Every finding on record at Crossroads Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 1, Resident #2, and Resident #3) reviewed for activities.The facility failed to provide Resident #1, Resident #2 and Resident #3 in room activities three times per week, as care planned, during the months of March 2026 and April 2026.This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included:1. Record review of Resident #1's face sheet, dated 05/01/2026, reflected a [AGE] year-old male, admitted [DATE], with a diagnoses of cognitive communication deficit (having difficulty with communication due to problems with thinking skills such as memory, attention, problem-solving, and organization), spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and often the face, due to brain damage, causing stiff muscles that make movement difficult, leading to severe mobility issues, speech/swallowing problems, and sometimes intellectual/seizure challenges, requiring lifelong support), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and contracture of left and right elbow (the muscles, skin , or tissues around these joints have tightened and shortened, severely limiting normal bending and straightening, often due to injury, prolonged in activity, making simple tasks difficult).Review of Resident # 1's Annual MDS Assessment, dated 08/07/2025, reflected Resident #1 had poor short and long-term memory recall. Record review reflected Resident #1 was rarely to never understood and was unable to complete the assessment for mental status. Further record review reflected Resident #1's activity preferences included music and doing his favorite activities. (did not specify his favorite activities)Record review of Resident #1's Quarterly MDS Assessment, dated 03/04/2026, reflected Resident #1 had poor short and long term memory recall. Record review reflected Resident #1 was rarely/never understood and was unable to complete the assessment for mental status.Record review of Resident #1's Comprehensive Care Plan, revised on 03/12/2026, reflected Resident #1 had impaired cognitive function (a decline in a person's ability to think, remember, and process information) or impaired thought processes (date problem was initiated was on 07/24/2024. Interventions: date initiated was on 07/24/2025). Resident #1 was able to remember one/two/three instructions, find his room, sit for an hour, and do puzzles. Engage Resident #1 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities for Resident #1 that accommodates the resident's abilities. Resident #1 was dependent on staff for activities, cognitive stimulation, social interaction related to immobility, and physical limitations. (Problem was revised on 07/24/2024. Interventions: date initiated was on 02/23/2023 reflected provide Resident #1 with materials for individual activities as desired. Resident #45 enjoys the following independent activities such as: listening to music, socializing with staff members, playing with personal toys, and watching movies. Resident #1 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #1 does come out to dining room occasionally for lunch. In room visits with toys and tv will be continued by the Activity Director. (date initiated was 11/22/2023 and was revised on 07/24/2024). Interventions: Resident #1 will be encouraged and reminded of current activities. (date initiated was 11/22/2023)Record review of Resident #1's Activity Assessment, dated 02/10/2026 and signed by Activity Director A, who was no longer an employee, reflected Resident #1 enjoyed listening to music and doing favorite activities.Record review of the Activity Participation Records for Resident #1 indicated he did not receive in-room activities for the months of March 2026 and April 2026.During an observation and interview on 05/01/2026 at 11:30 a.m., Resident #1 was in his room in bed, watching television (unsure of the name of the television show he was watching, however, it was appropriate for Resident #1). Resident #1 was not interviewable.2. Record review of Resident # 2's face sheet, dated 05/01/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of contracture of right and left elbow, right and left hand (the muscles, skin, or tissues around these joints have tightened and shortened, severely limiting normal bending and straightening, often due to injury, prolonged in activity, making simple tasks difficult), sequelae of cerebral infarction (a condition that occurs when blood flow to the brain was disrupted, leading to brain cell death), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension - when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and repeated falls (two or more unintentional falls within a specific timeframe, most commonly a 12-month period, and signal a significant health concern, especially in older adults, indicating underlying issues with balance, strength, or other conditions that require medical evaluation for prevention).Record review of Resident #2's Annual MDS Assessment, dated 09/30/2025, reflected Resident #2 had a BIMS score of 0, indicating severely impaired cognition. Resident #2's activity preference was listening to music. Record review of Resident #2's Quarterly MDS Assessment, dated 04/02/2026, reflected Resident #2 had a BIMS score of 0, indicating severely impaired cognition. Record review of Resident #2's Comprehensive Care Plan, revised on 04/03/2026 and initiated 02/06/2024, reflected Resident #2 needed in room activities for mental and emotional stimulation, initiated 2/6/2024, He will respond to one on one in room visits such as listening to music, following movement, and conversation. Intervention: (date initiated was on 02/08/2024) The Activity Director will provide Resident #2 with one- on-one visits 3 times a week. Record review of Resident #2's Activity Assessment, dated 07/04/2025, reflected the following activities was Resident #2's preferences: listening to music and doing residents favorite activities. Record review of Resident #2's Activity Assessment, dated 04/20/2026, reflected the following activities was Resident #2's preferences: listening to music and doing favorite activities.Record review of Resident #2's Activity Participation record reflected he did not receive in-room activities during the months of March 2026 and April 2026.During an observation and interview on 05/01/2026 at 11:40 a.m., Resident #2 was lying in bed, watching television (talk show) Resident #2 was not interview able. 3. Record review of Resident #3's face sheet, dated 05/01/2026, reflected a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with a diagnoses of unspecified quadriplegia (paralysis of all four limbs and the torso - from the neck down where the specific cause, severity or exact level of spinal cord injury has not been detailed or determined), bed confinement status (unable to be out of bed), and unspecified injury of cervical spinal cord, subsequent encounter (does not specify the exact nature of precise vertebral level of the damage to the spinal cord, though it is located in the neck).Record review of Resident #3's admission MDS Assessment, dated 12/16/2026, reflected Resident #3 had a BIMS score of 14 indicating his cognition was intact. Resident #3's activity preference very important to him was listening to music. Record review reflected it was very important to Resident #3 to do his favorite activities, however, he could not do it or he did not have a choice.Record review of Resident #3's Comprehensive Care Plan, dated 04/03/2026, reflected Resident #3 had impaired cognitive function or impaired thought process. Intervention: Provide Resident #3 a program of activities that accommodates his abilities. Use task segmentation to support short term memory deficits. Resident #3 needed in room socialization and sensory stimulation (date initiated 12/19/2025). Intervention : The Activity Director will provide Resident #3 with one-on-one visits with sensory stimulation at least 3 times per week. (date initiated on 12/19/2025).During an observation and interview on 05/02/2026 at 11:50 a.m., Resident #3 was lying in bed. He stated he was not receiving any activity visits from the staff. He asked what was one on one activities. Resident #3 stated he had not been visited by anyone in the activity department that he can recall. He stated if the person did not identify their position he may not realize the person was an activity staff. Resident #3 stated he would enjoy someone to come visit him approximately 4 or 5 times per week. He stated it would help him to be around other people. Resident #3 denied being depressed or sad. He stated sometimes he gets tired of watching television. Resident #3 stated he loved music and wished he had something so he could hear music. He stated he liked country and some of the old rock and roll music. Resident#3 stated no one had offered him an opportunity to listen to music. During an interview on 05/01/2026 at 10:10 am, Activity Director B stated Resident #1, Resident #2, and Resident #3 required in-room activities at least 3 times per week. She stated she began working at the facility 04/09/2026. Activity Director B stated she had not provided in-room activities to Resident #1, Resident #2, or Resident #3. She stated she did not have any participation records for in-room activities for these 3 residents (Resident #1, Resident #2 and Resident #3) for the month of March 2026. Activity Director B stated there was an activity director working during the month of March 2026. She stated she had worked as an Activity Director in another facility and had her certificate. She stated Resident #1, Resident #2, and Resident #3 would benefit from in-room activities. Activity Director B stated she was learning the residents activity preferences by speaking to the staff or calling the families. She stated she was going to review past activity assessments to gather more information on the residents. Activity Director B stated if a resident needed in-room activities and they were not receiving them, there was a possibility a resident may become depressed, bored and/or his quality of life would decrease. Interview on 05/01/2026 at 12:20 pm, the Administrator stated Activity Director B had begun working at the facility April 2026. He stated it was very important for the residents unable to come out of their room or unable to participate in group activities to receive activities in their room. He stated Activity Director B was over the activity department and he was her supervisor. He stated there was a possibility that a resident may become lonely if they were not receiving activities in their room. Record review of Activity Director B's personnel file revealed she began working at the facility on 04/09/2026. She had an activity director certificate issued on 08/25/2025.Record review of the Facility's Activity Programming, dated 2011, revealed The Activity Director and staff will provide for ongoing Activity Programs. Activity Programs are based on the resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities. Programming included large groups, small groups, individual and independent opportunities. The resident population is cognitively assessed routinely to determine the number of functional level programs needed. Record review of the Facility's Job Description of the Activity Director, signed by Activity Director B on 04/09/2026, revealed the following:1. Ability to organize, document, and implement detailed programs.2. Ability to develop, organize and implement a program of activities for the social, emotional, physical, and other therapeutic needs of the residents.3. Maintain detailed records of the activity programs and participation of individual residents, identifying progress toward established care plan goals.Record review of the facility's policy titled, Activity Documentation-General Guidelines, dated 05/26/2025, revealed, A qualified Activity professional will complete all required medical record documentation per state and federal regulations. The Activity Director shall coordinate and supervise all documentation and be responsible for all areas of documentation, according to required time limits and practice guidelines. The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner.1. Interdisciplinary team will assess the need for activities and reflect on the resident care: Problems, Goals and Appropriate approaches to related problems.2. Progress Notes at least quarterly.3. Resident Participation records.General guideline when completing any of the above areas of required documentation include:1. Documentation is maintained in the residents' clinical medical records.2. Only approved medically related abbreviations are used.3. All entries in the medical record are to be signed (including the author's signature and title) and dated by a qualified Activity professional.4. All documentation is completed consistent with health care center policy and applicable state and federal laws.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12.9% based on 4 out of 31 opportunities, which involved 1 of 4 residents (Resident #13) and 1 of 2 MAs (MA D) observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA D failed to administer Resident #13's physician ordered medications acidophilus lactobacillus and artificial tears. 2. The facility failed to ensure MA D failed to administer Resident #13's B12 vitamin as ordered by the physician. 3. The facility failed to ensure MA D did not administer Resident #13 a multivitamin tablet without a physician order. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include:Review of Resident #13's face sheet dated 12/03/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure (the lungs cannot adequately exchange oxygen and carbon dioxide leading to decreased oxygen levels and increased carbon dioxide), protein calorie malnutrition, and macular degeneration (eye disease that affects central vision). Review of Resident #13's quarterly MDS assessment dated [DATE] reflected that she was assessed to have a BIMS score of 13 indicating her cognition was intact. Review of Resident #13's comprehensive care plan reflected a focus area dated 05/15/2025 that The resident has nutritional problem related to diagnosis of dysphagia (difficulty swallowing) and malnutrition. Interventions included Administer medications as ordered. Review of Resident #13's consolidated physician orders dated 12/03/2025 reflected orders for acidophilus lactobacillus give one caplet orally one time a day for gut health, artificial tears instill two drops in both eyes two times a day for dry eyes, multivitamin-minerals one tablet by mouth one time a day for protein calorie malnutrition. Cyanocobalamin (B12) 500 mg give two tablets by mouth one time a day related to protein calorie malnutrition. Observation and interview on 12/03/2025 at 8:05 AM, revealed MA D prepared Resident #13's medication for administration. MA D prepared seven medications for administration which did not include her physician ordered acidophilus lactobacillus or artificial tears. MA D pulled out a multivitamin tablet and placed it in the medication cup after already putting in a multivitamin-mineral tablet. Surveyor stopped her and asked if she was sure Resident #13 got both a multivitamin and a multivitamin-mineral tablet and MA D stated Yes, she gets both. MA D then placed one vitamin B12 500 mg tablet into the medication cup. In an interview on 12/03/2025 at 8:49 AM, MA D stated she only gave one vitamin B12 tablet and stated the order did reflect she was supposed to get two tablets to equal 1000mg. MA D stated she did not give Resident #13 her physician ordered acidophilus lactobacillus because it was not on the cart. MA D stated she did not give Resident #13 her artificial tears eye drops and stated she did not know why she did not give it; she stated she was just learning. MA D stated Resident #13 did not have an order for both a multivitamin-mineral tablet and a regular multivitamin. MA D did not provide an explanation as to why she administered Resident #13 a multivitamin tablet that was not ordered. Observation and interview on 12/03/2025 at 9:30 AM, revealed Resident #13 was in her room in bed. Resident #13 stated she was fine and did not have any stomach upset. Resident #13 stated she did not realize she did not get all her medication, and she relied on the medication aids to make sure she received all her medication. In an interview on 12/04/2025 at 9:30 AM, the RNC stated that she felt the medication errors were caused by a lack of training and not following the facility's policy and procedures. She stated she expected staff to ask questions if they do not know what to do and expected staff to stop the medication pass and go find a medication if it is not on the cart. The RNC stated the facility could always get over the counter medications, and there was no excuse for not giving the medication. Review of the facility's Medication Administration and General Guidelines policy dated (with only the year) 2025 reflected Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available.Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order is unrelated to the resident's current diagnosis or condition, the physician is contacted for clarification prior to the administration of the medication. The interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. Adheres to the 6 Rights of Medication Administration: 1) Right Dose, 2) Right Route, 3) Right Resident, 4) Right Medication, 5) Right Time, 6) Right Documentation.

