Every finding on record at Grand Trace Health and Rehabilitation

Based on observation, record review, facility policy review and interviews, the facility failed to prevent the potential for spread of infections as evidenced by not implementing Enhanced Barrier Precautions (EBP) during wound care for one (1) of three (3) sampled residents with pressure injuries. Resident #3Findings Included:Record review of the facility policy titled, Pressure Injury Prevention and Management with a review/revision date of 11/07/25 revealed, This facility is committed to the prevention of avoidable pressure injuries.and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Record review of the facility policy titled, Clean Dressing Change with a review/revision date of 11/0725 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross-contamination.Record review of the Care Profile revealed an order dated 1/20/26 for EBP- r/t (related to) wounds. On 3/31/26 at 12:40 PM, observation revealed that as Registered Nurse (RN) #1 provided wound care to the open pressure sore on the right ankle and heel and pressure area on the left ankle without donning (putting on) a gown. On 4/01/26 at 11:10 AM, during an interview the Director of Nurses (DON) revealed she expected the nurses to be provide all wound care in a manner according to current standards of infection control and prevention, She confirmed that the facility had an ample supply of all personal protective equipment (PPE) required for care of residents on EBP and she expected staff to use the appropriate PPE for direct care.On 4/01/26 at 12:12 PM, during an interview the Staff Development Coordinator stated that she provided staff with in-service training monthly and as needed and provided orientation training with newly hired nursing staff. She stated that hand hygiene and PPE competency checkoffs were required for nurses' staff during their orientation, prior to working directly with residents. She stated that RN #1 had completed competency checkoff for wound care on 3/31/26.On 4/01/26 at 1:00 PM, during an interview Registered Nurse (RN) #1 revealed that Resident #3 had a pressure ulcer on each of his outer ankles and that EBP were in place for direct contact care for Resident #3. She stated that she was not aware of the requirements for direct care of residents with open wounds or EBP. She confirmed that Resident #3 had printed signage posted on the door with a list and pictures of necessary PPE needed, a list of interactions that required the PPE and that she had not worn a gown for wound care provided for Resident #3 on 3/31/26. On 4/01/26 at 4:30 PM, during an interview the Administrator revealed he expected the nurses to provide care, including pressure sore treatments in a manner to prevent infections.Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 8/05/25 and the resident had diagnoses of aphasia, dysphagia, cerebral infarction (stroke), PRESSURE ULCER (PU) OF LEFT HEEL, UNSTAGEABLE, PRESSURE ULCER OF RIGHT HEEL, UNSTAGEABLE, both added to diagnosis information on 12/12/25 and PRESSURE ULCER OF RIGHT ANKLE, UNSTAGEABLE added to diagnosis information on 12/5/2025.Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment and that the resident had four (4) pressure ulcers at the time of the assessment.

Based on observation, interview, record review, and facility policy review the facility failed to ensure staff provided incontinent care using proper infection control techniques for one (1) of six (6) sampled residents. Resident #3. Findings Included:Record review of the facility policy titled, Incontinence with a review/revision date of 11/07/25 revealed, .4. Residents that are incontinence of bladder or bowel will receive appropriate treatment to prevent infections.Record review of the Skill Competency Assessment: Perineal Care dated 6/19/25 and signed by Certified Nursing Assistant (CNA) #1 revealed, . Male Resident.b) Wash penis with peri wash (add directly to wash cloth), soap and water or disposable peri-wipes, moving in a circular motion form the tip of the penis using downward strokes.c) Using a fresh wash cloth clean and rinse the scrotal area. 10. Clean anal area with peri-wash and clean washcloth or disposable peri wipes, using front to back strokes without contaminating perineal area.On 3/31/26 at 12:15 PM, during an observation revealed during incontinent care, CNA #1 took three premoistened disposable wipes and wiped Resident #3's penis and anterior (front) perineal area front to back resulting in visual discoloration of the wipes and then wiped back and forth three (3) more times without changing sides of the wipes or changing wipes with the soiled wipes. CNA #1 then discarded the soiled wipes, got three more premoistened disposable wipes and wiped Resident #3's rectal area back and forth (3) times and then wiped his scrotum with the same wipes.On 3/31/26 at 12:25 PM, during an interview CNA #1 that she did not verbally respond when asked if she was aware of the correct procedure or facility protocol for incontinence care.Record review of the Kardex Report dated 4/01/26 for Resident #3 revealed Resident care interventions for Resident #3 included .Toileting Hygiene: Helper is doing all of the task.Bed Mobility Rolling Left and Right: Helper performs more than 50% (fifty percent) of the task.Toilet Transfer: Not attempted d/t (due to) medical condition.Toileting: Clean peri area with each incontinence episode. On 4/01/26 at 11:10 AM, during an interview the Director of Nurses (DON) stated she expected the nurses to supervise the care of residents and she expected the CNA s to provide incontinence care in a manner that would prevent infection, including wiping only front to back (1) time with clean surface of the cleaning cloth (washcloth or premoistened disposable wipe) and then ensuring each wipe was accomplished with a clean surface. She confirmed that wiping back and forth multiple times with soiled cleaning surface could lead to urinary tract infection.On 4/01/26 at 12:12 PM, during an interview the Staff Development Coordinator stated that she provided staff with in-service training monthly and as needed, and provided orientation training with newly hired nursing staff, CNAs and nurses. She explained that competency checkoffs on incontinence care procedures were required for all CNAs during their first (90) days of employment at the facility and that CNA #1 had successfully completed competency checkoff on 6/19/25. She said competencies were repeated annually.On 4/01/26 at 4:30 PM, during an interview the Administrator revealed he expected the nurses to supervise the care of the residents and that incontinent residents would receive care in a manner to prevent infections.Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 8/05/25 and the resident had diagnoses of aphasia, dysphagia, cerebral infarction (stroke), PRESSURE ULCER (PU) OF LEFT HEEL, UNSTAGEABLE, PRESSURE ULCER OF RIGHT HEEL, UNSTAGEABLE, both added to diagnosis information on 12/12/25.Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/26 for Resident #3 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment and that the resident had four (4) pressure ulcers at the time of the assessment.

Based on observation, record review, facility policy review and interviews, the facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer and prevent infection for one (1) of three (3) sampled residents with pressure injuries. Resident #3Findings Included:Record review of the facility policy titled, Pressure Injury Prevention and Management with a review/revision date of 11/07/25 revealed, This facility is committed to the prevention of avoidable pressure injuries.and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Record review of the facility policy titled, Clean Dressing Change with a review/revision date of 11/0725 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and /or cross-contamination.12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. (that is) clean outward from the center of the wound) .Record review of the Care Profile under the clinical section revealed orders for Resident #3 dated 12/12/2025 to Cleanse pressure ulcer to right lateral foot with wound cleaner, pat dry, apply wet to dry betadine dressing, apply border gauze, wrap with kerlix and secure with tape with a start date of 11/25/25; an order Cleanse area to right heel with wound cleaner, pat dry apply wet to dry betadine dressing, apply border gauze, wrap with kerlix and secure with tape. Once daily and prn (as needed) one time a day related to PRESSURE ULCER OF RIGHT HEEL, UNSTAGEABLE with a start date of 12/13/25 and discontinue date of 3/18/26. An additional order with a start date of 12/13/25 revealed Cleanse area to left heel with wound cleaner, pat dry, and apply border gauze once daily and prn (as needed) one time a day related to PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE. On 3/31/26 at 12:40 PM, during an observation revealed that as Registered Nurse (RN) #1 provided wound care to the open pressure sore on the right ankle and heel of Resident #3, she wiped the dime sized open area over Resident #3's right ankle four times from above the open wound to below it (directionally toe to heel) with gauze wet with wound cleanser, then disposed of the gauze, obtained a clean wet (with wound cleaner) gauze and wiped four times from above the open area to below the wound with the same surface of the wet gauze. RN #1 provided wound care to the pressure sore on the left ankle of Resident #3 without gown, and wiped the open wound four times from above the open wound to below it (directionally toe towards heel) with gauze wet with wound cleanser, then disposed of the gauze, got a clean wet (with wound cleaner) gauze and wiped twice with the same surface of the wet gauze. Record review of the March 2026 Treatment Administration Record (TAR) revealed documentation that RN #1 had provided treatment for the pressure ulcer to right lateral foot, and the area to right heel, left heel on 3/31/26. Documentation indicated treatment was provided by RN #1 on 3/31/26. On 4/01/26 at 11:10 AM, during an interview the Director of Nurses (DON) revealed she expected the nurses to provide all wound care in a manner according to current standards of infection control and prevention, which she said included cleaning away from any areas of open wounds and using clean surfaces of cleaning material such as gauze for each contact with open areas/wounds. On 4/01/26 at 12:12 PM, during an interview and record review the Staff Development Coordinator stated that she provided staff with in-service training monthly and as needed, and provided orientation training with newly hired nursing staff, Certified Nursing Assistants (CNAs) and nurses. She stated that hand hygiene competency checkoffs were required for nurses' staff during their orientation, prior to working directly with residents. She stated that RN #1 had completed competency checkoff for wound care on 3/31/26. Record review of the Validation Checklist Wound Care dated 3/31/26, signed by RN #1 and the Staff Development Coordinator revealed the Procedure included Cleansed wound thoroughly with prescribed cleansing agent, taking care to not contaminate other skin surfaces or other surfaces of the wound.On 4/01/26 at 1:00 PM, during an interview, RN #1 revealed that Resident #3 had a pressure ulcer on each of his outer ankles. She stated that she had wiped over the open area of the pressure ulcers on both of Resident #3's ankles multiple times with the same side of the same wet gauze because she was trying to remove something like discharge or slough that she observed at the open wound site and said, that's just me, then asked State Agency (SA) what was the correct way to clean a wound. She stated she was not aware of facility wound care protocols. She stated that the facility did not provide a protocol to follow.On 4/01/26 at 4:30 PM, during an interview the Administrator revealed he expected the nurses to provide care, including pressure sore treatments in a manner to prevent infections.Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 8/05/25 and the resident had diagnoses of aphasia, dysphagia, cerebral infarction (stroke), PRESSURE ULCER (PU) OF LEFT HEEL, UNSTAGEABLE, PRESSURE ULCER OF RIGHT HEEL, UNSTAGEABLE, both added to diagnosis information on 12/12/25 and PRESSURE ULCER OF RIGHT ANKLE, UNSTAGEABLE added to diagnosis information on 12/5/2025.Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/26 for Resident #3 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment.

Based on interviews, record review, and facility policy review, the facility failed to ensure the resident's right to receive visitors of her choosing for one (1) of five (5) residents sampled for resident rights. Resident #1.Findings include:A review of the facility's policy titled, Resident Rights, with Review/Revision Date 11/14/25, revealed, .Resident Rights. The resident has the right to dignified existence, self-determination, and communication and access to person and services inside and outside the facility.5. Self-determination.d. The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner, that does not impose on the rights of another resident .On 2/17/26 at 11:30 AM, during an interview, Resident #1 reported she was aware that on the afternoon of 1/11/26 her friend had been turned away by staff and was not allowed to visit her.On 2/17/26 at 3:16 PM, during a telephone interview, the complainant reported he was a friend of Resident #1 and had visited her several times each week without prior concern. He explained that during a visit one afternoon in January 2026, between lunch and dinner, staff told him to leave the facility and refused to allow him to stay or notify Resident #1 that he was there.On 2/17/26 at 3:50 PM, during an interview, Resident #1 stated, I really hope I get to see my friend again. We didn't do anything wrong and we are both adults.On 2/17/26 at 5:30 PM, during an interview, the Interim Director of Nursing (IDON) reported she was aware residents have the right to visitors of their choice at a time of their choice. She confirmed Resident #1 had a friend she met at a day program and that the complainant had been prohibited from visiting Resident #1 in January 2026. She stated, I'm the one that asked him to leave the premises, and confirmed staff did not notify Resident #1 that she had a visitor.On 2/17/26 at 5:32 PM, during a telephone interview, the Administrator reported he was not aware of the situation in which a resident's visitor had been asked to leave the facility. He stated residents have the right to receive visitors of their choosing at a time of their choosing. He explained that if safety concerns exist, the facility can implement care-planned interventions such as supervision or a designated location for visits.A record review of the admission Record revealed the facility admitted Resident #1 on 11/2/22 with diagnoses including Major Depressive Disorder.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated she was cognitively intact.

Based on record review and interviews the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were accurately documented for one (1) of eight (8) sampled residents. Resident #1.Findings include:Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizoaffective disorder-bipolar type with onset date 11/02/22 (upon admission). There was no diagnosis of dementia included. Record review of the Social Service Progress Review for Resident #1 dated 7/07/2023 revealed that the resident had impaired daily decision making with described impairment listed as resident has dementia. Record review of the Social Service Progress Review for Resident #1 dated 2/02/2024 revealed the that the resident had impaired daily decision making with described impairment listed as resident has dementia.Record review of the Social Service Progress Review for Resident #1 dated 6/11/2024 revealed the assessment indicated that the resident had impaired daily decision making with described impairment listed as resident has dementia and is manic depressive.On 8/25/25 at 8:15 AM, an interview with the Complainant revealed she had concerns related to Resident #1 had not received appropriate assessment, diagnostic tests or diagnosis while a resident at the facility, therefore rendering her care not appropriate for her actual condition, which she alleged was not discovered until she had discharged from the facility, spent a month at a different facility where she suffered a severe fall and head trauma and then spent a number of days at a third facility where she suffered a second severe fall with additional head trauma. She stated that she was in no way alleging that Resident #1 had not suffered from psychiatric illness of schizoaffective disorder-bipolar type but instead said that it was her belief that she also suffered from frontotemporal dementia. She stated that she was confused because after Resident #1 discharged from the facility she obtained a copy of her entire medical record and noted three (3) documents, specifically social services review notes, which clearly stated that the resident had dementia.On 8/26/25 at 5:17 PM, during a telephone interview with the former Social [NAME] Director (SSD), she stated that she was aware but concerned that Resident #1 showed signs of dementia and discussed this with the interdisciplinary team (IDT). She confirmed that she was aware that the resident had multiple head CT scans during her residence at the facility. She confirmed that she had documented that the resident had dementia in her notes throughout Resident #1's residence at the facility. She stated that the documentation was in error and said she thought she had inaccurately documented the resident's diagnosis of dementia and manic depression because, maybe I thought I heard someone say that. She confirmed that she had not reviewed Resident #1's diagnosis list or medical record to ascertain her actual diagnoses. On 8/27/25 at 3:30 PM, during a telephone interview the primary healthcare provider (physician) confirmed that Resident #1 was admitted by the facility with diagnosis of schizoaffective disorder-bipolar type. He said the during Resident #1's stay at the facility he received regular reports from his Nurse Practitioner (NP) and that the resident's behaviors were in line with the signs and symptoms of her diagnosis. He confirmed that the signs and symptoms exhibited by Resident #1 were also associated with frontotemporal dementia and that usually radiographic study may reveal the differential diagnosis. He confirmed that the resident had multiple head CT scans during her residence at the facility, read by a radiologist with no noted change or addition to the diagnosis she had at the time of admission by the facility. He stated that if he had been made aware of a new diagnosis the treatment would not have changed, because the treatments are basically the same in as much as the symptoms/behaviors were targeted and treated the same. He stated that he did not believe that the resident was inappropriately placed and said that her preexisting diagnosis would have limited her appropriateness for dementia or memory care units. He stated that since the resident had been diagnosed with impaired cognition of unknown etiology, the facility care planned and provided care in the same manner to a resident who had an official dementia diagnosis. On 8/27/25 at 4:30 PM, during an interview the Director of Nursing (DON) confirmed that Resident #1 did not have a diagnosis of dementia during her residence at the facility but did have a care planned diagnosis of impaired cognition. She confirmed that any documentation of dementia was inaccurate. She stated that resident diagnoses were listed in their entirety on each resident's admission record. She confirmed that it was important for documentation to be accurate for each resident in order for staff to provide appropriate patient centered care and that inaccurate documentation could result in care for the resident that was not directed towards the needs of the resident. On 8/27/25 at 5:00 PM, during an interview the Executive Director (ED) stated that Resident #1 did not have a diagnosis of dementia during her residence at the facility but did have a care planned diagnosis of impaired cognition. She confirmed that any documentation of dementia was inaccurate. She confirmed that resident diagnoses were listed in their entirety on each resident's admission record. She confirmed that it was important for documentation to be accurate for each resident in order for staff to provide patient centered care and that inaccurate documentation could result in care for the resident that was not directed towards the needs and strengths of the resident at either the facility or at other admitting facilities.

