Every finding on record at Choctaw Nursing and Rehabilitation Center

Based on observations, interviews, and facility policy review, the facility failed to maintain the kitchen in a sanitary condition in order to serve and prepare food for one (1) of two (2) kitchen tours. Findings Include: Review of the facility policy titled Sanitary Conditions of the Food Service Department with an originated date of 9/04, revealed the following policy statement, Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. During the initial kitchen tour on 6/28/2026 at 2:20 PM with Dietary #1, Dietary #2, and Dietary #3, observations were made regarding the cleanliness of the kitchen environment. The pantry door frame facing the kitchen contained accumulated dirt and dried food residue. Above the left side of the door frame on the ceiling contained multiple dried food splatter marks, approximately six (6) inches in diameter. Dietary #3 stated, That's been there forever. Further observation revealed the vent hood above the cooking area contained accumulated grease and food residue on the lower portion of the structure. Dietary #1 confirmed the buildup could flake off into food during meal preparation and confirmed that it needed to be cleaned. During an interview on 6/29/2026 at 10:45 AM, the Certified Dietary Manager (CDM) confirmed the food residue and dirt observed on the ceiling, door frame, and vent hood had been cleaned after the initial observation. The DM stated the conditions observed were not consistent with facility's expectations for maintaining a clean kitchen environment and that this was in a food prep and serve area. During an interview on 6/29/2026 at 2:45 PM with the Administrator, she stated it is the facility's expectation that the kitchen be maintained in a clean and sanitary condition.

Based on interview and record review, the facility failed to accurately complete Section P of the Minimum Data Set (MDS) assessment related to alarms for one (1) of 19 residents reviewed for MDS accuracy. Resident #9Findings Include:The facility provided a statement on letterhead that read, We do not have a policy concerning accuracy of MDS. We do however follow the guidance of the MDS RAI (Resident Assessment Instrument) manual.Record review of Resident #9's Physician Order revealed an order dated 7/18/25, Ensure chair alarm is turned on and functioning properly.Record review of Resident #9's MDS with an Assessment Reference Date (ARD) of 5/19/26 revealed Item P0200 did not identify the resident's use of a wheelchair alarm during the assessment reference period.An interview with the MDS Nurse on 6/30/26 at 1:10 PM confirmed Resident #9 had a wheelchair alarm during the May assessment reference period and acknowledged it should have been coded in Item P0200 of the MDS. She stated, I just missed it. She further revealed the MDS should be accurate to provide an individualized picture of the resident.Record review of the admission Record revealed the facility re-admitted Resident #9 on 7/26/24 with medical diagnoses that included Parkinson's Disease without Dyskinesia and Hemiplegia Unspecified Affecting left Nondominant Side.Record review of the MDS with an ARD of 5/19/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #9 was cognitively intact.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to develop and implement comprehensive, person-centered care plans for two (2) of nineteen (19) residents reviewed for care planning. The facility failed to develop a comprehensive care plan addressing urinary catheter care for one (1) resident (Resident #1) and failed to implement the established care plan related to diabetic nail care for one (1) resident (Resident #15). Findings include:Review of facility policy titled Comprehensive Care Plan undated revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .Resident #1Record review of Resident #1's care plan revealed no mention of catheter care on foley catheter.During an interview on 06/30/2026 at 9:54 AM the Minimum Data Set (MDS) Nurse reviewed Resident #1's foley catheter care plan and confirmed that the care plan had not fully been developed to include providing catheter care. She stated that she doesn't normally put it on the care plan, just on the tasks for the aides. MDS nurse confirmed the purpose of the care plan was, To show a person how to take care of a person.Record review of the admission Record indicated Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included Retention of Urine, unspecified; and Infection and Inflammatory reaction due to indwelling urethral catheter, subsequent encounter. Record review of the MDS, with an Assessment Reference Date (ARD) of 6/9/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #1 had moderate cognitive impairment.Resident #15Record review of Resident #15's care plan for Diabetes Mellitus revealed, diabetic nail care to be done monthly and as needed (PRN) by Registered Nurse (RN).During observations and interviews with Resident #15 on 6/28/2026 at 2:51 PM and again on 6/29/2026 at 2:11 PM, his fingernails were observed to be approximately one (1) inch in length with jagged edges and a dark brown substance underneath. He stated the RN usually trims them every couple of weeks. He agreed they needed to be trimmed.During an interview on 06/30/2026 at 10:00 AM the MDS Nurse confirmed Resident #15's Diabetes care plan was not implemented by the facility staff to provide PRN nail care for Resident #15. The MDS nurse stated the purpose of a care plan was, To show a person how to take care of a person.Record review of the admission Record indicated Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Psychosis not due to a substance or known physiological condition.Record review of the MDS, with an ARD of 4/21/2026, revealed under Section C a BIMS score of 15, indicating Resident #15 was cognitively intact.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care necessary to maintain personal hygiene for one (1) of 56 residents observed. (Resident #15)Findings include:Review of facility policy titled Activities of Daily Living undated revealed, .Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .Record review of Resident #15's Order Summary Report revealed an order dated 7/7/2024, Diabetic nail care to be done monthly and as needed (PRN) per Registered Nurse (RN).On 6/28/2026 at 2:51 PM and again on 6/29/2026 at 2:11 PM, during observations and interviews with Resident #15 his fingernails were observed to be approximately one (1) inch in length with jagged edges and a dark brown substance underneath. He stated the RN usually trims them every couple of weeks. He agreed they needed to be trimmed.During an interview on 6/29/2026 at 2:12 PM, the Director of Nursing (DON) confirmed Resident #15's fingernails needed to be trimmed. She stated diabetic nail care should be completed weekly by the RN. The DON confirmed that long jagged nails could cause a skin tear.Record review of the admission Record indicated Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Psychosis not due to a substance or known physiological condition .Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/21/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #15 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to periodically reassess a resident's wheelchair alarm to determine whether it remained necessary and appropriate based on the resident's current assessed needs for one (1) of three (3) residents reviewed for falls. Resident #9Findings Include:Review of the facility policy titled Accidents and Supervision revealed under, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .Review of the facility policy titled Resident Alarms revealed under, Policy: It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practical level of physical, mental, and psychosocial well-being. Additionally revealed under, Monitoring and modification: . c. Ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. Interventions will be modified, as needed, to address any changes. d. Considerations for discontinuation of alarms include, but are not limited to: i. The medical symptoms or risks warranting the use of the alarms are no longer present.An observation of Resident #9 on 6/28/26 at 4:10 PM revealed she was sitting in her wheelchair in the front lobby with other residents watching television. A sensor alarm was attached to the back of the wheelchair. The resident stated she had no idea why she had the alarm. After inquiry about recent falls, she indicated she had not fallen in a long time and stated it had been years.Record review of Resident #9's Physician Order revealed an order dated 7/18/25, Ensure chair alarm is turned on and functioning properly.Record review of Resident #9's Incident Report dated 5/4/24 revealed, Patient in front lobby, up from wheelchair unassisted and attempting to ambulate by herself before falling on floor. No apparent injuries noted. An interview with the Director of Nursing (DON) on 6/29/26 at 2:00 PM revealed the resident had the chair alarm due to a history of falls. She confirmed the residents last fall was on 5/4/24. When inquired how the facility reassessed the continued need for the alarm, she replied, We assess it every time we have a care plan meeting, we talk about it. She confirmed there were no evaluations completed to ensure the ongoing need for the alarm.An interview with Licensed Practical Nurse (LPN) #2 on 6/30/26 at 8:20 AM revealed the resident did not try to get up from her wheelchair, had no recent falls, and the alarm was used as a preventative measure to prevent falls.Record review of Resident #9's Quarterly Fall Risk Evaluation dated 2/26/26 revealed the resident was chairbound and remained free from falls in the past 3 months.Record review of Resident #9's Quarterly Fall Risk Evaluation dated 5/19/26 revealed the resident was chairbound and remained free from falls in the past 3 months. Further review of both Quarterly Fall Risk Evaluations revealed there was no documented reassessment of the resident's continued need for the wheelchair alarm, evaluation of its effectiveness, consideration of less restrictive interventions, or trial reduction despite the resident remaining chair-bound and being free from falls since May 2024.An interview with the Minimum Data Set (MDS) Nurse on 6/30/26 at 9:30 AM revealed the facility tried to reduce alarm usage and, if a resident had not had a fall in a while, the alarms were removed. She stated there should be documentation supporting the ongoing need for Resident #9's alarm but she did not see any. She stated the resident had the alarm due to fall risk and, when inquired why a reduction had not been attempted since the resident had not fallen in two years, replied, I can't answer that. An interview with the DON on 6/30/26 at 11:08 AM revealed the resident could not walk and was unable to get up from the wheelchair without assistance. She stated the alarm was in place for fall prevention and confirmed the facility had not attempted a trial reduction of the alarm.Record review of the admission Record revealed the facility re-admitted Resident #9 on 7/26/24 with medical diagnoses that included Parkinson's Disease without Dyskinesia and Hemiplegia Unspecified Affecting left Nondominant Side.Record review of the MDS with an Assessment Reference Date (ARD) of 5/19/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #9 was cognitively intact. Additionally, revealed under section GG, the resident was dependent for sit to stand transfers.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure staff used proper technique with catheter care to prevent a Urinary Tract Infection (UTI) for one (1) of two (2) residents with catheters. (Resident #1)Findings include:Review of facility policy titled Catheter Care, undated, revealed, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care .Compliance Guidelines .Assist resident to a lying position .Perform hand hygiene. [NAME] gloves .Using circular motion, cleanse the meatus with a clean cloth .With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place .During an observation of catheter care on 6/29/2026 at 3:33 PM, Certified Nursing Assistant (CNA) #1 used the same wipe throughout the entire catheter care procedure while cleansing the urinary meatus and catheter tubing.During an interview with CNA #1 following catheter care, she confirmed she should have used a new wipe with each step of cleaning the urinary meatus to help prevent the spread of infection, specifically to prevent a UTI.During an interview with the Infection Control Nurse, she confirmed CNA #1 should have used a new wipe with each step of cleaning the urinary meatus and catheter tubing. She stated failure to follow proper catheter care technique increased the resident's risk for infection, including UTIs.During an interview on 6/29/2026 at 3:55 PM, the Director of Nursing (DON) confirmed a new wipe should have been used for each step of cleaning the urinary meatus and catheter tubing during catheter care.Review of the admission Record indicated Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included Retention of Urine, unspecified and Infection and Inflammatory reaction due to indwelling urethral catheter, subsequent encounter. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/9/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #1 had moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review the facility failed to ensure a self-administered medication was securely stored resulting in the medication being accessible to unauthorized individuals for 1 (one) of 56 residents reviewed. Resident #49 Findings Include: Review of the facility policy Medication Storage revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, light, ventilation, moisture control, segregation, and security . An observation on 06/28/26 at 3:03 PM revealed Resident #49 sitting on his bed with oxygen in use and there was an Albuterol Inhaler on top of his bedside table. He revealed that his lungs were bad and he's had to wear oxygen and use breathing treatments and inhalers for a long time. Resident #49 revealed that he kept the albuterol inhaler in his room and used it when he needed it. He also confirmed that he did not have a lock box in his room to keep the inhaler secured while not in use. An observation on 06/29/26 at 7:40 AM revealed Resident #49's Albuterol inhaler on top of his bedside table and he was not in his room at this time. An interview on 06/29/26 at 10:50 AM with Resident #49 revealed him lying in bed in his room. He revealed that he kept his inhaler in his pocket or on the bedside table and used it when he got short winded and stated, Some days I use it, some days I don't. Resident #49 revealed that he used it when he couldn't get to his nebulizer, like when he was in therapy or outside. Resident #49 confirmed that he had just returned from being outside and that he had left his inhaler in his room. He stated, I usually have it in my pocket when I leave my room in case I need it. On 06/29/26 at 1:25 PM, an interview with Licensed Practical Nurse (LPN) #1, revealed that Resident #49 was assessed and self-administered his inhaler as he needed it. She revealed that he either kept the inhaler on his bedside table or in his pocket. LPN #1 confirmed that medication should not be left in a room unattended and that by doing so, could result in other residents coming in and taking something they were not supposed to have. She revealed that they did have residents with dementia who wandered and this could cause problems if a resident took a medication that they were allergic to. On 06/29/26 at 1:40 PM, an interview with Director of Nursing (DON) revealed that Resident #49 was assessed to be competent with self-administration of his inhaler. She revealed that he had breathing problems and anxiety and on admission requested that he keep his inhaler. She revealed that the inhaler was normally on his person or on the bedside table within his sight for easy access when he needed a rescue breath. DON revealed that his inhaler should not have been left on bedside table in his room without him present and she would reiterate to him again. She confirmed that they had some residents who wandered in and out of rooms and stated that by leaving medications out and unsecured could result in residents taking something they were not supposed to have and agreed that this could result in adverse reactions. Record review of Resident #49's Order Summary Report revealed an order effective 05/19/26 for Albuterol Sulfate HFA (Hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Micrograms/Actuation) (Albuterol Sulfate) 2 (two) puff inhale orally every 4 (four) hours as needed for SOB (Shortness of Breath)/WHEEZING related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. Record review of Resident #49's Order Summary Report also revealed an order effective 05/22/26, RESIDENT MAY SELF ADMINISTER HIS ALBUTEROL HFA PRN (AS NEEDED) SOB/WHEEZING . Record review of Resident #49's admission Record revealed that he admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Primary Pulmonary Hypertension, and anxiety disorder. Record review of Resident #49's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/25/26 under Section C, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he had no cognitive deficits.