Every finding on record at Aspire Senior Living Oak Grove

Based on observation, interview and record review, the facility failed to ensure to follow Insulin manufactures safety guidelines regarding giving long-acting insulin with reported low blood sugars; failed to ensure to obtain and transcribe long-acting insulin parameters action to take related to low blood sugars for one sampled resident (Resident #89) who had a history of low blood sugars and was sent to the emergency room after receiving long acting insulin after a confirmed low blood sugar; and failed to ensure hospice (end of life care) orders included diagnosis for one sampled resident (Resident #10) out of 19 sampled residents. The facility resident census of 86 residents. Review of the facility's Insulin Policy dated 2022 showed:-Always review physician orders prior to administering any medication.-Document the dosage, site, and time in the medication record along with nurse signature. Review of insulin manufacture reference dated 2025 Sanofi. All rights reserved showed:-Prescription Lantus insulin is a long-acting man-made-insulin used to control high blood sugar in adults and children with diabetes mellitus. -Lantus is not used to treat diabetic ketoacidosis (represents a serious, potentially life-threatening complication of diabetes characterized by hyperglycemia).-Do not take Lantus during episodes of low blood sugar or if you are allergic to insulin or any of the inactive ingredients in Lantus. Review of the facility's undated Hospice policy and procedure showed:-The purpose was to provide collaboration and coordination of care and services for the resident receiving hospice care. -The facility should ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of services furnished by the facility to provide care with the goal of attaining or maintaining the resident's highest practicable physical, mental and psychological well-being.-The policy did not show what the physician's orders for hospice should include. 1. Review of Resident's #89's admission record showed the resident admitted to the facility with the following diagnoses:-Type II Diabetes Mellitus (is a chronic metabolic disorder where the body develops insulin resistance, causing high blood sugar levels because cells cannot properly use insulin, often compounded by a, over time, reduced insulin production).-Chronic Kidney disease (is a long-term condition where kidneys are damaged and cannot filter blood properly, causing waste to build up). Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/3/26, showed:-He/She was cognitively intact and able to make his/her needs known. -He/she had a diagnosis of Diabetes Mellitus. -He/She received insulin injection during last assessment review. Review of the resident's physician order sheet (POS) dated 4/1/26 to 4/31/26 showed:-Accu-Chek blood sugar testing four times a day every day, was ordered on 2/5/26. (average fasting blood sugar before breakfast was less than100 milligrams (mg)/ deciliter (dL) (the standard unit in the U.S. for measuring blood glucose concentration), with normal average range of 70-130mg/dL).-Insulin Glargine Subcutaneous Solution 100 unit/milliliter (ml) to inject 80 unit subcutaneously two times a day for Type II Diabetes Mellitus.-Insulin Lispro Injection Solution 100 units/ml (short acting Insulin), Inject as per sliding scale: if blood sugar range 0 - 150 = 0 units/ml, (no insulin to be given), subcutaneously three times a day per sliding insulin scale for Type II Diabetes Mellitus. Review of the resident's Pharmacy Medication Record Review (MRR) was dated 4/15/26 and did not have recommendation for physician orders related to long-acting insulin. Review of the residents' Medication Administration Record (MAR) dated 4/1/26 to 4/30/26 showed:-Accu-Chek (blood sugar testing) daily four times a day. -Had documentation the resident blood sugar was 59 the morning of 4/17/26, prior to being given long-acting insulin (Lantus). -Insulin Glargine Subcutaneous Solution 100 unit/ml, to inject 80 units subcutaneously two times a day for diabetes mellitus.-On 4/17/26, Registered Nurse (RN) A had documented having given the resident 80 units of Lantus insulin to the resident that morning.-NOTE: Did not have a physician order to include parameter of a low blood sugar range, to indicate action to be taken if blood sugar too low for long-acting insulin or when to notify the resident physician for low blood sugars. The resident had been given 80 units of long-acting insulin the morning of 4/17/26, when his/her blood sugar was documented at 59. (low range for fasting blood sugars) Review of the resident's health status note dated 4/17/26 at 7:26 A.M., written by RN A showed:-The resident complained of the same stomach symptoms as last night. Not satisfied with current measures. The resident was hypoglycemic (low blood sugar) and refused to eat. -Called Emergency Medical Services (EMS) at resident's request. EMS arrived and took the resident to an unknown medical center destination.-Would follow up with the fire department to determine location of transport. During interview on 4/17/26 at 12:36 P.M., Paramedic A said:-EMS arrived at the facility on 4/17/26 at 7:09 A.M. -The facility nurse was giving report to EMS and said the resident's blood sugar was in the 60's and the patient did not want to eat. -EMS was at the facility due to the patient not wanting to eat and burning pain in stomach. -EMS did not know what the resident's physician order was regarding the insulin. -The facility had tried to give the resident breakfast that morning, and he/she did not want to eat. -He/she had dinner the night before. -EMS was not informed if the resident had any juice or milk. -During transport the patient's blood sugar was found to be 46 by EMS. The blood sugar was corrected by EMS.-EMS gave the resident 10% Dextrose in Water Intravenous (IV) fluid (D10, is a sterile solution used primarily for treating severe hypoglycemia (low blood sugar), providing quick calories, and managing fluid replenishment) used to correct the resident's low blood sugar issue. -He/She did not know if the doctor was aware of the situation.-EMS arrived at 8:40 A.M. at the receiving hospital and informed them of the resident situation and low blood sugar with action taken. During an interview on 4/20/26 at 9:05 A.M., the resident and family member A said:-He/she had low blood sugar the morning of 4/17/26 as assessed by RN A. -He/she was not sure if he/she had received insulin that morning.-He/she had complaints of stomach issues and not being able to eat that morning.-The resident had been given apple juice earlier that morning by the family member due to having low blood sugar. -His/her only complaint was of burning pain in chest/stomach area and the facility sent the resident to hospital via EMS for evaluation and treatment.-There were no changes in insulin dosage while at the hospital. During an interview on 4/20/26 at 9:49 A.M., RN A said:-He/She followed the nursing standard of practice, to not hold long-acting insulin with low blood sugars.-He/She should have given protein or glucagon for the resident's low blood sugar. -The resident refused to eat or take medication. -He/She gave the resident his/her 80 units of Lantus insulin on the morning of 4/17/26. -The resident refused to eat or drink anything after receiving the medication.-With long-acting insulin, wouldn't place parameter range for long-acting insulin, due to the amount given over an extended period of time. -He/She did tell EMS the resident had received 80 units of long-acting insulin that morning. -EMS had started an intravenous (IV) line and gave IV fluids for low blood sugar. During an interview on 4/20/26 at 10:15 A.M., Pharmacist A said:-The resident was on high dose of Lantus 80 units two times a day.-It would depend on the resident and the medical situation if the Lantus should have been held or not. -Sometimes place parameter when to hold or to call the physician if concerned with low blood sugar. -Lantus was a long-acting insulin and sometimes it would be given since the resident had a history of the blood sugars increasing in short period of time after a low blood sugar. On 4/20/2026 at 10:51 A.M. a message was left for the resident's physician. No return call was received as of 4/21/26. During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said: -The resident's Lantus insulin was long-acting and released in an extend period of time.-Should not give long-acting insulin unless they had perimeters or an order to give even when the residents blood sugar was low. -If nursing staff were not sure to give the long-acting insulin due to a low blood sugar, he/she would expect nursing staff to call the residents physician to get clarification of the long-acting insulin order related to low blood sugars. 2. Review of Resident #10's Face Sheet showed the resident was admitted with the following diagnoses:-Breast cancer.-Cellulitis (a common, potentially serious bacterial skin infection affecting the skin's deep layers (dermis and subcutaneous tissue).-Anxiety (a natural human emotion characterized by feelings of fear, dread, unease, or tension, often arising as a reaction to stress, danger, or uncertain situations).-Pain.-Sleep apnea (a common, chronic disorder where breathing repeatedly stops and starts during sleep, leading to low blood oxygen and fragmented, non-restorative rest).-Depression (a serious, common medical illness characterized by persistent sadness, low mood, and a loss of interest in activities once enjoyed).-Asthma (a chronic, non-curable lung disease that causes long-term inflammation and narrowing of the airways, making breathing difficult and triggering wheezing, coughing, and chest tightness.). Review of the resident's admission MDS dated [DATE] showed the resident:-Was cognitively intact without confusion.-Showed signs and symptoms of depression noted without any behaviors.-Was independent with eating, hygiene and needed moderate assistance with bathing, dressing, toileting, and touching assistance for transferring.-Used a wheelchair for mobility.-Received oxygen therapy.-Received hospice services. Review of the resident's hospice contract dated 1/29/26 showed:-The resident was admitted to hospice for malignant neoplasm of upper outer quadrant of the left breast (breast cancer) as of 1/29/26.-Hospice services provided to the resident included nursing services monthly and as needed, chaplain services monthly, nurse aide services weekly and social work services monthly. Review of the resident's care plan dated 1/20/26 showed the resident had a terminal prognosis related to cancer of the left breast and was on hospice services. Interventions showed staff would:-Maintain the resident's dignity and autonomy at the highest level through the review date.-Adjust provision of care to compensate for resident's changing abilities. Encourage participation to the extent the resident wished to participate.-Assess the resident's coping strategies and respect resident wishes.-Consult with the resident's physician and social services to have hospice care for resident in the facility.-Encourage the resident to express his/her feelings, listen with non-judgmental acceptance and compassion.-Encourage support system of family and friends.-Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near.-Observe the resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain.-Refer the resident for psychiatric consult if indicated.-Review the resident's living will and ensure it is followed. Involve family in discussion.-Work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.-Work with nursing staff to provide maximum comfort for the resident.-NOTE: The resident's care plan did not incorporate the hospice services provided in addition to the facility interventions. Review of the resident's POS dated April 2026, showed the following physician's orders:-Hospice to evaluate and treat if indicated (ordered 1/28/26).-Admit to hospice. No directions specified for order (ordered 1/19/26).-NOTE: The hospice orders did not show the diagnosis for admission to hospice. Observation on 4/15/26 at 1:23 P.M., showed the resident was sitting up in his/her recliner dressed for the weather without odors, with glasses on and with call light within reach. The resident said:-He/She was very pleased with the facility staff and with the hospice staff and thought they gave him/her good care. -The hospice staff were very attentive when they visited and were trying to manage his/her pain levels as well as they could. He/She was receiving hospice for breast cancer, and he/she had good days and bad days.-He/She didn't want to get up this morning but felt better this afternoon. -Hospice came in four days weekly and the nurse would come in the afternoon. -He/She ate well and also had his/her own snacks in the refrigerator if he/she didn't want to eat anything from the kitchen, but they did try to accommodate him/her. During an interview on 4/16/26 at 1:45 P.M., Registered Nurse (RN) A said:-The resident received hospice services.-Usually, they would have a generic physician's order for hospice to evaluate the resident if the resident/family had not chosen a hospice provider yet.-Once the resident/family chose a hospice provider, the physician's order would change to show the resident was admitted to hospice and would show the name of the hospice provider, the diagnosis for admitting him/her and the date.-The resident's care plan should also reflect the information and the coordination of services between the facility and hospice. During an interview on 4/20/26 at 12:12 P.M., the DON said:-The physician's orders should show the resident would be evaluated for hospice services.-When the hospice accepted the resident for services, the physician's order was written and should include the name of the hospice, diagnosis and start date.-Hospice services should be included in the resident's care plan. 2986861

Based on interview and record review, the facility failed to provide the required 12 hours of nurse aide in-service training either at the time of hire or within the last 12 months that included the topics of dementia (a progressive mental disorder causing confusion, and impairment of control, memory, judgement, and impulses), Abuse, Neglect and Exploitation (ANE) and behavior management (focuses on person-centered, non-pharmacological approaches to address challenging behaviors (e.g., aggression, wandering) as communication of unmet needs) for four sampled Certified Nursing Assistants (CNA H, CNA L, CNA J, and CNA K) and failed to provide the required training for the topic of dementia and behavior management for one sampled CNA (CNA E) out of five sampled employees. The facility census was 86 residents. Review of the facility's undated Nursing Services and Competency of Nursing Staff policy showed:-Definitions:Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.-The facility will ensure that there is always sufficient qualified nursing staff available to provide nursing and related services to meet resident needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.-The facility will ensure that all nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet resident needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.-The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment.-The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for resident needs, as identified through resident assessments, and described in the plan of care.-Competency in skills and techniques necessary to care for resident needs includes but is not limited to competencies in areas such as:a. Resident rightsb. Person-centered carec. Communicationd. Basic nursing skillse. Basic restorative servicesf. Skin and wound careg. Medication managementh. Pain managementi. Infection controlj. Identification of changes in conditionk. Cultural competency1. Review of the facility's training records for the last 12 months for CNA E showed:-He/She had not completed training on the topics of dementia or behavioral management.-He/She had a total of 6.5 hours of training completed.-He/She completed ANE training in February 2026.2. Review of the facility's training records for the last 12 months for CNA H showed:-He/She had not completed training on the topics of ANE, dementia, and behavioral management.-He/She had a total of 7.0 hours of training completed.3. Review of the facility's training records for the last 12 months for CNA L showed:-He/She had not completed training on the topics of ANE, dementia, and behavioral management.-He/She had a total of 3.0 hours of training completed.4. Review of the facility's training records for the last 12 months for CNA J showed:-He/She had not completed training on the topics of ANE, dementia, and behavioral management.-He/She had a total of 1.5 hours of training completed.5. Review of the facility's training records for the last 12 months for CNA K showed:-He/She had not completed training on the topics of ANE, dementia, and behavioral management or any other training topics.-He/She had a total of 0.0 hours of training completed.6. Review of the facility's in-service education log showed that dementia training was offered in August 2025 and that ANE training was offered in February and March of 2026.7. During an interview on 4/20/26 at 9:00 A.M., Certified Medication Technician (CMT) C said:-He/She wasn't sure when their last in-service was but believed it was around 6 months ago or so. A hospice company, not sure which one, came in and did dementia/Alzheimer's training.--NOTE: the facility did not provide any documentation of the training.-The Relias (a specialized, cloud-based software suite and training platform designed for senior care providers to manage staff training, regulatory compliance, and performance) program was new as of 2-3 weeks and was not fully set up where they were getting recommended training alerts yet.--NOTE: the CMT pulled up his/her Relias account which showed 0 trainings completed, to do, and overdue.During an interview on 4/20/26 at 9:30 A.M., CNA C said:-He/She had worked at the facility on and off since 2016.-He/She could not remember the last in-service he/she participated in.-The Director of Nursing (DON) was responsible for making sure in-services and trainings were completed.During an interview on 4/20/26 at 9:48 A.M., Registered Nurse (RN) A said:-He/She had worked at the facility for a year.-He/She had in-service trainings quarterly.-He/She attended in-service training in February or March of 2026.-The DON was responsible for making sure that in-services and trainings were completed.During an interview on 4/20/26 at 10:50 A.M., the Director of Nursing (DON) said:-He/She had been in the role since March 2026.-He/She had not had a chance to figure out when the last trainings were done and was in the process of conferring with the nurse managers to determine what needed to be done.-The goal was to do in-service trainings monthly and as needed.-If staff did not sign the in-service sheet, they did not attend and did not receive the education.-CNAs were required to have at least 12 hours of training annually.-As of April 2026, the facility had begun setting up all staff in Relias and by May 2026, it would be initiated completely.-He/She was responsible for making sure that all trainings and in-services were done.

Based on interview and record review, the facility failed to ensure the infection control and prevention program had ongoing immunization monitoring and documentation of the screening and eligibility process to receive the COVID-19 (an infectious respiratory illness caused by the SARS-CoV-2 virus, highly contagious, spreading mainly through respiratory droplets) vaccine; failed to provide and document education related to the COVID-19 benefits and potential side effects of the vaccine, for four sampled residents (Resident #12, #60, #81 and #89) out of five sampled residents who did not have a separate consent or refusal form for COVID-19 completed to include with acknowledgement of risk and benefits of the COVID-19 vaccine. It has potential to affect all residents who reside at the facility. The facility resident census of 86 residents. Review of the facility undated Immunization of resident policy showed to ensure all residents are afford the opportunity to receive vaccinations for preventable disease.Review of Center of Medicare and Medicaid Services (CMS-20054) infection control pathway dated July 2025 showed:-Review the records of the five residents (influenza, pneumococcal, and COVID-19) for documentation of: Screening and eligibility to receive the vaccine(s). -The provision of education related to the COVID-19 vaccines (such as the benefits and potential side effects). The administration of vaccines in accordance with national recommendations, which includes doses administered. -Facilities must follow the from Centers for Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) recommendations for vaccines. Allowing a resident or representative to accept or refuse the influenza and COVID-19 vaccines. If not provided, documentation as to why the vaccine(s) was not provided.1. Review of Resident #12's admission Record showed the resident had the following diagnoses:-Pulmonary Nodule (is small growths that can develop in the lungs).-History of influenza on 3/21/25. Review of the resident's Influenzas vaccine Consent Form dated 9/18/25 showed:-The resident had refused COVID-19 vaccine on 9/18/25.-Handwritten documentation in the upper right-hand corner of the resident influenza consent form was no COVID (refused vaccine). -Did not have COVID-19 vaccine consent section and no information about COVID-19 vaccine and the risk and benefits of the immunization.2. Review of Resident #60's admission Record showed the resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD a disease process that decreases the ability of the lungs to perform ventilation).Review of the resident's Influenzas Vaccine Consent Form dated 9/18/25 showed:-Handwritten documentation in the upper right-hand corner of the resident influenzas consent form was yes both (indicating the flu and COVID vaccine to be given).-A handwritten note to side of the form was COVID and under the COVID was a lot number and expiration date of the COVID vaccine was given. -Did not have COVID-19 vaccine consent section and no information about COVID-19 vaccine and the risk and benefits of the immunization.3. Review of Resident #81's admission Face sheet showed a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses)Review of the resident's influenzas vaccine consent form dated 9/18/25 showed:-Handwritten documentation in the upper right-hand corner of the resident influenzas consent form was allergic to flu and no COVID. (no vaccine given).-Did not have COVID-19 vaccine consent section and no information about COVID-19 vaccine and the risk and benefits of the immunization.4. Review of Resident #89's admission record showed the resident admitted to the facility with the following diagnoses:-Type II Diabetes Mellitus (is a chronic metabolic disorder where the body develops insulin resistance, causing high blood sugar levels because cells cannot properly use insulin, often compounded by a, over time, reduced insulin production).-Chronic Kidney disease (is a long-term condition where kidneys are damaged and cannot filter blood properly, causing waste to build up).-Recent treatment for pneumonia. Review of the resident's' immunization consent form dated 9/18/25 showed:-Received the COVID-19 vaccine and influenzas vaccine on 9/18/25. -Handwritten in right-hand corner of the influenza vaccine consent form yes for both (to indicate yes for COVID -19 and influenza vaccine). -The vaccine consent form that was signed consent for influenzas only and did not have COVID-19 vaccine section for consent and information COVID-19 vaccine of the risk and benefits.5. During an interview on 4/16/26 at 2:30 P.M., [NAME] Principle (VP) of Clinical said:-He/she had documented in the upper right corner of the flu consent form, yes or no for the influenza vaccine or COVID vaccine were offered and or given. -The facility did not have documentation for any refusal of vaccine showing education and documented refusal of vaccine completed and signed by resident or representative and facility staff. -The facility did not have a separate consent form for the COVID-19 vaccine that included risk and benefits of the COVID-19 vaccine. -Residents #12, #60, #81, and #89 did not have a consent form for the COVID-19 vaccine.-Residents #12, #60, #81, and #89 did not have documentation that indicated they received or refused the COVID-19 vaccine or that education was provided for the risks and benefits of the COVID-19 vaccine. During an interview on 4/17/26 at 9:28 A.M., Registered Nurse (RN) A said:-During an immunization day, the facility would obtain consent from residents and family members.-He/She would have completed an exemption/refusal form to show resident and or the resident's guardian were provided education on the risk and benefits t of vaccine offered. -The form should be signed by nursing staff and signed by the resident or resident representative. -He/she not aware of protocol for offering the COVID-19 vaccine.-A physician's order would be required to provide or offer any immunization. During an interview on 04/17/26 10:08 A.M., the Infection Control Preventionist (ICP) and VP of Clinical said:-Resident immunizations were being tracked by the VP clinical nurse. -He/She had documentation in the corner on the influenza consent form with yes or no when offered the COVID vaccine. -The facility did not have separate form for each vaccine such as COVID-19 vaccines. During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said:-He/She would expect nursing staff to ensure the residents were educated on the COVID-19 vaccine and to document the education provided.-He/She would expect to have COVID-19 vaccine consent forms to be completed by nursing staff when the vaccine was offered, the education was provided and signed by the resident or resident representative and nursing staff provided the education and vaccine.-He/She was not sure if facility nursing staff had documented immunization given in the resident's electronic medical record. -Residents #12, #60, #81, and #89 should have had documentation that indicated if they received or refused to COVID vaccine and had education to the risks and benefits of the vaccine.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness and upkeep of the kitchen due to paint was found to be peeling from the ceiling, the walls under the two dishwashing areas were in disrepair, there was dust on a pipe that was over the dessert preparation area this had the potential to affect all residents that ate food prepared in the kitchen. The facility also failed to maintain the cleanliness and proper temperature of resident's private room refrigerators for three sampled residents (Resident #6, #35 and 45) out of 21 sampled residents. The facility census was 86 residents.1. Observation on 4/15/26 during the lunch meal preparation between 8:42 A.M.-11:30 A.M., showed:-Paint chipping around the vent over the clean dishes and over the serving area.-The vent cover over the coffee area was coming off the ceiling.-There were food splatters on the ceiling between the three-compartment sink and preparation area.-A hole in the wall under the three-compartment sink.-The wall covering was coming apart and pushing back under the spray nozzle by the dish machine. -There was no covering over a hole that was under the sink in the corner of the dish machine area.-There was dust on the white pipe above the dessert preparation area. During an interview on 4/16/26 at 12:45 P.M., the Dietary Manager said:-The kitchen staff have checklist that they were to use when cleaning the kitchen. -Maintenance was in charge of all structural repairs and maintenance. -Maintenance was aware of the ceiling needing some repairs, but it had not been done since the facility had been without a Maintenance Director for a while. -He/She was not aware of the hole under the three-compartment sink or by the dish machines area. 2. Observations on 4/13/26 at 12:03 P.M. and 4/14/26 at 12:20 P.M. of Resident #6's personal refrigerator showed:-A monthly temperature chart was attached to the refrigerator, staff documented the temperature daily, and every day the temperature ranged anywhere from 46-48 degrees Fahrenheit ( F).-At the time of observations, the thermometer in the refrigerator read 47 F.-There was a buildup of ice in the freezer and spilled residue on the bottom part of the refrigerator. 3. Observations on 4/13/26 at 12:55 P.M., 4/14/26 at 12:57 P.M., and 4/16/26 at 12:36 P.M. of Resident #35's personal refrigerator showed a large amount of ice buildup and spilled residue along with black (mold like) spots inside the refrigerator. 4. Review of the Resident #45 quarterly Minimum Data Set (MDS) dated [DATE], showed the resident had a brief interview for mental status (BIMS) score of 13 indicating he/she was cognitively intact. Observations on 4/13/26 at 12:40 P.M., 4/14/26 at 12:42 P.M., and 4/16/26 at 12:38 P.M. of the resident's personal refrigerator showed:-A monthly temperature chart was on the refrigerator, staff documented the temperature each day, and the log showed the refrigerator temperature was recorded to be around 50 F.-The thermometer in the refrigerator read 50 F during each observation. During an interview on 4/17/26 at 8:32 A.M., Resident #45 said:-No one had asked him/her if they could turn down his/her refrigerator.-The sodas hardly get cold now. -They keep track of the temperature every day, but no one had talked to him/her about turning it down. 5. During an interview on 4/16/26 at 2:11 P.M. the Environmental Services Supervisor said:-The temperatures were kept track of twice a day by the housekeepers. -Refrigerators were supposed to be defrosted monthly.-Refrigerators were supposed to be cleaned monthly. -Some residents would not let the staff touch their stuff and turn the refrigerators down, but he/she had no documentation to show that this had occurred. -He/She did not know that Resident #35 refrigerator had ice built up and was dirty. During an interview on 4/16/26 at 2:39 P.M. Housekeeper A said he/she:-Looked inside the refrigerators every day.-Had never cleaned inside of the Residents #35 refrigerator because there was nothing in it. -Would clean the refrigerators on a as needed basis. -Resident #45 would not let him/her turn down the thermostat in the refrigerator. During an interview on 4/20/26 at 12:10 P.M., the Director of Nursing (DON) said he/she was not sure who was responsible for the refrigerators in the residents room.

