Every finding on record at Lavaca Bay Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 3 of 5 residents (Resident #1, #2 and #3) reviewed for accuracy of assessments. 1.The facility failed to reflect Resident #1's diagnosis of anxiety disorder (condition of nervousness and restlessness) as an active diagnosis in the 5-day MDS assessment dated [DATE]. 2.The facility failed to reflect Resident #2's diagnosis of anxiety disorder as an active diagnosis in the quarterly MDS assessment dated [DATE]. 3. The facility failed to reflect Resident #3's diagnosis of anxiety disorder as an active diagnosis on the significant change MDS assessment dated [DATE]. These failures could place residents at risk of inadequate care. The findings included: 1.Record review of Resident #1's electronic face sheet dated 08/27/2026 reflected an [AGE] year-old male admitted on [DATE] and passed away at the facility on 08/20/2026. His diagnoses include depression (condition that affects mood, lack of interest in things) and cerebral infarction (lack of blood flow to the brain). Record review of Resident #1's 5-day MDS assessment dated [DATE] reflected he could usually understand others and was understood. Resident #1 scored 5 out of 15 on the BIMS which signified his cognitive status was severely impaired. He was dependent on staff for ADLs. Resident #1's MDS assessment did not reflect an active diagnosis of anxiety disorder, when he was prescribed and administered anti-anxiety medication. He was noted to have taken an antianxiety medication during the last 7 days and had an indication noted for the medication. Record review of Resident #1's comprehensive care plan dated 08/21/2026 reflected Problem, uses anti-anxiety medication, Interventions, administer anti-anxiety medication as ordered by physician, monitor for side effects q shift. Record review of Resident #1's Active Orders as of: 07/09/2026 reflected a physician's order for lorazepam (antianxiety medication) oral concentrate 2 mg/ml, give 0/5ml by mouth every hour as needed for anxiety with a start date of 07/09/2026. Record review of Resident #1's MAR dated 07/01/2026 to 07/31/2026 reflected he received three doses of lorazepam in the look back period, 2 doses on the 12th and one on the 13th of July. 2.Record review of Resident #2's electronic face sheet dated 08/27/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis was dementia (loss of cognitive function) and anxiety (restlessness, nervousness). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected she could usually understand and understood by others. Resident #2 scored a 2 out of 15 on the BIMS which signified her cognitive status was severely impaired. She required supervision by staff for ADLs and was located on the memory care unit. Resident #2's MDS assessment did not reflect an active diagnosis of anxiety disorder, when she was prescribed and administered anti-anxiety medication. She was noted to have taken antianxiety medication during the last 7 days and had an indication noted for the medication. Record review of Resident #2's Active Orders as of: 06/01/2026 reflected she was prescribed buspirone HCL Oral tablet 10mg, on tablet by mouth two times a day for anxiety with a start dated of 06/17/2026 and Xanax oral tablet 0.25mg, give 1 tablet by mouth two times a day for anxiety. Record review of Resident #2's MAR dated 06/01/2026 to 06/30/2026 reflected she was administered a dose of xanax and buspirone HCL on the 17th of June 2026 during the lookback period. An observation on 08/27/2026 at 10:00 a.m. of Resident #2 on the Memory Care Unit revealed she ambulated aimlessly, and left her walker in the main area where an activity was being offered. 3.Record review of Resident #3's electronic face sheet dated 08/27/2026 reflected a [AGE] year-old male admitted on [DATE]. He had a diagnosis of anxiety disorder. Record review of Resident #3's significant change MDS assessment dated [DATE] reflected he could usually understand and be understood by others. Resident #3 scored 2 out of 15 on the BIMS which signified his cognitive status was severely impaired. He was dependent on staff for ADLs. Resident #3's MDS assessment did not reflect an active diagnosis of anxiety disorder. The MDS noted Resident #3 took an anti-anxiety medication during the previous 7 days with an indication for the medication. Record review of Resident #3's comprehensive care plan dated 07/25/2026 reflected resident uses anti-anxiety medication r/t anxiety disorder, intervention, administer medication as ordered. Record review of Resident #3's Active Orders as of 07/01/2026 to 07/30/2026 reflected lorazepam oral concentrate 2 mg/ml, give 1 ml by mouth every 6 hours as needed for anxiety, start date 07/09/2026. Record review of Resident #3's MAR dated 07/01/2026 to 07/31/2026 reflected he was administered lorazepam for anxiety on July 11th and July 14th, 2026, during the lookback period. During an observation on 08/27/2026 at 10:15 a.m., Resident #3 was lying in bed putting his fists up in the air and when he spoke, he was difficult to understand. During an interview on 08/27/2026 at 2:10 p.m., LVN C stated Resident #1 was very verbal and would get restless. She stated Resident #1 was prescribed an anti-anxiety medication, and nursing staff monitored him for anxiety. During an interview on 08/27/2026 at 2:15 p.m., CNA D stated Resident #2 was restless and continued to move around. She stated Resident #3 picks his fists up when he was anxious. During an interview on 08/27/2026 at 2:28 p.m. RN A, the MDS Coordinator who completed Resident #1's MDS assessment stated the importance of having an accurate MDS assessment was to show what care a resident required, so the care would not be inaccurate or missed. She stated the MDS nurses were accountable for the MDS, and she did not know why she missed Resident #1's active diagnosis of anxiety disorder. During an interview on 08/27/2026 at 2:44 p.m., RN B, the MDS Coordinator who completed Resident #2 and Resident #3's MDS assessments stated she did not know why she missed an active diagnosis of anxiety disorder on both Residents #3 and #4. She stated she was accountable for the MDS's and an inaccurate MDS could lead to inaccurate or missed care. During an interview on 08/27/2026 at 3:20 p.m., the DON stated residents' care and medical needs must accurately be reflected on the MDS or care could be missed. She stated the facility did not have a separate MDS accuracy policy or procedure and used the RAI manual as a resource. During an interview on 08/27/2026 at 3:40 p.m. the ADM stated MDS accuracy was important because of care and what a resident required, or the care could be wrong or missed. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 5 days a week, for 1 of 1 facility reviewed for nurse staffing. The facility failed to have RN coverage for 5 days on 11/08/2025, 11/22/2025, 11/27/2025, 11/30/2025, and 01/31/2026. This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide.The findings included: Review of the facility's RN timecards from 10/01/2025 through 03/23/2026, revealed there were no RN hours for 11/08/2025, and 11/30/2025. The review of the RN timecards revealed there were less than eight hours for RN coverage on Saturday,11/22/2025, 11/27/2025, and 01/31/2026. Review of the facility census dated 11/08/2025 documented a population of 96 residents. The census dated 11/22/2025 documented a population of 94 residents. The census dated 11/27/2025 documented a population of 96 residents. The census dated 1/30/2025 documented a population of 95 residents, and the census dated 01/31/2026 documented a population of 95 residents. During an interview with the administrator on 03/27/2026 at 9:05AM, the administrator stated he could not confirm there was RN coverage on 11/08/26, 11/22/25, 11/27/25, 11/30/25, and 01/31/26. On days 11/08/2025 and 11/30/2025 there were zero RN Covered hours. On 11/22/2025, 11/27/2025, and 01/31/2026 there were less than eight hours covered by an RN within a 24-hour period. The administrator reported the nurses had either called in late or didn't show up and it fell under the DON responsibility to ensure there was RN coverage. During a follow up interview with the administrator on 03/27/26 at 9:32 AM, The Administrator said he doesn't have a policy for RN coverage and followed the CMS rules. During an interview with the DON on 03/27/2026 at 9:42AM, The DON reported for the days there was no RN coverage, someone could have called in sick. The DON stated an RN was needed for the staff in case there was a situation that required an assessment or something more than an LVN could provide. The DON stated she didn't think an RN not being at the facility would compromise the patient. The DON reported that some of the LVN staff struggled communicating with the doctor and therefore the RN was needed. The DON stated if an RN was not available the staff members could call her as well if there was a problem.

Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 12 residents (Residents #12, #13, and #65) who were reviewed for resident assessments. 1. The facility failed to document Resident #13's use of anxiolytic and hypoglycemic medications on the quarterly MDS (Minimum Data Set) assessment. 2. The facility failed to document Resident #65's diagnosis of schizoaffective disorder as an active diagnosis on the resident's MDS. 3.The facility failed to document Resident #12's diagnosis of schizoaffective disorder as an active diagnosis on the resident's MDS These failures could place residents at risk of improper or incorrect care or of not receiving services necessary for their physical, mental, and psychosocial well-being.The findings included: 1. Record review of Resident #13's admission sheet dated 12/28/23 documented a [AGE] year-old male resident with diagnoses including dementia, type 2 diabetes mellitus, insomnia, depression, hyperlipidemia (high cholesterol), hypertension (high blood pressure), paranoid schizophrenia, and anxiety. Record review of Resident #13's quarterly MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition. Further review of Resident #13's MDS in Section N0415. High-Risk Drug Classes: Use and Indication revealed the assessment did not record the use of anxiolytic or hypoglycemic medications. Record review of Resident #13's order summary documented an order for Temazepam (a benzodiazepine which slows down the central nervous system) with an order date of 4/29/2025, and an order for Janumet (a combination dipeptidyl peptidase-4 inhibitor and biguanide which lowers blood glucose) with an order date of 01/16/2025. Temazepam was ordered as Temazepam 15mg, Give 1 capsule by mouth at bedtime. Janumet was ordered as Janumet 50-1000mg, Give 1 tablet orally two times a day. Record review of Resident #13's December 2025 and January 2026 MARs revealed the resident received Temazepam and Janumet daily as prescribed during the seven day lookback period from 12/31/25 through 01/06/2026. Record review of Resident #13's care plan with an initiation date of 6/01/2025 documented the resident has Diabetes Mellitus ., with a goal of The resident will have no complications related to diabetes through the review date. Further review of Resident #13's care plan with an initiation date of 12/10/2025 documented the resident has a psychosocial well-being problem (potential) r/t Pain, Social isolation, Depression, Schizophrenia, Delusional d/o, Anxiety ., with a goal of The resident will have no indications of psychosocial well being problem by/through review date. 2. Record review of Resident #65's face sheet dated 3/25/26 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, schizoaffective disorder, anxiety disorder, major depressive disorder, and disorder of adult personality and behavior. Record review of Resident #65's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills. Record review of Resident #65's quarterly MDS assessment, under Section I – Active Diagnosis indicated the resident had Non-Alzheimer's Dementia, Anxiety Disorder, and Depression, but did not indicate the resident was diagnosed with Schizophrenia (e.g., schizoaffective and schizophreniform disorders). Record review of Resident #65's quarterly MDS assessment, under Section N - Medications indicated the resident was treated with antipsychotic medications on a routine basis. Record review of Resident #65's Order Summary Report dated 3/25/26 reflected the following: - Olanzapine oral tablet 5 mg, give 1 tablet by mouth at bedtime for schizophrenia related to schizoaffective disorder with order date 7/28/25 and no end date. - Trazadone oral tablet 100 mg, give 1 tablet by mouth at bedtime related to schizoaffective disorder, with order date 3/24/26 and no end date. Record review of Resident #65's document titled Physician Review of Active Diagnosis, signed by the physician and dated 12/1/25 reflected the resident had a diagnosis of schizoaffective disorder. Resident #65's Physician Review of Active Diagnosis document reflected the physician certified that the referenced diagnoses were active and have a direct relationship to the resident's skilled care, current functional status, mood or behavior, treatments, nursing monitoring, or risk of death. Record review of Resident #65's document titled Physician Review of Active Diagnosis, signed by the physician and dated 2/26/26 reflected the resident had a diagnosis of schizoaffective disorder. Resident #65's Physician Review of Active Diagnosis document reflected the physician certified that the referenced diagnoses were active and have a direct relationship to the resident's skilled care, current functional status, mood or behavior, treatments, nursing monitoring, or risk of death. Record review of Resident #65's initial psychiatric assessment dated [DATE] reflected the resident had a primary diagnosis of major depressive disorder, and was treated for schizoaffective disorder, depressive type. Resident #65's initial psychiatric assessment document reflected the resident was referred related to anxiety, psychosis, hallucinations, wandering, obsessive/compulsive thoughts or behaviors, medication evaluation, and had previous mental health diagnosis including schizophrenia. 3. Record review of Resident #12's face sheet dated 03/25/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, unspecified (mental health condition that combines symptoms of schizophrenia and mood disorders without specifying the type of mood disorder present),. Record review of Resident #12's MDS dated [DATE] documented a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS under Section I – Active Diagnoses Psychiatric/Mood Disorder revealed the assessment did not include a diagnosis of schizoaffective disorder in the box next to I6000 Schizophrenia (e.g., schizoaffective and schizophreniform disorders. Record review of Resident #12's March 2026 MAR documented the following orders: -Sertraline HCI Tablet 100 MG: Give 1 tablet by mouth at bedtime related to schizoaffective disorder, unspecified with a start date of 01/16/2026 -Behavior monitoring- Antidepressants Behavior code: 0. None, 1. Withdrawn, 2. Loss of Appetite, 3. Crying, 4. Lack of Interest, 5. Apathy, 6. Feeling of Helplessness, 7. Feelings of Worthlessness, 8. Suicidal ideations, 9. Insomnia, 10. Other (Document in PN) Interventions: Document in PN every shift. with a start date 01/16/2026 Record review of Resident #12's care plan provided on 03/25/2026 revealed a focus area for the following: [Resident #12] uses antidepressant medication (SERTRALINE) r/t schizoaffective disorder., initiated on 02/11/2026, with interventions including Monitoring behaviors, notify MD of new or worsening behaviors initiated on 02/11/2026. Record review of Resident #12's admission history and physical dated 04/16/2025 with Resident #12's physician signature dated 01/22/2026 recorded schizoaffective disorder under the assessment section. Record review of Resident #12's psychiatric periodic evaluation dated 1/2/2026, at their previous facility, recorded a diagnosis of F25.9 Schizoaffective disorder, unspecified condition under the diagnosis, assessment and plan section. During an interview with the Administrator on 3/25/26 at 3:37 PM, the Administrator stated they only have a policy on MDS timelines and use the RAI manual for everything else. During an interview with the MDS RN C on 3/26/26 at 4:13 PM, MDS RN C stated each staff member is responsible for ensuring the accuracy of the information they include on the MDS assessment. MDS RN C further stated it was important for the MDS to be accurate, because it drives the care plan of a resident and helps in providing good resident care. MDS RN C stated they do not want inaccuracies on the MDS, because depending on the section, it could affect resident care. During an interview with MDS RN B on 3/26/26 at 4:40 PM, MDS RN B stated they use the RAI manual when they asked if they have an MDS policy. During an interview with the DON on 3/26/26 at 5:07 PM, the DON stated if the MDS requires medication to be included, then the medication should be coded on there. The DON further stated it was important for the MDS to be accurate because they use MDS to let insurance know what they are billing, for the services they are giving to the resident, and the psychotropic medication monitoring. The DON stated her expectation for the MDS was that they reflect what a resident's chart says, and if they think there is an error, they should question it before the MDS is submitted. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, noted in section N0415: High-Risk Drug Classes: Use and Indication, Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day lookback period . and Coding Instructions Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Further revealed noted in Section I: Active Diagnosis reflected in part, Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.Coding Instructions. Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.Active Diagnoses.Psychiatric/Mood Disorder.schizophrenia (e.g., schizoaffective and schizophreniform disorders).Coding Tips. There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist of active diagnosis.The physician may specifically indicate that a condition is active. Specific documentation may be found in progress notes, most recent history and physical, transfer notes, hospital discharge summary, etc.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for one of four medication carts (400/right side 600 nurse medication cart) observed for drug storage and labeling. 1.The facility failed to ensure all insulin pens located inside the 400/right side 600 nurse medication cart were properly labeled with opened dates.2.The facility failed to ensure Resident #37 did not have a bottle of allergy medications at the bedside. These failures could place residents at risk of receiving inadequate treatments and medication misuse.The findings included: 1.During an observation on 3/26/26 at 2:33 PM of the 400/right side 600 nurse medication cart, an undated insulin pen was observed lying in the top drawer of the cart with no opened date written anywhere on the pen itself or on the label on the pen. During an interview with LVN E on 3/26/26 at 2:33 PM, LVN E stated it was important for the opened date to be documented on the pen because of the longevity of the pen and once it goes past its longevity, you get rid of it and get a new one. LVN E stated when she sees an undated pen in the cart, she should get a new one since the undated insulin might not have the desired effect for a resident. LVN E stated she would discard the undated pen. During an interview with the DON on 3/26/26 at 5:07 PM, the DON stated it was important to date insulin when it was taken out of the refrigerator, because they know when it will expire based on the date of removal. The DON further stated her expectation for staff was that they would not use any insulin from a medication cart if it was undated, and it was unknown how long it had been out of the refrigerator. The DON stated she expected her staff to dispose of any undated insulins in the medication carts. 2. Record review of Resident #37's face sheet dated 3/25/26 reflected an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included lack of coordination, chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe due to airflow blockage and inflammation in the airways), anxiety disorder, allergy, heart failure, and need for assistance with personal care. Record review of Resident #37's most recent quarterly MDS assessment dated [DATE] reflected the resident had impaired vision, used corrective lenses, and was cognitively intact for daily decision-making skills. Record review of Resident #37's Order Summary Report dated 3/25/26 reflected the following: - Cetrizine oral tablet 10 mg, 1 tablet by mouth one time a day related to allergy with order date 10/6/25 and no end date. Record review of Resident #37's comprehensive care plan with revision date 11/18/25 reflected the resident had impaired cognitive function/impaired thought processes related to advanced age with interventions that included to administer medications as ordered. During an observation and interview on 3/24/26 at 12:02 p.m., Resident #37 stated she was given medications by the facility staff but stated she was perfectly capable of giving herself medications. Resident #37 was observed with a small nightstand next to her recliner on the right with the top drawer open approximately halfway. The top drawer of the nightstand was observed with a bottle of allergy pills. Resident #37 stated she had last taken an allergy pill from the bottle seen in the top drawer last night (3/23/26) and believed the staff were aware she kept the medication at the bedside. During an observation and interview on 3/26/26 at 8:00 a.m., Resident #37 was observed with a small nightstand next to her recliner on the right with the top drawer open approximately halfway. The top drawer of the nightstand was observed with a bottle of allergy pills. Resident #37 stated she preferred to keep her own bottle of allergy pills at the bedside and stated she believed the nursing staff were aware she kept the medication at the bedside because it was in plain sight. Resident #37 stated she took an allergy pill last night (3/24/26) and it helped. During an observation and interview on 3/26/26 at 8:20 a.m., Med Aide H stated she was not aware Resident #37 could administer her own medications. Med Aide H stated, as far as I know, there are no residents in the facility who were care planned to take their own medications. Med Aide H observed a bottle of allergy pills in the top drawer of Resident #37's nightstand and stated she was not aware the resident had the allergy pills and would have to take the medication and give it to the DON. Med Aide H stated any medications left at the bedside could possibly be consumed by another resident or Resident #37 could have an off day and take too many and have a negative reaction. Med Aide H stated, there's a reason why we're here. During an interview on 3/26/26 at 8:30 a.m., LVN I stated, during the shift change, nursing staff made initial rounds of the residents and then received report. LVN I stated, Resident #37 was capable of self-medication and was able to keep medications at the bedside, not pills though. LVN I stated, any medications given orally were given by a nurse or medication aide. LVN I stated, for a resident to self-medicate there needed to be a doctor's order, an assessment, an observation to ensure the resident was capable of self-medicating, and it needed to be care planned. LVN I stated Resident #37 could not self-medicate with medications the staff were not aware she had and the resident could possibly overmedicate, another person could take the medication not intended for them, and the resident could have a drug reaction to other medications prescribed. LVN I stated during initial rounds most residents are still sleeping, and the lights are out, and rounds are to ensure the resident is safe. LVN I stated she would have to confiscate Resident #37's allergy pills and investigate if it was a medication she had already been prescribed. LVN I stated, Resident #37 already took scheduled physician ordered allergy medications at night and stated, I guess she's double dosing. During an interview on 3/26/26 at 5:18 p.m. the DON stated Resident #37 had an assessment to self-medicate from February 2026 for the use of eye drops. The DON stated, after being made aware Resident #37 had a bottle of allergy pills at the bedside, the resident was ok to use it. The DON stated she had educated the resident's family member, who provided Resident #37 with the bottle of allergy pills, to give the medication to nursing staff. The DON stated, right now, there are no residents in the facility who can self-medicate, they need to be assessed for it. Record review of the facility document titled Medication Policies with revision date 10/1/19 reflected in part, .When medication is ordered for use at the bedside, the medication label contains, in addition to the instructions for use, a notation that may be self-administered and stored at bedside. Review of the facility policy titled Labeling of Medications with a revision date of 10/01/19 noted All drugs and biological in the Facility are labeled in accordance with all Federal and State regulations . and Prescription medications will be labeled with the following information H. Expiration date.

Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 5 residents (Resident #82), reviewed for accidents. The facility failed to ensure Resident #82 did not have scissors and nail clippers in her room. This failure could place the resident at risk of injury and contribute to avoidable accidents and a decline in health.The findings include: Record review of Resident #82's face sheet dated 03/25/2026 revealed a [AGE] year-old female readmitted to the facility on [DATE], with an original admission date of 06/11/2025, with diagnoses that include anxiety disorder (uncontrollable worry about everyday issues, affecting everyday functioning), major depressive disorder recurrent, mild (persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and muscle weakness. Record review of Resident #82's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating no cognitive impairment and recorded the needed use of setup or clean-up assistance with personal hygiene. Record review of Resident #82's care plan provided on 03/25/2026 revealed a focus area for the following: [Resident #82] has an ADL self-care performance deficit r/t weakness, impaired mobility., initiated on 09/17/2025, with interventions including Functional performance: personal hygiene: The resident requires (setup or cleanup assistance) for personal hygiene initiated on 09/17/2025. During an observation on 03/24/2026 at 3:32 p.m., revealed Resident #82 had 1 pair of scissors and 2 nail clippers lying on their bedside table. During an observation and interview on 03/25/2026 at 8:55 a.m., revealed Resident #82 1 pair of scissors and 2 nail clippers lying on their bedside table. Resident #82 stated she was not sure if staff knew about the scissors or nail clippers, but that staff were very vigilant when they came in and out of her room. Resident #82 stated she has clipped her fingernails but cannot do her toenails. Resident #82 stated they have not been told they can not have nail clippers or scissors in their room. Resident #82 stated she had not had any issues with using either scissors or nail clippers. Resident #82 stated every morning her family member does come into her room. During an interview on 03/26/2026 at 12:03 p.m., CNA D stated residents were not allowed to have nail clippers or scissors in their rooms and if they did, CNA D would have to let a nurse know. CNA D stated Resident #82 should not have scissors or nail clippers in their room. CNA D stated that sometimes confused residents have wandered in and out of rooms and some residents like to go to other residents' rooms to visit. CNA D stated the risk to residents that have scissors or nail clippers in their room would be residents might hurt themselves on accident or hurt others. During an interview on 03/26/2026 at 12:20 p.m., RN A stated residents could not have knives or anything they could turn into harming themselves. RN A stated they were not aware of anyone on the hall Resident #82 resides that could have scissors or nail clippers in their room. RN A stated they were not sure if Resident #82 could have scissors or nail clippers in their room and would have to ask the ADON or DON. RN A stated they had seen residents go in and out of other residents' rooms to visit but not wander. RN A stated the danger of having scissors or nail clippers in the resident's room could be a bleeding risk or if they were not cognitively aware they would not be able to understand how to use them. During an interview on 03/26/2026 at 12:36 p.m., the ADON stated residents were not supposed to have scissors or nail clippers in their rooms. The ADON stated if a resident could independently use sharp items, it would be kept in the nurse's cart or medication room and brought to the resident when needed. The ADON stated they were not aware of any residents who could have nail clippers or scissors in their room. The ADON stated the risk could be residents with dementia could go in there and get them, residents could cut themselves, or cut their nails too short and risk infection During an interview on 03/26/2026 at 12:47 p.m., the DON stated residents cannot have anything sharp in their room unless they had a lock box and the items were kept in there but that they really do not allow sharps in resident rooms. The DON stated sharps that belong to residents were kept in the medication room. The DON stated if residents could use clippers independently it would have been documented in the Kardex and the resident would have to have to had return demonstrate safe use of nail clippers. The DON stated they have seen residents wander but mainly in the memory care unit. The DON stated the risk could be residents could clip their skin or other residents could get ahold of the sharps. During an interview on 03/26/2026 at 2:47 p.m., the DON stated they did not have a policy regarding sharps but provided a document from the admission packet with a list of prohibited items. Record review of the facility's policy, Visitation, Spousal Arrangements & Other Accommodations, no date, revealed:Prohibited Items- . no sharps objects (including razor blades, straight razors, knives or push pins) .

Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #14) reviewed for resident rights. CNA F referred to Resident #14 as honey and sweetie during catheter/incontinent care. This failure could place residents at risk of loss of dignity and self-worth.The findings included: Record review of Resident #14's face sheet dated 3/26/26 reflected a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included mixed receptive-expressive language disorder, aphasia following cerebrovascular disease, dysphagia, and depression. Record review of Resident #14's most recent comprehensive MDS assessment dated [DATE] reflected the resident's speech clarity was clear, was sometimes understood - ability was limited to making concrete requests, and responded adequately to simple, direct communication. Resident #14's comprehensive MDS reflected he was severely cognitively impaired for daily decision-making skills. Record review of Resident #14's comprehensive care plan with revision date 7/6/25 reflected the resident had impaired cognitive function or impaired thought processes related to dementia and inattention with interventions that included to use the resident's preferred name, face the resident when speaking and make eye contact. Resident #14's comprehensive care plan reflected the resident understands consistent, simple, directive sentences. Observation on 3/26/26 at 10:15 a.m. during incontinent care, CNA F addressed Resident #14 as sweetie and honey when asking the resident to lower his legs. Resident #14 had to be assisted to lower his legs. During an interview on 3/26/26 at 10:45 a.m., Resident #14 nodded his head to indicate that he had been offended when referred to as honey and sweetie. Resident #14 could not elaborate on why he was offended by being referred to as honey and sweetie. Resident #14 was asked by the State Surveyor if he should be addressed by his name, and Resident #14 nodded, indicating yes. During an interview on 3/26/36 at 10:47 a.m., CNA F stated she should not have referred to Resident #14 as honey or sweetie because it was considered a dignity issue and the resident should have been addressed with respect, perhaps by saying his name. During an interview on 3/26/26 at 5:26 p.m., the DON stated it was her expectation for the staff to refer to the residents by their proper name, unless the resident agreed to the use of a resident nick name. The DON stated terms of endearment should not be used, unless the residents agreed to it. Record review of the facility document titled Rights of Elderly Individuals, undated reflected in part, .An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's skin assessments dated 11/13/2025 and 11/25/2025 accurately reflected a bruise on his knee or the bruise on his cheek. The facility failed to accurately document skin issues on Resident #1 according to his care plan. This failure could place residents at risk of inadequate care due to an inaccurate skin assessment. Findings include:Record review of Resident #1's face sheet, dated 11/25/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental function), heart failure, chronic obstructive pulmonary disease (chronic progressive lung disease), type 2 diabetes mellitus without complications (high blood sugar), major depressive disorder (mental health disorder characterized by persistent depressed mood), hypertension (high blood pressure), delusional disorder (serious mental illness that causes unshakeable false beliefs for at least a month), and dementia (memory, thinking, difficulty). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 99, which indicated unable to complete the interview. Record review of Resident #1's care plan, dated 10/07/2025, revealed Resident #1 was at risk of falls. The care plan also revealed Resident #1 has episodes where he will move from his bed to the floor mat beside his bed. Sometimes he is found kneeling beside the bed in a praying position and sometimes he will lay all the way down on the floor and put his pillow under his head. Resident #1 has an ADL self-care performance deficit related to shortness of breath, Alzheimer's, Dementia, limited mobility. Interventions were The resident requires (EXTENSIVE ASSISTANCE) by one staff to turn and reposition in bed. The care plan also revealed resident requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Record Review of Resident #1's skin assessment dated [DATE] revealed that Resident #1's bruise on his knee and the bruise on his left cheek was not on the assessment. Record review of Resident #1's skin assessment completed by LVN A, dated 11/25/2025 at 10:03a.m., revealed Resident #1's bruise that covered his whole knee was not reported on the skin assessment. The skin assessment also did not have the bruise on his left cheek bone. Observation of Resident #1's peri-care on 11/25/2025 at 12:49p.m., revealed that Resident #1 had a bruise on his right knee. The bruise covered most of his kneecap; was yellow and purple. The bruise on Resident #1's cheek was dark purple. During an interview with Resident #1's RP on 11/25/2025 at 10:55a.m., revealed that his father falls a lot because of his dementia. He said he had a fall and was on his knees, he believed that was possibly how his father got the bruise on his knee. He said that he did not feel like his father was being abused or neglected. He said he visits Resident #1 often and feels like he is being taken care of. During an interview with the TN on 11/25/2025 at 4:00p.m., she said she was notified of the bruises on Resident #1's knee and on his face that morning. She said the CNA should have seen the bruise on Resident #1's knee when he was given a shower. She also said when the nurse did the skin check that morning, she should have seen the bruise on his knee and on his face. She said