Every finding on record at Grand Oaks Care

Based on interview and record review, the facility failed to follow the Physicians Order (PO) for one of four sampled residents (Resident 1) for a urology (surgical specialty of the urinary tract) referral. This resulted in Resident 1 not being seen by a urologist (medical doctor specializing in diagnosing and treating diseases of the urinary tract) and potential for untreated urinary tract disease.Findings:During a review of Resident 1's PO dated 5/12/25, the PO indicated, refer to Urology. refer for hematuria (blood in urine).During a concurrent interview and record review on 3/12/26 at 2:01 p.m. with Director of Nurses (DON), DON reviewed Resident 1's clinical records. DON confirmed Resident 1 had an order for a urology referral on 5/12/25. DON was unable to find documented evidence; the urology referral was made. DON stated PO for urology referral should have been completed.During an interview on 3/12/26 at 3 p.m. with Infection Control Preventionist (ICP), ICP stated Resident 1 had re-current Urinary Tract Infection (UTI) and Resident 1's physician had ordered a urology consult for Resident 1 on 5/12/25. ICP reviewed Resident 1's clinical record and was unable to find documented evidence of a urology referral. ICP stated the urology order might have gotten missed.During a review of the facility's policy and procedures (P&P) titled, Provision of Physician Ordered Services, dated 1/26, the P&P indicated, 2. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.

Based on observation, interview and record review, the facility failed to implement effective infection control practices for five of 22 sampled residents (Resident 82, Resident 36, Resident 19, Resident 62, and Resident 32) when staff did not provide hand hygiene before eating. This failure had the potential to spread infection to residents. Findings: During a concurrent observation and interview on 2/9/26 at 11:57 a.m. with Certified Nursing Assistant (CNA) 5, in the hallway outside of Resident 82's room. CNA 5 handed Resident 82 her lunch tray, CNA 5 stated, she did not provide hand hygiene to Resident 82 and stated she should have provided hand hygiene to the resident. During a concurrent observation and interview on 2/9/26 at 11:59 a.m. outside Resident 82's room, Resident 82 was eating her lunch. Resident 82 stated she was not provided hand hygiene prior to receiving her lunch. Resident 82 stated she would have liked for her hands to be cleaned. During a review of Resident 82's Brief Interview for Mental Status ([BIMS], a screening tool used in long term care to evaluate cognitive function.13-15 points: cognitively intact; 8-12 points: moderate cognitive impairment; 0-7 points: severe cognitive impairment), dated 11/11/25, the BIMS score was 11. During a concurrent observation and interview on 2/9/26 at 12:05 p.m. in Resident 36's room, Resident 36 was eating her lunch. Resident 36 stated staff did not provide hand hygiene before serving her meal. Resident 36 stated sometimes they do give me a wash cloth or wipe but not today Resident 36 stated she would like to clean her hands before each meal. During a concurrent observation and interview on 2/9/26 at 12:16 p.m. in Resident 19's room, Resident 19 was eating her lunch using her hands. Resident 19 stated staff did not provide her hand hygiene before her meal was served. Resident 19 stated she used tissue paper that she had found on her bedside table to wipe her hands before she started eating. Resident 19 stated she would like to be able to clean her hands before she eats. During a review of Resident 19's BIMS the indicated, BIMS Summary Score 12. During a concurrent observation and interview on 2/9/26 at 12:17 p.m. in Resident 62's room, Resident 62 was eating her for lunch. Resident 62 stated staff did not provide hand hygiene before serving her meal and stated she sometimes she askes for assistance. During a review of Resident 62's BIMS, dated 1/22/26, the BIMS indicated, BIMS Summary Score 15. During a concurrent observation and interview on 2/9/26 at 12:28 p.m. in Resident 32's room, Resident 32 was eating a salad for lunch. Resident 32 stated staff did not provide hand hygiene before serving her meal. Resident 32 stated sometime her meal tray will have a wipe she can use to wash her hands. Resident 32 stated, I guess it's when they feel like it. Resident 32 stated she would like to clean her hands before each meal. During a review of Resident 32's BIMS, dated 1/12/26, the BIMS indicated, BIMS Summary Score 15. During a review of the facility's policy and procedure (P&P) titled, Serving a Meal, dated 2026, the P&P indicated, 1. Prepare the room or serving area for mealtime (decrease noise level, provide lighting position comfortably) and make sure hands and face are clean.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Care Plans, for two of 12 sampled residents (Resident 31 and Resident 101). This failure had the potential to not meet residents' physical, psychosocial (related to thought or behavior), and functional needs. Findings: During an observation on 2/9/26 at 10:49 a.m. in Resident 31's room, Resident 31 had a one-to-one (one staff assigned to monitor one resident only) staff member monitoring the resident. During an interview on 2/11/26 at 9:52 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she does not know the reason Resident 31 is on one-to-one monitoring. During an interview on 2/11/26 at 9:56 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 31 is being monitored for falls. CNA 2 stated she started one-to-one monitoring a month ago with Resident 31. During a concurrent interview and record review on 2/11/26 at 4:21 p.m. with Director of Nursing (DON), Resident 31's Care Plan, (CP) (undated) was reviewed. The CP indicated no goals or interventions for one-to-one monitoring. DON stated the one-to-one monitoring was for behaviors and it should have been care planned. During a review of Resident 31's Order Summary Report,(OSR) dated 1/31/26, the OS indicated, Monitor 1:1 every shift. During a review of Resident 101's OSR, dated 2/11/26, the OSR indicated, Admit to HOSPICE [end of life care] care effective 2/7/26. Admit Resident to [Hospice Care Agency], .with any change in condition and/or any change in medication or refill. During a concurrent interview and record review on 2/11/26 at 2:20 p.m. with DON, DON reviewed the electronic medical record (eMAR) for Resident 101's care plan for Hospice Care/End of life Care. DON reviewed all the care plans in the eMAR for Resident 101 and was unable to provide documented evidence a care plan for Hospice Care/End of life Care was developed. DON stated, He [Resident 101] was picked up [admitted to hospice care]. DON was unable to find a hospice care plan and stated, it should have been implemented [referring to care plan]. During a review of the facility's P&P titled, Comprehensive Care Plan, dated 2025, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive-person centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs and All services that are identified in resident's comprehensive assessment and meet professional standards of quality . Professional standards of quality means that care and all services are provided according to accepted standard of clinical practice. Standard may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting . Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care all services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 1) had a post (after) hemodialysis (dialysis, life sustaining medical treatment that uses a machine to filter waste, toxins and excess fluid from the blood when kidneys are unable to function properly) assessment after returning to the facility. This failure had the potential for post dialysis complications and side effects (bleeding from dialysis access site, pain, low blood pressure, nausea/vomiting) to go unnoticed and untreated.Findings:During a review of Resident 1's Order Summary Report (OSR), dated 10/8/25, the OSR indicated, Dialysis.at [dialysis centers name].every day shift.Mon [Monday], Wed [Wednesday], Fri [Friday] for hemodialysis.During a concurrent observation and interview on 2/9/26 at 10:26 a.m. with Director of Staff Development (DSD) outside of Resident 1's room, Resident 1 was not in the room. DSD stated Resident 1 was at the dialysis center receiving dialysis.During an observation on 2/9/26 at 3:09 p.m. at the nurse's station, Resident 1 arrived by medical transport to the facility and was in a wheelchair. Transportation staff placed Resident 1 in her wheelchair next to the nurse's station. Resident 1 placed a white dialysis communication binder on the nurse's station counter. Resident 1 requested to make a phone call.During an observation on 2/9/26 p.m. at 3:12 p.m. at the nurse's station, Resident 1 ended her phone call and informed staff she wanted to go to her room. Staff then took Resident 1 to her room.During an observation on 2/9/26 from 3:12 p.m. to 3:41 p.m., no staff entered Resident 1's room to assess or obtain vital signs (VS, used to assess physical well-being, monitor health status and detect a medical problem using body temperature, heart rate, breathing rate, and blood pressure).During an observation on 2/9/26 at 3:48 p.m. in the hallway outside of Resident 1's room, a staff member took the VS monitor into another resident room. No staff entered Resident 1's room to assess or obtain VS.During an observation on 2/9/26 at 3:52 p.m. in the hallway outside of Resident 1's room, a staff member pushed the VS machine in the direction of another hallway in the facility. No staff entered Resident 1's room to assess or obtain VS.During an interview on 2/9/26 at 3:57 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she checks residents' VS at the start of her shift (2:30 p.m.), and when the nurse requests. CNA 1 stated she had not obtained Resident 1's VS since the resident returned back to the facility from the dialysis center.During an observation on 2/9/26 at 3:59 p.m. in the hallway outside of Resident 1's room, no staff entered Resident 1's room to assess or obtain VS since she had returned back to the facility from the dialysis center.During an observation and interview on 2/9/26 at 4:01 p.m. in the hallway on the 400 wing, Licensed Vocational Nurse (LVN) 3 was standing next to a medication cart. LVN 3 stated he was starting to pass medications to his residents. LVN 3 stated he was aware that Resident 1 had returned to the facility from the dialysis center. LVN 3 stated residents should be assessed as soon as they return from the dialysis center. LVN 3 stated he had not completed Resident 1's post dialysis assessment. LVN 3 stated Resident 1 should have been assessed as soon as she returned from the dialysis center.During an interview on 2/11/26 at 9:34 a.m. with Registered Nurse (RN) 1, RN 1 stated residents that receive dialysis treatments should be assessed and VS obtained upon arrival back to the facility. RN 1 stated the assessment should consist of monitoring for pain and ensuring the resident was not in any distress. RN 1 stated there should have been a visual assessment of the dialysis access site to ensure the dressing was intact and that there was no bleeding. RN 1 stated post dialysis assessments are completed by either an RN or LVN.During an interview on 2/11/26 at 11:47 a.m. with Director of Nursing (DON), DON stated it was her expectation that Resident 1's nurse would assess the dialysis access site, assess for any pain and obtain VS, as soon as Resident 1 arrived back at the facility.During a review of the facility's policy and procedure (P&P) titled, Hemodialysis Catheters- Access and Care of, dated February 2023, the P&P indicted, Care Immediately Following Dialysis Treatment.If there is major bleeding from the site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Notify MD. The nurse should document in the resident's medical record.1. Location of dialysis location site.any part of report from dialysis nurse post- dialysis.Observations post-dialysis.

