Every finding on record at Cottonwood Nursing & Rehabilitation

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort, which included submitting a complete and accurate request for nursing facility specialized services (NFSS) which included a customized manual wheelchair. The facility failed to submit a complete and accurate request for nursing facility specialized services form within 20 business days from the Interdisciplinary Team Meeting held on 04/22/26 for Resident #1. On 07/08/26, a meeting was held when it was discovered the original NFSS form had not been submitted and was submitted late on 07/27/26. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.Findings included: Record review of Resident #1's face sheet, dated 07/21/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cognitive communication deficit (a breakdown in communication caused by impaired mental processes like attention, memory, and executive function rather than a pure loss of speech or language mechanics), major depressive disorder (a serious medical condition that causes a lasting sad mood, loss of interest in activities, and low energy for at least two weeks) and severe intellectual disabilities (a neurodevelopmental condition diagnosed when an individual has an IQ typically between 20 and 34 and significant deficits in adaptive functioning). Record review of Resident #1's Quarterly MDS assessment, dated 06/03/26, reflected a BIMS score of 02, which indicated severely impaired cognition. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed partial assistance with oral hygiene, personal hygiene and upper body dressing. It further revealed Resident #1 needed substantial assistance with lying to sitting on the side of the bed and sitting to lying and needed supervision rolling left and right. Record review of Resident #1's care plan, revised 06/12/26, reflected Resident #1 had intellectual disabilities and was PASARR positive. The interventions included: specialized services, habilitation services would be provided per LA recommendation, LA would be invented annually and quarterly to the care plan meeting for review of specialized services. Record review of Resident #1's PASARR Level 1 Screening conducted on 04/01/2026, revealed the resident was positive for intellectual developmental disabilities. Record review of Resident #1's care plan reflected the first care conference on 04/22/26. Record review of Simple LTC PASARR NFSS form portal history reflected: On 04/29/26 the form was pending submission. Record review revealed Resident #1's PASARR Comprehensive Service Plan Form reflected the quarterly meeting was on 07/08/26. The Administrator, DON, ADON, SW, MDS Coordinator, LA-IDD, Legally Authorized Representative and Resident #1 participated in the quarterly meeting. The list of nursing facility specialized services Resident #1 needed was a customized motorized wheelchair. Record review of Simple LTC PASARR NFSS showed that a request for a customized manual wheelchair was submitted on 07/27/26. During an interview on 07/21/26 at 9:48AM, the Administrator stated it was the responsibility of the MDS nurse to get PASARR documents submitted. The Administrator stated she did not know if the NFSS documents had been submitted but the MDS nurse was usually on top of it. The Administrator stated she had not checked to see if the NFSS documents for Resident #1 had been submitted. The Administrator stated the risk for not submitting the specialized services form in a timely manner was a delay in the residents' needed services. During an interview on 07/21/26 at 10:14AM, the DON stated she could not recall if there was a PASARR meeting for Resident #1 as she was new to the position and was being oriented to her position. She stated from her knowledge it was the responsibility of the MDS nurse to get the NFSS documents submitted. She stated she was unaware if it was submitted. The DON stated she had not received an email from PASARR Unit Program Specialist. During an interview on 07/21/26 at 12:11 PM, the MDS Nurse stated she was responsible for submitting Resident #1's NFSS form. She stated she had not submitted the specialized services form within the 20-day time frame because she had not received the doctor's signature. The MDS Nurse stated she did not remember when she received the signature needed. She stated the risk was denial of needed services for the resident. During a follow-up interview on 07/21/26 at 12:21 PM, the Administrator revealed she had not received an email from PASARR Unit Program Specialist. During an observation on 07/21/26 at 1:05 PM, Resident #1 was in bed asleep on his back. Record review a policy titled, PASARR Nursing Facility Specialized Services Policy and Procedure, revised 2023, reflected the following: Policy: It is the policy of [the company] in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. Utilize the following resources:HHSC Companion Guide for completing the NFSS FormsHHSC Detailed Item Guide for NFSS formsTMHP Manual: Long Term Care Guide for PASARR for Nursing FacilitiesHHSC Detailed Item Guide for PCSP FormsProcedure:PL1 is completed.If PL1 is coded as suspicion of MI, ID or DD, then a PE is required.The LA completes the PE and if Positive, a PCSP Initial Meeting is scheduled.NF PCSP meetings scheduled within 14 days of admission and annually. Note: the Annual PCSP NF meeting must be at least 334 days from previous NF PCSP.Bring a copy of the Resident's current MESAV and verify Payor Source at time of the Meeting with BOM/PCC Census.CHECK THE MESAV to ensure Resident is admitted as a MEDICAID RESIDENT at the time of the meeting. If the resident is Medicare or another payor source than MEDICAID per the Daily Care (3618) on the MESAV, any recommended NFSS services should only be noted in the Comment Section. See page 2 of the Item by Item Guide for PCSP. The IDT may recommend NFSS services for ID/DD and dual MI + ID/DD Residents.Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter the PCSP Form after the PCSP meeting).The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form.NFSS will be inputted in SIMPLELTC within 24 hours of receipt of the Assessment/Service from therapy and the Alert section of SIMPLELTC will be monitored daily for approval/denial.The MDS Case Manager is to send an email to Medicare_hotline@csnhc.com alerting Hotline of a new recommendations for Therapy or DME or CMWC.The NFSS Form is entered in SIMPLELTC under the NFSS Tab by the MDS CM or Therapist rev. 2023The MDS CM is to notify the Medicare_hotline@csnhc.com that the NFSS has been entered in SimpleLTC and awaits confirmation from the Hotline that all requirements are Met and may transmit.Monitor for Approval/Pending Denial in the Alert Section of SimpleLTC.For Therapy Approval: provide a copy of the MESAV to Therapy.Therapy must start providing services within 3 business days after receiving approval from HHSC for Therapy PASARR Services.For DME and/or CMWC approval: Notify the DME CompanyThe NF must order the DME/CMWC within 5 business days after receiving approval from HHSC.Complete the PASARR TRACKING LOG for each Section during the NFSS Process to ensure compliance. Coding Tips:#1- Therapy Signature Date and Date of Assessment on the NFSS Form cannot be more than 29 days from the date of service. This is for DME, Therapy and/or CMWC.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices on each resident that were complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for accuracy of record. The facility failed to ensure LVN A documented Resident #2's medication administration of her PRN pain medication, Fioricet (barbiturate combination analgesic) when she documented on the Individual Control Drug Record paperwork but failed to document them on Resident #2's e[DATE] times from 3/30/26 to 6/29/26. This failure could place residents at risk for incorrect medication administrations due to misinformation from incomplete and inaccurate medical records. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included: Cerebral Infarction (stroke; when a blocked/narrowed blood vessel cuts off blood flow to part of the brain), Cognitive Communication Deficit (difficulty with speech or interaction stemming from disrupted brain functions like memory, attention or executive function), Chronic Kidney Disease (gradual loss of kidney function over time), Chronic Pain, Dorsalgia (back pain), Chronic Obstructive Pulmonary Disease (COPD; a progressive lung disease that makes breathing difficult), Anxiety (a feeling of fear, dread and uneasiness) and Major Depressive Disorder (mood disorder characterized by pervasive, persistent sadness and a severe loss of interest or pleasure in activities). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 11 which meant moderate cognitive impairment. Resident #2's MDS revealed she had received PRN pain medication or was offered and declined. Resident #2's MDS revealed she had pain almost constantly; it would frequently effect sleep and interfere with day-to-day activities.Record review of Resident #2's care plan, dated 6/13/26, revealed she was on pain medication therapy for generalized pain and weakness. Her care plan revealed she had a potential for uncontrolled pain due to Arthritis.Record review of Resident #2's eMar and Individual Control Drug Record paperwork for Fioricet (a barbiturate combination analgesic) revealed LVN-A signed out the medication on the Individual Control Drug Record paperwork but failed to document the dispensed the drug on the e[DATE] times from 3/30/26 - 6/29/26; 3/30/26, 4/9/26, 4/17/26, 4/28/26, 5/11/26, 5/18/26, 5/24/26, 5/29/26, 6/1/26, 6/19/26 and 6/29/26.Interview on 7/7/26 at 10:05 a.m. with the DON revealed LVN-A reached out to the ADON about signing a form for TPAPN/Texas Peer Assistance for Nurses (when nurse has had problems with a drug in the past). The Compliance Nurse/CN was in the facility and started an audit of the narcotics as part of protocol. The corporate nurse noticed LVN-A was the main one giving Resident #2 her PRN narcotic medication. The DON stated LVN-A signed off on the Individual Control Drug Record paperwork but had not clicked the medication was administered on the eMar. The DON stated when she and the Admin. interviewed LVN-A, she stated she forgot to click off the medication in the eMar. She stated LVN-A was terminated for not following proper protocol and administration of medications.Interview on 7/7/26 at 1:42 p.m. the Compliance Nurse/CN stated the ADON notified her LVN-A wanted TPAPN paperwork signed. The CN stated she triple-checked all narcotics and everything was correct except for Resident #2's Fioricet (barbiturate combination analgesic) PRN pain medication since the end of March 2026. The CN stated LVN-A was only checking out the medication on the Individual Control Drug Record paperwork, but she was not clicking off the medication administered on the eMar. The CN stated Resident #2 did not remember asking for the PRN pain medication or remember taking it. She stated the medication count was correct with the Individual Control Drug Record paperwork and the amount of pills left. The CN stated LVN-A did not give a statement as far as she knew. The CN stated they terminated LVN-A for lack of documentation.Interview on 7/7/26 at 1:51 p.m. by phone with the ADON stated LVN-A came and asked her about writing a work summary for her TPAPN. She stated she let the CN know. The ADON stated the CN talked to Resident #2 and she did not remember asking or getting her narcotic pain medication. The ADON stated the CN verified everything was signed out in the narcotic book ( Individual Control Drug Record)paperwork, but it was not signed out in the eMar. The ADON stated LVN-A made a statement that sometimes a CNA would say the resident needed something for pain so she would give her the Fioricet, PRN pain medication. Interview on 7/7/26 at 2:04 p.m. with LVN-A stated she was sick back in April 2026. She stated she was taking the medication as prescribed while at work which made her sleepy. She stated one of her co-workers accused her of drug abuse. She wound up getting put on TPAPN (Texas Peer Assistance Program for Nurses). LVN-A stated she was doing random drug test since June 2026 but had to get a nursing manager involved to write a statement of how she was doing at work. LVN-A stated Resident #2 had one PRN pain medication prescribed to her. She stated when she first saw the residents at the beginning of her shift, she would ask them if they needed pain medication. LVN A stated she signed out Resident #2's pain medication on the Individual Drug Control Record paperwork but sometimes forgot to click it off on the eMAR. The facility had her do a random drug test which was negative. The facility terminated her on 7/6/26. Record review of the facility's Controlled Medications - Administration, dated 4/6/26, revealed under Procedure.6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record:-Date and time of administration-Amount Administered-Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility failed to ensure Resident #2 was free from abuse on 6/21/26, when Resident #1 approached Resident #2 in the smoking area and hit Resident 2 in the face. No injuries were observed.This failure could place residents at risk of abuse and physical harm.Findings include: 1. Record review of Resident #1's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Schizoaffective disorder, Delusional disorder, Dementia, hostility, cognitive communication deficit, and other psychoactive substance use. These diagnoses indicated impaired judgment, altered thought processes, impaired cognition, and the potential for aggressive or impulsive behaviors. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Record review of Resident #1's care plan dated 02/09/2026 reflected interventions to continually monitor for behaviors and adverse effects of medications and notify the physician or nurse practitioner as required. The care plan directed staff to document behaviors and medication side effects weekly and each shift, implement resident-centered interventions to reduce behaviors, and verbally report any observed behaviors or medication side effects to a licensed nurse. Record review of Resident #1's progress note dated 06/21/2026 indicated that while residents were outside in the smoking area, Resident #2 looked at Resident #1, and Resident #1 became upset. Documentation reflected Resident #1 stood up and pushed Resident #2's head into the wall. The residents were immediately separated, Resident #1 was placed on one-to-one supervision, and psychiatric services were contacted. Documentation further reflected an order obtained to transfer Resident #1 to an inpatient psychiatric facility for evaluation. Record review of Resident #1's progress note dated 06/21/2026 reflected Resident #1 was observed on the telephone with his family member screaming and yelling. Documentation indicated Resident #1 was extremely agitated, red in the face, and recounting the incident from outside, telling his family member exactly what he had done. The nurse documented concerns for the safety of Resident #1 and the safety of other residents. Record review of Resident #1's progress note dated 06/22/2026 reflected Resident #1 was observed at the nurses' station and stated, I'm being transferred to another facility because I smashed Resident #2's head into the wall, but he deserved it. Documentation reflected Resident #1 continued to acknowledge his actions and demonstrated a lack of remorse for the incident. 2. Record review of Resident #2's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included moderate dementia with agitation, mild cognitive impairment, cognitive communication deficit, active primary progressive multiple sclerosis, and anxiety disorder. These diagnoses indicated impaired cognition, impaired communication, and the potential for altered awareness of events. Record review of Resident #2's Quarterly MDS dated [DATE] reflected a BIMS score of 07, indicating Resident #2 was severely cognitively impaired. Record review of Resident #2's care plan dated 09/24/2025 reflected interventions directing staff to provide resident-centered interventions to reduce behaviors, continually monitor for behaviors and medication adverse effects and notify the physician or nurse practitioner as required, analyze key times, places, circumstances, triggers, and interventions that de-escalate behaviors, and notify the charge nurse of any abusive behaviors. Record review of Resident #2's nursing progress note dated 06/21/2026 reflected Resident #2 was outside in the smoking area when Resident #1 became upset after Resident #2 looked at him. Documentation reflected Resident #1 pushed Resident #2's head into a wall. The residents were immediately separated, and Resident #2 was assessed from head to toe. No injuries were observed, and Resident #2 denied pain. Documentation further reflected a skull X-ray series was initiated as a precaution with negative results. Resident #2 stated that Resident #1 hit him, causing his head to strike the wall. Record review of Resident #2's social services progress note dated 06/21/2026 reflected the social worker interviewed Resident #2 regarding the resident-to-resident altercation. Documentation reflected Resident #2 stated he was doing alright, reported the incident did not bother him, denied being fearful, denied head pain, and stated he felt okay before proceeding to an unrelated conversation. Record review of Resident #2's discharge progress note dated 06/30/2026 reflected Resident #2 was transported to another facility with his personal belongings, medications, order summary, and discharge paperwork. Interview with Family Member #1 on 07/01/2026 at 12:00 p.m. revealed he was aware of the resident-to-resident altercation involving Resident #1. Family Member #1 stated Resident #1 had a long history of psychiatric illness and impulse control deficits and believed the incident occurred while Resident #1's psychiatric medications were being adjusted. Family Member #1 stated Resident #1 perceived Resident #2 was staring at him, which contributed to the altercation in conjunction with Resident #1's mental illness and impulse control deficits. Family Member #1 reported Resident #1's condition had improved following the medication adjustments and stated he had no concerns regarding the care provided by the facility or its staff. Interview with CNA A on 07/01/2026 at 12:10 p.m. revealed the resident-to-resident altercation occurred during an evening smoke break. CNA A stated Resident #1 told Resident #2 that he was looking at him in a bad way. CNA A stated Resident #1 then approached Resident #2 and slapped him in the face. CNA A reported Resident #2 appeared afraid and shaken following the incident and slid down in his chair. CNA A stated she called for assistance, helped Resident #2, and the residents were immediately separated. CNA A stated she had not previously observed Resident #1 become physically aggressive toward another resident but had observed Resident #1 make rude comments to others. CNA A stated Resident #1 did not threaten Resident #2 prior to the incident but instead told Resident #2 to stop looking at him before striking him. Interview with Family Member #2 on 07/01/2026 at 12:18 p.m. revealed an initial telephone call was placed, and a return call was received shortly thereafter. Family Member #2 stated Resident #2 had been transferred to another facility. Family Member #2 reported the facility notified her of the resident-to-resident altercation that occurred in June involving Resident #2. Family Member #2 stated she believed the facility handled the incident appropriately by notifying her and did not believe the facility caused the altercation. Family Member #2 stated she was glad Resident #2 had transferred to another facility and hoped he would do well in his new placement. Interview with the Social Worker on 07/01/2026 at 12:28 p.m. revealed she was not present when the resident-to-resident altercation occurred. The Social Worker stated Resident #1 had been experiencing increased agitation prior to the incident but had not previously displayed physical aggression toward other residents and was typically able to be redirected. The Social Worker stated Resident #2 had a history of aggressive behaviors toward staff. She stated she believed Resident #2 may have been staring at Resident #1 prior to the altercation but did not witness the incident. Interview with the DON on 07/01/2026 at 12:40 p.m. revealed Resident #2 had a history of aggressive behaviors, including striking a staff member and throwing coffee on another resident. DON stated Resident #1 had a history of verbal outbursts and had refused medications in the past but had not previously displayed physical aggression toward residents. DON stated she was informed that the resident-to-resident altercation occurred during a scheduled smoke break after Resident #2 looked at Resident #1, and Resident #1 struck Resident #2, causing Resident #2's head to hit the wall. DON stated Resident #1 reportedly threatened the nurse who intervened following the altercation. DON reported the residents were immediately separated, Resident #1 was placed on one-to-one supervision, and Resident #2 underwent skull X-rays, which were negative, and was placed on neurological checks. Interview with Resident #3 on 07/01/2026 at 1:00 p.m. revealed she witnessed the resident-to-resident altercation during the 7:00 p.m. smoking break on 06/21/2026. Resident #3 stated Resident #2 was seated in his wheelchair wearing sunglasses and was looking in the direction of Resident #1 while mumbling under his breath, which she stated was typical behavior for Resident #2. Resident #3 stated Resident #1 asked Resident #2 why he was looking at him and appeared agitated but did not make any verbal threats. Resident #3 stated Resident #1 then stood up and slapped Resident #2 without warning. Resident #3 stated the incident appeared unprovoked and staff immediately intervened and separated the residents. Interview with the Administrator on 07/01/2026 at 1:20 p.m. revealed Resident #2 had a history of behaviors, particularly surrounding smoking, and had previously displayed aggression toward staff and another resident. The admin stated Resident #2 required close supervision during smoking breaks due to these behaviors. The Administrator stated she was informed Resident #2 did not provoke the incident and that Resident #1 became upset because he believed Resident #2 was looking at him. The Administrator stated Resident #1 had no prior history of physical aggression toward other residents and was typically redirectable, even when experiencing psychiatric symptoms. The Administrator stated following the altercation, Resident #1 was placed on one-to-one supervision, agreed to an inpatient psychiatric evaluation, and was transferred from the facility to a psychiatric hospital the following day. At the time of the interview Resident #1 was still in the psychiatric hospital. The admin stated she counseled Resident #1 that someone looking at him was not a reason to place his hands on another resident. Interview with the Corporate Nurse on 07/01/2026 at 1:33 p.m. revealed she was notified of the resident-to-resident altercation when it occurred. The Corporate Nurse stated she was informed Resident #1 became upset during a scheduled smoking break and struck Resident #2. The Corporate Nurse stated she was familiar with Resident #1 due to his history of psychiatric symptoms but was not aware of any prior physical aggression toward other residents. The Corporate Nurse stated Resident #2 had a history of resident-to-resident and resident-to-staff aggression and had been involved in previous incidents as the aggressor. The Corporate Nurse stated the facility had been pursuing an alternative placement for Resident #2 prior to the incident due to his behavioral history Record review of the facility's undated Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revealed that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property. The policy indicated that the facility is responsible for protecting residents from abuse by anyone, including other residents, and for identifying, investigating, and reporting all allegations of abuse. The policy requires implementation of interventions to prevent recurrence and ensure resident safety during and after investigations.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for accident prevention for 1 of 4 resident halls (Hall 3) observed for safety hazards. The Maintenance Director failed to ensure his toolbox was closed and secure from residents gaining access to it on Hall 3. This failure could result in the residents accessing the toolbox and using tools to potentially harm themselves or others. Findings include: In an observation on 01/29/26 at 09:06 AM, a large toolbox was observed open at the end of Hall 3, unsecured. The toolbox exposed numerous tools, such as a cordless drill, screwdrivers, wrenches, and a hammer, which may be harmful to a resident. Residents were observed entering and exiting their rooms, and one resident was observed wandering the hall. In an observation and interview on 01/29/26 at 9:08 AM, the Administrator was shown the unsecured opened toolbox. She stated maintenance was using the toolbox to make repairs. She stated the toolbox should not have been left unsecure because it was a safety concern for residents. In an interview on 01/29/26 at 11:37 AM, the Maintenance Director was informed of his toolbox being left on the hall unsecured. He stated the Administrator spoke with him about leaving his toolbox out. He stated the toolbox needed to be secured because it could be a trip hazard and the tools in his toolbox could harm a resident. The facility's policy Resident Rights (undated) reflected The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide--1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' food and drink was palatable, attractive, and at a safe and appetizing temperature for 37 of 39 residents on regular, mechanical, or pureed diets. The Dietary Manager failed to ensure the residents' meals were at a safe and appetizing temperature. This failure could result in the residents consuming food at unsafe temperatures and experiencing unhealthy weight loss. Findings included: In an interview on 01/29/26 at 10:30 AM, Resident #2 stated she was the Resident Council President and for the past 6 months, she and the residents who attended the meeting were complaining about the food being served for all meals. She stated the main concern was the food was always cold. She stated she had provided this feedback to the Dietary Manager. In an interview and observation on 01/29/26 at 12:30 PM, the Dietary manager provided a test tray of a regular, mechanical, and pureed diet. The food was lukewarm. The DM stated she sometimes checked to ensure the cook was checking the temperature of the food as it was prepared, but she did not check it regularly. She stated she received the temperature logs from the cooks at the end of the day but was not present when the temperature was taken. She stated if the food was too cold, residents would not want to eat, and they would lose weight. The DM could not provide a temperature log for the breakfast and lunch meals served on 01/29/26. In an interview on 01/29/26 at 1:30 PM, the outgoing Administrator was informed of the complaint about the temperature of the food. She stated she spoke with the DM and found out the warming plate was malfunctioning, and they would get it repaired. She was informed of the DM stating she did not monitor the cooks to ensure they were checking the temperature of the food. She stated she would ensure the kitchen was checking the temperature of the food prior to it being dispersed to the residents to ensure it was meeting the preferable temperature for residents. She stated she had never received any feedback about the food being cold. In an interview on 01/29/26 at 2:56 PM, the incoming Administrator stated she was made aware of the concerns with the temperature of the food being cold by the Outgoing Administrator and the DM. She stated they were in the process of in-servicing the kitchen staff on ensuring the food was at the correct recommended temperature and they will get operational warming plates. In an interview on 01/29/26 at 2:56 PM, [NAME] C stated he had been at the facility for 4 months. He stated he usually got the temperature of the food when he removed it from the stove, and the food was well over the required temperature of 165. He stated the temperature of the cooked food was not verified by anyone, he just turned the temperature information at the end of his shift. He stated he was never instructed on when to check the temperature of the food. Record review of the facility's temperature logbook on 01/29/26, reflected no temperature log for breakfast and lunch served to residents on 01/29/26. The facility's policy Resident Rights (undated) reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.