the nurse should have documented the bruises on the skin assessment. When asked how an inaccurate skin assessment could affect Resident #1, she said she did not know how to answer the question. She said she was responsible for monitoring to ensure the nurses were completing the skin assessments correctly. She said the treatment nurse monitored the skin assessments. She said the treatment nursed monitored by running a report to check that skin assessments are done correctly. She said skin assessments were supposed to be done weekly. She also said CNAs should report any skin issues to the nurse. She said she did not know why the bruises were not reported. During an interview with CNA B on 11/25/2025 at 4:34p.m., she said she was supposed to check for any skin issues when she gave a resident a bath. She said she worked with Resident #1 all the time. She said she did not notice the bruise when she worked three days prior. She said the nurse saw the bruise on Resident #1's face that morning after shift change. She said the previous CNA did not report any skin issues to her during shift report. She said the CNAs were responsible for reporting skin issues to the nurse. She said if skin issues were not reported the resident may not get the proper care. She said that she did not know how Resident #1 got the bruise on his knee or the one on his face. During an interview with LVN A on 11/25/2025 at 4:54p.m., revealed that she did not know about the bruise on Resident #1's knee. She said the nurses were supposed to do skin assessments once a week on all residents. She said if she saw a skin issue, she would check the residents medical record and see if it was documented. She said it the skin issue was not documented she would start an incident report and notify the administrator. She also said it the skin issue was serious she would take care of it before doing anything else. She said if a bruise or skin issue was not reported it would be considered neglect. She said she thought the treatment nurse monitored the skin assessments. She said she did not know how she monitored the skin assessments. She said she did not know that he had a bruise on his knee. She said when she went into his room that morning, she said he was on his knees. She said that was when she noticed the bruise on his left cheek. During an interview with the DON on 11/25/2025 at 5:15p.m., revealed the charge nurses were to do a skin assessment on each resident weekly. She said the skin assessments were broken down, and each shift was responsible for doing certain residents. She said skin assessment are done every 7 days for all residents. She said the skin assessments were documented in the computer. She said the nurse was to complete a skin assessment for any skin issues. She said it would depend on the resident and what was going on with the resident on how not reporting a skin issue could affect a resident. She said the IDT team monitored the skin assessments. She said the IDT team pulled up the skin assessments and the skin assessment would be put on the 24-hour report. She said the bruise on Resident #1's eye was from that morning. She also said that Resident #1's eye was puffy and that since the morning the puffiness had gone down. She said she did not know why the bruise on his knee was not on the skin assessment. She said she would assume the nurses were rushing. During an interview with the ADM on 11/25/2025 at 5:31p.m., revealed that the nurses and CNAs were responsible for checking the residents for skin issues. He said the staff should check the resident's skin every week. He also said staff should be checking for skin issues when getting a resident dressed or giving them a shower. He said if staff were not checking the resident's skin and a resident had a skin issue or bruise the facility would not be able to provide treatment that the resident might need. He said staff should report any skin issues when they first see it. He said the DON was responsible for monitoring to ensure skin issues are being reported. He said that the DON would bring up the skin issues on any resident in the morning start up meeting. He said he was told the bruise on Resident #1's face was from that morning. He said he did not know why the bruise on Resident #1's knee was not noticed or put on the skin assessment. Record review of Skin Assessment Policy dated 4/24/2025 revealed It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. Procedure: Wash hands. Explain the procedure to the resident. Provide privacy and adequate lighting. Put on gloves. Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. Remove any special garments or devices, if not contraindicated or ordered to remain in place. Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. Note any skin conditions such as redness, bruising, rash.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and misappropriation for 2 of 24 residents (Resident #31 and #64) reviewed for misappropriation. The facility did not conduct training after an allegation of misappropriation of $20 involving Resident #31 on 11/22/24. The facility did not conduct training after an allegation of misappropriation involving the missing of two NARCO pills for Resident # 64 on 11/27/24. This failure could place residents at risk for misappropriation, a diminished quality of life, and psychosocial harm. The findings were: Record review of facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated Revised 2021 read: .Provide staff orientation and training/orientation programs that includes topics such as abuse prevention, identification and reporting of abuse . [ANE policy given to surveyor did not fully address the 7 elements to include investigation response] 11/22/24 Misappropriation Record review of Resident #31's face sheet, dated 12/16/24, reflected a male age 70. The resident was admitted on [DATE] with diagnoses that included: acute kidney failure, hypertension, and Parkinson's disease (brain disease). The RP was listed as: family member. Record review of Resident #31's admission MDS, dated [DATE], reflected a BIMS score was 13 (cognitively intact). Observation and interview on 12/16/24 at 12:25 PM, revealed Resident #31 was in bed watching TV. The resident was alert and oriented to person and place. The resident stated, .my [family member] gave me the $20 dollars when I went to the hospital. I put the $20 in my lunch box. I cannot prove that the money was stolen. My [family member] told the Administrator about the missing money. [11/22/24] I do not have safe, nor do I want one. I do not keep money in my room. There was no other theft of other property. The resident stated the past Administrator was aware of the missing $20 but the resident was not certain as to whether other staff were aware of the missing $20. During interview on 12/16/24 at 1:00 PM, the past interim Administrator stated he visited with the family and the money was lost or misplaced. The past Administrator stated, the facility's investigation did not reveal that anyone entered his (Resident #31) room. The past Administrator stated that the current plan was to replace the money. The past Administrator stated the resident was offered a locked box or to put money in a trust, but the resident refused. The Administrator stated there were no cameras in the room. The past Administrator stated, Abuse and neglect training was not done .yes we had an allegation of theft . The Administrator stated that in general we do abuse and neglect training when there was an allegation .we should have done the training as part of the 7 elements of ANE. The Administrator added that training was part of the overall ANE facility's policy. The Administrator stated that the family and resident made the allegation of the missing $20 on 11/22/24. The past interim Administrator stated that there was no grievance process to include required training. During interview on 12/16/24 at 2:20 PM, the DON stated she started employment on 12/09/24 and was not aware of the incident involving the alleged theft of $20 involving Resident #31. The DON stated when the incident was reported of alleged misappropriation in November 2024 training on ANE should have started for all staff as part of the facility's ANE policy. The DON stated the training needed to be done for staff to know how to report ANE and recognize ANE. The DON stated that she did not know why the training was not done on 11/11/24. [Except for the past Administrator, the staff was not aware of the missing $20 on 11/22/24.] During an interview on 12/16/24 at 3:10 PM, LVN A stated when there was an allegation of ANE an in-service needed to be conducted for staff to know the signs of ANE and whom to report. LVN A stated she worked with Resident #31 for about 9 months. LVN A stated she did not remember whether she attended an in-service on ANE in November 2024 for the incident on 11/22/24. During an interview on 12/16/24 at 3:10 PM, Med Aide K stated: when there was an allegation of ANE an in-service needed to be conducted so staff knew the signs of ANE and whom to report. Med Aide K stated she worked with Resident #31 for about 3 years. During an interview on 12/17/24 at 8:30 AM, the past Administrator stated that the training done on 12/5/24 incorporated the incident on 11/22/24 but the training was not specific to the incident on 11/22/24. During a telephone interview on 12/17/24 at 10:00 AM, RN B stated the training on ANE on 12/5/24 was general training on ANE and not specific to the incident on 11/22/24. RN B stated, the training did discuss the incident of 11/22/24 as an example of misappropriation and a second example presented at the in-service involved as an example of neglect. Record review of facility's staff list dated 12/16/24 reflected the number of paid staff was 90. Record review of facility's general ANE training reflected training was done on 12/5/24 which was 13 days after the incident on 11/22/24. Record review of facility's grievance log form 11/22/2024 reflected a family member alleged that $20 was missing out of the Resident #31's shaving kit. Resolution: money was returned on 12/16/24 [after surveyor's entrance]. 11/27/24 Misappropriation Record review of Resident #64 's face sheet, dated 12/18/24 reflected a male age 74. The resident was admitted on [DATE] with diagnoses that included: joint replacement, cancer, and pain. The RP was listed as: resident. Record review of Resident #64 's admission MDS, dated [DATE], reflected the resident's BIMS score was 15 (cognitively intact). Record review of Resident #64's Physician' Orders, dated November 2024, reflected, hydrocodone NARCO) 10-325 every 6 hours for pain and arthritis PRN. Record review of Resident# 64's MAR, dated November 2024, reflected: 11/26/24-No PRN NARCO given. 11/27/24-No PRN NARCO given. 