Based on observation, interviews, record reviews, and policy review, the facility failed to develop and implement comprehensive, resident-centered care plan interventions for one (1) of (20) residents reviewed for care plans, Resident #33. Findings included: A review of the facility policy Plans of Care, dated 09/25/17, revealed: Policy . Procedure: Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to appropriate staff or professionals in the disciplines as determined by the resident's needs A review of the Care Plan Report, initiated 03/24/25, revealed Focus: The resident has a pressure injury sacrum .Interventions .Cleanse the sacral wound with normal saline or wound cleanser, pat dry, apply normal saline wet-to-dry gauze, and cover with bordered dressing Record review of the Care Plan Report revealed, initiated 3/24/25 revealed Focus: The resident has a Stage 2 Pressure injury Interventions .Treat pain per orders prior to treatment/turning, etc.to ensure the resident's comfort A review of Order Summary Report with active orders as of 3/26/25 revealed orders to Cleanse the Stage II pressure ulcer to the left elbow with normal saline or wound cleanser, pat dry, apply calcium alginate and a bordered gauze; Cleanse the left and right heels with normal saline or wound cleanser, pat dry, apply Betadine, and wrap with Kerlix; Cleanse the sacral wound with normal saline or wound cleanser, pat dry, apply normal saline wet-to-dry gauze, and cover with a bordered dressing. An additional order dated 3/14/25 for Acetaminophen Tablet 325mg-Give 650 mg .every 6 hours as needed for pain. On 03/26/25 at 10:53 AM, during an observation of wound care, Licensed Practical Nurse (LPN) #1 performed wound care assisted by two Certified Nurse Aides (CNAs). LPN#1 did not follow physician-ordered wound care protocols listed in the care plan. LPN #1 failed to pat wounds dry after cleansing, as ordered, and failed to cleanse the heels with normal saline or wound cleanser prior to applying Betadine. Resident #33 displayed facial grimacing and moaning throughout the procedure. LPN #1 acknowledged that pain medication had not been administered prior to the procedure and admitted she had forgotten to ensure it was given. On 03/26/25 at 11:55 AM, during an interview with LPN #1 who completed the wound care, she stated she had not administered or confirmed the administration of pain medication prior to the procedure. She acknowledged the resident was likely in pain and that pain control is important prior to wound care. She also confirmed she did not follow wound care orders exactly as written. On 03/26/25 at 3:53 PM, during an interview with LPN#1 responsible for wound care and infection prevention, she confirmed the wound care performed on 03/26/25 did not follow physician orders or the care plan. She stated orders are necessary to support wound healing and reduce complications. She acknowledged a breakdown in communication regarding pain medication and accepted responsibility for the oversight. On 03/26/25 at 3:53 PM, during an interview with the LPN #1, she admitted she did not follow the care plan when cleaning the resident's wound and acknowledged the care plan should always be followed. On 03/27/25 at 12:04 PM, during an interview with Registered Nurse (RN) #1, who serves as the Minimum Data Set (MDS) and Care Plan Nurse, she emphasized that it is important for staff to follow the care plan, explaining its purpose is to ensure residents receive adequate and good quality care. She stated all staff utilize the care plan to some extent. A review of the Admission Record revealed the facility admitted Resident #33 on 09/11/18 with diagnoses including Osteomyelitis of the vertebra, sacral, and sacrococcygeal region. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was unable to participate in the interview and had severely impaired cognition.

Based on observation, interview, record review, and policy review, the facility failed to follow physician orders and professional standards of practice related to wound care, as evidenced by wounds not being cleansed and dried according to physician orders, pain not being managed during treatment, and all treatment orders not being completed, resulting in inadequate wound care for a resident with multiple pressure ulcers for one (1) of two (2) residents observed for wound care (Resident #33), Findings included: On 03/26/25 at 10:53 AM, an observation of wound care was conducted by Licensed Practical Nurse (LPN) #1 with assistance from Certified Nurse Aides (CNAs). LPN #1 removed soiled dressings from the sacrum, performed hand hygiene between glove changes, and applied a new dressing without pat drying the wound as ordered. When addressing the elbow and heel wounds, LPN #1 again failed to pat dry and applied Betadine to the heel without cleansing it first with normal saline or wound cleanser. Resident #33 displayed facial grimacing and moaning throughout the procedure. On 03/26/25 at 11:55 AM, during an interview with LPN #3, she stated she did not ensure pain medication had been given prior to care. She acknowledged this error likely contributed to the resident's signs of pain. On 03/26/25 at 3:53 PM, LPN #1, the wound care nurse, confirmed physician orders were not followed and stated she was told pain medication had been given, which was not true. She accepted responsibility for the oversight. On 03/27/25 at 10:09 AM, the Nurse Practitioner confirmed she had not seen Resident #33 since the resident returned from the hospital and that wound care had been referred to an outside provider. On 03/28/25 at 5:28 PM, during a post survey exit interview, the Corporate Nurse stated she was aware of Resident #33's care needs. A record review of Resident #33's Physician Orderswith active orders as of 3/26/25 revealed orders to cleanse Stage II pressure wound to left elbow with normal saline or wound cleanser, pat dry, and apply calcium alginate with a bordered gauze dated 3/24/25. Cleanse left and right heels with normal saline or wound cleanser, pat dry, apply Betadine, and wrap with Kerlix dated 3/22/25. Cleanse sacral wound with normal saline or wound cleanser, pat dry, apply normal saline wet-to-dry gauze, and cover with bordered dressing dated 3/24/25. A review of Resident #33's Weekly Skin Integrity Reviews dated 02/21/25 and 02/28/25 both revealed skin was intact. A review of Pressure Ulcer Rounds dated 03/15/25 revealed a sacral wound measuring 12 centimeters (cm) in length, 7 cm in width, and 3.5 cm in depth, Stage IV, with yellow slough, rolled edges, and serous drainage. The sacral wound on 03/20/25 measured 8.5 cm in length, 11 cm in width, and 2.3 cm in depth, Stage IV, with pink granulation tissue and no drainage. A review of the Admission/Readmission Data Collection dated 03/14/25 at 4:50 PM revealed a Stage IV sacral wound and discolored heel upon admission. A review of the facility's Weekly Wound Report: Pressure Injury dated 02/24/25-02/28/25 and 03/17/25-03/21/25 revealed a facility-acquired deep tissue injury to the left inner heel on 02/27/25 and a Stage IV coccyx wound. A review of Resident #33's Braden Scales dated 02/20/25 revealed scores of eight (8) and 12, indicating very high and high risk, respectively. A review of the Electronic Treatment Administration Record (ETAR) revealed no documentation that wound care treatments were provided on 03/16/25 and 03/22/25. A review of Resident #33's Electronic Medication Administration Record (EMAR) revealed no documentation that pain medication was administered prior to wound care on 03/26/25. A record review of Resident #33's Admission Record revealed an admitted [DATE] with diagnoses including Osteomyelitis of vertebra sacral and sacrococcygeal region. A review of Resident #33's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 revealed severely impaired cognition.

Based on observation, interview, and record review, the facility failed to manage pain for residnets when the facility failed to ensure pain medication was administered prior to wound care for Resident #33, resulting in the resident exhibiting signs of pain during the procedure and failed to ensure ordered pain medication was available for Resident #169, resulting in unaddressed pain and a lack of adequate symptom control for two (2) of 20 sampled residents. Findings included: A review of the facility's policy titled Pain Management Guideline, with a revision date of 02/21/25 revealed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the residents' goals and preferences . To assist a resident in maintaining his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: 1. Assess residents for pain on Admission . 2. Manage or prevent pain, consistent with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. A review of the facility's policy titled Omnicell Access and Inventory, dated 05/24/24, revealed, .Omnicare provides access to an Automated Emergency Kit (Omnicell) in your facility. This helps ensure that you have the medications your residents need for new orders, new admissions, and emergencies. The Omnicell is an important tool to help ensure Medication Availability . Resident #33 On 03/26/2025 at 10:53 AM, during an observation of wound care provided by Licensed Practical Nurse (LPN) #1 revealed during wound care Resident #33 displayed facial grimacing and moaned. LPN #1 continued with wound care. When asked what pain medication was administered, LPN #1 stated she did not know but believed the cart nurse had provided it. On 03/26/2025 at 11:55 AM, during an interview, LPN#1 stated she had not administered any pain medication to Resident #33 before wound care and had forgotten. She acknowledged the resident likely experienced pain during the care. On 03/26/2025 at 3:53 PM, during an interview with the Wound Care/Infection Prevention Nurse, she confirmed she had asked the cart nurse to administer pain medication and was told it had been given but later confirmed it had not. She stated it was her responsibility to ensure pain medication was administered and acknowledged the resident displayed pain symptoms. She explained failure to provide pain medication could negatively impact the resident physically and mentally and hinder wound healing. On 03/26/25 at 4:28 PM, an interview with Corporate Nurse (CN) stated she was aware Resident #33 was in pain during wound care. A record review of Resident #33's Physician Orderswith active orders as of 3/26/25 revealed orders to cleanse Stage II pressure wound to left elbow with normal saline or wound cleanser, pat dry, and apply calcium alginate with a bordered gauze dated 3/24/25 cleanse left and right heels with normal saline or wound cleanser, pat dry, apply Betadine, and wrap with Kerlix dated 3/22/25 cleanse sacral wound with normal saline or wound cleanser, pat dry, apply normal saline wet-to-dry gauze, and cover with bordered dressing dated 3/24/25 A record review of Resident #33's Admission Record revealed an admitted [DATE] with diagnoses including Osteomyelitis of the vertebra sacral and sacrococcygeal region. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/2025 revealed the resident had severely impaired cognition. Record review of the Order Summary Report with active orders as of 3/26/25 revealed an order dated 3/14/25 for Acetaminophen Tablet 325mg-Give 650 mg .every 6 hours as needed for pain. A record review of the resident's Electronic Medication Administration Record (EMAR) revealed no pain medication was administered prior to wound care on 03/26/2025. Resident #169 On 03/24/25 at 11:45 AM, during an interview and observation, Resident #169 was observed lying in bed. The resident was alert and oriented to person, place, and time. Resident #169 reported he was admitted on Saturday, 03/22/25 at 5:45 AM and stated that he had a horrible weekend and was planning to leave the facility as soon as possible. The resident explained that he had not received his pain medications over the weekend because the pharmacy did not deliver them. He expressed that he depends on his Oxycodone and, while he had his Duragesic patch, it was not sufficient. He added that therapy staff had visited and said they would check on his medications, but he had not seen them again. A record review of Resident #169's Admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain, Unspecified. A review of the Order Summary Report as of 03/26/25 revealed orders for multiple pain-related medications including Acetaminophen 325 milligrams (mg), Baclofen 10 mg, Fentanyl Transdermal Patch 50 micrograms/hour, Gabapentin 600 mg, Ibuprofen 600 mg, and Oxycodone HCL 10 mg and 20 mg. The order also included Oxycodone HCL 20 mg, one and a half tablets every four (4) hours as needed for pain. A review of the March 2025 Medication Administration Record (MAR) revealed no Oxycodone was administered until 03/25/25 at 9:05 AM. Prior to that, on 03/23/25 and 03/24/25, pain levels were documented as 10, with only Ibuprofen 600 mg administered. A record review of the Pain Evaluation dated 03/22/25 revealed an incomplete assessment with no pain assessment documented. A record review of Resident #169's Admission Data Collection dated 03/22/25 at 04:16 (AM) revealed .B. Cognition . alert, oriented to person, place, time, memory okay L. Resident experiencing pain. If yes, complete additional pain evaluation .N1. Contractures .Fingers, hand, wrist, elbow, shoulder of dominant side/Non Dominat side .Strength .Weakness, paresis, paralysis of upper extremity . Resident arrived at the facility at approximately 4:00 AM and required assistance d/t (due to) paralysis of upper extremities. There was no record of an additional pain evaluation noted as required in Section L (Pain). A record review of Resident #169's Hospitalist Admission History and Physical dated 01/12/25 revealed the diagnoses of Neck Pain and Pain. A record review of Resident #169's Discharge Instructions from (Proper Name of Acute Hospital) revealed orders for Oxycodone HCL 20 mg Give 1.5 tablet PO every 4 hours as needed for pain give 1 and a half tablet to equal 30 mg. On 03/25/25 at 9:30 AM, during an interview with Licensed Practical Nurse (LPN)#4, she confirmed the resident did not receive pain medications on 03/24/25 and reported pain levels of 10. She stated the pharmacy had not yet delivered the narcotics due to the absence of hard-copy prescriptions. She also stated the facility has an Omnicell system with backup medications but was unsure if Oxycodone was stocked in it. On 03/27/25 at 11:50 AM, during an interview with the facility's Nurse Consultant, she stated that no resident should go without pain medication and that the issue should have been resolved on 03/22/25 using the facility's Omnicell system. On 03/27/25 at 12:10 PM, during a phone interview with Corporate Admissions/Marketing, she confirmed she was unaware the resident arrived at 4:45 AM on 03/22/25 and did not know he went the entire weekend without pain medications. She stated the admission paperwork and prescriptions were not faxed ahead and only processed once the resident physically arrived. On 03/27/25 at 12:40 PM, during a phone interview with the Weekend Night Supervisor/Registered Nurse #2, she confirmed that the resident arrived at 4:00 AM on 03/22/25. She did not complete a pain assessment upon admission and reported that the admission package did not include hard-copy prescriptions. She contacted the Nurse Practitioner but did not follow up afterward. On 03/27/25 at 1:10 PM, during an interview with the facility's Nurse Practitioner, she stated that she was only informed on Monday morning, 03/24/25, about the resident's need for pain medications. She confirmed the hard-copy prescriptions were delivered on that date and Oxycodone was administered for the first time on 03/25/25. 43283

Based on interviews and record review, the facility failed to ensure the presence of a Registered Nurse (RN) for at least eight (8) hours a day, seven (7) days a week as required, for eight (8) of (19) days reviewed. Findings included: On 03/27/25 at 11:50 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that she had been told by the facility's Nurse Consultant that the Director of Nursing (DON) could be counted as the RN and that she, as the LPN, could also be included on the staffing grid. She stated that at a previous facility, she was not allowed to count the DON or herself on the staffing report unless they completed direct care hours. She confirmed that the DON is the only RN in the facility Monday through Friday, although another RN occasionally serves as Charge Nurse. LPN #1 explained that the DON often counts herself as both the Charge Nurse and the DON and helps where needed, including acting as Charge Nurse when no one else is available. A record review of the facility's staffing grids and nurse/Certified Nursing Assistant (CNA) schedules for the week of 03/06/25 through 03/24/25 revealed eight (8) days where no RN coverage was documented for a full 24-hour period. On 03/27/25 at 12:20 PM, during an interview with the Nurse Consultant, she explained that she was not aware the DON had been counting herself as the Charge Nurse during the week. She believed the DON could be counted if the census was low, regardless of licensed bed capacity. She also believed the Staff Development Nurse counted toward RN coverage. The Nurse Consultant confirmed that on the days in question, the facility's census was greater than sixty (60). On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he explained that he had only been in the facility for three (3) weeks and was still learning the facility's operations, staff, and residents. He stated that he expected the facility to follow federal staffing regulations and its own staffing assessment. A review of a signed statement, undated, provided by the Interim Administrator revealed Facility staffs according to census, acuity and/or facility assessment based on resident needs. A review of another signed statement from the Interim Administrator revealedQuality of Care: Facility follows policy related to the specific area of care. A review of the facility's Facility assessment dated [DATE] revealedEvaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident's needs . Licensed nurses providing direct care equaled 9, Nurse Aides equaled 21, Other Nursing personnel (e.g., those with administrative duties) equaled 3 . Describe your general staff plan to ensure that you have sufficient staff to meet the needs of the residents at any given time . DON . 1 RN DON .