Based on observations, interviews, and record reviews the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal canula was properly stored in a bag when not in use on 01/06/26. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 01/29/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had acute respiratory failure with hypoxia (low oxygen intake). Record review of Resident #1's Quarterly MDS Assessment, dated 12/19/25, reflected Resident #1 had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had an active diagnosis of respiratory failure. Record review of Resident #1's Physician Orders, dated 01/29/26, reflected Oxygen LPM: 2-4 L via nasal canula as needed for acute respiratory failure. In an observation and interview on 01/29/26 at 9:13 AM, Resident #1 was observed in the hallway in his wheelchair. A nasal canula was observed sitting on top of his bed, unbagged. The resident stated he only used the oxygen device at night and had not used it since getting out of bed this morning. In an observation and interview on 01/29/26 at 9:15 AM, LVN A was shown Resident #1's nasal canula sitting on top of his bed unbagged. She stated the night nurse should have bagged the nasal canula to avoid the nasal canula from contamination. She stated the resident used oxygen at night, but he sometimes used it during the day. She stated it was the nurse's responsibility to ensure the nasal canula was bagged when not in use. In an interview on 01/29/26 at 9:55 AM, the Regional Nurse was informed of Resident #1's nasal canula not being bagged and she stated it should have been bagged when not in use. She stated not bagging it could result in the resident getting an infection. She stated it was the nurse's responsibility to ensure the nasal canula was bagged. In an interview on 01/29/26 at 01:32 PM, the ADON stated she was told about Resident #1 not having his nasal canula bagged when not in use. She stated it needed to be bagged to prevent him getting an infection. She stated it was the nurse's responsibility to ensure it was bagged once when he was not using it. Review of the facility's policy Oxygen Administration, 10/2010, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen for food and nutrition services.1. The facility failed to seal, label and date refrigerator and freezer food items.2. Dietary staff failed to dispose of expired foods items in the pantry and refrigerator.These deficient practices could place residents at risk for cross-contamination and foodborne illness.Findings include: Observation on 08/12/2025 from 9:10 AM to 9:45 AM in the facility's kitchen revealed: -Two Sandwiches wrapped in plastic, located in the refrigerator with no label or expiration date. - One Gallon size bag of Cheddar Cheese, located in the refrigerator, dated 07/31/25 with a use by date of 08/07/25.- One Plastic Bin containing assorted unpackaged sliced cheese, located in the refrigerator, dated 07/24 with a use by date of 07/30/25. - One Flat of Mushrooms kept in a cardboard box on the middle shelf in one of the refrigerators, labeled 07/10/25 but not labeled with a use by date. The mushrooms had a dried-out appearance. - One Block Cream Cheese in the refrigerator Manufacture use by date of 07/18/2025, marked in sharpie 07/24/25. - One Large Freezer bag which contained 3 separate Smoked Sandwich meat, in the freezer which had visible freezer burn. - One 2lb Smoked Turkey Breast, in the freezer which had visible freezer burn. - One 2lb Smoked Turkey Breast, in the freezer that had visible freezer burn. - One Gallon size freezer bag, in the freezer with four fish fillets that had visible freezer burn. - One Freezer bag in the freezer labeled Chix Pieces, dated 07/18/25. with a use by date of 07/22/25. - Three 2 Gallon size Freezer bags which contained chicken thighs in the freezer, which had visible freezer burn. - One Clear bag which contained a Pie crust, dated of 07/17/25, and a use by date of 07/22/25. - One Gallon size bag which contained (five) individual biscuits in the bread pantry, dated 08/01/25, with a use by date of 08/08/25. - One Loaf of bread in the bread pantry which had visible Green/Black mold. - Four Loaves of bread in the bread pantry, dated 07/31/25, with a use by date of 08/08/25. - Three Loaves of bread in the bread pantry, dated 07/17/25, with a use by date of 07/30/25. _One loaf of bread in the bread pantry, dated 07/03/25, with a use by date of 07/18/25. During an interview on 08/14/2025 at 10:15 AM, the DM stated she had been the DM for about 4 months, and prior to that was the cook at the facility for a year. The DM stated she was the person overall responsible for ensuring the kitchen met guidelines for food storage and kitchen sanitization. The DM acknowledged the surveyor observations. The DM stated she was responsible for kitchen sanitation and proper storage of food products and the deficient practices were oversights. She stated the risk of all the concerns observed in the kitchen could result in residents getting sick. The DM stated the risk of the concerns not being addressed could result in food-borne illnesses .DM stated if food items were not dated when opened then they will not be able to know how long it will last. Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. DM stated the fridge and freezer should be checked daily for spoiled foods. During an interview on 08/14/2025 at 12:39 PM, the ADMIN stated she oversaw all departments, and ensured residents were taken care of. The ADMIN said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. She said the risk to residents, if the policy was not followed was, they could get sick from food borne illnesses. She said the worst thing that could happen was, residents got sick and ended up in the hospital or worse. The ADMIN stated she expected staff to ensure they followed policies and procedures of the facility kitchen policy, to protect residents and to deliver good care.Record review of the facility's Dietary Services Policy & Procedure Manual, dated 2012, indicated .6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year . Any product with a stamped expiration date will be discarded once that date passes. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor, or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. food spoilage is observed prior to the best by date, the product will be discarded. If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging. Record review of the U.S. Food and Drug Administration (FDA ) Code (2022) revealed, Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of fifteen residents (Resident #6 and Resident #44) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E changed their gloves during Resident #6's incontinent care on 08/13/2025. 2. The facility failed to ensure LVN A did not put Resident #44's catheter bag on top of the bed's linen. 3. The facility failed to ensure LVN performed hand hygiene and wore a gown while turning Resident #44 on 08/12/2025. 4. The facility failed the ensure CNA E did not touch the new linens after touching the catheter when changing Resident #44's beddings on 08/12/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings include: 1. Record review of Resident #6's face sheet, dated 08/13/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic kidney disease (a condition where the kidneys were damaged and cannot filter the blood). Record review of Resident #6's Comprehensive MDS Assessment, dated 05/30/2025, reflected the resident had severe impairment in cognition with a BIMS score of 02. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #6's Comprehensive Care Plan, dated 04/27/2025, reflected the resident had incontinence, one of the interventions was provide pericare after each incontinent episode. Observation on 08/13/2025 at 1:42 PM revealed CNA D and CNA E were about to provide incontinent care to Resident #6. Both CNAs washed their hands and put on a pair of gloves. CNA E pulled the resident's bed and went to the resident's left side. CNA D went to the resident's right side. Both CNAs unfastened the soiled brief and tucked it between the resident's legs. CNA E proceeded in cleaning the resident's perineal area (area between the legs) using the front to back technique. After cleaning the perineal area, the resident was assisted to roll to her side and CNA E cleaned the resident's bottom. After cleaning the resident's bottom, CNA E rolled, pulled the soiled brief, and threw it in the trash can. CNA D helped in rolling the soiled brief. After throwing the soiled brief, CNA E took the new brief placed it on the resident's side, put it under the resident, and fixed it. CNA D helped in fixing the new brief. Both CNAs did not change their gloves after cleaning the bottom and after touching the new brief. In an interview on 08/13/2025 at 1:58 PM, CNA E stated she already knew she forgot to do something. She said she was not able to change her gloves after she cleaned Resident #6's bottom because her gloves were deemed soiled after touching the soiled linen and after cleaning the resident's bottom. She said her action could result to UTI. She said she would be mindful the next time she would do incontinent care to change gloves as needed and to sanitize in between changing of gloves. In an interview on 08/13/2025 at 2:02 PM, CNA D said she assisted during Resident #6's incontinent care. She said she did touch the soiled brief when it pushed between the legs and when it pulled from the resident. She said, at that point, she should have changed her gloves before touching the new brief because her gloves were already dirty and it could result to cross contamination and infection. She said the resident might get infected because of the dirty brief. 2. Record review of Resident #44's face sheet, dated 08/13/2025, reflected a [AGE] year-old female who admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness) and obesity. The face sheet indicated the resident was on enhanced barrier precaution due to an open wound and catheter. Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had an indwelling catheter and needed assistance rolling to the left and right. Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to wear gloves and gowns during bed mobility. Observation and interview on 08/12/2025 at 11:11 AM, LVN A stated Resident #44 wanted to have a bowel movement. She said she would turn the resident to her side because the resident preferred to be on her side every time she had a bowel movement. It was observed the resident had an indwelling catheter. LVN A put on a pair of gloves but did not do hand hygiene before putting on a pair of gloves. LVN A also did not wear a gown while turning the resident. It was observed there was signage and a PPE cart outside the resident's room. The signage stated the resident was on enhanced barrier precaution. It was also observed when LVN A turned the resident, she placed the catheter bag on top of the bed, adjacent to where the resident's wound would be if the resident was rolled back. In an interview on 08/12/2025 at 11:38 AM, LVN A stated she should have worn a gown when turning Resident #44 because she had a catheter and an open wound. She said turning the resident was a high contact activity. She said EBP was required for doing treatment for residents with a catheter and open wounds to prevent the spread of resistant organisms and to protect the residents from such organisms. She said hand hygiene should be done before and after every care. She said it did not hit her that the catheter bag should not be placed on the top of the bed because the catheter bag was dirty. She said her actions could contribute to cross contamination and the development of infections. 3. Observation on 08/12/2025 at 11:30 PM revealed after LVN A was done with wound care, she told CNA E to change Resident #44's bed linens. CNA E gathered the bed linens she needed, put on a pair of gloves and a gown, and proceeded with changing the linens. She did not do hand hygiene before putting on a pair of gloves. In the process of changing the linen, CNA E unhooked the resident's catheter and placed it on top of the new linen. She then hooked the catheter back to the railings below the resident's bed. She did not change her gloves after touching the catheter and continued touching the new linen. In an interview on 08/12/2025 at 12:08 PM, CNA E stated she should not place the catheter on top of the new linen because the catheter bag was dirty making the new linen was dirty as well. She said the linen should be cleaned because Resident #44 did not want to wear a brief and had wounds at the back of the left thigh. She said dirty linens could cause infection. She said she should have changed her gloves as well after touching the catheter because the catheter bag was always presumed dirty. In an interview on 08/14/2025 at 7:02 AM, the ADON stated the purpose of hand hygiene and changing of gloves was to prevent cross contamination and spread of infection in the facility. She said gloves should be changed after cleaning the resident's bottom and after touching the catheter, hand hygiene should be performed before doing any care, the catheter bags should not be placed on top of the bed. She also said if a resident was on enhanced barrier precaution, the staff should wear a gown. She said all the issues discussed could lead to infection. She said the expectations were for all the staff to be mindful with how they took care of the residents and to be compliant with the policy of infection control. She said she would coordinate with the DON to do in-services regarding infection control. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated after touching something soiled, the staff should change their gloves. She said, she was not a clinician, but she knew that before every care, hand hygiene should be performed. She said the catheter bag was dirty and should not be placed on top of the bed or touch the new linen. She said gowns should be worn for residents who were on EBP. She said the concerns discussed would all contribute to the development of infection. She said she would coordinate with the DON and the ADON about infection control. In an interview on 08/14/2025 at 10:13 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after cleaning the resident's bottom and after touching the catheter bag. She said the catheter should never be placed adjacent to any wound. She said if the resident had a catheter or an open wound, wearing a gown was required. She said the issue discussed could all cause probable infection. She said she would do an in-service about infection control and would personally monitor the staff's adherence to the policy and procedure of infection control. Record review of the facility's, undated, policy Enhanced Barrier Precautions, reflected EBP are indicated for residents with any of the following . Wounds and/or indwelling medical devices . Indwelling medical device examples include central lines, urinary catheters . don gloves and gown . turn and reposition or assist with bed mobility. Record review of the facility's policy Perineal Care Female Nursing Policy and Procedure Manual 2003 , revised December 8, 2009, reflected Purpose: To clean the female perineum without contaminating the urethral area . wash hands . H. Wash hands and put on clean gloves for perineal care. Record review of the facility's policy Infection Control Plan: Overview, updated 03/2023, reflected, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary . environment and to help prevent the development and transmission of disease and infection . Linens: Personnel will handle . linens so as to prevent the spread of infection . Preventing Spread of Infection . The facility will require staff to wash their hands after each direct resident contact for which hand washing . Gloves are worn . To reduce the likelihood that hands of personnel contaminated with microorganisms . and hands washed after gloves are removed. Record review of the facility's policy Hand Hygiene/Handwashing Infection Prevention and Control Policies and Procedures, revised May 15, 2023, reflected Policy: Hand Hygiene/Hand washing is the most important component for preventing the spread of infection . 1. Hand hygiene/hand washing is done . C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids . H. After removal of medical/surgical or utility gloves . C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #5, Resident #9, and Resident #40) of twenty-one residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #5, Resident #9, and Resident #40's rooms were in a position that was accessible to the resident on 08/12/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #5 Record review of Resident #5's Face Sheet, dated 08/12/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #5's Quarterly MDS Assessment, dated 06/09/2025, reflected the resident had a severe impairment (the resident required significant assistance and support in daily life) in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident was dependent to staff for transfers. Record review of Resident #5's Comprehensive Care Plan, dated 05/21/2025, reflected the resident was at risk for falls and one of the interventions was a reachable call light. Observation and interview on 08/12/2025 at 8:58 AM revealed Resident #5 was in her bed, awake. It was observed that the resident's call light was pinned between her bed and the wall and could not be pulled. When asked about what she used when she needed to call the staff, the resident did not answer. Resident #9 Review of Resident #9's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Review of Resident #9's Quarterly MDS Assessment, dated 07/18/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident required maximal assistance for toileting hygiene, dressing, bed mobility, and transfer. Review of Resident #9's Comprehensive Care Plan, dated 06/15/2025, reflected the resident was at risk for falls one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 01/14/2025 at 9:20 AM revealed Resident #9 was in her bed, awake. It was observed that the resident's call light was clipped on curtain located at the foot part of the bed. When asked about her call light, the resident did not reply. Observation and interview on 08/12/2025 at 9:27 AM, CNA E stated the call lights were used by the resident to call the staff if they needed something or if they needed assistance. She said without the call lights, the residents might fall if they tried to do things by themselves. She said the call lights were for all the residents, whether independent or dependent residents. She went inside Resident's #9's room and saw the call light was clipped to the curtain. She unclipped it and placed it near Resident #9's hand. She said she did not notice that Resident #9's call light was clipped in the curtain. She said she would also go to Resident #5's room and would place Resident #5's call light where the resident could reach it. She said she was responsible in making sure the call lights were with the residents on the hall assigned to her. Resident #40 Review of Resident #40's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Review of Resident #40's Quarterly MDS Assessment, dated 07/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident required maximal assistance for toileting hygiene, shower, dressing, and transfer. Review of Resident #40's Comprehensive Care Plan, dated 06/15/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 08/12/2025 at 9:02 AM revealed Resident #40 was in his bed with eyes closed. It was observed that the resident's call light was on the floor, between his bed and his roommate's. Observation and interview on 08/12/2025 at 9:17 AM, the RCN stated call lights should be with the residents in case they needed the staff. She went inside Resident #40's room and pulled the call light from the floor and placed it beside the resident's hand. She said she would start an in-service about call light. She said the staff should make sure that the call lights were with the residents before they leave the room. In an interview on 08/14/2025 at 7:02 AM, the ADON stated call light should be with the residents at all times when the residents where inside the room, whether the resident was in their bed or in their wheelchair, because the call light was the only way they could reach out to the staff if they were in distress or just needed water. She said the call light were for all residents, whether independent or dependent. She said an independent resident might be having a heart attack and could not call anybody because the call light was not with the resident. She said she was one of the responsible in checking if the call lights were with the residents. She said an in-service had been going around and that she would coordinate with the DON to randomly check if the call lights were with the residents. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the staff should make sure that the call lights were with the residents before they leave the room. some staff could have clipped the call light when they were doing care, but they have to place it with the resident after the care was done. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights. In an interview on 08/14/2025 at 10:13 AM, the DON stated call lights were safety measures wherein the residents could call the staff if they needed something or needed to do something that needed assistance. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries. The DON said all the staff were responsible for the call lights, including her. The DON said the expectation was for the staff to scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said s an in-service was already initiated but she would monitor the staffs' compliance about call lights. Record review of the facility's policy Resident Rights Social Services Manual 2003, no revision date revealed, We believe each resident has a right . communication with and access to persons and services inside and outside our facility. Policy specific to call light being within reach of the residents requested on 08/13/2025 at 1:05 PM via email and verbally requested on 08/14/2025 at 7:42 AM. The RCN stated the facility did not have a policy specific for call light.

