Every finding on record at Community Care Center

Based on observation, interview, and record review the facility failed to provide safe discharge teaching and caregiver training, including return demonstration and evaluation of the caregiver's ability to assist with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), for one of three sampled residents (Resident 1) reviewed for discharge planning. As a result, the facility discharged Resident 1 to a hotel with a son identified as the primary caregiver despite concerns related to unstable housing, reported intoxication, lack of caregiver training, and failure to evaluate caregiver competency to safely meet Resident 1's 24-hour care needs. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),cerebrovascular (CVA- stroke, loss of blood flow to a part of the brain) disease affecting left side, difficulty in walking, and need for assistance with personal care. A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/20/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 out of 15, which indicated Resident 1 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 1's MDS dated [DATE] with self-care indicated, Resident 1 required dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity or, more helpers are required for the resident to complete the activity).Shower/bathing: Required substantial/maximal assistance (Helper does does more than half the effort; helper lifts, holds, or supports trunk or limbs.Lower body dressing, and footwear: Required partial/moderate assistance (Helper does less than half the effort; helper lifts, holds, or supports trunk or limbs. Personal hygiene: Required partial/moderate assistance (Helper does less than half the effort; helper lifts, holds, or supports trunk or limbs). A record review of Resident 1's MDS dated [DATE] with mobility indicated, Resident 1 required dependent assistance with tub/shower transfer and walking 10 feet, partial assistance with toilet, chair/bed transfers and sit to lying. On 6/2/26 at 11:08 A.M., an interview and record review was conducted with the Social Service Assistant [SSA]. The SSA stated Resident 1 had been at the facility for several years, starting on 4/29/24, and was ultimately discharged on 5/2/26 to a hotel, identified as [HOTEL NAME].The SSA reviewed Resident 1's progress notes titled SOCIAL SERVICES PROGRESS NOTES dated 4/10/2026 at 11:01 A.M. indicated: .Resident's son approached social services requesting initiation of discharge planning. Son, [NAME], stated that he has cared for his mother throughout his life and is currently experiencing difficulty working with facility staff. He expressed a preference for his mother to return in his care. SS [Social, Services] spoke with the resident. The resident stated that if the facility could assist her temporarily until she receives her Social Security check, she would like to discharge to her son's home. The patient became tearful and expressed that she simply wanted to be with her son.The SSA further stated, she was aware the son stayed at hotels intermittently but did not believe he had a permanent home. The SSA stated that Resident 1 required 24-hour care and the facility had attempted to locate placement in an assisted living (AL-a housing option where older adults live in private apartments but get help with daily tasks like cooking, cleaning, and taking medication) that could provide 24-hour care, but Resident 1 wanted a location where her son could also stay. The SSA stated there was no documentation Adult Protective Services (APS) was notified, despite concerns related to the son's unstable housing situation and Resident 1 being discharged to a hotel. A review of Resident 1's assessment titled INTERDISCIPLINARY [IDT-group of different experts who work closely together as one unit to formulate a plan of care]-DISCHARGE SUMMARY dated 5/2/26 indicated, .Skilled OT [occupational therapy] interventions provided this reporting period include ADL re-training incorporating compensatory strategies, body mechanics, and safety awareness; BUE[bilateral upper extremity] AROM [active range of motion]/strengthening open and closed kinetic chain[exercises or movements] ther-ex [exercise] for joint integrity/mobility and GMC [sic]; functional dynamic training for static/dynamic balance, functional reaching, postural control; and functional activity tolerance and aerobic capacity to improve functional endurance.Skilled PT interventions completed with focus on bed mobility training, transfer training, gait training, and patient education for safety awareness. However, there was no evidence (last progress noted from therapy 7/21/25-9/12/25) the facility completed or documented hands-on caregiver training, return demonstration, or competency evaluation to ensure Resident 1's son could safely provide the assistance required for Resident 1's ADLs and 24-hour care needs prior to discharge to a hotel setting (since notifying SS on 4/10/2026). On 6/2/25 at 12:14 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 had left-sided weakness from prior stroke (CVA) and although she (Resident 1) was able to move extremities (arms/hands, legs/feet), Resident 1's left side was weaker and slower to move. CNA 1 stated Resident 1 required increased assistance with transfers and mobility-related ADLs for safety. On 6/2/26 12:21 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was able to make her own decisions; however Resident 1 was not fully independent with ADLs. Resident 1 required assistance with ambulation (she was on Restorative Nursing for ambulation using parallel bars) and transfers for safety and was unable to walk independently due to left-sided weakness from a prior stroke.LN 1 stated Resident 1 required assistance with transferring and toileting and used a wheelchair for mobility. LN 1 stated she provided diabetic and medication education to Resident 1 prior to discharge, including insulin administration and blood pressure medication instructions on the day of discharge. LN 1 stated Resident 1 was not observed to determine if she could self-administer medications (i.e. insulin [medication of DM] injections) safely, stating, there was no return demonstration conducted for teaching. LN1 stated Resident 1 did not have physician orders for self-administration training prior to discharge. LN 1 stated because Resident 1's son was not present on the day of discharge, no caregiver teaching or return demonstration to evaluate safety was completed with Resident 1's son. LN 1 stated Resident 1's son should have participated in discharge teaching and safety monitoring. LN 1 stated Resident 1 would have been better in assisted living or community that provided around the clock care.LN 1 further stated concerns with son existed regarding the son's ability to safely provide care as he would get intoxicated and yes, this would be a safety issue as well. LN 1 stated staff previously smelled marijuana on the son during a facility visit which was noted in the progress notes on 8/31/25 at 19:47 (7:47 P.M.).On 6/2/26 at 1 P.M., an interview and record review was conducted with the Director of Rehab (DOR). The DOR stated Resident 1 continued to require assistance with toileting, transfers, ambulation and mobility and was not independently ambulatory. The DOR stated Resident 1 ambulated only with parallel bars and staff assistance. The DOR stated therapy staff did not re-evaluate Resident 1 for discharge readiness and did not complete caregiver training with Resident 1's son prior to discharge. The DOR stated, .No we did not pick her [Resident 1] up for therapy to re-evaluate for discharge and the need with Resident and care giver training with her son.The DOR stated Resident 1 would have been safer at an Independent Living (IL) or AL, or other 24-hour care wherever she went. The DOR stated Resident 1's son was expected to be the primary caregiver after discharge; however, the discharge summary did not contain evidence of caregiver training or return demonstration. The DOR stated, Care giver training is needed for safe discharge and carry over with family and to prevent injury, rehospitalization with discharge. The DOR further stated, We didn't provide any more training for a safe discharge (last progress noted from therapy 7/21/25-9/12/25). On 6/2/26 at 1:34 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 1's son notified the facility on 4/10/26, that he wanted Resident 1 discharged from the facility. The DON stated the discharge plan should have been updated with the IDT, including nursing and rehabilitation (rehab) services, to ensure a safe discharge process prior to Resident 1's discharge on [DATE].The DON further stated concerns existed regarding the son's behavior and its impact on safety within the facility. The DON stated the situation with the son raised safety concerns involving Resident 1's two female roommates. The DON stated stated I don't want to accuse that there were drugs involved, but he did show some signs in the past while he visited her. The DON stated she would have been safer for an AL or 24-hour care, the acknowledged that the son's behavior raised concerns related to Resident 1's safety and supervision.The DON stated the facility should have completed additional discharge teaching, including return demonstrations, to evaluate Resident 1's and caregiver's (son) ability to safely manage medications, treatments, and ongoing care needs after discharge, The DON stated caregiver training and return demonstrations were necessary to make sure the resident is safe on their own after they discharge from the facility. The DON stated Resident 1's son, identified as the primary caregiver after discharge, was not present at the time of discharge and no caregiver training or competency evaluation were completed with him prior to Resident 1 being discharged to a hotel setting. The DON stated, It could potentially harm the resident (Resident 1) without proper, safe discharge planning. On 6/3/26 at 3:22 P.M., an interview was conducted with the DON. The DON stated, APS was not called regarding concerns related to Resident 1's discharge. The DON stated social services provided information regarding in-Home Support Services (IHSS); however, the son reportedly needed identification documentation in order to apply for IHSS, and there was no evidence IHSS caregiver services were established or approved prior to discharge. The DON stated, I don't have any doubt that he could take care of his mom, but also acknowledged uncertainty regarding whether APS should have been contacted due to the circumstances surrounding the discharge. The DON stated, I'm in between resident's rights and safe discharge.The DON further stated the discharge process occurred quickly after Resident 1's son requested discharge from the facility. The DON stated staff wanted to get [Name of Resident 1's son] out of the facility to protect other residents, indicating concerns existed regarding the son's behavior and presence in the facility. A record review of Resident 1's clinical chart indicated no documented evidence of APS notification. A review of the facility's policy and procedure titled, Discharge Summary and Plan dated December 2016, indicated .Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan . The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include. arrangements that have been made for follow-up care and services.the degree of caregiver/support person availability, capacity and capability to perform required care.The resident or representative (sponsor) should provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed .

Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of four sampled residents (Residents 73, 4, and 50) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. In addition, for Resident 50, an administration was documented on the MAR, but not signed out on the CDR. These failures had the potential for diversion (unlawful distribution or use), inadequate narcotic accountability, and the potential to not meet the needs of the residents in the facility.Medications were not administered as prescribed for one of four residents sampled for controlled medication audits (Resident 50) and for one of five residents sampled for unnecessary medications (Resident 8). These failures had the potential for Residents 50 and 8 to potentially experience negative health outcomes.Ozempic (an injectable medication for diabetes, a condition characterized by impaired blood sugar control) was not available for administration for Resident 8 two times in an eight-week period. This failure had the potential for Resident 8 to not get the full therapeutic effect of his medication.Insulin (a medication used lower blood sugar) pens (devices used to deliver an injectable drug into the body) in one of four inspected Medication Carts were observed without an open date recorded for Residents 4, 31, and 8. This failure had the potential to negatively alter the drug's stability, physical properties and effectiveness, which could result in adverse resident outcomes.Findings:1. During an inspection of Station 1 Medication Cart 2 conducted with Licensed Nurse (LN) 33 on 4/27/26 at 9:11 A.M., the CDRs for two random residents receiving PRN (as needed) controlled medications were requested for review. An additional CDR was requested from Station 2 Medication Cart 1 for review on 4/28/26 at 11:10 A.M. from LN 34. Another CDR was requested from Station 2 Medication Cart 2 on 4/28/26 at 3:13 P.M. from LN 35.A review of Resident 73's medical record indicated an order for hydrocodone-acetaminophen (a controlled medication used to manage pain) 7.5/325 milligram (mg, unit of measurement) tablet - one tablet by mouth every 6 hours as needed for moderate to severe pain (7-10 level pain out of 10, 0 being no pain and 10 being the worst pain imaginable), dated 4/15/25.During a concurrent interview and record review with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 4/30/26 at 11:41 A.M., a review of Resident 73's CDR for hydrocodone-acetaminophen 7.5/325 mg and April 2026 MAR indicated the nursing staff signed out of the CDR, but did not document the medication administration on one occasion: 4/18/26 at 4 A.M.The DON confirmed there was no documentation on the MAR on 4/18/26 at 4 A.M. A review of Resident 4's medical record indicated orders for oxycodone-acetaminophen (a controlled medication used to manage pain) 5/325 mg tablet - give one tablet by mouth every 6 hours as needed for moderate to severe pain (4-10 level pain), started 4/15/26.During a concurrent interview and record review with the DON and ADON on 4/30/26 at 11:41 A.M., a review of Resident 4's CDR for oxycodone-acetaminophen 5/325 mg and April 2026 MAR were reviewed. The CDR indicated the nursing staff signed out one tablet of oxycodone-acetaminophen 5/325 mg, but did not document the medication administration on one occasion: 4/24/26 at 3:50 A.M.The DON confirmed the lack of documentation in the medical record for 4/24/26 at 3:50 A.M. A review of Resident 50's medical record indicated orders for morphine sulfate (a controlled medication used to manage pain), including the following:morphine sulfate oral solution (in liquid form) 100 mg per 5 mL (milliliters, unit of measurement for volume) - give 0.25 mL by mouth every 4 hours as needed for severe pain (7-10 level pain), started 11/3/25 and discontinued 11/8/25, andmorphine sulfate oral solution 100 mg per 5 mL - give 0.25 mL by mouth every 4 hours as needed for moderate to severe pain (4-10 level pain), started 11/9/25 and discontinued 12/5/25.During a concurrent interview and record review with the DON and ADON on 4/30/26 at 11:41 A.M., a review of Resident 50's medical record was conducted. Resident 50's CDR indicated nursing staff signed out of the CDR, but did not document the medication administration on the following dates:11/4/25 at 1 A.M.11/6/25 at 1:30 A.M.11/6/25 at 5:30 A.M.11/11/25 at 1 A.M.11/11/25 at 5:30 A.M.11/12/25 at 12:30 A.M.11/12/25 at 5:30 A.M.11/13/25 at 12 A.M.11/13/25 at 4 A.M.The DON confirmed she could not find any documentation of administration on Resident 50's November 2025 MAR for the above dates and times.Additionally, there was an administration documented on the MAR for 11/7/25 at 3:05 P.M., but not signed out on the CDR. The DON acknowledged the CDR was not signed out on 11/7/25 at 3:05 P.M.The DON stated documentation should be accurately charted on the CDR and MAR. The DON stated the documentation on the CDR and MAR should match. A review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised 4/19, indicated, .The nurse administering the medication is responsible for recording.time of administration.quantity of the medication remaining.signature of nurse administering medication. 2a. A review of Resident 50's medical record indicated orders for morphine sulfate, including the following:morphine sulfate oral solution 100 mg per 5 mL - give 0.25 mL by mouth every 4 hours as needed for severe pain (7-10 level pain), started 11/3/25 and discontinued 11/8/25,morphine sulfate oral solution 100 mg per 5 mL - give 0.25 mL by mouth every 4 hours as needed for moderate to severe pain (4-10 level pain), started 11/9/25 and discontinued 12/5/25,morphine sulfate oral solution 100 mg per 5 mL - give 0.25 mL by mouth every 4 hours as needed for severe pain (7-10 level pain), started 1/30/26, andmorphine sulfate oral tablet extended release (ER, signed to release slowly) - give one tablet by mouth every 12 hours for pain management, started 11/11/25 and discontinued on 2/4/26.During a concurrent interview and record review on 4/30/26 at 11:41 A.M. with the DON and ADON, Resident 50's medical record was reviewed.Resident 50's CDR was signed out on 12/26/25 without a time. There was no MAR documentation for morphine sulfate oral solution on 12/26/25. Resident 50's medical record indicated there was no active morphine sulfate oral solution order on 12/26/25.The DON stated morphine sulfate oral solution should not have been given on 12/26/25 because that order was not active at that time. Resident 50 received a dose of morphine sulfate oral solution, as documented on his February 2026 MAR, despite having a pain level less than 7 on 2/2/26 at 8:10 A.M. when his pain level was 6.The DON acknowledged this documented administration on Resident 50's February 2026 MAR. The DON stated the morphine sulfate oral solution was ordered for pain levels greater than or equal to 7. 2b. A review of Resident 8's medical record indicated orders for the following medication:metoprolol tartrate (a medication used to treat hypertension, high blood pressure) 25 mg tablet - give half a tablet one time a day for hypertension. Hold if SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110 or apical pulse (heart rate) less than 60, started 2/21/24.During a concurrent interview and record review on 4/29/26 at 3:11 P.M. with the DON, Resident 8's medical record was reviewed. Documentation on Resident 8's April 2026 MAR indicated Resident 8 received doses of metoprolol tartrate despite having a SBP less than 110 on the following dates:4/2/26 blood pressure (BP) 103/744/10/26 BP 98/62The DON acknowledged the above entries in Resident 8's April 2026 MAR. The DON stated the medication should have been held (not administered) on 4/2/26 and 4/10/26 because Resident 8's BP was outside the hold parameter. A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders. 3. A review of Resident 8's medical record indicated orders for the following medication:Ozempic (a medication used to treat diabetes) - inject 2 mg subcutaneously (into the fat under the skin) in the evening every Friday for DM (diabetes mellitus) management, started 2/6/26 and discontinued 3/29/26, reinitiated 4/3/26.Resident 8's medical record indicated Ozempic was not given, as documented on his March 2026 and April 2026 MARs, on the following dates:3/13/26 code 134/3/26 code 13The MAR indicated code 13 = Drug Not Available.The DON confirmed the meaning of the code 13 and acknowledged the MAR entries on the above dates for Ozempic. The DON stated nursing staff were expected to follow up with pharmacy if medications were unavailable for administration and inform their charge nurse or the DON of the unavailability.A review of the facility's P&P titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, effective 1/15/25, indicated, Medications.are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. 4. During a concurrent observation and interview on 4/27/26 at 9:11 A.M., an inspection of Station 1 Medication Cart 2 was conducted with LN 33. Four insulin pens were observed with blank date open stickers affixed to them.insulin glargine-yfgn (a type of long-acting insulin) pen for Resident 4insulin glargine-yfgn (a type of long-acting insulin) pen for Resident 31Lantus Solostar (a type of long-acting insulin) 100 units/mL pen for Resident 8insulin lispro (a type of rapid-acting insulin) 100 units/mL pen for Resident 8LN 33 confirmed that the date open stickers affixed to the pens were blank. LN 33 stated all four insulins had been opened and were being used.Each one of the insulin pens had a note on the prescription label that read, Refrigerate unopened.pens. Once in use, do not refrigerate. Store.pen in use at room temperature. DISCARD UNUSED PORTION AFTER 28 DAYS.During an interview with the DON on 4/29/26 at 3:11 P.M., the DON stated nursing staff were to label any medications removed from the refrigerator. The DON stated if those medications were in the medication carts, they needed to be labeled with the date it was opened.A review of a leaflet provided by the facility, titled Instructions for Use, for insulin glargine-yfgn, revised 3/25, indicated, .Keep new pens in the refrigerator.After first use: Keep.pen at room temperature.Only use.pen for up to 28 days after its first use. Throw away the Insulin Glargine-yfgn pen you are using after 28 days, even if it still has insulin left in it.A review of the Lantus package insert (PI, document from the drug manufacturer on how to safely and effectively use medications) and Instructions for Use for Lantus Solostar, provided by the facility, revised 5/25, indicated, .Keep new pens in the refrigerator.After first use [k]eep.pen at room temperature.Only use.pen for up to 28 days after its first use. Throw away the LANTUS Solostar pen you are using after 28 days, even if it still has insulin left in it.A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame.12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (17) had access to personal funds when the resident requested money to purchase clothing of choice. As a result, Resident 17 was unable to purchase desired clothing and continued to wear a hospital gown.Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record.During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she wore the hospital gown because she did not have enough personal clothing. Resident 17 stated she wanted to buy clothing of her choosing and had requested access to her money, but the facility had not provided access to her money. Resident 17 stated she was supposed to receive around $1000 from social security on a monthly basis.During a concurrent observation and interview with Resident 17 and licensed nurse (LN) 1 on 4/29/26 at 10:12 A.M., Licensed Nurse (LN) 1 stated Resident 17 had requested additional clothing. LN 1 stated she was not aware Resident 17 had personal funds available. LN 1 stated social services handled the management of all resident funds. During an interview and record review on 4/29/26 at 10:33 A.M., the social service director (SSD) confirmed Resident 17 previously resided at a board and care facility (BCF) before admission to the facility on 5/8/25. The SSD reviewed two social services progress notes (SSPN). A SSPN dated 7/9/25 indicated the SSD conferred with the BCF regarding Resident 17's and determined the resident required a higher level of care than the BCF could provide. The SSPN further indicated Resident 17 would be unable to return to the BCF. The 7/9/25 SSPN did not indicate the SSD discussed Resident 17's social security income, personal funds, or access to funds with the BCF. The SSD stated she did not speak with the BCF again until 4/24/26 and did not know Resident 17 received social security income until 4/24/26.A review of a SSPN, dated 4/24/26, indicated Resident 17 received social security income which the BCF had continued the resident's money to pay $1,440 in monthly rent. A review of SSPN's following the 7/9/24 note up to the 4/24/26 indicated facility did not document any attempts to contact the BCF regarding Resident 17's social security income or personal funds. During an interview and record review on 4/29/26 at 10:48 A.M., the business office manager (BOM) stated the facility used the MC 171 admission and discharge notification form to identify resident income and benefits, including social security income. Review of Resident 17's MC 171 signed, 5/11/25, indicated Resident 17's current income was marked as none. The BOM stated the business office was not notified after the facility determined Resident 17 would not return to the BCF on 7/9/25, and the business office did not submit and updated MC 171 to reflect Resident 17's current income or reassess Resident 17's social security benefit status. The BOM stated Resident 17 declined to sign the form the financial institution needed to open a resident trust account. The BOM was unable to provide documentation that Resident 17 declined to sign the form. During a review of Resident 17's admission packet, the BOM acknowledged Resident 17 had signed the document titled, Resident Trust Fund Authorization (RTFA), on 5/11/26 along with a facility representative giving the facility permission to manage the residents money. The BOM stated the form for opening the trust with the financial institution was separate from the RTFA form. The BOM stated she did not notify the SSD that Resident 17 declined to sign the form the bank needed to open a resident trust account.During a follow-up interview on 4/30/26 at 2:42 P.M., the SSD stated the facility had no documentation that social services or the business office contacted the BCF regarding Resident 17's income after Resident 17 became a long-term care resident at the facility. The SSD stated she did not know Resident 17 had declined to sign the form the bank needed to open a resident trust account. The SSD stated because Resident 17 did not have access to her personal funds the resident could not purchase items of her choosing.During an interview on 4/30/26 at 3:24 P.M., the director of nursing (DON) stated she was not made aware of Resident 17's financial request until 4/29/26. The DON stated if Resident 17 received income it was the facility's responsibility to help ensure all residents had access their personal money. A review of the facility document titled, RESIDENT TRUST FUND AUTHORIZATION, signed by Resident 17 on 5/11/25, indicated, .The resident has the right to manage his/her own financial affairs while in a nursing facility. the resident may wish to deposit personal funds with the facility. The facility will accept those funds and manage them according to the requirements of federal and state law. This allows the resident to have access to his/her personal funds when requested. the facility will comply with the following. The facility will provide the resident convenient access to his/her funds within a reasonable time frame. Resident or resident's representative authorizes the facility to deposit any Social Security checks. into the resident trust account.Resident or resident's representative authorizes the facility to disburse funds to pay for any resident authorized charges.A review of the facility policy titled, Resident Rights Guidelines for All Nursing Procedures, revised 10/2010, indicated, Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including . d. Protection of resident funds and personal property;. h. Resident freedom of choice.

