Every finding on record at Diversicare of Eupora

Based on staff interview, record review, monthly pharmacy reviews, and facility policy review, the facility failed to ensure its pharmacy services and drug regimen review process identified and addressed irregularities in as needed (PRN) opioid medication documentation for 13 of 25 residents on medication cart B. Resident #9, #12, #22, #27, #38, #43, #44, #47, #61, #65, #68, #95 and unsampled Resident D. Findings Include:Review of the facility policy titled Drug Regimen Review reviewed 4/23, revealed under, Policy: Drug Regimen Review consists of a review and analysis of prescribed medication therapy and medication use, including nursing documentation, medication ordering, and administration. The Consultant Pharmacist reviews the medication regimen and medical record of each resident at least monthly. Recommendations and identified irregularities are reported in writing to the Director of Nursing, the Attending Physician, and the Medical Director.Record reviews of the January and February 2026 Medication Administration Record (MARs) revealed 13 residents had active physician orders for PRN opioid pain medications, including Norco (12 residents) and Oxycodone (1 resident).Review of the January and February 2026 MARs for 13 residents receiving PRN pain medication revealed repeated documentation of administration to multiple residents at identical times on numerous dates across different rooms throughout both months by Licensed Practical Nurse (LPN #3). The highest cluster occurred on 2/21 and 2/22, where PRN pain medication was documented for 12 residents at 7:01 AM. This documentation did not reflect real-time documentation of medication administration times.Record review of the Proper Name of Pharmacy Services Monthly Consultant Review dated October 2025 revealed a med pass observation - Med Preparation & MAR documentation audit was conducted with LPN #3. The nurse did not check meds against MAR prior to administering them, did not document them as administered directly after giving the meds to the patient.Record review of the Monthly Consultant Pharmacist Review dated December 2025, January 2026 and February 2026 revealed a drug regimen review was conducted for all the residents residing in the facility. MARS were reviewed for appropriate documentation along with an evaluation of PRN medication usage with documentation.Record review of the Controlled Substance Inventory Record dated 12/04/25 for Resident #9 revealed a narcotic sign out sheet for Norco 5/325 quantity 60 pills with sign out times by LPN #3 of 0700, 1230 and 1830 for 58 of the 60 doses given. LPN #3 had signed out 58 of the 60 doses as administered by her to Resident #9.An interview with the Pharmacy Consultant, on 2/25/26 at 10:55 AM revealed that she came monthly and reviewed the medication dispensing machine, the medication rooms, the medication carts, did medication pass observations with the nurses, and conducted medication cart audits and narcotic log audits. She revealed that she did the monthly medication regimen reviews for the residents to ensure that PRN pain medication was documented accurately. She revealed that she did audit the narcotic log and stated that she had noticed one nurse (LPN#3) had signed out narcotics frequently and had made a note of this in her cover page in October 2025 and let the Director of Nursing (DON) know. She stated that she did a medication pass with LPN #3 in October, and during that time, she noted that the nurse did not compare the medications to the MAR prior to administering and she did not sign the medications out immediately after administering them. She revealed that they had not identified any narcotic discrepancies or concerns with the PRN pain medications during the monthly regimen reviews conducted. But she did confirm that she had reviewed the Controlled Substance Inventory Record dated 12/04/25 for Resident #9 and had noted that LPN #3 had signed for 58 of the 60 doses and she had brought it up in her exit meeting with the Administrator and the DON.A telephone interview with Licensed Practical Nurse (LPN) #3 on 2/27/26 at 9:13 AM revealed she administered all PRN pain medication during routine medication pass (morning, noon, and evening) and selected one set time for all residents (referring to repeated documented times of 7:01 AM and 12:31 PM) so residents could receive medication again depending on physician orders. LPN #3 confirmed the residents' medical records did not accurately reflect actual administration time. She stated this was not how she had been trained to administer medication and should be charting the medications immediately after giving them.An interview with the DON on 2/27/26 at 3:30 PM confirmed that after reviewing all 13 residents' MARs a pattern of documentation inconsistencies related to LPN #3 was identified. She stated the nurse had worked at the facility for 11 years and had prior medication documentation issues, for which a medication administration competency had recently been completed. The DON revealed the facility had not identified any pain medication irregularities with LPN #3 and confirmed that the facility failed to identify narcotic documentation irregularities.Record review of the admission Record revealed the facility admitted Resident #9 on 10/17/23 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #9 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #12 on 8/10/21 with medical diagnoses that included Chronic Respiratory Failure.Record review of the MDS with an ARD of 1/22/26 revealed under section C, a BIMS summary score of 15, indicating Resident #12 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #22 on 3/17/16 with a medical diagnosis that included Unspecified Dementia.Record review of the MDS with an ARD date of 12/12/26 revealed under section C, a BIMS summary score of 2, indicating Resident #22 was severely cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #27 on 8/6/25 with medical diagnoses that included Peripheral Vascular Disease.Record review of the MDS with an ARD of 2/13/26 revealed under section C, a BIMS summary score of 11, indicating Resident #27 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #38 on 2/9/23 with medical diagnoses that included Nonalcoholic Steatohepatitis.Record review of the MDS with an ARD date of 1/15/26 revealed under section C, a BIMS summary score of 15, indicating Resident #38 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #43 on 2/13/26 with medical diagnoses that included Encounter for other Specified Surgical Aftercare.Record review of the MDS with an ARD of 2/19/26 revealed under section C, a BIMS summary score of 15, indicating Resident # 43 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #44 on 2/12/26 with medical diagnoses that included Pain and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 2/18/26 revealed under section C, a BIMS summary score of 10, indicating Resident #44 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #47 on 10/21/21 with medical diagnoses that included Chronic Diastolic (Congestive) Heart Failure.Record review of the MDS with an ARD of 2/6/26 revealed under section C, a BIMS summary score of 11, indicating Resident # 47 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #61 on 4/14/23 with medical diagnoses that included Adjustment Disorder with Mixed Anxiety and Depressed Mood.Record review of the MDS with an ARD of 1/14/26 revealed under section C, a BIMS summary score of 14, indicating Resident #61 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #65 on 1/22/26 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side.Record review of the MDS with an ARD of 1/27/26 revealed under section C, a BIMS summary score of 6, indicating Resident #65 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #68 on 2/13/26 with medical diagnoses that included Cerebral Infarction.Record review of the MDS with an ARD of 2/19/26 revealed under section C, a BIMS summary score of 8, indicating Resident #68 was severely cognitively impaired.Record review of the admission Record revealed the facility admitted Resident #95 on 12/12/24 with medical diagnoses that included Displaced Fracture of Base of Neck of Right Femur.Record review of the MDS with an ARD of 2/8/26 revealed under section C, a BIMS summary score of 9, indicating Resident # 95 was moderately cognitively impaired.Record review of the admission Record revealed the facility admitted unsampled Resident D on 2/20/26 with medical diagnoses that included Pressure Ulcer of Sacral Region. The resident transferred to the hospital and was discharged on 2/22/26, therefore, a BIMS summary score was not conducted.

Based on staff and resident interviews, record review, and facility policy review, the facility failed to ensure licensed nursing staff followed professional standards of practice related to accurate and individualized documentation of as needed (PRN) pain medication administration for 13 of 25 residents reviewed on the B-hall medication cart. This deficient practice resulted in repetitive clustered documentation of PRN narcotic pain medications at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation of care provided. Resident #9, #12, #22, #27, #38, #43, #44, #47, #61, #65, #68, #95 and unsampled Resident D. Findings Include:Record review of the facility policy tilted Medication Administration with a review date of 4/23 revealed under, Policy; Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so.Record review of the facility policy titled Purpose of the Patient Record undated, revealed under, Guidelines: To ensure Patient Clinical Health information records are maintained in accordance with professional practice standards. Also revealed under, Process: Clinical records are maintained to provide complete and accurate patient information for continuity of care.Record review of the facility Clinical Care System Guidelines titled Pain Management Guidelines revealed under, Purpose: To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life.During initial tour on 2/23/26 at 11:14 AM, a resident who wished to remain anonymous revealed she was prescribed Norco 10 milligrams every 6 hours as needed for pain. The resident stated she had concerns regarding pain medication administration. She reported the nurse brought medications in a cup and attempted to administer them without allowing her to visually verify the medication. The resident stated she questioned whether her pain medication was included and was told yes; however, she did not receive relief afterward. She further stated that on one occasion she looked into the medication cup and did not see her Norco. When questioned, the nurse indicated the pill was broken. The resident stated the pill did not resemble her usual Norco, which she described as a white, oblong, football-shaped pill. The resident stated she initially did not report concerns because she liked the nurse and did not want to cause conflict. She later requested her physician schedule pain medication routinely due to continued concerns. She stated Norco typically controlled her pain but had not since residing in the facility.An observation and interview on 2/23/26 at 3:10 PM revealed Resident #9 lying in bed. He denied pain, and stated he did not take pain medication, and reported refusing pain medication when offered by nursing staff.Record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed under Section J that, in the last five days, the resident experienced frequent pain affecting sleep and limiting day-to-day activities.Record review of Resident #9's January and February 2026 Medication Administration Record (MAR) revealed Norco 5/325 mg (milligrams) ordered every six hours as needed for moderate pain. Documentation reflected administration by Licensed Practical Nurse (LPN) #3 at consistent times of 7:01 AM, 12:31 PM, and evening times ranging between 6:31 - 6:49 PM (1831-1849). Record review of the Controlled Substance Inventory Record dated 12/04/25 for Resident #9 revealed a narcotic sign out sheet for Norco 5/325 quantity 60 pills with sign out times by LPN #3 of 0700, 1230 and 1830 for 58 of the 60 doses given. LPN #3 had signed out 58 of the 60 doses as administered by her to Resident #9.An observation and interview with Licensed Practical Nurse (LPN) #2 on 2/24/26 at 8:50 AM, while preparing morning medications, revealed Resident #9 did not usually take pain medication. During medication administration, the resident stated, I don't want any pain medication.An interview with Licensed Practical Nurse (LPN) #4 on 2/24/26 at 4:26 PM revealed Resident #9 had Tylenol and Norco available but had never reported pain or requested pain medication from her. She stated the resident was cognitively intact and capable of communicating pain needs. Review of the narcotic log with LPN #4 confirmed LPN #3 had repeated documentation of administering Norco multiple times daily when working.An additional interview with Resident #9 on 2/24/26 at 4:36 PM revealed he did not take pain medication, did not want pain medication, and denied pain. He stated, I think you have mixed me up with my roommate because he takes pain medication.Record review of Resident #9's February 2026 MAR revealed pain was monitored every shift. When Licensed Practical Nurse (LPN) #3 worked, pain scores were documented as 8-9 on a scale of 0-10 with 10 being the worst pain. On all other shifts, pain scores were documented as zero.An interview with Licensed Practical Nurse (LPN) #3 on 2/25/26 at 8:25 AM revealed Resident #9 had surgery a year ago and requested pain medication at that time. She verbalized she continued to administer it and stated the resident reported generalized pain all over. She stated he had no observable physical signs of pain or