Every finding on record at Desoto Retirement & Rehab Ctr, LLC

Based on record review, observations, and interviews the facility failed to provide a sanitary, comfortable, and homelike environment for residents, staff and the public by failing to:1. Remove and replace stained/discolored ceiling tiles, and2. Maintain HVAC ventilation grilles. Findings:Review of the facility's undated Resident Rights policy revealed, in part:.The resident has a right to a safe, clean, comfortable and homelike environment. Observation on 08/25/2026 at 8:35 a.m. revealed front lobby HVAC grille appeared moist, had peeled paint, and had gray/black discoloration. Observation on 08/25/2026 at 8:45 a.m. revealed locked unit lobby HVAC grille had gray/black discoloration, peeled paint and ceiling tile next to HVAC grille had gray/black discoloration. Observation on 08/25/2026 at 8:49 a.m. revealed lobby ceiling tile close to exit sign and nurses' station had gray/black discoloration. Observation on 08/25/2026 at 8:55 a.m. revealed a ceiling tile between room [ROOM NUMBER] and 44 had gray/black discoloration. During an interview on 08/26/2026 at 8:30 a.m. S2 Maintenance confirmed front lobby HVAC grille had peeled paint, gray/black discoloration and was moist. During an interview on 08/26/2026 at 8:35 a.m. S1 Administrator confirmed locked unit lobby HVAC grille had gray/black discoloration and peeled paint and ceiling tile next to HVAC grille had gray/black discoloration. During an interview on 08/26/2026 at 8:38 a.m. S1 Administrator confirmed lobby ceiling tile close to exit sign and nurses' station had gray/black discoloration and a ceiling tile between room [ROOM NUMBER] and 44 had gray/black discoloration. During an interview on 08/26/2026 at 8:40 a.m. S1 Administrator confirmed discolored ceiling tiles, discolored and peeled paint HVAC grilles were not sanitary, homelike, or comfortable for residents and guests.

Based on record review and interviews, the facility failed to refer 1 (#3) of 1 resident with a new diagnosis of schizoaffective disorder for a Level II PASARR.Findings:Review of Resident #3's medical record revealed an admit date of 02/15/2023 with the following diagnoses, including in part: unspecified psychosis not due to a substance or known physiological condition, unspecified mood (affective) disorder. Further review revealed a new diagnosis of schizoaffective disorder dated 12/15/2023.Review of Resident #3's medical record failed to reveal a Level II PASARR referral was completed for a new diagnosis of schizoaffective disorder.During an interview on 04/22/2026 at 10:00 a.m., S1Social Services Director confirmed Resident #3 was admitted on [DATE] and Resident #3 had a new diagnosis of schizoaffective disorder on 12/15/2023. S1Social Services Director acknowledged a Level II PASARR should have been submitted.