Based on observation, interview, and record review, the facility failed to ensure the Infection Control Preventions program had implemented guidelines from Centers for Disease Control (CDC) of posted signage for Enhanced Barrier Precautions (EBP, is an infection control intervention designed to reduce transmission of resistant organisms) and the use personal protective equipment (PPE, gown and gloves) during high contact resident care; failed to ensure handwashing was performed to prevent cross contamination during a transfer for one sampled resident (Resident #5); failed to maintain aseptic technique during enteral feeding for one sampled resident (Resident #11) who had an in dwelling device (medical devices inserted into the body); failed to ensure staff used proper hand hygiene during incontinence care for one sampled resident (Resident #80) out of 19 sampled residents. The facility census was 86 residents. Review of reference for Centers for Disease Control (CDC) and prevention for implement personal protective equipment (PPE) use in nursing homes dated 7/2024 showed: -Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs.-EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs the targeted gown and glove use during high contact resident care activities.-EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. -Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) -For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves-Make PPE, including gowns and gloves, available immediately outside of the resident room.-Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room).-Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. An infection control policy was requested but not provided prior to the date of exit. An enteral feeding policy was requested but not provided prior to the date of exit. Review of the facility's undated Standard Precautions policy showed:-Hands must be washed between any task that has the possibility of transferring bacteria from resident to resident.-PPE will be used whenever staff anticipate exposure to blood and/or body fluids. Review of the facility's undated Hand hygiene policy showed:-Hand washing will be regarded by this facility as the single most important means of preventing the spread of infection.-Hands should be washed for at least 20 seconds using soap and water under the following conditions:--After handling used dressings, contaminated equipment, etc.--After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin.--After handling items potentially contaminated with blood, body fluids, excretions or secretions.--Before putting on gloves.--After removing gloves.--Hand sanitizers containing at least 60% alcohol may be used when soap and water are not readily available. Review of the facility's Perineal Care Policy dated June 2020 showed instruction in the following steps:-After cleaning perineal area, removing wet linen and placing dry linen and/or brief underneath the resident, staff was to remove gloves and wash hands or use hand sanitizer.--NOTE: Do not touch anything with soiled gloves after procedure (curtain, side rails, clean linen, call bell, etc.)-Put on clean gloves.-Clean and return equipment to its proper place.-Place soiled linen in proper container.-Remove gloves.-Wash hands. 1. Review of the facility infection control prevention program during survey process from 4/13/26 to 4/20/26 showed: -The facility did not have EBP signage posted on resident doors for those residents who were potentially at risk of infection due to indwelling devices, open wounds and other infections. -The facility had isolation carts (ISO carts) in hallways with gowns, gloves and mask and with red container in hallways. -No infection control signage posted on type of PPE (gowns, gloves, mask, face shield, foot covers) to be used when providing direct resident care for those residents on EBP. During an interview on 4/17/26 at 10:08 A.M., Infection Control Preventionist (ICP) and VP of Clinical Nurse said:-EBP was for the residents who had indwelling medical devices or wounds.-The facility had identification of resident on EBP by placing a yellow dot on the resident's name plate outside the resident room. -The facility at the time was not aware of the CDC requirement for posting infection control detailed signage for residents with EBP and other transmission based precautions. -The facility did not have EBP signage posted to include type of PPE required when providing direct care for the residents on EBP. -Care staff should wear gloves and gowns with any direct contact care for the resident on EBP. -ISO carts were kept on each hallway with gowns and gloves. -The ISO carts were to be re-stocked by central supply staff.-The facility kept a red container with a red bag at the end of the hallways for the disposal of used gowns and gloves. During an interview on 4/20/26 at 12:12 P.M., Director of Nursing (DON) said: -The facility infection control program had been using a special-colored dot on the resident's doorways to identify residents on EBP. -He/She was not aware of the requirement of posting detailed EBP signage on the doorway of residents on special infection control precautions, such as EBP. -The staff should wear gloves and gowns during direct care activity with residents on EBP. 2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE] with diagnoses including respiratory failure, heart failure, sleep apnea, high blood pressure, chronic obstructive pulmonary disease (COPD-a progressive, long-term lung disease that makes breathing difficult by causing inflammation and damaging airways) repeated falls, pain, diabetes, muscle weakness and arthritis. Review of the resident's care plan dated 11/25/24, showed the resident had limited physical mobility related to weakness and required two persons to transfer with the sit to stand mechanical lift. Interventions showed:-The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. -Invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility.-Monitor/document/report as needed any sign or symptom of immobility.-Provide gentle range of motion as tolerated with daily care.-Provide supportive care, assistance with mobility as needed. Document assistance as needed.-Provide physical therapy, occupational therapy as ordered, as needed. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/6/26 showed the resident:-Was alert and oriented without confusion.-Had lower extremity impairment on both sides and used a wheelchair for mobility.-Required moderate to maximal assistance for hygiene and dressing, maximum assistance for transferring.-Used a non-invasive ventilator (provides breathing support using positive pressure delivered through a sealed mask (nasal, face, or helmet). Observation on 4/15/26 at 9:38 A.M., showed the resident was sitting in his/her bed with oxygen on via nasal cannula. Certified Nursing Assistant (CNA) E and CNA F entered the resident's room with the Rehabilitation Director. The following occurred: There was a sit to stand mechanical lift in front of the resident's bed and the resident's wheelchair was behind it. CNA E informed the resident they were going to transfer the resident.-Without washing their hands, both CNA E and CNA F put on gloves and began assisting the resident with positioning him/her at the side of the bed to prepare for the transfer to his/her wheelchair.-CNA E assisted to put the resident's shoes on while CNA F assisted to move the resident's legs to the side of bed, positioning the resident to sit up on the side of the bed.-CNA F and the Rehabilitation Director assisted with putting the sling around the resident and positioning the resident's feet so he/she could stand on the lift. -CNA E used the lift to assist the resident into a standing position, moved the resident to his/her wheelchair and lowered the resident into his/her wheelchair while CNA F and the Rehabilitation Director provided standby assistance.-CNA E and CNA F removed the sling, placed the footrests on the wheelchair and placed the resident's feet on the footrests. They ensured the resident was comfortable and was properly positioned. CNA F gave resident his/her call light while CNA E made his/her bed, opened the blinds. -CNA F and CNA E both degloved and washed their hands prior to leaving the resident's room. During an interview on 4/15/26 at 9:51 A.M., CNA E and CNA F said:-They were supposed to wash or sanitize their hands prior to or upon entering the resident's room.-They were supposed to wash or sanitize their hands between glove changes and whenever they completed a dirty task.-They were supposed to wash their hands prior to or upon leaving the resident's room.-Before they entered the resident's room, they washed their hands in the utility room down the hall and then came to the resident's room to transfer the resident. 3. Review of Resident #11's Quarterly MDS dated [DATE] showed the resident was:-Cognitively intact.-Able to make his/her needs known.-Receiving nutrition via a feeding tube (a medical device used to deliver nutrition, fluids, and medication directly into the stomach or small intestine when a person cannot eat or swallow safely).-Diagnoses included: Gastrotomy Status (refers to the presence of a functioning feeding tube (G-tube) in the stomach, used for long-term nutrition when oral intake is unsafe or insufficient) and Gastrotomy Malfunction (a mechanical complication of a gastrostomy tube (G-tube) that disrupts its proper functioning, it involves structural or positional issues). Review of the residents' Order Summary Report dated 4/16/26 showed the resident had the following orders:-Isosource (nutritionally complete, calorically dense tube feeding formula contains fiber to help support digestive health and bowel function) 1.5-1 carton bolus/gravity feeding four times a day related to gastrostomy malfunction, ordered on 03/13/26.-May crush medications together during tube feed administration, ordered on 10/31/24.-Cleanse tube site with wound cleanser and pat dry. Apply triple antibiotic ointment (TAO - a topically applied, over-the-counter medicine containing three active ingredients Bacitracin, Neomycin, and Polymyxin B) and split sponge daily and as needed for soiling every day shift. Observation on 4/13/26 at 10:16 A.M., on 4/14/26 at 8:30 A.M., on 4/16/26 at 1:12 P.M., and on 4/20/26 at 9:00 A.M. showed there was no EBP signage posted outside of the resident's room. Observation on 4/13/26 at 12:23 P.M. showed:-Licensed Practical Nurse (LPN) A cleaned the bedside table with a disinfectant wipe and place the syringe, graduated cylinder (commonly used for accurate liquid dispensing, such as in enteral feeding or medication administration) and carton of enteral feeding formula on the table without first placing a barrier on the table.-He/She performed hand hygiene with sanitizer and put on gown and gloves.-He/She attached the syringe to the enteral feeding tube and drew back to check for residual then injected the residual back into tube.-He/She flushed the tube with water from the graduated cylinder via gravity.-He/She slowly added one carton of enteral feeding formula to the tube.-LPN A did not check for placement prior to adding water or feeding formula via measuring the tube.-He/She flushed the tube with the remainder of the water via gravity for a total of 130 cubic centimeters (cc).-He/She clamped the tube and disconnected the syringe.-He/She took off gloves and gown and discarded them into the trash bin, washed hands with soap and water, gathered items and left the room.-LPN A did not change the residents' visibly soiled dressing over the enteral tube site at that time. Observation on 4/14/26 at 8:30 A.M. showed:-LPN A cleaned a bedside table with a sanitizing wipe and placed the syringe, graduated cylinder and two medication cups containing the resident's morning medications onto the bedside table without first placing a barrier on the table.-The DON performed hand hygiene, put on gown and gloves and entered the room to assist LPN A.-The DON placed a towel on the bedside table and then replaced the supplies on top of it.-LPN A attached the syringe and drew back on it to check for residual. The residual was replaced into the tube.-The DON checked for placement using a stethoscope but did not clean it prior to placing it directly against the resident's abdomen.-The DON and LPN A did not check for tube placement by checking the measurement of the tube. -LPN A flushed to tube with water from the graduated cylinder via gravity.-LPN A administered the crushed and liquid medication to the resident's feeding tube. After some difficulty, was able to get them to go down.-LPN A flushed the tube with the remainder of the water from the graduated cylinder.-LPN A flushed the tube with the remainder of the water via gravity for a total of 130 cc.-He/She clamped the tube and disconnected the syringe.-He/She took off gloves and gown and discarded them into the trash bin, washed hands with soap and water, gathered items and left the room.-LPN A did not change the residents' visibly soiled dressing over the enteral tube site at that time. During an interview on 4/14/26 at 8:52 A.M., LPN A said:-He/She was not sure what EBP stood for, but included wounds, catheters, ostomies, and tubes.-EBP residents were identified by a yellow dot outside of their room beside their name. No signage was necessary because they used the yellow dot system.-A barrier should have been placed between the supplies and the table. He/She did not use one on 4/13/26 or 4/14/26.-Placement of the feeding should be checked prior to administration of enteral feeding and medication administration, he/she should have checked prior.-He/She was taught to check for placement using a pH test (involved using a syringe to draw back (aspirate) a small amount of stomach fluid and checking its acidity by placing a few drops onto a pH testing strip and comparing the color change to the chart provided by the manufacturer) and auscultation of abdomen in tube site area.-He/She was not sure if measurement of tube was an option for checking placement.-The tube site dressing was changed daily by the nurses.-He/She had not had an in-service on tube feeding. Observation on 4/16/26 at 1:12 P.M., showed Registered Nurse (RN) A was in the resident's room administering an enteral feeding without a gown on. During an interview on 4/16/26 at 1:30 P.M., RN A said:-He/She was not sure what EBP meant but included residents with catheters, tubes, and transmissible infections.-PPE consisted of gown, gloves, and eye shield.-He/She would expect there to be EBP signage outside of the resident's room, but they used yellow dots to identify the residents.-He/She should have put on all PPE including a gown before entering the resident's room and administering a feeding and removed it before exiting.-Possible outcomes by not doing this were transmission of infection and bacteria. During an interview on 4/20/26 at 10:50 A.M., the DON said:-He/She thought that EBP signage could be posted inside of the residents' rooms.-Staff knew if a resident was on EBP's if there was a yellow dot outside of the room.-The PPE required for performing cares or administering medications for a resident on EBP was gown and gloves.-A gown and gloves should not necessarily need to be put on before entering a resident's room and administering enteral feeding or medication but with cares, yes.-Contamination of the field during tube feeding was prevented by placing a barrier on the field and then placing items on top of that.-If the supplement and/or equipment came in contact with a field that did not have a barrier, the nurse should stop immediately, clamp the resident's tubing, grab more supplies and start over.-The tube site split sponge should be changed every shift and as needed.-Placement always be checked prior to feedings by aspiration of tube contents and then listening with stethoscope as you reintroduce it.-Checking residual alone should not be used to check for placement. Staff needed to auscultate upon reinsertion while placing stethoscope above the tube site.-Nurses were trained on tube feeding procedures through in-services and would be through Relias (cloud-based software program that helps staff improve patient outcomes and meet regulations through personalized, accredited courses) but it had not been fully initiated yet.-He/She was going to put all policies and procedures in a binder that would be kept in his/her office initially and eventually at the nurse's stations for staff to access.-He/She was not sure how often policies were reviewed and revised but would be done by corporate.-The Infection Control Preventionist (ICP) was responsible for making sure skills check offs were completed. The DON was responsible for making sure that in-services were completed. 4. Review of Resident #80's Quarterly MDS dated [DATE] showed the resident was:-Severely cognitively impaired.-Rarely/never understood by others.-Rarely/never understand others.-Always incontinent.-Totally dependent on staff for incontinence care.-Diagnoses included: Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) with late onset. Psychosis (mental state involving loss of contact with reality and causing deterioration of normal social functioning), Weakness, lack of coordination and a personal history of urinary tract infections (UTI - an infection of one or more structures in the urinary system). Review of the residents' Order Summary Report dated 4/16/26 showed:-Transfer: two person assist with gait belt.Review of the resident's undated care plan showed he/she:-Had an Activities of Daily Living (ADL - are essential self-care tasks—specifically bathing, dressing, eating, transferring (mobility), toileting, and continence—that indicate a person's functional independence) performance deficit and required a two person assist.--Interventions: Personal hygiene: one person assist. Observation on 4/14/26 at 12:30 P.M. of the resident's incontinence care showed:-CNA A entered room, washed hands, and put on gloves.-CNA D entered room, washed hands, removed foot pedals from the resident's wheelchair, and put on gloves.-CNA B closed the door to room with his/her forearm to provide privacy.-The resident was transferred by both CNA B and CNA D from the wheelchair to the bed with a gait belt.-The resident's clothing on lower body was removed by both CNA B and CNA D, the resident was laid flat onto bed, and the bed was raised and adjusted flat.-CNA B and CNA D removed gloves.-CNA D put on a new pair of gloves without performing hand hygiene first.-CNA D collected the residents' clothing and put it into a new trash bag grabbed from the trash bin.-CNA B removed the resident's brief, cleansed the peri area and buttocks with wipes previously pulled from the package. The used wipes and brief were handed to CNA D to discard.-CNA B removed gloves and put on a new pair of gloves without performing hand hygiene first.-CNA B placed a new brief underneath the resident and his/her clothing was put on lower body.-The resident was moved up in bed by both CNA B and CNA D.-CNA D did not remove dirty gloves before touching resident's linens to pull them over the resident, touching the resident, and touching the call light.-Fall mats were put on both sides of the resident's bed by both CNA B and CNA D. -CNA B adjusted bed to the lowest level using the bed remote.-CNA B removed gloves and did not perform hand hygiene before exiting the room.-CNA D removed gloves and with bare hands collected the trash liner that contained soiled materials, out of the trash bin and carried it down the hall to the shower room to discard it. -No hand hygiene was performed after. During an interview on 4/14/26 at 12:44 P.M., CNA B said:-Hand hygiene should be performed before contact with resident, when going from a clean to dirty task and vice versa, and after removing gloves.-Hand hygiene should be done after performing dirty tasks and before touching the resident or any other items in the room. During an interview on 4/14/26 at 12:47 P.M. CNA D said:-Hand hygiene should be done after cares and before leaving the room.-An infection control and hand hygiene in-service was done in March 2026 but not a skills checkoff and covered handwashing times and proper hand washing technique.-In January of 2026 there was infection control training through Relias. During an interview on 4/20/26 at 9:48 A.M., RN A said:-Hand hygiene should be performed before and after resident contact and between glove changes.-He/She had been at this facility for a year.-There was infection control and hand hygiene in-services quarterly. The last one was in February or March 2026 with the former DON.-He/She had not had an infection control or hand hygiene skills checkoff.-The DON was responsible for making sure all in-services were done, the ICP was responsible for return demonstration. During an interview on 4/20/26 at 10:50 A.M., the DON said:-Hand hygiene should be performed before and after patient care and contact, when serving meals, after peri care, when hands are visibly soiled and after contact with blood or bodily fluids.-He/She would expect hand hygiene be performed between glove changes.-He/She was responsible for making sure all trainings and in-services were done.