distress.Record reviews of the January and February 2026 Medication Administration Record (MARs) revealed 13 residents had active physician orders for PRN opioid pain medications, including Norco (12 residents) and Oxycodone (1 resident), requiring administration based on assessed pain. Further review of the MARs revealed pain scores were documented on all shifts.Record review of the January and February 2026 MARs for 13 residents receiving PRN pain medication revealed repeated documentation of administration to multiple residents at identical times on numerous dates across different rooms throughout both months by LPN #3. The highest cluster occurred on 2/21 and 2/22, where PRN pain medication was documented for 12 residents at 7:01 AM. This documentation did not reflect individualized assessment or real-time documentation of medication administration times.JANUARY 2026 MARMorning Administration Pattern 7:01 AM (0701)LPN #3 documented PRN pain medication administration at 7:01 AM for multiple residents on numerous January dates: 1/1 - 8 residents 1/2 - 8 residents 1/5 - 4 residents 1/6 - 8 residents 1/9 - 4 residents 1/10 - 8 residents 1/11 - 7 residents 1/14 - 4 residents 1/15 - 7 residents 1/19 - 4 residents 1/20 - 8 residents 1/23 - 5 residents 1/24 - 7 residents 1/25 - 6 residents 1/28 - 5 residents 1/29 - 7 residentsMid Morning Administration Pattern 11:01 AM (1101)PRN pain medication was repeatedly documented at 11:01 AM, most commonly for 1-2 residents across the above January work dates.Midday Administration Pattern 12:31 PM (1231)Documentation at 12:31 PM showed repeated clustered administration: 1/1 - 6 residents 1/5 - 5 residents 1/6 - 4 residents 1/9 - 6 residents 1/10 - 5 residents 1/11 - 6 residents 1/14 - 6 residents 1/15 - 5 residents 1/19 - 6 residents 1/20 - 5 residents 1/23 - 4 residents 1/24 - 5 residents 1/25 - 5 residents 1/28 - 5 residents 1/29 - 4 residentsAfternoon Administration Pattern 3:01 PM (1501)Documentation at 1501 reflected repeated grouping of residents on many dates (commonly 2 residents).Evening Administration Pattern 6:31 PM- 6:46 PM (1831-1846)Evening administration times demonstrated clustered documentation within minutes apart reflecting multiple residents documented in close succession.FEBRUARY [DATE]Morning Administration Pattern 7:01 AM (0701)LPN #3 documented PRN pain medication administration at 7:01 AM for multiple residents on nearly every shift worked in February: 2/2 - 5 residents 2/3 - 8 residents 2/6 - 4 residents 2/7 - 9 residents 2/8 - 8 residents 2/11 - 4 residents 2/12 - 8 residents 2/16 - 5 residents 2/20 - 9 residents 2/21 - 12 residents 2/22 - 12 residents 2/25 - 5 residentsMid Morning Administration Pattern 11:01 AM (1101)PRN pain medication was repeatedly documented at 11:01 AM, most commonly for 2 residents on multiple February dates.Midday Administration Pattern 12:31 PM (1231)Documentation at 12:31 PM showed repeated clustered administration: 2/2 - 6 residents 2/3 - 5 residents 2/6 - 5 residents 2/7 - 6 residents 2/8 - 6 residents 2/11 - 6 residents 2/12 - 5 residents 2/16 - 7 residents 2/20 - 6 residents 2/21 - 8 residents 2/22 - 9 residentsAfternoon Administration Pattern 3:01 PM (1501)Documentation at 1501 reflected repeated clustering: 2/2 - 2 residents 2/3 - 3 residents 2/11 - 2 residents 2/20 - 3 residents 2/21 - 4 residents 2/22 - 3 residentsEvening Administration Pattern 6:31 PM to 6:49 PM (1831-1849)Evening administration times demonstrated clustered documentation within minutes apart, frequently between 6:31PM to 6:49 PM (1831 and 1849), with multiple residents documented at consecutive minute intervals.A telephone interview with Licensed Practical Nurse (LPN) #3 on 2/27/26 at 9:13 AM revealed she administered all PRN pain medication during routine medication pass (morning, noon, and evening) and selected one set time for all residents (referring to repeated documented times of 7:01 AM and 12:31 PM) so residents could receive medication again depending on physician orders. LPN #3 confirmed the residents' medical records did not accurately reflect actual administration times. She stated she did not always ask residents about their pain and confirmed some pain level documentation was entered without asking the residents and she confirmed that she falsely documented the pain levels. She revealed she did not ask Resident #9 about pain and administered medication without the resident's consent. She confirmed she documented pain scores of 8 and 9 for Resident #9, which were inaccurate. She stated this was not how she had been trained to administer medication and should be charting the medications immediately after giving them. She confirmed that this practice was not in accordance with the standards of nursing practice.An interview with the Director of Nursing (DON) on 2/27/26 at 3:30 PM confirmed that after reviewing all 13 residents' MARs a pattern of documentation inconsistencies related to LPN #3 was identified. She stated the nurse had worked at the facility for 11 years and had prior medication documentation issues, for which a medication administration competency had recently been completed. Record review of LPN #3's Progressive Discipline Form dated 11/19/22 revealed under, Summary of Incident: Nurse failed to follow procedure for properly counting all narcotics at each shift change or relinquishing of narcotic keys. Copy of Controlled Substance Accountability Guide provided to nurse. Record review of LPN #3's Progressive Discipline Form dated 9/17/24 revealed under, Summary of Incident: Medication was found at bedside of 2 residents. Record review LPN #3's Progressive Discipline Form dated 5/8/25 revealed under, Summary of Incident: Lack of professionalism displayed by making inappropriate comments regarding upper management to other staff in regard to physical assistance in the building for coverage of open shifts. Copying and pasting of skilled notes. 1:1 to be performed on Monday 5/12/25 with Director of Nursing Services. Record review of the Proper Name of Pharmacy Services Monthly Consultant Review dated October 2025 revealed a Med pass observation - Med Preparation & MAR documentation audit was conducted with LPN #3. The nurse did not check meds against MAR prior to administering them, did not document them as administered directly after giving the meds to the patient.Record review of the Licensed Nurse Core Clinical Competency dated 12/4/25 revealed the Director of Nursing conducted a competency observation with LPN #3 on medication administration following pharmacist identified concerns with med pass in October 2025.Record review of LPN #3's Progressive Discipline Form dated 12/4/25 revealed medication competency checklist to be reviewed, completed with supervisor check off by 1/4/26.Record review of the In-services dated 2/26/25 revealed LPN #3 attended an in-service with the topics of narcotic destruction, cart organization, non-narcotic medication destruction. As part of the in-service LPN #3 received the following education Immediately after punching out narcotics to be administered, sign narcotic book. Then administer the medication to resident return to cart and sign out in EHR (electronic heath record)/EMAR (electronic medication administration record). Record review of the In-service with the topic of Medication Pass Guideline, dated 2/18/25 revealed LPN #3 attended the in-service dated 2/27/25. Record review of LPN #3's Course Completion History revealed the nurse complete an online course on documenting medications dated 11/16/25.Record review of the admission Record revealed the facility admitted Resident #9 on 10/17/23 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #9 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #12 on 8/10/21 with medical diagnoses that included Chronic Respiratory Failure.Record review of Resident #12's MDS with an ARD of 1/22/26 revealed under section C, a BIMS summary score of 15, indicating Resident #12 was cognitively intact. Record review of Resident #12's January and February 2026 Medication Administration Record (MAR) revealed an order dated 7/3/24: Norco oral tablet 7.5/325 mg (milligrams) give one (1) tablet by mouth every six (6) hours as needed for moderate pain.Record review of the admission Record revealed the facility admitted Resident #22 on 3/17/16 with a medical diagnosis that included Unspecified Dementia.Record review of the MDS with an ARD date of 12/12/26 revealed under section C, a BIMS summary score of 2, indicating Resident #22 was severely cognitively impaired. Record review of Resident #22's January 2026 MAR revealed an order dated 4/30/24: Norco oral tablet 10/325 mg give 1 tablet by mouth every 6 hours as needed for pain.Record review of the admission Record revealed the facility admitted Resident #27 on 8/6/25 with medical diagnoses that included Peripheral Vascular Disease.Record review of the MDS with an ARD of 2/13/26 revealed under section C, a BIMS summary score of 11, indicating Resident #27 was moderately cognitively impaired. Record review of Resident #27's January and February 2026 MAR revealed an order dated 8/11/25: Hydrocodone-acetaminophen oral tablet 7.5/325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain.Record review of the admission Record revealed the facility admitted Resident #38 on 2/9/23 with medical diagnoses that included Nonalcoholic Steatohepatitis.Record review of the MDS with an ARD date of 1/15/26 revealed under section C, a BIMS summary score of 15, indicating Resident #38 was cognitively intact. Record review of Resident #38's January and February 2026 MAR revealed an order dated 11/6/23: Norco oral tablet 7.5/325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain.Record review of the admission Record revealed the facility admitted Resident #43 on 2/13/26 with medical diagnoses that included Encounter for other Specified Surgical Aftercare.Record review of the MDS with an ARD of 2/19/26 revealed under section C, a BIMS summary score of 15, indicating Resident # 43 was cognitively intact. Record review of Resident #43's February 2026 MAR revealed an order dated 2/13/26: Hydrocodone-acetaminophen oral tablet 10/325 mg give 1 tablet by mouth every 6 hours as needed for pain.Record review of the admission Record revealed the facility admitted Resident #44 on 2/12/26 with medical diagnoses that included Pain and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 2/18/26 revealed under section C, a BIMS summary score of 10, indicating Resident #44 was moderately cognitively impaired. Record review of Resident #44's February 2026 MAR revealed an order dated 2/13/26: Hydrocodone-acetaminophen oral tablet 5/325 mg give 1 tablet by mouth every eight (8) hours as needed for pain.Record review of the admission Record revealed the facility admitted Resident #47 on 10/21/21 with medical diagnoses that included Chronic Diastolic (Congestive) Heart Failure.Record review of the MDS with an ARD of 2/6/26 revealed under section C, a BIMS summary score of 11, indicating Resident # 47 was moderately cognitively impaired. Record review of Resident #47's January and February 2026 MAR revealed an order dated 2/19/25: Hydrocodone-acetaminophen oral tablet 10/325 mg give one tablet by mouth every four (4) hours as needed for moderate to severe pain.Record review of the admission Record revealed the facility admitted Resident #61 on 4/14/23 with medical diagnoses that included Adjustment Disorder with Mixed Anxiety and Depressed Mood.Record review of the MDS with an ARD of 1/14/26 revealed under section C, a BIMS summary score of 14, indicating Resident #61 was cognitively intact. Record review of Resident #61's January and February 2026 MAR revealed an order dated 11/15/24: Norco oral tablets 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain.Record review of the admission Record revealed the facility admitted Resident #65 on 1/22/26 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side.Record review of the MDS with an ARD of 1/27/26 revealed under section C, a BIMS summary score of 6, indicating Resident #65 was moderately cognitively impaired. Record review of Resident #65's February 2026 MAR revealed an order dated 2/12/26: Hydrocodone-acetaminophen oral tablet 5/325 mg give 1 tablet by mouth every 6 hours as needed for pain.Record review of the admission Record revealed the facility admitted Resident #68 on 2/13/26 with medical diagnoses that included Cerebral Infarction.Record review of the MDS with an ARD of 2/19/26 revealed under section C, a BIMS summary score of 8, indicating Resident #68 was severely cognitively impaired. Record review of Resident #68's February 2026 MAR an order dated 2/18/26: Hydrocodone-acetaminophen oral tablet 5/325 mg give 1 tablet by mouth every 6 hours as needed for pain.Record review of the admission Record revealed the facility admitted Resident #95 on 12/12/24 with medical diagnoses that included Displaced Fracture of Base of Neck of Right Femur.Record review of the MDS with an ARD of 2/8/26 revealed under section C, a BIMS summary score of 9, indicating Resident # 95 was moderately cognitively impaired. Record review of Resident #95's January and February 2026 MAR revealed an order dated 12/12/24, Oxycodone oral tablet 5 mg give 1 tablet by mouth every 4 hours as needed for moderate to severe pain.Record review of the admission Record revealed the facility admitted unsampled Resident D on 2/20/26 with medical diagnoses that included Pressure Ulcer of Sacral Region. The resident transferred to the hospital and was discharged on 2/22/26 therefore, a BIMS summary score was not conducted. Record review of Unsampled Resident D's February 2026 MAR revealed an order dated 2/21/26: Hydrocodone-Acetaminophen oral tablet 10/325 mg give 1 tablet by mouth every 6 hours as needed for pain.