Based on record reviews, observations, and interviews the facility failed to protect resident's right to be free from verbal abuse by a staff member for 1 (Resident #2) of 3 sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Findings: Review of the facility's Abuse Prevention and Intervention Policy (undated) revealed in part:Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of Resident #2's medical record revealed an admit date of 09/23/2025 with diagnoses that included but not limited to cerebral infarction of right middle cerebral artery, cerebral vascular accident affecting left non-dominant side, peripheral vascular disease, type 2 diabetes mellitus, hypertensive heart disease, chronic obstructive pulmonary disease, unspecified acute kidney failure, urinary tract infection-site not specified, generalized anxiety disorder, recurrent major depressive disorder, chronic peripheral venous insufficiency, chronic pain syndrome, restless leg syndrome, other abnormalities of gait and mobility, unspecified lack of coordination, generalized muscle weakness, muscle wasting and atrophy, cognitive communication deficit, other symbolic dysfunctions, and unspecified dementia with other behavioral disturbance. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status score of 13 which indicated Resident #2 was cognitively intact. Further review of Resident #2's MDS Assessment revealed Resident #2 had impairment in functional range of motion to upper and lower extremities on one side of her body and required partial to moderate assist with bed mobility and transfers. Review of Resident #2's comprehensive care plan revealed a problem of receiver of verbal abuse revised 11/18/2025. Resident #2's care plan goals included resident will be free from any type of abuse through next review. Resident #2 care plan interventions included: monitor for any psychosocial trauma responses such as increased sadness, crying, loss of appetite; monitor for any type of abuse; and staff in-services provided per protocol. Review of the facility's Self-Reported Incident Management System (SIMS) reports revealed a report initiated 11/07/2025 in part, as follows:Occurred: 10/30/2025Discovered: 10/31/2025Victim: Resident #2Accused: S5 Certified Nursing Assistant (CNA)Allegation: Verbal Abuse-unsubstantiatedProtective Actions: Suspended Pending OutcomeS5 CNA was immediately suspended on 10/31/2025 pending investigation. On 10/31/25 the facility initiated the following: Life satisfaction rounds were implemented on Resident #2 and residents who resided on the secured unit with Resident #2; Hourly nurse rounds on the secure unit were implemented; Statements were obtained from S5 CNA and other staff; In-service training was implemented to staff regarding abuse and customer service; and Life satisfaction rounds continued on 8 residents a week for 8 weeks then randomly. During an interview on 12/02/2025 at 11:40 a.m. with S1 Administrator, S3 Corporate Nurse, and S4 Director of Nursing (DON), S3 Corporate Nurse reported S2 Former Administrator and S4 DON initiated investigation into incident following observation of video involving Resident #2 and S5 CNA that Resident #2's family showed them. S3 Corporate Nurse indicated S4 DON had not viewed the full video. S3 Corporate Nurse reported S2 Former Administrator was terminated as a result of how this incident was handled. S1 Administrator reported he relieved S2 Former Administrator on 11/11/2025 following her termination. S1 Administrator reported on his arrival to the facility he begin speaking with Resident #2's family and the Ombudsman and indicated in speaking with them he realized he did not have all the information related to the incident. S1 Administrator requested the full video from family. S1 Administrator reported after he received and viewed the full video he filed a police report, reopened the SIMS investigation, suspended S5 CNA again, and S5 CNA was terminated following substantiation of verbal abuse. Review of the signed undated statement provided by S5 CNA revealed in part: S5 CNA wrote she entered Resident #2's room at 10:30 p.m. to find Resident #2 was on the mattress on the floor and was wet and dirty. S5 CNA wrote she was upset because Resident #2 was left like that. S5 CNA wrote she was not particularly talking to Resident #2 but was referring to the condition she was in and said I'm sick of this f***ing s**t every night I just got to work. S5 CNA wrote she recalled telling Resident #2 to get on her knees so she could get back in bed. S5 CNA wrote she informed Resident #2 that her back was hurt and she could not pick her up and told Resident #2 several more times to get on her knees so she could get back in bed. S5 CNA wrote Resident #2 was crying that she was trying and she kept telling her to get back on the bed. S5 CNA wrote she did as much as she could to help Resident #2 by adjusting the bed and helping Resident #2 on her weak side. S5 CNA wrote she did not remember cursing Resident #2 directly. During an interview on 12/02/2025 at 2:10 p.m. Resident #2 denied staff ever cursing or talking ugly to her. Resident #2 reported she felt safe and respected. Resident #2 denied feeling disrespected by staff. Resident #2 reported if anyone talked ugly to her she would probably cuss them out. During an interview on 12/02/2025 at 3:30 p.m. Resident #2's mother was at Resident #2's bedside. Resident #2's mother reported she visited Resident #2 daily at various times and had not observed any staff being abusive to Resident #2 or other residents in any way. Resident #2's mother reported Resident #2's sister had video footage she showed the administrator and reported something about a CNA. Resident #2's mother reported she had not viewed the video footage and did not know the details. Resident #2's mother reported she had not noted any changes in Resident #2 following knowledge of the video. Observation on 12/02/2025 at 4:50p.m of the video including audio regarding Resident #2 and S5 CNA with S1 Administrator revealed a 7 minute video in three segments in part as follows:First video segment dated 10/30/2025 at 10:23:30 p.m. revealed in part: S5 CNA entered the room and made a loud statement get you're a** up off the floor got piss all over everything, as soon as I walk in the door there is s**t going on, makes no d*** sense. S5 CNA turned toward the door talking to someone I don't wanna hear nothing S5 CNA continued talking loudly telling Resident #2 to grab onto the bed grab bar and get on her knees. A hand came in view reaching toward the grab bar. Second video segment dated 10/30/2025 at 10:24:40 p.m. revealed in part: S5 CNA continued loudly instructing Resident #2 to just get up in bed. Resident #2 was observed moving toward the grab bar on the bed. Resident #2 stated she couldn't and she was sorry. A voice heard through the video camera talked directly to Resident #2 and asked Resident #2 if she was ok. Resident #2 responded she was ok and S5 CNA continued to instruct Resident #2 to grab the rail and continued to fuss about who left her like she was. The same voice heard through the video camera instructed Resident #2 to grab the bar and pull up back in bed. S5 CNA at that time attempted to assist Resident #2 mid way through Resident #2 crawling back in bed. Resident #2's appeared to be in a short gown or long shirt and Resident #2's brief appeared clean and dry with no signs of urine soakage or feces. S5 CNA continued stating she would find out who left Resident #2 like this and left the room. Resident #2, lying in bed on her left side, continued conversing with voice heard through the video camera. Resident #2 did not appear upset or tearful, continued to interact with S5 CNA in a calm manner. Resident #2 reported she was ok and conversed calmly with the voice on the camera about someone being able to get something and the voice reported they would bring it tomorrow. Third video segment dated 10/30/2025 at 10:30:30 p.m. revealed in part: Resident #2 was observed resting in bed to left side with no conversing going on. S5 CNA walked back into the room and asked Resident #2 was she still talking to her family through the camera. S5 CNA reported she wanted to tell them she was going to find out who left her in that condition. Resident #2 reported she was not still talking to family but they were probably still there and Resident #2 called out to family on video audio with no response and video goes off. Observation on 12/03/2025 at 10:15 a.m. revealed Resident #2 sitting in her wheelchair in the common area of the secured unit with other residents no distress noted. During a telephone interview on 12/03/2025 at 11:54 a.m. S5 CNA reported on 10/30/2025 she got to work and was running late and found out she had to work by herself. Reported she probably got on the locked unit at 10:30 p.m. S5 CNA reported she found Resident #2 on the floor full of feces and urine. S5 CNA reported she said she was sick of this f***ing s**t every night I just got to work and have to deal with this. S5 CNA reported she told Resident #2 to get up and get back in bed so she could change her. S5 CNA reported she knew there was a camera in the room but there was not supposed to be audio and the camera was supposed to be pointed at Resident #2 only. When asked if she had spoken abusively to Resident #2, S5 CNA reported what she said might not have been appropriate but it was said in the heat of the moment and she meant no harm to Resident #2. S5 CNA confirmed she was suspended, then allowed to return to work off of the unit on a different hall. S5 CNA reported then then S1 Administrator suspended her again and she was terminated. S5 CNA reported she made a mistake and should not have vented about frustrations while caring for Resident #2. During a telephone interview on 12/03/2025 at 12:32 p.m. S6 LPN reported she worked on the secured unit with S5 CNA on 10/30/2025. S6 LPN reported she did not know of the incidents that evening. S6 LPN reported she was aware the family had a camera in Resident #2 room but was told there was not supposed to be audio on the camera. S6 LPN reported S5 CNA told her Resident #2 was on the floor mattress wet when she came on and while caring for Resident #2, Resident #2's family started talking through the camera audio. S6 LPN reported when she went to assess Resident #2 no one was talking on the video. S6 LPN reported there were 2 CNAs on the secure unit that evening but could not recall the name of the other CNA. S6 LPN reported she had not witnessed any abusive behavior to a resident by S5 CNA or any other staff and if she were to know of abuse she would report it to administration. During an interview on 12/03/2025 at 1:49 p.m. S4 DON reported she was first made aware of the incident with S5 CNA and Resident #2 on 10/31/2025 when S2 Former Administrator told her Resident #2's sister had texted her about a recording with S5 CNA. S4 DON reported around 4:00 p.m. that day, S2 Former Administrator called her to her office and she and Resident #2's sister were looking at a video recording on Resident #2's sister's phone. S4 DON reported the recording was not a continuous video but Resident #2's sister was scrolling through the recording on her phone. S4 DON reported she heard S5 CNA tell Resident #2 get your ass up get on hour knees so I can help. S4 DON reported she told Resident #2's sister that it was not acceptable for S5 CNA to talk to Resident #2 in that way. S4 DON reported S2 Former Administrator called S5 CNA and S5 CNA reported to them what she later wrote in her statement. S4 DON reported S2 Former Administrator suspended S5 CNA on 10/31/2025 and an investigation was started. S4 DON reported S5 CNA came back to come back to work on 11/01/2025 following completion of life satisfaction rounds with no concerns. S4 DON reported S2 Former Administrator called her into her office on 11/07/2025 and was speaking with the Ombudsman. S4 DON reported S5 CNA was suspended again on 11/7/2025. S4 DON reported at that time she had only seen the video that Resident #2 sister showed in S2 Former Administrator's office and was not sure if S2 Former Administrator had viewed more. S4 DON reported a SIMS report was submitted by S2 Former Administrator and S2 Former Administrator indicated at that time S5 CNA could be brought back to work because they had submitted the report. S4 DON reported the Administrator was the abuse coordinator of the facility and typically initiated SIMS reports. S4 DON reported S2 Former Administrator had a meeting with corporate on 11/10/2025 and did not return. S4 DON reported S1 Administrator came on 11/11/2025. S4 DON reported she did not view the full 7 minute video until 11/17/2025 with S1 Administrator and reported S5 CNA was very inappropriate and it was abuse. S4 DON reported she was suspended for not investigating fully and confirmed she was in-serviced on abuse investigation. During an interview on 12/04/2025 at 11:38 a.m. S4 DON provided staff assignment records and confirmed S5 CNA worked regularly on Sundays through Thursdays was suspended on the following dates 10/31/2025, 11/09/2025, 11/10/2025, 11/15/2025, and 11/16/2025. S4 DON reported when S5 CNA returned to work she was assigned the halls and if she worked the unit was not assigned Resident #2. Observation on 12/08/2025 at 11:30 a.m. revealed Resident #2 eating lunch with other residents in the dining area on the secured unit. Resident #2 appeared calm and no distress was noted. During an interview on 12/08/2025 at 1:10 p.m. Resident #2 denied staff treating her ugly or being abusive in any way. Resident #2 reported her good side was getting better and she was working on pulling herself up. Resident #2 requested to call her sister and staff accommodated her request. During the survey, in-service records and monitoring records were reviewed and it was determined that the facility had implemented the actions to correct the deficient practice prior to surveyor entrance to the facility. Review of the facility's corrective actions plan initiated on 10/31/2025 with a completion date of 11/17/2025 consisted of the following: The accused S5 CNA was first suspended on 10/31/2025 and ultimately terminated on 11/17/2025. On 10/31/2025 the facility initiated the following: Life satisfaction rounds were implemented on Resident #2 and residents who resided on the secured unit with Resident #2; Hourly nurse rounds on the secure unit were implemented; Statements were obtained from S5 CNA and other staff; In-service training was implemented to staff regarding abuse and customer service; and Life satisfaction rounds continued on 8 residents a week for 8 weeks then randomly. On 11/07/2025 additional actions were taken following corporate staff being notified of alleged verbal abuse: S5 CNA was again suspended; Resident #2 life satisfaction round performed with no concerns noted; On 11/10/2025 S2 Former Administrator was terminated; Additional actions taken following additional investigative findings: On 11/15/2025 after receiving full video footage the police were contacted to report suspected abuse; on 11/15/2025 S5 CNA was suspended again pending completion of additional investigation; on 11/17/2025 elderly protective services were notified; On 11/17/2025 S5 CNA was terminated; on 11/17/2025 S4 DON was suspended for 2 days for failure to thoroughly investigate alleged abuse per policy.On 11/17/2025 S1 Administrator, S4 DON, and administrative nurses were in-serviced by S3 Corporate Nurse on facility protocol for abuse investigation. Validation of past non-compliance: Throughout the survey multiple staff interviews confirmed in-service training on abuse and customer service. Results of monitoring were reviewed in daily quality assurance meetings and audit reports were submitted to the administrator and quality assurance and performance improvement committee for new interventions to be implemented as needed.

