Every finding on record at Diversicare of Luling

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #35) reviewed for accidents and hazards. The facility failed to ensure Resident #35 received 2 persons assistance during bed mobility using a draw sheet when an unnamed male staff member pulled on his hand and/or arm, resulting in a fracture on or about July 7-10, 2026. This failure could place residents at risk of injury or accidents. Findings included: A record review of Resident #35's face sheet dated 07/23/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of nondisplaced fracture (avulsion) of the medial epicondyle of the left humerus (small bone injury at the inner bony bump of the upper arm near the elbow. The avulsion part means a small piece of bone is pulled away by a tendon or ligament, but the main bone remains in place), unspecified fracture of the upper end of left humerus (broken arm near the shoulder joint), unspecified fracture of second metacarpal bone right hand (broken finger), severe morbid obesity, heart failure, acute kidney failure, cellulitis of right and left lower limb (bacterial skin infection in both lower legs), and gout (form of arthritis). A record review of Resident #35's admission MDS assessment dated [DATE] reflected a BIMs score of 13, which indicated no cognitive impairment. Resident #35 used a wheelchair and was completely dependent on rolling left to right (bed mobility), chair to bed transfer, toileting hygiene, and lower body dressing. He was a substantial/maximal assistance for shower/bathe self and tub/shower transfer. A record review of Resident #35's care plan last revised on 07/23/2026 reflected that he had a visual and hearing deficit and self-care deficit with interventions requiring 2-person assistance for bathing, bed mobility, dressing and 2-person assist with hoyer lift (an assistive medical device used to move people who cannot safely stand, pivot, or bear weight on their own) for transfers. A record review of Resident #35's centralized daily nursing tasks dated 07/22/2026 reflected resident required 2-person assistance for bed mobility. Record review of the provider investigation report, dated 07/17/2026 and signed by the ADM, reflected Resident #35's X-rays showed a punctuate avulsion fracture fragment involving left medial distal humeral epicondyle (left elbow). Resident #35's witness statement dated 07/11/2026 and signed by the DON, reflected On Tuesday (07/07/2026) or Wednesday (07/08/2026) the guy pulled my left hand to move me in the bed. I should have given him my other hand, but by the time I thought about it, it was too late. I then had pain in my left shoulder when I raise my arm or when they roll me. RN J's witness statement dated 07/11/2026 reflected Resident #35 said pain started after a guy pulled on my arm to adjust me in bed. CNA F's witness statement dated 07/11/2026 reflected that Resident #35 complained of shoulder pain on 07/10/2026 and 07/11/2026 and said it hurt for a day or two and did not know why. RN K's witness statement dated 07/12/2026 reflected Resident #35 said pain in his left arm started after being repositioned in bed and reported on 07/10/2026 that his left shoulder hurt for several days. Record review of the DOR's statement dated 07/21/2026 reflected the DOR worked with Resident #35 on 07/09/2026 and 07/10/2026 and resident complained of left arm pain. The DOR did not work the weekend (July 11-12, 2026) and when he returned to work (on 07/13/2026) Resident #35 stated someone hurt his arm over the weekend. Record review of the PTA's statement dated 07/21/2026 reflected he worked with Resident #35 on 07/20/2026 and Resident #35 reported injured left upper extremity due to being pulled on by a male employee between 07/08/2026 - 07/12/2026. Attempts to interview Resident #35 on 07/21/2026 at 7:20 a.m. and 9:30 a.m. were unsuccessful due to resident being asleep and later being hospitalized . During a telephone interview on 07/22/2026 at 10:46 a.m. and 07/23/2026 at 8:02 a.m. Resident #35's FM stated Resident #35 had been in the hospital and was not available for interview. The FM stated Resident #35 told her that LVN H had repositioned him in bed by pulling on his left hand/arm, which Resident #35 believed caused the injury, but could not recall the specific date. The FM stated Resident #35 normally required two staff members for repositioning, but only one staff member assisted that day, and Resident #35 told her he had given LVN H the wrong hand by mistake. During an interview on 07/22/2026 at 12:10 p.m. the DOR stated he had been trained in proper transfers and bed mobility. The DOR stated Resident #35 required a 2 person assist for bed mobility, but one staff member could reposition him. The DOR stated he repositioned Resident #35 by holding his right hand, shoulder, or arm after Resident #35 complained of left arm pain. The DOR stated that when he returned to the facility on [DATE], Resident #35's left arm was in a sling. The DOR stated Resident #35 told him a male staff member helped him but grabbed the wrong arm. The DOR denied pulling on Resident #35's left arm. Attempts to interview RN J via telephone on 07/22/2026 at 1:42 p.m. and 07/23/2026 at 12:07 p.m. were made by leaving voicemail messages. During an interview on 07/22/2026 at 2:48 p.m. and 07/23/2026 at 10:02 a.m., the ADON stated Resident #35 required a 2 person assist for transfers and bed mobility and that staff were expected to use the bed sheet for repositioning rather than pulling on residents' arms. The ADON stated Resident #35 was previously assisted with bed mobility using repositioning bars and was upset by the investigation. The ADON stated Resident #35 could, or did, not identify a staff member and could not recall a specific date but stated a male staff member held his arm the wrong way when he turned. The ADON stated Resident #35 had not complained of elbow pain, and staff were unaware of the fracture until X ray results were received. The ADON stated the facility immediately initiated an investigation and in serviced staff on abuse and neglect, safe handling of residents, and safe transfers and repositioning. During an interview on 07/23/2026 at 3:19 p.m. CNA A stated she had been trained in proper transfers and bed mobility. CNA A stated Resident #35 required a 2 person assist for bed mobility, repositioning, and hoyer lift transfers. CNA A stated she repositioned residents by using a bed sheet/pad and avoided pulling on residents' bodies to prevent injury. CNA A stated she heard a nurse say (no name or date recalled) that LVN H hurt Resident #35's arm by trying to transfer him alone. CNA A stated she had never seen staff move or transfer Resident #35 without assistance. During a telephone interview on 07/23/2026 at 3:40 p.m. RN K stated she had been trained in transfers and bed mobility and used the drawsheet to avoid injury. RN K stated Resident #35 complained of shoulder pain on 07/10/2026 and required a 2 person assist for transfers and bed mobility. RN K stated Resident #35 told her his left arm hurt after being repositioned but did not identify staff or the date. During a telephone interview on 07/23/2026 at 3:46 p.m. CNA F stated she had been trained in transfers and bed mobility and repositioned residents by using the sheet underneath them rather than pulling on their bodies. CNA F stated Resident #35 told her LVN H pulled his arm too hard while repositioning him. Resident #35 did not say whether LVN H had been alone. CNA F stated she reported the concern to her charge nurse but did not recall who it was. CNA F stated Resident #35 required a 2 person assist for transfers and bed mobility and stated she had never seen staff reposition him alone. An attempt to interview LVN H via telephone on 07/23/2026 at 3:39 p.m. was unsuccessful due to call restrictions. During a telephone interview on 07/23/2026 at 4:00 p.m. CNA E stated he had been trained in transfers and bed mobility and used draw sheets to avoid injury. CNA E stated he had changed Resident #35's brief using two staff members and denied pulling on Resident #35's arm or seeing anyone else do so. During an interview on 07/23/2026 at 5:06 p.m. the DON stated Resident #35 sustained a pull fracture to his left elbow when he had been moved inappropriately by a male staff member who pulled on his arm. The DON stated Resident #35 had been upset about the investigation and did not identify staff. The DON stated Resident #35 required a 2 person assist for transfers, cares, bed mobility, and repositioning. The DON stated the facility's policy required staff to use draw sheets for bed mobility and rolling and not to pull on residents' body parts to prevent injury. The DON stated she and the ADON were responsible for ensuring staff were trained in safe transfers and repositioning and that staff had been in serviced, with therapy support, on safe resident handling and abuse and neglect. The DON stated she reported the incident to the NP, ADM, and the State, assessed Resident #35, sent him to the ER, assessed his pain, and notified the FM. During an interview on 07/23/2026 at 5:37 p.m. the ADM stated LVN H was terminated on 07/13/2026 for reasons unrelated to the incident and was not interviewed about the incident. The ADM stated Resident #35 required a 2 person assist for transfers and bed mobility and that staff were expected to use bed sheets for repositioning to avoid injury. The ADM stated the ADON and DON were responsible for ensuring staff had the knowledge and training to safely reposition residents. The ADM stated interventions after the incident included notifying the NP, sending Resident #35 to the ER, in servicing staff on bed mobility, transfers, and abuse and neglect, monitoring Resident #35, updating the care plan, limiting therapy services, and ordering a special movement bar to assist with repositioning. Record review of an in-service dated 07/11/2026 reflected staff were trained on Safe Patient Handling (Transfers)/ Record review of the facility's policy titled, Nursing Policy and Procedure Manual undated, revealed: Bed MobilityTurning a resident in bedProcedure:.6. Grasp the turning sheet (draw sheet) at the shoulder and lower back level.7. Pull the resident toward the side of the bed using the turning sheet.8. Place resident's arm over his chest and.9. Then lift the sheet and turn, he should be on his side. Safe Patient HandlingThe facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable, safe transfer, repositioning, and resident movement. Nurses will identify residents in need of transfer, repositioning, or movement assistance.Nurses will assess the risks associated with lifting, transferring, repositioning, or movement assistance.5. Nurses will be educated regarding correct safe handling procedures.

Based on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that must include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for staff and other individuals providing services for 9 of 10 staff members (ADM, DON, RN I, CNA A, CNA B, CNA C, DM, DS, and Cook).The facility failed to ensure documentation of TB screening was completed for 9 facility staff members (ADM, DON, RN I, CNA A, CNA B, CNA C, DM, DS, and Cook), as required by the facility's infection prevention and control policies and procedures.This failure had the potential to prevent the facility from identifying staff with communicable disease risk and implementing appropriate infection prevention and control measures to protect residents, staff, and visitors from the transmission of communicable disease. Findings included:Record review [KA59.1][SR59.2]of facility staff files (ADM, DON, CNA A, DM, and Cook) for review reflected, no current TB screening documentation for ADM, DON, CNA A, DM, and Cook. Recorded review reflected ADM date of hire 04/29/2024, DON date of hire 05/20/2026, CNA A date of hire 05/27/2026, DM date of hire 12/13/2024, and [NAME] date of hire 01/24/2025, which there were no TB screenings completed.During an interview on 07/22/2026 at 1:30 p.m., ADM[KA60.1][SR60.2] stated he did not have any current tuberculosis screening documentation since coming to this facility and the conversion with a new company. The ADM stated DM, and [NAME] did not have updated tuberculosis documentation. The ADM stated he, along with DM, and [NAME] were receiving tuberculosis testing today, 07/22/2026.During an interview on 07/22/2026 at 2:10 p.m., ADM stated he did not have any current TB screening documentation provided by the previous company to the new company. ADM stated DM and [NAME] did not have access to the previous TB documentation due to the conversion with a new company. ADM stated that DON and CNA A were new to the facility in which they both just received a TB screening[KA61.1][SR61.2] on 07/21/2026. Record review of updated facility staff files reflected the ADM completed TB screening on 07/22/2026, the DON completed TB screening on 07/21/2026, CNA A completed TB screening on 07/21/2026, the DM completed TB screening on 07/22/2026 and the [NAME] completed TB screening on 07/22/2026. During an interview on 07/23/2026 at 9:25 a.m. with ADM, he stated that it is[KA62.1][SR62.2] the DON's responsibility to ensure all staff have TB screenings completed and the appropriate documentation. ADM stated there have been multiple leadership changes in the past few months, which was the reason not all staff have completed TB screenings within the two weeks of staff hire date. ADM stated it is[KA63.1][SR63.2] the overall responsibility of the ADM to monitor that all TB screenings have been completed within timeframe and ensure there is supporting documentation. ADM stated CNA C did not have a complete TB screening and last day of employment at this facility was 07/08/2026. ADM stated DS did not complete a TB screening and last day of employment was 07/08/2026. ADM stated RN I completed a TB screen on 07/21/2026 due to not having documentation from conversion of previous company. ADM stated CNA B completed a TB screen on 07/22/2026 due to not having documentation from conversion of previous company.Record review of additional facility staff (RN I, CNA B, CNA C, and DS) files for review reflected, no TB screening documentation. Recorded review reflected CNA C date of hire 06/02/2026 did not have a completed TB screening and last day of employment at this facility was 07/08/2026, DS date of hire 05/08/2026 did not complete a TB screening and last day of employment was 07/08/2026, RN I date of hire 06/24/2026 did not complete a TB screen until 07/21/2026, and CNA B date of hire 05/28/2026 did not complete a TB screen until 07/22/2026.Record review of updated facility staff files reflected: ADM completed TB screening on 07/22/2026, DON completed TB screening on 07/21/2026, CNA A completed TB screening on 07/21/2026, DM completed TB screening on 07/22/2026, [NAME] completed TB screening on 07/22/2026, RN I completed a TB screening on 07/21/2026, and CNA B completed a TB screening on 07/22/2026.During an interview on 07/23/2026 at 11:12 a.m., [NAME] stated he had worked at this facility for one year and five months. [NAME] stated he had no training on TB screening, and he was asked by administrative to complete one on 07/22/2026. [NAME] stated when he was hired on to this facility, he did not complete one and was not asked to complete a TB screening. [NAME] stated TB screening goes over tuberculosis infections and helps prevent the spread of infection towards residents. [NAME] stated it's important to conduct TB screenings due to it helps prevent any infection control issues or exposures. [NAME] stated there was no TB screening in-service or training and this was the first time he heard of it in which he did not have to do one from the previous facility he came from. [NAME] stated not having TB screenings conducted for all staff can cause infections issues toward others. [NAME] stated it's the responsibility of the ADM and DON to ensure all staff have TB screenings completed. [NAME] stated facility staff not having TB screenings and supporting documentation it was completed can affect the residents quality of life because an individual may have health or infection issue that could get residents exposed to of the spread of infection for example, if he got sick then there is a potential of getting residents sick. [NAME] stated that TB screenings from his understanding needed to be completed two weeks from hire date and it is ultimately the overall responsibility of the ADM to monitor TB screenings and the corresponding supporting documentation.During an interview on 07/23/2026 at 11:22 a.m. with DM, he stated the following: he had worked at this facility for two years. DM stated he had been trained when TB screening needs to be completed from the date of hire. DM stated TB screenings go over the stopping and spread of infections being transmitted to others. DM stated it's important to conduct TB screenings due to it helps prevent any spread of infections and helps individuals' immune systems work at this facility. DM stated the last TB screening in-service or training completed was when he first started two years ago during orientation. DM stated he had TB screening done a couple years ago during onboarding, but the company had a conversion in which he thinks the paperwork went missing. DM stated he conducted a TB screening yesterday, 07/22/2026. DM stated not having TB screenings conducted for facility staff and the appropriate supporting documentation can potentially affect residents should an individual get or is sick. DM stated it's the responsibility of the DON to ensure all facility staff have TB screenings and supporting documentation. DM stated that staff not having TB screenings can affect the resident's quality of life by causing a resident to get infected or the resident may be carrying something that can spread to facility staff. DM stated it's ultimately the overall responsibility of the ADM to ensure TB screenings are completed by all staff.During an interview attempt on 07/23/2026 at 12:43 p.m. with offsite RN I, via by phone, there was no answer. A detailed voicemail with call back information was left. During an interview on 07/23/2026 at 12:50 p.m. with CNA B, she stated the following: she had worked at this facility for a few months. CNA B stated she had been trained on when TB screenings needed to be completed. CNA B stated TB screening goes over tuberculous and to make sure individuals who are positive or negative in which if positive, the individual will get chest x-rays. CNA B stated it's important to conduct TB screenings to help individuals' health wise and it helps prevent any infection to others. CNA B stated the facility has not provided TB screening in-service or training. CNA B stated not having TB screenings conducted for staff and the appropriate supporting documentation can cause issues towards residents as everyone should know if they are positive or negative for protection. CNA B stated it's the responsibility of the ADM and DON to ensure facility staff have TB screenings and support documentation. CNA B stated she completed a TB screening on Tuesday, 07/21/2026 and did a TB screening a while back with the previous company that underwent the conversion. CNA B stated staff not having TB screening completed and or the appropriate supporting documentation can affect the resident's quality of life by causing health issues. CNA B stated it's ultimately the overall responsibility of the ADM to ensure TB screenings were monitored and completed by all staff for infection purposes. During an interview on 07/23/2026 at 1:47 p.m. with RN I, she stated the following: she had worked at this facility for a month. RN I stated she had been trained in TB screening when it needs to be completed, and she has not been trained on TB information. RN I stated she was asked to complete TB screening on Tuesday, 07/21/2026. RN I stated she does not know who conducts it. RN I stated she has no more answers to provide as she is just a staffed nurse at this facility and did not handle TB screenings or protocols. RN I stated she did not have further answers to questions.During an interview on 07/23/2026 at 4:54 p.m. with DON, she stated the following: she had worked at this facility since May 2026. DON stated she had been trained on TB screening needing to be completed upon hire during orientation before facility staff work with residents. DON stated TB screening goes over recognizing signs and symptoms, timelines when to give and administer TB testing, and the different types of TB test screenings. DON stated she is unaware of training provided to facility staff besides providing them with education and signs of TB. DON stated it's important to conduct TB screenings to catch TB and exposure risks. DON stated she conducted a TB screening on Tuesday, 07/21/2026, which was not in the timeframe per the facility requirements, and she was not asked to complete a TB screening when hired until now. DON stated not having TB screenings conducted for all staff may be an issue as it can cause exposure and outbreaks. DON stated she, as the DON, needs to be diligent to conduct and keep up with staff TB screenings to prevent any infection issues. DON stated when she came to this facility, it was understood that all staff had already underwent TB screening since there was a company conversion and later found there was a list of individuals that did not receive TB screenings. DON stated it's the responsibility of the DON to ensure facility staff have TB screenings and supporting documentation. DON stated that staff not having TB screening and its supporting documentation can affect the resident's quality of life by causing a resident to get infected if there is a missed positive screening which is a big deal in the geriatric community. DON stated it's ultimately the overall responsibility of the ADM to monitor that TB screenings are completed by all staff. DON stated the expectation is for all staff to undergo TB screening and for it to be completed prior to facility staff starting their first shift at the facility. During an interview on 07/23/2026 at 5:23 p.m. with ADM, he stated the following: he had worked at this facility for over a year. ADM stated he had been trained on when TB screening needs to be completed in which is upon hire or prior before facility staff start shift working with residents. ADM stated TB screening goes over during orientation the policy of what is expected for TB screenings and the importance of TB screenings. ADM stated it's important to conduct TB screenings so that there is no potential chance for a resident or facility staff to get sick, to prevent spreading of infections, and for there to be no chances of an outbreak as well as to have the supporting documentation for TB screenings. ADM stated there has not been any in-service or training conducted for TB screenings outside of orientation. ADM stated not having TB screenings conducted for facility staff and the appropriate supporting documentation can be an issue as there is no information for a potential chance that someone who has a TB infection can be an exposure risk for others. ADM stated the DON is responsible for conducting and keeping up with staff TB screenings for infection control as well as the ADM is to make sure this is completed. ADM stated it's ultimately the responsibility of the ADM and DON to ensure all facility staff have TB screenings and the supporting documentation. ADM stated facility staff not having TB screening and supporting documentation can pose and affect the resident's quality of life by causing a resident to get infected if there is an unknown facility staff member who is infected. ADM stated the expectation is for all facility staff to undergo TB screening before hitting the floor, working with residents, and for there to be supporting documentation in staff files. Record review of the facility Employee Tuberculosis Program policy with no date reflected, new employees will be required to be screened for TB according to CDC, Guidelines prior to delivering resident services. The individual must consent to TB skin testing prior to the injection. The employee should receive informed consent and have a consent form documented in the personnel record. An employee with TB infection who cannot take or does not accept or complete a full course of preventive therapy cannot be excluded from work. The employee is counseled through the nursing administrator or designee and the ICP, about the risk of developing active TB and should be instructed on a regular basis to seek evaluation promptly through a private physician is symptoms related to TB develop, especially if there is an exposure to a high-risk resident. In general, these guidelines for interpreting skin test reactions should also be applied to persons who may have occupational exposure to TB. All employees will receive tuberculosis education as a part of the facility orientation and at least annually. The level of education may vary based upon the employee's job description.Education will include the following: - TB transmission, pathogenesis, and diagnosis- Signs and symptoms- Potential occupational exposure- Infection Control practices related to prevention of TB- Purpose of skin testing- Principles of preventive therapy for latent TB and drug therapy for active TB- Employee medical evaluation for signs and symptoms of TB or skin test conversions- Exposure control program to include prophylaxis and follow-up medical care as necessary- TB as it relates to immunocompromised persons- All employees will attend a mandatory annual TB training session

