Every finding on record at Bedford Care Center of Petal

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain food under sanitary conditions by failing to ensure prepared and opened food items were properly packaged, sealed, labeled, and dated in accordance with facility policy for one (1) of four (4) kitchen observations.Findings include:A review of the facility's policy titled, Food Receiving and Storage, reviewed 10/03/2022, revealed, .Foods shall be received and stored in a manner that complies with safe food handling practices . Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 13. Foods that have been cooked and are to be stored will be labeled and dated. They will be used or discarded within three (3) days .On 07/13/2026 at 5:45 PM, during an initial kitchen observation and interview with Head [NAME] (DD #1), the State Agency (SA) observed multiple food storage concerns. In Freezer #2, cooked ribs dated 06/29/2026 were loosely wrapped in aluminum foil rather than securely packaged. In Refrigerator #3, five prepared sandwiches were stored without dates or labels. In the dry storage room, an opened package of taco seasoning dated 07/05/2026 was rolled closed but not securely sealed, an opened container of grape drink mix was not resealed, and an opened package of yellow cake mix was not securely closed or repackaged. During the interview, DD #1 stated prepared foods should be covered, securely packaged, labeled, and dated before storage. DD #1 further stated dietary staff were responsible for ensuring opened food items were properly resealed or repackaged and appropriately labeled and dated after opening.A record review of dietary staff in-service records dated 12/22/2025 revealed staff received education regarding food safety.On 07/15/2026 at 11:55 AM, during an interview, the Dietary Manager (DD #2) stated dietary staff were expected to store and label food items in accordance with regulatory requirements and confirmed all dietary staff shared responsibility for maintaining proper food storage practices.On 07/16/2026 at 1:45 PM, during an interview, the Director of Nursing (DON) stated she expected dietary staff to properly package, label, date, and store food items in accordance with federal regulations to reduce the risk of food contamination and foodborne illness.On 07/16/2026 at 2:30 PM, during a post-exit interview, the Administrator stated she expected dietary staff to properly package, seal, label, date, and store food items to maintain sanitary conditions and protect residents from foodborne illness.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments by incorrectly coding feeding tube status for one (1) resident and weight loss status for two (2) residents, for three (3) of (14) MDS assessments reviewed (Residents #10, #29, and #34).Findings include: A record review of the facility policy titled, Resident Assessment Instrument with revised date 6/17/22 revealed . A comprehensive assessment of a resident's needs shall be made upon the resident's admission and periodically as mandated by the OBRA (Omnibus Budget Reconciliation Act) and Medicare guidelines. Policy Interpretation and Implementation: . 6. Dietary to complete and enter into computer system MDS (Minimum Data Set) sections K, V, and Z. 8. Each discipline will use the computerized audit system for their assigned section of MSD as section is completed. Any flags for this MDS section will be reviewed and resolved prior to submission of the MDS to ensure accuracy of MDS. Additional audits will be completed by facility through weekly quality assurance meetings to review MDS's and complete the triple check process to assure accuracy of MDS.10. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. 14. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. Resident #10 On 07/13/2026 at 7:51 PM, during an interview and observation, the State Agency (SA) observed Resident #10 lying in bed with head of bed elevated and a syringe used for enteral feeding was hanging from a pole adjacent to the resident's bed. During an interview Resident #10 stated she had a feeding tube and receives feeding during the day. On 07/13/2026 at 8:46 PM, during an interview, Licensed Practical Nurse (LPN)#1 stated Resident #10 experienced a decline in condition with poor oral intake several months earlier, resulting in placement of the feeding tube. On 07/14/2026 at 3:05 PM, during an interview, LPN #2 stated that Resident #10 did not receive any bolus feeding that day and only received routine feeding tube flushes. On 7/16/26 at 10:46 AM and again at 12:45 PM, during an interview, Dietary Manager (DD #2) reviewed the MDS assessments and acknowledged the weight loss coding for Residents #29 and #34 was coded incorrectly. DD #2 confirmed Resident #29 met the criteria for significant weight loss and should have been coded accordingly, while Resident #34 did not meet the weight loss criteria. On 07/16/2026 at 1:21 PM, during an interview with Dietary Department #1, she confirmed that she completes Section K of the residents' MDS and collects her information from weights, physician orders, and meal intakes. She confirmed Resident #10 had an existing feeding tube, although the resident had not required bolus feeding because oral intake had improved. She acknowledged the presence of the feeding tube should have been coded on the MDS and stated the omission was an error. On 07/16/2026 at 2:00 PM, during an interview, MDS Nurse (LPN #3) stated each discipline was responsible for accurately completing its assigned MDS section. She acknowledged completed sections were not routinely verified once staff became experienced and confirmed Resident #10's feeding tube should have been coded on the MDS. On 7/16/26 at 2:00 PM, during an interview, the Director of Nursing (DON) stated each department was responsible for ensuring the accuracy of the MDS sections assigned to them and expected questionable information to be communicated and resolved through the interdisciplinary assessment process before the MDS was submitted. On 07/16/2026 at 2:05 PM, during an interview, the Interim Administrator stated she expected each section of the MDS to accurately reflect the resident's current condition and expected assessments to be verified for accuracy prior to submission. On 7/16/26 at 2:25 PM, during an interview, MDS Nurse (LPN #3) for Residents #29 and #34 revealed each department was responsible for completing MDS sections and acknowledged she did not routinely verify coding completed by other disciplines after staff became experienced. LPN #3 reported the need to manually verify weight data due to potential inaccuracies in the electronic system. A record review of Resident #10's admission Record revealed the facility admitted the resident on 2/11/25 with the diagnoses including Personal History of Transient Ischemic Attack (TIA), And Cerebral Infarction Without Residual Deficits and Moderate Protein-Calorie Malnutrition. A record review of Resident #10's Order Summary Report revealed orders for Physician orders for LCS (Low Concentrated Sweets) NAS (No Added Salt) diet, Regular texture, Regular Consistency, Finger foods, with start date 5/12/26. Enteral Feed Order after meals and at bedtime Diabeta Source - 1can (250ml (milliliters)) if resident consumes 50% (percent) or less of a meal, with start date 5/12/26. A record review of Resident #10's Quarterly MDS with an Assessment Reference Date (ARD) of 6/19/26 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 2, which indicated severe cognitive impairment. Review of Section K revealed.K0520 Nutritional Approaches. B. Feeding tube (e.g., nasogastric or abdominal (PEG) (Percutaneous Endoscopic Gastrostomy)) had no documentation and K0710 Percent Intake by Artificial Route A. and B. had no documentation, despite documentation and staff interviews confirming the resident had an existing feeding tube. Resident #29A record review of Resident #29's admission Record revealed