Based on observation, interview and record review the facility failed to ensure one of one sampled resident (17) reviewed for dignity had sufficient personal clothing of choice and footwear.This failure resulted in Resident 17 remaining in a hospital gown instead of personal clothing and without available footwear, with the potential to diminish the resident's sense of self-worth.Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record.During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she was in her hospital gown because she did not have enough personal clothing and wanted to purchase clothing of her choice. Resident 17 stated she had requested access to her personal funds to buy clothing, but the facility had not provided the money after she made the request. Resident 17's closet contained one jacket, one dress, and some folded pants at the bottom of the closet. The closet did not contain shoes. One slipper was present in the closet, but the matching pair was unable to be located.During an observation and interview in Resident 17's room on 4/29/26 at 10:12 A.M., Licensed Nurse (LN) 1 stated she was aware Resident 17 had requested additional clothing and had provided Resident 17 clothing from the facility's donated clothing supply. LN 1 stated she was unaware Resident 17 had personal funds and wanted to buy clothing. During an observation of the clothing in Resident 17's closet, LN 1 acknowledged Resident 17's limited personal clothing, one slipper without the matching slipper, and no other footwear. LN 1 stated Resident 17 not having sufficient footwear or being able to purchase and choose personal clothing was a dignity concern. During an interview on 4/30/26 at 3:24 P.M., the director of nursing (DON) stated the facility was expected to provide for residents' basic needs, such as clothing and food. DON stated if Resident 17's request to buy clothing and have access to basic footwear was not met, it could impact the resident's emotional well-being and dignity. A review of the facility policy titled, Dignity, revised 2/2021, indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation:. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 3. Individual needs and preferences of the resident are identified through the assessment process. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are:. c. encouraged to dress in clothing that they prefer.A review of the facility policy titled, Resident Rights Guidelines for All Nursing Procedures, revised 10/2010, indicated, Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation:m1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: b. Resident dignity and respect;. Resident freedom of choice.

The facility did not ensure professional standards were followed when a resident's change in condition was not followed up on for one of three residents (Resident 10) observed for changes in condition. This failure had the potential for harm due to no follow up of a noted change.Resident 10 was originally admitted to the facility on [DATE], with diagnosis that included: acute (sudden, new) and chronic (over six months) respiratory failure (the lungs cannot deliver enough oxygen to the body and remove carbon dioxide, causing organ damage), muscle spasm; contracture of right and left knees (Contractures are the permanent, abnormal tightening of skin, muscles, tendons, or ligaments, causing joint stiffness and limited movement range {ROM}, according to Resident 10's admission record.On 4/29/26 at 9 A.M., a simultaneous interview and record review was held with the Director of Rehab. (DRH). A Restorative Nurse's Aide (RNA- a health care worker with training in physical therapy) weekly summary dated 4/11/26 was reviewed. The note reflected Resident 10 had increased resistance, and the LN (licensed nurse) was notified. Prior weekly summary notes were reviewed, back to November of 2024. The DPT stated the RNA weekly summaries were non-specific, and used the same language. The DPT stated it could be an issue of copied notes, or the RNA just used the same sentence structures. Either way the notes were non-specific for Resident 10, and had not listed joint motion limits.The DPT also stated the RNA program was overseen by the nursing staff, and meetings were held twice monthly with the lead RNA, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD), and the residents on the RNA programs were discussed. The physician's order, dated 4/22/26, was also reviewed. The DPT stated the order was entered incorrectly for one time only for three months and should have been entered correctly three times weekly for three months. The DPT stated she would alert staff to correct the order. On 4/29/26, at 1:45 P.M.,an interview and record review was held with the DON and the ADON. The RNA notes for Resident 10 were reviewed, including the RNA note dated 4/11/26, which reflected the LN was notified for non-specific tightening to unspecified joints for Resident 10. The DON and ADON stated there are twice monthly meetings for the RNA program residents. The DON and ADON also stated they had no memory of Resident 10's name coming up in those meetings, but there was a documented list of residents discusssed. The DON and ADON were unable to locate a record that noted LN was notified or followed up to a report of joint tightening. The weekly RNA summary was signed by an LN. The DON stated it was expected the LN would perform further follow up; and depending on the issue reported, the follow up could be for another evaluation, change in the RNA program or another change that needed to be done. On 4/29/26 at 2:10 P.M., Resident 10's RNA care plan, the most recent RNA weekly assessments for the past four weeks, and a copy of the listing of the residents discussed in the RNA meetings in April 2026 was requested. The RNA unavailable for interview. The documents were not received by the exit. The facility policy: Restorative Nursing Services, dated July 2017, reflectedResidents will receive restorative nursing care as needed to help promote optimal safety and independence.3. Resident goals and objectives are individualized and resdient centered, and are outlined in the resident's plan of care.5. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b.maintaining or strengthening his/her physiological (related to the physical abilities of the organism) .resources.

Based on observation, interview and record review, the facility failed to record and document fluid intake for one resident (118) on intravenous (IV - a medical method of delivering fluids, medication, or blood directly into a vein using a small tube and needle) therapy.This failure had the potential for fluid mismanagement that can lead to fluid overload (when the body retains too much water, causing it to build up in blood vessels and tissues) or dehydration (when the body loses more fluids than it takes in, causing it to lack enough water to function normally) to Resident 118.Per the facility's admission sheet, Resident 118 was admitted to the facility on [DATE] with diagnoses that included dysphagia (trouble swallowing). On 4/27/26 at 8:10 A.M., an observation was conducted of Resident 118 in his room. Resident 118 had a peripheral intravenous (PIV - a small, flexible plastic tube inserted into a minor vein to deliver fluids, medication, or blood directly into the bloodstream) line on the back of his right hand and was receiving Dextrose-Sodium Chloride Intravenous Solution 5-0.9 % (IV fluids).On 4/27/26 at 2:30 P.M., a record review was conducted of Resident 118's clinical record. Per the physician's order on 4/16/26, staff was to .Monitor Intake and Output (I&O - a medical check that tracks all fluids going into a patient's body versus everything coming out) every shift x 30days. Further review of the physician's orders indicated that Resident 118 was started on Dextrose-Sodium Chloride Intravenous Solution 5-0.9 % - Use 100 ml/hr intravenously every shift for Hydration x3 days for 3 Days.On 4/28/26 at 9:31 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that nursing does not record or document IV fluid intake.On 4/29/26 at 2:30 P.M., a concurrent interview and record review was conducted with the Director of Nursing. Resident 118's clinical record indicated that the IV fluids started on 4/21/26 were not being recorded and documented by nursing staff every shift. The DON stated fluid intake includes IV fluids and that it was her expectation nurses record and document the IV fluids every shift.Per the facility policy titled Intravenous Administration of Fluids and Electrolytes, dated March 2022, indicated document.in the resident's medical record and on the intake/output record.Per the facility policy titled Intake, Measuring and Recording, dated October 2010, indicated .fluids taken intravenously are recorded by the licensed nurse.