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure staff performed appropriate hand hygiene and changed gloves between a contaminated task and a clean resident care task to help prevent the spread of infection during one (1) of four (4) resident care observations (Resident #1). Findings include:Review of facility policy titled Standard Precautions Infection Control undated revealed, .During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces .During an observation of catheter care on 6/29/2026 at 3:33 PM, Certified Nursing Assistant (CNA) #1 assisted Resident #1 with removal of his clothing and undergarment. CNA #1 then proceeded to provide catheter care while wearing the same gloves used during the clothing removal and did not perform hand hygiene before initiating catheter care.During an interview with CNA #1 following catheter care, she confirmed hand hygiene should have been performed before providing catheter care to help prevent the spread of infection, specifically urinary tract infections (UTIs).During an interview with the Infection Control Nurse on 6/29/2026 at 3:50 PM, she confirmed CNA #1 should have performed hand hygiene before proceeding with catheter care. She stated that failure to perform hand hygiene during catheter care increased the resident's risk for infection, including UTIs. She further stated she had recently educated staff regarding peri care and hand hygiene.During an interview on 6/29/2026 at 3:55 PM, the Director of Nursing (DON) confirmed hand hygiene should have been performed after assisting Resident #1 with clothing removal and before initiating catheter care to help prevent the spread of infection.Review of the admission Record indicated Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included Retention of Urine, unspecified; and Infection and Inflammatory reaction due to indwelling urethral catheter, subsequent encounter. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/9/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #1 had moderate cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to ensure pneumococcal immunizations were administered in accordance with physician oversight, facility policy, and current CDC recommendations for one (1) of five (5) residents reviewed for immunizations (Resident #42). Specifically, after the resident representative consented to pneumococcal vaccination, the facility failed to notify the physician when the electronic medical record generated a contraindication alert related to long-term steroid therapy. Instead, the vaccine was incorrectly documented as refused without physician evaluation to determine whether administration was appropriate. This deficient practice resulted in Resident #42, who had pulmonary fibrosis and was receiving long-term systemic corticosteroid therapy, not receiving a recommended pneumococcal vaccine despite having conditions that increased the resident's risk for pneumococcal disease. Findings Include:Record review of the facility policy titled Pneumonia Vaccine (Series) revealed under, Policy: It is our policy to offer residents and staff immunizations against pneumococcal disease in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations. Additionally revealed under, Policy Explanation and Compliance Guidelines: . 7. A pneumococcal vaccination is recommended for adults who have certain chronic medical conditions or other risk factors which may include: . e. Chronic lung disease . o. Iatrogenic immunosuppression, including long-term systemic corticosteroids .Record review of Resident #42's Immunization Record revealed she did not receive the pneumonia vaccine due to refusal.Record review of the Pneumococcal Vaccine Consent dated 4/3/26 revealed the resident representative (RR) signed the consent for administration of the vaccine. Further review revealed documentation by the Infection Preventionist (IP), RP (responsible party) notified that resident is unable to receive this vaccine d/t (due to) prolong use of steroid use. Contraindicated.An interview with the IP on 6/30/26 at 9:11 AM revealed the RR for Resident #42 consented to the pneumonia vaccine. The IP explained that when she entered the vaccine into the facility's charting system to be administered, the system generated an alert indicating the vaccine was contraindicated because the resident was taking steroids. She confirmed she did not reach out to the physician to ensure the vaccine was safe to administer and called the RR to notify them it was contraindicated, documenting the vaccine as refused. She acknowledged that a resident taking steroids was at an increased risk for infections. The IP further revealed the resident also had pulmonary fibrosis, which made her more susceptible to respiratory infections.An interview with the Director of Nursing on 6/30/26 at 11:04 AM revealed the IP should have notified the physician if she received a contraindication alert on the pneumonia vaccine. The DON further stated it was important for a resident taking steroids to receive a pneumonia vaccine since they were at increased risk for infections.Record review of the admission Record revealed Resident #42 was admitted on [DATE] with medical diagnoses that included Unspecified Dementia and Pulmonary Fibrosis.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/26 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 7, indicating Resident #42 was severely cognitively impaired.

Based on policy and procedure reviews, interviews, observations, and record reviews, the facility failed to ensure safety and to prevent an accident of a fall during bed mobility, resulting in multiple fractures to Resident #1. Resident #1 was one (1) of three (3) residents reviewed for accidents and safety. Findings Include: The facility policy and procedure titled Safe Resident Handling/Transfers dated 1/1/22 revised 1/5/25 and signed by the facility Director of Nursing (DON) read: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The interdisciplinary team designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight, cognitive status. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as need arises or changes in equipment occur. Record review of the facility's investigation documentation DATE? revealed the facility had documented that the fall of Resident #1 was caused by Certified Nursing Assistant (CNA) #1 not following the care plan for bed mobility and transfers with a two (2) person assist required for bed mobility and transfers. On 1/29/25 at approximately 7:00 AM the third shift 11 PM- 7 AM CNA #1 was in the facility finishing her care to Resident #1 when the resident rolled off the bed and fell on to the floor during incontinent care. CNA #1 immediately called for help and two additional staff assisted CNA #1 to get Resident #1 up off the floor and back onto the bed. The Registered Nurse (RN) #2 assessed Resident #1 and found that she had pain and injury to her lower extremities. RN #2 called the physician and they had Resident #1 transported to the hospital emergency room (ER) for evaluation and x-rays. The ER found that Resident #1 had fractures to both her legs and they sent resident out to another hospital for surgery. The incident report dated 1/29/2025 07:10 stated: While 1900-0700 CNA was performing incontinence care on resident this morning (approximately 0710, resident rolled off of bed (per CNA report). Bed was not in lowest position, as staff member was at bedside assisting resident. CNA reported that resident rolled onto right side and continued rolling, thus falling off the bed. Resident found lying in floor on her left side in a semi fetal position. Resident's initial complaint is of only bilateral knee pain. No open wounds noted. Some redness surrounding left eye. Slight bruising to bilateral knees. Resident reports not being sure what exactly happened, but states she fell off the bed and was unable to get back into bed. Resident reports bilateral knee pain with palpation/movement. Resident taken to the hospital. Oriented to person Injury Type Bruise 37) Right Knee (front) Bruise 38) Left knee (front). Numerical Level of Pain is 8 on a scale of 1-10. Record review of the emergency room x-rays dated 01/29/2025 12:35 PM revealed: X-ray Right knew 1 or 2 views History Right Knee Pain and Injury. Findings: There is a comminuted fracture of the distal femur. The fracture extends to the articular surface in the region of the intercondylar space. There is no discoloration. Impression: 1. Comminuted fracture of the distal femur. The x-ray report also read: Left Knee Pain and Injury Findings: There is a comminuted fracture of the distal femur. There is one shaft width posterior displacement of the distal femur fracture fragment. Impression 1. Comminuted fracture of the distal femur. Interview on 3/18/25 at 12:45 PM with the DON revealed that the facility conducted a full investigation and obtained a written statement from CNA #1 that was assigned to Resident #1 at the time of the incident on 1/29/25 at approximately 7:00 AM. CNA #1 admitted that she was alone with Resident #1 delivering care when Resident #1 fell from her bed on to the floor. DON stated that at the time of the incident on 1/29/25 that Resident #1 was assessed for a two (2) person assist with bed mobility and transfers. DON stated that CNA #1 did not follow that assessment and was in the room alone with the resident for bed mobility and the resident slid out of the bed to the floor causing the injury. DON stated that this CNA #1 was a