Based on 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 1 of 5 residents reviewed for infection control practices. A) The facility failed to ensure the ADON used aseptic technique during wound care for Resident #16By not cleaning the wound care supplies prior to treatment, not setting up the clean field per facility policy, not performing hand hygiene or glove changes at all appropriate opportunities not performing hand hygiene or glove changes between wounds, and not re-cleaning the wounds after they were contaminated during the treatment. B) The facility failed to ensure MA D did not contaminate Resident #13's medication during medication pass by not performing hand hygiene during medication administration and not sanitizing the blood pressure cuff prior to using on Resident #13. These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include:A) Review of Resident #16's face sheet dated 12/03/2025 reflected Resident #16 was admitted to the facility on [DATE] with the following diagnoses coronary artery disease, diabetes mellitus and dementia. Review of Resident #16's quarterly MDS assessment dated [DATE] reflected he was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #16 was assessed to not have wounds at the time of the assessment. Observation on 12/03/2025 at 3:25 PM revealed the ADON was outside of Resident #16's room preparing for wound care. The ADON gathered supplies and placed them on a piece of wax paper. She placed border gauze dressings, four normal saline vials, xeroform dressing, and an entire tube of Medi-honey on the wax paper. The ADON took a pair of scissors out of her pocket and placed them on her clean field without cleaning the scissors. The ADON took the supplies into the room and placed them on his overbed table without cleaning the table. The ADON took a sheet she found in the room to place on the overbed table which had food remnants on it. She then removed the dressing from both the inside right knee and outside of right knee of Resident #16. She changed her gloves then cleaned the inside knee wound and then cleaned the outside knee wound without changing gloves. She then stated she was out of gloves. The ADON used the sheet on Resident #16's bed to cover his leg with the wounds uncovered and left the room. She came back in the room and donned new gloves without hand hygiene. She then uncovered the leg by removing the sheet. Without change her gloves or recleaning the wounds, she used the dirty scissors to cut the xeroform dressing into two small squares. The ADON then applied the Medi-honey to both wounds using a different applicator for each wound, placed the xeroform dressing on the wound, and coved the wound with a dry gauze dressing. After the treatment, the ADON took all the unused supplies back to treatment cart which included the tube of Medi-honey, the remainder of the xeroform dressing, and two vials of normal saline. In an interview on 12/03/2025 at 3:45 PM, the ADON stated she should have cleaned her scissors prior to placing them on the clean field. She stated she should have cleaned the table prior to putting her clean field on it. The ADON stated she should have re-cleaned the wounds after she had covered them with the dirty sheet. The ADON stated she did not think about it at the time. She stated it was the facility's policy to treat each wound independently, and she should have cleaned one wound, performed hand hygiene, and changed gloves between each wound to prevent cross contamination. She stated she should not have brought the unused supplies back to the cart since they were considered dirty. She stated she thought it was ok since Resident #16 was the only one who used it. In an interview on 12/04/2025 at 9:30 AM, the RNC stated the ADON performing wound care should have cleaned the overbed table with an approved cleanser prior to putting down the clean field. The RNC stated the ADON should have cleansed the scissors and should not have brought anything that was in the room back to the treatment cart since it was considered contaminated. She stated the ADON should have treated each wound independently, and performed hand hygiene and glove changes between each wound. She stated the ADON should have recleaned the wounds after using the sheet the cover the wounds because the wounds were contaminated by the sheet. B) Review of Resident #13's face sheet dated 12/03/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses chronic respiratory failure (the lungs cannot adequately exchange oxygen and carbon dioxide leading to decreased oxygen levels and increased carbon dioxide), protein calorie malnutrition, and macular degeneration (eye disease that affects central vision). Review of Resident #13's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 13 indicating her cognition was intact. An observation on 12/03/2025 at 8:05 AM revealed MA D was finishing a medication pass on another resident on the hall then took her med cart to Resident #13's room. MA D began preparing Resident #13's medication without performing hand hygiene. While placing the medications into the medication cup from the medication bottles, MA D used her fingers to touch the pills to prevent the extra pills from falling into the medication cup. MA D repeated this with each pill dispensed. MA D then opened the bottom drawer of the medication cart, pulled a blood pressure cuff from her personal bag, and took it into Resident #13's room. Without hand hygiene, MA D took Resident #13's blood pressure and administered her medications. MA D then took the blood pressure cuff back to the medication cart. In an interview on 12/03/2025 at 8:49 AM, MA D stated she was new and just learning. She stated she did not perform hand hygiene, and she did touch Resident #13's pills while dispensing them. She stated the blood pressure cuff was her personal cuff and she did not clean it and did not know she could not use it. In an interview on 12/04/2025 at 9:30 AM, the RNC stated staff should always perform hand hygiene during medication administration, should not touch resident medication with their bare hands, and should always clean multi use equipment like blood pressure cuffs prior to each use to prevent cross contamination. Review of the facility's Treatment Table policy dated 2003 reflected 1. Wash hands. Put on gloves. 2. Place wax paper on wound care bedside table or small cart. 3. Gather treatment supplies. (i.e., medicine, dressings, tape, extra gloves, etc.) Open up and place on top of wax paper. One end will be considered clean, and the other end of table will be open for dirty. (To replace scissors, etc. to be cleaned) 4. Place wax paper over top of supplies. 5. On open end place linens, saline, red bag, scissors, pen, camera, etc. on top of second cover of wax paper. 6. Lock up treatment cart and proceed to residents' room. Refer to treatment protocol for treatment procedures and applications. 7. After treatment place dirty linens, red bags, scissors, pen, etc. to be cleaned on open end (considered dirty end of table). 8. Wash hands. Take bedside table/cart to treatment cart. Put on gloves. Discard linens, red bags, etc., using universal precautions. Clean scissors, pen, etc., with alcohol preps. 9. Clean top of treatment cart, bedside table/cart, IV pole and vacu-max if used with disinfectant. (See Infection Control manual for approved type) Remove gloves, wash hands. Review of the facility's undated Dressing Change Checklist policy reflected .Washes hands; Gathers dressing change supplies for each wound according to orders for wound care and facility policy; Prepares a clean/dry surface for dressing change supplies. Demonstrates that cross contamination does not occur for ointments/products applied to wounds; Ointments and creams are appropriately labeled for patient prescribed and in individual containers(do not mix ointments or creams). Washes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout dressing procedure; Utilizes gloves when in direct contact with patient according to facility policy. Changes gloves and wash/sanitize hands after removal of dressing and before cleaning wound or handling dressing supplies. Changes gloves and repeats procedure for each wound (more details) recommend separate set up each time they do a new wound unless in the same proximity or under the same dressing. Review of the facility's Medication Administration and General Guidelines policy dated 2025 reflected .The person administering medications adheres to Universal Precautions, using proper hand hygiene, gloves when appropriate, before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. Checklist for completing proper steps in the administration of medications; Washes hands using proper technique; Does not handle pills with bare hands.

Based on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of five residents ( Resident # 5, Resident # 45 and Resident #46) reviewed for activities.The facility failed to provide Resident #5, Resident #45, and Resident #46 in room activities three to five times per week during the months of October 2025 and November 2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included: Resident #5Review of Resident # 5's face sheet, dated 12/03/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses of contracture of right and left elbow, right and left hand ( the muscles, skin , or tissues around these joints have tightened and shortened, severely limiting normal bending and straightening, often due to injury, prolonged in activity, making simple tasks difficult), anoxic brain damage, not elsewhere classified (refers to brain injury from a total lack of oxygen (anoxia) that doesn't fit specific, predefined categories in medical coding (like stroke or drowning), often seen after events like cardiac arrest- sudden, sometimes temporary, cessation of the function of the heart- or carbon monoxide poisoning- happens when you breathe too much of this colorless, odorless gas-, leading to cell death and lasting confusion, physical, or emotional deficits), and cerebral infarction ( the death of brain tissue caused by lack of blood flow). Review of Resident #5's Annual MDS Assessment, dated 02/10/2025, reflected Resident #5 was in vegetative state/ no discernible consciousness. Resident #5 was total dependent on staff for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, transfers and bed mobility. Review of Resident #5's Quarterly MDS Assessment, dated 09/05/2025, reflected Resident #5 was in persistent vegetative state. She was dependent on staff for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, transfer and bed mobility. Review of Resident #5's Comprehensive Care Plan, with completion date of 11/12/2025, reflected activity problem and interventions was initiated on 02/11/2025. Resident #5 was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits, immobility, and physical limitations. Interventions: Resident #5 needed in room visits. She preferred activities such as listening to music on personal radio, and 1:1 socialization. Provide Resident #5 an activities calendar. Notify Resident #5 of any changes in activities documented on the calendar. Review of Resident #5's Activity Assessment, dated 11/07/2025, reflected Resident #5 somewhat enjoyed music. It was very important for Resident #5 to do her favorite activities. She cannot comprehend instructions. Signed by the Activity Director. Record review of Resident #5's Activity Participation Records revealed Resident #5 did not receive in-room activities for the months of October 2025 and November 2025. Observation and interview on 12/04/2025 at 11:45 AM, Resident # 5 was in bed. She did have television on in her room. Resident #5 was not interview able.Observation and interview on 12/05/2025 at 12:50 PM, Resident #5 was in bed, the television was turned off, her eyes were opened, and she was staring toward ceiling. She is not interview able. Interview on 12/04/2025 at 10:10 AM, the Activity Director stated Resident #5 was expected to receive in-room activities three to five times per week. She stated Resident #5 did not get out of bed very often and she needed interaction with others and sensory stimulation such as reading to her, talking to her, and maybe hand massages using lavender lotion. The Activity Director stated she did not visit and do any in-room activities with Resident #5 during the months of October 2025 and November 2025. She stated she did not have a reason why she did not do any in-room activities. The Activity Director stated she had visited Resident #5 and talked to her during these months but did not have any documentation of her visits. She stated she would go in her room and check on her and talk about different things and would stay about 5 minutes. The Activity Director stated she did not recall the dates or times of these visits. The Activity Director stated, I am responsible for in room activities and documenting in room activities on the participation record. The Activity Director did not respond when asked how long was appropriate for in-room activities. Resident #45Review of Resident #45's face sheet, dated 12/03/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of cognitive communication deficit ( having difficulty with communication due to problems with thinking skills such as memory, attention, problem-solving, and organization), spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy, affecting all four limbs, the trunk, and often the face, due to brain damage, causing stiff muscles that make movement difficult, leading to severe mobility issues, speech/swallowing problems, and sometimes intellectual/seizure challenges, requiring lifelong support), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and contracture of left and right elbow (the muscles, skin , or tissues around these joints have tightened and shortened, severely limiting normal bending and straightening, often due to injury, prolonged in activity, making simple tasks difficult).Review of Resident # 45's Annual MDS Assessment, dated 08/07/2025, reflected Resident #45 had poor short- and long-term memory recall. Resident #45 was rarely and never understood. He was unable to complete the assessment for mental status. Resident #45 activity preferences was the following: music and doing his favorite activities. Review of Resident #45's Quarterly MDS Assessment, dated 09/03/2025, reflected Resident #45 had poor short- and long-term memory recall. Resident #45 was rarely/never understood. He was unable to complete the assessment for mental status. Review of Resident #45's Comprehensive Care Plan, revised on 09/04/2025, reflected Resident #45 had impaired cognitive function (a decline in a person's ability to think, remember, and process information) or impaired thought processes ( date problem was initiated was on 07/24/2024. Interventions: date initiated was on 07/24/2025 Resident #45 was able to remember one/two/three instructions, find his room, sit for an hour, and do puzzles. Engage Resident #45 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities for Resident #45 that accommodates the resident's abilities. Resident #45 was dependent on staff for activities, cognitive stimulation, social interaction related to immobility, and physical limitations. ( Problem was revised on 07/24/2024. Interventions: date initiated was on 02/23/2023 reflected provide Resident #45 with materials for individual activities as desired. Resident #45 enjoys the following independent activities such as: listening to music, socializing with staff members, playing with personal toys, and watching movies. Resident #45 needs out of room social, spiritual, and stimulus activities and mental stimulation. Resident #45 does come out to dining room occasionally for lunch. In room visits with toys and tv will be continued by the Activity Director. ( date initiated was 11/22/2023 and was revised on 07/24/2024). Interventions: Resident #45 will be encouraged and reminded of current activities. ( date initiated was 11/22/2023).Review of Resident #45's Activity Assessment, dated 11/07/2025 reflected Resident #45 enjoyed listening to music and doing favorite activities. The assessment did not have a signature. Review of the Activity Participation Records for Resident #45 indicated he did not receive in-room activities for the months of October 2025 and November 2025.Observation and interview on 12/04/2025 at 12:30 PM, Resident #45 was in his room in bed, watching television. Resident #45 was not interview able. Observation and interview on 12/05/2025 at 1:15 PM, Resident #45 was in his room in bed, watching television. Resident #45 was not unreviewable. Interview on 12/04/2025 at 10:10 AM, the Activity Director stated Resident #45 required in-room activities. She stated he would benefit from in-room activities. The Activity Director stated Resident #45 needed in room activities at least 5 times a week. She stated he enjoyed watching tv and listening to music. She stated she did not have an answer of why he was not receiving in-room activities, and she forgot to put him on the list of residents who needed in-room activities. She stated she did visit Resident #45 but did not have any documentation of when she visited him and she did not recall the dates. The Activity Director stated Resident #45 does yell out sometimes in his room and when he does come out of his room. She stated she did not remember the amount of times Resident #45 came out of his room. The Activity Director stated if Resident #45 was not receiving in-room activities there was a potential he may become anxious, depressed and/or his quality of life would decrease. Resident #46Record review of Resident # 46's face sheet, dated 12/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of contracture of right and left elbow, right and left hand ( the muscles, skin , or tissues around these joints have tightened and shortened, severely limiting normal bending and straightening, often due to injury, prolonged in activity, making simple tasks difficult), sequelae of cerebral infarction ( a condition that occurs when blood flow to the brain is disrupted, leading to brain cell death), anxiety disorder (a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension- when your muscles feel tight, stiff, and uncomfortable, often due to stress, overuse, poor posture, or injury), and repeated falls (two or more unintentional falls within a specific timeframe, most commonly a 12-month period, and signal a significant health concern, especially in older adults, indicating underlying issues with balance, strength, or other conditions that require medical evaluation for prevention).Record review of Resident #46's Annual MDS Assessment, dated 09/30/2025, reflected Resident #46 had a BIMS score of 0, indicating severely impaired cognition. Resident #46 activity preference was listening to music. Record review of Resident #46's Comprehensive Care Plan, revised on 10/01/2025, reflected Resident #46 will respond to in room activities. Activity Director will read and play music. ( date initiated was on 02/06/2024). Intervention: (date initiated was on 02/08/2024) The Activity Director will provide Resident #46 with one- on-one visits 3 times a week. Review of Resident #46's Activity Assessment, dated 07/04/2025 reflected the following activities was Resident #46's preferences: listening to music and doing residents favorite activities. Signed by Human Resource Coordinator ( no longer an employee at the facility). Record review of Resident #46's Activity Participation record and he did receive in-room activities in November on the following dates: 1. 11/04/20252. 11/06/20253. 11/11/20254. 11/13/20255. 