Every finding on record at Beacon Healthcare Center

Based on interview and record review, the facility failed to ensure necessary care and services were provided for two of three sampled residents (Residents 1 & 2) when:a. Resident 1's ceftriaxone (an antibiotic medication used to treat urinary tract infections [UTI- an infection in the bladder/urinary tract]) order did not indicate the accurate reason for use.b. Resident 2's urinalysis (UA-a laboratory test that checks urine for signs of infection) and urine culture (a laboratory test that checks urine for bacteria) orders were not transcribed (written/ordered) and implemented as directed by the medical doctor (MD). These failures resulted in Resident 2 not receiving ordered laboratory tests and had the potential for Residents 1 and 2's medical needs not being addressed, posing a serious risk to the residents' overall health.Cross reference F770 Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/8/2026 with diagnoses including unspecified fracture of first lumbar vertebra (a broken bone in the lower back), subsequent encounter for fracture with routine healing (a follow up visit indicating the break is healing normally), unspecified fracture of unspecified thoracic vertebra (a broken bone in the middle of the back) subsequent encounter for fracture with routine healing, and unstable burst fracture of second lumbar vertebra (a severe break in the lower back), subsequent encounter for fracture with routine healing. During a review of Resident 1's History and Physical (H&P) dated 1/12/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's ceftriaxone order dated 1/20/2026, the order indicated for licensed staff to administer ceftriaxone 1 gram (gm-a unit of measurement) to be given intravenously (IV -fluids given directly into the blood stream) for increase white blood cells (WBC-a blood cell that helps attack infection or injury in the body). The order indicated the Medical Doctor (MD) was the prescriber and was confirmed by the Director of Nursing (DON). During a review of Resident 1's ceftriaxone order dated 1/22/2026, the order indicated for licensed staff to administer ceftriaxone 1gm to be given intramuscularly (injected into the muscle tissue) for increased WBCs. The order indicated that the MD was the prescriber and was confirmed by the Infection Prevention Nurse (IPN). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 was dependent on eating, oral/personal/toileting hygiene, bathing, and dressing and mobility. During a telephone interview on 7/21/2026 at 12:15 PM with the MD, the MD stated increased white blood cells would not be a reason to give ceftriaxone. The MD stated the MD would not order ceftriaxone to be given for increased WBCs. During a concurrent interview and record review on 7/21/2026 at 12:34 PM with the DON, Resident 1's ceftriaxone order dated 1/20/2026 was reviewed. The DON stated the DON did not remember why the order indicated ceftriaxone should be given for increased WBCs. The DON stated it was important to indicate an accurate reason for the use of ceftriaxone to ensure Resident 1 received the correct treatment. During a concurrent interview and record review on 7/21/2026 at 1:35 PM with the IPN, Resident 1's ceftriaxone order dated 1/22/2026 was reviewed. The IPN stated the IPN did not clarify the reason for the ceftriaxone use with the MD. The IPN stated it was important to indicate an accurate reason for ceftriaxone use to ensure Resident 1 received the correct treatment. b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 7/1/2026 with diagnoses including retention of urine (inability to completely empty the bladder), benign prostatic hyperplasia (BPH-enlargement of the prostate gland), and UTI. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) and supervision or touching assistance with self-care and mobility. During a review of Resident 2's H&P dated 7/6/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/9/2026, the SBAR's situation indicated, Blood-tinged urine, purulent output (cloudy or milky urine) in urinary tubing and tender abdomen. The SBAR's nursing notes indicated, .MD gave orders to change foley [catheter-a hollow tube inserted into the bladder to drain or collect urine] and send UA, urine culture.UA collected and stored in specimen fridge. During a review of Resident 2's Order Summary Report (OSR) dated 7/1/2026 - 7/15/2026, the OSR did not indicate a UA or a urine culture were ordered for Resident 2. During an interview on 7/20/2026 at 2:30 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/9/2026 Resident 2's urine was cloudy and red which could indicate Resident 2 had a UTI. LVN 1 stated the MD was informed of Resident 2's urine symptoms and responded with a text message indicating the MD wanted a urinalysis and urine culture to be done for Resident 2. LVN 1 stated Resident 2's urine was collected and placed in the specimen refrigerator. LVN 1 stated LVN 2 was supposed to document the UA and urine culture order in Point Click Care (PCC-an electronic health record). LVN 1 stated it was important to ensure the UA and urine culture were sent to the laboratory for examination to ensure Resident 2's condition was addressed. During an interview on 7/20/2026 at 3:07 PM with the IPN, the IPN stated on 7/9/2026, Resident 2's UA and urine culture were not ordered or sent to the laboratory to be tested. The IPN stated the order should have been placed in PCC but was not. The IPN stated it was important to test Resident 2's urine to find out if Resident 2 had a UTI. The IPN stated if Resident 2's urine was not tested, and the resident had a UTI then treatment would be delayed. During a concurrent interview and record review on 7/21/2026 at 11:07 AM with LVN 2, the facility phone's MD text messages were reviewed. The facility phone's text message dated 7/9/2026, timed at 2:21 PM indicated the MD texted, change foley and send UA, urine culture [for Resident 2]. LVN 2 stated the UA and urine culture order were not placed in PCC/computer system. LVN 2 stated it was important to ensure the MD orders were placed in PCC so nursing staff would know what needed to be monitored for Resident 2. LVN 2 stated the purpose of the UA and urine culture was to check for any infection in Resident 2's urine. During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders and Physician Notification, revised April 2025, the P&P indicated, The facility ensures that all resident care is provided in accordance with timely, complete.physician orders.All orders and notifications shall be documented accurately to ensure continuity of care and regulatory compliance. The P&P under physician orders indicated, .telephone orders must be.documented immediately.orders shall be implemented promptly. The P&P under responsibilities indicated, Licensed nurses: Identify changes, notify physicians, document accurately, and implement orders. During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical Protocol, revised November 2025, the P&P's assessment and recognition indicated, The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests.

Based on interview and record review, the facility failed to provide laboratory services for one of three sampled residents (Resident 2) when the facility failed to send a urinalysis (UA-a laboratory test that checks urine for signs of infection) and urine culture (a laboratory test that checks urine for bacteria) to be tested as ordered by the medical doctor (MD) for Resident 2. This failure resulted in Resident 2's urine not being tested and had the potential to result in the delay of necessary care and services potentially leading to sepsis (a life-threatening blood infection).Findings: During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 7/1/2026 with diagnoses including retention of urine (inability to completely empty the bladder), benign prostatic hyperplasia (BPH-enlargement of the prostate gland), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 2's Minimum Data Set (MDS- standardized assessment tool) dated 7/4/2026, the MDS indicated Resident 2's cognitive skills (ability to understand) for daily decision making were intact. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) and supervision or touching assistance with self-care and mobility. During a review of Resident 2's History and Physical (H&P) dated 7/6/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/9/2026, the SBAR's situation indicated, Blood-tinged urine, purulent output (cloudy or milky urine) in urinary tubing and tender abdomen. The SBAR's nursing notes indicated, .MD gave orders to change foley [catheter-a hollow tube inserted into the bladder to drain or collect urine] and send UA, urine culture.UA collected and stored in specimen fridge. During a review of Resident 2's Order Summary Report (OSR) dated 7/1/2026 - 7/15/2026, the OSR did not indicate a UA or a urine culture were ordered for Resident 2. During an interview on 7/20/2026 at 2:30 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/9/2026 Resident 2's urine was cloudy and red which could indicate Resident 2 had a UTI. LVN 1 stated the MD was informed of Resident 2's urine symptoms via text message. LVN 1 stated the MD responded on 7/9/2026 with a text message indicating the MD would like a urinalysis and urine culture to be done for Resident 2. LVN 1 stated Resident 2's urine was collected and placed in the specimen refrigerator. LVN 1 stated LVN 2 was supposed to document the urinalysis and urine culture order in Point Click Care (PCC-an electronic health record). LVN 1 stated it was important to ensure the UA and urine culture were sent to the laboratory for examination to ensure Resident 2's condition was addressed. During an interview on 7/20/2026 at 3:07 PM with the Infection Prevention Nurse (IPN), the IPN stated on 7/9/2026, Resident 2's UA and urine culture were not ordered or sent to the laboratory to be tested. The IPN stated the order should have been placed in Point Click Care (PCC-an electronic health record) but was not. The IPN stated it was important to test Resident 2's urine to find out if Resident 2 had a UTI. The IPN stated if Resident 2's urine was not tested, and the resident had a UTI then treatment would be delayed. During a concurrent interview and record review on 7/21/2026 at 11:07 AM with LVN 2, the facility phone's MD text messages were reviewed. The facility phone's text message dated 7/9/2026, timed at 2:21 PM indicated the MD texted, change foley and send UA, urine culture [for Resident 2]. LVN 2 stated the UA and urine culture order were not placed in PCC/computer system. LVN 2 stated it was important to ensure the MD orders were placed in PCC so nursing staff would know what needed to be monitored for Resident 2. LVN 2 stated the purpose of the UA and urine culture was to check for any infection in Resident 2's urine. During a review of the facility's Policy and Procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, revised November 2025, the P&P's assessment and recognition indicated, The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. During a review of the facility's P&P titled, Physician Orders and Physician Notification, revised April 2025, the P&P indicated, The facility ensures that all resident care is provided in accordance with timely, complete.physician orders.All orders and notifications shall be documented accurately to ensure continuity of care and regulatory compliance. The P&P under physician orders indicated, .telephone orders must be.documented immediately.orders shall be implemented promptly. The P&P under responsibilities indicated, Licensed nurses: Identify changes, notify physicians, document accurately, and implement orders.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) when Resident 1's discharge assessment (DA-a final evaluation conducted by healthcare workers before a resident leaves the facility) was not completed. This failure resulted in incomplete medical records for Resident 1 and had the potential for Resident 1 to receive inappropriate care and treatment.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/8/2026 with diagnoses including unspecified fracture of first lumbar vertebra (a broken bone in the lower back), subsequent encounter for fracture with routine healing (a follow up visit indicating the break is healing normally), unspecified fracture of unspecified thoracic vertebra (a broken bone in the middle of the back) subsequent encounter for fracture with routine healing, and unstable burst fracture of second lumbar vertebra (a severe break in the lower back), subsequent encounter for fracture with routine healing. During a review of Resident 1's History and Physical (H&P) dated 1/12/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated Resident 1 was dependent with eating, oral/personal/toileting hygiene, bathing, and dressing and mobility. During a concurrent interview and record review on 7/21/2026 at 12:57 PM with the Treatment Nurse (TN), Resident 1's DA dated 2/3/2026 was reviewed. The TN stated there was no head-to-toe assessment completed on Resident 1's DA dated 2/3/2026. The TN stated it was the policy of the facility to document a head-to-toe assessment prior to transferring a resident (in general) to the hospital. The TN stated it was important to document the head-to-toe assessment in case Resident 1 acquired a new injury while being transferred. During an interview on 7/21/2026 at 2:57 PM with the Director of Nursing (DON), the DON stated it was important to document the head-to-toe assessment on the DA to ensure the hospital was aware of Resident 1's medical condition. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised March 2025, the P&P indicated, Documentation in the medical record will be . complete, and accurate.