very good and responsible, dependable CNA and she had no prior incidents and there had been no issues with her delivery of care prior to or until 1/29/25. DON stated that CNA #1 gave a written statement that she was alone delivering care to Resident #1 and that she had not used the required two (2) person assist for bed mobility. DON provided the written statement of CNA #1 and DON confirmed that she called the agency and told them that CNA #1 was not to be allowed to return to work at the facility due to her not following the care needed for Resident #1 and that she had fallen and had received fractures as a result. DON confirmed that CNA #1 was informed that she would not be allowed to work at the facility any longer. On 3/18/25 at 1:40 PM surveyor placed a telephone call to CNA #1 and left a message on her voicemail to please return the call. Interview on 03/18/25 at 3:00 PM with CNA #2 revealed that she was working the same shift as CNA #1 on 1/29/25 and confirmed that she had assisted CNA #1 and RN #2 to get Resident #1 off the floor and placed her back in bed after the fall. She stated that all she remembered was that the resident was on the floor and that she assisted the nurse and the other CNA to place Resident #1 back in the bed. She stated that Resident #1 was voicing pain while the three (3) were placing her back in bed for an assessment. On 03/18/25 at 3:00 PM a telephone call was placed to RN #2 and there was no voicemail available. Continued to try and reach RN#2 and was unable to reach her for an interview. Interview on 03/18/25 at 3:05 PM with Licensed Practical Nurse (LPN) #2 revealed that she was the nurse trainer for all CNA's and had been the trainer for the past two (2) years. She confirmed that CNA #1 had been trained and educated that Resident #1 was a two (2) person assist with bed mobility. LPN #2 stated that when CNA #1 was hired through the agency as a contract worker for the facility that CNA #1 spent her first week at the local affiliate hospital completing a one (1) week orientation prior to coming to the floor of the nursing home. Interview and observation with Resident #1 on 03/18/25 at 3:15 PM revealed that she was a large framed obese female that was lying in her bed with the bed lowered to the lowest position. Resident was asked if she was in any pain and she stated No. Resident was pleasant but was severely cognitively impaired and she was a poor historian. Her facial expressions were relaxed and happy. She stated yes to the question that the staff were good to her and met her needs to her satisfaction. On 03/18/25 at 5:30 PM, CNA #1 returned the previous phone call that was made to her. CNA #1 stated that never at any time had Resident #1 been a two (2) person assist with any of her incontinent care in the bed. CNA #1 stated that she began working as a full time contract CNA at the facility in March of 2024. CNA #1 stated that she was devastated when Resident #1 rolled out of the bed and that it was very upsetting to her. CNA #1 stated that the facility staff told her that she was responsible for the injuries and fractures of Resident #1 and that upset her greatly because she always went the extra mile for all her residents and that she loved her work at the facility. CNA #1 stated that she had talked to the facility Administrator (ADM) and that she told her that she was loosing her job. CNA stated that Resident #1 was able to follow commands and was able to stand and pivot prior to 1/29/25. CNA #1 confirmed that she was delivering care to Resident #1 alone and that Resident #1 rolled out of the bed and on to the floor when she turned her to her right side to clean her during incontinent care. Record review of the CNA's Point Click charting system revealed that Resident #1 had a care that read: Bed Mobility The resident requires LIMITED ASSISTANCE by 2 staff to turn and reposition in bed. Transferring: The resident requires LIMITED ASSISTANCE by 2 staff to move between surfaces. Record review of the facility nursing notes dated 01/29/2025 14:00 and signed by the DON read: Received phone call from ER nurse who reports that resident had fractured both of her femurs and they are attempting to find an ortho doctor/hospital to accept. Daughter (name) notified via (name of RN #2). Record review of the face sheet of Resident #1 revealed that she was admitted to the facility on [DATE] with diagnoses that included, Heart Failure; Wheezing; Dementia; Type 2 Diabetes Mellitus; Major Depression; Hypertension; Gout; Muscle Weakness; among other diagnoses. Record review of the the Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 7 which indicated that she was severely cognitively impaired.

Based on interviews, record reviews, policy and procedure reviews, the facility failed to follow the Activity of Daily Living (ADL) care plan for Resident #1's bed mobility, which resulted in a fall with multiple fractures for Resident #1. Resident #1 was one (1) of three (3) Residents reviewed for care plans. The facility policy and procedure dated 2/18/22 and revised date of 1/5/25 titled Comprehensive Care Plans stated: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Record Review of the facility's investigation documentation revealed the facility had documented that the fall of Resident #1 was caused by Certified Nursing Assistant (CNA) #1 not following the care plan for bed mobility and transfers with a two (2) person assist required for bed mobility and transfers. On 1/29/25 at approximately 7:00 AM the third shift 11 PM- 7 AM CNA #1 was in the facility finishing her care to Resident #1 when the resident rolled off the bed and fell on to the floor during incontinent care. CNA #1 immediately called for help and two additional staff assisted CNA #1 to get Resident #1 up off the floor and back onto the bed. The Registered Nurse (RN) #2 assessed Resident #1 and found that she had pain and injury to her lower extremities. RN #2 called the physician and they had Resident #1 transported to the hospital emergency room (ER) for evaluation and x-rays. The ER found that Resident #1 had fractures to both her legs and they sent resident out to another hospital for surgery. Interview on 3/18/25 at 12:45 PM with Director of Nursing (DON) revealed that the facility conducted a full investigation and obtained a written statement from the attending CNA #1 that was assigned to Resident #1 at the time of the incident on 1/29/25 at approximately 7:00 AM. The CNA #1 admitted that she was alone with Resident #1 delivering incontinent care when Resident #1 fell from her bed on to the floor. DON stated that at the time of the incident on 1/29/25 that the ADL care plan for Resident #1 was for a two (2) person assist with bed mobility and transfers and that CNA #1 did not follow the care plan that was in place for Resident #1 on 1/29/25. Interview on 03/18/25 at 2:30 PM with Licensed Practical Nurse (LPN) #1 who completed the care plan revealed that she revised the care plans for the Resident #1 using the Minimum Data Set (MDS) as the basis for the care plans. She stated that Resident #1 was care planned at the time of the incident on 1/29/25 to be a two (2) person assist with bed mobility and that CNA #1 did not follow the care plan that was in place. On 03/18/25 at 5:30 PM, CNA #1 returned the previous phone call that was made to her and stated that never at any time had Resident #1 been a two (2) person assist with any of her ADL's. CNA #1 stated that Resident #1 was able to follow commands and was able to stand and pivot at the time of the incident and that she had rolled her to her right side to complete the incontinent care and that the resident continued to roll over on to the floor. CNA #1 stated that she was very upset that this had occurred and had immediately ran to get help and thought it was just a freak accident and did not in any way mean to injury the resident, nor was she being neglectful. Record review of the face sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, Heart Failure; Wheezing; Dementia; Type 2 Diabetes Mellitus; Major Depression; Hypertension; Gout; Muscle Weakness; among other diagnoses. Record review of the MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 7 which indicated that Resident #1 was severely cognitively impaired. Record review of the CNA's Point Click charting system revealed that Resident 1 had an ADL care sheet that read: Bed Mobility The resident requires LIMITED ASSISTANCE by 2 staff to turn and reposition in bed: The resident requires LIMITED ASSISTANCE by 2 staff to move between surfaces. Record review of the Care Plan for Resident #1 stated: BED MOBILITY: The resident requires LIMITED ASSISTANCE by 2 staff to turn and reposition in bed. Date Initiated: 10/02/2024 Revision on: 01/01/2025. The Care Plan for Resident #1 also read: TRANSFER: The resident requires LIMITED ASSISTANCE by 2 staff to move between surfaces. Date Initiated: 10/02/2024 Revision on: 01/01/2025.

Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to follow up on grievances from Resident council meetings related to missing silverware and condiments for four (4) of six (6) residents in the Resident Council Meeting. Resident #4, Resident #10, Resident #11, and Resident #35. Findings include: Record review of facility policy titled, Resident and Family Grievances, undated, revealed, It is the policy of this facility to support each resident's and family member's right to voice grievance without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . An interview on 04/17/24 at 1:45 PM, at the Resident Council meeting, revealed Resident #4 (Resident Council President), Resident #10, Resident #11, and Resident #35, had concerns that they were at times still missing silverware and condiments on their meal trays. They unanimously voiced that this has been addressed in many resident council meetings, and it does seem to be getting better at times, but it is still happening. An interview with the Activity Director on 04/17/24 at 02:35 PM, revealed for the past six months the main issue discussed in resident council meetings is the lack of silverware and condiments. She confirmed the residents say it is getting a little better, but it honestly hasn't been resolved. She revealed each month she had notified the Dietary Manager of the concerns. During an interview on 04/18/24 at 9:05 AM, the Dietary Manager confirmed he was aware of the issues from the past six months regarding missing silverware and condiments. He confirmed he educated his dietary staff but didn't take any disciplinary action and confirmed he did not do a thorough investigation and follow-up. In a phone interview on 04/18/24 at 9:26 AM, the Administrator revealed she was not aware of any issues from the resident council regarding missing silverware and condiments at meals. She revealed when an issue is brought forward in the resident council meeting it is sent to the Department Head to address. Record review of Resident Council minutes dated 10/30/23, revealed Items/silverware being left off trays continues to be an issue. Better at times but not always consistent. Record review of Resident Council minutes dated 11/27/23, revealed Condiments and silverware continue to be left off trays. Continues to be an issue from time to time. Record review of Resident Council minutes dated 12/27/23, revealed Silverware & beverages (of choice) being left off of trays. Continues to be an issue at times. Record review of Resident Council minutes dated 1/29/24, revealed Silverware missing off of trays at times, continues to be an issue. Record review of Resident Council minutes dated 2/26/24, revealed Residents stated that the issue with silverware is some better but is still a problem at times, ongoing issue at times. Record review of Resident Council minutes dated 3/25/24, revealed missing silverware at times, continues to be an issue. Dietary notified. Resident #4 Record review of the Face Sheet for Resident #4 revealed he was admitted to the facility on [DATE]. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #10 Record review of the Face Sheet for Resident #10 revealed she was admitted to the facility on [DATE]. Record review of Resident #10's MDS with an ARD of 3/21/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #11 Record review of the Face Sheet for Resident #11 revealed he was admitted to the facility on [DATE]. Record review of Resident #11's MDS with an ARD of 1/29/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #35 Record review of the Face Sheet for Resident #35 revealed she was admitted to the facility on [DATE]. Record review of Resident #35's MDS with an ARD of 3/11/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact.

Based on staff interviews, record review and facility policy review, the facility failed to submit accurate information into the Payroll Based Journal system as required by the Centers for Medicare and Medicaid Services (CMS) which was discovered through a CMS audit of period between January 1, 2023 through March 31, 2023. Due to the audit findings, the facility was lowered to a one star on the five-star staffing rating system for the quarter of October 1, 2023 through December 31, 2023 for one (1) of four (4) quarters reviewed. Based on the facility's implementation of corrective actions completed on 06/14/23, the State Agency (SA) determined this citation to be Past Non Compliance (PNC) prior to the SA's entrance on 4/15/24. Findings include: Record review of facility policy titled, Payroll Based Journal, undated, revealed, Policy: It is the policy of this facility to electronically submit timely to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. During an interview on 4/15/24 at 7:15 PM, the Director of Nursing stated there had been an audit of the Payroll Based Journal (PBJ) information submitted and CMS determined information was not accurately submitted. She stated the final determination by CMS was in October 2023 and all information submitted since that time was accurate. She confirmed the information submitted into the Payroll Based System must be accurate to represent the staffing available to care for the residents and the facility failed to submit accurate staffing information. During a phone interview on 4/18/24 at 9:20 AM, the Administrator stated the facility had received an audit request from CMS for the Payroll Based Journal submissions for the time frame of January 1, 2023 - March 31, 2023, and as she collected the information for the requested time frame, she determined information had been inaccurately submitted into the PBJ system. This included some staff that worked with the hospital as well as the nursing home had their hours submitted into the PBJ system. Another inaccuracy was the previous Director of Nursing, had hours submitted after she was no longer an employee. She stated she was uncertain how these occurred, but the technology staff with the program for staffing they used was able to immediately repair the system so only accurate information on active employees was entered. She stated that since the system was repaired immediately in June 2023, all submissions after that time were accurate. She stated in October 2023, the facility received the results of the PBJ verification audit and since inaccurate information was submitted into the system during the audited quarter, the facility received a one-star staffing rating in the five-star system for a three-month time frame. She stated the facility was never short staffed and was usually overstaffed, but because of the inaccurate information submitted into the PBJ system, the star rating was lowered and was told that even a small discrepancy would cause the rating to be lowered to one star. She confirmed the facility failed to submit accurate information into the PBJ system, but these areas had been corrected. Record review of the PBJ Staffing Data Report for October 1 - December 23, 2023, revealed, This Staffing Data Report identifies areas of concern that will be triggered . One Star Staffing Rating - Triggered. Record review of letter to the facility from CMS dated 6/12/23, revealed, Upon review of the data submitted by May 14, 2023, for the time frame of January 1 - March 31, 2023, we are conducting an assessment of the data for your facility that were submitted to the PBJ staffing hours system. Record review of letter to the facility from CMS dated 10/23/23, revealed, We have completed our review of the information provided to support data submitted to the Payroll Based Journal (PBJ) system for the quarter ending March 31, 2023 . As a result, your facility will receive a one-star staffing rating in the 5-star Quality Rating System, which may reduce the facility's overall (composite) rating by one star for three months. On 4/18/24 the State Agency (SA) validated through record review and interview: 1. The SA validated that CMS correspondence dated 6/12/23 and 10/23/23 was received and reviewed and addressed by the facility. 