11/18/2025 Interview on 12/04/2025 at 10:10 AM, the Activity Director stated Resident #46 was expected to receive in room activities 3- 5 times per week. She stated he did not receive in room activities 3-5 times per week during the months of October and November 2025. She stated providing Resident #46 in room activities two times per week was not enough and he needed more visits. The Activity Director stated he did receive in-room activities few times in November but not enough according to his needs. She stated he needed in-room activities 3 times per week or more. She stated she was expected to do in-room activities with Resident #46 three or more times per week due to his mental and physical condition. She stated he did not attend group activities. The Activity Director stated he does watch tv and listen to music, but he needed socialization with others. She stated she did not meet his activity needs during the months of October 2025 and November 2025. The Activity Director stated she did not have a reason why these in-room activities was not given to Resident #46. She stated if Resident #46 did not receive in-room activities there was a possibility he may have a decline in socialization with others, mental stimulation, isolation and decrease of his quality of life. She stated she had been an Activity Director in Nursing homes approximately 25 years. The Activity Director stated she has been certified as an Activity Professional over 15 years. Observation and interview on 12/04/2025 at 12:45 PM, Resident #45 was in his room in his specialty wheelchair, watching television. Resident #45 was not interview able. Observation and interview on 12/05/2025 at 1:30 PM,Resident #45 was in his room sitting in his specialty wheelchair, watching television. Resident #45 was not unreviewable. Interview on 12/04/2025 at 8:40 AM, the Administrator stated she expected in-room activities be provided to the residents needing these types of activities. She stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored and isolated. The Administrator stated the Activity Director was responsible for all activities in the facility and all documentation in the Activity Department including in-room activities. She stated the Administrator would be responsible for monitoring the Activity Director.Interview on 12/04/2025 at 2:18 PM, the ADON stated she was not aware of Resident #5, Resident #45, and Resident #46 did not have any significant changes with their emotional, psychosocial, cognitive or physical concerns. She stated Resident #5, Resident #45 and Resident #46 remained at their baseline during months of October 2025, and November 2025 the ADON stated Resident #45 did go into the dining room sometimes, however, he would become anxious when in a group of people and would yell out. She stated he was not anxious when he was in his room. The ADON stated Resident #5, Resident #45, and Resident #46 all needed in room activities. She stated if they did not receive in-room activities there was a possibility the residents may feel isolated, and it would affect their quality of life. Record review of the Activity Director's personnel file revealed she began working at the facility on 09/11/2025. She had her National Certification for Activity Professionals with expiration date of 10/01/2026. The license was to be renewed every two years. Review of the Facility's Activity Programming, dated 2011, revealed The Activity Director and staff will provide for ongoing Activity Programs. Activity Programs are based on the resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities. Programming included large groups, small groups, individual and independent opportunities. The resident population is cognitively assessed routinely to determine the number of functional level programs needed. Review of the Facility's Job Description of the Activity Director signed by the Activity Director on 09/11/2025 revealed the following:1. Ability to organize, document, and implement detailed programs.2. Ability to develop, organize and implement a program of activities for the social, emotional, physical, and other therapeutic needs of the residents. 3. Maintain detailed records of the activity programs and participation of individual residents, identifying progress toward established care plan goals.Review of the Facility's Activity Documentation-General Guidelines, dated 05/26/2025, revealed A qualified Activity professional will complete all required medical record documentation per state and federal regulations. The Activity Director shall coordinate and supervise all documentation and be responsible for all areas of documentation, according to required time limits and practice guidelines. The following areas are considered documentation responsibilities of the Activity Director and staff and should be completed in a comprehensive and timely manner.1. Interdisciplinary team will assess the need for activities and reflect on the resident care: Problems, Goals and Appropriate approaches to related problems.2. Progress Notes at least quarterly.3. Resident Participation records. General guideline when completing any of the above areas of required documentation include:1. Documentation is maintained in the residents' clinical medical records. 2. Only approved medically related abbreviations are used.3. All entries in the medical record are to be signed (including the author's signature and title) and dated by a qualified Activity professional. 4. All documentation is completed consistent with health care center policy and applicable state and federal laws.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen.The facility failed to ensure Dietary Aide A and Dietary [NAME] B used proper hand hygiene during food preparation on 12/03/2025. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 12/03/2025 at 10:35 AM, Dietary Aide A was not wearing gloves when she opened the kitchen door leading from kitchen to the dining room. She touched the side of her pants with her ring, middle and fore finger on her right hand as she walked toward the back of the kitchen near the dishwashing room. She returned to the food prep table in front of the steam table without washing her hands. She began to pour salad dressing into small clear cups used for sauces or dressing. Dietary Aide A touched top of the plastic small cups with the salad dressing inside the cups. She continued to pour the dressing into the cups and touched the top of two more of the cups after she poured the salad dressing. Interview on 12/03/2025 at 10:48 AM, Dietary Aide A said she did open the kitchen door and walked near the dishwashing room in back of the kitchen and returned to the food prep table to continue to pour the salad dressing in the cups. She stated she did not wash her hands. Dietary Aide A stated she was expected to wash her hands anytime she touched anything not sanitized. She stated she may have touched her clothes while she was walking sometimes, she accidentally does touch her clothes. She stated her hands was considered contaminated. She stated there was a possibility she did touch the top of the salad dressing when she was pouring it in the small cups and may have touched the top of the cups with her right hand. She stated the salad dressing, and the cups would be considered contaminated. Dietary [NAME] B stated if a resident ate the dressing there was a possibility the dressing became contaminated with bacteria. She stated there was a possibility a resident may become sick and have diarrhea or upset stomach. She stated she had been in-service on hand hygiene; however, she was unable to recall the date of the in-service. Observation on 12/03/2025 at 11:10 AM, Dietary [NAME] B had finished pureeing green beans and removed her gloves. She placed the gloves in the garbage can. When the Dietary [NAME] B was walking from garbage can she touched her scrub top and scrub pants with her little, ring, middle, fore fingers on her right hand. Dietary [NAME] B never washed or sanitized her hands. She walked to the food prep area and pulled aluminum foil with both hands. Dietary [NAME] B's middle, ring, little and fore fingers on both hands touched underneath the aluminum foil. She began to cover the pureed green beans with the aluminum foil and her ring, middle and fore finger touched the pureed green beans inside the silver container. She stated she learned in the hand hygiene in-service to wash hands anytime touch anything contaminated and before placing gloves on hands and after removing gloves. She stated clothes, hair, doorknob, cell phone, or another person hand would be considered contaminated. She stated she did not follow hand hygiene process for the kitchen staff. Interview on 12/03/2025 at 11:15 AM, Dietary [NAME] B stated she did remove her gloves after she pureed the green beans. She stated she did not wash her hands after she placed the gloves in the garbage can and before she covered the pureed green beans with the aluminum foil Dietary [NAME] B stated she did touch her clothes and touches underneath the aluminum foil that touched the pureed green beans container. She stated she accidentally touched the pureed green beans as she was covering them with the aluminum foil. Dietary [NAME] B stated there was a possibility the green beans may be contaminated from her hands. She stated if a resident ate the pureed green beans there was a potential the resident may become ill with stomach issues such as nausea, vomiting or maybe diarrhea. She stated it was possible a resident may need to go to the hospital for further treatment. Dietary [NAME] B stated she had been in-service on hand hygiene; however, she did not recall the date and time of the in-service. She stated she learned in the in-service to wash hands in between tasks if a staff touched any contaminated item such as clothes, hair, cell phone or keys. She stated if staff removed gloves to always wash hands before placing new gloves on or doing any type of food prep without gloves. Dietary [NAME] B stated she was expected to wash her hands, and she did not, and she did not follow hand hygiene policy. Interview on 12/03/2025 at 11:25 AM, the Dietary Manager stated she expected all staff to change gloves and wash hands in between tasks and when the staff touched their clothes, doorknob, or anything considered contaminated. She stated she had in serviced all dietary staff on hand hygiene. The Dietary Manager stated she could not recall the date of the in-service. She stated Dietary [NAME] B was expected to wash her hands after she had removed her gloves and before she began covering the pureed green beans. The Dietary Manager stated Dietary Aide A was expected to wash her hands after she touched the doorknob and before began pouring the salad dressing in the cups. She stated a resident could become ill if a resident ate any contaminated food. She stated the resident may develop stomach issues such as vomiting and diarrhea. The Dietary Manager stated she was responsible to ensure all the staff in the kitchen followed hand hygiene protocol. She stated she reviewed the hand hygiene policy during the in-service. Interview on 12/04/2025 at 8:40 AM, the Administrator stated her expectation was that beard restraints were to be worn by all staff in the kitchen., The Administrator stated she expected gloves to be changed, hands washed anytime staff touch contaminated items. She stated clothes and a doorknob would be considered contaminated. She stated there was a possibility if there was bacteria in food, a resident may develop a food borne illness. The Administrator stated the Dietary Manger was responsible for all protocols in the kitchen and she was responsible to monitor the Dietary Manager. Review of the Facility's Inservice Record on Hand Hygiene, dated 09/02/2025, reflected Dietary Aide A and Dietary [NAME] B was in attendance of the hand hygiene in-service. Review of the Facility's Protocol for Hand Hygiene is from the Texas Food Establishment Rules, not dated, reflected S228.38. Hands and Arms.(a) Clean Condition. Food employees shall keep their hands and exposed portions oftheir arms clean. (b) Cleaning Procedure.(1) except as specified in subsection (d) of this section, food employees shallclean their hands and exposed portions of their arms, including surrogate prosthetic devices forhands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink that isequipped as specified under S228.146 and S228.175. (2) food employees shall use the following cleaning procedure in the order statedto clean their hands and exposed portions of their arms, including surrogate prosthetic devicesfor hands and arms:(A) rinse under clean, running warm water; (B) apply an amount of cleaning compound recommended by the cleaningcompound manufacturer; (C) rub together vigorously for at least 10 to 15 seconds while:(i) paying particular attention to removing soil from underneath thefingernails during the cleaning procedure, and(ii) creating friction on the surfaces of the hands and arms orsurrogate prosthetic devices for hands and arms, fingertips, and areas between the fingers; (D) thoroughly rinse under clean, running warm water. and(E) immediately follow the cleaning procedure with thorough drying usinga method as specified under S228.175(c). S228.38 (b)(3) S228.38 (d)(9)(3) to avoid re-contaminating their hands or surrogate prosthetic devices, foodemployees may use disposable paper towels or similar clean barriers when touching surfacessuch as manually operated faucet handles on a handwashing sink or the handle of a restroomdoor. (4) if approved and capable of removing the types of soils encountered in the foodoperations involved, an automatic handwashing facility may be used by food employees to cleantheir hands or surrogate prosthetic devices. (c) Special Handwash Procedures. Employees not utilizing suitable utensils or single-usegloves when handling ready-to-eat foods shall wash hands using the cleaning proceduresspecified in subsection (b)(2) of this section and follow the approved procedures specified inS228.65(a)(5) of this title.(d) When to Wash. Food employees shall clean their hands and exposed portions of theirarms as specified under subsection (b) immediately before engaging in food preparationincluding working with exposed food, clean equipment and utensils, and unwrapped single serviceand single-use articles and:(1) after touching bare human body parts other than clean hands and clean,exposed portions of arms; (2) after using the toilet room; (3) after caring for or handling service animals or aquatic animals as specified inS228.44(2); (4) except as specified in S228.42(b) after coughing, sneezing, using ahandkerchief or disposable tissue, using tobacco, eating, or drinking; (5) after handling soiled equipment or utensils; (6) during food preparation, as often as necessary to remove soil andcontamination and to prevent cross contamination when changing tasks; (7) when switching between working with raw food and working with ready-to-eatfood; (8) before donning gloves to initiate a task that involves working with food; and(9) after engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure the storage of medications used in the facility in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed. The facility failed to ensure potential contaminants, including personal items, were not on the medication carts. This failure could place residents at risk of receiving contaminated medications resulting in adverse health consequences. Findings include: Observation and interview on 12/03/2025 at 8:05 AM revealed MA D during medication preparation for Resident #13. MA D opened the bottom drawer of the medication cart to reveal a large bag. MA D removed a blood pressure cuff from the bag. MA D stated the bag was hers, and that the blood pressure cuff was her personal blood pressure cuff. In an interview on 12/03/2025 at 8:49 AM, MA D stated she did not know she could not put her bag on the medication cart, and did not know why she should not have her bag on the medication cart. In an interview on 12/04/2025 at 9:30 AM, the RNC stated staff should absolutely not store personal items on the medication carts, because it can cause cross contamination. Review of the facility's Medication Storage policy dated (with only the year) 2025 reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication storage areas are kept clean, well lit, and free of clutter.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident #27 and Resident #39) reviewed for ADL care.The facility failed to ensure Resident #27 and Resident # 39's nails were cleaned and trimmed on 12/04/2025.This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident # 27's face sheet, dated 12/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side ( a stroke where blood supply to part of the brain is cut off, causing brain cells to die. Paralysis (hemiplegia) or weakness (hemiparesis) affecting one side of the body in this case, the right side. Weakness or inability to move the right arm, leg , and potentially the right side of the face), type 2 diabetes mellitus with unspecified complications ( a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively ( insulin resistance), leading to high blood sugar (glucose) level. Complications can involve damage to blood vessels and nerves, leading to a wide range of chronic issues and potentially acute, life-threatening conditions), and need assistance with personal care (helping someone with daily activities they find difficult, covering physical tasks like bathing, dressing, eating, toileting, and mobility. Resident #27 needed emotional support, and grooming, all to maintain dignity, safety, independence, whether temporarily or long term). Record review of Resident #27's Quarterly MDS Assessment, dated 09/29/2025, reflected the resident had a BIMS score of 6, which indicated his cognition was severely impaired. Resident #27 was dependent on staff for toileting hygiene, showers, and dressing, He required substantial/maximal assistance- ( helper does more than half the effort) with personal hygiene and oral hygiene. Record review of a Comprehensive Care Plan, with start date of 10/01/2025 and completed date of 10/19/2025 reflected Resident #27 had an ADL self-care performance deficit - problem initiated on 07/26/2025. Interventions: revised on 10/02/2025 Resident #27 was total dependent on staff for bathing, toileting, bed mobility, dressing, and mobility. During bathing staff was to check nail length and trim and clean on bath day and as necessary. If diabetic, the nurse will provide toenail care. Report any changes to the nurse. Observation and interview on 12/02/2024 at 9:45 AM, revealed Resident # 27 was lying in bed watching television. He stated he had concern about his fingernails on his left hand. He held out his left hand and his nails were long, approximately 1 inch pass the tip of all of his fingers on his left hand. His middle, ring and fore finer had blackish / brownish substance underneath his nails. Resident #27 stated he asked a staff if they could cut and clean his nails on Saturday and the staff explained to him, they would trim and clean his nails sometime next week ( referring to the week beginning 12/01/2025). Resident #27 did not recall the staff name. He stated he was afraid he would scratch himself and develop a sore on somewhere on his body. Resident #39 Record review of Resident #39's face sheet dated, 12/04/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction, unspecified ( a stroke occurred due to a blocked artery in the brain, causing brain tissue death (infarction), but the specify artery or cause isn't detailed in the medical record), pain in unspecified joint ( pain in joints is discomfort you can feel- not specified which joint in medical record), muscle weakness ( a loss of strength or inability to move muscles effectively), and other lack of coordination ( difficulty performing smooth, controlled movements, resulting in clumsiness, unsteadiness, poor balance, and trouble with tasks needing fine motor skills like writing or gross motor skills like walking). Record review of Resident #39's Quarterly MDS Assessment, dated 08/29/2025, reflected Resident #39 had a BIMS score of 5, which indicated his cognition was severely impaired. Resident #39 required substantial/ maximal assistance ( helper does more than half the effort) with personal hygiene and showers. He required supervision or touching assistance with the following: dressing, toileting hygiene, oral hygiene, transfers, and bed mobility. Record review of a Comprehensive Care Plan, revised on 09/29/2025, revealed Resident #39 had an ADL Self Care Performance Deficit. Interventions: Resident #39 required one staff assistance with personal hygiene and bathing. Check Resident #39's nail length. Trim and clean Resident #39's nails on bath day and as needed. Report any changes to the nurse. Observation and interview of Resident #39 on 12/02/2025 at 10:15 AM, revealed Resident #39 was lying in bed watching television. He stated he did not have any concerns and then stated look at my fingers. When he stretched out both of his arms and showed his fingernails on both hands, he had a fingernail beginning to curl on his right thumb. His nails was approximately 2 to 3 inches long on every finger on left and right hand. He stated he asked some people to cut and clean his nails, and they tell me they will do it later. He did not recall the name of the staff or the position of the staff. He stated he asked someone few days ago (he did not recall the exact date or time). Observation and interview of Resident #39 on 12/03/2025 at 8:05 AM, revealed Resident #39 was sitting in the dining room finishing his breakfast. Resident #39 smiled and stated, I remember talking to you yesterday about my nails. When he made this statement, he showed his nails and stated no one has cleaned or cut my nails. He stated they are so long it was difficult for him to pick up his fork to eat. Resident #39's nails continued to be 2-3 inches long on every finger on right and left hand. Interview on 12/03/2025 at 8:10 AM, the Regional Nurse Consultant stated Resident #27's are very long, and they are dirty. She stated one of his nails on his thumb was beginning to curl. She stated all residents' nails was expected to be trimmed and cleaned by CNA's and nurses. She stated if a resident was a diabetic the nurses would trim and clean the nails. The Regional Nurse Consultant stated the CNAs would trim and clean the non-diabetic nails. She stated residents was expected to have their nails checked, trimmed and cleaned during showers or as needed. She stated if a resident refused it would be documented in the nurses' notes. The Regional Nurse Consultant stated the CNAs was expected to