Based on interview and record review, the facility failed to ensure one of three sample resident (Resident 1) was provided with the Bed Hold Notification Form (BHNF) upon transfer to the General Acute Care Hospital (GACH) on [DATE]. This deficient practice resulted in Resident 1 not being able to readmit back to the facility upon discharge from GACH May of 2026.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer stage 4 (a severe, full-thickness wound where tissue loss exposes underlying bone, muscle, tendons, or ligaments) and chronic inflammatory demyelinating polyneuropathy (CIDP- a rare autoimmune disorder where the immune system attacks the myelin sheaths [the protective coating of nerves] in the peripheral nervous system). During a review of Resident 1's History & Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was dependent (helper does all the effort resident, resident does none of the effort to complete the activity, or requires the assistance of 2 or more helpers are required for the resident to complete the activity) on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. Resident 1 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) from staff for showering/bathing self. During a review of Resident 1's Bed Hold Notification Form (BHNF), undated, the BHNF indicated the form is to be completed on admission and upon transfer. The BHNF indicated Resident 1 acknowledged receipt of the BHNF by signing the form on the date of readmission to the facility on [DATE]. The BHNF indicated a section to be completed upon transfer. The BHNF did not indicate Resident 1's signature on the respective section when Resident 1 was transferred to GACH on [DATE]. During a review of GACH's facsmile (fax, telephonic transmission of scanned printed material) on [DATE] at 11 a.m., the fax indicated a successful transmission of the inbound notification that the facility received an inbound notification on [DATE] at 11:18 a.m. with Resident 1's updated clinical medical records for readmission to the facility. During a concurrent interview and record review on [DATE] at 1:30 p.m., with the admission Coordinator (AC), Resident 1's BHNF was reviewed. The AC stated Resident 1's BHNF was not filled out or signed by Resident 1 upon transfer to the GACH on [DATE]. The AC stated the BHNF should have been signed upon transfer to the GACH per the facility's policy and procedure (P&P). The AC stated the last time the facility received a fax from GACH to see if the facility could readmit Resident 1 back to the facility was May of 2026. During a concurrent interview and record review on [DATE] at 2:30 p.m., with the Director of Nursing (DON), Resident 1's BHNF was reviewed. The DON stated Resident 1's BHNF was not signed upon transfer to the GACH on [DATE]. During the same interview, the DON stated the facility did not follow the facility's P&P on bed hold notifications. During a review of the facility's P&P titled, Bed-Holds and Returns, revised [DATE], the P&P indicated, Policy Statement Residents and/or Representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. The P&P indicated under the Policy Interpretation and Implementation section:1. All residents/representatives are provided [with] written information regarding the facility and state bed-hold, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided [with] written notice about these policies at least twice:Notice 1: well in advance of any transfer (e.g., in the admission packet); andNotice 2: at time of transfer (or, if the transfer was an emergency, within 24 hours). [.]7. Resident who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-hold) are allowed to return to their previous room[,] if available or immediately to the first available bed in a semi-private room provided that the resident:Still required the services provided by the facility; and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. [.]9. If the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges.

Based on interview and record review, the facility failed to promptly notify one of five sampled residents' (Resident 1's) doctor of a change in condition in accordance with the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, when:a. Resident 1's doctor (DR 2) was not promptly informed of Resident 1's signs and symptoms (S&S) of a urinary tract infection (UTI- an infection in the bladder/urinary tract) which started on [DATE] at 12:00 PM.b. DR 2 was not promptly informed of an increase in size of Resident 1's right and left leg edema (swelling caused by too much fluid trapped in the body's tissues) which started on [DATE].These failures had the potential for Resident 1 not to receive timely treatment for Resident 1's changes in condition.(Cross reference F641, F658, F686, and F842)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included multiple fractures of the vertebrae (broken backbones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications (has DM but it has not resulted in further health problems), and dementia (a progressive state of decline in mental abilities). The AR did not indicate Resident 1 had peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed including rolling left and right, sitting to lying, and lying to sitting on side of bed and to transfer in and out of bed. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 1 had an impaired skin integrity related to edema on both legs. The CPR interventions included monitoring Resident 1's edema and reporting promptly to Resident 1's doctor if there was an increase in edema size.During a concurrent interview and record review on [DATE] at 3:32 PM with DR 2, Resident 1's Treatment Administration Record (TAR), for [DATE] and February 2026, were reviewed. The TAR for [DATE] indicated on [DATE] Resident 1's right and left leg edema increased in swelling from plus 1 (+1) to plus 2 (+2) according to the pitting edema scale (measures how deep an indentation [or pit] remains in the skin after applying firm pressure) and remained +2 until [DATE]. DR 2 stated DR 2 did not recall the facility informing DR 2 of Resident 1's increased edema on both legs. DR 2 stated the facility needed to inform DR 2 when a resident's (in general) edema size increased.During a concurrent interview and record review on [DATE] at 10:15 AM with the Infection Preventionist (IP) 1, Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form (SBAR), dated [DATE], and the facility's document showing screen shots of text messages to DR 2, dated [DATE], were reviewed. The SBAR indicated that on [DATE] at 12:00 PM, Resident 1 gained 6.6 pounds in one week, had generalized weakness, and had frequency and urgency with urinating. IP 1 stated S&S of a UTI included frequency and urgency with urinating, and foul-smelling urine. IP 1 stated Resident 1's nurse (in general) should have notified DR 2 of Resident 1's S&S of UTI. IP 1 stated the nurse should notify DR 2 or the facility's medical director (MD) within the same shift the S&S started. The screen shots indicated facility staff (unidentified) texted DR 2 on [DATE] at 7:35 AM that Resident 1 was experiencing general weakness and was unable to eat on their own. The screen shot indicated the facility staff (unidentified) did not inform DR 2 of Resident 1's frequency and urgency with urinating.During a concurrent interview and record review on [DATE] at 10:04 AM with the Director of Nursing (DON), Resident 1's TAR, for [DATE] and February 2026, were reviewed. The DON confirmed Resident 1's edema on both legs increased in size on [DATE]. The DON stated the increase in size would be considered a change in condition. The DON stated DR 2 should have been notified of the increase in size of Resident 1's edema on both legs. The DON stated the facility did not notify DR 2 of the increase in size since Resident 1's medical record did not document that DR 2 was notified.During a concurrent interview and record review on [DATE] at 11:01 AM with the MD, Resident 1's H&P, dated [DATE] was reviewed. The H&P indicated DR 2 documented Resident 1 did not have edema. The MD stated if facility nurses (in general) documented Resident 1 had edema, then Resident 1 had edema. The MD stated nursing documentation is generally more thorough than doctor's documentation.During a review of the facility's P&P titled, Acute Condition Changes - Clinical Protocol, revised [DATE], the P&P indicated, The physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The P&P indicated, The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less) . The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The nurse and physician will discuss and evaluate the situation. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when:1. On [DATE], Licensed Vocational Nurse (LVN) 4 inaccurately documented that Resident 1 did not have any edema (swelling caused by too much fluid trapped in the body's tissues).2. Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], inaccurately indicated Resident 1 did not have edema.3. Resident 1's, Resident 2's, and Resident 3's medical record did not contain documentation that the residents were turned and repositioned every two hours in accordance with the residents' care plans.These failures resulted in Resident 1's, Resident 2's, and Resident 3's medical records containing inaccurate information and had the potential for Resident 1, Resident 2, and Resident 3 to receive inappropriate care and treatment.(Cross reference F580, F641, F658, and F686)a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included multiple fractures of the vertebrae (broken backbones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications (has DM but it has not resulted in further health problems), and dementia (a progressive state of decline in mental abilities). The AR did not indicate Resident 1 had peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed including rolling left and right, sitting to lying, and lying to sitting on side of bed and to transfer in and out of bed. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated that the resident does not have the capacity to understand and make decisions. The H&P also indicated Resident 1 did not have any edema.During a review of Resident 1's Care Plan Report (CPR), initiated on [DATE], the CPR indicated Residernt1 needed assistance with repositioning and turning every two hours for ADLs.During a review of Resident 1's CPR, initiated on [DATE], the CPR indicated Resident 1 needed a turning and repositioning schedule for altered skin integrity. During a review of Resident 1's medical record, there was no documentation regarding repositioning and turning Resident 1 every two hours found in the medical record.During a review of Resident 1's Treatment Administration Record (TAR), for [DATE] and February 2026, the TAR indicated facility licensed nurses (in general) documented that Resident 1 had edema.During a concurrent telephone interview and record review on [DATE] at 3:10 PM with LVN 4, Resident 1's Admission/readmission Screener (ARS), dated [DATE], was reviewed. The ARS indicated Resident 1 did not have any edema. LVN 4 stated LVN 4 documented inaccurately. LVN 4 stated Resident 1 had edema on Resident 1's arms and legs when LVN 4 assessed Resident 1 on [DATE].During a concurrent interview and record review on [DATE] at 3:05 PM with the Director of Nursing (DON), Resident 1's ARS, dated [DATE], was reviewed. The DON stated LVN 4 should have documented Resident 1's edema on arms and legs when Resident 1 was admitted on [DATE].During a concurrent interview and record review on [DATE] at 11:01 AM with the facility's Medical Director (MD), Resident 1's H&P, dated [DATE], was reviewed. The H&P indicated Resident 1's doctor (DR 2) documented Resident 1 did not have edema. The MD stated if facility nurses (in general) documented Resident 1 had edema, then Resident 1 had edema. The MD stated nursing documentation is generally more thorough than doctor's documentation.b. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to facility on [DATE] with diagnoses including enterocolitis (an inflammation that occurs throughout intestines), acute respiratory failure with hypoxia (a life threatening condition where there's not enough oxygen or too much carbon dioxide in the tissues in body), and muscle weakness.During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 could make needs known but could not make medical decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired in cognitive skills. The MDS indicated Resident 2 was dependent on staff for ADLs.During a review of Resident 2's CPR, initiated on [DATE], the CPR indicated Resident 2 needed turning and repositioning schedule for altered skin integrity.During a review of Resident 2's CPR, initiated on [DATE], the CPR indicated Resident 2 needed turning and repositioning every two hours and as needed when in bed or wheelchair because Resident 2 was at high risk for developing pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence).During a review of Resident 2's medical record, there was no documentation regarding repositioning and turning Resident 2 every two hours found in the medical record.c. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to facility on [DATE] with diagnoses including fracture of fifth metatarsal bone (the long bone on the outside of the foot that connects the ankle to the pinky toe) and right foot and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 3's H&P, dated [DATE], the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was severely impaired in cognitive skills. The MDS indicated Resident 3 was dependent on staff with toileting hygiene, to shower/bathe self, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 3 required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort to complete the activity) with oral hygiene and personal hygiene.During a review of Resident 3's CPR, initiated on [DATE], the CPR indicated Resident 3 needed turning and repositioning schedule for altered skin integrity and coccyx (tailbone) pressure injury.During a review of Resident 3's CPR, initiated on [DATE], the CPR indicated Resident 3 needed turning and repositioning every two hours and as needed when in bed or wheelchair because Resident 3 was at high risk for developing pressure injury.During a review of Resident 3's Monitor - Tuning and Repositioning record (MTR), the MTR did not contain any documentation from [DATE] to [DATE].During an interview on [DATE] at 3:15 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated nursing staff (in general) should document repositioning and turning of residents after providing the service to the resident (in general).During an interview on [DATE] at 1:58 PM with CNA 3, CNA 3 stated Resident 1 is on repositioning and turning program which included repositioning and turning the resident every 2 hours and documenting the different time and position after performing the procedure. CNA 3 stated residents (in general) in the repositioning and turning program should have documentation in the medical record of the time the resident was repositioned and where the resident was positioned to. Documentation must be done soon after the care is provided.During a concurrent interview and record review on [DATE] at 11:10 AM with the Director of Nursing (DON), Resident 1, 2, and 3's CPR and MTR were reviewed. The DON stated there was no MTR or any turning and repositioning documentation for Resident 1 and 2 after Resident 1 and 2's care plan regarding repositioning and turning every two hours were initiated. The DON stated that there was no documentation on the MTR from [DATE] to [DATE] for Resident 3 after Resident 3 was placed in a repositioning and turning program on [DATE]. The DON stated that it is important to document on the MTR as evidence that care plan interventions were implemented and residents on repositioning and turning program were provided care.During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, revised [DATE], the P&P indicated, Documentation in the medical record will be . complete, and accurate.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a resident assessment tool) was accurate for one of five sampled residents (Resident 1) when Resident 1's MDS, dated [DATE], incorrectly indicated Resident 1 did not have any pressure ulcer/injury pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) upon discharge from the facility on 2/3/2026.This failure had the potential to result in Resident 1 not receiving appropriate treatment and/or services.(Cross reference F580, F658, F686, and F842)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/8/2026 with diagnoses that included multiple fractures of the vertebrae (broken backbones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications (has DM but it has not resulted in further health problems), and dementia (a progressive state of decline in mental abilities). The AR did not indicate Resident 1 had peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). The AR also indicated Resident 1's Family/Friend (RR 1) was one of Resident 1's emergency contact.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed including rolling left and right, sitting to lying, and lying to sitting on side of bed and to transfer in and out of bed. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.During a review of Resident 1's Grievance Report and Resolution Form (GRRF), dated 1/21/2026, the GRRF indicated RR 1 filed multiple complaints to the facility on 1/21/2026. The GRRF indicated to see the attached document for complaints by RR 1. The attached document indicated multiple complaints including, On January 20, 2026, I was advised that a nurse mischaracterized [Resident 1's] pressure sores (bedsores) as diabetic ulcers [Resident 1] has never had diabetic ulcers .During a concurrent interview and record review on 5/12/2026 at 11:18 AM with Treatment Nurse 1 (TN 1), Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form (SBAR), dated 1/13/2026 and timed at 5:10 PM, was reviewed. The SBAR indicated Resident 1's change in condition was regarding a diabetic ulcer (an open sore or wound on a person with diabetes, most commonly on the foot, caused by nerve damage [neuropathy] and poor circulation) on Resident 1's left fifth toe. The SBAR indicated on 1/13/2026 at 4:15 PM TN 1 noted a new wound on Resident 1's left fifth toe. The SBAR indicated, The patient is 6'3 in height and had been sliding down in bed, causing feet to make contact with the footboard. The bed was extended to accomodate [sic] the patient's height. TN 1 stated that on 1/13/2026, RR 1 visited Resident 1 and pointed out a new wound on Resident 1's left lateral (toward the side) metatarsal head (rounded, knobby end of the long bones in your midfoot that connects to your toe bones) of the fifth toe to TN 1. TN 1 stated TN 1 observed that the area of the foot where the wound developed was making contact with the bed's footboard. TN 1 stated TN 1 had the maintenance staff extend the frame of Resident 1's bed. TN 1 stated Resident 1's foot contact to the footboard caused skin injury to Resident 1's left fifth toe. TN 1 described the wound as non-blanchable redness (intact skin that is red and does not turn white when pressed; the earliest sign of a pressure injury). TN 1 stated since Resident 1 was diabetic, TN 1 documented the wound as being a diabetic ulcer. TN 1 stated TN 1 did not consult with the Wound Care Specialist (WCS) or with Resident 1's physician before identifying the wound as a diabetic ulcer.During a concurrent telephone interview and record review on 5/12/2026 at 12:28 PM with the WCS, Resident 1's wound care progress note (WCPN), dated 1/14/2026, was reviewed. The WCPN indicated the WCS evaluated and treated Resident 1's skin wounds on 1/14/2026. The WCPN indicated the WCS was a nurse practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) and a wound care specialist. The WCPN indicated the WCS determined Resident 1's wound to the left fifth toe was a diabetic wound. The surveyor asked the WCS why the WCS did not diagnose Resident 1's left fifth toe wound to be pressure injury since TN 1 documented pressure from Resident 1's footboard caused the injury. The WCS stated the WCS did not consider the etiology (the cause or origin of a disease or condition) of the wound when determining if the wound was a diabetic wound versus pressure injury. The WCS stated because Resident 1 had diabetes, the WCS determined the wound to be a diabetic wound. The WCS stated the WCS would not deny that the etiology of the wound was pressure from the footboard.During a concurrent interview and record review on 5/12/2026 at 12:47 PM with the MDS Coordinator (MDSC), Resident 1's MDS, dated [DATE], was reviewed. The MDSC stated because the WCS documented Resident 1's pressure injury as being a diabetic ulcer, MDSC documented in the MDS that Resident 1 did not have any pressure ulcer/injury.During a concurrent telephone interview and record review on 5/12/2026 at 1:40 PM with the WCS's supervising physician (DR 1), Resident 1's WCPN, dated 1/14/2026, was reviewed. DR 1 stated DR 1 had not assessed or treated Resident 1 while Resident 1 was at the facility. The Surveyor asked DR 1 if a diabetic resident (in general) could be diagnosed with a pressure ulcer or must the foot wound always be diagnosed as a diabetic wound. DR 1 stated a diabetic resident (in general) could have a pressure ulcer on the foot. The Surveyor asked DR 1 to explain how a WCS should determine whether a wound on the foot was a diabetic wound versus a pressure injury. DR 1 stated if the resident (in general) was diabetic, had poor sensation in the feet, and the wound was not over a bony area, the wound would be considered a diabetic wound. The surveyor asked DR 1 how a WCS determined if a resident (in general) had poor sensation to the feet. DR 1 stated a WCS should assess a resident's (in general) feet sensation by probing the feet and moving up the leg, assessing if the resident (in general) can feel the probing to the feet. The WCPN did not indicate the WCS assessed if Resident 1 had poor sensation to Resident 1's feet. The Surveyor asked DR1 if DR 1 would consider Resident 1's left fifth toe wound to be a pressure wound if the wound area on the foot was discovered sitting against the footboard of Resident 1's bed. DR 1 stated if Resident 1 was unable to move Resident 1's feet, and if the foot rested against the footboard for a long time, DR 1 would consider the wound to be a pressure injury (instead of a diabetic wound).During a review of the facility's manual titled, CMS's RAI Version 3.0 Manual, dated October 2025, the manual described a diabetic foot ulcer as, Ulcers caused by the neuropathic and small blood vessel complications of diabetes. Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape, and the wound edges are even with a punched-out appearance. These wounds are typically not painful. The manual described a pressure ulcer/injury as, A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The manual indicated, It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. The manual indicated, Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors.During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument, revised September 2024, the P&P indicated, The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment.

