Every finding on record at Galena Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to notify the Long-Term Care Ombudsman in writing of Resident (R) 41's discharge to the community. Findings included: -The Entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE]. R41's 05/19/2026, Medicare 5-day MDS revealed the resident had a Brief Interview for Mental Status, (BIMS) score of 15, indicating intact cognition. It further revealed an anticipated discharge date of three or fewer months. R41's Discharge MDS, dated 05/20/2026, documented the resident discharged to the community on 05/20/2026. A Social Service Progress Note, dated 05/15/2026 at 02:37 PM, revealed Social Service Staff X spoke with the resident regarding a projected discharge date of 05/26/2026. A Social Service Progress Note, dated 05/19/2026 at 2:24 PM, revealed R41 requested to discharge from the facility on 05/20/2026. The note revealed R41's physician wrote the discharge order. A Nursing Progress Note, dated 05/20/2026 at 10:47 AM, revealed R41 discharged from the facility to the community and left via private transport. Review of the monthly Ombudsman Discharge/Transfer Notification Log, for May 2026 lacked notification of R41's discharge on [DATE]. During an interview on 06/23/26 at 02:30 PM, Social Service Staff X confirmed she did not notify the ombudsman when residents discharged to the community. She stated she notified the ombudsman if residents went to the emergency room, and was not aware she should notify the ombudsman of discharge of residents to their home or community in her monthly report. Review of the facilities policy titled Transfer and Discharge (including AMA (Against Medical Advice)), dated 2025, revealed the facility would provide transfer/discharge notification to the ombudsman as indicated including non-emergency transfers and discharges.

The facility failed to provide appropriate activity of daily living (ADL) cares for three dependent Residents (R ) 3, R24, and R9, who had long, jagged, dirty nails. Findings included:1. R3's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She was dependent on staff for personal hygiene. R3's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/16/2026, did not trigger. R3's Modification of the Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She required substantial to maximal staff assistance with personal hygiene. R3's Care Plan, revised 06/23/2026, instructed staff R3 was dependent for personal hygiene cares. R3's EMR under the Task tab, from 05/26/2026 through 06/23/2026 (30 days), documented R3 was dependent on staff for personal hygiene, including nail care. On 06/22/2026 at 10:31 AM, R3 sat in her wheelchair in the front commons area. She had long, jagged, dirty fingernails. On 06/23/2026 at 07:50 AM, R3 continued to have long, jagged, dirty fingernails. 2. R9's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R9's admission Minimum Data Set (MDS), dated [DATE], documented R9 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She was dependent on staff for personal hygiene. R9's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/16/2026, did not trigger. R9's Quarterly MDS, dated [DATE], documented a BIMS score of three, indicating severe cognitive impairment. She was dependent on staff for personal hygiene. R9's Care Plan, revised 06/01/2026, instructed staff R9 was dependent on staff for personal hygiene. R9's EMR under the Task tab, from 05/25/2026 through 06/22/2026 (30 days), documented R9 was dependent on staff for personal hygiene, including nail care. On 06/22/2026 at 09:49 AM, R9 sat in her wheelchair in front of the nurse's station. Her fingernails were long, jagged, and dirty. On 06/22/2026 at 02:30 PM, Certified Nurse Aide (CNA) M and CNA N provided R9 with peri-care before taking in her wheelchair back to sit in front of the nurse's station. R9s continued to have long, jagged, dirty fingernails. On 06/23/2026 at 07:50 AM, R9 sat at the dining table eating breakfast. Her fingernails remained long, jagged, and dirty. On 06/22/2026 at 02:30 PM, CNA M stated staff provided nail care on their shower days. On 06/23/2026 at 07:50 AM, R3 continued to have long, jagged, dirty fingernails. 3. R24's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R24's admission Minimum Data Set (MDS), dated [DATE], documented R24 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She was dependent on staff for personal hygiene. R24's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/16/2026, did not trigger. R24's Care Plan, revised 06/07/2026, instructed staff R24 required substantial to maximal staff assistance with personal hygiene. R24's EMR under the Task tab, from 05/25/2026 through 06/22/2026 (30 days), documented R24 required partial to moderate staff assistance with personal hygiene, including nail care. On 06/23/2026 at 07:50 AM, R24 sat in her wheelchair at the dining table eating breakfast. Her fingernails were long, jagged, and dirty. On 06/24/2026 at 09:10 AM, R24 was participating in therapy. Her fingernails remained long, jagged, and dirty. On 06/23/2026 at 02:13 PM, Certified Nurse Aide (CNA) N stated staff do nail care on the resident's shower days and as needed (PRN). On 06/24/2026 at 09:20 AM, CNA O stated staff do nail care on resident's shower days. On 06/24/2026 at 02:57 PM, Administrative Nurse D stated it was the expectation for staff to ensure resident's fingernails are kept smooth and clean at all times. The facility's undated Resident Rights policy included: Residents have the right to a dignified existence with access to persons and services inside and outside of the facility.

Based on interview and record review, the facility failed to ensure two Residents (R)3 and R9 remained free from unnecessary medications related to blood pressure medication. Findings included: - R3's Electronic Medical Record (EMR), included the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) and hypertension (elevated blood pressure). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. R3's Care Plan, revised 06/23/2026, instructed staff to obtain blood pressure (BP) readings, as ordered. R3's EMR under the Orders tab included the following physician's orders: Clonidine (a HTN medication), 0.1 milligrams (mg), by mouth, as needed (PRN), every day, for a systolic blood pressure (SBP- the top number of a BP reading), greater than 160, one hour after medications, for a diagnosis of hypertension, ordered 01/14/2026. Obtain BP one hour after the administration of medications, ordered, 01/14/2026 R3's June Medication Medical Record (MAR), 2026, documented the following BPs taken one hour after the administration of hypertensive medications and the PRN Clonidine medication was not administered: On 06/11/2026, R3's BP was 163/75. On 06/13/2026, R3's BP was 170/88. On 06/14/2026, R3's BP was 164/78. On 06/21/2026, R3's BP was 193/67. On 06/24/2026 at 02:30 PM, Certified Medication Aide (CMA) R stated the PRN medication should have been given but was not. On 06/24/2026 at 02:57 PM, Administrative Nurse D confirmed the PRN medication had not been administered, as ordered. - R9's Electronic Medical Record (EMR) documented a diagnosis of hypertension (elevated blood pressure). R9's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. R9's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/16/2026, documented the resident had short-term memory loss. R9's Quarterly MDS, dated [DATE], documented she had a BIMS score of three, indicating severe cognitive impairment. R9's Care Plan, revised 06/01/2026, instructed staff to administer her cardiac medications, as ordered. R9's EMR under the Orders tab included the following physician's order: Norvasc (a hypertensive medication), 2.5 milligrams (mg), by mouth, every morning, for a SBP greater than 155; hold the medication if the SBP is below 155, ordered, 05/04/2026. R9's June Medication Medical Record (MAR), 2026, documented the following BPs taken before the administration of Norvasc: On 06/07/2026, R9's BP was 153/74. On 06/14/2026, R9's BP was 144/65. On 06/20/2026, R9's BP was 150/74. The June MAR for R9 documented Norvasc 2.5 mg was given on the above dates and the SBP was under 155 reading and should have been held by staff. On 06/24/2026 at 02:30 PM, Certified Medication Aide (CMA) R stated the PRN medication should have been held per the order. On 06/24/2026 at 02:57 PM, Administrative Nurse D confirmed the PRN medication had not been administered, as ordered. The facility policy for Following Physician/Practitioner Orders included: The facility shall provide care and services in accordance with each resident's physician orders.

Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which require targeted gown and glove use during high contact care) when providing direct care for Resident (R) 13 and 7 who had wounds and R1 for catheter care. Findings Included: - On 06/22/2026 at 11:27 AM, R1 rested in bed with the urinary catheter collection bag directly on the floor. The collection bag contained approximately 400 milliliters (mLs) of dark brown, tea colored urine. The door into R1's room had signage that read, This room is under Enhanced Barrier Precautions. The signage educated staff further on what to wear for Personal Protective Equipment (PPE) when in contact with wounds, urinary catheters, and infections, which included gown and gloves. On 06/22/2026 at 11:30 AM, Certified Medication Aide (CMA) L confirmed the catheter collection bag was directly on the floor and should be positioned off the floor. CMA L revealed the catheter bag would be sanitized after the contents of the bag were emptied. On 06/22/2026 at 11:31 AM, Licensed Nurse (LN) H entered the resident's room and CNA L notified LN H the residents full catheter bag was directly on the floor. CNA L held the full catheter bag in her ungloved hand. LN H instructed CNA L to sanitize the catheter collection bag. CNA L sanitized her hands, applied gloves retrieved a collection cylinder and emptied the urine from the resident's catheter bag without wearing a gown. On 06/22/2026 at 11:52 AM, R13 sat in the wheelchair (w/c) going through his dresser drawers. R13 had clean and intact dressings on bilateral legs from mid shin to ankles. His right leg had an uncovered, open lesion, with bright red blood and raised skin above the dressing. He reported prior to coming to the facility his legs blistered and broke open. He further stated he scratched the areas. R13 stated he had fluid retention in his legs and the fluid leaked out. R13 stated the staff use gloves when performing changes on his leg and during cares. He stated staff did not wear gowns during cares. On 06/23/2026 8:08 AM, R13's dressings to lower bilateral legs were clean and intact. Certified Nurse Aide (CNA) M and CNA O entered the resident room, sanitized hands and applied gloves. Staff failed to apply an isolation gown. CNA M and CNA O confirmed prior to entering the room staff should apply PPE. CNA O and CNA M reported R 13 did not have an infection, so they did not use gowns when providing care for R13. On 06/24/2026 at 11:10 AM, CNA O and CNA Q entered the resident's room with the full body lift to transfer R13 from the w/c to his bed. Staff failed to apply a gown prior to providing direct care with the resident. When asked by the surveyor, both CNA O and CNA Q applied gowns before continuing with the transfer. CNA O noted bright red blood on his glove and asked R13 where it came from. R13 stated it was his leg. Observation revealed R13 bleeding above the dressing on his right lower leg. Staff removed and disposed of PPE and sanitized hands prior to leaving the room. On 06/24/2026 at 11:40AM, Administrative Nurse D and Licensed Nurse (LN) H entered the resident's room. LN H sanitized her hands, applied a gown and gloves and informed R13 she was going to change his leg dressing. She attempted to remove the dressing from R13's left leg manually and could not get it loosened. She reported she did not bring her scissors with her. Administrative Nurse D left the room to retrieve bandage scissors from the desk and returned to the room and handed them to LN H. LN H placed the scissors blade directly under bandage of the left lower leg in direct contact to the leg. On inquiry, LN H stated she did not sanitize the scissors prior to removing the dressing to R13's left leg. LN H stated R13 scratched his legs and these areas were new. LN H did not place a dressing over the new areas to contain the wound and prevent exposure. LN H confirmed the open areas above the left leg dressing had multiple open superficial wounds from mid- calf to his knee, with exposed wound bed and blood present. LN H failed to remove gloves, sanitize hands, and apply new gloves and failed to sanitize scissors before she removed the blood-stained dressing from the right lower leg. LN H placed the bloody dressing on the side of the bed adjacent to residents left leg. LN H obtained clean dressing supplies from the resident's dresser with the same gloved hands. LN H removed old gloves, sanitized her hands, and applied new gloves and cleansed the wounds on both legs with the same gloved hands. LN H sprinkled a white powdered substance on both lower legs and applied a non-adhesive dressing to the top of both lower legs. LN H then wrapped the legs with rolled gauze. LN H failed to sanitize hands and re-glove between the application of dressings to each lower leg. Administrative Nurse D instructed LN H that the new area should have a dressing to prevent exposure. LN H measured the right lower leg wound and applied a dressing to the wound. LN H failed to sanitize hands and change gloves prior to applying the dressing. On 06/24/2026 at 01:30 PM, Therapy Staff CC reported he provided upper body strengthening and range of motion modalities to R13 that he did not use enhanced barrier precautions to include gowns because the resident wounds were on his lower legs. On 06/24/2026 at 02:30 PM Administrative Nurse D and Consultant GG provided a resident roster indicating which residents were on Enhanced Barrier Precautions and the indication. The facility confirmed there were six current residents at EBP. Staff confirmed that during direct cares, staff must wear gowns and gloves. Review of the 01/2026 facility policy Enhanced Barrier Precautions documented Enhanced Barrier Precautions should be used when a resident has a wound that should be covered to contain and prevent increased potential for environmental contamination and risk for transmission of a pathogen. EBP includes hand sanitizing, gloves, and gown use. This should be completed prior to the entrance of the resident's room when performing transfers, working with residents in the therapy gym and participation in close physical contact.

Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry. This created the risk of impaired safety and cleanliness. Findings included: - On 06/23/2026 at 02:032 PM, laundry tour with Laundry Staff U revealed the following concerns:The soiled laundry area had an area of sheet rock that measured approximately three inches by two inches that was gouged and unable to be sanitized.The ceiling vent had peeling paint surrounding it.The floor near the sewer drains covered with metal plates had four broken floor tiles. The tiles had brown residue and debris embedded in the broken areas of the tile.The base of washing machine number one had rust that was unable to be sanitized.The base of washing machine number two had rust and missing flooring. The washing machine base had brown debris near the bottom. This area was unable to be sanitized.There were multiple broken and missing floor tiles and build-up behind washing machine number two. Interview at this time with Laundry Staff U stated the previous laundry chemical dispenser leaked and the flooring was pulled up on 03/17/2026.A wall mounted folding table had missing laminate surrounding the outer edge of the table and was unable to be sanitized. The table was used for residents' personal laundry and linens.Three wall mounted shelves used for storing clean laundry/linen with unsealed bare wood.An area of the baseboard was loose from the wall and dust, and debris was observed behind the loose board. On 06/23/2026 at 02:58 PM, Administrative Staff A and Maintenance Director V joined the tour and confirmed above findings.On 06/24/2026 at 03:26 PM, Administrative Staff A reported the facility lacked a policy to address the identified concerns with maintenance repair and sanitation of the laundry.