Based on observation, interview and record review, the facility did not monitor for and treat signs of pain for one of one clients (23) reviewed. This failure caused Client 23 to experience avoidable discomfort.Findings: Resident 23 was admitted to the facility on [DATE], with diagnosis that included: anoxic brain damage (a condition where the brain was cut off from oxygen, leading to brain cell death) and acute (sudden) and chronic (long term, over six months) respiratory failure (a condition where the lungs cannot supply enough oxygen to organs). Resident 23 had a tracheostomy (a surgically created hole in the neck to allow air into the windpipe) and was totally fed via gastrostomy (g-tube: a surgically created hole in the stomach with a tube inserted to accept formula nutrition). Resident 23 was unable to speak, and dependent on staff for all Activities of Daily Living (ADL's - dressing, oral care, hygiene, etc.), according to her admission Record and her Plan of Care. On 4/28/26 at 11:05 A.M., Resident 23's records were reviewed. Resident 23's hospital discharge orders for medications, dated 3/30/26, included routine acetaminophen (tylenol), 325 milligram (mg-a unit of measure) tablet, two tablets via g-tube three times a day; and an as needed order for acetaminophen, 650 mg every 6 hours, as needed for pain or fever, not to exceed 4 grams/day (4,000 mg). This medication order list was compared to Resident 23's current medication list, which did not include routine acetaminophen for pain. An order for oxycodone, (a strong narcotic pain reliever) 5mg tablet, give 2.5 mg ( 1/2 tablet) every 4 hours as needed for severe pain, dated 3/21/26, was located. The record of pain medication administered by staff for Resident 23 in April 2026 was also reviewed. The record reflected oxycodone was given four times in April, with the nurse recording a pain level of 7 or 8 each time. Acetaminophen was not given to Resident 23 during April, according to the record. On 4/29/26, at 10:10 A.M. an observation and interview was conducted of Resident 23's wound care, with attention to Resident 23's facial expressions and response to care. Care was provided by two LN's, 11 and 12. Near the end of care Resident 23 frowned and grimaced, and did not respond to verbal re-assurance that care was almost completed. LN 11 and 12 observed Resident 23's face and LN 11 stated the frown and grimace appeared to be signs of pain. On 4/29/26 at 1:40 P.M., a simultaneous interview and record review was conducted with the Director of Nursing (DON) the Assistant Director of Nursing (ADON). The prior order from the hospital discharge, for acetaminophen three times a day, was read, and no physician's order for acetaminophen was located in the record.The DON was unable to state why the routine acetaminophen was not carried over to the admission orders of 3/30/26 at the facility. The DON stated a referral will be made to the pain specialist to see Resident 23 for pain and spasticity control. Resident 23's Nursing Care Plan for Pain reflected [Resident 23] has acute (new) and chronic (greater than six months) pain related to wounds and immobility. The interventions included: to watch for signs of pain such as .restlessness,. facial grimace,. crying, .breathing changes.Pain relief measures included .reposition .music. dim lights. reassurance. before pain medication was given.give pain medication as ordered.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 11.54% when three medication errors occurred out of 26 opportunities during the medication administration for three of five randomly observed residents (Residents 53, 85, and 106). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.Findings:During a medication administration observation on 4/27/26 at 7:51 A.M., Licensed Nurse (LN) 30 was observed preparing and administering six medications for Resident 53. The medications included the following tablet: calcium carbonate (a supplement for low calcium) 500 milligram (mg, unit of measurement) chewable tablet.A review of Resident 53's medical record indicated she had an active order for calcium carbonate oral tablet - give 500 mg by mouth four times a day for supplement, dated 10/28/23.A drug review of calcium carbonate from Micromedex (a nationally renowned drug information resource) indicated calcium carbonate 500 mg oral tablets were available as chewable and non-chewable forms.During a concurrent interview and record review of Resident 53's medical record with LN 30 on 4/27/26 at 3:48 P.M., LN 30 stated she did not see the word, chewable on the order.During an interview with the Director of Nursing (DON) on 4/29/26 at 1:41 P.M., the DON stated nursing staff were expected to clarify orders with the prescriber or pharmacy before medication administration if the dosage form on the medication on hand did not match the order. 2. During a medication administration observation on 4/27/26 at 8:45 A.M., LN 31 was observed preparing and administering five medications to Resident 85. LN 31 was observed crushing all of Resident 85's tablets together and mixing the medications with applesauce.Resident 85's medications included the following:levetiracetam (a medication for seizures) 500 mg tablet two times a day for seizure, started 7/16/24.During a concurrent interview and record review of the facility's drug handbook with LN 31on 4/28/26 at 10:56 A.M., the facility's drug handbook indicated levetiracetam tablets should be swallowed whole and shouldn't be chewed, broken, or crushed. LN 31 confirmed he crushed Resident 85's tablets. LN 31 stated based on drug literature levetiracetam should not be crushed.During an interview with the DON on 4/29/26 at 1:41 P.M., the DON stated nursing staff were expected to know which medications should not be crushed. The DON stated nursing staff should clarify orders prior to medication administration. 3. During a medication administration observation on 4/27/26 at 11:43 A.M., LN 32 was observed preparing and administrating nine medications for Resident 106. One of the medications was duloxetine (a medication for depression, a condition characterized by persistent sadness) DR (delayed release, designed to release slowly in the small intestine) 30 mg capsule (medication enclosed in a shell). A review of Resident 106's medical record indicated an active order for duloxetine oral capsule delayed release sprinkle 30 mg - give one capsule by mouth one time a day for depression, started 2/5/26. During a concurrent interview and record review of Resident 106's medical record with LN 32 on 4/27/26 at 3:51 P.M., LN 32 stated the medical record indicated, sprinkle, but she did not see that on the medication administered. During an interview with the Director of Nursing (DON) on 4/29/26 at 1:41 P.M., the DON stated nursing stated were expected to clarify orders with the prescriber or pharmacy before medication administration if the dosage form on the medication on hand did not match the order. A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescribed orders.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when one of five residents sampled for unnecessary medications (Resident 93) and two of four sampled residents for controlled medication use audits (Residents 73 and 4) received pain medications that were not in accordance with the prescribers' orders. This failure had the potential for diversion (unlawful distribution or use), as well as the potential for Residents 93, 73 and 4 to experience physical dependence (unpleasant symptoms if a medication is suddenly stopped) and adverse effects, such as sedation (sleepiness), dizziness and respiratory depression (slowed or shallow breathing).Findings:A review of Resident 93's medical record indicated an order for oxycodone-acetaminophen (a controlled medication used to manage pain) 7.5/325 mg (milligram, unit of measure) tablet - give one tablet by mouth every 4 hours as needed for severe pain (7-10 level pain, 0 being no pain, 10 being the worst pain imaginable), started 3/11/26.During a concurrent interview and record review on 4/29/26 at 3:11 P.M. with the Director of Nursing (DON), Resident 93's medical record was reviewed. Resident 93 received doses, as documented on his April 2026 Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety), despite a pain level less than 7 on the following dates:4/5/26 at 5:01 P.M. pain level 54/5/26 at 9:02 P.M. pain level 54/8/26 at 10:59 A.M. pain level 44/11/26 at 10:21 A.M. pain level 54/11/26 at 2:21 P.M. pain level 14/12/26 at 9:15 A.M. pain level was 54/12/26 at 2:00 P.M. pain level was 54/15/26 at 5:00 A.M. pain level was 04/18/26 at 1:37 P.M. pain level 54/24/26 at 6:49 A.M. pain level was 04/24/26 at 11:26 A.M. pain level 34/28/26 at 9:29 A.M. pain level was 64/28/26 at 2:17 P.M. pain level was 6The DON acknowledged the 13 entries on Resident 93's April 2026 MAR for the above dates and times. The DON stated she expected nursing staff to notify the prescriber if a resident is requesting a pain medication when the pain level is outside the parameter. 2. During a concurrent interview and record review of Resident 73's medical record on 4/30/26 at 11:41 A.M. with the DON and Assistant Director of Nursing (ADON), Resident 73's medical record indicated an order for hydrocodone-acetaminophen (a controlled medication used to manage pain) 7.5/325 mg tablet - one tablet every 6 hours as needed for moderate to severe pain (4-10 level pain), dated 4/15/26. Resident 73 received doses on two occasions, as documented on her April 2026 MAR, despite having a pain level of 0 (no pain) on the following dates:4/17/26 at 9:38 A.M. pain level 04/19/26 at 10:27 A.M. pain level 0The DON acknowledged the documented administrations when pain level was zero on the above dates and times. 3. During a concurrent interview and record review on 4/30/26 at 11:41 A.M. with the DON and ADON, Resident 4's medical record was reviewed. Resident 4's medical record indicated orders for oxycodone-acetaminophen 5/325 mg including the following:oxycodone-acetaminophen 5/325 mg - give one tablet by mouth every 8 hours as needed for moderate to severe pain (4-10 level pain), started 11/19/25 and discontinued on 4/15/26, andoxycodone-acetaminophen 5/325 mg - give one tablet by mouth every 6 hours as needed for moderate to severe pain (4-10 level pain), started 4/15/26 and discontinued 4/24/26.Resident 4 received doses of oxycodone-acetaminophen, as documented on her April 2026 MAR, despite having a pain level of 0 (no pain) on the following dates:4/1/26 at 11:10 A.M. pain level 04/15/26 at 12:21 P.M. pain level 04/23/26 at 8:10 A.M. pain level 0The DON acknowledged the documented administrations when pain level was zero on the above dates and times. A review of the facility's P&P titled, Administering Medications, revised 4/19, indicated, .4. Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure safe and effective prescription labeling when a portion of both a prescription label and the handwritten date opened were missing on a medication in one of four inspected Medication Carts for Resident 38. This failure had the potential to negatively alter the drug's stability and effectiveness and for Resident 38 to experience adverse health outcomes.Findings:During a concurrent observation and interview on 4/27/26 at 9:11 A.M. with Licensed Nurse (LN) 33, an inspection of the Station 1 Medication Cart 2 was conducted. Two plastic bags containing foil pouches of ipratropium-albuterol (a medication used to treat respiratory conditions) nebulizer (a device that changes a liquid medication into an inhalable mist) vials for Resident 38 were found. The prescription label on one of the plastic bags was observed to be missing part of the label which provided the directions for using the medication. LN 33 acknowledged that a portion of the prescription label was missing on that bag. The other bag contained an opened foil pouch of the medication. A handwritten date opened on the back of the foil pouch was observed to have been partially missing. The handwritten date that was intact read, 11/26. The product labeling on the front of the foil pouch instructed, Once removed from the foil pouch, the individual vials should be used within one week. LN 33 was read this and the remaining part of the handwritten date. LN 33 stated the opened pouch needed to be discarded.A review of Resident 38's clinical record indicated an active order for ipratropium-albuterol 0.5-2.5 mg (milligram, unit of measure) per 3 mL (milliliter, unit of measure for volume) - inhale orally every 4 hours as needed for shortness of breath or wheezing (a whistling sound caused by narrowed airways), started 1/24/26.During an interview with the Director of Nursing (DON) on 4/29/26 at 3:11 P.M., the DON stated nursing staff were not to write, touch or rip any prescription label. The DON stated nursing staff were to contact the pharmacy for any prescription labels that were removed. The DON stated nursing staff were to discard and reorder medications if they were unsure about the open date for safety. A review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised 4/19, indicated, .3. Labels for individual resident medications include all necessary information, such as.h. the expiration date.and i. directions for use.7. Only the dispensing pharmacy can label or alter the label on a medication container or package.A review of the facility's P&P titled, Storage of Medications, revised 11/20, indicated, .4. Drug containers that have missing, incomplete.labels are returned to the pharmacy for proper labeling before storing.

Based on observation, interview and record review, the facility failed to maintain sanitary food storage and food service practices when individual size milk cartons were stored in boxes saturated in standing water inside a refrigerator, and when resident meals were cooked and plated for service without verifying cooking and holding temperatures. This failure had the potential to expose residents to foodborne illness from consuming contaminated beverage cartons and serving food to residents without a verified safe cooking temperature.During an observation and interview on 4/27/26 at 9:30 A.M., the kitchen's dairy refrigerator was inspected with the dietary supervisor (DS). The three-door reach-in refrigerator had approximately one inch of standing water that extended across the entire bottom shelf of the refrigerator. Six large cardboard boxes containing 4-ounce cartons of milk had been spread across three large metal pans that were faced down in the water at the bottom of the refrigerator. The bottom of two large cardboard boxes were saturated with water. Upon inspection of the interior of the two boxes, water had seeped through the cardboard and contacted the exterior surfaces of the milk cartons. The DS acknowledged the water at the bottom of the refrigerator and the wet milk cartons in the two boxes. The DS stated the standing water and wet milk cartons were a sanitation and infection control concern. The DS stated that water had previously pooled on the interior of this refrigerator in the past. During an observation of the dairy fridge and interview on 4/27/26 at 9:53 A.M., the registered dietitian (RD) acknowledged the standing water at the bottom of the refrigerator and the wet cardboard boxes and milk cartons. The RD stated that refrigerator was her problem child and it had to be fixed before. The RD stated standing water was an infection control risk for all residents. A review of the facility's invoice from the refrigerator repair company, dated 4/6/26, indicated the cooler had a history of water filing up on the bottom of the cabinet. A review of the facility menu indicated zesty lasagna, Italian green beans, garlic bread, and a peanut butter cookie were to be served for lunch on 4/28/26. 2. During an observation of lunch prep and tray line service on 4/28/26 at 11:17 A.M., the facility chef (FC) placed metal bins full of prepped food in the warming trays and the FC removed the plastic wrap covering each container. At 11:46 A.M., tray line service began and FC began to plate resident diets for meal service. FC did not take the temperature of any meal item on the warming tray before beginning to plate resident meals. The FC continued to plate resident meal trays and loaded two meal delivery carts for distribution without checking the holding temperature of the food in the warming trays. During an interview on 4/28/26 at 11:56 A.M., The FC stated temperatures of all menu items were supposed to be taken and recorded in the temperature log before serving the residents. The FC stated she had not taken the temperature of any meal items after cooking or before serving and therefore did not record anything in the temperature log. FC stated it is important to take the temperature of the food to make sure it is safe for the residents to eat. During an interview and record review of the food temperature log on 4/28/26 at 12 P.M., the registered dietician (RD) stated there were no temperatures recorded for lunch meal item in the temperature log. The RD stated meal item temperatures should be taken before serving to ensure food is safe to serve to residents. The RD stated that undercooked food created a risk of foodborne illness for all residents.During an interview on 4/30/26 at 3:34 P.M., the director of nursing stated the facility should have contacted maintenance about the standing water in the refrigerator and stopped using that particular fridge. The DON stated it was an infection control concern for food items to be sitting in standing water. The DON stated food being served to residents needs to reach a certain temperature criteria to ensure it is safe. The DON stated she expects staff to take the temperature of all food before serving. A review of the facility policy titled, MEAL SERVICE, dated 2023, indicated, Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at appropriate temperatures. 2. The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer. 3. The food will be served on trayline at the recommended temperatures . and recorded on the daily therapeutic menu in the temperature column. of each food served.