the facility admitted the resident on 2/17/2025 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. A record review of the Quarterly MDS with an ARD of 5/26/2026 revealed Section C1000 Cognitive Skills for Daily Decision Making was coded 3. severely impaired and Section K0300 Weight Loss (loss of 5% or more in the last month or loss of 10% or more in the last 6 months was coded No indicating the resident had not experienced significant weight loss, despite documented weight losses meeting MDS coding criteria. A record review of the Mini Nutritional Health Assessment dated 5/28/2026 revealed the resident had weight loss greater than 3kg (kilograms) (6.6 lbs (pounds)) in the last three months. A record review of Resident #29's Weights and Vitals Summary revealed the following documented weights: 12/8/2025 160 pounds 1/5/2026 166 pounds 2/6/2026 151 pounds 6/9/2026 139 pounds Record review of documented weights revealed Resident #29 experienced a 15-pound (9.04%) weight loss between 01/05/2026 and 02/06/2026 and a 21-pound (13.12%) weight loss between 12/08/2025 and 06/09/2026, meeting the MDS criteria for significant weight loss. A record review of the Order Summary Report revealed Physician Orders for NAS (No Added Salt) diet, pureed texture, regular consistency dated 2/17/25. A record review of the Care Plan Report for Resident #29 revealed interventions to monitor weight closely for gain and loss. Resident #34A record review of Resident #34's admission Record revealed the facility admitted the resident on 2/14/2024 with the diagnoses of Type 2 Diabetes Mellitus without Complications. A record review of the Quarterly MDS with an ARD of 5/8/2026 revealed a BIMS score of 3, indicating severe cognitive impairment. Section K0300 Weight Loss indicated weight loss of 5% or more in one month or 10% in six months, which was inaccurate. A record review of Resident #34's Weights and Vitals Summary revealed the following documented weights: 12/8/2025 116 pounds 2/3/2026 118 pounds 5/3/2026 120 pounds 6/7/2026 120 pounds 7/10/2026 117.6 pounds Record review of documented weights revealed Resident #34 did not experience a 5% weight loss in one month or a 10% weight loss in six months. A record review of the Order Summary Report for Resident #34 revealed Active Physician orders for LCS (Low Concentrated Sweets) NAS diet, chopped meats texture, regular consistency, dated 6/24/26 and NSA (No Sugar Added) Med Pass Supplement two times a day for weight loss dated 6/20/26. A record review of the Care Plan Report for Resident #34 revealed interventions to monitor weight closely for gain/loss.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with dignity and to retain personal belongings when a Certified Nursing Assistant (CNA) removed a resident's personal cellphone against her wishes for one (1) of three (3) sampled residents, Resident #1.Findings include:A review of the facility's policy, Promoting Maintaining Resident Dignity - Resident Rights, dated 10/2/2022, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner.that maintains or enhances the resident's quality of life by recognizing each resident's individuality.Compliance Guidelines.11. Respect the resident's.personal possessions. Staff will not search a resident's.personal possessions without consent from the resident.A record review of the admission Record revealed the facility admitted Resident #1 on 6/3/25 with diagnoses including Epilepsy.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.A record review of the Investigative Summary - Final Report, with Date of Incident: 6/25/25 revealed Investigation Findings as interviews were conducted with staff members, resident's roommate, and resident and CNA stated that resident was taking pictures of her. CNA states she asked the resident for the phone and the resident gave it to her, where she went on to delete about ten photos of herself from the resident's phone. The resident states that she did not willingly give the CNA her phone. The Administrator came to the facility immediately and sent the CNA home and the resident's phone was returned to her, after the CNA had left it on a nurse's medication cart. Resident was interviewed that night and monitored for any signs of psychosocial harm. A full body audit was conducted that night and the Nurse Practitioner also conducted a full body audit on the next day. The resident denied taking any photos or recordings and the resident's representative went through the deleted photos with the Administrator present and there were no videos containing staff. Staff education and ins-services started on that night to include the topics of Abuse, Neglect, De-escalation and Misappropriation of Property. The Conclusion included that upon investigation, it was determined that this CNA exhibited inappropriate behavior and is not allowed to return to facility.A record review of a signed document provided by the Administrator, dated 11/25/25, revealed that the facility sent the employee in question home immediately, the resident's cell phone was returned to her, and she was assessed for bodily and psychosocial harm. Interviews were conducted and the family was notified. The incident was reported to the appropriate authorities. Staff in-services were started on Abuse, Neglect, and Misappropriation. On 6/26/25, and Emergency Quality Assurance meeting was held, with the Medical Director, to discuss interventions which included 100% of staff to be in-serviced before returning to work. The resident was assessed for psychosocial needs, and the employee was not allowed to return to the facility and the Agency was notified.On 11/24/25 at 7:20 PM, during an interview with Resident #1, she stated that on 6/25/25 CNA #1 entered her room, spoke to her in a demeaning manner. Resident #1 stated she pretended to record the CNA with her cellphone, after which CNA #1 demanded she surrender the phone. Resident #1 stated she refused, and CNA #1 took the phone from her and placed it on the Licensed Practical Nurse (LPN) medication cart. Resident #1 stated she did not voluntarily give up her phone and that she was later told CNA #1 was terminated.On 11/24/25 at 7:40 PM, during an interview with the Administrator, she stated CNA #1 reported taking the phone from the resident because the resident had attempted to record her. The Administrator stated the resident's family reviewed the device and did not find deleted photos. She stated CNA #1 was an agency nurse and she has not worked since she was told to leave the facility.On 11/24/25 at 7:51 PM, during an interview with CNA #2, she stated CNA #1 told her that Resident #1 had threatened to get her fired and was taking pictures of her. CNA #2 stated CNA #1 admitted to taking the resident's phone. CNA #2 told CNA #1 she needed to report the incident to the nurse because you can't take a resident's property, stating it was a dignity concern.On 11/24/25 at 7:55 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated CNA #1 placed Resident #1's cellphone on her medication cart and told LPN #1 she had taken it because Resident #1 was filming her. LPN #1 returned the phone to the resident. LPN #1 stated Resident #1 reported CNA #1 got on top of her and took the phone forcefully.On 11/25/25 at 1:11 PM, during an interview with CNA #1, she denied forcefully taking the phone and stated the resident was being combative and filming her. CNA #1 stated that she could not remember everything that occurred. CNA #1 stated she picked up the phone and deleted photos before giving it to LPN #1. Based on the facility's implementation of corrective actions completed on 6/26/25, the SA determined the deficiency to be Past Non-Compliance (PNC) and corrected as of 6/27/25, prior to the SA's entrance 11/24/25.Validation:The SA validated on 11/25/25 through interview and record review, that all corrective actions had been completed on 6/26/25 and the deficiency removed on 6/27/25, prior to the SA's entrance on 11/24/25.