Based on interviews and record review, the facility failed to ensure Resident (R) 1 remained free from abuse. On 03/21/26 at around 10:30-11:00 PM Certified Nurse Aide (CNA) M identified bruising on R1's right leg and reported it to Licensed Nurse (LN) G. LN G determined the bruising was probably from the wheelchair but did not report the bruises of unknown origin to the administrator. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G instructed the CNA to apply antifungal powder or cream but did not assess the area. The resident remained in her room with her representative, the alleged perpetrator (AP), with the door closed. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding. At 08:00 AM, CNA O provided peri care to R1 and identified dried blood on R1's labia and reported to LN I. At 08:30 AM LN I assessed R1 and noted dried blood on the labia and vaginal area, and bruising to the right hip and leg. LN I notified LN H. Around 02:22 PM, LN H and LN I assessed R1 and noted a large bruise on her right hip, purple bruises to R1's outer vaginal area and upward into the vagina with bleeding and notified Administrative Nurse D of the potential abuse at 03:00 PM; Administrative Nurse D notified the Administrative Staff A, approximately 16 hours after the initial bruising of unknown origin, allowing the AP to be alone with R1 resulting in progressive injuries and signs of sexual abuse. The facility failed to ensure R1 remained free from preventable and intentional physical and sexual abuse and psychosocial trauma which placed R1 in immediate jeopardy. Findings Included:- Review of the Electronic Medical Record (EMR) documented R1 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (damage to the left hemisphere of the brain, typically resulting in right-sided body weakness and often speech/language deficits). R1's admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 required substantial to maximum assistance for eating and bathing and was dependent on staff for all other activities of daily living (ADL). She was able to communicate with clear speech. The MDS documented R1 had no signs of depression and no behaviors; she had no skin conditions. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/28/26, documented it triggered secondary to R1's orientation, memory, and recall deficits noted during BIMS interview with contributing factors including short-term and long-term memory loss. R1's Care Plan, dated 02/03/26, documented R1 liked to participate in individual and group activities and directed staff to provide R1 with an activities calendar and encourage her to participate in activities of her choice. R1's Care Plan did not address the AP's involvement in care and listed the other son as the Durable Power of Attorney (DPOA). The 02/23/26 at 12:22 PM Nurse Advanced Skilled Evaluation documented no skin issues identified. The evaluation further documented two very small bruises, one on the left outer thigh and one on the abdomen. The 02/24/26 at 12:14 PM Nurse Advanced Skilled Evaluation documented no skin issues identified. The 03/03/26 at 10:48 AM Nurse Advanced Skilled Evaluation documented no skin issues were identified. Review of all Nurse Advanced Skilled Evaluation assessments from 03/03/26 through 03/22/26 revealed no mention of bruising or vaginal bleeding. R1's 03/09/26 Licensed Nurse Weekly Skin Assessment, documented R1 had no bruises and no open lesions, cuts, lacerations, or skin tears. The Licensed Nurse Weekly Skin Assessment, dated 03/16/26, documented R1 had no bruises and no open lesions, cuts, lacerations, or skin tears. R1's EMR did not document any additional Licensed Nurse Weekly Skin Assessment until 03/22/26. LN I's Nurse's Note dated 03/22/26 at 08:30 AM documented the CNA called the nurse to R1's room. The nurse observed dried blood on R1's labia and vaginal opening that the CNA noticed while cleaning R1. The note documented R1 also had dark bruises present in that area and noted the resident's representative (AP) was concerned that R1 had some itching. LN I documented she reported the findings to R1's charge nurse [LN H]. LN H's Nurse Advanced Skilled Evaluation dated 03/22/26 at 01:52 PM, prior to the assessment performed at 02:22 PM, inaccurately documented no skin issues were identified. LN H's Late Entry Nurse's Note dated 03/22/26 at 02:22 PM documented R1 had a large bruise on her right hip, and small dark purple bruising to her outer vaginal opening and upward into the vagina, with vaginal bleeding present. Staff notified Administrative Nurse D and called Emergency Medical Services (EMS). Staff called the hospital to request a same [sic] nurse (SANE-Sexual Assault Nurse Examiner) nurse be present to examine R1 due to the type of injury. LN I's Nurse's Note dated 03/22/26 at 02:33 PM documented she went with R1's charge nurse [LN H] and observed bruising on R1 that included vaginal bruising and a very large bruise on R1's right hip. There was also a small bruise on her right outer thigh. R1 was unable to say how she got the bruises but stated she did not have any itching. LN I notified Administrative Nurse D. Administrative Nurse D's Nurse's Note: Late Entry dated 03/22/26 at 11:20 PM documented the nurse received report that R1 had vaginal bleeding and bruising. The initial assessment revealed a large bruise to R1's right hip and suspected bruising to the labia with small lacerations. The nurses completed an immediate follow-up assessment with a second licensed nurse due to concern for an injury of unknown origin. Administrative Nurse D documented she arrived at the facility within 15 minutes of receiving the report to assess the injuries and updated Administrative Staff A and the regional nurse of the report. A full head-to-toe skin assessment revealed the following findings: large ecchymosis (bruising) area noted to the right hip with surrounding smaller areas of bruising, scattered ecchymosis was present to bilateral lower extremities, bruising to lower abdomen extending from superior pubic area measuring approximately 6.5 centimeters (cm) by 4 cm, labial area with multiple dark maroon/purple areas of bruising surrounding vaginal opening with scattered petechiae (pinpoint red, purple, or brown spots caused by broken capillaries bleeding under the skin), small laceration noted to the posterior vaginal opening measuring approximately 0.2 cm, and shearing injury noted to the left labia measuring approximately 0.6 cm by 0.5 cm. The note revealed the resident had vaginal bleeding at time of the assessment. R1's Licensed Nurse Weekly Skin Assessment, dated 03/22/26, documented a 0.2-centimeter (cm) bruise to R1's posterior labia and a 0.06 cm sheering to the inner left labia. R1's EMR lacked further notes regarding the incident until 03/23/26 at 09:33 AM, a Social Services Note documented R1 was sent to the emergency room (ER) due to vaginal bruising. R1's second representative was aware of and agreeable to the transfer. The note documented the ER Transfer Form was sent to R1's second representative and a linked correction at 11:17 AM documented a correction and the form was sent to the AP. R1's Hospital Record, dated 03/22/26 at 05:45 PM documented R1 had bleeding in the vaginal area with signs of injury present, which included scattered bruises on the extremities, especially on the hips and thighs. The exam further documented there was concern for possible sexual assault. The hospital documentation also noted that R1 would have increased agitation and would yell Noooo why would a man do that when hospital staff would clean her genitalia. Throughout the hospital documentation it was noted that the hospital documents had been blocked from the patient portal due to the hospital having reasonable belief that sharing of R1's hospital record could have resulted in harm to her life or her physical safety. The facility's investigation signed by Administrative Staff A on 03/27/26 documented at around 10:10 PM on 03/21/26, CNA M and CNA N provided personal care to R1 with the AP present. The AP was R1's DPOA and primary caregiver when R1 was at home. The CNA staff noted bruising and reported it to LN G. The AP suggested the bruising could be from therapy and was unsure of its origin; there was no blood present at that time. At 04:20 AM on 03/22/26, the same CNA staff provided personal care to R1 with the AP present. There was bright red blood in R1's brief, on her labia, and around the vaginal area. The AP suggested the bleeding might be due to itching and recommended medication to prevent itching and this was reported to LN G who instructed the CNA staff to apply antifungal powder, suspecting a yeast infection. The investigation documented there was no labia bruising at that time. At 06:00 AM, LN G passed on the report of vaginal bleeding suspected to be caused from itching or a yeast infection to LN I and LN H and recommended contacting R1's provider. At 08:00 AM, CNA O provided personal care to R1 with the AP present. She noted dried blood on R1's labia and reported it to the nurses. LN I assessed R1, noted the blood, bruising on R1's hip and laceration to R1's labia, and suspected the injuries were caused by itching and with no suspicion of abuse. At 03:00 PM [sic], LN H and LN I conducted a two-nurse skin assessment. During this assessment the AP left the room, which was unusual because he typically remained present and observed care. The nurse noted a large bruise on R1's right hip and leg resembling the shape of a hand. Additional bruising and injuries were noted on the labia and vaginal areas, including maroon/purple bruising, a small laceration on the posterior vaginal opening and a circular skin abrasion resembling a shearing. The resident displayed increased anxiety during the assessment, repeatedly saying Oh God. The investigation noted R1 was unable to say what happened. The AP had been at the bedside and present during all cares over the previous 23 hours. CNA M's Notarized Witness Statement dated 03/22/26 documented on 03/21/26, he noticed some significant bruising down R1's right leg. CNA M noted he reported the bruising to the charge nurse and it was left as bruising from her wheelchair. He noted later in the shift, he noticed some bleeding from the inside of her private area and a small black circle on one side of R1's labia that he thought was clotted blood but may have been a sore. CNA M's statement documented that he immediately reported it to the nurse but that it was not viewed by a nurse until the next shift came on. He documented that he reported the bruising to the nurse at around 10:30 -11:00 PM and the bleeding from the vagina at 04:20 AM. CNA T's Notarized Witness Statement, dated 03/22/26, documented she was in the room with CNA M on 03/20/26 as he provided cares to R1. She noted that she heard CNA M report bruising on R1 to the charge nurse and that the AP was present in the room as care was provided. LN G's Notarized Witness Statement dated 03/22/26, documented that CNA M informed her that it looked like R1 had been scratching at her vaginal area and blood on her brief. She documented that the AP had told her earlier in the shift that R1 had been scratching around the abdominal and thigh folds. LN G noted that CNA M showed her some antifungal powder, and she instructed the CNA to apply antifungal cream to R1's labia. She also noted that earlier in the shift, CNA M had informed her that R1 had bruising down the side of her right hip and leg. The bruises were small and linear and appeared old, and the AP had said he thought they happened in therapy. It appeared to be in a line from where R1 would sit down in the wheelchair and didn't get centered. CNA O's Notarized Witness Statement, dated 03/22/26, documented that on 03/22/26 around 08:00 AM she and CNA P performed cares on R1 and noticed dried blood all over R1's vaginal area and she had CNA P remain with R1 while she notified the nurse. CNA O also documented the AP remained in the room with R1 the entire time. CNA O also documented that for the rest of the day the AP remained with R1 and acted jittery, nervous and anxious. CNA O further documented she escorted and remained with R1 when she transported to the hospital and while at the hospital R1 asked her why she let that man do that (to R1). It was not documented if this statement was reported. CNA P's Notarized Witness Statement, dated 03/22/26, documented that while she performed cares on R1 on that day (03/22/26), R1 grabbed her hand and stated Son, why would you do this to me? The statement did not document if this was reported. CNA R's Notarized Witness Statement dated 03/22/26, documented that the AP frantically left the building on 03/22/26 after injuries were noticed on R1. LN H's Notarized Witness Statement, dated 03/22/26, documented that she had been called into R1's room at 02:45 PM (on 03/22/26) due to bruising on R1's right hip, right leg, posterior-outer labia, and there was small sheering to R1's left inner labia; staff notified Administrative Nurse D. LN I's Notarized Witness Statement, dated 03/23/26, documented she was called to R1's room (on 03/22/23) by CNA O to observe blood on R1's peri-area and upon assessment she found dried blood on R1's labia and vaginal opening. LN I noted that she then reported this to LN H (R1's nurse), and that the AP was present during the assessment. LN I also documented that she assessed R1 with LN H later that afternoon and discovered dark bruised areas that were visible on R1's labia and into her vagina and there was bruising to the right hip and leg and bruising visible on the lower abdomen and what appeared to be a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). LN I also documented that the AP would not make eye contact at that time and left the room for that assessment; she notified Administrative Nurse D. CNA Q's Notarized Witness Statement, dated 03/24/26, documented that when she performed cares and changed R1's wet brief the AP remained in the room and watched her actions closely. CNA Q's facility Witness Statement Form dated 03/24/26 documented that R1's room door was closed most of the time during 06:00 AM - 05:00 PM, 03/21/26 or 03/22/26, and the AP was in R1's room during that time. LN H's facility Witness Statement Form dated 03/24/26, documented that it was noticed the AP was alone in the room with R1 and he would remain in the room during cares and assessments. CNA R's facility Witness Statement Form dated 03/24/26, documented the AP would remain in R1's room all the time unless he had to go home to do laundry or let animals out. She further documented the AP left frantically after R1's injuries were noticed. CNA S's facility Witness Statement Form, dated 03/25/26, documented that when her and another CNA were getting R1 up for the day and providing peri-care, R1 told them not to touch her and when trying to change her shirt R1 said, Stop that son. CNA O's facility Witness Statement Form dated 03/25/26, documented that the AP remained in the room when cares were provided at 08:00 AM and remained in the room with R1 with the door closed after cares were completed at 08:30 AM. CNA O further documented the AP remained alone in the room, with the door closed, as cares were completed at 11:30 AM and remained in the room during the cares. LN G's facility Witness Statement Form dated 03/25/26, documented that during her shift she took R1's vitals and performed her skilled assessment and that it did not take very long. LN G also documented the AP would spend the night with R1 and he kept the door shut. CNA M's facility Witness Statement Form dated 03/26/26, documented that the AP usually stayed in the room when care was provided to R1 and the AP would stay in R1's room all night with the door closed. On 03/30/26 at 09:40 AM, Administrative Staff A stated the incident occurred on the night of 03/22/26 [sic] and R1 was sent to the hospital in [NAME], MO and the hospital refused to perform the SANE examination because they did not get consent from R1's legal representative because he had left. R1 was then released and sent back to the facility and Administrative Staff A took R1 to the hospital in Pittsburg, KS and they informed her that they did not have a qualified SANE nurse to perform the proper examination. Administrative Staff A returned to the facility and coordinated with local Law Enforcement (LE) and she then took R1 to the county Health Department, along with local LE, and the health department performed the SANE examination. She said that staff had not reported concerns about the DPOA prior to this incident. On 03/30/26 at 09:50 AM, Law Enforcement Officer (LEO) KK said he had spoken with the hospital nurses, including the SANE nurse, and they told him R1's wounds were some of the worst wounds they had assessed. LEO KK also said that since LE was notified of R1's assault allegations, LE had not been able to contact the AP, the AP had not answered any phone calls, and the AP had not answered the door when LE went to his residence. LEO KK further said that LE had to obtain a warrant for the SANE exam to be completed because the AP had been listed as R1's legal representative and the hospital was not able to obtain authorization before the AP had left the hospital the evening of 03/22/26. On 03/30/26 at 10:12 AM, Administrative Staff A stated that she was notified of the incident at 03:25 PM on 03/22/26. She also said the AP never did anything suspicious, but she did have an odd vibe regarding him. She also said there had never been any complaints about the AP with this visit or previous visits. Administrative Staff A reported that every time the AP stayed, which was 24 hours a day, seven days a week, the door would remain closed, and this happened with this stay and the previous two stays; he would only leave for 30 minutes to an hour and would return. On 03/30/26 at 10:20 AM, Administrative Nurse D stated she was notified by staff around 03:00 PM on 03/22/26 of suspected abuse with R1 and she proceeded to go to the facility and notified Administrative Staff A around 03:25 PM while she was driving to the facility; she further said that she should have been notified much sooner about the injuries to R1. She reported that the AP would always be sitting directly next to R1 and always would be holding her hand, and the room door was always closed, and he stayed 24/7 and anytime he would leave it would only be an hour at the most and when he returned, he would quickly walk through the halls back to R1's room. She also said that the AP would act fidgety and nervous anytime staff would interact with him or when cares were performed, and he would stand next to staff or at the end of R1's bed when cares were performed and that staff had reported that he would often interrupt and take over cares which included incontinent cares. She said that staff reported to her that they felt awkward performing cares on R1 while the AP was present. When Administrative Nurse D arrived on the evening of the allegations the AP was present and acted more nervous than usual. Administrative Nurse A also reported that R1 would act more relaxed and comfortable whenever the AP was not present and when the AP was around, she was quiet and would not participate in activities, the AP would keep her isolated. On 03/30/26 at 10:37 AM, CNA O stated that she and another CNA (CNA P) performed peri care on R1 around 08:00 AM on 03/22/26 and there were small cuts/lacerations around R1 vaginal area but did not notice bruising because she kept R1 covered for dignity and warmth. She said that the AP was present in the room and was standing at the foot of the bed watching the cares be performed. CNA O then informed the other CNA to remain with R1 and she then immediately notified the charge nurse (LN I) and LN I immediately arrived and examined R1 and told the CNAs that it was reported the night before that there was vaginal bleeding. CNA O also stated that there were several times that she felt awkward and uncomfortable with the AP, and he would get upset and refuse to leave when asked. CNA O had reported her discomfort and concerns to the charge nurse more than once and the response she received was that they did not take it seriously and nothing was done. She also reported that the AP stayed in R1's room [ROOM NUMBER]/7 and the door was always closed, when staff would leave the door open or cracked, the AP would close it. On 03/30/26 at 10:55 AM, CNA P stated that she assisted CNA O with performing peri cares on R1 around 08:00 AM on 03/22/26 and when doing so they noticed blood in the vaginal area of R1 and they reported it to the nurse and found out that night shift had reported it to the nurse, they also noticed wounds in the vaginal area. CNA P also said that the AP was in the room and at the end of the bed watching and would always be present during cares. She also stated that she felt unsettled when performing cares on R1 and the AP being present. CNA P also said that she had reported her concerns with the AP to the charge nurse previously and was told to honor the AP's wishes of being present and let it be. On 03/30/26 at 11:55 AM, LN I stated that she was the nurse on the south hall on 03/22/26 and she was notified by CNA O around 08:00AM that R1 needed to be seen by a nurse. She said that she went to R1's room and saw that R1 had blood and dried blood around her vaginal area along with vaginal bruising, LN I then found LN H, the nurse for that hall, and reported to her that R1 had bleeding and bruising around the vaginal area and informed her that further assessment was needed after the CNAs had finished with cares and cleaned her. LN I then stated that after 02:00 PM she and LN H assessed R1 and discovered extensive bruising on her thighs and abdominal area and the vaginal bruising was darkened. LN I also said that the AP was always present, even during intimate cares, and would not make eye contact at that time. LN I then notified Administrative Nurse D of the situation. On 03/30/26 at 12:25 PM, LEO JJ stated that she arrived at the emergency department (ED) in [NAME], MO and the AP had already left. She said she was unable to contact R1's other son and was informed by the hospital nurse that the AP had acted frantic and was yelling in the lobby before he left. On 03/30/26 at 01:35 PM, LEO II stated that he responded to the initial call and then passed the case onto the county detectives due to the nature of allegations. He took initial photographs of the resident room and collected all items that were on the bed as evidence. On 03/30/26 at 01:39 PM, Consultant GG stated that she had performed the SANE examination on R1 at the [NAME] County Health Department on 03/24/26 and during the examination she had collected labs samples, taken photographs and all evidence that was collected had been sealed and provided to the Cherokee County Sheriff's Department. Consultant GG then said it could be six months before final labs results would be provided. On 03/31/26 at 08:06 AM, LN G stated that prior to returning a call to the State Agency for interview she had spoken to Administrative Staff A and Consultant HH regarding the survey investigation, she then said that CNA M informed her that R1 had bruising that went down her right leg but did not recall the time. LN G said that she looked at the bruising and the AP was in the room with R1, the bruise appeared to be linear and old. LN G also reported that she looked at the bruise with the AP and he told her that it was from therapy, and she said that she believed it was from the wheelchair and said that she reviewed the EMR and said that the bruise was noted on 03/02/26. She also said that R1 would sit down hard and felt that that was the root cause of the bruising. LN G also stated that earlier in her shift the AP had told her that R1 had scratched her vaginal area and had a yeast infection, LN G had then provided CNA M antifungal cream and instructed him to clean R1 and apply the cream to the area but she did not asses this and she did not recall anything being reported to her about any injuries or bleeding when she received her shift report. LN G confirmed she had not suspected abuse so had not reported the bruising or vaginal bleeding to anyone except the oncoming shift. On 03/31/26 at 12:55 PM, LN H stated she took R1's vital signs the morning of 03/22/26 but had not assessed her because she was busy with other residents and did not remember anything about wounds reported during shift report that morning. LN H also said she was called into R1's room around 02:30 PM in the afternoon on 03/22/26. On 04/01/26 at 02:07 PM, email correspondence received from Consultant HH contained a Late Entry Nurse's Note with an effective date of 03/21/26 and time of 11:15 PM. The note documented it was entered on 03/30/26 at 06:43 PM by LN G, after the surveyor completed interviews with Administrative Staff A and Administrative staff D and other staff. The Late Entry Nurse's Note documented the CNA had notified the nurse that R1 had bruising that ran down the right side of her leg. When the nurse went to R1's room the AP was at the bedside, and both appeared relaxed and were watching television. The nurse observed a row of small, old purplish, fading bruises that ran down the back side of her right-lower-extremity and started from the upper thigh/hip region. The nurse asked the son if he knew what happened and he told her he thought it could have been from something done in therapy. They also talked about how R1 tended to lean towards the right and did not completely get centered in the wheelchair during her transfer. It appeared as if R1 had attempted to sit down in the wheelchair and bumped the arm rest of the wheelchair due to linear appearance. R1 took blood thinning medications Plavix (a medication used to prevent blood from clotting) and aspirin (a medication used to thin blood) which can cause bruising more easily. The AP reported to the nurse that R1 had been scratching herself around the peri area. Later in the shift the CNA told the nurse that while performing peri care it had appeared that she had been scratching around her vaginal area due to redness and scant amounts of blood on the brief. The nurse reported the findings to the oncoming day shift so they could attempt to notify the on-call or on the list to be seen during the Monday morning rounds. The facility policy Abuse, Neglect and Exploitation, dated 2025, documented the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The policy further documented that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives. On 03/30/26 at 04:00 PM, Administrative Staff A and Consultant HH received a copy of the Immediate Jeopardy [IJ] Template and was informed the facility's failure to provide R1 an environment free from abuse on 03/22/26, placed R1 in IJ. The facility identified and implemented the following corrective actions, completed on 03/24/26 and verified by record review and interviews during the onsite survey, that included re-education for abuse, neglect and exploitation (ANE) for all facility staff. Additionally, a protection plan was implemented for R1 that included all cares were performed with two staff, the room door was to remain open unless private cares were provided. Also included in the protection plan, if the AP entered the facility, then law enforcement (LE) was to be notified immediately, and a staff member was to go to R1's room and remain with her until LE arrived. The facility also implemented a sign-in sheet for all visitors to the facility and included a specific visitor log for R1. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J (isolated, immediate jeopardy) scope and severity based on reasonable person concept.