Based on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for six (Residents #2 #9, #10, #12, #29, and #44) of eight residents reviewed for care plan revision. The facility failed to complete a quarterly care plan for Residents #2, #9, #10, 312, #29, and #44. This failure could place the residents at risk of care and needs not being met. Findings included: Resident #2 Record review of Resident #2's Face Sheet, dated 08/12/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's Comprehensive Care Plan on 08/12/2025 reflected the quarterly care plan completed after 12/11/2024 was dated 06/15/2025. There should have been care plan dated 03/2025. Resident #9 Record review of Resident #9's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #9's Comprehensive Care Plan on 08/12/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/15/2025. There should have been a care plan dated 02/2025. Resident #10 Record review of Resident #10's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #10's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/10/2025. There should have been a care plan dated 02/2025. Resident #12 Record review of Resident #12's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #12's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 11/26/2024 was dated 06/15/2025. There should have been a care plan dated 02/2025. Resident #29 Record review of Resident #29's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #29's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 12/11/2024 was dated 06/15/2025. There should have been a care plan dated 03/2025. Resident #44 Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #44's Comprehensive Care Plan on 08/13/2025 reflected the quarterly care plan completed after 01/23/2024 was dated 06/15/2025. There should have been a care plan dated 04/2025. Observation and interview on 08/13/2025 at 12:02 PM, the MDS Coordinator stated it was her responsibility to update the care plans. She said the care plans should be updated if there was a change in condition, the resident came back from the hospital, or if the resident had a fall. She said care plans were done upon admission and quarterly afterwards. She logged on to her computer and saw that Residents #2 #9, #10, #12, #29, and #44's care plans were updated but had gaps and missing some quarterly care plans. She said it was an oversight on her part that some of the resident's care plans had a gap. She said the care plans should be updated to reflect the current conditions of the residents so applicable interventions could be applied. She said she would audit all the care plans to make sure they were updated. In an interview on 08/14/2025 at 7:02 AM, the ADON stated she was familiar with the care plans. She said the care plans were done during admission and were being updated quarterly. She said the care plans should be update if there was an acute change, new wound, resident now needed a blood thinner. She said the care needed to be in place so the staff would know if there were new interventions that needed to be done and to monitor the resident's response to the new interventions. She said if the care plans were not updated, it could mess up the monitoring side of the interventions. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated all the residents should be care planned accordingly and timely to make sure all the current care and needs of the residents were provided. She said the MDS Nurse was the primary responsible for making and updating the care plans, but she and the nurse managers were equally responsible in making sure that the care plans were up to date. She said without the care plan, there would not be continuity of care and the residents' health issues would not be addressed. She also said she would coordinate with the DON and the MDS Nurse to make sure the care plans were current. In an interview on 08/14/2025 at 10:13 AM, the DON stated every resident needed a thorough and updated care plan to ensure the residents receive proper care and in accordance with their current needs. She said the care plans should be reviewed because the needs of the resident's change, and they need to be congruent with these needs to provide quality care. She said, aside from acute changes, the care plans should be done quarterly to monitor if there were new interventions or to assess if the goals were not being met. She said if the care plans were not updated, the current needs of the residents might not be met. She said she would coordinate with the MDS to audit the care plans of the residents and to make sure, moving forward, that there the care plans would not have gaps on their quarterly. Record review of the facility's policy, Comprehensive Care Planning Nursing Policy & Procedure Manual, no revision date, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident . Comprehensive Care Plans . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #44) of four residents reviewed for quality of care. The facility failed to ensure that LVN A did not use one gauze to clean Resident #44's scattered wounds, non-pressure related wound to her left posterior (towards the back) thigh on 08/12/2025. This failure could place the residents with scattered wounds at risk for worsening of existing wounds and infection. Findings included: Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with non-pressure chronic ulcer of left thigh with fat layer exposed. Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needed little support) with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had a non-pressure chronic ulcer of left thigh. Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had two lymphedemic wounds to left posterior thigh and one of the interventions was to administer wound care treatment as ordered. Record review of Resident #44's Physician Order, dated 07/24/2025, reflected WOUND CARE: Cleanse area to the Left, posterior thigh with ns and pat dry. Apply Triad Paste one time a day for Wound healing AND as needed for wound healing. Can add adhesive dressing when in Wheelchair only. Observation and interview on 08/12/2025 at 11:22 AM, LVN A stated she would go ahead and do Resident #44's wound care on the resident's left thigh since the resident was already on a side-lying position. LVN A prepared the normal saline, gauzes, and the triad paste. She said the wound was left without a dressing to air dry. She said she would only put a dressing if the resident would be transferred to her wheelchair. It was observed that the resident had scattered wounds to her left thigh. She took a couple of gauze, poured normal saline on it, and started cleaning the wound. She started cleaning the top wound and proceeded to clean the other wounds. She did not change the gauze and used the same gauze that she used on the first wound to clean the other wounds. LVN A then took some gauze and dried the wounds. She used the same gauze to dry up the wounds. In an interview on 08/12/2025 at 11:38 AM, LVN A stated the right procedure in cleaning the wound was to clean the wound from inside to outside. She said she should have discarded the gauze that she used to clean one of Resident #44's wound and took another one to clean and dry the next wound, and so on and so forth. She said it seemed like the germs that gauze accumulated from the first wound were introduced to the other wound. She said she would be mindful the next time she would do a wound care not to use soiled gauze to clean the same wound or if the resident had other wounds. In an interview on 08/14/2025 at 7:02 AM, the ADON stated using the gauze used to clean the adjacent wounds of the resident was not the proper procedure in cleaning the wound. She said the best practice was to clean the wound from the cleanest to the dirtiest and then discard the gauze after one stroke. She said a new gauze should be used again to clean the same wound. She said the procedure was also applicable if the resident had scattered wounds on the same area. She said the gauze used to clean one wound could not be used to clean the other wounds because the bacteria from the first wound cleaned could be introduced to the other wounds. She said the expectation was to keep the bacteria out and not introduce them to the other wounds. She said the wrong procedure done could cause aggravation of the wounds and possible infection of the other wounds. She said she would coordinate with the DON to do an in-service for all the staff doing wound care about the propre procedures in doing wound care. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated not changing the gauze after each use was not ok. She said, if she visualized what happened was, the bacteria was not removed and were only transferred to the other wounds. She said this could result to infection or the wound not healing. She said she would coordinate with the DON and ADON to address the issue immediately. In an interview on 08/14/2025 at 10:13 AM, the DON stated she was made aware by the ADON about the issue during wound care. She said she already initiated an in-service about wound care and wound do a one-on-one with LVN A. She said she the wound should be cleaned from the least contaminated area; the gauze should be discarded after every stroke. She said using the same gauze could only introduce the bacteria, if there were, into the wound. Using the same gauze to clean the other wounds could result to introduction of the bacteria from the first wound to the other wounds that could result to cross contamination and probable infection. She said the expectation was for the staff doing wound care would do the right procedure. Policy specific to not using the same gauze in cleaning the wounds requested on 08/13/2025 at 1:05 PM via email and verbally requested on 08/14/2025 at 7:42 AM. The RCN stated the facility did not have a policy specific for wound care technique.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of three residents (Resident #40) reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure Resident #44 had an order to flush the g-tube before and after medication administration on 08/13/2025. This failure could place residents at risk for infection and development of obstruction of the g-tube. Findings include: Record review of Resident #40's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #40's Quarterly MDS Assessment, dated 07/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident had a feeding tube. Record review of Resident #40's Comprehensive Care Plan, dated 06/15/2025, reflected the resident required tube feeding and one of the interventions was to administer medications as ordered. Record review of Resident #40's Physician Order, dated 12/21/2020, reflected every shift Flush with at least 5mls of water between each medication. Record review of Resident #40's Physician Order, dated 11/09/2023, reflected Dilantin Infatabs Tablet Chewable 50 MG (Phenytoin) Give 3 tablet via GTube two times a day related to Epilepsy. Hold Feeding 1 Hour Before and 1 Hour After Giving. Record review of Resident #40 's Physician Order on 8/13/2025 reflected no order for flushing the g-tube before and after medication administration. Observation on 08/13/2025 at 8:57 AM revealed the ADON was about to administer Resident #40's medication via g-tube. The ADON flushed the resident's g-tube with 30 ml of water and proceeded to administer the medications one-by-one, flushing in between medications with 5 ml water. After she was done administering the medications, she flushed the g-tube with 30 ml of water. Observation and interview on 08/13/2025 at 9:20 AM, the ADON stated g-tubes should be flushed before and after medication administration to maintain its patency, to make sure all the medications went through, and nothing was left in the tube. She said, Resident #44 had Dilantin that was why the feeding was stopped one hour before medication administration and to resume one hour after. When asked if the resident had an order for flushing the g-tube before and after medication administration, the ADON checked her computer for the order and said there was no order for the flushing before and after medication administration. She said she knew what to do but there should be an order for the flushing. She said this should have been caught earlier by whoever was administering the resident's medications, so an order was put in place. She said there should be an order for everything done for the resident to ensure continuity of care. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated there should be an order for everything done for the residents to make sure all the staff were in sync with the residents' care. She said some staff would know the right procedure in administering medications to residents with a g-tube. She said but what about those new nurses that would follow religiously the order reflected in the residents' profile. She said she would collaborate with the ADON and the DON to make sure there were appropriate orders for g-tube. In an interview on 08/14/2025 at 10:13 AM, the DON stated the gtube should be flushed before and after medication administration to prevent clogging and to ensure delivery of the medications. She said since the feeding formula was stopped for an hour before the medications were administered, the formula inside the tube could thicken and cause blockages. She said even though the staff did the right procedure and knew that the g-tube needed flushing before and after administering medications via g-tube, there should still be an order for flushing before and after and how much should be used for flushing. She said, new nurses might not be familiar with how to administer medications via g-tube and end up not flushing the g-tube before and after, and then they would wonder why the g-tube was clogged. She said the expectation was for the nurses to check if the orders for g-tubes were complete. She said she would check the orders of the residents with g-tube to make sure they were completed. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual 2003, revised February 13, 2007, reflected Procedure . 6. Flush the tube with 30-60 ml water to clear the formula . Special Considerations . order from the physician. Record review of the facility's policy Physician's Orders Medical Records Manual 2015, with no revision date, reflected Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders . 2. The nurse will enter the order into PCC for the resident.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of sixteen residents (Resident #2, #11, #30, and #42) reviewed for medication storage. 1. The facility failed to ensure Resident #2's zinc oxide (medicated cream used to prevent skin irritation) was not left inside the resident's room on 08/12/2025. 2. The facility failed to ensure Resident #11's zinc oxide was not left inside the resident's room on 08/12/2025. 3. The facility failed to ensure Resident #42's zinc oxide was not left inside the resident's room on 08/12/2025. 4. The facility failed to ensure Resident #30's vials of solutions used for breathing treatment were not left inside the resident's room on 08/12/2025. These failures could place residents at risk of misuse of medications that could lead to overdosing or underdosing. Findings include: 1. Record review of Resident #2's face sheet, dated 08/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #2's Comprehensive MDS Assessment, dated 06/26/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had dementia and was at risk of developing pressure ulcers/injuries. Record review of Resident #2's Comprehensive Care Plan, dated 06/28/2025, reflected the resident had incontinence and one of the interventions was to apply barrier cream after each episode. Record review of Resident #2' Physician Order, dated 05/30/2024, reflected May apply barrier cream as needed every shift. 2. Record review of Resident #11's Face Sheet, dated 08/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a disorder that primarily affects memory). Record review of Resident #11's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident had Alzheimer's Disease and was at risk of developing pressure ulcers/injuries. Record review of Resident #11's Care Plan, dated 06/15/2025, reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per physician order. Record review of Resident #11's Physician Order, dated 12/01/2020, reflected May apply barrier cream as needed. Observation on 08/12/2025 at 8:57 AM revealed there were two tubes of zinc oxide inside Resident #2 and Resident #11's room. The zinc oxide was located beside the sink inside the room. Observation and interview on 08/13/2025 at 7:01 AM revealed the tubes of zinc oxide were still inside Resident #2 and Resident #11's room. The ADON went inside the rooms after being notified that there were zinc oxides on the said rooms and took the tubes of zinc oxide and said it should be inside the room, or it should be placed where the residents could not access them. She said it should be inside the cart. She said confused residents might could mistake it as toothpaste and place it in their mouth. She said the expectation was for the staff to make sure no zinc oxide was placed where the residents could access them. She said she would coordinate with the DON to do an in-service about medication storage. 3. Record review of Resident #42's face sheet, dated 08/13/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #42's Quarterly MDS Assessment, dated 06/27/2025, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident had dementia and was at risk of developing pressure ulcers/injuries. Record review of Resident #42's Care Plan, dated 06/01/2025, reflected the resident reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per the physician order. Record review of Resident #42's Physician Order, dated 12/08/2024, reflected May apply barrier cream as needed every shift. Observation on 08/12/2025 at 9:00 AM revealed Resident #42 was in his bed with eyes closed. It was observed that a tube of zinc oxide was on top of his side table. Observation and interview on 08/12/2025 at 9:16 AM, LVN A stated zinc oxide was a form of medication because to was used to prevent any pressure injury to the skin. She said it should not be inside the room, as confused residents might consume it. She said the cream should be stored in the cart and just put some in a cup for use or place it somewhere not accessible. She said she would go to Resident #42's room to get the zinc oxide. She said she would also check the other rooms. 4. Record review of Resident #30's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #30's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had a moderated impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #30's Comprehensive Care Plan, dated 05/28/2025, reflected the resident had shortness of breath and one of the interventions was to administer medications as ordered. Record review of Resident #30's Physician's Order, dated 04/26/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours for SOB or Wheezing via nebulizer **While awake, do not administer if res sleeping. In an interview on 08/12/2025 at 12:28 PM, LVN B stated she was the one administering Resident #30's breathing treatment. She said she saw the solutions for breathing treatment when he gave the resident's morning medications but forgot to grab them on her way out. She said the solutions should not be left inside the room because they were medications. she said the resident might use them every hour and no one would know until adverse reactions such as palpitations, chest pain, or headache. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the expectation was for the staff to be mindful with all the tubes of zinc oxide were not inside the residents' rooms where they could assess them and consume them. She said she would coordinate with the DON and the ADON about storing the tubes of zinc oxide. In an interview on 08/14/2025 at 10:13 AM, the DON stated medications should not be stored inside the resident's room. She said zinc oxide was a form of medications that could be harmful when ingested. She said some residents might be allergic to it and was able to get hold of the zinc oxide because the tubes were in plain view. She said the expectations were for the staff to always scan the residents' rooms to make sure they were not leaving the tubes of zinc oxide inside the room, putting them where the resident could not access them, or just put them in the cart. She said she would do an in-service about storing the zinc oxide accordingly. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17, revealed, 8. After the medication administration process is completed, the medication cart must be completely locked and stored in a locked medication room or otherwise secured.