Based on observation, interview, and record review, the facility failed to ensure residents receiving oxygen (O2) therapy received care according to professional standards, as evidenced by, O2 tubing was undated for three (3) of four (4) days of survey. Resident #150 Findings include: On 03/17/25 at 11:06 PM, an observation of Resident #150 revealed was receiving oxygen via nasal cannula at 3 liters per minute (LPM) for shortness of breath (SOB) every 24 hours as needed. The oxygen tubing was not labeled. On 03/18/25 at 1:16 PM, during a second observation of Resident #150 revealed the resident sitting up in a chair, receiving oxygen via nasal cannula at 3 LPM. The oxygen tubing was not labeled. On 03/19/25 at 2:19 PM, during a third observation and interview with Licensed Practical Nurse (LPN)#1 revealed Resident #150 was sitting up in a chair, receiving oxygen via nasal cannula at 3 LPM. The oxygen tubing was not labeled. LPN #1 reported the oxygen tubing and humidifier are changed every Sunday night and labeled with the date of change. However, she confirmed that the tubing in use at the time of this visit was not dated. During an interview on 03/19/25 at 2:30 PM, the Director of Nursing (DON) confirmed that facility practice requires oxygen tubing and humidifiers to be changed on Sunday nights and labeled with the date of change. She stated that this practice is in place to ensure compliance with protocols. A review of the Admission Record revealed the resident was admitted on [DATE] with diagnoses including Obstructive Sleep Apnea (Adult) (Pediatric) and Essential (Primary) Hypertension. A review of Order Audit Record revealed a physician order dated 3/18/25 O2 at 3L (liters) for SOB (shortness of breath). Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by-date, food items without an identifying label, and food items not discarded prior to or by the use-by date for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy Food Safety Requirements, revised 11/21/22, revealed, .Food will be stored .in accordance with professional standards for food service safety .Policy Interpretation and Implementation .3. Facility staff will .ensure timely and proper storage .c. Refrigerated storage .iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded . On 10/02/23 at 11:00 AM, an observation of the kitchen and interview with the Dietary Manager (DM), revealed the following: 1. In Freezer #1, there were seven (7) unopened packages of bologna, with a use-by date of June 12, 2023. There was one (1) unopened bag of a food item with no identifying label and no use-by date. The DM identified the food item as beef tips. There was one (1) shrink-wrapped package of a food item with no identifying label and no use-by date. The food item was identified as pork ribs by the DM. The DM reported the pork ribs had been in the freezer since she started working at the facility, which was two (2) months ago, and the pork ribs were not on the four-week menu rotation. There was one (1) half-pint carton of 2 percent (%) milk with a use by date of 09/30/23. There was one (1) bag of an opened food item with no identifying label and no use-by date. The DM identified the food item as tater tots. 2. In Freezer #2, there was one (1) opened box and (1) unopened box of a food item with no identifying labels. The DM identified the boxes as cobblers. 3. In Refrigerator #1, there was one (1) plastic storage container of a food item, with no use-by date and no identifying label. The DM identified the food item as cut apples. There was one container of a food item, with no use use-by date and no identifying label. The DM identified the food item as buttermilk pie. There were six (6) egg cartons containing two and a half (2 1/2) dozen eggs, with no use-by date. The DM stated that she was unaware of the outdated foods and that any food items in the freezers and refrigerators required an identifying label and use-by date. On 10/03/23 at 11:57 AM, an interview with the Registered Dietician (RD), she confirmed the facility had no written policy related to the use or disposal of food that is near or past the use-by date. The RD reported the facility used the first-in, first-out method for refrigerated and frozen foods and the facility purchased only frozen meat, rather than fresh, so it is used by the date on the package. On 10/05/2023 at 07:30 AM, an interview with the facility Administrator confirmed she was aware of the potential hazards of foods that are undated, have no identifying label, and are not discarded per the use-by or expiration date. She stated that she expected the dietary staff to follow professional standards related to food storage. Record review of a training document dated 6/27/23, 6/29/23, and 6/30/23, revealed the facility provided training on Food Safety.