Based on record reviews and interviews, the facility failed to ensure staff identified Resident (R) 1's signs of physical and sexual abuse, and report to the Administrator immediately and the appropriate state entities within the required time. On 03/21/22 at around 10:30-11:00 PM Certified (CNA) M and CNA N identified bruising on R1's right leg and reported it to Licensed Nurse (LN) G. LN G spoke to the resident's representative, the alleged perpetrator (AP), who offered a rationale for the injury which LN G accepted without investigation. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G instructed the CNA to apply topical cream but failed to assess the area. LN G did not document the bruising, the conversation with the AP or the change in condition of R1's vaginal area and failed to report bruising or vaginal bleeding to Administrative Staff A. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding and bruising. Neither LN H or LN I identified the injuries and vaginal changes as potential sexual abuse and reported to Administrative Staff A, Law Enforcement (LE) or the State Survey Agency (SA). At 08:00 AM, CNA O provided peri care to R1 with the AP present and identified dried blood on R1's labia and reported to LN I. At 08:30 AM LN I visualized R1's peri-area, confirmed the dried blood and bruising on R1's labia and vaginal area and reported it to LN I but did not report to Administrative Staff A, LE, or SA. Around 02:22 PM, six hours later, LN H accompanied LN I to R1's room and assessed R1. They noted a large bruise on R1's right hip, purple bruises to R1's outer vaginal area and upward into the vagina with active bleeding. LN I and LN H then notified Administrative Nurse D of the potential sexual abuse at 03:00 PM and Administrative Nurse D notified Administrative Staff A at 03:25 PM. During the delay in reporting, after identification of injuries of unknown origin and signs of physical and sexual abuse yielding serious bodily injury, R1 remained in the room alone with the AP.Findings Included:- The facility's investigation for the incident dated 03/22/26 and signed by Administrative Staff A on 03/27/26 documented at around 10:10 PM on 03/21/26, CNA M and CNA N provided personal care to R1 with the AP present. The AP was R1's Durable Power of Attorney (DPOA) and primary caregiver when R1 was at home. The CNA staff noted bruising and reported it to LN G. The AP suggested the bruising could be from therapy and was unsure of its origin; there was no blood present at that time. At 04:20 AM on 03/22/26, the same CNA staff provided personal care to R1 with the AP present. There was bright red blood in R1's brief, on her labia and around the vaginal area. The AP suggested the bleeding might be due to itching and recommended medication to prevent itching; this was reported to LN G who instructed the CNA staff to apply antifungal powder, suspecting a yeast infection. The investigation documented that there was no labia bruising at that time. At 06:00 AM, LN G passed on the report of vaginal bleeding suspected to be caused from itching or a yeast infection to LN I and LN H and recommended contacting R1's provider. At 08:00 AM, CNA O provided personal care to R1 with the AP present. She noted dried blood on R1's labia and reported it to the nurses. LN I assessed R1, noted the blood, bruising on R1's hip and laceration to R1's labia, and suspected the injuries were caused by itching and with no suspicion of abuse. At 03:00 PM [sic], LN H and LN I conducted a two-nurse skin assessment. During this assessment the AP left the room, which was unusual because he typically remained present and observed care. The nurse noted a large bruise on R1's right hip and leg resembling the shape of a hand. Additional bruising and injuries were noted on the labia and vaginal areas, including maroon/purple bruising, a small laceration on the posterior vaginal opening and a circular skin abrasion resembling a shearing. The resident displayed increased anxiety during the assessment, repeatedly saying Oh God. The investigation noted R1 was unable to say what happened. The AP had been at the bedside and present during all cares over the previous 23 hours. The investigation documented the facility notified local LE but did not indicate the time though LE arrived at the facility at 05:25 PM per the investigation.Review of the email communication sent to the SA from the facility with the initial reporting of an injury of unknown origin was time stamped 03/22/26 at 07:29 PM, almost 20 hours after the initial injury of unknown origin was identified and four hours after Administrative Staff A learned of the physical and sexual abuse.LN I's Nurse's Note dated 03/22/26 at 08:30 AM documented that the nurse was called to R1's room by the CNA. The nurse observed dried blood on R1 labia and vaginal opening that the CNA noticed while cleaning R1. The note documented R1 also had dark bruises present in that area and noted the resident's representative (AP) was concerned that R1 had some itching. LN I documented she reported the findings to R1's charge nurse [LN H].LN H's Late Entry Nurse's Note dated 03/22/26 at 02:22 PM documented R1 had a large bruise on right hip, and small dark purple bruising to her outer vaginal opening and upward into the vagina with vaginal bleeding present. Staff notified Administrative Nurse D and called Emergency Medical Services (EMS). Staff called the hospital to request a same [sic] nurse (SANE-Sexual Assault Nurse Examiner) nurse be present to examine R1 due to the type of injury.LN I's Nurse's Note dated 03/22/26 at 02:33 PM documented she went with R1's charge nurse [LN H] and observed bruising on R1 that included vaginal bruising and a very large bruise on R1's right hip. There was also a small bruise on the right outer thigh. R1 was unable to say how she got the bruises but stated she did not have any itching. LN I notified Administrative Nurse D.Administrative Nurse D's Nurse's Note: Late Entry dated 03/22/26 at 11:20 PM documented the nurse received report that R1 had vaginal bleeding and bruising. The initial assessment revealed a large bruise to R1's right hip and suspected bruising to the labia with small lacerations. The nurses completed an immediate follow-up assessment with a second licensed nurse due/ to concern for an injury of unknown origin. Administrative Nurse D documented she arrived at the facility within 15 minutes of receiving the report to assess the injuries and updated Administrative Staff A and the regional nurse of the report. A full head-to-toe skin assessment revealed the following findings: large ecchymosis (bruising) area noted to the right hip with surrounding smaller areas of bruising, scattered ecchymosis was present to bilateral lower extremities, bruising to lower abdomen extending from superior pubic area measuring approximately 6.5 centimeters (cm) by 4 cm, labial area with multiple dark maroon/purple areas of bruising surrounding vaginal opening with scattered petechiae (pinpoint red, purple, or brown spots caused by broken capillaries bleeding under the skin), small laceration noted to the posterior vaginal opening measuring approximately 0.2 cm, and shearing injury noted to the left labia measuring approximately 0.6 cm by 0.5 cm. Resident noted with vaginal bleeding at time of assessment.CNA M's Notarized Witness Statement dated 03/22/26 documented on 03/21/26, he noticed some significant bruising down R1's right leg. CNA M noted he reported the bruising to the charge nurse and it was left as bruising from her wheelchair. He noted that later in the shift, he noticed some bleeding from the inside of her private area and a small black circle on one side of R1's labia that he thought was clotted blood but may have been a sore. CNA M's statement documented that he immediately reported it to the nurse, but it was not viewed by a nurse until the next shift came on. He documented that he reported the bruising to the nurse at around 10:30 -11:00 PM and the bleeding from the vagina at 04:20 AM.CNA T's Notarized Witness Statement, dated 03/22/26, documented she was in the room with CNA M on 03/20/26 as he provided cares to R1. She noted she heard CNA M report bruising on R1 to the charge nurse and the AP was present in the room as care was provided.LN G's Notarized Witness Statement dated 03/22/26, documented that CNA M informed her that it looked like R1 had been scratching at her vaginal area and had blood on her brief. She documented the AP told her earlier in the shift that R1 had been scratching around the abdominal and thigh folds. LN G noted that CNA M showed her some antifungal powder, and she instructed the CNA to apply antifungal cream to R1's labia. She also noted that earlier in the shift, CNA M had informed her that R1 had bruising down the side of her right hip and leg. The bruises were small and linear and appeared old, and the AP had said he thought they happened in therapy. It appeared to be in a line from where R1 would sit down in the wheelchair and didn't get centered.CNA O's Notarized Witness Statement, dated 03/22/26, documented on 03/22/26 around 08:00 AM she and CNA P performed cares on R1 and noticed dried blood all over R1's vaginal area and she had CNA P remain with R1 while she notified the nurse. CNA O also documented the AP remained in the room with R1 the entire time. CNA O also documented that for the rest of the day the AP remained with R1 and acted jittery, nervous and anxious. CNA O further documented that she escorted and remained with R1 when she was transported to the hospital and while at the hospital R1 asked her why I let that man do that? It was not documented if this statement was reported.CNA P's Notarized Witness Statement, dated 03/22/26, documented that while she performed cares on R1, R1 grabbed her hand and stated Son, why would you do this to me? The statement did not document if this was reported.CNA R's Notarized Witness Statement dated 03/22/26, documented that the AP frantically left the building on 03/22/26 after injuries were noticed on R1.LN H's Notarized Witness Statement, dated 03/22/26, documented that she was called into R1's room at 02:45 PM due to bruising on R1's right hip, right leg, posterior-outer labia and there was small sheering to R1's left inner labia and staff notified Administrative Nurse D.LN I's Notarized Witness Statement, dated 03/23/26, documented that she was called to R1's room by CNA O to observe blood on R1's peri-area and upon assessment she found dried blood on R1's labia and vaginal opening. LN I noted that she then reported this to LN H (R1's nurse), and the AP was present during the assessment. LN I also documented that she assessed R1 with LN H later that afternoon and discovered dark bruised areas that were visible on R1's labia and into her vagina and there was bruising to the right hip and leg and bruising visible on the lower abdomen and what appeared to be a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). LN I also documented the AP would not make eye contact at that time and left the room for that assessment and she notified Administrative Nurse D.On 03/30/26 at 09:40 AM, Administrative Staff A stated that the incident occurred on the night of 03/22/26 [sic] and R1 was sent to the hospital in [NAME], MO and the hospital refused to perform the SANE examination because they did not get consent from R1's legal representative because he had left. R1 was then released and sent back to the facility and Administrative Staff A then took R1 to the hospital in Pittsburg, KS and they informed her that they did not have a qualified SANE nurse to perform the proper examination. Administrative Staff A returned to the facility and coordinated with local LE, and she then took R1 to the county Health Department, along with local LE, and the health department performed the SANE examination. She said that staff had not reported concerns about the DPOA prior to this incident.On 03/30/26 at 10:12 AM, Administrative Staff A stated that she was notified of the incident at 03:25 PM on 03/22/26. She also said that the AP never did anything suspicious, but she did have an odd vibe regarding him. She also said that there had never been any complaints about the AP with this visit or previous visits. On 03/30/26 at 10:20 AM, Administrative Nurse D stated that she was notified by staff around 03:00 PM on 03/22/26 of suspected abuse with R1 and she proceeded to go to the facility and notified Administrative Staff A around 03:25 PM while she was driving to the facility; she further said that she should have been notified much sooner about the injuries to R1. On 03/30/26 at 10:37 AM, CNA O stated that she and another CNA (CNA P) performed peri care on R1 around 08:00 AM on 03/22/26 and there were small cuts/lacerations around R1 vaginal area but did not notice bruising because she kept R1 covered for dignity and warmth. She said the AP was present in the room and was standing at the foot of the bed watching the cares be performed. CNA O then informed the other CNA to remain with R1 and she then immediately notified the charge nurse (LN I) and LN I immediately arrived and examined R1 and told the CNAs that it was reported the night before that there was vaginal bleeding. CNA O also stated there were several times she felt awkward and uncomfortable with the AP and he would get upset and refuse to leave when asked. CNA O reported her discomfort and concerns to the charge nurse more than once and the response she received was that they did not take it seriously and nothing was done. She also reported that the AP stayed in R1's room [ROOM NUMBER]/7 and the door was always closed, when staff would leave the door open or cracked, the AP would close it.On 03/30/26 at 10:55 AM, CNA P stated that she assisted CNA O with performing peri cares on R1 around 08:00 AM on 03/22/26 and when doing so they noticed blood in the vaginal area of R1 and they reported it to the nurse and found out that night shift had reported it to the nurse, they also noticed wounds in the vaginal area. CNA P also said the AP was in the room and at the end of the bed watching and would always be present during cares. She also stated that she felt unsettled when performing cares on R1 and the AP was present. CNA P also said she reported her concerns with the AP to the charge nurse previously and was told to honor the AP's wishes of being present and let it be.On 03/30/26 at 11:55 AM, LN I stated she was the nurse on the south hall on 03/22/26 and she was notified by CNA O around 08:00AM that R1 needed to be seen by a nurse. She said she went to R1's room and saw that R1 had blood and dried blood around her vaginal area along with vaginal bruising, LN I then found LN H, the nurse for that hall, and reported to her that R1 had bleeding and bruising around the vaginal area and informed her that further assessment was needed after the CNAs had finished with cares and cleaned her. LN I then stated that after 02:00 PM she and LN H assessed R1 and discovered extensive bruising on her thighs and abdominal area and the vaginal bruising was darkened. LN I also said that the AP was always present, even during intimate cares, and would not make eye contact at that time. LN I then notified Administrative Nurse D of the situation.On 03/31/26 at 08:06 AM, LN G stated that prior to returning a call to the state agency for interview she had spoken to Administrative Staff A and Consultant HH regarding the survey investigation, she then said that CNA M informed her that R1 had bruising that went down her right leg but did not recall the time. LN G said she looked at the bruising and the AP was in the room with R1, the bruise appeared to be linear and old. LN G also reported that she looked at the bruise with the AP and he told her that it was from therapy, and she said that she believed it was from the wheelchair and said that she reviewed the EMR and said that the bruise was noted on 03/02/26. She also said that R1 would sit down hard and felt that that was the root cause of the bruising. LN G also stated that earlier in her shift the AP had told her that R1 had scratched her vaginal area and had a yeast infection, LN g had then provided CNA M antifungal cream and instructed him to clean R1 and apply the cream to the area but she did not asses this and she did not recall anything being reported to her about any injuries or bleeding when she received her shift report.On 03/31/26 at 12:55 PM, LN H stated she took R1's vital signs the morning of 03/22/26 but had not assessed her because she was busy with another resident. She did not remember anything about wounds being reported during shift report that morning.The facility policy Abuse, Neglect and Exploitation, dated 2025, documented that the the facility would have reporting procedures for all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. The policy further documented that the facility would report immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.By 03/24/26, prior to the onsite survey, the facility completed all corrective actions which included reeducation and training of staff regarding recognizing signs or potential abuse, and reporting signs of potential abuse to the facility Administrator immediately, and LE and SA within the required timeframes. The deficient practice was deemed past noncompliance and existed at G (isolated, actual harm).