11/28/24-10:52 AM-No entry that the medication (NARCO) was given on 11/28/24 at 3: AM as claimed by LVN H). Count was short 2 NARCO pills. Record review of Resident #64's Nurse's Notes dated from 11/27/24 and 11/28/24 reflected no notes establishing that NARCO was given to Resident #64. During an interview on 12/18/24 at 2:22 PM, the past Administrator stated: he was informed during the change shift on 12/6/24 that the narcotic count was short in an unknown cart. The past Administrator stated, The cart with the missing narcotics (NARCO) [for Resident # 64] was put out service and double locked pending an investigation. The past Administrator stated the DON did a reconciliation and two NARCO pills belonging to Resident #64 were found missing. The past Administrator stated that LVN H was suspended pending an investigation. The past Administrator stated that the facility's investigation could not account for the missing NARCO belonging to Resident #64. The past Administrator stated that LVN H signed the reconciliation form on 11/26/24 and could not account for the missing NARCO. The past Administrator stated that no in-service training was done for the staff except for LVN H on ANE. Record review of facility's investigation file reflected: NARCO count dated 11/27/24- was short 2 pills. Resident #64 was prescribed Hydrocodone 10-325 Mg (delivery of 40 pills on was 7/18/24). Written Statement by LVN H dated 12/2/24 reflected LVN H had no idea how there were 2 missing NARCO although he/she had signed for the blister pack. LVN H stated he/she left the cart opened and unsecured to help another resident for a short period of time. Statement 11/27/24: LVN A (night shift) identified that the reconciliation was incorrect and notified the DON. Statement 11/27/24: LVN I (day shift) count was incorrect for Resident #64. No in-service training sheets on ANE were present. During an interview on 12/18/24 at 3:21 PM, the DON stated she investigated the diversion and discovered the card in question was delivered in July 2024. The DON stated, the resident discharged home in September 2024 with the NARCO order. The DON stated the resident was readmitted [DATE] with 38 NARCO tablets and there were 2 missing from the card. [The DON stated that the count started with 38 and therefore no NARCO went missing] The card was signed in with 38 NARCOs by 2 nurses. On 11/26/24 the count was off 2 NARCO but LVN H signed for the 2 missing NARCOs. The DON stated LVN H signed for the additional 2 NARCOs. The DON stated, LVN H stated he left the cart opened on 11/27/24 during the night shift. The DON stated, LVN H accepted responsibility for the 2 missing NARCOs caused by the unsecured cart. The DON stated that she realized on 12/16/24 [date of surveyor's entrance] that training was not initiated on the day of the incident on 11/27/24 per the ANE policy; but training was started at the time of surveyor's entrance. [DON tried to explain that LVN H signed a card missing 2 NARCO and the incoming LVN A refused to accept the shift change reconciliation because 2 NARCO pills were missing. LVN H stated that the unsecured medication cart resulted in the 2 missing NARCO] During telephone interview on 12/18/24 at 3:44 PM, LVN A stated she identified that the reconciliation was incorrect on 11/27/24 at 6:00 AM and notified the DON. LVN A stated that LVN H did not give her a reason for the missing NARCO. LVN A stated that LVN H told her that he/she gave the medication (NARCO) to the Resident #64 on 11/27/23 at 3:00 AM and forgot to update the MAR. During a telephone interview on 12/18/24 at 4:17 PM, LVN H stated I was getting the pills for [Resident #64} around 3:00 AM in the morning of 11/27/24 and a call light went off .I left my cart unsecured .that is on me .there was a resident awake (Resident #50) near the cart and might have access to the unsecured cart .I gave the {Resident #64] his medication and at the end of shift if was when 11/27/24 at 6:00 AM) the missing NARCO was discovered . LVN H stated he forgot to document the narcotic sheet for Resident #64 of the NARCO given and also forgot to annotate the MAR November 2024. {The missing NARCO was a PRN medication for Resident #64 and not given on 11/27/24] During telephone interview on 12/18/24 at 5:30 PM, RN J stated she received a call on 11/27/24 about the drug diversion from another staff member. She directed that the Administrator be notified. RN J stated the cart with the missing medication was secured. RN J stated LVN H was suspended pending an investigation. RN J stated that LVN H did not give her an explanation on how the NARCO went missing.

Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 days of 30 days for November 2024 (11/10/24, 11/16/24, 11/18/24, 11/23/24, and 11/30/24) upon review for nursing services. The facility had less than 8 hours a day of RN coverage for 11/10/24, 11/16/24, 11/18/24, 11/23/24, and 11/30/24 for a total of 5 days from November 1, 2024 through November 30, 2024. This failure could result in residents not receiving the required services to meet their needs. The findings were: Record review of the facility timesheets revealed less than 8 hours a day of RN coverage for 11/10/24 (6.23 hours), 11/16/24 (5 hours), 11/18/24 (6.23 hours), 11/23/24 (6.23 hours), and 11/30/24 (5.5 hours). During an interview on 12/17/24 at 5:15 PM with the VP of Clinical, the VP of Clinical stated their nurses began to enter the facility on a consulting basis the first week of December 2024. The VP of Clinical stated the current acting ADON began serving as the acting ADON on 12/03/24, and that the current acting DON began serving as the acting DON on 12/09/24. During an interview on 12/18/24 at 10:09 AM with the acting DON, when asked what could happen if there was not a registered nurse present in the facility for 8 consecutive hours a day for seven days a week, the acting DON stated residents might have to get transferred to a hospital to receive the services they need that must be provided by a registered nurse, or there might be a delay in needed services if the resident was waiting for a registered nurse to arrive at the facility. Record review of the Nursing Services-Registered Nurse (RN) policy, dated 10/24/22, reflected the facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 18 residents (Resident #23 and #74) reviewed for incontinence care. 1. CNA Y wiped in the wrong direction and did not complete care when providing incontinent care to Resident #23. 2. When CNA-L and CNA-M were providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/24, CNA-L did not clean the resident's genital area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #23's face sheet, dated 12/18/24 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), lack of coordination, stage 3 chronic kidney disease (kidneys are damaged and can't filter blood the way they should), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #23's most recent quarterly MDS assessment, dated 11/6/24 revealed the resident was severely cognitively impaired for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #23's comprehensive care plan, with edit date 11/20/24 revealed the resident was at risk for impaired skin integrity related to incontinence of bowel and bladder with approaches that included to monitor for incontinence and provide incontinence care as needed. Observation on 12/18/24 at 2:58 p.m., revealed during incontinent care to Resident #23, CNA Y, after cleaning Resident #23's vaginal area, was assisted by CNA Z and positioned Resident #23 onto her left side to expose her anal and buttock area. Resident #23 was observed with a copious amount of stool to the anal area. CNA Y took a wipe and wiped in the wrong direction from back to front on three different occasions to Resident #23's anal area. During each pass with a wipe to Resident #23's anal area, copious amounts of stool was observed. CNA Y then placed a clean brief on the bed and assisted by CNA Z, rolled Resident #23 onto her back. CNA Y and CNA Z acknowledged they completed incontinent care to Resident #23. The Surveyor requested CNA Y and CNA Z to unfasten the clean brief from Resident #23 and assisted the resident onto her left. The Surveyor requested CNA Y take a clean wipe and wipe Resident #23's anal area. CNA Y took a wipe and wiped Resident #23's anal area and revealed a copious amount of stool. CNA Y wiped Resident #23's anal area with several wipes until there was no stool seen on the wipe. During a joint interview on 12/18/24 at 3:19 p.m., CNA Y acknowledged she had caught herself when she wiped Resident #23's anal area in the wrong direction. CNA Y and CNA Z revealed, wiping in the wrong direction, from back to front could cause the resident to develop an infection, especially since the resident was elderly and had stool. CNA Y stated, You should stop wiping when the wipe does not have anymore stool, it comes out clean. CNA Y and CNA Z stated they had not had training on providing incontinent care while working for the facility but had been trained while working for the facility's sister facility. During an interview on 12/18/24 at 4:00 p.m., the DON stated the facility provided competency training on incontinent care recently. The DON stated it was her expectation when providing incontinent care to wipe from front to back to prevent infection and an increase in urinary tract infections. The DON further stated, when providing incontinent care, the aides should visualize the area and wipe the area until no stool was visualized. The DON stated, not wiping the area completely or correctly could result in skin breakdown if stool was left on the area. 2. Record review of Resident #74's face sheet, dated 12/19/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of dementia (impairment of brain functions), peripheral vascular disease (reduced blood flow to the limbs), neuromuscular dysfunction of bladder (lack of bladder control), urinary tract infection (bladder infection), and hypertension (high blood pressure). Record review of Resident #74's quarterly MDS, dated [DATE], reflected his BIMS score was 3 of 15 reflecting he had severe cognitive impairment. Further record review of Resident #74's quarterly MDS, dated [DATE], indicated the resident had indwelling urinary catheter and was dependent (helper does all of the effort) for toilet hygiene and always incontinent to bowel. Record review of Resident #74's care plan, edited 10/02/2024, revealed The resident is at risk for infection related to indwelling medical device; to prevent the infection, all staff will utilize gown, gloves, and hand hygiene during high-contact resident care activities and the resident is incontinent of bowel as related to cognitive impairment. For intervention, monitor for incontinence and provide incontinent care as needed. Observation on 12/18/2024 at 10:15 a.m. revealed CNA-M held Resident #74, and CNA-L was cleaning the resident's groin area and indwelling urinary catheter. The CNA-M and CNA-L turned the resident to his right side and started cleaning the resident's buttock area, then put a new brief to the resident without cleaning the resident's penis. Interview on 12/18/2024 at 10:36 a.m. CNA-L stated she did not clean Resident #74's penis and cleaned only the catheter. The CNA-L stated she should have cleaned the resident's penis with a circular motion. Further interview CNA-L said she was nervous and forgot about cleaning Resident #74's penis. Interview on 12/18/2024 at 3:59 p.m. the DON stated CNA-L should have cleaned the resident's penis with a circular motion to prevent a possible urinary tract infection. The current DON said the previous DON completed the CNA-L's clinical skills checklist for perineal care on 12/07/2024, and CNA-L passed it. The DON had the responsibility to monitor and check the CNAs' skills. Record review of CNA Y's Clinical Skills Checklist dated 12/7/24 revealed the CNA had satisfied the requirements for performing incontinence care. Record review of CNA Z's Clinical Skills Checklist dated 12/9/24 revealed the CNA had satisfied the requirements for performing incontinence care. Record review of the facility policy and procedure, titled Perineal care, dated 10/24/2022, revealed in part, . It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown .9. If perineum (the region of the body located between the anus and the external genitalia) is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard .a. Cleanse buttocks and anus, front to back .12. Males . e. hold the shaft of the penis with one hand and was with the other. Begin cleansing tip of penis at urethral meatus using a circular motion and working outward. 39075