Based on observation, interview, and record review, the facility failed to ensure medications and chemical cleaning/disinfecting agents were stored separate in one of two medication carts. This failure had the potential to result in cross contamination of stored medications and chemical cleaning/ disinfecting agents.Findings:During a concurrent observation and interview on 2/11/26 at 8:26 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 was opening the 300 medication cart bottom right drawer. The following was noted inside the medication cart: the drawer divided into three sections, the first section contained an opened/used container of Sani disinfectant wipes and 11 medication bubble packets, the second section contained an opened/used container of Sani wipes bleach, and the third section contained 12 medication bubble packets. LVN 2 stated, the containers of Sani wipes [Sani disinfectant wipes and Sani Bleach wipes] should be stored on one side and the medication should be stored on the other side. LVN 2 stated they should not be stored together. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 2007, the P&P indicated, 4.1 STORAGE OF MEDICATION Policy Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . 9. Potentially harmful substances (such as urine test reagents tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications.

During an observation, interview, and record review, the facility failed to ensure one of two cooks (Cook 2) followed its DRESS CODE policy and procedures (P&P), when [NAME] 2 did not have a beard cover. This failure had the potential for food contamination. Findings: During an observation on 2/10/26 at 12:13 p.m. in the kitchen, [NAME] 2 had a full beard on his face. [NAME] 2 was not wearing a beard cover and was serving food. During an interview on 2/10/26 at 12:15 p.m. with [NAME] 2, [NAME] 2 stated he should have worn a beard cover. During a concurrent observation and interview on 2/10/26 at 12:21 p.m. with Certified Dietary Manager (CDM) in the kitchen, CDM stated it is the expectation for all kitchen staff with beards to wear beard covers. During a review of the facility's P&P titled, DRESS CODE' dated 2023, the P& P indicated, Hair net for hair, if hair is long (over the ears or cover), including beard nets or face covers (if applicable).

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled resident's (Resident 1) medical record contained accurate documentation. This failure had the potential to result in delayed treatment for the resident who was returning from hemodialysis (dialysis, life sustaining medical treatment that uses a machine to filter waste, toxins and excess fluid from the blood when kidneys are unable to function properly).2. Ensure one of one sampled resident's (Resident 10) physicians order for oxygen administration was followed as ordered. This failure had the potential to result in low oxygen saturation levels for Resident 10.3. Ensure one of two sampled residents (Resident 58) had an emergency dialysis kit at bedside. This failure had the potential for staff not to properly treat Resident 58 in the event of an emergency. Findings: 1.During an observation on 2/9/26 at 3:09 p.m. at the nurse's station, Resident 1 arrived by medical transport to the facility and was in a wheelchair. Transportation staff placed Resident 1 in her wheelchair next to the nurse's station. During an observation on 2/9/26 from 3:12 p.m. to 3:41 p.m., no staff entered Resident 1's room to assess or obtain vital signs ([VS], used to assess physical well-being, monitor health status and detect a medical problem using body temperature, heart rate, breathing rate, and blood pressure). During a concurrent interview and record review on 2/11/26 at 11:47 a.m. with Director of Nursing (DON), Resident 1's Nurses Dialysis Communication Record (NDCR), dated 2/9/26, indicated, Post-Dialysis Monitoring: RETURNED TO UNIT AT: 1420 [2:20 p.m.]. DON stated Resident 1's NDCR was signed by Licensed Vocational Nurse (LVN) 1. DON was informed that LVN 1 would not have been able to complete the post dialysis monitoring at this time because Resident 1 had not returned to the facility from dialysis until 3:09 p.m. DON stated she was unsure of what happened. DON stated all assessments should be documented when completed with the correct date and time. During an interview on 2/11/26 at 2:12 p.m. with DON, DON stated LVN 1 had informed her that LVN 1 had accidentally charted Resident 1's Post- Dialysis Monitoring assessment at the wrong time, and stated she had assessed Resident 1 at 3:20 p.m. and not at 2:20 p.m. DON was informed that the statement from LVN 1 was inaccurate as State Auditor (SA) had observed Resident 1 on 2/9/26 from 3:12 p.m. to 3:41 p.m. and no assessment or VS were completed. DON did not respond. During a concurrent interview and record review on 2/11/26 at 2:46 p.m. with LVN 1, Resident 1's NDCR, dated 2/9/26 was reviewed. the NDCR indicated, Post-Dialysis Monitoring: RETURNED TO UNIT AT: 1420. LVN 1 stated she worked on 2/9/26. LVN 1 stated she normally works from 6:30 a.m. to 3 p.m. but on 2/9/26 she stayed until 4:44 p.m. to complete her charting. LVN 1 stated she was charting at the nurse's station and LVN 3 gave her a paper with Resident 1's VS. LVN 1 stated LVN 3 had asked her to chart Resident 1's assessment in Resident 1's NDCR. LVN 3 informed LVN 1 that Resident 1's assessment was not completed when she came back and that it was about an hour late. LVN 1 stated she did not take Resident 1's VS or complete her assessment on 2/9/26. LVN 1 stated she did not know what time Resident 1's VS and assessment were completed. LVN 1 stated she should not have documented LVN 3's assessment of Resident 1. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, All services provided to the resident.shall be documented in the resident's medical record.Documentation in the medical record will be objective.complete, and accurate.Entries may only be recorded in the residents clinic [clinical record] by the licensed personnel.in accordance with state law and facility policy. 2. During a concurrent interview and observation on 2/9/26 at 11:06 a.m., inside Resident 10's shared bedroom, Resident 10 was in bed, with nasal canula (device carry oxygen for respiratory care) tubing around both ears and resting under the nose. Resident 10 stated she was receiving 2 liters (unit of measurement) of oxygen [oxygen gas]. Resident 10's oxygen concentrator (machine used to deliver oxygen) was noted at the bedside and the concentrator gauge indicated the oxygen delivery amount to be 3 liters. During a concurrent observation and interview on 2/9/26 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 1, inside Resident 10's bedroom, LVN 1 examined the oxygen concentrator at Resident 10's bedside, LVN 1 stated the oxygen concentrator had been running at 3 liters per the concentrator gauge. During a review of Resident 10's Order Summary Report (OSR), dated 2/9/26, the OSR indicated, OXY [Oxygen]: Monitor O2 [Oxygen] Sats [saturation – amount of oxygen in the blood] every Shift. Goal to maintain O2 Stats [saturation] Greater Than 90%, every shift for PLEURAL EFFUSION [is abnormal accumulation of excess fluid in the pleural space, the thin, fluid-filled area between the lungs and the chest cavity wall, can cause significate quality of life impairment], life related to PLEURAL EFFUSION . Oxygen @(at) 2 L [liters]/min [minute] via [delivery through] nasal cannula continuously every shift related to PERSONAL HISTORY OF COVID-19 [respiratory infection affecting the lungs]. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2010, the P&P indicated, Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . Assessment Before administering oxygen, and while the resident is receiving oxygen therapy. 3. During a concurrent observation and interview on 2/11/26 at 10:04 a.m. with LVN 2, in Resident 58's room no dialysis emergency kit (emergency kit containing gloves, gauze, tape, torniquet and clamp) was available for use. LVN 2 was unable to locate the emergency kit in Resident 58's room. LVN 2 stated the kit is usually hanging on the wall behind the residents bed. During a concurrent observation and interview on 2/11/26 at 10:11 a.m. with LVN 4, in Resident 58's room no dialysis emergency kit hanging above A or B bed. LVN 4 stated she did not see the emergency kit. LVN 4 stated Resident 58 was moved from A bed to B bed and did not see the emergency kit hanging above either bed area's. LVN 4 Resident 58 should have an emergency kit in her room. During a review of Order Summary, (OS) dated 1/27/26, the OS indicated, Ensure Emergency Kit is placed at bedside (Gloves, Gauze, Tape, Torniquet, and clamp) every shift for Hemodialysis every shift. During a review of the facility's P &P titled, Comprehensive Care Plans, dated 2025 Revisions, the P & P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident . and timeframes to meet a resident's medical . psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview and record review, the facility failed to ensure one of four sampled Licensed Vocational Nurses (LVN) was qualified to provide residents care when LVN 1 was working without a current license. This failure had the potential for harm, compromise quality of care, and medication errors for all residents residing in the facility.Findings:During a review of LVN 1's employee file, the file indicated LVN 1 was hired on [DATE]. Licensure verification on file indicated LVN 1's license expired on [DATE]. During a review of LVN 1's work schedule dated 6/29 through [DATE], the work schedule indicated LVN 1 worked on 6/30, 7/5, 7/14, 7/15, 7/16, 7/17, 7/18, 7/21, 7/22, 7/23, 7/24, 7/25,7/29, 7/30, 7/31, 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, and 8/9. LVN 1 worked 22 days with an expired license.During an interview on [DATE] at 11:53 a.m. with Director of Nurses (DON), DON stated LVN 1's license had expired on [DATE]. DON reviewed LVN 1's work schedule dated 6/29 through [DATE] and confirmed LVN 1 had worked 22 days with an expired license. DON stated LVN 1 should not have been working without a current license.During a review of the facility's job description titled, Charge Nurse dated 2023, the job description signed by LVN 1 of acknowledgment on [DATE] indicated, Required Qualifications. Current unrestricted license as a Registered Nurse (RN) or Licensed Practical Nurse [also known as LVN] in practicing state.