The facility failed to implement protective measures after injuries of unknown origin and signs of potential sexual abuse were identified to prevent further abuse. On 03/21/22 at around 10:30-11:00 PM Certified (CNA) M and CNA N identified significant bruising on R1's right leg and reported it to Licensed Nurse (LN) G. R1 was unable to state how she obtained the injuries. LN G spoke to the resident's representative, the alleged perpetrator (AP), who confirmed he did not know where the bruising came from but offered a rationale for the injury which LN G accepted without further investigation. Staff left R1 in the room with the AP. Around 04:20 AM on 03/22/26, CNA M reported to LN G that R1 had vaginal bleeding. LN G did not assess R1 but instructed the CNA to apply an antifungal to R1's peri area. After the care was completed, staff left R1 alone in the room with the AP, with the door closed. At 06:00 AM, LN G told LN H and LN I that R1 had some vaginal bleeding, but the nurses did not assess the situation at that time. At 08:00 AM, CNA O provided peri care to R1 with the AP present, identified dried blood all over R1's vaginal area and reported it to LN I. At 08:30 AM LN I assessed R1, confirmed the dried blood and bruise on R1's labia and vaginal area. LN I left R1 in the room with the AP and reported her findings to LN I. Around 02:22 PM, LN H accompanied LN I to R1's room and assessed R1. They noted a large bruise on R1's right hip, purple bruises to R1's outer vaginal area and upward into the vagina with active bleeding. Staff notified Administrative Nurse D of the potential abuse at 03:00 PM; Administrative Nurse D notified Administrative Staff A at 03:25 PM. R1 remained in the room alone with the AP during those 16 hours.Findings Included: - Review of the Electronic Medical Record (EMR) documented R1 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (damage to the left hemisphere of the brain, typically resulting in right-sided body weakness and often speech/language deficits). R1's admission Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 required substantial to maximum assistance for eating and bathing and was dependent on staff for all other activities of daily living (ADL). She was able to communicate with clear speech. The MDS documented R1 had no signs of depression and no behaviors; she had no skin conditions. The Cognitive Loss/Dementia CAA, dated 01/28/26, documented it triggered secondary to R1's orientation, memory, and recall deficits noted during BIMS interview with contributing factors including short term/and long-term memory loss. R1's Care Plan, dated 02/03/26, documented that R1 liked to participate in individual and group activities and directed staff to provide R1 with an activities calendar and encourage her to participate in activities of her choice. R1's Care Plan did not address the AP's involvement in care and listed the other son as the Durable Power of Attorney (DPOA). R1's EMR lacked documentation regarding the bruising to R1's right hip and/or thigh, as reported to LN G by CNA O on 03/21/26. LN I's Nurse's Note dated 03/22/26 at 08:30 AM documented the nurse was called to R1's room by the CNA. The nurse observed dried blood on R1's labia and vaginal opening. The note documented R1 also had dark bruises present in that area and noted the resident's representative (AP) was concerned that R1 had some itching. LN I documented she reported the findings to R1's charge nurse [LN H]. LN H's Late Entry Nurse's Note dated 03/22/26 at 02:22 PM documented R1 had a large bruise on right hip, and small dark purple bruising to her outer vaginal opening and upward into the vagina with vaginal bleeding present. Staff notified Administrative Nurse D and called Emergency Medical Services (EMS). Staff called the hospital to request a same [sic] nurse (SANE-Sexual Assault Nurse Examiner) nurse be present to examine R1 due to the type of injury. LN I's Nurse's Note dated 03/22/26 at 02:33 PM documented she went with R1's charge nurse [LN H] and observed bruising on R1 that included vaginal bruising and a very large bruise on R1's right hip. There was also a small bruise on the right outer thigh. R1 was unable to say how she got the bruises but stated she did not have any itching. LN I notified Administrative Nurse D. Administrative Nurse D's Nurse's Note: Late Entry dated 03/22/26 at 11:20 PM documented the nurse received report that R1 had vaginal bleeding and bruising. The initial assessment revealed a large bruise to R1's right hip and suspected bruising to the labia with small lacerations. The nurses completed an immediate follow-up assessment with a second licensed nurse due to concern for an injury of unknown origin. Administrative Nurse D documented she arrived at the facility within 15 minutes of receiving the report to assess the injuries and updated Administrative Staff A and the regional nurse of the report. A full head-to-toe skin assessment revealed the following findings: large ecchymosis (bruising) area noted to the right hip with surrounding smaller areas of bruising, scattered ecchymosis was present to bilateral lower extremities, bruising to lower abdomen extending from superior pubic area measuring approximately 6.5 centimeters (cm) x 4 cm, labial area with multiple dark maroon/purple areas of bruising surrounding vaginal opening with scattered petechiae (pinpoint red, purple, or brown spots caused by broken capillaries bleeding under the skin), small laceration noted to the posterior vaginal opening measuring approximately 0.2 cm, and shearing injury noted to the left labia measuring approximately 0.6 cm x 0.5 cm. Resident noted with vaginal bleeding at time of assessment. R1's EMR lacked further notes regarding the incident until 03/23/26 at 09:33 AM, a Social Services Note documented R1 was sent to the emergency room (ER) due to vaginal bruising. R1's second representative was aware of and agreeable to the transfer. The note documented the ER Transfer Form was sent to R1's second representative and a linked correction at 11:17 AM documented a correction and the form was sent to the AP. The facility's investigation signed by Administrative Staff A on 03/27/26 documented at around 10:10 PM on 03/21/26, CNA M and CNA N provided personal care to R1 with the AP present. The AP was R1's Durable Power of Attorney (DPOA) and primary caregiver when R1 was at home. The CNA staff noted bruising and reported it to LN G. The AP suggested the bruising could be from therapy and was unsure of its origin; there was no blood present at that time. At 04:20 AM on 03/22/26, the same CNA staff provided personal care to R1 with the AP present. There was bright red blood in R1's brief, on her labia and around the vaginal area. The AP suggested the bleeding might be due to itching and recommended medication to prevent itching; this was reported to LN G who instructed the CNA staff to apply antifungal powder, suspecting a yeast infection. The investigation documented that there was no labia bruising at that time. At 06:00 AM, LN G passed on the report of vaginal bleeding suspected to be caused from itching or a yeast infection to LN I and LN H and recommended contacting R1's provider. At 08:00 AM, CNA O provided personal care to R1 with the AP present. She noted dried blood on R1's labia and reported it to the nurses. LN I assessed R1, noted the blood, bruising on R1's hip and laceration to R1's labia, and suspected the injuries were caused by itching and with no suspicion of abuse. At 03:00 PM [sic], LN H and LN I conducted a two-nurse skin assessment. During this assessment the AP left the room, which was unusual because he typically remined present and observed care. The nurse noted a large bruise on R1's right hip and leg resembling the shape of a hand. Additional bruising and injuries were noted on the labia and vaginal areas, including maroon/purple bruising, a small laceration on the posterior vaginal opening and a circular skin abrasion resembling a shearing. The resident displayed increased anxiety during the assessment, repeatedly saying Oh God. The investigation noted R1 was unable to say what happened. The AP had been at the bedside and present during all cares over the previous 23 hours. CNA M's Notarized Witness Statement dated 03/22/26 documented on 03/21/26, he noticed some significant bruising down R1's right leg. CNA M noted he reported the bruising to the charge nurse and it was left as bruising from her wheelchair. He noted that later in the shift, he noticed some bleeding from the inside of her private area and a small black circle on one side of R1's labia that he thought was clotted blood but may have been a sore. CNA M's statement documented that he immediately reported it to the nurse but that it was not viewed by a nurse until the next shift came on. He documented that he reported the bruising to the nurse at around 10:30 -11:00 PM and the bleeding from the vagina at 04:20 AM. LN G's Notarized Witness Statement dated 03/22/26, documented that CNA M had informed her that it looked like R1 had been scratching at her vaginal area and blood on her brief. She documented that the AP told her earlier in the shift R1 had been scratching around the abdominal and thigh folds. LN G noted that CNA M showed her some antifungal powder, and she instructed the CNA to apply antifungal cream to R1's labia. She also noted that earlier in the shift, CNA M had informed her that R1 had bruising down the side of her right hip and leg. The bruises were small and linear and appeared old, and the AP had said he thought they happened in therapy. It appeared to be in a line from where R1 would sit down in the wheelchair and didn't get centered. CNA O's Notarized Witness Statement, dated 03/22/26, documented that on 03/22/26 around 08:00 AM she and CNA P performed cares on R1 and noticed dried blood all over R1's vaginal area and she had CNA P remain with R1 while she notified the nurse. CNA O also documented that the AP remained in the room with R1 the entire time. CNA O also documented for the rest of the day the AP remained with R1 and acted jittery, nervous and anxious. CNA O further documented that she escorted and remained with R1 when she was transported to the hospital and while at the hospital R1 asked her why I let that man do that? It was not documented if this statement was reported. CNA P's Notarized Witness Statement, dated 03/22/26, documented that while she performed cares on R1, R1 grabbed her hand and stated Son, why would you do this to me? The statement did not document if this was reported. LN H's Notarized Witness Statement, dated 03/22/26, documented that she had been called into R1's room at 02:45 PM due to bruising on R1's right hip, right leg, posterior-outer labia and there was small sheering to R1's left inner labia; staff notified Administrative Nurse D. LN I's Notarized Witness Statement, dated 03/23/26, documented that she was called to R1's room by CNA O to observe blood on R1's peri-area and upon assessment she found dried blood on R1's labia and vaginal opening. LN I noted that she then reported this to LN H (R1's nurse), and that the AP was present during the assessment. LN I also documented that she assessed R1 with LN H later that afternoon and discovered dark bruised areas that were visible on R1's labia and into her vagina and there was bruising to the right hip and leg and bruising visible on the lower abdomen and what appeared to be a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). LN I also documented that the AP would not make eye contact at that time and left the room for that assessment, and she notified Administrative Nurse D. CNA Q's Notarized Witness Statement, dated 03/24/26, documented when she performed cares and changed R1's wet brief the AP remained in the room and watched her actions closely. CNA Q's facility Witness Statement Form dated 03/24/26 documented that R1's room door was closed most of the time during 06:00 AM - 05:00 PM on 03/21/26 or 03/22/26, and that the AP was in R1's room during that time. LN H's facility Witness Statement Form dated 03/24/26, documented that she noticed that the AP was alone in the room with R1 and that he would remain in the room during cares and assessments. CNA R's facility Witness Statement Form dated 03/24/26, documented that the AP would remain in R1's room all the time unless he had to go home to do laundry or let animals out. She further documented that the AP left frantically after R1's injuries were noticed. CNA S's facility Witness Statement Form, dated 03/25/26, documented when her and another CNA were getting R1 up for the day and providing peri-care, R1 told them not to touch her and when trying to change her shirt R1 said, Stop that son. CNA O's facility Witness Statement Form dated 03/25/26, documented on 03/22/26, the AP remained in the room when cares were provided at 08:00 AM and remained in the room with R1 with the door closed after cares were completed at 08:30 AM. CNA O further documented the AP remained alone in the room, with the door closed, as cares were completed at 11:30 AM and remained in the room during the cares. LN G's facility Witness Statement Form dated 03/25/26, documented that during her shift on she took R1's vitals and performed her skilled assessment and that it did not take very long. LN G also documented that the AP would spend the night with R1 and he kept the door shut. CNA M's facility Witness Statement Form dated 03/26/26, documented that the AP would usually stay in the room when care was provided to R1 and that the AP would stay in R1's room all night with the door closed. On 03/30/26 at 09:40 AM, Administrative Staff A stated that the incident occurred on the night of 03/22/26 [sic] and R1 was sent to the hospital in [NAME], Missouri and the hospital refused to perform the SANE examination because they did not get consent from R1's legal representative because he had left. R1 was then released and sent back to the facility and Administrative Staff A then took R1 to the hospital in Pittsburg, KS and they informed her that they did not have a qualified SANE nurse to perform the proper examination. Administrative Staff A returned to the facility and coordinated with local LE, and she then took R1 to the county Health Department, along with local LE, and the health department performed the SANE examination. She said that staff had not reported concerns about the DPOA prior to this incident. On 03/30/26 at 10:12 AM, Administrative Staff A stated she was notified of the incident at 03:25 PM on 03/22/26. She also said that the AP never did anything suspicious, but she did have an odd vibe regarding him. She also said that there had never been any complaints about the AP with this visit or previous visits. Administrative Staff A reported that every time the AP stayed, which was 24/7, the door would remain closed, and this happened with this stay and the previous two stays; he would only leave for 30 minutes to an hour and would return. On 03/30/26 at 10:20 AM, Administrative Nurse D stated that she was notified by staff around 03:00 PM on 03/22/26 of suspected abuse with R1 and she proceeded to go to the facility and notified Administrative Staff A around 03:25 PM while she was driving to the facility; she further said that she should have been notified much sooner about the injuries to R1. She also said the AP would act fidgety and nervous anytime staff would interact with him or when cares were performed, and he would stand next to staff or at the end of R1's bed when cares were performed and staff had reported that he would often interrupt and take over cares which included incontinent cares. She said that staff reported to her that they felt awkward performing cares on R1 while the AP was present. When Administrative Nurse D arrived on the evening of the allegations, the AP was present and acted more nervous than usual. On 03/30/26 at 10:37 AM, CNA O stated that she another CNA (CNA P) performed peri-care on R1 around 08:00 AM on 03/22/26 and there were small cuts/lacerations around R1 vaginal area but did not notice bruising because she kept R1 covered for dignity and warmth. She said that the AP was present in the room and was standing at the foot of the bed watching the cares be performed. CNA O then informed the other CNA to remain with R1 and she then immediately notified the charge nurse (LN I) and LN I immediately arrived and examined R1 and told the CNAs that it was reported the night before that there was vaginal bleeding. CNA O also stated that there were several times that she felt awkward and uncomfortable with the AP and he would get upset and refuse to leave when asked. CNA O had reported her discomfort and concerns to the charge nurse more than once and the response she received was that they did not take it seriously and nothing was done. On 03/30/26 at 10:55 AM, CNA P stated that she assisted CNA O with performing peri-cares on R1 around 08:00 AM on 03/22/26 and when doing so they noticed blood in the vaginal area of R1 and they reported it to the nurse and found out that night shift had reported it to the nurse, they also noticed wounds in the vaginal area. CNA P also said that the AP was in the room and at the end of the bed watching and would always be present during cares. She also stated that she felt unsettled when performing cares on R1 and the AP being present. CNA P also said that she had reported her concerns with the AP to the charge nurse previously and was told to honor the AP's wishes of being present and let it be. On 03/30/26 at 11:55 AM, LN I stated she was the nurse on the south hall on 03/22/26 and she was notified by CNA O around 08:00 AM that R1 needed to be seen by a nurse. She said that she went to R1's room and saw that R1 had blood and dried blood around her vaginal area along with vaginal bruising, LN I then found LN H, the nurse for that hall, and reported to her that R1 had bleeding and bruising around the vaginal area and informed her that further assessment was needed after the CNAs had finished with cares and cleaned her. LN I then stated that after 02:00 PM she and LN H assessed R1 and discovered extensive bruising on her thighs and abdominal area and the vaginal bruising was darkened. LN I also said the AP was always present, even during intimate cares, and would not make eye contact at that time. LN I then notified Administrative Nurse D of the situation at that time. On 03/31/26 at 08:06 AM, LN G stated that prior to returning a call to the State Agency for interview she had spoken to Administrative Staff A and Consultant HH regarding the survey investigation, she then said that CNA M informed her that R1 had bruising that went down her right leg but did not recall the time. LN G said that she looked at the bruising and the AP was in the room with R1, the bruise appeared to be linear and old. LN G also reported that she looked at the bruise with the AP and he told her that it was from therapy, and she said that she believed it was from the wheelchair and said that she reviewed the EMR and said that the bruise was noted on 03/02/26. She also said that R1 would sit down hard and felt that that was the root cause of the bruising. LN G also stated that earlier in her shift the AP had told her that R1 had scratched her vaginal area and had a yeast infection, LN G said she provided CNA M antifungal cream and instructed him to clean R1 and apply the cream to the area but she did not asses this and she did not recall anything being reported to her about any injuries or bleeding when she received her shift report. LN G confirmed she had not suspected abuse so had not reported the bruising or vaginal bleeding to anyone except the oncoming shift. On 03/31/26 at 12:55 PM, LN H stated she took R1's vital signs the morning of 03/22/26 but had not assessed her because she was busy with other residents and did not remember anything about wounds being reported during shift report that morning. LN H also said that she was called into R1's room around 02:30 PM in the afternoon on 03/22/26. On 04/01/26 at 02:07 PM, email correspondence was received from Consultant HH contained a Late Entry Nurse's Note with an effective date of 03/21/26 and time of 11:15 PM that was entered on 03/30/26 at 06:43 PM by LN G, after the surveyor had completed interviews with Administrative Staff A and Administrative staff D and other staff. The Late Entry Nurse's Note documented that the CNA had notified the nurse that R1 had bruising that ran down the right side of her leg. When the nurse went to R1's room the AP was at the bedside, and both appeared relaxed and were watching television. The nurse observed a row of small, old purplish, fading bruises that ran down the back side of her right-lower-extremity and started from the upper thigh/hip region. The nurse had asked the son if he knew what had happened and he told her he thought it could have been from something done in therapy. They also talked about how R1 tended to lean towards the right and did not completely get centered in the wheelchair during her transfer. It appeared as if R1 had attempted to sit down in the wheelchair and bumped the arm rest of the wheelchair due to linear appearance. R1 took blood thinning medications Plavix (a medication used to prevent blood from clotting) and aspirin (a medication used to thin blood) which can cause bruising more easily. The AP reported to the nurse that R1 had been scratching herself around the peri-area. Later in the shift the CNA told the nurse that while performing peri care it had appeared that she had been scratching around her vaginal area due to redness and scant amounts of blood on the brief. The nurse reported the findings to the oncoming day shift so they could attempt to notify the on-call or on the list to be seen during the Monday morning rounds. The facility policy Abuse, Neglect and Exploitation, dated 2025, documented that the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. The policy further documented that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives. The likelihood of a serious adverse outcome is evidenced by the existence of physical sexual abuse injuries which progressed during the time the resident was left alone with the AP as well as the likelihood for severe psychosocial trauma related to sexual abuse. By 03/24/26, prior to the onsite survey, the facility completed all corrective actions which included reeducation and training to staff regarding recognizing signs or potential abuse and implementing immediate protective measures to prevent further abuse. The facility additionally implemented a visitors log to monitor visitors inside the facility including an individual log for R1 to ensure only authorized visitors attend R1. The deficient practice was deemed past noncompliance and existed at G (isolated, actual harm).