Based on interview and record review, the Wound Care Specialist (WCS) inaccurately diagnosed on e of five sampled resident's (Resident 1's) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) on the left fifth toe as a diabetic wound (diabetic ulcer, an open sore or wound on a person with diabetes, most commonly on the foot, caused by nerve damage [neuropathy] and poor circulation).This failure had the potential for Resident 1 to receive inappropriate care and treatment for Resident 1's pressure injury on the left fifth toe.(Cross reference F580, F641, F686, and F842)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included multiple fractures of the vertebrae (broken backbones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications (has DM but it has not resulted in further health problems), and dementia (a progressive state of decline in mental abilities). The AR did not indicate Resident 1 had peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). The AR also indicated Resident 1's Family/Friend (RR 1) was one of Resident 1's emergency contact.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed including rolling left and right, sitting to lying, and lying to sitting on side of bed and to transfer in and out of bed. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries.During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated that on [DATE], Resident 1 developed a skin breakdown on Resident 1's left lateral (toward the side) metatarsal head (MTH, rounded, knobby end of the long bones in your midfoot that connects to your toe bones) of the fifth toe. The CPR interventions included initiating a wound assessment and providing appropriate treatment as ordered.During a review of Resident 1's Grievance Report and Resolution Form GRRF, dated [DATE], the GRRF indicated RR 1 issued multiple complaints to the facility on [DATE]. The GRRF indicated to see the attached document for complaints by RR 1. The attached document indicated complaints including, On [DATE], I was advised that a nurse mischaracterized [Resident 1's] pressure sores (bedsores) as diabetic ulcers. [Resident 1] has never had diabetic ulcers. [Resident 1] has never had pressure sores (bedsores).During an interview on [DATE] at 10:55 AM with RR 1, RR 1 stated RR 1 was Resident 1's caregiver. RR 1 stated when Resident 1 was admitted to the facility, Resident 1 was admitted to a bed that was too short for Resident 1. RR 1 stated RR 1 was not aware that Resident 1's bed was too short until [DATE]. RR 1 stated RR 1 was visiting Resident 1 on [DATE] and that Resident 1 could not move Resident 1's legs. RR 1 stated RR1 removed the sheet from over Resident 1's legs and observed Resident 1's feet pressed against the footboard of the bed. RR 1 stated RR 1 notified a nurse (unidentified), so facility staff extended Resident 1's bed frame.During a concurrent interview and record review on [DATE] at 11:18 AM with Treatment Nurse 1 (TN 1), Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form (SBAR), dated [DATE] and timed at 5:10 PM, was reviewed. The SBAR indicated Resident 1's change in condition was regarding a diabetic ulcer (an open sore or wound on a person with diabetes, most commonly on the foot, caused by nerve damage [neuropathy] and poor circulation) on Resident 1's left fifth toe. The SBAR indicated on [DATE] at 4:15 PM TN 1 noted a new wound on Resident 1's left fifth toe. The SBAR indicated, The patient is 6'3 in height and had been sliding down in bed, causing feet to make contact with the footboard. The bed was extended to accomodate [sic] the patient's height. TN 1 stated that on [DATE], RR 1 visited Resident 1 and pointed out a new wound on Resident 1's left lateral (toward the side) MTH of the fifth toe to TN 1. TN 1 stated TN 1 observed that the area of the foot where the wound developed was making contact with the bed's footboard. TN 1 stated TN 1 had the maintenance staff extend the frame of Resident 1's bed. TN 1 stated Resident 1's foot contact to the footboard caused skin injury to Resident 1's left fifth toe. TN 1 described the wound as non-blanchable redness (intact skin that is red and does not turn white when pressed; the earliest sign of a pressure injury). TN 1 stated since Resident 1 was diabetic, TN 1 documented the wound as being a diabetic ulcer. TN 1 stated TN 1 did not consult with the Wound Care Specialist (WCS) or with Resident 1's physician before identifying the wound as a diabetic ulcer.During a concurrent telephone interview and record review on [DATE] at 12:28 PM with the WCS, Resident 1's wound care progress note (WCPN), dated [DATE], was reviewed. The WCPN indicated the WCS evaluated and treated Resident 1's skin wounds on [DATE]. The WCPN indicated the WCS was a nurse practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) and a wound care specialist. The WCPN indicated the WCS determined Resident 1's wound to the left fifth toe was a diabetic wound. The surveyor asked the WCS why the WCS did not diagnose Resident 1's left fifth toe wound to be pressure injury since TN 1 documented pressure from Resident 1's footboard caused the injury. The WCS stated the WCS did not consider the etiology (the cause or origin of a disease or condition) of the wound when determining if the wound was a diabetic wound versus pressure injury. The WCS stated because Resident 1 had diabetes, the WCS determined the wound to be a diabetic wound. The WCS stated the WCS would not deny that the etiology of the wound was pressure from the footboard.During a concurrent telephone interview and record review on [DATE] at 1:40 PM with the WCS's supervising physician (DR 1), Resident 1's WCPN, dated [DATE], was reviewed. DR 1 stated DR 1 had not assessed or treated Resident 1 while Resident 1 was at the facility. The Surveyor asked DR 1 if a diabetic resident (in general) could be diagnosed with a pressure ulcer or must the foot wound always be diagnosed as a diabetic wound. DR 1 stated a diabetic resident (in general) could have a pressure ulcer on the foot. The Surveyor asked DR 1 to explain how a WCS should determine whether a wound on the foot was a diabetic wound versus a pressure injury. DR 1 stated if the resident (in general) was diabetic, had poor sensation in the feet, and the wound was not over a bony area, the wound would be considered a diabetic wound. The surveyor asked DR 1 how a WCS determined if a resident (in general) had poor sensation to the feet. DR 1 stated a WCS should assess a resident's (in general) feet sensation by probing the feet and moving up the leg, assessing if the resident (in general) can feel the probing to the feet. The WCPN did not indicate the WCS assessed if Resident 1 had poor sensation to Resident 1's feet. The Surveyor asked DR1 if DR 1 would consider Resident 1's left fifth toe wound to be a pressure wound if the wound area on the foot was discovered sitting against the footboard of Resident 1's bed. DR 1 stated if Resident 1 was unable to move Resident 1's feet, and if the foot rested against the footboard for a long time, DR 1 would consider the wound to be a pressure injury (instead of a diabetic wound).During a review of the facility's manual titled, CMS's RAI Version 3.0 Manual, dated [DATE], the manual described a diabetic foot ulcer as, Ulcers caused by the neuropathic and small blood vessel complications of diabetes. Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape, and the wound edges are even with a punched-out appearance. These wounds are typically not painful. The manual described a pressure ulcer/injury as, A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The manual indicated, It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. The manual indicated, Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors.