Based on observation, interviews, record reviews, and facility policy review, the facility failed to provide a resident who was unable to carry out activities of daily living (ADLs) with the necessary services to maintain good grooming and personal and oral care for one (1) of (20) sampled resident reviewed for personal hygiene and grooming, Resident #67. Findings included: A review of the facility ' s policy titled Activities of Daily Living, dated 02/01/22, revealed Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing, and assistance as necessary. ADL includes bathing, dressing, grooming, hygiene, toileting . On 03/24/25 at 12:38 PM, during an interview and observation, Resident #67 was observed lying in bed with a moderate amount of gray hair under her chin. She stated she wanted her chin hair shaved and reported her last shower was on Thursday. She stated she used to receive bed baths three (3) times per week. On 03/25/25 at 8:55 AM, during an observation, Resident #67 was observed lying in bed with her eyes closed. A strong odor of urine was noted in the room. On 03/25/25 at 3:15 PM, during an interview and observation, Resident #67 was observed with visible hair on her chin. A faint odor of urine was again noted in the room. The resident stated she had not received a bath that day. On 03/27/25 at 10:10 AM, during an interview, Resident #67 stated she would not receive a bath or be shaved until later that evening. On 03/27/25 at 2:33 PM, during an interview, Resident #67 stated that no staff had asked her about receiving a bed bath or shower during the current week. On 03/28/25 at 5:28 PM, during an interview, the Corporate Nurse confirmed she was aware of the care concerns related to Resident #67. A record review of Resident #67's Admission Record revealed the facility admitted the resident on 2/25/25 with diagnoses including Muscle Weakness, Other Reduced Mobility, and Lack of Coordination. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident's cognition was moderately impaired. Section GG documented that Resident #67 required total assistance/dependent for bathing and showering. A review of Resident #67's Comprehensive Care Plan revealed no documentation related to refusals of care. The care plan indicated the resident required substantial to maximal assistance with activities of daily living.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the facility had adequate supplies for residents for four (4) of (20) sampled residents, with the potential to affect all residents in the facility. (Residents #13, #34, #41, #60) Findings included: A review of the facility's policy titled Purchasing Department, with an effective date of 11/30/2014, revealed, The Company has established a corporate purchasing department. Its purpose is to ensure that we receive standardized quality goods and services at the lowest available price . On 03/24/25 at 11:00 AM, the State Agency (SA) observed strong odors of urine and body odor noted upon entering the facility and walking to the conference room down the 400 Hall. Several residents were observed still in bed and others sitting in their wheelchair sitting around the nurse's station. Resident #13 On 03/24/25 at 2:24 PM, during an interview with Resident #13, she stated she wears a 2XL brief, but the staff only provided her with extra-large briefs. She explained that she has to place a pad inside the briefs to avoid wetting herself and said she uses the bathroom independently. An observation of her room revealed extra-large pull-ups. On 03/25/25 at 10:28 AM, in an interview with a Licensed Practical Nurse (LPN)#4, who was assigned to Resident #13, confirmed that the extra-large briefs presented were too small for the resident. She stated central supply was responsible for stocking the supplies. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed Resident #13 was admitted by the facility on 7/25/2024, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and had current diagnoses including Diabetes Mellitus. Resident #34 On 03/25/25 at 03:30 PM, during an interview and observation with Resident #34, resident observed lying in the bed with shirt and brief on. Resident #34 explained he get up every day and goes to therapy and does not get laid back down until about 3 PM every day. He does use his urinal at times but when he is up it's difficult and needs to be changed. He is usually soaked and sometimes through his pants when he gets back in bed. On 03/26/25 at 10:40 AM, observed Resident #34 in the therapy room involved in activities. Resident #34 was well-groomed and no odors noted. Resident #34 reported that the facility did not have briefs last night to fit him and this has happened several times since he was admitted to the facility a month ago. He explained that he is a huge man and needs at least 2XL briefs. A record review of Resident #34's Admission Record revealed the facility admitted the resident on 02/28/25 with the diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side. A record review of Resident #34's Admission MDS with an ARD of 03/07/25 revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Section H indicated the resident was occasionally incontinent of bladder. Resident #41 On 03/25/25 at 8:50 AM, Resident #41 explained that the pull-up he was wearing was too small, but he was told that was the only size the facility had available. A record review of Resident #41's Admission Record revealed the facility admitted the resident on 01/09/24 with the diagnoses that included Other Sequelae of cerebral infarction. A record review of Resident #41's Quarterly MDS with an ARD of 02/04/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Section H revealed the resident was frequently incontinent of bladder. Resident #60 On 03/24/25 at 12:46 PM, Resident #60 stated that they ran out of pull ups and was out for one week. She stated her daughter bought her some. On 03/27/25 at 10:27 AM, during a phone interview with the Resident Representative (RR) for Resident #60, she stated her mother had called her in February to report the facility was out of briefs. She confirmed she purchased and brought briefs to the facility herself. She stated this had occurred once. A record review of Resident #60's Admission Record revealed the facility admitted the resident on 01/17/25 with diagnoses including Other Abnormalities of gait and mobility, Pain in right leg, Muscle Weakness (Generalized), and Difficulty in walking, not elsewhere classified. A record review of Resident #60's MDS with an ARD of 02/08/25 revealed a BIMS score of 10, which indicated the resident was moderately cognitively impaired. On 03/25/25 at 9:10 AM, during an interview with Certified Nurse Aide (CNA)#3, she explained there have been problems with supplies including briefs, gloves, and wipes mostly for the past month. There is never enough of the size of briefs the residents need and have to use smaller briefs that do not fit, causing residents to complain and have clothes soiled more frequently. The gloves are never the size needed and either too small and can barely get on or are too large that makes care difficult. On 03/25/25 at 9:30 AM, during an interview with Licensed Practical Nurse (LPN)#4, she explained that the facility had experienced supply shortages in recent months. She stated the facility's corporate operations filed bankruptcy, and she was unsure if that contributed to the issues. She added the facility had run out of briefs, gloves, and wipes, and that a nurse previously had to purchase briefs locally. She also stated the correct sizes were often not available, resulting in smaller briefs being used that did not fit properly. On 03/25/25 at 10:32 AM, during an interview with the Central Supply Coordinator, he stated there were 2XL briefs in the outdoor storage room. An observation of the storage area revealed one box of 2XL daily wear briefs. He confirmed that was all the briefs available in that size at the time. On 03/25/25 at 02:55 PM, during an interview with LPN#3, she explained the facility has had continuous problems with supplies in the past couple months. The facility does not have enough briefs, wipes, and gloves at times. She has had residents complaining about not having their size and briefs and have noticed residents waiting longer periods of time for changing and positioning due to not being able to find the correct size of briefs for the residents. The Director of Nursing (DON) has explained that the shipping company has had problems and would only get partial of the orders and the orders have been a hit and miss. The DON did go out and buy some briefs before but that was only a temporary fix and then the facility would be out again. On 03/25/25 at 3:50 PM, during an interview with CNA#1, she stated the facility had experienced shortages of gloves, briefs, and wipes over the past few months. She explained that truck deliveries had been inconsistent. She reported that available gloves were usually too small and that pull-ups were used in place of briefs by tearing the sides. She stated residents had complained about the lack of preferred products. On 03/26/25 at 10:05 AM, during an interview with CNA#4, she explained she has witnessed shortage of supplies mostly in the last few weeks it was the worst. The facility only had the pull-ups for residents and not the correct size and some residents don't like the pull-ups some days. Due to lack of supplies some residents have to wait for extended periods to be changed. There were only small gloves that did not fit and this made care difficult. She reported the wipes were also not available, but she used wash clothes and towels. The shortage was reported to the DON and was told to use what you had. On 03/26/25 at 11:50 AM, during an interview with CNA #5, she explained the facility has run out of gloves, briefs, and wipes recently in the past month making it difficult to care for the residents as needed. The facility runs out of extra-large briefs more than anything else and the resident have to wear briefs that are too small causing leaks and residents needing to be changed more frequently. On 03/26/25 at 2:00 PM, during an interview and observation with the Central Supply Coordinator/Ward Clerk, he explained he was responsible for retrieving supplies from the shed and central supply room. He stated that since being hired, he had not placed any orders but was instructed to take inventory on the 1st and 15th of each month and to leave the supply list in the DON's mailbox. He reported that after submitting the most recent inventory list, the DON informed him on 03/23/25 that the list had been lost. He stated there had been no recent deliveries of gloves, briefs, or wipes, and he was unable to confirm if items were out of stock or if orders had been placed. He reported numerous staff and residents had complained about supply shortages. An observation of the shed revealed several loose and opened packages of briefs with no organization. The shed was unsecured. On 03/26/25 at 2:30 PM, during an interview with the Wound Care Nurse/LPN#1, she explained that the DON had previously purchased briefs for residents, but she was unsure of the date of the last purchase. On 03/27/25 at 11:50 AM, during an interview with LPN#5, reported that the facility has been running out of supplies including gloves and briefs. Incontinent wipes have also not been available, but she has instructed staff to use soap and water and clothes. The briefs do not fit the residents properly causing more irritation and complaints. The residents have complained that they had to wait for extended periods to be changed or cleaned due to no supplies. On 03/27/25 at 12:45 PM, during an interview with the Nurse Consultant, she stated she was not aware of any supply shortages. She explained it was her expectation that the facility maintains adequate supplies for all residents at all times. On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he explained that he had only been in the position for three (3) weeks and was not aware of any supply shortages. He stated he had only approved one supply order during his tenure. He reported that his expectation was for the facility to always have appropriate supplies readily available to provide quality care, uphold residents' rights, and maintain respect. A record review of a signed statement provided by the Interim Administrator revealed Quality of Care: Facility follows policy related to the specific area of care. A record review of the facility's Supplier Invoice dated 02/28/25 revealed an order for two (2) cases of large gloves, twelve (12) packs of 3XL Prevail briefs, two (2) cases of medium gloves, three (3) cases of Per-Fit 360 2XL briefs, and three (3) cases of 3XL Per-Fit 360 briefs. A record review of the facility's Purchase Order dated 03/03/25 revealed orders for four (4) cases each of large gloves, medium gloves, large Per-Fit 360 briefs, and 3XL Prevail briefs. A record review of the facility's Purchase Order dated 03/13/25 revealed (1) case of 3XL Prevail briefs, eight (8) packs of 3XL Per-Fit 360 briefs, and additional orders for protective underwear and briefs. No gloves were included in this order. A record review of the facility's Supply Order List dated 03/01/25 revealed items not on the shelf included adult diapers in sizes medium through 2XL and gloves in sizes medium through extra-large. A record review of the Supply List dated 03/15/25 revealed items needed included yellow diapers (58-73 inches), blue diapers (46-62 inches), bariatric white diapers, and gloves in medium and large sizes. During an interview with the Central Supply staff on 03/27/25 at 2:30 PM, he stated the DON had misplaced the inventory list, possibly causing a delay in ordering supplies.