report any issues with nails to the nurse supervisor. She stated the DON, ADON and Nurse Supervisors was responsible to ensure the residents was receiving ADL care including nail care. Interview on 12/03/2025 at 1:50 PM, CNA G stated nursing staff was responsible for trimming, cleaning and filing resident nails. She stated the CNA's does all nail care on all residents except the residents with diagnosis of diabetes. She stated the nurses was responsible for residents with diabetes. CNA G stated staff was required to perform nail care when residents received showers and as needed. She stated she had given care to Resident # 27 and Resident #39. She stated sometimes Resident # 39 will refuse showers, but he does not refuse nail care. CNA G stated Resident # 27 did not refuse showers or nail care. She stated if a resident nails was too long there was a possibility the resident may scratch themselves or another resident. CNA G stated she did not know when the last time Resident #27 or Resident #39 had their nails trimmed or cleaned. She stated if a resident refused the CNA reports the refusal to the nurse supervisor and they documented in their progress notes. She stated if the scratch was deep enough on the skin it may result in a skin tear. She also stated if resident had blackish/brownish substance underneath their nails and they swallowed the blackish/ brownish substance there was a potential a resident may become physically ill with stomach issues such as nausea, vomiting, and/ or diarrhea. She stated she had been in-service on nail care; however, she did not recall the date and time of the in-service. In an interview on 12/03/2025 at 2:05 PM, CNA H stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA H stated the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA H stated if a resident's nails were too long there was a possibility the resident cut their eyeball if they scratched their eyes or receive a skin tear. She stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 27 and Resident # 39, and they did not refuse nail care. CNA H stated she did not know the last time these residents' nails were trimmed or cleaned she would need to check the medical records. In an interview on 12/04/2025 at 2:10 PM, the ADON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The ADON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON was responsible for monitoring the nurse supervisors. The ADON stated if a resident refused nail care the CNA was expected to report any issues to the nurse and the nurse would document refusal in the nurses' notes. She stated she was not aware of Resident # 27 or Resident #39 refusing nail care. She stated she was not aware of any resident in the facility refusing nail care. ADON stated she knew Resident # 39 sometimes refused showers but not often. She stated it was not reported in morning meetings or any type of nursing meetings of Resident #39 or Resident # 27 refusing nail care. She stated anytime a resident refused care it was mentioned in reports with nurses and in morning meetings. Review of the Facility's Policy on Nail Care, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic pulmonary disease ( long term lung conditions that block airflow, making it hard to breathe and leading to shortness of breath, wheezing, and a persistent cough with mucous), or cardiac disease ( conditions affecting the heart and blood vessels, including blocked arteries, irregular heartbeats, or heart failure). Goals1. Nail care will be performed regularly and safely.2. The resident will be free from abnormal nail conditions.3. The resident will be free from infection.When nail care performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #33) of five residents reviewed for care plans, in that:1. The facility failed to complete a person-centered care plan for Resident #33's primary language as a Spanish . 2. The facility failed develop a care plan for Resident #33's refusals to take showers (refusal timeline unknown). This failure placed residents at risk of unaddressed needs, fragmented care, emotional distress (anxiety, depression), poor health outcomes, and a loss of dignity/autonomy, leading to a lower quality of care and not receiving goals and interventions for the residents' individual needs for person-centered care.Findings included: Record review of Resident #33's face sheet, dated 12/03/25, revealed a seventy-six-year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His admitting diagnoses included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) unspecified severity, acute kidney failure (a sudden and often reversible reduction in kidney function, as measured by increased creatinine or decreased urine volume), and difficulty in walking. Record review of Resident #33's MDS dated [DATE] reflected (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns revealed a score of 3 indicating severe cognitive issues and Section A - A1005 Ethnicity Mexican, Mexican American, Chicano and Section A - A1110 what is your preferred language - English. Record review of Resident #33's care plan revealed a focus dated 10/09/25 Resident #33 had a diet order other than regular and was at risk for unplanned weight loss or gain. Resident #33 was not care planned for his primary language being Spanish and that he refuses to take showers. For example, Hard to make food preferences know Spanish speaking with intervention dated 10/09/25 determine food preferences and provide within dietary limitations and provide Spanish speaking staff to assist with food preferences review as needed. Focus dated 04/02/25 [Resident #33] has a communication problem r/t (no information provided on the care plan focus after the abbreviation r/t) with interventions dated 10/09/24 and 04/02/25: anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty, focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express, monitor effectiveness of communication strategies and assistive device, monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed, monitor/document frustration level. Wait 30 seconds before providing resident with word, CNA - Monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend, monitor/document/report to MD PRN changes in: Ability to communicate, potential contributing factors for communication problems, potential for improvement, [Resident #33] is able to communicate by: (SPECIFY Lip reading, writing, using communication board, gestures, sign language, translator, CNA - [Resident #33] prefers communicating:(Specify; face to face, while family is present to translate, with the TV off etc.), CNA - OT/PT/Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use of sign language as alternate communication to speech, provide a program of activities that accommodates the residents communication abilities, refer to speech therapy for evaluation and treatment as ordered. Observation on 12/02/25 at 2:30 pm of Resident #33 speaking Spanish.Observation on 12/03/25 at 3:00 pm with Resident #33 reflected he smelled of urine. Interview on 12/03/25 at 11:01 am with CNA G reflected she worked with Resident #33, and she said he refused his showers. She said she knew they were supposed to make a documentation in the POC (the act of recording clinical information while providing patient care) that he refused to take a shower. She said she would ask him a couple of times to take a shower and if he still refused, she would tell a nurse. Interview on 12/03/25 at 2:00 pm with CNA I reflected Resident #33 refused his showers a lot, and she had reported it to the nurse. She said all she could do was encourage him to take a shower. She said she was not responsible for care plans, but she had looked at resident Kardex (a desktop file system that gives a brief overview of each resident). She said she filled out a shower sheet indicating that a resident refused to take a shower when they refused.Interview on 12/03/2025 3:13 pm by telephone by Spanish speaking member of the survey team with Resident #33's Spanish speaking RP reflected she wanted to know if Resident #33 was getting his showers. The RP said she noticed he smelled and appeared to not have showered. Interview on 12/04/25 at 10:05 am with the Social Worker reflected that she both organized and participated in care plan meeting. She said she can modify and add to a resident's care plan. She said Resident #33 should have been care planned as a Spanish speaker with interventions. She said they should have caught it, and it should be in his care plan. She said he should have had an intervention of a communication board. She said the MDS nurse was responsible for making sure Resident #33 was care planned as a Spanish speaker. She said the negative effect of not care planning Resident #33 as a Spanish speaker was staff could miscommunicate with him. Interview on 12/04/25 10:30 am with the MDS Coordinator reflected care plans were collaborative. She said care plans were individualized for each resident, and it should have been in Resident #33's care plan that he spoke Spanish. She said because he was a Spanish speaker in a predominantly English-speaking facility his language needs needed to be addressed to provide better care for him. It was important to discuss in the care plan how to accommodate him as a Spanish speaker. She said the facility had not had an MDS Coordinator for a while, but she had been going back into care plans as time provided to update resident care plans. She said Resident #33 should have been care planned as a Spanish speaker and for shower refusals. Interview on 12/04/25 at 10:42 am CNA J reflected she worked with Resident #33 daily and communicated with him to the best of her ability. She said he did speak some English, and she spoke slowly, in English, and tried her best to get him to understand what she was going to do to help him. She said most of the time he understood and when he did not understand, she tried to find someone to speak Spanish to him. She said the people who spoke Spanish were not at the facility all the time. She said she thought a communication board would be helpful to facilitate communication. She said she had not spoken with the Administrator or the ADON about how to communicate with him. CNA J said Resident #33 refused showers and was non cooperative no matter if you told him in English or Spanish. She told his nurses that he did not want to take his showers. Interview on 12/04/25 at 10:55 pm with LVN K reflected she worked with Resident #33, and he spoke fluent Spanish and some English. She said Spanish worked better for him. She said some nurses used the google language translation application on their phones to communicate with Resident #33, but there was no communication board. She did not know if Resident #33 was care planned as Spanish speaking. She said she had access to care plans and could amend care plans. She said the definition of a care plan was an outline of the of the care needs for a resident and should include anything including his Spanish speaking. She said the MDS Coordinator did care plans, and not all the nurses knew how to do care plans. She said all resident care refusals should be care planned. She said it was a fight to get Resident #33 to take a shower. She said his shower refusals should have been care planned and documented. She said a possible negative effect of not documenting in the care plan that he was not taking showers was skin breakdown. He could have skin break down because of his refusals to take showers but the reason for the breakdown was not documented. She said the care plan was a complete picture of the resident's care, and if you did not document in the care plan Resident#33's shower refusals or his primary language, you do not have a complete picture of Resident #33's care. Interview on 12/04/25 at 11:22 am by telephone with RN L reflected she was the weekend supervisor and worked with Resident #33. She said Resident #33 spoke some English but mostly Spanish. She said sometimes there was someone at the facility who could translate with Resident #33. She said a care plan was the overview of how they provided the best care for residents and listed the interventions of how to meet the residents' needs and track how the residents progressed with goals. She said there was nothing in Resident #33's care plan regarding how to communicate with him and said it for sure would be good to get some interventions. She said the possible negative effect of not having care planned interventions for his language would be a possibility of not being able to have an accurate assessment if he was in pain. She said any resident who required specialized communication should be care planned for ways to communicate. She said she felt like Resident #33 had refused to take showers. She said she felt like shower refusals should be care planned if they were a consistent problem. She said residents with dementia sometimes di not understand the importance of taking showers. She did not know who was responsible for making sure there was a language intervention in Resident #33's care plan, but interventions would help. Interview on 12/04/25 at 11:38 pm with the RCN said Resident #33's shower refusals and his language preference should have been care planned. A possible negative effect of Resident #33 refusing showers was that no one would know he refused and therefore staff did not discuss ideas on how they could get him to take a shower. It was the responsibility of the whole team to put together communication interventions for Resident #33 and his communication as a Spanish speaker should have been care planned. The possible negative effects of not having a communication plan would be not knowing his wishes and possibly not knowing when he was feeling bad or if he could not tell staff how he was feeling. She said the whole IDT team was responsible for care plans. She said the IDT team consisted of nurses, the Administrator, CNAs, the social worker, therapy, dietary manager and all department heads. Interview on 12/04/25 at 11:50 pm with the ADON reflected she did not know if Resident #33 was care planned for his language because she did not do care plans. She said the language of a resident should be care planned with interventions on how to communicate. She said a care plan was a plan of how to care for a resident. She said if they knew a resident had a language barrier it should be care planned with set goals for how they would understand the resident. She did not recall if anyone reported to her that he refused showers. She said shower refusal should be care planned. She said a negative effect of not care planning shower refusals would be that staff were not aware of him refusing his showers.Interview on 12/04/25 at 12:59 pm with the Administrator reflected a care plan broke down everything about the residents, including likes and dislikes and how to care for the residents. She said the MDS Coordinator, nurses, the DON, and the activities director were responsible for care plans. She said a resident's primary language of communication should be care planned. She said a negative effect of language preference not being in the care plan was the resident could not get the right type of care that was needed. She said Resident #33's shower refusals should absolutely be care planned. She said the refusal of care needed to be care planned so they knew there was a behavior, and they knew how to address it and put interventions in place. Record review of the facility's Comprehensive Care Planning policy undated reflected the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Based on observation, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 4 residents reviewed for accommodation of needs (Resident #33 and Resident #45. A) The facility failed to follow their facility policies and procedures and provide full time translation or interpretation services to Resident #33, a Spanish speaking resident. B) The facility failed to ensure Resident #45 specialty wheelchair was in safe working order so he could safely get out of bed. This failure could place residents at risk of miscommunication between the resident and staff, lead to misunderstandings about a resident's medical condition and treatment options, and improper care or inappropriate treatments or prescriptions. This failure further placed residents at risk for decreased quality of life, discomfort, and possible skin alterations. A) Record review of Resident #33's face sheet, dated 12/03/25, revealed a seventy-six-year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His admitting diagnoses included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) unspecified severity, acute kidney failure ( a sudden and often reversible reduction in kidney function, as measured by increased creatinine or decreased urine volume), and difficulty in walking. Record review of Resident #33's MDS dated [DATE] reflected (clinical assessment to determine resident's strength and needs) Quarterly Assessment reflected a BIMS score of 3 indicating severe cognitive issues, the resident identified an ethnicity of Mexican, Mexican American, Chicano, and preferred language was English. Record review of Resident #33's care plan revealed a focus dated 10/09/25 Resident #33 had a diet order other than regular and was at risk for unplanned weight loss or gain. Hard to make food preferences know Spanish speaking with intervention dated 10/09/25 determine food preferences and provide within dietary limitations and provide Spanish speaking staff to assist with food preferences review as needed. Focus dated 04/02/25 [Resident #33] has a communication problem r/t (no information provided on the care plan focus after the abbreviation r/t) with interventions dated 10/09/24 and 04/02/25: anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty, focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express, monitor effectiveness of communication strategies and assistive device, monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed, monitor/document frustration level. Wait 30 seconds before providing resident with word, CNA - Monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend, monitor/document/report to MD PRN changes in: Ability to communicate, potential contributing factors for communication problems, potential for improvement, [Resident #33] is able to communicate by: (SPECIFY Lip reading, writing, using communication board, gestures, sign language, translator, CNA – [Resident #33] prefers communicating:(Specify; face to face, while family is present to translate, with the TV off etc.), CNA - OT/PT/Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or use of sign language as alternate communication to speech, provide a program of activities that accommodates the residents communication abilities, refer to speech therapy for evaluation and treatment as ordered. Observation on 12/02/25 at 2:30 pm of Resident #33 revealed he spoke Spanish. Interview on 12/02/25 at 3:00 pm with Resident #33 reflected he spoke Spanish. The surveyor attempted to speak with Resident #33 through an approved HHSC translator, but the HHSC translator said Resident #33 was not answering the translator's questions. Interview on 12/3/2025 at 2:55 pm with Resident #33 translated by a Spanish-speaking member of the survey team reflected Resident #33 said he could understand a little English. He said there were staff who spoke to him in Spanish. The Spanish-speaking surveyor was unable to ask additional questions because Resident #33 was responding to the questions with unrelated answers to her questions. Interview on 12/03/2025 at 3:13 pm translated by a Spanish-speaking member of the survey team with Resident #33's Spanish-speaking RP reflected the RP said Resident #33 knew a little English. The RP said that there were a few people at the facility who translated for him. Resident #33's RP said Resident #33 would benefit from a translation or communication service because she was not always there to interpret for Interview on 12/03/25 at 11:01 am with CNA G reflected she worked with Resident #33, and Resident #33 spoke Spanish. She said to communicate with him, she sometimes would get an interpreter and sometimes she would use sign language. She said he did not have a communication board, but she used an App (software application designed to run on a mobile device) to assist with translation. She said the facility did not have an interpreter 24 hours a day. She said language interventions would probably be helpful, but she felt like they had a routine, and they understand each other now. She said if Resident #33 had a fall they could use the google language translation application on their phones to communicate with Resident #33. Interview on 12/03/25 at 2:00 pm with CNA I reflected she worked with Resident #33, and it was kind of hard to communicate with him because he did not speak English at all. She said when she spoke to him, he would direct and point. She said she would get someone to translate. She said because she worked with him a little while, she could make out what he was saying. She said he would use his hands to point to where he was hurt. She said if they worked with him for a little while, they could pick up his pattern and tell what he wanted or needed. She said the facility had not put anything in place to help communicate with Resident #33. She said he did not have a communication board to assist with translations from Spanish to English, but she thought it would be very helpful. She said she had not spoken with anyone about getting a better way to communicate with Resident #33. She thought the Administrator would be responsible for getting something to communicate with Resident #33. She thought that a communication board would be helpful if he had an injury because they might be able to communicate with him better. Interview on 12/04/25 at 10:05 am with the Social Worker reflected there was a translation board for Resident #33 and staff used the google language translation application on their phones to communicate with Resident #33. She said that the therapy department had a translation board and therapy used the google language translation phone application. She said if staff did not speak Spanish, all aides and nurses used the phone App to communicate with Resident #33. She said there was no translator at the facility 24 hours a day and the negative effect of not having effective translation for Resident #33 was miscommunication of the resident's needs. Interview on 12/4/25 10:30 am with the MDS Coordinator reflected because Resident #33 was a Spanish speaker in a predominantly English-speaking facility, his language needed to be addressed to provide better care for him. She said the social worker was responsible for accommodating any issues involving any possible language barriers. She said there were some Spanish-speaking employees who spoke with him in his language. She said he spoke broken English. She said the possible negative effect of not being able to communicate with a resident who spoke another language was that if the resident was in pain, the resident might not be able to express it fully and might not get what they needed. Interview on 12/04/25 at 10:42 am, CNA J reflected she worked with Resident #33 daily and communicated with him to the best of her ability. She said he did speak some English, and she spoke slowly and tried her best to get him to understand what she was going to do to help him. She said most of the time, he understood and when he did not understand, she tried to find someone to speak Spanish to him. She said the people who spoke Spanish were not at the facility all the time. She said she thought a communication board would be helpful to facilitate some communication. She said she had not spoken with the Administrator or the ADON about how to communicate with him. Interview on 12/04/25 at 10:55 pm with LVN K reflected she worked with Resident #33, and he spoke fluent Spanish and some English. She said Spanish worked better for him. She said some nurses used the google language translation application on their phones to communicate with Resident #33, but there was no communication board. Interview on 12/04/25 at 11:22 am by telephone with RN L reflected she was the weekend supervisor and worked with Resident #33. She said Resident #33 spoke some English, but mostly Spanish. She said sometimes there was someone at the facility who could translate. She said there was nothing in his care plan regarding how to communicate with him and said it for sure would be good to get some interventions. Interview on 12/04/25 at 11:38 pm with the RCN reflected she said Resident #33 did not have a communication board or interventions in place to communicate with Resident #33 as a Spanish speaker. She said it was the responsibility of the whole team to get this together. She said the possible negative effects of not having a communication plan would be to not know Resident #33's wishes and possibly not know when he was feeling bad. Interview on 12/04/25 at 11:50 pm with the ADON reflected she had given care to Resident #33, and he understood simple questions, and she used gestures to communicate with him. She felt like using a more formal way to communicate with Resident #33 could help. Interview on 12/04/25 at 12:59 pm with the Administrator reflected She had not seen the staff communicate with Resident #33. She said she thought they communicated using the google language translation application on their phones and using gestures. She said they did not have a formal program in place to communicate with Resident #33, who was a Spanish-speaking resident. The problem with not following the facility policy for translation was something could be missed in Resident #33's care and a translation policy should be in place for to all for proper resident assessment. Record review of the facility's Interpreter Services, undated, reflected access to basic health care services is the right of every resident. Access to information regarding basic health care services is an essential element of that right. Where language or communication barriers exist, the facility will make provisions to optimize communication between the residents and staff members. When language or communication barriers exist between residents and the staff of Facility, arrangements will be made at the facility level for interpreters. Bilingual professional staff may also be used to facilitate communication between residents and staff. Facility will post notices to advise residents and their families of the availability of interpreters and the procedure for obtaining an interpreter. The facility will also prepare and maintain a list of interpreters in the community. The facility will notify employees of the facility's commitment to provide interpreters to all residents that request them. The facility will have adopted and reviewed annually a policy for providing language assistance services to residents. The policy will include procedures for providing, to the extent possible, the use of an interpreter whenever a language or communication barrier exists. When a resident, after being informed of the availability of the interpreter service, chooses to use a family member or friend who volunteers to interpret, the facility will respect the resident's decision to use the family member. However, the facility will continue to obtain education for the staff or utilize outside resources to enhance communication on the facility's behalf. The procedure used by the facility will ensure to the extent possible, as determined by the facility, that interpreters are available either on the premises or accessible by telephone 24 hours per day. Personnel will contact Social Services or the DON for interpreter resources and for availability for access to TDD phones. Family members and friends should not be used as interpreters. The only case when this is acceptable is when the resident has been made aware of the advisability of qualified interpreters at no additional charge and without any coercion whatsoever, chooses the services of family members or friends. B) Review of Resident #45's face sheet dated 12/04/2025 reflected Resident #45 was admitted to the facility on [DATE] with the following diagnosis spastic quadriplegic cerebral palsy (Spastic quadriplegia cerebral palsy is a type of cerebral palsy that affects both arms and legs and often the torso and face. Quadriplegia is the most severe of the three types of spastic cerebral palsy.), contracture left elbow, contracture right elbow (a condition of shortening and hardening of muscles, tendons or other tissue) and muscle wasting and atrophy. Review of Resident #45's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 99 indicating severe cognitive impairment. Resident #45 was assessed to be dependent on staff for all ADLs. Review of Resident #45's comprehensive care plan reflected a focus area dated 04/17/2023 Resident has an ADL self-care performance deficit. Interventions included Transfer with Hoyer lift times 2 staff and may use Geri-chair. Observation on 12/02/2025 at 9:00 AM revealed Resident #45 was in his room in bed. Observation on 12/02/2025 at 12:10 PM revealed Resident #45 was being fed in his room in bed. Observation on 12/02/2025 at 4:30 AM revealed Resident #45 remained in bed. Observation and interview on 12/03/2025 at 11:55 AM revealed CNA F was working on Resident #45's hall. She stated Resident #45 was able to get up out of bed, but his seat belt is broken in his wheelchair, and it is not safe for him to get up. She stated everyone knows about his wheelchair being broken. She stated she did not know how long it has been broken, but it has been broken awhile. Observation on 12/03/2025 at 12:00 PM revealed Resident #45 was in his room in bed, and was not gotten up for lunch. In an interview on 12/04/2025 at 8:30 AM, the RNC stated she did not know Resident #45's wheelchair was broken. She stated she would investigate it. In an interview on 12/04/2025 at 9:00 AM, the RNC stated Resident #45's wheelchair was broken. The RNC stated the staff told her Resident #45 was not getting up because they did not think he could get in a Geri-chair. She stated they would be getting in touch with physical therapy about getting his wheelchair fixed. She stated, truthfully, the situation had been going on for a while. She stated she would get an order to use the Geri-chair so he can get up. In an interview on 12/04/2025 at 9:43 AM, Resident #45's RP stated he did not know Resident #45 was not getting up. He stated he wanted Resident #45 to be gotten up so he can get out of the room and have stimulation. Observation on 12/04/2025 at 9:47 AM revealed Resident #45 up in a Geri-chair in the communal area. Review of the facility's Resident Rights policy dated 11/28/2016 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.The right to receive the services and/or items included in the plan of care.

Based on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to develop and implement individualized interventions for Resident #1 after the resident experienced multiple falls. This failure placed residents with falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or significant changes in condition.Findings included: Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was assessed to have functional limitation in range of motion on both sides for her upper and lower extremities. Resident #1 was further assessed to require supervision or touching assistance with transfers. Resident #1 was assessed to have falls since admission. Review of Resident #1's Event Nurses' notes-fall reflected she had falls on 01/18/2025, 01/25/2025 x 2, 01/26/2025, 01/29/2025, 02/07/2025, 02/12/2025, 04/19/2025, 06/01/2025, and 08/12/2025. Review of Resident #1's fall event note dated 08/12/2025 reflected Resident #1 had a fall in room at 5:44 am which was unwitnessed and resulted in an abrasion to her right forearm. Description of the event Discovered on floor as light was on. Abrasion to right forearm, bruise to wrist lateral and right forearm. 08/12/2025 reflected LVN B documented Resident #1's RP was notified on 08/12/2025 at 5:50 am. Review of Resident #1 comprehensive care plan reflected a focus area dated 01/20/2025 The resident is risk for falls. Goals included The resident will be free of falls through the review date. Interventions included: call don't fall sign hung in room, Date Initiated: 04/22/2025; Anticipate and meet the resident's needs; Date Initiated: 01/20/2025; Be sure the resident's call light is within reach and encourage the resident to use it, Date Initiated: 01/20/2025; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Date Initiated: 01/20/2025; Ensure resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Date Initiated: 01/20/2025;frequent reminders to use call light for assistance, Date Initiated: 01/27/2025, Keep furniture in locked position, Date Initiated: 01/20/2025; Keep needed items, water, etc., in reach, Date Initiated: 01/20/2025; low bed w/ fall mat, Date Initiated: 01/27/2025; mat to floor at bedside, Date Initiated: 01/20/2025; med review, Date Initiated: 02/14/2025; non- skid foot wear, Date Initiated: 01/20/2025; Pt evaluate and treat as ordered or PRN, Date Initiated: 01/20/2025; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Date Initiated: 01/20/2025; Scoop mattress, Date Initiated: 01/27/2025; Staff x 2 to assist with transfers, Date Initiated: 01/20/2025; The resident needs activities that minimize the potential for falls while providing diversion and distraction, Date Initiated: 01/20/2025; therapy screen for cognition/safety awareness Date Initiated: 02/07/2025; Therapy to provide reacher, Date Initiated: 06/04/2025; Toilet and/or ensure clean/dry prior to going to bed, Date Initiated: 01/29/2025. The care plan did not address her actual falls and was not updated after her unwitnessed fall on 08/12/2025. In an interview on 09/03/2025 at 2:00 pm the DON stated it was her expectation that all resident change in conditions be reported to the responsible party to ensure the resident gets the care they need. She stated regarding the care plan that the facility only had a [NAME] MDS nurse, and the care plan should have been reviewed and updated after Resident #1's 08/12/2025 fall to prevent further falls. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident #1's care plan should have been reviewed and interventions updated as appropriate. She stated Resident#1's fall on 08/12/25 had not yet been reviewed by the IDT and the care plan is updated after the review occurs. She stated it should have been up after the fall to make sure the root cause of the fall was identified to prevent reoccurrence. Review of the facility's policy fall policy undated reflected Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. Appropriate education will be provided to all staff members as needed on fall prevention.

Based on interview and record review, the facility failed to immediately inform the resident representative when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party after Resident #1 experienced an unwitnessed fall on 08/12/2025 that resulted in an abrasion. This deficient practice could place residents at risk of not having their responsible party notified of changes, resulting in a delay in medical intervention and decline in health.Findings included: Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was assessed to have functional limitation in range of motion on both sides for her upper and lower extremities. Resident #1 was further assessed to require supervision or touching assistance with transfers. Resident #1 was assessed to have falls since admission. Review of Resident #1's comprehensive care plan reflected a focus area dated 01/20/2025 The resident has impaired cognitive function/dementia or impaired thought processes. Interventions included .Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers. Review of Resident #1's fall event note dated 08/12/2025 reflected Resident #1 had a fall in room at 5:44 am which was unwitnessed and resulted in an abrasion to her right forearm. Description of the event Discovered on floor as light was on. Abrasion to right forearm, bruise to wrist lateral and right forearm. 08/12/2025 reflected LVN B documented Resident #1's RP was notified on 08/12/2025 at 5:50 am. Review of Resident #1's nursing progress note dated 08/12/2025 at 5:57 pm entered by the ADON reflected this nurse tried twice to notify RP of resident's fall but kept getting a business signal. In an interview on 09/03/2025 at 12:30 pm Resident #1's RP stated she was not contacted on 08/12/2025 about Resident #1's fall and did not find out until 4 or 5 days later when Resident #1 was complaining of pain. She stated when she asked Resident #1 what happened she told her she fell. Resident #1's RP was asked about the documentation of her being notified at 5:50 am on 09/03/2025. She stated the documentation was not true that she did not get a call. She stated they have called her at all hours of the night before and she answers. She stated she always has her phone by her. She stated she does not have a land line so her cell phone does not have a busy signal if she does not answer it goes to voicemail, she stated the must have been calling the wrong number. In an interview at 1:30 pm the ADON stated she worked on the floor the day of 08/12/2025 and the night nurse LVN B told her he was not able to reach Resident #1's RP after her fall so he passed it on to the ADON. She stated she keep getting a busy signal. She stated she could not remember who came in next and could not remember if she passed on the need to notify the family. She stated she should have followed up to make sure the family was notified of the Resident's fall. She stated she just got caught up with working on the floor and forgot about it. Attempts to contact LVN B during the investigation on 09/03/2025 at 12:20 pm and 3:30 pm were unsuccessful. In an interview on 09/03/2025 at 2:00 pm the DON stated it was her expectation that all resident change in conditions be reported to the responsible party to ensure the resident gets the care they need. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident#1's RP should have been notified after the fall and staff should have ensured follow up was done if they were not able to reach the family. Review of the facility's undated policy Notifying the physician of change in status reflected .The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. Review of the facility's undated policy Resident Rights 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. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 4. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

Based on observation, interview and record review the facility failed to develop, and implement a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan updated interventions after Resident #1 experienced multiple falls. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being.Findings include:Review of Resident #1's face sheet dated 09/03/2025 reflected she was admitted to the facility on [DATE] Fracture of left femur (left hip fracture) unsteadiness on feet, diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and osteoarthritis (happens when the protective cartilage that cushions the ends of the bones wears down over time.), left knee. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 9 indicating moderate cognitive impairment. Resident #1 was assessed to have functional limitation in range of motion on both sides for her upper and lower extremities. Resident #1 was further assessed to require supervision or touching assistance with transfers. Resident #1 was assessed to have falls since admission. Review of Resident #1's Event Nurses' notes-fall reflected she had falls on 01/18/2025, 01/25/2025 x 2, 01/26/2025, 01/29/2025, 02/07/2025, 02/12/2025, 04/19/2025, 06/01/2025, and 08/12/2025. Review of Resident #1's fall event note dated 08/12/2025 reflected Resident #1 had a fall in room at 5:44 am which was unwitnessed and resulted in an abrasion to her right forearm. Description of the event Discovered on floor as light was on. Abrasion to right forearm, bruise to wrist lateral and right forearm. Review of Resident #1 comprehensive care plan reflected a focus area dated 01/20/2025 The resident is risk for falls. Goals included The resident will be free of falls through the review date. Interventions included: call don't fall sign hung in room, Date Initiated: 04/22/2025; Anticipate and meet the resident's needs; Date Initiated: 01/20/2025; Be sure the resident's call light is within reach and encourage the resident to use it, Date Initiated: 01/20/2025; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Date Initiated: 01/20/2025; Ensure resident is wearing appropriate footwear when ambulating or mobilizing in w/c, Date Initiated: 01/20/2025;frequent reminders to use call light for assistance, Date Initiated: 01/27/2025, Keep furniture in locked position, Date Initiated: 01/20/2025; Keep needed items, water, etc., in reach, Date Initiated: 01/20/2025; low bed w/ fall mat, Date Initiated: 01/27/2025; mat to floor at bedside, Date Initiated: 01/20/2025; med review, Date Initiated: 02/14/2025; non- skid foot wear, Date Initiated: 01/20/2025; Pt evaluate and treat as ordered or PRN, Date Initiated: 01/20/2025; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Date Initiated: 01/20/2025; Scoop mattress, Date Initiated: 01/27/2025; Staff x 2 to assist with transfers, Date Initiated: 01/20/2025; The resident needs activities that minimize the potential for falls while providing diversion and distraction, Date Initiated: 01/20/2025; therapy screen for cognition/safety awareness Date Initiated: 02/07/2025; Therapy to provide reacher, Date Initiated: 06/04/2025; Toilet and/or ensure clean/dry prior to going to bed, Date Initiated: 01/29/2025. Further review revealed the care plan did not address her actual falls, cause of falls, and was not updated after her unwitnessed fall on 08/12/2025. In an interview on 09/03/2025 at 12:28 pm Resident #1 stated she had a lot of falls, and she was impatient and if they do not come right away, she will just do it herself. Resident #1 stated she could not transfer herself at times. She stated she did not recall her last fall or why she fell. Resident #1 stated she did hurt her wrist. In an interview on 09/03/2025 at 2:00 pm the DON stated the facility only had a regional MDS nurse, and the care plan should have been reviewed and updated after Resident #1's 08/12/2025 fall to prevent further falls. In an interview on 09/03/2025 at 2:25 pm the RNC stated Resident #1's care plan should have been reviewed and interventions updated as appropriate. She stated Resident#1's fall on 08/12/25 had not yet been reviewed and the care plan was updated after the review occurred. She stated it should have been updated after each fall to make sure the root cause of the fall was identified to prevent reoccurrence. Review of the facility's policy comprehensive care planning undated reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on interviews and record reviews the facility failed to implement a comprehensive person-centered care plan for one (1) resident (Resident #1) of six (6) residents reviewed for care plans. The facility failed to ensure Resident #1 care plan was updated and revised after behavior events on 11/2/2024 and 11/7/2024, causing Resident #1 injuries to her face on 11/7/2024. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being for residents. Findings included: 1. Review of Resident #1's face sheet dated 11/19/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (memory loss disorder), Diabetes Mellitus (blood sugar disorder), senile degeneration of the brain (age related brain disorder) and abnormality of gait and mobility. Review of Resident #1's admission MDS dated [DATE] reflected a BIMS of 0 suggesting severe cognitive impairment. Review of the Behavior section of the MDS reflected Resident #1 did not have any behaviors since her admission seven days prior on 9/11/2024. Review of Resident #1's progress note dated 11/2/2024 at 10:58 am reflected Resident rolled up to another resident while he was asleep and slapped his arm. Review of Resident #1's progress note dated 11/3/2024 at 10:31 am reflected Resident hit another resident arm Interventions: PRN lorazepam given. Review of Resident #1's progress note dated 11/7/2024 at 9:25 am reflected The resident was involved in an incident where she was sitting next to another resident and was repeatedly putting her hands in his face. The other resident stated that he asked her not to put her hands in his face multiple times, but she continued to do so and laughed about it. The last time he asked her to stop she slapped him in his face causing him to react and hit her back .This resident has an area to the upper right lip, right side of the nose and underneath the right eyebrow that has a scratch from the incident. Review of Resident #1's current care plan as of 11/19/2024 reflected no problems related to behaviors. Review of Resident #1's care plan as of 11/20/2024 at 11 am reflected no problems related to behaviors. Review of Resident #1's care plan as of 11/20/2024 at 2 pm reflected a problem: Resident exhibits behaviors of touching other resident on the arm/face/hands with interventions: 1:1 when experiencing this behavior in excess, do no place her close by when she is having this behavior, referral to [behavioral hospital] and resident appropriate activities. During an interview on 11/19/2024 at 3:18 pm, FM #1 stated they were the responsible party for Resident #1 and he had received calls for both incidents involving Resident #1 hitting Resident #2. FM #1 stated during the second incident, Resident #1 had been hit back and got scratched up pretty close to her eye and on her lip. FM#1 stated they were concerned about how close the injury was to Resident #1's eye and that it could have been a lot worse If Resident #1 had been hit in her eye. He stated Resident #1 had severe dementia and didn't even remember what had happened but the FM#1 was still very concerned with how bad it could have been if the injury had been just a little bit closer to her eye. 2. Review of Resident #2's face sheet dated 111/19/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: High blood pressure, vascular dementia (decreased blood flow to the brain causing memory issues) and Diabetes mellitus with diabetic retinopathy. (Vision disorder related to blood sugar disorder) Review of Resident 2's quarterly MDS dated [DATE] reflected a BIMS of 8 suggesting moderate cognitive impairment. During an interview on 11/20/2024, Resident #2 stated he has not had any other problems with Resident #1 since the second time she hit him, and he hit her back. He stated she would wheel up to him and slap him and it would scare him. He stated he had vision problems, and he did not like anyone being all up in my face and she came up and got in my face and I told her to stop, and she didn't so I hit her back. He stated there had been 2 different times when she slapped him, the first time he was sleeping in his wheelchair, and she came up and slapped him and it scared him awake. He stated he hollered for staff, and they came and got her. The second time, he was in the dining room, and she just came up and started hitting his face, so he hit her back and scratched her face and busted her lip. During an interview on 11/10/2024 at 2:00 pm, the ACN stated the care plans in the EMR system were current. She stated when they checked Resident #1's care plan, it was not in there and it should have been, so the DON went in and put it in today. She stated the care plan had not been updated on 11/2/2024 and 11/7/2024 when Resident #1 had behaviors because it had been overlooked. She stated it needed to be in there, so they fixed it this afternoon. During an interview on 11/20/2024 at 3:00 pm, the DON stated she had updated Resident #1's care plan today. She stated when the investigator asked for Resident #1's care plan on 11/20/24, she had noticed the care plan had not been updated. She stated the IDT was responsible for updating care plans and it would either have been her (the DON) or the MDS Nurse. She stated the MDS nurse had been out sick and the MDS nurse thought she had done it and she (the DON) had thought the MDS nurse had updated it. She stated updating care plans are important because it tells them how to care for the resident and what's going on with that resident She stated the interventions were in place, but the care plan had not been updated. She stated if care plans are not updated, they won't know what is going on with that resident. During an interview on 11/20/2024 at 4:10 pm, the AD stated he did not know the care plan for Resident #1 had not been updated after the incident on 11/2/2024 or 11/7/2024. He stated the care plan should have been updated right after the first incident on 11/2/2024 and when the DON discovered it today, she went in and updated the care plan. He stated it was important to update care plans quickly because that's how we know how to care for the resident. He stated they will be educating nurses on documentation and updating care plans to address this issue. Record review of undated facility policy Comprehensive Care Planning reflected the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Further, the policy stated, Residents preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representation, if applicable, so that changes can be reflected in the comprehensive care plan. Also, The resident's care plan with 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 an in response to current interventions.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of five (Resident #7 and Resident #47) residents reviewed for dignity. 1. The facility failed to ensure Resident #7 had a privacy cover on their urinary catheter bag. 2. The facility failed to ensure Resident #47 was served lunch at the same time as the other residents at her table for two days. These failures could affect the resident's dignity and affect their quality of life. Findings included: 1. Review of Resident #7's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and 07/21/2024 with diagnoses of surgical amputation of left leg below knee, hypertension (elevated blood pressure), and type 2 diabetes (disease that affects how your body uses insulin and glucose). Review of Resident #7's Quarterly MDS assessment, dated 07/16/2024 reflected a BIMS score of 04 indicating severe cognitive impairment. MDS further reflected resident had a urinary catheter. Review of Resident #7's care plan, dated 09/04/2024, reflected resident had an indwelling urinary catheter and the bag should be placed in a privacy bag. Observation on 09/08/2024 at 09:45 AM in Resident #7's room revealed the resident had a urinary catheter bag hanging from the bed without a privacy cover and contents exposed to anyone who enters the room. Observation on 09/09/2024 at 11:30 AM in Resident #7's room revealed the resident's urinary catheter bag still exposed with no privacy cover in place. In an interview on 09/10/2024 at 09:45 AM Resident #7 stated she would like her catheter bag to be covered. Informed resident that the bag now has a cover on it for privacy. In an interview on 09/10/24 at 10:03 AM CNA D stated urinary catheter bags should always have a blue slipcover on them to maintain privacy and dignity of the residents. In an interview on 09/10/24 at 10:08 AM RN B stated urinary catheter bags should have a cover on them at all times, even if the resident is alone in their room with the curtain pulled. She stated she did not realize Resident #7 did not have a cover because the previous nurse changed the catheter a couple nights ago and did not put one on and she has since corrected it and placed a cover on the bag. She stated it is policy to always have a cover on the bag. In an interview on 09/10/24 at 10:55 AM the DON stated urinary catheter bags should be covered at all times, even when the resident is in their room. She stated the reason Resident #7's bag was not covered was because it had been changed the night before and the staff did not put the cover back on. She stated although the policy does not specifically reflect the use of covers, it is the expectation to maintain dignity for the residents. In an interview on 09/10/2024 at 12:55 PM the ADM stated urinary catheter bags need be covered when out of the room or when visible to others from the doorway. He stated the purpose of the bag is to maintain dignity for the residents. Review of facility policy for Catheter Care, dated 02/13/2007 does not address the use of a dignity cover under general guidelines for catheter care. 2. Record review of the undated Face Sheet for Resident #47 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Myocardial Infarction (heart attack). Record review of the Quarterly MDS assessment for Resident #47 dated 07/11/2024 reflected she had a BIMS score of 8 indicating moderate cognitive impairment. Section GG - Functional Abilities and Goals reflected she required supervision or touching assistance with eating. Record review of the Care Plan for Resident #47 dated 05/20/2024 reflected she was at risk for unplanned weight loss or gain. Goal: Resident will maintain ideal weight and receive proper nutrition X 90 days. Interventions: Encourage meal completion. Serve diet and snacks as ordered. On 09/08/2024 an observation was made at 11:45 AM of Resident #47. Resident #47 was sitting at a table with other residents, she had been sitting there since before trays were served. All trays at her table were served. Resident #47 made a few comments to the other residents at her table saying she was still waiting for her food. Resident #47 waited approximately 20 minutes after the other residents at her table were served before she received her food tray. On 09/09/2024 at 11:50 AM Resident #47 was observed sitting at the same table as before with the same other residents. All the trays at her table were served and Resident #47 waited approximately 25 minutes after her table mates were served when her food tray was served. On 09/09/2024 at 12:15 PM an interview with Resident #47 revealed she does not usually eat in her room, that she always eats at the dining room. On 09/10/2024 at 11:15 AM an interview was completed with Resident #47. Resident #47 stated she always ate in the dining room. She stated that her tray was always late compared to her table mates. On 09/10/2024 at 12:00 PM an interview was conducted with DON. DON stated Resident #47 typically comes into the dining room for meals, but if they are taking too long she would leave and go to her bedroom. DON stated that a negative outcome of not providing a tray to all residents at the same time could cause a resident to feel forgotten about. DON stated that the policy states to try and serve all residents at a table together if it is possible. On 09/10/2024 at 12:11 PM an interview was conducted with the Kitchen Manager. KM stated the process of passing trays out consists of looking out the kitchen window to see who was in the dining room and trying to serve the trays from tables front right to back left if possible. She stated if a new resident comes to the table, the staff in the dining room lets the kitchen staff know and that is how they ensure that all residents get a tray at the table. KM stated if a resident was missed at a table it was likely due to the staff not letting the kitchen know that there was a resident at the table. On 09/10/2024 at 12:17 PM an interview was conducted with RN A. RN A stated she always helps in the dining room. RN A stated Resident #47 always eats in the dining room for her meals. She stated she is always seated at the same table with the same residents. RN A stated the method used for serving trays is the kitchen provides the trays on a cart, and the staff in the dining room pass them out. She stated if a table is served except for one resident, they let the kitchen know and the kitchen quickly gets the tray out to the resident. RN A stated a resident could feel forgotten about due to not being provided a tray with the rest of their table. RN A stated the trays are served from table to table starting at the front right table closest to the kitchen. On 09/10/2024 at 12:50 PM an interview was completed with the administrator. ADM stated the expectation for the dining room is to pass out trays and to try to serve the whole table at the same time. The staff should then hand sanitize in between trays. He stated the reason a resident may be forgotten at the table possibly if a resident comes in late they may not get their tray on time. He stated a resident having to wait for their tray table for a long time could leave the resident feeling hungry. On 09/10/2024 the facility provided a policy for Nursing Responsibilities at Meal Service dated 2012. This policy revealed the following: 3. Communicate to the dietary department if a resident will be eating in other than the usual area. Dietary must be notified prior to beginning the tray line. 4. Distribute food trays to residents in resident rooms, dining rooms, and ancillary dining rooms. Try to serve residents seated together at the same time, when possible. 5. A tray sequence is used in dining rooms so all residents at a table are served at the same time. 49851

Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #49) of two residents reviewed for pressure injuries. The facility failed to ensure RN C followed Physician's orders for wound care for Resident #49. The facility failed to ensure RN C documented the wound care she provided for Resident #49 without a Physician order. These failures could have delayed the progress of the coccyx wound healing for Resident #49. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles, tendons (cord like tissues that connect muscles to bones or other structures), and ligaments (short band of connective tissue which connects two bones or holds together a joint), can also expose bone). Record review of the Quarterly MDS assessment dated [DATE] for Resident #49 reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Record review of the Care Plan for Resident #49 dated 07/24/2024 and revised on 08/19/2024 reflected Resident #49 had a pressure ulcer Stage 4 to coccyx with wound vac [a wound dressing system that uses a suction pump to apply negative pressure to a wound to promote healing] in place to be changed 3 X week. Goal: Resident #49's pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose ormissing dressings PRN. Specify treatment: WOUND VAC. Record review of Physicians orders dated 07/23/2024 for Resident # 49 reflected Stage 4 pressure wound to coccyx. Clean with n/s, pat dry, apply granular foam in both ends and connecting in the middle, dress with clear wound vac tape 150 mmHg continuous pressure. 3 times per week. Observation and interview on 09/08/2024 at 10:07 AM Resident #49 stated the wound on his coccyx (tailbone) was supposed to have a wound vacuum attached to it but the nurse who did his wound care that morning told him she had applied a wet to dry dressing. He stated he was ready to go home and had been at the facility for a little over a month. A wound vacuum machine was observed on his bedside table without a reservoir and was not attached to anything. In an interview on 09/08/2024 at 1:09 PM LVN E stated RN C was the treatment nurse who had changed Resident #49's dressing that morning. LVN E stated RN C had told her she had put a wet to dry dressing on his wound but did not indicate why the treatment had changed. She stated RN C did not give her any other information regarding Resident #49's wound care and had left for the day. In an interview on 09/08/2024 at 1:17 PM LVN E stated she had called the Nurse Practitioner for an order for a wet to dry dressing for Resident #49 since RN C had failed to call the clinician. In a phone interview on 09/08/2024 at 2:10 PM, RN C stated she was a weekend supervisor and was not a wound care nurse per se and it was not her forte. She stated there was no order for a wet to dry dressing however that is what she put on Resident #49's wound that morning. She stated she had completed the wound care around breakfast time, and she was aware she had not charted the wound care. She further stated she was coming back to the facility that day. In an interview on 09/08/2024 at 3:18 PM RN C stated she had been with the company since 2017 and had been in the facility since 2021. She stated she had been a floor nurse then started working prn in December 2024. She stated she had completed a wound care training course before 2017. She stated technically she had not had any wound care training at the facility. She was shown a checkoff list for the wound vacuum dated 08/24/2024 that had her name on it and was signed by the DON. She stated that was probably when she was shown how to do Resident #49's wound vacuum dressing. She stated she was making wound care rounds on Sunday 09/08/2024 and she needed an extra hand to help her with the resident. She stated his wound vac needed to be changed out and she was having problems doing it. She stated she should have called the on-call nurse for assistance. She stated she had decided the next best thing would be to put a wet to dry dressing on the wound. She stated she forgot to document the actions she took and did not call the Physician for orders or to notify them she was unable to complete the dressing change as ordered. She stated she should have stayed at the facility and taken her time. She stated wound care was probably not her strong point. Observation and interview on 09/08/2024 at 2:33 PM the DON and Medical Records Clerk showed that there were three wound vac canisters available in the central supply room. The Medical Records Clerk stated she was present when RN C was in the facility on Sunday 09/08/2024 and RN C had not asked for any supplies for Resident #49's wound care. In an interview during a wound care observation on 09/09/2024 at 1:45 PM Resident #49 stated Why did that nurse remove the wound vac yesterday? She should have put the wound vac back on. I need to call those state people. I'm trying to get well. The DON stated there were two state people in the room and the nurse should have replaced the wound vac instead of putting on a wet to dry dressing. In an interview on 09/09/2024 at 2:25 PM Resident #49 stated the lady who put that patch (dressing) on yesterday said the wound vac did not need to go back. He further stated that was the second time that nurse had not replaced his wound vac. He stated he was at the facility to get well and go home. He stated, that nurse should have known better. In an interview on 09/10/2024 at 9:45 AM the DON stated her expectations were for wound care to be done as ordered, that nurses document anything they do, notify the physician and family of any changes to the wound care. She further stated the potential risk to the resident was it could have halted progress on his wound healing. In an interview on 09/10/2024 at 12:55 PM the ADM stated his expectations were for Dr. orders to be followed and the nurse probably should have documented her care. He stated he did not know what the potential risk for the resident could be of the nurse not following the Dr. orders for wound care. Record review of a facility Policy and Procedure titled Skin Integrity Management dated 2003 and revised on October 5, 2016, reflected General Guidelines: 3. Wound care should be performed as ordered by the physician.

Based on 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 one Residents (Resident #49) reviewed for pressure ulcers wound care. The facility failed to ensure RN A followed standard precautions during wound care for Resident #49's Stage 4 coccyx pressure ulcer when she contaminated supplies prior to wound care and used contaminated scissors to cut foam used for wound care which she then placed into the open wound. This failure could place residents at risk for developing wound infections. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles, tendons (cord like tissues that connect muscles to bones or other structures), and ligaments (short band of connective tissue which connects two bones or holds together a joint), can also expose bone). Record review of the Quarterly MDS assessment dated [DATE] for Resident #49 reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Record review of the Care Plan for Resident #49 dated 07/24/2024 and revised on 08/19/2024 reflected Resident #49 has a pressure ulcer. Stage 4 to coccyx with wound vac [a wound dressing system that uses a suction pump to apply negative pressure to a wound to promote healing] in place to be changed 3 X week. Goal: Resident #49's pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Specify treatment: WOUND VAC. Record review of Physicians orders dated 07/23/2024 for Resident # 49 reflected Stage 4 pressure wound to coccyx. Clean with n/s, pat dry, apply granular foam in both ends and connecting in the middle, dress with clear wound vac tape 150 mmHg continuous pressure. 3 times per week. Observation on 09/09/24 at 1:35 PM of wound care for Resident #49 revealed RN A unlocked the treatment cart, sanitized her hands, and donned gloves. She opened the unclean drawer with her gloves on, obtained a piece of wax paper and patted the inside of the paper using her contaminated gloves. She grabbed extra gloves with her contaminated gloves and placed them on the wax paper. She then grabbed 4 X 4 gauze and placed it on the wax paper using the same contaminated gloves. She removed her gloves, sanitized her hands, donned gloves, and removed the dressing from the resident's coccyx area. She removed her gloves, sanitized her hands, re-gloved and placed wound prep around the wound. She used sanitized scissors to cut pieces of the tape used to seal around the wound. She placed those scissors on an unclean draw sheet which had been under the resident. She then used those contaminated scissors to cut foam which was then placed into the wound. She cut a hole in the dressing she had placed over the foam using the contaminated scissors and attached the dressing to the wound vac. In an interview on 09/09/2024 at 2:30 PM RN A stated the wound care training she had received was not formal but rather on the job in a hospital medical/surgical unit and when she had worked in hospice care. She stated she was not wound care certified and did not perform wound care very much. She stated the facility had asked her to fill in to do wound care for the current week and she normally did floor nursing. She stated the potential risk to the resident of not following standard infection control practices during wound care was for infection and introducing bacteria into the wound. In an interview on 09/09/2024 at 3:24 PM the DON stated her expectation for nurses performing wound care was for no contamination and for the wound to remain free of infection. She stated the staff need education on infection control and wound care. She stated the potential risk was delayed wound healing, infection, and potential sepsis (serious condition in which the body responds improperly to an infection and the infection fighting processes turn on the body.) In an interview on 09/10/2024 at 12:55 PM the ADM stated his expectation for infection control during wound care was that the nurse should follow the protocols for wound care. He stated the potential risk was it could contaminate the wound and could cause infection. Record review of a facility policy and procedure dated 2003 and titled Treatment Table reflected 3. Gather treatment supplies. Open up and place on top of wax paper. One end will be considered clean, and the other end of the table will be open for dirty (to replace scissors, etc. to be cleaned) No other wound care protocols were provided by the DON. 49851

Based on observation, interview, and record review the facility failed to immediately inform the resident's Physician when the nurse was unable to follow wound care orders for one of one Residents (Resident #49) reviewed for physician notification of changes. The facility failed to ensure RN C notified the Physician and family of her inability to follow wound care orders for Resident #49. This failure could have delayed the progress of the coccyx wound healing for Resident #49. Findings included: Record review of the undated Face Sheet for Resident #49 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Pressure Ulcer of sacral (bony area of the spine) region, Stage 4 (open sore extending into muscles, tendons (cord like tissues that connect muscles to bones or other structures), and ligaments (short band of connective tissue which connects two bones or holds together a joint), can also expose bone). Record review of the Quarterly MDS assessment dated [DATE] for Resident #49 reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Record review of the Care Plan for Resident #49 dated 07/24/2024 and revised on 08/19/2024 reflected Resident #49 had a pressure ulcer Stage 4 to coccyx with wound vac [a wound dressing system that uses a suction pump to apply negative pressure to a wound to promote healing] in place to be changed 3 X week. Goal: Resident #49's pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose ormissing dressings PRN. Specify treatment: WOUND VAC. Record review of Physicians orders dated 07/23/2024 for Resident # 49 reflected Stage 4 pressure wound to coccyx. Clean with n/s, pat dry, apply granular foam in both ends and connecting in the middle, dress with clear wound vac tape 150 mmHg continuous pressure. 3 times per week. Observation and interview on 09/08/2024 at 10:07 AM Resident #49 stated the wound on his coccyx (tailbone) was supposed to have a wound vacuum attached to it but the nurse who did his wound care that morning told him she had applied a wet to dry dressing. He stated he was ready to go home and had been at the facility for a little over a month. A wound vacuum machine was observed on his bedside table without a reservoir and was not attached to anything. In an interview on 09/08/2024 at 1:09 PM LVN E stated RN C was the treatment nurse who had changed Resident #49's dressing that morning. LVN E stated RN C had told her she had put a wet to dry dressing on his wound but did not indicate why the treatment had changed. She stated RN C did not give her any other information regarding Resident #49's wound care and had left for the day. In an interview on 09/08/2024 at 1:17 PM LVN E stated she had called the Nurse Practitioner for an order for a wet to dry dressing for Resident #49 since RN C had failed to call the clinician. In a phone interview on 09/08/2024 at 2:10 PM, RN C stated she was a weekend supervisor and was not a wound care nurse per se and it was not her forte. She stated there was no order for a wet to dry dressing however that is what she put on Resident #49's wound that morning. She stated she had completed the wound care around breakfast time, and she was aware she had not charted the wound care. She further stated she was coming back to the facility that day. In an interview on 09/08/2024 at 3:18 PM RN C stated she had been with the company since 2017 and had been in the facility since 2021. She stated she had been a floor nurse then started working prn in December 2024. She stated she had completed a wound care training course before 2017. She stated technically she had not had any wound care training at the facility. She was shown a checkoff list for the wound vacuum dated 08/24/2024 that had her name on it and was signed by the DON. She stated that was probably when she was shown how to do Resident #49's wound vacuum dressing. She stated she was making wound care rounds on Sunday 09/08/2024 and she needed an extra hand to help her with the resident. She stated his wound vac needed to be changed out and she was having problems doing it. She stated she should have called the on-call nurse for assistance. She stated she had decided the next best thing would be to put a wet to dry dressing on the wound. She stated she forgot to document the actions she took and did not call the Physician for orders or to notify them she was unable to complete the dressing change as ordered. She stated she should have stayed at the facility and taken her time. She stated wound care was probably not her strong point. Observation and interview on 09/08/2024 at 2:33 PM the DON and Medical Records Clerk showed that there were three wound vac canisters available in the central supply room. The Medical Records Clerk stated she was present when RN C was in the facility on Sunday 09/08/2024 and RN C had not asked for any supplies for Resident #49's wound care. In an interview during a wound care observation on 09/09/2024 at 1:45 PM Resident #49 stated Why did that nurse remove the wound vac yesterday? She should have put the wound vac back on. I need to call those state people. I'm trying to get well. The DON stated there were two state people in the room and the nurse should have replaced the wound vac instead of putting on a wet to dry dressing. In an interview on 09/09/2024 at 2:25 PM Resident #49 stated the lady who put that patch (dressing) on yesterday said the wound vac did not need to go back. He further stated that was the second time that nurse had not replaced his wound vac. He stated he was at the facility to get well and go home. He stated, that nurse should have known better. In an interview on 09/10/2024 at 9:45 AM the DON stated her expectations were for wound care to be done as ordered, that nurses document anything they do, notify the physician and family of any changes to the wound care. She further stated the potential risk to the resident was it could have halted progress on his wound healing. In an interview on 09/10/2024 at 12:55 PM the ADM stated his expectations were for Dr. orders to be followed and the nurse probably should have documented her care. He stated he did not know what the potential risk for the resident could be of the nurse not following the Dr. orders for wound care. Record review of a facility Policy and Procedure titled Skin Integrity Management dated 2003 and revised on October 5, 2016, reflected General Guidelines: 3. Wound care should be performed as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Resident #1 and Resident #2) of 4 residents reviewed for respiratory care. The facility failed to ensure that Resident #1's oxygen tubing with nasal cannula and humidifier bottle was replaced every seven (7) days. The facility failed to ensure that Resident #1's air concentrator filter was cleaned and free of dust and debris particles. The facility failed to ensure that Resident #2's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days. These failures could place residents at risk for respiratory compromise and infection. Findings Included: A) Review of Resident #1's Face Sheet dated 06/20/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and Dysphagia (swallowing difficulties). Review of Resident #1's MDS Comprehensive Assessment, dated 03/14/2024 revealed Resident #1 had a BIMS Score of 13, which indicated cognition was intact. Resident #1's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy, which occurred while she was a resident. Review of Resident #1's Comprehensive Care Plan revealed The resident has Oxygen Therapy, PRN with an intervention for Oxygen at 2L/min per nasal cannula if O2 sat<90% or if Res feels SOB, with both revised on 10/07/2020. Review of Resident #1's Order Summary Report reflected an indefinite order on 03/12/2022 for May have O2 @ 2L/min via NC continuously with directions for every shift for sob/wheezing related to GENERALIZED ANXIETY DISORDER. Further review revealed an indefinite order on 4/6/2023 for Change respiratory concentrator water, clean filter q7d with directions for every night shift every Sun. Review of Resident #1's Treatment Administration Record from 06/1/2024 - 06/20/2024 reflected, Change respiratory concentrator water, clean filter q7d every night shift every Sun and indicated it was completed on Sunday, 06/02/2024, Sunday, 06/09/2024, and Sunday, 06/16/2024. Observation on 06/20/2024 at 12:00 PM, Resident #1 was in her bed receiving oxygen via nasal cannula from an air concentrator. A check of her oxygen tubing and concentrator revealed the humidifier bottle had 6-10-24 recorded on the top of it, with no date present on the tubing. Resident #1 was receiving air from the concentrator at 2L per minute and a check of the filter on the back of it revealed it was covered in dust and debris particles. Interview and observation on 06/20/2024 at 2:56 PM, Resident #1 had her tubing and nasal cannula hanging off the side of her bed side table and stated it was off because she just received a bath. Resident #1's humidifier bottle had the same date as earlier observation and had not been changed. Resident #1 stated that her oxygen tubing and cannula were not changed on 06/20/2024 but stated they do change it out. Resident #1 stated that she could not recall in days or weeks when the last time was that they changed out her oxygen tubing with cannula. B) Review of Resident #2's Face Sheet dated 06/20/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Athetoid Cerebral Palsy (movement disorder cause by damage to the developing brain characterized by abnormal, involuntary movement), Cystic Fibrosis (disease that causes thick, sticky mucus to build up in the lungs, digestive tract, and other areas of the body), and Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain). Review of Resident #2's Quarterly MDS Assessment, dated 05/23/2024 revealed Resident #2 had a BIMS Score of 00, which indicated severe cognitive impairment. Resident #2's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy, which occurred while she was a resident. Review of Resident #2's Comprehensive Care Plan revealed The resident has impaired cognitive function r/t dementia dx with an intervention for Administer meds as ordered, with both revised on 08/28/2023. Resident #2's Comprehensive Care Plan did not specifically address the use of her nebulizer. Review of Resident #2's Order Summary Report reflected an order on 08/15/2023 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML with directions for 1 dose via trach every 4 hours. Review of Resident #2's Treatment Administration Record from 06/1/2024 - 06/20/2024 reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 dose via trach every 4 hours as needed for Shortness of Breath; Wheezing documented as PRN with no indication of treatment for dates reviewed. The Treatment Administration Record further reflected Change Nebulizer Tubing and Delivery Device every 8 hours as needed related to UNSPECIFIED TRACHEOSTOMY COMPLICATION documented as PRN with no notations of completion for the dates reviewed. Observation on 06/20/2024 at 12:04 PM, revealed that Resident #2 was in her bed with a nebulizer present on her nightstand, with a plastic bag in front of it. The bag had Resident #2's last name recorded on the front of it as well as 6/3. The bag contained tubing and a mask with attached nebulizing chamber, none of which had a date recorded on them. Interview and observation on 06/20/2024 at 2:58 PM, revealed that Resident #2's nebulizer mask with chamber and tubing remained bagged at her bedside with a date of 6/3. Resident #2 was not interviewable but acknowledged with a smile that she was alright when questioned. Interview on 06/20/2024 at 3:22 PM, LVN B stated all respiratory equipment including mask, cannulas, tubing, and humidifier bottles are to be changed out every seven days by a nurse on Sunday night. LVN B stated they are also supposed to clean the filter on the residents' air concentrator at the same time. LVN B stated they normally record the date of change on the humidifier bottle for concentrated air and on the mask or the outside of the bag for nebulizer equipment. LVN B stated that failure to properly change and maintain oxygen / nebulizer equipment increases a resident's chance of respiratory infection. Interview on 06/20/2024 at 3:35 PM, RN A stated oxygen and nebulizer equipment are to be changed out every Sunday night by a nurse or more frequently if they become soiled. RN A stated oxygen tubing with cannulas have the date recorded on a piece of tape that is stuck to the tubing or have the date recorded on the humidifier bottle, because they are supposed to be changed at the same time. RN A stated dates for nebulizer equipment can be placed on the mask itself or the outside of the bag. RN A stated failure to properly change out oxygen equipment could lead to respiratory issues for the resident. Interview and observation on 06/20/2024 at 3:37 PM, the ADON stated mask, tubing, cannulas, and humidifier bottles are to be changed out every seven days by the night nurse on Saturday to Sunday. The ADON stated the filters on air concentrators are also to be cleaned every seven days or more often if necessary. The ADON stated when they change out oxygen tubing with cannulas and the humidifier bottle, they will record the date on the bottle or will place the date on the tubing at the concentrator port. The ADON stated failure to properly change and maintain respiratory equipment could result in illness or worsen a resident's condition. At 3:39 PM, the ADON entered the room of Resident #1 and checked her oxygen concentrator and equipment. The ADON stated it was not correct because it had not been changed out within the past seven days. The ADON stated the filter on the concentrator had also not been cleaned in over seven days based off the dust and debris build up on it. At 3:45 PM, the ADON entered the room of Resident #2 and checked her nebulizer and equipment. The ADON stated that Resident #2's nebulizer equipment was not correct and had not been changed out every seven days per their procedures. Interview on 06/20/2024 at 4:00 PM, the Administrator stated her expectation was for all respiratory equipment to be changed out weekly or more often if soiled. The Administrator stated that the documented observations were not within policy and could result in illness. Review of the facility's Respiratory Policies and Procedures Manual dated 6/1/2006 revealed, POLICY TITLE: 10.0 Respiratory Equipment/Supply Disinfection/Cleaning, 9. In addition to surface disinfection, perform the following: 9.4 Oxygen Concentrators: Rinse and dry the external filter weekly and prn when visibly dusty. 11. Schedule for Supply Changes, Item, Nebulizers/Aerosols/Humidifiers, Frequency, Every 7 days. POLICY TITLE: 10.1 Oxygen Concentrators, PROCESS 9. Label, date and attach water bottle.