Based on observation, interview, and record review, the facility failed to prevent one of five sampled residents (Resident 1) from developing a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) when:a. Licensed Vocational Nurse (LVN) 4 failed to document a skin assessment on Resident 1 upon Resident 1's admission to the facility on 1/8/2026.b. Resident 1's bed was too short for Resident 1.These failures resulted in Resident 1 developing pressure injury to Resident 1's left fifth toe on 1/13/2026.(Cross reference F580, F641, F658, and F842)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/8/2026 with diagnoses that included multiple fractures of the vertebrae (broken backbones), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications (has DM but it has not resulted in further health problems), and dementia (a progressive state of decline in mental abilities). The AR did not indicate Resident 1 had peripheral neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). The AR also indicated Resident 1's Family/Friend (RR 1) was one of Resident 1's emergency contact.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort to complete the activity) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed including rolling left and right, sitting to lying, and lying to sitting on side of bed and to transfer in and out of bed. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 1's height was 75 inches (6 ft 3 in).During a concurrent observation, interview, and record review on 5/13/2026 at 2:00 PM with the Maintenance Supervisor (MS), an unoccupied bed was observed in an empty room. The MS stated the bed was the standard bed all residents in the facility used. The MS confirmed Resident 1 had the same bed since Resident 1 was admitted to the facility. The bed frame measured 81 inches from the headboard to the footboard. The MS demonstrated how the bed could be extended to accommodate a taller resident. The length of the bed extended was 85.5 inches from headboard to footboard. The facility's manual, titled Service Manual for Basic American's Matrix 709 Series, indicated the sleep surface of the bed was 76 inches (Resident 1's height is 75 inches) and 80 inches when extended.During a review of Resident 1's Grievance Report and Resolution Form GRRF, dated 1/21/2026, the GRRF indicated RR 1 issued multiple complaints to the facility on 1/21/2026. The GRRF indicated to see the attached document for complaints by RR 1. The attached document indicated multiple complaints including, [Resident 1] .developed pressure sores .on [Resident 1's] toes, feet, ankles and legs because [Resident 1] was placed in a bed that was too short.During an interview on 5/6/2026 at 10:55 AM with RR 1, RR 1 stated RR 1 was Resident 1's caregiver. RR 1 stated when Resident 1 was admitted to the facility, Resident 1 was admitted to a bed that was too short for Resident 1. RR 1 stated RR 1 was not aware that Resident 1's bed was too short until 1/13/2026. RR 1 stated RR 1 visited Resident 1 on 1/13/2026 and Resident 1 could not move Resident 1's legs. RR 1 stated RR1 removed the sheet from over Resident 1's legs and observed Resident 1's feet pressed against the footboard of the bed. RR 1 stated RR 1 notified a nurse (unidentified), so facility staff (unidentified) extended Resident 1's bed frame.During a concurrent interview and record review on 5/12/2026 at 11:18 AM with TN 1, Resident 1's Admission/readmission Screener (ARS), dated 1/8/2026, was reviewed. The ARS did not indicate Resident 1 had any skin issues. TN 1 stated TN 1 assessed Resident 1's skin on 1/9/2026, the day after Resident 1 was admitted to the facility. TN 1 stated Resident 1's skin issues should have been assessed and documented by the admitting nurse (in general) when Resident 1 was admitted on [DATE].During a concurrent interview and record review on 5/12/2026 at 11:18 AM with Treatment Nurse 1 (TN 1), Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form (SBAR), dated 1/13/2026 and timed at 5:10 PM, was reviewed. The SBAR indicated Resident 1's change in condition was regarding a diabetic ulcer (an open sore or wound on a person with diabetes, most commonly on the foot, caused by nerve damage [neuropathy] and poor circulation) on Resident 1's left fifth toe. The SBAR indicated on 1/13/2026 at 4:15 PM TN 1 noted a new wound on Resident 1's left fifth toe. The SBAR indicated, The patient is 6'3 in height and had been sliding down in bed, causing feet to make contact with the footboard. The bed was extended to accomodate [sic] the patient's height. TN 1 stated that on 1/13/2026, RR 1 visited Resident 1 and pointed out a new wound on Resident 1's left lateral (toward the side) metatarsal head (rounded, knobby end of the long bones in your midfoot that connects to your toe bones) of the fifth toe to TN 1. TN 1 stated TN 1 observed that the area of the foot where the wound developed was making contact with the bed's footboard. TN 1 stated TN 1 had the maintenance staff extend the frame of Resident 1's bed. TN 1 stated Resident 1's foot contact to the footboard caused skin injury to Resident 1's left fifth toe. TN 1 described the wound as non-blanchable redness (intact skin that is red and does not turn white when pressed; the earliest sign of a pressure injury).During a concurrent telephone interview and record review on 5/12/2026 at 12:28 PM with the WCS, Resident 1's wound care progress note (WCPN), dated 1/14/2026, was reviewed. The WCPN indicated the WCS evaluated and treated Resident 1's skin wounds on 1/14/2026. The WCPN indicated the WCS was a nurse practitioner (NP- a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) and a wound care specialist. The WCPN indicated the WCS determined Resident 1's wound to the left fifth toe was a diabetic wound. The surveyor asked the WCS why the WCS did not diagnose Resident 1's left fifth toe wound to be pressure injury since TN 1 documented pressure from Resident 1's footboard caused the injury. The WCS stated the WCS did not consider the etiology (the cause or origin of a disease or condition) of the wound when determining if the wound was a diabetic wound versus pressure injury. The WCS stated because Resident 1 had diabetes, the WCS determined the wound to be a diabetic wound. The WCS stated the WCS would not deny that the etiology of the wound was pressure from the footboard.During a concurrent telephone interview and record review on 5/12/2026 at 1:40 PM with the WCS's supervising physician (DR 1), Resident 1's WCPN, dated 1/14/2026, was reviewed. DR 1 stated DR 1 had not assessed or treated Resident 1 while Resident 1 was at the facility. The Surveyor asked DR 1 if a diabetic resident (in general) could be diagnosed with a pressure ulcer or must the foot wound always be diagnosed as a diabetic wound. DR 1 stated a diabetic resident (in general) could have a pressure ulcer on the foot. The Surveyor asked DR 1 to explain how a WCS should determine whether a wound on the foot was a diabetic wound versus a pressure injury. DR 1 stated if the resident (in general) was diabetic, had poor sensation in the feet, and the wound was not over a bony area, the wound would be considered a diabetic wound. The surveyor asked DR 1 how a WCS determined if a resident (in general) had poor sensation to the feet. DR 1 stated a WCS should assess a resident's (in general) feet sensation by probing the feet and moving up the leg, assessing if the resident (in general) can feel the probing to the feet. The WCPN did not indicate the WCS assessed if Resident 1 had poor sensation to Resident 1's feet. The Surveyor asked DR1 if DR 1 would consider Resident 1's left fifth toe wound to be a pressure wound if the wound area on the foot was discovered sitting against the footboard of Resident 1's bed. DR 1 stated if Resident 1 was unable to move Resident 1's feet, and if the foot rested against the footboard for a long time, DR 1 would consider the wound to be a pressure injury (instead of a diabetic wound).During a concurrent telephone interview and record review on 5/12/2026 at 3:10 PM with LVN 4, Resident 1's ARS, dated 1/8/2026, was reviewed. The ARS failed to indicate Resident 1's skin issues. LVN 4 stated Resident 1 had some scabs on Resident 1's arms and legs but LVN 4 forgot to document on the ARS. During a concurrent telephone interview and record review on 5/14/2026 at 10:04 PM with the Director of Nursing (DON), Resident 1's Delivery Ticket (DT), dated 1/13/2026 was reviewed. The DT indicated a mattress extender was delivered to the facility for Resident 1's bed. The DON stated the facility ordered a mattress extension for Resident 1 because Resident 1 would slide down in bed and Resident 1's feet might touch the footboard.During a review of the facility's manual titled, CMS's RAI Version 3.0 Manual, dated October 2025, the manual described a diabetic foot ulcer as, Ulcers caused by the neuropathic and small blood vessel complications of diabetes. Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape, and the wound edges are even with a punched-out appearance. These wounds are typically not painful. The manual described a pressure ulcer/injury as, A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The manual indicated, It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. The manual indicated, Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors.During a review of the facility's Policy and Procedure (P&P) titled, Prevention of Pressure Injuries, revised September 2025, the P&P indicated, Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. The P&P indicated, Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.