Based on observation, staff interview, record review, and the facility policy review, the facility failed to ensure residents on contact isolation precautions received disposable tableware and silverware to prevent the possible spread of infection for two (2) of two (2) residents on contact isolation precautions. Resident #48 and Resident #110 Findings include: A record review of the facility's policy, Transmission Based (Isolation) Precautions), revised 5/22/23, revealed . It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission . Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Policy Explanation and Compliance Guidelines .8. Initiation of Transmission- Based Precautions (Isolation Precautions)- . g. Use disposable or dedicated noncritical resident-care equipment . Resident #48 On 10/02/23 at 11:06 AM, during an observation, Resident #48 had contact isolation signage and Personal Protective Equipment (PPE) on the door of his room. On 10/02/23 at 11:35 AM, during an observation, Certified Nurse Aide (CNA) #2 entered the room of Resident #48 with a meal tray. The meal tray had washable dinnerware and silverware. When the resident completed her meal, CNA #2 removed the same tray from the resident's room and placed it on the collection cart located on the hallway. The dirty tray, dinnerware, and silverware had no special identification and was placed with the other dirty meal trays collected from other residents. A record review of the Admission Record revealed the facility admitted Resident #48 on 7/28/2023 with a diagnosis of Atrial Fibrillation. A record review of the Order Listing Report for Resident #48 revealed a Physician Order, with a start date of 9/29/23, for Contact Isolation precautions r/t (related to) c-diff (Clostridium difficile, a type of bacteria). Resident #110 On 10/02/23 at 11:00 AM, during an observation, Resident #110 had PPE and isolation signage on her door. On 10/02/23 at 12:00 PM, during an observation, CNA #1 delivered Resident #110's lunch tray with dinnerware and silverware that were not disposable. On 10/02/23 at 12:25 PM, during an interview with CNA #1, she confirmed that Resident #110 had regular, washable dinnerware and silverware. She stated the resident's meal tray should consist of disposable items since she was on contact isolation. She said that she had been told that Resident #110 was on contact isolation because she had Shingles (a viral infection). A record review of the Admission Record revealed the facility admitted Resident #110 on 09/28/23 with a diagnosis of Zoster (Shingles). A record review of the Order Summary Report, with active orders as of 10/05/23, revealed Resident #110 had a Physician Order, dated 9/28/2023, for Contact precautions for shingles. On 10/04/23 at 01:20 PM, during an interview with the Director of Nursing (DON), she confirmed that residents on isolation precautions should receive disposable meal items and that any items taken into their rooms should be discarded prior to leaving the room. She explained the communication process for residents on isolation was that a dietary slip was completed and given to the kitchen staff, but there was no paper trail of the slip. The slips were not used to communicate the resident's diet, but indicated any special treatments for the resident, such as isolation. She confirmed she was made aware that the residents were not served meals with disposable items, and that they should have been to prevent the possible spread of infection to other residents. On 10/05/23 at 11:00 AM, during an interview with the Administrator, she explained she expected all staff to be aware that if a meal was delivered on a regular tray for a resident on isolation precaution, to notify the kitchen and have it corrected to disposable items before it was delivered to the resident. In an interview with the Dietary Manager (DM) on 10/05/2023, at 3:00 PM, she confirmed that residents with isolation precautions should not receive regular trays, including dinnerware and silverware. She explained that the meals should have been served on disposable items and should have been discarded in the resident's room. She stated she was unaware that the non-disposable meal trays were delivered to the residents and commented that most of her staff were new employees. 47873

Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 21 sampled residents. Resident #26 Findings include: Review of the facility's policy Resident Assessment Instrument, revised 06/17/22, revealed . A comprehensive assessment of a resident's needs shall be made upon the resident's admission and periodically .Policy Interpretation and Implementation .9. The purpose of the assessment is to .identify significant impairments in functional capacity. 10. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning . Record review of the Admission Record revealed the facility admitted Resident #26 on 1/26/22 and she had diagnoses including Chronic Kidney Disease and Paraplegia. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/22/23, indicated Resident #26 did not have one or more unhealed pressure ulcers. Record review of the Order Listing Report revealed Resident #26 had a Physician's Order with a start date of 8/16/23, for Stage 2 Pressure Injury to Coccyx, which indicated Resident #26 had an unhealed pressure ulcer. During an interview on 10/03/23 at 3:41 PM, the MDS Coordinator confirmed Resident #26 had a Stage 2 pressure ulcer during the MDS lookback period and she had incorrectly coded the MDS to indicate the resident did not have a pressure wound. During an interview 10/05/23 at 3:55 PM, with the Director of Nursing (DON), she stated she expected the MDS to be coded correctly.