Based on observation and interview, the facility failed to maintain the restroom ceiling vents free of a heavy buildup of dust in resident rooms, on the 300 Hall, the 100 Hall and the 200 Hall; failed to maintain the ceiling vents in the shower rooms located in the Special Care Unit (SCU) and the 200 Hall free of a heavy buildup of dust; failed to maintain the ceiling vents in the Special Care Unit (SCU) and main dining rooms free from a heavy buildup of dust; failed to maintain the floors in resident rooms 319, 320, 317, 307, 109, 210, 206, in good repair; failed to maintain the restroom floor in resident room [ROOM NUMBER] free of grime; failed to maintain a shower mat in the 200 Hall shower room in an easily cleanable condition because there were damaged areas in the shower mat; and failed to inform the Central Supply Coordinator of a stand-up lift with a crack in its base. This practice potentially affected at least 70 residents who reside in or used those areas. The facility census was 86 residents. 1. Observation on 4/15/26 from 10:20 A.M. to 12:55 P.M. with the Maintenance Director showed:-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the ceiling vent of the SCU shower room [ROOM NUMBER].-There was a heavy buildup of dust inside the ceiling vent of the SCU shower room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER].-There was a heavy buildup of dust inside the ceiling bents in the special care unit (SCU) shower room. -There was a heavy buildup of dust inside the ceiling vents in the SCU dining room. -There was a heavy buildup of dust inside the ceiling vents in the 200-hall shower room. -There was a heavy buildup of dust inside the ceiling vents in the main dining room.During an interview on 4/15/26 at 10:48 A.M., the Maintenance Director said he/she had not had a chance to clean the ceiling vents during his/her four months at the facility.2. Observation on 4/15/26 from 9:54 A.M. to 12:28 P.M. with the Maintenance Director showed:-There was a 2 foot (ft.) long crack on the floor on the window side of resident room [ROOM NUMBER].-There was a 15 ft. 5 inch (in.) long crack on the floor on the window side of resident room [ROOM NUMBER].-There was a1 ft. long crack on the floor on the window side of resident room [ROOM NUMBER].-There was a 15 ft. long crack on the floor on the window side of resident room [ROOM NUMBER].-There was a 5 ft. long crack on the floor on the window side of resident room [ROOM NUMBER].During an interview on 4/15/26 at 11:12 A.M., the Maintenance Director said he/she had not had a chance to inspect the floor in the resident rooms in the four months he/she had worked at the facility. 3. Observation on 4/16/26 at 11:17 A.M., with the Housekeeping Supervisor showed a 26 in. long section of cove base (a flexible, durable trim installed at the joint between walls and floors to protect against damage, water, and debris) that was missing from the area under the climate control unit in resident room [ROOM NUMBER].During an interview on 4/16/26 at 11:17 A.M., the Housekeeping Supervisor said:-If housekeepers saw damaged areas in the resident rooms, they should use the facility system called TELs (a platform for building management in senior living, covering maintenance and safety) to communicate any issues.4. Observation on 4/13/26 at 10:10 A.M., showed the presence of grime on the restroom floor of resident room [ROOM NUMBER].Observation on 4/16/26 at 11:20 A.M., with the Housekeeping Supervisor showed the presence of grime on the restroom floor and a buildup of grime around the handwashing sink of resident room [ROOM NUMBER].During an interview on 4/16/26 at 11:21 A.M., the Housekeeping Supervisor said he/she expected the housekeepers to spend more time cleaning behind the commode and the handwashing sink.5. Observation on 4/16/26 at 9:21 A.M. showed a shower mat in the 200 Hall shower room with a 7 in. tear and another tear that was 22 in. long.During an interview on 4/16/26 at 9:26 A.M., the Central Supply Coordinator said no one had notified him/her about obtaining a replacement shower mat.During an interview on 4/16/26 at 9:27 A.M., Certified Medication Technician (CMT) A said he/she normally worked on the 100 Hall, and he/she didn't know about the damaged shower mat in the 200 Hall shower room.6. Observation on 4/20/26 at 9:15 A.M., showed a stand-up lift (mechanical devices designed to help individuals with partial weight-bearing capability move from a seated to a standing position, aiding in transfers) in the 200 Hall with a two in. crack in the base of that lift.During an interview on 4/20/26 at 9:30 A.M., Certified Nursing Assistant (CNA) M said:-He/She had not checked the base of the lift for any damage.-They had not used the stand-up lift that morning.During an interview on 4/20/26 at 9:34 A.M. CNA E said:-He/She would check to see if the battery was charged and that it was functional.-The stand-up lift in the 200 Hall was from a rental company.During an interview on 4/20/26 at 9:40 A.M. the Director of Nursing (DON) said:-Staff should check to see if the stand-up lift was charged and functioned properly.-Staff should check the base of the lift after he/she saw the crack in the base.During an interview on 4/20/26 at 10:38 A.M., the Central Supply Coordinator said:-He/She was unaware of the cracked base on the stand-up lift. -He/She would contact the rental company for an exchange.

Based on observation and interview, the facility failed to ensure the drainage from the washing machines in the laundry flowed without blockage; failed to ensure the ductwork box was properly affixed to the ceiling of the laundry room; and failed to ensure the faucet valves at the handwashing sink in resident room [ROOM NUMBER], were installed in proper format because the hot water valve was installed on the right and the cold water valve was installed on the left; and failed to ensure there was proper water drainage at the handwashing sink in resident room [ROOM NUMBER] . This practice potentially affected the laundry area and 2 residents in resident room [ROOM NUMBER]. The facility census was 86 residents. 1. Observation on 4/15/26 at 1:11 P.M., with the Maintenance Director, showed the trough (the drainage area behind the washing machines) with stagnant water and a pungent odor that emanated from the stagnant water.During an interview on 4/15/26 at 1:11 P.M., Laundry Aide (LA) A said:-He/She washed a few loads of laundry.-He/She had not noticed the water not draining from the trough.-That trough had clogged up before.-He/She smelled the stagnant water.During an interview on 4/16/26 at 2:51 P.M., the Housekeeping Supervisor said:-The left side of the trough was really stagnant.-The trough did not drain properly when the washing machines were not operating.-He/she was not sure what it would entail in helping the drainage to flow better.During a phone interview on 4/24/26 at 4:07 P.M., the Regional Director of Operations said:-There was a filter that was attached to the washing machine. -The facility staff needed to consistently clean those. -He/she wondered if an item going through those attached filters caused the water to not drain from the trough properly.-He/she advised facility staff to call a local plumbing company to take a look at the trough.2. Observation on 4/15/26 at 1:17 P.M., with the Maintenance Director, the ductwork box was not properly affixed to the ceiling in the laundry area.During an interview on 4/15/26 at 1:18 P.M., the Maintenance Director said that issue with the ductwork box was before his/her tenure at the facility.During an interview on 4/15/26 at 1:19 P.M., LA A said there used to be a clothes dryer at that location which caused the ductwork box to be affixed to the ceiling, but that clothes' dryer was removed about a year ago.3. Observation on 4/15/26 at 2:52 P.M., with the Maintenance Director showed in resident room [ROOM NUMBER]:-The installation of the faucet valves with the hot water valve on the right side and the cold-water valve on the left.-The handwashing sink drained slowly when the water was allowed to flow for two minutes or more.During an interview on 4/15/26 at 2:54 P.M., the Maintenance Director said:-He/She did not know about the faucet valves because he/she had not had a chance to go around to all the resident rooms as of yet.-He/She did not know about the handwashing sink draining slowly.

Based on observation, interview, and record review, the facility failed to ensure to bathing was offered and documented per resident preference for four sampled residents (Resident #6, #7, #37, and #79) out of 19 sampled residents. The facility census was 86 residents. Review of the facility Shower/Tub Bath Policy undated showed:-Promote cleanliness and comfort, relax the residence, stimulate circulation, and facilitate observation of the resident skin condition.-Be certain that the bath area was at a comfortable temperature for the residents.-Encourage the resident to participate in the bath as he or she was able.-Stay with the resident throughout the bath, never leave the resident unattended in the tub or shower.-Document in the system shower and complete shower sheet to give to the charge nurse.-Handle the resident as gently as possible do not rush the procedure allow the resident to take rest breaks as needed.1. Review of Resident #79's bath sheets dated March 2026 showed:-There was no documentation showing that a bath had been offered or given between 3/4/26 and 3/11/26. -There was no documentation showing that a bath had been offered or given after 3/11/26. Review of the resident's bath sheets dated April 2026 showed there was no documentation showing that a bath had been offered or given after 4/4/26.Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/14/26, showed the resident:-Was cognitively intact.-Used a wheelchair.-Required partial to moderate assistance for bathing. Review of the resident's current care plan showed:-A risk of impaired communication.-Limited physical mobility related to dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), seizures (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles), and osteoporosis (decrease in bone mass and density and enlargement of bone spaces producing fragility). -Impaired cognitive function/dementia or impaired thought process.-There were no notes in the care plan about the residents bathing assistance needs. During an interview on 4/13/26 at 10:35 A.M. the resident said:-He/She only got a bath once a week and was supposed to get it twice a week. 2. Review of Resident #6's quarterly MDS dated [DATE], showed the resident:-Was cognitively intact. -Used a wheelchair.-Used a walker. -Required substantial maximum assistance for bathing. Review of the resident's bath sheets dated March 2026 showed:-There was no documentation showing that a bath had been offered or given between 3/4/26 and 3/12/26. -On 3/12/26 the resident was offered a bath but refused. -There was no documentation showing that a bath had been offered or given between 3/12/26 and 3/18/26. -On 3/21/26 the resident was offered a bath but refused. -There was no documentation showing that a bath had been offered or given after 3/21/26. Review of the resident's bath sheets dated April 2026 showed there was no documentation showing that a bath had been offered or given after 4/1/26.Review of the resident's current care plan reviewed showed:-The resident required assistance with transferring. -There were no notes in the care plan about residents bathing assistance needs. During an interview on 4/13/26 at 12:03 P.M. the resident said:-The facility seemed to be short staffed on the weekends.-His/Her bath days were Wednesdays and Saturdays. -He/She did not always get a bath on Saturdays. 3. Review of Resident's #7 bath sheets dated March 2026 showed there was no documentation showing that a bath had been offered or given after 3/11/26Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was cognitively impaired. -Used a wheelchair.-Required substantial to maximal assistance for bathing. Review of the resident's current care plan showed:-Limited physical mobility.-Had impaired cognitive function and difficulty with communication.-A full body mechanical lift was needed for transfer. -Periodic paralysis.-Muscle Spasms.-The resident required assistance with transferring. -There were no notes in the care plan about resident's bathing assistance needs.4. Review of Resident's #37's bath sheets dated March 2026 showed there was no documentation showing that a bath had been offered or given from 3/22/26 to 3/28/26. Review of the resident's bath sheets dated April 2026 showed there was no documentation showing that a bath had been offered or given after 4/1/26. Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was cognitively intact. -Used a wheelchair.-Used a walker. -Required partial to moderate assistance for bathing. Review of the resident's current care plan showed:-Limited physical mobility.-Impaired visual function.-There were no notes in the care plan about residents bathing assistance needs. During an interview on 4/13/26 at 12:40 P.M. the resident said:-There were times he/she would only get one bath a week.-Bathing schedule was Wednesdays and Saturdays.-Did not always receive baths on Saturdays. 5. During an interview on 4/16/26 at 3:01 P.M. Certified Medication Technician (CMT) A said:-His/Her responsibilities would change somedays he/she was a CMT, some days a Certified Nursing Assistant (CNA), somedays a bath aide like today. -He/She would document on the shower sheets and in the computer system. -If a resident refused a bath/shower, he/she would write it on the bath sheet and let the charge nurse know.-If a resident was cognitively intact then he/she would have the resident sign as well saying that they refused.-If a resident was not cognitively intact, he/she would let the charge nurse know, but would not have the resident's signature of refusal.-He/She was supposed to give 22 showers today and when a resident refused, he/she would not have time to go back.-If a resident had a doctor's appointment, he/she would try to get their bath in before the appointment. -Resident #79 would refuse a lot, especially on Saturdays. -He/she was not sure about the other residents. -He/She thought the charge nurses were in charge of tracking baths but didn't know. During an interview on 4/17/26 at 8:47 A.M. the Registered Nurse (RN) A said: -The bath aides were responsible for bathing unless they were pulled to the floor then their duties would be divided. -He/She thought they gave around 20 baths a day give or take. -They would bring him/her the shower sheets and let them know if anyone had refused. -He/She was only responsible for signing the sheets in the front half not the ones in the memory care side. -If the person refusing didn't have a history of refusing then he/she would go talk to them to find out what was wrong. -Resident #79 refused a lot but there should still be a shower sheet on file. -There was no tracker that he/she knew of for ensuring baths got done.-There was a couple of weeks that the receptionist was gone, and he/she was responsible for uploading the baths into the system and there was a big backlog. -The computer system can only go back so many days. -Resident #79 there was no bathing documentation uploaded. -Resident #6 did not have anything showing in the system. -Management would be responsible for keeping track to see if baths were getting done. During an interview on 4/17/26 at 9:29 A.M. the receptionist said:-He/She was responsible for scanning the shower sheets in and would send them to the Director of Nursing (DON). -There was a book, and it was for a month, and it had dividers in it by the numbers of the month. -There was no certain time they had to be scanned in. -He/She was gone from 2/27/26 to 3/23/26 and there was a big back log of bath sheets.-He/She would scan them by the numeral day. During an interview on 4/20/26 at 12:10 P.M., the DON said:-The shower aides would be scheduled and would be responsible for the baths.-The charge nurse would sign off on them. -He/She did not know how many baths they were supposed to give a day.-They created a tracker two days ago to keep track of the bathing.-If a bath aide ran out of time they could stay until they got them done. -If a resident refused then staff would let the charge nurse and should try again later that day. -The bath aide would write refused on the sheet and if the resident was able, they would have them sign it as well. -The bath aide would give the completed shower sheet to the charge nurse, and he/she would put it in the binder.-Not sure who was responsible to ensure the baths were being done. -There should be shower sheets.