Based on record reviews and interviews the facility failed to complete required reporting to the State Survey Agency in accordance with State law in a timely manner for 1 (Resident #2) of 2 sampled residents who required reporting to be submitted. The facility failed to report an allegation of verbal abuse from a staff member to Resident #2 within 2 hours after the allegation was made.Findings: Review of the facility's Abuse Prevention and Intervention Policy (undated) revealed in part:Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.Policy Explanation and Compliance Guidelines:2. The facility has designated the Administrator as the Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the facility's Self-Reported Incident Management System (SIMS) reports for the past 6 months revealed the following SIMS:Allegation: Verbal AbuseEntered: 11/07/2025 3:49 p.m.Occurred: 10/30/2025Discovered: 10/31/2025 4:47 p.m. Report due date: 11/18/2025Victim: Resident #2Accused: S5 Certified Nursing Assistant (CNA)Incident Description (in part): Resident #2's sister presented the facility with video recording of S5 CNA repeatedly told Resident #2 come on Resident #2, get your a** up'. S2 Former Administrator and S4 Director of Nursing (DON) assured Resident #2's sister that S5 CNA did act in an unprofessional manner and was not providing quality customer service. At this time an investigation was initiated and S5 CNA was suspended pending investigation to rule out abuse. Observation on 12/02/2025 at 4:50p.m of the video including audio regarding Resident #2 and S5 CNA with S1 Administrator revealed a 7 minute video in part as follows:Video segment dated 10/30/2025 at 10:23:30 p.m. revealed in part: S5 CNA entered the room and made a loud statement get you're a** up off the floor got piss all over everything, as soon as I walk in the door there is s**t going on, makes no d***sense. S5 CNA turned toward the door talking to someone I don't wanna hear nothing S5 CNA continued talking loudly telling Resident #2 to grab onto the bed grab bar and get on her knees. A hand came in view reaching toward the grab bar. During an interview on 12/03/2025 at 1:49 p.m. S4 DON reported the abuse coordinator for the facility was the administrator and the administrator entered SIMS reports in the system. S4 DON reported S2 Former Administrator was terminated on 11/10/2025. S4 DON reported she and S2 Former Administrator were made aware of the verbal abuse allegation incident between S5 CNA and Resident #2 by Resident #2's sister on 10/31/2025. S4 DON acknowledged the SIMS report was not entered into the system and reported until 11/07/2025 and should have been entered and reported on 10/31/2025 within 2 hours of the allegation being made.