Based on interviews, record review, and facility policy review, the facility failed to ensure that a resident was treated with dignity and respect for one (1) of three (3) sampled residents. Resident #1. Findings include: Record review of the facility's policy, Promoting Maintaining Resident Dignity - Resident Rights, dated 10/2/2022, revealed, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Compliance Guidelines .10. Speak respectfully to residents Record review of the facility's Investigation revealed that on 10/9/22 at approximately 11:30 AM, Certified Nursing Aide (CNA) #1 was assisting with feeding Resident #2, when Resident #1 walked over to the air conditioner and watching CNA #1's interaction with the roommate (Resident #2). CNA #1 asked Resident #2, You don't want your food? CNA #1 then attempted to give Resident #2 her container of Ensure and the resident turned her head. CNA #1 then repeated the same question (to Resident #2), You don't want your food? Resident #1 then told CNA #1 that she can't tell her (Resident #2) not to eat, that is why she is not eating. CNA #1 responded to Resident #1, explaining that she was not making a statement, but she was asking a question. CNA #1 asked Resident #1 to go back to her side of the room so she may assist with feeding Resident #2. Resident #1 became agitated and stated that CNA #1 cannot tell her where to go. Resident #1 admitted refusing to leave the area and pointing her finger at CNA #1's face. CNA #1 used profanity directed at the resident (Resident #1) and immediately left the room and went to the Director of Nursing (DON). Resident #1 followed CNA #1. CNA #1 was very agitated when entering the DON's office. CNA #1 stated to the DON that she needs to get the resident away from her, while using more profanity. The DON then told CNA #1 to stay in her office and immediately walked Resident #1 back to her room. Once the resident was interviewed and found to be safe, the DON sent CNA #1 to the Administrator's office where she explained the situation and was requested to give a written statement. CNA #1 was very upset, crying, and apologizing throughout the statement. After recording her information, CNA #1 was immediately sent home pending investigation. An investigation was started, and the event was reported to the appropriate agencies. After conducting interviews with the DON, CNA #1, and Resident #1, Social Services and the DON conducted a separate interview with Resident #1 to determine if there was a negative psycho-social impact on the resident from the incident. During this process social services stated that Resident #1 found the incident comical, laughing throughout conversation. All the statements collected matched each other with a consistent picture being painted. It was found that this was an isolated scenario of the misconduct of an employee that had no negative impact on the resident. It was determined that the situation did not rise to the level of abuse. However, CNA #1 was terminated from the facility and all staff was educated on zero tolerance of profanity in the workplace. Record review of the Admission Record revealed the facility admitted Resident #1 on 4/26/22 with a diagnosis of [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/22, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she is cognitively intact. On 11/15/22 at 10:40 AM, during an interview with the Administrator, he confirmed that the information as written in the Investigation was obtained through interviews. He explained that the facility determined that CNA #1 admitted to using foul language toward Resident #1. The facility has a policy of no foul language used in the workplace, and CNA #1 was terminated for that behavior. Following the incident, the facility monitored Resident #1 for emotional distress, in which she stated she had none and demonstrated none. On 11/16/22 at 10:00 AM, during an interview with Resident #1, she stated that she remembered the incident in which CNA #1 used profanity to her, but she had no issues or felt unsafe following the incident. On 11/16/22 at 11:00 AM, during an interview with the DON, she confirmed that the facility reported the incident to the SA when CNA #1 used foul language to a resident. It was determined that CNA #1 acted against the policy with profanity and was terminated immediately. The DON revealed that the facility's expectation is that the staff are not allowed to speak with profanity toward residents.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection related to cross contamination during wound cleansing, failure to remove soiled gloves and perform hand hygiene prior to starting wound care for Resident #7, and applying ointments directly to open wounds with a gloved hand for Resident #7 and Resident #9 for two (2) of three (3) pressure wound care observations Resident #7 and Resident #9. Findings Include: The facility's, Wound Care procedure, dated February 2016, revealed staff should put on exam gloves, loosen the tape, remove the old dressing, pull the gloves over dressing and discard into appropriate receptacle. This policy noted staff should then wash and dry hands thoroughly. The facility's, Standard Precautions policy, revised October 2018, revealed the staff should conduct hand hygiene after contact with items in the resident's room. This policy noted gloves are changed as necessary during the care of a resident to prevent cross-contamination from one body site to another. Gloves should be changed as necessary during the care of a resident. Resident #7 An observation on 02/01/21, at 12:10PM, revealed Resident #7 sitting in a wheelchair. Resident #7 stated she has a wound on her buttocks, but the wound is healing. On 2/3/2021 at 11:10 AM, observed Registered Nurse (RN) #2 perform wound care to a Stage 2 Pressure Ulcer on Resident #7's sacrum. RN #2 used a clean right gloved hand to pull the curtain for privacy, then used the same gloved hand to remove the soiled dressing. RN #2 then used the same right gloved hand to touch Resident #7's sacral wound during an assessment of the wound. RN #2 changed gloves and conducted proper hand hygiene then cleaned the wound with a back and forward motion, with the gauze soaked with wound cleanser, across the wound eight (8) times. RN #2 applied zinc cream to her gloved index finger and applied it to the wound area directly with her gloved hand. RN #2 then picked up the new border dressing with the same soiled gloved hand and applied it directly to the wound. On 2/4/20, at 10:51 AM, in an interview with RN #2/Staff Development/Infection Control Nurse, she stated she should have changed her gloves when she used her right gloved hand to close the privacy curtain. RN #2 stated she should have washed her hands and changed her gloves after cleaning the wound because it can cause contamination of the wound. RN #2 stated she should clean the wound in one direction and not in a back and forth motion. RN #2 stated cleaning the wound back and forward can cause cross contamination and skin damage. She stated she should have used an applicator to apply zinc to wound and confirmed it was the facility's policy to use an applicator. RN #2 stated the most harmful thing she did when providing wound care to Resident #7, was cleaning the wound back and forth and applying the zinc with a gloved finger. On 2/4/21 at 11:14 AM in an interview with RN #1 Director of Nursing (DON) , she stated the facility's policy is to clean a wound by wiping in one direction and dispose of the 4x4 and then use another 4 x4 to repeat the process. The DON stated when RN #2 did not follow the facility's policy for wound care, it could cause infection to the resident's wound. The DON stated RN #2 should have applied the zinc ointment directly on the gauze and should have not used her finger to apply the zinc ointment to the wound area. The DON stated the most serious thing that RN #2 did when cleaning the wound for Resident #7 was to improperly clean the wound. Record review of Resident #7's Face Sheet revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A record review of the Physician order [REDACTED]. A record review of the Comprehensive Minimum Data Set (MDS) for Resident #7, with an Assessment Reference Date (ARD) of 11/2/20, revealed the MDS was coded for pressure ulcer. Resident #9 On 02/01/21, 11:35 AM, an observation revealed Resident #9 lying in bed, with a boot on the right foot. On 2/3/2021, at 11:25 AM, observed RN #2/ Infection Control Nurse perform wound care on Resident #9's right lateral ankle Stage 2 Pressure Ulcer. RN #2 used hand sanitizer and applied gloves prior to removing Resident #9's protective boot and sock. RN #2 then used the same gloved hands and removed Resident #9's soiled wound dressing and examined the wound without changing gloves. She then changed the soiled gloves and used hand sanitizer and applied clean gloves. RN #2 then picked up the saturated gauze, that had been saturated with wound cleaner, and used a back and forth motion ten (10) times to clean the wound and then used her index gloved finger to apply the Santyl ointment. RN #2 then applied the dressing to the wound without sanitizing her hands and changing her gloves. On 2/4/21, at 11:02 AM, in an interview with RN #2/Staff Development Nurse/Infection Control Nurse, stated that by cleaning the wound in a back and forward motion it can cause cross contamination of the wound. RN #2 stated she should have not applied the Santyl to the wound with her finger and should have used an applicator. RN #2 stated by using her finger, it can get on other skin that surrounds the wound and can cause skin problem. On 2/4/21, at 11:19 AM, in an interview with DON, she stated that RN #2 should never have clean wound in a back and forward motion and stated that it can cause cross contamination of the wound. The DON stated RN #2 should have used an applicator instead of using a finger. The DON stated the Santyl could get on more than wound area. The DON stated that Santyl is a debridement agent and can eat your healthy tissue causing damage. A record review of Residents #9's Physician Order, dated 1/20/21, revealed an order for [REDACTED]. A record review of the Comprehensive MDS with the ARD date of 11/6/20, revealed in Section M, Resident #9 was coded for pressure wounds. Record review of Resident #9's Face Sheet revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A record review of RN #2's Treatment/Skin Care Skills Checklist, dated 06/24/2020 and 12/3/2020, revealed she passed both the skill tests that included care of the Pressure Ulcer. A record review of an in-service on Infection Control, dated 11/23/20 revealed RN #2's signature on the sign in sheet.

