of the Surveyor.<BR/>Record reviews of facility in-services for abuse, personal cell phone usage, and HIPPA were completed. Some of the in-services were not dated and some were dated 03/16/25. The facility also completed safe surveys with residents. <BR/>Interviews with facility staff and residents on 03/18/25 from 9:15 AM to 3:00 PM revealed staff knew not to take pictures of residents and the residents said no one had taken their picture. <BR/>Review of the facility policy, Abuse, revised 05/09/17, reflected:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, <BR/>and exploitation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance.<BR/>The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care.<BR/>The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he would address the issue with showers and staffing. The Administrator stated lack of enough staff would affect the resident's quality of life. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 3 (Residents #1, #2, #3) of 5 residents reviewed for sufficient staffing.<BR/>The facility failed to ensure the facility had sufficient staffing to meet the needs of Residents #1, #2, #3. <BR/>This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was [AGE] years old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he will address the issue with showers and staffing. The Administrator stated lack of enough staff will affect the resident's quality of life. The Administrator did not provide the sufficient nursing staff policy. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident call light system was maintained within reach for 4 of 6 residents (Resident #14, Resident #3, Resident #21, and Resident #69) reviewed for call light system access. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain on the floor at the foot of the bed, out of the resident's reach. The facility failed to ensure Resident #3 had access to their call light by allowing it to remain draped over a light fixture about the resident's bed, out of the resident's reach. The facility failed to ensure Resident #21 had access to their call light by allowing the cord to become unattached from the clip, resulting in the call light to dangle from the wall, out of the resident's reach. The facility failed to ensure Resident #69 had access to their call light by allowing it to remain on the floor in a shoe, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Record review of Resident #14's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), Dementia (severe decrease in memory and intellectual functioning), hypertension (high blood pressure), and muscle weakness (less strength or control in muscles). She required substantial/maximal assistance for daily care tasks like toileting hygiene, bathing, dressing, and grooming. She also required similar support for mobility tasks like toilet transfer, rolling from side to side, chair/bed-to chair transfer. She was dependent on staff to assist with walking, taking steps, picking up objects and utilized a wheelchair for mobility. Record review of Resident #14's Comprehensive Care plan dated 05/15/2025 reflected a fall focus: [Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. Review of Resident #14's Comprehensive Care Plan also revealed a communication focus. [Resident] has a communication problem. Goal: Resident will be able to make basic needs known by (specify) [sic] on a daily basis through the review date. Interventions included: Ensure/provide a safe environment: Call light in reach. During an interview and observation on 08/24/2025 at 9:44 AM, Resident #14 was observed in bed. The call light was on the floor at the end of the bed, out of the reach of the resident. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 10:15 AM, Resident #14 was observed in bed. The call light remained in the same location, on the floor and not accessible. During an interview with LVN A on 08/24/2025 at 10:56 AM, in response to the Resident's call light placement, LVN A reported Resident #14 did not use her call light and they would check on her every 30 minutes to an hour. Record review of Resident #3's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included heart failure, Type 2 Diabetes (a condition where the body does not use insulin properly, causing high blood sugar levels over time), nuclear cataract (a clouding of the center of the eye's lens that make vision blurry), hypertension (high blood pressure), visual loss to both eyes, difficulty in walking and unsteadiness on feet. Resident #3 was independent with eating and oral hygiene, completing these tasks safely without staff assistance. For toileting hygiene, putting on/taking off footwear, and personal hygiene, the resident required setup assistance, with staff placing necessary supplies within reach; however, the resident completed the activities independently once prepared. With showering/bathing, upper body dressing, and lower body dressing, the resident required supervision and occasional touching assistance, including staff presence for safety, verbal cueing, and light physical guidance as needed. The resident was fully independent with rolling left and right, moving from sitting to lying and lying to sitting at the side of the bed, standing from a seated position, transferring between a chair and bed, using the toilet, and walking 10 feet. He required supervision or minimal assistance for tub/shower transfers, walking 50 feet with two turns, and walking 150 feet. The resident experienced frequent bowel incontinence and occasional urinary incontinence. Record review of Resident #3's Comprehensive Care plan dated 5/23/2025 reflected a fall focus: {Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #3 was observed in bed, awake and alert. The Resident's call light was observed hanging over a light fixture above his bed. Resident #3 stated he had his call light yesterday but could not locate it in his bed. He stated his bed was usually where his call light would be placed. During an observation on 08/24/2025 at 10:35 AM, Resident #3 was observed in bed and the call light remained in the same location, hanging over the light fixture and out of reach of the resident. During an interview with LVN A on 08/24/2025 at 11:06 AM, she confirmed the location of the call light hanging over the light fixture and immediately arranged the call light to be clipped next to the resident. She stated she was not sure who put it there or how long it had been like that. She stated the resident was blind and confused and she would check on him every 30 minutes to an hour. She reported she did not notice it was out of his reach during her last check at 9:00 AM. Record review of Resident #21's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), transient ischemic attack and cerebral infarction (a type of stroke caused by blood vessel in the brain), generalized anxiety disorder, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), muscle wasting in upper right and left arms, and muscle weakness. The resident was independent with eating and oral hygiene. She was dependent on staff for toileting hygiene, showering/bathing, and putting on/taking off footwear. She required setup assistance for both upper and lower body dressing, as well as for personal hygiene tasks such as washing her face and hands, shaving, and combing hair. She demonstrated very little mobility and required significant staff assistance for nearly all movements. She needed substantial assist to roll in bed, transition from sitting to lying, and move from lying to sitting at the side of the bed. All other mobility activities including standing, transferring between chair and bed, toilet and tub/shower transfers, and walking short distances were fully dependent on staff. Record review of Resident #21's Comprehensive Care Plan dated 07/15/2025 reflected the following focus: [Resident] uses one quarter or two quarter rails to enhance functional independence & promote skin integrity. Goal: [Resident] will maintain or increase functional independence through each use of: one partial (half) rail or two partial rails through the next review. Interventions included: Place the call light cord within easy reach. Focus: [Resident] is at risk of falls related to CVA (Cerebrovascular Accident, commonly known as a stroke, caused by interruption of blood flow to the brain, resulting in neurological changes), hemiplegia, pain, obesity, weakness in radiculopathy (nerve pain). Goal: [Resident] will have no injuries through the next review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:15 AM, Resident #21 was observed in bed, awake and alert. The resident's call light was hanging down the wall and not clipped near the resident within her reach. She reported her call light clip had broken, and the call light cord would keep detaching from the clip. She pointed to the clip that was attached to her pillowcase that would hold the call light cord. She reported it had been broken for around a week and she had reported it to several staff. The resident stated she was told by staff it would be fixed but nothing had been done. She reported she would use her reach extender (a tool for reaching and grasping objects from a distance) to bring the call light closer to her when it would come unattached from the clip. She reported feeling frustrated about her call light and felt worried if she needed immediate assistance, she would not be able to get to her call light. During an observation on 08/24/2025 at 10:20 AM, the resident was observed in bed and the call light remained in the same location, out of reach of the resident. During an interview with LVN A on 08/24/2025 at 10:15 AM, LVN A confirmed the location of the call light that was out of reach of Resident #21. LVN A stated she had not been made aware that the cord kept coming detached from the clip. She stated she also had not been made aware that Resident #21 had to utilize a reach extender to access her call light. LVN A reattached the resident's call light back to the original clip. Record review of Resident #69 annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), hypertension (high blood pressure), depressive disorder (a condition that causes persistent sadness, loss of interest, and low energy that affects daily life), dysphagia (difficulty speaking or understanding language), and muscle weakness. Resident #69 was dependent on staff for self-care tasks such as eating, oral hygiene, toileting hygiene, shower/bathing, dressing, putting on/off footwear, and personal hygiene. The resident was independent with some mobility, namely walking. She was dependent on staff for tub/shower transfers, toilet transfers, and the ability to roll from lying on back to her left or ride side. The resident experienced frequent urinary and bowel incontinence. Record review of Resident #69's Comprehensive Care plan dated 08/07/2025 reflected a fall focus: {Resident] is at risk for falls related to Alzheimer's Disease and pain. Goal: [Resident] will have no injuries due to falls through the next quarterly review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:12 AM, Resident #69 was observed lying in bed. The call light was in the resident's shoe on the floor near the bed. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 11:10 AM, LVN A confirmed the location of the call light and LVN A immediately clipped it near the resident. LVN A stated she was not sure how it got there. She stated every staff member is responsible for ensuring the call light is within reach of the resident. During a follow up interview with LVN A on 08/24/2025 at 1:45 PM, she reported that she was unaware of any risk to residents due to them not being able to reach the call light. She reported she would check on her residents every 30 minutes. When asked if she did that on 08/24/2025 she reported it was more like every hour. During an interview with CNA G on 08/26/2025 at 1:15 PM, she reported it was everyone's responsibility to answer call lights. She reported it was also everyone's responsibility to ensure the call light is within reach of each resident. She reported she checked on residents as needed and every 30 minutes to an hour. During an interview with Regional Compliance Nurse on 08/26/2025 at 3:00 PM, he reported every staff member at the facility was responsible to ensure call lights were within reach of each resident. He reported the risk of it not being within reach was not being able to call for assistance if they needed water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (Resident #1) of six residents reviewed for decent living environment. 1. The facility failed to ensure Resident #1 had access to her bathroom. This failure could place residents at risk for diminished quality of life due to a lake of a well-kept environment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy level), Impulse Disorder (Inability to resist strong urges), and Cognitive Communication Deficit (Communication difficulty). Record review of Resident #1's Quarterly MDS Assessment, dated 05/01/25, reflected Resident #1 had a BIMS score of 03, which indicated Resident #1 was severely impaired. In an observation and interview on 07/18/25 at 5:18 PM, Resident #1's bathroom in her room was locked. The Maintenance Director stated the bathroom was locked, because Resident #1 put all items down the toilet like clothes and briefs. He stated her toilet caused other toilets in memory care to back up in the memory care unit. In an interview on 07/18/25 at 6:50 PM, the DON stated Resident #1's bathroom was locked, because she had a behavior of throwing things down the toilet. She stated the door was locked to prevent flooding in the memory care unit. The DON stated the staff took her to the community restroom in the memory care unit if Resident #1 needed to use the bathroom. The DON stated the memory care unit community bathroom was locked, but the staff were able to unlock the community bathroom door. The DON stated she felt there was no risk since it was for Resident #1's safety and it prevented plumbing issues. In an interview on 07/18/25 at 8:10 PM, the Corporate Nurse stated the Administrator was suspended and no longer in the building. He stated Resident #1's bathroom was unlocked and would be cleaned for use. He stated he did know about the risks, but stated Resident #1 should have had access to an unlocked bathroom. Record review of the facility's undated policy, titled, Resident Rights, reflected the following: Resident Rights A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-- A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for one (Resident #66) of six residents on psychoactive medication in that: The facility failed to ensure that Resident #66 had orders for psychotropic medication Lorazepam (brand name Ativan, a medication in the benzodiazepine class used to reduce anxiety, help with sleep, or control seizures) that did not contain PRN orders beyond 14 days without an end date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. Record review of Resident #66's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had moderate cognitive impairment, as indicated by a BIMS score of 9. This score suggested the resident experienced some difficulty with memory and orientation but was still able to engage in conversation and participate in decision-making with support. Diagnoses included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), hypothyroidism (underactive thyroid gland that did not make enough hormone), muscle wasting and atrophy (when a part of the body, like a muscle or tissue, shrinks or wastes away from lack of use or disease), major depressive disorder (severe, persistent sadness and loss of interest that interferes with daily life), generalized anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), Type 2 diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications). Record review of Resident #66's Comprehensive Care Plan dated 05/28/2025, reflected a Medication Focus: [Resident] requires antidepressant medication Depression [sic]. Goal: [Resident] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (Specify: antidepressant drugs being given). Medication Focus: The resident requires anti-psychotic medications. Goal: [Resident] will be/remain free from drug related complications, including movement disorder, discomfort, constipation/impaction or cognitive/behavioral impairment through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family re [sic] ongoing need for use of medication. Medication Focus: [Resident] uses anti-anxiety medications. Goal: [Resident] will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. PARADOXICAL SIDE EFFECTS: mania, hostility and rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #66's Pharmacy Order Summary Report dated 08/26/2025 reflected an order for Lorazepam 0.5 mg oral tablets, with a start date of 06/20/2025. The order instructed that one tablet be given by mouth every 12 hours as needed for anxiety. The report did not state an end date for the medication. Record review of Resident #66's Medication Regimen Review, re: Psychotropic Medication Review: PRN Psychotropic, dated 05/02/2025 reflected a pharmacist recommendation of discontinuing Lorazepam Oral Tablet 0.5 mg unless there was a clinical rationale to continue the medication. The signing physician did not include a rationale in continuing the medication and their response checked on the form showed they agreed with the recommendation and was signed on 06/05/2025. Record review of Resident #66's monthly MAR, dated June 2025 reflected Lorazepam was administered to Resident #66 on 06/01/2025, 06/02/2025, 06/03/2025, 06/04/2025, and 06/05/2025. Record review of Resident #66's monthly MAR, dated July 2025 reflected Lorazepam was administered to Resident #66 on 07/04/2025, 07/05/2025, 07/06/2025, 07/14/2025, 07/15/2025, 07/25/2025, 07/26/2025, 07/28/2025, 07/29/2025, and 07/30/2025. Record review of Resident #66's monthly MAR, dated August 2025 reflected Lorazepam was administered to Resident #66 on 08/02/2025, 08/04/2025, 08/05/2025, 08/06/2025, 08/07/2025, 08/08/2025, 08/11/2025, 08/12/2025, 08/14/2025, and 08/15/2025, 08/16/2025, 08/18/2025, 08/20/2025, 08/22/2025, 08/25/2025, and 08/26/2025. In an interview on 08/26/2025 at 11:46 AM, Regional Compliance Nurse stated the ADON was responsible for following up with gradual dose reductions (slowly lowering a medication's dose over time to see if it is still needed or to reduce side effects safely). RN F reported the ADON was responsible to make sure residents who were on PRN antipsychotic medications were assessed every 14 days for the resident to continue with the medication. RN F stated the ADON had only been working at the facility for a couple of weeks, and they would begin an audit on all pharmacy recommendations. RN F stated the risk for residents continuing PRN medications past 14 days was that they might no longer benefit from the medication. Review of the facility policy undated, titled Psychotropic Medication, reflected: The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Also, residents will only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic. Based on a comprehensive assessment of a resident, the facility will ensure that: Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs; Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for antidepressant, hypnotic, and antianxiety drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #8) of six residents reviewed for PASRR services. The facility failed to ensure Resident #8 was properly screened for PASRR services. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Record review of Resident #8's quarterly MDS Assessment, dated 07/11/25, revealed a [AGE] year-old-male admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included: dementia in other diseases classified elsewhere (memory loss and thinking problems caused by another medical condition, rather than Alzheimer's itself), other bipolar disorder (a mood disorder causing unusual swings between high (manic) and low (depressive) moods), and major depressive disorder (a mental health condition causing severe, persistent sadness and loss of interest that interferes with daily life. Resident #8 required setup assistance with eating and oral hygiene. For toileting hygiene, putting on/taking off footwear, and personal hygiene, showering/bathing, upper body dressing, and lower body dressing, the resident required substantial assistance with the helper doing more than half the effort to complete the activity. Record review of Resident #8's PASRR Level I screen, dated 06/14/24, reflected the resident did not have a history of mental illness. Record review of Resident #8's Comprehensive Care plan dated 07/14/2025 reflected a medication focus: [Resident] requires anti-psychotic medications Behavior management [sic]. Goal: [Resident] will reduce the use of psychoactive medication through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate. Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. Under [XXXX] management. Antidepressant Medication Focus: [Resident] requires antidepressant medication. Goal: [Resident] will be free from discomfort or adverse reactions related to antidepressant therapy through the next review date. Interventions: Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of (Specify: anti-depressant drugs being given.) Behavior Problem Focus: [Resident] has a behavior problem of attention-seeking and accusatory behaviors, distorting the truth in attention seeking efforts and/or making false allegations, making negative statements about staff, excessive calling out for nursing staff but when the nursing staff go to attend to him, he states he is not ready for them, that he is watching his favorite television show. Goal: Reductions or absence or false accusations/attention seeking. Interventions: Encourage resident to participate in his care Give the resident as many choices as possible about care and activities. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. An interview on 08/26/25 at 11:46 AM with the MDS Nurse revealed she was responsible for entering PASRR information. The MDS Nurse reported the PASRR Level 1 for Resident #8 was received from a hospital upon his admission to the facility and was documented as it was. The MDS Nurse reported the resident did not receive an updated evaluation upon or after his admission to the facility and he did not receive a PASRR Level 2 screening. The MDS Nurse stated the resident was at risk of not receiving PASRR services. During an interview on 08/26/25 at 12:16 PM with Regional Compliance Nurse, he stated that the MDS Nurse was responsible for PASRR screenings. He reported he was unaware of how the resident's screening was missed. He reported the resident was at risk to miss out on PASARR services if his PL 1 was incorrect. A request on 08/25/2025 at 2:25 PM was made to review the facility's PASRR process and policy and was not provided by the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance.<BR/>The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care.<BR/>The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he would address the issue with showers and staffing. The Administrator stated lack of enough staff would affect the resident's quality of life. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 received treatment immediately after she complained of having symptoms of a urinary tract infection. <BR/>This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 5/28/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating no impaired cognition. Her diagnoses included hypertension (high blood pressure); type 2 diabetes, stroke, amputation, and progressive neurological conditions. <BR/>Record review of Resident #1's Care Plan Report dated 5/28/25 reflected no indication of the resident with urinary tract infection. <BR/>Review of Resident #1's Physician Order as of 5/28/25 reflected there were no orders for urinalysis, antibiotics, or medications to treat a urinary tract infection. <BR/>Review of the facility 24-report for 5/28/25 reflected there was no information documented about Resident #1.<BR/>Review of Resident #1's progress notes from 5/23/25 through 5/28/25 reflected no progress notes regarding Resident #1's complaint of a urinary tract infection.<BR/>Observation and interview on 5/28/25 at 10:40 AM revealed Resident #1 was in her room, resting in bed. She appeared well-dressed and groomed. Resident #1 stated she was having signs and symptoms of urinary tract infection, voiding frequently and burning when voiding. The resident stated she informed the charge nurse in the morning of Friday, but she did not remember the name of the charge nurse. She stated she was still having the signs and symptoms of urinary tract infection, and nothing had been done yet. <BR/>In an interview on 5/28/25 at 2:30 PM with RN B she stated she was the charge nurse for Resident #1 for the 2-10 shift. She stated the resident had not reported having any signs or symptoms of infection. She also stated LVN E did not inform her of the resident's change of condition or obtaining the urine specimen. She stated if the resident had a change of condition the resident's primary care provider was to be notified and follow the doctor's orders. If laboratory test was required, the staff was expected to fill the laboratory request online and document in the 24-hours report and progress notes. RN B stated urinalysis was to be completed timely to prevent the symptoms from getting worse. <BR/>In an interview on 5/28/25 at 2:34 PM with LVN D she stated while completing the resident's wound assessment with the wound doctor on 5/27/25, the resident stated she was having signs and symptoms of urinary tract infection. The resident stated she had already notified the nurse assigned to her, so she did not follow up with the charge nurse on the hall. <BR/>In an interview on 5/28/25 at 3:40 PM with ADON C she stated she was not aware of the resident having a change of condition. She stated the resident had not reported having signs and symptoms of infection to her. She stated early today (5/28/25) a laboratory personnel had come to the facility and asked for Resident #1 urine specimen, ADON C checked in the specimen fridge and there was no urine specimen for Resident #1. ADON C stated she failed to do a follow up and find out why the urine specimen was required for the resident. ADON C stated if there was a change of condition the charge nurse was expected to assess the resident and notify the resident's primary care provider and follow the orders. The charge nurse was expected to document the orders in the physician orders and document in the progress notes and in the 24-hour report, and if a laboratory test was required the charge nurse was to fill out the laboratory request online. When ADON C reviewed the laboratory request she saw a urinalysis laboratory request that was completed on 5/26/25 but was unable to tell who completed the request because the system does not a section to fill the nurse who filled the request. ADON C stated laboratory tests was to be completed timely to prevent the symptoms getting worse, and if the resident was having signs and symptoms of infection to prevent the resident being septic. <BR/>In an interview on 5/28/25 at 6:27 PM with LVN E she initially stated the resident reported to her on Friday (5/23/25) she was having signs and symptoms of urinary tract an infection. LVN E contacted the resident's primary care provider and was given and order for urinalysis for the resident. LVN E then stated it was not on Friday when the resident informed her it was on Tuesday (5/27/28). LVN E stated she did not document in the progress notes or in the 24 hours reports and did not write the order. LVN E stated she was supposed to follow the primary care providers orders and obtain the specimen and if she was not able to, she was supposed to inform the oncoming charge nurse. The nurse was not able to give a reason why she did not document or write the order. LVN E stated not completing the orders could worsen the resident's symptoms and could be septic if the resident had an infection. LVN E also stated she was expected to document in the 24 hours report and progress notes and inform the ADON of the resident's change of condition. <BR/>Contacted the resident's primary care provider on 5/28/25 at 6:38pm and was unable to reach the primary care provider. <BR/>Review of the facility policy revised 3/11/13 and dated Notifying the Physician of Change in Status reflected, . 1. <BR/>The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Resident #1, Resident #2 and Resident #4) of seven residents reviewed for treatment/services for pressure ulcers.<BR/>1. The facility failed to ensure Resident #2, who had a pressure ulcer on his coccyx, had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/18/25. <BR/>2. The facility failed to ensure Resident #3 and Resident #4 had a functioning low air loss mattress available to use to promote healing of their sacral wounds on 06/18/25. <BR/>3. The facility failed to ensure Resident #3 wound dressing was changed daily as per orders.<BR/>These failures placed residents at risk of developing new or worsening pressure ulcers.<BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. <BR/>Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. <BR/>Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. The wound care NP's note also reflected a summary of previous visits:<BR/>- 04.11.25: Pt admitted to facility 04.08.25 under hospice services. Pressure injury to coccyx and wounds of undetermined etiology to right toes 1-5. Pt on air mattress .Continue pressure offloading and incontinence management.<BR/>-05.28.25: .Pt tolerated debridement of coccyx wound. No s/s of infection noted . Air mattress in place.<BR/>-06.06.25: Wounds stable. Tolerated debridement of coccyx wound without complications. <BR/>-06/13/2025: Coccyx pressure injury stage 4 stable. Wound debridement tolerated. Recommend continuing offloading and frequent repositioning while in bed.<BR/>Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: May have pressure relieving mattress every shift (start date 04/08/25); Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25).<BR/>Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. The nurse who initiated she checked his low air loss mattress on the morning (6AM) on 06/18/25 was charge nurse LVN D. <BR/>Record review of Resident #2's weights recorded for the past three months reflected he weighed 162.2 pounds on 06/05/25, 160.4 pounds on 05/15/25 and 161.6 pounds on 04/08/25. <BR/>Observation of Resident #2's low air loss mattress on 06/18/25 at 10:32 AM revealed the unit was set to a weight of 280 pounds and normal pressure. <BR/>An interview with Resident #2 on 06/18/25 at 10:40 AM revealed he felt the mattress was uncomfortable and lumpy. He stated he weighed somewhere between 160 to 180 pounds, but nowhere near 280.<BR/>An interview with LVN D on 06/18/25 at 10:41 AM revealed she observed Resident #2's low air loss mattress and said the charge nurses were usually responsible for setting the mattresses at the correct weight. She was not sure how much Resident #2 weighed but surmised he was not 280 pounds and would follow up on it. <BR/>2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes (disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), aphasia (a language disorder that affects the ability to communicate), stroke (occurs when blood flow to the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), anoxic brain damage (occurs when the brain is deprived of oxygen, leading to cell death and potential neurological damage) and dysphagia (difficulty swallowing). Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed.<BR/>Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. <BR/>Record review of a Weekly Skin assessment dated [DATE] by the wound care nurse WC LVN C reflected Resident #3 had redness to his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) noted under other skin findings present.<BR/>Record review of the Wound Care NP's visit dated 06/06/25 reflected in a Skin and Wound Care Note that Resident #3 was being seen for a new skin and wound consult. The NP stated, 06.06.25: Pt being seen for new consult of breakdown to sacrum. On exam, fragility noted to sacrum with small superficial openings. No s/s of infection noted. Recommendations as noted in wound plan. Recommend continuing incontinence management and repositioning interventions. The primary etiology (cause) of the wound was noted to be incontinence associated dermatitis (skin inflammation, characterized by symptoms like itchiness, redness, and dryness) that was 4.5 cm x 5 cm x 0.1 cm and a surface area of 22.5 sq cm. The wound base was 100% epithelial , 0% granulation , 0% slough , 0% eschar with exposed dermis (middle layer of skin) tissue, attached wound edges and an intact and fragile periwound (the area of skin immediately surrounding a wound, extending outward from the wound's edge). There was no exudate (a fluid that leaks out of blood vessels into surrounding tissues, often due to inflammation or injury) and no wound pain. Treatment orders reflected, Wound # 3 Sacrum Incontinence Associated Dermatitis (IAD) Treatment Recommendations: 1. Cleanse with wound cleanser; 2. apply [name] paste to base of the wound; 3. secure with Leave open to air; 4. change Daily, and PRN. Preventative measures included, Continue with turning and repositioning schedule per protocol for pressure prevention. Use pillows for positioning to prevent pressure to bony prominences. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, incontinence of urine and stool.<BR/>Record review of Resident #3's physician order summary reflected, May have pressure relieving mattress every shift (start dated 10/17/24); Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). <BR/>Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. <BR/>An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25. <BR/>An interview with LVN E on 06/18/25 at 10:08 AM occurred where she was asked about the low air loss mattress not being in place for Resident #3, to which she replied, We don't leave him in bed all day, we like to keep him in his wheelchair until after lunch. LVN E did affirm that Resident #3 had a wound on his sacrum. <BR/>3. Record review of Resident #4's Face Sheet dated 06/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and had active diagnosis of lupus erythematosus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissues and organs), adult failure to thrive (a decline in physical and cognitive function, accompanied by weight loss, decreased appetite, and reduced activity levels), vascular dementia (a condition where damage to blood vessels in the brain impairs blood flow, leading to cognitive decline), diabetes (a disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), psoriasis (a chronic, immune-mediated skin disease that causes red, scaly patches on the skin) and dysphagia (difficulty swallowing). <BR/>Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she had long and short-term memory problems and severely impaired cognitive skills for decision making. Resident #4 did not have any behavioral symptoms or rejection of care issues. Resident #4 was totally dependent on staff for all ADLs, movement and bed mobility. She had no range of motion issues and used a wheelchair for ambulation. Resident #4 was always incontinent of bowel and bladder, weighed 127 pounds and was at risk of developing pressure ulcers/injuries. She did not have any identified wounds, ulcers or skin issues during the look back period but under the Skin and Ulcer/Injury Treatments, the box was checked that she had a pressure reducing device for her bed and applications of ointments and medications to areas other than feet. Resident #4 was also receiving hospice services and had a life expectancy of less than six months. <BR/>Record review of Resident #4's care plan initiated 12/08/22 and last updated related to wounds on 01/23/24 reflected, Goal: [Resident #4] has a potential for skin breakdown r/t lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue, causing inflammation and damage to various organs) and psoriasis (a chronic, immune-mediated skin condition that causes red, scaly patches on the skin); Interventions: .Provide pressure reducing mattress on bed, Weekly skin assessment to be completed. The care plan did not reflect she had a new skin alteration on her bottom. <BR/>Record review of Resident #4's physician order summary reflected, Left buttock: Cleanse with wound cleanser pat dry, apply honey and calcium alginate. Cover, secure with border foam dressing. every day shift every Mon, Wed, Fri for wound management Hospice nurse will assess once a week (start date 06/18/25) . Right buttock: Cleanse with wound cleanser pat dry, apply xeroform and cover with border foam dressing every day shift every Mon, Wed, Fri for wound management (written 06/19/25 with a start date of 06/20/25). Resident #4 did not have an order for a pressure reducing mattress.<BR/>An observation of Resident #4 on 06/18/25 at 10:25 AM revealed she was in bed, was not able to be interviewed as she was no responsive to questions. Resident #4 was observed to not have a low air loss mattress in place. She had a pillow minimally offloading her right butt cheek and another pillow under her thighs. The wound dressing was observed to be intact and on her left butt cheek and was dated 06/18/25 by WC LVN C.<BR/>An interview with LVN D on 06/18/25 at 10:25 AM revealed Resident #4 had a blister on her bottom that had popped and was currently receiving treatment for it. <BR/>4. An interview with ADON A on 06/18/25 at 3:16 PM revealed the purpose of an air loss mattress was for when a resident had compromised skin or to prevent skin breakdown from happening or getting worse, to promote healing and to make the resident feel comfortable. He stated the setting for the pump should go by the weight of the resident according to what the rental company staff for the mattress have told him, But I am not exactly sure, mostly when they [DME rental company] comes, they set it up for us. Then the nurses check it to make sure it is running with that parameter. ADON A stated the charge nurse was supposed to be checking the low air loss mattress and pump settings during a daily routine check. ADON A said in order to prevent pressure ulcers from getting worse, as a unit manager, he assesses residents with wounds and made sure there was a low air loss mattress in place for a new or reopened wound. ADON A stated using pillows versus a low air loss mattress would depend on the physician's order. He stated, Mostly from my experience, I don't know if a pillow is enough for a pressure ulcer, we need a low air loss mattress. I don't know if you can replace that with a pillow. But to prevent a wound, you can reposition, use pillows but once the wound starts forming, we need a low air loss mattress. <BR/>An interview with ADON B on 06/19/25 at 10:45 AM revealed the purpose of a low air loss mattress was to prevent pressure ulcers or other wounds and the setting should go by the resident's weight. She said the setting should be monitored daily by the ADONs, treatment (wound care) nurse and the DON. <BR/>An interview with WC LVN C on 06/19/25 at 11:15 AM revealed the purpose of a low air loss mattress was to prevent wounds and the setting should go by the weight of the resident. She did not know who was responsible for setting the pump to the correct setting. WC LVN C stated, I probably should check the setting on the mattress, I should know how it is being effective with the wound, but I don't do it with every wound. <BR/>An interview with the ADM on 06/19/25 at 11:45 AM revealed after investigator intervention, Residents #3 and #4 were ordered and provided a low air loss mattress. He stated central supply was present during the stand-up meetings and when she was made aware of the need for a low air loss mattress, she ordered it and it would usually come within the same day or within 24-48 hours. He stated hospice delivered Resident #4's and Resident #3's came in on 06/19/25. The ADM stated he was not sure why there was a delay in getting them. <BR/>An interview with LVN F on 06/19/25 at 12:58 PM revealed the purpose of a low air loss mattress was to help with pressure sores and positioning. LVN F stated she would know if the mattress was not set correctly because an alarm would go off and give an alert on the pump unit. She said when the dial was turned on, It goes to 250 and that is where it should be put, it is the amount of air going into the mattress. LVN F stated the low air loss mattresses were usually for residents who might be at risk for pressure ulcers as well as for those residents who could not reposition themselves in bed. She stated the setting for the pump to ensure accuracy was usually monitored by the charge nurses and CNAs. <BR/>5. Review of the facility's policy titled, Skin Integrity Management revised October 16, 2016, reflected, .14. Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as was possible for 1 (Resident #17) of 11 residents reviewed accident hazards.