The facility reported a census of 39 residents with 15 residents sampled, including 6 residents reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide necessary ADL cares for four sampled resident, Resident (R)16 was not shaven, R6 had dirty clothes, R29 did not get showered, and R17 received no feeding assistance. This deficient practice placed the affected residents at risk for impaired quality of life, weight loss and poor hygiene. Findings included: - The Physician Order Sheet (POS) for R16, documented the resident had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and chorea (movement disorder). The Annual Minimum Data Set (MDS) for R16, dated 01/20/25, documented a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. He required substantial to maximum assistance for bathing. The Functional Abilities Care Area Assessment, dated 01/20/25, triggered secondary to R16 required assistance in ADLs and had functional impairment in activity. The Quarterly MDS, for R16, dated 10/22/24, documented a BIMS of nine. The MDS recorded bathing and showering was not applicable. R16's Care Plan for ADLs, dated 02/10/25, instructed staff to provide hygiene setup assistance. A look-back review of R16's electronic medical record (EMR) from 03/19/25 through 04/14/25 revealed the resident received showers on the following dates: 03/19/25, 03/26/25, 03/29/25, 04/13/25. No other bathing opportunities were documented for the resident. It further documented that the resident was independent to requiring staff supervision for personal hygiene. Observation on 04/15/25 at 07:23 AM, R16 propelled himself in wheelchair from his room to the dining room for breakfast. R16 was unshaven. During an interview on 04/15/25 at 09:31 AM, Certified Nurse Aide (CNA) M reported that the residents had a shower schedule. CNA M stated that there was a list of showers placed shower room listing who were due showers. She further reported that residents were shaven on shower day and then documented in the EMR. CNA M reported that R16 has not refused cares and that he has not always been shaven on shower days but should have been. During an interview on 04/15/25 at 12:05 PM, Certified Medication Aide (CMA) R stated that residents are showered twice weekly and that is when they are shaven. CMA R reported that the bath aide has been providing showers to the residents, but she has had to work the floor quite a bit due to call ins, so residents have not always been getting two showers per week. CMA R confirmed R16 needed to be shaven. During an interview on 04/15/25 at 02:05 PM, Licensed Nurse (LN) G reported that residents should be bathed/showered twice weekly, but this has not been happening due to not having enough staff. LN G stated that the shower aide has been pulled off of doing showers and has had to work the floor. She further stated that showers are documented in the EMR by the CNAs. LN G stated that she noticed the resident was needing to be shaved at breakfast and asked one of the CNAs to shave him. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D reported that residents had a choice as to how many showers they get, it's usually been at least two showers per week. Administrative Nurse D stated that the bath aide has been pulled to help on the floor, but it has usually been just to help out in the morning. She further stated that residents are generally shaven on the bath days based off the care plan preferences. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R6, documented the resident had a diagnosis of delusional disorder (a mental illness characterized by persistent, fixed false beliefs [delusions] that are not based in reality) and dementia (a general term for the loss of memory and other thinking abilities that interfere with daily life). The Annual Minimum Data Set (MDS) for R6, dated 12/30/24, documented a Brief Interview for Mental Status (BIMS) of two indicating severe cognitive impairment. She was dependent on staff for dressing the upper portion of her body and rolling left and right in bed. The Cognition Care Area Assessment, dated 01/20/25, triggered related to the diagnosis of dementia and short-term memory loss, impaired communication, presence of delusions, and fluctuating episodes of inattention and disorganized thinking. She was recently admitted to hospice services related to Alzheimer's dementia that is progressive. The Quarterly MDS, for R6, dated 09/29/24, documented a BIMS of one indicating severe cognitive impairment. She was dependent on staff for dressing the upper portion of her body and rolling left and right in bed. R6's Care Plan ADL, dated 02/25/25, documented R6's ADL were impaired related to weakness and impaired balance, and she dependent on staff for locomotion in a Broda (specialty wheelchair with the ability to tilt and recline) chair, dependent on staff for transfers with a Hoyer lift and substantial to maximum assistance of staff for dressing. During an observation on 04/14/25 at 09:09 AM, R6 was sat at the dining table with Activity Director Z eating breakfast per self. R6's blue sweatshirt had a large wet area on the front. During an observation on 04/14/25 at 12:37 PM, Administrative Nurse E propelled R6 from the dining room where she had eaten lunch, and the front of her sweatshirt continued to be soiled with food and liquids. Administrative Nurse E parked the R6 in front of the nurse's desk in the soiled clothing before walking away. During an observation on 04/14/25 at 02:07 PM, R6 appeared to be resting in bed and continued to wear the soiled sweatshirt. During an observation on 04/14/25 at 03:17 PM, Certified Medication Aide (CMA) R, checked on R6 who was awake in her bed and did not offer to change the resident's soiled shirt. During an observation on 04/15/25 at 11:27 AM, R6 was sat at dining room table in a Broda chair awaiting lunch. She wore black pants with food debris on the thighs. During an interview on 04/15/25 at 09:41 AM, CMA R stated the resident was dependent on staff for all cares to include dressing. During an interview on 04/15/25 at 09:31 AM, Certified Nurse Aide (CNA) M stated [NAME] R6 was dependent for all cares and needed staff to dress her. CNA M further stated that R6's clothes should have been changed if they were dirty, it wouldn't have been right to take a R6 to the dining room in dirty clothes. During an interview on 04/14/25 at 12:37 PM, Administrative Nurse E stated that R6 would be left in her wheelchair by the nurse's station because she used to be a nurse there at the facility. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D stated she expected staff to change a resident's clothing if it were soiled. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R29, documented the resident had a diagnosis of cerebral infarction accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Admission Minimum Data Set (MDS) for R29, dated 11/18/24, documented a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. He required substantial to maximum assistance for personal hygiene. The Functional Abilities Care Area Assessment, dated 11/18/24, triggered related to R29 had actual ADL and self-care abilities declined related to weakness after an acute care stay related to congestive heart failure (CHF-decreased cardiac function). The Quarterly MDS, for R29, dated 02/18/25, documented a BIMS of six indicating moderate to severe cognitive impairment. R29 required substantial to maximum assistance to shower/bathe and setup/clean-up assistance for personal hygiene. R29's Care Plan ADL, dated 03/19/25, documented ADLs had declined related to weakness after an acute care stay related to CHF, R29 was independent with eating and required substantial assistance with bathing, personal hygiene and transfers. R29's Electronic Health Record (EHR) look-back from 03/19/25 through 04/14/25 revealed R29 received a shower on the following dates: 03/19/25--Partial/mod assist, *03/26/25--Res unavailable, *03/29/25--Res refused, *04/05/25--Not attempted, 04/09/25--Sub/max assist, *04/12/25--Not attempted. Review of the R29's EHR from 03/19/25 through 04/14/25 revealed he required setup or cleanup assist to substantial to maximal assist of staff for personal hygiene, including shaving. During an observation on 04/15/25 at 07:25 AM, R29 was sat at the dining table unshaven, and his hair appeared greasy and dirty. During an interview on 04/15/25 at 09:31, Certified Nurse Aide (CNA) M stated that R29 had declined recently and he's now incontinent where he wasn't before. She reported that his dementia has gotten worse, but he hasn't refused cares. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D reported that residents had a choice as to how many showers they get, it's usually been at least two showers per week. Administrative Nurse D stated that the bath aide has been pulled to help on the floor, but it has usually been just to help out in the morning. She further stated that residents are generally shaven on the bath days based off the care plan preferences. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R17, documented the resident had a diagnosis of cerebral infarction accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS) for R17, dated 04/22/24, documented a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. He was listed as independent with eating. The Nutritional Status Care Area Assessment, dated 04/22/24, triggered related to R17 was at risk for alteration in nutritional status related to a diagnosis of Diabetes Mellitus with insulin use, altered dental status (see dental CAA), and elevated Body Mass Index (MDI). The Quarterly MDS, for R17, dated 01/23/25, documented a BIMS of nine. R17 required substantial to maximum assist with eating. R17's Care Plan for ADL, dated 02/04/25, documented R17 required substantial to maximal assist with eating. During an observation on 04/15/25 at 08:01 AM, R17 ate part of his food without assistance and then stared at his uneaten eggs. No staff assisted R17 at this time. During an observation on 04/15/25 at 08:05 AM, R17 fell asleep at the dining table and, a staff member walked by him. No staff assisted R17 at this time. During an observation on 04/15/25 at 08:13 AM, R17 continued to sit at the dining table and had not taken a drink and continued staring at his food as several staff walked by. No staff assisted R17 at this time. During an observation on 04/15/25 at 08:17 AM, Licensed Nurse (LN) G assisted R17 with his eggs and he ate them right away with staff assistance. During an observation on 04/15/25 at 11:38 AM, staff provided R17 with his lunch and cut it up. Staff provided a clothing protector and walked away. At 11:40 AM, R17 was looking around and not eating. During an observation on 04/15/25 at 11:57 AM, staff sat down beside R17 and assisted him with eating and there were no problems. During an interview on 04/15/25 at 08:26 AM, Certified Medication Aide (CMA) R stated that R17 sometimes needs help, lately he's needed more assistance. During an interview on 04/16/25 at 08:56 AM, Administrative Nurse D stated that the facility no longer had a restorative nurse, but the CNAs should have assisted R17 with the restorative program and with eating. She stated she would investigate it. During an interview on 04/16/25 at 03:24 PM, Administrative Nurse D stated that she educated the staff that R17 was supposed to get assistance with meals, The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. 34056 The facility reported a census of 39 residents with 15 residents sampled, including six residents reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide the necessary ADL cares for four sampled residents, Resident (R)16 was not shaven, R6 had dirty clothes, R29 did not get showered, and R17 received no feeding assistance. This deficient practice placed the affected residents at risk for impaired quality of life, weight loss and poor hygiene. Findings included: - The Physician Order Sheet (POS) for R16 documented the resident had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and chorea (movement disorder). The Annual Minimum Data Set (MDS) for R16, dated 01/20/25, documented a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. He required substantial to maximum assistance for bathing. The Functional Abilities Care Area Assessment, dated 01/20/25, triggered secondary to R16 required assistance required in ADLs and had functional impairment in activity. The Quarterly MDS, for R16, dated 10/22/24, documented a BIMS of nine. The MDS recorded bathing and showering was not applicable. R16's Care Plan for ADLs dated 02/10/25, instructed staff to provide hygiene setup assistance. A look-back review of R16's electronic medical record (EMR) from 03/19/25 through 04/14/25 revealed the resident received showers on the following dates: 03/19/25, 03/26/25, 03/29/25, 04/13/25. No other bathing opportunities were documented for the resident. It further documented that the resident was independent to requiring staff supervision for personal hygiene. Observation on 04/15/25 at 07:23 AM, R16 propelled himself in wheelchair from his room to the dining room for breakfast. R16 was unshaven. During an interview on 04/15/25 at 09:31 AM, Certified Nurse Aide (CNA) M reported that the residents had a shower schedule. CNA M stated that there was a list of showers placed shower room listing who were due showers. She further reported that residents were shaven on shower day and then documented in the EMR. CNA M reported that R16 has not refused cares and that he has not always been shaven on shower days but should have been. During an interview on 04/15/25 at 12:05 PM, Certified Medication Aide (CMA) R stated that residents are showered twice weekly and that is when they are shaven. CMA R reported that the bath aide has been providing showers to the residents, but she has had to work the floor quite a bit due to call-ins, so residents have not always been getting two showers per week. CMA R confirmed R16 needed to be shaven. During an interview on 04/15/25 at 02:05 PM, Licensed Nurse (LN) G reported that residents should be bathed/showered twice weekly, but this has not been happening due to not having enough staff. LN G stated that the shower aide has been pulled off of doing showers and has had to work the floor. She further stated that showers are documented in the EMR by the CNAs. LN G stated that she noticed the resident was needing to be shaved at breakfast and asked one of the CNAs to shave him. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D reported that residents had a choice as to how many showers they get, it's usually been at least two showers per week. Administrative Nurse D stated that the bath aide has been pulled to help on the floor, but it has usually been just to help out in the morning. She further stated that residents are generally shaven on the bath days based off the care plan preferences. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R6, documented the resident had a diagnosis of delusional disorder (a mental illness characterized by persistent, fixed false beliefs [delusions] that are not based in reality) and dementia (a general term for the loss of memory and other thinking abilities that interfere with daily life). The Annual Minimum Data Set (MDS) for R6, dated 12/30/24, documented a Brief Interview for Mental Status (BIMS) of two indicating severe cognitive impairment. She was dependent on staff for dressing the upper portion of her body and rolling left and right in bed. The Cognition Care Area Assessment, dated 01/20/25, triggered related to the diagnosis of dementia and short-term memory loss, impaired communication, presence of delusions, and fluctuating episodes of inattention and disorganized thinking. She was recently admitted to hospice services related to Alzheimer's dementia that is progressive. The Quarterly MDS, for R6, dated 09/29/24, documented a BIMS of one indicating severe cognitive impairment. She was dependent on staff for dressing the upper portion of her body and rolling left and right in bed. R6's Care Plan for ADL dated 02/25/25, documented R6's ADL were impaired related to weakness and impaired balance, and she was dependent on staff for locomotion in a Broda (specialty wheelchair with the ability to tilt and recline) chair, dependent on staff for transfers with a Hoyer lift and substantial to maximum assistance of staff for dressing. During an observation on 04/14/25 at 09:09 AM, R6 sat at the dining table with Activity Director Z eating breakfast per self. R6's blue sweatshirt had a large wet area on the front. During an observation on 04/14/25 at 12:37 PM, Administrative Nurse E propelled R6 from the dining room where she had eaten lunch, and the front of her sweatshirt continued to be soiled with food and liquids. Administrative Nurse E parked the R6 in front of the nurse's desk in the soiled clothing before walking away. During an observation on 04/14/25 at 02:07 PM, R6 appeared to be resting in bed and continued to wear the soiled sweatshirt. During an observation on 04/14/25 at 03:17 PM, Certified Medication Aide (CMA) R, checked on R6 who was awake in her bed and did not offer to change the resident's soiled shirt. During an observation on 04/15/25 at 11:27 AM, R6 sat at the dining room table in a Broda chair awaiting lunch. She wore black pants with food debris on the thighs. During an interview on 04/15/25 at 09:41 AM, CMA R stated the resident was dependent on staff for all cares to include dressing. During an interview on 04/15/25 at 09:31 AM, Certified Nurse Aide (CNA) M stated [NAME] R6 was dependent for all cares and needed staff to dress her. CNA M further stated that R6's clothes should have been changed if they were dirty, it wouldn't have been right to take a R6 to the dining room in dirty clothes. During an interview on 04/14/25 at 12:37 PM, Administrative Nurse E stated that R6 would be left in her wheelchair by the nurse's station because she used to be a nurse there at the facility. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D stated she expected staff to change a resident's clothing if it were soiled. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R29 documented the resident had a diagnosis of cerebral infarction accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Admission Minimum Data Set (MDS) for R29, dated 11/18/24, documented a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. He required substantial to maximum assistance for personal hygiene. The Functional Abilities Care Area Assessment, dated 11/18/24, triggered related to R29 had actual ADL and self-care abilities declined related to weakness after an acute care stay related to congestive heart failure (CHF- decreased cardiac function). The Quarterly MDS for R29, dated 02/18/25, documented a BIMS of six indicating moderate to severe cognitive impairment. R29 required substantial to maximum assistance to shower/bathe and setup/clean-up assistance for personal hygiene. R29's Care Plan for ADL dated 03/19/25 documented ADLs had declined related to weakness after an acute care stay related to CHF. R29 was independent with eating and required substantial assistance with bathing, personal hygiene and transfers. R29's Electronic Health Record (EHR)s look-back from 03/19/25 through 04/14/25 revealed R29 received a shower on the following dates: 03/19/25--Partial/mod assist, *03/26/25--Res unavailable, *03/29/25--Res refused, *04/05/25--Not attempted, 04/09/25--Sub/max assist, *04/12/25--Not attempted. Review of the R29's EHR from 03/19/25 through 04/14/25 revealed he required setup or cleanup assist to substantial to maximal assist of staff for personal hygiene, including shaving. During an observation on 04/15/25 at 07:25 AM, R29 sat at the dining table unshaven, and his hair appeared greasy and dirty. During an interview on 04/15/25 at 09:31, Certified Nurse Aide (can) M stated that R29 had declined recently and he's now incontinent where he wasn't before. She reported that his dementia has gotten worse, but he hasn't refused cares. During an interview on 04/15/25 at 02:41 PM, Administrative Nurse D reported that residents had a choice as to how many showers they get, it's usually been at least two showers per week. Administrative Nurse D stated that the bath aide has been pulled to help on the floor, but it has usually been just to help out in the morning. She further stated that residents are generally shaven on the bath days based off the care plan preferences. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. - The Physician Order Sheet (POS) for R17, documented the resident had a diagnosis of cerebral infarction accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS) for R17, dated 04/22/24, documented a Brief Interview for Mental Status (BIMS) of nine indicating moderate cognitive impairment. He was listed as independent with eating. The Nutritional Status Care Area Assessment, dated 04/22/24, triggered related to R17 was at risk for alteration in nutritional status related to a diagnosis of Diabetes Mellitus with insulin use, altered dental status (see dental CAA), and elevated Body Mass Index (MDI). The Quarterly MDS, for R17, dated 01/23/25, documented a BIMS of nine. R17 required substantial to maximum assist with eating. R17's Care Plan for ADL dated 02/04/25, documented R17 required substantial to maximal assistance with eating. During an observation on 04/15/25 at 08:01 AM, R17 ate part of his food without assistance and then stared at his uneaten eggs. No staff assisted R17 at the time. During an observation on 04/15/25 at 08:05 AM, R17 fell asleep at the dining table and a staff member walked by him. No staff assisted R17 at the time. During an observation on 04/15/25 at 08:13 AM, R17 continued to sit at the dining table and had not taken a drink and continued staring at his food as several staff walked by. No staff assisted R17 at the time. During an observation on 04/15/25 at 08:17 AM, Licensed Nurse (LN) G assisted R17 with his eggs and he ate them right away with staff assistance. During an observation on 04/15/25 at 11:38 AM, staff provided R17 with his lunch and cut it up. Staff provided a clothing protector and walked away. At 11:40 AM, R17 was looking around and not eating. During an observation on 04/15/25 at 11:57 AM, staff sat down beside R17 and assisted him with eating and there were no problems. During an interview on 04/15/25 at 08:26 AM, Certified Medication Aide (CMA) R stated that R17 sometimes needs help, lately he's needed more assistance. The facility policy for Activities of Daily Living (ADLs), undated, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene.

The facility identified a census of 39 residents. The sample included 15 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, interview, and record review, the facility failed to address necessary dialysis assessments, care, and services on Resident (R) 143's baseline care plan. This deficient practice had the risk of adverse outcomes and dialysis complications for R143 due to uncommunicated care needs. Findings: - R143's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. The Admission Minimum Data Set (MDS), was in progress. R143's Baseline Care Plan, dated 04/04/25, was reviewed on 04/14/25 at 03:48 PM. It documented R143 was a full code (desired resuscitative measures) and on skilled services with therapy. R143'sBaseline Care Plan lacked documentation that R143 received dialysis or any direction for dialysis care and services. R143's EMR under the Orders tab lacked evidence of orders related to dialysis care and services. R143's EMR revealed the following: An admission Progress Note on 04/04/25 at 07:50 PM documented R143 received dialysis on Monday, Wednesday, and Friday and his representative transported him. On 04/15/25 at 08:44 AM, R143 finished eating then staff assisted him to lie down in bed. R143 reported he went to dialysis on Monday, Wednesday, and Friday but he sometimes went on Tuesday if he had too much fluid. R143 reported the facility nurses did not do anything prior to him leaving including not obtaining his vital signs, pre-dialysis weight, or dialysis site assessment. He reported that sometimes he left before breakfast. So dialysis gives him a protein bar while he is there. On 04/15/25 at 12:41 PM, Certified Nurse Aide (CNA) N stated R143 was on a fluid restriction that just started because he went to dialysis. She was not aware of anything else related to dialysis treatment. On 04/15/25 at 01:35 PM, Licensed Nurse (LN) G stated that the facility missed R143's orders for assessment and monitoring for dialysis on admission. LN G stated the nurses did not do any pre or post-assessment for dialysis. LN G stated R143's representative took him to dialysis, so the facility missed his dialysis assessments. LN G verified the facility had not put anything on R143's Baseline Care Plan related to dialysis and said it should have been on admission. On 04/15/25 at 01:50 PM, Administrative Nurse D verified staff had not put any dialysis instructions on R143's Baseline Care Plan that was completed on admission and further said it should have included dialysis. Administrative Nurse D stated they expected the nurse to listen to R143's bruit (blowing or swishing sound heard when blood flows through a shunt) and feel the thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt) of his dialysis shunt, complete a pre and post dialysis assessment, weigh R143 daily, and provide communication between the dialysis center and the facility. Administrative Nurse D stated staff should receive education that no blood pressure should be done on that arm with the dialysis shunt. The facility policy for Baseline Care Plans, undated, included: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care.