Based on record review and interview the facility failed to ensure resident's assessments accurately reflected the resident's status during the observation period for 3 (#5, #21, #50) of 18 (#5, #15, #21, #22, #24, #28, #35, #38, #41, #43, #49, #50, #58, #63, #66, #67, #118, #119) residents reviewed for assessment. The facility failed to ensure the MDS (Minimum Data Set) were coded accurately for restraints and use of bedrails. Findings: Resident #5 Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses that include in part, major depressive disorder, anxiety disorder, pain and paranoid schizophrenia. Review of Resident 5's physician orders revealed an order dated 7/27/2024: 1/4 side rails up times 2 to assist with bed mobility Review of the Resident #5's MDS dated [DATE] revealed Resident #5 had a BIMS (Brief interview for mental status) score of 6 out of 15 indicating severely impaired mental cognition. Further review revealed Resident #5 was impaired on one side to upper and lower extremities and required extensive 1 person physical assistance for bed mobility. Review of Resident #5's MDS indicated bed rails were not in use. Resident #21 Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses that include in part, transient cerebral ischemic attack, malignant neoplasm of unspecified site of right female breast, rheumatoid arthritis, and history of falling. Review of Resident 21's physician orders revealed an order dated 7/27/2024: 1/4 rails to aide in bed mobility. Review of Resident #21's quarterly MDS dated [DATE] revealed Resident #21 had a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Further review revealed Resident #21 was dependent for toileting, and hygiene. Review of Resident #21's MDS indicated bed rails were not in use. Resident #50 Review of Resident #50's medical record revealed an admitted [DATE] with diagnoses that include in part parkinsonism, schizoaffective disorder, dementia-severe with agitation, major depressive disorder and chronic kidney disease stage 3B. Review of Resident #50's physician orders revealed an order dated 12/30/2024: enablers times 2 to aide in bed mobility and safety. Review of Resident #50's annual MDS dated [DATE] revealed Resident #50 had a BIMS score of 10 out of 15 indicating moderate cognitive impairment. Further review revealed Resident #50 required limited 1 person assistance with bed mobility and transfers with substantial maximum assistance with toileting. Review of Resident #50's MDS indicated bed rails were not in use. During an interview on 02/19/2025 at 11:40 a.m. S4MDS reviewed Resident #5, Resident #21 and Resident #50's physician orders and MDS assessments for restraints and verified it did not include the use of bedrails and should have.

Based on record reviews and interview, the facility failed to develop a comprehensive person- centered care plan to meet the resident's medical, nursing and mental and psychosocial needs for 2 (#28, #118) out of 31 sampled residents reviewed. Findings: Resident #28 Review of Resident #28's medical records revealed an admitted [DATE] with the following diagnoses, including in part: chronic obstructive pulmonary disease/unspecified, type 2 diabetes mellitus without complications, acquired absence of left leg below knee, peripheral vascular disease/unspecified, unspecified lack of coordination, personal history of other venous thrombosis and embolism, transient ischemic attach (TIA), cerebral infarction without residual deficits and unspecified abnormalities of gait and mobility. Review of Resident #28's comprehensive care plan failed to include problems and approaches for oxygen therapy, type 2 diabetes mellitus, hypertension,activities of daily living self-care deficit, impaired mobility/amputation, anticoagulant therapy, unsafe smoker and diuretic use. During an interview on 02/19/2025 at 9:30 a.m. S4 MDS acknowledged Resident #28's comprehensive care plan did not include oxygen therapy, type 2 diabetes mellitus, hypertension, activities of daily living self-care deficit, impaired mobility/amputation, anticoagulant therapy, unsafe smoker and diuretic use and should have. Resident 118 Review of Resident #118's medical records revealed an admitted [DATE] with the following diagnoses, including in part: hypertensive heart disease without heart failure, obesity/unspecified, anemia/unspecified, and insomnia/unspecified. Review of Resident #118's comprehensive care plan failed to problem and approaches for include nutrition, hypertension, insomnia and anemia. During an interview on 02/19/2025 at 9:30 a.m. S4 MDS (Minimum Data Set) acknowledged Resident #118's comprehensive care plan was not complete and did not include nutrition, hypertension, insomnia and anemia and should have.