Based on observation, interview and record review, the facility failed to ensure activities provided were individualized and tailored to the resident's preferences; failed to include activity preferences in the care plan; and failed to ensure the care plan goals were measurable for four sampled residents (Resident #38, #2, #7, and #79) out of 19 sampled residents. The facility census was 86 residents.Review of the facility's Activity policy and procedure showed:-Activities are based on the resident's preferences as well as the comprehensive assessment and care plan. -Activities are designed to meet the interests of and support the physical, mental, and psychological well-being of each resident as well as encourage independence and interaction in the community.-The Activity Director provides direction in the preferences, development, and implementation of activities in accordance with the resident's needs and goals; completes or delegates the completion of the activity component of the resident's assessment process; contributes or directs the contribution to the comprehensive care plan of activity goals and approaches that are individualized to match the skills, abilities and interests/preferences of each resident; monitors and evaluates the resident's response to activities and revises the approach as needed; and develops, implements, supervises and evaluates the activity program. Review of the Activity Director Policy not dated showed:-Ensure that a qualified activities director directs the activities program.-Activities were based on the residence preferences as well as the comprehensive assessment and care plan.-Activities were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident as well as encourage independence and interaction in the community.-Provides direction in the preferences, development, and implementation of activities in accordance with resident needs and goals.-Complete our delegates the completion of the activities component of the resident assessment process.-Contributes or directs the contribution to the comprehensive care plan of activity goals and approaches that were individualized to match the skills, abilities, an interests/preferences of each resident.-Monitors and evaluates the resident's response to activities and revises the approaches as needed.-Develops, implements, supervises, and evaluates the activities program. Review of the Activity Interest Survey policy not dated showed:-In order to promote the physical, mental, and psychosocial well-being of residence and activity interest survey would be conducted and maintained for each resident.-The activity coordinator would meet with each new resident within 72 hours of moving into the facility to complete an activity interest survey to assist in developing an activity plan that reflects the choices, interest, and preferences of the resident.-A list of activities that were currently provided were reviewed with the resident when developing the activity interest survey.-Information obtained from this survey would be used to encourage and involve the resident and activity and volunteer opportunities.-Each residence activity plan must be developed in conjunction with his or her comprehensive assessment and should reflect individual needs/desires/preferences.-Completed survey records were maintained by the activity department and were updated as necessary, at least annually. 1.Review of Resident # 38's Face Sheet showed the resident was admitted with the following diagnoses:-Muscle weakness.-Pain. -Malnutrition.-High blood pressure.-Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Reduced mobility.-Colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, connecting the healthy part of the large intestine (colon) to the outside of the body). Review of the resident's care plan dated 11/13/25, showed the resident would attend activities of choice. Interventions showed:-The resident would participate in activities of choice. -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.-Invite/encourage the resident's family members to attend activities with the resident in order to support participation.-Modify the resident's daily schedule and treatment plan as needed to accommodate the resident's activity participation as requested by the resident.-Monitor/document the impact of his/her medical problems on activity level.-Remind the resident that he/she may leave activities at any time and was not required to stay for the entire activity.-The resident needed a variety of activity types and locations to maintain interests.-The resident needed assistance/escort to activity functions.-NOTE: The activity care plan was not individualized to show what the resident's activity level was or his/her activity type and preferences. It did not show the resident's limitations to attending activities or whether the resident preferred one-to-one activities to large group activities. It did not show activities the resident liked to do or already participated in. The resident's activity goal was not measurable. Review of the resident's significant change Minimum Data Set (MDS-federally mandated assessment tool completed by facility staff for care planning) dated 12/6/25, showed:-Having choices about routine daily cares were very important to the resident.-Activities such as music, animals/pets and going outside were very important to the resident. -Activities such as magazines/newspapers, activities with groups of people and religious services were somewhat important to the resident. Review of the resident's Quarterly Activity assessment dated [DATE], showed: -The resident participated in one-to-one activities.-His/Her favorite activities included word search/puzzles and dog visits.-His/Her activity related focus remained appropriate according to the resident's care plan.-His/Her activity goals were met and activity interventions were effective in meeting his/her activity goals. Review of the resident's one to one Activity Participation Record showed there were several activity codes listed that identified a variety of activities such as reality awareness, pet visits, art projects, exercise, music, religion, games, reading, conversations, sensory stimulation and rehabilitation/goal support. The records showed:-February 2026-showed one on one activities were offered four times during the month on 2/5/26, 2/13/26, 2/19/26 and 2/27/26. Activities provided were local newspaper and on 2/19/26 voting was also provided. The resident refused an activity (unknown) on 2/27/26.-March 2026-showed one on one activities were offered five times during the month on 3/5/26, 3/6/26, 3/20/26, 3/24/26 and 3/26/26. Activities provided were local newspaper on 3/6/36 and 3/20/26 and snack cart on 3/26/26. The resident refused nail care on 3/5/26 and an unknown activity on 3/24/26.-April 2026 showed one on one activities were offered on 4/1/26 and 4/2/26. Activities were snack cart and conversation on 4/1/26 and local newspaper on 4/3/26.-NOTE: Activities provided did not coordinate with to the resident's preferences or interests and for those refused activities, there were no other opportunities provided to participate in activities. Observation and interview on 4/14/26 at 1:50 P.M., showed the resident was sitting up in his/her bed in his/her room. He/She was alert, oriented and was watching television (tv). There were personal belongings on his/her tray table within reach including beverages, snacks and a word puzzle book. The resident said he/she did not want to get up to participate in the party and entertainment activity that was occurring at this time. Observation and interview on 4/14/26 at 2:45 P.M., showed the resident was sitting up in his/her bed watching tv. On his/her tray table were beverages and a package of cookies that were within reach. The resident said he/she had no concerns at this time. Observation and interview on 4/15/26 at 7:19 A.M., showed the resident was sitting up in his/her bed watching tv. There were beverages and a word puzzle book on his/her tray table within reach. He/She said the nursing staff had not come in to check him/her for cares, but he/she was not going to participate in the exercise activity this morning. Observation and interview on 4/15/26 at 9:31 A.M. showed the resident was sitting up in her bed watching tv. The resident said:-He/She participated in activities that he/she chose to participate in, and staff would get him/her up when he/she asked them to. -He/She liked watching certain tv shows during the day and movies, he/she liked to read books, complete puzzles/word search, liked music and a variety of activities she liked to complete in his/her room.-The staff invited him/her to the activities, but he/she did not like to or want to get up to go to activities. -The activity staff did not provide one-to-one activities with him/her. -Activity staff brought the newspaper to him/her occasionally and delivered snacks when the snack cart came around (he/she did not consider this to be one to one activities).-His/Her family brought puzzle books and word search books to him/her.-He/She usually watched tv in his/her room most of the time or was on his/her cell phone (applications/entertainment) unless on occasion he/she asked staff to take him/her to an activity in the facility. During an interview on 4/16/26 at 12:47 P.M., Certified Nursing Assistant (CNA) A said:-They invited the resident to all the activities daily.-The resident usually declined to participate in any of the scheduled activities.-He/She went to the resident's room to see if he/she would participate in restorative care and the resident would agree to do stretching exercises, but the resident did not want to get out of the bed most days.-The resident had his/her own puzzle books, and he/she liked to watch crime shows on tv. -He/She thought the Activity Director provided one-to-one activities with the resident but did not know what the activities provided were. During an interview on 4/16/26 at 1:00 P.M., Certified Medication Technician (CMT) A said: -The resident usually refused to get out of bed. -Last week he/she went to the beauty salon to get his/her hair done but that was it. -The resident normally stayed in his/her room in bed all day.-He/She did not go to any group activities even though they invited him/her. -He/She was unaware of any one-to-one activities that were provided to the resident, but the resident primarily watched television in his/her room and liked crime tv.-The resident's power of attorney brought books for him/her to read at times. -He/She had not seen anyone provide one-to-one activities with the resident.-He/She had not provided any activities for the resident in his/her room. During an interview on 4/20/26 at 9:56 A.M., the Activity Director said:-The resident refused participating in the group activities most of the time and preferred to remain in his/her room. -The resident usually watched television, but he/she also liked to read and complete word search puzzles.-He/She offered group activities to the resident daily, but he/she also tried to provide one-to-one activity at least weekly.-The resident usually refused group activities. -He/She did not document every time the resident refused the group activity, but he/she kept documentation of his/her one-to-one activities.-He/She provided the resident with one-to-one activities such as newspaper, coloring packets that include word search, room bingo, and nail care.-The facility also had a comfort dog come in once monthly-the comfort dog did not come last month-and the resident usually interacted with the dog.-He/She completed the resident's quarterly activity assessment and that included reviewing the resident's activity preferences.-He/She thought he/she had documented this on the resident's monthly one on one log. -He/She was aware that the resident's activities should be individualized and according to the resident's preferences.-He/She understood that the resident's care plan goals were not measurable and did not include all his/her preferences. 2. Review of Resident #2's Face Sheet showed the resident was admitted to the facility with the following diagnoses:-Acute embolism and thrombosis of unspecified vein (a blood clot in a deep vein in the thigh or leg)-Dysphagia, oropharyngeal phase (inability or difficulty in swallowing). -Parkinson's Disease without Dyskinesia, without mention of fluctuations (Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait).-Psychotic disorder with hallucinations due to known physiological condition psychotic disorders (a mental disorder in which there was a severe loss of contact with reality).-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was cognitively impaired.-Used a wheelchair.-Independent for eating.-Needed substantial/maximal assistance for toileting.-Needed substantial/maximal assistance for bathing.-Needed substantial/maximal assistance for upper body dressing.-Dependent on lower body dressing. -Supervision or touching assistance for personal hygiene. -Needed substantial/maximal assistance for transferring.-Needed substantial/maximal assistance for positioning. Review of the resident's current care plan showed:-A self-care performance deficit and needed assistance. -A communication problem neurological symptoms from Parkinson's and dementia. -The resident would participate in activities of choice.-Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident.-Remind the resident that the resident may leave activities at any time and was not required to stay for the entire activity.-The resident needed assistance/escort to the activity functions.-NOTE: There was no mention of goals, preferences, and likes or dislikes. Review of the resident's group activity participation records showed: -4/1/26 attended sit and fit exercise group, and egg hunt.-4/7/26 attended church and movie.-4/8/26 listened to music.-4/10/26 listened to music.-4/13/26 attended sit and fit exercise group. -NOTE: There were no records provided for one on one or what goals had been created and if they were met. Observation on 4/13/26 at 2:47 P.M., showed the resident was sitting in a recliner in the dining room listening to bingo. Observation on 4/14/26 at 9:49 A.M., showed:-The resident was sitting at the nurse's desk hunched over an activity board that was sitting on the desk. -The resident was not playing with it and was looking at the ground. Observation on 4/14/26 at 2:57 P.M., showed the resident was sitting in a recliner in the dining room listening to the music that was being played. 3. Review of Resident #7's Face Sheet showed the resident was admitted to the facility with diagnoses that included:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Muscle weakness.-Need for assistance with personal care.-Hemiplegia and hemiparesis following cerebral infraction affecting left non-dominate side Left hemiplegia describes (paralysis of the left side of the body due to neurological injury). -Acquired absence of right leg above knee.-Acquired absence of left leg below knee. -Chronic combined systolic (congestive) and diastolic (congestive) heart failure.-Cognitive communication deficit. Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was cognitively impaired. -Used a wheelchair.-Was independent for eating. -Required substantial to maximal assistance for bathing, transfers, and assistance from sitting to lying down.-Was dependent on assistance for toileting, lower body dressing-Required partial to moderate assistance for upper body dressing, personal hygiene, and positioning. Review of the resident's current care plan showed:-Limited physical mobility.-Had impaired cognitive function and difficulty with communication.-Dementia.-A full body mechanical lift was needed for transfers. -Periodic paralysis.-Muscle Spasms.-The resident required assistance with transferring. -The resident would attend activities of choice.-Establish and record the residence prior level of activity involvement and interest by talking with the resident, caregivers, and family on admission and as necessary.-Invite/encourage the residence family members to attend activities with resident in order to support participation.-Modified daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident.-Monitor/document for impact a medical problem on activity level.-The resident needs assistance/escort to activity functions.-There was no mention of goals, preferences, and likes or dislikes. Review of the resident's Quarterly Activity assessment dated [DATE] showed:-Goals were met.-NOTE: There was no documentation saying what the goals were and how they were met. -There was no documentation was provided on one on one. Review of the resident's group activity participation records showed: -4/1/26 listened to music. -4/2/26 attended church.-4/3/26 attended to movie and popcorn.-4/7/26 attended church and movie.-4/9/26 attended church.-4/13/26 listened to music and television. Observation on 4/13/26 at 2:47 P.M., showed:-The resident was in a wheelchair sitting at the table in the dining room by himself/herself watching bingo. Observation on 4/14/26 at 9:16 A.M., showed:-The resident was in a wheelchair sitting at the table in the dining room by himself/herself. Observation on 4/14/26 at 2:57 P.M., showed:-The resident was in a wheelchair sitting at the table in the dining room listening to music. Hair was combed and dressed appropriate for the weather. 4. Review of Resident #79's Face Sheet showed the resident was admitted to the facility with diagnoses that included:-Dysphagia following cerebral infarction (inability or difficulty swallowing).-Dysarthria following cerebral infarction (speech impairment). -Unsteadiness on feet.-Type 2 diabetes mellitus with diabetic chronic kidney disease (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's quarterly MDS dated [DATE], showed the resident:-Was cognitively intact.-Used a wheelchair.-Was independent with eating, toileting, upper and lower body dressing, personal hygiene, and transfers. -Was independent with toileting.-Required partial to moderate assistance for bathing. Review of the resident's current care plan reviewed showed:-A risk of impaired communication.-Limited physical mobility dementia, seizures, and osteoporosis. -Impaired cognitive function/dementia or impaired thought process.-Resident would attend activities of choice.-Establish and record the residents prior level of activity involvement and interest by talking with the resident, caregivers, and family on admission and as necessary.-Invite/ encourage the residents family members to attend activities with the resident in order to support participation.-Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident.-NOTE: There was no mention of goals, preferences, and likes or dislikes. Review of the resident's Quarterly Activity assessment dated [DATE] showed:-Goals were met.-NOTE: There was no documentation saying what the goals were and how they were met. -There was no documentation provided for one on one. Review of the resident's group activity participation records showed: -4/1/26 attended bingo.-4/2/26 attended church, and nail care.-4/3/26 attended bingo.-4/6/26 attended sit and fit exercise group and bingo.-4/8/26 attended bingo.-4/10/26 attended bingo.-4/13/26 attended bingo. Observation on 4/13/26 at 2:47 P.M., showed:-The resident was in a wheelchair sitting at the table in the dining room playing bingo. Observation on 4/14/26 at 2:57 P.M., showed:-The resident was in a wheelchair sitting at the table in the dining room listening to music. Observation on 4/15/26 at 7:00 A.M., showed:-The resident was in a wheelchair sitting at the table in the dining room waiting for breakfast. 5. During an interview on 4/17/26 at 9:02 A.M., the Activities Director said:-He/She had never kept track of the goals for the residents. -He/She had tried to do one on one with the residents but could not provide documentation. -One on one activities consisted of pushing around the snack cart.-Would ask if the residents would like to talk and hangout, he/she would offer crayons, coloring books, word searches, newspapers, and board games. -Did not have anything to do with the activity section in the care plan, the Care Plan Coordinator took care of it he/she just reviewed what the Care Plan Coordinator wrote and then signed off on it. -He/She asked in Resident Council for any activity ideas from the residents.-He/She had only kept track of group activities. -The majority of the residents come to the group activities. During an interview on 4/17/26 at 10:05 A.M., the Care Plan Coordinator said:-The Activities Director would tell him/her to what to put in the care plan for activities.-Each resident had their own review cycle of when their care plan would need to be reviewed.-An alert would pop up saying it was time for that resident to have their care plan reviewed. -Each department would review it and sign off on it.-If there were changes, they would tell him/her. During an interview on 4/20/26 at 12:10 P.M., the Director of Nursing (DON) said:-The Activities Director was responsible for making activity goals for the residents.-The Activities Director and the Care Plan Coordinator were responsible for the activity's section in the care plan and documenting goals and preferences. -The Activities Director was responsible for making sure residents were getting options to participate in the things they like. -The Activity Director was responsible for activity assessments which should be comprehensive. -The Activities Director was responsible for doing one on one. -Activities should be according to the resident's ability and capacity to participate-Activities should be documented for each resident.-Activities should be individualized and according to the resident's activity preferences.-The Care Plan should be goal oriented and measurable and should include the resident's activity preferences and activities provided that were goal directed.-The Care plan should say at what capacity the resident was able to function in the activity. -The Activity Director was responsible for ensuring one-to-one activities were provided and were according to the resident's preferences.

Based on observation, interview and record review, the facility failed to ensure physician's orders were complete to include monitoring and caring for respiratory equipment, including face masks, oxygen tubing and nasal cannulas (a lightweight, flexible medical device used to deliver supplemental oxygen to individuals with breathing difficulties.), failed to develop a respiratory care plan and failed to ensure respiratory equipment remained covered when not in use to prevent cross contamination for three sampled residents (Resident #10, #5 and #60) out of 19 sampled residents. The facility census was 86 residents. Review of the facility's oxygen policy and procedure dated March 2015, showed there was no documentation showing how oxygen equipment was to be stored when not in use. 1. Review of Resident #10's Face Sheet showed the resident was admitted with diagnoses including breast cancer, cellulitis (a common, potentially serious bacterial skin infection affecting the skin's deep layers (dermis and subcutaneous tissue), anxiety (a feeling of fear, dread, and uneasiness, often characterized by apprehension and physical tension in anticipation of future, uncertain dangers), pain, sleep apnea (a common, chronic disorder where breathing repeatedly stops and starts during sleep, leading to low blood oxygen and fragmented, non-restorative rest), depression (a serious, common medical mood disorder characterized by persistent sadness), and asthma. Review of the resident's care plan dated 1/20/26, showed:-There was no documentation showing the resident had a respiratory diagnosis to include sleep apnea or asthma. There were no interventions showing how the facility managed or monitored his/her respiratory diagnoses.-There was no documentation showing the resident wore or used any respiratory equipment, such as a continuous positive airway pressure (CPAP- a treatment device that uses mild air pressure, delivered through a mask, to keep the airways open while sleeping, effectively treating obstructive sleep apnea and reducing severe snoring) machine to assist with breathing at any time. There were no interventions for maintaining the resident's respiratory status documented. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/29/26 showed the resident:-Was cognitively intact without confusion.-Showed signs and symptoms of depression noted without any behaviors.-Was independent with eating, hygiene and needed moderate assistance with bathing, dressing, toileting, and touching assistance for transferring; and used a wheelchair for mobility.-Received oxygen therapy. Review of the resident's hospital nursing assessment dated [DATE] showed the resident utilized a CPAP machine while sleeping due to obstructive sleep apnea. Review of the resident's physician's order sheet (POS) dated April 2026, showed a physician's order for:-CPAP on at night, every night shift, due to asthma and obstructive sleep apnea (ordered 1/23/26).-There were no physician's orders showing how staff was to monitor the CPAP to include the pressure settings, the mask type, accessories (humidifier, tubing), cleaning/caring for it (frequency of refilling/changing the water and water type) and monitoring. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated February 2026, March 2026 and April 2026 showed:-There were no physician's orders for the resident's CPAP machine.-There was no documentation showing the nursing staff were changing the water, cleaning the machine or tubing regularly (daily/weekly) or how they were monitoring it. Review of the resident's Medical Record showed there was no documentation showing the resident's care plan was updated to show the resident was using a CPAP machine and included the parameters of use and cleaning/monitoring instruction/interventions. Observation on 4/14/26 at 2:44 P.M. showed the resident was in his/her room laying on his/her back in bed with his/her call light in reach. He/She was wearing his/her CPAP with his/her eyes closed resting comfortably. Observation on 4/15/26 at 1:23 P.M., showed the resident was sitting up in his/her recliner dressed for the weather without odors with glasses on and call light within reach. His/Her tray table was within reach and contained several personal items including his/her CPAP machine. The face mask and tubing was uncovered and not in use. During an interview on 4/15/26 at 1:23 P.M. the resident said:-He/She had to wear his/her CPAP whenever he/she was laying down due to snoring/sleep apnea.-He/She also had asthma and had difficulty breathing at times.-He/She took his/her mask off in the morning.-Staff did not usually say anything about how to store his/her mask when it was not being used. During an interview on 4/16/26 at 12:47 P.M., Certified Nursing Assistant (CNA) A said:-Oxygen equipment was supposed to be stored in bags when not in use.-The storage bags were kept on the unit in a closet and the supply room attendant ensured they were there when staff needed them. Staff could access the storage bags as needed.-The nurses' completed daily rounds to ensure they had the equipment and bags, but during daily activities of going in/out of resident rooms, nursing staff were to check to ensure the face masks for CPAP machines, tubing and nasal cannulas were also in bags. -The resident used a CPAP at night and whenever he/she was laying down, so his/her face mask should be covered when he/she was not using it. During an interview on 4/16/26 at 1:45 P.M., Registered Nurse (RN) A said:-The resident had a CPAP that he/she used at night for sleep apnea.-The facility did not obtain the CPAP for the resident (it was obtained by hospice) and that may be why he/she did not have specific orders for use.-There should have been physician orders that included details about the use of the machine including the diagnosis, when to check and change the water, tubing, setttings of the machine, monitoring and cleaning of the machine.-There should be care plan interventions that included the care and monitoring of the resident's CPAP machine and use and monitoring of the resident's respiratory status.-The face mask should be covered when not in use. 2. Review of Resident #5's Face Sheet showed the resident was admitted with diagnoses including respiratory failure, heart failure, sleep apnea, high blood pressure, chronic obstructive pulmonary disease (COPD-a progressive, long-term lung disease that makes breathing difficult by causing inflammation and damaging airways) repeated falls, pain, diabetes, muscle weakness and arthritis. Review of the resident's care plan dated 11/25/24, showed the resident had oxygen therapy and used a bilevel positive airway pressure (BIPAP-a noninvasive ventilator that helps patients breathe by delivering pressurized air through a mask) machine at night related to sleep apnea. Interventions showed: -Change the resident's position every 2 hours to facilitate lung secretion movement and drainage.-Encourage or assist with ambulation as indicated.-Provide extension tubing or portable oxygen.-Give medications as ordered by physician. Monitor/document side effects and effectiveness.-Oxygen still must be given to the resident but in a different manner during meals (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal.-Monitor for signs and symptoms of respiratory distress and report to the physician as needed.-Oxygen settings were at 2 liters via nasal cannula.-Position resident to facilitate ventilation/perfusion matching: Use upright position whenever possible to allow for optimal diaphragm. When on side, the good side should be down (e.g., damaged lung should be up).-Prevent abdomen compression and respiratory embarrassment by routinely checking the resident's position so that he or she does not slide down in bed.-Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, keep head of bed elevated.-Provide reassurance and alleviate anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress.-Suction as needed. Review of the resident's POS dated April 2026, showed physician's orders for:-Oxygen: tubing and humidifier, change monthly (ordered 11/1/24)-Obtain oxygen saturation as needed and notify the physician if below 90 percent (ordered 11/1/24).-Oxygen at 3-4 liters per face mask; may wear nasal cannula during meals every shift related to sleep apnea (ordered 11/1/24).-Bipap while sleeping 16/12 centimeters (cm) of water with oxygen bled in at 3 liters per minute for sleep apnea (9/17/25). Review of the resident's annual MDS dated [DATE] showed the resident:-Was alert and oriented without confusion.-Had lower extremity impairment on both sides and used a wheelchair for mobility.-Required moderate to maximal assistance for hygiene and dressing, maximum assistance for transferring.-Used a non-invasive ventilator (provides breathing support using positive pressure delivered through a sealed mask (nasal, face, or helmet). Review of the resident's health status note dated 4/8/26 showed during a resident interview on 4/3/26, the resident reported that he/she elevated the head of the bed to prevent getting shortness of air while lying flat. He/She received continuous oxygen and wore a BIPAP at night. Observation on 4/13/26 at 11:20 A.M., showed:-The resident was not in his/her room. -There was a BIPAP machine on his/her nightstand beside the resident's bed with the face mask laying on the dresser uncovered. -There was an oxygen concentrator (a medical device that filters and concentrates oxygen from surrounding ambient air) beside the opposite side of his/her bed. -The nasal cannula and tubing were laying across the resident's bed uncovered. -There was a plastic bag at the side of the oxygen concentrator. -The resident was in the dining room eating lunch. Observation on 4/13/26 at 2:46 P.M., showed:-The resident was not in his/her room. -His/Her bipap machine was sitting on his/her dresser. -The face mask was uncovered and laying face down on the dresser. -The bed remote was on top of it. -The resident's oxygen concentrator was sitting on the floor next to his/her bed and the nasal cannula and tubing were laying across the resident's bed uncovered. Observation and interview on 4/14/26 at 2:47 P.M., showed the resident was dressed for the weather and was sitting in his/her wheelchair in his/her room with oxygen on via nasal cannula. His/Her BIPAP machine was sitting on his/her dresser, and the face mask was beside it uncovered. He/She said:-He/She had to wear oxygen continuously and also had portable oxygen.-He/She wore the BIPAP at night due to difficulty breathing.-He/She had a bag for his/her oxygen tubing but did not have one for his/her face mask.-Staff assisted him/her to get up daily and they made his/her bed while he/she was out of the room and put his/her nasal cannula on the bed. Observation on 4/15/26 at 7:09 A.M., showed:-The resident was laying in his/her bed with head of bed up and call light within reach. -His/Her eyes were closed, and he/she was wearing oxygen via a nasal cannula. -He/She seemed to be resting comfortably. -His/Her BIPAP machine was sitting on the nightstand beside his/her bed and the face mask was laying beside it uncovered. Observation on 4/15/26 at 9:17 A.M., showed:-The resident was in bed with head of bed up.-His/Her call light was within reach, and he/she was wearing oxygen via his/her nasal cannula. -His/Her BIPAP machine was on the dresser and the facemask was beside it, uncovered.-His/Her wheelchair was sitting in front of his/her bed and the portable oxygen container was on the back of the wheelchair with the nasal cannula and tubing sitting in the seat of the wheelchair, uncovered. 3. Review of Resident #60's admission Record showed he/she admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's care plan dated 8/4/25 showed:-The resident had COPD. -There were no interventions related to the use of oxygen and the care of the oxygen concentrator and tubing. Review of the resident's Quarterly MDS dated [DATE], showed:-The resident was mildly cognitively impaired. -He/she was able to make his/her needs known. -He/she had diagnosis of COPD-Received oxygen while a resident at the facility. Review of the residents' POS dated 4/1/26 to 4/14/26 showed:-Continues O2 at two liters per minute every shift, for COPD was ordered on 3/11/26. -NOTE: There was no detailed physicians order for ongoing monitoring for the use of oxygen and how often to change oxygen tubing and the storage of the oxygen tubing when not in use. Observation on 4/13/26 10:34 A.M., of the resident's room showed:-The resident was not in his/her room.-He/she had an oxygen concentrator with the nasal canula tubing draped over small trash can.-The oxygen tubing did not have a date on the tubing when it was last changed. -There was no storage bag found by oxygen tubing or oxygen concentrator. Observation on 4/13/26 at 12:20 P.M., of the resident's room showed the O2 tubing was draped over the resident's small trash can beside his/her O2 concentrator. Observation on 4/14/26 at 10:00 A.M., of the resident's room showed:-The O2 tubing was on the ground by the concentrator.-There was no O2 tubing storage bag. Observation on 4/15/26 at 10:02 A.M., of the resident showed: -He/She was sitting in his/her wheelchair with oxygen in place per nasal cannula and tubing attached to O2 tank on back wheelchair. -The resident's room oxygen concentrator had the nasal cannula tubing on the ground next to the concentrator.-There was no plastic storage bag located in the resident room. -O2 nasal cannula tubing was not labeled with date last changed. 4. During an interview on 4/16/26 at 1:00 P.M., Certified Medication Technician (CMT) A said:-Oxygen nasal cannulas, tubing and face masks were supposed to be stored in plastic bags when not in use. -There should be bags in the resident's room. -The nurse usually changed out all of the oxygen equipment weekly and they place bags in the resident's room for the oxygen equipment. -They also had plastic bags available for staff if they see that the resident didn't have a bag to store oxygen supplies in. -They should check to ensure all oxygen equipment was stored properly as they went in and out of resident rooms throughout the day. During an interview on 4/17/26 at 9:11 A.M., CMT B said:-The licensed nursing staff were responsible for monitoring and replacement of oxygen tubing at least monthly.-The oxygen nasal cannula and tubing should be stored in plastic bag when not in use. During an interview on 4/17/26 at 9:28 A.M., Certified Nurse Assistant (CNA) B said: -The nasal cannula was normally stored in plastic bags when not in use. -The storage bag should be on the oxygen concentrator.-All staff would be responsible to ensure proper storage of oxygen tubing when not in use. -Oxygen tubing should not touch the ground or be draped over a trash can when not in use. During an interview on 4/17/26 at 9:31 A.M., Registered Nurse (RN) A said:-There should have been detailed physician orders that included when to check and change respiratory supplies.-He/She changed oxygen tubing every month. -He/She did not date the tubing when changed.-Nursing staff would be responsible for ensure tubing changed at least monthly, -The resident's oxygen tubing should be stored in plastic bag when not in use. During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said:-He/she expected nursing staff to ensure to have comprehensive physician's orders for the use of oxygen. -The resident's oxygen tubing, nasal cannula and face masks should be stored in plastic bag when not in use.-The nurse would be responsible for checking oxygen storage and use every shift.-Oxygen equipment including nasal cannulas, face masks and tubing (including nasal cannulas) should be stored in personal plastic bags when not in use.-Resident #10, Resident #5, and Resident #60's, oxygen tubing should be stored in plastic bags when not in use.-The oxygen tubing should not be on the floor or draped across a trash can when not in use. -The charge nurse was responsible of ensuring the bags were in the rooms, equipment was changed out weekly and the oxygen equipment was stored properly when not in use.-He/she would expect the charge nurse to date the oxygen tubing when it was changed. -He/She would expect there to be complete physician's orders for the CPAP and BIPAP machines and it should be tracked on the resident's MAR/TAR for Resident #10 and Resident #5.-Resident #10 and Resident #5's care plans should include care and monitoring of the resident's CPAP and BIPAP machine.