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure for one of two sampled residents (Resident 1) when Attending Physician (AP) was not notified of Resident 1's refusal of ordered Buspirone (used to treat symptoms of anxiety such as fear, tension, and irritability) medication. This failure resulted in a physical altercation with Resident 2 and had the potential for adverse reactions including worsening in health and increased symptoms.Findings:During a review of Resident 1's Physicians Orders (PO), for the month of 4/25, 5/25, 6/25, and 7/25, the PO indicated, Buspirone HCl (hydrochloride) oral tablet 7.5 mg (milligram) give 2 tablets by mouth two times a day for anxiety MB (manifested by) unprovoked physical aggression towards staff and others. During a review of Resident 1's Electronic Medication Administration Record (EMAR), for the month of 4/25, the EMAR indicated Resident 1 refused the Buspirone medication 57 times. For the month of 5/25, the EMAR indicated Resident 1 refused the Buspirone medication 55 times. For the month of 6/25, the EMAR indicated Resident 1 refused the Buspirone medication 56 times and for the month of 7/26, the EMAR indicated Resident 1 refused the Buspirone medication 57 times. During a review of Resident 1's Progress Notes (PN), dated 7/21/25 at 4:28 p.m., the PN indicated, Res. (Resident 1) was witnessed to be yelling at (Resident 2) while he was passing by him in the hallway. (Resident 1) reaching over and grabbed (Resident 2's) arm and dug nails into skin, causing skin tear. During a concurrent observation and interview on 7/29/25 at 1:10 p.m., Resident 1 was observed sitting in a wheelchair in the middle of the hallway watching television. One on one Sitter standing nearby Resident 1 stated Resident 1 has behaviors, gets aggressive sometimes and can hit other residents, requiring a one-on-one sitter. Sitter stated on 7/21/25 Resident 1 reached and grabbed Resident 2 by the forearm really hard causing Resident 2's forearm to bleed. During a concurrent interview and record review on 7/29/25 at 2:46 p.m. with Director of Nurses (DON), DON reviewed Resident 1's PO and EMAR dated 4/1/25 through 7/29/25. DON confirmed Resident 1 had an order for Buspirone medication and refused the ordered Buspirone medication as listed above. DON reviewed Resident 1's PN and was unable to find documented evidence Resident 1's AP was notified of Resident 1's refusal to take the ordered Buspirone medication. DON stated it was the facility policy for AP to be notified of three consecutive medication refusal. DON confirmed policy was not followed. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 2/21, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): f. refusal of treatment or medications two (2) or more consecutive times: Acceptable POC and EOC for F0580 2486706 and 2486707 / 5D7511 exited on 7/3/2025 with compliance date of 7/7/25. POC elements included: inservice education on Change of Condition (COC) policy, Medical Records audits on COC daily, MRD or DON Designee will monitor SBAR/COC, RCA conducted, QAPI, DON overall responsibility of ensuring implementation of this POC.

Based on interview and record review, the facility failed to ensure the responsible party (R/P) was notified when there was a change of condition for one of three sampled residents (Resident 1). This failure resulted in the R/P being unaware of Resident 1's change of condition.Findings:During a review of Resident 1's S (situation) B (background) A (appearance) R (Review and Notify) Communication Form (SBAR-used to notify the physician of a change of condition), dated 6/14/25 at 11:24 p.m., the SBAR indicated, At 8:11 p.m. res (resident) was note (sic) with gurgling sounds to throat, upon assessment, it was noted that patient had burning sensation when urinating per patient, increased confusion per staff, and res stated throat hurts. MD (Doctor of Medicine) (physician name) made aware at 8:15 p.m. and made order to suction res prn (as needed) and for an ST (speech therapy) eval (evaluation). Advised staff and patient to increase fluids. There was no documentation the R/P was notified.During a concurrent interview and record review on 7/3/25 at 1:16 p.m. with Assistant Director of Nursing (ADON), ADON reviewed Resident 1's SBAR dated 6/14/25 and stated the R/P was not notified of the change of condition and she should have been.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when.there is a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to notify the physician of one of three sampled resident ' s change of condition when Resident 1 ' s blood sugar/glucose levels were above 200 (normal is 70 - 99 mg [milligrams]/dL [deciliter]) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being sent to the acute hospital and being admitted for dehydration (too little fluid in the body [can occur when the kidneys try to excrete sugar, in response to high blood sugar levels, thru urination leading to dehydration]), hyperglycemia (elevated blood sugar), and hypernatremia (elevated sodium level in the blood [can occur when there is an increase in urination related to high blood sugar and the kidneys lose more water than they retain]). Findings: During a review of the Physician Orders (PO), the PO indicated, Accu-check (device used to check a blood sugar) BID (twice a day) without coverage notify MD (Doctor of Medicine) if BS (blood sugar) less than 60 (mg/dL) or greater than 200 (mg/dL) .start date 4/21/25. During a review of Resident 1 ' s Weights and Vitals Summary (WVS), the WVS indicated the following results: 4/21/25 7:36 p.m. 387 mg/dL 4/21/25 11:49 p.m. 367 mg/dL 4/22/25 5:14 a.m. 308 mg/dL 4/22/25 7:10 p.m. 396 mg/dL 4/23/25 5:26 a.m. 407 mg/dL 4/23/25 8:58 a.m. 360 mg/dL 4/24/25 7:06 p.m. 372 mg/dL 4/25/25 7:06 p.m. 384 mg/dL. During a review of Resident 1 ' s S (Situation) B (Background) A (Appearance) R (Review and Notify) Communication Form [SBAR - a communication tool used between healthcare professionals i.e. between the nurse and physician] ' dated 4/26/25 at 12:30 a.m., the SBAR indicated, Resident has deep chest cough, elevated pulse (normal pulse is 60 - 100 beats per minute), temperature 102 (normal temperature is 98.6 degrees Fahrenheit [F - unit of measurement]).decision to transfer to acute (hospital) for evaluation. During a review of Resident 1 ' s ED Note Physician (EDNP - completed at the acute hospital), dated 4/26/25 at 12:59 a.m., the EDNP indicated, Biba (brought in by ambulance) from (facility name) for fever and non productice [sic] cough for a few days.CMP (comprehensive metabolic panel - blood test) with significant hypernatremia to 151 (normal is 135-145 milliequivalents per liter [mEq/L])), as well as hyperglycemia 532 (mg/dL).Given this patient ' s significant free water deficit (amount of water required to correct dehydration), hyperglycemia concerning for possible HHS (hyperosmolar hyperglycemic state - a serious complication of diabetes characterized by extremely high blood sugar levels.severe dehydration that is a life-threatening condition that requires immediate medical attention).Sodium level (concentration of sodium level in the blood) 4/26/25 at 1:47 a.m. 151.0 High (normal is 135-145 mEq/L]).Glucose level 4/26/25 at 1:47 a.m. 532 (mg/dL) critical.UA (urine test) glucose 4/26/25 at 1:48 a.m. > (greater than)=1000 abnormal.Final Diagnosis.hyperglycemia.dehydration.hypernatremia.Disposition.Admit. During a concurrent interview and record review on 5/9/25 at 12:23 p.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON stated on 4/21/25, 4/22/25, 4/23/25, 4/24/25 and 4/25/25 Resident 1 had blood sugar results that were above 200 mg/dL. DON was unable to provide documentation the physician was notified of the elevated blood sugar levels that were greater than 200 mg/dL. DON stated when Resident 1 ' s blood sugar was above 200 mg/dL the physician should have been notified right away. During a concurrent interview and record review on 5/14/25 at 4:26 a.m. with Registered Nurse (RN) 1, Resident 1 ' s clinical record was reviewed. RN 1 stated when Resident 1 ' s blood sugar on 4/22/25 at 5:14 a.m. was 308 mg/dL he did not notify the physician of the blood sugar result, and he should have. RN 1 stated on 4/23/25 when the blood sugar result was 407 mg/dL the physician was notified but he did not document. RN 1 stated he should have documented when the physician was notified. During a concurrent interview and record review on 5/14/25 at 8:12 p.m. with RN 2, Resident 1 ' s Medication Administration Record (MAR) dated 4/2025, was reviewed. Resident 1 ' s blood sugar was greater than 200 mg/dL on 4/22/25, 4/23/25, 4/24/25 and 4/25/25. RN 2 stated she did not notify the physician because she was unaware of the physician ' s order indicating the physician was to be notified for blood sugars greater than 200 mg/dL. RN 2 stated she did not notify the physician, and she should have. During a review of the facility ' s policy and procedure (P&P) titled Diabetes - Clinical Protocol) dated 11/2020, the P&P indicated, The Physician will order appropriate lab tests.and adjust treatments based on these results and other parameters.The physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/21, the P&P indicated, The nurse will notify the resident ' s attending physician or physician on call when there has been a(an).specific instruction to notify the physician of changes in the resident ' s condition.