Based on observation, interview, record review, and policy review, the facility failed to ensure a resident's right to dignity and communication by not providing an accessible call light for one (1) of twenty (20) sampled residents (Resident #169). Findings included: A review of the facility ' s policy titled Resident Rights with an effective date of 11/30/14 revealed .The facility will ensure that the resident is not deprived of his/her rights . A resident shall be treated with dignity and respect . On 03/24/25 at 11:45 AM, during an observation and interview, Resident #169 was in bed with a touch call light at the foot of the bed. The resident explained he could not use that call light, as he was unable to raise his chin or head to activate the button. He stated he had experienced long wait times for staff assistance with repositioning. On 03/24/25 at 4:10 PM, during an observation and interview with Certified Nurse Aide (CNA) #1, observed Resident #169's push call light lying on the floor. CNA#1 stated this was her first time working with the resident and confirmed call lights are to remain within the resident's reach at all times. Resident #169 told her he could not use the type of call light provided. On 03/25/25 at 2:25 PM, during an interview with CNA #3, she explained that it was her first day working with the resident. She had reviewed the resident's medical record and spoken with the nurse regarding care. She confirmed the resident told her he could not use the call light due to paralysis, but the CNA stated she had not yet looked at the resident's call light. On 03/25/25 at 3:30 PM, Resident #169 was observed lying in bed. He explained he had not been provided with a call light he could use. On 03/26/25 at 2:45 PM, Resident #169 was again observed in bed. He explained that he still did not have an accessible call light and was dependent on staff checking in on him. He said his roommate sometimes helped at night, but during the day he had no assistance. The call light was observed lying on the floor between the two beds. On 03/26/25 at 4:10 PM, during an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed the resident's call light was lying on the floor and not within reach. She stated she was unaware of any other call light options at the facility besides the regular and touch button types. The resident explained that at previous facilities he used a blow-call light. On 03/27/25 at 10:00 AM, during an interview with Social Services #1, she stated she was not aware the resident had requested a room closer to the nurse's station or that he had no call light he could use. On 03/27/25 at 11:50 AM, during an interview with the facility Nurse Consultant, she asked whether the resident was paralyzed and stated she had not been informed that he needed a blow-call light. On 03/27/25 at 12:40 PM, during a phone interview with Registered Nurse (RN) #2, the Weekend Supervisor for Night Shift, she confirmed she provided the resident with a push button call light but did not assess whether the resident could use the touch button. She stated the resident was admitted as a paraplegic and could not use his hands. A record review of Resident #169's Admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia. A record review of Resident #169's Admission Data Collection dated 03/22/25 revealed the resident was alert and oriented to person, place, and time, with memory noted as okay. The assessment noted contractures and paralysis.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights to a clean, safe, homelike environment for three (3) of (20) sampled residents, as evidenced by unclean floors and bathrooms in resident rooms (Resident #11 and Resident #44) and improper handling of personal belongings (Resident #60). Findings include: A record review of the facility policy, Cleaning and Disinfection of Environmental Surfaces, revised 8/19, revealed, Policy Statement . Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard . Policy Interpretation and Implementation . 1 . 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . A review of the facility policy, Your Rights with no date, revealed, Dignity and Self-Determination . You have the right to: Be treated with consideration . Receive reasonable accommodation of your individual needs . Keep and use your personal possessions . Resident #11 On 03/24/25 at 11:25 AM, during an observation and interview with Resident #11, the floor in his room was noted to be dirty with dried food smeared on both his side and his roommate's side of the room. The resident stated the room was filthy and had been that way since his admission. He added that it smelled like urine and reported that when he requested cleaning, staff would ignore him. An observation of the resident's bathroom revealed dried fecal matter inside the toilet bowl and dried urine stains. On 03/24/25 at 1:11 PM, during an interview with the Laundry and Housekeeping Supervisor, she stated that the housekeeping department was fully staffed and that staff work Monday through Friday from 7:00 AM to 2:30 PM. She explained that cleaning is completed during the first half of the shift and then staff return after lunch to touch up rooms, including bathrooms and trash cans. She confirmed that all rooms should have been cleaned by the time of the interview. She walked with the State Agency (SA) to Resident #11's room and confirmed the floor had dried food smeared on it and the bathroom toilet contained dried fecal material. A record review of Resident #11's Admission Record revealed the facility admitted the resident on 01/17/2025 with diagnoses including Unspecified Hearing Loss and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Right Dominant Side and Abnormalities of Gait and Mobility. A record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was rarely or never understood. Resident #44 On 03/24/25 at 12:01 PM, during an observation and interview with Resident #44, the resident's room floor was observed to be dirty with trash on the floor and full trash cans. The resident stated the room was often like that. He also reported that he had three (3) pairs of size 40P pants that were sent to the laundry and never returned. He stated his brother had recently purchased the pants, and when he notified laundry staff, they stated they would look for the items, but he had not received any further information. On 03/24/25 at 1:11 PM, during an observation and interview with the Laundry and Housekeeping Supervisor of Resident #44's room she confirmed that the floor was very dirty and had trash scattered throughout. The supervisor stated she was unsure why the rooms had not been cleaned, as they were supposed to be done by that time. On 03/26/25 at 3:16 PM, during an interview with Resident #44's Resident Representative, he stated he visits monthly due to living out of town. He reported that during his visits, the facility was visibly dirty, with trash on the floors and debris stuck to the floor. He stated the bed sheets often appeared unclean and that he had seen roaches in the facility. On 03/27/25 at 9:01 AM, during an observation and interview with Resident #44, the resident stated that the floors were cleaner but added, That's only because you're here. Once you leave, it'll go back to how it was. A record review of Resident #44's Admission Record revealed the facility admitted the resident on 02/11/2022 with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. A record review of Resident #44's quarterly MDS with an ARD of 12/4/24 revealed a BIMS score of 12, which indicated the resident was cognitively intact. On 03/27/25 at 9:30 AM, during an interview with the Administrator, he stated that he expects the facility to be a homelike environment. He explained, We keep our homes clean, so this is the residents' home and should be kept clean as well. Resident #60 A record review of Resident #60's Admission Record revealed the facility admitted the resident on 01/17/25 with diagnoses including Idiopathic Neuropathy and Abnormalities of Gait and Mobility. A record review of the MDS with an ARD of 02/08/25 revealed a BIMS score of 10, which indicated moderate cognitive impairment. The resident could participate in interviews. On 03/27/25 at 11:09 AM, in an interview with Resident #60, she stated that staff had not replaced her missing gray pants or her black pajama shirt with a bear design. She explained she had sent both items to the laundry after spilling ice cream on them, but they never came back. She stated she informed the Laundry Aide, who told her she would look for the clothing but never provided an update. Resident #60 expressed sadness about the missing clothing, especially since she had not worn the new pants much and felt that her personal belongings were not valued. On 03/27/25 at 11:12 AM, during an interview with a Laundry Aide, she confirmed that Resident #60 reported missing items to her. She stated she searched for them and told the resident she could not locate them. She also reported the issue to her supervisor. On 03/27/25 at 11:15 AM, during an interview with the Laundry and Housekeeping Supervisor (LHS), she stated she was only aware of the missing pajama shirt. She reported searching for the item without success. When asked about the next step, she acknowledged that the incident should have been reported to the Director of Nursing (DON) or the Administrator, but she had not done so. She stated that had she followed proper protocol, the items may have been replaced. She acknowledged that the loss of personal items could cause distress to the resident. On 03/27/25 at 11:28 AM, during an interview with the Administrator, he stated he had not been informed of the missing items. He confirmed that if it had been reported, the facility would have replaced the missing clothing.

Based on interview, observation, and record review, the facility failed to adhere to accepted standards of practice for the timely replacement of oxygen tubing for one (1) of four (4) residents observed with oxygen in use, Resident #18. Findings included: A review of the facility policy Equipment Change Schedule, dated 11/30/14, revealed: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer ' s recommendations and standards of practice. Procedure: Equipment/When Changed . Nasal Cannula, every seven (7) days or when contaminated . On 03/24/25 at 12:58 PM, during an observation, Resident #18 was lying in bed. Oxygen was flowing at two (2) liters per minute via nasal cannula. The oxygen tubing was dated 02/10/24. There was no signage posted on the door indicating oxygen was in use. On 03/24/25 at 5:45 PM, during an interview and observation with the Licensed Practical Nurse (LPN)/Infection Preventionist (IP) in Resident #18 ' s room, she confirmed there was no oxygen-in-use signage on the door and that the tubing was dated 02/10/24. She stated the tubing is supposed to be changed every Sunday on night shift and acknowledged the tubing may be nasty. The tubing was discolored and cloudy. The LPN/IP confirmed signage should be posted to make staff and visitors aware that oxygen was in use. A review of Resident #18's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #18's Physician Orders revealed an order for oxygen at two (2) liters per minute via nasal cannula as needed for oxygen saturation less than 92% or dyspnea. A review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete an interview.

Based on interviews, record review, and facility policy review, the facility failed to implement the baseline care plan related to pain medications for one (1) of (1) residents reviewed for baseline care plan implementation. (Resident #169). Findings included: A review of the facility's policy, Plans of Care, with a revision date of 09/27/17, revealed, . An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Procedure: . Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed . A record review of the Baseline Care Plan dated 03/22/25 revealed a goal for Resident #169 to maintain comfort to the highest degree possible. Interventions included monitoring for pain, administering pain medications as ordered, and eliminating or reducing causative factors. A record review of Resident #169's Admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain. A record review of Resident #169's Hospitalist Admission History and Physical dated 01/12/25 revealed diagnoses of Neck Pain and Pain. A record review of Resident #169's Order Summary Report with active orders as of 03/25/25 revealed Oxycodone HCL 10 mg PO every four (4) hours as needed for severe pain; and Oxycodone HCL 20 mg PO every four (4) hours as needed for pain. A record review of the Medication Administration Record (MAR) revealed no Oxycodone was administered until 03/25/25 at 9:05 AM with a documented pain level of 10. On 03/22/25 and 03/23/25, medications were not administered or marked as refused. A record review of Resident #169's Admission Data Collection dated 03/22/25 at 04:16 (AM) revealed .B. Cognition . alert, oriented to person, place, time, memory okay L. Resident experiencing pain. If yes, complete additional pain evaluation .N1. Contractures .Fingers, hand, wrist, elbow, shoulder of dominant side/Non Dominat side .Strength .Weakness, paresis, paralysis of upper extremity . Resident arrived at the facility at approximately 4:00 AM and required assistance d/t (due to) paralysis of upper extremities. There was no record of an additional pain evaluation noted as required in Section L (Pain). A review of Resident #169's Progress Notes from 03/22/25 to 03/28/25 revealed multiple complaints about pain and lack of medications. Notes from 03/22/25 through 03/24/25 document ongoing complaints about pain and the lack of medication, with the first administration of Oxycodone recorded on 03/25/25 at 9:05 AM. On 03/24/25 at 11:45 AM, during an interview and observation, Resident #169 was observed lying in bed, alert and oriented to person, place, and time. The resident reported being admitted on Saturday, 03/22/25, at 5:45 AM and stated he had experienced a difficult weekend and planned to leave the facility as soon as possible. He further explained he had not received his pain medications all weekend because the pharmacy did not deliver them. He stated that while the Duragesic patch was acceptable, he required his other medications, specifically Oxycodone. He reported that therapy staff said they would follow up on the medications, but he had not seen them again. On 03/26/25 at 3:50 PM, during an interview with the Care Plan Nurse, she confirmed the presence of a pain care plan but stated it was the responsibility of the staff to follow the plan.

Based on interviews, record reviews, and a review of the facility's policy, the facility failed to complete a Pre-Admission Screening (PAS) accurately for a resident with a diagnosis of Schizophrenia on admission for one (1) of two (2) sampled residents for Preadmission Screening and Resident Review (PASRR) Level II. Resident #7. Findings include: A review of the facility's policy, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/08/2021, revealed, . The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines . It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission . If it is learned that after admission that a PASRR Level II screening is indicated it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results . Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency . On 03/24/25 at 11:00 AM, during an interview with the Nurse Consultant, she explained the resident did have a PAS screening and did not require a PASRR Level II on admission. A record review of the PAS revealed the resident had a diagnosis of mental illness and had been taking medications. A record review of the resident's Admission Record revealed the facility admitted the resident on 01/02/2024 with the diagnosis of Schizophrenia, Unspecified. The Proper Name discharge paperwork dated 01/01/2024 noted a diagnosis of Chronic Schizophrenia. A record review of the resident's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section E revealed no behavior in the seven (7)-day lookback. Section I was not coded for Schizophrenia. On 03/24/25 at 01:00 PM, during a phone interview with a staff member from the Level II screening provider, she explained that the documentation provided at the time of the PAS screening did not include the diagnosis of Schizophrenia or the psychotropic medications. She stated the facility should have completed a Status Change once the resident had the diagnosis and after being admitted to an inpatient psychiatric unit. On 03/24/25 at 01:30 PM, during an interview with the Nurse Consultant, she confirmed that Resident #7 had a diagnosis of Schizophrenia on admission, and the PAS screen dated 01/02/2024 did not include this diagnosis. On 03/26/25 at 04:00 PM, during an interview with Social Services, she explained that the PAS screenings are completed prior to admission by the Corporate Office. On 03/27/25 at 12:15 PM, during a phone interview with a corporate staff member, she reported that she completes admissions and the PAS screenings for the facility. She did not remember the resident or the PAS screening but stated that she uses the information from the admission orders to complete the screening and acknowledged she missed the diagnosis of Schizophrenia. On 03/27/25 at 03:30 PM, during an interview with the Interim Administrator and the Nurse Consultant, both explained that the facility and management expect PAS screenings to be completed accurately.

Based on observation, interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Assessment (SCSA) after a return from the hospital with a newly inserted PEG (Percutaneous Endoscopic Gastrostomy) tube and a Stage IV sacral pressure ulcer for one (1) of (20) sampled residents, Resident #33. Findings include: A review of the facility's Minimum Data Set (MDS) policy, revision date 9/25/2017, revealed, .The center conducts initial and periodic standardized, comprehensive and reproducible assessments no later than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and or/state required RAI (Resident Assessment Instrument) . On 03/24/25 at 3:59 PM, Resident #33 was observed with enternal feeding flowing at 50 cc (cubic centimeters)/hour. The head of the bed was elevated to 45 degrees. The resident was lying in bed with eyes closed. On 03/26/25 at 4:28 PM, during an interview with the Corporate Nurse, she stated she was aware that Resident #33 returned from the hospital with a sacral wound and a PEG tube. On 03/27/25 at 12:04 PM, during an interview with Registered Nurse (RN) #1, who also serves as the MDS and Care Plan Nurse, she stated she forgot to complete a Significant Change in Status Assessment for Resident #33. She explained that a significant change assessment is completed to notify staff of a resident's care needs and acknowledged it should have been completed when the resident returned from the hospital with a PEG tube and Stage IV sacral wound. Record review of the re-entry MDS dated [DATE] revealed the resident returned from a short term general hospital but there was not a Significant Change MDS completed. A record review of Resident #33's Admission Record revealed an admitted [DATE] with diagnoses including Osteomyelitis of vertebra sacral and sacrococcygeal region. A record review of Resident #33's Physician Orders dated 03/14/25 revealed continuous Glucerna 1.5 at 50 ml(milliliters)/hour with 120 ml water flush every four hours, providing 1800 kcal (kilocalories), 100 grams of protein, and 910 ml of free water. Orders also included PEG tube feedings twice a day for dietary support. Wound care orders included cleansing the sacral wound with normal saline or wound cleanser, patting dry, applying normal saline wet-to-dry gauze, and covering with a bordered dressing. A review of Resident #33's Annual MDS with an Assessment Reference Date (ARD) of 01/01/25 revealed severely impaired cognition.