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eight residents (Resident #30) reviewed for pharmaceutical services. The facility failed to ensure vials of solutions used for breathing treatment were not left inside Resident #30's room for the resident to administer by himself on 08/12/2025. This failure could place residents at risk of not receiving medications as ordered by the physician, potential overdose, and adverse effects. Findings include: Record review of Resident #30's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #30's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had a moderated impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #30's Comprehensive Care Plan, dated 05/28/2025, reflected the resident had shortness of breath and one of the interventions was to administer medications as ordered. Record review of Resident #30's Physician's Order, dated 04/26/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours for SOB or Wheezing via nebulizer **While awake, do not administer if res sleeping. Record review of Resident #30's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. Observation and interview on 08/12/2025 at 12:18 AM revealed Resident #30 was in his wheelchair, awake. A nebulizer machine was observed on top of the resident's side table and beside the nebulize machine were four plastic vials of solutions used for breathing treatment. The plastic vials were not opened and still had the solutions inside. Resident #30 said he was the one administering his breathing treatment. He said the nurse would leave several vials with him so he could do the breathing treatment if he needed to. He said he did not call or tell the nurse he did a breathing treatment. In an interview on 08/12/2025 at 12:28 PM, LVN B stated she was the one administering Resident #30's breathing treatment. She said she was not aware the resident was doing it by himself. She said she saw the solutions for breathing treatment when he gave the resident's morning medications but forgot to grab them on her way out. She said the solutions should not be left inside the room because they were medications. she said the resident might use them every hour and no one would know until adverse reactions such as palpitations, chest pain, or headache. In an interview on 08/13/2025 at 7:16 AM, Resident #30 said the nurses gave his breathing treatment on evening of 08/12/2025. He said but before that date, he would usually do his breathing treatment. In an interview on 08/14/2025 at 7:02 AM, the ADON stated medications should not be left with a resident to administer unsupervised. She said the staff administering the breathing treatment should stay with the resident until the resident was done with it. She said the resident might not take them, someone else might, or the resident might administer it not as ordered. She said if the resident did not have an assessment that he could administer the medications by himself, the staff should do it, and medications should not be left inside the room. She said the medication should be in the cart because the nurses were the one who was supposed to administer it. She said she would coordinate with the DON to do an in-service about not leaving the medications with the residents. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated no medications should be left inside the room because the resident might overmedicate. She said the expectation was for the staff not to leave any medication inside the room for the resident to administer by himself. She said she would coordinate with the DON and the ADON to do an in-service about not leaving the medications with the resident. In an interview on 08/14/2025 at 10:13 AM, the DON stated staff should never leave the solutions at the bedside for the resident to administer unsupervised. She said the staff must ensure the resident had the breathing treatment as scheduled. She said the residents could overdose as manifested by increased heart rate and chest pain. She said if the resident was the one administering the breathing treatment, there should be proper assessment that the resident was capable to do so. If the resident was capable, the solutions should still not be on top of the side table were other confused residents could assess it and consume it. The DON said she would do an in-service not leaving any medication inside the residents' room. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17. reflected, 1. All medications are administered by licensed medical or nursing personnel.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of twelve residents (Resident #29 and Resident #31) reviewed for respiratory care.1. The facility failed to ensure Resident #29 's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 08/13/2025. 2. The facility failed to ensure there was a sign outside Resident #29's room that reflected oxygen was in use. 3. The facility failed to ensure Resident #31's breathing mask was stored properly when not in use on 08/12/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: 1. Record review of Resident #29's face sheet, dated 08/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #29's Quarterly MDS Assessment, dated 06/30/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and was on oxygen therapy. Record review of Resident #29's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had chronic obstructive pulmonary disease and one of the interventions was give oxygen therapy as ordered. Record review of Resident #29's Physician's Order, dated 07/14/2025, reflected Resident may have Oxygen 2-4 LPM as needed to keep above 92%. Observation on 08/13/2025 at 8:10 AM revealed Resident #29 was not inside the room. It was observed that an oxygen concentrator was at the bedside with a nasal cannula connected to it. The nasal cannula was inside the trash can and was not bagged. it was also observed that there was no Oxygen in Use sign outside the resident's room. Observation and interview with LVN C on 08/13/2025 at 8:13 AM, LVN C stated the nasal cannula should be inside the bag to prevent cross contamination and respiratory infection. She went inside Resident #29's room and saw the nasal cannula that was inside the trash can. She disconnected the nasal cannula and threw it on the trash can. She went out of the room, went to the storage room, and took a plastic bag and a new nasal cannula. She said the resident needed assistance during transfer. She said whoever transferred the resident should have made sure the nasal cannula was stored properly or called her attention that the nasal cannula was in the trash can, so she could change it. She also said she would get signage for oxygen use so staff and visitors would know that oxygen was being used to prevent accidental fire. She was one of the responsible in making sure that there was a sign outside the resident's room. In an interview on 08/13/2025 at 1:32 PM revealed Resident #29 only shrugged his shoulders when asked who removed his nasal cannula earlier that day. 2. Record review of Resident #31's face sheet, dated 08/13/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #31's Quarterly MDS Assessment, dated 06/09/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and was on oxygen therapy. Record review of Resident #31's Comprehensive Care Plan, dated 07/29/2025, reflected the resident had chronic obstructive pulmonary disease and one of the interventions was give aerosol (substance released in fine mist) or bronchodilators (medication that caused widening of the air passages) as ordered. Record review of Resident #31's Physician's Order, dated 08/01/2025, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 dose inhale orally every 6 hours as needed for SOB. Observation and interview on 08/12/2025 at 9:06 AM revealed Resident #31 was in her bed, awake. It was observed the nebulization machine was on top of the resident's side table with a breathing mask connected to it. The breathing mask was not bagged and was on the floor. The resident said nurses would give it to her and would come back to take it off. When asked when was the last time she had the breathing treatment and if she knew her mask was on the floor, the resident did not reply. Observation and interview on 08/12/2025 at 9:17 AM, the RCN stated if the resident was not using the breathing mask, it should be inside a clean plastic bag to ensure cleanliness for the next use. She said, if she was correct, the order for Resident #31's breathing treatment was as needed. She went inside the resident's room and saw the breathing mask on the floor. She disconnected the breathing mask and threw it in the trash can. She said the breathing mask should be bagged properly or disconnected and just connect a new one if needed. She said the nurse administering the breathing treatment was the one responsible in bagging the breathing mask. She said not bagging the breathing mask could lead to respiratory infection. She said she would start an in-service about bagging the breathing mask. In an interview on 08/14/2025 at 7:02 AM, the ADON stated the breathing mask should be stored properly to prevent cross contamination and respiratory infections. She said whoever administered the breathing treatment was responsible for cleaning it and storing it in a plastic bag. She said whoever transferred any resident with a nasal cannula should put it inside a plastic bag, so it would be clean for the next use. She said the expectation was for the staff to bag the nasal cannula and the breathing mask to when not in use. She said another expectation was for the staff to check if there was an Oxygen in Use sign outside the door of residents that were using oxygen. She said the sign for oxygen use was to remind the staff and visitors to be careful not to cause any ignition that could cause fire. She said she would coordinate with the DON to do an in-service about the issue about respiratory care and oxygen administration. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the expectation was for the staff to bag the nasal cannula and the breathing mask when not in use to prevent respiratory issues. She said she would coordinate with the DON and the ADON on how to deal with the issue because they were vigilant in reminding the staff to make sure the nasal cannula and the breathing masks should be bagged when not in use. In an interview on 08/14/2025 at 10:13 AM, the DON stated the staff were responsible in making sure the nasal cannula and the breathing masks were bagged when not in use to prevent respiratory infection. She said it was her responsibility to check if the staff were compliant. She said an in-service was already initiated on 08/12/2025. She said, moving forward, she would still randomly monitor the staff if they were bagging them when not in use. Record review of the facility's policy Oxygen Administration Nursing Policy & Procedure Manual 2003, revised February 13, 2007, reflected Goals . 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen . Procedure . 11. Place NO SMOKING signs in area when oxygen is administered and stored. In an interview on 08/14/2025 at 7:42 AM, the RCN stated the facility did not have a policy specific for bagging the nasal cannula and the breathing mask when not in use. Policy specific to bagging the nasal cannula and breathing mask requested on 08/13/2025 at 1:05 PM via email but was not provided prior to exit.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #44) two residents reviewed for catheter care. The facility failed to ensure that LVN A placed Resident #44's catheter bag (collects urine from the urinary bladder) below the bladder on 08/12/2025. This failure could place residents with catheter at risk for urinary tract infection. Findings included: Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had a Foley catheter and one of the interventions was to position the catheter bag and tubing below the level of the bladder. Observation and interview on 08/12/2025 at 11:11 AM, LVN A stated Resident #44 wanted to have a bowel movement. She said she would turn the resident to her side because the resident preferred to be on her side every time she had a bowel movement. It was observed that the resident had an indwelling catheter. LVN A turned the resident but before she turned the resident, she unhooked the resident's catheter and placed it on top of the resident's bed. It was observed that the catheter bag was at the same level of the resident's bladder and urine from the catheter bag travelled back to the catheter's tubing. Observation on 08/12/2025 at 11:22 AM revealed LVN A proceeded with wound care after Resident #44 tried to have a bowel movement since the resident was already on her side. It was observed that the catheter bag was still on top of the bed, at the same level of the bladder and urine was still observed on the tubing. In an interview on 08/12/2025 at 11:38 AM, LVN A stated she placed Resident #44's catheter bag on top of the bed so it would not be pulled that could cause injury to the resident. She said she should have pulled the bed and hang the catheter on the other side to prevent backflow of the urine that could cause urinary retention and UTI. In an interview on 08/12/2025 at 11:58 AM, Resident #44 stated some staff would pull her bed to transfer her catheter when she needed to be turned. She said some staff did not and would just put the catheter bag on top of her bed. In an interview on 08/14/2025 at 7:02 AM, the ADON stated the catheter bag should always be below the bladder to prevent backflow of the urine to the bladder. She said what should have done was to pull the bed to transfer the catheter bag or turn the resident to where the catheter bag was hooked. She said the expectation was for the catheter bag be below the bladder to allow the urine to drain by gravity and prevent backflow that could potentially introduce bacteria to the bladder that could lead to infection. She said she would coordinate with the DON to do an in-service about catheter care. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the expectation was for the catheter bag be below the bladder to prevent infection. She said she would collaborate with the ADON and the DON to make sure the said issue would be addressed. In an interview on 08/14/2025 at 10:13 AM, the DON stated the catheter bag should always be below the bladder to prevent backflow of the urine to the bladder that could result to urinary retention or infection. She said the Resident #44's bed should have been pulled to place the catheter on the other side. She said the expectation was for the staff would make sure that the catheter bag was below the bladder and make adjustments if needed, like pull the bed or turn the resident to where the catheter was hooked. She said she would initiate an in-service about catheter care and would do a one-on-one with LVN A. Record review of the facility's policy Catheter Care Nursing Policy and Procedure Manual 2003 revised February 13, 2007, revealed, 15. Keep drainage bag below level of bladder when cleaning the urethral area.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for two (Resident #40 and Resident #44) of eight residents reviewed for privacy and confidentiality. 1. The facility failed to ensure the ADON closed, locked, or minimized her laptop's monitor while preparing Resident #40's medication via g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) on 08/13/2025. 2. The facility failed to ensure LVN A closed the door while performing ADL on Resident #44 on 08/12/2025. These failures could place the residents at risk of not having their personal privacy maintained during ADLs and their medical information exposed to unauthorized individuals. Findings included: 1. Review of Resident #40's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Review of Resident #40's Quarterly MDS Assessment, dated 07/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Review of Resident #40's Comprehensive Care Plan, dated 06/15/2025, reflected the resident required tube feeding and one of the interventions was to administer medications as ordered. Record review of Resident #40's Physician Order, dated 11/09/2023, reflected Dilantin Infatabs Tablet Chewable 50 MG (Phenytoin) Give 3 tablet via GTubetwo times a day related to EPILEPSY (a medical condition characterized by recurring seizures) . HOLD FEEDING 1 HOUR BEFORE AND 1 HOUR AFTER GIVING. Record review of Resident #40's Physician Order, dated 02/28/2025, reflected Fluoxetine HCl Capsule 10 MG Give 4 capsule via G-Tube one time a day for depression (persistent feeling of sadness or loss of interest). Record review of Resident #40's Physician Order, dated 08/14/2024, reflected Gemfibrozil Oral Tablet 600 MG (Gemfibrozil) Give 600 mg via peg tube (a flexible feeding tube inserted directly to the stomach) two times a day for Elevated cholesterol. Record review of Resident #40's Physician Order, dated 03/13/2024, reflected Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 2.5 ml via Gtube one time a day related to EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS EPILEPTICUS. Record review of Resident #40's Physician Order, dated 02/05/2025, reflected Vitamin C Tablet (Ascorbic Acid) Give 500 mg via Gtube two times a day for Supplement. Record review of Resident #40's Physician Order, dated 07/25/2025, reflected Xarelto Oral Tablet 20 MG (Rivaroxaban) Give 1 tablet by mouth one time a dayrelated to PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS (formation of blood clots) AND EMBOLISM (blockage in the blood vessel that originated from somewhere and traveled to other parts of the body). Observation on 08/13/2025 at 8:57 AM revealed the ADON was about to administer Resident #40's medication via g-tube. She went inside the resident's room to sanitize the overbed table. She left her laptop, that was on top of her cart, open and the displayed the resident's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, that the resident was on gtube, name of the NP, and several physician orders. The screen of the computer was facing the hallway. In an interview on 08/13/2025 at 8:59 AM, the ADON stated she should have locked her computer when she went inside Resident #40's room to clean the resident's table. She said it was a HIPAA violation because the resident's personal and medical information were exposed. She said the said information should be secured and confidential. 2. Record review of Resident #44's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident needed assistance rolling to left and right. Record review of Resident #44's Comprehensive Care Plan, dated 06/15/2025, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with bed mobility. Observation and interview on 08/12/2025 at 11:11 AM, LVN A stated Resident #44 wanted to have a bowel movement. She said she would turn the resident to her side because the resident preferred to be on her side every time she had a bowel movement. She turned the resident without pulling the privacy curtain or closing the door and the assistance being given to the resident could be seen from the hallway. In an interview on 08/12/2025 at 11:38 AM, LVN A stated she was not aware that the door was open when she repositioned Resident #44. She said she should have pulled the privacy curtain and closed the door to make sure privacy was provided when giving assistance to the resident. She said the resident might be embarrassed that people would see her condition that she needed assistance to turn to her side. In an interview on 08/12/2025 at 11:58 AM, Resident #44 stated it would be nice if her door was closed so nobody would see if staff was helping her with her limitation. In an interview on 08/13/2025 at 7:38 AM, SNA F she was engrossed with what she could learn and did not notice that the door was open when Resident #44 was turned. She said the door should be close to provide privacy. In an interview on 08/14/2025 at 7:42 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent awkwardness and that the medical information of the residents were secured and protected to prevent improper use of their information. She said the expectation was for the staff to be mindful about privacy when providing care and confidentiality of the residents' medical records. She said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality. In an interview on 08/14/2025 at 10:13 AM, the DON stated the door should be closed when repositioning the residents to provide privacy. She said ADLs, such as repositioning the residents, should be done with the door closed or the privacy curtain pulled. She said privacy should be provided during care to avoid embarrassment. She said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. The DON stated all the medical information of all the residents should be protected and not be visible for everybody to see because those were confidential information. She said it was a HIPAA violation when unauthorized individuals would see the medical information of the residents. She said all the staff, including her, were expected to provide full privacy during care and to secure all confidential information of the residents. The DON said she would start an in-service about privacy during care and confidentiality of the residents' information. Record review of the facility's policy, Resident Rights Social Services Manual 2003, no revision date revealed, 8. Each resident is treated with . including privacy in treatment and in care . 22. Each resident is ensured confidential treatment of all information .