Based on observation, interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for five (5) (Resident #23, #25, #73, #74, and #78) of 18 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to obtain a consent for Resident #23 to reside in the secure unit. 2. Resident #25 was in the secure unit, but there was no physician order for putting the resident in the secure unit. 3. The facility failed to obtain a consent and a physician's order for Resident #73 to reside in the secure unit. 4. Resident #74 was in the secure unit, but there was no physician order for putting the resident in the secure unit. 5. The facility failed to obtain a consent and a physician's order for Resident #78 to reside in the secure unit. This failure placed facility residents at risk for lack of resident right due to misinformation by incomplete and inaccurate medical records. The findings included: 1. Record review of Resident #23's face sheet, dated 12/18/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), abnormalities of gait and mobility, major depressive disorder, recurrent, severe with psychotic symptoms, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #23's most recent quarterly MDS assessment, dated 11/6/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #23's comprehensive care plan, dated 12/10/24 revealed the resident wandered and was an elopement risk and resided in the HOPE UNIT (secure unit) related to cognitive impairment secondary to advanced age. Record review of Resident #23's Physician Order Report, dated 12/1/24-12/18/24 revealed the following order: - May Reside on Hope Unit (secure unit), with order date 10/10/23 and no stop date Record review of Resident #23's electronic health record revealed there was no consent obtained for the resident to reside in the secure unit. Observation on 12/18/24 at 2:58 p.m. revealed Resident #23 in the secure unit assisted by CNA Y and CNA Z during incontinent care. 2. Record review of Resident #25's face sheet, dated 12/19/2024, revealed an [AGE] year old male, admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included encephalopathy (brain dysfunction), heart failure (not pumping blood enough), pulmonary edema (too much fluid in the lung), type 2 diabetes mellitus (not control blood sugar in the body), and hypertension (high blood pressure). Record review of Resident #25's quarterly MDS, dated [DATE], reflected his BIMS score was 3 out of 15 which reflected he had severe cognitive impairment and not coded for behaviors. Further record review of Resident #25's quarterly MDS, dated [DATE], indicated the resident required dependent (helper does all of efforts) to sit to stand, char-to-bed transfer, and toilet transfer. Record review of Resident #25's care plan, dated 2/11/2024, indicated the resident wanders (elopement risk), so resides at HOPE unit (secure unit) related to cognitive impairment secondary to advance age. For intervention, the facility staff will provide adequate supervision and assistance on performing activities dual livings and monitor resident's whereabouts to ensure safety. Record review of Resident #25's Consent for Placement in Secure Unit, dated 12/18/2024, indicated Resident #25's representative gave the consent for putting the resident in the secure unit. Record review of Resident #25's physician order, dated 12/01/2024 to 12/19/2024, indicated there was no physician order regarding putting the resident in the secure unit. Observation on 12/16/2024 at 2:40 p.m. revealed Resident #25 was sleeping on his bed in his room which was located in the secure and locked unit. Interview on 12/18/2024 at 5:12 p.m. with the DON stated to put residents in the secure unit, the facility needed to have an elopement assessment, BIMS score, care plan, consent, and physician order. There was no physician order for Resident #25 regarding putting the resident in the secure unit. The facility did not know why the resident did not have the physician order. The DON stated not having a physician's order might cause a lack of resident's right. 3. Record review of Resident #73's face sheet dated 12/17/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), abnormalities of gait and mobility and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #73's most recent significant change MDS assessment, dated 10/31/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #73's Physician Order Report, dated 12/1/24-12/19/24 revealed there was no order for the resident to reside in the secure unit. Record review of Resident #73's comprehensive care plan, dated 12/10/24 revealed the resident had cognitive loss and dementia and resided in the Hope Unit (secure unit) related to history of wandering. Record review of Resident #73's electronic health record revealed there was no consent obtained for the resident to reside in the secure unit. Observation on 12/16/24 at 3:24 p.m. revealed Resident #73 in the secure unit sleeping in her room. Observation on 12/18/24 at 1:12 p.m. revealed Resident #73 with an unidentified staff in the secure unit being assisted from the wheelchair to the bed. 4. Record review of Resident #74's face sheet, dated 12/19/2024, revealed a [AGE] year old male, admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included dementia (impairment of brain functions), peripheral vascular disease (reduced blood flow to the limbs), neuromuscular dysfunction of bladder (lack of bladder control), urinary tract infection (bladder infection), and hypertension (high blood pressure). Record review of Resident #74's quarterly MDS, dated [DATE], reflected his BIMS score was 3 of 15 which reflected he had severe cognitive impairment. Further record review of Resident #74's quarterly MDS, indicated the resident required dependent (Helper does all of the effort) to toilet hygiene and substantial/maximal assistance (helper does more than half the effort) to chair/bed-to-chair transfer, and always incontinent to bowel. Record review of Resident #74's care plan, edited 12/10/2024, revealed the resident wanders (elopement risk), so resides at HOPE unit (secure unit) related to cognitive impairment secondary to advance age. For intervention, the facility staff will provide adequate supervision and assistance on performing activities dual livings and monitor resident's whereabouts to ensure safety. Record review of Resident #74's Consent for Placement in Secure Unit, dated 12/18/2024, indicated Resident #74's representative gave the consent for putting the resident in the secure unit. Record review of Resident #74's physician order, dated 12/01/2024 to 12/19/2024, indicated there was no physician order regarding putting the resident in the secure unit. Observation on 12/16/2024 at 2:36 p.m. revealed Resident #74 was sleeping on his bed in his room which was located in the secure and locked unit. 5. Record review of Resident #78's face sheet dated 12/18/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychotic disorder (any clinical symptom that entails a marked loss of contact with reality, notably including delusions, hallucinations, disorganized speech, or disorganized behavior), anxiety (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations), abnormalities of gait and mobility, and bipolar disorder (mental health condition characterized by extreme mood swings). Record review of Resident #78's most recent quarterly MDS assessment, dated 11/15/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #78's Physician Order Summary, dated 12/1/24 to 12/18/24 revealed there was no order for the resident to reside in the secure unit. Record review of Resident #78's comprehensive care plan, dated 12/10/24 revealed the resident had cognitive loss, dementia and was an elopement risk and resided in the HOPE UNIT (secure unit) related to exit seeking behaviors secondary to cognitive impairment and advance age. Record review of Resident #78's electronic health record revealed there was no consent obtained for the resident to reside in the secure unit. During an interview on 12/18/24 at 5:12 p.m., the DON acknowledged Resident #23, #25, #73, #74 and #78 did not have a record of consent for the residents to resided in the secure unit. The DON further acknowledged Resident #25, #73, #74 and #78 did not have a physician's order for the residents to reside in the secure unit. The DON revealed the facility needed to implement an elopement assessment, BIMS score, care plan, consent, and physician order to place residents in the secure unit. The DON revealed the facility could not justify a reason why these residents did not have these elements implemented. The DON acknowledged, obtaining an elopement assessment, BIMS score, care plan, consent, and physician's order was needed to protect the resident's rights. On 12/19/24 at 9:14 a.m., the Administrator provided the Survey Team with an electronically signed consent for Resident #23, #25, #73, #74 and #78 to reside in the secure unit, all dated 12/18/24. Record review of the facility policy and procedure document titled, Charting and Documentation, revision date July 2017 revealed in part, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record .c. Treatments or services performed .7. Documentation of procedures and treatments will include care-specific details . 39075