Based on record review, observations, and interviews the facility failed to ensure a resident who is unable to carry out ADLs (activities of daily living) received the necessary services to maintain good grooming and personal hygiene for 2 (#43, #63) of 5 (#28, #38, #43, #63, #119) residents reviewed for activities of daily living. The facility failed to ensure residents received nail care. Findings: Review of the facility's Nail Care Policy (un-dated) provided by S2 DON on 02/19/2025 revealed the following: The purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and inspection of nails will be provided during activities of daily living care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail care will be provided between scheduled occasions as the need arises. 3. Principles of Nail care: a. Nails should be kept smooth to avoid skin injury b. Only licensed nurses shall trim or file fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems should only be filed only. c. If a resident has a toe infection, diabetes mellitus, neurologic disorders, renal failure, or PVD (peripheral vascular disease), toenail trimming should be performed by a physician or practitioner. Resident #43 Review of Resident #43's medical record revealed an admitted [DATE] with a diagnosis of but not limited to cerebrovascular disease affecting left non-dominant, heart failure, epilepsy, chronic atrial fibrillation, and end stage renal disease. Review of Resident #43's MDS (Minimum Data Set) revealed resident #43 was assessed to have a BIMS (Brief Interview Mental Status) score of 11 indicating moderately impaired cognition. Further review revealed resident #43 was assessed to be dependent and required assistance to complete bathing, dressing/grooming, and using the toilet. Review of Resident #43's Comprehensive Care Plan revealed the following: Imapired Physical Mobility related to a diagnosis cerebrovascular accident with left sided hemiplegia: resident requires extensive assistance with bed mobility and dressing/grooming tasks. Observation on 02/17/2025 at 11:30 a.m. with S2 DON revealed Resident #43's fingernails had a brown colored substance underneath the nails and protruded past the nail bed on both hands. During an interview on 02/17/2025 at 11:30 a.m. in the presence of S2 DON, Resident #43 answered, Yes when asked do you want your fingernails trimmed? During an interview on 02/18/2025 at 2:00 p.m. S2 DON confirmed resident #43's fingernails should have been trimmed. Resident #63 Review of Resident # 63's medical record revealed an admitted [DATE] with diagnoses of but not limited to wedge compression fracture of T5-T6 vertebra, subsequent encounter for fracture with routine healing, need for assistance with personal care, unspecified lack of coordination, and generalized muscle weakness. Review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #63's Comprehensive Care Plan revealed Resident #63 had impaired mobility with interventions to assist with ADL's as needed. Observation on 02/17/2025 at 9:30 a.m. revealed Resident #63's toenails were long and had grown over the nail bed. During an interview on 02/17/2025 at 9:30 a.m. Resident #63 reported she did not like her toe nails that long. Observation of Resident #63's toenails with S5 LPN on 02/18/2025 at 3:45 p.m. revealed Resident #63's toe nails were long and grown over the nail bed. During an interview on 02/18/2025 at 3:45 p.m. S5 LPN confirmed Resident #63's toe nails were long and needed to be trimmed. 36921

Based on record reviews, observations, and interviews, the facility failed to ensure 1 (#49) of 1 resident reviewed for limited range of motion received treatment and care in accordance with professional standards of practice by failing to follow physician orders for a palm protector for Resident #49's right contracted hand, accurately assess Resident #49's limitation in range of motion and for refusals of care and services and ensure Resident #49's fingernails were trimmed. Findings: Review of Resident #49's face sheet revealed an initial admitted [DATE] and a re-entry admitted [DATE] with the following diagnoses but not limited to end stage renal disease, hypertensive heart disease without heart failure, and major depressive disorder. Review of Resident #49's February 2025 physician orders dated 11/05/2024 for palm protector to right hand as tolerated and to monitor skin integrity to right hand every day for signs and symptoms of status change related to palm protector use; one time a day for prevention. Review of Resident #49's Quarterly MDS (Minimum Data Sets) dated 12/28/2024 revealed a BIMS (Brief Interview of Mental Status) of 11 out of 15 indicating moderately impaired cognition. Review of Resident #49's Quarterly MDS failed to reveal Resident #49 rejected care. Further review of Resident #49's Quarterly MDS revealed Resident #49 had no limitation in range of motion to upper and lower extremities. Review of Resident #49's care plan revealed the Resident #49 has limited physical mobility with a goal to remain free of complications related to immobility, including contractures and was at risk for impaired skin integrity related to history of skin breakdown, altered cognition, decreased mobility and poor circulation with interventions to monitor skin integrity every day related to usage of right hand palm protector; palm protector to right hand as tolerated. Further review of Resident #49's medical record failed to reveal refusal of care or attempts of wearing the palm protector to the right hand. Observation of signage above Resident #49's bed revealed: Put my palm protector on right hand. Observation on 02/17/2025 at 3:00 P.M. failed to reveal the palm protector on Resident #49's contracted right hand. Observation on 02/18/2025 at 3:45 P.M. with S5 LPN (Licensed Practical Nurse) failed to reveal the palm protector on Resident #49's contracted right hand. Further observation revealed S5 LPN attempted to open Resident #49's tightly closed hand to assess his palm revealed Resident #49 grimaced and said ouch. Observation when S5 LPN slightly opened Resident #49's hand revealed discolored, thick and long fingernails had grown over the nail bed. During an interview on 02/18/2025 at 3:45 P.M. Resident #49 reported he did not wear the palm protector on his right palm. Resident #49 further reported he did not know where the palm protector was. During an interview on 02/18/2025 at 3:45 P.M. S5 LPN reported Resident #49 wears the palm protector sometimes and refuses sometimes, but was unable to recall the last time Resident #49 actually wore the palm protector. S5 LPN was unable to locate Resident #49's palm protector. S5 LPN reported Resident #49's care plan should be updated after MDS reviewed the nurses daily charting and morning meetings to see how often Resident #49 refused care/palm protector. S5 LPN acknowledged Resident #49's fingernails were long and had grown over the nail bed and could cause skin breakdown in Resident #49's contracted hand.

Based on observations, record review and interviews the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were accurately assessed for the risk of entrapment from bed rails and an informed consent was obtained from resident or resident representative prior to installation for 2 (#43, #63) of 5 (#5, #21, #41, #43, #63) residents reviewed for bed rails. Findings: Review of the facility's Bed Rail policy (undated) revealed the following: If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails including but not limited to the following elements: a. assess the resident for risk for entrapment from bed rails prior to installation b. review risk an benefits of bed rails with the resident size and weight c. the facility must document in the residents care plan specific interventions and services for use of a bed rail. Resident #43 Review of Resident #43's medical record revealed an admitted [DATE] with a diagnosis of but not limited to cerebrovascular disease affecting left non-dominant, heart failure, epilepsy, chronic atrial fibrillation, and end stage renal disease. Review of Resident #43's MDS (Minimum Data Set) revealed resident #43 was assessed to have a BIMS (Brief Interview Mental Status) score of 11 indicating moderately impaired cognition. Further review revealed Resident #43 was assessed to be dependent and required two person assistance with bed mobility. Observation on 02/17/2025 at 8:30 a.m. revealed Resident #43 had bilateral bed rails on his bed. Observation on 02/18/2025 at 4:00 p.m. revealed Resident #43 in bed with both bed rails up. Review of Resident #43's Comprehensive Care Plan failed to reveal a problem with interventions specific for bed rail use. Review of Resident #43's Medical Record failed to reveal a signed consent for bed rail use. Resident #63 Review of Resident # 63's medical record revealed an admitted [DATE] with diagnoses of but not limited to wedge compression fracture of T5-T6 vertebra, subsequent encounter for fracture with routine healing, need for assistance with personal care, unspecified lack of coordination, and generalized muscle weakness. Review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further review revealed Resident #63 was assessed to require 1/4 (quarter) side rails up times two to assist with bed mobility. Observation on 02/17/2025 at 9:30 a.m. revealed Resident #63 had raised quarter side rails to both sides of the bed. Review of Resident #63's Comprehensive Care Plan failed to reveal a problem with interventions specific for quarter side rail use. Review of Resident #63's medical record failed to reveal a signed consent for the use of quarter side rails. Further review of Resident #63's medical record failed to reveal an assessment for risk for entrapment was done prior to installation of quarter side rails. During an interview on 02/19/2025 at 9:45 a.m. S2 DON (Director of Nurses) confirmed resident #43 and Resident #63's care plan did not a problem with interventions specific for bedrail use and did not have a signed consent for bed rail use. S2 DON also confirmed Resident #63 did not have a risk for entrapment assessment done prior to installation of bed rails. 36921 39897

Based on record reviews, observations and interviews, the facility failed to ensure nursing staff provided nursing services to assure residents maintained the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by individual plans of care. The facility failed to ensure medication was administered prior to documentation of medication for Resident #24 and proper storage of medication for Resident #26. Findings: Resident #24 Observation of medication administration on 02/17/2025 at 3:38 P.M. revealed S3 LPN (License Practical Nurse) administered Sucralfate 1gm to Resident #24. Review of Resident #24's EMAR (electronic medication administration record) revealed S3 LPN signed off on 4:30 P.M. administration of 8 units of Humalog (Insulin Lispro) per sliding scale. During an interview on 02/17/2025 at 3:50 P.M. S3 LPN reported she had not administered Humalog (Insulin Lispro) to Resident #24 that was due at 4:30 P.M. S3 LPN reported Resident #24's blood sugar was 310 when checked earlier. S3 LPN further reported Resident #24 would require 8 units of Humalog (Insulin Lispro) that would be administered closer to meal time. During an interview on 02/19/2025 at 11:40 A.M. S2 DON (Director of Nursing) confirmed medications should not be documented in the EMAR (Electronic Medication Administration Record) until they are actually given. Resident #26 Observation of medication administration on 02/18/2025 at 8:45 A.M. with S5 LPN revealed Resident # 26's Fluticasone-Salmeterol Inhaler Aerosol 115-21 MCG (microgram) medication was not available on the medication cart. Further observation revealed Fluticasone-Salmeterol Inhaler Aerosol 115-21 MCG was in Resident #26's room. During an interview on 02/28/2025 at 8:45 A.M. S5 LPN confirmed Fluticasone-Salmeterol Inhaler Aerosol 115-21 MCG should be stored on the medication cart and not in Resident #26's room. During an interview on 02/19/2025 at 11:40 AM S2 DON reported Resident # 26 did not have an order for self-administration of Fluticasone-Salmeterol Inhaler Aerosol 115-21 MCG and should not have been kept in Resident # 26's room.

Based on record review, observations and intreviews, the facility failed to provide current pharmaceutical services to meet the needs of each resident as evidenced by having expired medications available for resident use on 2 of 2 medication carts in the facility. Findings: Review of facility's policy for Medications - Administering (not dated) revealed: Policy statement: Medications shall be administered in a safe and timely manner, and as prescribed. Expiration/Beyond Use Dates: 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Observation of the Medication Cart 1 for Hall 1 on 02/17/2025 at 10:15 A.M. with S5 LPN (Licensed Practical Nurse) revealed Vitamin D 25 mcg (microgram) had a best used by date of 01/2025. During an interview on 02/17/2025 at 10:15 A.M. S5 LPN confirmed Vitamin D 25 mcg was expired and should not have been available on the medication cart for usage. Observation of the Medication Cart for Hall 2 on 02/17/2025 at 10:25 A.M. with S3 LPN revealed Vitamin D 25 mcg had a best used by date of 01/2025. During an interview on 02/17/2025 at 10:25 A.M. S3 LPN confirmed Vitamin D 25 mcg was expired and should not have been available on the medication cart for usage. During an interview on 02/19/2025 at 1:45 P.M. S2 DON (Director of Nursing) reported the facility medication carts should have been checked at the end of each month and expired medications should have been discarded.

Based on record reviews, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices to prevent infection and cross contamination. The facility failed to ensure (1) incontinence care was provided in a sanitary manner for Resident #62 that was observed for incontinence, and (2) proper storage of patient equipment Findings: Review of facility's Incontinence Care policy (undated) revealed: Equipment and Supplies: 2. wash basin; wash clothes 3. Incontinent brief (disposable or cloth) 4. non-drying soap and water and/or incontinence spray cleaner (periwash) 6. plastic bag for soled linen Steps in Procedure: 3. Fill the wash basin with warm water. (Note: If a premixed solution is used, run warm water over the container to assure that the solution is warm). 5. Place plastic bag within reach to hold soiled linen and laundry. 11. Place disposable items into special waste container. 13. Remove gloves and discard into appropriate receptacle. 15. wash hands 1. Review of Resident #62's face sheet revealed an admitted [DATE] with unspecified macular degeneration, and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of Admission MDS (Minimum Data Sets) dated 11/25/2024 revealed a BIMS (Brief Interview of Mental Status) of 10 out of 15 indicating moderately impaired cognition. Review of Resident #62's baseline care plan revealed Resident #62 required extensive assistance to total assistant with grooming and hygiene. Observation of incontinence care on 02/19/2025 at 9:36 A.M. revealed S6 CNA (Certified Nurse Assistant) performed incontinence care on Resident #62. Further observation revealed before S6 CNA entered Resident #62's room she stopped by the linen cart and retrieved three towels and a draw pad used to protect the bed during incontinent episodes. S6 CNA then put on gloves and placed one small bath towel, and draw pad on Resident #62's over bed table along with Resident #62's personal items that were already on the over bed table. S6 CNA went into Resident #62's bathroom to wet the towels and apply soap. S6 CNA then placed the two wet towels on Resident #62's over bed table. S6 CNA performed perineal care to Resident #62 with one of the wet towels then dried the perineal area and placed the used towel on Resident #62's over bed table. S6 CNA then proceeded to clean the perineal area with the second wet towel and placed the used towel on Resident #62's over bed table. S6 CNA assisted Resident #62 in turning to his right side. S6 CNA then removed Resident #62's incontinence brief and placed the used incontinence brief on the floor. S6 CNA then reused the towels that were placed on Resident #62's over bed table that were used to clean Resident #62's perineal area to clean Resident #62's buttocks and rectal area. After cleaning Resident #62's buttocks and rectal area and removing the dirty incontinence brief and draw pad, S6 CNA placed the dirty incontinence brief, draw pad and towels that were used during incontinent care on the floor. S6 CNA then placed a clean incontinence brief on Resident #62 and a clean draw pad under Resident #62. Further observation revealed S6 CNA then lowered Resident #62's bed using bed remote, pulled the string to turn off the lights over Resident #62's bed, pulled the curtain, opened the door touching the door knob with the same gloves that were used to provide incontinence care to Resident #62. During an interview on 02/19/2025 at 2:44 P.M. S2 DON (Director od Nursing) reported dirty incontinence briefs and dirty linen should not have been placed on Resident #62's overbed table or on the floor. During an interview on 02/19/2025 at 2:58 P.M. S7 LPN (Licensed Practical Nurse)/CNA Instructor reported S6 CNA should have used a water basin to provide incontinence care. S7 LPN/CNA Instructor reported dirty linen used during incontinence care should have been placed in a trash bag or pillow case. S7 LPN/CNA Instructor reported S6 CNA should have changed gloves at appropriate times during and after incontinence care before touching Resident #62's personal items to prevent cross contamination. 2. Observation on 02/17/2025 at 9:00 A.M. of the secured unit revealed a water cooler with ice used for resident drinking was stored in an occupied resident's room. During an interview on 02/17/2025 at 9:15 A.M. S8 CNA confirmed the water cooler with ice was stored in an occupied resident's room at this time. S8 CNA reported there is no where else to store the water cooler on the secured unit. During an interview on 02/19/2025 at 3:50 PM S2 DON reported there were 19 residents on the locked unit. S2 DON further reported the water cooler with ice for residents on the secured unit should be stored on the hallway and not in a resident's room.

Based on record review and interview, the facility failed to transmit within 7 days after a completed resident's assessment for 1 (#118) resident out of 31 sampled residents reviewed. Findings: Review of Resident #118's medical records revealed an admitted [DATE] with the following diagnoses, including in part: hypertensive heart disease without heart failure, obesity/unspecified, anemia/unspecified, and insomnia/unspecified. Review of Resident #118's MDS (Minimum Data Set) assessment dated [DATE] revealed the status was in progress. During an interview on 02/19/2025 at 9:30 a.m. S4 MDS acknowledged Resident #118's MDS assessment dated [DATE] was completed but had not been transmitted and it should have been.

Based on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (#119) resident out of 31 sampled residents reviewed. Findings: Review of Resident #119's medical records revealed an admitted [DATE] with the following diagnoses, including in part: unspecified protein-calorie malnutrition, generalized anxiety disorder, undifferentiated schizophrenia, unspecified dementia with agitation, anorexia, other specified extrapyramidal and movement disorders, major depressive disorder/recurrent/moderate, impulsive disorder/unspecified, and gastrostomy status. Review of Resident #119's medical record failed to reveal a baseline care plan was completed on admission. During an interview on 02/19/2025 at 9:30 a.m. S4 MDS (Minimum Data Set) acknowledged Resident #119 did not have a baseline care plan developed on admission and should have.

Based on observations, interviews and record reviews the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#28) out of 1 (#28) residents reviewed for respiratory care. The facility failed to ensure oxygen concentrator filter was cleaned weekly. Findings: Review of Facility's Respiratory Equipment - Infection Control Guidelines dated June 2024 revealed: Oxygen concentrators, nebulizers, suction machines. The nursing department is responsible for all the following except: 3. Housekeeping will be responsible to clean oxygen concentrator filters weekly. Oxygen concentrators: 4. Rinse filters from oxygen concentrators weekly in water. Squeeze dry and return to use. Review of Resident #28 medical records revealed an admitted [DATE] with the following diagnoses, including in part: chronic obstructive pulmonary disease (COPD)/unspecified. Review of Resident #28 Physician's orders revealed an order dated 01/20/2025 for O2 (oxygen) at 2 liters/NC (nasal cannula) PRN (as needed) shortness of breath or O2 sat (saturation) < 90% every 1 hours related to chronic obstructive pulmonary disease/unspecified. Observation on 02/17/2025 at 8:30 a.m. revealed Resident #28 wearing continuous oxygen at 2 liters per minute via nasal cannula. Further observation revealed oxygen concentrator filter with moderate amount of fluffy gray particles. Observation on 02/17/2025 at 2:45 p.m. revealed Resident #28 wearing continuous oxygen via nasal cannula. Further observation revealed oxygen concentrator filter with moderate amount of fluffy gray particles Observation on 02/18/2025 at 9:20 a.m. revealed Resident #28 lying asleep in bed wearing continuous oxygen via nasal cannula. Further observation revealed oxygen concentrator filter with moderate amount of fluffy gray particles. During an interview on 02/18/2025 at 9:30 a.m. S3 LPN (Licensed Practical Nurse) acknowledged Resident #28's oxygen concentrator filter was dirty and should have been cleaned. During an interview on 02/18/2025 at 9:30 a.m. S2 DON (Director of Nursing) acknowledged Resident #28's oxygen concentrator filter was dirty.