Based on observation, interview, record review, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) resident assessment, as evidenced by Resident #47 was coded for enteral feeding incorrectly and Resident #7 was not accurately coded as having a diagnosis of schizophrenia for two (2) of (20) sampled residents. Findings Include: A review of the facility's MDS policy, revision date 9/25/2017, revealed, .The center conducts initial and periodic standardized, comprehensive and reproducible assessments no later than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and or/state required RAI (Resident Assessment Instrument) . Resident #47 A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 02/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section K erroneously indicated in item K0520 Nutritional Approaches that the resident had a feeding tube. On 03/25/25 at 8:46 AM, during an observation and interview with Resident #47 she revealed she had never had a feeding tube since being admitted to the facility. She stated she ate whatever she wanted and had no problems with swallowing. On 03/25/25 at 2:55 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained Resident #47 had never had a feeding tube since she had been in the facility. She stated the resident had plenty of snacks and ate what she wanted. On 03/26/25 at 3:30 PM, during an interview with Certified Nurse Aide (CNA)#1, she confirmed Resident #47 ate well, had never had a feeding tube, and ate snacks regularly. On 03/26/25 at 3:50 PM, during an interview with Registered Nurse (RN)#1, she explained each interdisciplinary team member completed their assigned Minimum Data Set (MDS) sections, and she only signed off to mark the assessment as complete, but did not ensure accuracy. After reviewing Resident #47's Quarterly MDS with an ARD of 02/26/25, she confirmed the resident was incorrectly marked as having a PEG tube. She stated the resident had never had a PEG tube since admission. On 03/26/25 at 4:00 PM, during an interview with the Dietary Manager, she confirmed she completed Section K (nutrition) of the MDS for each resident and had held this position at the facility for five (5) years. She explained her usual process involved reviewing resident weights and physician orders prior to completion. She reviewed the Quarterly MDS with an ARD of 02/26/25 for Resident #47 and confirmed she erroneously marked the resident as having a PEG tube, explaining she must have confused the resident's record with another and selected the item in error. On 03/27/25 at 12:30 PM, during an interview with RN #1, she confirmed the MDS error was due to an incorrect entry by the Dietary Manager. She stated her expectation was that MDS assessments reflect residents' actual conditions. She explained that inaccurate assessments could lead to incorrect reimbursement, but this MDS had already been corrected and would not impact reimbursement. A record review of Resident #47's Admission Record revealed the facility admitted the resident on 11/02/22 with diagnoses including Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction Without Residual Deficits. A record review of the Order Summary Report with active orders as of 3/25/25 revealed no orders for tube feeding. Resident #47 had a regular diet, regular texture, and regular/thin liquids consistency. Resident #7: A record review of the Admission Record revealed the facility admitted Resident #7 on 01/02/24 with a diagnosis of Schizophrenia, Unspecified. A record review of the 5-Day MDS with an ARD of 02/11/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Section I item I6000 was not coded for a diagnosis of Schizophrenia. On 03/24/25 at 1:30 PM, during an interview and confirmation with the Nurse Consultant, she confirmed Resident #7 had a diagnosis of Schizophrenia upon admission. On 03/27/25 at 2:23 PM, during an interview with RN #1, she confirmed the MDS was inaccurately coded regarding the resident's active diagnoses. She stated Resident #7 had a diagnosis of Schizophrenia, and it was missed in error. 50751

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents for one (1) of (20) sampled residents, with the potential to affect all residents, Resident #67. Findings included: A record review of a signed statement, undated, from the Interim Administrator revealed: Facility staffs according to census, acuity and/or facility assessment based on resident needs. A review of the Facility assessment dated [DATE] revealed: .Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident ' s needs . Licensed nurses providing direct care equaled 9, Nurse Aides equaled 21, Other Nursing personnel (e.g., those with administrative duties) equaled 3 . Describe your general staff plan to ensure that you have sufficient staff to meet the needs of the residents at any given time . Director of Nursing (DON) . 1 Registered Nurse (RN) DON . 1- RN as Assistant DON (ADON) . 1 Staff dev. Licensed Practical Nurse (LPN) . 1 wound care LPN . RN Charge 7-3 (1) 3-11 (1) 2 LPN days and evening and 2 LPN nights . Direct care staff days 8 . evening 7 . nights 6 . Resident #67 On 03/24/25 at 12:38 PM, during an interview and observation with Resident #67, she was observed lying in bed with visible hair under her chin. The resident stated she wanted her chin hair shaved and explained that her last shower was on the prior Thursday. The room had a strong odor of urine. She stated she used to receive bed baths three times per week. A review of Resident #67 ' s Admission Record revealed an admitted [DATE] with diagnoses including Muscle weakness, other reduced mobility, and Lack of coordination. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was cognitively intact. Section GG revealed the resident was dependent for bathing and showers. On 03/24/25 at 4:10 PM, during an interview with Certified Nurse Aide (CNA) #2, she stated she worked part-time on both the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. She explained that the number of CNAs varied by day and shift, ranging from as few as three (3) to as many as ten (10). When only three CNAs were present, it was difficult to check and change residents every two (2) hours, and residents had to wait longer for care. On 03/25/25 at 9:10 AM, during an interview with CNA #3, she reported caring for an average of sixteen (16) residents per shift, depending on staffing. She explained the average number of CNAs was five (5), but there were days with fewer. On those days, residents often had to wait longer for care and might not receive scheduled showers. On 03/25/25 at 1:10 PM, during an interview with CNA #6, she stated she typically worked eight (8)-hour shifts but had recently worked more twelve (12)-hour shifts due to staffing shortages. She cared for six (6) to (10) residents per shift. She reported that residents may have to wait longer than two hours to be changed or repositioned when staffing was low, and showers were sometimes delayed when a designated shower aide was unavailable. On 03/25/25 at 2:55 PM, during an interview with Licensed Practical Nurse (LPN) #3, she reported working (12)-hour shifts on a rotating schedule. She cared for over (30) residents and sometimes more, depending on the census. She explained she had worked extra hours and days to help cover due to ongoing staffing shortages among nurses and CNAs. On 03/26/25 at 8:24 AM, during an interview with LPN #2, she stated she worked in medical records but was currently working the medication cart due to low staffing. She stated, I worked last night, went home for a couple of hours, and I'm back this morning. On 03/26/25 at 10:05 AM, during an interview with CNA #4, she reported working all shifts and was called in to work that day. She cared for approximately (15) residents per shift. She stated that some days there was a designated shower aide and other days there was not. She explained that due to low staffing, residents had to wait extended periods for care and noted that only small gloves were available, which made providing care difficult. On 03/26/25 at 11:50 AM, during an interview with CNA #5, she stated she worked part-time, primarily on the 7:00 AM-3:00 PM shift. She reported having over (20) residents on some shifts when only (3) CNAs were present. On those days, residents were often not gotten out of bed and had to wait extended periods to be changed. On 03/26/25 at 12:48 PM, during an interview with CNA #7, who also worked in restorative care, she stated that due to CNA shortages, she worked on the hall in addition to her restorative and whirlpool duties. She worked as a restorative aide (2) to (3) days per week and as a floor CNA the remainder of the week. On 03/26/25 at 4:10 PM, during a follow-up interview with LPN #2, she confirmed she had worked the cart the night before from 7:00 PM to 2:00 AM and returned the next morning to work the cart again. She stated there was no regular nurse scheduled for that rotation, and the on-call nurse often had to work the cart. On 03/27/25 at 11:30 AM, during an interview with the Nurse Consultant, she stated the Director of Nursing (DON) had been off that week due to a family emergency. She confirmed that the DON created the nursing schedule and the Staff Developer created the CNA schedule. On 03/27/25 at 11:50 AM, during an interview with LPN #5, she confirmed she had worked full-time in her current role since April 2024 and part-time at the facility for over (2) years. She confirmed that she created the CNA schedule and the DON created the nurse schedule. She stated staffing was short and that many staff only worked a few hours to assist as needed. She explained that LPNs usually worked twelve (12)-hour shifts and CNAs worked eight (8)-hour shifts. She confirmed that the Medical Records nurse had worked both night and day shifts due to call-ins, which was a frequent pattern. She reported that residents had complained about waiting long periods to be changed or cleaned due to low staffing. A review of the staffing schedules and staffing grids for March 2025 revealed the following: On 03/06/25, three (3) CNAs were assigned to care for (67) residents on the 7:00 AM-3:00 PM shift. On 03/09/25, only two (2) CNAs were assigned to care for (67) residents on the 11:00 PM-7:00 AM shift. On 03/21/25, 03/22/25, and 03/23/25, only (3) CNAs were scheduled for the 7:00 AM-3:00 PM shift, with resident counts ranging from (67) to (69). On 03/15/25, three (3) CNAs were scheduled for the 3:00 PM-11:00 PM shift and (2) CNAs for the 11:00 PM-7:00 AM shift, for (67) residents. On 03/27/25 at 2:00 PM, during an interview with the Interim Administrator, he stated he had only been at the facility for three (3) weeks and was still learning about the facility, staff, and residents. He explained that he expected the facility to follow federal staffing regulations and conduct staffing assessments.

Based on interviews, record reviews, and facility policy review, the facility failed to send a Status Change for Preadmission Screening and Resident Review (PASRR) after a resident was admitted to an inpatient behavioral health unit for one (1) of two (2) sampled residents reviewed for PASRR, Resident #7. Findings included: A review of the facility ' s policy, Preadmission Screening and Resident Review (PASRR), with a revision date of 11/08/21, revealed .The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines .Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission .4. If it is learned that after admission that a PASRR Level II screening is indicated it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results .7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency . A record review of Resident #7's Admission Record revealed the facility admitted the resident on 01/02/24 with the diagnoses of Schizophrenia, Unspecified. A discharge summary dated 01/01/24 also noted Chronic Schizophrenia. A record review of Resident #7's Order Summary Report with active orders as of 03/26/25 revealed orders May refer to Behavioral Health Unit (BHU) order date 1/22/25 . May refer to (Name of local BHU) order date 4/02/24 . May transfer to (Proper Name of County Hospital) BHU order date 4/03/24. A record review of Resident #7's Discharge Minimum Data Sets (MDS) with Assessment Reference Dates (ARDs) of 04/03/24 and 01/23/25 revealed discharge to an inpatient psychiatric facility. On 03/25/25 at 3:25 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained that Resident #7 had exhibited ongoing behavioral issues toward both staff and residents. She stated that prior to the most recent transfer to the BHU, the resident had become upset with staff and broke the facility door. She added that the resident continues to curse at staff, particularly when denied cigarettes. She noted the resident used to refuse medications but has been more compliant since returning from the BHU. On 03/26/25 at 4:00 PM, during an interview with the facility's Social Services, she explained that PASRR Level I screenings are completed by the corporate office prior to admission. She stated that if a status change occurs, she is responsible for submitting a referral for a PASRR Level II, which should be done within seven (7) days of the resident's return. On 03/27/25 at 10:00 AM, during a follow-up interview with Social Services, she reviewed Resident #7's medical records and confirmed that the resident had been transferred to an inpatient BHU on 04/03/24 and again on 01/23/25. She acknowledged that no Status Change was submitted following either admission and stated it was an oversight. She reported that she had initiated an audit of all residents who may require a PASRR Level II. On 03/27/25 at 3:30 PM, during an interview with the Interim Administrator and the facility's Nurse Consultant, both stated that it is the facility's expectation that PASRR screenings be completed accurately and that Status Change referrals be submitted in a timely manner when required.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was transported in the facility van in a safe manner. Resident #1's wheelchair tilted causing a fall during transport, resulting in injury for one (1) of five (5) residents reviewed for accidents. Resident #1. Findings include: Review of facility policy and procedure, Driver/Vehicle Safety dated 8/30/17, revealed, Purpose: To provide guidance for safe handling and operating of center owned vehicle while transporting patient/residents. Process: .4. Wheelchairs to be secured 5. Complete Transport Securement checklist each time a resident wheelchair is placed in the vehicle . Record review of the facility investigation titled Verification of Investigation dated 8/04/23 at 12:00 PM, revealed .Detailed Description of event . Van driver call DON (Director of Nurses) stated that she had a problem then stated that she made a turn and (Proper name of Resident #1's) chair tilted to the left and he hit his head up against the paneling .Assessment of Resident/Describe Injury: Resident noted to have blood running down left side of face. Upon assessment noted 0.3 x 0.2 x 0.1 laceration to left ear and a 0.5 x 0.2 x 0.1 skin tear noted to left elbow . Record review of the Facility Investigation dated 8/04/23, revealed that during transport in the facility van, driven by the Transportation Aide, Resident #1's wheelchair tilted to the left when the driver made a right turn from the facility driveway onto the highway. Resident #1's head hit the van's paneling, resulting in a laceration to the resident's left ear and a skin tear to his left elbow. On 9/06/23 at 3:30 PM, an interview with the Director of Nurses (DON) revealed that she became aware of the accident on 8/04/23, a few minutes after 12 PM, when she received a telephone call from the Transportation Aide. The DON reported that the accident occurred as the van pulled out of the (facility) driveway, as Resident #1 was being transported to a dialysis appointment. She said the Transportation Aide had reported that she immediately pulled over to a safe area, and reportedly, with the assistance of Certified Nursing Assistant (CNA) #1, who was also on the van, got the resident's wheelchair back upright and secured it. The Transportation Aide was instructed to return to the facility and upon their arrival the DON had assessed Resident #1 and administered first aid and called an ambulance to transport Resident #1 to the local hospital's Emergency Department (ED) for assessment and treatment. She stated that Resident #1 received sutures (could not recall how many) to the left ear, a tetanus shot, antibiotic therapy and physician orders for ten (10) days of continued antibiotic therapy at the ED. She confirmed that Resident #1 also sustained a skin tear to his left elbow, because of the fall. The DON confirmed that Resident #1 returned to the facility, however, had been discharged to home on 8/05/23, as previously planned. The DON also revealed that the Transportation Aide was no longer employed by the facility, as the facility had terminated the employee for reasons not related to the accident. Record review of the (Name of local hospital) Emergency Department( ED) reported revealed, Discharge Instructions .Arrival Date: 8/04/23 .Diagnosis .Fall from non-moving wheelchair; Laceration without foreign body of left ear . Resident #1 was treated on 8/04/23 following the accident/fall with Acetaminophen, Tetanus Toxoid injection, Cefazolin antibiotic intravenously (IV) and closure of left ear laceration with stitches (the number of stitches was not documented). Resident #1 had lab tests, chest x-ray and a CT (computed tomography) of head with no other injuries noted. The Discharge Instructions included physician orders for Cephalexin antibiotic 250 milligrams by mouth four times daily for ten (10) days and suture removal after one (1) week. On 9/06/23 at 3:55 PM, the State Agency (SA) attempted to contact the Resident Representative (RR) for Resident #1 by telephone without success and was unable to leave a message. On 9/06/23 at 4:00 PM, during an interview with CNA #1, she confirmed that she had been seated on the front seat, behind the driver on 8/04/23, at the time of the accident. She confirmed the accident occurred when the van turned right out of the facility driveway. She stated that she and the Transportation Aide were immediately aware of the accident and the van was pulled over. CNA #1 revealed that she had not observed the Transportation Aide secure the wheelchair or the resident prior to leaving the facility. She noted that when the van was leaving the facility driveway, she heard a clicking noise and the wheelchair tilted over to the left. She stated that she knew for sure that all four (4) metal hooks of the floor anchors had been attached to the wheelchair because she observed them following the accident when she assisted the Transportation Aide in righting the wheelchair. The CNA confirmed that while the hooks were attached to the wheelchair, the chair had been able to tilt and fall over to the left. On 9/06/23 at 5:30 PM, an observation of the facility van and an interview with the Plant Operations Director (POD), revealed that on 8/04/23, following the accident, he had inspected the wheelchair securement system in the facility van and found no problems with any components. He stated that he had accompanied the Transportation Aide to transport another resident back to the facility, completed a competency skill check and directly observed the procedure to secure the wheelchair and the resident and noted no issues with the procedure. However, he confirmed that he had not observed Resident #1 being secured in the van prior to transport. On 9/07/23 at 10:10 AM, during a telephone interview with the Transportation Aide, she stated I don't know how that wheelchair tilted over. I strapped it down just like I always did. She stated she had not observed any component of the wheelchair securement system that was malfunctioning. She stated that the tie downs were still hooked to the wheelchair when she pulled over, following the accident. She explained that she had loaded Resident #1 into the facility van in his wheelchair, secured the wheelchair using all four (4) tie downs and S hooks and secured the resident with waist and shoulder seat belts. The Transportation Aide confirmed that when she left the facility driveway, she turned right onto the highway and heard the wheelchair of Resident #1 tilt over to the left. After pulling over, she and CNA #1 righted the wheelchair of Resident #1 and administered first aid to the resident. She stated she quickly telephoned the facility DON and was instructed to return to the facility. She said that upon return to the facility, the DON assessed and treated Resident #1. She said that Resident #1 was then transported to by ambulance to the local hospital ED. On 9/07/23 at 10:30 AM, observation and an interview with the POD on the facility van, he provided a demonstration of the proper use of the van's wheelchair securement system. His demonstration was compared to the manufacturer's guidelines and no problems were noted. The POD revealed he had driven the facility van for transportation of residents since the accident on 8/04/23. He stated that he had inspected the van and wheelchair securement system prior to each transport and had not noted any problems with any component. The POD demonstrated how the wheelchairs could be rocked back and forth to take up slack and ensure proper tension as listed in the Use Instructions for the wheelchair securement system installed in the van. He stated that if the tie downs were not properly tensioned that the wheelchair was not secured. It was noted that there was a clicking noise when the straps (tie downs) were pulled from the floor restraint. The POD confirmed that the Transportation Aide was supposed to complete a 'Vehicle Inspection Form' prior to transportation of any resident each day and was supposed to complete a 'Wheelchair Van Check List' for Safety form for each resident transported in a wheelchair every time. He revealed that the DON confirmed that neither form had been completed by the Transportation Aide prior to transportation of Resident #1 on 8/04/23. He stated that the forms were completed following the return of Resident #1 to the facility after the accident on 8/04/23. On 9/07/23 at 3:48 PM, an interview with the Administrator revealed he confirmed that the cause of the fall was either mechanical failure or human error. He stated he did not believe that mechanical failure caused the fall of Resident #1 during transportation in the facility van on 8/04/23. Record review of the Admission Record for Resident #1 revealed the resident was initially admitted by the facility on 7/12/23 and had diagnoses that included End Stage Renal Disease and Cerebrovascular Disease. Record review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/19/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on policy review, observation, and interview, the facility failed to ensure all nursing staff were competent in providing nursing care for residents who received glucose testing, that was safe to prevent the potential for acquiring an infection. This affected seven (7) of 12 facility residents observed to receive glucose testing, Resident #21, Resident 51, Resident #281, Resident #58, Resident #7, Resident #178 and Resident #46 who resided on Hallway 5 and Hallway 6. Licensed Practical Nurse (LPN) #1 and #3 failed to have the necessary competencies to provide safe and sanitary glucose testing, by failure to wash hands, place an appropriate barrier, don gloves, disinfect the glucometer, and dispose of used lancets properly between resident use, placing residents and themselves at risk for potential infections. The facility's failure to have nurses, who provided glucose testing, with the necessary competencies to perform adequate infection control procedures during blood glucose testing, placed the seven (7)identified residents, as well as the additional five (5) residents who required routine or as-needed blood glucose monitoring, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 5/2/19, when the observations of inadequate infection control practices were first made. The facility's Administrator, Director of Nursing, and Regional Director of Clinical Services were informed of the IJ on 5/3/19 at 5:26 PM. The facility provided an acceptable IJ Removal Plan on 5/4/19, in which the facility alleged all corrective actions were completed to remove the IJ on 5/4/19, and the IJ removed on 5/5/19. Healthcare Management Solutions, LLC (HMS) determined the IJ was removed on 5/5/19, prior to the exit, and the scope and severity for 42 CFR(s) 483.35(a)(3)(4)(c), F726, Competent Nursing Staff, was lowered from a K to an E, pattern of no actual harm with potential for more than minimal harm, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled Blood Glucose Monitoring and Disinfecting dated 11/30/14, directed staff to use the resident's glucose meter, which was kept in their rooms, perform hand hygiene and wear gloves during the blood glucose monitoring procedure and to disinfect the meter prior to and after use. Observation of LPN #3 on 5/2/19 between 11:30 AM and 11:50 AM, revealed LPN #3 performed blood glucose monitoring on three (3) residents (Resident #21, Resident #7 and Resident #51) where she failed to follow the facility policy to wear gloves, use the resident's personal meter and disinfect the meter before and after use. Observation of LPN #1 on 5/2/19 between 8:00 PM and 8:30 PM, revealed LPN #1 performed blood glucose monitoring on five (5) residents (Resident #281, Resident #58, Resident #7, Resident #178 and Resident #46) where she failed to follow the facility policy which included hand hygiene, wearing protective gloves and disinfecting the glucose meter prior to use and following use of each resident. Interview with the Director of Nursing on 5/2/19 at 12:16 PM, confirmed each resident was to have their own meter, the meter must be disinfected prior to and after use, staff were to perform hand hygiene before and after the procedure and wear gloves when performing the procedure of glucose testing. The facility provided an acceptable IJ Removal Plan on 5/4/19, with the following corrective actions: Please accept this as our plan of removal for the immediate jeopardy determined on (MONTH) 3, 2019 at 5:26 PM. The deficient practice during blood glucose monitoring. Brief Summary: 1. On (MONTH) 2, 2019 at 11:45 AM, License Practical Nurse (LPN) #1 performed Blood Glucose Monitoring for Resident (R) 7, Resident (R) 57 and Resident (R) 21 using a glucometer taken out of the medication cart without sanitizing the meter in between uses, without using a barrier for glucometer and without performing hand hygiene or donning gloves. LPN #1 was pulled in to Director of Nurses (DON) office for education. On (MONTH) 2, 2019 from 8:00 PM to 8:30 PM, Licensed Practical Nurse (LPN) #3 performed Blood Glucose Monitoring for Resident (R) 281 and Resident (R) 58 without washing her hands, donning gloves, or without using a barrier for the glucometer and without disposing of lancet appropriately. At this point the Infection Control Nurse (IFC) #1 intervened and asked her to wash her hands. The above observations were reported to the DON. LPN #1 and LPN #3 was immediately removed from providing further patient care. LPN #3 attended facility education regarding use of glucometers on (MONTH) 23, (YEAR). On (MONTH) 2, 2019 at 4:35 PM, LPN #3 was educated on Policy N 700 Blood Glucose Finger-stick and Disinfecting. On (MONTH) 3, 2019, LPN #3 was suspended and has not worked in facility. Corrective Action: 1. LPN #1 received Glucometer Competency Skills Checklist (MONTH) 14, 2019, with demonstration of competency in blood glucose monitoring and disinfecting. Director of Nursing (DON) #1 provided corrective action with LPN #1 (MONTH) 2, 2019 at 6:00 PM, regarding failure to use proper infection control procedure to prevent the spread of infection. LPN # 1 was educated (MONTH) 2, 2019 at 6:00 PM on Policy N- 700 Blood Glucose Monitoring and Disinfecting, with emphasis on performing blood glucose finger sticks, using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. Education with LPN #1 was conducted (MONTH) 3, 2019 at 11:45 PM on Policy N - 700 Blood Glucose Monitoring and Disinfecting , revision date (MONTH) 3, 2019 with emphasis on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. LPN #1 was suspended (MONTH) 3, 2019 for failure to perform competency. 2. LPN #3 was educated on Policy N 700 Blood Glucose Monitoring and Disinfecting, on (MONTH) 2, 2019 at 4:35 PM, with emphasis on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. LPN #3 was pulled from providing patient care (MONTH) 2, 2019 at 8:50 PM. Corrective action with LPN #3 was conducted (MONTH) 3, 2019 resulting in suspension. 3. Executive Director (ED) #1 provided corrective action to LPN #3 (MONTH) 3, 2019, with emphasis on inability to complete competency for blood glucose monitoring and disinfecting. 4. Audit was conducted of 12 Residents with physician orders for Blood Glucose Monitoring on (MONTH) 2, 2019 at 6:15 PM, by the DON to ensure Residents had individual Glucometers at bedside. Twelve of 12 had individual glucometers at bedside. 5. Glucometers on medication cart #1 and medication cart #2 were removed from circulation (MONTH) 2, 2019 at 6:00 PM, by the Unit Manager and DON. Blood Glucose Monitoring will be performed by licensed nurses using glucometers at bedside. 6. On (MONTH) 2, 2019 at 6:15 PM, 12 of 12 glucometers at bedside were disinfected and cleaned with approved disinfecting wipes by the DON, Unit Manager, and Infection Control Nurse. 7. On (MONTH) 2, 2019, Regional Director of Clinical Services (RDCS) #1 initiated demonstration and return demonstration at 4:35 PM, for nine (9) licensed nurses; 6:00 PM for three (3) licensed nurses; 9:00 PM for two (2) licensed nurses; and 11:17 PM for two (2) licensed nurses, on Policy N 700 Blood Glucose Monitoring and Disinfecting. Licensed nurses performed procedure appropriately during return demonstration. 8. On (MONTH) 3, 2019, Policy N-700 Blood Glucose Monitoring and Disinfecting policy was revised to add Apply pressure to puncture site with gauze pad or alcohol swab. 9. (MONTH) 3, 2019, education with licensed nurses was initiated by RDCS #1 on Policy N 700 Blood Glucose Monitoring and Disinfecting, revision date (MONTH) 3, 2019, with emphasis on donning gloves, providing a barrier for glucometer, proper hygiene, and disposal of lancets appropriately. Licensed nurses will not be allowed to work until return demonstration on Policy N-700 Blood Glucose Monitoring and Disinfecting has been performed and licensed nurse has demonstrated competency. Twenty of 33 nurses have completed education. 10. An Ad-Hoc Quality Assurance Performance Improvement ( QAPI) meeting was held on Friday, (MONTH) 3, 2019 at 8:00 PM, with Executive Director (ED), Director of Nursing (DON), MDS Coordinator (MDSC), Dietary Manager (DM), Activities Director (AD), Maintenance Supervisor ( MS), Human Resources (HR), Transportation Aide (TA), Social Services (SSD), Medical Records Clerk (MRC) , Central Supply (CS}, and the Medical Director, attending by telephone, to discuss the opportunity for improvement, and assess current situation of failure to perform blood glucose finger sticks to prevent the spread of infection. Root cause analysis, and plan of correction to include education with licensed nurses on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet, and donning gloves, and the revision of N-700 Blood Glucose Monitoring and Disinfecting to add, and alcohol swab. 11. Audit was conducted by the DON and Unit Manager on May, 4, 2019 at 4:45 PM, of 12 Resident's Care Plans with orders for Blood Glucose Monitoring to ensure individual glucometers are care planned. Twelve of 12 care plans include individual glucometers. 12. On (MONTH) 4, 2019 at 5:00 PM, 12 Residents with orders for Blood Glucose Monitoring, was assessed for signs and symptoms of infection. Twelve of 12 Residents showed no signs of infection. Twelve of 12 resident's vital signs were obtained by the DON and Unit Manager. The facility alleges all corrective actions were completed (MONTH) 4, 2019, and the Immediate Jeopardy was removed (MONTH) 5, 2019. HMS validated the facility's IJ Removal Plan and determined the IJ was removed on 5/5/19, prior to survey exit, through interviews with the Administrator, DON, Regional Director of Clinical Services, residents, and Licensed and Registered Nurses, observations blood glucose tests, and review of facility documentation of corrective actions for involved staff, ad-hoc quality assurance committee discussions, revised policies, and staff in-service education and competency testing. Validation of the IJ Removal Plan included: 1. HMS validated through interviews and observations the facility's policy and procedure to use resident-specific glucometers found in each resident's room, disinfect glucometers before and after use, perform hand hygiene and don gloves during blood glucose testing procedures, use a barrier between the glucometer and potentially hazardous surfaces, and dispose of the single-use lancets using sharps containers. 2. HMS validated through interviews and review of corrective action documentation that corrective actions and competency testing for LPN #1 and LPN #3 were completed and LPN #3 was suspended from duty. 3. HMS validated through interviews and review of ad-hoc QA committee meeting minutes and revised policies, the revision and approval of the new Blood Glucose Monitoring and Disinfecting policy. 4. HMS validated through interviews and observations that 12 of 12 residents had resident-specific glucometers at their bedside and that all 12 glucometers were tested for functioning and disinfected. 5. HMS validated through interviews and observations that back-up glucometers on both medication carts were removed. 6. HMS validated through interview and record review that on 5/2/19, demonstration and return demonstration was performed by the Regional Director of Clinical Services for 16 licensed nurses on Policy N 700 Blood Glucose Monitoring and Disinfecting. Licensed nurses performed procedure appropriately during return demonstration. 7. HMS validated through interviews and record reviews that on 5/3/19, education with licensed nurses was initiated by Regional Director of Clinical Services on the Blood Glucose Monitoring and Disinfecting policy, revision date 5/3/19. HMS also validated through review of in-service sign-in records and staffing schedules, licensed nurses were not be allowed to work until return demonstration on the Blood Glucose Monitoring and Disinfecting policy was performed. 8. HMS validated through record reviews that use of resident-specific glucometers was indicated on 12 of 12 residents' care plans. 9. HMS validated through record review 12 of 12 residents were assessed for signs and symptoms of infection and did not show any adverse consequences. HMS validated that all corrective actions were completed on 5/4/19, and the IJ removed on 5/5/19.

Based on observations, staff and resident interviews, and policy review, the facility failed to ensure staff followed adequate infection control practices during blood glucose testing for seven (7) of 12 residents (Resident #7, Resident #21, Resident #57, Resident #58, Resident #281, Resident #178, and Resident #46), who required blood glucose monitoring. The facility's failure to follow adequate infection control practices during glucose monitoring tests had the potential to result in significant harm or death related to blood-borne infections. On 5/2/19, from 11:30 AM to 11:45 AM, Licensed Practical Nurse (LPN) #1 was observed performing blood glucose testing using the same glucometer (testing meter) for Resident #7, Resident #57 and Resident #51,without sanitizing/disinfecting the glucometer between each resident. Additionally, LPN #1 did not use a barrier, between the glucometer and the bedside tables she placed the glucometer on, in each of the three (3) resident's rooms; and did not don gloves or perform hand hygiene during the observations. Furthermore, on 5/2/19, from 8:00 PM to 8:30 PM, LPN #3 was observed performing blood glucose testing for Resident #7, Resident #281, Resident #58, Resident #178, and Resident #46, without washing or sanitizing her hands, without donning gloves, without using an appropriate barrier between the glucometer and the over-bed tables, and without properly disinfecting the glucometer and disposing of the used lancets. The facility's failure to perform adequate infection control procedures during blood glucose testing placed the seven (7)identified residents, as well as the additional five (5) residents who required routine or as-needed blood glucose monitoring, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 5/2/19, when the observations of inadequate infection control practices were first made. The facility's Administrator, Director of Nursing, and Regional Director of Clinical Services were informed of the IJ on 5/3/19 at 5:26 PM. The facility provided an acceptable IJ Removal Plan on 5/4/19, in which the facility alleged all corrective actions were completed to remove the IJ on 5/4/19, and the IJ removed on 5/5/19. Healthcare Management Solutions, LLC (HMS) determined the IJ was removed on 5/5/19, prior to the exit, and the scope and severity for 42 CFR(s) 483.80(a)(1)(2)(4)(e)(f), F880, Infection Control, was lowered from a K to an E, pattern of no actual harm with potential for more than minimal harm, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility policy titled, Blood Glucose Monitoring and Disinfecting, dated 9/28/17, documented the procedure: Assemble the following equipment: -Alcohol swab -Gauze -Single use lancet -Gloves -Blood glucose meter (Resident specific) -Blood glucose reagent strip -Disinfecting wipes Perform hand hygiene Apply gloves . Prepare glucose meter for testing Wipe tip of finger with alcohol swab and allow to dry<BR/(NAME)the site with the lancet Transfer drop of blood to reagent strip Apply pressure to puncture site with gauze pad Test blood specimen per manufactures (sic) guidelines Read results Discard test strip and other materials Discard lancet in sharps container Remove gloves Perform hand hygiene Place meter in resident specific storage container Meter to be cleansed utilizing a disinfectant wipe (according to manufacturer's guidelines for wet time) if the meter is visibly soiled, or dropped. Document result in medical record. Per the facility's undated, EvenCare G3 Blood Glucose Monitoring System operator's manual, Users need to adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. A new pair of clean gloves should be worn by the user before testing each patient. The EvenCare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EvenCare G3 Meter: . Medline Micro-Kill Bleach Germicidal Wipes (EP Registration Number: -1). Step 1. Wash hands with soap and water Step 2. Put on single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoiding wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes . Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Allow the surface of the meter to remain at room temperature for: at least 30 seconds for Medline Micro-Kill Bleach (Germicidal Wipes). The facility policy titled, Hand Hygiene, dated 8/19/17, direct staff to perform hand hygiene before and after direct resident care and before and after contact with bodily fluids. Observation on 5/2/19 at 11:35 AM, revealed LPN #1 obtained a blood glucose meter from the top drawer of the medication cart. LPN #1 then entered the Resident #21's room, removed the glucose meter from the basket, and placed the meter on the over-bed table without a barrier. LPN #1 washed her hands, but did not don gloves prior to performing the blood glucose monitoring. LPN #1 did not disinfect the glucometer upon completion of the blood glucose monitoring for Resident #21. LPN #1 then took the basket with the glucometer and lancing devices to Resident #7's room, and on 5/2/19 at 11:40 AM, LPN #1 removed the glucometer from the basket and placed it on Resident #7's over-bed table without a barrier. LPN #1 then washed her hands, but failed to apply gloves prior to performing the test. LPN #1 did not sanitize the glucometer prior to using it to test Resident #7's blood. After the test, LPN #1 washed her hands, placed the glucometer in the basket, and proceeded to Resident #57's room without cleaning or disinfecting the meter. On 5/2/19 at 11:43 AM, LPN #1 placed the glucometer on the over-bed table without a barrier and without disinfecting the meter. LPN #1 washed her hands but failed to don gloves. LPN #1 obtained the fingerstick blood sample and performed the blood glucose monitoring for Resident #57. She then washed her hands, disinfected the glucometer per manufacturer's instructions, and returned to the medication cart. Interview with LPN #1 on 5/2/19 at 11:48 AM, confirmed she did not use resident-specific glucometers to test the blood glucose for Resident #21, Resident #7, and Resident #57, nor did she disinfect the glucometer between each resident's use. LPN #1 also confirmed she did not don gloves during the three (3) blood glucose tests, and stated that sometimes she wears gloves and sometimes she does not. When LPN #1 was asked why she used the back-up glucose meter from the medication cart, instead of the meter in each resident's room, designated for that specific resident, LPN #1 replied, because it is easier. Observation on 5/2/19 at 8:00 PM, revealed LPN #3 entered Resident #7's room, obtained the resident-specific glucose meter from Resident #7's nightstand, and placed the meter on the over-bed table, without disinfecting the meter. LPN #3 assembled the needed supplies on the over-bed table using a piece of toilet paper as a barrier. LPN #3 performed the blood glucose testing without wearing gloves, then placed the single use lancing device in her pocket, returned the meter to the storage pouch without disinfecting the meter, and exited Resident #7's room without washing her hands. On 5/2/19 at 8:10 PM, LPN #3 then entered Resident #281's room and explained she would be performing blood glucose testing. LPN #3 placed the resident-specific glucose meter from the resident's bedside pouch on the over-bed table without a barrier. LPN #3 failed to disinfect the meter prior to testing, failed to wash her hands prior to performing the blood glucose test with the single use lancing device, failed to wear gloves during the procedure, failed to disinfect the glucometer after use, and failed to wash her hands after the test. LPN #3 placed the single use lancing device in her pocket after use. On 5/2/19 at 8:15 PM, LPN #3 explained to Resident #58 she would be performing a blood glucose test. LPN #3 obtained the resident-specific glucose meter from Resident #58's bedside pouch and placed it on the over-bed table without a barrier. LPN #3 failed to disinfect the meter. After assembling the supplies, LPN #3 turned her back to Resident #58 and stated, and now I wash my hands, as she rubbed her hands together in the air. She did not actually wash with soap and water or sanitize with alcohol-based hand rub, and did not put on gloves. LPN #3 proceeded with the procedure, placed the used single use lancet in her pocket, placed the meter in the pouch without disinfecting it, and exited the room without performing hand hygiene. ON 5/2/19 at 8:20 PM, LPN #3 explained to Resident #178 she would be performing blood glucose testing. LPN #3 obtained the resident-specific meter from Resident #178's bedside pouch and placed it on the over-bed table without a barrier and without disinfecting the meter. After assembling supplies, LPN #3 turned her back to Resident #178 and stated, and now I wash my hands, again, as she rubbed her hands together in the air without actually washing or sanitizing them. LPN #3 did not wear gloves and proceeded with the procedure, placed the meter in the pouch without disinfecting it, and exited the room without performing hand hygiene. On 5/2/19 at 8:30 PM, LPN #3 explained to Resident #46 she would be performing blood glucose testing. The Infection Control Nurse (ICN) entered the room. LPN #3 obtained the meter from Resident #46's bedside pouch and placed it on the table without a barrier. LPN #1 assembled the supplies, turned her back to Resident #46 and stated, and now I wash my hands. The ICN asked LPN #3 to perform hand hygiene. LPN #3 verbally disagreed, stating she was showing' this surveyor how to perform the task. The ICN informed LPN #3 that she needed to perform hand hygiene, not just simulate hand washing. LPN #3 responded, I told you I did. The ICN then directed LPN #3 to, go into the bathroom and use soap and water. After washing with soap and water, LPN #3 performed the procedure without donning gloves. She had not disinfected the meter prior to use, and wiped the meter with an alcohol wipe following completion of the procedure. Interview with LPN #3 on 5/2/19 at 8:30 PM, with Registered Nurse (RN) #3 and the Administrator present, confirmed the lancets were placed in her pocket. LPN #3 stated, The rooms do not have sharps containers. LPN #3 then stated, What the hell did I do that was so wrong? and, I told you when I would wash my hands. The Director of Nursing (DON), interviewed on 5/2/19 at 12:16 PM, stated each resident should have their own glucose meter to be used only for that resident. On 5/3/19 at 4:25 PM, the DON stated the facility's policy was to use resident-specific glucometers, stored in separate containers for each resident; however, there was a back-up glucometer in the medication cart in case of malfunction. The facility removed the back-up glucose meter from the medication carts and ensured extra meters were available to be designated for single-resident use as needed. A tour was conducted of all 12 residents' rooms who receive blood glucose monitoring, and a resident-specific glucometer was found in a container in each resident's room. Each meter was tested with solution and was working appropriately. The facility provided extensive staff re-training for all nurses prior to the start of their shifts beginning on 5/3/19, and were implementing competency testing for all nursing staff. The DON explained her expectation was that the nurse would wash their hands prior to, and after performing the procedure, wear gloves during the procedure, and disinfect the glucometer before and after each use with the approved germicidal wipe, following the manufacturer's instructions for wipe use. The facility provided an acceptable IJ Removal Plan on 5/4/19, with the following corrective actions: Please accept this as our plan of removal for the immediate jeopardy determined on (MONTH) 3, 2019 at 5:26 PM. The deficient practice during blood glucose monitoring. Brief Summary: 1. On (MONTH) 2, 2019 at 11:45 AM, License Practical Nurse (LPN) #1 performed Blood Glucose Monitoring for Resident (R) 7, Resident (R) 57 and Resident (R) 21 using a glucometer taken out of the medication cart without sanitizing the meter in between uses, without using a barrier for glucometer and without performing hand hygiene or donning gloves. LPN #1 was pulled in to Director of Nurses (DON) office for education. On (MONTH) 2, 2019 from 8:00 PM to 8:30 PM, Licensed Practical Nurse (LPN) #3 performed Blood Glucose Monitoring for Resident (R) 281 and Resident (R) 58 without washing her hands, donning gloves, or without using a barrier for the glucometer and without disposing of lancet appropriately. At this point the Infection Control Nurse (IFC) #1 intervened and asked her to wash her hands. The above observations were reported to the DON. LPN #1 and LPN #3 was immediately removed from providing further patient care. LPN #3 attended facility education regarding use of glucometers on (MONTH) 23, (YEAR). On (MONTH) 2, 2019 at 4:35 PM, LPN #3 was educated on Policy N 700 Blood Glucose Finger-stick and Disinfecting. On (MONTH) 3, 2019, LPN #3 was suspended and has not worked in facility. Corrective Action: 1. LPN #1 received Glucometer Competency Skills Checklist (MONTH) 14, 2019, with demonstration of competency in blood glucose monitoring and disinfecting. Director of Nursing (DON) #1 provided corrective action with LPN #1 (MONTH) 2, 2019 at 6:00 PM, regarding failure to use proper infection control procedure to prevent the spread of infection. LPN # 1 was educated (MONTH) 2, 2019 at 6:00 PM on Policy N- 700 Blood Glucose Monitoring and Disinfecting, with emphasis on performing blood glucose finger sticks, using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. Education with LPN #1 was conducted (MONTH) 3, 2019 at 11:45 PM on Policy N - 700 Blood Glucose Monitoring and Disinfecting , revision date (MONTH) 3, 2019 with emphasis on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. LPN #1 was suspended (MONTH) 3, 2019 for failure to perform competency. 2. LPN #3 was educated on Policy N 700 Blood Glucose Monitoring and Disinfecting, on (MONTH) 2, 2019 at 4:35 PM, with emphasis on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet and donning gloves. LPN #3 was pulled from providing patient care (MONTH) 2, 2019 at 8:50 PM. Corrective action with LPN #3 was conducted (MONTH) 3, 2019 resulting in suspension. 3. Executive Director (ED) #1 provided corrective action to LPN #3 (MONTH) 3, 2019, with emphasis on inability to complete competency for blood glucose monitoring and disinfecting. 4. Audit was conducted of 12 Residents with physician orders [REDACTED]. Twelve of 12 had individual glucometers at bedside. 5. Glucometers on medication cart #1 and medication cart #2 were removed from circulation (MONTH) 2, 2019 at 6:00 PM, by the Unit Manager and DON. Blood Glucose Monitoring will be performed by licensed nurses using glucometers at bedside. 6. On (MONTH) 2, 2019 at 6:15 PM, 12 of 12 glucometers at bedside were disinfected and cleaned with approved disinfecting wipes by the DON, Unit Manager, and Infection Control Nurse. 7. On (MONTH) 2, 2019, Regional Director of Clinical Services (RDCS) #1 initiated demonstration and return demonstration at 4:35 PM, for nine (9) licensed nurses; 6:00 PM for three (3) licensed nurses; 9:00 PM for two (2) licensed nurses; and 11:17 PM for two (2) licensed nurses, on Policy N 700 Blood Glucose Monitoring and Disinfecting. Licensed nurses performed procedure appropriately during return demonstration. 8. On (MONTH) 3, 2019, Policy N-700 Blood Glucose Monitoring and Disinfecting policy was revised to add Apply pressure to puncture site with gauze pad or alcohol swab. 9. (MONTH) 3, 2019, education with licensed nurses was initiated by RDCS #1 on Policy N 700 Blood Glucose Monitoring and Disinfecting, revision date (MONTH) 3, 2019, with emphasis on donning gloves, providing a barrier for glucometer, proper hygiene, and disposal of lancets appropriately. Licensed nurses will not be allowed to work until return demonstration on Policy N-700 Blood Glucose Monitoring and Disinfecting has been performed and licensed nurse has demonstrated competency. Twenty of 33 nurses have completed education. 10. An Ad-Hoc Quality Assurance Performance Improvement ( QAPI) meeting was held on Friday, (MONTH) 3, 2019 at 8:00 PM, with Executive Director (ED), Director of Nursing (DON), MDS Coordinator (MDSC), Dietary Manager (DM), Activities Director (AD), Maintenance Supervisor ( MS), Human Resources (HR), Transportation Aide (TA), Social Services (SSD), Medical Records Clerk (MRC) , Central Supply (CS}, and the Medical Director, attending by telephone, to discuss the opportunity for improvement, and assess current situation of failure to perform blood glucose finger sticks to prevent the spread of infection. Root cause analysis, and plan of correction to include education with licensed nurses on performing blood glucose finger sticks using individual Resident glucometers, proper hand hygiene between Residents, using a barrier for glucometer, disposing of lancet, and donning gloves, and the revision of N-700 Blood Glucose Monitoring and Disinfecting to add, and alcohol swab. 11. Audit was conducted by the DON and Unit Manager on May, 4, 2019 at 4:45 PM, of 12 Resident's Care Plans with orders for Blood Glucose Monitoring to ensure individual glucometers are care planned. Twelve of 12 care plans include individual glucometers. 12. On (MONTH) 4, 2019 at 5:00 PM, 12 Residents with orders for Blood Glucose Monitoring, was assessed for signs and symptoms of infection. Twelve of 12 Residents showed no signs of infection. Twelve of 12 resident's vital signs were obtained by the DON and Unit Manager. The facility alleges all corrective actions were completed (MONTH) 4, 2019, and the Immediate Jeopardy was removed (MONTH) 5, 2019. HMS validated the facility's IJ Removal Plan and determined the IJ was removed on 5/5/19, prior to survey exit, through interviews with the Administrator, DON, Regional Director of Clinical Services, residents, and Licensed and Registered Nurses, observations blood glucose tests, and review of facility documentation of corrective actions for involved staff, ad-hoc quality assurance committee discussions, revised policies, and staff in-service education and competency testing. Validation of the IJ Removal Plan included: 1. HMS validated through interviews and observations the facility's policy and procedure to use resident-specific glucometers found in each resident's room, disinfect glucometers before and after use, perform hand hygiene and don gloves during blood glucose testing procedures, use a barrier between the glucometer and potentially hazardous surfaces, and dispose of the single-use lancets using sharps containers. 2. HMS validated through interviews and review of corrective action documentation that corrective actions and competency testing for LPN #1 and LPN #3 were completed and LPN #3 was suspended from duty. 3. HMS validated through interviews and review of ad-hoc QA committee meeting minutes and revised policies, the revision and approval of the new Blood Glucose Monitoring and Disinfecting policy. 4. HMS validated through interviews and observations that 12 of 12 residents had resident-specific glucometers at their bedside and that all 12 glucometers were tested for functioning and disinfected. 5. HMS validated through interviews and observations that back-up glucometers on both medication carts were removed. 6. HMS validated through interview and record review that on 5/2/19, demonstration and return demonstration was performed by the Regional Director of Clinical Services for 16 licensed nurses on Policy N 700 Blood Glucose Monitoring and Disinfecting. Licensed nurses performed procedure appropriately during return demonstration. 7. HMS validated through interviews and record reviews that on 5/3/19, education with licensed nurses was initiated by Regional Director of Clinical Services on the Blood Glucose Monitoring and Disinfecting policy, revision date 5/3/19. HMS also validated through review of in-service sign-in records and staffing schedules, licensed nurses were not be allowed to work until return demonstration on the Blood Glucose Monitoring and Disinfecting policy was performed. 8. HMS validated through record reviews that use of resident-specific glucometers was indicated on 12 of 12 residents' care plans. 9. HMS validated through record review 12 of 12 residents were assessed for signs and symptoms of infection and did not show any adverse consequences. HMS validated that all corrective actions were completed on 5/4/19, and the IJ removed on 5/5/19.