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of ten residents (Resident #1) reviewed for Infection Control. The facility failed to ensure CNA A and CNA B performed hand hygiene and changed their gloves while providing incontinent care to Resident #1 on 12/05/2024. This failure could place residents at risk of cross-contamination and development of infections. Findings include: Record review of Resident #1's Face Sheet, dated 12/05/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included anemia (low red blood cells) and muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 09/13/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated Resident #1 was always incontinent for both bowel and bladder. Record review of Resident #1's Comprehensive Care Plan, dated 10/03/2024, reflected the resident had an ADL self-care performance deficit and one of the interventions was the resident required two-person assist during incontinent care. Observation on 12/05/2024 at 9:56 AM revealed CNA A was observed already inside Resident #1's room and was cleaning the resident's perineal area (area between the thighs) using the front to back technique. CNA A said she was waiting for another aide to assist her in turning the resident. CNA B entered the room, put on a pair of gloves, and assisted CNA A in turning Resident #1. CNA B did not wash her hands before putting on the gloves. CNA A prepared the brief and put it at the side of the resident. She did not change her gloves before touching the new brief. CNA B started to clean the resident's bottom. After cleaning the resident's bottom, CNA B pulled the soiled brief, and threw it in the trash can. CNA B changed her gloves but did not sanitize her hands before putting on a new pair of gloves. CNA B took the brief from the side of the resident, placed it under the resident, fixed it, and fastened both side of the brief. CNA A assisted in fixing the brief and fastening it. CNA A still had on the same gloves she used in cleaning the front part of Resident #1. After fixing the brief, both CNAs assisted the resident to roll back. Both CNAs washed their hands. In an interview with CNA B on 12/05/2024 at 10:21 AM, CNA B stated she entered Resident #1's room to assist CNA A with incontinent care. She said she put on a pair of gloves as soon as she entered the room. She said she was supposed to wash her hands first before putting on the gloves. She said hands should be washed first before doing any care. She said she was supposed to sanitize also in between changing her gloves to prevent infection. She said she would make sure she washed her hands before and after incontinent care and sanitized her hands in between changing of gloves. She said she would also ask for a container of sanitizer so she would always have one. She said there was a sink inside the resident's room but the sanitizer was outside the room. She said she had in-services about hand hygiene but was not able to apply it. In an interview with CNA A on 12/05/2025 at 10:39 AM, CNA A stated she started cleaning Resident #1's perineal area while waiting for CNA B. She said she assisted in fixing the resident's brief when CNA B was done cleaning the resident's bottom. She said she should have changed her gloves after cleaning the resident's bottom because her gloves were already dirty. She said she would remember next time to change her gloves after cleaning the front part of the resident and even after cleaning the bottom of the resident to prevent infection. In an interview with the ADON on 12/05/2024 at 11:32 AM, the ADON stated hand hygiene was basic and always done before and after incontinent care. She said the hands should be washed before starting incontinent care and before putting on a pair of gloves. She said there was a sink inside Resident #1's room so it was easy for the staff to wash their hands prior to incontinent care. She said the hands should also be sanitized in between the changing of gloves and the gloves should be changed after cleaning the resident's front part and before touching the new brief. She said washing and sanitizing the hands and changing the gloves after touching soiled body parts were done to prevent cross contamination and spread of infection. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and when transitioning from a dirty site to a clean site. She said the staff should be mindful when they performed incontinent care to prevent infection. The ADON said she would do in-services about infection control and hand hygiene. She also said she already distributed hand sanitizer for the staff. In an interview with the DON on 12/05/2024 at 12:36 PM, the DON stated he was made aware by the ADON about the issue in hand hygiene and changing of gloves. He said hand hygiene was the most effective way to prevent infection. He said first, hands should be washed before and after any care. Secondly, hands should be sanitized when changing gloves. He said if the gloves were heavily soiled, the staff should wash their hands. Lastly, staff must change their gloves after touching soiled items or soiled body parts. He said expectation was the staff would do hand hygiene as required and change their gloves when transitioning from dirty to clean. He said he would do in-services and competency check-off about hand hygiene and infection control. He said he already did a one-on-one in-service with CNA A and CNA B. In an interview with the Administrator on 12/05/2024 at 1:14 AM, the Administrator stated she was already aware about the issue of the staff not washing the hands before cleaning the resident. She said not washing the hands and not changing the gloves could cause cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to hand washing and infection control. She said she collaborate with the DON on how to handle the issue about infection control and hand hygiene. Record review of the facility policy, Perineal (area between the thighs) Care Female Nursing Policy and Procedure Manual revised December 8, 2009 revealed Procedural Guidelines . A. Beginning Steps . a. wash hands .F. remove soiling . H. wash hands and put on clean gloves. Record review of the facility policy, Infection Control Plan: Overview Nursing Policy and Procedure Manual 2019, no revision date, revealed The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary . environment . to help prevent the development and transmission of disease and infection .

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two of (Resident #16 and Resident #20) eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #16 was care planned for smoking. 2. The facility failed to ensure Resident #20 was care planned for hospice and enteral Feeding. These failures could place the residents at risk of not receiving necessary care and services. Findings included: 1. Review of Resident #16's Face Sheet, dated 07/10/2024, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included seasonal allergic rhinitis and shortness of breath. Review of Resident #16's Quarterly MDS Assessment, dated 06/06/2024, reflected that Resident #16 had a severe impairment in cognition with a BIMS score of 03. Review of Resident #16's Safe Smoking Assessment, dated 07/04/2024, reflected the resident knew the location of the designated area for smoking and the resident could go the designated area independently. Observation and interview on 07/10/2024 at 8:28 AM revealed that Resident #16 was rolling her wheelchair on the hallway going towards the smoking area. Resident #16 said she was going out for a smoke. In an interview with Resident #16 on 07/10/2024 at 10:16 AM, Resident #16 stated she was a smoker and had been since when she was younger. The resident said she stopped for a couple of months but went back to smoking again. Review of Resident #16's Comprehensive Care Plan on 07/10/2024 reflected that Resident #16 had no care plan for smoking. 2. Review of Resident #20's Face Sheet, dated 07/09/24, reflected resident was a 77- year-old female admitted on [DATE]. Relevant diagnosis included cognitive communication deficit and dysphagia (difficulty in swallowing) Review of Resident 20's Comprehensive MDS Assessment, dated 05/29/2024, reflected resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was on tube feeding and was receiving hospice care while a resident of the facility. Review of Resident #20's Physician's Order, dated 06/10/2024, reflected every shift Fibersource HN or equivalent 70 ml/hour continuously. Stop for ADLs and restart immediately. Review of Resident #20's Physician's Order, dated 05/10/2024, reflected Hospice to evaluate and treat. Review of Resident #20's Care Plan on 07/09/2024 reflected Resident #20 had no care plan for tube feeding and hospice care. Observation on 07/09/2024 at 9:44 AM revealed Resident #20 was in her bed sleeping. The resident was connected to a feeding formula at approximately 600 ml and was running at a feed rate of 70 ml per hour. Observation on 07/11/2024 at 7:40 AM revealed Resident #20 was in bed, awake. Resident #20 had a feeding formula hanging from an IV pole. The feeding formula was not connected to the resident. In an interview with the Senior MDS Case Manager on 07/10/2024 at 11:39 AM, the Senior MDS Case Manager stated care plans were important to ensure the residents were getting the care needed. The Senior MDS Case Manager said care plans served as guide on how the staff will take care of the residents. The Senior MDS Case Manager said care plans were comprised of the problem lists, the goals, and the interventions appropriate to the needs of the residents. The Senior MDS Case Manager added that without the care plans, the staff could miss out significant interventions needed by the residents. The Senior MDS Case Manager said if a resident was a smoker, there should be care plan for smoking. She added if a resident was on tube feeding, there should be a care plan for tube feeding. She also said if a resident was admitted to hospice, there should be a care plan for hospice. The Senior MDS Case Manager logged onto her computer, searched for Resident #16's profile and said the resident did not have a care plan for smoking. She said she would add a care plan for smoking. After adding the care plan for smoking for Resident #16, the Senior MDS Case Manager said the Social Worker was responsible in making the care plan for smoking. She said the Social Worker was new and she should have oriented the Social Worker with regards to the care plan that she needed to do. She said she would talk to the Social Worker about the care plan for smoking. The Senior MDS Case Manager then went to Resident #20's profile and said the resident did not have a care plan for tube feeding and for hospice. The Senior MDS Case Manager said she would go ahead and add the care plan for both. After adding the care plan for tube feeding and hospice, she said she would audit the care plans of the residents. She said the staff and management discussed every morning if there was any changes about the residents. She said there was an oversight on her part. In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents receive the appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be in the same page. The DON said the care plan serveed as a communication tool for all individuals caring for the residents. He said the care plan should be comprehensive and should show what specific care the resident needed. He said the expectation was for all residents to have a complete and detailed care plan. He said he was responsible in checking if the care plans of the residents were comprehensive and in accordance with the current condition of the residents. He said he would coordinate with the ADON, the Senior MDS Case Manager, and the Social Worker to audit the care plans. In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated she was still learning how to do the care plans. The ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. The ADON said that for these cases, there should be a care plan for smoking, tube feeding, and hospice care. She added without the care plan, the current needs of the resident would not be addressed. In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff will ensure that every issue of the residents were care planned. She said she would coordinate with the DON and the Senior MDS Case Manager to make sure all the residents were care planned accordingly. In an interview with the Social Worker on 07/11/2024 at 11:38 AM, the Social Worker stated she did not know she was supposed to do the care plan for smoking, mood and behavior, and code status. She said that now that she knew, she would review and audit the care plans appropriately. She said the Senior MDS Case Manager told her that she would orient her about care planning. Record review of facility's policy, Comprehensive Care Planning, Nursing Policy & Procedure Manual, The facility will develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes . the resident's goals for admission and desired outcome . address the resident's medical . needs . Interventions are the specific care and services that will be implemented.