Based on interview and record review, the facility failed to ensure that the five sampled Certified Nursing Assistants (CNAs) and Licensed Nursing Staff had the appropriate competencies and skills check-off training to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being was completed annually and as needed. The facility census was 86 residents. Review of the facility's Nursing Services and Competency of Nursing Staff policy showed:-The facility would ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet resident needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being.-The facility must ensure that licensed nurses had specific competencies and skillsets necessary to care for resident needs, as identified through residentassessments, and described in the plan of care. Providing care includes but is notlimited to assessing, evaluating, planning, and implementing resident care plans andresponding to resident's needs.-The facility must ensure that nurse aides are able to demonstrate competency inskills and techniques necessary to care for resident needs, as identified throughresident assessments and described in the plan of care.-Competency in skills and techniques necessary to care for resident needs includebut is not limited to competencies in areas such as:a. Resident rightsb. Person-centered carec. Communicationd. Basic nursing skillse. Basic restorative servicesf. Skin and wound careg. Medication managementh. Pain managementi. Infection controlj. Identification of changes in conditionk. Cultural competencyReview of the Facility assessment dated [DATE] showed:-The staffing plan should be based on the resident population and identified needs for care and support, and it should describe the general approach to ensure that there was sufficient staff to meet the needs of the residents at any given time.-The plan of the facility was to ensure the facility maintained sufficient and competent staff to meet the 24-hour nursing needs in compliance with Centers for Medicare and Medicaid Services (CMS) and Missouri Department of Health and Senior Services (DHSS)-Based on census, acuity, Activities of Daily Living (ADL's) dependency, behavioral health needs and skilled services, staffing is adjusted daily based on those needs.-The facility employed a comprehensive training program beginning prior to hire during onboarding and continuing throughout employment by way of in-services and training programs.-All training goes into each employee's file.1. Review of the requested annual staff skills check-off information requested showed:-CNA C had no documentation of a performance competency skills check being completed. -CNA D had no documentation of a performance competency skills check being completed. -Certified Medication Technician (CMT) C had no documentation of a performance competency skills check being completed. -Licensed Practical Nurse (LPN) A had no documentation of a performance competency skills check being completed. -Registered Nurse (RN) A had no documentation of a performance competency skills check being completed. -The facility had no documentation of an annual performance competency skills check completed in 2025 or from 1/1/26 to 4/16/26.During an interview on 4/20/26 at 9:30 A.M., CNA C said:-He/She had been employed with the facility off and on since 2016.-He/She had not had a skills checkoff in the last year, and they were usually done up front at the time of hire and orientation.-The Director of Nursing (DON) would evaluate his/her skills.-The DON would be responsible for making sure his/her skills checkoffs were completed.During an interview on 4/20/26 at 9:48 A.M., RN A said:-He/She had been employed with the facility for one year.-He/She had not attended a skills checkoff since being employed.-He/She thought the DON, department nurse, and the Administrator would be responsible for evaluating his/her skills.-The DON was responsible for making sure his/her skills checkoffs were completed.During an interview on 4/20/26 at 10:50 A.M., the DON said:-He/She had been in the role since March 2026.-He/She was not sure how often a performance competency skills check should be completed.-He/She was still in the process of conferring with the nurse managers to see what had been done to this point and was not sure when the last skills check had occurred.-He/She was ultimately responsible for making sure that all nursing staff have completed performance competency skills checkoffs.

Based on interview and record review, the facility failed to maintain an infection control and prevention program to help prevent the development and transmission of communicable diseases, when the facility failed to have documentation of the screening and eligibility to receive the pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) vaccine; failed to provide and document education related to the pneumococcal such as the benefits and potential side effects of the vaccine for four sampled residents (Resident #12, #60, #68, and #81) out of the five sampled residents, who had no documentation of a pneumonia vaccine was offered or given and did not have documentation education and refusal of vaccine form were to be complete upon admission and annually, during the review of the facility infection prevention and control program. This has potential to affect all residents reside at the facility. The facility resident census of 86 residents. Review of the facility undated Immunization of resident policy showed:-Ensure all residents afford the opportunity to receive vaccinations for preventable disease. -The pneumococcal conjugate vaccine and the pneumococcal polysaccharide vaccine are currently recommended for use in adults 65 years or older. Review of the facility undated Influenza and Pneumococcal Immunization for Resident Policy showed: -Ensure documentation in the resident medical record of the information/education provided regarding the benefits and risk of immunization and the administration or the refusal of or medical contraindication to the vaccine.-All new resident assessed for pneumococcal vaccine status upon admission. -Resident without proof of previous pneumococcal vaccine status should be offered the pneumococcal vaccine unless contraindicated. -Each resident or the resident representative will receive education regarding the benefits and potential side effects of the immunization before the immunization is offered. -The resident medical record will include documentation that the resident or the resident representative was provided education regarding the benefits and potential side effects and the resident either received the immunization, did not receive the immunization due to medical contraindication or refusal of the immunization. Review of Center of Medicare and Medicaid Services (CMS-20054) infection control pathway dated July 2025 showed:-Review the records of the five residents for pneumococcal had documentation of: Screening and eligibility to receive the vaccine(s); The provision of education related to the pneumococcal vaccines (such as the benefits and potential side effects); The administration of vaccines in accordance with national recommendations, which includes doses administered. Facilities must follow the Centers for Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) recommendations for adult vaccines; and allowing a resident or representative to accept or refuse the pneumococcal vaccines. -If not provided, documentation as to why the vaccine was not provided.1. Review of Resident #12's medical record showed:-There was no documentation that indicated the pneumonia vaccine screening and eligibility form was completed to receive the vaccine.-There was no pneumonia vaccine consent/refusal form to include education.-There was no documentation that indicated the pneumonia vaccine was refused.-There was no documentation that indicated education was provided to the resident on the benefits and potential side effects of the vaccine upon admission and annually.2. Review of Resident #60's medical record showed: -There was no documentation that indicated the pneumonia vaccine screening and eligibility form was completed to receive the vaccine.-There was no pneumonia vaccine consent/refusal form to include education.-There was no documentation that indicated the pneumonia vaccine was refused.-There was no documentation that indicated education was provided to the resident on the benefits and potential side effects of the vaccine upon admission and annually. 3. Review of Resident #68's medical record showed: -There was no documentation that indicated the pneumonia vaccine screening and eligibility form was completed to receive the vaccine.-There was no pneumonia vaccine consent/refusal form to include education.-There was no documentation that indicated the pneumonia vaccine was refused.-There was no documentation that indicated education was provided to the resident on the benefits and potential side effects of the vaccine upon admission and annually.4. Review of Resident #81's medical record showed: -There was no documentation that indicated the pneumonia vaccine screening and eligibility form was completed to receive the vaccine.-There was no pneumonia vaccine consent/refusal form to include education.-There was no documentation that indicated the pneumonia vaccine was refused.-There was no documentation that indicated education was provided to the resident on the benefits and potential side effects of the vaccine upon admission and annually.5. During an interview on 4/16/26 at 2:30 P.M., [NAME] President (VP) of Clinical said:-The facility did not have pneumonia vaccine consent forms that showed the vaccine was offered or declined for Resident #12, #60, #68 and #81 who were eligible for the vaccine. -The facility did not have documentation of education being provided to Resident #12, #60, #68, and #81 or their representatives related to pneumonia vaccine. During an interview on 4/17/26 at 9:28 A.M., Registered Nurse (RN) A said:-During an immunization clinic day, the facility would have obtained immunization consent from resident and resident representative. -If the resident refused staff would have completed an exemption/refusal form to show resident or resident representative were provided education on risk and benefits of the vaccine.-The exemption/refusal form should be signed by nursing staff and signed by the resident or resident representative. -He/she was not aware of facility protocol for offering pneumonia vaccine. -A physician's order was required to provide or to offer any immunization to the residents. During an interview on 4/17/26 10:08 A.M., the Infection Control Preventionist (ICP) and VP of Clinical said:-Resident immunizations were being tracked by VP clinical nurse. -The facility did not have separate form for other vaccine such as pneumonia or COVID-19 vaccines. -The facility offered pneumonia vaccine to the resident upon admission. -The facility did not offer pneumonia vaccine to those residents who met guidelines to receive the pneumonia vaccine annually.During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said: -The pneumonia vaccine was offered to the resident by the admitting nurse.-He/She would expect pneumonia immunization consent forms to be completed to include education about the vaccine.-Any vaccine exemption or refusal of vaccine would be documented for each vaccine offered and refused. The form should be signed by the resident or the resident's representative to acknowledge the education of benefits and risk of the vaccine. -He/She was unsure if the nursing staff documented in the immunization section in the resident electronic medical record. -Resident #12, #60, #68, and #81 should have had documentation of either the pneumonia vaccine given or an exemption/refusal form signed.-Resident #12, #60, #68, and #81 should have had documentation that indicated the pneumonia vaccine was given or refused and education was provided.

Based on observation, interview and record review, the facility failed to maintain the hot water temperatures at or below 120 F (degrees Fahrenheit) in resident rooms 102, 205 and 200. This practice potentially affected 5 residents who resided in those rooms. The facility census was 86 residents. Review of the facility's policy titled Safe Water Temperatures dated 2021, showed:-It was the policy of this facility to maintain appropriate water temperatures in resident care areas.-Direct care staff would monitor residents during prolonged exposure to warm or hot water for any signs or symptoms or burns and will respond appropriately.-Staff would be educated on safe water temperatures upon employment and on a regular basis.-Thermometers would be available as needed for use by all staff.-Staff would report abnormal findings, such as complaints of water too cold or hot, burns or redness or any problems with water temperature to the supervisor and/or maintenance staff.-Water temperatures would be set to a temperature of no more than 120 F or the state's allowable maximum water temperature.-Maintenance staff would check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.1. Review of the hot water temperatures in the resident rooms' documentation dated 4/10/26, showed:-In room [ROOM NUMBER] the water temperature was 99 F.-In room [ROOM NUMBER], the water temperature was 98 F.-In room [ROOM NUMBER] the water temperature was 98 F.-In room [ROOM NUMBER], the water temperature was 98 F.-In room [ROOM NUMBER] the water temperature was 99 F.-In room [ROOM NUMBER], the water temperature was 99 F.-In room [ROOM NUMBER] the water temperature was 99 F.-In room [ROOM NUMBER], the water temperature was 98 F.2. Observation on 4/15/26, with the Maintenance Director showed:-At 12:52 P.M., the hot water temperature at the handwashing faucet in resident room [ROOM NUMBER] was 121.1 F.-At 2:52 P.M., the hot water temperature at the handwashing faucet in resident room [ROOM NUMBER] was 121.1 F.-At 3:12 P.M., the hot water temperature at the handwashing faucet in resident room [ROOM NUMBER] was 121.4 F.Review of a photograph dated 4/15/26 showed the hot water heater which served that section, was set at 135 degrees. During an interview on 4/16/26 at 9:05 A.M. the Maintenance Director said:-He/she checked water temperatures weekly.-He/she tried to let the water flow for two minutes.-He/she was unaware that the hot water was set so many degrees above 120 degrees.

Based on observation, interview, and record review, the facility failed to properly ensure all documentation regarding the code status was accurate for one sampled resident, (Resident #6) out of 19 sampled residents. The facility census was 86 residents. Review of the facility's Advance Directive-Code Status Policy dated 2020 showed:-It is the policy of this facility to adhere to residents' rights to formulate advanced directives. In accordance with these rights, this facility would implement procedures to communicate residence code status to those individuals who need to know this information.-Policy explanation and compliance guidelines:--The facility would follow facility policy regarding a resident's rights to request refuse and or discontinue medical or surgical treatment.--When an order is written pertaining to a residence presence or absence of an advanced directive, the directions would be clearly documented and designated sections of the medical record. Examples of directions to be documented include, but were not limited to:---Full code---Do not resuscitate (DNR)--Visual indicators:---Name plates outside resident rooms were labeled with colored stickers green for full code and red for DNR to ensure quick visual reference while maintaining confidentiality standards.-The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record.-The presence of an advanced directive or any physician directives related to the absence or presence of an advanced directive shall be communicated to social services.-The social services director shall maintain a list of residents who have an advanced directive on file.-The residence code status would be reviewed at least quarterly and documented in the medical record. 1. Review of Resident #6's face sheet showed he/she had the following diagnoses:-Periodic paralysis (a rare group of genetic or acquired muscle disorders characterized by sudden, temporary attacks of muscle weakness or paralysis, lasting from minutes to days).-Chronic obstructive pulmonary disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).-Chronic respiratory failure with hypoxia (is a long-term, progressive condition where the lungs fail to oxygenate blood).-Paroxysmal atrial fibrillation (AFib- is an irregular, rapid heart rhythm that starts and stops unexpectedly, usually lasting from a few minutes to seven days before self-terminating). Review of the residents' current physician orders dated 4/14/26 showed the resident had orders for a DNR dated 12/2/25. Review of the residents' care plan showed:-There was conflicting information in the care plan.-Some information indicated the resident had a DNR.-Some information indicated the resident was a full code. Observation on 4/13/26 at 12:03 P.M., 4/14/26 at 12:20 P.M, and 4/16/26 at 12:40 P.M. of the resident's door frame showed there was a green dot that indicated the resident was a full code. During an interview on 4/16/26 at 3:01 P.M. Certified Medication Technician (CMT) A said:-He/She would look at the dot on the door for the code status. -Green dots meant the resident was a full code and was supposed to receive resuscitation.-Red dots meant the resident was a DNR. -He/She thought the receptionist was in charge of the code status dots on the door but did not know for sure.-He/She thought the receptionist put them on when the resident first arrived.During an interview on 4/17/26 at 8:40 A.M. the Receptionist said:-He/She would put the code status dots on the door when the resident first arrived. -He/She would change them when a nursing staff member told him/her that it needed to be changed. -No one had ever said anything to him/her about a change in code status for the resident.During an interview on 4/17/26 at 8:47 A.M. Registered Nurse (RN) A said: -He/She thought the Receptionist or Social Services would be in charge of putting code status dots on the door.-He/She thought the Care Plan Coordinator would be in charge of updating the care plan. -He/She was not aware that the dot on the resident's door was green. During an interview on 4/17/26 at 9:45 A.M. the Social Worker Designee said: -He/She was not aware that the dot on the resident's door was still green. -At admission he/she would tell the nurses what the status was and if there were any changes. -He/She would get the DNR and let the nurses know that the code status had changed.-He/She and the receptionist were responsible for making sure the dots were accurate on the doors. -The Care Plan Coordinator was responsible for updating the care plan.-There was a care planning meeting every three months to see what the residents wanted their code status to be. -He/She did not know how often the code status dots were checked on the resident doors. During an interview on 4/17/26 at 10:05 A.M. the Care Plan Coordinator said: -He/She would find out what the code status was by the physician orders in the computer system and from Social Services. -He/She was not aware that there were still areas in the resident's care plan that said he/she was a full code.-He/She was responsible for updating the care plan.-He/She reviewed it and updated it every quarter.-He/She also would update it on an as needed basis. During an interview on 4/20/26 at 12:10 P.M., the Director of Nursing (DON) said: -The purpose of the dots on the door was to let staff know if the resident was full code and supposed to receive resuscitation or was a DNR. -He/She believed Social Services was responsible for the code status dots on the door.-The dots on the door should be checked monthly. -The DON and the Care Plan Coordinator were responsible for making sure the care plan was up to date. -The care plan should be reviewed monthly.