The facility reported a census of 39 residents, with 15 residents included in the sample. Based on observation, record review, and interview, the facility failed to complete a comprehensive care plan for one of the residents sampled, Resident (R)16, to include staff instruction for the use of foot pedals while propelling the resident in his wheelchair. Findings included: - Review of R16's electronic medical record (EMR) revealed the following diagnoses: chorea (movement disorder) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He had no impairment in functional range of motion (ROM) and was independent with his wheelchair for locomotion. The Functional Ability Care Area Assessment (CAA), dated 01/20/25, documented the resident would not have a further activity of daily living (ADL) decline. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine. He had no impairment in functional ROM and was independent with his wheelchair for locomotion. R16's Care Plan, revised 02/10/25, instructed staff the resident had jerking movements due to a diagnosis of chorea and was independent with his walker. R16's EMR, from 03/19/25 through 04/14/25, revealed the resident was mostly independent with his walker, and at times he was dependent on staff for mobility while in his wheelchair. On 04/14/25 at 08:57 AM, Social Services Staff X propelled the resident in his wheelchair from the dining room to his room following breakfast. The resident had shoes on and his feet were crossed at the ankle and tucked back underneath the seat of his wheelchair with the toe of his left foot skimming the floor. The wheelchair lacked foot pedals at that time. On 04/14/25 at 08:57 AM, Social Services Staff X stated the resident did not have foot pedals because he usually propelled himself in the wheelchair. On 04/15/25 at 12:05 PM, Certified Medication Aide (CMA) R stated the resident would propel himself in the wheelchair most of the time but did at times require staff assistance. CMA R said staff were to utilize the foot pedals on R16's wheelchair while propelling the resident. On 04/15/25 at 02:41 PM, Administrative Nurse D stated it was the expectation for the nurses to update the care plan when needed. The facility policy for Comprehensive Care Plans, undated, included: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes.

The facility identified a census of 39 residents, with 15 residents sampled, including two residents reviewed for quality of care. Based on record review, interview, and observation, the facility failed to ensure Resident (R) 5 had adequate care when the facility did not monitor R5's weights and notify the provider of weight fluctuations as ordered. This deficient practice placed the resident at risk for health complications. Findings included: - Review of the Electronic Medical Record (EMR) documented R5 had a pertinent diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The 11/03/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. R5's Care Plan dated 11/06/24, documented that R5 required a daily weight. The plan directed staff to notify heart failure of weight gain of three pounds overnight or five pounds in three days, increased shortness of breath, or increased swelling. R5's EMR from 02/01/25 through 04/14/25, revealed R5 gained weight on the following dates without provider notification: On 02/13/25 R5 gained 3.8 pounds from the previous day. No notification to provider. On 02/20/25 R5 gained 3 pounds from the previous day. No notification to provider. On 02/26/25 R5 gained 3.2 pounds from the previous day. No notification to provider. On 03/12/25 R5 gained 3.6 pounds from the previous day. No notification to provider. On 03/19/25 R5 gained 5.4 pounds in the past 3 days. No notification to provider. On 04/07/25 R5 gained 3.2 pounds from the previous day. No notification to provider. During an observation on 04/15/25 at 04:17 PM, R5 had edema to both legs and wore compression socks. During an interview on 04/16/25 at 11:48 AM, Licensed Nurse (LN) G stated that she was aware of the order to notify the provider with weight gain. LN G stated that the nurse enters the weights and looks at the previous one at that time. She would notify the provider for any weight gain. During an interview on 04/16/25 at 12:04 PM, Administrative Nurse D stated she expected staff to follow orders and notify the provider when appropriate. No policy was provided.

The facility reported a census of 39 residents with 15 residents sampled including four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R)16 when staff failed to have foot pedals in place when staff propelled the resident in the chair. This placed R16 at risk for avoidable accidents. Findings included: - Review of R16's electronic medical record (EMR) revealed the following diagnoses: chorea (movement disorder) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He had no impairment in functional range of motion (ROM) and was independent with his wheelchair for locomotion. The Functional Ability Care Area Assessment (CAA), dated 01/20/25, documented the resident would have a further activity of daily living (ADL) decline. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of nine. He had no impairment in functional ROM and was independent with his wheelchair for locomotion. R16's Care Plan, revised 02/10/25, instructed staff the resident had jerking movements due to a diagnosis of chorea and was independent with his walker. R16's EMR, from 03/19/25 through 04/14/25, revealed the resident was mostly independent with his walker and at times he was dependent on staff for mobility while in his wheelchair. On 04/14/25 at 08:57 AM, Social Services Staff X propelled the resident in his wheelchair from the dining room to his room following breakfast. The resident wore shoes and his feet were crossed at the ankle and tucked back underneath the seat of his wheelchair with the toe of his left foot skimming the floor. The wheelchair lacked foot pedals at that time. On 04/14/25 at 08:57 AM, Social Services Staff X stated the resident did not have foot pedals, because he usually propelled himself in the wheelchair. On 04/15/25 at 12:05 PM, Certified Medication Aide (CMA) R stated the resident would propel himself in the wheelchair most of the time but did at times require staff assistance. CMA R said staff were to utilize the foot pedals on R16's wheelchair while propelling the resident. On 04/15/25 at 02:41 PM, Administrative Nurse D stated she expected staff to utilize foot pedals while propelling R16 in his wheelchair. The facility did not provide a policy regarding safe transport of residents while in their wheelchairs.

The facility identified a census of 39 residents with 15 sampled. Based on observation, interview, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status by failing to properly follow the plan of care for Resident (R) 17. Also, the facility failed to properly assess nutritional status for R143. This deficient practice had the potential to negatively affect the residents physical well-being and nutritional status. Findings: - R17's Electronic Medical Record (EMR) revealed the following diagnoses: cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and loss of cognition. The 04/22/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of nine, indicating moderately impaired cognition. The MDS recorded R17's current weight was 174 and he had no weight loss. He consumed a regular textured diet with no eating or swallowing concerns. The 04/22/24 Cognitive Loss / Dementia (CAA) documented R17 had impaired mobility related to a stroke and required staff assistance with activities of daily life (ADL) performance and mobility. The 04/22/24 Nutrition CAA documented R17 was at risk for alteration in nutritional status. R17 was weighed at least monthly, and the weights reviewed. R17 will be reviewed in risk meetings per policy. The 01/23/25 Quarterly MDS documented a BIMS score of nine. He weighed 167 lbs. and had no significant weight loss. He ate a mechanically altered diet with no difficulty. The MDS documented R17 was independent with eating, but the staff documented he required substantial to maximal assistance with eating. R17's Care Plan documented R17 had impaired mobility related to a stroke and required staff assistance with care initiated on 06/15/22. An intervention on 10/30/24 documented R17 required substantial to maximal assistance with eating. An intervention dated 07/22/24 noted R17 required a soft diet with [NAME] portions; staff were directed to assist him with meals, and provide a lid with a straw in drinks. The plan directed R17 received mighty shakes (nutritional health shake). R17's EMR noted on 02/04/25, the resident weighed 165.2 pounds (lbs.) On 04/08/25, the resident weighed 152.2 lbs. which was a -7.87 % Loss. On 03/10/25, the resident weighed 161.9 lbs. On 04/08/25, the resident weighed 152.2 pounds which was a -5.99 % Loss. The Nutrition Risk Evaluation (NRE) - SNF - V 2 registered dietitian (RD) annual review dated 04/11/25 documented R17 was on a regular, soft diet. He received double portions as needed and mighty shakes two times a day. The RD noted a 13-pound weight loss in 60 days and recommended the addition of fortified foods with meals. The Progress Notes section of R17's EMR lacked documentation of weight loss. During an observation on 04/15/25 at 08:01 AM, R17 sat at the dining room table. He had already been assisted with his biscuits and gravy. He sat with the fork in his hand and stared at his uneaten eggs. During an observation on 04/15/25 at 08:05 AM, R17 rested with his head hanging down. Several staff walked by him, did not say a word, and just kept walking, R17 woke back up, stared down at his plate with his eggs, fork in hand not moving his hand. During an observation on 04/15/25 at 08:08 AM, Certified Medication Aide (CMA) S sat a health shake on the table beside R17. During an observation on 04/15/25 at 08:17 AM Licensed Nurse (LN) G asked R17 if he was done, and if he was going to eat the eggs. She sat down beside R17 and assisted him with the rest of his breakfast. R17 still had not taken a drink of the health shake and LN G did not offer it to him. During an observation on 04/15/25 08:22 AM R17 ate 100% with assistance from staff. LN G directed him to finish drinking his health shake and left. R17 picked up his health shake slowly then lowered it down. He did not take a drink. CMA R sat beside him and encouraged him to drink it, but did not assist him. R17 did not drink it. Staff then assisted R17 to the television room. During an observation on 04/15/25 at 11:38 AM, staff delivered R17's food and cut it up. She provided R17 a clothing protector and walked away. R17 sat at the table and looked around. He did not eat any food until 11:57AM when staff sat down to assist him. During an observation on 04/15/25 at 12:06 PM, with staff assistance, R17 had eaten all of the chicken pot pie. He ate part of the lima beans, but said he did not like them. The nurse left and R17 was able to slowly take one more bite of his dessert. During an observation on 04/16/25 at 03:32 PM, Social Services X assisted R17 in his wheelchair to be weighed. She placed his wheelchair on the scale and weighed him at 201.6 pounds. She noted the weight of the wheelchair on the side was 44.6 pounds. Social Service X stated the subtracted amount was three pounds more than she got this morning. During an interview on 04/15/25 at 08:26 AM, CMA R stated that R17's ability to feed himself varies, but lately, he has needed more assistance. During an interview on 04/16/25 at 08:56 AM, Administrative Nurse D reported that the facility had no restorative aide. The nurse aides do the program. Administrative Nurse D said the CNAs should assist R17 if he needed it. During an interview on 04/16/25 at 03:24 PM, Administrative Nurse D reported that R17 has been getting double portions and a health shake two times a day, Administrative Nurse D went to the kitchen with this surveyor and confirmed that R17 had not been getting double portions because the instruction did not flow over to the kitchen. Administrative Nurse D said she will put him on fortified foods, give double portions, and provide assistance. The facility policy for Weight Monitoring, undated, included: The facility will ensure that all residents maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible, or the resident's preferences indicate otherwise. Findings: - R143's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. The Admission Minimum Data Set (MDS), was in progress. R143's Baseline Care Plan, dated 04/04/25, was reviewed on 04/14/25 at 03:48 PM. It documented R143 was a full code (desired resuscitative measures) and on skilled services with therapy. R143 was to have a regular diet. R143's Baseline Care Plan lacked documentation that R143 received dialysis or any direction for dialysis care and services. R143's EMR under the Orders tab documented R143 was on a regular diet dated 04/04/25. The Discharge Instructions from the hospital dated 04/04/25 R143 was to be on a diabetic, heart healthy diet and gave instructions for this diet. R143's EMR under the Orders tab documented R143 had an order for daily weight before breakfast dated 04/11/25. Review of the EMAR showed that on 04/11/25 and 04/14/25 a weight was not obtained. Review of the EMAR showed R143 had a discontinued order for weekly weights on Mondays dated 04/04/25. This was not obtained on 04/08/25. Review of the EMR from 04/04/25 to 04/14/25 documented weights obtained on 04/04/25, 04/12/25, and 04/13 /25. R143's Nutrition Risk Evaluation (NRE) - SNF - V 2 dated 04/07/25 lacked documentation that he was on dialysis or any altered diet. R143's EMR revealed the following: A Progress Note on 04/06/25 at 01:27 AM documented R143 was on heart healthy diabetic diet. A Progress Note on 04/07/25 at 02:45 AM documented R143 was on heart healthy diabetic diet. On 04/15/25 at 08:44 AM, R143 finished eating then staff assisted him to lay down in bed. R143 reported he went to dialysis on Monday, Wednesday, and Friday but he sometimes went on Tuesday if he had too much fluid. R143 reported the facility nurses did not do anything prior to him leaving including not obtaining his vital signs or pre-dialysis weight, or dialysis site assessment. He reported that sometimes he left before breakfast. So, dialysis gives him a protein bar while he is there. On 04/15/25 at 12:41 PM, Certified Nurse Aide (CNA) N stated R143 was on a fluid restriction that just started because he went to dialysis. She was not aware of anything else related to dialysis treatment. On 04/15/25 at 01:35 PM, Licensed Nurse (LN) G stated that the facility missed R143's orders for assessment and monitoring for dialysis on admission including diet orders. LN G verified the facility had not put anything on R143's Baseline Care Plan related to dialysis and said it should have been on admission. On 04/15/25 at 01:50 PM, Administrative Nurse D verified staff had not put any dialysis instructions on R143's Baseline Care Plan that was completed on admission and further said it should have included dialysis. Administrative Nurse D stated they expected a diabetic resident on dialysis should have diet orders that address ESRD including a fluid restriction and phosphorous binders. Administrative Nurse D also reported the Registered Dietician should have addressed dialysis in her assessment. The facility policy for Hemodialysis, undated, included: The facility will coordinate and collaborate with the dialysis facility to assure that the resident's needs related to dialysis treatments are met. The facility policy for Weight Monitoring, undated, included: The facility will ensure that all residents maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible, or the resident's preferences indicate otherwise. New admits were to be weighed weekly unless daily weights were clinically indicated.