Based on interview and record review, the facility's nursing staff failed to maintain the dignity of one sampled resident (Resident 1) when Resident 1 arrived to the dialysis center (a facility where patients undergo a procedure to remove toxins from the blood) wearing only briefs and a blanket. This failure had the potential to cause the resident embarrassment and had the potential to lower self-esteem.Findings:During a record review on 6/13/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney failure), and dependence on renal dialysis.During a record review on 6/13/25, the Physician's Orders indicated Resident 1 was taken to an outside dialysis center every Monday, Wednesday, and Friday.During a record review on 6/13/25, the Minimum Data Set (MDS- an assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition, or mental processes such as memory, perception, decision making) of 00, which indicated his cognitive skills for daily-decision making were severely impaired.During a record review on 6/13/25, the Dialysis Communications form (a form used by the facility and dialysis center to communicate pertinent information about the resident such as vital signs, weight, medications given, etc) dated 6/9/25 indicated, Comments or special instructions post dialysis: .Pt [sic] arrived to clinic without gown [sic] just a blanket and his disposable brief.On 6/13/25 at 9 A.M., a telephone interview was conducted with the Dialysis Licensed Nurse (DLN) 1. DLN 1 stated he was familiar with Resident 1. DLN 1 stated Resident 1 had been a patient at the dialysis center for the past 4 years. DLN 1 stated he was on duty on 6/9/25 during Resident 1's dialysis treatment. DLN 1 stated Resident 1 arrived at the dialysis center wearing only disposable briefs, with a blanket over him. DLN 1 stated, .it's the first time that I witnessed [Resident 1 arriving without clothing]. He had a blanket on him, but its not enough. If that was my father, I'd be very upset. DLN 1 stated when Resident 1 still lived at home, and was transported to the dialysis center, .He always arrived fully dressed: shirt, pants, shoes. We were surprised he arrived like a newborn. There's no dignity in that. He was a [NAME] veteran, someone who served his time. DLN 1 stated dialysis typically lasted 3 to 4 hours. DLN 1 stated the temperature at the dialysis center was cold and he was worried Resident 1's comfort and blood pressure would be affected because he was only wearing briefs.On 6/13/25 at 10:16 A.M., an interview was conducted with Resident 2. Resident 2 stated she received dialysis at an outside dialysis center on Mondays, Wednesdays, and Fridays. Resident 2 stated she preferred to wear her own clothing to dialysis, and she would never go wearing only briefs. Resident 2 stated, .I don't want to go naked. It gets cold there.On 6/13/25 at 10:51 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was Resident 1's assigned CNA on 6/9/25 and got him ready for dialysis. CNA 1 stated on 6/9/25 she did not see any clothes in Resident 1's closet, but the facility had a clothing donation area. CNA 1 stated the clothes in the donation area were collected to use for residents who did not have personal clothing available. CNA 1 stated she did not offer clothing from the donation area to Resident 1. CNA 1 stated she dressed Resident 1 in a gown and disposable briefs to prepare him for dialysis on 6/9/25. CNA 1 stated she does not remember if Resident 1 removed his gown prior to going to dialysis.On 6/13/25 at 10:58 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 3. LN 3 stated prior to 6/9/25, she received reports from CNA's that Resident 1 would have episodes of removing his gown but she had never observed this behavior. LN3 stated she had observed Resident 1 remove his arm out of his gown, but did not know why. LN 3 stated there was no documentation that Resident 1 had a behavior of removing his clothing.On 6/13/25 at 11:44 A.M. a telephone interview was conducted with Resident 1's family member (FM) 1. FM 1 stated the dialysis center called her on [date] to let her know Resident 1 had arrived from the skilled nursing facility without clothes. FM 1 stated, I was [expletive for angry] when I heard about that.I thought, ‘its not right.' FM 1 stated Resident 1 had two pairs of sweaters and two pairs of pants. FM 1 stated she would have brought Resident 1 more clothing if he needed it. FM 1 stated, If he took off the gown, he was probably uncomfortable. FM 1 stated her expectation was for the facility to call her if the resident needed clothing.On 7/11/25 at 11:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated clothing from the donation area should have been offered to Resident 1 if he did not have personal clothing available. The DON stated it was important to maintain resident dignity at all times.A review of the facility's policy titled Dignity revised 2/2021indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.When assisting with care, residents are supported in exercising their rights. For example, residents are.groomed as they wish to be groomed.encouraged to dress in clothing they prefer.Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to prevent and treat three of five residents (Residents 99, 11 and 12) who were identified as being at risk of pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence) when: 1a. Resident 99 was not turned and repositioned every two hours; 1b. Resident 99 had missing entries on his daily wound treatment log; and 2. Resident 11 had missing entries on her daily wound treatment log; and 3. Resident 12 had missing entries on her daily wound treatment log. These failures had the potential for additional or worsening skin injuries to occur. 1a. Resident 99 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (damage to the skin and tissue caused by prolonged pressure on the skin) of the left heel, Stage 4, (a full-thickness tissue loss that exposes bone, muscle, and/or tendon), per the facility's Admission Record. An observation was conducted of Resident 99, in his room on 2/10/25 at 9:04 A.M. Resident 99 was lying in bed, on his back with the head elevated on two pillows. Resident 99's left heel was elevated on a pillow and he was wearing a green padded protective boot. The bed had a regular mattress and a low air loss mattress (LAL-designed to distribute a patient's body weight over a broad surface area and helps prevent skin breakdown), was not present. An observation was conducted of Resident 99, in his room on 2/10/25 at 2:21 P.M. Resident 99 was asleep in bed, lying on his back with the head of the bed elevated at 20 degrees. Additional observations of Resident 99 were conducted on 2/11/25 at 8:12 A.M., 10:15 A.M., 10:58 A.M., 1:36 P.M., and 3:40 P.M. Resident 99 was lying on his back, in bed with the head of the bed slightly elevated. There appeared to be no changes in his position and no use of pillows to elevate pressure from his hips or back. Resident 99's clinical record was reviewed on 2/11/25: According to the facility's Braden Scale (a tool used to predict a patient's risk of developing pressure ulcers), dated 1/15/25, Resident 99 had a score of 13, indicating moderate risk for pressure injuries. A care plan, titled At Risk for Pressure Injury, dated 1/15/25, listed interventions such as: Turn and reposition every 2 hours and as needed. A care plan, titled Unstageable Pressure Injury Stage 4, left heel, revised 2/9/25, also listed interventions such as: Turn and reposition resident at least every 2 hours and as needed. According to the Minimum Data Set, (a clinical assessment tool) Section M-Skin Conditions, dated 1/21/25, Resident 99 was identified for being at risk of developing pressure injuries, with a treatment listed as, Being on a turning/repositioning program. An interview was conducted with Treatment Nurse 1 (Tx LN 1) on 2/12/25 at 8:03 A.M., after a wound treatment had been observed and completed for Resident 99. Tx LN 1 stated Resident 99 should be turned and repositioned ever two hours to prevent additional pressure injuries from occurring. Tx LN 1 stated Resident 99 did not have a LAL mattress and maybe he should have one. An interview and record review was conducted with Certified Nursing Assistant 1 (CNA 1) on 2/12/25 at 8:21 A.M. CNA 1 stated residents should be turned in bed at least every two hours to prevent skin injuries from occurring. CNA 1 stated CNAs documented repositioning residents every two hours in the computer charting system called Point of Care (POC). CNA 1 reviewed Resident 99's POC charting for 2/11/25, which indicated the resident was turned every two hours, starting at 8 A.M. with a yes response, but the system did not have an option for what position the resident was placed in, i.e right side, left side, pillow support etc. An interview was conducted with Licensed Nurse 1 (LN 1) on 2/12/25 at 8:27 A.M. LN 1 stated repositioning residents every two hours was important to prevent skin injuries from developing. LN 1 stated the Treatment Nurses (Tx LNs) could initiate a low air loss mattress request for residents, if they felt it was important and they did not need to wait for a physician's order. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 10:46 A.M. The DON stated she expected all residents to be turned and repositioned every two hours to prevent skin breakdown. According to the facility's policy, titled Prevention of Pressure Injuries, dated April 2020, .Skin Assessment: .3 e. Reposition resident as indicated on the care plan .Mobility/Repositioning: 1. Reposition all residents with a risk of pressure injuries on an individual schedule .Support Surfaces and pressure Redistribution: 1. Select appropriate support surfaces based on the resident's risk factors . 1b. Resident 99 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of the left heel, Stage 4, (a full-thickness tissue loss that exposes bone, muscle, and/or tendon), per the facility's Admission Record. An observation was conducted of Resident 99, in his room on 2/10/25 at 9:04 A.M. Resident 99 was lying in bed, on his back with his head elevated on two pillows. Resident 99's left heel was elevated on a pillow and he was wearing a green protective boot. Resident 99's clinical record was reviewed on 2/11/25: According to Resident 99's Minimum Data Set, (a clinical assessment tool) Section M-Skin Conditions, dated 1/21/25, Resident 99 was admitted with one Stage 4 pressure ulcer that required dressing changes and ointment/medication, along with pressure injury care. According to Resident 99's physician's order, dated 1/22/25, .cleanse (Stage IV pressure injury) on Left Heel with normal saline, pat dry, apply Santyl (an enzyme/protein that breaks down collagen in damaged or dead skin), alginate (a highly absorbent dressing used for wounds that are draining, bleeding, or infected) and cover with dry dressing every day and as needed . According to Resident 99's care plan, titled Unstageable Pressure Injury Stage 4, left heel, revised 2/9/25, interventions listed: Evaluate skin condition on a daily basis, Treatment/medication as ordered. Heel boot to be worn as ordered, and turn and reposition resident at least every 2 hours and as needed. According to Resident 99's Treatment Administration Record (TAR), dated January 21 through January 31, 2025, Resident 99 had no wound treatments performed for four of 10 days. Resident 99's wound treatments were missed on 1/26/25 (Sunday), 1/27/25 (Monday), 1/29/25 (Wednesday) and 1/30/25 (Thursday). An interview and record review was conducted with The Treatment Nurse 1 (Tx LN 1) on 2/12/25 at 8:03 A.M., after observing Resident 99's daily wound treatment. The Tx LN 1 stated Resident 99's wound was improving, and the wound physician was examining the resident every Wednesday with wound measurements being performed. The Tx LN 1 reviewed Resident 99's January 2025 Treatment Administration Record (TAR), and stated he believed the staff just forgot to check off the treatment as being performed, for those four days. The TX LN 1 stated if the treatment was not documented, then no one knew for sure if the treatment was actually completed. The Tx LN 1 stated daily wound treatments were important to provide consistent care and to inspect the wound for signs of infection or a worsening condition. The TX LN 1 stated wound treatments should always be documented, to ensure they were completed as ordered. An interview was conducted with Licensed Nurse 1 (LN 1) on 2/12/25 at 8:37 A.M. LN 1 stated all wound treatments needed to be documented, so other staff knew it was completed. LN 1 stated daily wound treatments were important to help with healing and to identify early signs of infection. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 10:46 A.M. The DON stated if a wound treatment was not documented on the TAR, then it was not done, The DON stated she expected all wound treatments to be performed as ordered by the physician. According to the facility's policy, titled Prevention of Pressure Injuries, dated April 2020, .Monitoring: 1. Evaluate, report, and document . According to the facility's policy, titled Charting and Documentation, dated 2020, .2. the following information is to be documented in the resident medical record .c. Treatments or services performed . 48270 2. Resident 11 was admitted to the facility on [DATE] for physical therapy related to difficulty walking per the History and Physical. On 1/22/25, Resident 11 was noted with a right heel ruptured blister, per the wound consult note dated 1/22/25. On 2/10/25, at 8 A.M., an observation was conducted in Resident 11's room. Resident 11 was lying down on the bed and was noted to have a low air loss (LAL) mattress (a mattress designed to help prevent skin breakdown). Resident 11's right foot was noted to be elevated on pillows. A review of Resident 11's clinical record was conducted on 2/11/25. According to Resident 11's physician's order dated 1/30/25, the physician ordered to Paint Deep Tissue Injury (DTI - damage to the tissues underneath the skin, usually caused by prolonged pressure on a bony area) on right heel with Betadine (antiseptic for the treatment of common skin infections and leave open to air dry daily . According to the Treatment Administration Record (TAR), dated February 1 through February 12, 2025, Resident 11 had no wound treatments performed for two of the 12 days. Resident 11's wound treatments were missed on 2/5/25 (Wednesday) and 2/8/25 (Saturday). On 2/12/25, at 2 P.M., a concurrent interview and record review was conducted with Treatment Nurse 1 (Tx LN 1). The Tx LN 1 reviewed Resident 11's February 2025 Treatment Administration Record (TAR), and stated he believed the staff just forgot to check off the treatment as being performed, for those two days. The Tx LN 1 stated if the treatment was not documented, then no one knew for sure if the treatment was actually completed. The Tx LN 1 stated wound treatments should always be documented, to ensure they were completed as ordered. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 2:30 P.M. The DON stated if a wound treatment was not documented on the TAR, then it was not done. The DON stated she expected all wound treatments to be performed as ordered by the physician. According to the facility's policy, titled Prevention of Pressure Injuries, dated April 2020, .Monitoring: 1. Evaluate, report, and document . According to the facility's policy, titled Charting and Documentation, dated 2020, .2. the following information is to be documented in the resident medical record . Treatments or services performed . 3. Resident 12 had missing entries on her daily wound treatment log. Resident 12 was admitted to the facility on [DATE] with diagnoses that included stage 4 pressure ulcer of the left buttock and stage 4 pressure ulcer of the right hip, per the facility's Admission Record. On 2/11/25, a review of Resident 12's clinical record was conducted. According to Resident 12's physician's orders dated 1/15/25, the physician order to 1) cleanse stage 4 pressure injury on left buttock with normal saline .and cover with dry dressing daily . 2) cleanse stage 4 pressure injury on right hip with normal saline .and cover with dry dressing daily . According to Resident 12's Treatment Administration Record (TAR), dated February 1 through February 12, 2025, Resident 12 had no wound treatments performed for three of the 12 days. Resident 12's wound treatments were missed on 2/4/25 (Tuesday), 2/5/25 (Wednesday) and 2/8/25 (Saturday). On 2/12/25, at 2:15 P.M., a concurrent interview and record review was conducted with Treatment Nurse 1 (Tx LN 1). The Tx LN 1 reviewed Resident 12's February 2025 Treatment Administration Record (TAR), and stated he believed the staff just forgot to check off the treatment as being performed, for those two days. The Tx LN 1 stated if the treatment was not documented, then no one knew for sure if the treatment was actually completed. The Tx LN 1 stated wound treatments should always be documented, to ensure they were completed as ordered. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 2:30 P.M. The DON stated if a wound treatment was not documented on the TAR, then it was not done. The DON stated she expected all wound treatments to be performed as ordered by the physician. According to the facility's policy, titled Prevention of Pressure Injuries, dated April 2020, .Monitoring: 1. Evaluate, report, and document . According to the facility's policy, titled Charting and Documentation, dated 2020, .2. the following information is to be documented in the resident medical record . Treatments or services performed .