Based on interview and record review, the facility failed to ensure the right to be informed when two sampled residents (Resident #3 and #31) out of 19 sampled residents reviewed for unnecessary medications, were not provided information demonstrating the risks and/or benefits of the medication Lexapro (a prescription selective serotonin reuptake inhibitor (SSRI) antidepressant used to treat major depressive disorder and generalized anxiety disorder), Lorazepam (a benzodiazepine used for short-term relief of severe anxiety), Mirtazapine (antidepressant used to treat major depressive disorders and anxiety), (Quetiapine (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and as an adjunct treatment for major depressive disorder), Trazadone (used to treat depression, anxiety, or a combination of depression and anxiety) and Benzgalantamine (used to treat mild to moderate dementia (memory loss and mental changes) in patients with Alzheimer's disease. The facility census was 86 residents. A resident rights policy is usually found in the facility assessment but was not available prior to exit date.A psychotropic (chemical substances that affect the brain, altering mood, awareness, thoughts, feelings, or behavior) /psychoactive (chemical compounds that alter brain function, affecting mood, perception, consciousness, and behavior) medication policy was requested but was not provided prior to exit date.1. Review of Resident #3's admission record showed the resident was admitted with the following diagnoses:-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).-Depressive episodes (a period lasting at least two weeks, characterized by low mood, loss of interest (anhedonia), fatigue, and cognitive changes).-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus).Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/1/26 showed the resident:-Had severe cognitive impairment.-Was taking antipsychotic, antianxiety, antidepressant medications on a regular basis.Review of the resident's physician's order sheet (POS) dated 4/16/26 showed:-Lexapro oral tablet 10 milligram (mg) give one tablet by mouth in the morning related to anxiety disorder.-Mirtazapine oral tablet 15 mg by mouth at bedtime related to anxiety disorder.-Quetiapine fumarate oral tablet 25 mg give one tablet by mouth in the morning and give two tablets by mouth in the evening related to anxiety disorder.-Trazadone oral tablet 50 mg give one tablet by mouth three times a day related to anxiety disorder.Review of the resident's Electronic Health Record (EHR) showed no evidence the resident or his/her representative was informed of the risks and/or benefits of any of their psychotropic medications.2. Review of Resident #31's admission record showed the resident was admitted with the following diagnoses:-Alzheimer's disease (a progressive, irreversible neurodegenerative disease that acts as the most common cause of dementia).-Dementia.-Anxiety.-Major depressive mood disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).Review of the resident's Quarterly MDS dated [DATE] showed the resident:-Had severe cognitive impairment.-Was taking antipsychotic and antidepressant medication.Review of the resident's POS dated 4/16/26 showed a physician order for Benzgalantamine gluconate oral tablet delayed release 10 mg give one table by mouth two times a day related to dementia.Review of the resident's EHR showed no evidence the resident or his/her representative was informed of the risks and/or benefits of any of their psychotropic medications.3. During an interview on 4/20/26 at 9:48 A.M., Registered Nurse (RN) A said:-He/she was aware that residents needed to have a consent signed by the resident and/or their representative that included education of the risks and benefits of psychotropic medication use.-He/She was made aware since the start of this survey that it was the responsibility of the admitting nurse to obtain this.During an interview on 4/20/26 at 10:50 A.M., the Director of Nursing (DON) said:-Residents and/or their representatives had the right to be informed of the risks and benefits of psychotropic medications before starting them.-All nurses who were receiving a new order for psychotropic medications and the nurse who was admitting the resident if they were entering the facility with a prescription(s) for those medications would be responsible for making sure a signed consent was obtained.-If there was no documentation in the medical record then the consent had likely not been obtained.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan (a comprehensive, person-centered document detailing how a facility will meet a resident's medical, nursing, mental, and psychosocial needs) for pain management for one sampled resident (Resident #80) out of 19 sampled residents who was non-verbal and unable to communicate pain. The facility census was 86 residents. A care plan policy was requested but not provided prior to the exit date.Review of the facility's Pain Management policy dated 2022 showed:-The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.-In order to help a resident attain or maintain his/her highest practicable level of physical, mental andpsychosocial well-being and to prevent or manage pain, the facility will:a. Recognize when the resident is experiencing pain and identify circumstances when the pain can beanticipated.b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when asignificant change in condition or status occurs (e.g. after a fall, change in behavior or mentalstatus, new pain or an exacerbation of pain).c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, currentprofessional standards of practice, and the residents' goals and preferences.-Facility staff will observe nonverbal indicators which may indicate the presence of pain. Theseindicators include but are not limited to:a. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw).b. Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreasedparticipation in usual physical and/or social activities.c. Difficulty eating or loss of appetite.d. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming).-Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain.1. Review of Resident # 80's admission Record showed the resident was admitted with the following diagnoses:-Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) with late onset.-Psychosis (a mental health symptom involving a disconnection from reality, characterized by hallucinations, delusions, and disorganized speech).Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) dated 3/1/26 showed he/she:-Was rarely/never understood.-Rarely/never understood others.-Had severely impaired cognitive skills for daily decision making.-Was dependent on staff for mobility, hygiene, transfers, toileting, and dining.-Was taking scheduled opioid medication for pain.Review of the resident's undated Care Plan showed he/she:-Had impaired cognitive function and difficulty with communication related to Alzheimer's.--Goal was for resident to remain at current level of cognitive functioning.--Interventions were for staff to identify themselves at each interaction, face the resident when speaking and make eye contact. Reduce distractions. Provide resident with the necessary cues and stop and return if agitated. Present one thought, idea, question or command at a time.-Was on pain medication therapy.--Goal was for resident to be free of any discomfort or adverse effects.--Interventions were to administer analgesic medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. -Was at risk for pain related to weakness.--Goal was for resident to verbalize adequate relief of pain or inability to cope with incompletely relieved pain.--Interventions were to administer analgesia as ordered and give 30 minutes before treatments and care. Anticipate the residents' need for pain relief and respond immediately to any complaint of pain.-NOTE: The care plan did not address how to identify pain for this non-verbal resident or any accommodations or assistive devices to communicate with.Review of the residents' Order Summary Report dated April 2026 showed the following orders:-Pain monitoring - Assess for pain every shift.-Acetaminophen (a pain reliever and a fever reducer) oral tablet 325 milligram (mg). Give two tablets by mouth every six hours as needed for mild pain 1-5. Do not exceed three grams.-Hydrocodone (a narcotic pain reliever that can cause drowsiness)-Acetaminophen oral tablet 5-325 mg. Give 0.5 tablet by mouth every six hours as needed for pain.-Hydrocodone-Acetaminophen oral tablet 5-325 mg. Give 0.5 tablet by mouth one time a day for pain.Review of the residents' Licensed Nurse Administration Record dated April 2026 showed:-The pain assessment was documented with a rating of three or four on 10 out of 16 days.--NOTE: the resident was non-verbal and could not rate his/her pain on a 0-10 verbal scale. If staff were using the Wong-Baker Faces scale, there was no rating of three. There was no PRN (as needed) medication administered in the month of April 2026.Observation and interview on 4/13/26 at 10:30 A.M., showed the resident lying in a recliner in the common area. The resident did not respond to any questions verbally and only smiled in response. He/She was determined to be non-interviewable.Observation on 4/14/26 at 10:59 A.M., showed:-The resident was in the dining room seated for lunch and had a grimaced look on their face.-The resident refused to eat any of his/her meal when offered by staff.-In between sips of the nutritional shake that was offered, the resident frequently placed his/her head on the table.-The resident frequently muttered out in repetitive and loud tone.--NOTE: The resident's A.M. pain assessment was documented at 0.Observation on 4/14/26 at 12:25 P.M., showed the resident continued to sit at the table after lunch service and had a grimace look on his/her face.During an interview on 4/20/26 at 9:00 A.M., Certified Medication Technician (CMT) C said:-He/She would not know if the resident was in pain. The resident was non-verbal and could not tell staff if he/she was in pain.-The resident would make noises if they were agitated and/or the noise level got too high.-The family had offered pointers on giving cares to the resident but not communication.During an interview on 4/20/26 at 9:48 P.M., Registered Nurse (RN) A said:-The resident was non-verbal.-The resident did not communicate his/her needs.-The care plan should be person-centered and individualized.-If the resident was uncomfortable or distressed it would present in their facial expressions and/or deviation from their habits.-A verbal pain scale could not be used for a non-verbal person. He/She would use the faces scale.-The care plan indicated the communication method was to get face to face with the resident and get their attention.-The resident didn't use any communication accommodations, devices, or gestures.-The MDS Coordinator was responsible for implementing and updating care plans.During an interview on 4/20/26 at 10:20 A.M., the MDS Coordinator said:-He/She was not sure what the resident's current communication method was.-There was not a current communication method identified for the resident in his/her care plan.-The resident was non-verbal.-Non-verbal communication should be addressed in the care plan.-He/She was responsible for updating care plans.During an interview on 4/20/26 at 10:50 A.M., the Director of Nursing (DON) said:-Care plans should be individualized and person-centered.-Needs and preferences of a non-verbal resident were determined by anticipating needs, asking family or the responsible party. These should be included in the care plan.-The resident's care plan was not specific as to what communication methods he/she used and what staff should use with them.-The care plan was not individualized for the resident concerning pain, only partially.-The MDS Coordinator was responsible for updating care plans.

Based on observation, interview, and record review, the facility failed to review and revise resident care plans to include interventions put in place after a fall for two sampled residents (Resident #69 and #80) and one sampled resident (Resident #3) who had significant weight loss out of 19 sampled residents. The facility census was 86 residents. Review of the facility's undated Falls/Documentation Annual In-service showed no instruction to update or revise the care plan after an incident or change of condition.Review of the facility's undated Unplanned Weight Loss Management showed:-The care plan was to be updated within 7 days of identified weight loss and was to include identified causes, measurable goals, and specific interventions.-The resident and/or responsible party will be involved in care planning-Weekly weights until stabilized.-Weekly Interdisciplinary Team (IDT - collaborative groups of diverse professionals (physicians, nurses, therapists, social workers) who break down [NAME] to provide comprehensive, patient-centered care) review for ongoing weight loss.-Documentation of effectiveness of interventions.-Adjust plan as needed.-Progress notes must reflect assessment findings, notifications, interventions implemented, and resident response.-Alternative approaches must be attempted.-Documentation must reflect if end of life weight loss may be clinically unavoidable.1. Review of Resident #3's admission Record showed the resident was admitted to the facility with a diagnosis of periprosthetic (a broken bone occurring around the components of a total hip replacement) fracture around internal prosthetic right hip joint.Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/1/26 showed the resident had severe cognitive impairment.Review of the resident's undated Care Plan showed:-Nutritional status was regular diet, mechanical soft.--GOAL: Resident would consume 75% of ordered diet each day and would maintain weight.--INTERVENTIONS: Educate resident and representative regarding nutritional needs and requirements and modify diet as appropriate according to residents' food tolerances and preferences.-The resident had a right hip fracture.-There had been no new interventions since 7/1/25 related to weight loss.Review of the resident's Mini Nutrition Evaluation dated 7/1/25 and 2/18/26 showed the resident was at risk for malnutrition due to weight loss and poor appetite.Review of the resident's Order Summary Report dated 4/16/26 showed monthly weight was to be obtained.Review of the residents' hospice (end of life care) notes showed:-On 2/19/26, the nursing staff noted the resident only ate a few bites of food.-On 3/12/26, the nursing staff noted the resident continued to refuse food.-On 3/19/26, the nursing staff noted the resident was not eating and only taking sips of water.Review of the resident's Amount Eaten nutrition documentation dated 3/22/26 to 4/19/26 showed:-The resident ate greater than 75% of meal at 11 meals.-The resident refused meals on five separate occasions.Review of the residents' medical record of monthly weights showed:-On 10/13/2025, the resident weighed 114.8 pounds. -On 1/14/2026, the resident weighed 108.2 pounds. -On 3/11/2026, the resident weighed 107.4 pounds. -On 4/13/2026, the resident weighed 98 pounds.--The was a 8.75% loss in one month from 3/11/26.--This was a 9.43% loss in three months from 1/14/26.--This was a 14.63% loss in six months from 10/13/25.Review of the resident's family care plan dated 1/7/25 showed the resident did not eat much, had been losing weight and daughter brought in Ensure (designed as meal replacements or supplements, offering balanced nutrition with vitamins, minerals, and protein to support weight management and health).Review of the resident's progress notes dated 2/16/26 to 4/19/26 showed:-The resident had a poor appetite.-There was no physician/Nurse Practitioner (NP advanced practice registered nurses who diagnose, treat, and prescribe medication) notification made.-There was no communication with hospice related to weight loss.During an interview on 4/17/26 at 11:10 A.M., the Dietary Manager said:-He/She found out about any updates or changes to the residents' diets or care plans from the Registered Dietician who came into the facility twice per month and from the charge nurses who would come and verbally discuss changes or updates they wanted to implement. He/She could also run a report from the electronic medical record system.-The care plan Coordinator was responsible for the initial care plan, the Registered Dietician (RD) reviewed and then signed off on them.During an interview on 4/20/26 at 9:48 A.M., Registered Nurse (RN) A said:-After identifying weight loss, more frequent weights should be obtained, check if weight trends were off, put a notification in the doctor's book, notify hospice if applicable and notify the RD.-The process for handling the resident's weight loss should have been to coordinate with hospice, notify family of changes, contact the physician or NP via phone, document if there was a medication change, and documentation the communication in the electronic medical record.During an interview on 4/20/26 at 10:20 A.M., the Care Plan Coordinator said:-Care plans should be updated after a change in nutritional status such as weight loss.-For updates with weight loss, care plans should include the following: date, adding a house supplement, add medication pass 2.0 (a high-calorie, high-protein nutritional supplement designed to be administered in small, concentrated doses alongside routine medications. This strategy is used in clinical and long-term care settings to combat malnutrition and unintended weight loss without interfering with regular meal consumption), larger portions if applicable and offer snacks.-He/She did not recall receiving any new information about the residents' nutritional status or changes needed.-Care plans were updated quarterly and as needed.-He/She was responsible for updating and implementing care plans.During an interview on 04/20/26 at 10:50 A.M., the Director of Nursing (DON) said:-Care plans should be updated after a change in nutritional status such as weight loss if significant.-The procedure was to review the issue in the morning meeting, identify the reasons, identify what the charge nurse had done about it, review as a team, develop interventions, and have the care plan coordinator/MDS coordinator update the care plan.-Care plans should always be re-evaluated after updates have been implemented.-In the case of a change of condition or status, staff should notify the family or responsible party, notify the DON, notify the Administrator and document it.-He/She had not been aware of this resident's weight loss and poor appetite.-He/She would expect for the physician or NP of a change of condition such as significant weight loss.-Notification should be documented in a progress note.-If the physician doesn't respond, staff should call again then notify the DON and Administrator.2. Review of Resident # 69's admission Record showed the resident was admitted to the facility with the following diagnoses:-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Muscle weakness.-Lack of coordination-Altered Mental Status (AMS - a broad term for changes in brain function, including confusion, agitation, or lethargy).Review of the resident's Annual MDS dated [DATE] showed he/she:-Was severely cognitively impaired.-Used a walker for mobility.-Had a history of falls.Review of the resident's undated care plan showed he/she:-Had and unwitnessed fall on 4/9/26.--GOAL: Resident would resume activities without further incident through review date.--NOTE: There were no updated interventions following the 4/9/26 fall related to the prevention of falls.Observation on 4/13/26 at 3:11 P.M. showed:-The resident ambulating around unit with the assistance of a walker.-The resident had to be reminded constantly to use the walker due to walking away from it frequently.3. Review of Resident #80's admission Record showed the resident was admitted to the facility with the following diagnoses:-Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) with late onset.-Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning).-Lack of coordination.-Weakness.Review of the resident's Quarterly MDS dated [DATE] showed he/she:-Was rarely/never understood.-Rarely/never understood others.-Was visually impaired.-Was severely impaired, never made decisions regarding tasks of daily life.-Was dependent on staff for all cares and dining assistance.Review of the residents' undated care plan showed:-The resident was at risk for falls.--GOAL: The resident would not sustain serious injury.-The resident required a two person assist with cares and transfers.-The resident had a witnessed fall on 4/4/26.--NOTE: There were no updated interventions after the 4/4/26 fall.4. During an interview on 4/20/26 at 9:00 A.M., Certified Medication Technician (CMT) C said:-The residents' nutritional status during meals was charted in the electronic medical record by the CMT.-Changes were reported to the next shift or the charge nurse on duty.-He/She had not reported any nutritional changes with the resident, he/she always ate lightly, this was normal for him/her.-Policies and procedures of how to do something could be found in the controlled substance record book, there was a folder with the policies in it, this should be on all carts. There was a binder for Certified Nursing Assistants (CNA's) and one for nurses with policies at the nurses' station. Policies could maybe be found in Relias (a specialized, web-based training and compliance platform designed for senior care organizations, such as skilled nursing and assisted living facilities) but not sure where because it was new.During an interview on 4/20/26 at 9:48 A.M., Registered Nurse (RN) A said:-A recent change of condition he/she reported was a fall earlier this month.-The procedure for this was to do an evaluation of resident, report to the physician and family, and document.-Policies and procedures of how to do something could be found in the DON's office.-MDS Coordinator was responsible for making sure care plans were implemented and updated.During an interview on 4/20/26 at 10:20 A.M., the Care Plan Coordinator said:-Care plans should be individualized and person centered.-Nurses could access care plans but was not sure if they could make changes.-Resident issues were discussed in the morning meeting with all departments. This was how he/she became aware of changes and issues.-After a fall, the care plan should be updated with date, documentation of the fall circumstances and new interventions.-Care plans should be updated after a change in status such as a fall.-Care plans were updated quarterly and as needed.-He/She was responsible for updating care plans.During an interview on 4/20/26 at 10:50 A.M., the DON said:-He/She was going to create a binder that contained all policies and procedures on how to do something, this would be kept in his/her office initially.-Care plans should be individualized and person centered.-Care plans should be implemented and updated quarterly, as needed and with a change of condition.-MDS and care plan coordinator were responsible for this.-Care plans should be updated after each fall incident.-The procedure for implementing or updating a care plan was for the incidents to be reviewed in the morning meeting, identify the cause of the incident, review what the charge nurse did, review the issue as a team, and develop interventions. The MDS and care plan coordinator were responsible for implementing and updating this information.-Care plans should be re-evaluated after updates had been made.

Based on interview and record review, the facility failed to ensure the discharge summary included the recapitulation of stay, disposition of the resident, disposition of his/her belongings and medication were documented prior to or upon the resident's discharge from the facility for one sampled discharged resident (Resident #91), out of three sampled discharged residents. The facility census was 86 residents. Review of the facility's undated Discharge Planning policy and procedure showed:-The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions. -The facility's discharge planning process must be documented and completed on a timely basis based on the resident's needs and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan.-All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.-Discharge planning must identify the discharge destination and ensure it meets the resident's health and safety needs, as well as preferences.-The policy did not show that the facility would complete a recapitulation of the resident's stay and document the disposition of the resident's medications, belongings and any follow up care and services to assist with the resident's transition. 1. Review of Resident # 91's Face Sheet showed the resident was re-admitted with diagnoses including pain, atrial fibrillation (A-fib an irregular and often very rapid heart rhythm), stroke, high blood pressure, diabetes, skin cancer, history of flu and pneumonia. Review of the resident's Physician's Note dated 2/17/26 showed: -The resident was being seen for an acute visit related to foot pain and treatment for anxiety (a natural human response to stress, characterized by feelings of unease, worry, or fear regarding a diffuse or future threat) and depression (a common and serious mood disorder causing persistent sadness). -The resident roomed with his/her spouse, and his/her spouse had a decline in his/her health and was recently hospitalized and came back on hospice. The resident had been worried about him/her and was struggling with seeing him/her decline. He/She became teary eyed as we talked about everything that he/she was dealing with.-The resident was seen and examined. The resident expressed difficulty walking and was in need of diabetic shoes. -Plan of Care: To obtain new diabetic shoes for the resident. His/Her spouse returned to the facility and seemed to be in better condition which made the resident happy. The physician discussed the resident's pain and medications with nursing staff and will continue to monitor.-The physician's note did not discuss the resident possibly discharging from the facility or any future needs or plans once the resident's spouse passed away.Review of the resident's Health Status Note dated 2/20/26, showed the resident and family stated that they did not wish to continue with therapy services at this time. The therapy department was updated. There were no further Health Status Notes documented in the resident's medical record to include discharge planning notes.Review of the resident's Social Service Note dated 2/25/26 showed:-The resident did not need or want an interpreter to communicate with a doctor or health care staff. -Lack of transportation had not kept the resident from medical appointments, meetings, work or from getting things needed for daily living. -The resident sometimes needed assistance when reading instructions, pamphlets, or other written material from your doctor or pharmacy.-He/She sometimes felt lonely or isolated from those around him/her.-There were no additional Social Service Notes documented in the resident's medical record to include discharge planning notes.Review of the resident's Physician's Order dated 3/17/26, showed a physician's order dated 3/17/26, to discharge the resident home. Discharge orders did not show any follow-up health care instructions (home health services).Review of the resident's Medical Record showed:-Health status notes showed there were no progress notes documented after 2/27/26. -There was no discharge nursing note showing when or if the resident discharged , where he/she discharged to and if any home health services were provided to the resident. There were no notes showing the disposition of the resident's medications or belongings.-There was no social service notes dated after 2/25/26. -There were no notes showing if/when the resident was planning to discharge, if discharge was abrupt or why the resident was discharged from the facility. There was no documentation showing if any follow-up appointments were needed or made, or if follow-up services were offered or initiated. -There was no documentation in the resident's medical record that showed the resident's recapitulation of stay, discharge summary or disposition of his/her medications and belongings.During an interview on 4/17/26 at 9:48 A.M., Physical Therapist A said:-The resident was in the facility because his/her spouse was here, and they wanted to be together.-They provided physical therapy services to the resident for ambulation at the request of the resident's family due to some inconsistencies with using his/her walker, but the resident wanted to stop therapy because he/she said it was more stressful, and it was causing him/her more pain, so they stopped services.-They provided therapy to him/her from 2/16/26 to 2/23/26.-The resident's spouse became sick and went into the hospital and then he/she went on hospice (end of life) services and the resident wanted to be with him/her, so he/she spent a lot of time with him/her there.-His/Her spouse passed away, and the resident left abruptly soon afterward.-He/She did not know where the resident discharged to because the family had sold the resident's home after he/she and his/her spouse moved into the facility.During an interview on 4/17/26 at 10:06 A.M., the Social Services Director said:-The resident lived here with his/her spouse because he/she couldn't care for him/her at home, the resident's spouse went on hospice services, and they decided to come into the facility.-The resident's family said if anything happened to the resident's spouse, the resident would probably go live with him/her or another family member.-When the resident's spouse went into the hospital, the resident would not leave the hospital and stayed with his/her spouse. The resident's family would come to get his/her medications daily.-When the resident's spouse passed away on 2/28/26, the family took the resident to go make funeral arrangements and the resident would come back and forth and get his/her belongings out of the facility, but he/she never came back to the facility permanently.-The resident's family said the resident would not be coming back to the facility.-He/She offered the resident services (home health), but the resident declined.-While the resident lived at the facility, he/she was very independent and did not need assistance with cares.-The resident was taking medications while he/she was at the facility, but he/she did not know what the disposition of the resident's medications were and would have to ask the nursing staff.-The resident came back to the facility and picked up the rest of his/her belongings.-He/She spoke with the resident's daughter after the resident discharged from the facility about a follow up appointment that was scheduled and at that time the resident was still living with his/her family.-He/She did not document any of this information in his/her notes in the resident's medical record.-He/She was aware they were supposed to write a discharge summary to include a recapitulation of the resident's stay, disposition of the resident's medications and belongings and any follow up services needed.-He/She did not see any notes showing what happened to the resident, where the resident went to live or any aftercare follow up services or appointments in the resident's medical record.During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said:-He/She expected there to be a discharge summary that included a recapitulation of the resident's stay, disposition of medications and of his/her belongings and after care services upon the resident's discharge.-The interdisciplinary team should complete the recapitulation of the resident's stay. Each member should document their area of the resident's discharge disposition.-He/She would expect the nursing and social work staff to document notes leading up to the resident's discharge if they were aware of any changes in the resident's discharge disposition (resident status). -There should be documentation showing when the resident actually went home to include his/her health status on the day he/she left the facility, where the resident was discharged to, transportation, the disposition of the resident's medications and belongings and any follow-up care and services provided on the date of discharge.

Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of an indwelling catheter (a flexible tube inserted through the urethra into the bladder for continuously drain urine) connected to a catheter drainage bag (is a medical device that connects to a urinary catheter to collect urine. The key types include leg drainage bags for mobility and a bedside drainage bags for larger, overnight capacity) while in bed and up in wheelchair for two sampled residents (Resident #81 and #12) who were at risk for Urinary Tract Infections (UTI an infection of one or more structures in the urinary system); failed to transcribe detailed comprehensive physician's orders for an indwelling catheter to include the catheter type and size of catheter (size is described using French units (Fr) in diameter and the amount in cubic centimeter (cc) bulb/[NAME] to be inflated to hold catheter in place) for one sampled resident (Resident #81), and failed to ensure a comprehensive indwelling catheter care plan included the type and size of catheter, type of drainage bag to be used and when, and monitoring for catheter bag placement for two sampled residents (Resident #81 and #12) out of 19 sampled residents. The facility resident census was 86 residents. Review of Reference guidelines from medlineplus.gov showed:-The facility was to ensure that residents with indwelling catheters receive appropriate care and maintain their dignity and privacy when indwelling catheters are in use.-Foley catheter leg drainage bags must be always placed below the bladder to allow gravity drainage and prevent urine backflow, which can cause infection. -Leg bags are meant for daytime use (when you can monitor the fullness of the bag). If you lie down, nap or sleep with one, it could overflow or back up into your bladder. Review of the facility catheter policy dated 2021 showed: -Leg drainage bags may be used for ambulatory residents or per resident request.-Legs drainage bags may be worn during the day but need to be removed and a bedside drainage bag replaced on the catheter at night.-Legs drainage bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight.-Empty catheter drainage bags when bag is half-full or every 3 to 6 hours.-Ensure catheter drainage bag located below the level of the bladder to discourage back flow of urine.-NOTE: Did not have documentation related to foley catheter physician orders.1. Review of Resident #12's admission Record showed the resident had a diagnosis of Neuromuscular Dysfunction of bladder (is a general term for a group of disorders in which neurological lesions cause bladder and/or urethral dysfunction).Review of the resident's physician order sheet (POS) dated 4/1/26 to 4/14/26 showed: -Bactrim DS (antibiotic) Oral Tablet 800-160 milligrams (mg) (Sulfamethoxazole-Trimethoprim) Give one tablet by mouth one time a day for Prophylaxis UTI, was ordered on 3/6/26.-Urinary Catheter size of 18 fr with a 30-cc bulb/[NAME] to inflate to hold in place for Neurogenic bladder, was ordered on 4/10/2026-Ciprofloxacin HCl Oral Tablet 500 mg (an antibiotic) Give one tablet by mouth two times a day for UTI for five days, was ordered on 4/14/26. Review of the resident's Health Status note dated 4/13/26 at 11:25 A.M., showed: -Hospice (end of life care) nursing staff were there for hospice visit.-The resident's catheter could not be irrigated/ flushed. -He/She had dark urine with sediment. -A new catheter was placed and a new physician's order for urinalysis (UA) with culture and sensitivity, if indicated was obtained.Review of the resident's Health Status Note dated 4/13/26 at 12:19 P.M., showed:-The resident had excessive sediment and malodorous urine. -Hospice nurse was there. -Received physician's order to obtain a UA and an order to start Ciprofloxacin while urine culture was pending. Observation on 4/13/26 at 2:19 P.M., of the resident while in bed showed:-The resident was semi flat in bed. -There was no catheter drainage bag hung on the bed frame. Observation on 4/13/26 at 2:26 PM., of the resident while in bed showed:-The resident was semi flat in bed. -There was no catheter drainage bag hung on the bed frame. During an interview on 4/13/26 at 2:26 P.M. the resident said:-He/She had a catheter and had a leg drainage bag in place while lying in bed.-The leg drainage bag was at the level of the bladder and was not below the bladder. Observation on 4/14/26 at 9:48 A.M. of the resident's incontinent care and transfer showed:-Care was provided by Certified Nursing Assistant (CNA) G and CNA C.-CNA G and CNA C entered the resident's room to wash hands with soap and water, then applied new gown and gloves. -CNA G provided resident catheter care to include use of soapy wash cloth to clean the genital area then folded to a clean section of wash cloth to clean catheter tubing downward toward leg drainage bag, which was attached to left lower leg. -CNA G rinsed the soap off the genital area and catheter tubing. Then dried the area with a clean washcloth. -CNA G had removed soiled gloves and washed hands, then applied clean gloves to hands. -CNA C had resident turn to side and completed resident back side care.-CNA G applied the resident's clean brief and pants. -CNA G and CNA C then removed the soiled gloves and one new glove was applied to transfer the resident to his/her wheelchair. -CNA G and CNA C transferred the resident with two person assist and a gait belt. -The resident was able to stand and pivot. No issue with transfer. -The catheter drainage bag was underneath his/her pant leg attached to the left leg. 2. Review of Resident #81's admission Face sheet showed the resident had the following readmitting diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses)-Neuromuscular Dysfunction of bladder.Review of the resident's catheter care plan dated 5/1/25 showed: -The resident had an indwelling catheter.-Check tubing/catheter care as physician ordered.-Monitor and document urine intake and output as per facility policy.-Monitor for signs and symptoms of discomfort on urination and frequency.-Monitor/document for pain/discomfort due to catheter.-NOTE: The comprehensive care plan did not include the type of indwelling catheter, the size of the catheter and the amount to inflate the [NAME] and to ensure safe placement below bladder for foley catheter drainage bag and tubing placement.Review of the resident's POS dated 4/1/26 to 4/14/26 showed: -Urinary Catheter: Drainage Bag - Change one time a day every 7 days., order dated 2/20/26.-Urinary Catheter Care every shift ordered on 2/19/26.-NOTE: Did not have detailed comprehensive indwelling catheter physician order to include the type of indwelling catheter and the size of the catheter with [NAME]/bulb size and type drainage bag to be used and when. Observation on 4/13/26 at 10:34 A.M., of the resident showed:-He/she was in a low bed to the ground with catheter drainage bag hung on bed frame and was touching the ground and was not in a privacy bag.-The urine in catheter drainage bag was apple juice color.Observation on 4/15/26 at 10:46 A.M. of the resident showed:-The resident was in bed, did not have catheter drainage bag hung on bed frame at that time. -He/she was flat in bed with catheter leg drainage bag on left leg at the level of his/her bladder.During an interview on 4/15/26 at 10:46 A.M. the resident said he/she had a catheter. Observation on 4/16/26 at 12:45 P.M., of the resident sitting in his/her wheelchair showed: -His/Her catheter tubing was dragging on the ground underneath his/her wheelchair. -The drainage bag was inside the privacy bag that was hooked underneath the wheelchair.3. During an interview on 4/17/26 at 9:11 A.M., Certified Medication Technician (CMT) B said Nursing MRR would have detail catheter care physician orders on type, size of foley catheter and care needed. During an interview on 4/17/26 at 9:28 A.M., CMT A and Registered Nurse (RN) A said:-Residents who had a catheter leg drainage bag should be emptied every two hours and during incontinent care. -Catheter drainage bags should be always placed below the resident bladder.-Resident #12 had a catheter leg drainage bag due to his/her history of self-transfer from bed to wheelchair which had caused traumatic removal of the indwelling catheter in the past. -He/she was not aware of physician order for use of leg bag or if should have been care planned.-He/she had not thought about the placement of resident in bed with catheter leg drainage bag on, was not below the bladder, the leg drainage bag be at level with the resident bladder when lying flat. -Resident #12's and Resident #81's catheter did not have a special valve to prevent urine from flowing back into the bladder. -Resident #81 and Resident #12 should have detailed catheter physician's orders that included the catheter type and size, (size French, bulb/[NAME] size), catheter drainage bag to be used, catheter care each shift and ongoing daily monitoring of catheter site and placement. During an interview on 4/17/26 at 9:28 A.M., CNA B said: -Catheter leg drainage bag, large drainage bag should be emptied every 2 hours.-Catheter drainage bags should be below the bladder all times. -He/She would empty the leg drainage bag prior laying the resident down for nap or at night. -He/She had not thought about the leg drainage bag being at level with bladder, while resident was flat in bed. -CNA's and Licensed Nursing Staff would check the resident electronic medical record on how to care for resident and the CNA could also obtain report from changer nurse of any possible resident care changes. During an interview on 4/17/26 at 10:08 A.M., Infection Control Preventionist (ICP) said: -The resident catheter drainage bag should be hanging on bed frame while in bed and ensuring catheter drainage bag and tubing were not touching the ground. -The resident with catheter leg drainage should be changed to full catheter drainage bag while in bed for extend period.During an interview on 4/20/26 at 12:12 P.M., DON said: -He/she would expect nursing staff to ensure to have transcribed a detailed physician's order for catheter include type, size catheter with [NAME]/bulb size and when to provide catheter care and monitoring of urine output, when to change foley catheter and the type of drainage bags to used and when. -The resident's catheter leg drainage bag should be in his/her care plan and include reasons for use of leg bag (preference or incident with catheter).-He/she would expect nursing staff and care staff to ensure the resident's catheter drainage bag and tubing do not touch the ground while in bed or up in wheelchair.-While in bed the resident's catheter drainage bag should be always kept below the level of bladder with care, transfer, while in bed or up in chair. -If residents lay in bed for extended periods staff should ensure to change from the leg drainage bag to the bigger/nighttime catheter drainage bag. -The resident care plan should be comprehensive to reflect the resident current medical condition and should include type and size of catheter when to be changed and ongoing catheter care, type drainage placement.

Based on observation, interview and record review , the facility failed to ensure comprehensive physician's orders were documented on the resident's physician's order sheet (POS) and transferred to the medication administration sheet (MAR) and treatment administration record (TAR) for two sampled residents (Resident #60 and #38) who had a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, connecting the healthy part of the large intestine (colon) to the outside of the body); and failed to ensure the base line and comprehensive care included the supplies and care needed for one sampled resident (Resident #60) who had a colostomy out of 19 sampled residents. The facility census was 86 residents. Review of the facility undated Colostomy care Policy showed:-The facility must ensure that residents who require colostomy services receive such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.-A comprehensive assessment of each resident will be completed within 14 days of admission to the facility as well as periodically, as required.-The comprehensive care plan of the resident with colostomy will reflect measurable goals and intervention for the care of such ostomies. 1. Review of Resident #60's admission Face sheet showed he/she had a diagnosis of colostomy status. Review of the resident's colostomy care plan dated 8/4/25 showed: -The resident had an alteration in gastro-intestinal status related to colostomy.-Change colostomy bag as ordered.-NOTE: There was no detailed documentation in the comprehensive care plan to show the care of the colostomy site, type ostomy bag and size wafer to be used and how often to change the ostomy drainage bag/pouch and wafer. Review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning) dated 1/16/26, showed:-The resident was cognitively intact and able to make his/her needs known. -Had an ostomy while a resident at the facility. Review of the resident's POS and TAR dated 4/1/26 to 4/30/26 showed the resident:-Had a physician order for colostomy care every shift and as needed every shift dated 11/6/25.-NOTE: There was no detailed documentation on the POS and TAR to show the care of the colostomy site, type ostomy bag and size wafer to be used and how often to change the ostomy drainage bag/pouch and wafer and ongoing nursing monitoring/assessment of ostomy stoma site every shift and as needed. Review of the resident's Skin Check dated 4/13/26 at 10:30 A.M. showed:-His/Her skin was warm & dry, skin color was within normal limits and turgor (the state of firmness or tension in living cells) was normal. -No skin issues were identified.-NOTE: There was no documentation of a comprehensive nurse assessment of the resident's colostomy stoma site and surrounding skin. Review of the resident's TAR for colostomy care on 4/13/26 at 1:28 P.M., showed:-The resident did have a colostomy and care already provided for that day. -The resident would tell the care staff when the ostomy bag and wafer needed to be emptied or changed. Review of the resident's electronic medical record on 4/15/26 at 11:49 A.M., showed:-There was no documentation of an initial admission comprehensive assessment of ostomy stoma site.-There was no documentation of follow-up detailed nursing assessment of the stoma site and surrounding skin. Observation and interview on 4/16/26 at 2:00 P.M., during the resident's colostomy care showed:-Certified Nursing Assistant (CNA) N and CNA E and the Infection Control Preventionist (ICP) were present for resident care. -Care staff washed their hands prior to applying protective gown, gloves and mask. -CNA N removed the resident's ostomy bag and wafer and placed the soiled ostomy bag and wafer in a plastic bag.-CNA N cleaned the stoma and surrounding skin with a soapy washcloth then rinsed the stoma site and dried stoma site with a clean towel.-The resident's ostomy stoma was reddish in color, with no skin irritation around the stoma and surrounding skin.-The resident said he/she had no complaints of soreness at the stoma site or surrounding skin. -CNA N said the resident's stoma was assessed by CNA's and nursing when they changed the wafer weekly and as needed.-CNA A said the resident's ostomy wafer size was precut and the drainage bag clicked in place. He/she was not sure the actual wafer and bag size needed for the resident. The colostomy supplies were in the nursing locked medication room. He/she obtained the resident's ostomy supplies from the charge nurse. -CNA N and CNA E said he/she would notify the charge nurse if there were any skin changes to the stoma site. -The ostomy supplies obtained from the room behind nursing station should be labeled with the resident name on the ostomy supplies boxes. During an interview on 4/16/26 at 12:47 P.M., CNA A said:-The CNAs would clean around the resident's colostomy stoma site and would empty the ostomy bag when it was full.-He/She would check the ostomy stoma site and ostomy bag during resident rounds.-He/She would notify the charge nurse about any resident skin changes to include ostomy stoma site and surrounding skin. During an interview on 4/16/26 at 2:20 P.M., Registered Nurse (RN) A said:-The resident's colostomy supplies were locked in the medication room.-The box was not labeled and no signage posted with the resident's colostomy type, size of wafer and collection bag needed. -The boxes in the cabinet were not labeled with a resident name.-He/She just knew what size the resident ostomy wafer and drainage bag were.-He/She would expect to have a detailed physician's order and care plan for the colostomy size wafer and drainage pouch needed. -The POS should have the size and type of colostomy supplies and when care should be provided. During an interview on 4/17/26 at 9:11 A.M., Certified Medication Technician (CMT) B said:-The nursing Medication Administration Record (MAR) or TAR would have detailed orders to include the type and size of ostomy supplies the resident needed. During an interview on 4/17/26 at 9:28 A.M., RN A said:-The wound nurse would be responsible for monitoring and assessment of the resident's ostomy site.-The resident's ostomy site was stable and was a mature stoma (not new ostomy stoma site).-The admitting nurse would be responsible for competing the initial comprehensive skin assessment to include ostomy stoma site, and surrounding skin. -He/She would expect the resident's initial base line care plan and comprehensive care plan to include details related to the resident care for the ostomy site and the type and size of ostomy supplies needed. 2. Review of Resident # 38's Face Sheet showed the resident was admitted with a diagnosis including colostomy. Review of the resident's care plan dated 11/13/25, showed the resident had bowel incontinence related to his/her colostomy. Interventions showed:-The resident would have less than two episodes of incontinence per day through the review date.-Staff would check the resident every two hours and assist with toileting as needed and provide colostomy care as ordered.-Provide loose fitting, easy to remove clothing.-See care plans on mobility, activities of daily living (bathing, dressing, hygiene, toileting), cognitive deficit, and communication. Review of the resident's MAR and TAR dated February 2026, March 2026 and April 2026 showed:-There was no documentation showing physician's orders for the monitoring or treatment of the resident's colostomy or stoma site. -Documentation showed there was no indication of if or when the resident's colostomy bag was changed. Review of the resident's Weekly Skin Checks dated February 2026, March 2026 and April 2026 did not show the resident's colostomy was checked as part of the resident's skin assessment. Review of the resident's quarterly MDS dated [DATE] showed the resident:-Was alert and oriented without confusion.-Had no mood disorder or behavior problems and showed no signs or symptoms of depression.-Was dependent and needed maximal assistance for bathing, dressing and transferring.-Was dependent on staff for toileting and had an ostomy. Review of the resident's POS dated April 2026, showed:-There were no physician's orders for colostomy care to include the type and size of the pouch used and supplies needed, the frequency for changing the colostomy, monitoring for complications, and skin care treatment. During an interview on 4/15/26 at 7:19 A.M., the resident said:-He/She was here for rehabilitative services, and it was going well. -The nurse had not been in to check his/her colostomy yet, but he/she looked at it and it was not full and did not need to be changed. -The nurse completed his/her colostomy changes as needed and the nursing staff completed his/her colostomy care.-They checked it several times daily. -He/She did not want an observation of his/her care but was satisfied with the care that he/she received from the nursing staff. During an interview on 4/16/26 at 12:47 P.M., CNA A (also the Restorative Aide) said:-They cleaned around the resident's colostomy daily as part of his/her routine care and they empty the bag when it was full.-They would check the resident's colostomy throughout the day during rounds and whenever the resident let them know it needed to be emptied.-Yesterday the resident asked for it to be changed, and he/she changed the bag for the resident.-He/She knew which colostomy bag the resident used (he/she was unable to identify the bag size). During an interview on 4/16/26 at 1:00 P.M. CMT A said:-He/She had cleaned around the resident's stoma site and emptied his/her colostomy bag when it's been full.-The resident was to have the colostomy bag changed as needed. -The resident let them know when the colostomy bag was full and needed to be emptied or changed.-The nurse usually obtained the colostomy bags for the resident.-They checked the resident for incontinence throughout the day. During an interview on 4/16/26 at 1:45 P.M., RN A said:-The nursing staff performed colostomy care daily on the resident and they changed the resident's colostomy bag as needed.-He/She was familiar with the resident and knew what size colostomy bag the resident used, but the physician's order should show the resident had a colostomy, the size of the colostomy bag needed and care/monitoring.-He/She would expect to see the care and monitoring of the resident's colostomy on the resident's MAR and TAR.-He/She was unaware that the physician's order for the resident's colostomy was not on the resident's POS and on the MAR/TAR. During an interview on 4/20/26 at 12:12 P.M., the Director of Nursing (DON) said:-There should be an initial assessment showing in detail what the resident's colostomy looked like.-Regarding colostomy care, there should be an order on the POS for the resident's colostomy and care for the resident's stoma site.-The order should show the resident has a colostomy, the wafer bag size, how often the colostomy bag should be changed and when/how they would monitor it (every shift).-The order should also be on the resident's MAR and TAR and they should document that they were monitoring the site. -The colostomy should be care planned. -The facility MDS coordinator and nursing staff would be responsible to ensure the ostomy supplies were labeled with the resident's name for the wafer and sized required.-Resident #60 and Resident #38 should have detailed orders on their POS, MAR, TAR, they should have care plans that addressed the colostomy, and they should have ostomy supplies labeled with their name available.