2. The SA validated the October 2023, November 2023 and December 2023 schedule and working schedule the facility submitted correct working hours to the PBJ system? 3. The SA validated Information Technology (IT) documentation repaired the system on date so only accurate information on active employees was entered. 4. The SA validated the April 1 through April 15, 2024 schedule and working schedule the facility reviewed each employee's time care accurately indicated the hours worked. 5. The SA validated the PBJ report for 10/1/23 through 12/1/23 was entered accurately to reflect the hours worked by each employee. 6. The SA validated an inservice dated 6/12/23 the facility inserviced the Administrator and the Business Office Manager on PBJ reporting. 7. The SA validated the facility held a Quality Assurance meeting on 7/13/23 with the Administrator, Director of Nursing, Medical Director, Infection Preventionist, Social Service Director, Registered Nurse Treatment Nurse, Medical Records Nurse, Minimum Data Set Nurse, Dietary Manager, Activities Director, and another Registered Nurse. During the meeting, discussed areas included the correction of the errors which included ensuring only active employees were in the time system and ensuring software company adjusted the system so only hours worked in the facility would be included in the PBJ submissions. On 6/13/23, prior to the Quality Assurance meeting, the PBJ concerns as well as the resolutions initiated were discussed. Attendance for this meeting included the Administrator, Director of Nursing, Nursing Supervisor, Infection Control, Wound Care Nurse, MDS Nurse, Medical Records staff, Activities Director, Therapy Director, Social Service Director, Dietary Manager. The Medical Director was notified by phone of the PBJ concerns, plan, and resolution.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to notify the physician when a resident receiving enteral nutrition by a percutaneous endoscopic gastrostomy (PEG) tube developed drainage around insertion site for one (1) of two (2) residents observed with tube feedings. Resident #103 Findings include: Record review of facility policy titled, Care and Treatment of Feeding Tubes, undated, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible Policy Explanation and Compliance Guidelines .6. b. Examination of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection and notify MD when need arises .The facility will notify and involve the physician or designated practitioner of any complications and in evaluating and managing care to address the complications and risk factors. Record review of facility policy titled, Notification of Changes, dated February 2023, revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines .Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment.This may include a. New treatment . On 4/17/24 at 11:30 AM, during observation of care and an interview with Registered Nurse (RN) #1, the dressing around the PEG tube was removed and revealed a tan/brown substance in a 360-degree circle that had been around PEG tube insertion site. RN #1 cleaned around the site with normal saline and a clean gauze was applied. He stated since there was no order for the PEG tube care, he would notify the physician to verify the needed care, otherwise, care would not be done as needed. RN #1 confirmed with the drainage present on the dressing, the area needed to be monitored, cleaned, and dressing applied to prevent skin concerns and/or infection and the physician needed to be contacted for an order. During an interview with the Director of Nursing (DON) on 4/17/24 at 1:50 PM, revealed that Resident #103 did not have an order for PEG tube care or monitoring of the site. She stated when the resident was admitted to the facility from the hospital, the PEG feeding tube was new, and a nurse contacted the physician since there were no orders for PEG care. She stated the physician told the nurse to observe the site and if there was redness or drainage to notify the physician, otherwise no routine care was needed. She stated even if dressing was not needed, basic skin care was needed to keep the site clean. She confirmed routine monitoring and care, as well as documentation, for a PEG tube site was needed. She also confirmed the facility failed to notify the physician when the site began to have drainage, therefore, no orders for care and dressing changes were given. She confirmed that without adequate care of a PEG tube site, infection, skin irritation, or other complication associated with tube feedings could occur and without orders, care plan, and documentation the staff would not know what care was needed to be done. During an interview on 4/18/24 at 12:05 PM, the DON confirmed the staff did not notify the physician when the drainage was observed, and dressing was initially applied. She confirmed the facility failed to notify the physician of the change of condition of resident's PEG tube site, therefore, an order was not obtained. Record review of the Departmental Notes dated 3/28/24 at 11:10 AM, revealed .Called (Formal name of Physician) .No PEG site orders.She said that as long as there was no drainage or irritation that a dressing was not required . Record review of Resident #103's Face Sheet revealed the resident was admitted to the facility on [DATE]. Diagnoses included Pneumonitis due to inhalation of food and vomit, gastrostomy status and Dysphagia. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/24 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to discard soiled linen in a safe and sanitary manner to prevent the possibility of the spread of infection for one (1) of three (3) care observations. Resident #28 Findings Include: Record review of the facility policy titled Handling Soiled Linen undated, revealed Policy: It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection . Policy Explanation and Compliance Guidelines: 1. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants . 3. Linen should not be allowed to touch the . floor and should be handled as little as possible . 4. Used or soiled linen shall be collected at the bedside and placed in a linen bag or designated linen receptacle . An observation during catheter care for Resident #28, on 4/17/2024 at 10:15 AM, with Certified Nurse Aide (CNA) #1, revealed after completing the necessary care, she discarded two (2) soiled bath towels on the floor that had been used to provide catheter care. She picked up the towels and placed them into a trash bag before exiting the room. An interview with CNA #1 on 4/17/2024 at 10:31 AM, confirmed following catheter care for Resident #28, she discarded two (2) soiled bath towels on the floor. She revealed she should have placed them in a bag because they were contaminated to prevent the spread of germs. An interview with the Director of Nursing (DON) on 4/17/2024 at 12:50 PM, revealed that soiled linen was to be disposed of in a bag while the care was provided and not thrown on the floor to prevent the spread of infection. Record review of the Face Sheet revealed the facility admitted Resident #28 on 3/22/2022 with medical diagnoses that included Alzheimer's disease and Urinary Tract Infection.