Based on resident, resident representative, and staff interviews, along with facility policy review, the facility failed to ensure residents were treated with dignity and respect by providing timely toileting assistance and honoring residents right for two (2) of 25 sampled residents reviewed. Resident #5 and Resident #18. Findings Include: Review of the facility policy titled Resident Rights & Quality of Life Policy, with an effective date of March 13, 2020, revealed, It is the policy of 'Proper name of facility' that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center. Resident #5 During an interview on 2/23/2026 at 11:41 AM, Resident #5 revealed that at approximately 11:00 PM, she activated her call light requesting assistance to the bathroom, at which time Certified Nurse Aide (CNA) #1 responded and stated, Didn't someone come in here earlier and take you to the bathroom? The resident stated she informed CNA #1 that she had been asleep and needed to go at that time, and CNA #1 then assisted her. Resident #5 further revealed that at approximately 3:00 AM she again required toileting assistance. Although CNA #1 assisted her to the bathroom, she was left sitting on the toilet for approximately thirty (30) minutes without supervision. The resident stated she waited for CNA #1 to return and, when she did not, she activated the bathroom call light; upon returning, CNA #1 stated, I told you I was coming back. I had to make my rounds. Resident #5 stated she informed CNA #1 that she could not sit on the toilet for that length of time and should not have to remain there for an extended period and further reported that she notified the night nurse of the concern and was told the issue would be reported to Registered Nurse (RN) #2 in the morning. During an interview on 2/25/2026 at 2:10 PM, Registered Nurse (RN) #2 revealed she was not made aware of any complaints or concerns with Resident #5 on Monday morning. In an interview on 2/25/2026 at 2:15 PM, Licensed Practical Nurse (LPN) #1 revealed there have been prior issues involving CNA #1 that she was not professional and not friendly with the residents, which were reported to the Director of Nursing (DON). On 02/25/2026 at 3:05 PM, during an interview, the DON stated the CNA #1 can be kind of gruff in her tone, and further revealed that all residents are to be treated with the utmost respect and dignity. On 02/26/2026 at 9:05 AM, during a follow-up interview, the DON revealed CNA #1 has received multiple write-ups in the past. She stated she has provided verbal coaching to CNA #1 related to activities of daily living (ADL) care and service standards. The DON further revealed that CNA #1 previously received a write-up for leaving a resident on the toilet longer than appropriate. The DON revealed it is our expectation that residents receive timely toileting and confirmed that not doing so could place residents in discomfort and loss of personal dignity. Record review of the admission Record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/26 revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #5 was cognitively intact. Resident #18 An interview with a family member on 2/24/26 at 2:10 PM revealed she had entered the facility around 1:05 PM that day to visit Resident #18, whose call light was sounding because she was wet and needed to be changed. The family member revealed that the resident was left with 3 soiled towels on top of her chest from the lunch meal which was covered in spaghetti. The family member revealed that the call light had been going off for some time and the day shift CNA #5 entered the room to remove the soiled towels and stated to Resident #18, You're just showing out because your sister is here. A telephone interview with CNA #5 on 2/26/26 at 10:46 AM revealed she did not recall making the statement to Resident #18. She confirmed dirty towels were left on the resident's chest area from lunch. CNA #5 did confirm that the family was upset and that she just left the room to allow time for it to deescalate. An interview with the DON on 2/26/26 at 3:30 PM confirmed her expectations were that all residents have the right to be treated with dignity and respect. Record review of the admission Record revealed Resident #18 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Palsy. Record review of the MDS with an ARD of 1/26/26 revealed under Section C a BIMS summary score of 13, indicating Resident #18 was cognitively intact. Section H revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Additionally, Section GG revealed Resident #18 was dependent on staff for toileting and personal hygiene.

Based on observations, staff interviews, record review, and facility policy reviews, the facility failed to implement infection prevention and control practices to prevent the transmission of infections. Specifically, the facility failed to ensure oxygen delivery devices were stored in a sanitary manner when not in use for one (1) of four (4) days of survey and failed to ensure staff used Enhanced Barrier Precautions (EBP) during wound care during 1 of 4 resident care opportunities. (Residents #3 and #12) Findings include: Resident #3 Review of manufacture's guidelines titled (Proper Name) product guidelines for resp (respiratory) O2 (oxygen) tubing with no date, revealed, .Environmental Storage and Protection, For tubing not currently in use, containment should protect the material from degradation:.it should be contained in a clean, sealed plastic bag or container to protect it from dust, pet dander, and other contaminants. During observations on 2/23/2026 at 10:45 AM and again at 3:41 PM, Resident #3's oxygen tubing was lying on the floor at both observation times. During an interview on 2/23/2026 at 3:42 PM, Registered Nurse (RN) #1 confirmed the tubing should not be on the floor and stated it should be stored in the bag attached to the concentrator. She identified the tubing lying on the floor as an infection control concern. During an interview on 2/24/2026 at 1:45 PM, with the Director of Nursing (DON) confirmed each oxygen concentrator has a bag attached and that oxygen tubing should be stored in the bag when not in use. She further stated oxygen tubing lying on the floor was an infection control concern and placed Resident #3 at increased risk for infection. Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. Resident #12 Review of the facility's Infection Control Guide, dated 2025, revealed under Enhanced Barrier Precautions (EBP), The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. An observation and interview with Resident #12 on 2/23/26 at 10:44 AM revealed a sign outside the resident's doorway that indicated EBP. The resident stated he had orthopedic hardware exposed through the skin of his right ankle from an old injury that occurred 22 years ago. He revealed he had been on antibiotics off and on and had been hospitalized for sepsis, with the doctor recommending hardware removal. Record review of Resident #12's Treatment Administration Record revealed an order dated 2/8/26: Other erosion to right medial ankle - Clean wound with wound cleanser, pat dry with gauze, apply zinc oxide ointment 20% (percent) to peri wound, apply Mupirocin (antibiotic) ointment 2% (percent) to wound bed and cover with a folded 4 x (by) 4 gauze, ABD (abdominal) pad, wrap with kerlix and secure with tape every day shift for exposed surgical hardware. An observation of wound care with the Assistant Director of Nursing Services (ADNS) on 2/24/26 at 4:02 PM revealed she did not apply a gown for Enhanced Barrier Precautions (EBP) while providing wound care. An interview with the ADNS on 2/24/26 at 4:16 PM confirmed the resident was on EBP due to an open wound and acknowledged she did not wear a gown. She further revealed the purpose of the precautions was to protect the resident from getting an infection. Record review of the admission Record revealed the facility admitted Resident #12 on 8/10/21 with medical diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia, Presence of Right Artificial Ankle Joint, and Local Infection of the Skin and Subcutaneous Tissue. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #12 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was secured to prevent unauthorized access for one (1) of four (4) medication carts observed (B Wing). Findings Include: Review of the facility policy titled, Proper Name, Inc. Policies and Procedures, revised 04/22, stated, It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use . During an observation on 2/24/26 at 2:35 PM, the medication cart on B Wing was observed unlocked and unattended. Licensed Practical Nurse (LPN) #2 stated she got busy and forgot to lock her cart before sitting down to chart. She stated the cart should always be secured for the safety of the residents. On 2/25/26 at 2:30 PM, an interview was conducted with the Director of Nursing (DON), who stated medication carts should never be left unlocked when not in use. She stated medication carts are to be locked at all times when not in use for the safety of the residents.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were protected from accident hazards related to unsafe possession and storage of smoking materials for three (3) of nineteen residents identified as smokers. (Resident #88, Unsampled Residents A, and B)Findings Include:Review of the Facility policy titled Safe Tobacco Use with a revision date of November 3, 2022, revealed under, Purpose: 1. To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents. 4. Staff members will monitor or obtain fire igniting materials (matches/lighters) for the benefit of smokers at the nurses' station or other designated location .On 2/23/2026 at 11:30 AM, an observation revealed a gray box of cigarettes lying on the chest of drawers near the television in Resident #88's room.On 2/24/2026 at 9:45 AM, an observation and interview revealed two (2) boxes of cigarettes and a red lighter lying on Resident #88's bedside table, and one (1) additional box of cigarettes on the chest of drawers. Resident #88 stated, I can have my cigarettes and lighter in my room. I had them in my vest pocket when I came back from smoking. I usually put them on my bookcase, but I just laid them on my table this time.On 2/24/2026 at 3:00 PM, during scheduled smoke break time, observations and interviews revealed three (3) unsampled residents seated in the hallway near the exit door to the outside smoking area. Unsampled Resident A was seated in her wheelchair with a cigarette box visible in her cup holder and stated, We can keep our cigarettes and lighters with us. Unsampled Resident B, also seated in her wheelchair, stated she always keeps her cigarettes with her and takes them to her room.On 2/24/2026 at 3:30 PM, the Director of Nursing (DON) stated the facility expectation is that residents do not keep cigarettes or lighters on their person. The DON stated smoking materials are to be kept in a locked box and provided to residents at designated smoke times. The DON acknowledged residents sometimes obtain and keep cigarettes and lighters despite this expectation and stated that staff attempts to confiscate the items when observed.On 2/24/2026 at 3:40 PM, the Administrator stated the facility attempts to prevent residents from keeping cigarettes and lighters; however, she confirmed she has observed residents in possession of these items. She revealed the facility is attempting to address the issue through care planning and family education and acknowledged the presence of smoking materials constitutes an accident hazard. The Administrator further stated staff conduct morning room rounds and are expected to notify administration if smoking materials are observed.Record review of the admission Record revealed the facility admitted Resident #88 on 3/10/25 with medical diagnoses that included Emphysema, Atrial Fibrillation and Atherosclerotic Heart Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/3/2025 revealed under section C, A Brief Interview for Mental Status (BIMS) summary score of 15, which indicates Resident #88 is cognitively intact. Record review of the admission Record revealed the facility admitted unsampled Resident A on 1/7/2025 with medical diagnoses that included Chronic Obstructive Pulmonary Disease and Nicotine Dependence. Record review of the MDS with an ARD of 12/24/2025 revealed under section C, A BIMS summary score of 15, which indicates unsampled Resident A is cognitively intact. Record review of the admission Record revealed the facility admitted unsampled Resident B on 11/28/2021 with medical diagnoses that included Parkinson's Disease without Dyskinesia, and Major Depressive Disorder. Record review of the MDS with an ARD of 1/29/2026 revealed under section C, A BIMS summary score of 15, which indicates unsampled Resident B is cognitively intact.