Based on observation, interview, and record review, the facility failed to notify, one of one sampled resident's (Resident 8), physician (Physician 1) of Resident 8's weight changes on 9/1/2025 and 10/7/2025.This deficient practice had the potential to result in serious health complications to Resident 8 due to the lack of notification to Physician 1 and delayed implementation of interventions.Findings:During a review of Resident 8's admission Record (AR), the AR indicated the resident was admitted to the facility 7/16/2025 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD - irreversible kidney failure), and Hypersensitive chronic kidney disease (progressive kidney damage and loss of function caused by long-term uncontrolled high blood pressure that stiffens kidney arteries, reduce blood flow, and impair filtration creating a dangerous cycle where failing kidneys worsen blood pressure, leading to further damage and potential kidney failure or heart disease).During a review of Resident 8's Interdisciplinary Team (IDT, a collaborative group of professionals from different specialties who work together to provide resident centered care) Weight Change Review, dated 9/1/2025, the IDT review indicated Resident 8 had a weight change and gained 12.3 lbs. in one month.During a review of Resident 8's IDT Weight Change Review, dated 10/7/2025, the IDT review indicated Resident 8 had a weight change of an eight lb. weight loss in one month. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 10/19/2025, the MDS indicated Resident 8's cognition (anything related to thinking, learning, and understanding) was severely impaired for decision making. The MDS indicated Resident 8's cognitive (the ability to think and process information) was severely cognitively impaired for daily decision making.During an interview on 1/14/2026 at 11:41 AM with the Director of Nursing (DON), the DON stated on 10/7/2025 IDT [members] determined a weight loss of 8 lbs. for Resident 8. The DON stated Physician 1 should have been contacted [notified of Resident 8's weight loss] and [the notification should be] documented in the progress notes. The DON stated on 9/1/2025, the IDT discussed a weight gain of 12 lbs. for Resident 8. The DON stated licensed [nursing] staff should have notified Physician 1 and documented the notification the progress notes. The DON stated the DON could not find progress notes dated 9/1/2025 or 10/7/2025 indicating Physician 1 was notified of Resident 8's weight changes. During a concurrent interview and record review on 1/15/2026 at 9:16 AM with the DON, the facility's policy and procedure (P&P) titled, Nutrition Care, revised November 2025, was reviewed. The P&P's subject indicated weight variance P&P. The P&P indicated, The LN [license nurse] staff will document identified significant weight changes, MD [medical doctor] notification, and responsible party notification in the resident's medical record. The DON stated the P&P fit the scenario [Resident 8's weight changes] and further stated it was important to notify the MD [Physician 1] of weight changes to see if there were new orders from Physician 1 and to address the changes [carry out the orders].

Based on observation, interview, and record review the facility failed to effectively assess one of one sampled resident's (Resident 29) characteristics of pain as indicated in the facility's policy and procedure (P&P) titled, Pain Assessment.This deficient practice had the potential to result in ineffective pain management, unnecessary discomfort and pain to Resident 29, and had the potential to affect Resident 29's physical and psychosocial well-being.Findings:During a review of Resident 29's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including stage 3 chronic kidney disease (the kidneys have moderate damage and are not filtering waste as well, with function between 30-59%, leading to potential symptoms like fatigue, swelling, and higher risk for complications like high blood pressure, requiring careful management with diet and medication), and a urinary tract infection (UTI - an infection in the bladder/urinary tract).During a review of the Minimum Data Set (MDS- a resident assessment tool), dated 11/11/2025, the MDS indicated Resident 29's cognition (the ability to think and process information) was moderately impaired.During a review of Resident 29's Medication Administration Record (MAR), dated 1/2026, the MAR indicated Resident 29 had 5 out of 10 pain on 1/13/2026 and Resident 29 received 500 milligrams (unit of measurement) of Tylenol (medication used to treat pain).During an interview on 1/14/2026 at 11:21 AM in Resident 29's room with Resident 29, Resident 29 stated, yesterday [1/13/2026] Resident 29's family member spoke to the nurse (unidentified) about Resident 29's pain because Resident 29 felt pain during urination and despite completing antibiotics. Resident 29 stated they [staff] all knew [about] Resident 29's pain because Resident 29 told them, including the therapists (unidentified) and Resident 29 could not sleep well because Resident 29 was in pain.During an interview on 1/14/2025 at 1:46 PM with License Vocational Nurse (LVN) 2, LVN 2 stated, on 1/13/2026, Resident 29 complained of pain, under there and Resident 29 was rubbing Resident 29's stomach. LVN 2 stated LVN 2 assisted Resident 29 back to Resident 29's room and LVN 2 assessed Resident 29. LVN 2 stated [during the assessment] LVN 2 did not ask Resident 29 questions [relating to Resident 29's pain] such as if [the pain was] throbbing or stabbing. LVN 2 stated Resident 29 complained 6 out of 10 (10 being the strongest pain ever felt) inguinal (groin area) pain. LVN 2 stated asking questions about the location of the pain, type of pain, and [using the] pain scale during a pain assessment provided more details that helped treat the resident's pain (in general).During an interview on 1/15/2026 at 9:20 AM with the Director of Nursing (DON), the DON stated if a resident had pain, we [the facility] asked them [residents] what the nature of the pain was, the intensity of the pain [by using a pain] scale, assessed and palpated the site, and asked for the type [description] of pain: e.g., sharp, throbbing, etc.During a concurrent interview and record review on 1/15/2026 at 9:20 AM with the DON, the facility's P&P titled, Pain Assessment, revised November 2025 was reviewed. The P&P indicated, Assessing Pain: 1. During a comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): b. Characteristics of pain: (1) Location of pain; (2) Intensity of pain (as measured on a standardized pain scale); (3) Description of pain; (4) Pattern of pain; and (5) Frequency, timing and duration of pain. The DON stated the importance of [following the P&P] was to address the pain according to how intense the pain was [to know and describe the pain accurately] when reporting [the pain] to the doctor.

Based on observation, interview, and record review the facility failed to ensure a thermometer was easily visible inside one of two refrigerators (Reach-in Refrigerator 2) in the facility's kitchen on 1/14/2026 as indicated in the facility's Policy and Procedure (P&P) titled, Procedure for Refrigerated Storage.This failure had the potential to result in the food stored inside Reach-in Refrigerator 2 not being maintained at proper temperatures and the potential to result in foodborne illness (an illness caused by eating contaminated food) to the residents consuming the food.Findings:During a concurrent observation and interview on 1/12/2026 at 8:45 AM with [NAME] (CK) 1 in the kitchen, Reach-in Refrigerator 2 was observed without a thermometer visible on the inside of the refrigerator. CK 1 stated CK 1 could not find the thermometer and the thermometer should be located inside Reach-in Refrigerator 2. CK 1 stated the thermometer was used to verify the temperature on the thermometer located on the outside of Reach-in Refrigerator 2. CK 1 stated it was important to have a second thermometer inside of Reach-in Refrigerator 2 to ensure the refrigerator was at the correct temperature.During an interview on 1/14/2026 at 2:41 PM with the Dietary Supervisor (DSS), the DSS stated there should be a second thermometer located on the inside of Reach-in Refrigerator 2. The DSS stated it was important for there to be a second thermometer inside Reach-in Refrigerator 2 to ensure the food inside Reach-in Refrigerator 2 was cooled properly.During a review of the facility's P&P titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, two thermometers, placed to be easily visible for checking, should be inside all walk-in, reach-in refrigerators. The P&P indicated the second thermometer is a check against the first thermometer for accuracy.

Based on observation and record review, the facility failed to ensure two of two sampled residents (Residents 7 and 15), were provided privacy curtains for the residents during incontinence care. These failures prevented Residents 7 and 15 from having privacy during care and had the potential to affect Residents 7 and 15's dignity and self-worth. Findings: a. During a review of Resident 7's Admission Record, the Admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition [such as viral infection or toxins in the blood]), dysphagia (difficulty swallowing), and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the right and left hips, right knee and right and left ankles. During a review of Resident 7's Care Plan (CP) titled Activities of Daily Living (ADLs, activities related to personal care, initiated 6/24/2024, the CP indicated the goal was for Resident 7 to increase ADLs independently. The interventions indicated to provide Resident 7 with assistance and encourage all efforts at independence. During a review of review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 9/30/2024, the MDS indicated Resident 7 had moderate impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 7 depended (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for ADLs. During an observation for an incontinence care for Resident 7, Resident 7's curtain was not completely closed during the incontinent care. b. During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was initially admitted to the facility on ,d+[DATE] /2022 and readmitted on [DATE] with diagnoses including dysphagia, abnormal posture, and unsteadiness on feet. During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had an intact cognition and depended on staff for toileting hygiene. During an observation for an incontinence care for Resident 15, Resident 15's curtain was not closed during the incontinent care. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised on 11/2023, the P&P indicated for facility staff to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment. During a review of the facility's P&P titled, Quality of Life-Dignity, revised on 11/2023, indicated the facility staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The P&P indicated treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food handling service. During initial tour of the kitchen on 11/15/24, one open bag of frozen patties and one open frozen bag of eggrolls were unlabeled and undated in the facility freezer for one of one facility kitchen. This deficient practice had the potential to result in foodborne illnesses (illness caused by consuming contaminated food or beverages) to the residents. Findings: During an initial tour of the kitchen on 11/15/24 at 5:24 pm, with the Dietary Supervisor (DS), one open bag of four hamburger patties and one opened bag of eggrolls were observed inside the facility freezer. The DS stated open food items should be labeled and dated to determine the food item in the bags and to determine the good by date of the food to prevent possible food borne illness to the residents. During a review of the facility's Policy and Procedure (P&P) titled, Procedure for Frozen Storage: Freezer Storage, dated 2023, the P&P indicated all frozen food should be labeled and dated. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated All food items in the storeroom refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date .