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident receiving enteral feedings via percutaneous endoscopic gastrostomy (PEG) tube received appropriate care and services to prevent possible complications for one (1) of two (2) residents observed with tube feedings. Resident #103 Findings include: Record review of facility policy titled, Care and Treatment of Feeding Tubes, undated, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: .6. b. Examination of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection and notify MD when need arises .10. The facility will notify and involve the physician or designated practitioner of any complications and in evaluating and managing care to address the complications and risk factors. An interview with Licensed Practical Nurse (LPN) #2 on 4/17/24 at 11:00 AM, revealed she was uncertain what care was ordered for the PEG site since she was unable to find an order for the PEG tube care. She stated she thought the night shift, not the day shift, performed the PEG tube care so she had not observed the site or given care for the PEG tube since there was no order. On 4/17/24 at 11:27 AM, an observation and interview with Resident #103 revealed he receives feeding by his PEG tube and he does not eat by mouth. He stated he has a dressing on his feeding tube, and he raised his shirt, and a drain sponge dressing was noted to be in place around his feeding tube. During an observation of PEG site care and interview with Registered Nurse (RN) #1 on 4/17/24 at 11:30 AM, revealed RN #1 removed the dressing around the PEG tube. A tan/brown substance in a 360-degree circle was observed around the PEG tube insertion site. RN #1 stated since there was no order for the PEG tube care, he would notify the physician to verify the needed care, otherwise, care would not be done as needed. RN #1 confirmed the drainage present on the dressing and that the area needed to be monitored, cleaned, and dressing applied to prevent skin concerns and/or infection. In an interview with the Director of Nursing (DON) on 4/17/24 at 1:50 PM, confirmed Resident #103 did not have an order for PEG tube care or monitoring of the site. She stated when the resident was admitted to the facility from the hospital, the PEG feeding tube was new, and a nurse contacted the physician since there were no orders for PEG care. She stated the physician told the nurse to observe the site and if there was redness or drainage to notify the physician, otherwise no routine care was needed. She stated even if dressing was not needed, basic skin care was needed to keep the site clean. She confirmed routine monitoring and care, as well as documentation, for a PEG tube site was needed. She also confirmed there were no orders for care and dressing changes. She confirmed that without adequate care of a PEG tube site, infection, skin irritation, or other complication associated with tube feedings could occur and without orders the staff would not know what care was needed to be done. Record review of Resident #103's April 2024 Physician Orders revealed there were no orders for PEG tube care. Record review of Resident #103's April 2024 Electronic Treatment Administration Record (ETAR) revealed no treatments for the PEG tube was documented on the ETAR. Record review of Resident #103's Face Sheet revealed the resident was admitted to the facility on [DATE]. Diagnoses included Pneumonitis due to inhalation of food and vomit and Gastrostomy status. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/24 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident with a catheter had a catheter securing device for one (1) of six (6) catheters in the facility. Resident #28. Findings Include: Review of the facility policy titled Appropriate Use of Indwelling Catheters undated, revealed .Policy Explanation and Compliance Guidelines: . 7. Indwelling urinary catheters (urethral and suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible An observation during catheter care on 4/17/2024 at 10:15 AM, revealed Resident #28 did not have a catheter securement device, and the catheter was pulled tight with tension from the bedside drainage bag that was attached to the lower bed. An observation and interview on 4/17/2024 at 10:31 AM, with Certified Nurse Aide (CNA) #1 confirmed Resident #28 did not have a catheter securing device. An interview with the Infection Preventionist (IP) on 4/17/2024 at 11:06 AM, revealed Resident #28 should have a catheter securement device in place to prevent injury and the catheter from being ripped out during care. An interview with the Director of Nursing (DON) on 4/17/2024 at 12:50 PM, revealed the facility did not use catheter securement devices. She revealed it was not part of their routine care, and they had not seen a need for or had any issues with catheter injury or dislodgement. Record review of the Face Sheet revealed the facility admitted Resident #28 on 3/22/2022 with medical diagnoses that included Alzheimer's disease and Urinary Tract Infection.

Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for two (2) of 56 residents observed during the initial tour related to nail care. Resident #18 and Resident #36. Findings include: Review of the facility policy Activities of Daily Living (ADL's), undated, revealed .Care and services will be provided for the following activities of daily living: 1 .Bathing, dressing, grooming and oral care. 3 A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming and personal . hygiene. Resident #18 An observation on 4/16/24 at 9:05 AM, and again at 1:55 PM, revealed Resident #18 fingernails on both hands were approximately three-fourth (3/4) inches long and jagged with a brown substance under each nail. Resident #18 stated, I guess they need to cut them. During an observation and interview on 04/16/24 at 3:18 PM, the Director of Nurses (DON) confirmed Resident #18's fingernails were long and had a brown substance under her nails and revealed it looked like it could be food under her fingernails. Resident #18 acknowledged to the DON that she would like her fingernails cleaned. An interview and observation on 4/16/24 at 3:58 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #18's nails were long, jagged, and had a brown substance under them. She stated nail care is supposed to be done weekly and it looks like hers hasn't been done in a while. A record review of Resident #18's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified dementia and Mood disorder. Resident #36 An observation on 4/15/24 at 7:05 PM, revealed Resident #36's fingernails on both hands were approximately one-half (1/2) inch long and jagged with a brown substance underneath his fingernails. An observation on 4/16/24 at 9:15 AM, revealed Resident #36's fingernails long and jagged with a brown substance under each of his nails. An observation and interview on 4/16/24 at 2:50 PM, revealed Resident #36's fingernails remain uncut and with a brown substance under each fingernail. A family member at the bedside stated, I just told my husband that I need to cut and clean his nails, they look terrible. During an interview and observation on 4/16/24 at 3:00 PM, Certified Nurse Aide (CNA) #2 revealed she is assigned to Resident #36 today and she is responsible for his nail care and confirmed that she hadn't done them lately and wasn't sure when they were last done. During an interview and observation on 4/16/24 at 3:05 PM, the DON confirmed Resident #36's fingernails were long and needed to be cleaned and she would get it taken care of. A record review of Resident #36's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Sepsis and Nutritional deficiency.