Based on observation, interview and record review; the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse or resulted in serious bodily injury, to other officials (Including the State Agency) for 1 of 6 residents (Resident #1) reviewed for abuse .The facility failed to report an allegation of abuse immediately, but not later than 2 hours, to the state agency, after the allegation that occurred 6/25/26 in that Resident #2 blocked Resident #1's entrance to the facility, grabbed Resident #1's wrist which resulted in a bruise. The facility reported the incident to the state agency on 7/1/2026. The deficient practice could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, lasting physical impairment, or psychosocial harm.Findings Included: Review of face sheet for Resident #1, dated 07/09/2026, reflected a [AGE] year-old male, with an original admit date of 04/19/2026, with diagnosis of Chronic respiratory failure, COPD(chronic obstructive pulmonary disease), dysphagia (difficulty swallowing) osteoarthritis (form of arthritis-when protective cartilage that cushions the ends of the bones wears down over time), anxiety, and heart disease. Review of the MDS for Resident #1 dated 05/27/2026 reflected a BIMS of 15, indicating intact cognition. Review of face sheet for Resident #2, dated 07/09/2026, reflected a [AGE] year-old-male, with an original admit date of 03/12/2026, with diagnosis of Diabetes, COPD (chronic obstructive pulmonary disease), unsteadiness on feet, Dementia (Symptoms that affects cognition and memory), anxiety, and chronic kidney disease. Review of the MDS for Resident #2 dated 06/29/2026 reflected a BIMS of 99, indicating the resident was unable to complete the interview. Resident # 2's MDS reported he had physical behavioral symptoms directed toward others that occurred 1-to 3 days. Resident # 2's care plan dated 05/04/2026 incidcated, The resident has potential to demonstrate verbally abusive behaviors. Review of the Provider Investigation Report dated 07/01/2026 that involved Resident #1, and Resident #2 revealed the following:Date reported to HHSC: 07/01/2026, time: 11:30 p.m.Allegations were made by ADM on 07/01/2026 Incident Date: 06/3/2026 9:30 a.m.Location of incident:26Outside Patio Door.Alleged Victim: Resident #1Description of Allegation: Resident A (Resident #1) was entering the facility after smoke break. Resident B (Resident #2) wanted to go outside. Resident A (Resident #1) advised Resident B (Resident #2) he could not go outside by himself. Resident B (Resident #2) grabbed Resident A's (Resident #1) wrist. Resident A (Resident #1) closed the door and Resident B (Resident #2) let go. Description of Injury: Bruising on wristDescription of Assessment: Date 7/1/2026 at 23:06 (11:06 p.m.) revealed: Weekly Skin Assessment, bruise right wrist and forearm circumferential black and blue bruising.Provider Response: Investigation initiated immediately, both residents were assessed. In-service initiated. Hospice, family, and the NP were notified.Investigation Summary: After the resident notified the nurse of the physical incident with another resident both residents were assessed, the families were notified of the incident, and the hospice provider was notified, 1 on 1 monitoring was in progress for Resident # 2 .Investigation Findings: Confirmed Interview on 07/09/2026 at 10:32 a.m., Resident #2 stated he did not know why that guy (Resident #1) prevented him from going out to the smoking area. Resident #2 stated he did not recall grabbing the other resident (Resident #1) by the wrist. Observation and interview on 07/09/2026 at 10:40 a.m., revealed Resident #1 had discoloration and an appearance of black and blue on his left and right hands, wrists and arms. Resident #1 stated I have thin skin, and I bruise easily but I was not hurt by Resident #2. Resident #1 stated he tried to go outside, pulling the door closed when Resident #2 grabbed his right hand and pulled it away from the door handle. Resident #1 stated he had no lasting negative effects from the event. Interview on 07/09/2026 at 12:03 p.m., the ADON, stated she has been trained on abuse and neglect and was last trained on 07/08/2026. The ADON is aware the ADM is the abuse coordinator. The ADON stated the protocol for reporting was to report to the abuse coordinator, and the ADM has two hours to report to the state. The ADON recalled that around 9:30 a.m. on 06/26/2026 Resident #1 informed her of the incident that occurred on the evening of 06/25/2026 with Resident #2. The ADON recalled Resident #1 informed her that Resident #2 grabbed Resident #1's right wrist, it was bruised. The ADON stated she immediately called hospice. The ADON stated the ADM was told about the incident at the same time as she was notified.nterview on 07/09/2026 at 12:28 p.m., the DON stated she had been trained on abuse and neglect and she receives training once a week. The DON stated the protocol about abuse is to report to the abuse coordinator, he submits an incident report to the state, and they follow protocols. The DON stated that she was not informed of the incident between Resident #1 and Resident #2 until 07/01/2026. The DON stated the ADON informed her that Resident #2 grabbed Resident #1. The DON stated that ADON informed the ADM on 06/26/2026. Interview on 07/09/2026 at 12:47 p.m., LVN A stated on Friday, 6/26/26, Resident #1 came to the nursing station and reported to the ADON, him, and the ADM that the night before Resident #2 tried to go out the door behind him (Resident #1). LVN A stated Resident #1 put his arm up to stop Resident #2 then proceeded to grab ahold of Resident #1's wrist. LVN A stated the ADM instructed he and the ADON to call hospice, and perform an assessment on Resident #1. LVN A stated the ADM informed him that he (ADM) is going to speak to Resident #1 after he gets back from taking another resident to an appointment. LVN A stated there was an observation of bruising. LVN A stated he is unsure why the ADM did not report to the state immediately.Record review of the facility's Abuse/Neglect Policy, no date, revealed that:It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.E: Reporting2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called.3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property of injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24.a. If the allegation involve abuse or result in serious bodily injury, the report is to be made within 2 hours of allegation.b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of allegation.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary [NAME] G, and Dietary Aide H used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 05/07/2025 at 6:50 AM, revealed Dietary [NAME] G was not wearing gloves. He touched a disinfectant dish cloth and wiped a food prep table. Dietary [NAME] G placed the dish cloth in a container with other disinfectant dish cloths. He proceeded to puree food. Dietary [NAME] G exited from the puree food prep area to the steam table. Dietary [NAME] G placed his middle finger, fore finger, ring finger and small finger from the knuckles to the tip of his fingers inside the silver container sitting on the steam table and carried it the puree food prep table. Dietary [NAME] G did not sanitize or wash his hands after touching the disinfectant dish cloth. He placed puree hashbrowns inside the silver container he obtained from the steam table. Observation on 05/07/2025 at 7:15 AM, revealed Dietary Aide H's right palm and fingers on her right hand touched her top and her pants while she was obtaining a meal tray. Dietary Aide H was not wearing gloves. She gathered cups for the breakfast meal from a shelf. When she picked up the cups she placed her middle, ring, and forefingers from the knuckle to the tip of her fingers on her right hand inside of 5 small plastic cups to be used for breakfast. Dietary Aide H placed the cups on a small food prep area located beside the coffee maker. She also placed her fingers on her right hand inside the breakfast meal trays located on the meal cart. Dietary Aide H did not wash or sanitize her hands. Interview on 05/07/2025 at 1:40 PM Dietary Aide H stated she did touch her shirt and her pants prior to carrying cups to the food prep area by the coffee maker. She stated she did touch inside the cups and was expected to wash her hands after she touched anything that was dirty. She stated germs from her pants and shirt possibly transferred to her hands. She stated the germs on her hands may transfer to the inside of the cups and meal trays. Dietary Aide H stated if germs were inside the cups or on meal trays and transferred to drink or food, there was a potential a resident may become physically ill with stomach virus. She stated she had been in-service on hand hygiene. Dietary Aide H stated she did not recall the date of the in-service. Interview on 05/08/2025 at 10:45 AM Dietary [NAME] G stated on 05/07/2025 he did touch the disinfectant kitchen towel and wiped area on the food prep table. He stated he did not wash his hands and was not wearing any gloves. Dietary [NAME] G stated he did place his fingers inside the silver container when he picked up the silver container from the steam table and placed it by the food puree prep table. He stated he did place puree potatoes inside the silver container. Dietary [NAME] G stated there was a possibility germs transferred on the puree potatoes when they were transferred from the puree blender into the silver container. He stated there was a potential if germs were on the puree potatoes a resident may become ill with food borne illness such as nausea or vomiting. He stated he had been in-service on hand hygiene. He did not recall the date of the last hand hygiene in-service prior to 05/06/2025. Interview on 05/08/2025 at 11:25 AM the District Director of Operations for the kitchen stated the staff was expected to wash their hands between tasks. He stated if the staff were not washing their hands after touching contaminated items there was a potential of cross contamination. He stated the staff was in-serviced on hand hygiene. The District Director of Operations stated he would need to observe the staff not washing their hands prior to responding to any questions. Interview on 05/08/2025 at 12:40 PM the Dietary Manager stated all staff were required to wash their hands between tasks and whenever they touched their clothes or a disinfectant kitchen towel. She stated clothes and disinfectant kitchen towels were considered contaminated. The Dietary Manager stated food may become cross contaminated if there was bacteria on the staffs hands and the staff touched plates, food, plate covers and/or napkins. She stated it was a possibility a resident may become ill with stomach issues such as vomiting if they ingested bacteria transferred from staff's contaminated hands onto their food, silver container, cups, or meal trays. Review of the Facility's Policy on Proper Hand Hygiene, dated 2020, reflected While alcohol-based hand sanitizers containing 60 percent or more alcohol are the preferred method for cleaning your hands in most clinical situations, handwashing is the standard set by the 2017 Food Code, Section 2-301 for kitchen settings. Handwashing with soap and water is required in a dining service setting in the following situations: 1. When you take one step away from your workstation. 2. After touching your hair, face, or clothes. Between tasks: Example- switching between cutting chicken and cutting onion.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for one of one kitchen. The facility failed to keep overflowing garbage in a container without a lid on the kitchen utility cart away from clean dishes and the food prep area where dietary staff was preparing food for lunch. The failure could place residents at risk for exposure of germs and diseases carried by vermin and rodents. Findings include: Observation on 05/06/2025 at 9:18 AM revealed a kitchen utility cart with a garbage can attached to the utility cart. The garbage was not covered and was overflowing with food and containers. The utility cart was touching the area where staff prepped for drinks and there were clean cups on the small prep area beside the coffee maker. The utility cart was approximately 2-3 feet from the food prep table where food was lying on the food prep table beside the stove. Dietary [NAME] G was not standing near the food prep area. He was on the other side of the kitchen near the dishwasher (approximately 8 feet) from the food prep area and garbage. Observed the garbage container attached to the utility cart approximately 10 minutes. The dietary staff did not throw any food or anything in the garbage container. The dietary staff was not prepping food for lunch during the observation. In an interview on 05/07/2025 at 1:40 PM the Dietary Aide H stated any type of garbage container was expected to have a lid on the container. She stated the garbage was expected to be stored out of the kitchen area. She stated sometimes the cook would bring the garbage container into the kitchen when he needed to throw things away when someone was cooking a meal. She stated she had been in-service not to leave any type of garbage in the kitchen area and to always keep the lid on it. Dietary Aide H stated there was a possibility garbage in the kitchen area may cause bugs to come into the kitchen where food is prepped. She stated she had been in-serviced on garbage disposal. Dietary Aide H stated she did not remember the date of the in-service. Interview on 05/08/2025 at 10:45 AM Dietary [NAME] G stated the garbage is in the kitchen when the staff is preparing or cooking a meal. He stated it was easier and more convenient to have the garbage container in the kitchen area. He also stated if the garbage container was not being used, it should be located out of the kitchen. He stated he was not using the garbage container on 05/06/2025 in AM after breakfast and before lunch. He stated he heard staff answering questions about the garbage container and he stated at that time he was not using the garbage container and he would be the only one who needed the garbage container when he was preparing food and cooking. He stated they had an in-service on disposal of garbage, however, he did not recall the date and time. Interview on 05/08/2025 at 11:25 AM the District Director of Operations for the kitchen stated garbage containers did not require to have a lid on the container. He stated garbage containers were allowed to be in the kitchen. The District Director of Operations stated there was not anything wrong with the garbage being in the kitchen on 05/06/2025. He stated if dietary staff was prepping food, opened garbage containers was allowed in the kitchen. ( QA Reviewer he would not respond when asked during the observation of garbage in the kitchen was anyone prepping food. He would not respond if there was any negative outcome for having overflowing garbage in the kitchen He would not answer the question if garbage was sanitary He would not answer if the staff had been inserviced on garbage and who was responsible to monitor garbage) Interview on 05/08/2025 at 8:40 AM, the Interim Administrator (Regional [NAME] President of the facility) stated all garbage should not be near any food prep area or the stove. She stated the garbage was expected to be located away from the kitchen area around food. The Interim Administrator stated the kitchen did not have any pest issues, however, if there was overflowing garbage located near food prep area and near food there was a possibility the garbage may attract flies. Interview on 05/08/2025 at 12:40 PM the Dietary Manager stated garbage was allowed to remain in the kitchen. She stated the garbage container did not require to have a lid to cover the garbage. She stated any dietary staff could use a plastic bag to cover the top of the garbage. The Dietary Manager stated there was nothing covering the garbage container in the AM on 05/06/2025. She stated no one was prepping for lunch and there was food on the food prep table. She stated the utility cart was near the coffee maker and there were cups on small food prep area next to the coffee machine. The Dietary Manager stated garbage was not considered sanitary. ( this is for the QA reviewer. Dietary Manager was asked what negative outcome could be if there was flies landing on food or if there was rodents or flies in the kitchen. She did not respond. Asked if she considered having garbage next to food and clean dishes sanitary and she did not respond. She would not respond to any other questions and did not feel it was an issue to have uncovered over flowing garbage in the kitchen She would not respond if staff had been inservice on garbage storage or if the staff had been in-service on garbage disposal ) Record review of the facility's Environment policy, revised on 09/20217, reflected All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All trash will be contained in leak-proof containers that prevent cross contamination; trash container must be covered during meal service.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 residents (Resident #27, Resident #22, Resident #32 and Resident #31) reviewed for infection control. 1. The facility failed to ensure MA C cleaned the blood pressure cuff before using it on Residents #27, #22 and #32 during the AM medication pass on 5/07/2025. 2. The facility failed to ensure the ADON, ICP identified a resident who met the criteria for EHP during wound care. The facility failed to ensure RN A and LVN B performed Enhanced Barrier Precaution steps while providing wound care to Resident #31. These deficient practices could place residents in the facility at risk for acquiring MDRO infections that could lead to delayed wound healing, sepsis , and hospitalizations. Findings included: 1. Review of the undated Face Sheet for Resident #27 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of the Physician's Order dated 02/20/2025 for Resident #27 for a daily diuretic (medication that causes decreased fluid retention leading to lower blood pressure) reflected hold if SBP (systolic blood pressure - top number in a reading) is less than 110. Observation and interview on 05/07/2025 at 7:18 AM revealed MA did not clean the blood pressure cuff before or after taking Resident #27's blood pressure reading. MA C stated her blood pressure was 127/89. Review of the undated Face Sheet for Resident #22 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of a Medication Administration Record for Resident #22 reflected her blood pressure reading was recorded on 05/07/2025 by MA C prior to her receiving a morning blood pressure medication. Observation and interview on 05/07/2025 at 7:26 AM revealed MA C did not clean the blood pressure cuff before or after taking Resident #22's blood pressure reading. MA C stated her blood pressure was 134/68. Review of the undated Face Sheet for Resident #32 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of a Medication Administration Record for Resident #32 reflected her blood pressure reading was recorded on 05/07/2025 by MA C prior to her receiving a morning blood pressure medication. Observation and interview on 05/07/2025 at 7:41 AM revealed MA C did not clean the blood pressure cuff before or after taking Resident #32's blood pressure reading. MA C stated her blood pressure was 142/67. In an interview on 05/07/2025 at 7:58 AM MA C stated he had been an MA since 2012 and had been working at the facility since December 2024. He stated he had received an in-service on infection control and was aware he should have been cleaning the blood pressure cuff between residents. He further stated the blood pressure cuff should be cleaned with the purple top disinfecting cloths so that germs would not go from one person to another. He stated by not cleaning the blood pressure cuffs in between residents it was an issue with cross-contamination. He stated, It just slipped my mind. Observation on 05/07/2025 at 9:40 AM of a facility purple top container of germicidal (germ killing) disposable wipes revealed the wipes disinfected surfaces in two minutes. In an interview on 05/08/2025 at 08:54 AM the ADON, ICP stated equipment that was used for multiple residents, including blood pressure cuffs, should be cleaned in between residents. She stated if the equipment was not cleaned it could potentially spread infections. In an interview on 05/08/2025 at 9:31 AM the DON stated blood pressure cuffs should be sanitized with the purple top wipes before and between each resident use. She stated if the cuff was not cleaned it could spread germs to other residents. In an interview on 05/08/2025 at 11:48 AM the ADM stated her expectation was for a blood pressure cuff to be sanitized before use on a resident and in between residents. She stated there was a potential for cross contamination if the blood pressure cuff was not cleaned. Record review of a facility Policy and Procedure dated 05/2020 and titled Equipment and Departmental Cleaning/Maintenance Policy. Policy: Equipment is to be cleaned and maintained according to manufacturer's instructions. Policy Interpretation and Implementation: Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each patient care. This includes but not limited to: wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside tables and scales. Each piece of equipment should be cleaned with disinfectant wipe on [facility] formulary or product that is purchased for an approved list of EPA registered disinfectants. The manufacturer's instructions should be reviewed carefully for dry time after cleaning and before next use. Typical dry time is 3 minutes. Equipment should not be used between patients without being appropriately disinfected. 