Based on staff and family interview, record review, and facility policy review, the facility failed to ensure a resident who was dependent on staff for incontinent care received timely assistance with activities of daily living (ADLs) for one (1) of 25 sampled residents. Resident #18Findings Include:Review of the facility policy titled ADL's (Activities of Daily Living) dated 2025 revealed under, Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences .An interview with a family member on 2/24/26 at 2:10 PM revealed she entered the facility around 1:05 PM to visit Resident #18, whose call light was sounding because she was wet and needed to be changed. The family member stated that when second shift (2PM-10PM) Certified Nursing Assistants (CNAS) came in, Resident #18 was extremely soiled to the extent that the brief was saturated, appeared brown in color, and the bed sheets were wet. She further stated the resident had a bowel movement in her brief and waited over one hour to be changed. The family member reported this had been an ongoing issue with day shift not changing the resident timely and stated she had complained to administration the previous week.An interview with evening shift (2PM-10PM) CNA's #3 and #4 on 2/24/26 at 2:18 PM revealed that when they came on shift, Resident #18's call light was on. CNA #3 stated they both entered the room and changed the resident. CNA #3 and #4 confirmed the resident was soaked in urine, had a bowel movement, and had wet the bed sheets. Both aides confirmed this was an ongoing issue when coming in behind day shift and stated they did not make rounds timely to ensure residents were kept clean and dry. CNA #4 stated the resident was not a heavy wetter and that when rounds were made every two hours, as expected, this did not occur.An interview with Registered Nurse (RN) #3 on 2/24/26 at 2:32 PM revealed she observed the resident's call light on, went to the room, and answered the light. The family member notified her the resident was wet. RN #3 stated she turned the call light off and went across the hall to locate CNA #5, who was busy, so she returned and notified the resident it would be a minute. She explained the call light came on again later, so she returned to the room and found the resident was still waiting to be changed. She then checked again with the assigned aide, who was still busy, and returned to notify the resident the aide would be there shortly. RN #3 stated the call light came on again and she observed the aide walking down the hall away from the room. She confirmed the aide never addressed Resident #18's needs and by that time second shift had come in. RN #3 confirmed timely incontinent checks should be completed every two hours and as needed and that the resident should not have been left soiled which could cause skin breakdown.A telephone interview with Certified Nurse Aide (CNA) #5 on 2/26/26 at 10:46 AM revealed she was across the hall giving another resident a bath when Resident #18's call light was going off. She stated she could not stop what she was doing to address the residents' needs. CNA#5 revealed the last incontinent round completed for Resident #18 was around 10:00 AM and confirmed rounds should be made every two hours and as needed. She stated she entered the room before the end of her shift; however, tensions were high and the family member was upset, so she left to allow the situation to de-escalate. She stated the evening shift agreed to change Resident #18 and she confirmed that she left the resident soiled.An interview with the Director of Nursing (DON) on 2/26/26 at 3:30 PM confirmed that any staff member could provide incontinent care to a resident and further confirmed expectations were that rounds should be made every two hours and as needed.Record review of the admission Record revealed Resident #18 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Palsy.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed under Section C a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #18 was cognitively intact. Section H revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Additionally, Section GG revealed Resident #18 was dependent on staff for toileting and personal hygiene.

Based on observation, staff interview, and facility policy review the facility failed to provide a safe, clean environment as evidenced by overbed tables with a thick black substance on the metal base for three (3) of sixty-three resident rooms observed. (room [ROOM NUMBER], #18, and #28) Findings Include: Review of the facility policy titled Resident Rights & Quality of Life Policy, with an effective date of March 13, 2020, revealed, It is the policy of 'Proper name of facility' that all patients and residents have the right to a dignified existence .To receive services in a center environment that is safe, clean, and comfortable . On 2/23/2026, between 3:25 PM and 4:00 PM, observations on B Wing revealed that Rooms #16, #18, and #28 contained overbed tables with a thick black substance scattered across the metal bases. The condition was readily observable upon entering the residents' rooms.On 2/24/2026 at 1:30 PM, an observation and interview revealed the overbed table bases in Rooms #16, #18, and #28 remained coated with a thick black substance on the metal bases of both residents' overbed tables. Certified Nurse Aide (CNA) #6 stated the table bases appeared very rusty and in poor condition. CNA #6 reported staff are expected to notify nursing when equipment requires replacement, and nursing then notifies the maintenance department.On 2/25/2026 at approximately 2:15 PM, an observation and interview revealed the overbed tables in Rooms #16, #18, and #28 continued to have a thick black substance on the metal bases. CNA #2 stated that when staff identify items needing repair, a work order is submitted through the kiosk system to notify maintenance. CNA #2 stated she had not submitted a work order and had not noticed the condition of the overbed tables.On 2/25/2026 at 3:35 PM, the Director of Nursing (DON) confirmed the overbed tables in Rooms #16, #18, and #28 had a thick black substance on the metal bases. The DON stated the tables looked bad and did not represent a homelike environment.On 2/26/2026 at 9:11 AM, the Maintenance Supervisor stated he receives repair notifications through an electronic work order system. He reported he was unaware of any work orders submitted for cleaning or replacement of the overbed tables. He further stated that upon inspecting B Wing, he observed multiple overbed tables that were rusted and in need of replacement.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure that all allegations of abuse were immediately reported to the State Agency, failed to report allegations involving a licensed nurse to the appropriate licensing board, and failed to ensure staff recognized and reported abuse. This deficient practice was identified for one (1) of three (3) residents reviewed for abuse allegations. (Resident #1)Findings include: Cross-reference F 600Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed: All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, will be reported immediately to the Administrator, State Agency, and other officials in accordance with State law. Allegations involving licensed staff will be reported to the appropriate licensing authority.Record review of a facility-reported incident dated 7/29/25 revealed allegations of abuse were made against Licensed Practical Nurse (LPN) #1 involving Resident #1. The incident was reported to the State Agency; however, the facility did not notify to the Board of Nursing as required for allegations involving licensed staff.During an interview with Certified Nursing Assistant (CNA) #1 on 8/27/25 at 2:30 PM, she stated she witnessed the incident on 7/28/25 when LPN #1 used profanity and applied force to Resident #1. She stated she did not report the allegation until the next day because she assumed another nurse would have reported it.During a phone interview with CNA #2 on 8/27/25 at 2:40 PM, she confirmed she also witnessed the incident but delayed reporting until the following day because she assumed another nurse had already reported it.During a phone interview with LPN #2 on 8/27/25 at 3:30 PM, she stated she heard LPN #1 use profanity toward Resident #1 but did not consider it abuse and therefore did not report the allegation either. LPN #2 confirmed that it is never okay to use profanity towards a resident and that she was the supervisor over the CNAs and she should have reported the incident right away.During an interview with the Administrator and the Director of Nursing (DON) on 8/28/25 at 9:31 AM, they confirmed that staff failed to immediately report allegations of abuse that occurred on 7/28/25 related to LPN #1 and Resident #1. They also confirmed the allegation was not reported to the Board of Nursing because the facility did not substantiate the abuse, although they had statements of abuse from both CNAs.Record review of an in-service titled Abuse and Neglect, dated 7/1/25, revealed LPNs #1 and #2 and CNAs #1 and #2 attended the training and signed the attendance sheet. In-service material: If any allegations of abuse that is reported to any team member, it is to be reported immediately.Remember to always report any suspicion of abuse and neglect immediately. Different types of abuse.when in doubt report it.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse when a Licensed Practical Nurse (LPN) used profanity toward a resident diagnosed with Alzheimer's disease and was observed to have applied physical force during an incident, where the resident was laying flat on her back on the floor and the LPN forcefully pushed the resident's legs into her chest and used profanity toward the resident. This placed the resident at risk for humiliation, intimidation, and harm. This was identified for one (1) of six (6) residents reviewed for abuse (Resident #1). Findings include: Cross-reference F609Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, Purpose: To prohibit and prevent abuse. Physical Abuse - includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Corporal punishment is considered physical abuse. Verbal Abuse - may be considered a form of mental abuse and includes written, gestured, or spoken communication, or sounds made to residents within hearing distance, regardless of age, ability to comprehend, or disability. Mental Abuse - is the use of verbal or nonverbal conduct which causes, or has the potential to cause, humiliation, intimidation, fear, shame, agitation, or degradation Record review of a facility-reported incident revealed that on 7/29/25, Certified Nursing Assistants (CNAs) #1 and CNA #2 reported allegations of abuse by LPN #1 toward Resident #1.Record review of the admission Record revealed Resident #1 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia with agitation.Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired.During an interview with the Administrator and the DON on 8/28/25 at 9:31 AM, they confirmed that CNA #1 and CNA #2 told them they were at the nurse's station during the incident, placing them away from the immediate area. They stated LPN #2 reported hearing LPN #1 use profanity but not directed at the resident. They confirmed that, following their investigation, the facility substantiated the use of profanity but did not substantiate the allegation of abuse or improper physical force.During an interview on 8/27/25 at 2:30 PM, CNA #1 stated that on 7/28/25 sometime after 7:00 PM, Resident #1 was acting out, cursing, hitting, biting at staff, and had laid down in the hallway. She stated that staff were attempting to calm and redirect the resident's behaviors when LPN #1 was holding the resident's legs and the resident kicked LPN #1 in the stomach, LPN #1 then became angry and called the resident a stupid b**** and shoved her legs back into her chest. She stated it appeared as if LPN #1 just snapped when the resident kicked her. She confirmed she was in the hallway with LPN #1, LPN #2, CNA #2, and CNA #3 when the incident occurred and denied ever stating she was at the nurse's station. She stated that aside from sending a text message to the Administrator to report the incident, no one questioned her further.Review of a written statement provided by the Administrator and attributed to the interview that CNA #1 gave, revealed the following allegation: LPN #1 folded that lady's leg up to her chest then she kicked LPN #1 and LPN #1 called her a b**** and shoved her leg/knee back in her chest.During a phone interview with CNA #2 on 8/27/25 at 2:40 PM, she stated Resident #1 was confused, fighting, hitting, kicking, and biting at staff. She stated staff were blocking the resident from hitting and kicking while trying to calm her down. She stated the resident managed to kick LPN #1 in the stomach, and LPN #1 called the resident a stupid b**** and pushed the resident's leg back toward her head. She confirmed she was present in the hallway during the incident and denied telling the Administrator or Director of Nursing (DON) that she had been at the nurse's station. She confirmed that she had sent the Administrator a text to let her know about the incident.Record review of a written statement provided by the Administrator and attributed to CNA #2 revealed: I love LPN #1 to death, but she went entirely too far when Resident #1 kicked her. Then she called her a stupid b****.During a phone interview with LPN #2 on 8/27/25 at 3:30 PM, she stated she worked on 7/28/25 and recalled Resident #1 being confused, resisting care, and fighting, kicking, and biting staff. She stated that staff attempted to block the resident's arms and legs to prevent injury. She denied seeing the incident but confirmed she heard LPN #1 use profanity in an attempt to calm the resident. She stated that while she did not view it as cursing at the resident, she acknowledged that profanity and blocking movements could have made the resident feel threatened.Record review of a written statement provided by the Administrator and attributed to LPN #2 revealed: On 7/28/25 approximately 1900, LPN #1 did use profanity to get patient to stop kicking.Record review of an interview summary conducted by the Administrator and the DON revealed LPN #1 stated she heard a commotion, Resident #1 was on the floor in the hallway, kicking and biting. She stated she did not recall using any profanity during the situation. She stated she did push the resident's leg while trying to block the kick as the resident was trying to kick her and the CNAs.Record review of a Progressive Discipline Form for LPN #1 dated 8/5/25 revealed: On 7/28/25 it was reported that profane language was used with a resident. It was also alleged that physical force was used with the resident. Upon completion of the investigation, it was determined that profane language was used; however, no improper force was substantiated.Record review of an in-service titled Abuse and Neglect, dated 7/1/25, revealed LPN #1, LPN #2, CNA #1, and CNA #2 attended the training and signed the attendance sheet.