Based on record review, and staff interview the facility failed to have a completed Facility Assessment for five (5) of (5) five days of survey. Findings Include: Interview on 02/21/18 at 02:07 PM with the Administrator revealed the Facility's Assessment is a work in progress. Administrator stated I have finished some of it but have not completed. Review of Facility's Assessment revealed the Assessment was not completed. Interview on 02/26/18 at 04:15 PM with Administrator revealed the missing part of the Facility's Assessment missing was addressing staff education and resources in the community. Based on record review, and staff interview the facility failed to have a completed Facility Assessment for five (5) of (5) five days of survey.

Based on observation, interview, and facility policy review the facility failed to clean the thermometer between food items during tray lines temperature for one (1) of two (2) kitchen observation. Findings Include: An observation on 02/23/18 10:42 AM Dietary Staff (DS) #1 checked the temperatures of the following food items: chicken, turnips greens, green beans, lima beans, and pureed chicken. DS #1 used the same thermometer wipe to clean between each food item. Food particles collected on the edge of the wipe after each temperature check. Dietary Manager (DM) observed the temperature checks. An interview on 02/23/18 at 10:50 AM with DS #1 stated she was aware to change the cleaning wipes but had just forgot to change the wipes. DS #1 said she needed to clean between each food item for sanitary use of the thermometer. An interview on 02/23/18 at 10:50 AM DM confirmed the staff should clean the thermometer between each food item. DM said the staff get nervous when they were watched. DM said she didn't know if she could speak up with a surveyor watching. An interview on 02/26/18 03:07 PM revealed DM said there was not a specific policy for cleaning thermometers.

Based on observation, group interview, and the facility failed to resolve resident grievances related to providing cloth facial towels to resident for morning hygiene for 12 resident attending resident council meeting and for one of 12 council meeting minutes reviewed. Finding Include: During a Resident Council meeting on 02/21/18 at 10: AM, residents complained that bath cloths are not available to residents for washing their face in the mornings. The residents stated they have to use paper towels. Residents stated that they have complained about this before but due to recent changes with Administrator and other staff, they were unsure of who they told. Observation of the clean linen cart on 02/22/18 at 10:02 AM revealed approximately 30- 40 clean bath cloths available. On 02/22/18 at 01:46 PM an interview with the facility Administrator revealed the facility should not expect the residents to use a disposable wipe for their face. He stated that he would check to see why that was happening. Review of the resident council meeting revealed the residents had complained at the (MONTH) resident meeting about the lack of wash cloths available for them to wash their face. On 02/28/18 at 01:46 PM an interview with the facility Administrator revealed the facility has no policy for provision of towels for residents.

Based on observation, interview, and record review the facility failed to ensure residents were given a choice of roommate for two (2) of 55 residents in the building. Resident #34 and #45 Findings Include: Resident #34 On 02/21/18 09:41 AM, observation and interview with Resident # 34 revealed the resident was seated alone in her wheelchair in her room. Resident 34 stated that she wished that her husband who is also a resident here could share a room with her. She stated she has asked the facility staff if she could be in the room with her husband, but was told by facility staff that it was not allowed for a man and woman to share a room. because the facility was not set up to accommodate that. Interview with facility Licensed Practical Nurse (LPN) #1 on 02/23/18 02:11 PM revealed the LPN was unable to explain a reason why a married couple could not share a room. She stated that she guessed that because the resident rooms did not have private baths and four (4) residents shared one bath, the facility did not allow males and females to share rooms. Interview on 02/23/18 02:15 PM with Registered Nurse (RN) #1, RN #2, and the Administrator revealed the facility was concerned that by allowing a married couple to share a room, it would require the couple to share a bathroom with the residents in the next room. The Administrator stated he was not aware of the residents wanting to share a room. RN #2 stated if the female resident shared a bathroom with the other residents in the next room, there would be privacy issues. RN #2 and the Administrator both confirmed there were doors on the bathrooms and that only one toilet was in each bathroom. RN #1 confirmed Resident # 34 required extensive staff assistance to toilet and perform activities of daily living and would require staff to be present when resident toileted. On 02/26/18 at 09:17 AM an interview with Social Services Director (SSD) #1 revealed the initial social assessments for residents are completed by the Social Services Director and she was the current social services director. She stated she began working here the first (MONTH) (YEAR). SSD stated she did not do the assessment for Resident # 34 because she was admitted in (MONTH) (YEAR). She stated the previous SSD performed the resident's admission assessment. SSD provided section B, C, D, E, and Q of a Minimum Data Set (MDS) with the items entered by hand for the assessment. The SSD did not provide a comprehensive social assessment for the resident. Record review revealed a Life History Social History and Assessment for Resident #34 dated 12/29/17 and signed by SSD #1. The assessment revealed the resident had been married to Resident # 45 since she was [AGE] years old. Interview on 02/26/18 at 02:34 PM with the Facility Administrator revealed the facility was in the process of trying to work something out for Resident # 34 and Resident #45 to share a room. He stated he had called the residents' daughter and explained that the residents could move to another facility owned by the same corporate that could accommodate the residents sharing a room, but this facility was not set up to accommodate them. He stated that this facility could not allow them to share a room because it could be a dignity issue. He stated that the residents would have to share a bathroom and since a person can see through the bathroom, the female resident may see a male resident using the toilet. The Administrator verified that the facility coded the MDS for Resident # 34 requiring extensive staff assistance for toileting and was unable to ambulate without assistance and has a BIMS of 12. In an interview on 02/26/18 at 03:47 PM , the facility Administrator revealed that the facility did not discuss the lack of the facility allowing spouses to share rooms prior to admission, and the facility does not have a written policy related to spouses sharing rooms. Record review of the resident's face sheet revealed the facility admitted Resident #34 on 12/14/17. Resident #45 Observation and interview on 02/21/18 at 11:32 AM revealed Resident #45 was upset because his wife is not seated at his table during the lunch meal. Observation revealed the resident's wife (Resident #34) was seated two tables away with her back facing the resident. Resident #45 repeatedly looked toward his wife and appeared concerned. On 02/22/18at 11:20 AM, observation revealed the resident and his wife were seated together at the lunch table. On 02/22/18 at 02:21 PM, an interview with Resident # 45 revealed he and his wife have been married about [AGE] years and now they are in rooms beside each other in the facility. He stated that his wife is allowed to come to his room and watch TV some during the day. Record review revealed a nurses note dated 1/15/18 that read the resident was talking with staff about how much he loved his wife. Record review revealed an activity progress note dated 1/15/18 that read the resident occassionally does arts/crafts with his spouse. Record review of an activity note dated 1/26/18 revealed Resident #45 loves spending time with his wife that is also a resident at the facility. Record review of the resident's face sheet revealed the facility admitted Resident #45 on 12/20/17.