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice, when two green cutting boards with deep cuts and food stains were stored in the clean area. In addition, one red cutting board and one brown cutting board with deep cuts were also stored in the clean area, when reviewed for food sanitation. This failure exposed residents to contaminated food surfaces and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Findings: On 2/12/25 at 11:13 A.M. an observation and interview was conducted with Dietary Worker 1 (DW 1). A green chopping board was observed on the kitchen counter, next to the 3-compartment sink. The cutting board had multiple knife cuts and scratches on both sides. There were dark brown colored stains visible in the scratches and on the chopping board surface. DW 1 stated the cutting board had just been washed and was in the drying area. A second green chopping board was observed hanging above the 3-compartment sink, and had brownish stains and knife cuts on both sides. One red chopping board and one brown chopping board, both stored in the clean area, were observed with deep knife cuts. DW 1 stated, This [the green chopping board] needs to be changed. On 2/13/25 at 8:13 A.M., an interview was conducted with the Food Services Director (FSD). The FSD stated, It's important health wise not to use a cutting board that is stained .there's residue on it and in the cuts. We want to avoid contamination . According to the 2022 Federal FDA Food Code, section 4-501.12, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . A review of the facility policy titled Sanitation, dated 2023 indicated, .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas .2. Plastic ware .that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining .

Based on observation, interview, and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Service department when [NAME] 1 could not properly demonstrate how to calibrate a food thermometer, when reviewed for competency. This failure had the potential for food contamination, resulting in food borne illnesses for all residents who consumed food from the kitchen. Findings: During a joint observation and interview on 2/12/25 at 10:52 A.M. with [NAME] 1, [NAME] 1 was asked to demonstrate how to properly calibrate an analog thermometer (device that measures temperature by using mercury or alcohol). [NAME] 1 began to twist the thermometer's probe and stated, .I have to move the line [dial] to 0 [degrees Fahrenheit] then I put it in the water .you don't need to put it in the water if its already on 32 degrees . On 2/13/25 an interview was conducted with the Dietary Supervisor (DS). The DS stated it was his expectation for all kitchen staff to know how to calibrate thermometers properly, whether it is a digital or analog thermometer. The DS stated it was important to use a calibrated food thermometer to obtain an accurate food temperature reading. The DS stated, We use food thermometers to take food temperatures, to make sure nothing is undercooked. We don't want anyone to get sick. A review of the facility policy titled, Thermometer Use and Calibration, dated 2023 indicated, Checking the Accuracy and Calibrating .1. Fill a large class with crushed ice and add clean tap waster until slush is formed. Stir the mixture well .2. Put the thermometer's stem into the ice water so that the sensing area is completely submerged .The thermometer stem or probe must remain in the ice water one minute and during calibration process. 3. If the thermometer does not read 32 degrees Fahrenheit then the thermometer must be calibrated .Bimetal or analog thermometer .turn the face of the dial until the indicator is at 32 degrees .

Based on observation, interview, and record review, the facility failed to administer the correct amount of oxygen, according to the physician's order for one of two residents (Resident 99), reviewed for oxygen therapy. This failure had the potential for too much carbon dioxide to accumulate in the blood, affecting the body's blood pH, respiratory drive, and the blood cells affinity for oxygen. Findings: Resident 99 was admitted to the facility on [DATE], with diagnoses which included chronic (persisting for a long time) respiratory failure with hypoxia (insufficient amount of oxygen in the body's tissues) and encounter for attention to tracheotomy (a surgical procedure that creates an opening in the front of the neck [trachea] in order to provide an airway), per the facility's Admission Record. An observation was conducted of Resident 99 on 2/10/25 at 9:01 A.M. as he laid in bed. Resident 99 had a stoma (a surgical opening in the neck that allows a person to breathe without a tube inserted). The stoma was covered with an oxygen mask and tubing, attached to a oxygen concentrator (a medical device that supplies oxygen-enriched air) was on the floor, beside the bed. The oxygen condenser dial was set at 5, indicating it was delivering 5 liters (a unit that expresses flow rate) of oxygen per minute. An observation was conducted of Resident 99, in his room on 2/11/25 at 8:12 A.M. Resident 99's concentrator oxygen concentrator flow rate was set at 5 liters per minutes (LN/min), and an oxygen mask was over his stoma. Resident 99's clinical record was reviewed on 2/11/25: According to the physician's order, dated 1/15/25, .Respiratory: administer oxygen at 2 LN/min via trach mask continuously. Diagnoses: Acute hypercarbic (a serious condition that occurs when there is too much carbon dioxide in the blood), respiratory failure status post laryngectomy (a surgical procedure to remove their larynx [voice box], resulting in a permanent opening in the neck called a stoma through which they breathe), every shift . According to the care plan, titled Oxygen Therapy, dated 1/15/25, listed interventions such as; Oxygen Setting: The resident has O2 (oxygen) via trach mask at 2 L/min continuously. According to the facility's oxygen saturation rates (a measurement of the percentage of hemoglobin in the blood that carry's oxygen), documented from 1/15/25 through 2/10/25, the saturation rates ranged from 97% to 99% on room air (Normal 95% to 100%). An observation, interview, and record review was conducted with Licensed Nurse (LN) 1 of Resident 99's oxygen order and rate on 2/12/25 at 7:19 A.M. LN 1 stated the physician's order indicated Resident 99 was to receive oxygen at 2 L/min via his trach mask, continuously. LN 1 went into Resident 99's room to inspect the oxygen flow rate on the concentrator. LN 1 stated the oxygen was delivering 5 L/min, which was wrong. LN 1 stated by providing more oxygen then ordered, Resident 99 was at risk of having too much carbon dioxide in the blood stream. An interview was conducted with respiratory therapist 1 (RT 1- a licensed health professional who helps residents with breathing problems) on 2/12/25 at 7:45 A.M. RT 1 stated Resident 99 was bypassing his upper airway and breathing through his lower airway. RT 1 stated she expected the licensed nurses to following the physician's order on how much oxygen was being administered. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 10:46 A.M. The DON stated she expected the licensed nurses to follow the physician's order and to contact the physician if oxygen orders needed to be clarified. The DON stated too much oxygen could cause harm and lead to hypercarbic. According to the facility's policy, titled Oxygen Administration, dated October 2010, .Preparation: 1. Verify that there is a physician's order .Review the physician's order .Documentation: .The following information should be recorded in the resident's medical record .3. The rate of oxygen flow, route, and rationale .

Based on observation, interview, ad record review, the facility failed to accurately document antibiotic (drugs which treat infections) administration in one of two residents (Resident 88) clinical record, when reviewed for Antibiotic Therapy. This failure had the potential for Resident 88's clinical record to be incomplete and inaccurate. Findings: Resident 88 was admitted to the facility on [DATE], with diagnoses which included osteomyelitis (a bone infection) of the thoracic (upper spine) and lumbar (lower spine), region, per the facility's Admission Record. An observation was conducted of Resident 88 in his room on 2/10/25 at 10:17 A.M. Resident 88 was asleep in bed and an intravenous (IV-a medication bag which delivers fluid and medication to a vein) bag was infusing via an IV pump (a machine which delivers a certain amount of medication per minute). The exterior door to the resident's room was labeled as Contact precautions (infection control measures used to prevent the transmission of infectious agents that are spread through direct or indirect contact with an infected resident). Resident 88's clinical record was reviewed on 2/11/25: According to the physician's order dated 1/14/25, Contact precautions: related to positive for MRSA (Methicillin-resistant Staphylococcus aureus-a bacteria that is resistant to many antibiotics) and osteomyelitis. An additional physician's order dated 1/25/25, listed medications: Daptomycin (A drug used to treat certain bacterial bloodstream infections) 500 milligrams (mg) IV one time a day until 4/1/25, infuse over 1 hour, and Teflaro (an antibiotic used to treat infections) 600 mg two times a day for osteomyelitis, until 4/1/25, over 60 minutes. According to the Medication Administration Record, (MAR), reviewed from 1/25/25 through 1/31/25, Daptomycin 500 mg was not administered, on 1/28/25, at 6 P.M., and Teflaro was not administered on 1/28/25 for the evening dose (10 p.m.), as ordered. According to the care plan, titled MRSA in/on back, dated 1/14/25, listed interventions such as: Administer medications as ordered and contact isolation. According to the care plan, titled IV antibiotic therapy related to infection, dated 1/10/25, listed interventions such as: Administer medications as ordered (Daptomycin, Teflaro). Observe for possible side effects every shift. An interview and record review was conducted with Licensed Nurse 2 (LN 2) on 2/11/25 at 4:07 P.M. of Resident 88's MAR. LN 2 stated according to the MAR, Resident 88 did not receive his IV antibiotics on 1/25/25, as ordered by the physician. LN 2 stated the LNs should have documented why the medication was not given, and there was no documented notes, such as the medication had not been delivered or the resident was not in the facility. LN 2 stated Resident 88's antibiotic administration needed to be consistently administered, to maintain the medication threshold for fighting the infection. An interview and record review was conducted with LN 1 on 2/12/25 at 8:31 A.M. LN 1 acknowledged the missing IV medication entries in Resident 88's MAR for 1/28/25. LN 1 stated it was important to administer the medication consistently, so the medication was effective. LN 1 stated the facility had a separated IV Administration Record, and asked if she could retrieve it from the Medical Records Department. An interview and record review of the facility's IV Administration Record book for Resident 88 was conducted with LN 1 on 2/12/25 at 8:56 A.M. The handwritten entries indicated Daptomycin was administered on 1/28/25 at 6 P.M., and Teflaro was administered on 1/28/25 at 10 P.M. LN 1 stated it was important for the IV book to match the electronic MAR, so Resident 88's clinical record was accurate. LN 1 stated if someone just looked at the MAR, it appeared the medication was never administered. An interview was conducted with the Director of Nursing (DON) on 2/12/25 at 10:46 A.M. The DON stated she expected the MAR to match the IV Administration book, so the documentation was accurate and complete. According to the facility's policy, titled Charting and Documentation, dated 2020, .2. the following information is to be documented in the resident medical record: .b. Medications administered; c. Treatments or services performed .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents was free from unnecessary drugs when 1) Resident 1 did not have an appropriate diagnosis for a psychotropic medication. 2) An anti-anxiety medication was administered to Resident 1 past the 14 day limit without reassessment from the physician. These failures had the potential to harm Resident 1 when an unnecessary psychotropic medications was administered. Findings: 1. According to the Face Sheet, Resident 1 was admitted on [DATE] with diagnoses which included respiratory failure and cerebral palsy (a disorder that affects movement, balance, and posture) . According to the Minimum Data Set (MDS-an assessment tool) dated 8/11/21, Resident 1 was never or rarely understood, and was severely cognitively impaired. The MDS also indicated, Resident 1 had No speech- absence of spoken words, was Rarely/never understood and Rarely/never understands others. During a record review on 12/26/24, Resident 1's Physician's Orders dated 8/24/21 indicated, quetiapine (an antipsychotic medication) 25 mg (milligrams) 1 tablet .for schizophrenia . A record review of Resident 1's Progress Notes dated 8/24/21 indicated, .[Medical Doctor (MD)] gave an order to clarify quetiapine to schizophrenia as manifested by restlessness . There was no documentation from MD that indicated Resident 1 was assessed for or met the criteria for schizophrenia. On 1/10/25 at 8:46 A.M. an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was familiar with Resident 1. LN 1 stated Resident 1 did not have any behaviors that suggested hallucinations or delusions, symptoms of schizophrenia. LN 1 stated, He makes noises once in a while .he's not a difficult patient . LN 1 stated Resident 1 never appeared to be in emotional distress and, We would talk to him, and he smiles . On 1/22/25 at 2:12 P.M. a telephone interview was conducted with Resident 1's Family Member (FM) 1. FM 1 stated, He didn't have [schizophrenia]! Who said he had that? He couldn't even talk! On 1/24/25 at 1:08 P.M. a telephone interview was conducted with the Psychiatrist (PSYCH) 1 who stated, When [Resident 1] came in [to the facility] based on my recollection, he took [quetiapine]. It seemed to be helping him. I put unspecified schizophrenia .when we use the diagnosis [unspecified schizophrenia] we're trying to justify the continued use of the medication .we don't want to call someone schizophrenic when they might not be . PSYCH 1 stated, In [Resident 1]'s case, its not a confirmed diagnosis .its impossible to diagnose [Resident 1] because he's nonverbal . PSYCH 1 stated he did not discontinue the medication because it helped Resident 1 remain calm. A review of the facility's policy titled Antipsychotic Medication Use revised 7/22 indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition . 2. A review of Resident 1's Physician's Orders dated 10/26/21 indicated, Xanax (alprazolam-a medication used to treat anxiety) 1 tablet PRN (as needed) every 6 hours. For 14 days . On 1/10/25 at 8:56 A.M. a joint interview and record review was conducted with LN 1. LN 1 acknowledged alprazolam was administered to Resident 1 multiple times from 10/26/21 until 12/9/21 and according to the physician order it should only have been given for 14 days. LN 1 stated, the doctor should have given a new order if he wanted to continue to give it .[nursing] probably just forgot to put a stop date . LN 1 stated it was important to reassess the resident to see if he still needed the medication, .because it could sedate him . A review of the facility's policy titled Antipsychotic Medication Use revised 7/22 indicated, .16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rational for continued use .