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) care plan was implemented when Resident 1 did not have a staff member with him at all times. This failure had the potential for Resident 1 to exhibit aggressive behaviors towards other residents. Findings: During a review of Resident 1's Care Plan (CP), dated 12/16/24, the CP indicated, (Resident 1) was physically aggressive striking out at others 1/5/25.Interventions.(Resident 1) to be 1:1 supervision at all times. During an observation on 1/29/25 at 1:40 p.m. in Resident 1's room, Resident 1 was standing up on the side of the bed. Resident 1 was alone in his room. During a concurrent observation and interview on 1/29/25 at 1:42 p.m. with Director of Nursing (DON), in Resident 1's room, Resident 1 was observed alone in his room. DON stated Resident 1 was supposed to have a 1:1 staff with him always. During an interview on 1/29/25 at 2:14 p.m. with Nursing Assistant (NA), NA stated she was the assigned 1:1 for Resident 1. NA stated when she went to break, she did not ask anyone to relieve her, and Resident 1 was left alone. NA stated she should have asked someone to relieve her when she left the room. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 3/22, the CP indicated, The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Quality Assurance and Performance Improvement (QAPI - data-driven, proactive approach to improving the quality of care and services in the facility). This failure had the potential for the facility to not recognize, identify, address and correct resident safety, care and outcomes for 37 of 37 sampled residents. Findings: During a concurrent interview and record review on 10/10/24 at 2:35 p.m. with Administrator, the facility's QAPI dated 2024 was reviewed. The last QAPI meeting was 9/2024. During the 1/2024 QAPI meeting completing nursing staff competencies, quality of care, incomplete employee files and nursing documentation audits were identified. Administrator stated there was no measurable data discussed for completing the nursing staff competencies. The QAPI plan was not effective. The Administrator stated the analytical data was not available to put in the Process Improvement Projects (PIPs).The QAPI reports indicated no measurable data that were being monitored and evaluated every month. The Administrator stated the QAPI goals are not measurable for all their QAPI plan. The Administrator stated, I'm not documenting that [analyzing data collected for QAPI]. We're lacking the analytical part of it. The Administrator stated their QAPI plan was not effectively being monitored. During a review of the facility's P&P titled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, the P&P indicated, The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Key component of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement. systematically analyzing underlying cause of systemic quality deficiencies. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan.

Based on interview and record review, the facility failed to ensure: 1) A Licensed Nurse did not share her Electronic Protected health information (EPHI-resident clinical record) access code) and leave Graduate Vocational Nurse (GVN, unlicensed nursing staff) 1 unsupervised while administering narcotics (addictive pain medications) for three of three sampled residents (Resident 51, Resident 63, and Resident 18). This failure resulted in unauthorized access to residents' protected health information, falsification of residents' medical record and the potential for medication errors. 2) Physician Orders were followed when licensed nurse did not document wound care treatment for three of three residents (Resident 51, Resident 63, and Resident 18). This failure had the potential for worsening of Resident 51, Resident 63 and Resident 18's wounds. Findings: 50409 1. During an observation on 10/7/2024 at 11:38 a.m. in the 400 hallway, GVN 1 was administering medications to residents without licensed nurse supervision. During a concurrent interview and record review on 10/10/24 at 11:53 a.m. with ADON, the following documents were reviewed: Resident 71's Medication Count Sheet (MCS), dated October 2024 Resident 37's MAR, dated 10/7/24, Resident 5's MAR, dated 10/7/24 Resident 5's Controlled Drug Record (CDR), dated 10/7/24 Resident 71's Medication Count Sheet (MCS), dated October 2024 indicated GVN 1 dispensed and signed off Resident 71's Morphine Sulfate (controlled medication used for pain management) on 10/7/24 at 10 a.m. without a supervising licensed nurse. ADON stated GVN 1 was not supposed to dispense controlled medications and sign off on the controlled medication sheet by herself. Resident 37's MAR, dated 10/7/24, indicated the initials of the ADON was used by GVN 1 when GVN 1 administered medications. ADON stated she was not with GVN 1 during medication administration. Resident 5's MAR, dated 10/7/24, indicated, Oxycodone HCL [narcotic pain medication] 5 mg [milligram]. The MAR indicated the initials of the ADON was used by GVN 1 when the GVN administered a controlled medication without supervision. ADON stated she was not with GVN 1 during medication administration. Resident 5's Controlled Drug Record (CDR), dated 10/7/24, indicated a signature of the GVN 1 was signed to administer the controlled drug without a witness and a licensed nurse to co-sign on 10/7/24 at 7:30 a.m. ADON stated GVN 1 was not supposed to dispense controlled medications and sign off on the controlled medication sheet by herself. ADON stated, The GVN [1] is using my sign in [access to EPHI]. ADON stated she does not know how the medications were administered under her initials 'CC'. ADON stated, I was not physically passing medications this week. I only have to be there if [GVN 1] needs direction, [but] narcotics and insulin I am there for [GVN 1]. ADON stated, It's a narcotic, that is [GVN 1's] signature, I was not with her. That is a narcotic, yes I should've been there. ADON stated, No, I am not there to give every dose of insulin. During an interview on 10/10/24 at 3:44 p.m. with DON, DON stated the GVN did not have an EPHI access because they were not licensed. DON stated the expectation was for GVNs to be supervised while using a licensed nurse's EPHI access. DON stated it was unacceptable for a GVN to document under another licensed nurse's credentials when the GVN was not being directly supervised. During a review of the facility's P&P titled, Informed Access Management, dated August 2024, the P&P indicated, The level of access will be based on requirements necessary for the employees or business associates to complete their necessary functions. During a review of the facility's job description (JD) for Graduate Vocational Nurse, dated 2020, the JD indicated, Prepares and administers medications under the supervision of Licensed Nurse as per physicians' orders and observes for adverse effects. During a review of the facility's P&P titled, Controlled Substances, dated November 2022, the P&P indicated, Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. 2) During a concurrent interview and record review on 10/9/24 at 2:02 p.m. with DON, Resident 51, Resident 63, and Resident 18's Treatment Administration Record (TAR), dated October 2024 were reviewed. The TAR indicated missing licensed nurse initials for the following residents: a. Resident 51's TAR indicated on 10/4/24 day shift was missing licensed nurse initials for Cleanse (R [Right]) inner elbow with normal saline, pat dry and apply moisture barrier cream and leave open to air. b. Resident 63's TAR indicated on 10/4/24 pm shift, 10/5/24 day shift, and 10/6/24 day and pm shift were missing licensed nurse initials for Cleanse with soap and water, pat dry, apply moisture barrier cream. c. Resident 18's TAR indicated on 10/4/24 day and evening shift, and 10/6/24 evening shift were missing licensed nurse initials for Cleanse and irrigate wound to Left Lateral ankle with NS [Normal Saline - cleaning solution], pat dry. d. Resident 6's TAR indicated on 10/4/24 PM shift, 10/5/24 day shift, 10/6/24 day shift & PM shift were missing licensed nurse initials for Cleanse w/ [with] NS pat dry and apply Zinc Oxide [medicated cream for skin protection] and leave open to air. DON stated the missing licensed nurse initials meant the treatments were not done. During a review of the facility's P&P titled, Wound Treatment Management, dated May 2022, the P&P indicated, Treatments will be documented on the Treatment Administration Record or in the electronic health record. 51320