Based on observation, interview, and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurately completed for one of one sampled resident (Residents 99). Resident 99's MDS did not accurately reflect the resident's hearing abilities and limitations. This deficient practice had the potential for Resident 99 not to receive necessary treatment and/or services. Cross Referenced with F676 Findings: During a review of Resident 99's Admission Record (AR), the AR indicated Resident 99's was admitted to the facility on [DATE] with diagnoses that included intestinal obstruction (blockage in the intestine), hydronephrosis (swelling of the kidneys), atelectasis (complete or partial collapse of the lungs) and lack of coordination. During a review of Resident 99's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, the MDS indicated Resident 99 was cognitively intact (able to make decisions) and had adequate (no difficulty in normal conversation, social interaction) with hearing. The MDS also indicated Resident 99 did not use hearing aid or other hearing appliance. During an observation and concurrent interview with Resident 99 at the resident's bedside, on 11/15/2024 at 2:30 p.m. and on 11/16/2024 at 8:54 a.m., Resident 99 was asked questions by the surveyor. The surveyor was standing at the foot of Resident 99's bed. Resident 99 gestured to the surveyor to come closer to the resident's ear and stated, I can't hear you, come closer to me. The surveyor needed to speak within 1 foot of Resident 99's ear for the resident to hear the questions asked. During an interview with Family Member 2 (FM 2) on 11/16/2024 at 2:12 p.m. FM 2 stated Resident 99 was hard of hearing prior to admission to the facility. During an interview with Certified Nursing Assistant 1 (CNA 1), on 11/16/2024 at 3:23 p.m., CNA 1 stated Resident 99 could not hear well and often asks CNA 1 to come closer in order for Resident 99 to read CNA 1's lips while talking. CNA 1 also stated Resident 99 did not have hearing aids or any devices to assist with hearing. During an interview with the Activities Director (AD) on 11/16/2024 at 3:31 p.m., the AD stated Resident 99 was hard of hearing and AD would sit close to the resident to communicate. During an observation and concurrent interview at Resident 99's bedside, with the MDS coordinator (MDSC), on 11/16/2024 at 3:40 p.m., MDSC attempted to speak with Resident 99 from the foot of the resident's bed. Resident 99 pointed to her ear and gestured for MDSC to come closer stating I can't hear you.' MDSC walked towards Resident 99's head of bed and communicated with Resident 99. MDSC stated MDSC needed to speak about 10 inches from Resident 99's ear in order for the resident to hear the MDSC. The MDSC stated Resident 99 was hard of hearing. During the same observation, a concurrent record review of Resident 99's admission MDS was reviewed. The MDSC stated Resident 99's MDS indicated the resident had adequate hearing and the MDS was not accurate. MDSC stated, the resident's MDS assessment needed to be accurate in order for the facility to provide quality of care for Resident. 99. During an interview with Registered Nurse 1 (RN 1), on 11/16/2024 at 3:47 p.m., RN 1 stated Resident 99 was hard of hearing. RN 1 stated if a resident was admitted with hard of hearing, RN 1 would check if the resident utilized hearing aids, would provide temporary aids to ensure hearing, and would inform the resident's physician for a possible Ear Nose and Throat (ENT- a medical professional who specializes in diagnosing, treating, and preventing diseases and conditions of the ear, nose, and throat) consult to determine the cause of the hearing loss. RN 1 stated the ability to hear was important because Resident 99 needed to be informed of all aspects of the resident's care. During an interview and concurrent record review of Resident 99's chart, with LVN 1, on 11/16/2024 at 3:54 p.m., LVN 1 stated Resident 99 was hard of hearing. LVN 1 stated upon admission of a resident who was hard of hearing, licensed staff needed to determine if the resident used a hearing aid and inform the physician. LVN 1 stated LVN 1 did not inform Resident 99's physician that the resident was HOH, and there was no ENT consult ordered for Resident 99. LVN 1 stated hearing was important because that was how the resident communicated with others in order for staff to know the resident's needs. During a review of the facility's Policy and Procedure (P&P), titled Care of Hearing-Impaired Resident, revised 2/2024, the P&P indicated staff will assist hearing impaired resident to maintain effective communication with clinician, caregivers, other resident and visitors. Staff will assist the resident (or representative) with locating available resources To obtain needed services. When interacting with the hearing impaired or deaf residents, staff will implement the following: evaluate the resident's preferred method of communication (lip reading, tablet) with staff and other residents. Provide pencil and paper or tablet to communicate in writing. During a review of the facility's P &P titled Resident Assessment, revised on 9/2023, the P&P indicated all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. During a review of the facility's undated MDSC's - Job Description, the MDSC's job description indicated to evaluate each resident's condition and pertinent medical data to determine any need for special assessment activities . Complete accurate coding of the MDS with information obtained via medical record review as well as observation and interview with facility staff, resident and family members.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 99) received necessary treatment to prevent a decline, maintain or improve Resident 99's hearing abilities and quality of life. This deficient practice had the potential to result in Resident 99's decline in hearing, social interaction, and overall quality of life. Findings: During a review of Resident 99's Admission Record (AR), the AR indicated Resident 99's was admitted to the facility on [DATE] with diagnoses that included intestinal obstruction (blockage in the intestine), hydronephrosis (swelling of the kidneys), atelectasis (complete or partial collapse of the lungs) and lack of coordination. During a review of Resident 99's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, the MDS indicated Resident 99 was cognitively intact (able to make decisions) and had adequate (no difficulty in normal conversation, social interaction) with hearing. The MDS also indicated Resident 99 did not wear hearing aid or other hearing appliance. During a review of Resident 99's Admission/Readmission Screener dated 9/24/2024 completed by Licensed Vocational Nurse 1 (LVN 1), the Admission/Readmission Screener indicated Resident 99 had highly impaired hearing. During an observation and concurrent interview with Resident 99 at the resident's bedside, on 11/15/2024 at 2:30 p.m. and on 11/16/2024 at 8:54 a.m., Resident 99 was asked questions by the surveyor. The surveyor was standing at the foot of the resident's bed. Resident 99 gestured for the surveyor to come closer to the resident's ear and stated, I can't hear you, come closer to me. The surveyor needed to speak within 1 foot of Resident 99's ear for the resident to hear the questions asked. During an interview with Family Member 2 (FM 2) on 11/16/2024 at 2:12 p.m. FM 2 stated Resident 99 was hard of hearing prior to admission to the facility. During an interview with Certified Nursing Assistant 1 (CNA 1), on 11/16/2024 at 2:23 p.m., CNA 1 stated Resident 99 could not hear well and often asks CNA 1 to come closer in order for Resident 99 to read CNA 1's lips while talking. CNA 1 also stated Resident 99 did not have hearing aids or any devices to assist with hearing. During an interview with the Activities Director (AD) on 11/16/2024 at 3:31 p.m., the AD stated Resident 99 was hard of hearing and AD would sat close to the resident to communicate. During an interview with Registered Nurse 1 (RN 1), on 11/16/2024 at 3:47 p.m., RN 1 stated Resident 99 was hard of hearing. RN 1 stated if a resident was admitted with hard of hearing, RN 1 would check if the resident utilized hearing aids, would provide temporary aids to ensure hearing, and would inform the resident's physician for a possible Ear Nose and Throat (ENT- a medical professional who specializes in diagnosing, treating, and preventing diseases and conditions of the ear, nose, and throat) consult to determine the cause of the hearing loss. RN 1 stated the ability to hear was important because Resident 99 needed to be informed of all aspects of the resident's care. During an interview and concurrent record review of Resident 99's chart, with LVN 1, on 11/16/2024 at 3:54 p.m., LVN 1 stated Resident 99 was hard of hearing. LVN 1 stated upon admission of a resident who was hard of hearing, licensed staff needed to determine if the resident used a hearing aid and inform the physician. LVN 1 stated LVN 1 did not inform Resident 99's physician that the resident was HOH, and there was no ENT consult ordered for Resident 99. LVN 1 stated hearing was important because that was how the resident communicated with others in order for staff to know the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled Care of Hearing-Impaired Resident, revised on 2/2024, the P&P indicated staff will assist hearing impaired resident to maintain effective communication with clinician, caregivers, other resident and visitors. Staff will assist the resident (or representative) with locating available resources To obtain needed services. When interacting with the hearing impaired or deaf residents, staff will implement the following: evaluate the resident's preferred method of communication (lip reading, tablet) with staff and other residents. Provide pencil and paper or tablet to communicate in writing. During a review of the facility's P&P titled Resident Assessment, revised on 9/2023, the P&P indicated all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interview, and record review, the facility failed to properly apply a pressure relief boot (PRB) for one of three sampled residents (Resident 2) who had a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence because of pressure or pressure in combination with shear and/or friction) on Resident 2's right heel. This failure had the potential to worsen Resident 2's pressure ulcer. Findings: During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/1/2024 with diagnoses including pressure-induced deep tissue damage (a pressure injury, occurs when the tissue between the heel bone and the