Based on observation, interview, and record review, the facility to ensure the code status of a resident was consistent throughout the resident's medical record for one (1) of 15 residents sampled. Resident #45. Finding Include: Observation on 02/22/18 at 01:56 PM revealed a Full Code sticker on front page of chart. Review of Physician order [REDACTED]. Review of Resident #45's electronic record, revealed Advance Directive listed as Do Not Resuscitate. Observation and interview on 02/23/18 at 11:16 AM with the Director of Nurses (DON) and Registered Nurse (RN) #1 revealed the sticker on the front sheet of a resident's chart is used as a quick reference for code status reference for staff. RN #1 stated that if a resident is transferred to the hospital, a copy of the code sheet with copies of the face sheet and order are sent with the resident to the hospital. RN #1 stated that the code sheet for Resident # 45 is wrong. Observation with RN verified the code sticker read Full Code and was green in color. She stated the resident had a physician's orders [REDACTED]. She stated that with the sticker being listed as Full Code the facility would possibly be confused during an emergency situation.

Based on observation, record review and facility policy review the facility failed to provide a written summary for baseline care plan for one (1) of one (1) new admission out of total of 15 sampled residents. Resident #160 Findings Include: A review of the Plan of Care Comments for Resident #160, dated 02/06/18, revealed a family care plan conference was documented. There was no documentation of a written summary provided to family or Resident #160 at the time of care plan review. An interview on 02/23/18 01:28 PM Minimum Data Set/ Care Plan (MDS/CP) Nurse said Resident #160 did have an admission care plan meeting with family and the resident. She said the first meeting would be at the end of the first completed assessment, usually 14 days. MDS/CP Nurse said the documentation on the Plan of Care Comments meant the family attended. She said the facility did not provide a written summary of the care plan. An interview on 02/23/18 02:42 PM revealed Social Services (SS) said she was involved in the care plan meetings and would send the invitations for the care plan meetings at the time of scheduled assessments. SS said she had started this job the first of this year. SS confirmed the staff did have a meeting with the family on 02/06/18. SS said the facility did not give a written summary at the time of the baseline care plan. She said she had not been told in orientation about the summary to be provided to the family.

Based on observation, interview, and facility policy review the facility failed to revised the care plan related to significant weight loss for one (1) of 15 care plans reviewed. Resident #54 Findings Include: A review of the policy titled Care Plan Comprehensive revealed the care plans were to be revised as the resident's condition would dictate. A review of Resident #54's dietician note documented a significant weight loss of 5.22% from 134 to 126 for (MONTH) of (YEAR). The dietician note revealed she reviewed Resident # 54 weight loss on 1/30/18 and recommended adding a supplement. Review of Resident #54's comprehensive care plan, with an effective date of 5/2017, revealed the significant weight loss noted on the dietician note in (MONTH) of (YEAR) was not addressed on the care plan. An interview on 02/26/18 02:42 PM with Minimum Data Set/Care Plan (MDS/CP) Nurse confirmed the care plan for Resident # 54 did not address the significant weight loss. She said the new orders would be entered by her as soon as possible, each day. MDS/CP said each individual resident's changes and weight losses would be discussed during the stand up and monthly quality assurance meetings. She could not remember Resident # 54 weight loss being discussed.

Based on observation, record interview, and facility policy review the facility failed to notify family in writing upon transfer to the hospital for four (4) of four (4) residents records reviewed. Resident #34, #42, #44, #56,. Findings Include: Review of the facility policy titled, Transfer or Discharge Documentation, revised (MONTH) 2014, revealed the policy failed to address the notification of family with a residnet's transfer. Resident #34 Record review revealed the resident was admitted to the facility 12/14/17 then sent to hospital in (MONTH) (YEAR) due to abdominal pain. Resident # 34 required a cholecystectomy and returned to the facility 2/14/18. Interview on 02/26/18 at 02:05 PM with the Business Office Manager revealed she was not aware of any requirement to notify the family or ombudsman of resident transfers. She stated that she did contact the resident's family related to bed hold if a resident goes out to the hospital. On 02/26/18 at 02:09 PM, RN #1 verified that the resident's family was not notified in writing of the transfer. Resident #56 Record review revealed the resident was admitted to the hospital on [DATE] due to decreased L[NAME], decreased oxygen sat, and increase temp. Resident had a respiratory infection and was care planned for the hospitalization . She stated Resident # 56 had some kind of respiratory issue. She stated she thought it was pneumonia. She provided a Resident Sign-in/Sign-out Stamp 2 form with a box checked for Signing Out and a check marked Yes for Family Notified?. On 02/26/18 at 02:04 PM, interview with Registered Nurse (RN) #1 revealed she was unable to locate any written notice to the residents' families related to the recent hospitalization . She provided a transfer slip to FGH dated 2/9/18. Resident #44 A review of Resident #44 medical record revealed a written physician order of transfer on 12/22/17 to the hospital. A tracking Minimum Data Set (MDS) Section A, with an Assessment Reference Date of 12/22/17, revealed a documented transfer to acute care hospital. A review of nurses notes dated 12/23/17 revealed Resident # 44 was transferred to the hospital with the familiy notified but not the method documented A review of transfer record revealed notification of family on 12/23/17. An interview on 02/26/18 4:24 PM with Director of Nursing (DON) revealed the transfer record documented the notification of the family but no record of the written notification. DON said the notification was by the phone. Resident #42 Review on 02/26/18 at 02:00 PM of Resident # 42 medical record revealed there no letter of notification family related to hospitalization of the resident on12/27/2018. Interview on 02/26/18 at 02:08 PM with the Business office manager revealed she was not aware she needed to let the family know in writing about transferring the resident to the hospital. Interview on 02/26/18 at 02:17 PM with Registered Nurse (RN) Staff Development #1 revealed she did know about having to notify the ombudsmen or family in writing about the discharge to the hospital for Resident #42. RN stated Is this a new regulation? Interview on 02/26/18 at 02:27 PM with Staff Development Nurse #1 revealed she knew the facility was supposed to let family know about hospitalization but not in writing.Based on observation, record interview, and facility policy review the facility failed to notify family in writing upon transfer to the hospital for four (4) of four (4) residents records reviewed. Resident #34, #42, #44, #56,