Based on observation, interview, and record review the facility failed to implement infection control measure when three of nine Subacute resident rooms were reviewed. 1) A housekeeper was observed removing Personal Based onProtective Equipment (PPE-gown, gloves, masks) in the hallway outside of an Enhanced Barrier Precaution (EBP--a type of infection control strategy where PPE is worn when providing high-contact care to residents) resident room. 2) A visitor was in an Enhanced Barrier Precaution room providing care without wearing PPE. These failures had the potential to spread infection among staff and visitors. Findings: 1. During a tour of the facility on 1/8/25 at 11:15 A.M. Housekeeper (HK) 1 was observed exiting an Enhanced Barrier Precaution room [resident room [ROOM NUMBER]] wearing PPE. HK 1 was observed removing the PPE in the hallway and discarding it in the housekeeping cart outside the room. On 1/8/25 Resident 1's record was reviewed. According to the Face Sheet, Resident 1 was admitted on [DATE] with diagnosis which included chronic respiratory failure with hypoxia and traumatic brain injury. On 1/8/25 at 11:30 A.M., a joint observation and interview was conducted with the Infection Preventionist (IP). HK 1 was observed exiting [resident room [ROOM NUMBER]] wearing full PPE. room [ROOM NUMBER] had an EBP sign posted on the wall, outside the room. HK 1 was then observed handling a stack of wash cloths, placing it into a clean plastic bag, and placing the bag in the housekeeping cart. HK 1 then doffed (removed) her PPE and discarded it in the housekeeping cart, outside [resident room [ROOM NUMBER]]. On 1/8/25 Resident 2's record was reviewed. According to the Face Sheet, Resident 2 was admitted on [DATE] with diagnosis which included acute and chronic respiratory failure with hypoxia, dependence on a ventilator. The IP stated, [HK 1] should never wear her gown and gloves in the hallway-ever, especially after leaving an EBP room. You don't know what she touched with the dirty gloves . The IP stated HK 1's PPE was considered dirty after she entered the room, and the PPE should have been removed before she exited. The IP stated it was her expectation that PPE be doffed (removed) and discarded prior to exiting the room, to prevent the spread of infection. A review of the facility policy titled Infection Prevention and Control Program dated 10/28 indicated, 11 .a. Important facets of infection prevention include .educating staff and ensuring that they adhere to proper techniques and procedures . 2. According to the Face Sheet, Resident 3 was admitted on [DATE] with diagnoses which included respiratory failure and CRAB (carbapenem resistant Acinetobacter baumannii-a bacteria which is often resistant to nearly all antibiotics). During an observation in the Subacute Unit on 1/10/25 at 10 A.M., room [ROOM NUMBER] was observed with an Enhanced Barrier Precautions sign posted outside the door. A visitor (VIS) 1 was observed inside room [ROOM NUMBER] wearing a surgical mask, but no other PPE. Vis 1 used a white gauze to clean Resident 3's skin around the tracheostomy (an opening in the neck made for tube insertion to allow the patient to breathe) site. On 1/10/25 at 11:40 A.M. an interview was conducted with VIS 1. VIS 1 stated he was not aware that he needed to wear a gown and gloves when providing care to Resident 3. VIS 1 stated, I have a pregnant [family member] at home. I don't want to bring anything home to her. VIS 1 stated he would have donned (put on) PPE if he had known prior to entering the room. On 1/20/25 at 11:56 A.M. an interview was conducted with the IP. The IP stated it was important for anybody entering the room to don (put on) PPE, especially if there was going to be high-contact activities. The IP stated, .we should educate them as much as we can . to keep infection from spreading. A review of the facility policy titled Infection Prevention and Control Program dated 10/28 indicated, 13 .a. The facility has established policies and procedures regarding infection control among employees .visitors .precautions to prevent these individuals from contracting infections .

Based on interview and record review, the facility failed to follow the physician plan of care related to weekly weights and notification of the physician when the vital signs (blood pressure, heart rate, respiratory rate, and temperature) were outside of the parameters set (a measurable limit), for one of three residents (Resident 1), reviewed for care plans. This failure had the potential for the physician to be uninformed of changes, which could have negative consequences on Resident 1's overall health. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included down syndrome (a genetic condition which affects the brain and normal development) and severe constipation (hard, dry stool, that is difficult to pass), per the facility's Admission Record. A review of Resident 1's clinical record was reviewed on 12/18/24: According to the Admission Minimum Data Set (MDS-a clinical assessment tool), dated 11/11/24, the cognitive assessment score was 00, indicating cognition was severely impaired. The Functional Abilities assessment indicated Resident 1 required maximum assistance with rolling from side to side, transferring, eating, grooming, and sitting. According to the Bladder and Bowel assessment, a urinary catheter (an indwelling rubber, flexible plastic tube that drains urine into an external collection bag), was present, and Resident 1 had bowel in continence. According to the physician's order, dated 11/4/24, Resident 1 was to have weekly weights. According to the facility's Weights and Vitals Summary, Resident 1 had weekly weights performed on 11/4/24 and 11/9/24, by a mechanical lift, (a device that assist staff with moving a resident from one place to another). No additional weights were performed between 11/9/24, until Resident 1's discharge on 11/22/24. According to the physician's order, dated 11/4/24, Notify Medical Doctor if the patient has ANY of the following symptoms: Temperature less than 96.8 or greater than 99.0 (normal 98.6). Heart rate greater then 90, respiratory rate greater then 20, systolic (the top number) blood pressure less than 100. Record every shift. A review of the facility's Medication Administration Record (MAR) was conducted. Vital signs recorded from 11/4/24 through 11/22/24 indicated the heart rate was greater the 90 beats per minute, eight times out of 51 opportunities. The systolic blood pressure was below 100, seven times out of 51 opportunities. The nursing progress notes were reviewed for the dates when Resident 1's heart rate was above 90 and the systolic blood pressure was below 100. There was no documented evidence the physician was notified of a change outside of physician ordered vital sign parameters. An interview was conducted with Certified Nursing Assistant 1 (CNA 1) on 12/28/24 at 10:59 A.M. CNA 1 stated CNAs were responsible for performing weights weekly and obtaining vital signs at the beginning of every shift. CNA 1 stated the information of weights and vital signs were then provided to the Licensed Nurses (LNs) for interpretation and documentation. An interview and record review was conducted with LN 1 on 12/18/24 at 11:05 A.M., regarding Resident 1. LN 1 stated if Resident 1's vital signs were outside of the parameters of the physician's orders, then there should be a note in Resident 1's record to indicate the physician was notified. LN 1 reviewed the nurses notes for the dates indicated on the MAR, of when the heart rate was greater than 90 beats per minute and the systolic blood pressure was less than 100. LN 1 stated there were no nurse's notes that indicated the physician had been notified and there should have been documentation the physician was notified. LN 1 stated vital sign parameters in Resident 1's case was important to identify early signs of sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). LN 1 stated weekly weights were important for nutrition and hydration monitoring. LN 1 stated if weights were not completed weekly as ordered by the physician, Resident 1 might be at risk of dehydration or fluid overload. An interview was conducted with LN 2 on 12/18/24 at 11:22 A.M. LN 2 stated if vital signs were outside of the physician's parameters and not reported to the physician, the physician was unaware of what was currently going on with the resident. LN 2 stated weekly weights were important for residents on fluid restrictions to identify if too much or too little fluids was ingested, which could complicate the recovery period. An interview and record review was conducted with the Director of Nursing (DON) on 12/18/24 at 11:23 P.M. The DON stated by not performing weekly weights as ordered by the physician, the resident could have an increase or decrease in weight and staff would be unaware. The DON reviewed Resident 1's weight sheet and stated the weights should have been completed and documented weekly, but they were not. The DON stated she expected staff to follow the physician's orders, related to vital sign parameters and if the vital signs were outside of those parameters, the physician should be notified, and it should be documented. According to the facility's policy, titled Acute Condition Changes-Clinical Protocol, dated March 2018, 1. The physician will help identify' individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter .or someone with unstable vital signs .Treatment/Management: 1. The physician will help identify and authorize appropriate treatments . According to the facility's policy, titled Care Plans, Comprehensive Person-Centered, dated March 2022, . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and time frames; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physician, mental and psychological well-being .