Based on interview and record review, the facility failed to ensure an Advance Directive (AD-health care preferences, including decisions for end-of-life care) acknowledgement form was completed for ten of 20 sampled residents (Resident 443, Resident 40, Resident 20, Resident 6, Resident 37, Resident 51, Resident 18, Resident 43, Resident 54, and Resident 87). This failure had the potential to result in the residents' wishes or health choices not being honored. Findings: During a concurrent interview and record review on 10/10/24 at 8:42 a.m. with Admission Coordinator (AC), Resident 443's Advanced Directive Acknowledgement (ADA), dated 9/25/24 was reviewed. The ADA indicated, Resident 443 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 443 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:44 a.m. with AC, Resident 40's ADA, dated 7/17/24 was reviewed. The ADA indicated, Resident 40 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 40 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:45 a.m. with AC, Resident 20's ADA, dated 6/20/23 was reviewed. The ADA indicated, Resident 20 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 20 was offered/or received information on the right to formulate an AD. 51434 During a concurrent interview and record review on 10/10/24 at 8:46 a.m. with AC, Resident 6's ADA, dated 10/8/24 was reviewed. The ADA indicated, Resident 6 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 20 was offered/or received information on the right to formulate an AD. 51320 During a concurrent interview and record review on 10/10/24 at 8:47 a.m. with AC, Resident 37's ADA, dated 4/24/23 was reviewed. The ADA indicated, Resident 37 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 37 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:48 a.m. with AC, Resident 341's ADA, dated 10/8/24 was reviewed. The ADA indicated, Resident 341 had not completed an AD. AC stated the ADA form was incomplete. AC stated she was unable to provide documentation that Resident 341 was offered/or received information on the right to formulate an AD. 50409 During an interview on 10/8/24 at 8:07 a.m. with Resident 18, Resident 18 stated she did not remember being provided information on AD and would like further information on formulating an AD. During a review of Resident 18's Minimum Data Set (MDS - an assessment tool), dated 8/16/24, the MDS indicated Resident 18 had a BIMS (Brief Interview for Mental Status) score of 12 (score of 8 to 12 indicates moderate cognitive impairment). During a concurrent interview and record review on 10/8/24 at 1:18 p.m. with Social Services Supervisor (SSS), Resident 18's ADA, dated 8/13/24 was reviewed. The ADA indicated Resident 18 had not completed an AD. SSS stated she was unable to provide documentation that Resident 18 was offered/or received information on the right to formulate an AD. During an interview on 10/8/24 at 2:57 p.m. with Family Member (FM) 1, FM 1 stated neither he nor Resident 18 were provided information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:37 a.m. with AC, Resident 51's ADA, dated 10/8/24 was reviewed. The ADA indicated Resident 51 had not completed an AD. AC stated the ADA was incomplete. AC stated she was unable to provide documentation that Resident 51 was offered/or received information on the right to formulate an AD. 46958 During a concurrent interview and record review on 10/10/24 at 8:50 a.m. with AC, Resident 43's ADA, dated 10/8/24 was reviewed. The ADA indicated Resident 43 had not completed an AD. AC stated the ADA was incomplete. AC stated she was unable to provide documentation that Resident 43 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:52 a.m. with AC, Resident 54's ADA, dated 10/8/24 was reviewed. The ADA indicated Resident 54 had not completed an AD. AC stated the ADA was incomplete. AC stated she was unable to provide documentation that Resident 54 was offered/or received information on the right to formulate an AD. During a concurrent interview and record review on 10/10/24 at 8:55 a.m. with AC, Resident 87's ADA, dated 10/8/24 was reviewed. The ADA indicated Resident 87 had not completed an AD. AC stated the ADA was incomplete. AC stated she was unable to provide documentation that Resident 87 was offered/or received information on the right to formulate an AD. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated September 2022, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative.

Based on observation, interview and record review, the facility failed to ensure five of 18 sampled residents (Resident 33, Resident 50, Resident 64, Resident 67, and Resident 63) call lights were within reach. This failure had the potential for residents unable to call for assistance and potential for delaying care. Findings: During a concurrent observation and interview on 10/7/24 at 10:03 a.m. with Certified Nursing Assistant (CNA) 3, in Resident 33's room, Resident 33's call light was on the floor out of Resident 33's reach. CNA 3 stated the call light must have fallen on the floor, the call light should have been clipped to Resident 33's blanket and within Resident 33's reach. During a review of Resident 33's Minimum Data Set (MDS - an assessment tool), dated 8/9/24, the MDS indicated, Brief Interview for Mental Status (BIMS-cognition screening) score was 4 (score of 0-7 indicates severe cognitive impairment). The MDS indicated, under Functional Abilities and Goals, Resident 33 required maximal assistance for upper body dressing and rolling left to right indicating impairment with upper extremities. During a review of Resident 33's Care Plan (CP) dated 2/11/22, the CP indicated, Physical Functioning Deficit related to: ROM [range of motion] limitations, intervention: Call bell within reach. 44134 During a concurrent observation and interview on 10/7/24 at 10:46 a.m. with Restorative Nurse Assistant (RNA) 1, in Resident 50's room, Resident 50 was asleep on the bed with the call light on the floor. RNA 1 stated Resident 50 should have had the call light placed within Resident 50's reach. 50409 During a concurrent observation and interview on 10/7/24 at 10:07 a.m. with CNA 9 in Resident 64's room, Resident 64 was asleep on the bed with the call light on the floor. CNA 9 stated Resident 64 should have had the call light placed within Resident 64 's reach. During a review of Resident 64's MDS, dated [DATE], the MDS indicated, Resident 64 required substantial/maximal assistance (helper does more than half the effort) to total assistance with self-care and mobility. During a concurrent observation and interview on 10/7/24 at 10:07 a.m. with CNA 9, in Resident 67's room, Resident 67 was asleep on the bed with the call light on the floor. CNA 9 stated Resident 67 should have had the call light placed within Resident 67's reach. During a review of Resident 67's MDS, dated [DATE], the MDS indicated, Resident 67 required substantial/maximal assistance to total assistance with self-care and mobility. During a concurrent observation and interview on 10/7/24 at 10:10 a.m. with Resident 63, in Resident 63's room, Resident 63 was lying on the bed with the call light on the floor. Resident 63 stated she could not find the call light. During a concurrent observation and interview on 10/7/24 at 10:12 a.m. with Graduate Vocational Nurse (GVN, unlicensed nurse) 1, in Resident 63's room, Resident 63's call light was on the floor. GVN 1 stated Resident 63 should have had the call light placed within Resident 63's reach. During a review of Resident 63's MDS, dated [DATE], the MDS indicated, Resident 63 had a BIMS score of 11 (score of 8 to 12 indicates moderate cognitive impairment). The MDS indicated, Resident 63 required set up to substantial/maximal assistance with self-care and mobility. During a review of Resident 63's CP, dated 10/31/22, the CP indicated, Physical functioning deficit. Interventions Call bell within reach. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 2023, the P&P indicated, Staff will ensure the call light is within reach of resident and secured, the call system will be accessible to residents while in their bed or other sleeping accommodation within the resident's room.