2 . Observation on 05/07/2025 at 9:54 AM of wound care for Resident #31's right heel and right lateral (outer) ankle by LVN B and RN A, revealed they were not wearing gowns during the wound care. RN A's uniform top was touching the resident's bedding during the wound care as she was holding his leg up. There was no signage on the door to indicate Resident #31 should have been on EBP. In an interview on 05/07/2025 at 10:42 AM RN A stated Resident #31 had a chronic wound on his right lateral ankle. RN A stated her uniform had been touching the bed while she was holding Resident #31's leg up for LVN B to perform wound care. In an interview on 05/07/2025 at 11:14 AM LVN B stated residents should have been on EBP if they had an open area on their body, or had devices such as G-tubes , or urinary catheters. She stated they should have been wearing gowns while providing wound care for Resident #31. She stated if they had been wearing gowns, they would have been protecting Resident #31 from any bacteria on them and vice versa. She further stated by not wearing gowns it could have led to cross contamination. (when harmful bacteria or other pathogens transfer from one source to another during wound care procedures) In an interview on 05/07/25 at 11:20 AM RN A stated by not wearing a gown while providing wound care for Resident #31 the nurses, including herself, could have picked up bacteria and spread it to other residents leading to a cross contamination infection. Observation on 05/07/2025 at 3:26 PM revealed EBP signage was still not on Resident #31's door. In an interview on 05/08/2025 at 08:54 AM the ADON, ICP stated Resident #31 probably had a chronic wound, but she was not 100% sure. She stated the concept of EBP was kind of new to her. She stated on 05/08/2025 she had placed an EBP sign on Resident #31's door. She stated the two nurses (RN A and LVN B) who performed his wound care on 05/07/2025 should have been gowned and gloved. She stated by the nurses not wearing gowns during Resident #31's wound care there was an increased risk of pathogens being transferred to him or to other residents. She stated that would be considered cross contamination. She stated it was her responsibility to ensure EBP was put into place for appropriate residents. In an interview on 05/08/2025 at 9:31 AM the DON stated EBP should be used for residents who had catheters, tracheostomies , g-tubes, and chronic wounds. She stated those residents were at a higher risk of infection. She stated EBP should be used for any high contact activity such as wound care, perineal care, and bathing. She stated a gown, and gloves should be worn and if there was a high risk of body fluid splashes, then a face shield and mask should be worn. She stated Resident #31 should have been on EBP due to having a chronic wound. She stated she and the ADON ICP were responsible for ensuring EBPs were set up for the appropriate residents. She stated the potential risk if the EBP procedures were not followed was the transmission of MDRO (bacteria that have become resistant to certain antibiotics) infections to other residents. In an interview on 05/08/2025 at 11:48 AM the ADM stated her expectation was for staff to utilize EBP for residents that meet the criteria. She stated by not utilizing EBP, residents could be exposed to infections. Record review of a CDC document provided by the ADM, dated July 12, 2002, and titled Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) reflected, Key Points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Background Residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available [1-9]. Implementation of Contact Precautions is perceived to create challenges for nursing homes trying to balance the use of PPE and room restriction to prevent MDRO transmission with residents' quality of life. Thus, many nursing homes only implement Contact Precautions when residents are infected with an MDRO and on treatment. Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) which contributes to the silent spread of MDROs. With the need for an effective response to the detection of serious antibiotic resistance threats, there is growing evidence that the traditional implementation of Contact Precautions in nursing homes is not implementable for most residents for prevention of MDRO transmission. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. 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 regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator o Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, for 1 of 2 residents (Resident # 93) reviewed for the use of oxygen concentrator. The facility failed to ensure Resident #93 had continuous oxygen therapy. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress. Findings include: Review of Resident #93's face sheet, dated 05/08/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #93 had diagnoses which included acute respiratory failure with hypercapnia (the lungs cannot release enough oxygen into the blood, which prevents organs from functioning properly. Hypercapnia- shortness of breath, headaches, persistent tiredness during the day, and altered mental status), orthostatic hypotension (low blood pressure), and unspecified dementia without behavioral disturbance ( affects the memory, thinking and social abilities without any behaviors). Review of Resident #93's admission MDS, dated [DATE], reflected Resident #93 had a BIMS score of 6, which indicated her cognition was severely impaired. Resident #93 was dependent on staff for toileting, shower, dressing, transfers, and personal hygiene. She had a diagnosis of acute respiratory failure with hypercapnia. Resident #93 had shortness breath or trouble breathing with exertion (walking, bathing, or transferring), and shortness of breath or trouble breathing when lying flat). Resident #93 had a condition or chronic disease may result in a life expectancy of less than six months. She had respiratory treatments and was on oxygen therapy. Review of Resident #93's Comprehensive Care Plan, with completion date of 05/05/2025 reflected Resident #93 was on hospice services related to acute respiratory failure with hypoxia (lack of oxygen) . Interventions: Evaluate effectiveness of medications/interventions to address comfort. Keep family informed of change in condition. Notify hospice of any change in condition or medication changes. Resident #93 had oxygen therapy related to respiratory failure with hypercapnia. Interventions: Oxygen settings: O2 via nasal prongs at 2-4L/min. Monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed: respirations, pulse, increased heart rate, restlessness, diaphoresis (excessive sweating), headaches, confusion, cough, pain, and skin color. Promote lung expansion and improve air exchange by positioning with proper body alignment. Review of Resident #93's Physician's Order, last order date, 04/27/2025, reflected Resident #93 had a physician's order for oxygen via NC for SOB 2-4 L/min. Review of Resident #93's O2 sats, on 05/08/2025, reflected the last entry for O2 sats was on 05/05/2025 at 10:34 AM and she had 96 percent . Observation and interview on 05/06/2025 at 1:15 PM, revealed an oxygen concentrator was plugged into the outlet in the common area near the nurse's desk (one of one nurse's desk). There was not a resident near the concentrator. After approximately 5-8 minutes it was discovered the oxygen concentrator was Resident #93's. RN A and LVN B went to Resident #93's room and pushed the oxygen concentrator. Resident #93 was lying in bed without oxygen. Resident #93 would not respond to questions. She was not interviewable. Resident #93 had a sad expression on her face such as: furrowed brow, lips turned down, and pouting her lips. Review of Resident #93's nurses notes, dated 05/06/2025 at 2:08 PM , reflected Resident #93 was observed for brief time with no oxygen. RN A applied oxygen via NC @ 4 liter, no signs or symptoms of distress observed, respiratory even and unlabored, no shortness of breath, oxygen saturation 96 % 4 LMP NC. The Nurse Practitioner was informed of the situation with Resident #93. Resident #93 was assessed (unknown who assessed her). Resident #93 did not receive any new orders. Resident #93 denied any pain. Resident #93 vital signs was blood pressure 132/71, and 97.9% O2 setting at 4 LPM NC. Interview on 05/06/2025 at 1:35 PM, CNA D stated she was pushing the mechanical lift past the nurses' desk and she stopped and asked LVN B to assist her with Resident #93's oxygen concentrator. She stated LVN B stated ok. CNA D stated she entered Resident's #93's room with the mechanical lift and CNA E was in Resident #93's room to assist with transferring Resident #93 with the mechanical lift. CNA D stated Resident #93's oxygen concentrator was not in the room until Resident #93 was lying in bed. She stated she did not ask CNA D to move Resident #93's oxygen concentrator from the common area to the Resident #93's room. She stated Resident #93 was in her room without the oxygen concentrator when she was on another hall to locate the mechanical lift. CNA D stated Resident #93 was to always have oxygen. She stated it was approximately 20 minutes from assisting Resident #93 to her room and assisting her to bed prior to Resident #93 received her oxygen. Interview on 05/06/2025 at 1:50 PM, LVN B stated CNA D asked if I was available to assist with transferring Resident #93's oxygen concentrator from the common area to Resident #93's room. She stated CNA D was pushing the mechanical lift to Resident #93's room to transfer her from the wheelchair to the bed. LVN D stated, I was busy with the pharmacist and did not ask anyone else to assist [CNA D] with the oxygen concentrator. LVN B stated RN A was sitting at the nurses' desk. LVN B stated she did not ask RN A or any other staff to assist CNA D with Resident 93's oxygen concentrator. LVN B stated Resident #93 had a potential of having shortness of breath or hypoxia (low levels of oxygen in your body tissues. Symptoms such as: confusion, restlessness, difficulty with breathing, rapid heart rate, and bluish skin). LVN B stated Resident #93 had a physician's order for continuous oxygen. She stated oxygen was expected to be used on Resident #93 continuously throughout the day and night. LVN B stated she did not recall the last in-service the staff had on oxygen care. Interview on 05/06/2025 at 2:05 PM, RN A stated LVN B did not ask her to assist with Resident #93's oxygen concentrator. She stated she was not aware CNA D needed assistance with transferring Resident #93's oxygen concentrator from the common area to Resident # 93's room. She stated Resident #93 had a physician's order for continuous oxygen. RN A stated if a resident was not receiving continuous oxygen there was a possibility a resident may become hypoxia. She stated she did not recall the last time she had in-service on oxygen care and protocol. Interview on 05/06/2025 at 2:10 PM, CNA E stated CNA D asked her to assist transferring Resident #93 from the wheelchair to the bed with a mechanical lift. CNA E stated she was in Resident #93's room waiting for CNA D to locate a mechanical lift to use on Resident #93. She stated it was approximately 5-8 minutes prior to CNA D return to Resident #93's room with the mechanical lift. CNA E stated Resident #93 was not using oxygen. She stated she did not give care to Resident #93 and was not aware Resident #93 required oxygen. CNA E stated no one asked her to assist to move Resident #93's oxygen concentrator from the common area to Resident #93's room. She stated after she assisted with transferring Resident #93 from the wheelchair to her bed, she exited Resident #93's room. Interview via phone on 05/07/2025 at 9:05 AM, Resident #93's family member did not answer phone or return phone call after leaving a message. Interview via phone on 05/07/2025 at 9:40 AM , Resident #93's Physician did not answer phone or return phone call. Interview on 05/08/2025 at 11:45 AM the Director of Nurses stated only nurses could check the oxygen concentrator and place the tubing into a resident's nose. She stated anyone was capable of transferring oxygen concentrator from one area to another area. The Director of Nurses stated any resident not receiving continuous oxygen for several minutes the nurse was to do an assessment on resident to check the residents O2 sats and vital signs. She stated if a staff needed assistance in transferring oxygen concentrator the staff could ask a nurse, a CNA, or come to the nurse administration and asked for assistance. She stated if a resident was not receiving oxygen there was a potential a resident may become hypoxia or had shortness of breath. Record review of the Facility's Oxygen Guideline Policy, updated on 08/01/2024, Medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided accordance with a health care provider's order and in accordance with acceptable standards of practice.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure an expired medication was removed from the medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose and possible exacerbation of health conditions. Findings included: Observation on 5/06/2025 at 1:40 PM in the medication storage room revealed a bottle of Aspirin 325 mg with an expiration date of 4/2025. In an interview on 05/06/2025 at 1:50 PM RN A stated she had worked at the facility for almost ten years. She stated if an expired medication was given to a resident, it might not have the required potency. She further stated she thought the weekend medication aide might be responsible for checking the storage room for expired medications, but she was unsure. In an interview on 05/08/2025 at 9:31 AM the DON stated she typically checked for expired medications in the medication storage room on Monday mornings. She stated the weekend night MA was also responsible for checking for expired medications in the carts and storage room. She further stated the potential risk of a resident receiving an expired medication was that it would not be as effective. In an interview on 05/08/2025 at 11:48 AM the ADM stated there should not be any expired medications in the storage room. She stated she would assume that an expired medication would not have the proper potency. She further stated nursing leadership would be responsible. Record review of a facility policy and procedure titled Storage of Medications dated 09/2018 and revised on 08/2020 and 08/2024 reflected Policy Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. Procedures: General guidance: 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are removed form inventory, disposed of according to procedures for medication disposal, and recorded from the pharmacy if a current order exists.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #14) of 6 residents reviewed for care plans. The facility failed to update Resident #14's care plan to reflect current needs for oxygen as needed. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings include: Review of Resident #14's face sheet, dated, 05/07/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included chronic obstructive pulmonary disease, unspecified ( an ongoing lung condition caused by damage to the lungs), essential hypertension ( a chronic characterized by persistently elevated blood pressure with no identifiable underlying cause), and anemia (leads to a reduced ability to carry oxygen to the body's tissue and organs. Symptoms can include fatigue, weakness, and shortness of breath). Review of Resident #14's Quarterly MDS, dated [DATE], reflected Resident #14 had a BIMS score of 9 which indicated her cognition was moderately impaired. Resident #14 had a diagnoses of chronic obstructive pulmonary disease, anemia, essential hypertension, and pneumonia (a lung infection that causes the air sacs to be filled with fluid). Resident #24 had shortness of breath. Review of Resident 14's Physician's Order dated 04/27/2025 (last order reviewed) reflected Resident #14 had an order for oxygen at 2LPM via N/C as needed for shortness of breath or to keep sats >92 percent. Review of Resident #14's Comprehensive Care Plan, revised on 04/16/2025, reflected Resident #14 had alteration in respiratory status due to chronic obstructive pulmonary disease initiated on 02/202/2025. Interventions: did not include oxygen as needed. Resident #14 had shortness of breath related to chronic obstructive pulmonary disease initiated on 02/25/2025. Intervention: did not include oxygen as needed. Observation and interview on 05/06/2025 at 10:50 AM revealed Resident #14 was in her room lying in bed. She stated she did not feel very well. Resident #14 stated sometimes she could not breathe very well but I am breathing fine right now. Resident #14 stated I am very tired. An oxygen concentrator or any type of oxygen tanks was not located in Resident #14's room. Interview on 05/07/2025 at 3:30 PM LVN B stated Resident #14 was on oxygen as needed. She stated if any resident had a physician's order for oxygen as needed, it was required to be on the care plan. She stated it was the responsibility of the nurse supervisor to monitor any type of equipment any resident needed in their room. She stated the care plan assisted the nursing staff for what type of care a resident needed. LVN B stated if a resident needed oxygen as needed and it was not documented on the resident's care plan, it would be difficult for the nursing staff especially CNAs to know a resident may need oxygen if they reviewed the plan of care in the electronic system the CNAs followed from the care plan. Interview on 05/07/2025 at 4:00 PM CNA E stated she did give care to Resident #14. She stated she was not aware Resident #14 required oxygen as needed. CNA E stated all residents' care was in the electronic medical record for the CNAs. She stated CNAs did not have access to residents' physician's orders or any other medical records except what was documented in the electronic medical record. CNA E stated the information in the CNAs electronic records was from the residents care plan. She stated oxygen was not documented in the CNAs electronic medical record. CNA E stated she did view Resident #14's electronic records for the CNAs and oxygen were not on their records of what type of care a resident needed. Interview and record review on 01/28/2025 at 8:30 AM the MDS Coordinator stated it was her responsibility to ensure the comprehensive care plan was revised as needed. She reviewed the care plans and MDS for Resident #14 in the electronic medical records and stated Resident #14's care plan had not been revised to reflect Resident #14 needed oxygen as needed. She stated Resident #14 did have a physician's order for oxygen as needed when Resident #14's care plan was revised. The MDS Coordinator stated if there were changes in Resident #14's care during the MDS assessment or after the MDS assessment that was to be included in a comprehensive care plan with the other information for staff to follow to give medical, cognitive, and social needs. She stated it would be difficult for the nursing staff to know what type of care to give a resident if there was any change and if the care plan was not updated. The MDS Coordinator stated if Resident #14 began having symptoms of problems with breathing, heart racing or feeling tired throughout the day. She stated if the oxygen was not documented on the care plan in the CNAs' records there was a possibility a CNA may not realize Resident #14 needed oxygen and may not report issues to the nurse. Interview on 05/08/2025 at 11:45 PM the Director of Nurses stated any time there was a change in a resident's treatment the care plan was expected to be updated. She stated Resident #14 was on oxygen as needed per physician's orders. The Director of Nurses stated the physician's order for oxygen was not revised on Resident #14's care plan. She stated CNAs information was transferred from the care plan to the [NAME] (the CNAs information for the care each resident was expected to be provided). The Director of Nurses stated if the CNAs did not know Resident #14 required oxygen as needed there was a possibility Resident #14 may develop symptoms and the CNAs would not realize she needed oxygen to report to the nurse. (Director of nurses did not elaborate on what type of symptoms Resident #14 may develop). She stated it was her responsibility and the MDS Coordinator's responsibility to ensure the care plans are monitored and revised as needed. Review of the facility's Policy on Care Conference Guidelines, dated November 2017, reflected To involve residents, patients and their representatives with goals and preferences of care, and to integrate with those of the interdisciplinary team (IDT). This should be completed at the time of admission, regular intervals, and where there is a change in health status. It should be based on functional/nutritional goals and psycho-social needs.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure employees were sanitizing their hands in between tasks. This failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen on 03/19/2024 at 11:35am revealed CK F did not sanitize or wash her hands after getting the Puree blender from the dishwasher. CK F also did not change her gloves or sanitize or wash her hands after taking the hamburger meat out of the oven. It was also revealed that CK F picked up the pan the hamburger meat was in and folded up the paper liner and threw it away and did not change her gloves afterwards. Observation of CK F on 03/20/2024 at 10:35am revealed that CK F pureed the ham and touched the outside of the recipe manual and touched the recipe pages. CK F continued to puree the ham after touching the recipe manual and pages without changing her gloves. CK F proceeded to move from the prep table and open the oven door and back to the area where she was pureeing the ham. She placed her fore finger and middle finger on her right hand in the container of the puree ham. CK F did not change her gloves between tasks. Interview with the Corporate Dietary Manager on 03/20/2024 at 10:55am revealed CK F was expected to change her gloves after she touched the recipe manual. The Corporate Dietary Manger stated when the cook touched the oven door and the recipe manual CK F was to remove her gloves and wash her hands and place new gloves on. She stated the oven door, and the manual were considered contaminated. Interview with the Dietary Manager on 03/21/2024 at 9:09am revealed she was responsible for all staff in the kitchen and overseeing that they were following policy and procedures. She stated staff had been trained on how to wash their hands and when they should wash their hands. She stated that staff were to wash their hands after each task to prevent cross contamination. The Dietary Manager stated failing to wash or change gloves after each task could put the residents at risk of getting sick. She stated that hand washing is covered every month with the kitchen staff. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Food Preparation Policy dated 2/2023 revealed all staff will practice proper hand washing techniques and glove use. Record Review of facility policy titled Hand Hygiene Steps no date that is covered with staff revealed the following: When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

Based on interview, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In an interview on 03/19/2024 at 10:12 am, the Activity Director when asked to set up Resident Council meeting revealed the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would place signs on the privacy curtain. She stated she would notify staff before the meeting not to come in or out of the dining room until after the resident group meeting. The Activity Director offered to move the Resident Council meeting to her office so it would be private. In an interview on 03/20/2024 at 10:15am, during a confidential resident group meeting held in the Activity Director's office with five residents revealed their meetings were normally held in the dining room. The residents in attendance of the resident group meeting stated interruptions occurs every- time they had a Resident Council meeting. Residents in the meeting stated that it was disrespectful and that they had informed the Administrator several times, but staff continued to interrupt their council meetings. The residents in the meeting stated they would like some place private to meet. In an interview with the Activity Director on 03/21/2024 at 8:43am revealed that the resident council normally meets in the dining room. She stated she has signs that she puts on the curtain and tells staff they were not to go into the dining room until the meeting is over. She did not say she does anything to prevent the staff from coming in the dining room. She stated that the residents were supposed to have a private place to meet. She stated that they have asked for a more private place, but the facility did not have anywhere else big enough for them to meet. She stated that residents may feel like the facility was not respecting them or the resident may lash out if staff interrupted their meetings. She stated that when staff have interrupted, they would talk to them and inform them that they are not to go into the dining room when the residents are having their meeting. The Activity Director stated she has been trying to get a private place for the residents to meet. In an interview with the Administrator on 03/21/2024 at 11:32am revealed the residents had the right to meet in a private area, and someone must be invited to attend the meeting. He stated the residents may not feel comfortable voicing their concerns. He stated the facility was small and not a lot of room and that he was finding a private place for the residents to meet. Record Review of the Resident Council Policy dated 5/1/2012 revealed it is the responsibility of the Activity Director/Social Services Designee to provide the Resident Council with a private place to meet.

Based on observation, interview and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of six residents (Resident # 26, Resident #32, and Resident #140). 1. The facility failed to ensure Resident #26's facial hair was removed. 2. The facility failed to ensure Residents # 32's and #140's nails were cleaned and trimmed. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1.Record review of Resident #26's face sheet dated, 03/21/2024 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction, unspecified (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions), and muscle weakness ( a lack of strength in the muscles). Record review of Resident #26's Quarterly MDS assessment, dated 11/09/2023, reflected Resident #26 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #26 had poor short- and long-term memory recall. Resident #26 was dependent on the staff for ADLs including personal hygiene. Record review of Resident #26's Comprehensive Care Plan, dated 03/04/2024 reflected she was rarely/ never understood. Interventions: Anticipate resident needs. Use simple and direct communication to promote understanding. Resident #26 had neurological status (overall condition of the nervous system function) related to aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions) CVA (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) Intervention: Resident #26 required ADL assistance. Render care as needed. Observation on 03/19/2024 at 9:58 AM revealed Resident #26 was in bed. She had approximately 3-4 inches of white strands of hair on her chin and on both of her cheeks. Interview on 03/19/2024 at 10:00 AM revealed Resident #26 was not interviewable. Interview via telephone on 03/20/2024 at 9:49 AM Resident #26's family member stated she had reported to staff about the facial hair on Resident #26's face. She stated she did not recall when or who she spoke to about her concern of the facial hair. She also stated the staff had time before 03/20/2024 to remove the facial hair on Resident #26. 2. Record review of Resident #32's face sheet, dated 03/20/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete loss of movement on one side of the body - hemiparesis is diminished strength, without total paralysis), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements), muscle wasting and atrophy, not elsewhere classified, multiple sites ( the loss of muscle mass and strength due to a lack of physical activity or a condition that affects the muscles or nerves), diabetes (elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, and kidneys), and unspecified dementia ( affects memory, thinking and social abilities). Record review of Resident #32's Admission MDS Assessment, dated 03/08/2024, reflected Resident #32 had a BIMS score of a 7 which indicated his cognition was moderately impaired. Resident #32 did not refuse care. He required assistance with ADLs. Resident #32 required supervision or touching assistance with personal hygiene. Record review of Resident #32's Comprehensive Care Plan dated 03/15/2024 reflected Resident #32 had self-care deficit related to hemiplegia to right side (paralysis of the right side of the body), CVA (poor blood flow to the brain) and impaired cognition (a condition where a person has problems with memory, learning, concentration, or decision making). Interventions: Provide supervision and touching assistance with personal hygiene. Resident #32 had diabetes mellitus. Intervention: nails should always be cut straight across, never cut corners, file rough edges with emery board. Observation on 03/19/2024 at 10:54 AM revealed Resident #32 was sitting in his room watching television. The tips of his nails were not trimmed evenly, and his nails were approximately 2 inches long from the top of his fingers on his right hand. Resident #32 had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/19/2024 at 10:56 AM Resident #32 stated he asked someone to cut his fingernails, they were rough and not straight. He also stated he asked someone to clean his nails because he did not know what the black stuff was underneath his fingernails. Resident #32 stated he did not recall the name of the person who trimmed and clean his fingernails. He stated he wished someone would trim and clean them because they were dirty. He stated he was afraid to do it because in the past when he cleaned or trimmed his nails his fingernails had green stuff running out of the side of his fingernail. He stated he went to the doctor, and they told him his finger was infected. Resident #32 stated the infection of his finger happened when he lived at home. Interview and observation on 03/20/24 08:00 AM Resident #32 stated my nails are still dirty. They need to be cleaned; can you get someone to clean them sometime this week. I asked few times, and no one has cleaned my nails He stated he did not recall who he asked to clean nails and trim them His nails were dirty underneath all his nails on both hands. Observation on 03/20/2024 at 8:00 AM revealed Resident #32 was in his room lying in bed. His fingernails were still long and rough around the edges of the nails. There were not any changes in his nails since 03/19/2024 at 10:54 AM. The tips of his nails were not trimmed evenly, and his nails was approximately 2 inches long from the top of his fingers on his right hand. Resident #32's nails had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/20/2024 at 8:05 AM Resident #32 stated he did ask someone yesterday (3/19/2024) to cut and clean his nails and they said a nurse would need to clean and trim his nails. He stated no one came to his room on 3/19/2024 to clean or cut his nails. He stated he could try to find something and do it himself, but he was afraid of getting his fingers infected. 3. Record review of Resident #140's face sheet, dated 03/20/2024, reflected Resident #140 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included lymphedema (swelling due to build-up fluid in the body), essential hypertension (high blood pressure that is not due to another medical condition), and hyperlipidemia (high level of lipids -like cholesterol in your blood). Record review of Resident #140's MDS Admission Assessment revealed it was in progress. Record review of Resident #140's Baseline Care Plan dated 03/17/2024 reflected Resident #140 needed to improve ADL independence. Resident #140 also had barriers to transition such as: bathing, safety awareness, and self-care. Observation on 03/19/2024 at 11:45 AM revealed, Resident #140 was sitting in the small dining room with other residents. Resident #140's nails were approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview with Resident #140 on 03/19/2024 at 11:48 AM she stated she wished someone would cut and clean her nails, they looked bad, and she was embarrassed for anyone to see her dirty nails. She stated she did ask someone to clean them but did not recall their name. She stated she was new at the facility and did not know anyone. Observation on 03/20/2024 at 8:30 AM revealed Resident #140's fingernails had not been trimmed or cleaned since observation on 03/19/2024 at 11:48 AM. Resident #140's nails was approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview on 03/20/2024 at 8:33 AM Resident #140 stated she thought she had asked someone to cut her nails and clean her nails yesterday and when she came to this place (facility). She stated she was new and did ask someone to cut and clean her nails but did not recall the person's name. Resident #140 stated her nails looked bad and she did not have anything to clean her nails, or she would try to cut and clean her nails. In an interview on 03/21/24 at 08:35 AM CNA A stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA A stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA A stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. CNA A also stated if a female resident had facial hair on their face, it was the nursing staff responsibility to remove the hair with tweezers or a razor whichever the resident preferred. CNA A stated if a female resident had facial hair the resident may not want to come out of the room or be around others due to being embarrassed of her appearance. She stated she had been in-serviced on cleaning nails and removing facial hair on ladies. She stated Residents #26, Resident #32 and Resident #140 did not refuse care. In an interview on 03/21/2024 at 08:53 AM, the Administrator stated it was the CNA'S responsibility to do nail care. He stated nail care was expected to be completed during showers and/or as needed. He also stated any resident with a diagnosis of diabetes it was expected that their nails would be trimmed/cut by a nurse. The Administrator stated a resident had a potential of ingesting bacteria into their mouth. He stated there was a possibility a resident may become ill such as vomiting or diarrhea if the black substance was some type of bacteria. The Administrator stated if a female had facial hair, the nursing staff was responsible to remove the facial hair with tweezers. He also stated for a female with facial hair there was a possibility the female may be embarrassed for other people to see her and could be a dignity issue. The Administrator stated the charge nurse was responsible of monitoring the CNAs to ensure personal hygiene was completed daily. Interview on 03/21/24 at 9:22 AM CNA B stated it was the nurses and the CNAs responsibility to trim, cut, and clean residents' fingernails. She stated only the nurses can trim and clean residents with a diagnosis of diabetes. CNA B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth there was a possibility the feces could transfer from their fingers to their mouth. She also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach problems and resident may become dehydrated and the resident may need to be treated at the emergency room . She stated the symptoms of a stomach infection may include the following: diarrhea or vomiting. She stated if a female had facial hair, the facial hair was expected to be trimmed during showers or as needed. She stated a female may not want other people to look at them with hair on their face. CNA B stated a female resident may isolate themselves in their room due to being embarrassed. She also stated the CNAs completed nail care during showers and the CNAs would notify the nurses at that time if a resident with diagnosis of diabetes needed any nail care completed. She stated she had been in serviced on nail care and trimming female facial hair. She could not recall the last time she was in serviced. CNA B stated in the in-service it covered doing nail care on residents in the shower and as needed. Interview on 03/21/24 at 09:50 AM LVN C stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNA's responsibility to clean and trim all other residents' nails. LVN C stated the CNAs report to nurses of any diabetic resident's nails to be cleaned. She stated the nurses makes rounds and check residents, with diabetes, nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. LVN C stated if a female resident had facial hair the CNAs was expected to remove the facial hair with tweezers and if it was thick facial hair the CNA was to report to the nurse and the nurse would determine how to remove the hair without causing pain to the resident. She stated a female resident may be embarrassed to be around other people if they had facial hair and the resident may develop low self-esteem. She stated if a resident was not able to express, they wanted the hair removed and the family requested the hair to be removed the staff should remove the hair as soon as possible after the family made the request. She stated she had been in serviced on nail care but did not recall the date of the in-service. In an interview on 03/20/2024 at 10:33 AM, the Director of Nurses stated resident's nails were expected to be trimmed on Sunday's, during shower days, or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. The director of nurses stated if staff see a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. She stated if a female resident had facial hair it was expected to be remove immediately with tweezers or how the resident preferred the hair to be removed. She stated some female residents preferred the hair to be removed with a razor. She stated if a resident was not able to express how they wanted it to be remove or ask for the hair to be removed but the family requested it the staff would ask the family their preference of how they prefer the hair to be removed. She stated if a resident unable to express they have facial hair, and the family knows the resident did not want facial hair. The nurse supervisor was responsible to monitor the nail care and ensure residents were getting personal care. Record review of the facility's Performing Nail Care (undated) reflected the best time to provide nail care was during a patient's bath. Record review of the facility's policy on Hygiene (not dated) reflected prior to implementing any nail care, use clinical judgment to assess and analyze data about any existing or at-risk nail problems. Record review of all the CNAs Competency and Skills Checklist (dated on the hire date of each CNA) reflected the CNAs was trained on nail care, hair care and shaving male and females. 49097

Based on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 3 of 3 residents (Resident #10, Resident #26, and Resident #30) reviewed for infection control in that: CNA G and Speech Therapist did not sanitize or wash hands after touching contaminated items before feeding resident or touching residents' food placing residents at risk of food contamination This failure could place all residents at risk of getting sick from staff not performing proper hand hygiene. The findings were: Record review of Resident #10's face-sheet dated 03/21/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Atrial fibrillation, cognitive communication defect, history of falling, diarrhea, lack of coordination, under immunization status, urinary incontinence, abnormal levels of serum enzymes, vitamin D deficiency, constipation, too little calcium in the blood, high levels of fat particles in blood, high blood pressure, heart disease of coronary artery, kidney failure, anemia, heart failure, absence of left leg below the knee, type 2 diabetes. Record review of Resident #26's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with other behavior disturbance, bunion on foot, vitamin D deficiency, lack of coordination, infection of skin, abnormal posture, urinary tract infection, history of COVID 19, muscle wasting, insomnia, high blood pressure, difficulty swallowing, difficulty communicating, stroke, repeated falls, and curvature of the spine. Record review of Resident #30's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with agitation, chronic constipation, overactive thyroid, difficulty speaking after a stroke, repeated falls, acute heart disease, and depression. Observation of dining services on 03/19/2024 at 12:16pm revealed the Speech Therapist wiped her nose with her right hand. She then picked up the ground fruit cocktail bowl beside Resident #10's plate. When she picked up the fruit cocktail bowel her right ring finger and her middle finger touched inside the bowl. The Speech Therapist used her ring finger on her right hand to wipe her nose. She did not use a Kleenex or wash her hands before touching Resident #10's fruit cocktail bowel. Observation of dining services on 03/19/2024 at 12:21pm revealed CNA G touched her clothes with her right hand and proceeded to cut Resident #30's hamburger placing her whole palm of her right hand on the top bun and cutting into fourths. CNA G did not wash or sanitize her hands after touching her clothing. CNA G than touched the carpet looking material on the column in the small dining room that had a brown stain on it. CNA G then touched her clothing again. She then proceeded to roll a chair from behind the nurses' station to the small dining room beside Resident #26. CNA G touched a regular chair back and the arms of the two different wheelchairs. CNA G did not was or sanitize her hands after any of the mentioned tasks. CNA G did not sanitize or wash her hands and proceeded to touch the hands of two residents. CNA G sat to feed Resident #26 and cut the resident's burger placing her hand on the hamburger bun while cutting it. She still did not sanitize or wash her hands. CNA G fed Resident #26 the hamburger that she touched with her right hand. Interview with CNA G on 03/21/2024 at 9:31am revealed she had been trained on hand hygiene. She stated that staff were supposed to wash their hands before they touch a tray, anytime they touch something or their clothing. CNA G stated that if staff do not wash or sanitize their hands before touching a tray or after touching something they could cause contamination of the food and the residents could get sick. She stated she did not realize she had not sanitized her hands before touching Resident #26 and Resident #30's food. CNA G stated she wanted to get Resident #26's food cut so she could start eating. Interview with the Speech Therapist on 03/21/2024 at 9:40am revealed that she was trained on hand hygiene. She stated that staff were supposed to wash their hands after every resident and not touch food until you have washed your hands. The Speech Therapist stated that if staff do not wash their hands infections can spread. She stated she did not realize that she had wiped her nose and then touched Resident #10's fruit cocktail. She said that her allergies were bad and if she did not wipe her nose would drip. She stated that she knew better then to not wash her hands after touching her nose. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Infection Control Standard Precautions Policy dated 2022 revealed standard precautions are recommended practice for the care of all patients and residents receiving care in the facility. Standard Precautions include hand hygiene before and after patient/resident contact including after gloves are removed. Record Review of the facility policy titled Hand Hygiene Steps no date reviewed with staff revealed the following: When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

Based on observation, interview and record review, the facility failed to prepared puree food by methods that conserve nutritive value, flavor, and appearance as evidence by mixing the hamburger meat with water The extent is no actual harm with the possibility of more than minimal harm. The puree diet hamburger meat was mixed with water instead of thickener or a broth with nutrient value. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings include: Observation on 03/19/2024 at 11:35am revealed CK F pureed hamburger meat with water instead of the thickener on the counter. CK F did not have any recipes out for puree Interview with the Dietary Manager on 03/20/2024 at 1:45pm revealed that CK F was filling in from another facility and the Dietary Manager was not sure what training she had. She stated that when doing puree staff were to follow the puree recipe. The Dietary Manager revealed she is responsible for overseeing puree in the kitchen. She stated that she thought that CK F was trained and knew what to do. She stated if she knew CK F did not know puree she would have just done it herself. She stated staff were never supposed to mix water in puree food because it takes away the nutrients in the food. She stated that she did not realize that CK F mixed water in the puree until after it was served. Interview with CK F on 03/20/2024 at 2:44pm revealed that she had been trained on puree diets. She stated that she normally mixed the puree with broth, orange juice or milk. CK F stated that she got nervous and forgot everything. She stated she realized after that she mixed the hamburger meat with water. She stated that mixing the puree with water takes the nutrients away from the food. She stated by taking the nutrients away from the food it puts the resident at risk of weight loss or other health issues. Record Review of the Essential Functions of the Job no date revealed staff prepare food by methods that conserve nutritive value and flavor.

Based on observation, interview and record review, the facility failed to provide the physician prescribed therapeutic diet to 1 of 8 residents (Resident #3) reviewed for therapeutic diets, in that: Resident #3 was given salt when her meal ticket stated no added salt as ordered. This failure could place residents at risk for further health issues. Findings included: Record review of Resident #3's face-sheet dated 03/212024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Atrial fibrillation, stiffness of left hand, dehydration, hyperkalemia, personal history of urinary tract infections, hallux varus acquired left foot, stiffness of right hand, muscle wasting, contracture right hand, allergies, history of falling, never pain, age related disability, inner ear infections right ear, age related cognitive decline, difficulty in walking, unsteadiness on feet, unspecified abnormalities of gait and mobility, chronic obstruction pulmonary disease, heart failure, high levels of fat particles in blood, arthritis, high blood pressure, heart disease of coronary artery, contractors to fingers and thumb, muscle weakness, and lack of coordination. Record review of Resident #3's dietary orders dated 07/24/2023 revealed she was on a regular diet with no salt added. Observation of lunch on 03/19/2024 at 12:19pm revealed Resident #3's meal ticket stated she was on a regular diet no added salt. Resident #3 also had physician orders dated 07/24/2023 that stated resident was a no salt added. Resident #3 was given a salt packet with her meal. Interview with Resident #3 on 03/19/2024 at 2:10pm revealed that Resident #3 was on a no salt diet. Resident #3 stated that they give her salt all the time, but she does not use the salt. She stated that she knows she was not supposed to have salt. Observation of Breakfast on 03/21/2024 at 8:54am revealed Resident #3 was given salt with her breakfast. Interview with DA D on 03/21/2024 at 8:56am revealed that she put the condiments on the trays. DA D stated that she had been trained on therapeutic diets and how to read the dietary meal tickets. She stated that she was not aware of Resident #3's diet being a no salt diet. She stated she did not see the no salt on the meal ticket that she missed it. She stated the negative outcome could be the resident have a reaction to something if they were not supposed to have the food item. Interview with the Dietary Supervisor on 03/21/2024 at 9:09am revealed the aides were responsible for checking to ensure the trays are correct before leaving the kitchen. She stated that the nurses were also supposed to check the tray before it gets to the resident. She stated she was not sure why the resident received salt when it said on the meal ticket no salt. She stated the resident could have a reaction if not given the correct diet. Interview with LVN C on 03/21/2024 at 9:34am revealed that the nurses check the trays once they were put on the cart. She stated the condiments were usually clumped together and she was bad about checking the condiments also. She stated if a resident were to get the wrong diet or condiment the resident could have edema, end up in the hospital, all kinds of potential issues. LVN C stated she was not sure who checked Resident #3's tray. Interview with RN E on 03/21/2024 at 10:45am revealed that the nurses were supposed to check meal trays before they were given to the residents. RN E stated they check to ensure the diet was correct and matches the meal ticket. She stated if the diet was not correct, they send it back to the kitchen to be corrected. She stated that if a resident were given the wrong diet, it could cause different health issues depending on the diet. She stated she was not sure who gave Resident #3 her tray or who checked the tray. She also stated the DON and MDS nurse were checking the trays. Interview with the DON on 03/21/2024 at 11:01am revealed that the nurses were to check the trays before giving them to the residents. She stated the nurses check the trays to ensure the resident was getting the correct diet. She stated that if the diet was not correct the resident could choke if given thin liquids instead of thick liquids that were ordered. The DON stated she was not checking trays this morning that the MDS nurse was. She stated the dietary staff usually puts the condiments on the trays automatically. She stated she was not sure if they give residents salt on a regular basis when the resident was not supposed to have salt. Interview with the MDS nurse on 03/21/2024 at 11:12am revealed that the nurses were to check the trays before giving to the residents. Stated there could be several issues with a resident not getting the proper diet. She stated it would depend on if the diet were therapeutic and a resident was not supposed to get sugar because he/she are diabetic it could cause his/her blood sugar to rise. She stated she did check the trays in the morning, but she did not check Resident #3's tray because she came late to breakfast. The MDS nurse stated she was not sure if anyone checked Resident #3's tray. Record Review of Essential Functions of the Job for the Dietary Supervisor (no date) revealed review tray card to assure the current food information is consistent with foods served. Inspect special diet trays to ensure that the correct diet was served to residents.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1 and Resident #2) out of five residents reviewed for showers, in that: The facility failed to provide showers to Resident #1 and Resident #2 in compliance with their shower schedules. This failure placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, type II diabetes, chronic obstructive pulmonary disease (a type of progressive lung disease), and depression. Review of Resident #1's admission MDS assessment, dated 11/13/23, reflected a BIMS of 13, indicating no cognitive impairment. Section G (Functional Status) reflected she required extensive assistance with all ADLs. Review of Resident #1's admission care plan, dated 11/08/23, reflected she had a physical functioning deficit with transfers and required assistance of two people. Review of Resident #1's bathing task in her EMR, from 11/05/23 - 11/14/23, reflected no documentation that a shower/bath had been given. Review of the facility's shower sheets for the month of November 2023, reflected one documented shower sheet for Resident #1 dated 11/09/23. During and observation and interview on 11/14/23 at 9:02 AM revealed Resident #1 was in her room sitting on her bed with her head down. She stated she was upset because she felt dirty. She stated when she was given a shower it was always rushed but she rarely got one. She stated she could not remember the last time she received one and it made her feel bad. Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, muscle wasting and atrophy (wasting away), bed confinement, need for assistance with personal care, and age-related physical debility. Review of Resident #2's admission MDS assessment, dated 09/20/23, reflected a BIMS of 14, indicating no cognitive impairment. Section G (Functional Status) reflected she was totally dependent for ADL care. Review of Resident #2's admission care plan, dated 09/28/23, reflected she had an ADL self-care performance deficit related to lateral sclerosis (a nervous system disease that affects nerve cells in the brain and spinal cord) with lower extremity paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) with an intervention of extensive assistance from 1-2 staff with ADLs. Review of Resident #2's bathing task in her EMR, from 10/14/23 - 11/14/23, reflected she received four bed baths on 10/17/23, 10/26/23, 11/02/23, and 11/07/23. Review of the facility's shower sheets for the month of November 2023, reflected no documented shower sheets for Resident #2. During an observation and interview on 11/14/23 at 9:09 AM revealed Resident #2 in bed watching television. Her hair and face were greasy. She stated the aides used to give her bed baths, which she prefers, but they stopped weeks ago. She stated she know obtained her own wipes and tried to wash her chest and arm pits but that was all she could reach. She stated not getting a full bed bath regularly made her feel bad and not too clean. During an interview on 11/14/23 at 10:22 AM, CNA A stated she felt like they were short-staffed and it was hard to get all showers completed and there were some days residents would go without. She stated the aides documented showers in the kiosk and filled out shower sheets. During an interview on 11/14/23 at 12:26 PM, the DON stated it was her responsibility to ensure showers were being given and shower sheets were filed in the binder at the nurses' station. She stated she tried to review the binder every couple of days. She stated the aides were supposed to document showers in the kiosk and on the shower sheets. She stated if a resident refused a shower, the aides were to notify the nurses so they could try encouraging the resident and could document the refusal in their chart. She stated refusals were also to be documented on shower sheets. She stated a potential outcome of not receiving showers regularly was there would be a higher risk of infection. She stated they did not have a policy on ADL care or showers.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for eight (Resident #1, Resident #3, Resident #12, Resident #14, Resident #17, Resident #21, Resident #22, and Resident #27,) of 21 residents reviewed for quality of care, in that: A.) The DON failed to take immediate action for a severe rash on Resident #14 which allowed the rash to worsen resulting in excruciating pain and misery. B.) The facility failed to track and monitor skin issues to identify if the areas were improving or worsening for Resident #1, Resident #3, Resident #12, Resident #14, Resident #17, Resident #21, Resident #22, and Resident #27. These failures placed residents at risk of serious injury, pain, mental anguish, emotional distress, and a decreased quality of life. Findings included: A.) Review of Resident #14's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's most recent MDS, dated [DATE], reflected a BIMS of 13, indicating no cognitive impairment. Review of Resident #14's care plan, revised 9/7/21, reflected she had mixed bladder and bowel incontinence related to activity intolerance, impaired mobility and recent [CONDITION(S)] infection. The interventions included to apply barrier cream as needed to prevent skin breakdown and to monitor/document for signs and symptoms of [CONDITION(S)]. There was no documentation regarding a yeast infection or a rash. Review of Resident #14's care plan, revised 9/7/21, reflected she had an ADL self-care performance deficit related to activity intolerance, weakness, and lower back pain. She required extensive assistance with incontinent care. Review of Resident #14's physician order, dated 9/23/21, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/3/21 at 11:48 AM with Resident #14, she stated she had a [CONDITION(S)] in September and was prescribed an antibiotic. She stated the antibiotic caused her to develop a yeast infection. She stated she had gone weeks with the yeast infection, and it had worsened to the point that she had blisters on her vagina and inner thighs. She stated last weekend, 10/29/21 - 10/31/21, was when the blisters got really bad. She stated the aides would change her brief, the skin of the blister would pull off, causing her to bleed. She stated it caused her a deep-aching pain from the inside out, burned, and hurt so bad it made her nauseous. She stated it affected her emotionally as she felt helpless because she had no control on the issue; it was like no one cared. She stated she had been requesting an anti-fungal powder from the aides for weeks, but the aides would tell her they were out of it. She stated she had a yeast infection in the past that caused a rash, but it had never gotten to that point of extreme pain and blistering. She stated she had been begging the staff to take it seriously and she had been patient, but once she saw blood on her thighs and on her sheets, she put her foot down and requested to see the DON. She stated the DON assessed her peri area on 11/1/21 and expressed to her she could not believe how bad it had gotten and told her she would notify the NP. Resident #14 stated the NP saw her the following day (11/2/21), and it was the first time she had assessed the rash. She stated the NP told her, I'm so sorry this was not reported to me sooner. Resident #14 continued with tears in her eyes, stating she just did not understand why she had to go through so much excruciating pain for so long before anyone did anything. Observation on 11/3/21 at 12:02 PM, revealed peri care being conducted on Resident #14. Under her breasts there were areas of pink and peeling skin. Under her abdominal fold, the area was a darker pink, almost red peeling skin. The groin folds were dark red/maroon and had a rash (with what looked like to be popped blisters) that spread a few inches down her inner thighs. Her labia were dark red/maroon. The resident was in pain as her face grimaced and she clenched her fists during the process. Review of Resident #14's most recent Totally Body and Skin Assessment, dated 11/1/21, reflected no skin issues. During an interview on 11/3/21 at 2:38 with the DON, she stated she knew Resident #14 had a rash, but she first assessed Resident #14's rash on 11/1/21 when the aides notified her of the blisters and the blood. She stated she could not remember the last time she changed the resident's brief. The NP was notified of the findings and an anti-fungal powder was ordered. She stated the NP assessed the rash yesterday (11/2/21) but could not remember if the NP had assessed the rash before then, stating, I'd have to look. During an interview on 11/3/21 at 3:02 PM with CNA B, she stated she had worked at the facility since July. She stated she had provided care to Resident #14 on numerous occasions, and stated she had the rash for at least a month. She stated it had progressively gotten worse. She stated she had informed the charge nurse on multiple occassions. During an interview on 11/3/21 at 3:13 PM with the NP, she stated she was at the facility 2 times per week. She stated she had not assessed Resident #14's rash until yesterday (11/2/21) after she was notified on 11/1/21 that the rash had worsened, but she had been aware that she had a yeast infection. She stated there were blisters and it was bleeding, but it was not the worst rash she had ever seen. She stated the staff had been applying creams with Zinc for the rash for a while. When asked if it was normal for a yeast infection to take over two months to heal, she stated Resident #14 was old and diabetic and her blood sugars were out of control which could slow the healing. During an interview on 11/4/21 at 9:18 AM with CNA C, she stated Resident #14 had a rash in her peri area since she was admitted (9/3/21). She stated she applied a peri guard ointment after performing peri care. She stated she occasionally use a powder which she found on the nurse's cart, but it was not always available. She stated she never saw blood from Resident #14's rash. She stated from her experience, the rash was more severe than most she had seen. She stated she always notified any skin issues to the charge nurse, especially if they appeared to be getting worse. She stated she had brought it up to her charge nurse, letting her know that the rash would not clear up. During an interview on 11/4/21 at 9:24 AM with the ADM, she stated her expectations were if a powder was being applied to a resident, that there would be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it would not meet her expectations for the DON and/or NP to wait two months to assess a rash after it had developed. During an interview on 11/4/21 at 10:12 AM with the DON, she stated she had changed Resident #14's brief on 10/29/21. She stated it was a little pink, but nothing like how it was when she changed her on 11/1/21 (extremely red, blisters). During an interview on 11/4/21 at 10:52 AM with CNA D, she stated Resident #14 was admitted to the facility with a rash. She stated it had always been red, but on 10/26/21, the rash was really red and had definitely gotten worse. She stated she went and told the DON that she really needed to assess Resident #14's rash. She stated she was in shock when the DON did not see it as an issue and acted like it wasn't that bad. She stated the DON told her she would get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she went to the DON and asked her, I thought you were going to get powder for Resident #14? There are blisters around her peri area. She stated she kept note that day and she never saw the DON go to assess Resident #14. She stated on 10/29/21 was the first time she saw blood. She stated as she removed the brief from Resident #14, the top of the blisters appeared to be ripped out by the brief. She stated there was blood on her thighs and on her linens. She stated in her experience, she had never seen a yeast infection last that long, or a rash develop to that level of severity. During an interview on 11/5/21 at 10:15 AM with the MD, he stated he had not seen Resident #14's rash. He stated if a yeast infection was treated appropriately and aggressively, it would be gone in 2-3 days. He stated depending on a resident's health, it could take longer, 5-7 days. He stated it was not typical for a resident to have a yeast infection for 2 months. Review of Resident #14's EMR, on 11/3/21, reflected there was no mention of a rash or yeast infection in her progress notes, physician notes, or care plan. Review of Resident #14's physician order, dated 11/1/21, reflected the following: Miconazole [MEDICATION(S)] Powder 2% - Apply to perineal area/buttocks topically every day and night shift for yeast skin rash for 14 days. Cleanse perineal area and buttocks with NS, pat dry, apply miconazole powder to area BID x 14 days. B.) Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS of 7, indicating a severe cognitive impairment. Review of Resident #1's care plan, revised 7/19/21, reflected he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #1's most recent Total Body Skin Assessment, dated 10/28/21, reflected no skin issues. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's most recent MDS, dated [DATE], reflected a BIMS of 12, indicating no cognitive impairment. Review of Resident #3's care plan, revised 5/5/21, reflected she had an ADL self-care performance deficit with an intervention of requiring a skin inspection on bath days. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Review of Resident #3's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #3's most recent Total Body Skin Assessment, dated 11/3/21 at 9:03 AM, reflected no skin issues. Review of Resident #12's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's most recent MDS, dated [DATE], reflected a BIMS of 9, indicating a mild cognitive impairment. Review of Resident #12's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of #12's most recent Total Body and Skin Assessment, dated 11/1/21, reflected no skin issues. Review of Resident #17's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's most recent MDS, dated [DATE], reflected a BIMS of 8, indicating a mild cognitive impairment. Review of Resident #17's care plan, revised 4/14/21, reflected he had pressure ulcer and skin integrity risk with interventions of completing weekly skin assessments and providing thorough skin care after incontinent episodes and apply barrier cream. Review of Resident #17's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #17's most recent Skin Total Body Skin Assessment, dated 11/3/21 at 10:04 AM, reflected no skin issues. Review of Resident #21's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's most recent MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #21's care plan, 9/20/21, reflected he had pressure ulcer and skin integrity risk with interventions of completing weekly skin assessments and providing thorough skin care after incontinent episodes and apply barrier cream. Review of Resident #21's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #17's most recent Skin Total Body Skin Assessment, dated 10/30/21, reflected no skin issues. Review of Resident #22's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's most recent MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #22's care plan, revised 10/11/21, reflected she had altered skin integrity non pressure related to redness underneath bilateral breast and abdominal folds with interventions of conducting a weekly skin inspection and observing for signs of infection such as swelling or redness. Review of Resident #22's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #22's most recent Totally Body and Skin Assessment, dated 10/30/21, reflected no skin issues. Review of Resident #27's undated face sheet reflected [AGE] year-old woman who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's most recent MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #27's care plan, revised 10/14/21, reflected she had an ADL self-care performance deficit related to chronic pain and weakness with interventions of requiring a skin inspection to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Review of Resident #27's shower sheets from 9/4/21 - 11/2/21 (two months) reflected no documentation of any rashes, bruising, skin breakdown, or redness. Review of Resident #27's most recent Totally Body and Skin Assessment, dated 10/30/21, reflected no skin issues. During an interview on 11/4/21 at 10:30 AM with the ADM, she stated all nurses do skin assessments, not just the DON. She stated skin issues should be documented on all weekly skin assessments by the nurses and on shower sheets by the aides. She stated all skin issues - rashes, bruises, pressure ulcers - should be documented in their care plans and progress notes. She acknowledged that all shower sheets had no documentation of skin issues, nor did the skin assessments have any documentation of skin issues for Resident #1, Resident #3, Resident #12, Resident #14, Resident #17, Resident #21, Resident #22, and Resident #27. She stated after the Surveyors brought to her attention the horrible rash on Resident #14, she initiated a total body and skin assessment to be conducted by the DON and DON K on each resident in the facility. The following are the results for Resident #3, Resident #12, Resident #14, Resident #17, Resident #21, Resident #22, and Resident #27: Review of Resident #1's weekly skin assessment, dated 11/3/21, reflected a rash/boil on his groin and scrotum. Review of Resident #1's nursing progress note, dated 11/5/21, reflected the following: Resident observed area to left chest, left shoulder, back of neck, and left outer forearm. Area to left chest is small open area - no bleeding, drainage noted to area. Left shoulder resident has area that is raised and dry. Area with no bleeding, drainage, or signs and symptoms of infection noted. Area to back of neck is a small area that is light pink in color. Area is not open, no blisters, or bleeding noted. Area to left outer forearm is an area of discoloration that has a small s/t. Area has intact scab in place. No bleeding or drainage noted. Called and spoke with the MD about the above. Order received to cleanse area to left chest with NS, pat dry, apply TAO, and cover with NAD QD. Area to left shoulder received to monitor and refer to dermatology. Order wrote to refer to dermatologist. Area to back of neck order received to monitor area. Area to left outer forearm order received to monitor. Orders noted in EMR. Review of Resident #1's nursing progress note, dated 11/5/21, reflected the following: The WCD on site for visit. WCD agreed with treatment that primary MD prescribed. During an observation and interview on 11/4/21 at 4:06 PM, Resident #1 stated he had a rash in his groin area. He could not remember how long he had the rash and he could not remember if he had ever had a similar rash in the past. Resident #1 stated the rash was uncomfortable and itched a little. During the conversation, Resident #1 pulled down his pants to show the rash. The observation revealed Resident #1's inner thighs, groin, and scrotum to be red with some small bumps on the skin. During an observation and interview on 11/2/21 at 9:48 AM revealed Resident #3 sitting by herself in the dining room. She stated she had a rash on her arm that had been there for a couple of months. She stated it hurt a little and it itched a lot. She stated she had some salve to put on the rash, but it wasn't working. Observation of Resident #3's right arm revealed a red raised rash area on the dorsum of her hand. There was a large red raised circular rash on the forearm. Resident stated she had the same type of circular rash on her abdomen that started about three days ago. Review of Resident #3's weekly skin assessment, dated 11/3/21 at 7:01 PM, reflected a rash on lower abdomen, rash on right outer wrist, rash right dorsum, and left inner forearm. Review of Resident #3's physician order, dated 11/4/21 reflected: [MEDICATION(S)]-Triamcinolone Cream 0-0.1 UNIT/GM -% Apply to right wrist/hand, abdomen topically every day and night shift for rash for 14 days AND apply to left inner forearm topically every day and night shift for rash for 14 days. Review of Resident #12's weekly skin assessment, dated 11/3/21, reflected a Stage I pressure ulcer on her right buttock. Review of Resident #12's nursing progress note, dated 11/3/21, reflected the following: Resident observed with area to right buttock and left buttock. Area to right buttock is open with no drainage or signs or symptoms of infection noted to open area. Area to left buttock is red/pink - area with no blisters, bleeding, no signs or symptoms of infection noted to area. Area is intact at time of assessment. Notified NP - new order received to cleanse buttocks with NS, pat dry, apply skin protectant ointment to area every shift and PRN, and leave open to air. Order noted in EMR. Review of Resident #17's weekly skin assessment, dated 11/3/21, reflected an abrasion on his left hand, an abrasion on his left hand, abrasion on his left calf, and a bruise on his left elbow. Review of Resident #17's physician order, dated 11/5/21, reflected the following: Monitor area to left lower leg and left elbow for any signs/symptoms of infection. Review of Resident #21's weekly skin assessment, dated 11/3/21 at 6:49 PM, reflected a rash to his face, measuring 7.6 cm x 6.5 cm. Review of Resident #21's physician order, dated 11/4/21, reflected the following: Hydrocortisone Cream 1% Apply to face topically every day and night shift for rash to face for 7 days. Review of Resident #22's weekly skin assessment, dated 11/3/21, reflected a rash her right trochanter, rash on her right thigh, and rash under her breasts. Review of Resident #22's physician orders, dated 11/4/21, reflected the following: Miconazole [MEDICATION(S)] Powder 2% Apply to under bilateral breasts topically every day and night shift for rash. Miconazole [MEDICATION(S)] Powder 2% Apply to right thigh topically every day and night shift for rash for 14 days. Miconazole [MEDICATION(S)] Powder 2% Apply to right trochanter topically every day and night shift for rash until 11/18/21. Review of Resident #27's weekly skin assessment, dated 11/3/21, reflected a sacral abrasion on her left trochanter, measuring 9.6 cm x 2.0 cm, and a sacral maceration, measuring 9.5 cm x 7.7 cm. During an interview on 11/5/21 at 11:12 AM with the DON, she stated the skin assessment form did not have an area to document a rash; there were areas for skin turgor, skin color, temperature, moisture, and condition. She stated she would expect for rashes and other skin issues to be documented in a nursing progress note. When asked why none of the eight residents had progress notes regarding their skin issues, she had no answer. She stated it was her responsibility to ensure skin assessments and shower sheets were being completed regularly and accurately. Review of the facility's Skin Care Guideline Policy, date July 2018, reflected the following: Weekly review of the resident's skin will be completed by the nurse and will be documented in the EMR. Residents will be observed by the nurse aide team members daily for changes in skin condition. These changes will be reported to the licensed nurses and will be documented in the EMR.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in that 1.Several food items in the refrigerator had no 'use by' date. 2. The facility stored expired food in the refrigerator. 3.There were rotten vegetables in the refrigerator. 4.There were broken eggs in the refrigerator. 5.The storage had a piece of food item that was open and undated. These failures have the potential to affect the residents who ate food from the facility's kitchen placing them at risk of foodborne illness. Findings included: During observation of the kitchen on [DATE] at 8:50 a.m. indicated the following: Expired luncheon meat in a plastic bag that had use by date [DATE]. A block of cheese in a plastic bag dated [DATE] and ham in a plastic bag dated [DATE] had no 'use by' date. The opened boxes of glazed doughnuts in the storage were not dated appropriately. Spoiled tomatoes and broken eggs was stored in the refrigerator. There was a piece of bread on paper napkins placed above the chicken and turkey gravy storage box. Interview on [DATE] at 11:30 a.m., the dietary manager stated that the food items stored in the refrigerator should have been labeled with 'use by' date. She also stated that the expired and spoiled items had to be removed from the storage and discarded. Record review of facility's Food service Policy & Procedure dated [DATE] revealed that all food will be properly wrapped and/or stored in sealed containers and dated and labelled and food will be discarded within appropriate shelf life.

Based on observation, interview and record review the facility failed to use the results of an assessment to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for three (Resident #14, Resident #17, and Resident #26) of 31 residents reviewed for care plans in that: A.) Resident #17 and Resident #26's Comprehensive Care Plan did not accurately reflect their use of a bed rail. B.) Resident #14's Comprehensive Care Plan did not reflect her utilization of oxygen therapy. These failures placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being. Findings included: A.) Review of Resident #17's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 11/2/21 at 7:14 AM revealed Resident #17 was in his room sitting in his wheelchair. He was pleasantly communicative and voiced no concerns. There was a small, approximately 12-inch-long bed rails on the side of the head of his bed. He stated he did not know what it was for. Review of Resident #17's care plan, revised 9/21/21, reflected he was at risk for falls related to impaired balance and safety awareness due to dementia. There was no documentation in the interventions regarding the use of a bed rail. Review of Resident #26's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/2/21 at 7:17 AM of Resident #26 revealed him asleep in his bed with an approximately 12-inch-long bed rail on the side of the head of his bed. Review of Resident #26's care plan, revised 4/26/21, reflected he had an ADL self-care performance deficit related to history of [CONDITION(S)]. There was nothing in the interventions regarding the use of a bed rail. B.) Review of Resident #14's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 11/2/21 at 7:25 AM revealed Resident #14 was in her room utilizing continuous oxygen via oxygen concentrator. She stated she had been on continuous oxygen for a long time, before being admitted to the facility during her current stay (admitted [DATE]). Review of Resident #14's most recent care plan, dated 9/7/21, reflected no documentation of oxygen therapy. Review of Resident #14's most recent MDS, dated [DATE], reflected she utilized oxygen therapy before she resided at the facility and now while she is a resident of the facility. Review of Resident #14's physician order, dated 9/3/21, reflected her oxygen tubing and humidifier bottle should be changed every week. During an interview on 11/3/21 at 10:11 AM with the ADM, she stated the assistive device on the beds of Resident #17 and Resident #26 was called a bed cane. It was an assistive device that provided leverage for the resident when repositioning or getting out of bed. She stated she would expect for the bed cane to be documented in their care plans, because it was important to ensure anyone that may see the bed cane know it was not a restraint, but rather an assistive device. She stated she would also expect to see oxygen therapy and interventions documented in a care plan if they had orders for continuous or PRN oxygen. She stated the facility currently did not have an MDS coordinator, who was expected to keep care plans updated, but ADON L, their past MDS coordinator, was now their sister facility's ADON and was still helping them out. During an interview on 11/4/21 at 2:50 PM with ADON L, she stated she used to be the MDS Coordinator at the facility until she took another position at a sister facility. She stated she was no longer responsible for the facility's care plans but would assist if a staff needed to update a care plan immediately or if there was an emergency. She stated if a resident utilized a bed cane on their bed, it should be documented in the interventions on the resident's care plan. She stated if a resident utilized oxygen, it should also be care planned. She stated any acute problem should be updated in the care plan, normally be the following [MEDICATION(S)] the staff stand-up meeting. During an interview on 11/4/21 at 3:33 PM with the ADM, she stated the facility did not have a specific Care Plan Policy but followed the RAI manual.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1 and Resident #24) of six residents reviewed, in that: The facility failed to provide regular showers to Resident #1 and Resident #24 and regular incontinence care. These deficient practices placed residents at risk of poor personal hygiene, a decline in their sense of well-being, level of satisfaction with life, and feeling of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS of 7, indicating a severe cognitive impairment. Review of Resident #1's most recent MDS, dated [DATE], reflected he was totally dependent with bathing and required one-person physical assist with incontinent care. Review of Resident #1's care plan, revised 7/19/21, reflected had an ADL self-care performance deficit related to activity intolerance, weakness, and poor safety awareness. He was able to shower with extensive assist by one staff. He was able to toilet with supervision and required limited assistance with peri care after toileting. Review of Resident #1's bathing tasks in his EMR, dated 10/9/21 - 11/4/21, reflected he was totally dependent with the six showers he received during that time period: 10/11/21, 10/22/21, 10/25/21, 10/27/21, 10/29/21, and 11/1/21. Review of Resident #1's bladder elimination tasks in his EMR, dated 10/6/21 - 11/4/21, reflected he was incontinent on 14 instances, and continent on 15 instances. That task sheet further indicated, he was only urinating and/or being assisted with incontinent care 1-2 times per day. During an observation and interview on 11/2/21 at 8:12 AM with Resident #1, he was wheeling himself out of his room and stated he was doing OK. There was a strong foul urine odor from the hall outside of his room. His hair was greasy and disheveled. When asked if he was getting bathed regularly, he stated he had no idea. During an interview on 11/2/21 at 9:55 AM with the MAINTD, he stated Resident #1's room had always had a strong urine smell. He stated he believed the residents that resided in that room were not careful when they urinated. Review of Resident #24's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's most recent MDS, dated [DATE], reflected a BIMS of 14, indicating no cognitive impairment. Review of Resident #24's most recent MDS, dated [DATE], reflected she required total assistance with bathing and extensive assistance with incontinent care. Review of Resident #24's care plan, revised 10/11/21, reflected she had an alteration in elimination of bowel and bladder function due to debility from fall at home with left femur fracture. An intervention included check and change every two hours and PRN. Review of Resident #24's bathing task in her EMR, dated 10/4/21 - 10/31/21, reflected she had received two showers during that time frame, 10/12/21 and 10/21/21. She refused a shower on 10/9/21, 10/16/21, and 10/28/21 (three instances). Review of Resident #24's bladder elimination task in her EMR, dated 10/4/21 - 11/2/21 reflected she was incontinent on 22 instances, and continent on 18 instances. The task sheet further indicated, per the documentation, she was only urinating and/or being assisted with incontinent care 1-2 time per day. During an observation and interview on 11/2/21 at 8:32 AM with Resident #24, she stated her call light was on because she was waiting to be changed. She stated her call light had been on for a long time but she forgot to check the clock when she pressed the button. She stated a nurse had come in and told her she would have to wait until they finished passing breakfast trays. She stated she had not been showered in a while. She stated her main concern was getting changed regularly because she had a pressure ulcer awhile back and it was so painful that she did not want to develop another one. She stated she was just happy when someone came to change her. She stated she constantly tried to be patient as she waited and waited and waited. During an intrview on 11/2/21 at 8:45 AM with CNA C, she stated she was aware Resident #24 had been waiting to hae her brief changed, but she was waiting for the other aides to be done feeding the residents that needed to be fed. During an interview on 11/2/21 at 9:02 AM with CNA A, she stated residents should be changed whenever they were wet or dirty. She stated they were to document when they gave a resiednt a bath or changed their brief in the resident's EMR. During an observation and interview on 11/4/21 at 11:52 AM with the ADM, she stated peri care should be done on every residents every two hours and as needed. The Surveyor showed her the showering and bladder elimination tasks for Resident #1 and Resident #24 and she acknowledged that per what was documented, Resident #1 had only received six showers and Resident #24 had only received two showers per the time frames. She acknowledged that per what was documented, Resident #1 and Resident #24 were only receiving peri care 1-2 times a day. She stated not getting bathed, or at least offered a shower, three times a week was unacceptable. She stated only receiving peri care/incontinent care 1-2 times a day was unacceptable. She stated these ADLs were important to prevent skin break down, rashes, and poor hygiene. A request was made on 11/4/21 at 3:33 PM from the ADM for a copy of the facility's ADL policy on but was not provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure that a resident with pressure sores received the necessary treatment and services to promote healing, and prevent new pressure sores from developing for 1 of 3 residents (Resident #1) reviewed for pressure sores. Resident #1 was admitted with an unstageable necrotic pressure sore to his right heel on 07/25/2012. On 12/26/2012 Resident #1 developed an open area to his coccyx, left and right buttocks that was identified as non-pressure areas. The areas progressed to a Stage III pressure ulcer to Resident # 1's coccyx, three (3) Stage II pressure ulcers to his right buttock, and two (2) Stage II pressure ulcers to his left buttock on 01/04/2013. There was no plan of care for these pressure sores and the facility used an incorrect treatment to ensure healing of pressure sores. This deficient practice placed 3 residents at risk for not getting necessary medical treatment and services to promote healing, to prevent infection, and prevent development of pressure ulcers. Findings included: Review of Resident # 1's Face Sheet reflected a [AGE] year old male who entered the facility on 07/25/2012. Resident # 1's [DIAGNOSES REDACTED]. Observation on 01/02/2013 at 10:45 AM revealed Resident # 1 was laying supine, arms bent upwards toward his neck in bed with both legs thrashing. Resident # 1 had a gastrostomy (feeding tube) and a tracheotomy (opening in the throat to facilitate an airway). A surveyor attempted an interview with the Resident at this time but he did not respond. Resident # 1 had a pressure relieving mattress and a pillow under his left side, with a hand roll in his right hand.. Review of Resident # 1's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected a severe cognitively impaired resident who rarely/never understands or was understood. The assessment identified one (1) unstageable pressure ulcer. Review of Resident # 1's Significant Change MDS assessment dated [DATE] reflected a severely impaired cognitive resident who rarely/never understands or was understood. The assessment identified one (1) Stage III pressure ulcer upon admit/readmit measuring 2.0 centimeters (cm) x 2.5 cm x 1.0 cm. Review of Resident # 1's Comprehensive Care Plan dated 08/27/2012 reflected the resident had a "pressure ulcer to his right ankle. He has dressing changes ordered and is assessed weekly by staff for worsening or improvement. He wears a pressure relieving boot." Interventions included: Staff to perform dressing changes as ordered. Dietician to review diet and make any nutritional changes to ensure proper wound healing. Monitor wound and report any negative changes to MD (Medical Doctor) promptly. Keep pressure relieving boot on foot as ordered by MD. PT (Physical Therapy) to debride wound if necessary. If no improvement in the wound over 2 month's time of the same treatment report to MD for new orders. Continued review of this care plan dated 08/27/2012 reflected it had not been updated since 08/27/2012. There were no new interventions for prevention of further skin breakdown or pressure ulcers for Resident # 1. Review of Resident # 1's physician orders reflected a physician notification by facsimile (fax) dated 12/25/2012 which advised the physician that there was an " open area to coccyx and same area resident had in the past. Can we have [MEDICATION NAME] orders. " Review of Resident # 1's physician orders reflected a telephone order dated 12/27/2012 for " coccyx wound left and right cleanse with SNS (normal saline)/wound cleanser, pat dry, cover with [MEDICATION NAME]. Change every 3 days and as needed for soiling or dislodgement. " Review of Resident # 1's physician orders reflected a telephone order dated 12/31/2012 to: 1) Discontinue [MEDICATION NAME] to coccyx; 2) Start B coccyx cleanse with wound cleanser, pat dry, apply zinc oxide to area thickly. Wound care twice per day and as needed soiling and bathing; and 3) Turn patient every 2 hours. Review of Resident # 1's nursing notes from reflected no notes regarding the resident's pressure areas until: 12/29/2012: Resident turned every 2 hours and [MEDICATION NAME] intact to coccyx. 12/30/2012: Turned every two hours and kept off his coccyx. There was no mention of treatment. 01/03/2013: Turned every two hours with [MEDICATION NAME] applied to coccyx. In an interview on 01/02/2013 at 3:00 PM the Director of Nurses (DON) stated Resident # 1 had pressure areas to his ankle but the areas on his buttocks and coccyx was not caused by pressure but urine induced [MEDICAL CONDITION] and was being treated as such. In an interview on 01/03/2013 at 3:20 PM Licensed Vocational Nurse (LVN) D stated there was no treatment order for Resident # 1's buttocks and coccyx, just zinc oxide to be applied. Observation made on 01/03/2013 at 3:25 PM revealed Certified Nurse Aide (CNA) G cleansed the area on Resident # 1's left buttock and coccyx with an incontinent care wipe. LVN D then placed zinc oxide on the wounds. CNA G, nor LVN D used a wound cleanser as prescribed by the physician prior to applying the zinc oxide. Although there were no measurements taken during this observation there were three (3) pressure ulcers identified by the State Surveyor Registered Nurse as follows: Left Buttock - two (2) Stage II pressure ulcers. Coccyx - one (1) Stage III pressure ulcer. In an interview on 01/03/2013 at 4:30 PM the DON stated she disagreed with the surveyor's observation and findings for Resident # 1. The DON stated she had determined that these areas were from Incontinence Associated [MEDICAL CONDITION] (IAD) and not pressure. The DON stated Resident # 1 had a Foley catheter upon admission and the facility healed the coccyx. The Foley catheter was removed and the area reopened. The DON stated the areas on Resident # 1's buttocks and coccyx were not pressure areas, but IAD and the facility was using zinc oxide as a barrier cream and treatment. The DON stated she knew the facility nurses were not completing body audits and weekly pressure sore and non-pressure skin condition evaluations on a regular basis and had completed an action plan for this problem. The DON was asked to present the action plan to the Survey Team. No documentation of the facility action plan was presented to the Survey Team at the time of exit. Review of the pamphlet provided by the DON regarding "Differentiating IAD from Category/Stage II Pressure Ulcers undated, reflected IAD is a skin irritation that results from urinary and/or fecal incontinence. A more complete definition is Inflammation and skin erosion associated with exposure to urine and/or stool, the use of absorptive containment devices in which secondary cutaneous infection (usually fungal) is common " . The pamphlet describes a Category/Stage II pressure ulcer as " Partial-thickness loss of dermis presenting as a shallow, open ulcer with a red, pink wound bed, without slough. Stage II pressure ulcers may also present as an intact or open/ruptured serum-filled serosanguineous-filled blister. " A Category/Stage III pressure ulcer is full thickness skin loss involving damage to or necrosis (death) to subcutaneous tissue that may extend down to but not through, underlying fascia. Instructions in the pamphlet to protect the skin from IAD reflected to avoid zinc oxide, as it can damage skin to remove. Observation made on 01/04/2013 at 9:25 AM by a surveyor with the DON present revealed: Resident # 1 had six (6) open areas with three (3) on right buttock, two (2) on the left buttock and one (1) in the center of the coccyx. Measurements reflected: Right Buttock: Three (3) Stage II pressure areas - Approximately 1.0 cm x 1.0 cm x less than 0.1 cm each; 2 were round with edges. Left Buttock: Two (2) Stage II pressure areas measuring 2.0 cm x 2.0 cm x less than 0.1 cm and 2.0 cm x 3 cm x less than 0.1 cm. Both were round with edges. Coccyx: One (1) Stage III pressure area measuring 2.0 cm x 0.5 cm x greater than 0.1 cm depth. In an interview on 01/04/2013 at 9:25 AM the DON continued to disagree with the surveyor that the areas on Resident # 1's buttocks were caused from pressure. The DON stated she could concede and agree the area on the coccyx was due to pressure but did not agree the areas on Resident # 1's left and right buttocks were from pressure. The DON stated she was using zinc oxide for Resident # 1's skin condition and had forgotten the pamphlet advised against the use of zinc oxide. The DON stated she did not realize there was no plan of care for Resident # 1's risk for further skin breakdown or the areas that had occurred on his buttocks and coccyx. The facility Corporate Nurse whose title was Continuous Quality Improvement Director (CQID) made a later observation of Resident # 1's open areas to his coccyx, right and left buttock on 01/04/2013. Review of the CQID's assessment reflected: " Resident # 1's skin was observed to have six (6) separate wounds; three (3) on the right side and two (2) on the left with a larger area on the coccyx area.....All were clean with no odor, non-draining, and no signs/symptoms of infection. No maceration to the wound borders/edges was noted. Wounds appear pressure related and a re-current problem in light of the scar tissue area of the buttock/coccyx areas. I would recommend asking the physician for a wound gel to keep the wounds moist and covering with a dry sterile dressing and changing every day as needed. A [MEDICATION NAME] dressing has been placed over the wounds to protect them until different wound orders can be obtained. " The DON presented the Survey Team with an updated Plan of Care, Body Audit and Physician Order dated 01/04/2013 as follows: Plan of Care Resident # 1 has current skin concerns as evidenced by: Perineal/buttock irritations, Incontinence Associated [MEDICAL CONDITION] to the Left Buttock, 2 areas measuring 1.0 cm x 1.0 cm and 3.5 cm x 2.0 cm; 3 areas to the Right Buttock measuring 0.1 cm x 0.1 cm, 0.5 cm x 0.5 cm and 1.0 cm x 1.0 cm. Approaches included perform treatments per order, if no improvement x 2 weeks, report to MD; Monitor areas for increase breakdown, signs and symptoms of infection, report to MD; monitor for pain, give med per order, monitor for relief; encourage dietary/fluid intake with in dietary limits; keep MD and RP informed of resident's progress; Assess for possible reasons for skin concerns, report findings to MD. Resident # 1 has a pressure ulcer to the coccyx center, Stage II measuring 2.0 cm x 2.0 cm. Approaches included perform treatment per order, if no improvement within two weeks, report to MD; encourage p.o. and fluid intake within dietary limits; keep family/responsible party and MD informed of resident's progress; assist with turn/repositioning every two hours and as needed; use padding between pressure areas and positioning devices for proper body alignment and provide pressure relieving device for bed and wheel chair. Physician Order dated 01/04/2013 reflected "cleanse coccyx and bilateral buttocks with wound cleanser, pat dry, apply [MEDICATION NAME] every three days and as needed until healed. Apply barrier cream to bilateral buttocks after each incontinent episode." During interviews on 01/04/2013 at 3:30 PM with the DON and CQID, the DON stated she disagreed with the survey team evaluation and the CQID's Assessment of Resident # 1's Pressure Ulcers. The CQID stated she assessed the areas on Resident # 1's coccyx and buttocks to be from pressure. The CQID stated there was no maceration that indicted the wounds were from urine and requested the DON to treat them as such. The CQID requested the DON to revise the plan of care, physician order and to place all of Resident # 1's pressure ulcer areas on the weekly pressure ulcer report to be sent to her to monitor. Review of Resident # 1's pressure ulcer history and Weekly Pressure Ulcer Evaluations and Non-Pressure Skin Conditions Evaluations reflected Resident # 1's area to his right ankle heel was identified and treated as a pressure ulcer. Review of Resident # 1's clinical record for pressure ulcers to the coccyx, left and right buttock, reflected they had all been treated as non-pressure related skin conditions as follows: 07/25/2012 - Initial Body Audit and Nursing Assessment reflected Resident # 1 was admitted to the facility without a catheter and one necrotic area to his heel. There were no red/open areas to Resident # 1's buttocks or coccyx. 08/07/2012 - Body Audit reflected Resident # 1 had red, open areas to right and left buttocks. 08/09/2012 - Non-Pressure Skin Evaluation reflected: A denuded area to Resident # 1's right buttock, acquired in-house that measured 1.0 cm x 0.5 cm, no depth measurement, partial thickness and the wound bed was normal for skin, surrounding areas reddened and the wound had deteriorated. Progress note reflected "Resident has three areas to buttocks. Resident was placed on alternating pressure mattress and is turned every two hours with incontinent care every two hours. Barrier cream is applied every two hours." 08/09/2012 - Non-Pressure Skin Evaluation reflected: A denuded area to Resident # 1's left buttock, acquired in-house, measuring 3.0 cm x 2.0 cm with no depth. Characteristics reflected partial thickness with the wound bed normal for skin, surrounding skin was reddened and the wound had deteriorated. Progress notes reflected "Resident is being changed every two hours and repositioned. Barrier cream is applied to area every two hours when turned." 08/12/2012 - Nurses Notes reflected Resident # 1 was admitted to the hospital due to bilateral pneumonia and suspected [MEDICAL CONDITION]. 08/19/2012 - Nurses Notes reflected Resident # 1 was readmitted to the facility without a catheter. 08/19/2012 - Body Audit reflected Resident # 1 was readmitted with pressure sores to the heel and ankle. There was a red/open area to left and right buttocks. 08/22/2012 - Body Audit reflected Resident # 1 had 4 open areas that were red and macerated to his right and left buttock. 08/22/2012 - Non-Pressure Skin Condition Evaluation reflected: A denuded area to Resident # 1's right buttock, acquired in-house, that measured 1.0 cm x 1.0 cm, no depth measurement, partial thickness with dark pink/red tissue, surrounding skin normal for skin and no change in progress. The Progress Note reflected "Resident is repositioned every two hours. He has an alternating pressure mattress to help relieve pressure and promote healing. His treatment was changed to [MEDICATION NAME] dressing to protect areas and promote their healing. He receives nutritional interventions ([DEVICE] feedings, prostat and multivitamins) to promote healing." There were two Non-Pressure Skin Evaluations for 08/22/2012 that reflected denuded areas to the left buttock, acquired in-house, measuring (#1) 3.0 cm x 2.5 cm and (#2) 1.5 cm x 1.0 cm. Both reports reflected partial thickness with the wound bed pink, pale tissue, surrounding skin normal. Progress notes for area # 1 reflected "Area is pale pink and surrounding tissue is no longer reddened. [MEDICATION NAME] is being applied to area to protect skin and promote healing. Resident is repositioned every two hours and dried to promote healing." Progress notes for area # 2 reflected "Treatment changed today to [MEDICATION NAME] dressing to be changed every 72 hours and as needed. This is to protect area and promote healing. surrounding tissue is no longer reddened. Wound bed is clean with necrotic tissue." 08/22/2012 - Non-Pressure Skin Condition Evaluation reflected: A denuded area, present upon admission, to Resident # 1's coccyx measuring 2.0 cm x 1.0 cm, partial thickness, dark pink/red tissue wound bed and surrounding skin normal. Progress Notes reflected "Treatment changed to [MEDICATION NAME] dressing to better protect area and promote healing. Resident is turned and repositioned and dried every two hours. He is repositioned with pillows by shifting to sides. He has an alternating pressure mattress and receives [MEDICATION NAME] (liquid formula for gastrostomy tube feeding), Prostat(protein supplement) and multivitamins per [DEVICE] to promote healing." 08/23/2012 - Physician Order reflected insert Foley catheter "due to skin wounds that are being exacerbated by urine incontinence. [MEDICATION NAME] to denuded areas on buttocks and coccyx. Change every 3 days and as needed." 08/28/2012 - Non-Pressure Skin Condition Evaluation reflected 2 denuded areas to Resident # 1's left buttock, acquired in-house, measuring (#1) 2.0 cm x 1.0 cm (#2) 1.0 cm x 1.0 cm, both with partial thickness, wound bed and surrounding area normal. Progress notes for area # 1 reflected "Area shows decrease in size. Wound bed is healthy pink with good blood flow. Maceration to area has significantly improved and redness is gone." Progress notes for area # 2 reflected "Area has decreased in size and surrounding tissue show significant decrease in maceration since Foley cath was inserted and [MEDICATION NAME] dressing used. Will continue to monitor." 08/28/2012 - Non-Pressure Skin Condition Evaluation reflected Resident # 1 had a denuded area to the coccyx, present upon admission, that measured 2.0 cm x 0.5 cm, with partial thickness. The wound bed and surrounding skin was normal. Progress notes reflected "Area has decreased in size and surround tissue shows significant improvement without maceration and redness. Will continue current treatment and monitor." 08/29/2012 - Body Audit reflected 4 open areas to Resident # 1's right and left buttock. There was nothing on the body audit that reflected an area to Resident # 1's coccyx. 09/12/2012 - Non-Pressure Skin Condition Evaluation reflected Resident # 1 had a denuded area to his right buttock, acquired in-house. The progress note reflected "Area is healed." 09/12/2012 - Non-Pressure Skin Condition Evaluation reflected Resident # 1 had a denuded area to his coccyx, acquired in-house, that measured 1.0 cm x 0.5 cm, the skin was intact and surrounding skin normal. Progress notes reflected "Area continue to show improvement. Area is smaller and very superficial. Surrounding tissue is healthy." 09/16/2012 - There were two Non-Pressure Skin Condition Evaluations that reflected Resident # 1 had 2 denuded areas, acquired in-house, to his left buttocks. The areas measured (#1) 2.0 cm x 1.5 cm with partial thickness, wound bed and surrounding skin was normal; and (#2) measured 0.5 cm x 0.5 cm, was intact with dark pink/red tissue wound bed and surrounding skin was normal. Progress notes for (#1) reflected "Wound bed is clean and shows since of healing. Surrounding skin no longer looks macerated." Progress notes for (#2) reflected "Area shows great improvement. Skin is intact. There is a small area of reddened skin now." 09/22/2012 - Non-Pressure Skin Evaluation reflected: a denude area to the right buttock, acquired in-house with no measurements. The progress notes reflected the "area is healed. Tissue is intact." There were no additional Evaluations regarding the area to the right buttock, left buttock or coccyx for Resident # 1. 10/03/2012 - Body Audit for Resident # 1 reflected an open area to the coccyx. 10/04/2012 - Body Audit for Resident # 1 reflected an open area to the coccyx. 10/18/2012 - Physician Order reflected "d/c (discontinue) F/C (Foley catheter) buttocks healed." 10/19/2012 - Non-Pressure Skin Condition Evaluation reflected Resident # 1 had a denuded area, acquired in-house, to his left buttock without measurements. Progress notes reflected "All areas have healed and skin to buttocks and coccyx is intact. Foley Catheter has been removed. Resident is turned at regular intervals and receives incontinent care each time he is repositioned. Resident remains on alternation pressure mattress and is positioned with pillows." 11/14/2012 - Nurses Notes reflected Resident # 1 went to hospital due to episode of coffee ground emesis. 11/18/2012 - Nurses Notes reflected Resident # 1 was readmitted to the facility with Foley catheter in place. Resident # 1 was admitted to Hospice. 11/18/2012 - Body Audit reflected place on coccyx healed. There was no skin breakdown on Resident # 1's buttocks or coccyx. 11/19/2012 - Body Audit reflected red/open area to right and left buttocks. 11/22/2012 - Physician order reflected to Apply Zinc Oxide to coccyx with each bathing and each bowel movement. 11/23/2012 - Physician Order reflected "d/c Foley catheter." 12/06/2012 - Physician Order reflected "d/c zinc to coccyx." 12/19/2012 - Body Audit reflected no areas identified on Resident # 1's buttocks or coccyx. 12/26/2012 - Body Audit reflected an open area to Resident # 1's coccyx. Barrier cream applied. Physician notified on the 25th. 12/27/2012 - Physician order for [REDACTED]. " 12/31/2012 - Physician order to: 1) Discontinue [MEDICATION NAME] to B coccyx; 2) Start B coccyx cleanse with wound cleanser, pat dry, apply zinc oxide to area thickly. Wound care twice per day and as needed soiling and bathing; and 3) Turn patient every 2 hours. 01/02/2013 - Body Audit Reflected a red/open area on Resident # 1's right and left buttocks. No mention of the open area to Resident # 1's coccyx on this audit. Review of the weekly Pressure Sore and Non-Pressure Skin Condition Evaluations reflected no reports for the current areas that begun on 12/26/2012 on Resident # 1's left or right buttocks and coccyx. There was no treatment record of treatments to Resident # 1's right and left buttocks and coccyx from 12/26/2012 through present. As reflected above Resident # 1 had three (3) Stage II Pressure Ulcers to his right buttocks, two (2) Stage II Pressure Ulcers to his left buttocks and one (1) Stage III Pressure Ulcer to his coccyx. Review of the facility policy regarding Introduction to Prevention and Management of Wounds dated March 1, 2006, reflected information regarding an interdisciplinary team intervention program and debridement. The policy did not reflect information regarding measures to prevent, identify and treat pressure ulcers. In an interview on 01/04/2013 at 5:00 PM the DON stated there was no additional policy regarding Pressure Ulcers. The facility provided a list of 3 residents with pressure ulcers.

Based on observation, record review and interview the facility failed to ensure two (2) of two (2) residents (Residents # 4 and # 6) reviewed for services provided for limited range of motion, received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. A. The facility failed to provide Resident #4 with a physician ordered left hand splint and a carrot (a device to prevent contractures in the hand) to the right hand for bilateral contractures to prevent further development or decline of her hand contracture. Resident # 4's right hand became infected and her contractures worsened. B. The facility failed to continuously provide Resident # 6 with a physician ordered air hand splint and/or carrot to her left hand to prevent contractures. These deficient practices had the potential to decrease mobility, ROM and contribute to worsening contractures for three (3) residents identified with contractures. A. Review of Resident # 4's Face Sheet reflected an [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 4's [DIAGNOSES REDACTED]. Review of Resident # 4's Initial Minimum Data Set (MDS) assessment dated [DATE] reflected the resident scored 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) cognitive testing that is indicative of Resident # 4 was severely cognitive impairment. Resident # 4 showed signs of inattention and disorganized thinking. The assessment reflected Resident # 4 had impairment on both sides in range of motion limitation, upper and lower extremities. Review of Resident # 4's Quarterly MDS assessment dated [DATE] reflected the resident scored 3 out of a possible 15 on the BIMS cognitive testing that indicated Resident # 4 was severely cognitively impaired. Resident # 4 showed signs of inattention and disorganized thinking. The assessment reflected Resident # 4 had impairment on both sides in range of motion limitation, upper extremities only. Review of Resident # 4's Comprehensive Care Plan dated 05/03/2011 reflected Problem Onset of: "Resident # 4 requires extensive to total assist of one for all ADLs (Activities of Daily Living). Keeps fists tightly clenched all the time. Needs Carrot in both hands to prevent skin breakdown and infection, at times, Resident # 4 removes carrots from hands after staff have placed them." Interventions included "Cleanse hand daily before applying the carrots. They are left out during meals so that she can assist with feeding herself. Encourage her to keep carrots in her hands until staff take them out." Review of Physician order [REDACTED]. 02/09/2012 - Splint Wear Clarification: Discontinue left hand resting pan splint. Patient to wear wrist/hand air splints during the day as tolerated; Restorative Nursing Program Staff to apply air splints daily. May remove left hand splint for self-feeding. Remove air splints at night. Patient to wear hand carrot orthosis at all times when air splints are off. 05/25/2012 - Resident to wear left hand air splint during the day. May remove for self-feeding then re-apply. Remove at bed time and replace with finger/hand carrot orthosis. Right hand to have finger/hand carrot orthosis on at all times. 08/23/2012 - Notification by fax to physician "Resident # 4 observed with wound to right hand between ring finger and pinky. Strong odor. Requesting for physician to see wound". 08/23/2012 - Response from physician: "Will see in AM. Start Keflex 500 milligrams three times per day for 5 days (antibiotic). 11/11/2012 - Discontinue current treatment orders to right hand - healed. Review of Resident # 4's monthly replicated orders for December, 2012 and January, 2013 reflected the order dated 05/25/2012 for Resident # 4 to "wear left hand air splint during the day; May remove for self-feeding then re-apply; Remove at bed time and replace with finger/hand carrot orthosis; Right hand to have finger/hand carrot orthosis on at all times" had been left off of the monthly orders. Review of Resident # 4's OT records reflected the resident was admitted to OT on 11/18/2011. Further review reflected Resident # 4 was discharged from OT on 05/25/2012 to the Restorative Nursing Program with the following goals and approaches: 1. Maintain or improve bilateral hand positioning, joint alignment and range of motion. Approach: Passive range of motion, stretching to digits and wrists prior to splint application. 2. Splints Management: Patient to wear bilateral hand orthotics at all times to inhibit flexion fisting and allow for hand hygiene. Approach: Splint application to bilateral hands. Observation made on 01/02/2013 at 1:35 PM revealed Resident # 4 positioned on her left side in bed. Resident # 4 was observed to have severe contractures in both hands. Both hands were closed tight. There was no splint or carrot in Resident # 4's right or left hand. Observation made on 01/02/2013 at 3:40 PM revealed Resident # 4 positioned on her left side in bed. There was no splint or carrot in Resident # 4's right or left hand. Observation made on 01/02/2013 at 4:40 PM revealed Resident # 4 positioned on her left side in bed. There was gauze noted in her right hand. There was no splint, carrot or gauze in Resident # 4's left hand. There was an offensive odor noted in Resident # 4's right hand. Observation made on 01/03/2013 at 7:55 AM revealed Resident # 4 up in her wheel chair in the dining room at breakfast. Resident # 4's left hand was contracted with no device in place. There was gauze in Resident # 4's right contracted hand. In an interview on 01/03/2013 at 9:00 AM the Director of Nurses (DON) stated Resident # 4 was on the restorative program. The Director of Nurses (DON) stated she does not need an order for [REDACTED]. In an interview on 01/03/2013 at 10:00 AM Restorative Nurse Aide (RNA) L stated she puts on braces on Resident # 4's right or left hand, she was not sure which hand. She stated the braces are removed for showers. When asked RNA L stated she did not know where Resident #4's brace/splint was and that it could be in the laundry. RNA L went to the laundry and came back with Resident # 4's left hand splint. In an interview on 01/03/2013 at 10:15 AM the Occupational Therapist (OT) stated the therapy department had splints made to be used for Resident # 4. The OT stated she gets splints and facility staff loses them. The OT stated she gives her plans for resident care to the nursing department. Review of Resident # 4's current Restorative Nursing Plan of Care dated 01/01/2013 reflected Resident #4 will have improvement in bilateral hand positioning, joint alignment, range of motion and she will not have complaints of increasing pain to her hands. Approaches included "Staff will perform gently Passive Range of Motion to bilateral fingers and wrists and then replace splint to left hand and place hand roll/carrot to her right hand. Do not force wrist/fingers - if Resident # 4 refuses or complains of pain - inform the Licensed Nurse. Her right hand splint is to be removed so that she can feed herself at mealtimes. Observation made on 01/03/2013 at 2:30 PM revealed Resident # 4 was lying in bed. There was no splint or hand roll in Resident # 4's hand. Resident # 4's left hand splint was tied to her wheelchair. In an interview on 01/03/2013 at 3:45 PM, Certified Nurse Aide (CNA) H stated Resident # 4 does not resist care and does not remove her splint or carrot from either hand when placed. Observation on 01/03/2013 at 4:00 PM revealed Licensed Vocational Nurse (LVN) D demonstrated opening Resident # 4's left and right hands. The left hand was severely contracted with no splint in place. There was gauze in Resident # 4's right hand. Resident # 4 allowed LVN D to open both hands slowly and remove the gauze from her right hand. Resident # 4 did not resist care. Resident #4 did not have an open area on her right hand. Resident # 4's splint was tied to her wheel chair. In an interview on 01/03/2013 at 4:05 PM LVN D stated there is no treatment in place for Resident # 4's hand contractures, to keep hands clean and odor free. Observation made on 01/04/2013 at 8:15 AM revealed Resident # 4 was up in her wheel chair. There were no devices in Resident # 4's right or left hand. Resident # 4's splint was tied to her wheel chair. In an interview on 01/04/2013 at 9:15 AM the Assistant Director of Nurses (ADON) stated the DON is in charge of the Restorative Nursing Program. The ADON stated the DON writes the plans and monitors to ensure the plans are carried out. Observation made on 01/04/2013 at 9:20 AM with the ADON present revealed a carrot was placed in Resident # 4's left hand. There was no device in Resident # 4's right hand. In an interview on 01/04/2013 at 9:25 AM the ADON stated it is not "ok" for Resident # 4's hands to remain without devices. The ADON stated there should be a physician order [REDACTED]. In an interview on 01/04/2013 at 9:27 AM, RNA K stated she completes passive range of motion to Resident # 4's right and left hand because they are contracted and she has had a sore in one of her hands. RNA K stated she did not place splint in the Resident's hands today because of the sore. RNA K stated she had been completing passive range of motion to Resident # 4's right and left hand. Although Resident # 4's hand had healed on 11/11/2011, RNA K stated she did not know the sore was healed. Observation made on 01/04/2013 at 9:30 AM revealed RNA K found Resident # 4's orange carrot in her bed, not in her hand. Resident # 4 had a blue carrot in her left hand not the splint. The left hand splint was tied to her wheel chair. In an interview on 01/04/2013 at 9:30 AM the DON stated she was in charge of the Restorative Nursing Program and monitors by looking at the books and observations. The DON again stated she did not need an order for [REDACTED]." B. Review of Resident # 6's Face Sheet reflected a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident # 6's diagnosis' included Obstructive Chronic [MEDICAL CONDITION], Pneumonia, Dementia with Lewy Bodies, [MEDICAL CONDITION] Fibrillation, Dysphagia, Hypertension, [MEDICAL CONDITIONS], Hypopotassemia and [MEDICAL CONDITION]. Review of Resident # 6's Annual MDS assessment dated [DATE] reflected the resident scored 3 on the staff initiated cognitive test which indicated Resident # 6 is severely cognitively impaired. The assessment reflected Resident # 6 had no impairment in range of motion on either side, upper or lower extremities. Review of Resident # 6's Quarterly MDS assessment dated [DATE] reflected the resident scored 3 on the staff initiated cognitive test which indicated Resident # 6 is severely cognitively impaired. The assessment reflected Resident # 6 had no impairment in range of motion on either side, upper or lower extremities. Review of Resident # 6's Restorative Nursing Plan of Care for November 2012, December, 2012 and January, 2013 reflected a Goal of "Resident # 6 will maintain good hand and joint alignment in her left hand, without the development of contractures. Inform Resident # 6 of the Restorative Care you are going to do and offer fluids before and after care given. Approaches/Interventions reflected: Apply left hand splint daily, remove at night and place the hand carrot to maintain palm protection. Perform Passive Range of Motion/gentle stretching of her left hand and fingers before and after splint application. If Resident # 6 voices complaints of pain - STOP and inform the Licensed Nurse. Review of Resident # 6's physician orders [REDACTED]. 10/24/2012 - Occupational Therapy to evaluate and treat for contracture. 10/24/2012 - OT Clarification order: Patient to be seen in OT 5 times per week for two weeks for hand contracture management; orthotic fit/management and training. Manual Therapy; Ultra Sound. 11/05/2012 - Patient to wear left elbow air splint and left hand resting pan splint 6 hours per daytime wear. Remove at bedtime. Patient to have left blue hand finger carrot at all other times. 11/06/2012 - Discontinue from OT to RNP. Monthly physician orders [REDACTED]. Observation made on 01/03/2013 at 5:00 PM revealed Resident # 6 had no splint or carrot in her left hand. Observation made on 01/03/2013 at 5:30 PM revealed no splint or carrot in Resident # 6's left hand. Observation made on 01/03/2013 at 7:00 PM revealed no splint or carrot in Resident # 6's left hand. Observation made on 01/04/2013 at 9:20 AM revealed Resident # 6 did have her splint on in her left hand. In an interview on 01/04/2013 at 9:25 AM LVN E stated she knew at one time that OT was doing contracture management but she was not sure Resident # 6 had contractures at the moment. Observation made on 01/04/2013 at 9:30 AM revealed LVN E took Resident # 6's splint off of her left hand and moved her fingers and hand. LVN E was unable to move Resident # 6's left arm from a 90 degree angle. In an interview on 01/04/2013 at 9:35 AM LVN E stated Resident # 6 does clinch her hands and the facility does not want it to become a contracture. LVN E stated Resident # 6 was to wear the splint to prevent contractures. LVN E stated Resident # 6's arm did move when she completed her MDS assessment in June, 2012, and December, 2012. Observation made on 01/04/2013 at 2:45 PM revealed no carrot or splint in Resident # 6's left hand. In an interview on 01/04/2013 at 2:50 PM, CNA I stated she had never placed any form of splint or carrot in Resident # 6's hand. CNA I stated he had not been told to perform this duty. In an interview on 01/04/2013 at 2:55 PM, the ADON stated she did not know where Resident # 6's carrot was. The ADON stated the carrot should be in Resident # 6's hand when the splint was off. The ADON looked for the carrot in Resident # 6's room but could not find it. In an interview on 01/04/2013 at 3:15 PM the ADON stated she went to the therapy department and retrieved another carrot for Resident # 6's left hand to be placed when the resident was not wearing her splint. Review of the facility provided policy regarding Restorative Nursing Care dated August 1, 2012 reflected: Purpose: To provide nursing interventions to assist or promote the resident's ability to attain his/her maximum functional potential and to adapt and adjust to living as independently and safely as possible. Procedures 12. The nursing rehabilitation/restorative care programs will include, but not be limited to: Passive range of motion Active range of motion Splint or brace assistance 13. The facility will periodically audit and evaluate nursing rehabilitation/restorative care program. Monitoring of the program will be on going. The facility provided a list of 3 residents with contractures.