Based on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for two (2) of the nineteen resident care plans reviewed. Resident #18 and Resident #36 Findings include: Review of the facility policy titled, Comprehensive Care Plans undated revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #18 Record review of Resident #18's care plan revealed, Problem/onset: 06/20/2018 Activities of Daily Living (ADL). I require assistance with ADL care .Approaches .Provide nail care weekly and as needed (PRN). During an observation on 4/16/24 at 9:05 AM, and again at 1:55 PM with interview, revealed Resident #18's fingernails on both hands were approximately three-fourth (3/4) inches long and jagged with a brown substance under each nail. Resident #18 stated, I guess they need to cut them. During an observation and interview on 04/16/24 at 3:18 PM, the Director of Nurses (DON) confirmed Resident #18's fingernails were long and had a brown substance under her nails and revealed it looked like it could be food under her fingernails. Resident #18 acknowledged to the DON that she would like her fingernails cleaned. During an interview and observation on 4/16/24 at 3:58 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #18's nails were long, jagged, and had a brown substance under them. She stated nail care is supposed to be done weekly and it looks like hers hasn't been done in a while. A record review of Resident #18's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified dementia and Dementia. Resident #36 Record review of Resident #36's Care Plan revealed Problem onset: Activities of Daily Living . Approaches: Provide nail care weekly and PRN . An observation on 4/15/24 at 7:05 PM and again on 4/16/24 at 9:15 AM revealed Resident #36's fingernails on both hands were approximately one-half (1/2) inch long and jagged with a brown substance underneath his fingernails. During an interview and observation on 4/16/24 at 3:05 PM, the DON confirmed Resident #36's fingernails were long and needed to be cleaned and she would get it taken care of. During an interview on 4/16/24 at 4:34 PM, the Minimum Data Set (MDS) nurse confirmed she is responsible for developing the comprehensive care plans. She stated the care plan is developed so that each resident gets the appropriate individualized care they need. She confirmed the care plan for Resident #18 and Resident #36 was not followed regarding their ADL nail care and it should have been. During an interview on 4/16/24 at 5:05 PM, the DON confirmed the ADL care plan was not followed for Resident #18 and Resident #36. She revealed the Certified Nursing Assistants (CNAs) know what is required for ADL care and that it is part of hygiene and grooming. A record review of Resident #36's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Sepsis and Nutritional deficiency.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide treatment and services to prevent and heal pressure ulcers for two (2) of four (4) facility acquired pressure ulcers. Resident #2 and Resident #40 Findings include: Review of the facility policy titled Pressure Injury Prevention and Management revealed this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure/injury, prevent infection and the development of additional pressure ulcers/ injuries. Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revised the interventions as appropriate .4. Interventions for prevention and to promote healing: evidence-based interventions for prevention will be implemented for all residents who assessed at risk or who have a pressure injury present basic or routine care interventions could include, but not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.). ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. iii. Provide appropriate, pressure redistributing, support surfaces. iv. Provide nonirritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. Resident #2 An interview and observation on 01/09/23 at 2:15 PM, revealed Registered Nurse (RN) #1 is the treatment nurse and she was observed during wound care for Resident #2. RN #1 removed the resident's brief and it was noted there was no dressing to the wound bed. A large amount of brown fluid was noted on the brief and RN #1 confirmed the fluid on her brief was from the wound draining and it looked like the wound covering had not been there for quite some time since the drainage was dried. She revealed the resident is to have a silicone dressing on and maybe the aide changed her and took it off. She further revealed the aides are not to take off the dressings and she had no idea why there was not a dressing on the wound. RN#1 stated that if the dressing comes off the aides are always to notify the floor nurse or the treatment nurse and revealed she had not been notified of the dressing being off today. An interview on 01/09/23 at 3:10 PM, with Certified Nurse Aid (CNA) #1 revealed she is assigned to the resident today and her shift started at 7 AM. She revealed she changed the resident's brief shortly after coming in at 7 AM and the dressing to her wound was on her. She revealed that at 11:15 AM she changed her again and the dressing was intact. CNA #1 then revealed, at 11:15 AM I just looked at the front of Resident #2's brief and she wasn't wet, so I didn't change the resident and therefore didn't notice if the dressing was still on the wound. A phone interview on 01/10/23 at 3:47 PM, with CNA #4 revealed she worked 1/8/23 from 11 PM to 7 AM and was assigned to Resident #2. CNA #4 reported that she changed Resident #2's brief throughout the night but not a lot because she is not a heavy wetter, and the dressing was on, but it was a little loose. She revealed she gave her a bed bath around 4:30 AM and the dressing was loose and came off. She stated she told Licensed Practical Nurse (LPN) #4 that the dressing came off and she needed a new one. She revealed the nurse didn't come right away since she was doing her med pass so she went on ahead and put her brief on her and the wound was not dressed. She revealed she looked at the front of Resident #2's brief again around 6:30 AM but she wasn't wet, so she didn't change her anymore before her shift ended. An interview on 01/11/23 at 9:00 AM, with LPN #2 revealed if we need to do a PRN (as needed) dressing change, we document it under the Electronic Treatment Administration Record (E-TAR). She revealed she hasn't had to do any PRN wound treatments for Resident #2 this week. She revealed when RN #1 is working she does the PRN wound treatments since she is the treatment nurse. An interview on 01/11/23 at 10:29 AM, with LPN #3 revealed that the dressing being off, and the wound exposed to urine and feces could cause a wound infection. A telephone interview on 01/11/23 at 11:35 AM, with LPN #4 revealed she was working on the morning of 1/9/23 and that CNA #4 told her that Resident #2 just had a bath and needed a dressing on her wound. LPN #4 revealed I didn't do the treatment because I honestly forgot. I was busy giving my meds. She confirmed that the resident not having the wound covered could delay the healing process and cause the wound to become infected. Record review of Resident #2's Physician's Orders dated 1/8/2023, revealed, Clean Stage 3 to sacrum with Dakin's, apply Silvercel to wound bed, cover with silicone border dressing and PRN for soilage/drainage A record review of Resident #2's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebrovascular disease and Multiple Sclerosis. Record review of Resident #2's Minimum Data Set with an Assessment Reference Date of 11/7/22 revealed in Section C a Brief Interview for Mental Status of 04, which indicates the resident is severely cognitively impaired. Resident #40 On 01/08/23 at 3:24 PM, an observation and interview with Resident #40 revealed they (staff) told her the other day that she had a sore on her bottom. She stated they put pillows on her bed under her hips and confirmed she did not have it when she came to the facility. An observation, on 1/9/23 at 8:45 AM, 10:00 AM, 11:00 AM, and 2:10 PM, revealed Resident #40 in bed with the head of the bed up forty to forty-five degrees, positioned on her back. Resident #40 required extensive assist of one for turning and bed mobility. She was positioned in bed with pillows against her side. Her body was in the same position with only a slight change in her head and shoulders. Her sacral area was not off loaded. She remained in the position she was placed during every observation during the survey. An observation and interview on 1/9/23 at 4:30 PM, with the Administrator (ADM) revealed she had checked Resident #40, and the resident was being turned, but upon closer investigation the ADM removed the residents blanket to assess her and confirmed Resident #40 was not turned enough to have the pressure off-loaded from her sacral/coccyx area. An observation of the conversation between Resident #40 and the ADM revealed the resident agreed she would turn more onto her side and Resident #40 stated to the ADM that They could do her anyway they wanted to get it (pressure ulcer) well. An observation, on 1/10/23 at 2:30 PM, revealed wound care to the right buttock performed per Registered Nurse (RN) #1. Wound bed pink, no drainage. Wound measured 1.7 centimeters (cm) by 1.7 cm. An interview, on 1/11/23 at 11:00 AM, with the Director of Nursing (DON) stated that she could not say whether or not the residents were properly positioned because, she did not see them. An interview on 1/11/23 at 12:05 PM, with Certified Nursing Assistant (CNA) #2 revealed she was responsible for turning residents to keep bed sores from happening and stated she turns them, makes sure they are off their bottoms and uses foot protectors. She stated she also makes sure the residents eat all they can and drink their supplements. She confirmed that she had attended an in-service on turning residents. Record review of the in-service record dated 1/3/23, with the topic Turning and Repositioning; Proper Floating of Heels revealed Certified Nursing Assistant CNA #2 attended this in-service. Review of the wound assessment report, dated 12/27/22, revealed the wound was identified as a Stage 2 pressure ulcer to the right buttock on this date with measurements of 1.50 cm length, 1.40 cm width, and 0.20 cm depth. Wound assessment report dated 1/2/23 revealed 1.80 cm length, 1.70 cm width and 0.20 cm depth. Record review of the Face Sheet revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Essential Hypertension, Anxiety disorder, Psychotic disorder with Delusions, and Weakness. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/22 revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident #40 had moderately impaired cognition. 46013