Based on policy review, observation, record review and interview, the facility failed to prevent harm when the the necessary care and services was not provided to prevent a worsening contracture for one (1) of 23 residents reviewed for range of motion, Resident #4. Findings include: The facility's Contractures, Prevention, policy and procedure, revised 8/22/17, documented: .Each resident must be evaluated for need for contracture prevention procedures on admission, readmission and as needed.Residents with inactive extremities should have range of motion exercises done to those extremities as part of their daily care.Hand rolls may be placed in any hand that the resident cannot move. These can be commercial rolls or wash cloths rolled up and should be removed daily during care. The hand should be cleaned and dried thoroughly and observed for any reddened or broken areas prior to reapplication of the hand rolls. Resident #4's Admission Record documented she had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/4/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #4 had severe cognitive impairment. The MDS documented she required extensive assistance with personal hygiene and was dependent upon staff for bathing. The MDS documented Resident #4 had functional limitation in range of motion on one (1) side of her upper and lower extremities and had received no physical therapy (PT), occupational therapy (OT) or restorative nursing, including range of motion during the seven (7) days prior to the ARD. The Care Plan, dated 4/21/19, located in the resident's care plan binder, did not address she had a contracture of the right hand and fingers and did not list interventions to prevent worsening of the contracture of the right hand and fingers. Review of the Physician Orders, located under the Physician Tab in the chart, dated 2/01/19 to 5/1/19, revealed there were no orders for PT, OT, or restorative nursing. Also, there were no physician orders for range of motion and/or a handroll to be used to prevent further contracture of the resident's right hand and fingers. On 4/29/19 at 1:55 PM, Resident #4 was asked about the contractures of her right hand and fingers. She stated she had never worn a splint or handroll to prevent the contractures from worsening. She stated the contracture had gotten worsen over the past several months as her fingers were tighter into her hand and more painful to move now than a few months ago. She stated she could feel the fingernail digging into her palm. On 4/29/19 at 1:57 PM, Resident #4's right hand and fingers were observed to be severely contractured. She stated staff did not ever clean her right hand and/or put a handroll in her right hand to prevent the contracture from worsening. On 4/29/19 at 2:38 PM, Registered Nurse (RN) #2 was asked to look at the resident's right hand and fingers. Upon observing the resident's contractures of her hand and fingers, RN #2 stated the resident's right little finger nail was pressing tightly into her palm. The resident's index finger and third finger were severely contractured into the resident's palm. The hand was extremely odorous and the Director of Nursing (DON), who was also present in the resident's room, agreed the hand had a foul odor. Resident #4 yelled in pain as RN #2 tried to gently maneuver the resident's contractured fingers to clean hand and to trim the nails. On 4/29/19 at 4:06 PM, RN #2 was asked if a hand roll or other device had been used to prevent worsening of the contracture of the resident's right fingers. She stated OT provided the hand roll and placed it in the resident's hand. On 4/29/19 at 4:06 PM, the Director of Nursing (DON) was asked who was responsible to perform passive range of motion (ROM) for a resident with inactive extremities? She stated, We have restorative aides. If she (Resident #4) had been (discontinued) from restorative, then a CNA (certified nurse aide) was responsible for it. The DON was asked if the resident had received ROM for her right hand and fingers? She stated ROM should be documented by CNAs in the kiosk, an electronic system in which CNAs document details regarding the care/services provided for a resident during their shift. The above documented Contractures, Prevention policy was reviewed with the DON. She was asked if the facility's policy and procedure for a hand roll to be placed in a hand that cannot be moved by a resident had been followed? She stated a carrot, a type of handroll, had been used. The DON was asked if, per the facility's policy and procedure, a handroll had been placed in the resident's right hand, which was paralyzed? The DON stated, She has a carrot. Yes, it's been used. The DON was asked where the use of a handroll was documented in the resident's clinical record? She stated, In her ADLs (activities of daily living) and the nurses should have documented the use of a carrot. The DON stated the use of a handroll would have prevented the resident's fingernail from digging into her palm. On 5/02/19 at 8:43 AM, CNA #4 stated she had worked at the facility for two (2) months. She stated she had provided care for Resident #4. She was asked if she had ever been instructed to place a handroll in the resident's right hand? She stated, No. On 5/02/19 at 8:44 AM, CNA #5 stated she had worked at the facility for one (1) year and had provided care for Resident #4. She was asked if she had provided any special care for the resident's right hand and fingers? CNA #5 stated she had never noticed Resident #4's right hand to have contractures, even though she had bathed the resident several times. She stated she had never been instructed to place a handroll in the resident's right hand and had never been directed to perform passive ROM to her right hand and fingers. On 5/2/19 at 10:20 AM, the Minimum Data Set (MDS) Coordinator was interviewed. When asked if Resident #4's right hand and fingers contractures had been care planned and if interventions for maintenance/improvement, such has the use of a handroll and/or provision of passive range of motion had been addressed? She reviewed the care plan and stated, I didn't see it specifically. She further stated the contracture of the hand and interventions should have been care planned. On 5/2/19 at 1:20 PM, the occupational therapist (OT) stated she had completed an evaluation for Resident #4's contractured right hand on 4/26/19, at the request of the nursing staff. The OT stated the resident was unable to tolerate the use of a carrot at this time. She stated, I don't want them to use it now. It is very painful for her. The OT stated nursing had not notified her to request an evaluation of Resident #4's right hand contracture prior to 4/26/19. When asked if the resident seemed coherent to her during the OT evaluation, the OT stated, She was appropriate. On 5/2/19 at 1:48 PM, the DON was interviewed. She stated she had reviewed the CNA documentation for provision of range of motion to the right hand and/or placement of a handroll back to 2/1/19. She stated there was no documentation which indicated those services had been provided for the resident back to 2/1/19. When asked if the facility had provided the care and services necessary to prevent worsening of Resident #4's right hand contracture, she stated, No.

Based on policy review, observation, record review and interview, the facility failed to ensure comprehensive care plans were developed and/or implemented for three (3) of 21 sampled residents whose care plans were reviewed, Resident #4 for nailcare and contracture prevention, #24 for hospice, and #65 for monitoring behaviors. The failure to develop and implement a care plan for Resident #4 caused harm to the resident by failing to provide diabetic nail care and to prevent further contracture of her hand and decreased range of motion (ROM). Findings include: The facility's Plans of Care policy and procedure, revised 9/25/17, documented: .Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team.The Individualized Person Centered plan of care may include by is not limited to the following. Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements. The facility's Hospice Care policy and procedure, revised 09/20/17, documented: The center will ensure the care plan includes the most current hospice plan of care and the center's plan to attain or maintain the patient/resident's highest practicable physical, mental, and psychosocial well-being. Resident #4 Resident #4's Admission Record documented she had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/4/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #4 had severe cognitive impairment. The MDS documented she required extensive assistance with personal hygiene and was dependent upon staff for bathing. The MDS documented Resident #4 had functional limitation in range of motion on one side of her upper and lower extremities and had received no physical therapy (PT), occupational therapy (OT) or restorative nursing, including range of motion during the seven (7) days prior to the ARD. The Care Plan, dated 4/21/19, located in the resident's care plan binder, did not address she had a contracture right hand and fingers and did not list interventions to prevent worsening of the contracture right hand and fingers. The care plan, most recently reviewed/revised 2/8/19, documented the resident had a problem related to her requirement for extensive assistance with activities of daily living (ADL). Interventions included to provide Resident #4 with full assistance to bathe daily and as needed and to observe the resident's skin for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The care plan documented the resident needed extensive assistance with grooming and was dependent upon staff for bathing. The care plan did not include diabetic nail care. Review of the Physician Orders, located under the Physician Tab in the chart, dated 2/01/19 to 5/1/19, revealed there were no orders for PT, OT, or restorative nursing. Also, there were no physician orders for range of motion and/or a handroll to be used to prevent further contracture of the resident's right hand and fingers. On 4/29/19 at 1:55 PM, Resident #4 was asked about the contractures of her right hand and fingers. Stated she had never worn a splint or handroll to prevent the contractures from worsening. She stated the contracture had gotten worsen over the past several months as her fingers were tighter into her hand and more painful to move now than a few months ago. On 4/29/19 at 1:57 PM, Resident #4's right hand and fingers were observed to be severely contracture. She stated staff did not ever clean her right hand and/or put a handroll in her right hand to prevent the contracture from worsening. Resident #4 answered all questions appropriately and appeared to be lucid. She was observed to have brown debris under the nails and around the cuticles of her left hand. The right index fingernail was thick and brown. The end of the index fingernail was turned outward and contracted into the palm of her hand. The third and fourth fingernails could not be seen as those fingers were tightly contracted into the palm and the resident could not extend the fingers with her left hand to expose the fingernails. The resident stated she could feel them digging into her skin. The Treatment Administration Record (TAR) for Resident #4 dated 2/2019 and 3/2019, revealed no diabetic nail care was provided for Resident #4 as ordered by the physician. The TAR dated 4/2019, documented diabetic nail care had been performed for Resident #4 on 4/3/19 and 4/4/19. On 4/29/19 at 2:38 PM, Registered Nurse (RN) #2 was asked to observe Resident #4's right hand and fingernails. She found the nail of the third finger was long and had made an indention into the resident's palm. RN #2 acknowledged the right index fingernail was thick and brown and turned up at the end. When asked to look at the resident's right hand, RN #2 stated there was brown debris under the fingernails and around the cuticles. There were no open areas in the palm of Resident #4's hand. On 4/29/19 at 4:06 PM, RN #2 stated resident's with diabetes were to have nail care completed monthly and as needed. She stated Resident #4's nails should be trimmed more frequently than monthly. She stated the staff had not provided nail care for the resident as needed/required. RN #2 was asked if a hand roll or other device had been used to prevent worsening of the contracture of the resident's right fingers. She stated OT provided the hand roll and placed it in the resident's hand. On 5/2/19 at 10:20 AM, the Minimum Data Set (MDS) Coordinator was interviewed. When asked if Resident #4's right hand and fingers contractures had been care planned and if interventions for maintenance/improvement, such has the use of a handroll and/or provision of passive range of motion had been addressed? She reviewed the care plan and stated, I didn't see it specifically. She further stated the contracture hand and interventions should have been care planned. On 5/2/19 at 1:20 PM, the occupational therapist (OT) stated she had completed an evaluation for Resident #4's contracture right hand on 4/26/19 at the request of the nursing staff. The OT stated the resident was unable to tolerate the use of a carrot at this time. On 5/2/19 at 1:48 PM, the DON was interviewed. She stated she had reviewed the CNA documentation for provision of range of motion to the right hand and/or placement of a handroll back to 2/1/19. She stated there was no documentation which indicated those services had been provided for the resident back to 2/1/19. When asked if the facility had provided the care and services necessary to prevent worsening of Resident #4's right hand contracture, she stated, No. Resident #24 Resident #24's [DIAGNOSES REDACTED]. Per Resident #24's hospice Face Sheet, she was admitted for hospice services on 9/11/18, with a terminal illness [DIAGNOSES REDACTED]. The MDS, with an ARD of 9/18/18, revealed Resident #24's BIMS was 15, which indicated no cognitive impairment. The MDS documented the resident received hospice services. Review of Resident #24's care plan, reviewed/revised 3/6/19, revealed the resident received hospice services. An intervention included for hospice staff to attend the care plan meeting or to review and agree with the care plan. The care plan did not include the most current hospice care plan as specified in the facility's Hospice Care policy and procedure. There was no documentation in the resident's clinical record or care plan binder which indicated hospice staff had attended a care plan meeting or agreed with the facility's care plan since the resident's admission on 9/11/18. On 5/1/19 at 9:32 AM, the MDS Coordinator was asked if there was documentation which indicated hospice staff had either attended the care plan meeting or reviewed/agreed with the care plan. She stated she did not see documentation to that effect in the chart or care plan binder. She stated the Social Service Director (SSD) was responsible to invite hospice staff to care plan meetings. On 5/1/19 at 2:58 PM, the SSD stated she did not know she was supposed to invite hospice staff to the resident's care plan meeting. On 5/1/19 at 3:02 PM, the MDS Coordinator confirmed the care plan was not followed for hospice staff to participate in the resident's care plan meeting. On 5/1/19 at 3:35 PM, the MDS Coordinator was asked if the facility's Hospice Care policy had been followed to include the hospice provider's plan of care in the Resident's facility care plan. She stated, No. Resident #65 Review of the Admission Record revealed Resident #65's current [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Physician's orders, dated 5/1/19, documented the resident had a [DIAGNOSES REDACTED]. The MDS, with an ARD of 4/8/19, revealed Resident #65's BIMS score of 9, which indicated moderate cognitive impairment. The MDS documented the resident had exhibited no hallucination, delusions, or other behaviors during the seven (7) days prior to the ARD. The MDS documented Resident #65 received antipsychotic medication seven (7) of seven (7) days prior to the ARD. The care plan, reviewed/revised 4/5/19, documented the resident had a problem related to his use of an antipsychotic medication for the behavior of paranoia. An intervention for the problem was to monitor the resident's behavioral symptoms. Physician Orders, dated 5/1/19, documented the resident was to be administered [MEDICATION NAME], an antipsychotic medication, two (2) milligram (mg) at bedtime. the original order was dated 4/11/19. Review of the clinical record revealed no documentation Resident #65 was monitored for behaviors for which he was administered [MEDICATION NAME] during the months of 2/2019, 3/2019, or 4/2019. On 5/1/19 at 4:07 PM, the DON identified the target behavior for the use of [MEDICATION NAME] was paranoia. When asked to review the record for Resident #65, for documentation of behavior monitoring, per care plan, the DON confirmed Resident #65's record had no documented behavior monitoring for the months of February, March, or April, 2019, and the care plan was not followed.