Based on observation, interview, and record review, the facility failed to ensure two of three residents (Residents 1 and 2) reviewed for activities of daily living (ADLs, self-care activities, which included personal care) received assistance with grooming. This failure resulted in: - Resident 1 having tangled and matted hair, in which the resident verbalized feelings of negative self-image. In addition, the matted and tangled hair caused Resident 1 pain and discomfort, and the matted sections of hair had to be cut out close to the scalp. - Resident 2 having tangled and matted hair which caused the resident dissatisfaction. Findings: A review of the facility's Resident Face Sheet, dated 2/17/21, indicated Resident 1 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Resident Face Sheet, dated 2/17/21, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/17/21 at 1:00 P.M., a concurrent observation and interview was conducted with Resident 1 at the resident's bedside. Resident 1 was in bed wearing a facility gown. Resident 1 had thick clumps of tangled hair that stood up approximately four to five inches high on the top of her head. Resident 1 stated she was very unhappy about her hair. Resident 1 stated she had an injured shoulder and could not comb or brush her own hair. Resident 1 stated she had asked staff to help her brush her hair on more than one occasion, but help had not been provided. Resident 1 stated after making attempts for assistance, she kinda gave up on it and accepted it was a mess and no one would help. Resident 1 put her hand into a section of the clumped mass of hair and stated, see, when her hand became stuck in the tangled clumps. Resident 1 stated, With hair like this, I feel like a homeless person. Resident 1 further stated it makes me feel terrible about myself. Resident 1 stated she was glad visitors were not allowed (due to COVID-19 restrictions) as she did not want her family to see her with hair like that. Resident 1 stated she was glad there was no mirror in her room because she can't bear to look at it. Resident 1 looked down at her lap. The back of Resident 1's head had hair that was tightly matted and appeared to adhere to the scalp. Resident 1 stated she often experienced scalp pain when she laid her head against the pillow. Resident 1 stated she felt embarrassed about her hair and that it was very undignified. Resident 1 stated her hair was so bad she'd probably need her head shaved. Resident 1 stated, At this point that would be preferable. On 2/17/21 at 1:15 P.M., a concurrent observation and interview was conducted with Resident 2 at the resident's bedside. Resident 2 was Resident 1's roommate. Resident 2 stated she wanted staff to help her brush and comb her hair. Resident 2 stated, No one helps me brush it. Resident 2 had shoulder-length straight hair that framed her face. The hair at the back of Resident 2's head, was tangled and matted. Resident 2 placed her hand to the back of her head and stated, It's very tangled. Resident 2 stated her hair was so tangled because no one got her up and she laid in bed on her back all day. Resident 2 stated she did not like her hair being a mess. On 2/17/21 at 1:20 P.M., a concurrent interview and observation of Resident 1 and Resident 2's hair was conducted with certified nursing assistant (CNA) 1 while in the residents' room. CNA 1 was currently providing care to Resident 1 and Resident 2. CNA 1 stated Resident 1's hair was not acceptable and it was probably painful. CNA 1 stated Resident 1's hair had been in its current matted and tangled state since she began her employment at the facility in November 2020. CNA 1 stated she had not been able to comb or brush the resident's hair because it was not possible to do so, and any attempt would cause the resident pain. CNA 1 stated, The hair is stuck and can't be combed. CNA 1 stated when she had Resident 1 on shower days, she tried to loosen the resident's hair using petroleum jelly. CNA 1 stated that had not worked. CNA 1 stated she would feel embarrassed and upset if her own hair were in a similar state. CNA 1 stated Resident 2's hair was tangled and matted in the back. CNA 1 stated Resident 1 and Resident 2 needed help with grooming, and that it did not appear the residents had received any help. CNA 1 stated there was no excuse for the residents' hair to be like that. On 2/17/21 at 1:35 P.M., a concurrent interview and observation of Resident 1 and Resident 2's hair was conducted with the charge nurse (CN) while in the residents' room. The CN observed Resident 1's hair and stated, This is unacceptable. The CN stated no one who received care in a nursing home should have hair in a condition like that. The CN stated Resident 1's hair was very noticeable as the resident's entire head of hair was matted and tangled. The CN stated Resident 2 also had some tangled and matted hair at the back of the resident's head. The CN stated Resident 1 and Resident 2's tangled and matted hair was evidence of care not being provided. The CN stated daily grooming of Resident 1 and Resident 2's hair had not been done. The CN stated she felt bad and embarrassed for both residents. The CN stated she had not noticed the condition of the residents' hair while making rounds (checking on residents condition). On 2/17/21 at 1:45 P.M., a concurrent interview and observation of Resident 1 and Resident 2's hair was conducted with assistant director of nursing (ADON) and licensed nurse (LN) 1 while in the residents' room. The ADON stated both residents' hair was in an unacceptable state. The ADON further stated if Resident 1 had been provided daily grooming, her hair would not have been matted down and heavily tangled. The ADON stated Resident 1's hair did not end up like that overnight, and that it took time to become tangled and matted down like that. The ADON stated she would not feel good about herself if her own hair were in a similar condition. LN 1 stated she had not noticed the condition of Resident 1 or Resident 2's hair while rounding on the residents. A review of Resident 1's Minimum Data Set Assessment (MDS, an assessment tool), dated 12/30/20, indicated the resident scored 14 out of 15 on the cognitive assessment (a score of 13-15 meant a resident was cognitively intact). The Functional Status section of the MDS indicated Resident 1 required extensive assistance and the help of at least one staff to perform personal hygiene (to include combing hair). A review of Resident 1's ADL care plan, dated 8/27/20, indicated the resident was at risk for a self care deficit and for staff to Comb and brush hair daily and as needed. A review of Resident 2's MDS Assessment, dated 1/16/21, indicated the resident scored 15 out of 15 on the cognitive assessment. The Functional Status section of the MDS indicated Resident 2 required extensive assistance and the help of at least one staff to perform personal hygiene (to include combing hair). A review of Resident 2's ADL care plan, dated 1/9/19, indicated the resident was at risk for a self care deficit and for staff to Comb and brush hair daily and as needed. On 2/17/21 at 4:00 P.M., a concurrent interview and record review was conducted with the director of nursing (DON). The DON stated Resident 1 and Resident 2's hair condition was totally unacceptable. The DON stated Resident 1's hair looked like it had not been brushed or combed in a long time. The DON reviewed Resident 1's ADL care plan, dated 8/27/20, and Resident 2's ADL care plan, dated 1/9/19, and stated the residents' care plans had not been followed. The DON stated Resident 1 and Resident 2 required staff assistance to groom their hair. The DON stated the residents' hair would not have been in a tangled and matted condition if the residents' hair had been brushed or combed daily. The DON stated she would feel terrible if her own hair were in the same condition as the residents'. On 2/19/21 at 9:00 A.M., a joint interview and record review was conducted with the medical records director (MRD). The MRD provided copies of CNA ADL documentation for Resident 1 and Resident 2 from November 2020 through February 2021. The MRD stated there was no option for CNA documentation specifically for hair care. The MRD stated hair care would be considered as part of personal hygiene documentation. On 2/19/21 at 9:35 A.M., an interview was conducted with CNA 2. CNA 2 stated she provided care to Resident 1 in the past. CNA 2 stated Resident 1 needed help performing personal hygiene activities. CNA 2 stated Resident 1 was pleasant and did not refuse care. CNA 2 stated CNAs charted when they helped a resident perform ADLs. CNA 2 stated the CNA charting was non-specific, and documenting that personal hygiene occurred would include brushing a resident's hair. On 2/19/21 at 11:55 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she had observed Resident 1's hair on 2/17/21 and the resident's hair was in an unacceptable state. The DSD stated Resident 1's hair had been extremely tangled and matted, and it had been impossible to comb or brush. The DSD stated, there's no excuse for that. The DSD reviewed Resident 1's ADL care plan dated 8/27/20 and stated the resident's hair had not been combed or brushed daily, or the hair wouldn't have been like that. The DSD stated, It took a long time to get that way. The DSD stated Resident 1's ADL care plan had not been followed. The DSD stated the LNs were supposed to communicate a resident's care plan to the CNAs. The DSD stated she did not understand how LNs had missed Resident 1's hair condition during rounds and assessments. The DSD stated Resident 1's hair situation was embarrassing and undignified. On 2/19/21 at 1:10 P.M., another observation and interview was conducted with Resident 1 in the resident's room. Resident 1's hair had been cut. The hair framing Resident 1's face was thin and was approximately three to five inches in length. The hair at the back of Resident 1's head, had hair approximately half an inch to one inch in length. Resident 1 stated the process to untangle her hair so it could be cut had been uncomfortable. Resident 1 stated she was glad to have the tangled and matted hair removed, and anything was an improvement to what it was. On 2/19/21 at 1:20 P.M., a joint interview and record review was conducted with LN 2. LN 2 stated Resident 1 was very alert and not confused. LN 2 stated Resident 1 was compliant with care and treatment and he never heard of the resident refusing any care. LN 2 stated if his mother or grandmother had matted and tangled hair like Resident 1 had, I'd be ready to fight someone. LN 2 stated Resident 1's hair had been in a shameful state. LN 2 reviewed Resident 1's ADL care plan dated 8/27/20 and stated, There's no way her hair was brushed daily. LN 2 stated Resident 1's care plan had not been followed. LN 2 stated it was the LNs responsibility to communicate the care plan to CNAs and to ensure it was being implemented. LN 2 further stated LNs were in a habit of focusing their assessments on medical stuff and not the whole person. LN 2 stated LNs needed to look at the entire person. LN 2 stated if LNs had done a complete assessment, Resident 1's hair situation should not have been missed. LN 2 stated it was ridiculous that Resident 1's roommate (Resident 2) had similar hair issues. LN 2 stated hair care was obviously not being provided to both residents. On 2/19/21 at 2:12 P.M., a joint interview and record review was conducted with the MRD. The MRD provided a copy of Resident 1's undated admissions photo. Resident 1 had thick, shoulder-length straight hair. The MRD stated, She had really nice hair. On 2/24/21 at 10:44 A.M., a telephone interview was conducted with LN 3. LN 3 stated she had been asked to help fix Resident 1's hair on 2/18/21. LN 3 stated someone had worked at the tangles around the resident's face the day before (2/17/21). LN 3 stated she was specifically asked to try and work out the severely matted sections of the resident's hair. LN 3 stated she thought she was going to have to shave the matted sections off, but after working it for a while, she was able to lift up the matted hair from the scalp about one inch. LN 3 stated that was enough to get the clippers in there and cut away the matted sections. LN 3 stated trying to disentangle Resident 1's hair had caused the resident pain, and the hair had to be cut out to prevent further pain. LN 3 stated Resident 1's matted and tangled hair had been upsetting to see. LN 3 further stated Resident 2 was able to have the tangled and matted section combed out without having to cut the hair. On 2/26/21 at 1:00 P.M., a telephone interview was conducted with Resident 1's family member (FM). FM stated Resident 1 needed help to perform ADLs after sustaining a fall a couple of years ago. FM stated Resident 1 needed to have help to brush her hair as she was unable to lift her arm up to brush it independently. FM stated Resident 1 cared about her appearance. FM stated Resident 1 used to have a large mirror in her room and she would apply makeup and do her hair with staff assistance. FM stated Resident 1 loved her red lipstick and hats. FM 1 stated Resident 1 was always conscious of her looks and wanted to look nice for the gentlemen in the facility. FM stated Resident 1's nails, hair, and makeup were very important to her. FM stated having matted and tangled hair that had to be cut would have a significant effect on Resident 1. FM stated Resident 1 would not feel good about herself with hair in a matted and tangled condition. FM stated she had not been able to visit Resident 1 since the COVID-19 visitation restrictions. FM stated, They just leave her in bed all day and don't help her. FM stated if she were able visit Resident 1 in person, she would make sure the facility took better care of the resident. A review of the facility's policy and procedure titled, Brushing and Combing Hair, revised April 2007, indicated, . 1. Review the resident's care plan to assess for any special needs of the resident . 1. The resident's hair should be brushed every morning before breakfast and whenever necessary throughout the day A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, revised April 2009, did not provide guidance related to implementing the care plan.