Based on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #26, #30, and Resident #189) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure an Oxygen In Use sign was placed outside of Resident #26's room. 2. The facility failed to ensure Resident #189's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored. 3. The facility failed to ensure Resident #30's oxygen mask was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #26's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and acute respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #26's Comprehensive MDS Assessment, dated 05/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated Resident #26 was on oxygen therapy while a resident of the facility. Review of Resident #26's Comprehensive Care Plan, dated 07/06/2024, reflected the resident had oxygen therapy due to ineffective gas exchange and one of the interventions was oxygen at 2 lpm per nasal canula. Review of Resident 26's Physician's Order, dated 05/29/2024, reflected, OXYGEN 3-4L/MIN VIA NASAL CANNULA every shift for SOB/wheezing/LOW OXYGEN SAT LESS THAN 92% and prn. Observation on 07/09/2024 at 9:37 AM revealed Resident #26 was on oxygen therapy at 3 liters per minute via nasal cannula. It was observed that there was no Oxygen In Use sign outside the door of the resident. Observation and interview with LVN B on 07/10/2024 at 10:46 AM, LVN B said there should be a sign outside the room of the residents that use oxygen. LVN B said the sign was to remind the staff and the visitors that oxygen was being used inside the facility. She said oxygen could be a dangerous fire hazard. She said adequate precautions should be in place. LVN B said she would look for a Oxygen In Use sign. LVN B came back to the room and placed the Oxygen In Use sign outside Resident #26's room. 2. Record review of Resident #30's Face Sheet, dated 07/11/2024, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included COPD and obstructive sleep disorder. Record review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 07 (severe cognitive impairment) and an active diagnosis of COPD. Record review of Resident #30's physician's orders dated 07/11/24 revealed the resident had active orders for may use oxygen @ 4 L/M (liters per minute) via nasal cannula every shift. An observation on 07/09/24 at 11:01 AM revealed Resident #30 not being in his room and his oxygen mask was observed sitting on a stand exposed, and not in a sealed bag. In an interview and observation on 07/10/24 at 01:55 AM with RN M, she stated she was the floor nurse for the North Hall and she acknowledged that Resident #30 did use an oxygen concentrator. She stated that when the resident's mask was not in use, it had to be placed in a sealed bag. She was shown a picture of Resident #30's mask sitting exposed and uncovered. She stated she had observed that today and had made sure that it was bagged. She stated the CNAs were supposed to remind the nurses if they observed masks not stored in a bag. She stated the risk of not placing the resident's mask in a sanitized bag could result in the resident having respiratory concerns. 3. Review of Resident #189's Face Sheet, dated 07/09/2024, reflected that resident was a [AGE] year-old male admitted on [DATE]. Resident #189 had a diagnosis of obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #189's Comprehensive Care Plan, dated 07/05/2024, reflected resident required the use of CPAP related to sleep apnea and one of the interventions was the resident will use device as ordered. Review of Resident #189's Physician's Order, dated 07/05/2024, reflected, CPAP AT HS AND AS NEEDED FOR NAP IN DAY TIME. at bedtime for SLEEP APNEA. Observation and interview on 07/09/2024 at 9:08 AM revealed Resident #189 was in his wheelchair inside his room. Resident #189 had a CPAP machine on his bed side table and a CPAP mask was connected to the machine. The CPAP mask was noted on top of the CPAP machine. The CPAP mask was not bagged. Resident #189 stated he used the CPAP machine at night. The resident said staff would put the CPAP on him at night and would take it off in the morning. He said he never saw a plastic bag for the CPAP mask and nobody told him to put the mask one if ever he would take it off. Observation and interview with LVN B on 07/09/2024 at 9:53 AM, LVN B stated the CPAP mask should not have been exposed nor touching anything because it could cause contamination and possible infection. LVN B said the CPAP mask should be bagged when not in use. LVN B said she did not notice the CPAP mask was not bagged and that there was no bag for the CPAP mask. LVN B said the resident would sometimes take the CPAP mask off but said she should have monitored if it was in a plastic bag. LVN B saw the CPAP mask on top of the CPAP machine and said she would get a plastic bag for the mask, clean the mask, and place it inside the plastic bag. In an interview with DON on 07/11/2024 at 8:10 AM, the DON stated the CPAP mask should be bagged when not in use. He said if the CPAP mask was not bagged, exposed, or touching surfaces that were not clean, then oxygen administration could be compromised. The DON said it could also result to cross contamination and respiratory infections. He said the expectation was for the CPAP mask would be stored properly. He added the nasal cannula and the breathing mask for nebulization should also be bagged for the same reason. With regards to signage for oxygen, the DON said there should be a Oxygen In Use sign outside the door of the resident using oxygen. The sign was for safety purposes. He continued that oxygen was a flammable substance and could cause an explosion if somebody lit a cigarette near the room. He said the facility was a non-smoking facility but it would be prudent to remind the residents, staff, and visitors. He said he was responsible in putting the sign on the door of the resident and he must have overlooked it. He said the expectation was there would be an Oxygen In Use sign on every door of the residents using oxygen. The DON concluded that moving forward, he would do an in-service about bagging the CPAP mask and would continually remind them to be diligent in making sure the procedures for respiratory care were followed. He said he would also do a round to make sure all the residents using oxygen has a sign outside their door. In an interview with the ADON on 07/11/2024 at 8:39 AM, the ADON stated the CPAP mask should be bagged when the resident was not using it to prevent cross contamination and infection. She said the staff who take off the mask should put it in a bag. She said if the resident was the one taking it off, there should be a bag ready for them to put the mask in. She also said that the resident should be educated why the mask should be bagged. She said the expectation was for the staff to bag the CPAP mask. She said, not just the CPAP mask but also the nasal cannula and the mask used for nebulizer should also be bagged. She said it was important that there was an Oxygen In Use sign outside the door of a resident using oxygen. She said the sign was for safety precaution so everybody in the building would know oxygen was being used in the building. She said she would coordinate with the DON to do an in-service pertaining to bagging the CPAP mask, nasal cannula, and breathing mask when the residents were not using them and making sure there was a sign outside the doors of the resident in oxygen administration whether continuously or as needed. In an interview with the Administrator on 07/11/2024 at 8:49 AM, the Administrator stated that in general, the CPAP masks should be stored properly to prevent respiratory issues or exacerbation of whatever respiratory issues the residents already had. The Administrator said the expectation was for the staff to be mindful during their rounds and make sure the CPAP masks were bagged. The Administrator said it was important that there was sign outside the door of the residents using oxygen for safety purposes. She said oxygen was a flammable substance. The Administrator said she would check if the clinicians already did correct the issue. Record review of facility's policy, Oxygen Administration Nursing Policy & Procedure Manual 2003 revised February 13, 2007 revealed Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat . O2 therapy is also prescribed to ensure oxygenation of all body organs and systems . 11. Place . signs in area when oxygen is administered. A policy for masks being bagged was requested on 07/10/2024 at 1:45 PM and followed-up on 07/11/2024 at 9:40 AM. The Corporate Nurse said the facility did not have a policy specific for masks being bagged.

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #2) of two residents observed for wound care. 1. The facility failed to remove Resident#2's footboard on 03/30/22 per the Wound Care physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility staff failed to attempt alternative preventive measure on when Resident #2 refused to wear the sponge boot per the Wound Care physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The LVN failed to notify the wound care physician when Resident #2's wound to his right distal planter, lateral foot decline These failures could affect the residents by placing them at risk for a delay in treatment, worsening of pressure ulcers, infection, and discomfort. Findings included: Review of Resident #2's face sheet, dated 03/15/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission MD'S assessment, dated 03/22/22, reflected a [AGE] year-old male was readmitted to the facility on [DATE]. He had a BIMS of 10 which indicted he was cognitively impaired. He required extensive assistance with ADLs of bed mobility, transfers, toileting, dressing and personal hygiene. Resident was at risk for developing pressure ulcers. The resident had one unstageable pressure ulcer upon admission/re-entry with one unhealed pressure injury with coverage of the wound bed by slough and/or eschar. Record review of Resident #2's Comprehensive Care Plan, dated 1/17/22, update on, 04/05/22 and 04/11/22 reflected, resident has a potential for pressure ulcer development, Unstageable pressure ulcer to sacrum and DTI on Left and Right plantar. Interventions: Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible., Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD., Avoid positioning the resident on the location of the pressure ulcer, ensure heels are floated with the use of pillows, Footboard on bed removed to prevent skin tear/friction shear to bilateral feet and heels. Review of the Wound Care MD report on 03/30/22, the Treatment Nurse and the Wound Care MD identified a deep tissue injury to the right distal plantar lateral of the foot. Review revealed the wound care MD measured the affected area of 5x5 not measurable. Review of the Wound Care MD wound evaluation and management summary dated 03/30/22 revealed the wound to the distal plantar lateral of the right foot was 5x5x not measurable. The wound care MD ordered, [MEDICATION(S)] apply Q-shift (3xday) for 30 days to right foot (plantar), right forth toe . Review of the Wound Care MD report dated 03/30/22, revealed Coordination of Care: .Trauma wound of the right Dorsal fourth toe that is a new wound, Pressure wound of the right planter distal lateral foot is a new wound, and Un-DTI (unstageable deep tissue injury) pressure wound of the left Planter lateral foot that is a new wound. Observation on 04/10/22 at 11:08 AM revealed the resident was lying on his back with right foot pressed against the foot board with his legs in a scissor position with the left leg on top of the right leg. The Treatment Nurse and the CNA D pulled the resident up towards the head of the bed and turned him to his right side to perform sacral area wound care and noted the top of the 3rd and 4th toes on right foot had scabbing; the center of the right distal plantar was open with a small opening of 0.5 cm with the surrounding tissue deep dark purplish with unmeasurable black tissue scattered throughout the wound area that measured approximately 5x5x not measurable. Interview on 04/10/22 at 11:10 AM., the Treatment Nurse stated the resident slides down into bed, the staff attempt to pull the resident up. The wound care MD recommended the foot board be removed on 03/30/22. She said the DON or ADON told her the foot board could not be removed. The resident's daughter did not want the foot board removed. The Treatment Nurse called the wound care MD and informed that foot board could not be removed, and the MD ordered the Podous boot. Resident refused to wear the Podous boot (sponge boot). No other preventative measures were attempted. Observation on 04/11/22 at 9:40 AM revealed the foot board was removed by the maintenance man. In an interview on 04/11/22 at 1:10 PM the Treatment Nurse measured the wound as 5 x 5.5 cm. In an interview on 04/11/22 at 2:40 PM with Treatment Nurse stated the wound care doctor was contacted and notified of change in condition and stated she would see the resident on Wednesday 04/13/22. New orders were given to apply [MEDICATION(S)] to right foot planter, right foot fourth toe, and wrap with dry dressing three times a day for wound healing. The medical director was also contacted and stated she wanted the wound care MD to evaluate and treat. Review of Nurses Progress Note date 04/11/22, revealed Resident #2's Wound Care MD was notified of worsening DTI to right foot. a new order was given for the wound to now be staged as unstageable due to necrosis. no new orders at this time and wound MD stated, wound orders still stand. Wound MD will be notified of any change. will continue to monitor for any new or worsening change. will continue to encourage proper wound care, turning and repositioning and off-loading. Resident education was provided regarding the importance of off-loading wound. resident continues to refuse podous boots (sponge Boot) for offloading. resident to have follow up with Wound MD on Wednesday 04/16/22 Review of Resident #2's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#2's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/11/22 at 1:00 PM the resident's daughter stated the facility did not contact her about to removal of the resident's footboard. She stated she was made aware of the wound on the bottom of the resident's right foot last week and was told it was from being in bed all the time. The resident's daughter stated she did not know removing the footboard was an option and thought it would be a great idea to help with healing of the right foot wound. Interview with the Wound Care MD on 04/11/22 at 9:29 AM revealed the foot board was the source of the pressure ulcer of the right foot. Review of the facility's Abuse and Neglect Policy dated 03/2018 revealed Neglect: is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on the comprehensive assessment of a resident, the facility failed to ensure that one (Resident #6) of twelve residents, who were observed for pressure ulcers, did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable and that the resident received necessary treatment and services to promote healing. On 11/08/14, Resident #6, who had previously been assessed as being at high risk for pressure ulcer development, returned to the facility from the hospital after having surgical repair for fractures to the right knee and hip. The resident had an immobilizer brace to the right leg, and the physician ordered that the immobilizer be removed every shift for gentle range of motion and skin assessment starting on 11/11/14. On 11/20/14, during her weekly skin assessments, the ADON/Treatment Nurse noted that Resident #6 had discoloration to the right ankle area from the immobilizer brace, and noted her findings on the skin assessment sheets. The ADON did not share her findings with the charge nurses or DON so the area could be monitored, nor was the physician contacted or a treatment started. In addition, no further assessment or treatment of [REDACTED]. On 12/04/14, after surveyor inquiry, the brace was removed and the resident was assessed to have a total of four unstageable pressure ulcers on the right leg ankle area due to the immobilizer. It was determined then, that the brace had not been removed since 11/20/14, as the nurses had not been removing the brace every shift to assess the skin and to provide range of motion exercises, as ordered. The failure had the potential to result in development of new pressure ulcers and/or worsening of existing pressure ulcers to include possibility for infection and could affect the 40 residents, including Resident #6, who had limited mobility and were either bedfast or in the chair all or most of the time. Findings included: Resident #6's MDS assessment dated [DATE] reflected the resident was most recently re-admitted to the facility on [DATE]. The assessment reflected Resident #6 had the following Diagnoses: [REDACTED]. Resident #6's cognitive skills were identified as being severely impaired without the ability to understand others or be understood. Resident #6's functional status reflected she was totally dependent upon staff for assistance with her ADLs to include: bed mobility, dressing, eating, toileting and personal hygiene. Resident #6 was assessed to have impairment on one side of the lower extremity. She was assessed to be incontinent of bowel and bladder. The assessment also reflected Resident #6 was at risk for developing pressure ulcers, but she did not have a pressure ulcer at the time of the assessment. The Admission/Readmission form completed for Resident #6, dated 11/08/14, reflected Resident #6 returned to the facility with a leg brace to her right leg secondary to a right knee and [MEDICAL CONDITION]. Resident #6's December 2014 Physician order [REDACTED].