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 47, Resident 48, and Resident 51), had Restorative Nurse Assistant (RNA - therapy for residents with limited mobility) program orders. This failure had the potential for Resident 47, Resident 48, and Resident 51 to have an avoidable reduction in range of motion. Findings: During a concurrent observation and interview on 10/7/24 at 10:12 a.m. in Resident 47's room, Resident 47 stated he gets changed in his bed. During an observation on 10/7/24 at 10:22 am in Resident 48's room, Resident 48 was watching tv. Resident 48 was non-verbal. During a concurrent interview and record review on 10/9/24 at 11:52 a.m. with the Director of Rehabilitation (DOR), Resident 47 and Resident 48's Order Summary Report (OSR), dated October 2024 was reviewed. DOR stated neither Resident 47 nor Resident 48 had orders for RNA program. During a concurrent interview and record review on 10/9/24 at 3:24 p.m. with Assistant Director of Nursing (ADON), Resident 47 and Resident 48's OSR, dated October 2024 was reviewed. ADON stated there were no RNA orders for both residents. ADON stated both Resident 47 and Resident 48's orders should have been renewed. During a review of Resident 47's Care Plan (CP), dated 10/9/24, the CP indicated, Resident 47 has actual contractures/impaired functional range of motion of BLE [bilateral lower extremities] and right-hand related hemiplegia [inability to move one side of the body] and hemiparesis [weakness on one side of the body] .Restorative Nursing: RNA Program (R)PROM [Right Passive Range of Motion - staff does the effort to move extremities] or prolonged stretching for all three joints in all planes of motion. During a review of Resident 48's CP, dated 7/31/24, the CP indicated, Resident 48 has actual impairment in functional joint mobility related to decreased ability to self-perform ADLs [Activities of Daily Living] independent, inactivity resulting from a medical condition .RNA program (L) AAROM [Left Active Assisted Range of Motion - staff assisted with some resident assist to move extremities] for all three joints in all planes of motion 2 sets of 10. 50409 During an observation on 10/7/24 at 10:15 a.m. in Resident 51's room, Resident 51 was on the bed and had contractures on both hands. Neither contracted hands had palm protectors. During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated 8/9/24, the MDS indicated, Resident 51 had functional limitation in range of motion on both upper extremities. During a review of Resident 51's CP, dated 7/30/24, the CP indicated, Actual impairment in functional joint mobility. Interventions. RNA to apply devices [palm protectors] to affected joints as ordered. During a concurrent interview and record review on 10/9/24 at 9:32 a.m. with DOR, Resident 51's Order Listing Report (OLR), dated 10/9/24 was reviewed. The OLR indicated, Resident 51 had an RNA order for palm protectors for 90 days. The OLR indicated, the RNA order was ordered on 5/3/24. DOR stated the RNA order was completed in August 2024. DOR stated, It [RNA order] is something that should have been renewed to protect the integrity of the skin because of her contracted digits [fingers] and nail length we don't want any pressure wounds on the palm also to decrease infection and wound. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated July 2017, the P&P indicated, 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility.

Based on interview and record review, the facility failed to complete performance evaluations for three of eight sampled employees (Certified Nursing Assistant [CNA] 3, CNA 5 and Licensed Vocational Nurse [LVN] 1. This failure had the potential for employees not meeting performance standards providing care for residents. Findings: During a concurrent interview and record review on 10/9/24 at 11:53 a.m. with Director of Staff Development (DSD), CNA 3's employee personnel record (EPR), undated was reviewed. The EPR indicated, CNA 3's date of hire was on 8/1/24. DSD stated she was unable to find CNA 3's competency checklist. DSD stated CNA 3 should have had a competency checklist completed prior to working on the floor alone. During a concurrent interview and record review on 10/9/24 at 12:06 p.m. with DSD, CNA 5's EPR, undated was reviewed. The EPR indicated, CNA 5's most recent competency checklist was completed on 7/7/23. DSD stated, Yes [CNA 5] is due and should have had her annual review and competency checklist completed last July. During a concurrent Interview and record review on 10/9/24 at 2:47 p.m. with DSD, LVN 1's EPR, undated was reviewed. The EPR indicated, LVN 1's date of hire was on 7/1/24. DSD stated she was unable to find LVN 1's competency checklist. DSD stated LVN 1 should have had a competency checklist completed prior to working on the floor alone. DSD stated there should be a competency checklist completed on hire, prior to working on the floor alone and annually. During an interview on 10/9/24 at 4:41 p.m. with Assistant Director of Nursing (ADON), ADON stated LVN 1 did not have a competency checklist completed upon hire. ADON stated LVN 1 should have had a competency checklist completed prior to working on the floor. Facility's policy and procedure on staff competency was requested on 10/9/24 at 4:45 p.m. Facility failed to provide requested document.

Based on interview and record review, the facility failed to ensure social services assessments (SSA) were completed quarterly (every three months) for nine of 19 sampled residents (Resident 51, Resident 63, Resident 71, Resident 44, Resident 27, Resident 6, Resident 54, Resident 47, and Resident 48). This failure had the potential for the delay in providing medically related social services for the residents affecting their psychosocial needs. Findings: During a concurrent interview and record review on 10/9/24 at 9:41 a.m. with Social Services Supervisor (SSS), Resident 51, Resident 63, Resident 71, Resident 44, Resident 27, Resident 6, Resident 54, Resident 47, and Resident 48's SSAs were reviewed. The SSAs indicated they were not completed every three months for the following residents: a. Resident 51's last SSA was completed on 8/11/23 (11 months overdue). b. Resident 63's last SSA was completed on 4/20/23 (15 months overdue). c. Resident 71's last SSA was completed on 8/25/23 (11months overdue). d. Resident 44's last SSA was completed on 6/2/23 (13 months overdue). e. Resident 27's last SSA was completed on 4/20/23 (15 months overdue). f. Resident 6's last SSA was completed on 6/2/23 (13 months overdue). g. Resident 54's last SSA was completed on 1/8/24 (6 months overdue). h. Resident 47's last SSA was completed on 3/29/23 (16 months overdue). i. Resident 48's last SSA was completed on 3/22/23 (16 months overdue). SSS stated there should have been SSAs done every three months. During a review of the facility's job description (JD) for Social Services, dated 12/5/12, the JD indicated, Completes social and emotional assessments of residents on a quarterly [every three months] basis. During a review of the facility's policy and procedure (P&P) titled, Social Services, dated February 2023, the P&P indicated, The social worker, or social service designee, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident.