Based on record review and interview, the facility failed to ensure a quarterly assessment was completed for 1 (#57) out of 2 (#41, #57) residents reviewed for resident assessment. Findings: Review of Resident #57's Medical Record revealed an admitted [DATE] with the following diagnoses, in part: alcoholic cirrhosis of liver without ascites, chronic viral hepatitis C, and adult failure to thrive. Review of Resident #57's MDS (Minimum Data Set) Assessments revealed yearly assessment completed 10/17/2023, a significant change assessment completed 10/25/2023, and failed to reveal a MDS Quarterly Assessment was completed. During an interview on 03/20/2024 at 9:50 a.m. S1 DON (Director of Nursing) acknowledged Resident #57 has not had a MDS Assessment completed since 10/25/2023 and should have.

Based on record review and interview, the facility failed to ensure an accurate assessment was completed for 1 (#41) out of 2 (#41, #57) residents reviewed for resident assessment. Findings: Review of Resident #41's Medical Record revealed an admitted [DATE] and discharge date of [DATE] with the following diagnoses, in part: chronic obstructive pulmonary disease/unspecified, cognitive communication deficit and unspecified sequelae of cerebral infarction. Review of Resident #41's MDS (Minimum Data Set) Assessments revealed last assessment completed was on [DATE]. Review of Resident #41's notes dated [DATE] at 1:26 a.m. - revealed in part, resident pronounced deceased at 11:32 pm ([DATE]) During an interview on [DATE] at 9:50 a.m. S1 DON (Director of Nursing) acknowledged Resident #41 doses not have an accurate MDS Assessment completed following discharge on [DATE] and should have.

Based on record review, observation, and interview, the facility failed to ensure services were provided according to the resident's plan of care for 1 (#41) resident out of 5 (#4, #5, #41, #42, #50) residents reviewed for accidents. The facility failed to implement physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the record for Resident #41 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) dated 2/4/22 revealed Resident #41 required extensive assistance by one person with bed mobility, transferring, and toilet use. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3/1/22-Mattress at bedside 5/4/21-Pressure relief scoop mattress to bed 11/5/19-Anti roll back device to wheelchair Review of the medical record revealed Resident #41 was care planned for falls with approaches that included, in part, assistance by one staff member with ambulation, scoop mattress, fluorescent tape to call light, and fall mat replaced with a mattress. Observations on 3/13/22 at 12:12 PM, 3/14/22 at 8:50 AM, 11:25 AM, and 3:51 PM, and 3/15/22 at 7:45 AM and 9:38 AM revealed resident did not have a scoop mattress, a mattress on the floor by the bed, fluorescent tape to the call light, or an anti-roll back device to resident's wheelchair. Review of the incident and accident reports revealed Resident #41 had 11 falls in the past 120 days. During an interview on 3/15/22 at 9:38 AM, S1 DON (Director of Nurses) confirmed Resident #41 did not have a scoop mattress on the bed, a mattress on the floor by the bed, fluorescent tape to the call light, or an anti-roll back device to the resident's wheelchair. S1 DON confirmed these interventions were part of Resident #41's care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interview and record reviews the facility failed to provide necessary care and services in accordance to the professional standards of practice for 1 (#5) of 2 (#5, #18) residents observed regarding Respiratory Care. The facility failed to replace a disposable humidifier bottle that water level had fallen below the fill line. Findings: Review of facility's Oxygen Administration Policy revealed the following: Oxygen Administration Safety and Guidelines #11. Maintain the water level in the bottle high enough so that the water bubbles as the oxygen goes through it. #19. If disposable humidifier bottles are used replace when water level falls below the fill line. Observation on 3/14/2022 at 10:30 am revealed the water level in resident #5's disposable humidifier bottle had fallen below the fill line and needed to be replaced. During an interview on 3/14/2022 at 11:00 am S1 DON (Director of Nursing) confirmed resident #5's humidifier bottle was disposable and should have been replaced by S2 Infection Control Preventionist. Review of resident #5's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to ensure that a resident who required [MEDICAL TREATMENT] received services consistent with professional standards of practice for 1 (#59) of 1 (#59) resident reviewed for [MEDICAL TREATMENT] by failing to: 1. Communicate and collaborate with the [MEDICAL TREATMENT] facility and 2. Monitor the resident for complications before and after [MEDICAL TREATMENT] treatments. The facility reported 1 resident currently received [MEDICAL TREATMENT]. Findings: Review of Resident #59's medical record revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #59's physician's orders [REDACTED].>Review of Resident #59's Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 4, which indicated the resident had severe cognitive impairment. 1. Review of Resident #59's medical chart revealed the most recent [MEDICAL TREATMENT] communication sheet in chart was dated 11/23/2018. Interview on 11/18/2020 at 2:22PM, S1 DON (Director of Nurses) stated [MEDICAL TREATMENT] communication forms are kept in the resident's chart. S1 DON acknowledged no [MEDICAL TREATMENT] communication forms were found in Resident #59's chart since 11/23/18 because the [MEDICAL TREATMENT] center does not send it back very often. Interview on 11/18/2020 at 02:32 PM, S3 LPN (Licensed Practical Nurse) confirmed [MEDICAL TREATMENT] communication forms are kept in the resident's chart and [MEDICAL TREATMENT] doesn't ever send the form back with the resident. S3 LPN explained if there is a problem, [MEDICAL TREATMENT] will call the nursing facility and let them know. Interview on 11/19/2020 at 10:14AM, S4 LPN provided surveyor with two [MEDICAL TREATMENT] communication forms dated 11/9/2020 and 11/18/2020, which were incomplete. S4 LPN confirmed those were the only two she could find explaining they were not done because the facility was short staffed. 2. Review of the medical record revealed no documentation of Resident #59's blood pressure being taken before or after [MEDICAL TREATMENT]. Interview at 11:00AM on 11/19/2020, S1 DON confirmed the two [MEDICAL TREATMENT] communication forms provided were the only [MEDICAL TREATMENT] communication forms done recently and she could not find any documentation of the resident's blood pressure being taken before or after [MEDICAL TREATMENT].