Based on interview, and record review the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for medication/treatment errors. The facility failed to follow physician's orders for providing wound care to Resident #1, Resident #2, and Resident #3, on a regular basis. This failure could place residents at risk of delay in wound infection and healing process. Findings Included: Record review of Resident #1's admission record dated 05/24/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hyperlipidemia (Excess fat in blood), Hypertension, Osteomyelitis of vertebra ( infection on the vertebra), Protein-calorie malnutrition, Cerebral infarction (Stroke), Blindness right eye, Low vision left eye, Muscle weakness., Difficulty in walking, Abnormalities of gait and mobility, Muscle wasting, Lack of coordination and Cognitive communication deficit. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 11 indicating his cognition was moderately impaired. Section M of the MDS indicates Resident #1 has one unhealed pressure ulcer/injury, presenting as deep tissue injury a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #1's careplan dated 03/04/24 reflected, the resident has a stage 3 pressure ulcer to his R heel and the relevant interventions were: 1.Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. 2.Specify Treatment: wound vac to right heel with dressing changes 3xweek. 3.Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record Review of Resident #1's Order Summary Report dated 05/24/24 revealed the following orders: 1.Cleanse Stage 3 pressure ulcer to R heel with NS, Pat dry, apply Santyl, apply calcium alginate, apply foam dressing one time a day for Wound Healing related. to unspecified protein-calorie malnutrition. Record review of Resident #1's WAR of April and May,2024 revealed he did not receive this treatment on 04/07/24, 04/14/24, 05/17/24 and 05/21/24. 2.Negative pressure wound therapy granular foam, 125mmHg change 3x a Week one time a day every Tue, Thu, Sat for Wound Healing. Record review of Resident #1's WAR of April and May, 2024 revealed he did not receive this treatment on 04/25/24, 04/27/24, 05/04/24 and 05/11/24. 3.Santyl External Ointment 250 unit/gm (Collagenase). Apply to R heel topically one time a day for Wound Healing. Record review of Resident #1's WAR of April and May, 2024 revealed he did not receive this treatment on 04/07/24 and, 04/14/24. Record review of Resident #2's admission record dated 05/24/24 revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, Hyperlipidemia (excess fat in blood) , Hypertension, Dementia, Type 2 Diabetes Mellitus, Congestive Heart Failure, Major Depressive Disorder, Encounter for orthopedic aftercare following surgical amputation , Muscle weakness, Difficulty in walking, Unsteadiness on feet, Muscle wasting, Lack of coordination and Cognitive communication deficit. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 05 indicating her cognition was severely impaired. Section M of the MDS indicated Resident #2 Resident had surgical wounds, stage 2 ,stage 3 and unstageable pressure ulcers, a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #2's careplan dated 03/04/24 reflected the resident had: 1.One non pressure wound L anterior thigh. 2.One wound on R Posterior Thigh 3.One non pressure wound to L inner leg. 4.One Stage 2 pressure ulcer to L hip 5.One Stage 3 Pressure ulcer to R lower buttock 6.One Stage 3 pressure ulcer to R Lateral hip 7.One Stage 3 Pressure ulcer to Sacrum The relevant interventions were: 1.Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Specify Treatment: 2.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. 3.Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record Review of Resident #2's Order Summary Report dated 05/24/24 revealed the following orders: 1.Cleanse non pressure wound to L anterior thigh with NS, pat dry, apply xeroform gauze, cover with gauze island dressing one time a day for Wound Healing. Record review of Resident #2's WAR of April and May, 2024 revealed she did not receive this treatment on 04/25/24, 04/27/24 and 05/12/24. 2.Cleanse non pressure wound to L inner leg with NS, pat dry, apply calcium alginate, cover with gauze dressing one time a day for Wound Healing Record review of Resident #2's WAR of April and May, 2024 revealed she did not receive this treatment on 04/21/24, 04/25/24, 04/27/24 and 05/12/24. 3.Cleanse R Posterior Thigh with NS, pat dry, apply xeroform gauze, cover with gauze island dressing one time a day for Wound Healing. Record review of Resident #2's WAR of April and May, 2024 revealed she did not receive this treatment on 04/25/24, 04/27/24, 05/04/24 and 05/11/24. 4.Cleanse Stage 2 pressure ulcer to L hip with NS, pat dry, apply xeroform gauze cover with gauze island dressing one time a day for Wound Healing. Record review of Resident #2's WAR of April and May,2024 revealed she did not receive this treatment on 04/14 and 04/16/24. 5.Cleanse Stage 3 Pressure ulcer to R lower buttock with NS, pat dry, apply med honey, apply calcium alginate, cover with gauze island dressing one time a day for Wound Healing. Record review of Resident #2's WAR of April and May ,2024 revealed she did not receive this treatment on 04/25/24, 04/27/24, 05/12/24. 6.Cleanse Stage 3 pressure ulcer to R Lateral hip with NS, pat dry, apply med honey, apply calcium alginate, cover with gauze dressing one time a day for Wound Healing. Record review of Resident #1's WAR of April and May, 2024 revealed she did not receive this treatment on 04/25/24, 04/27/24, 05/12/24. 7.Cleanse Stage 3 Pressure ulcer to Sacrum with NS, pat dry, apply med honey, apply calcium alginate, cover with foam dressing one time a day for wound Healing. Record review of Resident #2's WAR of April and May, 2024 revealed she did not receive this treatment on 04/124/24, 04/21/24, 04/27/24, 05/124/24. Record review of Resident #3's admission record dated 05/24/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, Psychotic Disturbance, Mood disturbance, Anxiety, Hemiplegia and Hemiparesis (weakness or paralysis on one side of the body) ,Alcohol Dependence, Dysphagia( difficulty to swallow), need for assistance with personal care, Hypertension, , Cerebral infarction (Stroke), Lack of coordination and Cognitive communication deficit. Record review of Resident #3's MDS dated [DATE] revealed her BIMS assessment was not completed . Section M of the MDS indicated Resident #3 had unhealed stage 3 pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #3's careplan dated 05/24/24 reflected the resident had Stage 3 pressure ulcer (a bedsore or decubitus ulcer, is a full-thickness loss of skin that extends into the subcutaneous tissue, or fat layers, but does not reach muscle, tendon, or bone:) to her L axilla and the relevant interventions were: 1.Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. 2.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. 3.Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record Review of Resident #3's Order Summary Report dated 05/24/24 revealed the following orders: 1.Cleanse Stage 3 pressure ulcer to L axilla with NS, pat dry, apply med honey, cover with calcium alginate with silver and apply superabsorbent gelling fiber with silicone bordered dressing one time a day for Wound Healing. Record review of Resident #3's Wound Administration Record of April and May,2024 revealed he did not receive this treatment on 04/14/24, 04/21/24, 04/22/24, 04/25/24, 04/27/24, 05/5/24, 05/06/24, 05/07/24 and 05/13/24. 2.Nystatin External Powder 100000 unit/gm (Nystatin (Topical)) Apply to under R Axilla topically one time a day for Moisture Associated Skin Damage. Record review of Resident #3's Wound Administration Record of April and May,2024 revealed he did not receive this treatment on 04/07/24, 04/14/24, 04/21/24, 04/22/24, 04/25/24, 05/5/24, 05/06/24, 05/07/24 and 05/13/24. During a telephone interview on 05/24/24 at 11:30AM, LVN A stated she was the wound care nurse work in days shift at the facility and when on duty took care of the wound treatments for all the residents with wounds, as per the physician's order. She stated she completed her tasks diligently on a day-to-day basis on all the residents with wounds. She stated she accompanied the wound doctor on his weekly visits and participated in the assessment. LVN A stated she was sure she did the wound care without any neglect and if that was not reflecting on the WAR, it was the indication of omission of documentation not the treatment. During an interview on 05/24/24 at 4:30PM, the DON stated LVN A is the ADON at the facility as well as the treatment nurse. She said she was sure, as she observed, LVN A and other nurses on wound care duty, performing the wound care as per physician's order without any neglect. When the investigator showed her the incomplete WAR of April and May 2024, DON stated, by looking at the WAR it appeared the omissions were in documentation of the wound care. She stated neglect in providing care was unlikely, as she observed them completing their tasks without any fail. DON stated LVN A was a committed and hard-working nurse and observed her busy with wound care, every day. When investigator asked, by looking at the incomplete WAR, how she would be able to confirm if it was a documentation error or neglect in wound care, the DON stated she would not be able to distinguish between documentation error and treatment error by looking the incomplete WAR. She stated according to the nursing principles even if you completed a task and was not documented, it was taken as it was not done. The DON stated she did not do any auditing of MAR or WAR on a regular basis to identify mistakes in documentation however observed if the staff were doing their tasks diligently. She stated the progress in wound care were discussed in the daily meetings as well. Record review of facility policy titled Nursing policy and Procedure Manual 2003-Medication Administration Procedures revised on 10/25/2017 revealed: 1. All medications are administered by licensed medical or nursing personnel. 2.Medications are to be poured, administered, and charted by the same licensed person .5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse. All nurses administering medication must sign and initial the designated area of each resident's medication/treatment administration record or resident specific master signature log for identification of all initials used in charting. 6.If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy Record review of facility policy titled Nursing policy and Procedure Manual 2003-Documentation revised in May,2015 revealed: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC). All documentation and clinical records are confidential and can be released only with signed permission of the resident or legal representative. Goal: 1.The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2.The facility will ensure that information is comprehensive and timely and properly signed . . Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. If PCC is used for the assessment the signature and title of the person entering the information will be signed by entering their password

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 1 resident (Resident #3) reviewed for privacy. The facility failed to ensure DON, RN A and CNA A provided privacy by closing the privacy curtain during wound care for Resident #3. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings include: Record review of Resident #3's admission record dated 05/24/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, Psychotic Disturbance, Mood disturbance, Anxiety, Hemiplegia and Hemiparesis (weakness or paralysis on one side of the body), Alcohol Dependence, Dysphagia ( difficulty to swallow), Need for assistance with personal care, Hypertension, Cerebral infarction (Stroke), Lack of coordination and Cognitive communication deficit. Record review of Resident #3's MDS dated [DATE] revealed her BIMS assessment was not completed. Record review of Resident #3's careplan dated 05/24/24 reflected the resident had Stage 3 pressure ulcer (a bedsore or decubitus ulcer, is a full-thickness loss of skin that extends into the subcutaneous tissue, or fat layers, but does not reach muscle, tendon, or bone) to her L axilla (a person's armpit) and the relevant interventions were. 4. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. 5. 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. 6. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record Review of Resident #3's Order Summary Report dated 05/24/24 revealed the following orders: 3. Cleanse Stage 3 pressure ulcer to L axilla with NS, pat dry, apply med honey, cover with calcium alginate with silver and apply superabsorbent gelling fiber with silicone bordered dressing one time a day for Wound Healing. 4. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to under R Axilla topically one time a day for Moisture Associated Skin Damage. During an observation and interview on 05/24/24 at 2:00 pm Resident #3 was sitting in her bed and was awake and alert. She was sharing her room with another resident. Resident #3 resides to the left side of the room when facing her from the entrance door. Her roommate who resides at the right side of the room, was not in the room during the wound care. DON, RN B and CNA C were the designated team to provide the wound care. RN B did the wound care with the assistance of CNA C to Resident #3's pressure ulcer to L axilla. The DON supervised the care, occasionally helping them with wound care. DON, RN B and CNA C entered the room and closed the door however did not draw the privacy curtain of Resident #3. This exposed Resident #3's chest area to the entire room and would have been visible to Resident #3's roommate or anyone if they entered the room unexpectedly. During an attempted interaction by the investigator, Resident #3 was not able to answer questions about her right to have privacy. During an interview on 05/24/24 at 2:15PM., CNA C stated the privacy curtain should have been completely closed to prevent Resident #3 from being exposed to the room. CNA C stated the facility provided in-service on privacy however could not remember when it was exactly. During an interview on 05/24/2024 at 2:20 PM, RN B stated, by not pulling the privacy curtain while providing wound care, the privacy and dignity of resident #3 were compromised, as the exposed body of Resident #3 would have been visible to anyone, who entered the room at that time. When asked about the training she received on wound cate, RN B stated she received in-service on resident's rights at least once a year. During an interview with the DON on 05/24/24 at 4:30PM., she stated privacy must be provided during nursing care by drawing the privacy curtain. She stated Resident #3's roommate was the RCR at the facility, was a very active person and go in and out of her room frequently. The DON stated she had many visitors from the community as well as from the facility. Under these circumstances anyone could enter the room without any notice at the time of the wound care. The DON stated the wound care team was very nervous and forgot to draw the privacy curtain. She stated they could have done better to ensure full privacy of Resident # 3 by closing the curtain. During an interview on 05/24/24 at 5:00 pm the ADM stated residents' privacy should be maintained during wound care and other nursing care by closing the room door, window blinds and pulling the curtains. Record review of the in-services records from 01/01/2024 to 05/24/24 revealed there were no in-services conducted on residents' privacy and /or residents' rights during this period. Record review of the facility's policy titled Social Services Manual 2003-Resident Rights, revised on 11/28/16, reflected: The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States . . The resident has a right to be treated with respect and dignity .