skin is compressed and deformed by pressure, shear, or strain) of right heel, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/4/2024, the MDS indicated Resident 2 was moderately impaired in cognitive skills (decisions poor; cue/supervision required). The MDS indicated Resident 2 was dependent on staff for bathing, toileting, and dressing. The MDS indicated Resident 2 had multiple pressure injuries. During a review of Resident 2's IDT (Interdisciplinary Team) - Skin integrity Review, dated 10/11/2024, the IDT indicated Resident 2 had pressure injury to Resident 2's right heel. The IDT indicated nursing interventions included to float Resident 2's heel. During a concurrent observation and interview on 11/16/2024 at 9:36 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's PRB was observed to be on Resident 2's right foot incorrectly. The PRB was on Resident 2's foot upside-down. The surveyor asked LVN 1 if she noticed anything wrong with how Resident 2's right foot looked. LVN 1 stated she did not see anything wrong. LVN 1 removed the PRB from Resident 2's right foot and showed the surveyor the dressing on Resident 2's right heel. LVN 1 replaced the PRB in an upside-down position. The surveyor asked if the PRB was on Resident 2's right foot correctly. LVN 1 stated the PRB was on Resident 2's right foot correctly. The surveyor pointed out the tag on the PRB which showed an image of foot in the PRB. LVN 1 then confirmed the PRB was not properly applied to Resident 2's right foot. LVN 1 stated LVN 1 had never received training from the facility on how to apply the PRB to residents (in general). LVN 1 stated LVN 1 did not know who had incorrectly applied the PRB to Resident 2's right foot. During a concurrent observation and interview on 11/16/2024 at 10:49 a.m. with the Treatment Nurse (TN), Resident 2's right heel was observed. Resident 2 was wearing a PRB on the resident's right foot. The TN stated Resident 2 had a deep tissue injury (DTI, a form of pressure injury). The TN stated the purpose of the PRB to relieve pressure off Resident 2's right heel. The TN stated Resident 2 had an ulcer (an open sore) on Resident 2's right heel. The TN stated if Resident 2's right heel was not protected from pressure, Resident 2 might experience a delay in the resident's ulcer healing, or the pressure injury could worsen. The TN stated if the PRB was applied the wrong way to Resident 2's foot, Resident 2's right heel would not be provided proper pressure relief. During a concurrent interview and record review on 11/17/2024, at 8:58 a.m. with the Director of Nursing (DON), Resident 2's care plan titled, Pressure Injury; Rt Heel ., dated 10/4/2024, the care plan indicated, may have heel protector. The DON stated that residents (in general) with pressure sores on their heels need the intervention of offloading pressure from the heel. The DON stated the PRB provided the intervention to offloading pressure from the heel. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised September 2023, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 100) who received oxygen therapy, was provided safety in accordance with the facility's Policy and Procedure (P&P) on oxygen administration and professional standards of practice by ensuring a cautionary sign was posted on the resident's door indicating oxygen was in use. This deficient practice placed Resident 100's safety at risk regarding oxygen use. Findings: During a review of Resident 100's Admission Record (AR), the AR indicated Resident 100 was admitted to the facility on [DATE] with diagnoses that included compression fracture of the vertebra (a break in a bone in the spine), hypertension (elevated blood pressure) and hyperlipidemia (abnormally high concentration of fats in the blood). During a review of Resident 100's Physician Orders (PO) dated 11/12/2024, the PO indicated for Resident 100 to receive oxygen at two (2) liters per minute (L/min) via nasal cannula (NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) continuously to keep oxygen saturation (amount of oxygen carried in blood) above 93 percent (%). During a review of Resident 100's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/15/2024, the MDS indicated Resident 100 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 100 was dependent with staff with eating, oral hygiene, toilet hygiene, showers, and upper and lower body dressing. During an observation on 11/15/2024 at 6:36 pm, Resident 100 was asleep lying in bed connected to an oxygen machine with a nasal cannula. Resident 100's room did not have a sign posted to indicate oxygen was in used in the room and that smoking was prohibited. During a concurrent observation and interview on 11/15/2024 at 6:40 pm with Licensed Vocational 2 (LVN 2) in Resident 100's room, Resident 100 was asleep lying in bed with a NC, connected to an oxygen machine. LVN 2 stated there was no sign posted on Resident 100's door to indicate oxygen was in used in the room. LVN 2 stated there should be a smoking sign to remind visitors or other residents that oxygen was in use and be cautious. During an observation and concurrent interview with the Director of Staff Development (DSD) on 11/15/2024 at 6:45pm, outside Resident 100's room, the DSD stated oxygen in use sign should be posted at the entrance door of the resident receiving oxygen therapy for fire safety because oxygen was combustible (flammable). During a review of the facility's P&P titled, Oxygen Administrator, revised 3/2024, P&P indicated the purpose of the procedure is to provide guidelines for safe oxygen administration. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: No Smoking/Oxygen in Use signs.

Based on observation, interview, and record review, the facility failed to properly assess resident's pain for one of one sampled resident (Resident 23) during a medication pass observation. This deficient practice had the potential to negatively affect Resident 23's physical comfort and psychosocial well-being. Findings: During a review of the Admission Record, the Admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnosis including Dementia (a progressive state of decline in mental abilities) and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/28/2024, indicated Resident 23's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staffs for toileting/personal hygiene, upper and lower body dressing. A review of Resident 23's Order Summary indicated physician ordered the following: i. Dated 4/23/2024, Pain evaluation ever shift for pain scale 0-10 (score of 0 means no pain, and 10 means the worst pain you have ever felt) ii. Dated 9/2/2024, Acetaminophen (Tylenol, medication used to treat minor aches and pains, and reduces fever) 325 milligrams (mg - unit of measurement) give two tablets mouth every four hours as needed for pain scale of 1-3 (mild pain). iii: Dated 9/2/2024, Tramadol HCL oral table 50 mg, give 1 tablet by mouth every 24 hours as needed for pain scale of 7-10 (severe pain). During a concurrent observation of medication pass and an interview with Licensed Vocational Nurse (LVN) 3 on 11/17/2024 from 9:04 a.m. to 9:10 a.m., LVN 3 was observed administering the morning medication to Resident 23. LVN 3 asked Resident 23 Are you ok? Resident 23 stated I have a stomachache. LVN 3 stated Maybe you need to go to the bathroom more, the CNA reported to me you had a BM (bowel movement) today. LVN 3 stated, LVN 3 did not assess Resident 23 for pain when Resident 23 complained of pain due to Resident 23 always complaining of back pain when the resident was in a sitting position. LNV 3 stated Resident 23 would start to complain of pain when Resident 23 sat on the wheelchair for a while (for a short time). During a review of the facility's policy and procedures (P&P) titled, Pain Assessment and Management, revised on 11/2024, the P&P indicated, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents' choices related to pain management. The P&P indicated steps in the procedure included: a. Recognizing pain. b. Assessing Pain. c. Identifying the cause of pain. d. Defining Goals and appropriate interventions. e. Implementing pain management strategies. f. Monitoring and modifying approaches of the pain management.

Based on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three dates (11/14/2024) according to the facility's policy and procedure (P&P) titled, Consumer Information, revised 1/18/2023. This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents. Findings: During a concurrent interview and record review on 11/17/2024 at 9:19 a.m. with the Director of Staff Development (DSD), the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 11/14/2024 and Projection of Nursing Hours, dated 11/14/2024 were reviewed. The DHPPD indicated the actual total Certified Nursing Assistant (CNA) direct care service hours for 11/14/2024 was 92.34 hours. The Projection of Nursing Hours indicated there was supposed to be 97.5 hours of CNA direct care service hours scheduled for 11/14/2024. The DSD stated a Daily Direct Care Staffing was posted at Nurses Station 1. The Projection of Nursing Hours indicated there were supposed to be 4 CNA's working on the second shift. The DSD stated 3 CNAs worked the entire second shift and 1 CNA only worked 3 hours during the second shift. The DSD stated the DSD posted a Projection of Nursing Hours document by the nurse's station every evening for the following day's nursing hours. The DSD stated the posted nursing hours was just the projection and was not changed when a staff person where to call off. During a review of the facility's P&P titled, Consumer Information, revised 1/18/2023, the P&P indicated, The following consumer information shall be posted: 1. Posting of: . g. Staffing, based on resident census, the number of nursing staff on duty for each shift (staff to resident ratio), including registered nurses, licensed vocational nurses, certified nurse aides, any staff who provide direct care to residents or who supervise those giving direct care. h. The facility will post the nurse staffing data on a daily basis at the beginning of each shift. i. Data will be posted as follows: 1) Clear and readable format 2) In a prominent place readily accessible to residents and visitors ii. Posting will include: 1) Facility name 2) The current date 3) The total number and the actual hours worked by the following categories of licensed and licensed nursing staff directly responsible for resident care per shift: a) Registered nurses b) Licensed practical nurses or licensed vocational nurses (as defined under State Law) c)Certified Nurse Assistants 4) Resident census .