<BR/>The facility failed to ensure Resident #17's walker was repaired or replaced after it had been damaged during transport in February 2024. Resident #17 attempted to fix the walker himself utilizing zip ties, but the walker still malfunctioned and was described by Resident #17 as being scary to use. <BR/>This failure could place residents at an increased risk of accidents, such as falls.<BR/>Findings included:<BR/>Review of Resident #17's Face Sheet, dated 07/11/24, reflected he was a [AGE] year-old male who admitted to the facility on [DATE].<BR/>Review of Resident #17's MDS Assessment, dated 04/09/24, reflected he was cognitively intact. He had diagnoses including cellulitis (a common and potentially serious bacterial skin infection), lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph fluid in the tissues), and morbid (severe) obesity due to excess calories (a BMI of 40 or greater). Resident #17 was identified as utilizing a walker for mobility purposes.<BR/>Review of Resident #17's Care Plan, dated 07/09/24, reflected there was no mention of him utilizing a walker for mobility purposes.<BR/>Observation of Resident #17 on 07/09/24 at 10:00AM revealed he was sitting up in his bed. He was clean, well-groomed, and appropriately dressed. He was free from any odors. He displayed no obvious signs or symptoms of distress. There were no concerning marks or bruises noted on his person. There were no noted concerns regarding his appearance. Resident #17 had a walker by his bedside. It was noted that the walker had two zip-ties that were placed on each side of padded backrest. The padded backrest would not stay in an upright position.<BR/>During an interview with Resident #17 on 07/09/24 at 10:00AM, he stated the padded backrest of his walker was broken during a transport in February 2024. He said although he advised the Social Worker and someone in the therapy department that the walker had been broken, the facility had not yet repaired the walker. He said he had been asking consistently for months for his walker to be repaired. He stated he utilized zip ties to try to fix the walker himself, but the padded backrest still would not stay in an upright position. Resident #17 stated this made the walker scary to utilize, as he used the padded backrest as support on a regular basis.<BR/>During an interview with the Social Worker on 07/10/24 at 10:32AM, he stated in February 2024, Resident #17 advised that the padded backrest of his walker had been broken during transport with an independent transport company. The Social Worker stated he advised the therapy department that the walker had been broken and needed either repair or replacement. The Social Worker stated he did not believe there was a risk of the padded backrest of Resident #17's walker being broken, as Resident #17 did not get up and out of bed on a regular basis.<BR/>During an interview with the Director of Rehabilitation on 07/10/24 at 10:41AM, he stated he had not been made aware that the padded backrest of Resident #17's walker was previously broken during transport. He stated the facility was in the process of getting Resident #17 approved for a motorized wheelchair. The Director of Rehabilitation stated the risk of the padded backrest of Resident #17's walker was low, as there were other mechanisms of support included on the walker.<BR/>During an interview with the Director of Nursing on 07/11/24 at 1:20PM, she stated she had not been advised that the padded backrest of Resident #17's walker was broken until 07/10/24. The Director of Nursing stated the facility would be replacing Resident #17's walker. The Director of Nursing stated an improperly functioning and/or broken walker included an increased risk of falls.<BR/>A policy regarding the repair of assistive devices was requested on 07/11/24, but the Administrator advised during the exit conference on 07/11/24 that such a policy was unable to be located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #80) of 4 residents reviewed for oxygen administration. The facility failed to follow Resident #80's physician order for continuous oxygen. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and could result in a decline in health.Findings included: Record review of Resident #80's Face Sheet, dated 08/26/25, reflected she was an [AGE] year-old female, who originally admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (a sudden worsening of chronic obstructive pulmonary disease symptoms including shortness of breath), respiratory arrest (a serious medical condition caused by apnea or respiratory dysfunction), and dependence on supplemental oxygen (a condition where an individual requires supplemental oxygen due to respiratory disorders or other medical conditions). Record review of Resident #80's MDS Assessment, dated 07/13/25, reflected she had a BIMS score of 11, which indicated she had moderate cognitive impairment. Resident #80 was identified as requiring oxygen therapy. Record review of Resident #80's Physician's Orders, dated 08/26/25, reflected she had an order for continuous oxygen (2-5 liters per minute) for ineffective air exchange. The start date for this order was 08/20/25. Record review of Resident #80's Care Plan, dated 05/19/25, reflected she utilized oxygen therapy. Identified goals included for Resident #80 to have no signs or symptoms of poor oxygen absorption. Interventions included for Resident #80 to have continuous oxygen via nasal cannula, with settings at 2 liters per minute. Observation of Resident #80 on 08/24/25 at 9:43AM revealed she was ambulating throughout the facility in her wheelchair. Resident #80 had a portable oxygen tank hanging from her wheelchair; the oxygen level indicator reflected the oxygen tank was empty. During an interview with Resident #80 on 08/24/25 at 9:43AM, she stated she was unable to feel any oxygen coming from her nasal cannula and needed the oxygen tank replaced. During an interview with RN B on 08/24/25 at 9:55AM, she stated Resident #80 had a physician's order for continuous oxygen therapy. She confirmed the portable oxygen tank that Resident #80 was using had run out of oxygen and was empty. RN B stated she last checked the portable oxygen tank earlier this morning (unknown what time), and oxygen was being delivered at that time. RN B stated the risk of a resident not receiving continuous oxygen as ordered included the potential for shortness of breath, increased heartrate, and confusion. During an interview with the DON on 08/26/25 at 2:57PM, he stated the expectation for residents with physician's orders for continuous oxygen was for these residents to always have access to oxygen. The DON stated the risk of a resident not receiving continuous oxygen as ordered included not getting enough oxygen and the potential for shortness of breath. Record review of the facility's Oxygen Administration policy, dated 02/13/07, reflected, .Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions (low levels of oxygen in the blood) caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40% oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure biologicals were secured properly for one of one treatment cart reviewed for drug storage.<BR/>The facility did not ensure the treatment cart was locked and supervised.<BR/>This failure could place residents at risks for harm and drug diversion.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS assessment, undated, reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, recurrent, serve with psychotic symptoms, and Dementia. She had a BIMS of 09 indicating she had moderate cognitive intact. <BR/>Record review of Resident #1's Comprehensive Care Plan dated 05/31/18 reflected the following: An alteration in neurological status related to scope, TIA, Dementia, Major Depressive Disorder, recurrent, serve with psychosis, altered mental state. <BR/>An observation on 2/24/23 at 8:35 AM revealed treatment cart was located behind the nurse's station down hallway 600 with drawers facing outward toward the lobby. Observations revealed the treatment cart was unlocked and unsupervised. Observation revealed staff were not in view of the treatment cart. Observation revealed Resident #1 walked past the treatment cart. An observation revealed items on treatment cart included:<BR/>*Ready prep PVP (medication is used for first aid antiseptic and effective for skin and mucous membrane preparation prior to surgical procedures)<BR/>*Ammonium lactate topical (medication is used to treat dry, scaly skin conditions)<BR/>*Normal saline (This solution is used to supply water and salt (sodium chloride) to the body)<BR/>An interview on 2/24/23 at 8:40 AM with Wound Care Nurse revealed she was stocking the treatment cart. Wound Care Nurse stated that she left the treatment cart unlocked while she stocked it. Wound care Nurse stated the treatment cart supposed to be always locked when not in use and out of view. Wound care Nurse stated that all nursing staff had keys to the treatment cart and were responsible for the treatment cart. Wound care nurse stated residents are in danger of ingestion normal saline and PVP prep solution. <BR/>An interview on 2/24/23 at 10:15 AM with the LVN revealed the Wound Care Nurse had access to the treatment cart. LVN stated the treatment cart should be always locked.<BR/>An interview on 2/24/23 at 2:30 PM with Unit Nurse and Evening supervisor revealed there is one treatment cart for the facility. Unit Nurse Evening Supervisor stated there is one key for the treatment cart and the Wound Care Nurse is responsible for it. Unit Nurse Evening Supervisor stated residents could get into the cart and take something that they are not supposed to take. <BR/>An Interview with DON on 2/24/23 at 3:45 PM revealed There is only one key for the treatment cart. DON stated the Wound Care Nurse does treatments in the facility Monday through Friday. DON stated the Treatment Doctor came in Tuesday to do care with the Wound Care Nurse. DON stated on the weekend the Wound Care Nurse or RN dose treatment and had access to the treatment cart. DON stated you do not know what residents' mental status are and some resident will just open the drawers. <BR/>Review of the facility's policy titled, Nursing Services, Medication and Treatment Cart Security undated reflected, 2. Cart must have be kept locked at all times when not in use. 3. The nurse should be in direct visual line of the .treatment cart whenever the cart is open. 4. Any .treatment cart not in view of the nurse needs to locked at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident call light system was maintained within reach for 4 of 6 residents (Resident #14, Resident #3, Resident #21, and Resident #69) reviewed for call light system access. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain on the floor at the foot of the bed, out of the resident's reach. The facility failed to ensure Resident #3 had access to their call light by allowing it to remain draped over a light fixture about the resident's bed, out of the resident's reach. The facility failed to ensure Resident #21 had access to their call light by allowing the cord to become unattached from the clip, resulting in the call light to dangle from the wall, out of the resident's reach. The facility failed to ensure Resident #69 had access to their call light by allowing it to remain on the floor in a shoe, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Record review of Resident #14's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), Dementia (severe decrease in memory and intellectual functioning), hypertension (high blood pressure), and muscle weakness (less strength or control in muscles). She required substantial/maximal assistance for daily care tasks like toileting hygiene, bathing, dressing, and grooming. She also required similar support for mobility tasks like toilet transfer, rolling from side to side, chair/bed-to chair transfer. She was dependent on staff to assist with walking, taking steps, picking up objects and utilized a wheelchair for mobility. Record review of Resident #14's Comprehensive Care plan dated 05/15/2025 reflected a fall focus: [Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. Review of Resident #14's Comprehensive Care Plan also revealed a communication focus. [Resident] has a communication problem. Goal: Resident will be able to make basic needs known by (specify) [sic] on a daily basis through the review date. Interventions included: Ensure/provide a safe environment: Call light in reach. During an interview and observation on 08/24/2025 at 9:44 AM, Resident #14 was observed in bed. The call light was on the floor at the end of the bed, out of the reach of the resident. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 10:15 AM, Resident #14 was observed in bed. The call light remained in the same location, on the floor and not accessible. During an interview with LVN A on 08/24/2025 at 10:56 AM, in response to the Resident's call light placement, LVN A reported Resident #14 did not use her call light and they would check on her every 30 minutes to an hour. Record review of Resident #3's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included heart failure, Type 2 Diabetes (a condition where the body does not use insulin properly, causing high blood sugar levels over time), nuclear cataract (a clouding of the center of the eye's lens that make vision blurry), hypertension (high blood pressure), visual loss to both eyes, difficulty in walking and unsteadiness on feet. Resident #3 was independent with eating and oral hygiene, completing these tasks safely without staff assistance. For toileting hygiene, putting on/taking off footwear, and personal hygiene, the resident required setup assistance, with staff placing necessary supplies within reach; however, the resident completed the activities independently once prepared. With showering/bathing, upper body dressing, and lower body dressing, the resident required supervision and occasional touching assistance, including staff presence for safety, verbal cueing, and light physical guidance as needed. The resident was fully independent with rolling left and right, moving from sitting to lying and lying to sitting at the side of the bed, standing from a seated position, transferring between a chair and bed, using the toilet, and walking 10 feet. He required supervision or minimal assistance for tub/shower transfers, walking 50 feet with two turns, and walking 150 feet. The resident experienced frequent bowel incontinence and occasional urinary incontinence. Record review of Resident #3's Comprehensive Care plan dated 5/23/2025 reflected a fall focus: {Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #3 was observed in bed, awake and alert. The Resident's call light was observed hanging over a light fixture above his bed. Resident #3 stated he had his call light yesterday but could not locate it in his bed. He stated his bed was usually where his call light would be placed. During an observation on 08/24/2025 at 10:35 AM, Resident #3 was observed in bed and the call light remained in the same location, hanging over the light fixture and out of reach of the resident. During an interview with LVN A on 08/24/2025 at 11:06 AM, she confirmed the location of the call light hanging over the light fixture and immediately arranged the call light to be clipped next to the resident. She stated she was not sure who put it there or how long it had been like that. She stated the resident was blind and confused and she would check on him every 30 minutes to an hour. She reported she did not notice it was out of his reach during her last check at 9:00 AM. Record review of Resident #21's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), transient ischemic attack and cerebral infarction (a type of stroke caused by blood vessel in the brain), generalized anxiety disorder, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), muscle wasting in upper right and left arms, and muscle weakness. The resident was independent with eating and oral hygiene. She was dependent on staff for toileting hygiene, showering/bathing, and putting on/taking off footwear. She required setup assistance for both upper and lower body dressing, as well as for personal hygiene tasks such as washing her face and hands, shaving, and combing hair. She demonstrated very little mobility and required significant staff assistance for nearly all movements. She needed substantial assist to roll in bed, transition from sitting to lying, and move from lying to sitting at the side of the bed. All other mobility activities including standing, transferring between chair and bed, toilet and tub/shower transfers, and walking short distances were fully dependent on staff. Record review of Resident #21's Comprehensive Care Plan dated 07/15/2025 reflected the following focus: [Resident] uses one quarter or two quarter rails to enhance functional independence & promote skin integrity. Goal: [Resident] will maintain or increase functional independence through each use of: one partial (half) rail or two partial rails through the next review. Interventions included: Place the call light cord within easy reach. Focus: [Resident] is at risk of falls related to CVA (Cerebrovascular Accident, commonly known as a stroke, caused by interruption of blood flow to the brain, resulting in neurological changes), hemiplegia, pain, obesity, weakness in radiculopathy (nerve pain). Goal: [Resident] will have no injuries through the next review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:15 AM, Resident #21 was observed in bed, awake and alert. The resident's call light was hanging down the wall and not clipped near the resident within her reach. She reported her call light clip had broken, and the call light cord would keep detaching from the clip. She pointed to the clip that was attached to her pillowcase that would hold the call light cord. She reported it had been broken for around a week and she had reported it to several staff. The resident stated she was told by staff it would be fixed but nothing had been done. She reported she would use her reach extender (a tool for reaching and grasping objects from a distance) to bring the call light closer to her when it would come unattached from the clip. She reported feeling frustrated about her call light and felt worried if she needed immediate assistance, she would not be able to get to her call light. During an observation on 08/24/2025 at 10:20 AM, the resident was observed in bed and the call light remained in the same location, out of reach of the resident. During an interview with LVN A on 08/24/2025 at 10:15 AM, LVN A confirmed the location of the call light that was out of reach of Resident #21. LVN A stated she had not been made aware that the cord kept coming detached from the clip. She stated she also had not been made aware that Resident #21 had to utilize a reach extender to access her call light. LVN A reattached the resident's call light back to the original clip. Record review of Resident #69 annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), hypertension (high blood pressure), depressive disorder (a condition that causes persistent sadness, loss of interest, and low energy that affects daily life), dysphagia (difficulty speaking or understanding language), and muscle weakness. Resident #69 was dependent on staff for self-care tasks such as eating, oral hygiene, toileting hygiene, shower/bathing, dressing, putting on/off footwear, and personal hygiene. The resident was independent with some mobility, namely walking. She was dependent on staff for tub/shower transfers, toilet transfers, and the ability to roll from lying on back to her left or ride side. The resident experienced frequent urinary and bowel incontinence. Record review of Resident #69's Comprehensive Care plan dated 08/07/2025 reflected a fall focus: {Resident] is at risk for falls related to Alzheimer's Disease and pain. Goal: [Resident] will have no injuries due to falls through the next quarterly review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:12 AM, Resident #69 was observed lying in bed. The call light was in the resident's shoe on the floor near the bed. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 11:10 AM, LVN A confirmed the location of the call light and LVN A immediately clipped it near the resident. LVN A stated she was not sure how it got there. She stated every staff member is responsible for ensuring the call light is within reach of the resident. During a follow up interview with LVN A on 08/24/2025 at 1:45 PM, she reported that she was unaware of any risk to residents due to them not being able to reach the call light. She reported she would check on her residents every 30 minutes. When asked if she did that on 08/24/2025 she reported it was more like every hour. During an interview with CNA G on 08/26/2025 at 1:15 PM, she reported it was everyone's responsibility to answer call lights. She reported it was also everyone's responsibility to ensure the call light is within reach of each resident. She reported she checked on residents as needed and every 30 minutes to an hour. During an interview with Regional Compliance Nurse on 08/26/2025 at 3:00 PM, he reported every staff member at the facility was responsible to ensure call lights were within reach of each resident. He reported the risk of it not being within reach was not being able to call for assistance if they needed water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for (Resident #8) reviewed for gastrostomy tube management.<BR/>The facility failed to check the Resident #8's residual before administering medications via gastrostomy tube (G-tube: A tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #8's face sheet dated 05/17/23 revealed a 78- year-old-male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute and chronic respiratory failure (inability of the lungs to perform their basic task of gas exchange, the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from blood into exhaled air), dysphagia/aphagia (Is a language disorder. It affects how you speak and understand language), vascular parkinsonism, progressive bulbar palsy (is a set of conditions that can occur due to damage to the lower nerves. Clinical features of bulbar palsy range from difficulty swallowing and lack of gag reflex to inability to articulate words and excessive drooling), hyperlipidemia (is abnormally elevated levels of any or all lipids in the blood), hypertension (high blood pressure).<BR/>Record review of Resident #8's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 14. Cognitive skills for daily decision making identified Resident #8 as cognitively intact. Nutritional Status section identified use of a feeding tube. <BR/>Record review of Resident #8's Care Plan dated 01/05/2023 revealed: Focus: Resident #8 required tube feeding r/t Dysphasia, swallowing problem. Goal: Resident #8 will maintain adequate nutrition and hydration status and weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: check for tube placement and gastric contents/residual per facility protocol and record. <BR/>Observation on 5/16/23 01:15 PM reveled, RN C failed to check feeding tube residual before administering noon medication. <BR/>Interview on 05/17/23 12:04 PM RN C stated for the feeding tube, she disconnected the tubing use 30 ml water and push it to remove any plugging in the tubing. The RN C further stated she do check the residual in AM before she gave the medications, because it is more medications to give, and she did not check at noon, it is just one medication to give. RN C stated the [NAME] to check the residual, because if there is more food in the stomach, the resident may vomit, aspirate, if more 500 ml we should not give medication.<BR/>In an interview on 05/17/2023 at 01:04 PM ADON stated the new RN C received training regarding given medications via G-Tube feeding. ADON stated the staff should check the residual every time they give medications to prevent resident vomiting, and aspiration. The ADON further stated the staff should flush the GT by gravity with water, and give medications one by one by gravity, and flush with water after giving medications by gravity, and The ADON further stated the risk to resident emesis, nausea vomiting, and aspiration as well.<BR/>Review of the facility policy undated and titled Enteral Tube Care and feeding reflected, . PLACEMENT VERIFICATION: GT placement is verified before feedings, flush, or medications administration and PRN. RESIDUAL CHECK: residual is verified prior to each feeding and every 8 hours during feedings and PRN, if intolerance symptoms are noted contact MD for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for three (Residents #2 , #3 and #7) of seven residents reviewed for resident records. <BR/>1. The facility failed to document if wound care was provided for Resident #2 in June 2025 on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25.<BR/>2. The facility failed to document if wound care was provided for Resident #3 in June 2025 on three occasions: 06/10/25, 06/15/25 and 06/16/25.<BR/>3. The facility failed to document if wound care was provided for Resident #7 in May 2025 on four occasions: 05/05/25, 05/07/25, 05/21/25 and 05/26/25. <BR/>These failures could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management.<BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. <BR/>Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. <BR/>Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface ) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. <BR/>Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25).<BR/>Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected no documented treatment to his sacral wound on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25. <BR/>Record review of Resident #2's nursing progress notes for June 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. <BR/>2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes, aphasia, stroke, anoxic brain damage and dysphagia. Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed.<BR/>Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. <BR/>Record review of Resident #3's physician order summary reflected, Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). <BR/>Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected the following treatment was order from 06/01/25 through 06/16/25, Sacrum: Cleanse with wound cleanser and apply triad cream every day shift for wound management (discontinue date 06/16/25). The record did not indicate the nurse signed off for wound care treatment on 06/10/25, 06/15/25 and 06/16/25. <BR/>An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25.<BR/>3. Record review of Resident #7's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] after an acute hospital stay. Resident # 7's active diagnoses included cellulitis, local infection of the skin and subcutaneous tissue, non-pressure chronic ulcer of lower leg, secondary gout, pain, localized edema and lymphedema. <BR/>Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #7 had no rejection of care issues, had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #7 was at risk of developing pressure ulcers/injuries and had six venous and arterial ulcers present at the time of the assessment. He required a pressure reducing device for the bed, application of nonsurgical dressings and applications of ointments/medications.<BR/>Record review of Resident #7's care plan initiated 12/15/23 and last revised 06/09/25 reflected, Focus: [Resident #7] has a pressure ulcer or potential for pressure ulcer development; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan also indicated Resident #7 had a behavior problem of picking at his skin and refusing wound care. The care plan did not address the numerous venous/arterial ulcers Resident #3 had. <BR/>Record review of Resident #7's Order Summary reflected:<BR/>-Left Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 05/19/25)<BR/>-Left Posterior Leg: Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Left second toe: Cleanse with wound cleaner apply betadine secure with dry dressing every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Left Superior Lateral leg:Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen,<BR/>xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap.<BR/>every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Right Dorsal Leg: Wash with Hibiclens, rinse and pat dry thoroughly. Apply collagen, xeroform. And apply A&D ointment to areas of dryness, secure with rolled gauze and ace wrap.<BR/>every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Right Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25).<BR/>Record review of Resident #7's WAR/TAR for May 2025 did not indicate the nurse signed off for wound care treatment on 05/05/25, 05/07/25, 05/21/25 and 05/26/25.<BR/>Record review of Resident #7's nursing progress notes for May 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. <BR/>An interview was attempted and unsuccessful with Resident #7 while in the hospital on [DATE] at 1:08 PM and rang busy. <BR/>4. An interview with ADON B on 06/19/25 at 10:45 AM revealed after treatment was done for a wound, there was a WAR (wound administration record) to complete and the nurse should not forget to document the treatment was provided because the e-charting system for that treatment administration will stay red on the screen until resolved. ADON B stated nursing management could see who was missing medications and treatment administrations and if that happened, the nursing management would go and talk to the nurse in question. She stated, in order for the red administration notification to go away in the e-charting system, the nurse would have to document and put a progress note in the resident's chart to state why the treatment was not completed. <BR/>An interview with WC LVN C on 06/19/25 at 11:15 AM revealed she was responsible for documenting on the WAR when she changed a resident's wound dressing. She stated when there were blanks on the WAR, it could be because she was not at the facility working and the charge nurses were responsible for completing the wound care and WARs. <BR/>An interview with LVN F on 06/19/25 at 12:58 PM revealed she only did wound care if the wound care nurse was not present at the facility. She stated wound care treatment was documented on the WAR and if the wound care nurse or charge nurse did not click and enter that it was done, the treatment administration time would remain showing red on the e-chart and it meant you probably didn't do it or forgot to click it off.<BR/>An interview with the C-RN on 06/19/25 at 1:49 PM revealed the facility management had completed a one-on-one in-service with WC LVN C and ensured that she did do the wound care but did not check it off as completed on the WAR. He stated they did a one-on-one training to ensure she understood the point of doing treatment was to ensure the treatment was documented and if not clicked off at the point of care, then you get to the end of the day, you may forget.<BR/>5. Review of the facility's policy titled, Skin Integrity Management revised 10/05/2016, reflected, General Guidelines: 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified and treatment applied; .3. Wound care should be performed as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as was possible for 1 (Resident #17) of 11 residents reviewed accident hazards.<BR/>The facility failed to ensure Resident #17's walker was repaired or replaced after it had been damaged during transport in February 2024. Resident #17 attempted to fix the walker himself utilizing zip ties, but the walker still malfunctioned and was described by Resident #17 as being scary to use. <BR/>This failure could place residents at an increased risk of accidents, such as falls.<BR/>Findings included:<BR/>Review of Resident #17's Face Sheet, dated 07/11/24, reflected he was a [AGE] year-old male who admitted to the facility on [DATE].<BR/>Review of Resident #17's MDS Assessment, dated 04/09/24, reflected he was cognitively intact. He had diagnoses including cellulitis (a common and potentially serious bacterial skin infection), lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph fluid in the tissues), and morbid (severe) obesity due to excess calories (a BMI of 40 or greater). Resident #17 was identified as utilizing a walker for mobility purposes.<BR/>Review of Resident #17's Care Plan, dated 07/09/24, reflected there was no mention of him utilizing a walker for mobility purposes.<BR/>Observation of Resident #17 on 07/09/24 at 10:00AM revealed he was sitting up in his bed. He was clean, well-groomed, and appropriately dressed. He was free from any odors. He displayed no obvious signs or symptoms of distress. There were no concerning marks or bruises noted on his person. There were no noted concerns regarding his appearance. Resident #17 had a walker by his bedside. It was noted that the walker had two zip-ties that were placed on each side of padded backrest. The padded backrest would not stay in an upright position.<BR/>During an interview with Resident #17 on 07/09/24 at 10:00AM, he stated the padded backrest of his walker was broken during a transport in February 2024. He said although he advised the Social Worker and someone in the therapy department that the walker had been broken, the facility had not yet repaired the walker. He said he had been asking consistently for months for his walker to be repaired. He stated he utilized zip ties to try to fix the walker himself, but the padded backrest still would not stay in an upright position. Resident #17 stated this made the walker scary to utilize, as he used the padded backrest as support on a regular basis.<BR/>During an interview with the Social Worker on 07/10/24 at 10:32AM, he stated in February 2024, Resident #17 advised that the padded backrest of his walker had been broken during transport with an independent transport company. The Social Worker stated he advised the therapy department that the walker had been broken and needed either repair or replacement. The Social Worker stated he did not believe there was a risk of the padded backrest of Resident #17's walker being broken, as Resident #17 did not get up and out of bed on a regular basis.<BR/>During an interview with the Director of Rehabilitation on 07/10/24 at 10:41AM, he stated he had not been made aware that the padded backrest of Resident #17's walker was previously broken during transport. He stated the facility was in the process of getting Resident #17 approved for a motorized wheelchair. The Director of Rehabilitation stated the risk of the padded backrest of Resident #17's walker was low, as there were other mechanisms of support included on the walker.<BR/>During an interview with the Director of Nursing on 07/11/24 at 1:20PM, she stated she had not been advised that the padded backrest of Resident #17's walker was broken until 07/10/24. The Director of Nursing stated the facility would be replacing Resident #17's walker. The Director of Nursing stated an improperly functioning and/or broken walker included an increased risk of falls.<BR/>A policy regarding the repair of assistive devices was requested on 07/11/24, but the Administrator advised during the exit conference on 07/11/24 that such a policy was unable to be located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for (Resident #8) reviewed for gastrostomy tube management.<BR/>The facility failed to check the Resident #8's residual before administering medications via gastrostomy tube (G-tube: A tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #8's face sheet dated 05/17/23 revealed a 78- year-old-male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute and chronic respiratory failure (inability of the lungs to perform their basic task of gas exchange, the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from blood into exhaled air), dysphagia/aphagia (Is a language disorder. It affects how you speak and understand language), vascular parkinsonism, progressive bulbar palsy (is a set of conditions that can occur due to damage to the lower nerves. Clinical features of bulbar palsy range from difficulty swallowing and lack of gag reflex to inability to articulate words and excessive drooling), hyperlipidemia (is abnormally elevated levels of any or all lipids in the blood), hypertension (high blood pressure).<BR/>Record review of Resident #8's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 14. Cognitive skills for daily decision making identified Resident #8 as cognitively intact. Nutritional Status section identified use of a feeding tube. <BR/>Record review of Resident #8's Care Plan dated 01/05/2023 revealed: Focus: Resident #8 required tube feeding r/t Dysphasia, swallowing problem. Goal: Resident #8 will maintain adequate nutrition and hydration status and weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: check for tube placement and gastric contents/residual per facility protocol and record. <BR/>Observation on 5/16/23 01:15 PM reveled, RN C failed to check feeding tube residual before administering noon medication. <BR/>Interview on 05/17/23 12:04 PM RN C stated for the feeding tube, she disconnected the tubing use 30 ml water and push it to remove any plugging in the tubing. The RN C further stated she do check the residual in AM before she gave the medications, because it is more medications to give, and she did not check at noon, it is just one medication to give. RN C stated the [NAME] to check the residual, because if there is more food in the stomach, the resident may vomit, aspirate, if more 500 ml we should not give medication.<BR/>In an interview on 05/17/2023 at 01:04 PM ADON stated the new RN C received training regarding given medications via G-Tube feeding. ADON stated the staff should check the residual every time they give medications to prevent resident vomiting, and aspiration. The ADON further stated the staff should flush the GT by gravity with water, and give medications one by one by gravity, and flush with water after giving medications by gravity, and The ADON further stated the risk to resident emesis, nausea vomiting, and aspiration as well.<BR/>Review of the facility policy undated and titled Enteral Tube Care and feeding reflected, . PLACEMENT VERIFICATION: GT placement is verified before feedings, flush, or medications administration and PRN. RESIDUAL CHECK: residual is verified prior to each feeding and every 8 hours during feedings and PRN, if intolerance symptoms are noted contact MD for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult the resident's physician, when the resident had an injury and had the potential for requiring physical intervention and when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of six residents reviewed for resident rights.<BR/>The facility failed to notify the physician when Resident #1 complained of right leg pain on 05/22/23. There were multiple opportunities for the staff to notify the physician when it was noted by the facility staff and responsible party that Resident #1's leg was swollen and she was in pain. The physician indicated he should have been notified on 5/18/23, 5/22/23, and 5/28/23. As a result, she experienced continued pain per facility staff, and suffered fracture(s) of her left knee (acute transverse impacted fracture at proximal and fibular metaphysis which affects the neck of the bone (metaphysis), where the tibia starts to narrow down. Due to Resident #1's injury, she was sent to the hospital. <BR/>On 06/21/23 at 2:05 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/22/23, the facility remained out of compliance at a severity level of actual harm and scope of pattern.<BR/>This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death.<BR/>Findings included: <BR/>Review of Resident #1's Annual MDS Assessment, dated 04/21/23, reflected she was a [AGE] year-old who admitted to the facility on [DATE]. Her diagnoses included: hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, depression, and insomnia. Her BIMS score was 6 and indicated severe cognitive impairment. Her functional status reflected she required extensive assistance and one-person physical assistance with bed mobility, locomotion on unit, locomotion off unit, and personal hygiene. She required extensive assistance and two-person physical assistance with transfers, dressing, and toilet use. Her pain management revealed she received scheduled pain medication regimen.<BR/>Record review of Resident #1's Care Plan, undated, revealed she required assistance with ADLs and was at risk of falls due to dementia, Alzheimer's. Her goal was to attempt/complete ADL tasks with staff assistance and have no injuries due to falls thru the next review. Her interventions were required extensive assist with bed mobility, transfers, toileting, personal hygiene, and bathing. She required limited assist and one-person assist with locomotion, eating, and walking. Notify and update MD and family as needed. Evaluate possible causes of falls and address issues to the extent possible. She had a fracture of the left knee, problems were manifested by impaired mobility. Her goal was to heal the fracture without complications thru next review. Her interventions were to follow up with ortho as indicated. Monitor and medicate for pain as needed.<BR/>Record review of Resident #1's physician order recap report, dated 05/01/23 - 06/08/23, reflected she was ordered the following medications: Acetaminophen suppository 650 mg (every 4 hours as needed for pain), Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours), Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain), and Tylenol oral tablet (500 mg two times a day for pain).<BR/>Record review of Resident #1's physician orders, dated 06/01/23, reflected x-ray left knee 2 views for continued pain and left knee getting bigger. One time only for pain and swelling to left knee for past two days. <BR/>Record review of Resident #1's MAR , dated May 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 05/01/23 to 05/31/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 05/01/23 to 05/31/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day from 05/01/23 to 05/31/23.<BR/>Record review of Resident #1's MAR, dated June 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 06/01/23 to 06/02/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 06/01/23 to 06/02/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day on 06/01/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered once a day on 06/02/23.<BR/>Record review of Resident #1's pain levels, dated 05/18/23 - 05/23/23, reflected her pain level was 0/10. Her pain level on 05/24/23 - 05/28/23 was 2/10. Her pain level on 05/29/23 was 0/10. Her pain level on 05/30/23 was 2/10. Her pain level on 05/31/23 was 1/10. Her pain level on 06/01/23 was 2/10. <BR/>Record review of Resident #1's progress notes, dated 05/18/23, revealed she was administered Tylenol oral tablet twice a day for pain and did not have any signs/symptoms of pain (written by LVN A). <BR/>Record review of Resident #1's nursing notes, dated 05/22/23, reflected Resident #1 complained of left leg pain. Resident #1 refused PRN pain medication. Resident #1 received two-person incontinent care. Resident's RP assisted with turn and incontinent care at the beginning of shift. Resident #1 was assessed and stated ouch when left leg was touched. Will continue to monitor (written by LVN B). <BR/>Record review of Resident #1's nursing notes revealed there were no nursing notes from 05/23/23 to 05/31/23.<BR/>Record review of Resident #1's nursing notes, dated 06/01/23, reflected per family request, Resident #1 was to be a two-person assist with all transfers. The information was entered in Resident #1's plan of care for aides on 06/01/23. Resident #1 complained of continued pain to her left knee and family was concerned her left knee was getting bigger. The physician was notified and a new order for Resident #1 was received for left knee x-ray. Per aide Resident #1 did yell like she was in pain during transfer (written by LVN A).<BR/>Record review of Resident #1's nursing notes, dated 06/01/23, reflected her left knee x-ray results with impression of acute, transverse, impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) was sent to the physician. The physician recommended Resident #1 be sent to the ER in the morning of 06/02/23 or night of 06/01/23 as per her RP's request. Resident #1's RP was informed of the x-ray results and physician order to send her to the hospital. Resident #1's RP requested she be sent to the hospital in the morning (written by LVN C). <BR/>Record review of Resident #1's nursing notes, dated 06/02/23, reflected Resident #1 was transported the hospital the morning of 06/02/23. Resident had x-rays done and results showed an acute transverse impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) . Resident #1's RP was with her. Resident #1's morning medications were given. Resident #1's Eliquis (medication) was held, and the physician was notified. Resident #1 was to possibly receive surgery (Written by LVN A).<BR/>Record review of the facility's provider investigation report, dated 06/02/23, revealed the facility conducted confidential witness statements with staff on 06/02/23. The confidential witness statements reflected the following statements:<BR/>CNA D stated she noticed swelling on both of Resident #1's legs and was screaming out in pain when being turned to reposition. She stated swelling and screaming out in pain was reported to the nurse;<BR/>LVN B stated on 05/22/23, a CNA reported Resident #1 complained of pain. LVN B stated she assessed and upon light palpation Resident #1 stated ouch. LVN B stated the resident refused PRN pain medication. LVN B stated she did not notify the physician or complete change of condition assessment. LVN B stated a CNA continued to report pain from time to time. LVN B stated she physically assessed Resident #1 each time and she refused PRN pain medication. LVN B stated she did not note any swelling; <BR/>CNA E stated Resident #1 yelled out in pain and exhibited signs of grimacing (placed hand on left lower extremity and stated no) during incontinent care (turning/repositioning). During a two-person transfer Resident #1 did not yell out in pain. CNA E stated she noticed swelling to the left lower extremity. She stated she reported pain and swelling to the nurse; <BR/>LVN C stated Resident #1's RP reported increased pain on 05/31/23. LVN C stated he physically assessed Resident #1 and administered scheduled Acetaminophen. LVN C stated determining Resident #1's level of pain was hard because she always yelled out in pain during any care/repositioning; and<BR/>LVN A stated pain/swelling had not been reported to her in the past two weeks. LVN A stated Resident #1's RP called her on 06/01/23. The RP stated she had been reporting Resident #1's increased pain and swelling for the past two weeks. The RP also stated she requested two-person assistance with Resident #1. LVN A stated an x-ray was ordered. LVN A stated she initiated an order in Resident #1's electronic plan of care to transfer her by two-person assist. <BR/>In an interview with the RP on 06/08/23 at 11:10 AM revealed Resident #1's knee was swollen on 06/01/23. She stated she informed the nurse and the physician was notified. She stated the physician ordered an x-ray on 06/01/23. She stated the x-ray results revealed Resident #1's leg was broken in two places; below the left knee and her main bone was fractured. She stated Resident #1 was sent to the hospital on [DATE]. She stated Resident #1 was discharged from the hospital on [DATE] and transferred to another facility. She stated Resident #1 informed her facility staff provided one-person transfers. She stated Resident #1 was forgetful and did not recall when staff provided one-person transfers. She stated Resident #1 would yell out in pain and would not allow her to touch her leg during visits. She stated Resident #1 received pain medication routinely. She stated she frequently visited Resident #1 at the facility. She stated during visits she assisted staff with incontinent care because the facility only used one-person assistance. She stated she frequently informed the facility Resident #1 required two-person assistance and had leg pain. She stated she also informed the facility to leave Resident #1 in bed if two-person assistance could not be provided. She stated Resident #1 would not be returning to the facility due to systemic problems. She stated the facility staff improperly transferred Resident #1 which resulted in injury. She stated the facility staff needed more training and did not know how to complete adequate transfers with Resident #1.<BR/>In an interview with LVN B on 06/08/23 at 12:21 PM revealed a CNA reported Resident #1 was complaining of left leg pain on 05/22/23. She stated she did not remember which CNA. She stated the RP had assisted the CNA with incontinent care. She stated she assessed Resident #1 and touched her left leg. She stated Resident #1 yelled ouch when her left leg was touched. She stated she offered Resident #1 PRN pain medication and she refused. She stated she did not notify the DON or physician because she did not know if Resident #1's left leg pain was new or ongoing. She stated she continuously monitored Resident #1 throughout her 8-hour shift. She stated at the time of the assessment her response to Resident #1's pain was appropriate. She stated there were no risks to Resident #1 because she closely monitored Resident #1 throughout the shift. She stated she completed a facility in-service on 05/31/23 regarding change in condition. She stated she now believed she should have completed a change of condition evaluation and notified the physician on 05/22/23 because on 06/01/23 an x-ray revealed Resident #1 had a fracture. <BR/>In an interview with LVN A on 06/08/23 at 1:37 PM revealed Resident #1 did not complain of leg pain on 05/18/23 . She stated Resident #1 did not complain of pain until 06/01/23. She stated she assessed residents every time a complaint of pain was made. She stated she assessed residents, had residents point to where pain was located, observed any signs of grimacing, and provided PRN pain medication. She stated she would inform the ADON and DON about residents' pain during the morning meeting. She stated she would inform the oncoming nurse about residents' pain during report. She stated the physician would be notified if residents' pain reoccurred or PRN medication was not working. She stated during the first shift on 06/01/23 the RP contacted the facility and reported Resident # 1 needed two-person assistance instead of one-person assistance with transfers. She stated the RP stated Resident #1 was complaining of more pain and swelling in Resident #1's left knee. She stated she educated the CNA assigned to Resident #1 on 06/01/23 regarding two-person assistance and contacting the nurse immediately when a resident was in pain. She stated she assessed the ROM of Resident #1's leg. She stated Resident #1 yelled out in pain. She stated she noticed Resident #1's left knee was swollen. She stated she notified the physician on 06/01/23 and the second shift nurse regarding Resident #1's left knee pain and swelling. She stated the physician ordered an x-ray of Resident #1's left knee. She stated Resident #1 was administered scheduled Tylenol. She stated the x-ray revealed Resident #1 had a left knee fracture. She stated the physician recommended she be sent to the hospital. She stated she notified the RP. LVN A stated she completed an in-service regarding change of condition on 05/31/23. <BR/>In an interview with CNA D on 6/08/23 at 2:47 PM revealed she noticed swelling in both of Resident #1's legs on 05/18/23. She stated Resident #1 complained of left leg pain during care on 05/18/23. CNA D stated Resident #1 was favoring her left leg during incontinent care on 05/18/23. She stated Resident #1 was previously able to assist with incontinent care and was one-person assist. She stated Resident #1 required two-person assistance with transferring from bed to wheelchair. CNA D stated she informed LVN A Resident #1 was experiencing left leg pain and both legs were swollen. CNA D stated LVN A was observed entering Resident #1's room to assess her legs. CNA D stated she had not worked with Resident #1 since 05/18/23. <BR/>In an interview with CNA E on 06/08/23 at 3:32 PM revealed Resident #1's left knee was swollen on 05/28/23. CNA E stated the RP requested Resident #1 to be transferred to a shower chair for a shower. CNA E stated Resident #1 was lying in bed underneath her linens. CNA E stated she uncovered Resident #1's legs and her left knee was swollen. CNA E stated Resident #1's left knee and leg resembled the shape of a baseball bat (swelling of the knee). CNA E stated the RP alleged facility staff had twisted Resident #1's knee during a transfer. CNA E stated she left Resident #1's room and informed the nurse. CNA E stated she did not remember what nurse was assigned to Resident #1 on 05/28/23. CNA E stated the nurse did not assess Resident #1. CNA E stated the nurse informed her Resident #1 could be transferred into a shower chair for a shower. CNA E stated a CNA assisted her with transferring Resident #1 into the shower chair. She stated Resident #1 was grimacing in pain and would cover her knee for protection on 05/28/23. CNA E stated the nurse should have assessed Resident #1's left knee. CNA E stated Resident #1 was at risk of injury due to experiencing swelling and pain in her left knee.<BR/>In an interview with RNC on 06/08/23 at 3:57 PM revealed she was the acting DON. RNC stated Resident #1's care plan revealed she required one-person assistance with ADLs. RNC stated the RP requested Resident #1 receive two-person assistance. RNC stated she was unaware Resident #1's MDS assessment revealed two-person assistance was needed. RNC stated she referred to Resident #1's care plan regarding ADL assistance and not her MDS assessment. RNC stated CNAs should report any signs of pain and/or swelling to the nurse. RNC stated the nurse should assess the resident and offer pain medication. RNC stated if resident refused pain medication, the nurse should notify the physician. RNC stated the nurse would follow physician recommendations. RNC stated if the nurse did not assess the resident, the nurse would receive education and/or disciplinary action. RNC stated change of condition was anything different from baseline. RNC stated Resident #1 complained of pain to her left leg since admission [DATE]). RNC stated Resident #1 received scheduled pain medication. RNC stated CNAs were not able to accurately determine if Resident #1's knee was swollen because she had big legs. RNC stated LVN B should have notified the physician on 05/22/23 regarding Resident #1 experiencing left leg pain and stated ouch to touch. RNC stated the nurse on 05/28/23 should have assessed Resident #1's left knee swelling and pain. RNC stated the nurse on 05/28/23 should have also notified the physician. RNC stated there were no concerns regarding Resident #1's left knee pain and swelling because staff did not voice any concerns. RNC stated the CNAs stated the nurses were informed of Resident #1's left knee pain and swelling. RNC stated the nurses stated Resident #1 was assessed for left knee pain and swelling. RNC stated the nurses stated the physician was notified on 06/01/23. RNC stated nurses were in-serviced on 05/31/23 regarding change in condition. RNC stated on 06/01/23 the RP contacted the facility and informed an LVN that Resident #1 was experiencing more pain and swelling than usual. RNC stated the LVN assessed Resident #1, administered pain medication, and notified the physician on 06/01/23. RNC stated the physician recommended an x-ray of Resident #1's left knee. RNC stated the x-ray revealed Resident #1 had a fracture toward her left knee. RNC stated the physician recommended Resident #1 be sent to the hospital. RNC stated she did not know how Resident #1 acquired a fracture. <BR/>In an interview with the Physician on 06/08/23 at 4:17 PM revealed he was not notified by the facility on 05/18/23, 05/22/23, or 05/28/23 regarding Resident #1's left knee pain and swelling. He stated his expectation of the facility was for Resident #1 to be assessed for pain and swelling on 05/18/23, 05/22/23, and 05/28/23. He stated his recommendation for treatment would have been based on the results of Resident #1's nursing assessments. He stated the facility should have notified him regarding Resident #1's pattern of pain and swelling. He stated he was notified on 06/01/23 regarding Resident #1's left knee pain and swelling. He stated he ordered an x-ray of Resident #1's left knee on 06/01/23. He stated the x-ray results revealed a left knee fracture. He stated he ordered the facility to send Resident #1 to the hospital on [DATE]. <BR/>In an interview with LVN F on 06/08/23 at 5:13 PM revealed Resident #1 did not complain or exhibit any signs of pain and/or swelling on 05/28/23. He stated on 05/28/23, CNA E did not report Resident #1's left knee pain and swelling. He stated he monitored Resident #1 throughout his shift by making rounds. He stated he would have assessed Resident #1 if she complained or exhibited signs of pain and/or swelling. He stated after the assessment he would have notified the physician regarding change of condition.<BR/>In an interview with the Administrator on 06/08/23 at 5:54 PM revealed during the facility investigation of the incident, the RP, physician, and ombudsman were notified. She stated staff interviews and resident safe surveys were conducted. She stated staff were in-serviced regarding abuse/neglect and change of condition. She stated the facility reviewed Resident #1's chart. She stated the facility contacted the hospital regarding Resident #1's update. She stated the RNC discussed findings regarding staff interviews. The Administrator stated based on the provider investigation findings, LVN B should have completed a change of condition evaluation and notified the physician regarding Resident #1's leg pain on 05/22/23. She stated as of 06/08/23, LVN B was suspended and removed from the schedule pending further investigation. <BR/>Record review of the facility's policy titled, Change in Resident's Condition or Status, undated reflected, It is the policy of the facility to ensure that the resident's attending physician and representative are notified of changes in the resident's condition or status. The nurse will notify the resident's attending physician when: .there is a significant change in the resident's physical, mental, or psychological status .<BR/>This was determined to be an Immediate Jeopardy (IJ) on 06/21/23 at 2:05 PM. The Administrator was notified. The Administrator was provided with the IJ template on 06/21/23 at 2:05 PM.<BR/>The Facility Plan of Removal was accepted on 06/22/23. The plan of removal reflected:<BR/>The facility failed to notify the physician regarding Resident #1's change of condition.<BR/>Resident #1 was assessed on 6/1/2023 by LVN A charge nurse and was noted with swelling to the left knee, physician was notified and order for a stat x-ray was obtained. Facility received X-ray results noted an acute, transverse, impacted fracture at proximal received on 6/1/2023.<BR/>1.) <BR/>Resident#1's attending physician was notified on 6/1/2023 of Resident #1 x-ray result. Resident's attending physician gave an order to send resident to the E.R. for further evaluation.<BR/>2.) <BR/>On 6/1/2023 resident #1's family member was notified at resident #1's bedside of the fracture and physician orders to send resident to the hospital for further evaluation, but Resident#1's requested that be sent to the hospital the following morning 6/2/2023. Physician ok with s request.<BR/>3.) Resident #1 was transferred to the hospital 6/2/2023 and discharged to another facility from the hospital.<BR/>4.) <BR/>LVN B was in-serviced, then suspended on 6/7/2023 pending investigation and was terminated on 6/9/2023 due to investigation findings.<BR/>5.) <BR/>LVN F was in-serviced regarding documentation, proper assessments, and notifying physicians regarding change of conditions on 5/31/2023. <BR/>6.) <BR/>On 6/22/2023 a facility-wide 30 day look back audit was conducted to ensure that any resident who met the criteria for a change of condition, did, in fact, have this change of condition addressed per policy and regulation, to include making all appropriate notifications to the physician as well as the resident and/or the resident's responsible party. Additionally, to ensure that any appropriate assessments were completed and that any orders were obtained. Further, to see that the resident's care plan was revised as indicated. Any concerns were addressed.<BR/>Training:<BR/>A. <BR/>During a mandatory nurse's meeting on 5/31/2023 the ADON in-serviced licensed nurses regarding documentation, proper assessments, notifying physicians regarding change of conditions. All nurses at the facility were in-serviced at this time.<BR/>B. <BR/>On 6/21/2023 after the IJ was identified the ADON began in-servicing all nursing staff, regarding documentation, proper assessments, notifying physicians regarding change of conditions. The facility does not use any agency staff. In the event of agency staff use, the facility will provide the same in-servicing before agency staff could work at the facility.<BR/>o <BR/>Change of Condition policy<BR/>o <BR/>Discussion of examples of changes of condition (to include pain, swelling, and fractures)<BR/>o <BR/>What should you do, in your staff member role if you observe what you believe to be a change in condition in a resident? Whom do you tell? When? Why?<BR/>o <BR/>(Nurses) What do you do? Assess? When? Whom do you notify? What/When do you document? What if the change of condition meets reportable criteria? Whom do you notify? When?<BR/>o <BR/>Discussion --- Questions/Answers<BR/>Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated.<BR/>C. <BR/>Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, notifying physicians regarding change of conditions during facility orientation upon hire.<BR/>Any staff members who are unable to physically attend the in-service training in person will be in-serviced via phone and provided with in-service handouts via telephone or email. Staff members in-serviced over the phone will be required to obtain in person training prior to working completing the pre/post-tests. <BR/>During the in-service training there will be a discussion QA to ensure staff understanding and competency. Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated.<BR/>Nurses will not be allowed to work until they are in-serviced on documentation, proper assessments, and notifying physicians regarding change of conditions.<BR/>The Regional Nurse consultant will be responsible for monitoring and ensuring compliance. <BR/>Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated.<BR/>If there was changes or new policy and procedures to prevent the failure from recurring, effective date and completion dates, when and who will implement:<BR/>A. <BR/>Starting on 6/22/2023 as the daily practice of the Clinical Morning Meeting agenda, the ADON/designee will monitor the progress notes since the previous Clinical Morning Meeting to ensure that all appropriate steps were taken and protocols followed to address any situation that met Change of Condition criteria for any resident. This would include but not be limited to: performing any needed assessments, obtaining any needed orders, notifications to all appropriate and required parties, care planning and updating any CNA information guidance. Additionally, beginning on 6/22/2023 the Medical Director will make rounds on residents at the facility weekly to ensure that any changes in condition over the previous week were identified and addressed per policy.<BR/>B. <BR/>The ADON/designee will review 24-hour report to ensure nurses document timely notifications to the attending physician of resident changes of condition 2x week X 6 weeks. Additionally, beginning 6/22/2023, the DON/designee began monitoring 10 residents, (on rotating basis), weekly x 4 weeks to ensure that any change of condition over the previous week was identified and addressed per policy and regulation. After 4 weeks, 3 residents will be monitored weekly x 3 months to ensure ongoing compliance. After that, random monitoring will continue ongoing. Any concerns will be addressed if found. The weekly monitoring by the DON/designee will be presented to the QAPI committee for review at the weekly QAPI meetings. Any concerns will have been addressed. However, any patterns will be identified. If needed, an action plan will be written by the QAPI committee. Any written action plan will be monitored weekly by the administrator until resolved. Review will be documented on an audit report form. <BR/>C. <BR/>Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. <BR/>The regional nurse consultant will be responsible for the plan of removal and its monitoring.<BR/>Quality Assurance:<BR/>An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/21/2023 with the Medical Director at 4:30pm. The Medical Director has reviewed and agrees with this plan.<BR/>Monitoring of the Plan of Removal included the following:<BR/>Record review of facility in-service training reports dated 06/21/23 and 06/22/23 revealed staff were in-serviced regarding change of condition, completion of interact change of condition, antibiotics, fall-complete daily progress note, antibiotic report daily while on antibiotics, all changes must be reported to physician/family, and change of condition policy. Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, and notifying physicians regarding change of condition. Report any incident to the Administrator, DON, and ADON. Complete risk management, chart, and complete change of condition. No nurse will be able to work until all in-services are signed; to include changes of condition, (pain) follow up, assess when CNA reports to nurse resident pain or any change in condition (immediately). CNAs creating e-interact stop and watch, change in condition alerts. Licensed nurses monitor dashboard for any e-interact stop and watches. <BR/>Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. <BR/>Record review of employee disciplinary action report, dated 06/09/23, reflected LVN B was terminated regarding failure to properly assess Resident #1 after a change of condition and notify the physician.<BR/>Interviews were conducted on 06/22/23 starting at 4:20 PM through 06/23/22 at 10:37 AM with LVN A, LVN F, LVN C, RN G, LVN H, RN I, and MDS coordinator across all three shifts, the weekend, and PRN staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, notification of physician and RP, documentation, assessment, clinical dashboard, and policy on change of condition.<BR/>In an interview with RNC on 06/23/22 at 8:50 AM revealed she was the acting DON. RNC stated she was only at the facility for two to three days a week. RNC stated she supervised her staff to ensure policies/procedures were followed by making rounds. RNC stated the day shift nurses discuss the 24-hour report with her. RNC stated she informed nurses tasks that need to be completed and followed up on throughout the day. RNC stated she supervised nursing staff by delegating several tasks to the ADON because the facility did not have a DON. RNC stated she follows up behind the ADON to ensure tasks were completed. RNC stated there was a nurse on the weekends that assisted with nurse management tasks. RNC stated the facility received an IJ because HHSC identified a concurrent problem. RNC stated the facility had identified follow up issues with documentation and change of condition prior to the incident being reported to HHSC on 06/02/23. RNC stated staff in-servicing regarding change of condition was initiated on 06/02/23. RNC stated to prevent the reoccurrence of the IJ, the facility had additional staff reviewing the 24-hour report. RNC stated a f[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #1 received treatment immediately after she complained of having symptoms of a urinary tract infection. <BR/>This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 5/28/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. <BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating no impaired cognition. Her diagnoses included hypertension (high blood pressure); type 2 diabetes, stroke, amputation, and progressive neurological conditions. <BR/>Record review of Resident #1's Care Plan Report dated 5/28/25 reflected no indication of the resident with urinary tract infection. <BR/>Review of Resident #1's Physician Order as of 5/28/25 reflected there were no orders for urinalysis, antibiotics, or medications to treat a urinary tract infection. <BR/>Review of the facility 24-report for 5/28/25 reflected there was no information documented about Resident #1.<BR/>Review of Resident #1's progress notes from 5/23/25 through 5/28/25 reflected no progress notes regarding Resident #1's complaint of a urinary tract infection.<BR/>Observation and interview on 5/28/25 at 10:40 AM revealed Resident #1 was in her room, resting in bed. She appeared well-dressed and groomed. Resident #1 stated she was having signs and symptoms of urinary tract infection, voiding frequently and burning when voiding. The resident stated she informed the charge nurse in the morning of Friday, but she did not remember the name of the charge nurse. She stated she was still having the signs and symptoms of urinary tract infection, and nothing had been done yet. <BR/>In an interview on 5/28/25 at 2:30 PM with RN B she stated she was the charge nurse for Resident #1 for the 2-10 shift. She stated the resident had not reported having any signs or symptoms of infection. She also stated LVN E did not inform her of the resident's change of condition or obtaining the urine specimen. She stated if the resident had a change of condition the resident's primary care provider was to be notified and follow the doctor's orders. If laboratory test was required, the staff was expected to fill the laboratory request online and document in the 24-hours report and progress notes. RN B stated urinalysis was to be completed timely to prevent the symptoms from getting worse. <BR/>In an interview on 5/28/25 at 2:34 PM with LVN D she stated while completing the resident's wound assessment with the wound doctor on 5/27/25, the resident stated she was having signs and symptoms of urinary tract infection. The resident stated she had already notified the nurse assigned to her, so she did not follow up with the charge nurse on the hall. <BR/>In an interview on 5/28/25 at 3:40 PM with ADON C she stated she was not aware of the resident having a change of condition. She stated the resident had not reported having signs and symptoms of infection to her. She stated early today (5/28/25) a laboratory personnel had come to the facility and asked for Resident #1 urine specimen, ADON C checked in the specimen fridge and there was no urine specimen for Resident #1. ADON C stated she failed to do a follow up and find out why the urine specimen was required for the resident. ADON C stated if there was a change of condition the charge nurse was expected to assess the resident and notify the resident's primary care provider and follow the orders. The charge nurse was expected to document the orders in the physician orders and document in the progress notes and in the 24-hour report, and if a laboratory test was required the charge nurse was to fill out the laboratory request online. When ADON C reviewed the laboratory request she saw a urinalysis laboratory request that was completed on 5/26/25 but was unable to tell who completed the request because the system does not a section to fill the nurse who filled the request. ADON C stated laboratory tests was to be completed timely to prevent the symptoms getting worse, and if the resident was having signs and symptoms of infection to prevent the resident being septic. <BR/>In an interview on 5/28/25 at 6:27 PM with LVN E she initially stated the resident reported to her on Friday (5/23/25) she was having signs and symptoms of urinary tract an infection. LVN E contacted the resident's primary care provider and was given and order for urinalysis for the resident. LVN E then stated it was not on Friday when the resident informed her it was on Tuesday (5/27/28). LVN E stated she did not document in the progress notes or in the 24 hours reports and did not write the order. LVN E stated she was supposed to follow the primary care providers orders and obtain the specimen and if she was not able to, she was supposed to inform the oncoming charge nurse. The nurse was not able to give a reason why she did not document or write the order. LVN E stated not completing the orders could worsen the resident's symptoms and could be septic if the resident had an infection. LVN E also stated she was expected to document in the 24 hours report and progress notes and inform the ADON of the resident's change of condition. <BR/>Contacted the resident's primary care provider on 5/28/25 at 6:38pm and was unable to reach the primary care provider. <BR/>Review of the facility policy revised 3/11/13 and dated Notifying the Physician of Change in Status reflected, . 1. <BR/>The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for (Resident #8) reviewed for gastrostomy tube management.<BR/>The facility failed to check the Resident #8's residual before administering medications via gastrostomy tube (G-tube: A tube directly inserted through the skin to the stomach to deliver nutrition). <BR/>This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.<BR/>Findings include:<BR/>Record review of Resident #8's face sheet dated 05/17/23 revealed a 78- year-old-male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute and chronic respiratory failure (inability of the lungs to perform their basic task of gas exchange, the transfer of oxygen from inhaled air into the blood and the transfer of carbon dioxide from blood into exhaled air), dysphagia/aphagia (Is a language disorder. It affects how you speak and understand language), vascular parkinsonism, progressive bulbar palsy (is a set of conditions that can occur due to damage to the lower nerves. Clinical features of bulbar palsy range from difficulty swallowing and lack of gag reflex to inability to articulate words and excessive drooling), hyperlipidemia (is abnormally elevated levels of any or all lipids in the blood), hypertension (high blood pressure).<BR/>Record review of Resident #8's Comprehensive MDS dated [DATE] revealed the resident's BIMS score of 14. Cognitive skills for daily decision making identified Resident #8 as cognitively intact. Nutritional Status section identified use of a feeding tube. <BR/>Record review of Resident #8's Care Plan dated 01/05/2023 revealed: Focus: Resident #8 required tube feeding r/t Dysphasia, swallowing problem. Goal: Resident #8 will maintain adequate nutrition and hydration status and weight stable, no s/sx of malnutrition or dehydration through review date. Interventions: check for tube placement and gastric contents/residual per facility protocol and record. <BR/>Observation on 5/16/23 01:15 PM reveled, RN C failed to check feeding tube residual before administering noon medication. <BR/>Interview on 05/17/23 12:04 PM RN C stated for the feeding tube, she disconnected the tubing use 30 ml water and push it to remove any plugging in the tubing. The RN C further stated she do check the residual in AM before she gave the medications, because it is more medications to give, and she did not check at noon, it is just one medication to give. RN C stated the [NAME] to check the residual, because if there is more food in the stomach, the resident may vomit, aspirate, if more 500 ml we should not give medication.<BR/>In an interview on 05/17/2023 at 01:04 PM ADON stated the new RN C received training regarding given medications via G-Tube feeding. ADON stated the staff should check the residual every time they give medications to prevent resident vomiting, and aspiration. The ADON further stated the staff should flush the GT by gravity with water, and give medications one by one by gravity, and flush with water after giving medications by gravity, and The ADON further stated the risk to resident emesis, nausea vomiting, and aspiration as well.<BR/>Review of the facility policy undated and titled Enteral Tube Care and feeding reflected, . PLACEMENT VERIFICATION: GT placement is verified before feedings, flush, or medications administration and PRN. RESIDUAL CHECK: residual is verified prior to each feeding and every 8 hours during feedings and PRN, if intolerance symptoms are noted contact MD for further instruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one medication carts (700/500 hall nurses' medication cart) of two medication carts reviewed for pharmacy services in that:<BR/>The 500/700 hall medication cart had expired medications.<BR/>The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status.<BR/>Findings included:<BR/>1. Review on 05/16/2023 at 10:00 AM of nurse medication cart (Hall 700/500) reflected Hydrocodone/Acetaminophen 5-325 mg medications strip packaging with expiration date of 03/07/2023, 22 tablets left in the medication strip packaging of 60 tablets.<BR/>Review of Resident #7's face sheet, dated 05/17/2023, reflected he was a [AGE] year-old male admitted originally to the facility on [DATE], and readmitted on [DATE]. His diagnosis included sacral spina bifida, end stage renal disease on hemodialysis, type 2 diabetes Mellitus, hypertension, chronic pain syndrome. <BR/>Review of Resident #7's most recent Quarterly MDS Assessment, dated 03/01/2023, reflected he had a BIMS score of 15 indicating intact cognition, the pain assessment suction on the MDS was not complete. <BR/>Review of Resident #7's Care Plan dated 07/08/2021 reflected the following: Focus- (Resident#7) has a diagnosis of spina bifida, chronic pain and osteomyelitis which can cause episode of pain/discomfort. Goal-(Resident#7) will have pain managed with interventions through the next quarterly review. Interventions- give scheduled pain medications as ordered, observe, and assess for the effectiveness of as needed pain medication and document.<BR/>Record review reflected the last time the (resident#7) received the medication according to the narcotic count binder, and the e-MAR (electronic medications administration record) was on 05/11/2023.<BR/>In an interview on 05/17/23 at 12:01 PM with LVN P stated she did give the expired hydrocodone/ acetaminophen 5-325 mg tablet per mouth to (Resident #7), she did not notice any side effect on the (Resident#7), and that she should check the medication expiration date before she gives it to resident to prevent harming residents, and the risk to resident, the resident may get sick. LVN P further stated the facility wants the nurses to check the expiration dates of the medications in the carts, and before given it to residents.<BR/>Interview on 05/17/23 02:00 PM with ADON stated the nurses and medication aides were supposed to check the medications expiration date before given it to residents, according to medications administrations five rights. The ADON further stated she checked some medications last Monday (05/15/2023), but she was busy taking care of the residents in the hall she was assigned to. The ADON stated we check the medication's carts randomly, and she was going to put in place a system to start checking the medications carts, and medications storge room on scheduled time. <BR/>Record review of the facility policy, revised October 2010, titled Administering Oral Medications reflected, .5. Select the drug from the unit dose drawer or the stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR. 7. Check the expiration on the medication. Return any expired medications to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6%, based on 3 errors of 48 opportunities, which involved two residents of 10 residents observed (Residents #9 and #27) and 1 of 2 staff observed during medication administration for medication errors. <BR/>The facility failed to ensure the medications were administered per the physician orders for Residents #9 and #27. <BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>The findings include:<BR/>1. A record review of Resident #9's face sheet, dated 05/17/2023, revealed an admission date of 12/23/2022 with diagnoses which included gastro-esophageal disease, angina pectoris, hypertension, lower back pain, anemia, type 2 diabetes, seasonal allergic rhinitis. <BR/>A record review of Resident #9's annual MDS assessment, dated 3/20/2023, revealed Resident #9 was an [AGE] year-old female with a BIMS score of 15, which indicated intact cognition. The MDS further indicated the resident had cerebrovascular accident (stroke), traumatic brain dysfunction.<BR/>A record review of Resident #9's physician's orders revealed Resident #9 was to receive Fluticasone Propionate Suspension 50 mcg 1 spray in both nostrils two times a day for Sneezing/Itching.<BR/>During an observation on 05/16/2023 at 09:45 AM revealed RN A during morning medication administration removed the nasal spray bottle cap and hand it to resident#9. Resident # 9 spayed 2 sprays in each nostril, and handed the spray bottle back to RN A.<BR/>2. Record review of Resident #27's face sheet, dated 05/17/2023, revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, type 2 diabetes mellitus, vitamin B 12 deficiency anemia, alcohol dependency, hypertension(high blood pressure), pain.<BR/>Record review of the quarterly MDS assessment, dated 05/17/2023, revealed Resident #27 was a [AGE] year-old female with a BIMS score was not completed. Further review indicated the resident had a prior assessment BIMS score of 4, which indicated severe cognitive impairment.<BR/>A record review of Resident #27's physician's orders revealed Resident #27 was to receive Cyanocobalamin (vitamin B 12) Tablet 1000 mcg 1 tablet by mouth one time a day for supplement. <BR/>During an observation on 05/15/2023 at 11:10 AM revealed RN A give the (resident#27) vitamin D 10 mcg 1 tablet by mouth with morning medications administration.<BR/>In an interview on 05/17/2023 at 12: 04 PM with RN A she stated maybe she give (resident#27) vit-D and not vit B12 by mistake or may be because of the name cyanocobalamin she thought it's vitamin-D. RN A stated she give (resident#9) the nasal spray fluconazole to use it, and some time the resident put one spay in each nostril, some time the resident put two sprays in each nostril. RN A stated the risk of given the wrong medication to resident may harm the resident, the resident may have side effect from the none prescribed medications and miss the benefit of the right medication. <BR/>In an interview on 05/17/2023 at 01:04 PM with ADON she stated she expected the medications to be administered per the physician orders and for the staff to follow the five rights of medication administration to prevent side effect. ADON further stated the new nurse had 2 weeks of training during the new hire orientation process, and ADON stated she did follow up with the new nurse regarding given medications, and she is going to do another follow up today (05/17/2023). <BR/>Record review of the facility policy, revised October 2010, titled Administering Oral Medications reflected, 5. Select the drug from the unit dose drawer or the stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR. 8. Check the medication dose. Re-check to conform the proper dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure biologicals were secured properly for one of one treatment cart reviewed for drug storage.<BR/>The facility did not ensure the treatment cart was locked and supervised.<BR/>This failure could place residents at risks for harm and drug diversion.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS assessment, undated, reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, recurrent, serve with psychotic symptoms, and Dementia. She had a BIMS of 09 indicating she had moderate cognitive intact. <BR/>Record review of Resident #1's Comprehensive Care Plan dated 05/31/18 reflected the following: An alteration in neurological status related to scope, TIA, Dementia, Major Depressive Disorder, recurrent, serve with psychosis, altered mental state. <BR/>An observation on 2/24/23 at 8:35 AM revealed treatment cart was located behind the nurse's station down hallway 600 with drawers facing outward toward the lobby. Observations revealed the treatment cart was unlocked and unsupervised. Observation revealed staff were not in view of the treatment cart. Observation revealed Resident #1 walked past the treatment cart. An observation revealed items on treatment cart included:<BR/>*Ready prep PVP (medication is used for first aid antiseptic and effective for skin and mucous membrane preparation prior to surgical procedures)<BR/>*Ammonium lactate topical (medication is used to treat dry, scaly skin conditions)<BR/>*Normal saline (This solution is used to supply water and salt (sodium chloride) to the body)<BR/>An interview on 2/24/23 at 8:40 AM with Wound Care Nurse revealed she was stocking the treatment cart. Wound Care Nurse stated that she left the treatment cart unlocked while she stocked it. Wound care Nurse stated the treatment cart supposed to be always locked when not in use and out of view. Wound care Nurse stated that all nursing staff had keys to the treatment cart and were responsible for the treatment cart. Wound care nurse stated residents are in danger of ingestion normal saline and PVP prep solution. <BR/>An interview on 2/24/23 at 10:15 AM with the LVN revealed the Wound Care Nurse had access to the treatment cart. LVN stated the treatment cart should be always locked.<BR/>An interview on 2/24/23 at 2:30 PM with Unit Nurse and Evening supervisor revealed there is one treatment cart for the facility. Unit Nurse Evening Supervisor stated there is one key for the treatment cart and the Wound Care Nurse is responsible for it. Unit Nurse Evening Supervisor stated residents could get into the cart and take something that they are not supposed to take. <BR/>An Interview with DON on 2/24/23 at 3:45 PM revealed There is only one key for the treatment cart. DON stated the Wound Care Nurse does treatments in the facility Monday through Friday. DON stated the Treatment Doctor came in Tuesday to do care with the Wound Care Nurse. DON stated on the weekend the Wound Care Nurse or RN dose treatment and had access to the treatment cart. DON stated you do not know what residents' mental status are and some resident will just open the drawers. <BR/>Review of the facility's policy titled, Nursing Services, Medication and Treatment Cart Security undated reflected, 2. Cart must have be kept locked at all times when not in use. 3. The nurse should be in direct visual line of the .treatment cart whenever the cart is open. 4. Any .treatment cart not in view of the nurse needs to locked at all times.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of four residents, reviewed for infection control. <BR/>1. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. <BR/>2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #2.<BR/>These failures placed residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>1. Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMs score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting.<BR/>Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed.<BR/>An observation on 03/18/25 at 11:10 AM revealed CNA B was preparing to do perform incontinence care for Resident #1. CNA B cleaned the peri-area and buttocks, applied cream, and put on a clean brief. CNA B did not change his gloves or perform hand hygiene after cleaning the resident and before putting on the clean brief. <BR/>An interview on 03/18/25 at 12:45 PM with CNA B revealed he did not have to change gloves and perform hand hygiene after cleaning a resident. CNA B said he only had to perform hand hygiene and wear gloves before and after care. He said he did not see any reason to change his gloves during care. <BR/>2. Review of Resident #2's Quarterly MDS Assessment, dated 01/24/25, reflected the resident had a BIMs score of 00 and was severely cognitively impaired. The resident had diagnoses which included diabetes, stroke, and non-Alzheimer's dementia. The resident was always incontinent of bowel and bladder. The resident was completely dependent on staff for toileting.<BR/>Review of Resident #2's Comprehensive Care Plan, dated 12/06/22, reflected the resident required assistance with activities of daily living. Facility interventions included to assist resident as needed. <BR/>An observation and interview on 03/18/25 at 12:25 pm revealed CNA C was preparing to do incontinence care for Resident #2. CNA C cleaned the resident's peri-area and buttocks. CNA C changed gloves but did not perform hand hygiene. CNA C applied cream to the resident's buttocks and put on a clean brief. CNA C said she did not need to perform hand hygiene when changing gloves unless there was bowel movement on her gloves. <BR/>An interview on 03/18/25 at 1:00 PM with the DON revealed staff were supposed to change gloves and perform hand hygiene during incontinence care to reduce the risk of infection. <BR/>Review of the facility policy, Handwashing, dated 2012, reflected:<BR/>We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance.<BR/>The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care.<BR/>The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.<BR/> Findings Include:<BR/>Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. <BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS of 15, indicating no cognitive impairment. The resident required moderate to maximum assistance with activities of daily living. Resident #1 was incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan revised 06/14/24 reflected, Focus, (Resident #1) has an ADL Self Care Performance Deficit, Goal, The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date, Intervention, TOILET USE: The resident requires assistance max assist (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Observation and interview on 02/04/25 at 10:18 am with Resident #1 revealed the resident was in bed, and she was well groomed. In an interview with the resident, she stated she had just been provided with incontinent care. She stated at times she had to wait for 2-3 hours, most of the time to be provided with incontinent care when she had her call light, the delay to be changed was with all shift. Resident #1 stated staffing had been an issue in the facility and management were aware and it seemed like they were not addressing the issue. <BR/>Review of Resident #2's face sheet dated 02/04/25 reflected the resident was a 96-yearls old female, she was admitted on [DATE]. The resident was admitted with the following diagnoses, stroke, non-traumatic brain dysfunction, traumatic brain dysfunction, non-traumatic spinal cord dysfunction, traumatic spinal cord dysfunction, progressive neurological conditions, neurological conditions, amputation, hip and knee replacement, fractures and other multiple traumas. <BR/>Review of #2's quarterly assessment MDS dated [DATE] reflected the resident had a BIMS of 12, indicating moderate cognitive impairment. The resident required maximum assistance with activities of daily living, and he was dependent on showers and toileting. <BR/>Review of Resident #2's care plan revised 04/10/24 reflected, Focus, (Resident #2) has an ADL Self Care Performance Deficit, . Goal, (Resident #2) will improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score) through the review date. Intervention, . The resident requires max assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet.<BR/>Review of shower sheets documentation for Resident #2 from December 2024 through 02/04/25 reflected no shower sheet was documented. <BR/>Observation and interview on 02/04/25 at 11:25 am with Resident #2 revealed the resident was in her room in a wheelchair, and family members were at the bedside. Resident #1 was well groomed. In an interview with the resident revealed she had not been showered, she stated she was showered on Monday, Tuesday, and Friday but she did not get a shower on 02/03/25 which was on a Monday. Resident #2 stated she would like to be showered but she did not think the facility had enough staff to provide care. <BR/>Review of Resident #3's face sheet dated 02/04/25 reflected she was [AGE] years old female, and the resident was admitted on [DATE]. The resident had the following diagnoses, traumatic subdural hemorrhage(a collection of blood between the brain and the inner lining of the skull (dura mater) that occurs after a head injury) without loss of consciousness, kidney disease stage 3, idiopathic progressive neuropathy(a condition characterized by progressive damage to the peripheral nerves, the nerves outside the brain and spinal cord) muscle wasting and atrophy, hypertensive chronic kidney disease, muscle weakness (generalized), abnormalities of gait and mobility. <BR/>Review Resident #3's quarterly MDS assessment dated [DATE] reflected, Resident #3 had a BIMS of 15 indicating no cognitive impairment, and the resident required extensive assistance with activities of daily living. <BR/>Review of Resident #3's care plan revised 04/02/24 reflected, Focus . (Resident #3) has bladder incontinence r/t physical debility, Goal, (Resident #3) will remain free from skin breakdown due to incontinence and brief use through the review date.Intervention, ACTIVITIES: notify nursing if incontinent during activities. <BR/>Review of shower sheets documentation for Resident #3 from December 2024 through 02/04/25 reflected no shower sheet was documented.<BR/>Observation and interview on 02/04/25 at 12:35 pm with Resident #3 revealed the resident was in bed. She was well groomed. In an interview with Resident #3 she stated care was delayed in the facility and at times she was not provided with bed baths as scheduled, which was three times per week, and when she got the bed baths she had to frequently ask. Resident #3 stated the facility did not have enough staff to provide care to the residents. Resident #3 stated the issue with staffing had been ongoing for a long period. Resident #3 stated she did not have wounds due to lack of care. <BR/>In an interview on 02/04/25 at 12:47 pm with CNA A revealed she worked on the 6-2 shift but most times she will work 2-10 shift because there was not enough staff. CNA A was assigned to 15 to 22 residents on the shift, and none of the resident was independent. CNA A stated the issues with staffing had been ongoing for a while and even she had informed management that all the residents' assigned tasks were not completed because there was not enough staff. CNA A stated showers/bed baths were not completed per schedule because there was not enough staff to provide the care. CNA A stated she was supposed to document the shower sheets and in point click care of resident's ADLs but most of the time some of the tasks were not documented because they were not completed. If the residents were not provided to ADL care that would affect their self-esteem, they would have skin breakdown if they were not provided with incontinent care timely. <BR/>In an interview on 02/04/25 at 1:15 pm with LVN B revealed most of the residents' activities of daily living like showers/bed baths were not completed because there was not enough staff to provide the care to the residents. LVN B stated management was aware of the staffing issues, and it seemed like they were not addressing the issue. LVN B stated she was responsible to make sure the ADLs were completed per shift, but the aides were not enough to complete the assigned tasks. LVN B stated at times when their was call-ins, the aides were assigned more assignments which was hard for them to complete and meet the resident's care timely. LVN B stated lack of ADL care would affect the residents' self-esteem, it could make the resident be isolated if they were not groomed well and not clean. <BR/>In an interview on 02/04/25 at 2:18 pm the ADON stated staffing had been an issue for about two months and she had been trying to hire more staff, but it had not been successful. The ADON stated she had also identified shower issues because it had been reported by some of the residents during the morning rounds. Management discussed in December and the ADON put in place shower sheets that the aides were supposed to complete daily after showers, and she was to follow up and make sure the showers were completed. The ADON then stated she failed to follow up to make sure the showers were completed, and she was not able to provide Resident #1, #2, and #3's shower sheets, from December through 02/03/25. The ADON stated she was aware the facility did not have enough staff on hall shifts and the aides and nurses had reported that the facility did not have enough staff and they were not able to complete the daily tasks. The ADON stated lack of staffing in the facility will affect resident's quality of care and quality of life. <BR/>In an interview on 02/04/25 at 3:40 pm with the Administrator he stated he had been made aware of the staffing issues. He had been in the facility for two months, and he would address the issue with showers and staffing. The Administrator stated lack of enough staff would affect the resident's quality of life. <BR/>Review of resident advisory council minutes dated 01/08/25 reflected they were concerns of call light not answered timely, the residents were not receiving scheduled showers and beds were not made in a timely manner. Also reflected meals were not delivered to the resident's rooms timely, and not always there was enough staff assisting in the dinning room. <BR/>Review of resident advisory council minutes dated 12/04/24 reflected meals tray were not delivered timely to the resident rooms, there was not enough staff to assist in the dinning room, <BR/>Review of the facility policy dated 2003, titled Bath, Tub/Shower reflected, . The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed The resident will experience improved comfort and cleanliness by bathing.<BR/>Review of the facility policy dated 04/25/22 and titled Section, Nursing: Personal Care, Titled: Perineal Care, reflected, It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations.<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of four residents, reviewed for infection control. <BR/>1. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. <BR/>2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #2.<BR/>These failures placed residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>1. Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMs score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting.<BR/>Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed.<BR/>An observation on 03/18/25 at 11:10 AM revealed CNA B was preparing to do perform incontinence care for Resident #1. CNA B cleaned the peri-area and buttocks, applied cream, and put on a clean brief. CNA B did not change his gloves or perform hand hygiene after cleaning the resident and before putting on the clean brief. <BR/>An interview on 03/18/25 at 12:45 PM with CNA B revealed he did not have to change gloves and perform hand hygiene after cleaning a resident. CNA B said he only had to perform hand hygiene and wear gloves before and after care. He said he did not see any reason to change his gloves during care. <BR/>2. Review of Resident #2's Quarterly MDS Assessment, dated 01/24/25, reflected the resident had a BIMs score of 00 and was severely cognitively impaired. The resident had diagnoses which included diabetes, stroke, and non-Alzheimer's dementia. The resident was always incontinent of bowel and bladder. The resident was completely dependent on staff for toileting.<BR/>Review of Resident #2's Comprehensive Care Plan, dated 12/06/22, reflected the resident required assistance with activities of daily living. Facility interventions included to assist resident as needed. <BR/>An observation and interview on 03/18/25 at 12:25 pm revealed CNA C was preparing to do incontinence care for Resident #2. CNA C cleaned the resident's peri-area and buttocks. CNA C changed gloves but did not perform hand hygiene. CNA C applied cream to the resident's buttocks and put on a clean brief. CNA C said she did not need to perform hand hygiene when changing gloves unless there was bowel movement on her gloves. <BR/>An interview on 03/18/25 at 1:00 PM with the DON revealed staff were supposed to change gloves and perform hand hygiene during incontinence care to reduce the risk of infection. <BR/>Review of the facility policy, Handwashing, dated 2012, reflected:<BR/>We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of four residents, reviewed for infection control. <BR/>1. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. <BR/>2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #2.<BR/>These failures placed residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>1. Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMs score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting.<BR/>Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed.<BR/>An observation on 03/18/25 at 11:10 AM revealed CNA B was preparing to do perform incontinence care for Resident #1. CNA B cleaned the peri-area and buttocks, applied cream, and put on a clean brief. CNA B did not change his gloves or perform hand hygiene after cleaning the resident and before putting on the clean brief. <BR/>An interview on 03/18/25 at 12:45 PM with CNA B revealed he did not have to change gloves and perform hand hygiene after cleaning a resident. CNA B said he only had to perform hand hygiene and wear gloves before and after care. He said he did not see any reason to change his gloves during care. <BR/>2. Review of Resident #2's Quarterly MDS Assessment, dated 01/24/25, reflected the resident had a BIMs score of 00 and was severely cognitively impaired. The resident had diagnoses which included diabetes, stroke, and non-Alzheimer's dementia. The resident was always incontinent of bowel and bladder. The resident was completely dependent on staff for toileting.<BR/>Review of Resident #2's Comprehensive Care Plan, dated 12/06/22, reflected the resident required assistance with activities of daily living. Facility interventions included to assist resident as needed. <BR/>An observation and interview on 03/18/25 at 12:25 pm revealed CNA C was preparing to do incontinence care for Resident #2. CNA C cleaned the resident's peri-area and buttocks. CNA C changed gloves but did not perform hand hygiene. CNA C applied cream to the resident's buttocks and put on a clean brief. CNA C said she did not need to perform hand hygiene when changing gloves unless there was bowel movement on her gloves. <BR/>An interview on 03/18/25 at 1:00 PM with the DON revealed staff were supposed to change gloves and perform hand hygiene during incontinence care to reduce the risk of infection. <BR/>Review of the facility policy, Handwashing, dated 2012, reflected:<BR/>We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of three residents (Resident #3) reviewed for resident call system, in that.<BR/>Resident# 3's call light was not working on 08/26/2024.<BR/>These could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of Resident #3's electronic face sheet, printed on 08/26/24, revealed an [AGE] year-old male who was admitted to the facility initially 03/08/24 and readmitted on [DATE] with diagnoses that included but not limited to pressure ulcer of the sacral region, stage 4 and need for assistance with personal care.<BR/>Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating the resident was cognitively intact. <BR/>Record review of Resident #3 s care plan, dated 07/23/2024, reflected, the resident was a risk for falls and the intervention reflected, anticipate resident needs, be sure the call light was in reach, and encourage the resident to use it for assistance .<BR/> Interview and observation on 08/26/2024 at 11:45 AM with Resident #3 revealed he needed to call staff to let them know he was not able to find his wallet. Resident #3 attempted to use the call light however it did not light up indicating it was working. The Surveyor stepped into the hall to see if the light outside the door was lit indicating the call light was working and it was not. While in the hall the Surveyor flagged down the DON to inform her Resident #3 needed assistance and his call light was not working. The DON tested the call button and determined the call light was not working and stated she would let maintenance know.<BR/>Interview on 08/26/2024 at 1:40 PM with the Maintenance Director revealed he checked call lights on different halls each month. He stated Resident #3's call light was last checked the beginning of August 2024. He stated staff informed him today that Resident #3's call light was not working, and it had been fixed. The Maintenance Director stated the risk of call lights not working would be that Residents would not be able to call for assistance.<BR/>Interview on 08/26/2024 at 2:20 PM with the DON revealed staff should have been checking to ensure call lights were working and within reach during rounds. The DON stated maintenance also checked call lights monthly to ensure they worked properly. The DON stated the risk of not ensuring call lights were working would be that residents would not be able to call for assistance when needed. <BR/>A call light policy was requested from the Administrator on Director of Operations on 8/26/2024 at 2:06PM ,however was not provided prior to exit

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for two (Residents #25 and #45) of five residents whose records were reviewed for psychotropic drugs, in that:<BR/>1. Resident #25 had an order for the antipsychotic medication Risperdal 3mg, per the pharmacy recommendations the medication order was changed to 2mg but had not been implemented <BR/>2. Resident #45 had an order for the antipsychotic medication lorazepam as needed used longer than the 14 days. <BR/>These failures placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status.<BR/>The findings included:<BR/>1. Review of Resident #25's face sheet, dated 05/17/23, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Parkinson's diseases, anxiety, muscle weakness, bipolar disorder, severe depression and disorders of the central nervous system. <BR/>Review of Resident #25's quarterly MDS Assessment, dated 04/07/23, reflected she had a BIMS score of 15 indicating no cognitive impairment. Required limited to extensive assistance with activities of daily living. Further reflected Resident #25 was taking antianxiety, antidepressant, and antipsychotic medications. <BR/>Review of Resident #25's care plan, date 08/24/22, reflected the following:<BR/>[Resident #25] requires psychotropic medication to help alleviate: Psychosis .The following class(es) are prescribed: Antianxiety,.Antimanic/Mood Stabilizer. Goal Resident #25 will be maintained on the lowest therapeutic medication dosage Intervention Attempt gradual dose reduction (GDR) for anti-psychotic, anti-anxiety & /or hypotonic meds. <BR/>Review of Resident #25's May 2023 physician orders reflected an order for Risperdal tablet 3 mg, give one ablet by mouth one time a day for bipolar disorder psychotic features. The order date was 03/06/23. <BR/>Review of Resident #25's dated 04/20/23 reflected on 4/20/23 MRR recommendation for Risperdal 3 mg to be changed to 2 mg, the Dr signed the recommendation on 4/28/23 but the orders were not changed until 5/16/23.<BR/>2. Review of Resident #45's face sheet, dated 05/17/23, reflected she was admitted to the facility on [DATE]. Her diagnoses included adult failure to thrive, vascular dementia, essential hypertension, major depressive disorder, muscle weakness and systemic lupus. <BR/>Review of Resident #45''s significant change in status MDS Assessment, dated 03/16/23, reflected she had a BIMS score of 4 indicating severe cognitive impairment. Resident #45 required extensive assistance with activities of daily living and further indicated she had diagnoses of non-Alzheimer's disease, depression. <BR/>Review of Resident #45's care plan, dated 12/08/22, reflected the following:<BR/>[Resident #45] requires psychotropic medication to help manage & alleviate: Psychosis . Agitation and aggressive behaviors., Depression, behavior with depressive features.Anxiety, neurosis, anxiety disorder . Goal (Resident #45) will be maintained on the lowest therapeutic medication dosage . Intervention .Attempt gradual dose reduction (GDR) for anti - psychotic, anti-anxiety &/or hypnotic meds (every 6 months or per facility protocol).<BR/>Review of Resident #45's physician's orders for the month in May 2023 reflected and order for Lorazepam 2mg to be given as needed with an order date 04/26/23. <BR/>Review of Resident #45'sMRR dated 04/20/23 reflected the following:<BR/>This resident is currently receiving the following psychotropic (Non-Antipsychotic) medication on a PRN basis: Lorazepam 2 mg per regulatory guidelines, the duration of treatment with such medication on a PRN basis should be limited to 60 days for HOSPICE RESIDENT, however, a new order may be written to extend the duration beyond 60 days if the prescriber believes it is possible.<BR/>Please evaluate the continued need for this medication. If it is to be extended document the rationale for the extended time period . the MRR was signed on 4/28/23 by the resident's primary care provider indicating agree. <BR/>In an interview on 05/16/23 at 02:41 PM with ADON She stated she had been out and came back around February. At the time, the DON was the one completing the pharmacy recommendations and the ADON started completing them on April 2023 after the DON left. ADON stated when the primary care provider signed the pharmacy recommendations they went to the medical record and then the medical records personnel gave them her so she could implement the orders. ADON stated she did not know why the pharmacy recommendations were kept in the medical record's office. <BR/>In an interview on 05/16/23 at 03:11 PM RRC she stated she had been in the facility for two weeks. Regarding pharmacy recommendation follow by the facility, she stated the system is broke. RRC stated she was working with the facility to put measures in place to make sure the pharmacy recommendations were addressed timely and correctly and timely. RRC stated had identified some areas that the facility needed to improve on. Regarding Resident #25 and #45 she stated the pharmacy recommendations were to be addressed timely. <BR/>In an interview on 05/16/23 at 02:55 PM medical record personnel stated she did not receive the pharmacy recommendations when the physician signed them. Regarding Resident # 25 and #45 she stated she found the pharmacy forms with other documents and sorted them out and gave them to the previously DON. She stated she again found other pharmacy recommendations in a box in her office last month and she gave the forms to the ADON. Medical record personnel stated she did not receive pharmacy recommendation after they were signed by the primary care provider. She stated the forms were supposed to go to the nursing department. She stated she was not aware who placed the forms in her room. <BR/>Follow up interview on 05/17/23 at 01:30 PM with ADON she stated as soon as the primary care provider signed the pharmacy recommendations the facility should follow up and if there were any orders changes to be completed timely. ADON stated Resident #25 and #45 pharmacy recommendations were to be addressed timely and implemented. ADON stated she was responsible to making sure that GDR were completed and followed up timely because the facility did not have a DON. ADON stated DON left two weeks ago. She stated GDR were to be completed timely because it was a regulation and for the medications not to cause negative effects to the residents. <BR/>Review of the facility policy undated and titled Psychotropic Drugs usage reflected, .6. Dosage reduction of antipsychotics, anxiolytics, and hypnotics are attempted per CMS guidelines unless clinically contraindicated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for three (Residents #2 , #3 and #7) of seven residents reviewed for resident records. <BR/>1. The facility failed to document if wound care was provided for Resident #2 in June 2025 on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25.<BR/>2. The facility failed to document if wound care was provided for Resident #3 in June 2025 on three occasions: 06/10/25, 06/15/25 and 06/16/25.<BR/>3. The facility failed to document if wound care was provided for Resident #7 in May 2025 on four occasions: 05/05/25, 05/07/25, 05/21/25 and 05/26/25. <BR/>These failures could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management.<BR/>Findings included:<BR/>1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness).<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. <BR/>Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. <BR/>Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface ) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. <BR/>Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25).<BR/>Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected no documented treatment to his sacral wound on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25. <BR/>Record review of Resident #2's nursing progress notes for June 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. <BR/>2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes, aphasia, stroke, anoxic brain damage and dysphagia. Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed.<BR/>Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. <BR/>Record review of Resident #3's physician order summary reflected, Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). <BR/>Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected the following treatment was order from 06/01/25 through 06/16/25, Sacrum: Cleanse with wound cleanser and apply triad cream every day shift for wound management (discontinue date 06/16/25). The record did not indicate the nurse signed off for wound care treatment on 06/10/25, 06/15/25 and 06/16/25. <BR/>An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25.<BR/>3. Record review of Resident #7's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] after an acute hospital stay. Resident # 7's active diagnoses included cellulitis, local infection of the skin and subcutaneous tissue, non-pressure chronic ulcer of lower leg, secondary gout, pain, localized edema and lymphedema. <BR/>Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #7 had no rejection of care issues, had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #7 was at risk of developing pressure ulcers/injuries and had six venous and arterial ulcers present at the time of the assessment. He required a pressure reducing device for the bed, application of nonsurgical dressings and applications of ointments/medications.<BR/>Record review of Resident #7's care plan initiated 12/15/23 and last revised 06/09/25 reflected, Focus: [Resident #7] has a pressure ulcer or potential for pressure ulcer development; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan also indicated Resident #7 had a behavior problem of picking at his skin and refusing wound care. The care plan did not address the numerous venous/arterial ulcers Resident #3 had. <BR/>Record review of Resident #7's Order Summary reflected:<BR/>-Left Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 05/19/25)<BR/>-Left Posterior Leg: Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Left second toe: Cleanse with wound cleaner apply betadine secure with dry dressing every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Left Superior Lateral leg:Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen,<BR/>xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap.<BR/>every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Right Dorsal Leg: Wash with Hibiclens, rinse and pat dry thoroughly. Apply collagen, xeroform. And apply A&D ointment to areas of dryness, secure with rolled gauze and ace wrap.<BR/>every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25)<BR/>-Right Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25).<BR/>Record review of Resident #7's WAR/TAR for May 2025 did not indicate the nurse signed off for wound care treatment on 05/05/25, 05/07/25, 05/21/25 and 05/26/25.<BR/>Record review of Resident #7's nursing progress notes for May 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. <BR/>An interview was attempted and unsuccessful with Resident #7 while in the hospital on [DATE] at 1:08 PM and rang busy. <BR/>4. An interview with ADON B on 06/19/25 at 10:45 AM revealed after treatment was done for a wound, there was a WAR (wound administration record) to complete and the nurse should not forget to document the treatment was provided because the e-charting system for that treatment administration will stay red on the screen until resolved. ADON B stated nursing management could see who was missing medications and treatment administrations and if that happened, the nursing management would go and talk to the nurse in question. She stated, in order for the red administration notification to go away in the e-charting system, the nurse would have to document and put a progress note in the resident's chart to state why the treatment was not completed. <BR/>An interview with WC LVN C on 06/19/25 at 11:15 AM revealed she was responsible for documenting on the WAR when she changed a resident's wound dressing. She stated when there were blanks on the WAR, it could be because she was not at the facility working and the charge nurses were responsible for completing the wound care and WARs. <BR/>An interview with LVN F on 06/19/25 at 12:58 PM revealed she only did wound care if the wound care nurse was not present at the facility. She stated wound care treatment was documented on the WAR and if the wound care nurse or charge nurse did not click and enter that it was done, the treatment administration time would remain showing red on the e-chart and it meant you probably didn't do it or forgot to click it off.<BR/>An interview with the C-RN on 06/19/25 at 1:49 PM revealed the facility management had completed a one-on-one in-service with WC LVN C and ensured that she did do the wound care but did not check it off as completed on the WAR. He stated they did a one-on-one training to ensure she understood the point of doing treatment was to ensure the treatment was documented and if not clicked off at the point of care, then you get to the end of the day, you may forget.<BR/>5. Review of the facility's policy titled, Skin Integrity Management revised 10/05/2016, reflected, General Guidelines: 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified and treatment applied; .3. Wound care should be performed as ordered by the physician.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of four residents, reviewed for infection control. <BR/>1. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. <BR/>2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #2.<BR/>These failures placed residents at risk for healthcare associated cross contamination and infections.<BR/>Findings included:<BR/>1. Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMs score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting.<BR/>Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed.<BR/>An observation on 03/18/25 at 11:10 AM revealed CNA B was preparing to do perform incontinence care for Resident #1. CNA B cleaned the peri-area and buttocks, applied cream, and put on a clean brief. CNA B did not change his gloves or perform hand hygiene after cleaning the resident and before putting on the clean brief. <BR/>An interview on 03/18/25 at 12:45 PM with CNA B revealed he did not have to change gloves and perform hand hygiene after cleaning a resident. CNA B said he only had to perform hand hygiene and wear gloves before and after care. He said he did not see any reason to change his gloves during care. <BR/>2. Review of Resident #2's Quarterly MDS Assessment, dated 01/24/25, reflected the resident had a BIMs score of 00 and was severely cognitively impaired. The resident had diagnoses which included diabetes, stroke, and non-Alzheimer's dementia. The resident was always incontinent of bowel and bladder. The resident was completely dependent on staff for toileting.<BR/>Review of Resident #2's Comprehensive Care Plan, dated 12/06/22, reflected the resident required assistance with activities of daily living. Facility interventions included to assist resident as needed. <BR/>An observation and interview on 03/18/25 at 12:25 pm revealed CNA C was preparing to do incontinence care for Resident #2. CNA C cleaned the resident's peri-area and buttocks. CNA C changed gloves but did not perform hand hygiene. CNA C applied cream to the resident's buttocks and put on a clean brief. CNA C said she did not need to perform hand hygiene when changing gloves unless there was bowel movement on her gloves. <BR/>An interview on 03/18/25 at 1:00 PM with the DON revealed staff were supposed to change gloves and perform hand hygiene during incontinence care to reduce the risk of infection. <BR/>Review of the facility policy, Handwashing, dated 2012, reflected:<BR/>We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for one of three (Resident #1) residents reviewed for confidentiality of records.<BR/>The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information to include some of his medications.<BR/>This failure could affect residents by placing them at risk for loss of privacy and dignity.<BR/>The Findings included:<BR/>Review of Resident #1's electronic face sheet printed 08/26/2024 revealed a 87 year- old male admitted to the facility initially on 04/02/2024 and re admitted on [DATE] with diagnoses that included but not limited too acute combined systolic and diastolic heart failure(both types of left-sided heart failure that affect the heart's ability to pump blood), type 2 diabetes mellitus unspecified complication(chronic condition that causes high blood sugar levels due to a lack of insulin or insulin resistance and high blood pressure.<BR/>Observation and interview on 08/24/2024 at 12:20 PM revealed the computer screen on LVN A's medication cart unlocked for approximately 1-2 minutes while LVN A was inside Resident #1's room . The medication cart was approximately 2 doors down from Resident #1's room and facing the hall which exposed Resident #1's personal information including medication to staff and residents who were on the hall. The computer displayed the medication that was being provided to Resident #1. LVN A was found in Resident #1's room and stated he was responding to a call light. LVN A stated he should have locked the computer when he walked off however he was trying to respond to the call light quickly.<BR/>Interview on 08/26/2024 at 2:20PM with the Director of Nursing revealed during medication pass the computer screen should be locked or minimized when not in sight. The Director of Nursing stated the risk of leaving the computer unlocked would be patient information would be visible to residents or staff walking down the hall.<BR/>Review of the facility policy Resident Rights undated revealed The resident has a right to secure and confidential personal and medical records.