Based on observation, interview and record review, the facility failed to ensure that an acquired skin tear to the resident's left elbow did not deteriorate to a wound that had bone and tendon exposure and became infected and to have the right setting for the air loss mattress for a resident that weighs 140 pounds; to notify the resident's physician when there was a change in the condition of the resident's left elbow wound, to follow physician's orders [REDACTED]. to change the wound treatment order in a timely manner for one sampled resident (Resident #1); to identify an infected wound prior to the development of a scab to the resident's toe, to document a complete description of the wound weekly and to ensure accurate documentation (such as the wrong location and conflicting information between documents) of the wound for one sampled resident (Resident #4) out of 13 sampled residents. The facility census was 71 residents. Record review of the facility's policy titled Wound Care and Treatment dated March 2015 showed: -The purpose was to prevent and treat all wounds; -The guidelines were as follows were listed as to how to perform a dressing change; -Prevention Strategies included: --On-going skin assessment with weekly documentation of status; --Physicians should be notified of potential risks; -Consultations included: --Dietitian; --Quality Assurance Nurse; --Physical Therapy and/or Occupational Therapy; -Treatment guidelines listed included: --Universal precautions and strict hand washing procedure for all wound care and/or patient contact; --Remove existing dressing and dispose of old dressing properly; --Cleanse wound with appropriate cleanser for type of wound; and --Wound cleaning guidelines included: --Cleanse all wounds; --Dry around the wound without touching the wound bed; --Apply dressing as ordered; and --Use protective barrier wipe to peri-wound/tape area of intact skin. Record review of the facility's policy titled Wound Dressings dated March 2015 showed: -The different types of wounds; -The symptoms of the types of wounds; and -The treatment for [REDACTED]. 1. Record review of Resident #1's undated face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -[DIAGNOSES REDACTED] (a narrowing of the main artery of the heart which prevents the valve from fully opening which in turn obstructs blood flow from the heart into the rest of the body); -Low back pain; -Depression; and -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Record review of the resident's Significant Change MDS (Minimum Data Set a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/1/17 showed he/she: -Was severely impaired cognitively; -Required extensive assistance from one to two staff members with bed mobility, transfers, dressing, eating, personal hygiene, bathing and toileting; -Was incontinent of both bowel and bladder; -Was at risk for skin breakdown and -Was receiving hospice services ( end of life care). Record review of the resident's pressure ulcer care plan dated 2/1/17 showed he/she: -Was at risk for pressure ulcers related to being incontinent of bowel and bladder, requiring assistance with bed mobility; -Was to have moisture barrier to his/her skin as needed; -Was to be turned and repositioned every two hours and as needed (staff was saying he/she was to be repositioned every hour and every two hours and positioned from his/her back to left side and from his/her back to left and right sides); -Was to have all bony prominences separated from each other with pillows, wedges; -Was to have bunny boots (soft skin protectors that keeps heels and elbows from coming in contact with hard surfaces) on at all times for wound prevention; -Was to have all signs of skin breakdown reported to the charge nurse for appropriate intervention/treatment to be put into place; -Was to have a pressure reduction mattress when in bed; -Was to have a pressure reduction cushion in his/her wheelchair; and -Was to have skin assessments done weekly. Record review of the resident's nurse's notes dated 3/7/17 showed he/she: -Was being transferred by a full body mechanical lift and got a skin tear to his/her left lateral distal humerus (the area on the upper arm right above the elbow joint on the outer aspect of the arm); -Measurements of the skin tear were 0.5 centimeters (cm) X 0.5 cm; and -Treatment orders were to clean the site, put the skin back into proper position, apply steri strips (adhesive bandage strips that are applied across the laceration in a manner which pulls the skin on either side of the wound together), and check every shift. Record review of the resident's weekly skin assessments dated 3/7/17 showed he/she had intact skin and had none of the following skin issues: -Skin tears (Nurses notes showed he/she obtained a skin tear on 3/7/17 to his/her left elbow); -Bruises; -Rash/hives; -Any red or excoriated areas; -Blisters. Record review of the resident's nurse's notes dated 3/8/17 to 3/17/17 showed: -No documentation that mentioned the condition of the resident's left elbow skin tear; -No documentation that mentioned the resident's left elbow wound measurements and -No documentation that mentioned the resident's left elbow wound treatment of [REDACTED]. Record review of the resident's nurse's notes dated 3/18/17 showed he/she: -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. Record review of the resident's nurse's notes dated 3/22/17 to 3/31/17 showed the resident: -Had drainage on his/her left elbow dressing; -Had swelling and redness at his/her left elbow wound site; -The measurements of his/her left elbow wound were 3.7 cm X 2.0 cm (the wound was longer and wider since last measured 3/7/17); -Had a new physician's orders [REDACTED]. -Had a new physician's orders [REDACTED]. -On 3/25/17 his/her left elbow wound area was red with a yellow center, was warm to touch, and had brown drainage (there was no documentation that the resident's physician was notified of the change in the wound appearance and characteristics); -On 3/29/17 the documentation showed his/her left elbow continued to be red, warm to touch and had a moderate amount of drainage (the color of the drainage was not documented); -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. -Had a physician's orders [REDACTED]. -On 3/31/17, there was documentation that showed the wound nurse had been in the building but did not see the resident or treated the resident's left elbow wound; and -On 3/31/17 the acting Director of Nursing (DON) said the wound nurse required 48 hour notice to see a resident and treat any wounds (the order for the wound nurse to evaluate and treat was written on 3/29/17). Record review of the resident's weekly skin assessments dated 3/28/17 showed he/she had a wound to his/her left elbow with a dressing in place (this was the first weekly skin assessment in March that showed the resident had any skin issues when he/she actually had a skin tear since 3/7/17). Record review of the resident's wound log dated 3/31/17 showed he/she: -Had an unidentified type of wound on his/her left elbow that measured 3.5 cm X 2.2 cm X 0.2 cm (the wound was longer and wider and now has depth since last measured on 3/22/17); and -Had slough (dead tissue), an odor, and a moderate amount of drainage. (there was no documentation by the staff that the resident's physician was notified of the change in resident's left elbow wound). Record review of the resident's completed lab reports dated 4/2/17 showed: -The wound culture of the left elbow was positive for heavy growth of Proteus mirabilis (a bacterial found in fecal matter that causes infections in the skin, wounds and other locations); -A physician's orders [REDACTED]. -A physician's orders [REDACTED]. Record review of the resident's medical record showed on 4/5/17 a new treatment order was written for the resident's left elbow wound that included cleanse the resident's left elbow with wound cleaner, apply Calcium Alginate (A wound dressing used to manage drainage in partial to full-thickness wounds, providing a moist environment for healing) and cover with border gauze dressing and change the dressing daily and as needed. Record review of the resident's wound log dated 4/7/17 showed he/she: -Had an unidentified type of wound on the left elbow that measured 3.2 cm X 2.0 cm X 0.2 cm; -Had a deteriorated wound and -Had a large amount of drainage. Record review of the resident's medical record showed on 4/9/17 a new physician's orders [REDACTED]. Record review of the resident's completed x-ray report dated 4/10/17 showed the left elbow had no evidence of acute fracture, dislocation or osseous (bone) lesion, the joint spaces appeared preserved, there was no evidence of fat pad displacement to suggest joint effusion, the adjacent soft tissues appeared unremarkable. Record review of the resident's medical record showed on 4/11/17 a new physician's orders [REDACTED]. Record review of the resident's wound log dated 4/14/17 showed he/she: -Had a skin tear/unstaged ulcer that measured 2.5 cm X 1.5 cm X 0.3 cm (which showed the wound the length was less, the width was less and depth was deeper since last measured on 4/7/17); -Had no tunneling; -Had a moderate amount of serosanguinous (blood tinge yellowish fluid) drainage and -On 4/18/17 a new order was written for a pre-[MEDICATION NAME] (A protein that is made in the liver and released in the blood. It helps carry certain hormones that regulate the way the body uses energy and other substances through the blood. When [MEDICATION NAME] levels are lower than normal, it may be a sign of a poor diet (malnutrition) to be drawn on 4/19/17 for the left elbow wound. Record review of the resident's contracted wound care team report dated 4/21/17 showed the resident's left elbow wound: -Had an other/full thickness wound to the left elbow that measured 2.0 cm X 0.9 cm X 0.5 cm (which showed length of the wound was less, the width of the wound was less and the wound was deeper); -Was covered with 100% of slough (yellowish tan dead tissue); -Had a moderate amount of serosanguinous drainage; -Had excoriation (raw, irritated skin) and tenderness present; and -Had a treatment recommendation to apply Santyl to the wound and to change the dressing daily and as needed. Record review of the resident's Physician order [REDACTED]. -On 4/26/17 (five days after the wound care team made the recommendation) a physician's orders [REDACTED]. -Perform weekly skin assessments. Record review of the resident's wound care team report dated 4/28/17 showed the resident: -Had an other/full thickness wound to his/her left elbow that measured 1.6 cm X 1.4 cm X 0.5 cm (which showed the wound to less in length, wider and the depth of the wound remained the same since last measured on 4/21/17); -Had undermining (a separation of the skin and tissue from the structures underneath the area) of 0.8 cm from 1 O'clock to 7 O'clock (this is new and the wound had deteriorated since last measured on 4/21/17); -Had 80% slough, 10% necrotic (dead) tissue and 10% bone exposure (this is new); -Had a moderate amount of serosanguinous drainage; -Had excoriation, increased warmth, maceration (when the area of skin surrounding a wound has an excessive amount of moisture in it) and tenderness present (this was new); and -Had a recommendation of changing the treatment to Calcium alginate and to change the dressing daily and as needed. (This had deteriorated from when last seen by the wound care team on 4/21/17) Record review of the resident's wound care team report dated 5/5/17 showed the resident's left elbow wound: -Had a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present to the left elbow that had 0.5 cm undermining from 12 O'clock to 12 O'clock (no other measurements documented and this showed the undermining was around the entire wound edges); -Had 20% granulation tissue (part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound) and 80% tendon exposure (this was different); -Had a mild odor (this was different and did not have and odor on 4/21/17), moderate amount of serosanguinous drainage, redness, excoriation, increased warmth, maceration and tenderness was present; and -There was no changes to the wound treatment. Observation on 5/10/17 at 9:48 A.M., showed the resident: -Was in bed positioned on his/her back; -Had his/her left elbow positioned by his/her left side next to and touching the low air loss mattress bolster that was at the head of the bed; -Did not have any elbow protector of any kind on his/her left elbow; and -Had a low air loss mattress set at nine. (setting for a 350 pound person) Observation on 5/11/17 showed the resident: - At 8:43 A.M.; --Was sitting in his/her high back wheelchair with a full body mechanical lift sling under him/her; --Was positioned in the high back wheelchair with his/her left arm by his/her left side between his/her body and the wheelchair; --Did not have an elbow protector of any kind on his/her left elbow; - At 11:09 A.M.; --Was in bed positioned on his/her left side after having had incontinence care provided by the staff; --Had his/her left elbow positioned on the outer aspect, bent at the elbow joint with his/her hand towards his/her chest/face; --Did not have any kind of elbow protector on his/her left elbow; --Had his/her low air loss mattress in place set at five (set for a 210 pound person); -At 2:30 P.M.; --Was in bed positioned on his/her right side; --Did not have any kind of elbow protector on his/her left elbow; and --Had his/her low air loss mattress set at five (for a 210 pound person). Observation on 5/12/17 at 4:10 A.M., showed the resident: -Was in his/her bed positioned on his/her back; -Had his/her left elbow positioned by his/her left side next to and touching the low air loss mattress bolster that was at the head of the bed; and -Air loss mattress that was set on nine (the firmest setting for a 350 pound person). During an interview on 5/12/17 at 4:10 A.M. Certified Nursing Assistant (CNA) C said: -The resident was repositioned every two hours on the 6:00 P.M. to 6:00 A.M. shift when he/she was checked and changed; and -Was positioned on his/her back and left side. During an interview on 5/12/17 at 4:33 A.M., Certified Medication Technician (CMT) A said: -The resident was repositioned every hour on the 6:00 P.M. to 6:00 A.M. shift; and -Was positioned on his/her back and left side. During an interview on 5/12/17 at 6:06 A.M. Registered Nurse (RN) A said: -Hospice provided the low air loss mattress; -The company that delivered the mattress set the level; -The mattress should be set at five and no higher (five was the setting for a 210 pound person); -The mattress should not be set at nine; -The resident weighs around 140 pounds and -The setting of three seemed awfully low, but if the setting was based on the resident's weight than the mattress should be set at three. Observation on 5/12/17 at 9:58 A.M., showed the resident: -Had a dressing on his/her left elbow with a date of 5/11/17 in place; -Was pre-medicated with [MEDICATION NAME] ([MEDICATION NAME] a narcotic pain medication) 0.25 mg, 30 minutes before the treatment was completed; -Had tan drainage on the old dressing when it was removed; -Had dark pink/red tissue surrounding the elbow wound; -Had yellow/white wound edges all around the elbow wound; -Had a wound bed that had a small area of pink, but was mostly white (tendon or bone); -Had a wound opening that was positional and would freely move when the arm was positioned; -Did not have wound measurements taken at that time; and -Only had the visible wound bed cleaned (the wound was not assessed for any undermining and the wound opening was not repositioned to clean any other part of the elbow area that was occasionally visible). During an interview on 5/12/17 at 10:10 A.M. Registered Nurse (RN) A said: -The wound started as a skin tear; -The skin tear was caused by the resident's wheelchair arm rest because it was not padded; and -After the resident had the skin tear the facility added the padded wheelchair arm rests. During an interview on 5/16/17 at 10:07 A.M., the resident's Primary Care Physician said: -The contracted wound care team was seeing the resident and managing his/her wound care treatments; -The resident's left elbow had a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints); -The left elbow wound started as a skin tear, got infected and had continued to deteriorate; -The resident did not have any [DIAGNOSES REDACTED]. -The lab work and x-ray that were done to determine a cause for the wound deterioration did not show anything abnormal and -He/she did not know how a skin tear could deteriorate to the condition it was currently. During an interview on 5/16/17 at 2:53 P.M., the corporate Administrator said prior to 4/17/17 there was a Wound Nurse employed in the building. During an interview on 5/17/17 at 9:45 A.M. Licensed Practical Nurse (LPN) B said: -The resident was turned and repositioned every hour; -The resident got the skin tear on his/her left elbow during a transfer; -The resident's low air loss mattress was delivered and set by hospice; -The resident's low air loss mattress should be set based on the resident's weight; and -The resident did not have elbow protectors ordered until after the left elbow wound had deteriorated that it needed a treatment other than steri strips. During an interview on 5/17/17 at 11:40 A.M. the acting Director of Nursing (DON) said: -The left elbow wound started as a skin tear; -The wound care team was seeing the resident for all his/her wounds; -The facility deferred to the wound team for the type and stage of the wound; -The wound team made recommendations for treatments and they had to be approved by the primary care physician; -No one knows how the skin tear deteriorated to the wound that it was currently; and -The resident was on hospice, had poor nutrition and had co-morbidities including age, diagnoses, and medications that would delay wound healing. 2. Record review of Resident #4's care plan dated 10/31/16 showed he/she was at risk for impaired skin related to diabetes (when the body cannot produce any or enough insulin-which can put individuals at greater risk for skin problems) and included instructions for staff to: -Inspect his/her feet for any abnormalities; -Monitor his/her skin, avoid drying agents and apply skin moisturizers to prevent dryness, cracking and fissures; and -Report any slow or unhealing wounds. Record review of the resident's weekly skin assessment dated [DATE] showed the resident's skin was intact. Record review of the resident's medical records showed no documentation of any skin abnormality on the resident's right second toe on the resident's weekly skin assessment sheet and the CNA bath sheet from 2/20/17-2/23/17. Record review of the resident's CNA bath sheet dated 2/23/17 showed the resident's right middle toe was red and inflamed. Record review of the resident's nurse's note dated 2/24/17 showed: -There was no documentation regarding the resident's right middle toe; -A scabbed area was noted on the resident's right second toe; -The area around the scab was red, warm and swollen; -No drainage was noted; -A physician's orders [REDACTED]. -The resident's family was to bring in new shoes for the resident. Record review of the resident's CNA bath sheet dated 2/27/17 showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE], showed: -The resident's skin was intact; -He/she had no open areas; -There was a scabbed area on the resident's right second toe; -The resident was receiving an antibiotic for his/her infected right second toe; and -The resident's right second toe was to be left open to the air. Record review of the resident's primary care physician's nurse practitioner's note dated 2/28/17 showed the resident: -Was currently on [MEDICATION NAME] for [MEDICAL CONDITION] (an infection of deep tissue) to the resident's right second toe and it was tender to touch; and -Had a [DIAGNOSES REDACTED]. Record review of the resident's nurse's note dated 2/28/17 showed the resident's primary care physician's nurse practitioner saw the resident and ordered [MEDICATION NAME] (an antiseptic-inhibits the growth and development of microorganisms) to be applied to the resident's right second toe daily and ordered an x-ray of the resident's right second toe. Record review of the resident's radiology report dated 2/28/17 showed no acute [MEDICAL CONDITION] right second toe and there was no evidence of osteo[DIAGNOSES REDACTED] (an infection in the bone). Record review of the resident's Treatment Administration Record (TAR) dated 2/22/17 to 4/21/17 showed a physician's orders [REDACTED]. Record review of the resident's nurse's note dated 3/1/17 showed: -The resident's right second toe continued to be red and warm to the touch; and -The area continued to be a red area with a small scab in the middle of the red area. Record review of the resident's CNA bath sheet dated 3/2/17, showed no documentation regarding the resident's right second toe. Record review of the resident's nurse's notes dated 3/2/17 and 3/3/17 showed the resident's right second toe continued to be red. Record review of the resident's CNA bath sheet dated 3/6/17 showed no documentation regarding the resident's right second toe. Record review of the resident's nurse's note dated 3/6/17 showed the resident's right second toe was not as red as when the nurse (the nurse writing the note) last saw it on 3/3/17. Record review of the resident's weekly skin assessment dated [DATE] showed: -There was a scab on the resident's right second toe and it had some redness around it; and -[MEDICATION NAME] was applied as ordered. Record review of the resident's CNA bath sheet dated 3/9/17 showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE], showed: -The resident's skin was intact; -There were no open areas; -There was a scab on his/her right second toe; and -[MEDICATION NAME] daily was the treatment. Record review of the resident's CNA bath sheets dated 3/13/17, 3/16/17 and 3/20/17 showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE] showed there was a scab on the resident's right second toe. Record review of the resident's CNA bath sheet dated 3/23/17 showed no documentation regarding the resident's right second toe. Record review of the resident's nurse's note dated 3/24/17, showed: -The scab came off of the resident's right second toe when the nurse pulled the resident's sock off to do the treatment to the resident's right second toe; -There was no further description of the resident's right second toe; and -The resident's primary care physician was contacted and a new physician's orders [REDACTED]. Record review of the resident's TAR dated 3/22/17 to 4/21/17 showed a physician's orders [REDACTED]. Record review of the resident's CNA bath sheet dated 3/27/17 showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE] showed: -There was an open area on his/her right second toe; and -There was no redness. Record review of the resident's wound healing record dated 3/27/17 showed: -The date of onset of a wound to the resident's right second toe was 3/27/17; -The wound measured 2.5 cm x 0.6 cm; -There was no exudate (fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) however, the exudate type was marked as serous (watery, clear, or slightly yellow/tan/pink drainage); -There was no odor; -The surrounding tissue was bright red; -The tissue surrounding the open wound area was swollen; and -The physician's orders [REDACTED]. Record review of the resident's primary care physician's progress note dated 3/28/17 showed: -The resident had a [DIAGNOSES REDACTED].>-The scab on the resident's right second toe fell off; -The resident had an open wound on his/her right second toe; -There was decreased [MEDICAL CONDITION] and redness to the right second toe and it was nontender to touch; and -The x-ray of the resident's right second toe was negative for osteo[DIAGNOSES REDACTED]. Record review of the resident's CNA bath sheet dated 3/30/17 showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE] showed: -The resident's skin was intact; -There was scab on his/her right second toe; and -Alginate and a dry dressing was the treatment. Record review of the resident's CNA bath sheets dated 4/3/17 and 4/6/17 showed no documentation regarding the resident's right second toe. Record review of the resident's CNA bath sheet dated 4/10/17 showed the resident had an open area on the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE] showed: -There was an open area to his/her right toe; -No redness was noted; and -Continue with the treatment to the right second toe open area which was to cleanse with wound cleanser, apply Calcium Alginate and cover with dry dressing, and change daily and as needed. Record review of the resident's skin monitoring shower review sheet dated 4/13/17 showed the resident had an open area on the resident's right second toe. Record review of the resident's primary care physician's nurse practitioner's progress note dated 4/14/17 showed: -The resident had a [DIAGNOSES REDACTED].>-The resident had an open wound to his/her right second toe; and -There were no signs or symptoms of infection. Record review of the resident's nurse's note dated 4/16/17 showed: -The resident's old dressing to his/her right second toe had a scant amount of yellowish green drainage on it and the wound bed had slough covering it; -There were no measurements of the open area; -The resident's right second toe was red, swollen and warm; -The resident's primary care physician's nurse practitioner was notified and gave an order for [REDACTED].>-Additional orders included: --Lab work; --No shoe on his/her right foot; and --Bunny boot to be worn on his/her right foot at all times until wound on his/her right second toe was healed. Record review of the resident's skin monitoring shower review sheet dated 4/17/17, showed no documentation regarding the resident's right second toe. Record review of the resident's weekly skin assessment dated [DATE], showed: -There was an open area to his/her right toe (no measurements or further description was documented); and -Alginate was the treatment. Record review of the resident's nurse's note dated 4/18/17 showed the resident's left (should have been right) second toe had brown drainage on the old dressing and the tissue around the wound bed was red. Record review of the resident's nurse's note dated 4/19/17, showed: -The resident was on an antibiotic for a wound infection to his/her right second toe; -The wound on his/her right second toe had a moderate amount of serous drainage on the old bandage with a slight odor; and -New treatment orders for the resident's right second toe were obtained. Record review of the resident's TAR dated 3/22/17 to 4/21/17 showed a physician's orders [REDACTED]. Record review of the resident's skin monitoring shower review sheet dated 4/20/17 showed the resident's right middle toe (should have been 2nd) was being treated. Record review of the resident's outside wound company's weekly wound report dated 4/21/17 (the first complete documentation of the wound since 3/27/17) showed: -The resident had a wound that was described as: --A new wound; --Type was other/partial thickness (loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough) wound on his/her left (should have been right) foot; --It measured 1.0 cm x 1.5 cm x 0.1 cm; --The wound bed was 100% slough (this contradicts the partial thickness wound description in the same note), --It had a