Based on record review, staff interview, and facility policy review, the facility failed to revise the care plan related to use of a catheter strap with an indwelling Foley catheter use as evidenced by no approaches to manage dislodgement or excessive urethral tension for Resident #3, for 1 (one) of 14 resident care plans reviewed. Findings Include: Review of the facility's policy entitled, Using the Care Plan reviewed January 2015, revealed, 5. Changes in the resident's condition must be reported to the MDS (Minimum Data Set) Coordinator so that the resident's care assessment and care plan can be made. Review of the care plan for risk for urinary tract infection due to indwelling catheter revealed no revisions for catheter related injuries such as dislodgement or excessive urethral tension. Interview on 10/9/2015 at 2:10 PM with Licensed Practical Nurse # 2 revealed the intervention for securing the tubing was not listed on the care plan. Review on the facility's face sheet revealed the facility admitted the resident on 7/13/2009. Resident #3's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 8/25/2015 revealed Resident #3 had cognitive impairment. Section H for Bowel and Bladder revealed the resident had a catheter.

Based on interview, record review and facility policy review, the facility failed to develop a care plan for an identified pressure ulcer for one (1) of ten (10) residents reviewed, Resident #1. Findings include: Review of facility policy entitled Care Plan-Comprehensive revised January 2013 revealed, the comprehensive care plan has been designed to incorporate identified problem areas. Review of Resident #1's current Care Plan did not reveal a problem for the identified pressure ulcer, eschar, documented on the 09/03/15 Initial Wound assessment by Registered Nurse (RN) #1. Interview with LPN #2 on 10/08/15 at 3:15 PM revealed LPN #2 said The care plans are developed, of course, from MDS (Minimum Data Set) and also from the MD (physician) orders. I get a copy of the MD orders every morning. The skin prep, I think, is a part of the standing orders but the nurse didn't write the order for the skin prep so it didn't get care planned until the order was written on 09/16/15. LPN #2 said the standing orders should be written on the physician's orders [REDACTED]. Review of the facility's face sheet revealed the facility admitted Resident #1 on 12/23/09. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/29/15 revealed Resident #1's Brief Interview for Mental Status (BIMS) score was two (2) indicating Resident #1 had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow the care plan for incontinent care for Resident #1 and failed to provide Activities of Daily Living (ADL) Care for Resident #6 for two (2) of 12 care plans reviewed; Resident #1 and Resident #6. Findings included: Review of facility policy entitled Using the Care Plan, revised August 2006, revealed the care plan was used to develop the residents' daily care routines and was available to staff responsible for providing care of services for the resident; the nurse supervisor used the care plan to direct care provided by Certified Nursing Assistants (CNAs) and nurses. Review of Resident #1's care plan revealed, Clean after each episode of incontinence. Incontinence briefs- check and change when wet every two hours and PRN (as needed). Observation on 10/08/15 at 2:15 PM revealed CNA #2 performed incontinent care for Resident #1. CNA #2 wiped Resident #1's buttocks and rectal area from back to front towards the urinary meatus and wiped the midline perineum area twice, using the same cloth. Interview on 10/08/15 at 2:35PM CNA #2 said the CNA Care Guide does not include how to perform incontinent care. CNA #2 said she had not had a check off for incontinent care since beginning employment in January 2015. Interview on 10/08/15 at 3:15PM Licensed Practical Nurse (LPN) #2 said, The care plan does not include instructions for perineal/incontinent care; that is part of CNA training. When you see incontinent care on the care plan, you should know how to do it per training and policy. Review of the facility's face sheet revealed the facility admitted Resident #1 on 12/23/09. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/19/15 revealed Resident #1's Brief Interview for Mental Status (BIMS) score was two (2) indicating Resident #1 had severe cognitive impairment. Resident #6 Review of care plans revealed the problem for risk for poor hygiene as resident needs physical help in dressing, toileting, personal hygiene, eating and bathing due to dementia. Interventions included extensive assistance of one staff member for personal hygiene. Problem for Resident #6 included the resident cannot communicate wants and needs. Intervention included staff needed to recognize signs from resident indicating wants and needs. On 10/07/15 at 11:30 AM, an observation revealed Resident #6 seated in a high backed wheel chair at a small table with other residents with several patches of thick chin hair. On 10/08/15 at 2:35 PM, observation revealed Resident #6 seated in a high backed wheel chair with group of female residents near the television with chin hair noted. Interview on 10/08/2015 at 2:35 PM with Certified Nursing Assistant (CNA) #1 revealed the removal of facial hair was supposed to be done on the resident's bath days. CNA #1 confirmed the presence of chin hair. Record review revealed the task for removal of facial hair was not included on the daily care guide on the computer kiosk. Review of the facility's face sheet revealed facility admitted the resident on 02/10/2012. Resident #6 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 08/25/2015 revealed the Brief Interview of Mental Status (BIMS) score was unable to be completed due to impaired cognitive status. Section G for Functional Status for Personal Hygiene revealed the resident required extensive assistance of one staff member for completion.