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care, and professional standards of practice to meet resident's physical needs for one (1) of five (5) residents reviewed for quality of care. Resident #3 Findings include: Record review of facility policy titled, Notification of Change in Patient/Resident Health Status dated June 2017, revealed, Purpose: to ensure all interested parties are informed of the patient's/resident's change in health status so that a treatment plan can be developed which is in the best interest of the patient/resident . C. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Depending on the nursing assessment appropriate notification may be immediate to 48 hours . Record review of facility policy titled, Skin Care Guidelines, dated July 2018, revealed, Purpose: To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity . When an open area is identified: Implement resident specific interventions immediately . Notify physician and document notification. During a phone interview on 4/16/25 at 8:50 AM, Resident #3 stated she had been admitted to the facility on the afternoon of Friday, 3/21/25. She revealed she had been an insulin-dependent diabetic for several years and had been in the hospital due to cellulitis of a diabetic ulcer to the toe. She acknowledged she administered insulin three times daily prior to each meal and informed the facility nurse of this on admission and prior to her evening meal. She was informed that the doctor did not order her insulin when she was discharged from the hospital. She asked the nurse to notify the provider since she needed her insulin, and she had the continuous glucose monitoring (CGM) device and her blood sugars had not been low. She knew the provider did not discontinue her insulin and felt that the hospital made an error when reconciling her medications at discharge. This continued Saturday, Sunday, and Monday morning. The resident stated that the nurses refused to contact her physician for a clarification regarding her insulin. She stated she also had a diabetic ulcer on her toe and it was covered with a dressing on admission to the facility. She asked about dressing changes, but was told she did not have an order for wound care or dressing changes. She asked the nurse if she would contact the physician for an order for wound care as well as for insulin, but this was not done. The nurses did change the dressing on Saturday and on Sunday, but she was uncertain what they used for the treatment. She asked multiple people on Friday, Saturday, Sunday, and Monday morning about her insulin and wound care, but no one contacted the provider for orders for her needed care. The provider came in on Monday and ordered the wound treatment and was going to order insulin, but the resident told the provider she would continue to use her own insulin pen that she had brought from home since she was transferring to another facility that day or the next day and she did not want that added to her bill. During an interview on 4/16/25 at 10:20 AM, the Registered Nurse Treatment Nurse stated he had left the building for the day when the resident was admitted from the hospital on 3/21/25 and he did not assess her until Monday 4/24/25. He stated the treatment being used was Hydrofera Blue so he spoke with the Nurse Practitioner and received a new order for collagen with silver for wound care. He stated if he was not in facility when a new resident was admitted , it was the nurses' responsibility to assess and document the wounds and he would measure and take pictures when he returned. He also stated the provider would be notified if the resident needed orders for care. An interview with the Director of Nursing (DON) on 4/16/25 at 1:55 PM, revealed Resident #3 was admitted to the facility with a diabetic wound on Friday, 3/21/25. She acknowledged the resident had a diagnosis of Type 2 Diabetes Mellitus with long-term current use of insulin, and on the paperwork received from the hospital, her insulin was discontinued at discharge. The DON confirmed that the resident informed the staff that was a mistake and the physician needed to be contacted. Resident #3 had her own insulin pen and was administering her own medication even though the nurses informed her that that was a safety concern, and she had not been assessed for self-administration of medications. She stated a nurse attempted to contact the provider with no response and there was no documentation of this attempt. She acknowledged the Medical Director needed to be contacted if there was no response from other providers, but he was not contacted to verify orders for the insulin as well as for the wound care. She stated each resident in the facility had the right to the treatments and medications needed for their well-being and the facility failed to obtain orders for wound care and insulin and therefore, failed to give treatments and medications per those orders for this resident. Record review of Resident #3's Clinical Summary revealed diagnoses of Insulin Dependent Diabetes Mellitus dated 8/15/18 and Type 2 Diabetes Mellitus with long term current use of insulin dated 12/24/24. Record review of Resident #3's History and Physical dated 3/18/25, revealed resident with history of .Type 2 Diabetes Mellitus with long-term current use of insulin. Blood glucose at that time was listed as 201 (High) with reference range of 70-110. Record review of Resident #3's Discharge Summary with discharge date of [DATE], revealed discharge diagnosis of, Type 2 Diabetes Mellitus, with long-term current use of insulin. Record review of Resident #3's Order Summary Report for March 2025, revealed an order dated 3/24/25 for Right great toe diabetic ulcer - clean wound with wound cleanser, pat dry with gauze, apply collagen with silver, cover with small piece of xeroform, secure with 2 x 2 bordered gauze, change daily. No order for insulin was noted on the Order Summary Report. Record review of Resident #3's electronic Medication Administration Record (EMAR) for March 2025 revealed the resident had no insulin administrations listed or documented. Record review of Resident #3's electronic Treatment Administration Record (ETAR) for March 2025 revealed the resident had a treatment to toe ordered on 3/24/25 and received this treatment on 3/25/25. No other treatments were listed or documented as done on the ETAR. Record review of Resident #3's Progress Note dated 3/22/25 at 1400, revealed, Resident is self medicating herself with her own insulin. She is monitoring BS (blood sugar) with a device. Resident does not have an order for insulin. Charge nurse and Director of Nursing printed off orders and shown her that she was not on the insulin. Will continue to monitor. Record review of Resident #3's Progress Notes Behavior Charting dated 3/24/25 at 0812 revealed, Describe Behavior/Mood, what the resident was doing, interventions attempted and effectiveness: Nurse went into resident's room this AM to check on resident. Resident was upset stating that her medication wasn't correct upon admit. Resident stated, I'm supposed to be on insulin. I need insulin due to my diagnosis of Diabetes Mellitus and I have to have my insulin. This nurse explained to resident that facility has to follow discharge orders that was sent with her when admitted . This nurse went over medications with resident. Resident then stated, 'they didn't notify me at the hospital that they discontinued my insulin'. This nurse assured resident that her medications would be assessed by Nurse Practitioner (NP) and primary physician. Resident then continued to state, 'That's okay, I have my own insulin that I've been giving myself and I'm keeping it. You're not gonna take it'. This nurse explained to resident that was unsafe. Resident then reported that she didn't care and was keeping her insulin. DNS (Director of Nursing Services)/Administration and NP aware. Record review of Progress Note from Nurse Practitioner dated 3/24/25 at 22:59, revealed, per hospital documentation (Discharge Summary) patient has diagnosis of Type 2 Diabetes with long-term current use of insulin. Patient reports that she has been taking insulin for several years. However, per hospital documentation (After Visit Summary) under the Instructions section, stated for patient to STOP taking: Insulin Aspart 100 unit/milliliter injection (Novolog). Patient currently has a Insulin Aspart Injection Pen on her bedside table and states that she is using her pen to give herself insulin. Patient states, she takes Insulin Aspart 15 units before (AC) meals. Blood sugars noted with fluctuations. Ranging from 112-366 since admission on 3/21. NP offered to restart insulin. Patient states, no don't order me any insulin, I will just continue to use my own insulin, because I'm leaving today or tomorrow anyway. Record review of Progress Note dated 3/24/25 at 12:57 revealed, Resident is alert and oriented sitting on side of the bed. Resident is incontinent of bowel/bladder. Resident stated that she giving herself her own insulin that she has in her room. Record review of Clinical Health Status Evaluation dated 3/21/25, revealed, Barriers to Transition . Wound Care/Skin Integrity. Also, revealed, Self-Administration medications: Medication-Self Administration - Does the resident wish to self-administer medication? No. Record review of Daily Skilled Nurses Note dated 3/22/25 and 3/23/25, revealed, Skin . c. Treatment (per orders/nurses note); d. dressing clean, dry, intact . Wound Observation Nursing Note (enter any other documentation related to wounds): Diabetic Ulcer to right great toe. No information of treatment documented. Record review of Daily Skilled Nurses Note dated 3/24/25 revealed, Resident stated that she was giving herself her own insulin that she has in her room. Record review of RN Treatment Nurse's documentation Skin and Wound Evaluation dated 3/24/25, revealed, Wound appears stable, callus noted to periwound, wound bed dry. Patient reports she has been using Hydrofera Blue as primary wound dressing. Report given to NP and new order received to clean wound with wound cleanser, pat dry with gauze, apply collagen with silver to wound bed, cover with small piece of xeroform, secure with 2 x 2 border dressing, change daily. Patient tolerated treatment well. Record review of Resident #3's Admission Record revealed the facility admitted her on 3/21/25. Diagnoses included Type 2 diabetes Mellitus with foot ulcer and Cellulitis of right toe. Record review of Resident #3's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that a resident's rights were honored when a staff member refused to assist a resident with toileting for one (1) of four (4) survey days. Resident #2 Findings include: Review of the facility policy titled, Resident Rights & Quality of Life, with an effective date of March 13, 2020, revealed, .It is the policy that all residents and patients have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center . An observation and interview on 8/27/24 at 12:00 PM, revealed Resident #2 sitting in her wheelchair in her room. Resident #2 stated My bladder is about to bust. I've got to go to the bathroom so bad. I just returned from an appointment and haven't been to the bathroom since leaving the facility this morning. The resident was observed using her call light to ask for help. The resident stated they won't do it right now. They always say they can't while they are passing out trays. The resident kept urgently saying, Oh, I've got to go so bad. Resident #2 engaged her call light, and Registered Nurse (RN) #1 entered the room; the resident stated, Please, I've got to go to the bathroom so bad! Registered Nurse (RN)#1 stated to the resident, They can't right now. They are passing trays. When asked why they couldn't assist the resident in going to the bathroom, she stated, We've always been told we can't take anyone to the bathroom during meals or passing trays. Requested the Director of Nurses (DON) to come to the resident's room, so RN #1 left the room to go get the DON, but neither the nurse nor the DON came back to the room. An interview with the DON at 12:07 PM, in her office revealed we can't change or toilet residents while they are feeding other residents. She stated I will have to look at the cross-contamination policy as to the reason why. She revealed that she knew the resident had the right to go to the bathroom when needed, but that she would have to look at the policy first. The DON then instructed RN #1 to take the resident to the shower room to use the bathroom. An interview on 8/27/24 at 12:20 PM, Certified Nurse Aide (CNA) #1 revealed we are not supposed to toilet residents during mealtimes. She stated it gets us in trouble with the residents because we have to tell them that we can't change them because we could get in trouble for doing it during mealtime. She revealed that we were told that it is a state thing and that if the state came into the building and we were changing someone or taking them to the bathroom, we would get in trouble. In an interview on 8/27/24 at 12:25 PM, CNA #8 revealed We have always been told that we are not allowed to take anyone to the bathroom or change anyone's briefs during mealtime. They have always just said because it is cross-contamination. In an interview on 8/27/24 at 2:20 PM, the DON revealed I have started doing in-services to all the staff on the floor and stated, Using the bathroom trumps everything; they have a right to be changed and assisted to the restroom at any time. Record review of Resident #2's Admission Record revealed an admitted [DATE] with medical diagnoses that included Overactive bladder,Type 2 Diabetes Mellitus, and Heart failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/24, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve grievances related to food concerns and bed linens not being changed for five (5) of seven (7) residents with grievances. Resident #3, #19, #26, #88, and #108. Findings Include: Review of the Facility policy titled Customer Concern (Grievance) Policy dated 7/2018, revealed Purpose: Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution .Process . The Administrator will ensure a thorough investigation is conducted and will respond to the customer (patient/resident) The Administrator shall follow up on the correction of the problem and finalize the Customer Concern Form validating the resolution of the concern including who did what, when, and where It is best practice for the Administrator to follow up with the customer after a period of time to ensure the customer remains satisfied with the concern resolution. This follow up should be recorded on the log. Maintaining evidence demonstrating the results of all grievances . Record review of the Customer Concern/Grievance Communication Form dated 7/30/2024 revealed Resident #26 filed a grievance regarding the quality of food services and presentation of meals specifically with egg salad. Revealed under, Steps Taken to investigate Concern: Spoke with Dietary Manger; staff educated on service, presentation of meals. The grievance was marked as resolved. An interview on 8/27/2024 at 11:45 AM, with Certified Nursing Assistant (CNA) #1 revealed the residents complain all the time about the food. I have told the residents to talk about it in resident council when they go, when they come back from resident council they will tell us that they told them about the food. She revealed it has been a problem and everyone knows about the food issues. A resident council meeting was held on 8/27/2024 at 3:05 PM in which Resident #3, #19, #88, and #108 all revealed food concerns were discussed every month in resident council meetings, and they had not seen anything done to address their concerns. During the meeting Resident # 108 revealed the residents do not have food choices. She explained they had a set menu, and they can only get what was on the menu or two alternates to choose from every day, which is either a hamburger or a chicken sandwich. She stated, I'm a vegetarian and so is my roommate, and they don't have options for us. She revealed the food was disgusting and had no seasoning or flavor. Furthermore, she explained that she had been served lunch before and the next day was served the exact same thing for lunch and supper. She revealed the food was always cold and stated the vegetables were watery and ran together with other foods on the plate. Resident's #3 and #19 revealed the cornbread was so flat and hard there was no way to chew and swallow it. Resident # 88 revealed he was served mashed potatoes almost every day. He explained the vegetable medley and green beans were watery and agreed with Resident #108 that it merged with other foods on the plate. Resident#108 stated the food was as though they just threw something together and occasionally the foods were not cooked thoroughly. Resident #19 and #108 confirmed they had received foods that were not cooked thoroughly before. All resident voiced they had spoken about these food concerns in resident council with the Activity Director, the Dietary Manager and the Administrator in attendance. Resident #19 brought up his sheets were not being changed but about every 2 weeks. He revealed he asked them to change them, but usually, it does not get done because they say they are busy. Resident #108 stated her linens get changed only when her room gets deep cleaned which was twice monthly. The resident's voiced they would like to have their linen changed on their shower days. On 8/27/2024 at 4:07 PM, an interview with the Dietary Manager (DM) revealed, she was aware Resident #26 had complaints on the food. She explained they tried to accommodate everyone but thought it was the menu the residents did not like. An interview with Social Services (SS) #1 on 8/27/2024 at 4:20 PM revealed, Resident #26 had not voiced food concerns to her, but she was aware that the resident had voiced food concerns with several other facility staff members. An interview with the Administrator (ADM) on 8/28/2024 at 9:39 AM, revealed, Resident #26 was particular about her food and stated, she had talked to the resident a million times about her food issues. The ADM revealed that the resident even requested that she come and taste her food. She confirmed that she had not formerly filled out a grievance related to the resident's food concerns. Record review of the Resident Council Minutes dated 2/15/2024, revealed under, Old Business: Several stated sheets were still not being changed and were unsure of scheduled times to be changed. Activity Director then called for the Administrator to attend meeting, and she explained times the sheets are to be changed and answered all other concerns at this meeting with success. Also revealed under, New Business: Dietary: Several had likes and dislikes that they wanted updated. List of names given to the Dietary Manger in Dietary for review. Record review of the Resident Council Minutes dated 3/1/2024, revealed under, Old Business nothing was documented to address the previous concerns voiced in resident council meeting. Also revealed under, New Business: Dietary: Everyone went over some issues with Dietary Manager about seasoning on meat and potatoes. She talked with the residents about their concerns in meeting and all were ok. Record review of the Resident Council Minutes dated 4/5/2024, revealed under, Old Business nothing was documented to address the residents' concerns that were voiced in the previous meeting to ensure issues were resolved. An interview with Activity Director (AD) on 8/27/2024 at 3:22 PM confirmed the residents had been reporting food concerns in the resident council meetings. She explained that most of the concerns were regarding no seasoning or flavor on the food. She revealed Resident #108 had many special requests due to her diet choices of being a vegetarian. The AD revealed after the meetings she gave a copy of the meeting minutes to the Administrator and the Dietary Manager for the concerns to be addressed. An interview with the Dietary Manager on 8/27/2024 at 3:55 PM, revealed she was not aware of any recent concerns from the resident council meeting regarding food. She stated to her knowledge the residents were satisfied with the menu. The DM revealed the residents were allowed to choose between the meal on the menu or a hamburger or chicken sandwich. She confirmed she was aware of the resident complaints regarding a lack of variety of food choices. An interview with the Administrator on 8/27/2024 at 4:10 PM, revealed she was aware of the resident concerns regarding the food. She explained the residents did complain about the food for several months in resident council back in February and March 2024, but they did not mention it again in the April meeting. She confirmed a grievance was not completed and stated she instructed the Dietary Manager to go and speak with the residents and update their likes and dislikes. The ADM revealed they have a dietary contract with proper name and right now, they were working at the corporate level to find a solution to the food concerns. An interview with SS #1 on 8/28/2024 at 9:30 AM, revealed she goes to resident council meetings if she has time. She confirmed she was responsible for completing a grievance if a concern was brought to her. She revealed she was aware of the resident's food concerns and confirmed she did not complete a grievance. SS#1 stated a food complaint would be handled by the Dietary Department and revealed that the dietary usually goes and speaks with the resident to handle the concern. She revealed a food complaint would not be relevant to her position. An interview with the Administrator on 8/28/2024 at 1:40 PM, revealed she was aware of resident concerns regarding the linen not being changed but thought that issue was better. She explained the last time she was invited to resident council the residents told her the linen issue was better. She confirmed there was no documentation in the resident council meeting minutes that proved anything was done to address the resident's concerns regarding the linens not being changed. An interview with the Dietary Manager (DM) on 8/28/2024 at 2:06 PM, revealed when resident concerns were voiced in resident council about food, she personally went to speak with the residents in resident council. She confirmed that she did not have any documentation to show that the residents concerns were addressed and failed to follow up on to ensure the issues were resolved. Resident #3 Review of the Admission Record revealed the facility admitted Resident #3 on 5/28/24 with medical diagnoses that included Type 2 diabetes mellitus without complications. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/2024 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 9, which indicates Resident #3 is moderately cognitively impaired. Resident #19 Review of the Admission Record revealed the facility admitted Resident #19 on 12/23/2023 with medical diagnoses that included Mixed conductive and sensorineural hearing loss. Review of the MDS with an ARD of 7/30/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #19 is cognitively intact. Resident #26 An interview with Resident #26 on 8/26/2024 at 11:00 AM, revealed the food was not good and they needed to cook more vegetables. She revealed it does not do any good to talk about it in resident council because the food stays the same. An interview with Resident #26 on 8/27/2024 at 11:05 AM, revealed, breakfast was the only decent meal she got. She explained she used to go to resident council meetings, but it did not do any good to voice her opinion. She revealed she had talked to the Administrator multiple times regarding the food and even had her take pictures of her plate. The resident stated, I don't know if they've changed where they get their food or if there's a new crew in the kitchen; I've been here for 8 years and this is the first time I've had to say, I can't eat this. Review of the Admission Record revealed the facility admitted Resident # 26 on 6/1/2021 with medical diagnoses that included Type 2 diabetes mellitus with diabetic neuropathy. Review of the MDS with an ARD of 6/20/2024 revealed under section C, a BIMS summary score of 14, which indicates Resident #26 is cognitively intact. Resident #88 Review of the Admission Record revealed the facility admitted Resident #88 on 2/9/2023 with medical diagnoses that included Type 2 diabetes mellitus without complications. Review of the MDS with an ARD of 7/18/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #88 is cognitively intact. Resident #108 During an interview on 8/27/2024 at 10:55 AM, Resident #108 revealed we discuss the food issues all the time in our monthly resident council meeting. As a matter of fact we had resident council the beginning of this month, the Administrator and the Activities Director was in the meeting. They know all about the food issues we are always complaining about it, and stated the food just does not taste good. Review of the Admission Record revealed the facility admitted Resident #108 on 6/6/2024 with medical diagnoses that included Type 2 diabetes mellitus with diabetic neuropathy. Review of the MDS with an ARD of 6/13/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #108 is cognitively intact.

Based on resident and staff interviews, record view, facility policy review, the facility failed to implement a care plan for nail care for Resident #41 and failed to develop a care plan for the application of leg braces for Resident #51 and failed to develop a behavior monitoring care plan for Resident #113 for three (3) of 26 resident care plans reviewed. Resident #41, #51 and #113 Findings include: Record review of facility policy titled, Care Plans dated October 2021, revealed, Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #41 Review of the Care Plan undated for Resident #41 revealed, Self Care Deficit related to: decreased functional abilities, weakness. Also revealed, Nail, hair, and oral care daily and as needed. On 8/26/2024 at 11:36 AM, an observation of Resident #41 revealed, fingernails on both hands were long and measured approximately one-half (1/2) inch in length. On 8/27/2024 at 10:58 AM, an interview with Licensed Practical Nurse (LPN) #5, confirmed Resident #41's nails were long and needed to be cut. An interview with the Minimum Data Set (MDS) Nurse on 8/29/2024 at 8:51 AM revealed, the purpose of the care plan was for staff to know how to take care of the resident. She confirmed the care plan for nail care was not followed for Resident #41. Review of the Admission Record revealed the facility admitted Resident #41 on 10/26/2023 with a medical diagnoses that included Type 2 Diabetes mellitus with diabetic neuropathy. Resident #51 Record review of Resident #51's care plan revealed no care plan was developed for leg brace usage for the resident's range of motion needs. During an interview on 8/26/24 at 11:50 AM, Resident #51 stated he should be wearing leg braces two times a day to help the mobility in his legs, but the staff were not applying these. He stated he had recently completed therapy and they would pick him back up when his movement improved, but he needed the braces to help improve his limited range of motion. Interview with the Physical Therapist (PT) on 8/27/24 at 2:35 PM, revealed the resident's therapy was discontinued on 8/23/24 and the team met to discuss the plan for the resident to continue to use the braces two times a day for one to one and a half hours each time. He stated he was unaware that resident had not worn these since therapy stopped last week and the braces are needed to regain his functional mobility and to increase his potential to walk. An interview with the Minimum Data Set (MDS) Coordinator on 8/29/24 at 8:45 AM revealed she was responsible for the development of the care plans. She confirmed the care plan for Resident #51's brace use was not developed due to a failure in the communication process for nursing to enter orders from the therapy department. She confirmed the care plan's purpose was to provide information on the care needed for the residents and the facility failed to develop a care plan for this resident's leg brace use. During an interview with the Director of Nursing (DON) on 8/29/24 at 9:15 AM, she confirmed the facility failed to develop a care plan for the brace usage for Resident #51. She confirmed there was a failure in their communication system and after the Nurse Practitioner signed the order for these braces, it was not received by nursing staff to put into their system and the care plan was not developed. An interview with the Administrator on 8/29/24 at 10:00 AM, revealed the facility failed to follow the process to enter the orders from therapy into their system for nursing service to follow, and a care plan was not developed. She confirmed the facility failed to ensure a care plan was developed for the resident's range of motion. Record review of Resident #51's Admission Record revealed the facility admitted the resident on 2/23/22. Diagnoses included Paraplegia, Muscle wasting and Atrophy. Record review of Resident #51's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/10/24, revealed a Brief Interview for Mental Status (BIMS) of 14 which indicated the resident was cognitively intact. Resident # 113 Record review of the Admission Record revealed the facility admitted Resident # 113 on 7/19/24 with a diagnosis of Type 2 Diabetes with Hyperglycemia and Schizophrenia and was readmitted on [DATE] with a diagnosis of Binge Eating Disorder. Review of the care plans for Resident #113 revealed there was not a care plan developed related to the diagnosis of Binge Eating Disorder. During a record review and interview with the Registered Nurse (RN) Director of Clinical services on 8/28/24 at 1:55 PM, she confirmed after reviewing the care plans for Resident #113 there was not a care plan developed related to Binge Eating. She stated the diagnosis must not have gotten picked up when she came back from the hospital on 8/14/24. In an interview with the Director of Nursing (DON) on 8/28/24 at 2:00 PM, she revealed after review of Resident # 113's care plans, there was no care plan developed related to the behavior of Binge Eating. In an interview with the RN/MDS Coordinator on 8/28/24 at 3:45 PM, she revealed the purpose of the care plan is to accurately reflect the specific needs of a resident and staff can properly provide care for the residents. Record review of Resident # 113's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/24, Section C revealed a Brief Interview for Mental Status (BIMS) score was 5, indicating the resident was severely cognitively impaired. 41878 47157

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide personal hygiene as evidenced by failure to provide nail care for one (1) of 24 sampled residents. Resident #41 Findings Include: Review of the facility policy titled ADL's dated 8/2021 revealed Policy: Ensure ADL's (Activities of Daily Living) are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences . An observation and interview with Resident #41 on 8/26/2024 at 11:36 AM, revealed, she was sitting in her wheelchair in her room. She held up her hands and stated, I need my nails cut. I keep scratching myself. The resident revealed her nails had not been cut in a long time and stated she was a diabetic. The nails on both hands were long and measured approximately one-half (1/2) inch in length. An interview with Licensed Practical Nurse (LPN) #5 on 8/27/2024 at 10:58 AM, confirmed Resident #41's nails were long. She revealed that nail care had to be completed by a nurse since the resident was a diabetic. LPN #5 explained that diabetic nail care was not scheduled for the nurses to perform, it was just something the nurses did when it was needed. She confirmed long nails could cause a skin injury for the resident. An interview with the Director of Nursing (DON) on 8/27/2024 at 11:26 AM, confirmed diabetic nail care should be completed as part of the daily personal hygiene care. She revealed they did not have nail care set up on the Treatment Administration Record (TAR) for the nurses to perform, but her expectations were for the nail care to be performed when it was needed. Review of the Admission Record revealed the facility admitted Resident #41 on 10/26/2023 with a medical diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/2024 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 9, which indicates Resident #41 is moderately cognitively impaired.

Based on staff interview, record review and facility behavior monitoring document review, the facility failed to ensure a resident with a new diagnosis of Binge Eating Disorder received appropriate behavioral monitoring and interventions to address the disorder for (1) one of (3) residents reviewed with behaviors. (Resident #113) Findings include: Review of a statement on facility letter head titled, Behavior Monitoring undated, revealed Specific behaviors are identified based on resident assessments. Behaviors are monitored by the nurses and quantitatively recorded in the medical record. Record review of the Admission Record revealed the facility admitted Resident # 113 on 7/19/24 with a diagnoses that included Type 2 Diabetes with Hyperglycemia and Schizophrenia. Resident #113 was readmitted on [DATE] with a new diagnosis of Binge Eating Disorder. In an interview with Certified Nurse Assistant (CNA) #2 on 8/27/24 at 2:00 PM, she revealed that Resident #113 was always wanting and looking for snacks and has been known to take food off the food carts. She stated that she was aware the resident was a diabetic and only gave her low sugar snacks when she wanted them. CNA #2 confirmed she was unaware of the diagnosis of Binge Eating Disorder. In an interview with Registered Nurse (RN) #2 on 8/28/24 at 8:00 AM, she revealed that Resident #113 was always hungry and asked for snacks and has been known to walk up to a tray cart and take food from the cart. In an interview with CNA #3 on 8/28/24 at 10:30 AM, she revealed she was unaware that Resident #113 had a Binge Eating Disorder. She then revealed the resident would take food from the desk or food cart and was always asking for more. Record review of the Medication Administration Record revealed an order dated 8/14/2024 Document number of episodes per shift of target behavior: 1. Hallucinations 2. Delusions 3. Paranoia 4. Aggressiveness 5. None . There was no monitoring for the Behavior of Binge Eating Disorder. During a record review and interview with Director of Clinical Services on 8/28/24 at 1:55 PM, she revealed after review of the Medication Administration Record for Resident #113, she was unable to find monitoring related to Binge Eating behavior. She stated the diagnosis must not have gotten picked up when she came back from the hospital on 8/14/24. In an interview and record review on 8/28/24 at 2:00 PM, the Director of Nursing (DON) revealed after review of the Medication Administration Record for Resident #113 that there was no behavior monitoring in place for the Binge Eating Disorder diagnosis. She revealed she received that diagnosis when she returned from the hospital on 8/14/24. The DON confirmed Resident #113 should have been monitored for that behavior. She revealed the purpose of behavior monitoring is timely management of the behaviors. The DON then revealed that her binge eating could lead to elevated blood sugars. Record review of Resident # 113's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/24, Section C revealed a Brief Interview for Mental Status (BIMS) score was 5 indicating the resident was severely cognitively impaired.

Based on observation, resident and staff interviews, record review and facility policy review the facility failed to ensure foods were palatable, attractive and at a safe and appetizing temperature, for seven (7) of 12 residents sampled for dining. Resident #19, #41, #52, #88, #101, #102, and #108. Findings include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 9/2017 revealed Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs . Resident #19 During the resident council meeting on 8/27/24 at 3:05 PM, Resident #19 revealed the cornbread was so flat and hard there was no way to chew and swallow it. Resident #19 confirmed he had received foods that were not cooked thoroughly before. Review of the Admission Record revealed the facility admitted Resident #19 on 12/23/2023 with a medical diagnosis of Mixed conductive and Sensorineural hearing loss. Review of the MDS with an ARD of 7/30/2024 revealed, under section C, a BIMS summary score of 15, which indicates Resident #19 is cognitively intact. Resident #41 An interview with Resident #41 on 8/26/2024 at 12:15 PM, revealed the facility did not fix the things she liked to eat. She explained that she liked rice with gravy, but they never added the gravy. She revealed she had spoken with the Dietary Manager, but the gravy continued to be an issue. Resident #41 stated the food tasted bad and had no flavor and she could not eat the food on most days. An observation and interview with Resident #41 during a lunch meal on 8/27/2024 at 12:10 PM, revealed the meal consisted of mashed potatoes, diced potatoes, a hamburger patty with Barbeque sauce on a bun. The resident revealed she did not think she needed two different potatoes and the bun due to being a diabetic. Review of the Admission Record revealed the facility admitted Resident #41 on 10/26/2023 with a medical diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/2024 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 9, which indicates Resident #41 is moderately cognitively impaired. Resident #52 An interview with Resident #52 on 8/26/2024 at 1:38 PM revealed the food tasted bad. He stated he could ask for something else, but you probably couldn't eat it either. He explained that he got a hamburger every night because what they cooked at night was awful. The resident confirmed he had told the Dietary Manager, and he had told staff in resident council meeting and revealed nothing ever gets done. Review of the Admission Record revealed the facility admitted Resident #52 on 9/23/2022 with medical diagnoses that included Bipolar disorder. Review of the Quarterly MDS with an ARD of 7/18/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #52 is cognitively intact. Resident #101 An interview with Resident #101 on 8/27/2024 at 8:41 AM, revealed the food tasted terrible and was cold. He explained the food was not cooked right and the chicken was not cooked thoroughly. He stated, It looks like they just throw some things together to make a meal. The resident stated they need more options for food and revealed the only thing they can get besides the main meal was a hamburger or chicken sandwich. An observation of Resident #101 lunch meal on 8/28/2024 at 12:15 PM, revealed the resident sent his tray back with the aide to be warmed up in the microwave due to being cold. Resident #101 received 2 hamburgers on buns, diced potatoes and a blueberry muffin. Review of the Admission Record revealed the facility admitted Resident #101 on 8/6/2024 with a medical diagnosis of Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema Review of the Quarterly MDS with an ARD of 8/13/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #101 is cognitively intact. Resident #102 An observation and interview on 8/26/24 at 11:50 AM, revealed Resident #102 sitting up on the side of her bed eating her lunch which consisted of a ham pasta, creamed spinach, bread, fruit cup, and water. Observed to only eaten a small amount of lunch at that time. She stated she did not like the food and even though there are alternate items, she often does not order these in time to receive. She stated the food is bland and not seasoned and it's just not good and she kept snacks available so she would have something to eat. She stated she had talked to the Dietary Manager about her likes and dislikes, but even if an item is on her likes list, it still does not taste good. An observation and interview on 8/27/24 at 11:40 AM, revealed Resident #102 sitting up on side of her bed eating her lunch which consisted of a chunky chicken salad sandwich (which she had eaten approximately 95% of), cubes potatoes that were not browned (appeared to be the full serving still on plate), [NAME] slaw (full cup remained), chocolate chip cookie, and water. Meal ticket revealed a tuna salad sandwich was served which was incorrect. She stated the food was not good. Resident #102 stated the potatoes were not tender or fully cooked and the [NAME] slaw tasted ruined or was leftover and too much mayonnaise was added. During an interview on 8/27/24 at 2:50 PM, the Dietary Manager revealed both tuna and chicken salad were served for lunch so the wrong item was served. The Dietary Manager stated she had talked to the resident about her preferences and likes and dislikes and options she would like to use as substitute items. She confirmed there had been concerns about the food expressed to her by this resident and other residents. A sample tray was received from the kitchen on 8/27/24 at 11:35 AM. The food consisted of a barbeque hamburger patty on a bun, diced (hash brown cube like) potatoes, salad with lettuce and a slice of tomato, [NAME] slaw, cookie, tea. Hamburger patty sampled and was not warm and the flavor was bland. The [NAME] slaw was sampled by State Agency and noted too much mayonnaise was in the [NAME] slaw. The flavor tasted like eating mayonnaise from the jar. The potatoes were not warm and were not browned on the outside or tender on the inside. Record review of Resident #102's Admission Record revealed the facility admitted the resident initially on 12/5/23 with the most recent admitted [DATE]. Diagnoses included Type 2 Diabetes Mellitus and Gastro-esophageal reflux disease. Record review of Resident #102's MDS with and ARD of 7/3/24, revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #108 During the resident council meeting on 8/27/24 at 3:05 PM, Resident # 108 revealed the residents do not have food choices. She explained they had a set menu, and they can only get what was on the menu or two alternates to choose from every day, which is either a hamburger or a chicken sandwich. She stated, I'm a vegetarian and so is my roommate, and they don't have options for us. She revealed the food was disgusting and had no seasoning or flavor. Furthermore, she explained that she had been served lunch before and the next day was served the exact same thing for lunch and supper. She revealed the food was always cold and stated the vegetables were watery and ran together with other foods on the plate. Resident#108 stated the food was as though they just threw something together and occasionally the foods were not cooked thoroughly. Review of the Admission Record revealed the facility admitted Resident #108 on 6/6/2024 with a medical diagnosis of type 2 diabetes mellitus with diabetic neuropathy. Review of the MDS with an ARD of 6/13/2024 revealed under section C, a BIMS summary score of 15, which indicates Resident #108 is cognitively intact. 41878

Based on staff interview, record review, and facility policy review the facility failed to address dietary recommendations to change and/or increase a peg (percutaneous gastrostomy) tube feedings and water flushes to meet the nutritional needs for one (1) of three (3) residents reviewed who received enteral nutrition. (Resident #112) Findings include: A review of the policy titled Queuing RD (Registered Dietician) Recommendations & Follow-up, with an effective date of 7/1/21 revealed .Recommendations for changes to enteral feedings, enteral flush orders . is reviewed to ensure that the supervising physician is in agreement with nutrition therapy orders. The order is then signed, acknowledged and activated in the electronic medical record by a licensed nurse . Record review of a Progress Note for Resident #112 by the RD dated 8/5/24 at 9:57 AM, revealed: Note Text: Consult for tube feeding (TF) caloric intake: CBW (Current body weight) 148.9. EEN (exclusive enteral nutrition) 1692-2030 kcal (kilocalorie).Glucerna 1.2 237 cc (cubic centimeters) bolus with 200 ml (milliliters) water flushes provides 948 cc formula, 1127 kcal. Concerned that current orders are inadequate to meet the nutritional needs. Recommend: 1.) Discontinue current TF/flush order. 2.) Start Glucerna 1.5 237 cc bolus five times a day with 100 cc flush before and after each bolus to provide 1185 cc formula, 1780 kcal, 100 grams protein, 900 cc plus medication flush 900 cc free water plus 1000 cc flush. Record review of the Order Summary Report with active orders as of 8/9/24 revealed a physician's orders dated 8/02/24 Enteral Feed Order every 6 hours Glucerna 1.2 calorie (237 ml) bolus via peg tube with 200 ml water flushes. An interview with the Director of Nursing (DON) on 8/29/24 at 8:00 AM revealed she was not notified of the RD's recommendations until 8/9/24 and the resident was no longer in the facility. A phone interview with the RD on 8/29/24 at 8:35 AM, she revealed after review of her records she assessed Resident #112 on the morning of 8/5/24 and sent the recommendation to the interdisciplinary team email group the same morning at 10:12 AM. A review of the email sent by the RD revealed the email to the Interdisciplinary team was documented as sent on 8/5/24 at 10:12 AM with recommendation for Resident #112. A follow-up interview with the DON on 8/29/24 at 9:00 AM, revealed after review of the emails sent from the RD with the that she failed to see the recommendation for Resident #112 in the email on 8/5/24. She stated that she normally gets the dietary recommendations for tube feeders, obtains approval from the provider and writes the orders. She stated Licensed Practical Nurse (LPN) #1 also takes care of those recommendations. The DON then stated the provider should have been notified and the orders to change and increase tube feedings/flushes should have been written and carried out. An interview with LPN #1 on 8/29/24 at 9:15 AM, she confirmed she did get the email on 8/5/24 from the RD with the recommendations for Resident #112. She then stated that she only takes care of the dietary recommendations if the DON asks her to and confirmed the DON did not ask her to take care of Resident #112's RD recommendations. Review of the Admission Record revealed the facility admitted Resident #112 on 8/2/24 with diagnoses that included Cerebral Infarction and Encounter for attention gastrostomy.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for two (2) of twenty-six MDS reviewed. Resident #46 and Resident #96. Findings include: Record review of the facility policy titled, RAI Process Guideline dated September 2020, revealed, . All items in the MDS are to be coded per the instructions of the CMS Long-Term Care Facility Assessment User's Manual MDS 3.0 . Resident #46 Record review of the MDS with an Assessment Reference Date (ARD) of 07/24/24, revealed under section N, Resident #46 received seven (7) days of Anticoagulant medication for the observation look back period of 7/18/24 through 7/24/24. Record review of the Electronic Medication Administration Record (eMAR) for the MDS 7-day observation look-back period for anticoagulant medication revealed Resident #46 did not receive anticoagulant medication between 7/18/24 and 7/24/24. Record review of the Admission Record for Resident #46 revealed he was admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease, Tachycardia, and Atherosclerotic heart disease. Resident #96 Record review of the MDS with an ARD of 07/20/24, revealed under section N, Resident #96 received seven (7) days of Anticoagulant medication for the observation look back period of 7/14/24 through 7/20/24. Record review of the MDS with an ARD of 07/20/24, revealed under section N, Resident #96 did not receive seven (7) days of Antibiotic medication for the observation look back period of 7/14/24 through 7/20/24. Record review of the eMAR for the MDS 7-day observation look-back period for anticoagulant medication revealed Resident #96 did not receive anticoagulant medication between 7/14/24 and 7/20/24. Record review of the eMAR for the MDS 7-day observation look-back period revealed Resident #96 received antibiotic medication between 7/14/24 and 7/20/24. Record review of the Admission Record for Resident #96 revealed he was admitted to the facility on [DATE] with diagnoses that included Cerebral infarction and Hyperlipidemia. During an interview on 08/28/24 at 8:50 AM, the MDS Coordinator confirmed that Resident #46 was coded on the 7-day look-back period for receiving an anticoagulant medication but had instead received an antiplatelet medication, which was coded in error. The MDS Coordinator confirmed that Resident #96 was coded on the 7-day look-back period for receiving an anticoagulant medication and was receiving an antiplatelet medication instead. She confirmed Resident #96 was on Macrobid, an antibiotic, and was not coded for antibiotic during that 7-day look-back period. The MDS Coordinator confirmed these were coded incorrectly by a remote MDS worker.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (1) of three (3) residents reviewed for range of motion. Resident #51 Findings include: Record review of facility policy titled, Splinting and Orthotics dated 9/5/17, revealed, It is the policy of (proper name of rehabilitation service) that therapist recommend, within their scope of practice, appropriate splinting and orthotics for patients currently receiving therapy services, as the need arises. For splinting/orthotic needs that the therapist deems outside their scope of practice or expertise, therapist will notify the facility and make appropriate referrals to outside sources Therapy personnel will work with the facility, patient and caregivers to recommend appropriate materials for fabrication/modification and/or to recommend prefabricated splinting/orthotic options. Once trained by therapy, the facility is responsible for .implementing the wearing schedule to include donning/doffing (putting on/taking off) devices as recommended . In an interview on 8/26/24 at 11:50 AM, Resident #51 stated he was supposed to be wearing leg braces two times a day to help improve the mobility in his legs, but the staff were not applying these. He stated he had recently completed therapy and they would pick him back up when his movement improved. He stated the braces are designed to gradually increase his ability to straighten his legs with his goal to eventually walk. He expressed his concern that he had told the staff that he needed his braces, but they had not applied since he completed therapy last week. Braces were observed to be in a box against the wall in the resident's room. Observations and interviews with the resident on 8/26/24 at 1:50 PM, 8/27/24 at 8:30 AM, 8/27/24 at 10:30 AM, and 8/27/24 at 2:20 PM revealed the braces were noted to be in the box in the same position as previously observed. Each interview of the resident revealed the staff had not applied the braces. During an interview with the Physical Therapist on 8/27/24 at 2:35 PM, revealed the resident's therapy was discontinued on 8/23/24 and the team met prior to discharge to discuss the plan for the resident to continue to use the braces two times a day for one to one and a half hours each time. He acknowledged the time frame for the braces to be used was decided on based on the resident's preference for his daily activity choices since he was required to be in bed while wearing. He stated he was unaware that resident had not worn these since therapy stopped last week and the braces are needed to regain his functional mobility and to increase his potential to walk. Interview with the Director of Nursing (DON) on 8/27/24 at 3:00 PM revealed she was unaware of the concern with the braces. She stated she did not see an active order for the use of the braces and the resident was not one to refuse care. Interview with the DON at 3:40 PM on 08/27/24 she acknowledged she spoke with therapy and it appears the facility failed to put an order into the system when the resident was discontinued from therapy. She stated therapy had a plan of care and had in-serviced several nursing staff members on the splint use, but the staff failed to follow through and put the order in, therefore no tasks were entered for the staff to follow. She confirmed the facility failed to provide the resident with range of motion services to increase his mobility. An interview with Certified Nursing Assistant (CNA) #6 on 8/28/24 at 9:00 AM, revealed she worked with Resident #51 and had been trained on the use of the braces, but he had refused to put these on. She stated she worked 6 AM until 2 PM and when she came to work in the morning, she would attempt to put these on him and he declined. She reported this to the night shift nurse, but she did not report to the day shift nurse or go back to the resident later during her shift. She stated she was unaware that the reason to follow the time frame requirement was for the resident's preference for his day to day activities. During an interview on 8/28/24 at 9:45 AM, the Physical Therapy Assistant (PTA) revealed the facility staff failed to put the braces on the resident as required. She stated therapy and the resident worked out a schedule from 7:30 AM - 9:00 AM so he would be able to go to smoke break at 9:00 AM. He had to be lying in bed for the braces to be on, and he did not want to miss his smoke break. She stated he was being asked to put the braces on at 6:00 AM and he did not want these on at that time after it was agreed upon with therapy to have on at 7:30 AM. She stated he had been in therapy until last week and therapy had been ensuring the braces were used as ordered. She stated since his therapy was discontinued, they were unaware the staff members were not applying the braces. She stated the goal of these braces was for the resident to regain functional mobility to be able to meet his goal to stand and walk and this would offer him the chance to meet that goal as his range of motion improved. During an interview on 8/28/24 at 9:50 AM, Resident #51 stated, Thank you for getting' this done for me. I might not ever walk again, but this gives me a chance to be able to. He stated he was hopeful the system they now have in place would work so this would not happen again. He acknowledged the time frame that had been agreed upon would allow him to go outside to smoke. He stated he had to be in bed while he was wearing the braces, but that was not a problem as long as he could go to his smoke breaks. He then stated, Thank you very much! Resident observed lying in bed with braces on both legs. During an interview with the DON on 8/29/24 at 9:15 AM, she confirmed that after the Nurse Practitioner signed the order for these braces, it was not received by nursing staff to put into their system. An interview with the Administrator on 8/29/24 at 10:00 AM, revealed the facility failed to enter the orders from therapy into their system for nursing service to follow. Record review of Prescription-Standard Written Order dated 6/11/2024 revealed .Positional orthosis, Rigid Support right .and left .Medical Necessity: Pt (patient) is contractured, improves ROM (range of motion) . Record review of In-service Training Report dated 7/2/24 with therapy training four nursing staff members on the knee brace/orthotics. Recommendation/approaches listed as Patient will wear knee braces and .orthotics twice daily (one time in morning and one time in afternoon) up to patient's tolerance with understanding that patient will doff orthotics. Preferably wear from 7:30 - 9:00 AM and 1:30 - 3:00 PM to improve patient's wearing tolerance to in turn improve patient's functional mobility tasks. This was signed by four nursing service staff members. Record review of Resident #51's Admission Record revealed the facility admitted the resident on 2/23/22 with diagnoses that included Paraplegia, Muscle wasting and Atrophy. Record review of Resident #51's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/10/24, revealed a Brief Interview for Mental Status (BIMS) of 14 which indicated the resident was cognitively intact.