Every finding on record at Greenbough Health and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement comprehensive, person-centered care plans to address residents identified Activities of Daily Living (ADL) and skin integrity needs. The facility failed to develop a care plan related to nail care for (Residents #2, #21, and #24); failed to implement the care plan related to grooming and dressing (Resident #21); and failed to develop a care plan related to pressure ulcer prevention (Resident #4) for four (4) of 21 resident care plans reviewed. Findings include: Review of the facility policy titled Comprehensive Care Plan with a review date of 11/14/2025, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Resident #2 On 1/5/2026 at 11:05 AM, during initial rounds Resident #2 was observed lying in bed wearing a hospital gown with approximately one-half of an inch (1/2) in length nails with jagged edges and a thick, brown substance underneath. During an interview on 1/7/2026 at 11:45 AM, the Minimum Data Set (MDS) Coordinator confirmed that the care plan was not developed to include nailcare as part of their daily care. She stated that the care plan is developed and implemented for the resident based on his/her care needs and that nail care should have been included in his care plan. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia. Record review of the quarterly MDS with an Assessment Reference Date (ARD) of 1/02/2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severely impaired cognition. Resident #4 Record review of the care plan revealed Resident #4 .refused to be turned or repositioned every two (2) hours because it interferes with me watching T.V. The care plan did not include interventions to prevent the development of pressure ulcers. Review of the Wound-Weekly Observation Tool, dated 8/18/25, revealed Resident #4 developed a suspected deep tissue Injury (SDTI) to the left (L) heel measuring 60 millimeters (mm) length x 50mm width x 1mm depth on 8/18/25. Record review of the Task List Report revealed the task for off-loading of extremities was not initiated until 12/10/2025. During an interview on 1/6/2026 at 2:15 PM, the MDS Nurse confirmed that the care plan was not developed to include off-loading of extremities to prevent pressure ulcers from developing on the heels. She stated the purpose of the care plan is to guide staff in providing individualized care to residents. On 1/6/2026 at 2:45 PM, during an interview the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that preventative measures were not implemented until 12/10/25. The DON stated her expectation was that preventative measures be implemented prior to the development of pressure ulcers. Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease, Unspecified. Record review of the quarterly MDS with an ARD of 11/10/2025 revealed under Section C a BIMS score of 01, indicating the resident had severely impaired cognition. Resident #21 Record review of Resident #21's Care Plan revealed an ADL self-care performance deficit related to confusion with interventions including extensive assistance of one person physical assist for bathing/hygiene/dressing. On 1/5/2026 at 10:31 AM, during initial rounds Resident #21 was observed lying in bed wearing a hospital gown with a dried, brownish substance on the top right side of the gown, approximately softball-sized, consistent in appearance with food or possible emesis. The resident also had visible scattered dark hair on her chin and long fingernails, approximately three-fourths of an inch (3/4) in length, with jagged edges. During an interview on 1/7/2026 at 2:51 PM, the MDS Coordinator confirmed that the care plan was not developed to include nailcare as part of their daily care nor was the Activities of Daily Living (ADLs) care plan implemented related to grooming and dressing. She further stated the purpose of the care plan is to guide the staff how to best provide care for the residents. Record review of the admission Record revealed Resident #21 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Other Seizures, Unspecified Mood (Affective) Disorder, Pseudobulbar Affect, and Moderate Intellectual Disabilities. Record review of the quarterly MDS with an ARD of 11/18/2025 revealed under Section C a BIMS score of 00, indicating the resident had severely impaired cognition. Resident #24 On 1/5/26 at 11:00 AM, observation of Resident #24 revealed that her fingernails on both hands were approximately one-fourth (1/4) inch past her fingertips and jagged. Record review of Comprehensive Care Plan revealed no nail care plan of care was developed for the trimming and/or cleaning of fingernails. During an interview on 1/7/2026 at 2:51 PM, the MDS Coordinator confirmed that the care plan was not developed to include nail care as part of their daily care. She further stated the purpose of the care plan is to guide the staff how to best provide care for the residents. Record review of the admission Record revealed that the facility admitted Resident #24 on 5/11/24 with a diagnosis of Cognitive Communication Deficit.

Based on staff interviews, record reviews, and facility policy reviews, the facility failed to ensure the prevention of an avoidable pressure injury for one (1) of seven (7) residents with pressure ulcers, (Resident #4), and delayed treatment for one (1) of seven (7) residents with pressure ulcers. (Resident #58) Findings include: Review of facility policy titled Pressure Injury Prevention and Management, with a review date of 11/7/2025, revealed, Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Resident #4 Review of the Wound-Weekly Observation Tool, dated 8/18/25, revealed Resident #4 developed a suspected deep tissue Injury (SDTI) to the left (L) heel measuring 60 millimeters (mm) length x 50mm width x 1mm depth on 8/18/25. Review of the Wound-Weekly Observation Tool, dated 10/2/25, revealed the SDTI to left (L) heel had progressed to a Stage 3 pressure ulcer measuring 60mm length x 50mm width x 1mm depth, intact and mushy. Review of the care plan revealed Resident #4 .refused to be turned or repositioned every two (2) hours because it interferes with me watching T.V. The care plan did not include interventions to prevent the development of pressure ulcers. Review of the Task List Report revealed the task for off-loading of extremities was not initiated until 12/10/2025 and the wound was identified on 08/18/25 as a SDTI. During an interview on 1/6/2026 at 2:45 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that preventative measures were not implemented until 12/10/25. The DON stated her expectation was that preventative measures be implemented prior to the development of pressure ulcers. Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Type 2 Diabetes Mellitus with Hyperglycemia, and Peripheral Vascular Disease, Unspecified. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 01, indicating the resident had severely impaired cognition. Resident #58 Record Review of the Wound-Weekly Observation Tool, dated 9/15/25, revealed Resident #58 developed a Stage II pressure ulcer on sacrum, it is noted to have been identified on 9/13/2025. Record Review of orders to treat were received on 9/15/2025. Registered Nurse (RN) #1 received the physician orders and performed wound care. During an interview on 1/7/2026 at 3:00 PM with RN #1, she stated she was unaware of wound until 9/15/25. This resulted in a two-day delay in physician notification, obtaining treatment orders, and initiation of wound care for Resident #58's Stage II pressure ulcer. During an interview on 1/7/2026 at 4:10 PM, the DON and ADON confirmed that the wound should have been reported, orders obtained and treated the same day the wound was identified and there should not be a delay in treatment. Record review of the admission Record revealed Resident #58 was admitted to the facility on [DATE] with medical diagnoses that included Giardiasis. Record review of the quarterly MDS with an ARD of 9/11/2025 revealed under Section C a BIMS score of 14, indicating no cognitive impairment.

Based on observation, staff and resident responsible party interview, record review, and facility policy review the facility failed to ensure a resident received necessary care and treatment to maintain the highest practicable level of well-being by failing to obtain physician orders for wound dressings identified upon admission (Resident #16) for one (1) of 21 residents reviewed for skin and wound concerns. Findings Include: Review of the facility policy titled Provision of Quality Care with no revision date revealed, Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Resident # 16 Observation on 01/05/26 at 11:45 AM revealed the Resident #16 had an undated dressing located on the left upper arm. Record review of the admission Record revealed the facility re-admitted Resident #16 to the facility on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. Record review of a General Progress Note dated 12/30/25 revealed .Resident has pressure dressing to left upper arm . Record review of December 2025 and January 2026 Order Summary Report revealed no physician order for a dressing or treatment to the resident's left upper arm. Interview with Licensed Practical Nurse (LPN) #1 on 01/05/26 at 11:48 AM, confirmed the dressing was not dated and she was unsure why the dressing was present on the left upper arm of the resident. LPN #1 stated that the resident's family reported the dressing may have been placed there during her recent hospital stay, when staff attempted to start intravenous (IV) fluids. Interview with the Registered Nurse (RN) #1 on 01/05/26 at 11:50 AM, confirmed there were no orders for a dressing to the resident's left upper arm. RN #1 was unsure why the dressing remained in place or how long it had been present. Telephone interview with Resident #16's Resident Representative (RR) on 01/05/26 at 2:08 PM, he confirmed that during a hospitalization in December 2025, prior to re-admission, hospital staff attempted IV access to the resident's left upper arm, which resulted in bleeding and placement of a dressing. Interview with the Director of Nursing (DON) on 01/05/26 at 2:15 PM, she confirmed the dressing should have been removed and the left arm assessed upon admission to determine the condition of the skin and orders obtained for care. The DON stated failure to remove the dressing or assess the resident's arm could have resulted in skin breakdown or infection.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure one (1) of 50 residents was treated with dignity when staff allowed the resident to remain in the dining room awaiting the lunch meal without adequate clothing coverage, resulting in exposure of bare skin in a public area. (Resident #31)Findings Include:Review of facility policy titled Promoting/Maintaining Resident Dignity, with a review date of 11/7/2025, revealed, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity.On 1/5/2026 at 11:45 AM, Resident #31 was observed sitting in the dining room waiting for lunch to be served. The resident's pants were down underneath her buttocks, and her bare skin was exposed. When asked about her clothing, she stated she did not know why staff left her in that condition. At the time of the observation, approximately 12 other residents and staff were present in the dining room.During an interview on 1/5/2026 at 11:48 AM, the Assistant Director of Nursing (ADON) confirmed that Resident #31's pants were down past her buttocks and that her bare skin was exposed. She stated this was unacceptable and that residents should not be present in the dining room in that condition. She further confirmed this situation constituted a dignity concern and stated it should never occur. During an interview on 1/6/2026 at 3:40 PM, the Director of Nursing (DON) confirmed her expectation that residents be dressed appropriately while in common areas and that staff are responsible for ensuring residents' clothing is properly positioned to maintain dignity. Record review of the admission Record revealed Resident #31 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction due to Embolism of Unspecified Cerebral Artery.Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 07, indicating the resident had moderately impaired cognition.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents received mail on Saturdays for two (2) of 17 residents who attended the Resident Council meeting. (Residents #7 and #8)Findings include:Review of facility policy titled Resident Rights with a review date of 11/14/2025, revealed, .Resident Rights.Information and communication.The resident has the right to send and receive mail.During the Resident Council meeting on 1/7/2026 at 2:15 PM, Resident #7 and Resident #8 stated that mail was not delivered on Saturdays and was distributed only Monday through Friday.During an interview on 1/8/2026 at 9:00 AM, the Director of Nursing (DON) confirmed that resident mail was distributed Monday through Friday only and that mail received on Saturdays was held until the next business day because no staff member was assigned responsibility for mail distribution on weekends.During an interview on 1/8/2026 at 9:14 AM, the Administrator stated he was unaware, until the previous day, that mail was not being delivered on weekends. He confirmed that residents have the right to receive mail on the weekends when mail is delivered by the post office. Record review of the admission Record revealed Resident #7 was admitted to the facility on [DATE].Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Record review of the admission Record revealed Resident #8 was admitted to the facility on [DATE].Record review of the Annual MDS with an ARD of 12/31/2025 revealed under Section C a BIMS score of 15, indicating the resident was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure resident trust fund withdrawals were safeguarded from misappropriation, when resident funds were withdrawn without documentation verifying goods or services were provided, for two (2) of 40 residents with trust fund accounts. (Residents #5 and #49). Findings Included: Record review of the facility policy titled Abuse, Neglect and Exploitation revealed, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property.Resident # 5 An interview with Resident #5 on 1/6/26 at 9:02 AM, she stated that $700.00 was taken out of her trust fund account in May of 2025. She verified that she signed the Resident Trust Fund Withdrawal form but received no goods or services in return. She stated that the facility did replace the money that had been taken out of her account. She further stated that she receives a quarterly trust fund statement. Record review of the Resident Trust Fund Withdrawal form, dated 5/15/25, for Resident #5 indicated that she signed for $700.00 to be withdrawn for personal use. The form listed the Receptionist as the Fund Custodian. An interview with Activities Director on 1/6/26 at 9:38 AM, she stated that the Business Office Manager (BOM) #1 instructed her that Resident #5 needed to withdraw money from her trust fund for personal use. She stated she completed the Resident Trust Fund Withdrawal form, obtained the resident signature and retuned the form to BOM #1. She stated that she is usually the one who takes residents shopping or shops for them, but that she had not done this in May 2025 for Resident #5. She further stated that she was not aware of what the money was spent on. Resident # 49 An interview with Resident # 49 on 1/6/26 at 9:55 AM, he verified money had been taken out of his trust fund account but was unsure how much it was or when it was. He indicated that he did sign the Resident Trust Fund Withdrawal form but did not recall receiving any goods or services in return. He also verified that the facility replaced the money that was removed and that he receives a quarterly trust fund statement. Record review of the Resident Trust Fund Withdrawal form, dated 7/1/25, for Resident #49 indicated that he signed for $1115.00 to be withdrawn for other: cash advance. The form listed the facility Receptionist as the Fund Custodian and was witnessed by Transporter #1 and Transporter #2. Further review of Resident Trust Fund Withdrawal form, dated 7/23/25, for Resident #49 indicated that he signed for $1700.00 to be withdrawn for other: cash advance. The form listed Receptionist as the Fund Custodian and was witnessed by Certified Nursing Assistant (CNA) #3 and the Maintenance Man. An interview with the Receptionist on 1/6/26 at 10:04 AM, she stated that the BOM is her supervisor. She stated that the BOM would notify her when the resident needed to withdraw money from their trust fund and what it was for. She stated she was responsible for filling out the Resident Trust Fund Withdrawal form, explaining what the withdrawal was for, and getting the resident signature. She then turns the form into the BOM who withdraws the money. She verified that two (2) witnesses are required if the resident has difficulty signing. She stated that on 7/1/25 and 7/23/25 that BOM #1 told her that Resident #49 was withdrawing the money to spend down his account so that he was not over the resource limit for Supplemental Security Income (SSI). She stated that she was unsure what the money was spent on.An interview with CNA #3 on 1/6/26 at 10:33 AM, she verified that she witnessed Resident #49 sign the Resident Trust Fund Withdrawal form on 7/23/25. She stated that she was not aware of what the money was spent on. Record review of the initial audit performed by the facility and corporate office on 9/25/25 indicated that $1115.00 was withdrawn from Resident #49's' account on 7/1/25 and $1700.00 was withdrawn from his account on 7/23/25 with no receipt and the check made out to [Proper name of the facility].Further record review of the initial audit performed by the facility and corporate office indicated that $700.00 was withdrawn from Resident #5's account on 5/15/25 with no receipt and the check made out to [Proper name of the facility]. An interview with BOM #2 on 1/7/26 at 9:00 AM, she stated that she had received a letter from the Social Security Administration on 9/18/25 for a resident indicating that the resident's income exceeded the resource limit for SSI and it prompted her to initiate an audit of resident trust fund accounts beginning 9/22/25 to 9/24/25. She indicated this audit identified withdrawals from the resident's trust fund account with no receipts of where the money went. BOM #2 stated that if the resident wishes to withdraw money from their account or needs to spend down their account she informs the receptionist who completes the Resident Trust Fund Withdrawal form, obtains the resident's signature, with witnesses if required, and returns the form to her. She then enters the information into the computerized resident fund management service, indicating what the transaction is for and a check is generated. She further explained that the facility has specific persons who are allowed to sign the checks, and two (2) signers are required. A third employee will take the check to the bank to be cashed, and the money is brought back to the facility and secured until it is given to the resident or sent with the Activity Director for shopping. She stated that receipts are returned to her so she can reconcile what was withdrawn with what was spent. She verified there were no receipts for the 5/15/25 withdrawals from Resident #5's account or the 7/1/25 and 7/23/25 withdrawals from Resident 49's account.An interview with the Administrator (ADM) 1/7/26 at 9:25 AM, he stated that after receiving a letter from the Social Security Administration for a resident indicating that the resident's income exceeded the resource limit for SSI the BOM #2 notified him and the corporate office for a full audit of the resident trust fund accounts. He verified the audit identified unauthorized withdrawals and/or withdrawals lacking supporting documentation from resident trust fund accounts. He stated the facility identified BOM #1 as the alleged perpetrator at the time of the withdrawals. The ADM confirmed affected residents required reimbursement due to missing funds. ADM verified that BOM #1 was terminated from her employment at the facility on 7/31/25. An interview with the ADM on 1/7/26 at 12:00 PM, and a record review of the facility investigation, audits, in-service sign in sheets and trust fund deposit record verified that on 9/22/25 - 9/24/25 an investigation and audit was performed to determine if withdrawal of funds from resident's trust fund accounts were either not authorized by resident or responsible party or lacked supporting documentation for the withdrawal. The facility replaced funds for any residents with discrepancies in their accounts. Responsible parties of each resident identified were notified by nursing staff on 9/24/25. Education was provided on 9/24/25 to the BOM, the Activity Director, and the ADM on the policy and procedures for resident trust in relation to resident shopping and spend downs by the regional Business Office Manager. All facility staff received education on Abuse and Neglect with an emphasis being placed on misappropriation of funds/residents rights which began on 9/24/25. Affected residents were reimbursed on 10/8/25. A follow-up interview with the ADM on 1/8/26 at 9:05 AM, confirmed that the incident and investigation results were presented to the Quality Assurance Committee on 9/24/25, during which the facility policy was reviewed with no revisions made and the facility continued to monitor all transactions monthly.Record review of the admission Record revealed the facility admitted Resident #5 on 5/3/19 with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. Record review of the Brief Interview for Mental Status dated 10/9/25 indicated that Resident # 5 was cognitively intact. Record review of the admission Record revealed the facility admitted Resident #49 on 4/28/23 with a diagnosis Systemic Lupus Erythematosus.Record review of the Brief Interview for Mental Status dated 10/24/25 indicated that Resident # 49 was cognitively intact.Based on the implementation of the facility's corrective actions on 10/8/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 10/9/25, prior to the State Agency (SA) entrance into the facility on [DATE].Validation:The SA validated on 1/8/2026, through interview and record review that all corrective actions had been implemented as of 10/8/25, and the facility was in compliance as of 10/9/25, prior to the SA's entrance on 1/5/26.

Based on staff interview, record review, and facility policy review, the facility failed to ensure required Ombudsman notification was completed and documented when a resident was transferred to the hospital for one (1) of three (3) transfers/discharges reviewed. Resident #55. Findings Included: Record review of the facility policy Transfer and Discharge [including Against Medical Advice (AMA)] revealed 9. Non-Emergency Transfers or Discharges .d. The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. Record review of a Progress Note for Resident #55 revealed that he was transferred to the hospital on [DATE]. Interview with the Director of Nursing on 1/7/26 at 1:00 PM she stated that there was no documentation of Ombudsman notification of the resident's transfer on 11/25/25 because it was not sent. Interview with the Administrator on 1/7/26 at 1:10 PM, he stated that the Social Worker (SW) was responsible for sending the Ombudsman notifications, however she was on leave during that timeframe. He stated that it was his expectation that Medical Records (MR) personnel would send the notifications to the Ombudsman in the SW absence. Interview with MR personnel on 1/8/26 at 9:05 AM, she stated that she does not recall being assigned to send out Ombudsman notifications while the SW was out.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents who required assistance received grooming and personal hygiene, including nail care (Resident #2, 21 and 24) and cleanliness of clothing (Resident #21) for three (3) of 50 residents observed for activities of daily living (ADLs). Findings Include: Review of facility policy titled Activities of Daily Living (ADLs), with a review date of 11/7/2025, revealed, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Resident #2 During initial rounds on 1/5/2026 at 11:05 AM, Resident #2 was observed lying in bed wearing a hospital gown with approximately one-half of an inch (1/2) in length nails with jagged edges and a thick, brown substance underneath. During an interview and observation on 1/6/2026 at 10:35 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the Certified Nursing Assistants (CNA)s are responsible for ensuring residents nails are kept clean, and the nurse is responsible for trimming his nails. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/02/2026 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severely impaired cognition. Resident #21 During initial rounds on 1/5/2026 at 10:31 AM, Resident #21 was observed lying in bed wearing a hospital gown with a dried, brownish substance on the top right side of the gown, approximately softball-sized, consistent in appearance with food or possible emesis. The resident also had visible scattered dark hair on her chin and long fingernails, approximately three-fourths of an inch (3/4) in length, with jagged edges. During an observation and interview on 1/5/2026 at 11:38 AM, CNA #1 confirmed Resident #21's gown had a dried, brownish substance on the top right side consistent in appearance with food or possible emesis, visible dark hair on her chin, and long, jagged fingernails. CNA #1 stated that Resident #21 typically had more facial hair than was present at the time, stating, She must have been shaved recently because there are usually lots more. During an interview on 1/6/2026 at 3:53 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that CNAs are responsible for ensuring residents receive assistance, or total care if needed, with ADLs each morning, including bathing or hygiene care as needed, dressing, and grooming. The DON stated residents should not be left with visible grooming concerns, including soiled clothing, unaddressed facial hair, or long, jagged fingernails. She further stated that long, jagged fingernails pose a potential risk for infection related to skin tears and that wearing soiled clothing and female residents having unwanted facial hair are dignity concerns. Record review of the admission Record revealed Resident #21 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Other Seizures, Unspecified Mood (Affective) Disorder, Pseudobulbar Affect, and Moderate Intellectual Disabilities. Record review of the quarterly MDS with an ARD of 11/18/2025 revealed under Section C a BIMS score of 00, indicating the resident had severely impaired cognition. Resident #24 Observation of Resident #24 on 1/5/26 at 11:00 AM, revealed that her fingernails on both hands were approximately one-fourth (1/4) inch past her fingertips and jagged. Interview with CNA #2 on 1/5/26 at 11:36 AM, she verified that Resident #24 had long jagged nails and she stated that she thought the shower team was responsible for cutting nails. Interview with the DON she stated that the shower aid is responsible for nail care on shower days, but if the resident refused a shower the floor CNA should have cut the nails. She agreed that the nails were long and put Resident #24 at risk for injury. Record review of the admission Record revealed that the facility admitted Resident #24 on 5/11/24 with a diagnosis of Cognitive Communication Deficit.

Based on record review, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of seven (7) residents on fluid restrictions. Resident #7. Findings Included: Record review of the facility policy titled Fluid Restriction date reviewed 11/5/25 revealed It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders . Record review of the Order Summary Report for Resident # 7 revealed an active order, dated 7/11/2025 for fluid restriction 1000 cubic centimeters (CC). Total nursing 300cc nursing days, 120cc evening, 90cc night. Total dietary 700cc breakfast, 340cc lunch, 120cc supper -240cc. Record review of Resident #7's January 2026 Electronic Medical Record (Emar) and interview with Registered Nurse #2 (RN) on 1/7/26 at 9:45 AM, she stated that the resident was on a fluid restriction related to being on dialysis. She verified that there was no documentation of Resident #7's intake, but there should be. She agreed that the resident's intake should be monitored and documented to ensure that the fluid restriction is being followed. She stated that it is important to keep up with the resident's intake to ensure the resident did not have fluid overload. Interview with the Director of Nursing (DON) on 1/7/26 at 9:50 AM, she stated that it was her expectation that the nursing staff would monitor and document the intake of a resident who has an order for a fluid restriction. Record review of the admission Record revealed that the facility admitted Resident #7 on 2/24/23 with a diagnosis of End Stage Renal Disease.

Based on staff interview, record reviews, and facility policy review, the facility failed to ensure newly prescribed medications were accurately transcribed onto the Medication Administration Record (MAR) for one (1) of five (5) residents reviewed for unnecessary medications. This failure resulted in the resident's antipsychotic medication being abruptly discontinued for 12 consecutive days. (Resident #21)Findings include:Review of facility policy titled Medication Orders, with a review date of 11/7/2025, revealed, .Documentation of Medication Orders.When a new order changes the dosage of a previously prescribed medication, discontinue (DC) previous entry by writing DC'd and the date, or discontinue the order and per the electronic software instructions and retype the new order.Record review of the Psych Progress Notes for Resident #21, dated 11/12/25, revealed, .Recommendations: Decrease Seroquel from 200 milligrams (mg) twice a day (BID) to 200 mg every (q) at bedtime (hs) .Record review of the Psych Progress Notes for Resident #21, dated 11/19/25, revealed, .Recommendations: Decrease Seroquel again - decrease to 50 mg by mouth (PO) every (q) at bedtime (hs) from 200 mg q hs. Record review of the November 2025 MAR revealed Seroquel 200 mg twice daily (BID) was discontinued on 11/12/25; however, the revised order not transcribed until 11/25/2025. According to the November 2025 MAR, Resident #21 did not receive Seroquel from 11/13/25 through 11/24/25.During an interview on 1/8/2026 at 11:24 AM, the Director of Nursing (DON) confirmed that Resident #21's Seroquel was discontinued on 11/12/25 and was not restarted until 11/25/25. She confirmed the psychiatric recommendation dated 11/12/25 was not fully implemented, resulting in the resident abruptly stopping the medication. She stated that abruptly discontinuing an antipsychotic medication could result in adverse effects for the resident. She further stated her expectation was that psychiatric recommendations to be followed in their entirety. Record review of the admission Record revealed Resident #21 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Other Seizures, Unspecified Mood (Affective) Disorder, Pseudobulbar Affect, and Moderate Intellectual Disabilities. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severely impaired cognition.

Based on observations, staff interviews, record review, and facility policy reviews, the facility failed to implement infection prevention and control practices to prevent the transmission of infections. The facility failed to ensure that staff used Enhanced Barrier Precautions (EBP) during medication administration and failed to ensure oxygen delivery devices and wash basins were stored in a sanitary manner when not in use during three (3) of nine (9) resident care opportunities. (Residents #5, #9 and #21) Findings Include:Review of facility policy titled Oxygen Administration with a review date of 11/7/2025, revealed, .Policy Explanation and Compliance Guidelines.Keep delivery devices covered in plastic bag when not in use.Review of facility policy titled Enhanced Barrier Precautions (EBP) with a review date of 11/13/2025, revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.An order for enhanced barrier precautions will be obtained for residents with any of the following:.indwelling medical devices (e.g.feeding tubes.even if the resident is not known to be infected or colonized with a multidrug drug resistant organism (MDRO).Review of facility policy titled Safe and Homelike Environment with a review date of 10/14/2025, revealed, In accordance with residents' rights, the facility will.preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes.equipment used in the completion of the activities of daily living.Resident #5During initial rounds on 1/5/2026 at 10:35 AM, Resident #5's nebulizer mask and Continuous Positive Airway Pressure (CPAP) mask were observed lying uncovered on the bedside table and not stored in a clean, protective bag, creating a risk for contamination of respiratory equipment. During an interview on 1/6/2026 at 3:59 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that all respiratory mask/cannula and tubing should be stored in a plastic bag when not in use. The DON stated that the tubing and masks being left out on the bedside table put Resident #5 at an increased risk for infection and was not an acceptable practice. She further stated that her expectations were that plastic storage bags should always be used when the masks/tubing was not in use. Record review of the admission Record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified, and Hypertensive Heart Disease with Heart Failure. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/2025 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.Resident #9During medication administration observation on 1/7/2026 at 10:00 AM, with Licensed Practical Nurse (LPN) #3, revealed that LPN #3 failed to follow infection control procedures for EBP during medication administration through Resident #9's feeding tube. LPN #3 confirmed she forgot to wear the gown during medication administration and stated that EBP should have been used due to Resident #9 having a feeding tube to help prevent the possible spread of infection.During an interview on 1/7/26, the DON confirmed that EBP should have been used during medication administration since Resident #9 had a feeding tube used for feeding and medication administration. She verbalized that EBP was to be used as ordered for the prevention of infection.Record review of the admission Record revealed Resident #9 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified. Record review of the quarterly MDS with an ARD of 12/15/2025 revealed under Section C that a BIMS was not assessed.Resident #21During initial rounds on 1/5/2026 at 10:35 AM, observation of five (5) wash basins that were stored directly on Resident #21's bathroom floor, uncovered and not stored in a bag or container. During an interview on 1/7/2026 at 1:55 PM, the Director of Nursing (DON) confirmed that reuseable bath basins should be labeled with the resident's name and stored in a bag or container off the floor for infection control purposes. Record review of the admission Record revealed Resident #21 was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Other Seizures, Unspecified Mood (Affective) Disorder, Pseudobulbar Affect, and Moderate Intellectual Disabilities. Record review of the quarterly MDS with an ARD of 11/18/2025 revealed under Section C a BIMS score of 00, indicating the resident had severely impaired cognition.

Based on staff interviews and record review the facility failed to put safety measures in place to prevent an accident during van transport for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of Instructions for loading and unloading a resident with a wheelchair lift on a transport vehicle, provided by the Administrator, revealed Securing the resident in the vehicle. Secure vehicle supplied safety seat belt around the resident. Interview with the Staff Development Nurse on 5/21/25 at 12:15 PM, she verified that the facility did not have a policy on accident prevention or van transport. Record review of the facility investigation revealed on 5/2/25, during transportation to a physician's appointment Resident #1 fell from the wheelchair on to the van floor. Emergency Medical Services (EMS) was contacted, and the resident was transferred to the local emergency room . Resident #1 had no injuries and was transported back to the facility. Record review of Resident #1's hospital records dated 5/2/25 revealed that she sustained no injuries and no treatment was required. An interview with Certified Nursing Assistant (CNA) #1 on 5/21/25 at 12:05 PM, she stated that on 5/2/25 she was transporting Resident #1 from the nursing home to a physician's office approximately two (2) hours away from the facility. She stated when she stopped at a red light down the street from the doctor's office, she checked her rearview mirror and did not see the resident. She stated she drove to where she could pull over to check on the resident and noticed that she was lying on her side on the floor. CNA #1 stated that she was unsure how long the resident had been on the floor of the van. She stated the resident responded to her and she was instructed by the Director of Nursing to call EMS. She stated that EMS arrived and transported the resident to the local emergency room . CNA #1 stated that the resident must have slid out of the wheelchair and admitted that the seat belt was not buckled. She stated that she secured the wheelchair to the van but confirmed that she did not put the safety seat belt around the resident. An interview with the Administrator and Director of Nursing (DON) on 5/21/25 at 12:10 PM, they verified that CNA #1 did not put the safety seat belt around the resident, and it was their expectation that she would have. They agreed that failure to apply the seat belt could result in injuries. Record review of the Admission Record revealed that the facility admitted Resident #1 on 4/18/25 with diagnoses including Acquired Absence of Left Leg Below Knee.

Based on record review, staff interview and facility policy review the facility failed to ensure residents were free from significant medication errors for seven (7) of 30 residents reviewed. Resident #1, #2, #3, #4, #5, #6, and #7. Findings Include: Record review of the facility policy, titled Administering Medications with a revision date of 04/2019 revealed Policy Statement, Medications are administered in a safe and timely manner and as prescribed . Record review of a facility investigation revealed that on 2/20/25 Registered Nurse (RN) #1 notified the Director of Nursing (DON) that she had not given medication to seven (7) of the residents she was assigned to for the 7:00 AM to 3:00 PM shift. The DON conducted an audit and verified that seven (7) out of 30 residents RN #1 was assigned to for the 7:00 AM to 3:00 PM shift had not received their scheduled medications. Record review of Resident #1 and Resident #7's written statement dated 2/21/25 confirmed the resident did not receive their scheduled medicines on time on 2/20/25. Record review of the Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/25 for all residents in the facility revealed that Residents #1, #2, #3, #4, #5, #6 and #7 had no documentation of administration of medications scheduled between 7:00 AM and 3:00 PM on 2/20/25. Resident #1 Record review of the Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #1 had active orders that included Metoprolol Succinate ER Oral Tablet Extended Release 24-hour 25 milligram (mg) give one (1) tablet by mouth one time a day with missed dose at 9:00 AM, Eliquis Oral Tablet 5 mg give 1 tablet by mouth two (2) times a day with missed dose at 9:00 AM, Cozaar Oral Tablet 50 mg give one (1) tablet by mouth one time a day with missed dose at 9:00 AM, and Dilantin Oral Capsule 100 mg 2 capsules three (3) times a day, with a missed dose at 9:00 AM and 1:00 PM. Record review of the Admission Record revealed that the facility admitted Resident #1 on 2/13/25 with diagnoses that included Cerebral Infarction, Hyperlipidemia, Occlusion and Stenosis of Bilateral Carotid Arteries, and Hypertension. Resident #2 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #2 had active orders that included Rivaroxaban Tablet 20 mg give 1 tablet by mouth one time a day, with a missed dose at 9:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #2 on 10/29/21 with diagnoses that included Acute Kidney Failure, Protein-Calorie Malnutrition, Peripheral Vascular Disease and Hypertension. Resident #3 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #3 had active orders that included Hydralazine Hydrochloride (HCL) Tablet 100 mg give 1 tablet by mouth 3 times a day, with a missed dose at 9:00 AM and 1:00 PM. Keppra Tablet 500 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Amlodipine Besylate Tablet 10 mg give 1 tablet by mouth one time a day, with a missed dose at 9:00 AM. Carvedilol Tablet 12.5 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Spironolactone Oral Tablet 25 mg give 12.5 mg by mouth one time a day, with a missed dose at 9:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #3 on 12/8/18 with diagnoses that included Cerebral Infarction, Hypertension, Congestive Heart Failure, Other Seizures, and Cardiomyopathy. Resident #4 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #4 had active orders that included Hydralazine Hydrochloride (HCL) Tablet 25 mg give 1 tablet by mouth 1 time a day, with a missed dose at 9:00 AM. Keppra Tablet 500 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Coreg Tablet 3.125 mg give 1 tablet by mouth 2 times a day, with a missed dose at 9:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #4 on 2/1/25 with diagnoses that included Diabetes Mellitus, Hypertension, Chronic Venous Hypertension, Gastro-Esophagel Reflux Disease, and Atherosclerotic Heard Disease. Resident #5 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #5 had active orders that included Metformin HCL Oral Tablet 500 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Lisinopril Oral T ablet 2.5 mg give 1 tablet by mouth 1 time a day, with a missed dose at 9:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #5 on 1/30/25 with diagnoses that included Diabetes Mellitus, Hypertension, and Dementia. Resident #6 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #6 had active orders that included Amlodipine Besylate Oral Tablet 5 mg give 1 tablet by mouth 1 time a day with a missed dose at 9:00 AM. Lacosamide Oral Tablet 200 mg give 1 tablet 1 time a day with a missed dose at 9:00 AM. Levetiracetam Oral Tablet 750 mg give 1 tablet in the morning with a missed dose at 9:00 AM. Cephalexin Oral Tablet 500 mg give 500 mg by mouth 2 times a day with a missed dose at 9:00 AM. Hydralazine HCL Oral Tablet 50 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Lasix Oral Tablet 40 mg give 1 tablet by mouth 2 times a day with a missed dose at 9:00 AM. Sinemet Oral Tablet 25-100 mg give 1 tablet by mouth 3 times a day with missed doses at 10:00 AM and 2:00 PM. Record review of the Admission Record revealed that the facility admitted Resident #6 on 2/28/24 with diagnoses that included Parkinsonism, Angina Pectoris, Congestive Heart Failure, Myoclonus, Visual Hallucinations, Tremor, and Unspecified Convulsions. Resident # 7 Record review of Medication Administration Audit Report, Documentation Type: Missed dated and timed 2/20/25 at 3:59 PM for medications scheduled for 2/20/2 revealed Resident #7 had active orders that included Enalapril Maleate Oral Tablet 10 mg give 1 tablet 1 time a day with a missed dose at 9:00 AM. Record review of the Admission Record revealed that the facility admitted Resident #7 on 2/21/24 with diagnoses that included Protein-Calorie Malnutrition and Hypertension. An interview with the Staff Development Nurse (SDN) on 2/26/25 at 10:00 AM, she confirmed that on 2/20/25 RN #1 was assigned to the medication cart for 7:00 AM to 7:00 PM due to a call in. She stated that if there is a call in then an on-call nurse or supervisor is pulled to the cart to cover. She stated that she offered to assist RN #1 but was told she did not need any help. She stated that she offered to assist RN #1 again by checking blood sugars and vital signs around lunch but was told that she did not need help. She stated later in the afternoon she overheard RN #1 complaining to other staff and she called her into the DON ' s office to talk with her. She stated at that time RN #1 became agitated and turned in her resignation. She stated at that time RN #1 informed the DON of a list of residents that she had not yet administered medications to. SDN stated she assisted the DON with the care of the residents in that section. An interview with RN #2 on 2/26/25 at 10:30 AM, she stated that the Supervisor may get pulled to work the med cart once about every two (2) weeks. She stated that all staff is trained to administer medications and if they are not comfortable then they can notify the Supervisors or DON in order to get more training. She stated that she tries to watch staff to see if they need help and help them. An interview with Licensed Practical Nurse (LPN) #1 on 2/26/25 at 10:45 AM, she stated that she worked on 2/20/25 and was assigned the opposite hall from RN #1. She revealed that she did hear the SDN offer to assist RN #1 with med pass. LPN #1 revealed she did not have any trouble getting assistance if needed and that administrative staff was very helpful. A telephone interview with RN #1 on 2/26/25 at 11:16 AM, she revealed that she had worked at the facility for about a month and 2/20/25 was the first time she had worked independently on medication administration and no one offered her any assistance. She then admitted that she had previously followed a nurse on medication administration. She revealed that around 3:00 PM the SDN called her into the DON's office about her attitude and at that time she gave report, counted narcotics and gave the DON a list of residents that she had not given medications to yet. She stated she had just not gotten to those residents yet. A follow up interview with the SDN on 2/26/25 at 11:30 AM, she stated that RN #1 had never complained about working on the medication cart before and that she had previously worked on the med cart on 2/10/25, 2/14/25 and 2/19/25 with no issues noted. An interview with the Administrator on 2/26/25 at 2:05 PM he verified that he was present and heard the SDN offer RN #1 assistance, but she declined it. He verified that it was his expectation that RN #1 would have administered the residents' medications timely as ordered.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that the Infection Preventionist (IP) had completed the required training for the Infection Preventionist role for three (3) of three (3) survey days observed. Findings include: Record review of the facility policy Infection Prevention and Control Program with a revision date of October 2018 revealed under, Policy Interpretation and Implementation: .5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). An interview on 6/04/2024 at 3:05 PM, Licensed Practical Nurse (LPN) #1 revealed she was the facility Infection Control nurse. She explained that when she started working in January of this year, she was not aware that she had to have formal training or a certification for the Infection Preventionist role. She revealed she had started the training with the World Health Organization (WHO) to be certified as an Infection Preventionist but had not completed her training. An interview on 6/04/2024 at 3:41 PM, the Director of Nurses (DON) revealed we have three (3) nurses involved in the Infection Preventionist training including myself, however, at this time we have no one who has completed the course. She revealed that we are just doing our best to care for the residents at this time. An interview on 6/05/2024 at 9:46 AM, the Administrator (ADM) revealed, he was made aware when he became Administrator back in April that the facility did not have an Infection Preventionist that was certified. He revealed he was made aware that the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 were signing up for the course at that time but was unaware that it had not been completed.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to ensure a resident was clean and dry for one (1) of seventeen sampled residents. Resident #45 Findings Include: Review of the facility policy titled Activities of Daily Living revealed under, Policy: To encourage resident choice and participation in activities of daily living (ADL) and provide oversight, cuing and assistance as necessary. ADLs include bathing, dressing, grooming, hygiene, toileting and eating. An observation on 6/4/2024 at 12:31 PM, revealed Certified Nurse Aide (CNA) #5 entered Resident #45's room and delivered a lunch tray, then exited the room. An observation and interview with Resident #45 on 6/4/2024 at 12:32 PM, revealed him lying in bed with his lunch tray sitting on top of the overbed table covered. The resident instructed the Survey Agent not to touch the side of the bed because it was wet. Resident #45 explained that he was wet, but he could not recall if he had told any of the staff he needed changing. The resident had a disposable pad over the top of a cloth pad that was fully saturated in yellow urine, which covered the entire pad on the left side of the resident. CNA #5 entered the room holding a flat sheet of which she applied over the residents' legs. The Survey Agent inquired was she going to change the resident and CNA #5 replied, We don't change during mealtimes; I was just bringing a sheet for his legs because he did not have one and left the room. The resident further explained that staff has told him in the past they cannot change him during meals. He revealed he was told it was a facility rule that he must wait until after mealtime and trays were picked up to get changed. An interview with the Director of Nursing (DON) on 6/4/2024 at 12:42 PM, revealed the aides and nurses were responsible for changing and toileting the residents during mealtimes. She revealed if a resident required changing, the aides were to stop passing the trays and take care of the resident at that point. She stated leaving a resident wet during mealtimes was unacceptable and confirmed this could cause skin concerns. An interview with CNA #5 on 6/4/2024 4 at 2:18 PM, revealed that she was a shower aide and was helping pass out lunch trays today. She revealed that when she entered Resident #45's room, he did not tell her that he was wet. She stated that she went to go get him a sheet because he did not have one to cover his legs. CNA #5 revealed to her knowledge she was not supposed to change a resident that was soiled during mealtime because if someone else was eating on the other side of the room it would cause infection concerns. She acknowledged that leaving a resident wet during mealtimes could cause skin concerns. Record review of the Admission Record revealed the facility admitted Resident #45 on 12/30/22 with diagnoses including Sarcopenia.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan regarding turning and repositioning for a resident that was dependent on staff for one (1) of seventeen care plans reviewed. Resident #18 Findings Include Cross Reference F684 Record review of the facility policy titled, Plans of Care with a revision date of 09/25/17 revealed, Procedure .Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs . Record review of Resident #18's care plans revealed the resident had a care plan for ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Confusion, Limited Mobility and interventions that included that the resident required extensive assistance x 2-person physical assist to reposition and turn in bed. An observation on 06/04/24 at 08:15 AM, revealed Resident #18 was lying in bed with the head of bed (HOB) at 90 degrees while a staff member was feeding the resident breakfast. An observation on 6/4/24 at 9:00 AM, 10:30 AM, 11:15 AM and 12:30 PM revealed Resident #18 in the same position, lying in bed with the HOB at 90 degrees. An interview on 6/4/24 at 1:30 PM, with Licensed Practical Nurse (LPN)/ Minimum Data Set (MDS) nurse confirmed that Resident #18 would need to be turned every two (2) hours because she cannot do that on her own. She revealed that the resident has a care plan regarding the need for ADL assistance, but nothing is in there about turning. She stated that should just be common sense. She stated she is responsible for putting in the resident's care plans, and they do not always put turning and repositioning in a resident's care plan. An interview on 6/4/24 at 1:45 PM, with CNA #4 confirmed that residents need to be turned every 2 hours and most of them have that in their POC (Plan of Care) where the CNA's document. She revealed a resident's care plan tells them what care the resident needs. An interview and record review on 6/4/24 at 1:50 PM, with LPN #2 revealed Resident #18 did not have reposition/turn on her POC but did have that the resident needed assistance. She revealed that the purpose of the care plan was to provide information regarding the care a resident needed. She confirmed that turning and repositioning was to prevent skin breakdown and pressure ulcers. An interview on 6/5/24 at 8:00 AM with the DON confirmed that Resident #18 did not have turning/repositioning on her POC which comes from the care plans that are put in by Minimum Data Set (MDS) and that could use some improvement. She stated that Resident #18 should have had turning and repositioning on her care plan to prevent skin breakdown. Record review of Resident #18's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Lack of Coordination, Unspecified Dementia and Cognitive Communication Deficit. Record review of Resident #18's MDS with an Assessment Reference Date (ADR) of 4/16/24 revealed in Section C no Brief Interview for Mental Status (BIMS) score of, which indicated the resident was severely cognitively impaired and in Section GG that the resident needs substantial/maximal assistance with rolling left to right.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure Advanced Directive for code status preference was discussed and completed by the resident's representative for one (1) of 24 residents in initial pool. Resident #22 Findings include: Record review of the facility policy titled, Advanced Directives, with revision date of 11/14/18, revealed, The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Process: 1. Upon admission, Social Service Director or Business Development Coordinator/designee will: a) Communicate to resident and/or representative his or her right to make choices concerning health care and treatments, including life sustaining treatments. 5. Advanced Directives will be reviewed: Quarterly . Record review of Resident #22's electronic Order Summary Report revealed a physician order dated 2/1/18 for a full code status. Record review of Resident #22's electronic and paper record revealed there was no signed document to indicate the desired end of life care for this resident. The record review revealed the facility's Notification and Consent Form which contained advance directives options was not completed by the resident or the resident's representative. During an interview on 6/4/24 at 10:05 AM, the Director of Nursing revealed Resident #22 had an electronic order for a full code but did not have the advance directive document used by the facility that indicated the resident's or the resident representative's desire for end-of-life care. She revealed the social service director was responsible for completing this on admission as well as quarterly to ensure the facility maintains accurate documentation for end-of-life care. She confirmed that end-of-life care choice should be honored and the facility failed to discuss with the resident and/or representative the options for end-of-life care and failed to obtain a consent for the desired care for the resident. Record review of Admission Record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included Dementia with behavioral disturbance, Congestive Heart Failure, and Type 2 Diabetes Mellitus. Record review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/24 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 which indicated the resident had severe cognitive impairment.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's choice for salt with meals for one (1) of twenty-four residents included in the initial pool. Resident #45 Findings Include: Review of the facility policy titled Resident Rights with an effective date of 11/30/2014 revealed, Policy: The facility will ensure that the resident is not deprived of his/her rights An observation and interview with Resident #45 on 6/3/2024 at 10:46 AM, revealed him lying in bed. The resident voiced that he had asked staff several times for salt with his meals, but they would not allow it because he had high blood pressure. He revealed he could not eat the food without some salt for flavor. Record review of Resident #45's Order Summary revealed an order, NAS (No Added Salt) diet . An interview with the Dietary Supervisor #1 on 6/4/2024 at 1:14 PM, confirmed Resident #45 had a physician's order for a No Added Salt (NAS) diet; therefore, he would not be given salt on his tray or if he requested it to add to his food. She revealed that she had spoken to the resident a couple of times because he was requesting salt. She explained that she educated him that he could not have it due to his diagnosis of high blood pressure and potential outcomes such as swelling. An interview with the Director of Nursing (DON) on 6/4/2024 at 3:16 PM, revealed Resident #45 had the right to request and be given salt with his meals. She stated she was not aware that the resident requested salt, and acknowledged he could have signed a waiver. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/2024 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicates Resident #45 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #45 on 12/30/22 with a medical diagnosis of Peripheral Vascular Disease and Essential (Primary) Hypertension.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a resident with a wheelchair in good repair as evidenced by torn and tattered arm rest and a broken wheelchair brake for one (1) of 17 sampled residents. Resident #16 Findings Include: Review of the facility policy titled Maintenance with an effective date of 11/30/2014 revealed, Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify areas/items in need of repair .Procedure: All employees will report physical plant areas or equipment in need of repair or service to their supervisor . An observation and interview with Resident #16 on 6/3/2024 at 10:39 AM, revealed him sitting in a wheelchair in his room. The resident explained that his wheelchair brake was broken and had been broken for some time. The right brake was hanging down loosely and would not fasten to secure the wheel in place. The right arm rest was tattered and torn on the edges, with black foam exposed. An observation and interview on 6/4/2024 at 9:40 AM, with the Maintenance Director revealed he was not aware that Resident #16's wheelchair was in disrepair. He explained that he was responsible for making rounds and ensuring that resident equipment was in good working order. He confirmed that the resident needed a new armrest and voiced the brake could be repaired. An interview with the Director of Nursing (DON) on 6/4/2024 at 9:43 AM, revealed the aides wash and clean the wheelchairs at night and were responsible for notifying the Maintenance Director either verbally or by leaving a note of resident equipment in disrepair. She confirmed resident equipment should be in good working condition. Record review of the Admission Record revealed the facility admitted Resident #16 on 10/19/2023 with a medical diagnosis of Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting the right dominant side.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure a resident's privacy during a bed bath for one (1) of 17 residents sampled. Resident #33 Findings Include: Review of the facility policy titled, Privacy with an effective date of 11/30/14 and no revision date revealed, Policy .It is the policy of The Company to give all residents the opportunity for privacy .Procedure: #2 Residents privacy will always be respected. An observation on 06/03/24 at 10:25 AM, revealed Resident #33 lying in bed uncovered with only a brief on and the privacy curtain was not pulled between her and Unsampled Resident #40 (roommate). Certified Nurse Assistant (CNA) #2 was at the resident's bedside and did not announce patient care when the State Agent (SA) knocked on the resident's room door for entry. This observation revealed the resident was receiving a bed bath. Resident #33 was yelling randomly, difficult to understand and unable to answer questions. Record review of Resident #33's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Moderate Intellectual Disabilities and Pseudobulbar Affect. An interview on 06/03/24 at 2:20 PM, with CNA #2 confirmed she did not have the privacy curtain pulled between Resident #33 and her roommate while she gave her a bed bath this morning. She admitted the curtain should have been pulled for the resident's dignity and privacy. An interview on 6/4/24 at 9:29 AM, with CNA #3 confirmed that the privacy curtain should be pulled when you are giving a resident a bed bath just in case someone walks in the room or to give privacy between roommates. She stated it provides the resident with the dignity of privacy from people seeing their private areas. An interview on 06/04/24 at 09:39 AM, with the Director of Nurses (DON) confirmed that a privacy curtain should be pulled for any type of care provided to a resident not just bed baths. She stated it was important to provide the residents with dignity and privacy and that was a big pet peeve of mine and nursing 101. Record review of Resident #33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 5/10/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 03, which indicates the resident is severely cognitively impaired.

Based on observations, staff interviews, record reviews and facility policy review the facility failed to promote healing of pressures ulcers and prevent new ulcers from developing for one (1) of five (5)residents reviewed for pressure ulcers, Resident #22. Findings Include: Record review of the facility policy titled, Skin and Wound with a revision date of 01/24/22 revealed under Policy .To promote a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. This review revealed under Process: Pressure Injury Prevention .#3 Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record and under Skin Impairment Identification #1. Document presence of skin impairment(s)/new skin impairment(s), when observed and weekly until resolved. Resident #22 An interview on 01/09/23 at 09:19 AM, with Resident #22 revealed that he has a sore on his left heel that the staff have told him is a blister. He revealed the staff have to help him get out of bed and into his wheelchair, but he usually gets up every day and pushes his wheelchair with his hands. An observation at this time revealed the resident had socks on his feet. An interview on 01/10/23 at 7:40 AM, with the Director of Nursing (DON) confirmed that Resident #22 had a pressure ulcer that was facility acquired on his left heel and first discovered on 12/11/22. She revealed the resident has to be turned by the staff, but he can assist. She confirmed that Resident #22 did not have any preventative measures in place prior to the development of his left heel pressure ulcer, except turning every 2 hours. She revealed she is responsible for wound treatments, but does have an agency Registered Nurse (RN) that comes in at night some and a As Needed (PRN) RN that works a few days a month and both of those RN's help with wound treatments. She confirmed that there are 25 wound treatments due today. An observation and interview on 01/10/23 at 7:45 AM, with the DON revealed Resident #22 was lying in bed, feet pushed against the foot board, no heel protectors and heels not floated. The DON revealed his heel protectors may have been sent to laundry, but she would get him some more. The DON confirmed that the resident's feet were pushed up against the footboard and he needed a pad or bed extender on his bed to keep his feet from pushing up against the footboard. An interview on 01/10/23 at 3:00 PM, with the DON confirmed that Resident #22's last weekly body audit was in November, 2022. She revealed there is no formal documentation of wound assessments with measurements. She revealed the resident's wound measurements are on scrap pieces of paper and notebook paper stuck on the wall and her desk with not all having names and dates. She revealed that if the weekly body audits had been done then these wounds could have been caught at an earlier stage. An observation on 01/10/23 at 3:40 PM, revealed Registered Nurse (RN) #1 perform the ordered treatment to Resident # 22's left heel along with obtaining a measurement. This observation revealed the wound measured 5.0 centimeters (cm) x 6.2 cm x 0.0 cm with black scar tissue present and no drainage. Record review of Resident #22's Admission Record revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included Type 2 Diabetes Mellitus, Morbid Obesity and Unspecified Abnormalities of Gait and Mobility. Record review of Resident #22's Braden Scale for Predicting Pressure Ulcer Risk dated 07/11/22 revealed a score of nine (9), which indicates the resident is Very High Risk for Pressure Ulcers. Record review of the residents written progress notes revealed that Resident #22's left heel Deep Tissue Injury (DTI) was discovered on 12/11/22. Record review of Resident #22's Wound-Weekly Observation Tool revealed that the resident had not had a weekly body audit since 11/26/22. Record review of Resident # 22's physician's orders revealed Resident #22 did not have any preventative measures ordered prior to the development of his left heel DTI that was discovered on 12/11/22. Record review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, which indicates the resident is cognitively intact and in Section M it revealed that the resident did not have a pressure ulcer but was at risk of developing one. 47157

Based on staff interview, record review and facility policy review the facility failed to develop and implement a comprehensive care plan for three (3) of 22 residents care plans reviewed. Resident's #7, #22, and #32. Findings include: Record review of the facility policy titled, Plans of Care with a revision date of 09/25/2017 revealed under Procedure .develop and implement an individualized person-centered comprehensive plan of care by the interdisciplinary team that includes but is not limited to -the attending physician, registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the resident representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). Resident #7 Record review of Resident #7 care plans revealed the following care plan initiated 12/5 2019 revealed, Focus: I have an ADL (Activity of Daily Living), Self-Care Performance Deficit related to confusion, impaired balance, limited mobility, and stroke .Goal: I will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date .Interventions/Tasks: .BATHING/HYGIENE: I am independent with no set up or physical help from staff for bathing/hygiene . An observation on 01/08/23 at 3:30 PM, revealed that Resident #7 was sitting up in his wheelchair in his room with long jagged nails on his right hand. An observation on 01/09/23 at 4:25 PM, revealed that Resident #7 was sitting up in his wheelchair in his room with long jagged nails on his right hand. An interview on 01/11/23 at 8:00 AM, with CNA #1 revealed he is responsible for doing Resident #7's nails. He revealed it was his fault that the resident's nails were long and needed trimming, because he thought the resident was a diabetic and the treatment nurse was going to do it. He revealed he should have looked at the resident's record to verify he was a diabetic. He revealed that Resident #7 had a stroke that affected his right side, so he cannot trim his own nails. An interview on 01/11/23 at 9:20 AM, with the Minimum Data Set (MDS) LPN confirmed she is responsible for developing and updating the care plans based on the resident's orders. She confirmed that the purpose of the care plans was to provide information on how to take care of the residents, such as weight bearing and skin issues. An interview on 01/11/23 at 11:00 AM, with the Director of Nurses (DON) confirmed that Resident #7 could not trim his own nails. Record review of Resident #7's Admission Record indicated the resident was admitted to the facility on [DATE] with medical diagnoses that included Contracture of the right hand and Cognitive communication deficit. Record review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 12/31/22 revealed in Section C a Brief Interview for Mental Status (BIMS) of 06 , which indicates the resident is severely cognitively impaired. Resident #22 Record review of Resident #22's care plans revealed the following care plan, revised 01/10/2023, I am at risk for a potential skin problem .DTI to left heel .Goal: I will have no complications from . DTI to left heel through the review date .Interventions/Tasks . I will have weekly skin observation by nurse. Date initiated: 07/15/2022. In an interview on 01/10/23 at 7:50 AM, with the DON confirmed that there was a written progress note dated 12/11/22 that Resident #22's left heel Deep Tissue Injury (DTI) was first discovered. Interview with the DON on 01/10/23 at 9:08 AM, confirmed the residents care plans are developed and updated by the MDS-LPN (Licensed Practical Nurse) based on MDS assessments and new orders. She revealed the purpose of the care plans are to provide instructions for care for the resident's and the care plans are accessible by all nurses and CNA's. An interview on 01/10/23 at 3:00 PM, with the DON confirmed that Resident #22's last weekly body audit was in 11/22. An interview on 01/10/23 at 3:09 PM, with LPN #4 revealed that the care plan's purpose are to give us guidance on the care of the resident. Record review of Resident #22's Admission Record sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus, Morbid obesity and Unspecified abnormalities of gait and mobility. Record review of Resident #22's Wound-Weekly Observation Tool revealed that the resident had not had a weekly body audit since 11/26/22. 47157 Resident #32 A record review of the Care plan with an onset date of 12/17/2018 and a revision date of 08/20/19, I have an ADL Self Care Performance Deficit r/t (related to) Limited Mobility***I have Hemiplegia which increases dependency on staff for ADL completion . Interventions/Tasks . Bathing/Hygiene : I require extensive assistance x (times) one person physical assist with bathing and hygiene . An observation of Resident # 32 on all three shifts during the survey revealed, resident with long nails with dark substance under the nail beds, a dried orange substance in beard and wearing a white stained shirt. Record review of Resident # 32's care guide revealed fourteen shifts with no documentation of showers and fifteen shifts of documented Not applicable /Not available for the month of January 2023 and has fifteen shifts of with no documentation of personal hygiene. Record review revealed Resident # 32 has not been documented out of the facility. An observation and interview with the DON on 1/10/23 at 07:37 AM, confirmed Resident #32's finger nails were long with brown substance under the nails, the resident was wearing a dirty stained white shirt and beard was long and unkept. A record review of Resident #32's Admission Record revealed she was admitted [DATE] with diagnosis which include, Hemiplegia and Hemiparesis following a Cerebral Infarction the right dominant side. A record review of Resident # 32's MDS with an ARD of 11/24/2022 revealed in Section C a BIMS score of 4, indicating severely impaired for decision making. An interview on 01/11/23 at 11:30 AM, with the Administrator confirmed that each resident needs a comprehensive care plan developed and implemented because that is what tells us what we need to do to care for the resident.