The facility identified a census of 39 residents. The sample included 15 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to provide the necessary dialysis assessment, care, and services for Resident (R) 143. This deficient practice had the risk for adverse outcomes and dialysis complications for R143. Findings: - R143's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. The Admission Minimum Data Set (MDS), was in progress. R143's Baseline Care Plan, dated 04/04/25, was reviewed on 04/14/25 at 03:48 PM. It documented R143 was a full code and on skilled services with therapy. The Baseline Care Plan lacked documentation that R143 received Dialysis services or any direction for dialysis care and services. R143's EMR under the Orders tab lacked evidence of orders related to dialysis care and services. R143's EMR revealed the following: An admission Progress Note on 04/04/25 at 07:50 PM documented R143 received dialysis on Monday, Wednesday, and Friday and his representative transported him. A Progress Note on 04/05/25 and 04/06/25 documented R143 received dialysis three times a week and his representative transported him. The fistula was intact. A Progress Note on 04/07/25 lacked documentation that R143 went to dialysis, returned from dialysis, or assessment related to dialysis. A Progress Note on 04/09/25 lacked documentation that R143 went to dialysis, returned from dialysis, or assessment related to dialysis. A Progress Note on 04/11/25 lacked documentation that R143 went to dialysis or assessment related to dialysis. A Progress Note on 04/11/25 at 05:21 PM documented R143 returned from dialysis with his representative at approximately 04:00 PM. R143 had no complaints at that time and staff documented his vital signs. The Progress Note lacked evidence of a fistula assessment. The facility was unable to provide any completed dialysis communication forms before and after dialysis. On 04/15/25 at 08:44 AM, R143 finished eating then staff assisted him to lay down in bed. R143 reported he went to dialysis on Monday, Wednesday, and Friday but he sometimes went on Tuesday if he had too much fluid. R143 reported the facility nurses did not do anything prior to him leaving including not obtaining his vital signs or pre-dialysis weight, or dialysis site assessment. He reported that sometimes he left before breakfast. So dialysis gives him a protein bar while he is there. On 04/15/25 at 12:41 PM, Certified Nurse Aide (CNA) N stated R143 was on a fluid restriction that just started because he went to dialysis. On 04/15/25 at 01:35 PM, Licensed Nurse (LN) G stated that the facility missed R143's orders for assessment and monitoring for dialysis on admission. LN G stated the nurses did not do any pre or post assessment for dialysis. LN G stated R143's representative took him to dialysis, so the facility missed his dialysis assessments. On 04/15/25 at 01:50 PM, Administrative Nurse D stated the facility did not put R143's dialysis orders in on admission. Administrative Nurse D stated they expected the nurse to listen to R143's bruit (blowing or swishing sound heard when blood flows through a shunt) and feel the thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt) of his dialysis shunt, complete a pre and post dialysis assessment, weigh R143 daily, and provide communication between the dialysis center and the facility. Administrative Nurse D stated staff should receive education that no blood pressure should be done on that arm with the dialysis shunt. Administrative Nurse D stated the facility planned to get a new dialysis form and proper orders and education were being completed. The facility's Hemodialysis policy, undated, directed the facility coordinated and collaborated with the dialysis to assure that the resident's needs related to dialysis treatments were met.

The facility identified a census of 39 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure blood pressure monitoring was conducted related to the use of midodrine (a medication used to increase blood pressure) for Resident (R)143. This placed R143 at risk of complications related to abnormal blood pressure. Findings included: - Review of R143's electronic medical record (EMR) revealed a diagnosis of hypotension (low blood pressure). The 04/10/25 Admission Minimum Data Set (MDS) was in progress. The 04/1/425 Baseline Care Plan dated 04/04/25 documented that midodrine (a medication used to increase blood pressure) had a Black Box Warning on it. It also gave instructions for staff to take a blood pressure before giving the medication and have the resident sitting upright when they do. It directed staff not to give the medication while the resident was laying down, or within four hours of bedtime. Review of R143's EMR revealed the following physician's order: Midodrine 10 milligrams (mg), by mouth, every eight hours as needed for a diagnosis of hypotension. Staff were to monitor the resident's blood pressure (BP) and give the medication if his systolic blood pressure (SBP- the top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 100 millimeters of Mercury (mm/Hg) ordered 04/04/25. Review of the resident's BPs in her EMR, from 04/04/25 through 04/14/25, revealed the following: On 04/06/25 at 09:09 AM, R143 had a SBP of 97, no midodrine was given, and the doctor was not notified. On 04/14/25 at 04:48 PM, R145 had a SBP of 98, no midodrine was given, the doctor was not notified. During an observation on 04/15/25 at 08:44 AM, R143 finished eating and was assisted to lay down in bed. During an interview on 04/16/25 at 11:48 AM, Licensed Nurse (LN) G stated that she was now aware of the order to give the midodrine. LN G said the Certified Medication Aides (CMA) should notify the nurse if there was a blood pressure that is out of range. LN G stated they will look into a better way to put the order into the EMR so it does not get missed. She said she would notify the provider for any blood pressures that were out of range. During an interview on 04/16/25 at 12:04 PM, Administrative Nurse D stated she expected staff to follow orders and notify the provider when appropriate. No policy was provided.

The facility reported a census of 39 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) for Resident (R) 5 who had a foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and for R37 who received a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) and wound care. Additionally, R7, who had an ostomy (a surgical procedure that creates an opening in the abdomen to allow waste or urine to pass out of the body) lacked EBP in place. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: - During an observation on 04/14/25 at 08:30 AM, no EBP signage or precautions were noted outside any of the residents' doors in any of the hallways during an initial tour of the facility. During an observation on 04/14/25 08:42 AM, R37 sat in her room in her wheelchair. She had open wounds to her arm, buttock, and back. There was no EBP personal protective equipment (PPE) available and no signage present. During an observation on 04/14/25 01:13 PM, R7 had an ostomy in place, no EBP PPE was placed at or around the resident's room to be used when providing cares. During an observation on 04/15/25 at 10:15 AM, R7 had no EBP PPE or signage outside or around his room. During an observation on 04/14/25 at 02:47 PM, R5 had a foley catheter with a drainage bag and there were no EBP PPE, or signage placed. During an interview on 04/14/25 at 08:42 AM, R37 reported that staff did not use gowns when taking care of her. She further stated she received tube feedings. During an interview on 04/14/25 at 02:47 PM, R5 reported that he had a catheter leg bag on, he further stated that staff did not wear gowns or anything when they provided cares. During an interview on 04/14/25 at 10:11 AM, Certified Medication Aide (CMA) R reported that EBP were used when a resident had a foley catheter or if there were wounds. CMA R stated that the EBP PPE would be set-up outside the resident's room and a sign would be placed on the resident's door. During an interview on 04/14/25 at 10:15 AM, Licensed Nurse (LN) G reported that EBP would be utilized when a resident had an infection or a foley catheter. During an interview on 04/15/25 at 01:27 PM, CMA R stated they had not been doing EBP, but they had been trained that day and EBP had now been placed. During an interview on 04/15/25 at 01:30 PM, LN G stated that they had not been using EBP due to the Director of Nursing being new, and they had just forgotten to use them. The facility's undated policy Enhanced Barrier Precautions documented that all staff received training upon hire and at least annually and they are expected to comply with all designated precautions. The policy documented the following conditions require EBP; wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (urinary catheters, feeding tubes) even if the resident is not known to be infected or colonized with a multidrug-resistant bacteria organism (MDRO). Make gowns and gloves available immediately near or outside the resident's room.

The facility reported a census of 39 residents with 15 residents sampled. Based on observation, interview, and record review, the facility failed to inspect Resident (R)6's bed frame and mattress, as part of a regular maintenance program to identify areas of possible entrapment. This placed the resident at risk for injuries. Findings included: - Review of R6's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She was dependent on staff for rolling left and right while in bed and had no limitation in range of motion (ROM). The Functional Ability Care Area Assessment (CAA), dated 12/30/24, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. She had limitations in ROM to her bilateral lower extremities (BLE) and was dependent on staff for rolling left and right while in bed. R6's Care Plan for hospice, revised 02/25/25, instructed staff that hospice would supply the resident's bed and mattress. On 04/14/25 at 02:07 PM, the resident rested in bed with her eyes closed. Observation of the resident's bed revealed a gap of approximately six inches from the top of the resident's mattress to the head of her bed (HOB). On 04/15/25 at 09:41 AM, Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R transferred the resident from her wheelchair to her bed with the use of a full-body lift. Observation of the resident's bed revealed a gap of approximately six inches from the top of the resident's mattress to the HOB, remained. On 04/15/25 at 09;41 AM, CMA R stated the resident's mattress has been shorter than her bed frame for a long time. On 04/16/25 at 11:45 AM, Maintenance Staff U stated he had not checked the resident's bed to ensure it was in good working condition as it was not a facility bed. On 04/15/25 at 02:41 PM, Administrative Nurse D stated she expected the resident's mattress to fit the resident's bed frame. The facility policy for Accommodation of Needs, undated, included: The facility will make reasonable accommodations to individualize the resident's physical environment including their bedroom.

The facility reported a census of 42 residents. Based on interview and record review, the facility failed to conduct Quality Assurance Performance Improvement (QAPI) leadership meetings with the medical director in attendance at least quarterly as required. Findings included: Review of the facility QAPI sign in sheets, revealed a lack of documentation of the medical director in attendance for the following QAPI meetings: July 2022, August 2022, September 2022, October 2022, November 2022, (no documentation of a meeting conducted December 2022 or January 2023) February 2023, May 2023, June 2023, and July 2023. Interview, on 07/26/23 at 10:20 AM, with Administrative Staff B, revealed she thought the medical director did attend meetings at least quarterly but may have been by telephone. Interview, on 07/27/23 at 02:25 PM, with Consultant Nurse GG, revealed the facility conducted monthly QAPI meetings and expected the medical director to attend at least quarterly, either in person or via phone. The QAPI Plan, effective 07/01/23, instructed staff the members of the committee included the medical director and meet at a minimum monthly. The facility failed to ensure the medical director's presence in the QAPI meetings as required.

The facility reported a census of 42 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment in two resident shower rooms for the residents of the facility. Findings included: - During an environmental tour on 07/27/23 at 11:57 AM with Housekeeping/Maintenance Staff U and Administrative Staff A, the following areas of concern were noted: 1. The shower room on [NAME] Hall had a full bag of trash resting directly on the toilet seat. A sharps container (used to hold needles, razors and other sharp objects) rested directly on the floor underneath the sink. On 07/27/23 at 11:57 AM, Certified Nurse Aide (CNA) M stated, she had put the trash on the toilet seat until she was able to take the trash out to the dumpster. CNA M confirmed residents used the toilet seat where the trash had been placed. CNA M further stated the sharps container should not be stored on the floor, but in a cabinet in the shower room. 2. The shower room on Mockingbird Hall contained one unopened box of 100 count briefs, two unopened boxes of 80 count briefs and one unopened box of 1,000 trash can liners, which lacked a barrier and rested directly on the floor. On 07/27/23 at 11:57 AM, Housekeeping/Maintenance Staff U confirmed the boxes should not rest directly on the floor without a barrier. On 07/27/23 at 11:57 AM, Administrative Staff A confirmed the boxes should not rest directly on the floor without a barrier. The facility policy for Standard Precautions Infection Control Protocol, undated, included: The facility shall develop procedures for routine care, cleaning/disinfection of environmental surfaces. The facility failed to maintain a clean, comfortable and homelike environment in two resident shower rooms for the residents of the facility.

The facility reported a census of 47 residents, including 4 with pressure ulcers. Based on observation, interviews, and record review, the facility failed to provide adequate position changes and treatment to prevent the development of new pressure ulcers for 1 (#5) of 3 sampled residents with pressure ulcers. Findings included: - The facility admitted resident #5 on 4/15/10. [DIAGNOSES REDACTED]. The 3/28/11, MDS (minimum data set) assessment identified the resident with short and long term memory loss, in need of 2 staff assist with all activities of daily living, including transfers and repositioning. The assessment also identified a history of skin breakdown on the left second toe. The 3/28/11 plan of care identified the need for 2 assist with repositioning every 2 hours while in bed and while in the wheelchair. The assessment identified the resident with continuous urinary incontinence and occasional bowel incontinence. The plan included scheduled toileting every 2-3 hours during the day and check every 3-4 hours at night. The plan identified a previous history of skin breakdown with current treatment to a toe. On 12/22/10 and 4/27/11, the pressure sore risk assessments scored the resident at 16, high risk(above 10 high risk for pressure sores). On 4/27/11 at 1:30 P.M., certified nurse aides H and I toileted the resident and placed the resident back into the wheelchair following refusal to lay down. Observations, on 4/27/11, revealed the resident remained in the wheelchair at bedside asleep at 2:00 PM, 2:30 P.M., 3:00 P.M., 3:30 P.M., 4:00 P.M. At 4:30 P.M., certified nursing staff L transported the resident to the dining room in the wheelchair. When questioned staff L reported the resident remained in the wheelchair and only hands and face washed before transported to the dining room. At 4:45 P.M., the surveyor notified licensed nursing staff M of the lack of repositioning of this resident. Staff responded, "(Resident) is eating." The resident remained in the wheelchair at the table and fed self the evening meal. The resident even ate a second bowl of strawberries. At 5:20 P.M., certified nursing staff L and N reported the day shift failed to mention the resident remained up after lunch. They transferred the resident to bed with a mechanical lift. Staff removed a urine saturated brief from the resident and instantly the resident started urinating a large amount of urine. The resident's buttocks displayed 3 new open areas. Licensed nursing staff K entered the room, failed to measure the new areas but placed A and D ointment on the open areas. On 4/28/11 at 7:00 A.M., observation revealed licensed nursing staff J assessed the buttocks, measured and documented in the nurses notes, "Three stage 2, (top one) 1.0 x 0.7 cm, (centimeters), #2 lower one, 0.7 x 0.5 cm, beefy red with no drainage, #3 inner aspect of Lt. (left) 0.5 x 0.5 cm, beefy red with no drainage and no odor." At this time, licensed nursing staff J acknowledged the open areas not there the day before. Nurse J verified the aides notified the evening staff the resident up since 1:30 P.M. The facility's Proper Positioning Policy, (undated), included, "Any individual who is assessed to be at risk for developing pressure sores should be repositioned at least every 2 hours ..." The facility nursing staff failed to adequately provide position changes as planned and as outlined in the facility positioning policy for this high risk for pressure ulcer resident. The resident sat in a wet brief without any repositioning attempt for 3 hours and 50 minutes. The resident developed three, stage II pressure ulcers.