#6 had an immobilizer in place due to a fractured femur. The physician orders [REDACTED]. Resident #6 was observed in her room in bed, during initial tour of facility with RN A on 12/03/14 at 9:45 a.m. The resident was lying in her bed with the head of the bed elevated to approximately 40 degrees, and her mattress was noted to be an air mattress. The resident was observed to have a leg brace/immobilizer on her right leg that extended from her ankle to above her knee. The immobilizer had Velcro straps to secure the device to the resident's leg. A pillow was observed under her right leg to support the immobilizer. RN A stated Resident #6 had been a resident at the facility for eight years, and she recently returned to the facility after a recent femur fracture. She stated the resident wore an immobilizer brace to keep her right leg straight. She stated the resident would be returning to the surgeon for a follow-up appointment. RN A stated Resident #6 was bedfast, incontinent of bowel and bladder, diabetic, and received continuous tube feedings. She stated Resident #6 was unable to communicate or make her needs known so the staff monitored the resident's facial expressions to monitor for pain. RN A stated Resident #6 did not have any pressure ulcers or skin concerns, other than the healing surgical incisions, which were closed. On 12/04/14 at 10:45 a.m., CNA H and CNA I were observed preparing to give Resident #6 a bed bath. The resident had the immobilizer brace on her right leg, and she wore a white sock on the right foot. Prior to bathing the resident, LVN B was called to the room to disconnect the resident's feeding tube. At that time, the surveyor asked if the brace would be removed, and CNA I stated the brace was not to be removed. She stated it was only removed the nurse. When LVN B was in the room, she removed the brace on Resident #6's right leg, and the leg looked dry and ashy. The resident's right knee was swollen and steri-strips were observed covering the incision area. Observation of Resident #6's right ankle revealed four areas where the skin was broken and had scabbed over. The areas were covered with a dark-scab like covering, and the depth could not be determined. The injured tissue covered an area of approximately 2-3 inches in size, but the three individual wounds were smaller. Also, there was a small scab-like wound on the right thigh where the immobilizer was. LVN B was asked to identify the areas, and she stated the areas were from the immobilizer rubbing and pressing on the side of the ankle. When asked how long they had been there, she stated the areas had been there about three days. LVN B was asked if the resident was receiving treatment for [REDACTED]. LVN B stated it did not appear like the area was being treated since it was not covered with a dressing. In addition, she stated there was a physician order [REDACTED]. She stated she thought the ADON was removing it. LVN B proceeded to measure the four wounds, and the measurements were as follows: right thigh - 0.5 cm x 0.5 cm right ankle - 1.3 cm x 0.4 cm, 1.0 cm x 0.3 cm, and 1.5 cm x 1.5 cm Interview with the ADON on 12/04/14 at 11:00 a.m. revealed she was unaware there were open wounds under Resident #6's immobilizer. The ADON stated she recalled the brace loosening up and rubbing on Resident #6's right ankle a couple of weeks ago, so she placed a sock on her foot to help pad the area. The ADON stated the area was discolored when she last saw it, and she documented the observation on the weekly skin assessment sheets. She acknowledged she had not looked at the area since then because she did not work four days last week. The ADON stated she thought the nurses would be observing the residents' skin when she was out. The ADON stated she was responsible for the weekly skin assessments and would complete them on Thursdays and Fridays, but since she did not work those days last week, they were not completed. The ADON stated the charge nurses should have been checking the residents' skin and documenting on the weekly skin assessments. The ADON stated she did not think any of the residents had a skin assessment done the previous week. After observing Resident #6's wounds, the ADON stated the wounds would be classified as pressure ulcers due to the pressure and friction caused by the immobilizer. In addition, she staged them as unstageable pressure since it could not be determined how deep the wound was under the eschar (scab). The ADON stated she would contact the physician and get an order for [REDACTED]. On 12/04/14 at 11:20 a.m. an interview was conducted with the DON. The DON stated residents, who wore a brace or immobilizer, should have the device removed each shift. She also stated their skin should be assessed when the device was removed. In addition, the DON stated charge nurses were responsible for checking their residents' skin and should have been filling out skin sheets. The DON stated the nurses did not complete their skin sheets, and the weekly skin assessments were not documented. The DON was asked what was supposed to happen when there were changes in a resident's skin condition. The DON stated the nurses should contact the family, the physician, and follow-up by referring the condition to the ADON, who would initiate the treatment. The DON stated she would begin in-serving staff. On 12/04/14 at approximately 12:45 PM, the ADON informed surveyor that when she was cleansing the wounds, one of the scabbed areas, located on the right thigh, had come off when she wiped it with gauze to dry it. The areas were observed again for wound care on Resident #6 on 12/05/14 at 9:30 AM by the ADON and there was a light pink area on the right thigh where the wound had been, as it was healed and the scab came off. The ADON stated the wounds were caused by the brace pressing up against the leg as there was a metal rod along the brace. An interview was conducted with CNA H on 12/04/14 at 1:15 p.m. regarding Resident #6's brace/immobilizer. She stated she never removed the immobilizer from Resident #6's leg because the nurses were responsible for removing it. Interview with LVN D on 12/04/14 at 1:50 p.m. revealed she had not been removing the brace to view the skin under it. LVN D stated she would only remove the brace if she noticed swelling or unusual color on the surrounding skin. LVN D stated the ADON was responsible for all the treatments, and she assumed the ADON was observing Resident #6's skin daily. LVN D was shown the treatment MAR and verified her initials signing off on completing active range of motion and skin assessments for Resident #6. LVN D stated she would no longer rely on another nurses' assessment and would be completing her own assessment from now on. Resident #6's Care Plan, dated 09/17/14 reflected the resident had the potential to develop pressure ulcers. Review of the listed approaches for the plan of care revealed there were no interventions addressing skin assessments or the use of the immobilizer on Resident #6. The listed approaches were as follows: "1) Encourage po (by mouth) and fluid intake within dietary limits. 2) Use padding between pressure areas and positioning devices for proper body alignment, (bed and w/c (wheelchair)) 3) Monitor labs and report abn's (abnormal labs) to MD (physician). 4) Dietary consult for proper nutrition to resolve any pressure areas...." Review of all of Resident #6's Care Plans revealed there was not a plan of care to address the use of the immobilizer. The Braden Scale -- For Predicting Pressure Sore Risk assessment completed for Resident #6 for the months of February, May, August, and December 2014 reflected Resident #6 had a score of 13 for each of the months. Closer review of the assessment tool reflected the facility miscalculated the score, and each of the months she should have been scored as a nine (9) which indicated she was at high risk for developing pressure ulcers. The Clinical Conditions Predicting High Risk for Pressure Sore Development tool completed for Resident #6 reflected the resident was assessed to be at high risk for pressure ulcer development for the months of February, May, August, and December 2014 due to having more than more clinical condition that placed her at risk. The assessed conditions that placed her at risk included cognitive impairment, history of healed/closed ulcers, diabetes. For the assessment completed in December 2014, she was also assessed to have chronic urinary incontinence and use of restraints. The Skin Assessment Flow Sheet -- Non-Pressure Ulcer Conditions form completed for Resident #6 reflected the initial assessment was done on 11/08/14, and the care plan problem identified was a right leg incision The initial assessment reflected the resident had a brace to the right leg, and the right leg had an incision with staples. The treatment documented was to monitor. A noted documented on the Flow Sheet, dated 11/20/14, reflected: "brace is causing some discoloration to Rt (right) ankle area, area padded with sock." There was no documented evidence on the Flow Sheet that an assessment was completed on 11/27/14 for Resident #6. The Weekly Skin Assessment sheets for Resident #6 reflected skin assessments were completed on 10/02/14, 10/09/14, 10/16/14, and 10/23/14 with no skin impairment noted. The note for the assessment completed on 11/13/14 reflected: "Bruising on Rt (right) leg/hip suture lines healed" The note for the assessment completed on 11/20/14 reflected: "incisions closed." There was no documented evidence a weekly skin assessment had been completed for Resident #6 on 11/27/14. The next documented skin assessment was following surveyor inquiry on 12/04/14 when the pressure ulcers were discovered on Resident #6's right leg. Progress Notes, dated 12/04/14 at 11:10 a.m. reflected the following nursing entry documented by the ADON: "Noted discolored somewhat scabby areas to lower Rt (right) leg shearing from brace to Rt leg #1 small closed area 0.5 x 0.5x discolored next area is linear also closed 1.3 x 0.4 #3 1 x 0.3 also closed discolored skin #4 1.5 x 1.5x scab no (symbol used) drainage or s/s (signs or symptoms) of infection noted from any of these areas. (Physician N) notified of areas and request order..." Physician's Telephone Orders for Resident #6, dated 12/04/14, reflected: "Clean RLL (right lower leg) with (symbol used) normal saline apply [MEDICATION NAME] and drsg (dressing) daily & prn (as needed)." Resident #6's Comprehensive Plan of Care initiated on 12/04/14 reflected the resident had a pressure ulcer on her right lower leg which measured 0.5 cm x 0.5 cm x 0 cm and was unstageable. A second Comprehensive Plan of Care initiated on 12/04/14 reflected the resident had a pressure ulcer on her right lower leg which measured 1.3 cm x 0.4 cm x 0 cm and was unstageable. A third Comprehensive Plan of Care initiated on 12/04/14 reflected the resident had a pressure ulcer on her right lower leg which measured 1.0 cm x 0.3 cm x 0 cm and was unstageable. The fourth Comprehensive Plan of Care initiated on 12/04/14 reflected the resident had a pressure ulcer on her right lower leg which measured 1.5 cm x 1.5 cm with a scab and was unstageable. Resident #6's Medication Flow Sheet for December 2014 reflected the following physician order: "Gentle ROM (range of motion) without immobilizer daily. Immobilizer at all other times, check skin qs (every shift) for breakdown, every shift. DX (diagnosis): FX (fracture), femur, other. Start date: 11/11/14." The Medication Flow Sheet for Resident #6 also had three separate columns where the nurse on each shift would sign off after removing the immobilizer and performing the physician ordered range of motion. This indicated that all three shifts were responsible for removing the immobilizer and performing the range of motion and to check the skin. The columns were designated days, evenings, and nights. There were nurses' initials in each of the boxes, indicating the nurses signed off on these tasks as completed. The November 2014 Medication Flow Sheet was requested multiple times and was not produced by exit on 12/05/14. The facility's current Skin-Preventive Guideline for Resident at Risk for Pressure Sores policy and procedure, dated January 2008 and revised March 2012, reflected the following: "POLICY It is the policy of this home that a resident who enters the home without a pressure ulcer will not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable. DEFINITIONS Avoidable The resident developed a pressure ulcer(s), or that an existing pressure ulcer deteriorated or failed to heal adequately (or heal as well as could be expected for end-of-life conditions) and that the home failed to thoroughly perform the steps of recognition, problem and cause identification, prevention and management, or monitoring in accordance with recognized standards of practice. Unavoidable The resident either developed a pressure ulcer(s) or experienced a failure of pressure ulcer(s) to heal as a result of the resident's clinical condition...despite proactive and thorough the homes efforts to treat or prevent the development of pressure ulcer(s) (evaluating the resident's clinical condition and pressure ulcer risk factors, defining and implementing interventions that are consistent with resident needs, resident goals, and recognized standards of practice, evaluating the impact of the interventions, and revising the approaches as appropriate). ...RISK FACTORS (Examples include, but are not limited to)... - Decreased cognition or level of consciousness; - Generalized physical deconditioning and inactivity; - Impaired mobility due to...fractures... - Long-standing diabetes mellitus... - Previous pressure ulcer(s) - Inadequate pressure reducing devices or interventions, for example repositioning. PRESSURE RELIEF 1. Relieve the underlying cause of pressure, addressing pressure, sheer, other physical friction and maceration/moisture factors. 2. Encourage mobility/ambulation. Reposition/turn at least every two (2) hours. ...4. Implement range of motion exercises if mobility status warrants. 5. Position body with pillows, foam wedges and/or other support devices turning resident at angles to avoid pressure over body prominences. ...10. Avoid friction: a. consider protective devices ...f. provide padding for casts, braces and splints .... " The facility's current Skin Integrity Monitoring System policy and procedure effective January 2008 and revised March 2012 reflected the following: "POLICY It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed and preventive measures will be in place to prevent the development of pressure ulcers. 3. A system will be in place to assure any type of skin conditions that do not constitute pressure ulcers, will be monitored closely for any type of complications." PROCEDURE ASSESSMENT AND MONITORING 1. (Braden Scale) will be completed within 24 hours of admission/readmission and every week times four weeks for new admits/readmits ...then quarterly and with any significant change in condition. 2. Residents well be screened daily through the use of the (Nursing Assistant Daily Body Observation Form). 3. All residents will be assessed weekly using the (Weekly Skin Assessment) form for any type of skin integrity complications; this will include pressure ulcers and non-pressure related complications. The (Weekly Skin Assessment) will be documented on the (Weekly Skin Assessment). 4. When pressure ulcers are identified, the assessment of the ulcer must be documented on the (Skin Assessment Flow Sheet-Pressure Ulcer Form).... DEFINITIONS Pressure Ulcer - localized injury to the skin and/or underlying tissue. Pressure ulcers usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. Pressure ulcers are staged to classify the degree of tissue damage observed. Pressure Ulcer Stages: Per the National Pressure Ulcer Advisory Panel (NPUAP), wounds are not back staged (once a stage IV always a stage IV). Suspected Deep Tissue Injury (SDTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue. Stage I: Intact skin with non-blanchable redness of a localized area, usually over a boney prominence. Darkly pigmented skin may not have visible blanching, its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to surrounding skin. ...Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until the slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. GOALS 1. Prevent the development of pressure ulcers by performing routine skin and risk assessments on all residents at admission and specified intervals with appropriate intervention as per policy to prevent tissue destruction. 2. Accurately identify existing tissue destruction and optimize healing by utilizing consistent treatment." The facility's Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 12/03/14 reflected there were no residents listed as having a pressure ulcer and 40 residents identified with limited mobility, who were either bedfast or in the chair all or most of the time.