Based on interview and record review, the facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for the month of July 2024. This failure had the potential for residents' adverse health outcomes due to physician was not notified of the pharmacy recommendations. Findings: During a review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident (PSHUR), dated 7/1/24 until 7/28/24, the PSHUR indicated, there were 99 pharmacy recommendations the facility did not act on. There were no documentation of notification of the physician. During an interview on 10/9/24 at 11:13 a.m. with Director of Nursing (DON), DON stated the July 2024 pharmacy recommendations were not acted upon. DON stated she did not check if the pharmacy recommendations in July 2024 were completed. During a review of the facility's Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response (CPMRRARLFR), dated 7/1/24 until 7/28/24, the CPMRRARLFR indicated, there were 55 pharmacy recommendations which were not acted on. During an interview on 10/9/24, at 11:14 a.m. with DON, DON stated the Assistant Director of Nursing (ADON) did not complete the CPMRRARLFR in July 2024. DON stated she did not check if the CPMRRARLFR was completed. During a review of the facility policy and procedure (P&P) titled, Medication Regimen Review dated 2024, the P&P indicated, Facility staff shall act upon all recommendations according to the procedures for addressing medication regimen review irregularities.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the plan of care was followed when the facility failed to use a Hoyer lift ([a commonly use brand] mechanical lift are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical support) for one of four sampled residents (Resident 1) during transfer from her bed to the wheelchair. This failure resulted in Resident 1 falling to the floor, sustaining a right ankle fracture (broken bone). 2. Ensure one of four sampled residents (Resident 2) was transferred to the bathroom by a qualified staff. This failure resulted in Resident 2 falling to the bathroom floor, sustaining a left shoulder fracture. Findings: 1. During an interview on 3/15/23, at 10:10 AM, with Director of Nurses (DON), DON stated, on 3/9/23, at approximately 8 AM, Certified Nursing Assistant Students (CNAS) 1 and CNAS 2, transferred Resident 1 from her bed to the wheelchair without the use of a Hoyer lift. During the transfer, Resident 1's knees buckled (bend), and a pop was heard in Resident 1's right ankle. CNAS 1 and CNAS 2 then eased Resident 1 to the floor. DON stated, on 3/9/23, Resident 1 sustained a right ankle fracture. During a concurrent observation and interview on 3/15/23, at 11:33 AM, in Resident 1's room, Resident 1 was noted lying in bed. Resident 1 stated, I had the two girls [CNAS 1 and CNAS 2] stand me up and just two seconds of standing, my knees gave out and I slid unto the floor. During an interview on 3/15/23, at 1:17 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 required two-person assistance with transfers using a Hoyer lift. LVN 1 stated, Resident 1 had upper body strength but doesn't have a lot of strength in her lower legs. LVN 1 stated, Resident 1's fall incident on 3/9/23, could have been prevented if a Hoyer lift was used to transfer Resident 1 from the bed to the wheelchair. During an interview on 3/15/23, at 1:18 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had worked with Resident 1 for approximately six months and was very familiar with Resident 1's care. CNA 1 stated, Resident 1 could not bear weight and required two-person assistance with the use of a Hoyer lift with transfers. During an interview on 3/15/23, at 1:25 PM, with CNA 2, CNA 2 stated, he had worked with Resident 1 for approximately nine months and was very familiar with Resident 1's care. CNA 2 stated, Resident 1 was unable to bear weight and required two-person assistance in transferring from the bed to the wheelchair using a Hoyer lift. CNA 2 stated, Resident 1's fall incident on 3/9/23, could have been prevented if a Hoyer lift was used during the transfer from the bed to the wheelchair. During an interview on 3/15/23, at 1:45 PM, with Physical Therapy Assistant (PTA), PTA stated, Resident 1 was Weak.unsafe.we recommended Hoyer lift during transfer. PTA stated, attempts were made for Resident 1 to walk but once we started the session, she couldn't, her knees would start buckling [bending]. During an interview on 3/15/23, at 2:08 PM, with CNAS 1, CNAS 1 stated, on 3/9/23, Resident 1 requested to be changed and dressed. CNAS 1 stated, Resident 1 was on the heavy side, and she asked CNAS 2 to help her transfer Resident 1 from the bed to the wheelchair. CNAS 1 stated, she stood behind Resident 1's wheelchair to prevent the wheelchair from rolling back while she observed CNAS 2 transfer Resident 1 from the bed to the wheelchair. CNAS 1 stated, [CNAS 2] had her [Resident 1] in a sitting position on the edge of the bed with gait belt [assistive device used to transfer residents from one location to another] around her waist.she [Resident 1] was able to stand but she started saying my knees are giving out.she [CNAS 2] tried to lift her [Resident 1] but she was too heavy, so she [CNAS 2] just placed her [Resident 1] to the ground. CNAS 1 stated, she did not know Resident 1 required a Hoyer lift to transfer. During an interview on 3/15/23, at 4:04 PM, with CNAS 2, CNAS 2 stated, on 3/9/23, she went to Resident 1's room with CNAS 1. CNAS 2 stated, after they (CNAS 1 and CNAS 2) changed Resident 1's adult brief and clothes, they (CNAS 1 and CNAS 2) attempted to transfer Resident 1 from the bed to the wheelchair. CNAS 2 stated, She [Resident 1] was telling us she was a little scared and nervous.she said she needed a sling [used for safe lifting], we didn't know what it was for at first, we kept trying to stand her and at the last try, she started falling, her leg went behind her.she was wobbly [unsteady] when we stood her up. CNAS 2 stated, she did not know Resident 1 required a Hoyer lift with transfers. During an interview on 3/15/23, at 4:23 PM, with Student Instructor (SI), SI stated, the students had only been at the facility for two days. SI stated, on 3/9/23, all students were instructed to only answer call lights. SI stated, My students cannot transfer anybody without me or CNA in the facility present. SI stated, both CNAS 1 and CNAS 2 have not been signed off on their transferring competency. SI stated, They [CNAS 1 and CNAS 2] should not have transferred her [Resident 1]. During a concurrent interview and record review on 5/9/23, at 11:37 AM, with DON, Resident 1's Care Plan (CP), dated 10/28/21, was reviewed. The CP indicated, I have a physical functioning deficit related to generalized weakness. Intervention included Transfer assistance of 2 person assist with use of Hoyer for all transfers. DON confirmed the findings and stated Resident 1 required a Hoyer lift for transfers. During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool) dated 1/18/23, the MDS indicated, Resident 1 had a BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 12 (score of 8-12 moderately impaired cognition). The MDS indicated, Resident 1 required extensive assistance with two+ person physical assist for transfer [how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position.]. Resident 1 was Not steady, only able to stabilize with staff assistance when moving from seated to standing position. During a review of Resident 1's right ankle Radiology Report (RR), dated 3/9/23, the RR indicated, Findings: .There are fractures of the distal tibial and fibular diametaphysis [ankle fracture]. 2. During an interview on 4/13/23, at 9:27 AM, with DON, DON stated, on 4/3/23, Resident 2 was assisted by the one to one sitter (Hospitality Aid [HA 2] also known as one to one sitter [staff whose role is to provide one to one observation to a resident for a period of time]) to the bathroom. DON stated, Resident 2 attempted to get up, fell , and sustained a left shoulder fracture. During a concurrent observation and interview on 4/13/23, at 9:45 AM, with Resident 2, in the activity room, Resident 2 was observed wearing a black sling (used to ease pain, support healing and protect the arm from further injury) on her left arm. Resident 2 stated, she did not know what happened to her left arm. Resident 2 stated, I must have broken it somehow. During a concurrent observation and interview on 4/13/23, at 9:50 AM, with HA 1, in the activity room, HA 1 was sitting right behind Resident 2. HA 1 stated, Resident 2 was unsteady on her feet, and it was her (HA 1) job duty as the one to one sitter to keep an eye on her [Resident 2], make sure she doesn't just get up and go. HA 1 stated, when Resident 2 needed to use the bathroom, she would notify a CNA for assistance. HA 1 stated, she was not trained to provide resident care, including assisting Resident 2 to the bathroom. During an interview on 4/13/23, at 10:03 AM, with LVN 2, LVN 2 stated, on 4/3/23, she heard screaming coming from Resident 2's room. LVN 2 stated, upon entering Resident 2's room, she noted Resident 2 alone in the bathroom floor with Resident 2's head towards the door. LVN 2 stated, Resident 2's assigned one to one sitter (HA 2) had taken Resident 2 to the bathroom, transferred Resident 2 on the toilet, and stood outside the bathroom door. LVN 2 stated, Resident 2 was alert to self, was impulsive, had no safety awareness, and was a high risk for falls. LVN 2 stated, HA 2 should not have assisted Resident 2 to the bathroom by herself. During an interview on 4/13/23, at 11:26 AM, with DON, DON stated, HA 2 did not ask for assistance when Resident 2 needed to use the bathroom on 4/3/23. DON stated, HA 2 was not trained to assist and/or transfer residents. DON stated, HA 2's job duty included providing supervision, protection, and safety of the resident they were (HA) assigned one to one. During an interview on 4/13/23, at 3:30 PM, with HA 2, HA 2 stated, on 4/3/23, she was in the dining room with Resident 2, and Resident 2 needed to use the bathroom. HA 2 stated, she pushed Resident 2 back to her room, hoping to find a CNA along the way to assist with Resident 2. HA 2 stated, she was unable to find any CNA and she decided to take Resident 2 in the bathroom and transfer Resident 2 to the toilet by herself. HA 2 stated, she had instructed Resident 2 to activate the call light once done and she (HA 2) stepped outside the bathroom door. HA 2 stated, she heard Resident 2 making noises, and when she looked inside the bathroom, Resident 2 had already fallen to the floor. HA 2 stated, she was not trained to provide resident care including transferring. HA 2 stated, The rule has always been not to do any resident care.to get a CNA or use a call light for help. During a concurrent interview and record review on 5/5/23, at 9:59 AM, with DON, the Hospitality/Sitter job description, undated, was reviewed. DON confirmed the findings and stated the Hospitality/Sitter job description did not include transferring residents. During a review of Resident 2's Progress Notes (PN), dated 4/3/23 at 2:06 PM, the PN indicated, Resident 2 had a fall incident in the bathroom, Resident 2 was noted to be laying on stomach with legs extended out.had pain to left shoulder.was unable to move affected extremity [left shoulder]. During a review of Resident 2's CP, date initiated on 6/22/21, the CP indicated, Resident 2 was At high risk for falls related to history of falls, unsteady gait. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had a BIMS score of 10 (moderately impaired cognition). The MDS indicated, Resident 2 was Not steady, only able to stabilize with staff assistance when moving on and off toilet. During a review of Resident 2's left shoulder RR, dated 4/3/23, the RR indicated, Findings: .Transverse left humeral neck fracture [left shoulder fracture]. During a review of the facility's policy and procedure (P&P) titled, Safe Resident Handling/Transfers, dated 5/1/22, the P&P indicated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident.All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on interview and record review, the facility failed to assess, report, and document changes when skin issues were first identified on 3/17/21, for one of four sampled residents (Resident 1). This failure resulted in Resident 1's delayed treatment, development of gangrene (dead tissue caused by an infection or lack of blood flow), hospitalization , and amputation of Resident 1's left hallux (great toe) and left second toe. Findings: During an interview on 3/30/21, at 2:53 PM, with Resident 1's Family Member (FM) 1, FM 1 stated Resident 1 had been at the facility for approximately one month. FM 1 stated the facility did not make FM 1 aware of any concern or issues regarding Resident 1's left foot. FM 1 stated, on 3/22/21, FM 2 visited Resident 1 at the facility and had noted Resident 1's legs to be real dry, his left foot had scabs. FM 1 stated he notified the facility on 3/22/21, spoke to a charge nurse, and inquired about Resident 1's left foot but the charge nurse didn't know anything about it [left foot]. FM 1 stated Resident 1 was transferred to the acute hospital on 3/24/21 and had undergone amputation to his left foot great toe and left second toe. FM 1 stated, I just don't understand how they [the facility] didn't see that. During a review of Resident 1's shower sheet dated 3/17/21, an outline of a human body had a line between the left great toe and second toe with the words hand-written slight bigger. The shower sheet's signature line, for the Charge Nurse (Licensed Vocation Nurse [LVN] - nurse in charge) on the bottom of the sheet had no signature, it was left blank. During an interview on 4/7/21, at 12:09 PM, with Certified Nursing Assistant (CNA), CNA stated, on 3/17/21, he assisted Resident 1 during his shower and saw Resident 1's left foot great toe and left second toe to be different, looked bigger. CNA stated, he documented the observation on Resident 1's shower sheet and placed the shower sheet in a box located in the nurses' station for the assigned nurse to review. CNA stated, he does not recall whether the assigned nurse had assessed Resident 1's left foot and stated, The sheet would have been signed by the nurse if the assessment was done. During a concurrent interview and record review on 4/7/21, at 12:41 PM, with Director of Staff Development (DSD), Resident 1's shower sheet, dated 3/17/21 was reviewed. DSD stated, it was the facility practice for charge nurses to review residents' shower sheet before the end of the shift. DSD stated, the Charge nurse looks at it [shower sheet], signs it acknowledging it was reviewed. If there is a skin issue noted on the shower sheet Charge Nurse must do a Change of Condition (COC), notify MD [medical doctor] and RP [responsible party], create a care plan, start a treatment, and must document on nurses note of the finding. DSD stated the charge nurse should have signed Resident 1's shower sheet and assessed Resident 1. DSD reviewed Resident 1's medical record. DSD was unable to find documented evidence the charge nurse had assessed Resident 1's left foot, was unable to find a COC note, care plan, treatment, or nurse's note. During a concurrent interview and record review on 4/7/21, at 12:46 PM, with Assistant Director of Nurses (ADON), Resident 1's medical record was reviewed. ADON was unable to find documented evidence of an assessment, COC note, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON stated she had reviewed Resident 1's shower sheet, dated 3/17/21. ADON stated, The assigned nurse should have reviewed Resident 1's shower sheet, signed it and assessed his [Resident 1] left foot. During a concurrent interview and record review on 4/7/21, at 1:15 PM, with Director of Nurses (DON), DON reviewed Resident 1's medical record. DON stated the charge nurse should have reviewed and signed Resident 1's shower sheet, dated 3/17/21, and assessed Resident 1. DON stated, It looks like the shower sheets were being done but nobody seems to be looking at it. DON was unable to find documented evidence Resident 1's left foot was assessed on 3/17/21. During an interview on 4/12/21, at 1:49 PM, with LVN, LVN stated, upon receipt of the residents' shower sheets from the CNAs, the charge nurse would sign off the shower sheets acknowledging the shower sheet was reviewed. LVN stated, If there is a new skin issue, we do a COC, notify family/MD [Medical Doctor], notify treatment nurse as well so she can take a look and make sure the treatment started is ok. LVN stated she does not recall reviewing Resident 1's shower sheet dated 3/17/21 and stated, If I did, I would have signed it. During a review of Resident 1's Nurses Notes (NN), dated 3/23/21, (6 days later) the NN indicated discoloration to left foot . dark/black/brown/dry tissue noted to top distal end of the great and second toe . At top lateral side of left foot, excessive dryness and cracked skin is noted. Brown and red in color. Scant serosanguinous [yellowish fluid draining from wound] drainage. During a concurrent interview and record review on 4/21/21, at 1:19 PM, with Treatment Nurse (TN), the NN, dated 3/23/21, and Resident 1's shower sheet, dated 3/17/21, were reviewed. TN stated, on 3/23/21, at approximately 5 PM, she was made aware of the discoloration to Resident 1's left foot. TN stated, she assessed Resident 1's left foot and noted what was documented on the 3/23/21 NN. TN stated, she was not aware of Resident 1's skin issue noted on Resident 1's shower sheet, dated 3/17/21. TN stated the assigned charge nurse should go and assess . they [charge nurse] should have done a COC, notify MD, RP, put an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Alteration in Respiratory care plan, initiated on 2/19/21, interventions included Observe feet and hands for [CONDITION(S)], warmth, and color. If increased [CONDITION(S)] or significant discoloration noted, notify MD. During a concurrent interview and record review on 5/14/21, at 9:25 AM, with Nurse Practitioner (NP), NP stated, he visited Resident 1 at the facility on both 3/19/21, and 3/23/21. NP stated face-to-face visits included reviewing residents' medical records, visiting, and talking with residents, and assessing residents. NP stated when the charge nurse made him aware of concerns for a resident, he would do a thorough head-to-toe assessment, otherwise he only performed a quick assessment wherever the resident was at the time of visit including their room, hallway, etc. NP stated, If they [Residents] are in the hallway I will briefly look and talk to the patient. NP reviewed Resident 1's physical exam note dated 3/19/21 and 3/23/21 and stated he had documented Resident 1 having no rash or bruising. NP stated the charge nurse did not make him aware of Resident 1 having any skin issues and he did not assess Resident 1's left foot on either 3/19/21 or 3/23/21. During a review of Resident 1's Emergency Documentation, dated 3/24/21, the Emergency Documentation indicated, Examination demonstrates left hallux and left second toe dry gangrene and minimally erythematous [skin redness] left foot with eschar [a dry dark scab] formation on the dorsum [bottom, sole] of the foot. Patient reports that symptoms began 3 weeks ago. During a review of Resident 1's hospital Operative Report, dated 3/29/21, the Operative Report indicated, Resident 1 was diagnosed as having gangrene to left foot and underwent Left foot great toe and left second toe amputation. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2017, the P&P indicated, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to protect Resident 1 from verbal abuse, which caused the resident to become scared. Findings: During an interview with the Administrator on 7/16/12 at 11:15 AM, he stated the facility's investigation verified that Certified Nursing Assistant (CNA) A had used foul language while taking care of Resident 1, but he felt it was directed at the situation and not the resident. During an interview with Resident 1 on 7/16/12 at 11:40 AM, she stated CNA A came into her room to help her to the restroom. She stated when CNA A saw Resident 1 had soiled herself, she started using foul language. Once they were in the restroom, she stated CNA A continued to use foul language while she was cleaning her up. She stated, "I knew she (CNA A) was upset about something, I didn't ask what was wrong. I didn't want her to get more upset. I felt scared." The personnel file for CNA A was reviewed on 7/19/12 at 1 PM. The performance appraisal for CNA A, written by the Director of Nursing (DON) dated 2/23/12, read "Need to work on interpersonal relationship with residents." A memorandum from the DON and administrator for CNA A dated 7/3/12, read "Spoke with employee regarding resident interaction during cares and maintaining composure." During an interview with CNA A on 7/19/12 at 3:15 PM. She stated when she went into Resident 1's room, she had feces all over the bed, her clothes, and herself. She stated, "When we were in bathroom, (Resident 1) kept using the toilet paper to clean herself up. I told her a couple of times not to do that and wait till I could get some wash cloths but she kept doing it." When asked if she used foul language during the incident, she stated, "I don't recall using that language, I don't recall." The clinical record for Resident 1 was reviewed on 7/19/12 at 3:05 PM. The history and physical written by the attending physician, for Resident 1 dated 1/2/12, read "This resident has the capacity to understand and make decisions." The quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) for Resident 1 dated 6/26/12, indicated Resident 1 had minimal cognition (the mental faculty of knowing, which includes perceiving, recognizing, conceiving, judging, reasoning, and imagining) problems with a score of 14 out of 15 possible points. This MDS also indicated Resident 1 was able to make her self understood and had the ability to understand others. Also, according to this MDS, she did not have any problems with [MEDICAL CONDITION], mood, or behaviors. The facility policy and procedure titled "Reporting Abuse to Facility Management" undated, read, "Our facility will not condone resident abuse by anyone, including staff members. . . To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability."