Every finding on record at Alhambra Healthcare & Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure Licensed Practical Nurses (LPN) were board certified to administer intravenous (IV) infusion of medications for three residents (#1, #3, and #4) out of five residents sampled for medication administration. Findings included: https://www.fha.org/common/Uploaded%20files/FHA/Health%20Care%20Issues/Growing%20the%20Health%20Care%20Workforce/Issue%20Brief%20on%20Licensed%20Practical%20Nurse%20Scope%20of%20Practice.pdf showed the following:Approved Programs for IV CertificationsThe Board of Nursing (Board) specifies the requirements for LPNs to practice infusion therapy (IVs), pursuant to the Rule 64B9-12.005, Florida Administrative Code, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy. The Board recognizes that after appropriate education and training, an LPN may perform intravenous therapy under the direction of a registered professional nurse and is approved by the facility to expand the LPNs scope of practice based on the completion of the program.Appropriate education and training require: A minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours requiredfor intravenous therapy education. Training must include didactic and clinical practicum instruction outlined in rule. Skills practicum is recommended, and facility must determine competency with skills checklists.State ComparisonsMost states, including Florida, prohibit licensed practical nurses from initiating IV therapy to patients unless they receive a certification demonstrating they have completed the required training. After receiving the required certification, the LPN can initiate certain IV therapy for adult patients under the direct supervision or direction of a physician or registered nurse. When states require under supervision, a registered nurse or physician is required to be physically in the room during the procedure. A record review for Resident #3's current physician orders showed an order for Cefepime HCL (hydrochloride) intravenous solution 2 GR/100 ml (grams/milliliters) every 12 hours for infected wound left foot for 6 weeks, ordered 02/02/2026. A review of the Medication Administration Record (MAR) for the month of March 2026 showed a scheduled time for 09:00 a.m. and 21:00 (9:00 p.m.) A physician order for Insert PICC (Peripherally Inserted Central Catheter) line to administer IV ABT (antibiotic) every day in the evening shift for one day ordered date 02/02/2026. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/central-line-and-central-line-placement A peripherally inserted central catheter (PICC) would be considered an example of a central venous catheter. On 3/03/2026 at 8:45 a.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN acknowledged she was assigned to Resident #3. At 9:25 a.m., Staff B, LPN stated the antibiotic ordered for Resident #3 would have to be administered by the Assistance Director of Nursing (ADON). Staff B, LPN, stated she was fairly new to working at the facility and did not provide her certificate of completion for the intravenous infusion course. At 9:35 a.m., an interview was conducted with the ADON in the Director of Nursing's (DON) office. The ADON stated she does not have her intravenous infusion certificate of completion in the state of Florida and because of this, the DON will be administering the IV antibiotic. At 9:38 a.m., an interview was conducted with Staff D, LPN (agency) assigned to the east hallway residents, who stated she was with an agency and confirmed she was not IV certified. At 10:05 a.m., the DON approached Staff B, LPN and requested Resident #3's antibiotic and tubing. Staff B, LPN stated the ADON had administered it. The DON corrected Staff B, LPN and stated she (DON) would be administering the IV antibiotic for Resident #3. At 11:08 a.m., an interview was conducted with Staff C, LPN. Staff C, LPN stated she was a staff employee but does not administer prescribed IV antibiotics to PICC lines. Staff C, LPN stated she did the course a year ago but was never provided with a certificate. Staff C, LPN stated she would have to reach out to the organization in which she took the course. Staff C, LPN, stated her employment with the facility had been close to a year. A record review of Resident #1 physician orders showed the following:Vancomycin HCL intravenous solution reconstitute 2GM, use 2G intravenously every 18 hours for wound infection until 12/08/2025 pharmacy to dose, ordered on 11/13/2025 and discontinued on 11/22/2025Vancomycin HCL intravenous solution reconstituted 2G vancomycin HCL used 2G intravenously every 18 hours for wound infection until 11/22/2025 pharmacy to dose order date 11/22/2025Vancomycin HCL intravenous solution reconstituted 1.5g , use 1.5g intravenously every 12 hours for wound infection until 12/08/2025 order date 11/22/2025, discontinued on 11/25/2025A record review of Resident #1's MAR for the month of November 2025 showed the following administration entries for Vancomycin HCL per physician orders:On 11/15/2025 an entry at 11:13 a.m. by Staff G, LPNOn 11/16/2025 an entry at 05:54 a.m., by Staff F, LPNOn 11/16/2025 an entry at 01:57 a.m., by Staff H, LPNOn 11/18/2025 an entry at 14:28 (2:48 p.m.) by Staff I, LPNOn 11/21/2025 an entry at 13:26 (1:26 p.m.) by Staff I, LPNOn 11/23/2025 an entry at (no time) by Staff E, LPNOn 11/24/2025 an entry at (no time) by Staff E, LPNA record review of Resident #3's physician orders showed the following:Cefepime HCL intravenous solution 2 grams/100 ml ( milliliters), every 12 hours for infected wound left foot for 8 weeks, ordered on 02/20/2026.Vancomycin HCL in dextrose solution 1 gram/200 milliliters, use 200 ml intravenously one time a day for infected wound left foot for 6 weeks, pharmacy to dose, ordered 02/06/2026.A record review of Resident #3's MAR for the month of February 2026 showed the following administration entries for Cefepime HCL 2 grams/100 ml:On 02/04/2026 an entry at 9:00 a.m. by Staff J, LPNOn 02/10/2026 an entry at 9:00 a.m. by Staff J, LPNOn 02/16/2026 an entry at 9:00 a.m. by Staff J, LPNOn 02/17/2026 an entry at 9:00 a.m. HELD by Staff C, LPN with no orders to holdOn 02/18/2026 an entry at 9:00 a.m. by Staff J, LPNOn 02/18/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/19/2026 an entry at 9:00 a.m. by Staff L, LPNOn 02/19/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/20/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/23/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/24/2026 an entry at 9:00 a.m. by Staff L, LPNOn 02/24/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/25/2026 an entry at 21:00 (9:00 p.m.) by Staff E, LPNOn 02/26/2026 an entry at 9:00 a.m. HELD by Staff C, LPN with no orders to holdOn 02/28/2026 an entry at 9:00 a.m. by Staff B, LPNOn 02/28/2026 an entry at 21:00 (9:00 p.m.) by Staff B, LPNA record review of Resident #3's MAR for the month of February 2026 showed the following administration entries for Vancomycin HCL one gram/200 ml intravenously one time a day:On 02/23/2026 for the 6:00 a.m. dose as no entry.A record review of Resident #3's MAR for the month of March 2026 showed the following administration entries for Cefepime HCL 2 grams/100 ml:On 3/02/2026 an entry at 21:00 (9:00p.m.) by Staff E, LPNA record review of Resident #4 physician orders showed the following:Cefazolin Sodium Intravenous Solution reconstituted 1 (one ) GM, use 2 grams intravenously three times a day for osteomyelitis for 39 days every 8 hours ordered 02/09/2025A record review of Resident #4's MAR for the month of February 2026 showed the following administration entries for Cefazolin Sodium per physician orders:On 02/10/2026 an entry at 10:00 a.m. by Staff J, LPNOn 02/14/2026 an entry at 2:00 a.m. by Staff I, LPNOn 02/15/2026 an entry at 2:00 a.m. by Staff E, LPNOn 02/16/2026 an entry at 2:00 a.m. by Staff E, LPNOn 02/16/2026 an entry at 10:00 a.m. by Staff J, LPNOn 02/17/2026 an entry at 10:00a.m. by Staff C, LPNOn 02/18/2026 an entry at 10: a.m. by Staff J, LPNOn 02/ 18/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 02/19/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 02/20/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 02/23/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 02/24/2026 an entry at 10:00 a.m. by Staff J, LPNOn 02/25/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 02/26/2026 an entry at 10:00 a.m. by Staff C, LPNOn 02/28/2026 an entry at 02:00 a.m. by Staff K, LPNOn 02/28/2026 an entry at 10:00 a.m. by Staff B, LPNOn 02/28/2026 an entry at 18:00 (6:00 p.m.) by Staff B, LPNOn 03/02/2026 an entry at 18:00 (6:00 p.m.) by Staff E, LPNOn 3/03/2026 at 4:30 p.m., during an interview with the DON, ADON and Regional Nurse Consultant, Resident #4 had not received his 10:00 a.m. dose of Cefazolin sodium one gram. Resident #4's next dose of Cefazolin sodium was scheduled for 6:00 p.m.

Based on observations, interviews, and record review, the facility failed: 1) to ensure proper PPE (personal protective equipment) was utilized for one resident (#5) on Enhanced Barrier Isolation, 2) to properly store a nebulizer for one resident (#3) receiving respiratory treatments, 3) to provide timely dressing changes for a Peripherally Inserted Central Catheter (PICC) for one resident (#3), and 4) to properly dispose of potentially contaminated personal protective equipment and linen for two residents (#3 and 5) out of five sampled residents for infection control. Findings included: On 3/02/2026 at 9:55 a.m., an observation was made in Resident #5's room of one small trash receptacle without a disposable liner. An observation was made of another small trash receptable in the resident's bathroom without a disposable liner. The trash receptacle in the room had gloves, gown and garbage inside. A sign for Enhanced Barrier Precautions was observed outside taped to the door. A record review of physician orders for Resident #5 showed an order for Enhanced Barrier Precautions-right side nephrostomy and indwelling suprapubic catheter dated 02/27/2026.On 3/03/2026 at 10:30 a.m., an observation was made in Resident #3's room. The Director of Nursing (DON) was present during observations. On Resident #3's night stand was an exposed nebulizer mask not properly stored, opened normal saline flush, and a dirty surface area of the nightstand. On 3/03/2026 at 10: 35 a.m., an observation and interview was conducted with the DON regarding Resident #3's PICC line dressing. Resident #3's PICC line dressing was labeled 2/23. The DON stated PICC line dressings are changed every seven days with the evening shift responsible for changing dressing. The DON stated the dressing should have been changed yesterday. The DON changed the dressing. On 03/03/2026 at 11:05 a.m., an observation was made of Resident #3's room after observation of intravenous administration of antibiotic and PICC line dressing change. Resident #3 and her roommate's trash receptacle was in front of Resident #3's footboard under her wheelchair with PPE hanging over. An observation was made by the DON who stated we should have larger trash bins for residents on isolation. On 3/03/2026 at 2:43 p.m., an observation was made with the DON of an unidentified Certified Nursing Assistant (CNA) providing care for Resident #5. Resident #5 was on Enhanced Barrier Precaution with proper signage posted outside on the door. The unidentified CNA was not wearing a gown. The DON entered wearing appropriate gown and gloves to further instruct the CNA on proper use of gown during resident care. The CNA exited the resident's room, donned a gown and returned to the room, doffed the isolation gown and removed the liner from the trash bin and exited the room. On 3/03/2026 at 3:45 p.m., an observation was made of a small trash receptacle full of doffed gloves and gowns with no trash liner. The trash receptacle was located in front of Resident #5's roommate's bed. Resident #5 had extensive wound dressings and line dressings completed by the DON and Staff A, Registered Nurse (RN). An observation was made of dirty linen tossed on a chair with a removal of a blanket to be returned to the resident. A second small trash receptacle was located in the resident's bathroom missing a liner. The DON found one inside the receptacle and pulled out to place doffed items in. An observation was made of Resident #5's roommate accompanied by a family member entering the room with the overflowing trash receptacle with no liner full of doffed gloves and isolation gowns. A review of the facility's policy titled, Standard Precautions Infection Control, revised date of 8/15/2022, showed the following policy statement:Staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors.Policy Explanation and Compliance Guidelines:.2. Using personal protective equipment (PPE): a. All staff who have contact with residents and/ or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. b. Multiple factors determine the appropriate selection of PPE for a particular task. Refer to the facilities personal protective equipment policy for indications and consideration for use of PPE. 5. Resident care equipment and instruments/devices: a. Policies and procedures have been established for containing, transporting, and handling resident care equipment and instruments/devices that may be contaminated with blood or body fluids. Personnel are trained in the use of these procedures. b. Where PPE (e.g., gloves, gowns, etcetera.) When handling resident care equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids.6. Care of the equipment: a. Policies and procedures have been established for routine and targeted cleaning of environmental surfaces as indicated by the level of resident contact and degree of soiling personnel are trained in the use of the procedures .8. Employee education and training: Employees are provided job and/ or task specific education and training on preventing transmission of infectious agents associated with health care during their orientation program, annually, during regular scheduled infection control training programs, and when new or modified procedures are implemented in the facility.Photographic evidence obtained

Based on observation, interviews, and record review, the facility failed to provide necessary treatment and services for pressure ulcers in a timely manner for one resident (#5) out of two residents sampled.Findings included: On 3/02/2026 at 9:55 a.m., an interview was conducted with Resident #5 in his room. Resident #5 stated he was admitted on [DATE] from the hospital. Resident #5 stated he had sores to his bottom. Resident #5 stated he had not received a bath/shower and could not recall if his wounds were addressed. A record review of Resident #5's 3008 Section T. Skin Care-Stage & Assessment Pressure Ulcers (indicate stage and location(s) of lesions using corresponding number showed pressure areas for coccyx, bilateral buttocks and bilateral thighs. A record review of Resident #5's initial admission skin assessment, dated 02/27/2026, showed:Sacrum 9 x 7Left buttock 6 x 3Right buttock 5 x 2Left gluteal fold 2 x 2Right gluteal fold 2 x 3All were noted as pressure wounds. A record review of Resident #5's physician orders showed:-An order, dated 02/27/2026, for daily monitoring of sacral wound use codes below for supplementary documentation. Dressing- a. present b-absent c-N/A (not applicable). Dressing status- a. dry/intact b. leaking/strike through c. N/A. Surrounding skin- a. Normal b. abnormal see NN (nurse's notes). Presence of possible complications- a. None observed b. Present see NN. Presence of pain- a. Yes seen NN b. No - every shift for skin observations.-An order dated 02/27/2026 for Enhanced Barrier Precautions.-No orders for wound care were noted. On 03/03/2026 at 2:43 p.m., an observation was made of Resident #5's skin during a head- to- toe skin assessment with the Director of Nursing (DON). Resident #5 was able to turn to his right side with minor assistance to expose his back. An observation was made of small areas of drainage to the incontinence briefs and further observation showed no dressings for wound management present to be removed. An observation was made of Resident #5's lower back with a large open area palm size and a dark black area in the center of this open area. An observation was made of a small open area to the left lower buttocks/ upper thigh area. An observation was made of a small open area to the right lower buttocks/ upper thigh area. An observation was made of the DON, assisted by Staff A, Registered Nurse (RN), cleansed the open areas with normal saline and applied two large, bordered dressings. An observation was made of Resident #5's nephrostomy tube dressing not dated. On 03/03/2026 at 3:20 p.m., an interview was conducted with Staff A, RN. Staff A, RN stated she recalled the resident arrived at the facility with dressings on. Staff A, RN stated she could not explain why there were no dressings currently. Staff A, RN stated she is the designated nurse to assist the wound nurse practitioner every Wednesday during wound rounds. Staff A, RN stated the wound nurse practitioner will see the resident Wednesday. On 03/03/2026 at 3:58 p.m., a telephone interview was conducted with the wound nurse practitioner (NP). The NP stated she makes rounds every Wednesday. She stated the facility will email her new admits or readmits to see. The NP stated if the facility requested a visit for a concern she would come into the facility sooner. The NP stated if the facility wanted to ask questions regarding current treatment or questions regarding a resident prior to her arrival for wound rounds, she would be available. The NP reviewed her email and stated there was no communication to see Resident #5 sooner than her normal weekly visit or questions on his current wound management for this resident. The NP stated her understanding was to see the resident during her normal weekly rounds and no sooner. A review of the facility's policy titled, Wound Treatment Management revised 11/23/2022 showed a policy statement:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence- based treatments in accordance with current standards of practice and physician orders.Policy explanation and compliance guidelines: include but not limited to:wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 5. Treatment decisions will be based on: a. Etiology of the woundi. Pressure injuries will be differentiated from non- pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. b. Characteristics of the wound: i. Pressure injury stage or level of tissue destruction if not a pressure injury ii. -size-including shape, depth, and presence of tunneling and for undermining. iii. Volume and characteristics of exudate iv. Presence of pain v. Presence of infection or need to address bacterial bioburden vi. Condition of tissue in the wound bed vii. Condition of peri-wound skin c. Location of the wound .

Based on observation, record review, and interview, the facility failed to ensure adequate provision of care and services for activities of daily living, toileting services for two residents (#14 and #10) of sixteen sampled residents. Findings included: 1.On 12/03/2025 at 12:48 p.m. an observation of Resident #14 was conducted. The resident was in bed, covered up to neck, alert, and agreed to an interview. She stated she could now transfer herself out of bed. When asked if she needed assistance with the bathroom use, she stated when I got here, I did. I came in the evening before Thanksgiving. When asked about call bell light response, if it was timely. She stated, the waits happen mostly at night. I was upset one night; I could not transfer myself out of bed to go to the bathroom. I had to lay in my feces and urine for hours. I told the medical records girl. I do not know her name. She said she would speak to people and see it did not happen again. I could not walk. I had an arterial bypass in my leg; had incision; the pain was excruciating.A review of Resident #14's clinical record, the admission Record, documented an admission of 11/26/2025. Her diagnosis information included but was not limited to peripheral vascular disease, and chronic obstructive pulmonary disease.A review of Resident #14's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form (AHCA Form 3008), dated 11/26/2025, documented physical function to be ambulates with assistance, 1 assistant.A review of Resident #14's admission Nursing Comprehensive Evaluation, dated 11/27/2025, documented the admission on [DATE] at 17:43; A Brief Interview for Mental Status (BIMs) score of 15, which meant the resident was cognitively intact; The resident was documented to be interviewable. Resident's continence status showed, needs help with toileting, incontinence care. Resident's toileting ability was requires staff assist of 1. The nursing summary: Resident has two surgical incisions. One to right lower extremity with 12 staples intact, one upper right thigh with 21 staples intact.Resident is alert and oriented X 3 and able to make needs known. Resident states she is unable to bear weight to right lower extremity.The Baseline Care plan, dated 11/27/2025, documented: Bowel and Bladder Needs-Initial Goals included: I will be kept clean, dry and odor free. Bowel and Bladder tasks: Provide hands-on assist with toileting. A review of Review of Resident #14's comprehensive Care Plan reflected: Focus area: Resident is at risk for falls and / or fall related injury r/t (due to): generalized weakness, impaired balance, unsteady gait, requires staff assist with transfer and ambulation, uses w/c (wheelchair) as primary mode of locomotion, receives psychotropic meds, initiated 12/01/2025. Interventions included: Provide incontinence care/ toileting per resident's needs, initiated 12/01/2025.A review of the comprehensive care plan revealed no focus area had been created for bowel and bladder as of the date of survey, 12/03/2025.A review of Resident #14's, the Occupational Therapy (OT), OT Evaluation & Plan of Treatment, dated 11/28/2025, showed Resident #14's baseline for toileting on 11/28/2025 as Mod(A) (moderate assist). Pain with movement=8/10; Frequency=Intermittent; location right lower leg and right groin; pain description/type: aching, cramping, and discomfort. Pain limits the following functional activities: Walking. Clinical Impression: Patient currently presents with increased weakness, unsteadiness, and pain causing her to require increased assistance with ADLs (activities of Daily Living)/ IADLs, transfers, and functional mobility as well as putting her at an increased risk for falls.A review of Resident #14's Toilet and Transfer documentation revealed the following assistance was provided to the resident:11/26, 19:12: marked Dependent-helper does ALL of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity.11/27, 6:59: marked Not Applicable.11/27, 14:49: marked Dependent.11/27, 22:49: marked Not Applicable.11/28, 14:49: marked Dependent.11/28, 18:06: marked Partial / moderate assistance.11/29, 6:59: marked Not Applicable.11/29, 14:54: marked Dependent.11/30, 14:35: marked Dependent.12/01, 14:23: marked Setup or clean-up assistance.12/01, 17:32: marked Not Applicable.12/02, 14:34: marked Supervision or touching assistance12/02, 21:25: marked Independent12/03, 4:20: marked Supervision or touching assistance.12:03, 13:10: marked Partial/ moderate assistance.Review of the toileting assistance revealed eighteen (18) shifts (6 days X 3 (eight-hour shift) from 11/27 through 12/02. The staff documented they provided toileting assistance eight times during the eighteen shifts.For the date of 11/30, the resident was last documented to receive toileting assistance on 11/29 at 14:54, and then the next documentation was 11/30 at 14:35.On 12/03/2025 at 2:50 p.m., an interview was conducted with the Medical Records manager. She stated she had been the manager on duty on Sunday, 11/30. She stated she had gone around and asked about Resident #14's status. She stated Resident #14 said she was wet and needed to be changed. This was around 10:30 a.m. or 10:45 a.m. and her light was on. The Medical Records manager said, she (Resident #14) said she was wet, she said she had redness on the back of her tail bone. I would have changed her, but the aid went in and changed her. On 12/03/2025 at 3:23 p.m. a review of Resident #14's ADL sheet, Toileting Transfer documentation was reviewed with the Regional Minimum Data Set Coordinator. She said, should see documentation of assistance for the resident at least one time per shift. During the interview, the Director of Nursing reviewed the ADL sheet, she stated Resident #14's toileting assistance was documented to be one time per day, she said, that is what it appears to be. 2. On 12/03/2025 at 11:56 a.m. Resident #10 was observed in his room, self-propelling in a w/c, dressed in seasonally appropriate clothing. He agreed to be interviewed. He stated the call bell in the bathroom works. He stated he needed assistance using the bathroom. He confirmed he could use the call light. When asked if staff answered the call bell light in a timely manner, he stated, no. He stated one lady is great, she knows our schedule, others it can take 30-40 minutes, and others, not at all. A review of Resident #10's admission Record, showed an admission in 09/2024. His diagnosis information included but not limited to heart failure and Need for assistance with personal care. A review of Resident #10's BIMs summary score, dated 10/06/2025, documented a score of 15, which indicated the resident was cognitively intact. A review of Resident #10's Care Plan revealed a focus area: Resident is noted to have actual skin impairment . initiated, 06/05/2025. Focus area: (Resident) is at risk for falls and / or fall related injury r/t (due to) generalized weakness, impaired balance, unsteady gait, requires staff assist with transfers and ambulation, uses w/c as primary mode of location., initiated, 09/30/2024. Focus area: (Resident) has an alteration in elimination AEB (as evidenced by): Is incontinent of bowel and bladder, . r/t (due to) decreased mobility, side effects of meds, initiated, 06/22/2025. Interventions included: Provide hands on assistance with toileting upon resident request and as needed, initiated, 06/22/2025. A review of Resident #10's ADL documentation for Toilet Transfer for the dates of 11/04 through 12/02, which was 29 days, thus 29 x 3 (eight hour) shifts per day=87 shifts. The resident was documented to have received assistance 56 times. Further review of the Toilet Transfer documentation revealed: On 11/06, 11/09, 11/12, 11/14, 11/15, 11/28, and 11/30, the resident was documented to receive toileting assistance once during a 24-hour period. On 11/10 and 11/16, the resident had no documentation of having received assistance with toileting services.

Based on observation, record review, and interview, the facility failed to ensure pharmacy services for timely procurement of pain medication for one (#14) resident and failed to ensure a system of accurate accounting of dispensed controlled substances for one (#14) resident of three residents reviewed for pain medications.Findings included: 1. On 12/03/2025 at 12:48 p.m., an observation of Resident #14, in bed, covers up to neck, alert, agreed to an interview. She stated upon admission to the facility, I could not walk. I had an arterial bypass in my leg; had incision; the pain was excruciating. When I first came, it took me until Monday, 12/01 to get medications. I was upset. They did not have hydrocodone. They could not find the order. The doctor was out.A review of Resident #14's admission Record showed an admission date of 11/26/2025. Her diagnosis information included but not limited to atherosclerosis of native arteries of extremities with claudication, peripheral vascular disease, and chronic obstructive pulmonary disease.A review of Resident #14's admission Nursing Comprehensive Evaluation, dated 11/27/2025, showed a Brief Interview for Mental Status (BIMs) score of 15, which meant the resident was cognitively intact; for pain, she answered yes to have had pain, frequently with a level of 7 out of 10 scale. The nursing summary: Resident has two surgical incisions. One to right lower extremity with 12 staples intact, one upper right thigh with 21 staples intact.Resident is alert and oriented X 3 and able to make needs known. Resident states she is unable to bear weight to right lower extremity.A review of the Baseline Care plan dated 11/27/2025 documented: Pain: Give pain medications as ordered; observe for effectiveness.A review of Resident #14's Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 11/28/2025, showed Resident #14's pain assessment, Pain at rest=6/10; Frequency=intermittent; location: right lower leg and right groin; pain description/ type: aching. Pain with movement=8/10; Frequency=Intermittent; location right lower leg and right groin; pain description/type: aching, cramping, and discomfort. Pain limits the following functional activities; Walking.Resident #14's record revealed a scanned in hard copy of a prescription for Norco 5 mg-325 mg oral tablet, PRN (as needed) pain, 1-2-tab (s) PO (by mouth) q (every) 4-6 hour for 7-day (s) PRN pain, quantity of 30, signed and dated by the physician on 11/20/2025. The prescription revealed initials at the bottom right corner with faxed 11/27, no time information was available.A review of Resident #14's Medication Administration Record (MAR) for 11/2025, revealed a showed physician order: Evaluate resident for pain by using appropriate pain scale: 0: No pain, 1-3: Mild pain, 4-6: Moderate pain; 7-10: severe pain. Every shift for pain monitoring, order date 11/26/2025.A review of Resident #14's MAR showed a physician order, Acetaminophen Tablet 325 mg, give 2 tablet by mouth every 4 hours as needed for general discomfort. Not to exceed greater than 3000 mg in 24 hours, order date 11/26/2025.The resident had the following documentation under this monitoring:11/26, 1948, pain level was 3.11/27, 1317, pain level was 7.11/28, 1411, pain level was 7.A review of the Medication Monitoring Control Record for Resident #14's Hydrocodone, the pharmacy label documented the medication was dispensed on 11/27/2025, a quantity of 26. The Control form listed the following withdrawals for the medication, one pill each recording:11/28, withdrawn at 0937; 1506; 2000.11/29, withdrawn at 0633; 12:56; 15:50.11/30, withdrawn at 1031; 1614 and 2228 (this entry had no nurse signature).12/01, withdrawn at 0400; 1200; 1800; 2300.12/02, withdrawn at 0749; 1600; 2100.12/03, withdrawn at 0108; 0818; 1309.Review of Resident #14's medical record revealed no documentation of efforts made by the facility to obtain the Hydrocodone from the time of admission, 11/26 at 17:43 until receipt on 11/28, more than 24 hours after admission time.A review of the MAR, Hydrocodone-Acetaminophen oral tablet 5-325 Mg (Hydrocodone Acetaminophen), give 1 tablet by mouth every 4 hours as needed for moderate to severe pain (5-10) for 14 days, order date 11/27/2025, 1234.The resident had the following medication administration documented under this order, 11/27, no administration was documented.11/28, 1035, pain level= 10; 1506, pain level= 9.11/29, 0633, pain level= 5; 12:56, pain level= 911/30, 1031, pain level= 8; 16:14, pain level= 8; 2228, pain level= 712/01, 0359, pain level= 8; 0800, pain level= 8; 1200, pain level= 8; 1800= pain level= 8.12/02, 0749, pain level= 8; 1600, pain level= 8; 2100, pain level= 8.12/03, 0107, pain level= 8; 0818, pain level= 7; 1309, pain level= 7. Comparing the MAR with the Medication Monitoring Control Record revealed the withdrawals on the following dates had no record of documentation on the MAR.11/28 at 2000; 11/29 at 1550;12/01 at 2300.An interview conducted on 12/03/2025 at 3:34 p.m. with the Director of Nursing (DON), she stated nursing staff should document steps taken in order to get medication if an issue. When asked about pharmacy deliveries times, she stated it varies, normally at least 2 times.At 3:50 p.m., the DON stated Resident #14's MAR and the Medication Monitoring Control Record for the Hydrocodone did not match. During the interview, for medication procurement for newly admitted residents, the DON stated the medications should be received within a reasonable time frame. She stated she did not have a policy and procedure regarding that. The Chief Nursing Consultant stated that a reasonable time would be the next pharmacy run.On 12/03/2025, 4:42 p.m., a phone interview was conducted with the facility's pharmacy consultant. Medications for new admission should be at the facility by the next morning. There is plenty of opportunity, unless there is a need for clarification. There are three deliveries per day. For schedule II medications, I do spot checks. The control sheets should match the administration documentation. A review of the facility's Controlled Substance Administration & Accountability policy and procedure, last revised 10/2023, documented the policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safe guards in place in order to prevent loss, diversion or accidental exposure. The compliance guidelines included: .g. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy.

Based on observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable homelike environment for 6 resident rooms (105, 110, 112, 205, 212, and 109) out of 16 rooms observed related to absent caulking around commodes, discoloration on commodes, unclean resident room and bathroom flooring, and discoloration on privacy curtain. Findings include: On 12/03/2025, at 9:10 a.m., a tour of the facility was conducted. room [ROOM NUMBER], the resident's bathroom, the commode had no caulking present. The flooring around the commode was darker than the rest of the flooring and presented as unclean.room [ROOM NUMBER], two areas of orange-colored semi-dried sticky puddles, approximately 4-5 inches in circular size were observed on the resident's floor. The floor had clear glistening splotches visible which presented to be sticky.room [ROOM NUMBER], the resident's bathroom, the caulking around the base of the commode had an orangish brown color, the flooring around the commode extending out approximately 12 inches had intermittent black, gray discolor build -up present. room [ROOM NUMBER], the privacy curtain between bed A and B, approximately waist high, had a dark brownish red discolor mark in the shape of a T approximately the size of a hand with two additional small discolor spots.room [ROOM NUMBER], the resident bathroom, the commode was observed to have brownish marks on the outside of the commode, the commode at the floor juncture was heavily discolored-dark black, brown color approximately 1-3/4 inch in depth surrounding the base, and the floor surrounding the commode was scattered with discolor marks. The floor was observed to be unclean in appearance. Underneath the toilet seat, the inner edges had reddish brown matter present, dried in appearance.A corner molding, at the bottom was observed to be detached from the wall and laying on the hallway floor at the entrance to the 100 hall.room [ROOM NUMBER], the resident's bathroom, the commode was observed not to have caulking present at the base and floor juncture. The floor in the bathroom was heavily soiled with discolor marks and use build up, a dark grayish brownish color, which presented as unclean. On 12/03/2025 at 3:00 p.m., an interview was conducted with the Maintenance Director. He stated he had worked for the facility for seven weeks. He said he was still catching up on work orders that were put in before he was hired.

Based on observation, record review, and interview, the facility failed to ensure an effective pest control program to maintain a pest free environment for two residents (#15 and #10) of sixteen sampled residents. Findings included: On 12/03/2025, at 9:10 a.m., a tour of the facility was conducted. At 9:35 a.m., Resident #15's room was observed. A line of tiny ants was observed crawling on the floor next to Resident #15's nightstand. The floor was observed to have food debris present. Resident #15 was present and stated he had seen a couple of ants on his bed.At 11:56 a.m. Resident #10 was interviewed in his room. He stated he had seen ants in his bathroom by the window. He said he told them about them a long time ago. An observation of the bathroom was conducted at this time; the windowsill had a line of tiny ants crawling just below the sill.On 12/03/2025 at 3:00 p.m., an interview was conducted with the Maintenance Director. He stated the pest control company comes every other Friday and every time the facility calls. He said he has had complaints about bugs, and a rodent in the attic since he started working for the facility.A review of pest control service invoices was conducted. The invoice, dated 11/19/2025, documented treatment to the exterior for pest management, cockroaches, mosquitos, and ants. The invoice for 12/03/2025 showed an inspection of all logbooks for reports of pests and found no reports. The invoice showed treatment for exterior doors, kitchen, and common areas for pest prevention. No treatment for ants was mentioned. On 12/03/2025 at 3:48 p.m., an interview was conducted with the Environmental Service Manager (ESM). He stated he had complaints about ants on Sunday, 11/30/2025. He had seen them in room [ROOM NUMBER] due to a chocolate cookie on the floor. He stated room [ROOM NUMBER] had been deep cleaned on 12/01/2025. The ESM confirmed he could see where the ants were entering the room. He stated he did not enter the ant sighting in the pest logbook. He said he thought the pest company came in the next day on 12/02/2025 or on 12/03/2025.A review of the policy titled Pest Control Program with a revision date of 4/10/2024 revealed the following: Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pest (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Policy Explanation and Compliance Guidelines: 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.Photographic evidence obtained.

Based on record review and interviews, the facility failed to document room change notifications for three residents (#2, #3, and #4) of three residents sampled.Findings included: 1.) Review of Resident #2's census revealed Resident #2 changed rooms on 9/29/2025, 9/19/2025 and 9/15/2025. Review of Resident #2's progress notes revealed no documentation of notification of the room changes were located for 9/19/2025 and 9/15/2025. 2.) Review of Resident #3's census revealed Resident #3 changed rooms on 09/24/2025 and 09/19/2025. Review of Resident #3's progress notes revealed no documentation of notification of the room changes for 09/24/2025 and 09/19/2025. 3.) Review of Resident #4's census revealed Resident #4 changed rooms on 09/30/2025. Review of Resident #4's progress notes revealed no documentation of notification of the room changes for 09/30/2025. During an interview on 10/15/2025 at 12:46 P. M., the Director of Nursing (DON) stated the Social Services Director (SSD) was out of the building and was not reachable. The DON stated the SSD notifies the family of any room changes and nursing staff completes the room transfers. The DON stated resident room changes are performed for different reasons, they can be for personal preferences or by request of the facility. The DON stated residents, and their representatives are supposed to be notified of a room change each time. The DON stated normally the SSD will document notification of the room change in the progress notes. The DON reviewed Resident #2's census and confirmed Resident #2 changed rooms 4 times during her stay. The DON said, I see one progress note about one of the room changes. It appears Resident #2 was moved the first time because we needed a private isolation room. I would expect to find a note in the progress notes documenting the other room changes. During an interview with the DON on 10/15/2025 at 02:30 P. M., the DON looked at the Census for Resident #3. The DON stated the resident had a room change and according to progress notes, the notification of the room change was not documented. The DON also looked at Resident #4's census and stated Resident #4 had changed rooms within the last thirty days and notification and the reason why, was not documented in progress notes. A policy titled Standards and Guidelines: Residents Rights, and revised 12/2016 showed: Standard: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;j. be informed about his or her rights and responsibilities.

Based on observation interviews and policy review, the facility did not ensure medications were stored and labeled appropriately in three medication carts (Split back, East front and [NAME] front) of three medication carts observed. Findings included: 1. An observation on 7/21/2025 at 2:25 P.M. of the Split Back Cart Medication Cart revealed an undated used bottle of Latanoprost eye drops, two undated Breo Inhalers and an undated Combivent inhaler. The boxes containing the Breo inhalers were labeled expires six weeks after opening and the Combivent inhaler was labeled expires three months after opening. The boxes did not show an opening date.An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 7/21/2025 at 2:32 P.M. She stated if she found medications that were not labeled in the medication cart, she would discuss it with the shift supervisor. She stated she never discards medications from the medication cart without speaking to a supervisor. The nurse placed all the undated medications back into the medication cart. Staff B, LPN stated it was her second day working at the facility and she did know what pharmacy they use. 2. An observation on 7/21/2025 at 2:37 P.M. of the East Front Medication Cart revealed a bottle of Ibuprofen which was opened. There was no date to indicate when the bottle was opened.An interview was conducted with Staff A, LPN on 7/21/2025 at 2:43 P.M. She stated the medication was probably opened today. Staff A proceeded to label the medication with a date of 7/21/2025. She stated she did not give this medication to any residents today. 3. An observation on 7/21/2025 at 3:00 P.M. of the [NAME] Front Medication Cart revealed an undated empty bottle of Omeprazole which was in the top drawer of the cart, an undated used bottle of Latanoprost eye drops, two undated used bottles of Loteprednol eye drops, an undated used bottle of Timolol eye drops and an undated used Breo Inhaler. The box the inhaler was stored in read, expires six weeks after opening. There was no date to indicate when the bottle was opened.An interview was conducted with the Director of Nursing (DON) on 7/21/2025 at 3:08 P.M. She said all medications should be labeled with the date it was opened and the expiration date. She said the inhalers always expire before the printed manufacturer's date on the inhaler box, if they are opened. She stated the facility had a lot of agency staff at this time, but they were trying to recruit permanent staff. The DON stated her expectations were for the nurses to follow the pharmacy's recommended expiration dates.A review of the facility policy titled Medication Labeling and Storage reviewed on 3/2023 revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The policy and interpretation and Implementation section titled, Medication Labeling showed: 1. Labeling of the medications and biological dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: d: expiration date and g: appropriate instructions and precautions. 8: If the medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. A review of the facility policy titled, Pharmscript Storage of Medications revised on 8/2024 showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy's General Guidance, reads, 8: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. The policy's Expiration Date (Beyond-Use Dating) reads, 3: Certain medications or package types, such as IV (Intravenous) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. 5: When the manufacturer has specified a useable duration after opening (i.e. beyond use date, the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating; b: If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly. 6: The nurse will check the expiration date of each medication before administering it. 8: All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on observation and record review, the facility did not ensure up-to-date staffing information was posted on one day (3/24/25) of three days observed. Findings included: Upon entering the facility on 3/24/25 at 9:00 AM, an observation was made of a posting titled, Daily Staffing Projection, dated 3/22/25 with census of 60. On 3/24/25 at 10:12 AM, the staffing posting was still not updated. Review of the facility's policy and procedure dated 11/19/2019 titled Nursing Services - Nurse Staffing Information showed: INTENT: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. POLICY: 1. The facility will post the following information on a daily basis: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses or licensed vocational nurses (as defined under State law). iii. Certified nurse aides. d. Resident census. 2. The facility will post the nurse staffing data on a daily basis at the beginning of each shift. 3. Data must be posted as follows: a. Clear and readable format. b. In a prominent place readily accessible to residents and visitors. 4. The facility will, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. 5. The facility will maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. Photographic Evidence Obtained

Based on observations and interviews, the facility did not follow professional standards for food service safety as evidenced by food not maintained for safe consumption and improper labeling and dating of food items in the main kitchen and dining room. Findings included: On 3/24/25 at 9:56 a.m., an initial tour of the facility's kitchen was conducted with the facility's Certified Dietary Manager (CDM). An observation of the dish machine area, that was in use by Staff E, Cook, revealed pliers with a red handle on the machine's base. Further observations on the top area of the dish machine revealed light brown colored crumbs and other food particles. An observation of the dish machine hood revealed multiple dark brown and black spots along the top and sides. The multiple spots observed appeared to be signs of rust. On 3/24/25 at 10:03 a.m., an observation of the walk-in cooler, conducted with the CDM, revealed strips of bacon in a clear storage bag with an open date of 3/17/25, but no use by date. The CDM identified the food as, Vegan bacon, and stated the staff should have kept the original package label to determine the expiration date. She proceeded to remove the vegan bacon strips. Observations of the right side of the walk-in cooler revealed a box of two large lettuce heads with leaves that were separated. The separated leaves had areas that were yellow, brown, and black in color. She proceeded to remove the separated lettuce leaves, while the other two lettuce heads were left in the box. Further observations of the right side of the walk-in cooler revealed a box of potatoes that had multiple blue, gray, and white spores/bio growth. The CDM proceeded to remove the box of potatoes. At 10:11 a.m., an interview with the CDM revealed the Kitchen Manager should be reviewing the walk-in cooler for proper storage of food and beverage items, to include labeling and dating. On 3/24/25 at 10:11 a.m., an observation of the reach-in refrigerator, identified as #2, was conducted with the CDM. Observations of reach-in #2 revealed a shallow pan containing lemons and limes that had multiple gray and black spots. The CDM was observed removing the pan with the lemons and limes. Further observations of reach-in #2 revealed a stick of butter was not properly sealed and the top part was exposed to the air. On 3/24/25 at 10:32 a.m., an observation of the refrigerator/freezer in the dining room area was conducted with the facility's Director of Nursing (DON). She stated the refrigerator/freezer was for resident's food. An observation of the refrigerator revealed a food item with a resident's name, but no date or other labeling. The DON could not confirm how long the food had been there. An observation of the freezer revealed two individual ice cream packages. The DON confirmed the ice cream was not provided by the facility. The DON confirmed the two ice cream items did not have a resident's name. On 3/25/25 at 12:48 p.m., an interview was conducted with the facility's Kitchen Manager. The Kitchen Manager stated the pliers observed on 3/24/25 on the dish machine base were potentially there since last week. He stated the dish machine pipe was being fixed by maintenance last week and the maintenance staff member was using those pliers. Regarding observations of the top part of the dish machine, he stated it's part of the cleaning schedule. He stated the staff member that used the dish machine is responsible for cleaning that area and, It should have been cleaned. Regarding the dish machine hood, the Kitchen Manager stated he's not sure when it's been cleaned as it's not part of the cleaning schedule. He stated, It's been overlooked. On 3/25/25 at 1:06 p.m., interviews were conducted with the Kitchen Manager and CDM. The Kitchen Manager stated all staff are responsible for proper storage, labeling, and dating and he conducted daily monitoring of storage, labeling, and dating. He stated the dietary staff's monthly meeting, conducted on 2/21/25 and 3/17/25, included topics such as labeling/dating and expectations for personal items. A review of the sign-in sheet revealed all staff attended. He stated he talked about storage, labeling, and dating every month. The Kitchen Manager stated reviews of the refrigerator/freezer in the dining room is on the cleaning list for dietary staff. He stated Certified Nursing Assistants (CNA's) are expected to label and date food/beverage items. The CDM stated items should be discarded if it's in there for more than 3 days or if items are not labeled or dated. She stated dietary staff are expected to review the refrigerator/freezer in the dining room at least once a day, as they have to put beverages in there. The Kitchen Manager stated he reviewed the refrigerator/freezer in the dining room once a day. A review of the facility's policy titled Labeling and Dating dated 8/12/23 revealed the following, Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. (i.e. salad dressings, pickles, etc.). Further review of the policy, under Procedure, revealed the following, 1. 7 day shelf life including date of preparation -label includes: a. Name of food item, b. Discard date (to be discarded at end of 7th day) . 2. 30 day shelf life, usually applies to items that are shelf stable until opened - label includes: a. Name of food item if not clearly identified on container b. Discard date (i.e. opened 4/20, discard 5/30) . A review of the facility's policy titled Food Storage revealed the following, All food stock and food products are stored in a safe and sanitary manner. All food stock is dated and used on a first in, first out basis. A review of the facility's policy titled FIFO (First In First Out) revealed the following under Procedure, 1. Date all food items upon receipt. (If item has vendor delivery date label, further dating is not required unless individual cans, boxes, etc. are removed from the dated packaging) . 5. Food products are used by the expiration date, if not, food items are discarded. Photographic Evidence Obtained

Based on record review, review of policy and procedures, and interviews, the facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASRR) screening was completed for five residents (#48, #29, #6, #13, and #2) of 15 residents sampled. Findings included: 1. A review of Resident #48's Admission Record showed an admitted [DATE] with diagnoses of Post-Traumatic Stress Disorder (PTSD), unspecified dementia, alcohol abuse, and cocaine abuse. The diagnosis of major depressive disorder was added on 9/26/2024. A review of Resident #48's Level I PASRR screen completed on 11/13/2024 showed in Section A. Mental Illness (MI) or suspected MI, depressive disorder, substance abuse, and PTSD were checked. Section II showed, Question #5: Does the individual have a primary diagnosis of Dementia? The response was checked Yes. Section II: Other Indications for PASRR Screen Decision-Making also showed, A Level II PASRR evaluation must be completed if the individual has a primary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator. The facility did not complete a Level II PASRR screen for Resident #48. 2. A review of Resident #29's Admission Record showed an admitted [DATE] with diagnoses of paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, and PTSD. A diagnosis of major depressive disorder was added on 8/15/2024. A review of Resident #29's Level I PASRR screen completed on 1/20/2025 showed in Section A. Mental Illness (MI) or suspected MI, depressive disorder, schizophrenia, and unspecified psychosis not due to a substance or known physiological condition and PTSD, checked. A review of Resident #29's most recent psychiatric progress note with a service date of 2/27/2025 showed the rationale behind diagnoses for schizophrenia as, the history of this patient shows that the patient has chronic inconsistent psychosis. These symptoms cause significant distress and functional impairment to the patient. The patient has had a history of psychosis for more than one month, causing emotional and behavioral disturbance for six months or more. A Level II PASRR screen was not completed for Resident #29 for his severe chronic serious mental illness of schizophrenia. 48223 3. Review of Resident #6's Admission Record showed an admitted [DATE] with a diagnosis of PTSD. Diagnoses of dissociative identity disorder and borderline personality disorder were added on 6/25/2024 and a diagnosis of major depressive disorder was added on 10/16/2024. Review of Resident #6's Level I PASRR screen completed on 11/13/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, question 2. C. Adaption to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system, was checked no. Review of Resident #6's Psychology Subsequent Note dated 3/5/2025 revealed under Assessments and Plan, Resident #6 had a treatment objective to learn to adjust to living in the facility by building resiliency skills and engaging in enjoyable activities. Review of Resident #6's record did not reveal a Level II PASRR screen. 4. Review of Resident #13's Admission Record showed an admitted [DATE]. Diagnoses included bipolar disorder and major depressive disorder, added 8/15/2024; and dementia, added 2/4/2022. Review of Resident #13's Level I PASRR screen completed on 11/9/2024 showed in Section A. Mental Illness (MI) or suspected MI, bipolar disorder, depressive disorder, and unspecified dementia, unspecified severity, were checked. Section II showed, Question #5: Does the individual have a primary diagnosis of Dementia? The response was checked Yes. Section II: Other Indications for PASRR Screen Decision-Making also showed, A Level II PASRR evaluation must be completed if the individual has a primary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator. The facility did not complete a Level II PASRR screen for Resident #13. 5. Review of Resident #2's Admission Record showed an admitted [DATE]. Diagnoses included anxiety disorder, added 11/21/2024; major depressive disorder, added 10/16/2024; and schizoaffective disorder, added 9/9/2021. Review of Resident #2's Level I PASRR screen completed on 11/9/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, question 2. C. Adaption to change: The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system, was checked no. Review of Resident #6's Psychology Subsequent Note dated 2/26/2025 revealed Resident #2 has been being seen for major depressive disorder, with a follow up scheduled for the following week due to the resident not feeling well. Review of Resident #2's record did not reveal a Level II PASRR screen. During an interview on 3/26/2025 at 1:14 PM, the Social Services Director (SSD) and the Director of Nursing (DON) confirmed being responsible for completing the PASRR screens. The SSD and DON confirmed according to the directions on the Decision-Making Screen, a Level II PASRR evaluation is needed if the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. The SSD and DON continued to state they have never really thought of the questions being indicated for them to complete, and confirmed, in reading the questions in Section II, they should be completing the questions if the residents are being treated or have the characteristics on a continuing or intermittent basis. The SSD and DON confirmed in the examples above the sections should have been marked yes and then a Level II evaluation would have been indicated. Review of the facility's policy and procedures titled Preadmission Screening and Resident Review (PASRR) with a revision date of March 2019 showed: Policy Statement: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. Policy Interpretation and Implementation: 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The hospital or facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level Il (evaluation and determination) screening process. (1) The social worker or designee is responsible for making referrals to the appropriate state designated authority. c. Upon completion of the Level Il evaluation, the state PASARR representative determines if the individual has a physical or men I condition, what specialized or rehabilitative services he or she needs, and whether placement in facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified.

Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment in two resident rooms (#201 and #214) of 32 rooms in the facility. Findings included: During an observation and interview on 3/24/25 at 10:45 AM and 3/26/25 at 12:15 PM, in room [ROOM NUMBER], the resident stated the dark brown armoire's drawer is broken and will not open. The resident who resided in the room stated the furniture has not worked for a while and would like to be able to use the space. The face of the top drawer of the dark brown armoire was observed separated from the rest of the drawer on the left side facing the drawer. During an observation and interview on 3/24/25 at 11:00 AM and 3/26/205 at 9:00 AM, in room [ROOM NUMBER], the toilet base was not secured to the floor. Both residents of the room stated they utilized the toilet. During an interview on 3/25/25 at 10:45 AM, Staff D, Certified Nursing Assistant (CNA), stated both residents in room [ROOM NUMBER] utilized the bathroom with assistance. If the staff noticed anything in need of repair a work order should be placed in the facility electronic work order system. During an observation and interview on 3/26/25 at 9:15 AM, the Housekeeping Director (HD) stated housekeeping cleans the bathrooms daily. If the housekeeping staff notices anything in need of repair, the housekeeping staff would let them know, as the housekeeping staff do not have access to the facility electronic work order system. The HD stated being responsible for relaying the information to the Maintenance Director (MD) of the area of concern. The HD observed the toilet in room [ROOM NUMBER] and stated, oh yeah, that needs to be fixed. During an observation and interview at 3/26/25 at 9:30 AM, the MD confirmed not having a work order for room [ROOM NUMBER]. Upon entering the bathroom of room [ROOM NUMBER], the MD stated the toilet is not affixed to the floor and would need to be corrected. During an observation and interview at 3/26/25 at 12:26 PM, the MD confirmed not having any work orders for room [ROOM NUMBER]. Upon observation of the armoire in room [ROOM NUMBER], the MD confirmed it was in need of repair. A facility policy for Building/Equipment Maintenance was requested on 3/25/25 and 3/26/25, but no policy was provided by the facility. Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to develop an individualized plan of care to include goals and interventions for two residents (#11 and #9) of forty two residents sampled. Findings included: 1. On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review of Resident #11's psychiatry notes, dated [DATE], [DATE], and [DATE], revealed the following, . History of Present Illness: This is a [AGE] years old patient with a past psychiatric history of depression, anxiety, dementia, insomnia and PTSD. PTSD (Post Traumatic Stress Disorder): The history suggests that this patient suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. These symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one months and have occurred without any substance abuse or organic brain pathology . Care Plan for PTSD diagnosis: Trauma: history of abuse from father (Both physical and sexual) as a child. Further review of psychiatry notes, dated [DATE], revealed the following, . PTSD Section: Twin died , mistreated by family (provided by facility) No triggers noted. Due to cognitive impairments associated with dementia the patient is unable to elaborate on current symptoms or provide detailed history. However, staff and caregivers report no observable PTSD symptoms, such as nightmares, hypervigilance, flashbacks, or avoidance behaviors. Care Plan for PTSD diagnosis: Trauma: history of abuse from father (Both physical and sexual) as a child. Triggers: Approach . Corrected/Confirmed Diagnosis: Added PTSD dx [diagnosis] and care plan in the chart: As pt [patient] has active symptoms of PTSD such as flashbacks, nightmares, hypervigilance, causing distress, I added PTSD dx. The trauma is Twin died , mistreated by family (provided by facility). The current triggers are not reported. A review of Resident #11's care plan, revised on [DATE], revealed the following: [Resident name] has risk or actual diagnosis of PTSD and has potential for re-traumatization R/T [related to] Childhood trauma: twin died , felt unloved by family. A review of goals revealed the following, Resident will remain free from episodes of re-traumatization AEB [as evidenced by]: (personalize) through the next review. Revision on: [DATE]. Target Date: [DATE]. Resident will remain free from episodes of re-traumatization AEB no flashbacks or upsetting dreams through the next review Target Date: [DATE], Resident will have minimal triggers of re-traumatization thru the next review. Target Date: [DATE], Resident will have minimal negative changes in thinking and mood through the next review Target Date: [DATE]. A review of interventions include the following, . Establish a relationship of trust with the resident, Date Initiated: [DATE], Created on: [DATE], . Provide calming and reassuring environment, Date Initiated: [DATE], Created on: [DATE], . Use calm approach. Explain action during cares. Date Initiated: [DATE], Created on: [DATE], . Avoid positioning yourself between the resident and the door Date Initiated: [DATE], Created on: [DATE] ., Provide female caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE]. Provide male caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE] . On [DATE] at 9:18 a.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA) who stated she looked at the care card to view a resident's diagnoses. Staff C, CNA stated she would go into the resident's electronic medical record or speak with the nurse to determine what their needs are. She stated she's not sure where to view in their chart how to approach a resident related to triggers for someone diagnosed with PTSD. She stated she thinks the care card or Kardex would have that. She stated, The care card tells you everything about the resident. Staff C, CNA confirmed she hasn't had training or education related to PTSD. Regarding Resident #11, she stated she worked with the resident often. Staff C, CNA stated she didn't know the resident had PTSD and could not identify her triggers. On [DATE] at 9:56 a.m., an interview was conducted with the Social Services Director (SSD). He stated for residents with PTSD they, Determine the root cause and psych follows them. He stated for the diagnosis of PTSD, there is a care plan in place. The SSD stated the care plan included how to approach the person, their environment, avoid putting yourself in front of them and between the door, medication management as needed, observing for changes in behaviors, and psychiatry/psychology (psych) services as needed. He stated for sexual abuse or assault they determine if the resident feels comfortable with a male or female staff. The SSD stated the care plan, Has prefilled boxes to check off, however, they could be filled in. He stated he hasn't had to put individualized triggers for any PTSD care plans. Regarding Resident #11, the SSD stated he knows the resident has PTSD. He stated the resident told him her trauma stemmed from the loss of her twin, and she felt her family didn't love her. He stated he reviewed Resident #11's psych notes and confirmed the psych provider attended monthly interdisciplinary team meetings. The SSD stated he printed and looked at every psych note. He confirmed he had not seen the psych notes which included documentation related to physical and sexual abuse. The SSD confirmed Resident #11's care plan should include interventions related to approach and determining her preferences for care. 48223 2. Review of the Admission Record for Resident #9 revealed an admitted [DATE] and a readmission on [DATE] with diagnoses to include hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease; end stage renal disease (ESRD); and dependence on renal dialysis. Review of the Minimum Data Set (MDS) from admitted d [DATE] revealed Resident #9 was on hemodialysis. Review of Resident #9's Order Summary Report dated [DATE] revealed the following orders: - [DATE]: Check dialysis access site for signs of infection (warmth, redness, tenderness or edema) when performing routine care at regular intervals every shift - [DATE]: Dialysis center to maintain dressing changes to dialysis access site. - [DATE]: If there is major bleeding from the access site, apply pressure to insertion site, contact emergency services and dialysis center period verify any clamps are closed on lumens if not an AV shunt. This is a medical emergency. Do not leave the resident alone until EMS (Emergency Medical Services) arrives. As needed for major bleeding. - [DATE]: Mild bleeding from the access site (post dialysis) can't be expected. For mild bleeding, reinforce pressure dressing. Contact the dialysis center or physician for further instructions. As needed for mild bleeding. - [DATE]: Remove pressure dressing after return from dialysis (enter dialysis days Monday Wednesday and Friday) per dialysis orders. In the evening every Monday, Wednesday, Friday. - [DATE]: Dialysis access site: (Left Upper Arm). Type of Access: Fistula. every shift - [DATE]: Dialysis Monday, Wednesday, Fridays; Pick up time: 11:30 am Center Address [listed address, phone, transportation company] every day shift every Monday, Wednesday, Friday. - [DATE]: Do not use the dialysis access site arm to take blood pressure, blood sample, administer IV (intravenous) fluids, or give injections. Left arm, every shift. - [DATE]: Palpate the dialysis fistula access site to feel the Thrill use stethoscope to hear the Bruit of blood flow through the access site. Left upper arm, every shift for fistula monitoring left upper arm. Review of Resident #9's care plan revealed a Focus area, Resident has potential for complications related to hemodialysis for treatment of ESRD. Shunt site is located: (Specify shunt location), Receives dialysis on: (Mon., Wed., Fri), Receives dialysis at: (insert dialysis center name, address, phone number), Date Initiated: [DATE], Revision on: [DATE]. Goal showed: Resident will remain free from avoidable complications related to hemodialysis thru the next review date. Target Date: [DATE]. During an interview on [DATE] at 11:45 a.m. the Minimum Data Set (MDS) Coordinator confirmed being responsible for updating and completing the care plans. The MDS Coordinator reviewed Resident #9's care plan for dialysis and stated I must have missed updating the information. The information should be updated and individualized as needed. During an interview on [DATE] at 9:28 a.m., the Director of Nursing (DON) stated in general staff are educated to, Look for behaviors and report behaviors to the nurse, the nurse reports to the doctor, and CNAs are educated on a, Need to know basis and it wouldn't be appropriate for them to go through diagnoses for each resident. The DON stated she was unaware of Resident 11's triggers but knew Resident #11 had PTSD. The DON confirmed PTSD triggers should be on the care plan and knowing the resident's and their triggers would assist the staff in knowing how to approach individuals. The DON confirmed care plans should be individualized and updated as needed. Review of the facility's policies and procedures dated revised [DATE] and titled Care Plans, Comprehensive Person-Centered revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas/conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 11. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. .

Based on observations, record review, and interviews, the facility failed to identify specific triggers related to post traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for one resident (#11) of one residents reviewed for PTSD. Findings included: On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review of Resident #11's care plan, revised on [DATE], revealed the following: [Resident name] has risk or actual diagnosis of PTSD and has potential for re-traumatization R/T [related to] Childhood trauma: twin died , felt unloved by family. A review of goals revealed the following, Resident will remain free from episodes of re-traumatization AEB [as evidenced by]: (personalize) through the next review. Revision on: [DATE]. Target Date: [DATE]. Resident will remain free from episodes of re-traumatization AEB no flashbacks or upsetting dreams through the next review Target Date: [DATE], Resident will have minimal triggers of re-traumatization thru the next review. Target Date: [DATE], Resident will have minimal negative changes in thinking and mood through the next review Target Date: [DATE]. A review of interventions include the following, . Establish a relationship of trust with the resident, Date Initiated: [DATE], Created on: [DATE], . Provide calming and reassuring environment, Date Initiated: [DATE], Created on: [DATE], . Use calm approach. Explain action during cares. Date Initiated: [DATE], Created on: [DATE], . Avoid positioning yourself between the resident and the door Date Initiated: [DATE], Created on: [DATE] ., Provide female caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE]. Provide male caregivers ONLY to assist with cares per resident/responsible party preference. Date Initiated: [DATE], Created on: [DATE] . On [DATE] at 9:18 a.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA) who stated she looked at the care card to view a resident's diagnoses. Staff C, CNA stated she would go into the resident's electronic medical record or speak with the nurse to determine what their needs are. She stated she's not sure where to view in their chart how to approach a resident related to triggers for someone diagnosed with PTSD. She stated she thinks the care card or Kardex would have that. She stated, The care card tells you everything about the resident. Staff C, CNA confirmed she hasn't had training or education related to PTSD. Regarding Resident #11, she stated she worked with the resident often. Staff C, CNA stated she didn't know the resident had PTSD and could not identify her triggers. On [DATE] at 9:28 a.m., an interview with the Director of Nursing (DON) revealed staff are educated, To look for behaviors. She stated she expected CNAs to report behaviors to the nurse, then the nurse would report to the provider. She stated CNAs are educated on a, Need to know basis. The DON stated it wouldn't be appropriate to specify diagnoses to staff for each resident. She stated if a resident was displaying behaviors, she'd tell staff to, Watch for certain behaviors and keep them on enhanced monitoring. The DON stated she doesn't know about Resident #11's triggers. She stated she knows the resident has PTSD. The DON stated she knows Resident #11's PTSD comes from, Military. The DON confirmed PTSD triggers should be on the care plan as she expected nurses to look there. She stated staff, Learn the residents and their triggers to identify how to approach. She stated Resident #11 doesn't have behaviors or outbursts, Only if she had a UTI [urinary tract infection]. The DON stated staff are provided general education about behaviors and behaviors being charted. On [DATE] at 9:56 a.m., an interview was conducted with the Social Services Director (SSD). He stated for residents with PTSD they, Determine the root cause and psych follows them. He stated for the diagnosis of PTSD, there is a care plan in place. The SSD stated the care plan included how to approach the person, their environment, avoid putting yourself in front of them and between the door, medication management as needed, observing for changes in behaviors, and psychiatry/psychology (psych) services as needed. He stated for sexual abuse or assault they determine if the resident feels comfortable with a male or female staff. The SSD stated the care plan, Has prefilled boxes to check off, however, they could be filled in. He stated he hasn't had to put individualized triggers for any PTSD care plans. Regarding Resident #11, the SSD stated he knows the resident has PTSD. He stated the resident told him her trauma stemmed from the loss of her twin, and she felt her family didn't love her. He stated he reviewed Resident #11's psych notes and confirmed the psych provider attended monthly interdisciplinary team meetings. The SSD stated he printed and looked at every psych note. He confirmed he had not seen the psych notes which included documentation related to physical and sexual abuse. The SSD confirmed Resident #11's care plan should include interventions related to approach and determining her preferences for care. A review of the facility's policy titled Trauma Informed Care revised [DATE] revealed the following: Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Preparation: 1. All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting . General Guidelines: . 2. Trauma-informed care is culturally sensitive and person-centered. 3. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers .

Based on observations, interviews, and record review the facility failed to ensure measures were in place related to elopement prevention for two (Residents #2 and #3) out of three residents sampled for elopement. Resident #2 eloped unwitnessed from the facility and protocols were not followed after the resident was found and returned. Elopement risk assessments were not completed at required intervals for Resident #3. Findings included: 1. A review of the facility incident log for February 2023 through 04/03/23 revealed one elopement incident: Resident #2 eloped on 03/28/23. Review of facility census for 04/03/23 revealed Resident #2 was residing in the facility on the West wing. Resident #2 was observed on 04/03/23 at 10:18 a.m. She was seated in a wheelchair on the West wing in front of the nurse's station. She appeared alert and calm. She was engageable but confused, oriented to self. She was not able to provide any information about eloping from the facility. There was an elopement alarm bracelet on her right ankle. An interview was conducted with Staff A, Registered Nurse (RN) on 04/03/23 at 10:47 a.m. She confirmed Resident #2 had gotten out of the facility but stated she would not consider it an elopement because a Certified Nursing Assistant (CNA) saw her outside. Regarding when this occurred, Staff A responded it had been the week prior. She stated on that day, one of the CNAs was looking out of a resident room window, saw Resident #2 sitting outside, and then they (2 CNAs) went and brought her back inside. Staff A identified the CNAs as Staff D and Staff E. Staff A was not certain of the date the elopement occurred, but said the time was between 3:25 p.m. and 3:40 p.m. She stated she had been Resident #2's nurse for the 7 a.m. - 3 p.m. shift that day, and Staff B, RN was assigned for the 3 p.m. to 11 p.m. shift. Staff A stated she informed Staff B Resident #2 had gotten out of the facility and was back inside before leaving for the day. She confirmed she was not involved in the event any further. Regarding how Resident #2 exited the facility, Staff A reported she thought she went out the front door but wasn't sure. Staff A stated, around that time we had paramedics coming in (the front door) for something else and I think in the commotion she went out. Staff A reported Resident #2 had not been known to be exit seeking. She confirmed Resident #2 had cognitive impairments and was alert with confusion. An interview was conducted with Staff C, Receptionist on 04/03/23 at 10:35 a.m. She confirmed she worked at the front desk in the facility lobby at the front door Monday - Friday, 8 a.m. - 5 p.m. She reported the front door was always locked and confirmed she was responsible for monitoring and opening the door and for getting coverage if she needed to leave the area. She reported when the door was locked it could not be opened unless a code was entered in the keypad next to the door or unless she opened it using an activation switch behind the front desk. She confirmed there were elopement alarm sensors at the door and the right panel of the door was an egress panel and would open and alarm after 15 seconds of pushing on it. Staff C confirmed Resident #2 had gotten out of the building the previous week, she could not be certain of the date but reported the time was between 3 p.m. and 3:30 p.m. She stated, I personally do not know which door she got out of, I just know she was found up here outside, she was trying to get out in the street, it was shift change. Staff C confirmed she was working at the front desk when Resident #2 eloped and stated she did not observe the resident in the lobby area or exiting the front door during that time. She stated facility CNAs brought the resident back inside and she heard from them she was found out front near the street. She reported Resident #2 did not have an elopement alarm bracelet at that time. Staff C confirmed she was familiar with Resident #2 and said, she is more on the confused side, she wheels herself around, she is pretty fast. Staff C reported during the time Resident #2 eloped, Emergency Medical Services (EMS) had come to the facility and there was commotion in front of the building and in the front door/lobby area while they entered with their equipment. A telephone interview was conducted with Staff D, CNA on 04/03/23 at 12:54 p.m. She confirmed Resident #2 had eloped from the facility the previous week, was not certain what date, but stated it happened between 3 p.m. and 4 p.m. Staff D reported she was not assigned care of Resident #2 when she eloped but she was in room [ROOM NUMBER] caring for another resident and looked out the window and saw Resident #2 sitting in her wheelchair outside in front of the facility, right there at the end of the pavement, she was just sitting there. Staff D said, when I saw her, I ran up out the room and yelled out that she was outside, so me and (Staff E, CNA) went outside to get her. Staff D reported Resident #2 was willing to come back inside. She stated she had never seen her exit seek and did not know of any other time she had left the building. Staff D reported Resident #2 did not have an elopement alarm bracelet when she eloped. Staff D reported Resident #2 was not in distress and was not injured when they got to her and brought her inside. She stated when they got her inside, she took Resident #2 to the nurse (Staff A, RN) and that was the end of her involvement. A telephone interview was conducted with Staff E, CNA on 04/03/23 at 1:11 p.m. She confirmed she was involved in bringing Resident #2 back inside the facility after she was seen outside by Staff D, CNA. She reported the elopement occurred on 03/28/23. She reported she had been working on East wing that day 7 a.m. - 3 p.m. and was clocking out at the time clock in the lobby at 3:35 p.m. when Staff D exited room [ROOM NUMBER] and reported Resident #2 had gotten out. Staff E said, I went to the front door and it was a little chaotic because a paramedic was coming in at that time, I stepped out the door to the right and saw (Resident #2) right by the driveway so I ran down, she had her brakes locked, she was right by the end of the driveway, she was just sitting there looking around, she asked me what I was doing and I told her I was there to take her back inside, she hesitated a little bit with me, she was a little agitated because she wasn't understanding what I was doing, she was dressed and had sneakers on, I brought her in the front door but the front by West (unit) was a little chaotic because of paramedics and fire department there so I brought her to the dining room where it was calmer, there were two other staff in the area plus another resident, I left then for the day. Staff E reported because she worked on the East wing, she had never been assigned to care for Resident #2, but she knew her from the dining room and being in the facility. Staff E said, I had seen her (Resident #2) sitting by the font door during the day right around the receptionist, never seen her push on the door, just sitting there looking around. Regarding which door Resident #2 exited on 03/28/23, she said I am assuming had to be the front door and reported when she (Staff E) was in the lobby clocking out, the receptionist was at the desk, the phone was going off a lot, if somebody entered the code to leave the building (open the front door) it is possible a resident could go out if the receptionist were having to attend to something else. A telephone interview was conducted with Staff B, RN, on 04/03/23 at 2:10 p.m. She confirmed she was assigned care of Resident #2 on 03/28/23 for the 3 p.m. to 11 p.m. shift. She confirmed she was aware that Resident #2 had gotten out of the building that day because when she was going down the hallway with her cart, Staff A, RN came to her and told her Resident #2 was outside. Staff B stated the conversation with staff A had to have been around 3:00 p.m. Staff B said, I guess (Staff A) had told the CNA to get her and she was then put in the dining room. Staff B said, I went down to the dining room, I assessed her, she seemed to be fine. Regarding whether she documented that assessment or took any other actions, Staff B stated she did not remember if she documented and said that day had quite a few things going on. Staff B sated she did not know anything about a facility protocol for actions a nurse was supposed to take post-elopement and said, I was not aware I was supposed to do anything, I thought responsibility was day shift and I did not think I was supposed to do anything additional; I just did her regular care for the shift. Staff B reported she did not contact Resident #2's responsible party about the elopement. Staff F reported she was not aware of any safety checks with Resident #2 after the incident and was not aware of any orders for an elopement alarm bracelet. Staff B said, she (Resident #2) was fine for the shift, not exit seeking at all. Review of Resident #2's medical record was conducted. The admission record revealed she was [AGE] years old, admitted to facility on 08/05/22 with diagnoses that included dementia. A family member was listed as the resident's responsible party. The most recent completed Minimum Data Set (MDS) assessment dated [DATE] was reviewed: section C revealed a Brief Interview for Mental Status (BIMS) score of 5 which meant the resident had severe cognitive impairment, section E revealed no wandering behavior, section G revealed Resident #2 required extensive physical assistance for transfers and locomotion on and off of the unit and was dependent on wheelchair for mobility, section P revealed no use of wander/elopement alarm. The most recent elopement risk evaluation prior to the elopement event was dated 03/13/23 and revealed a score of 2 which meant the resident was not at risk for elopement. The next elopement risk evaluation was dated 03/29/23 and revealed a score of 11 which meant the resident was at risk for elopement, and interventions documented for prevention included, Place picture in elopement book. Apply wanderguard, if facility has system available. Documentation on the evaluation revealed physician orders had been requested, family/responsible party had been notified per facility policy, and the care plan had been reviewed and updated. Physician orders revealed order for wanderguard (elopement alarm bracelet), start date/time 03/29/23 3:52 p.m.: Wanderguard - check placement and function q (every) shift for elopement risk. Review of the Treatment Administration Record (TAR) revealed initial documentation of wanderguard in place was evening shift on 03/29/23. Review of progress notes revealed no entries related to elopement on 03/28/23. The first note that made mention of the elopement had date and time of 03/29/23 1:40 p.m.: The IDT (interdisciplinary team) met to discuss the following care areas: Falls, Elopement. Elopement score indicates RISK FOR ELOPEMENT. Wanderguard orders are in place. Elopement book updated. Care plan/Kardex updated . A late entry progress note titled Administrative Note effective date/time 03/29/23 08:45 a.m. written by the facility Administrator (NHA) documented, On 03/28/23 at approximately 8:45am, this writer received a message to call [Resident #2's] grandson, [name], upon arriving to the facility related to resident 'getting out'. Writer called [grandson name] immediately and explained the facility was investigating. When this writer had more information she would call him back. Writer stated that the resident was in the building and safe . An encounter note was documented by Resident #2's primary care physician (PCP), date/time of visit 03/29/23 1:00 p.m., and documented, Nursing staff asking to see patient today because she seems to be not herself. Patient is more confused .Per nursing staff patient wandered off facility. I do not know details at this time. Facility staff is investigating. Will order wanderguard. No behavioral problems. Patient is very pleasant and cooperative as always. A document titled PRN (as needed) Skin Check dated 03/29/23 revealed no new skin impairments. Resident #2's care plan revealed a focus area for elopement risk initiated 03/29/23, [Resident #2] has a potential for elopement due to: is exit seeking, wanders the unit & wanders near exit doors. Interventions in the care plan included, perform frequent observation of residents whereabouts every shift, provide redirection when observed going towards exit doors, apply wanderguard as ordered, include resident in elopement book, update physician and responsible party if resident elopes. A telephone interview was conducted with Resident #2's PCP on 04/04/23 at 11:35 a.m. The PCP confirmed she was also the Medical Director for the facility. She confirmed she was aware that Resident #2 had eloped from the facility. She reported she was informed about the elopement in the morning on 03/29/23 and said, when I came to the facility on Wednesday morning (03/29/23) I was told about it briefly, was one of the nurses who came to me, and she briefly mentioned what happened. The PCP reported after receiving that information from the nurse she went and assessed Resident #2. The PCP stated that she knew Resident #2 very well said, she does have dementia so the only thing that is reliable is what's happening in the moment, not 20 minutes ago. She confirmed Resident #2 was vulnerable because of her cognitive impairments. The PCP stated she verbally told the nurse (Staff A, RN) to put an elopement alarm bracelet on Resident #2 and also spoke to the facility Director of Nursing (DON) about getting an elopement alarm bracelet in place. Regarding whether actions taken in response to Resident #2's elopement met her expectations she responded, we should have known/been notified earlier, we should have known about it the moment it happened, that is typically the expectation. A telephone interview was conducted with Resident #2's grandson on 04/04/23 at 2:09 p.m. He confirmed he was the designated responsible party for the resident. He reported he was informed of the elopement the day after it occurred and stated the NHA contacted him on 03/29/23 and told him she didn't know about it until she had arrived for work at the facility on the morning of 03/29/23. He reported he asked the NHA about their procedure and that she told him they didn't do anything. He said, my biggest thing is that she was able to get out and she would have gotten hit by a car, that made me really angry, she has dementia. An interview was conducted with the NHA, DON and corporate Regional Nurse Consultant (RNC) on 04/03/23 at 2:32 p.m. They confirmed Resident #2 had eloped from the facility on 03/28/23 and reported their investigation had narrowed down the time of elopement (time from exit to return) to between 3:30 p.m. and 3:35 p.m. They reported their timeframe had come from staff statements and from EMS company reports: Resident #2's CNA, Staff G, reported she saw the resident seated on West wing in front of the nurse's station at 3:00 p.m. and then she clocked out for the day at 3:13 p.m. at the time clock in the lobby near the front door; a nurse working 7 am. to 3 p.m. shift on West wing clocked out at time clock in the lobby at 3:23 p.m. and did not see Resident #2 in the lobby or outside at that time; the EMS company was called by the facility at 3:24 p.m., they arrived and were entering the front door at 3:30 p.m.; Staff E, CNA was at the time clock in the lobby clocking out at 3:35 p.m. when she was notified by Staff D, CNA that Resident #2 was outside, she immediately ran outside and brought the resident back in. The reported Resident #2 was seated in her wheelchair at the street level in front of the facility at the end of the driveway. They stated her brakes were on and she was just sitting there watching what was going on. They reported Resident #2 had not been known to exit seek before. The NHA reported that it was usual for Resident #2 to sit in front of the nurse's station on West wing and said, she can propel herself with her wheelchair so there are times she will make her way and sit by the tree in the lobby but she does not try to go out the door, it is unusual to see her anywhere besides between the nurse's station and the lobby. The NHA confirmed Resident #2 had cognitive impairments and was confused and her baseline was alert and oriented to self. Regarding which door Resident #2 exited, they reported nobody had witnessed her leaving any door and the facility did not have a camera system. Based on lack of any witnesses, they used the location where she was found to narrow the most likely possibilities down to the front door or an exit door near room [ROOM NUMBER] on West wing. They reported they ruled out the exit door near room [ROOM NUMBER] because it was maintained locked with a code required for opening, and alarmed when opened, additionally there were gates to get through outside that door and the terrain was somewhat rough and difficult to navigate in a wheelchair and they did not feel Resident #2 would have been capable of navigating all those obstacles. They confirmed Staff C, Receptionist, was working at the front desk during the time Resident #2 eloped and her statement was that she did not see the resident in the lobby during that time but there was a lot of commotion in the area due to EMS arrival and entry with their personnel and equipment, the door was opened by Staff C for EMS to enter. The NHA confirmed the facility began investigating and reporting the incident as soon as she was made aware of it on 03/29/23. Regarding the delay in reporting and response, the NHA confirmed nobody reported it to her until 03/29/23. The NHA stated Staff B, RN should have notified the NHA and the DON, the PCP, and the family immediately on 03/28/23 and should have performed and documented a head-to-toe assessment including skin assessment, an elopement risk evaluation, and should have put in orders for an elopement alarm bracelet. The NHA confirmed none of these actions were done on 03/28/23. The NHA stated she herself was in the building at the time of Resident #2's elopement. Regarding how she hadn't been made aware of the incident despite being there on-site she responded, great question . there was a lot of commotion at that time, change of shift, EMS in the building, staff thinking they should go to their immediate supervisor instead of reporting to me. The NHA confirmed she was made aware of the elopement incident at 8:45 a.m. on 03/29/23 and she immediately began all response procedures including contacting Resident #2's family, reporting the incident, beginning investigation, and getting elopement alarm bracelet in place for Resident #2. Regarding whether any supervision measures were put in place for Resident #2 immediately after the elopement, the RNC reported hourly checks were done and revealed documentation which showed hourly checks documented beginning on 03/29/23 at 5:00 p.m. Review of facility policy titled, Wandering and Elopements, revision date March 2019 revealed: 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. 4. When the resident returns to the facility, the Director of nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file and incident report; and f. Document relevant information in the resident's medical record. 39438 2. On 04/03/23 at 10:45 a.m., Resident #3 was observed in the hallway sitting in her wheelchair asking another resident to take off her wanderguard. The wanderguard was observed on her left wrist. On 04/03/23 at 1:30 p.m., the resident was observed sitting in her wheelchair near the main entrance pushing on the door handle. The receptionist attempted to redirect the resident, but she continued to hold the door handle down. The receptionist called the nurse over to assist her to remove the resident from the entry way. On 04/04/23 at 4:50 p.m., Resident #3 was observed sitting in her wheelchair near the main entrance pushing on the door handle. Staff was able to redirect the resident. The Admission Record revealed Resident #3 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to post traumatic stress disorder, generalized anxiety disorder, bipolar disorder, unspecified psychosis not due to substance or known physiological condition, and vascular dementia. Section C Cognitive Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 indicating severe impairment. A review of the Order Summary Report with active orders as of 04/05/23 revealed the following orders: (03/30/22) Wanderguard every shift for poor safety awareness. Check function. (03/30/22) Wanderguard every shift. Check for placement. The Quarterly Nursing Comprehensive Evaluation dated 06/28/22 revealed Resident #3 had an elopement score of 2 indicating she was not at risk for elopement. The next elopement assessment was not completed until 03/30/23. The assessment indicated the resident was actively exit seeking. Resident #3 had an elopement risk score of 14 indicating at risk for elopement. A wanderguard was applied and the resident was added to the elopement book on all units and front door. On 04/04/23 at 4:39 p.m., the corporate Regional Nurse Consultant (RNC) reported she completed the elopement risk assessment on 03/30/23 because she saw the resident wander through the facility touching doors, hanging around the front door, and pushing on the handle on the door. She confirmed that prior to 03/30/23, the last elopement risk assessment was completed on 06/28/22. On 04/05/23 at 9:47 a.m., the RNC stated the elopement assessments should be completed quarterly. She stated there was a problem in Point Click Care because they should automatically populate. There was a glitch, but it was fixed towards the end of March. The Director of Clinical Services stated the elopement risk assessment should be completed at admission and every ninety days.

Based on observations, interviews, and policy reviews, the facility failed to properly store and secure medications in two of three medication carts, one medication stock room, one of three medication refrigerators, and for one (Resident #208) of one resident reviewed. Findings include: An observation was made on 1/4/23 at 4:11 p.m. of an unlocked medication cart on the West Back Unit. Two nurses were standing five feet away from the medication cart. At 4:15 p.m. both nurses had walked out of the hall and the cart remained unlocked. There were no nurses in sight of the cart and the medication cart was sitting in one of the main resident hallways. After four minutes had passed, a nurse on the opposite hall asked if there was a problem. She was notified the medication cart was unlocked. She stated she would call the nurse who was using the cart. At 4:20 p.m., Staff Q, Licensed Practical Nurse (LPN) walked to the unlocked medication cart. Staff Q stated she walked away from the cart because she had to go put orders in the computer. She said she is new to Long-Term Care and still trying to figure things out. She said she had worked in the facility for over a year. She confirmed she had training and knew she should lock the medication cart when not using it. (Photographic evidence obtained.) On 1/5/23 at 9:00 a.m. an audit was completed of the East Medication Storage room with the Director of Nursing (DON.) The DON stated over-the-counter medication was kept in Central Supply, not in the medication storage room. Central Supply was observed to have a locked, ventilated cabinet with medication inside. A random review of medication revealed 1 bottle of CO Q-10 that expired on 9/22, 2 bottles of Vitamin E 1000 IU that expired on 6/22, 2 bottles of Vitamin E 400 IU that expired on 9/22 and one that expired on 6/22, and 1 bottle of Docusate Calcium that expired on 9/22 and 10 that expired on 12/22. The DON stated the Central Supply Clerk should be checking the medications and cleaning them out every month. She stated there should not be expired medication in the cabinet. The DON mentioned that medications get delivered to the Supply Clerk's office. An interview was conducted with the Regional Nurse Consultant on 1/5/23 at 9:24 a.m. She stated medications should be cleaned out monthly and no expired medications should be in the storage area. On 1/5/23 at 11:30 a.m. a follow-up interview was conducted with the DON. She confirmed medications were delivered and sometimes kept in the Supply Clerk's office. The DON was observed walking in the Supply Clerk's office. The office was located on the East Hall and the door was unlocked. No one was in the office at that time. Two bottles of Sodium Chloride tablets were on the desk, 1 bottle of Vitamin B Complex, 1 bottle of Vitamin E, 1 bottle of Fiber tablets, and 1 bottle of Aspirin were sitting on top of a filing cabinet. A prescription bottle was observed to be sitting on the front of the desk. The bottle contained Humulin R 500 units/ml for Resident #208. The prescription was dated 8/30/21 and the vial of insulin expired 11/22. The DON stated she didn't know why the insulin was in there and stated there should not be any prescription medications in the office. A review of admission records revealed Resident #208 was admitted to the facility on [DATE] and was discharged on [DATE]. A review of orders revealed an order for Humulin R U-500 Solution. Inject 100 units subcutaneously three times a day related to Type II Diabetes Mellitus. Order date 8/30/21. A telephone interview was conducted with the facility's Consultant Pharmacist on 1/5/23 at 12:30 p.m. The pharmacist stated expired medications or medications from discharged residents should be returned to the pharmacy. He stated this was the only facility he had seen that did not keep over-the-counter medication in the medication storage room. He stated he did not audit the supply room but did ensure the medications were locked and sealed. Regarding prescription insulin being in the Supply Clerk's office he stated, prescription medication should not be stored in there at all. On 1/5/23 at 12:45 p.m. the Regional Nurse Consultant was observed entering the Supply Clerk's office. The door was unlocked, no one was in the office, and three residents were sitting within 10 feet of the door. The Regional Consultant confirmed the presence of expired medication in the office. She said she didn't know why it was there and confirmed no prescription medication should be in the office. On 1/5/23 at 12:55 an interview was conducted with Staff R, Supply Clerk. She stated when over-the-counter medication was expired, she put it in her office to remind her to reorder it. She stated she forgot the insulin was on her desk. Staff R confirmed she was not a nurse. She said she had the insulin in her office because it needed a particular needle that she was trying to find. She stated she was having a hard time finding it, then the resident was discharged , and she forgot about it. A facility provided job description for Central Supply Clerk was reviewed. The job description stated the following: Administrative Functions -Organize storage, issue and delivery of supplies and equipment in accordance with established policies and procedures. -Ensure inventory is updated as required, when receiving and issuing supplies and equipment. -Ensure storage instructions are followed. Safety and Sanitation -Maintain supply and storage rooms in a safe, clean, and orderly condition. A facility policy titled Storage of Medications was reviewed. The policy stated the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked area, under proper temperature, light and humidity controls. Only persons authorized to order, store, manage and prepare and administer medications have access to locked medications. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Over the Counter medications or supplies handled by authorized facility personnel are discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy, or source or destroy. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 46973

Based on observations and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment to include one of one main hall through ways (East unit), and one of one main dining rooms, during three of three days observed (1/3/2023, 1/4/2023, and 1/5/2023). Findings included: 1. On 01/03/2023 at 10:00 a.m., the main throughway/hallway in the East 100 hall was observed with a section of flooring in disrepair with raised edges and sunken areas. The floor in disrepair was between resident rooms 104/106 and 103/105. The plastic/vinyl flooring was a different size and color as the original, not matching the rest of the floor, and were not glued down appropriately, causing trip hazards and feet scuffing risks. Observations on 01/03/2023 at 11:10 a.m., revealed an employee scuffed her feet while passing over the floor. She was observed to scuff over the raised sections of the plastic/vinyl flooring. Photographic evidence was taken. 01/03/2023 at 11:45 a.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA were in the main hallway walking toward the nursing station and clipped a raised portion of the floor, almost tripping. An interview with Staff B confirmed she had scuffed her feet on the floor between resident rooms 104/106 and 103/105. She also confirmed the flooring was not even and not glued all the way down. She did not remember how long ago the flooring was changed out and repaired. On 01/04/2023 between 8:15 a.m. and 10:45 a.m., two staff members were observed to scuff and slightly trip over the raised edges of the un-glued plastic/vinyl flooring. On 01/04/2023 at 12:30 p.m., Staff C, CNA was observed carrying a lunch meal tray from the tray cart and then down the 100 hall to resident room [ROOM NUMBER]. As she was walking, she slightly tripped and scuffed her feet, almost losing her footing. She looked down and shook her head and walked to room [ROOM NUMBER] to drop off the lunch tray. When she left the room she was asked about almost falling/tripping. She indicated she was not aware the floor was sticking up and she hit her feet on the edges. On 01/04/2023 at 8:15 a.m., the same floor area was observed with high traffic of both employees and residents. Residents were observed either walking on their own or with a rolling walker or were self propelling while in a wheelchair. There were two observations of various staff members who scuffed their feet on the sinking area of the floor and with parts of the flooring sticking up at the edges. Also, there were staff observed at 12:30 p.m. while passing meal trays in the area, who tripped slightly on the slightly raised corners of the flooring. On 01/05/2023 at 7:43 a.m., Staff A, CNA was observed to scuff her feet on the floor in the areas where it was slightly sunken. She was holding a meal tray and tripped slightly when walking through the area. She confirmed this happened at times but tried to remember the area was not even when walking on it. On 01/05/2023 at 12:40 p.m., an interview with the Maintenance Director and the Nursing Home Administrator (NHA) both revealed about three months ago (approximately 10/2022), the front lobby restroom toilets started to back up and they, along with outside services, worked to correct the problem. The NHA and Maintenance Director both revealed the problem expanded to other resident room bathrooms to include the low 100's. The Maintenance Director said they had an outside service investigate the problem and they suggested to put in vent plates in the main hallway in between resident rooms 103/105. He revealed they put in the vent plates and the problem still existed. The NHA said once the problem persisted, he along with Maintenance Department, tried to do an in house fix with the flooring that would not stay affixed to the ground. He revealed they tried various heavy duty double tapes, and heavy duty vinyl/plastics glue which did not work. He said around 12/29/2022, he received a outside service quote in order to correct the floor problem. The NHA revealed he provided the quote to the facility's corporate office and it was just finally approved as of 1/5/2023, which was during the state annual inspection. The NHA said he had no documentation to support continued monitoring of the floor area in question and that the flooring had been little by little becoming more unsecured to the floor, and causing scuffing and/or trip hazards. 2. On 01/03/2023 at 12:10 p.m., during a lunch meal observation in the main dining room, the room was observed with seven tables, and twelve residents seated at them in preparation for lunch. During the meal observation, there was a long section in the side of the room approximately thirty feet. This section had four sets of double glassed doors. The set of doors on the far left or (East) side of the room, and located near the television, were observed with heavy dust/debris build up on the doors, the plastic shutter blinds, the wall corners, and the windows themselves. Photographic evidence was taken. On 01/05/2023 at 12:45 p.m., an interview with the Housekeeping Director revealed he along with up to three other housekeeping staff were responsible for the general cleaning maintenance of the building to include residents spaces, specifically rooms, bathrooms, dining rooms, etc. The Housekeeping Director revealed the general cleaning of the main dining room was after each meal service which included wiping and sanitizing the tables, sweeping and mopping the entire floor, and cleaning and wiping high touch surfaces to include furniture, and window shutters. He also indicated his staff should be wiping down high touch surfaces as need and in between meal services if need be. The Housekeeping Director confirmed the large amount of dust and debris on the window shutters in the main dining room and indicated that those shutters should have been cleaned more often. On 01/05/2023 at 1:00 p.m. the Director of Nursing provided the Housekeeping Aide job description with a last revisit dated of 01/01/2015. The job description revealed; The primary and purpose of this position is to perform the day-to-day activities of the Environmental/Housekeeping Department in accordance with current, federal, state local standards, guidelines and regulations governing our facility, and may be directed by the Environmental Services Director and/or Administrator, to assure that our Facility is maintained in a clean, safe, and comfortable manner. Duties and Responsibilities include but not limited to: Administrative Functions - Ensure that work and cleaning schedules are followed as closely as practical. Safety and Sanitation - Ensure that assigned work areas are maintained on a clean, safe, comfortable, and attractive manner. - Report all hazardous conditions or equipment to your supervisor. Housekeeping Services - Perform day-to-day housekeeping functions as assigned. - Clean and polish furnishings, fixtures, ledges, room heating or cooling units, etc., in resident rooms, recreational areas, etc. daily as instructed. - Clean windows and mirrors in resident rooms, recreational areas, bathrooms, and entrance or exit ways. - Remove dirt, dust, grease, film, etc. from surfaces using proper cleaning or disinfecting solutions.

Based on observations, record review, and interviews, the facility failed to ensure care planning with problem areas, goals, and interventions was developed for three (Residents #108, #3, and #10), of twenty residents related to contracture management, splint/bracing management, and PTSD/Trauma behavior management. Findings included: 1. On 12/3/2023 at 10:20 p.m. and 1:45 p.m., Resident #108 was observed in his room and seated in a wheelchair next to his bed. The call light was placed within his reach and he was dressed for the day. He appeared pleasant and had no immediate concerns. He was not presenting with any behaviors, pain or discomfort at the time of the visit and agreed to be interviewed. He was observed with a hard plastic splint on his left forearm up to his elbow that was held on with two expanding stretch fabric strips. He indicated he was right handed and had a contracture in his left arm due to a stroke in the past, and used the splint to manage his contracture. He said he put the splint on himself. Staff did not help him with it. The dresser positioned behind him was observed with two other types of arm/hand splints. He could not explain their use and said he used the one he had on. He confirmed the splint was not uncomfortable and took it off when he got uncomfortable. Resident #108 was not sure if staff were still helping him with contracture management to help reduce the risk for further decline of his left arm and hand. He said he was helped by therapy but they were no longer assisting him. On 12/04/2023 at 7:30 a.m., Resident #108 was observed in his room, lying in bed, and with the call light placed on his right side (dominant side and side without contracture). He was awake and not presenting with any behaviors, pain or discomfort. He was observed wearing his left arm splint. He said he would take it off shortly when he got his breakfast. He was asked about the other two splints that were placed on his dresser. He did not know why they were there. He was also not aware if the staff assisted him with the placing on and taking off the splint and did not believe they washed the splint either. At 8:07 a.m., Resident #108 was observed receiving his breakfast meal tray from staff. The staff set up the tray and positioned the plate in a manner where he could easily reach it with his right hand. His left splint/brace was observed lying on the over the bed table. He said the staff did not take off the splint but he was able to do it himself, but with great effort. On 12/04/2023 at 8:27 a.m., an interview was conducted with the Rehab Director, Staff D, related to Resident #108. He said Physical Therapy (PT)/Occupational Therapy (OT) did not currently have the resident on case load and would print out the discharge assessment for both PT/OT related to the resident. The Rehab Director confirmed the resident had developed a contracture on his left elbow and they had him on contracture management. He confirmed direct care staff were responsible for assisting him with his splint/brace daily. However, he believed the resident could don and doff it himself. The Rehab Director was not sure if the resident was care planned with interventions and goals with use of the splint/brace or care planned for contracture management. On 01/04/2023 at 9:24 a.m. an interview with the Minimum Data Set (MDS)/Care Plan Coordinator, Staff E revealed she was aware and knew Resident #108 to include his care and services. Staff E was asked about the resident's splint on the left arm/elbow. She confirmed he utilized the splint as tolerated. She said direct care staff should assist with the splint but the resident also put the device on and took it off himself. She was not sure who monitored his daily use of the splint/brace. She confirmed they had not developed care plan problem areas or care interventions related to the left elbow splint/brace. She confirmed the Care Planning/MDS department to include herself, had just realized there was no care planning for the splint and would make one with problem areas, goals, and interventions. The MDS/Care Plan Coordinator confirmed the resident was not currently on a restorative nursing program for contracture/range of motion management. On 01/04/2023 at 9:30 a.m., an interview with Staff F, Certified Nursing Assistant (CNA) revealed she knew Resident #108 was assigned to him at times. She confirmed he utilized a left arm splint/brace. She confirmed there were no care plan interventions related to the CNAs' responsibility to maintain and clean the splint/brace. She did not know who was responsible for monitoring the brace/splint use, skin issues, or how long he wore it during the shift. Staff F was asked about the other two splints that were placed on the resident's his dresser. She did not know what the splints were for and said they had been in the room over two to three weeks. A review of Resident #108's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed Resident #108 was his own responsible party. A review of the diagnosis sheet revealed diagnoses to include: Cerebral Infarction, Rhabdomyolysis, Dysphagia, Muscle weakness, and Depression. There were no diagnoses listed to include contractures upon his admission. A review of the current Physician's Order Sheet (POS) dated for the month of 1/2023 revealed orders to include but not limited to: 1. Apply splint/brace (Left elbow extension splint), during daytime as tolerated and monitor skin integrity when applying and removing, every day and evening shift, with an order date of 12/19/2022; 2. Apply splint/brace L[eft] WHFO (Wrist, hand, finger orthosis) at night as tolerated, monitor skin integrity when applying and removing, every day and evening shift with an order date of 12/19/2022; 3. May participate in restorative program as needed and tolerated with an order dated of 6/27/2022. Review of the Minimum Data Set (MDS) most recent Quarterly assessment, dated 12/30/22022 revealed, Cognition/Brief Interview Mental Score or BIMS score - 15 of 15, which indicated intact cognition; Activities of Daily Living (ADL) - Bed Mobility at Extensive assistance with one person, Eating at Independent with One person assistance, Personal Hygiene at Extensive assistance with one person assistance; The ADL Functional Limitation Range of Motion section was not checked for limited ROM and indicated no limitation. Review of the Monthly Summary dated 11/06/2022 revealed Needs assistance with Personal Hygiene, Bed Mobility and Independent with Eating. Review of the Monthly Summary dated 12/06/2922 also revealed Needs assistance with Personal Hygiene, Bed Mobility and Independent with Eating. Review of the nurse progress notes dated, revealed: - 10/12/2022 09:52 (9:52 a.m.) - Care area review IDT - Eats independently, Resident is currently on adaptive eating equipment (Divided Plate). Wears a universal cuff to help with meals - 10/18/2022 07:58 (7:58 a.m.) - ITD met. Resident currently on adaptive equipment (divided plate). Wears a universal cuff to help with meals and has limited mobility/contractures. - 10/24/2022 21:18 (9:18 p.m.) MD progress note - Developed weakness in left arm and left leg was admitted to hospital and dx.(diagnosis) Cerebrovascular Accident (CVA). PT also with mild cognitive impairment dx. Encephalopathy. Pt stabilized and admitted to Skilled Nursing Facility (SNF). Continue with functional treatment (tx). CVA with Left side Hemi. Review of the Treatment Administration Record (TAR) dated for the month of 1/2023 revealed: Apply splint/brace (L elbow extension splint) during daytime as tolerated, monitor skin integrity when applying and removing, Every day and evening shift with original order date 12/19/2022. This was initiated as completed each shift. (Signed and initialed each day night and day shift all days in 1/2023). Also, apply splint/brace (L WHFO) at night as tolerated and day and night original order 12/19/2022 and (signed and initialed each day night and day shift days in 1/2023) Review of the 12/2022 TAR revealed the following: - Apply splint/brace (L elbow extension) during daytime as tolerated and monitor skin integrity when applying and removing every day and evening shift. Original order date 12/19/2022. It was documented by nursing each shift that skin was monitored. - Apply splint/brace (L WHFO) at night as tolerated and monitor skin integrity when applying and removing. Every day and evening shift. Original order date 12/19/2022. It was documented each shift the skin was monitored by nursing. A Multi-disciplinary Rehab Screening assessment dated [DATE] revealed - Change in condition to include: Change in ambulation/function mobility status, Change in Active Range of Motion (AROM)/Passive Range of Motion (PROM) or contracture status, Change in ability to feed self. A ROM Functional Limitation screen dated 06/28/2022 revealed - Upper extremity function (SHOULDER) ROM Left checked as Slight Limitation ROM; Right checked as No limitation; Upper extremity function (ELBOW) range of motion (ROM) Left checked as Minimal Limitation ROM; Right checked as No limitation. Comments - Left elbow PROM limited. A ROM/Function limitation screen dated 10/05/2022 revealed - Upper extremities (SHOULDER) ROM Left checked as Minimal Limitation in ROM; Right checked as No limitations (ELBOW) ROM Left checked as Minimal Limitation ROM; Right checked as No limitation A review of the Physical Therapy discharge summary dated 10/05/2022, revealed in the comments summary notes - E-Stim (Electrical muscle stimulation) applied to Left Lower Extremities (LLE) Quads in order to increase ROM, decrease muscle spasms, stimulate innervated muscles to cause a muscular contraction to strengthen and assist in functional activities. Pt and caregiver education on safety precautions and use of assistive devices in order to facility improved functional abilities. A review of the Occupational Therapy discharge summary dated 12/19/2022 revealed in the comments section - Pt will increase Left elbow extension to 120 degrees, will tolerate Left elbow extension splint and L WHFO for 8 hours in order to initiate wear schedule outside of therapy services, and to include: L WHFO 4 hours, Left elbow splint up to 2 hours. Interventions to include Left Upper Extremities (LUE) PROM in preparation for splinting and contracture prevention/management. The Care Planning policy and procedure dated 2001 revealed; Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The implementation section of the policy revealed; 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). #5. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan. The Assistive Devices policy and procedure dated 2001 revealed; Our facility maintains and supervises the use of assistive devices and equipment for residents. The implementation section of the policy revealed; #3. Recommendations for the use of device and equipment are based on the comprehensive assessment and documented in the resident care plan. #6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition - the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. b. Personal fit - the equipment or device is set only according to its intended purpose and is measured to fit the resident's size and weight. c. Device condition - devices and equipment are maintained on schedule and according to manufacturer's instruction. d. Staff practices - staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed. The Resident Mobility and Range of Motion policy and procedure dated 2001 revealed; 1. Residents will not experience an avoidable reduction in range of motion (ROM), 2. Residents with limited Range of Motion will receive treatment and services to increase and/or prevent a further decrease in ROM, 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The implementation section of the policy revealed the following pertinent areas: #4 The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. #5 The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. #6 Interventions include therapies, the provision of necessary equipment, and/or exercise and will be based on professional standards of practice and be consistent with state laws and practices acts. #7 The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. #8 Documentation of the resident's progress towards the goals and objectives will include attempts to address changes or decline I the resident's condition or needs. 47666 2. Evaluation of the electronic medical record (EMR) for Resident #3 revealed she was initially admitted to the facility on [DATE] with diagnoses including, but not limited to post-traumatic stress disorder (PTSD). An interview was conducted with Resident #3 on 01/03/2023 at 9:24 a.m. She was observed sitting in her wheelchair by the nurse's station, dressed for the day and with a blanket covering her lap. Resident #3 had a pleasant demeanor and was without behaviors or signs/symptoms of PTSD. A review of Resident #3's EMR Minimum Data Set (MDS) quarterly assessment dated [DATE] provided that Resident #3 had a brief interview for mental status (BIMS) conducted, with a total score of 15 indicating intact cognition. The MDS for Resident #3 included a patient health questionnaire (PHQ-9) with a total score of 9, indicating mild depression. The MDS for Resident #3 also documented active diagnoses that included PTSD. Behavior documentation was included in the MDS and stated that Resident #3 was without indicators of psychosis, had no behavioral symptoms (physical/verbal/other), and no rejection of care behaviors. Review of a Psychiatric Periodic Evaluation dated 09/15/2022 within Resident #3's EMR provided documentation from the medical provider that Resident #3 asserts that she has been having a lot of good days lately, but she still tends to focus on the negative memories of her past at times. The medical provider also documented that other than reliving the past verbal and emotional abuse issues from her past she has not had any other PTSD sxs [signs/symptoms] such as nightmares or hypervigilance. Review of an OBRA (omnibus budget reconciliation act) Social Service Evaluation dated 12/12/22, stated Resident #3 was followed by psychiatric services on a regular basis for depression and PTSD. Active physician orders for Resident #3 were reviewed in the EMR and included orders for Alprazolam (Xanax) 0.25 mg every 24 hours as needed for anxiety, Alprazolam 1 mg once daily for anxiety, and Guanfacine Hydrochloride (HCl) 2 mg once daily related to hypertension, among other active orders. However, upon review of a Psychiatric Periodic Evaluation dated 12/15/2022, the medical provider indicated in Resident #3's care plan Guanfacine 2 mg P.O. [by mouth] nightly for PTSD. Additionally on that visit, Resident #3 was stated to have a stable mood on her current medication regime, and she had denied any recent PTSD symptoms. Review of active care plans for Resident #3 as of 01/03/2023 provided a care plan with a focus of alteration in thought process related to periods of forgetfulness, age-related cognitive decline, with psych diagnoses of PTSD and bipolar disorder. Active interventions on this care plan included addressing Resident #3 by her preferred name, introducing self when speaking to resident, administering medications as ordered and observing for effectiveness and side effects, encouraging and allowing Resident #3 to make decisions regarding daily cares and educating on unsafe choices as needed, orienting Resident #3 to time or place as needed, providing occupation therapy and speech language pathology screens as needed, continuing psychiatric consultation as ordered, and observing for changes in Resident #3's cognitive function and notifying the physician if noted. Review of active care plans for Resident #3 as of 01/03/2023 did not reveal a plan of care dedicated exclusively to providing trauma-based care for Resident #3's active diagnoses of post-traumatic stress disorder. An interview was conducted with Resident #3 on 01/04/2023 at 12:02 p.m. Resident #3 was observed in her room lying in bed watching television. She stated she was waiting for lunch, and was observed to have a pleasant mood and demeanor. She was without any behaviors or observable symptoms of PTSD. An interview was conducted on 01/05/2023 at 11:46 a.m. with Staff G, Licensed Practical Nurse (LPN), regarding Resident #3's diagnosis of PTSD. Staff G stated that she was unaware of the resident's PTSD diagnosis and she had never seen the resident display any behaviors associated with PTSD. Upon re-review of active care plans for Resident #3 on 01/05/2023, a care plan was observed to have been initiated on 01/05/2023 with a focus of providing care for Resident #3's PTSD diagnosis related to childhood trauma and interventions were included that focused on providing trauma informed care. An interview was conducted on 01/05/2023 at 12:50 p.m. with Staff E, MDS/Care Plan Coordinator, and Staff H, Regional MDS Consultant. Staff E stated Resident #3's PTSD diagnosis was related to childhood trauma and flashbacks of verbal abuse from her mother. Staff E stated Resident #3 did not talk much about her flashbacks and typically did not have behaviors associated with PTSD. Staff E stated she thought the PTSD care plan initiated on 01/05/2023 had already been in place previously. Staff H stated the PTSD care plan was a fairly new care plan pathway and they did not become aware of the care plan option until around the time of the recent hurricanes in 2022. Staff E stated she was responsible for reviewing care plans on a daily basis related to provider's orders and then also quarterly for all residents. 46234 3. A review of Resident #10's Psychiatric Periodic Evaluation, dated 12/1/22, indicated a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the resident's care plan revealed there was no care plan in place for Trauma/PTSD. A review of admission records indicated Resident #10 was initially admitted [DATE] with a re-admission on 11/29/22 with diagnoses including alcohol abuse and recurrent depressive disorders. PTSD was not listed as a diagnosis in the resident's electronic medical record. A review of Resident #10's Minimum Data Set (MDS,) dated 12/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating he is cognitively intact. Section I, Active Diagnoses, in the MDS did not indicate a diagnosis of PTSD. A review of Resident #10's progress notes revealed a Physician Note on 1/20/22 stating the resident was being seen for an acute follow-up psychiatric visit per request for evaluation of nightmares. The note stated the resident reported having the same nightmare over and over for years, it consisted of him riding in a large bus that was traveling over a bend in the road and the bus fell off the bed and crashed. The nightmares woke the resident up and were frightening. The resident admitted to having past trauma and stated at the age of 15 he watched a car hit his mother which resulted in her death. He stated he vividly remembered the day he observed this. He reported he was working at an ice cream shop and his mother was crossing the street in a yellow coat. He reported frequently reliving this event throughout his life sometimes causing him anxiousness. He also reported hypervigilance to the physician. On 1/4/23 at 3:54 p.m. an interview was conducted with the Director of Nursing (DON.) She stated a new diagnosis can be entered into the medical record by the DON, the Assistant Director of Nursing (ADON,) the MDS Coordinator, or the physician. She stated if a resident had a new diagnosis it was discussed in morning meetings and would be added to the electronic medical record. On 1/4/23 at 5:22 p.m. an interview was conducted with Staff T, Registered Nurse (RN). When asked if Resident #10 had PTSD, she stated, Not that I know of. She stated the resident had depression but took medication for that and he was fine. A telephone interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 1/5/23 at 8:11 a.m. Staff S confirmed he was regularly assigned to Resident #10 on night shift. He stated he had not witnessed the resident having nightmares. When asked if the resident had PTSD, he stated he knew the resident was in the military and served time in prison. Staff S said, I don't know what impact that had on him. He said the resident did get extremely agitated over wanting cigarettes. An interview was conducted with the DON and ADON on 1/5/23 at 8:44 a.m. When discussing the resident having falls, the ADON stated the resident was initially having falls related to nightmares. She said they had psychiatry see the resident. The ADON said the resident had PTSD from seeing his mom get killed. She also stated he spent [AGE] years in prison. She stated the psychiatrist adjusted the resident's medication. The DON stated after the medication was adjusted the resident went a long stretch with no falls. When asked why Resident #10 did not have a diagnosis or care plan related to PTSD, she stated, that is a good question. The DON was observed reviewing the resident's electronic medical record. The DON confirmed there was no PTSD diagnosis in the system. The ADON and DON confirmed they had known about the resident's PTSD. An interview was conducted with the MDS Coordinator on 1/5/23 at 9:29 a.m. She stated if the resident had a new diagnosis the doctor or nurse should let her know, then she would put the diagnosis and care plan in the system. She stated she did not know Resident #10 had a PTSD diagnosis. She confirmed there was no diagnosis or care plan related to Trauma/PTSD in the resident's medical record. She stated she was adding it immediately and would review everyone in the facility. A follow up interview was conducted with the DON on 1/5/23 at 9:37 a.m. The DON stated Resident #10's PTSD diagnosis, and nightmares were discussed several times at morning meetings. She stated the MDS Coordinator was present and should have known. The DON stated there were no notes for these meetings. On 1/5/23 at 11:45 a.m. an interview was conducted with Resident #10. The resident confirmed he did have nightmares. He repeated his recount of the nightmares as the physician previously noted. He stated they have improved with medication changes. A facility policy titled Care Planning-Interdisciplinary Team, dated September 2013, was reviewed. The policy stated the following: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individual comprehensive care plan for each resident.

Based on observations, interviews, and record review, the facility did not ensure activities of daily living (ADLs) related to showers and hair care were provided for one (Resident #17) of three residents reviewed. Findings included: During a facility tour on 01/04/23 at 12:22 p.m., an interview was conducted with Resident #17. She stated she felt neglected. The resident said, look at my hair, it's like a lump of a nest. They haven't tried to assist me, no one has attempted to comb or brush my hair since I have been here. Resident #17 stated her hair was matted because they left her hair uncombed for a long time. The resident stated she had one shower that she could remember. She stated one of the CNAs told her she should cut her hair. Resident #17 said, I said No, they can take the time to comb it. It is not fair to me. I am dependent on staff for care. The resident stated she had not refused to shower. She stated there was one incident, the only one time she received a shower. The CNA was not comfortable with the lift. The resident stated they argued, and it made her mad. Resident #17 stated since the incident, no one had offered her a shower. Resident #17 stated she received a bed bath here and there. Resident #17 was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. A Minimum Data Set (MDS) dated [DATE], section C, showed a brief interview for mental status (BIMS) of 13, indicating intact cognition. Section G showed Resident #17 was dependent on staff for ADLs, including personal hygiene, toilet use and dressing. The resident was totally dependent on staff for bathing/showers, requiring two staff physical assist. Review of Resident #17's Certified Nurses' Aide (CNA) task log, under bathing task showed from 12/06/22 to 1/4/23 the resident received one shower documented on 12/24/22. The record showed three bed baths were offered during a 30-day period. A care plan for Resident #17 dated 10/13/22, showed Resident #17 had a self-care deficit with dressing, grooming, bathing related to generalized weakness and chronic pain. The resident participated with ADLs with cues from staff. Interventions included to gather and set up supplies for care, cue/encourage resident to participate in ADLs tasks, allow resident ample time to attempt/complete ADL task, provide hands on assistance with dressing, grooming, bathing, staff to anticipate resident's needs with ADLs decline in ADL function, and report to physician as indicated. An interview was conducted with Resident #17 on 01/03/23 at 10:10 a.m. Resident #17 was observed in her room lying in bed, facing the wall, her hair was noted uncombed, matted, and tangled in a clamp. The resident appeared disheveled and untidy. Resident #17 did not respond to the interview. On 01/03/23 at 12:42 p.m., Resident #17 was observed in her room during lunch. The resident was asked if she had received assistance with showers/bath. Resident #17 said, what assistance? The resident stated she had not received assistance with her hair. On 01/04/23 at 12:25 p.m., an interview was conducted with Staff I, CNA. She stated Resident #17 was dependent on staff for all care, and she did not get out of bed often. Staff I stated the resident did not typically refuse care, but you had to ask her what she needed. Staff I stated they count on her to initiate her care needs. Staff I stated the resident was alert and oriented, and made her needs known. Staff I stated she thought the resident received showers as scheduled. She stated she had not given her a shower or bath. On 01/04/23 at 12:32 p.m., an interview was conducted with Staff N, CNA. Staff N stated she worked with Resident #17 often and the resident was dependent on staff. Staff N stated the resident stayed in bed all the time, per her preference. Staff N stated they assisted the resident as needed. She stated she did not necessarily refuse care, but sometimes she was not compliant. Staff N stated she washed the resident off as needed, especially after changing her. Staff N stated she had not given Resident #17 a shower lately. On 01/04/23 at 12:34 p.m., an interview was conducted with Staff J, LPN. She stated the resident kept to herself and was not aware that she was refusing any care today. She stated the resident did refuse showers sometimes. She was scheduled to shower three times a week . Staff J showed the surveyor a shower schedule confirming Resident #17 should be showering three times a week if she wished, on Tuesdays, Thursdays, and Saturdays. Staff J stated on the day of scheduled shower, the CNA went to the room and offered the resident a shower/bath. If the resident refused a full bath or shower, but accepted a bed bath, they provided it. If the resident was refusing showers/baths, it would be noted in the CNA task log. Staff J said, No they do not document elsewhere. If you can't find it in the resident's EMR, then it is not there. Staff J stated Resident #17 came in with her hair put up in a bun and she just noticed last week that it was completely matted. Staff J stated she then asked the resident if she would like it combed. Staff J stated the resident said she preferred to go to a salon because it was already matted. Staff J stated the resident was upset because a CNA said they would cut it off. Staff J stated she did not know if they could take the resident to a salon, but social services would have to figure that out. An interview was conducted with the Director of Nursing (DON) on 01/04/23 at 3:25 p.m. The DON stated the resident refused showers which should be documented. She stated the CNAs should be documenting refusals and not document N/A (not applicable). The DON said, Not applicable should not be an option. She either showered or she did not. The DON stated she had initiated education for the CNAs who were documenting N/A and would have a discussion with the resident. The DON stated she discussed the resident's refusal to shower in October. The DON stated she did not remember specifically discussing Resident #17's hair and could not recall why the issue of her matted hair had not surfaced. The DON confirmed if a resident was refusing care, it should be documented. The DON stated the care plan should reflect the resident refused care, and appropriate interventions should be in place. The DON reviewed the CNA task log and saw only one documented shower. She stated, I get what you are saying, it does not look good. A follow-up was conducted on 01/04/23 at 03:42 p.m., with the Regional Clinical Nurse. She reviewed the shower task log and said, Yes, it makes sense she should be getting more showers or there should be more refusals documented. She stated it did make sense to care plan the refusals if there was a pattern. She reviewed the behavior log for the resident and confirmed there were no documented behaviors or shower/bath refusals. She stated she spoke to the resident and observed her hair was matted. She said, Oh, that's not good. I saw her hair. I can't believe it got that bad. Regional Clinical Nurse stated she spoke with Resident #17, and she expressed her preference to receive bed baths in the evenings. The Regional Clinical Nurse confirmed she would expect the resident's wishes to shower or receive a bath to be honored. Review of a facility policy, revised March 2018, showed residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition grooming and personal and oral hygiene. Residents will be provided with care treatment and services to ensure that their activities of daily living do not diminish unless the circumstance of their clinical condition demonstrates that diminishing ADLs are unavoidable. If residents with cognitive impairment or dementia resist care staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. A residents' ability to perform ADL's will be measured using clinical tools, including the MDS. [Total dependence] means full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire seven-day look back. Interventions to improve or minimize resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.