Based on interviews and record review, the facility failed to provide required training on restraints for 5 of 25 (Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist) staff sampled for licensure and training. The facility failed to ensure that the Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist had completed their mandatory restraints training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of the facility's training log, undated, showed no evidence of training for restraints for the Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that several sampled employees were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that the Activity Director, CNA Q, PTA O, CNA N and the Speech Therapist were missing training for restraints. The facility was provided time to locate and verify the missing trainings. During a second interview on 12/18/24 at 3:30 PM with the acting HR Coordinator, verified that the Activity Director, CNA Q, PTA O, CNA N and the Speech Therapist did not receive training for restraints. During an interview on 12/18/24 at 5:00 PM with the acting HR Coordinator and the Regional VP of Operations, the HR Coordinator stated that at the facility where she was the full time HR Coordinator, she and the Staffing Nurse were responsible for ensuring staff were receiving necessary trainings, and she was not sure who was responsible for training oversight at this facility. When asked what could happen to residents who were receiving care from staff who do not have all the required trainings, the acting HR Coordinator stated there could be consequences, and that residents could experience neglect or adverse outcomes if staff do not have the training to respond appropriately to situations like falls. Review of the Training Requirements policy dated 10/13/22, stated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles. Review of the Nursing Services and Sufficient Staff policy dated 10/24/22, stated it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 10 of 25 (Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E) staff sampled for licensure and training. The facility failed to ensure that Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E had completed their mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff. The findings included: Review of the facility's training log, undated, showed no evidence of training for QAPI for Housekeeper P, MA R, CNA S, the Food Service Director, RN T, LVN U, the Speech Therapist, the Social Worker, the Occupational Therapist, and LVN E. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that Housekeeper P, MA R, CNA S, the Food Service Director, RN T, LVN U, the Speech Therapist, the Social Worker, the Occupational Therapist, and LVN E were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that Housekeeper P, MA R, CNA S, the Food Service Director, RN T, LVN U, the Speech Therapist, the Social Worker, the Occupational Therapist, and LVN E, were missing training for QAPI. The facility was provided time to locate and verify the missing trainings. During a second interview on 12/18/24 at 3:30 PM with the acting HR Coordinator, verified Housekeeper P, MA R, CNA S, the Food Service Director, RN T, LVN U, the Speech Therapist, the Social Worker, the Occupational Therapist, and LVN E had not received the QAPI training. During a third interview on 12/18/24 at 5:00 PM with the acting HR Coordinator and the Regional VP of Operations, the HR Coordinator stated that at the facility where she was the full time HR Coordinator, she and the Staffing Nurse were responsible for ensuring staff were receiving necessary trainings, and she was not sure who responsible for training oversight at this facility. When asked what could happen to residents who were receiving care from staff who do not have all the required trainings, the acting HR Coordinator stated there could be consequences, and that residents could experience neglect or adverse outcomes if staff do not have the training to respond appropriately to situations like falls. Review of the Training Requirements policy dated 10/13/22, stated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles. Review of the Nursing Services and Sufficient Staff policy dated 10/24/22, stated it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on interviews and record review, the facility failed to provide required training on behavioral health for 2 of 25 employees sampled for licensure and training. The facility failed to ensure that 2 of 25 staff reviewed for behavioral health training (RN V and the Physical Therapist) had completed this mandatory training. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: Review of the facility's training log showed no evidence of training for behavioral health for RN V and the Physical Therapist. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that several sampled employees were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that 2 of 25 employees sampled for licensure and training, were missing training for behavioral health. The facility was provided time to locate and verify the missing trainings. During a second interview on 12/18/24 at 3:30 PM with the acting HR Coordinator, the missing trainings were verified. During a third interview on 12/18/24 at 5:00 PM with the acting HR Coordinator and the Regional VP of Operations, the HR Coordinator stated that at the facility where she is the full time HR Coordinator, she and the Staffing Nurse are responsible for ensuring staff are receiving necessary trainings, and she is not sure who responsible for training oversight at [NAME] Senior Living. When asked what could happen to residents who are receiving care from staff who do not have all the required trainings, the acting HR Coordinator stated there could be consequences, and that residents could experience neglect or adverse outcomes if staff do not have the training to respond appropriately to situations like falls. The Regional VP of Operations stated that multiple applicants were being considered for the role of HR Coordinator and that until the position was filled, the Administrator would be responsible for staff training. Review of the Training Requirements policy dated 10/13/22, stated it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles. Review of the Nursing Services and Sufficient Staff policy dated 10/24/22, stated it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 resident units (300 unit) reviewed for dignity. Laundry Aide X walked into several resident rooms in the 300 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: During an interview on 12/17/24 at 8:17 a.m., Resident #75, who resided on the 300 unit revealed sometimes staff had entered her room without knocking and it bothered her because it was an invasion of privacy. Resident #75 stated, what if they come in and I'm naked or something? Record review of Resident #75's most recent quarterly MDS assessment, dated 9/18/24 revealed the resident was cognitively intact for daily decision-making skills. Observation on 12/17/24 beginning at 8:51 a.m., revealed Laundry Aide X, who was delivering laundry on the 300 unit entered the following resident rooms without knocking: room [ROOM NUMBER] at 8:51 a.m. room [ROOM NUMBER] at 8:51 a.m. room [ROOM NUMBER] at 8:53 a.m. room [ROOM NUMBER] at 8:54 a.m. re-entered room [ROOM NUMBER] at 8:54 a.m. room [ROOM NUMBER] at 8:55 a.m. re-entered room [ROOM NUMBER] at 9:00 a.m. room [ROOM NUMBER] at 9:02 a.m. During an interview on 12/17/24 at 9:04 a.m., Laundry Aide X acknowledged she had entered resident rooms without knocking and revealed if the door was open to a resident room, she assumed there was no resident in the room and only knocked if a resident door was closed. Laundry Aide X acknowledged she was supposed to knock on the resident room door and announce laundry before entering the room. Laundry Aide X revealed she was working without help. Laundry Aide X stated, I should be knocking before going into a room because there could be patient care going on even if the door is open. I have been taught that I need to knock on the door to let the resident know I am coming in but sometimes some residents don't mind. I say yes, it is a violation of their rights. During an interview on 12/18/24 at 9:43 a.m., the Administrator acknowledged, not knocking on the door to a resident's room was not appropriate. The Administrator revealed it was his expectation for staff to knock on the resident's door before entering and announce themselves to gain permission from the resident. The Administrator acknowledged it was a resident rights issue. Record review of the facility policy and procedure titled, Resident Rights, dated February 2021 revealed in part, .Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .

Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential resident group meeting on 12/17/24 at 3:00 p.m., 3 of 10 members of the resident group stated they never received mail on Saturdays because the Receptionist was off on the weekends. During an interview on 12/17/24 at 5:11 p.m., the Receptionist acknowledged she worked as the receptionist Monday through Friday and did not work on the weekends. The Receptionist revealed, during the week she collected the mail from the mailbox and the local post office. The Receptionist revealed, once she collected the mail, it was placed in a small nook labeled Activities behind the receptionist area. The Receptionist revealed, the Activity Director or the Activity Aide would then collect the mail from the small nook and distribute the mail to the residents from Monday to Friday. The Receptionist acknowledged any mail delivered on Saturday stayed in the mailbox until she returned to work on Monday. During an interview on 12/18/24 at 8:49 a.m., the Activity Director revealed she typically worked Monday through Friday and occasionally popped in on Saturdays. The Activity Director acknowledged the Receptionist was tasked with collecting the mail from the mailbox and the post office, and then the Activity Director or her aide were responsible for distributing the mail to the residents Monday through Friday. The Activity Director acknowledged that any mail delivered on Saturday stayed in the mailbox until the Receptionist returned to the facility the following Monday. The Activity Director stated, If I am able to get mail on Saturday, so should the residents. During an interview on 12/18/24 at 9:39 a.m., the Administrator revealed, the residents should be getting their mail everyday as it was a resident right. Record review of the facility policy and procedure titled, Mail and Electronic Communication, revision date 2017 revealed in part, .Resident are allowed to communicate privately with individuals of their choice and may send and receive personal mail, e-mail and other electronic forms of communication confidentially .4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries) .

Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 4 staff (CNA-K) reviewed for competencies. The facility failed to ensure CNA-L had competencies to care as evidence by CNA-L did not clean the resident's genital area when CNA-L was providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/2024. This failure could potentially affect residents by placing them for cross contamination and infections due to staff who lack the appropriate skills and competencies to provide minimize infections. Findings included: Record review of Resident #74's face sheet, dated 12/19/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of dementia (impairment of brain functions), peripheral vascular disease (reduced blood flow to the limbs), neuromuscular dysfunction of bladder (lack of bladder control), urinary tract infection (bladder infection), and hypertension (high blood pressure). Record review of Resident #74's quarterly MDS, dated [DATE], reflected his BIMS score was 3 of 15 reflecting he had severe cognitive impairment. Further record review of Resident #74's quarterly MDS, dated [DATE], indicated the resident had indwelling urinary catheter and required dependent (Helper does all of the effort) to toilet hygiene and substantial/maximal assistance (helper does more than half the effort) to chair/bed-to-chair transfer, and always incontinent to bowel. Record review of Resident #74's care plan, edited 10/02/2024, revealed The resident is at risk for infection related to indwelling medical device; to prevent the infection, all staff will utilize gown, gloves, and hand hygiene during high-contact resident care activities and the resident is incontinent of bowel as related to cognitive impairment. For intervention, monitor for incontinence and provide incontinent care as needed. Observation on 12/18/2024 at 10:15 a.m. revealed CNA-M hold Resident #74, and CNA-L was cleaning the resident's groin area and indwelling urinary catheter. The CNA-L and CNA-M turned the resident to right side and started cleaning the resident's buttock area, then put a new brief to the resident without cleaning the resident's penis. Interview on 12/18/2024 at 10:36 a.m. with CNA-L stated she did not clean Resident #74's penis and cleaned only the catheter. The CNA-L stated she should have cleaned the resident's penis with circular motion. Further interview with the CNA-L said she was nervous, forgot cleaning Resident #74's penis, and the facility conducted skill check off every year. Interview on 12/18/2024 at 3:59 p.m. the DON stated CNA-L should have cleaned the resident's penis with a circular motion to prevent a possible urinary tract infection. The current DON said the previous DON completed the CNA-L's clinical skills checklist for perineal care on 12/07/2024, and CNA-L passed it. The DON had the responsibility to monitor and check the CNAs' skills. Record review of CNA-L's clinical Skills Checklist for Perineal care for male, dated 12/07/2024, indicated the CNA-L had performed all skills satisfactory which included .10. Wash perineal area starting with urethra and working outward. (If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.) gently rinse and dry the area. A. retract fore skin of the uncircumcised male. B. wash and rinse urethra area using a circular motion, and C. continue to wash the perineal area including the penis, scrotum, and inner thigh. Do not reuse the sane washcloth or water to clean the urethra.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services {including procedures that assure accurate acqyuiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of four carts reviewed for accuracy. 1. Resident #64 had 2 missing hydrocodone (NARCO)tablets that were not documented as given and could not be accounted for during November 27, 2024. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion. The findings included: Record review of Resident # 64's face sheet, dated 12/18/24 reflected a male age 74. The resident was admitted on [DATE] with diagnoses that included: joint replacement, cancer, and pain. RP was listed as: resident. Record review of Resident #64's admission MDS, dated [DATE], reflected the resident's BIMS score was 15 (cognitively intact). Resident as incontinent of both bladder and bowel; transfer and bed mobility were extensive assistance. Record review of Resident #64's Physician' Orders, dated November 2024, reflected, hydrocodone NARCO) 10-325 every 6 hours for pain and arthritis PRN. Record review of Resident# 64's MAR, dated November 2024, reflected: 11/26/24-No PRN NARCO given. 11/27/24-No PRN NARCO given. 11/28/24-10:52 AM-No entry that the medication (NARCO) was given on 11/28/24 at 3: AM as claimed by LVN H). Record review of Nurse Note dated from 11/27/24 and 11/28/24 reflected no notes establishing that NARCO was given to Resident #64. During an interview on 12/18/24 at 2:22 PM, the past Administrator stated he was informed during the change shift on 12/6/24 that the narcotic count was short in an unknown cart. The past Administrator stated, the cart with the missing narcotics was put out service and double locked pending an investigation. The past Administrator stated the DON did a reconciliation and two NARCO pills belong to Resident #64 were found missing. The past Administrator stated that LVN H was suspended pending an investigation. The past Administrator stated that the facility's investigation could not account for the missing NARCO belonging to Resident #64. The past Administrator stated that LVN H signed the reconciliation form on 11/26/24 and could not account for the missing NARCO. The past Administrator stated that no in-service training was done for the staff except for LVN H on ANE. Record review of facility's investigation file reflected: NARCO count dated 11/27/24- was short 2 pills. Resident # 64 was prescribed Hydrocodone 10-325 Mg (delivery of 40 pills on was 7/18/24). Written Statement by LVN H dated 12/2/24 stated LVN H had no idea how there were 2 missing NARCO although he/she had signed for the blister pack. LVN H stated he/she left the cart opened and unsecured to help another resident for a short period of time. Statement 11/27/24: LVN A (day shift) identified that the reconciliation was incorrect and notified the DON. Statement 11/27/24: LVN I (day shift) count was incorrect for Resident #64. During an interview on 12/18/24 at 3:21 PM, the DON stated she investigated the diversion and discovered the card in questioned was delivered in July 2024. The DON stated the resident discharged home in September 2024 with the NARCO order. The DON stated the resident was readmitted [DATE] with 38 NARCO tablets and there were 2 missing from the card. The card was signed in with 38 NARCOs by 2 nurses. On 11/26/24 the count was off 2 NARCO but LVN H signed for the 2 missing NARCOs. The DON stated LVN H signed for the additional 2 NARCOs. The DON stated LVN H stated he left the cart opened on 11/27/24 during the night shift. The DON stated LVN H accepted responsibility for the 2 missing NARCOs caused by the unsecured cart. During telephone interview on 12/18/24 at 3:44 PM, LVN A stated she identified that the reconciliation was incorrect and notified the DON. LVN A stated that LVN H did not give her a reason for the missing NARCO. LVN A stated that LVN H told her that he/she gave the medication (NARCO) to the Resident #64 on 11/27/23 at 3:00 AM and forgot to update the MAR. During a telephone interview on 12/18/24 at 4:17 PM, LVN H stated, I was getting the pills for Resident [#64] around 3 AM in the morning of 11/27/24 and a call light went off .I left my cart unsecured .that is on me .there was a resident awake [R#50] near the cart and might have access to the unsecured cart .I gave the Resident [#64]his medication and at the end of shift it was when the missing NARCO was discovered . LVN H stated he forgot to document the narcotic sheet for Resident #64 of the NARCO given and also forgot to annotate the MAR November 2024. During telephone interview on 12/18/24 at 5:30 PM, RN J stated she received a call on 11/27/24 about the drug diversion from another staff member. She directed that the Administrator be notified. RN J stated the cart with the missing medication was secured. RN J stated LVN H was suspended pending an investigation. RN J stated that LVN H did not given her an explanation on how the NARCO went missing. Record review of facility's Controlled Substances policy dated April 2019 reflected: .controlled substances .are secured and maintained in a locked cabinet or compartment .Accurate accountability of the inventory of all controlled dugs is maintained at all times .

Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for two residents (Residents #34 and #59) of five residents whose medications were reviewed. 1. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #34's Mirtazapine for depression on 11/25/2024. However, the facility failed to ensure communicating to the resident's primary care physician regarding the recommendation. 2. The facility's Pharmacy Consultant recommended adding Do Not Crush to Resident #59's medication administration record for the resident's Diltiazem for hypertension (high blood pressure) on 10/22/2024. However, the facility failed to ensure adding the recommendation to the medication administration record. The failures could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. The findings were: 1. Record review of Resident #34's face sheet, dated 12/19/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of dementia (impairment of brain functions), micturition (urinary incontinence), muscle weakness, hypertension (high blood pressure), and depression. Record review of Resident #34's annual MDS, dated [DATE], reflected her BIMS score was 99 reflecting she could not complete cognitive assessment. Further record review of Resident #34's annual MDS, dated [DATE], indicated the resident was taking an antidepressant as ordered. Record review of Resident #34's care plan, edited 12/17/2024, revealed the resident has a diagnosis of depression and is at risk for increased depression, social isolation, and adverse consequences related to receiving an anti-depression medication, and for intervention, administer medication per physician orders and gradual dose reduction if indicated by physician as ordered/indicated. Record review of Resident #34's physician order, dated 02/12/2024, indicated the resident had the order of Remeron (Mirtazapine) 7.5 mg by mouth once a day at bedtime for major depressive disorder. Record review of Resident #34's medication administration record from 12/01/2024 to 12/31/2024 indicated the resident was receiving Remeron (Mirtazapine) 7.5 mg by mouth once a day at bedtime for major depressive disorder as scheduled time from 6:30 PM to 10:30 PM. Record review of Resident #34's Expanded Drug Regimen Review Report, dated 11/25/2024, indicated Please, follow up on letter to physician regarding trial discontinue of Mirtazapine in progress. Record review of Resident #34's medical chart from 11/25/2024 to 12/19/2024 indicated there was no medical records regarding facility communication of the pharmacist recommendation for discontinue of Mirtazapine for Resident #34's depression to the resident's primary care physician. Interview on 12/18/2024 at 4:26 p.m. the DON stated she could not find any record regarding facility communication of the pharmacist recommendation for discontinue of Mirtazapine for Resident #34's depression to the resident's primary care physician. The DON and all leadership group took over the facility on 12/16/2024 because a new company bought the facility, so they received the pharmacy review binder on 12/16/2024 from the previous leadership group. The DON did not know why the previous leadership group did not follow the pharmacist recommendation. It was the DON's responsibility to report all pharmacy recommendations to the physicians, and Resident #34 might not have the chance of gradual dose reduction. 2. Record review of Resident #59's face sheet, dated 12/19/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of dementia (impairment of brain functions), hypertension (high blood pressure), muscle weakness, encephalopathy (brain dysfunction), type 2 diabetes mellitus (not control blood sugar in the body), and heart failure (not pumping blood enough). Record review of Resident #59's quarterly MDS, dated [DATE], reflected his BIMS score was 5 out of 15 which reflecting he had severe cognitive impairment. Further record review of Resident #59's quarterly MDS, dated [DATE], indicated the resident had active diagnosis of heart failure and hypertension. Record review of Resident #59's care plan, edited 10/30/2024, revealed the resident has a diagnosis of hypertension and is at risk for decreased cardiac output, activity intolerance and imbalanced nutrition. For intervention, administer medication per the physician orders. Refer to medication administration record for current medications. Record review of Resident #59's physician's order, dated 09/13/2024, indicated the resident had the order of Diltiazem tablet 6.0 mg at bedtime by mouth Hold of systolic blood pressure less than 120 or heart rate less than 60 for hypertension. Record review of Resident #59's medication administration record from 12/01/2024 to 12/31/2024 indicated the resident was receiving Diltiazem tablet 6.0 mg at bedtime by mouth Hold of systolic blood pressure less than 120 or heart rate less than 60 for hypertension as scheduled time from 6:30 AM to 10:30 AM. Further record review of the medication administration record indicated there was no Do Not Crush. Instructions reflected. Record review of Resident #59's Expanded Drug Regimen Review Report, dated 10/22/2024, indicated Recommended adding Do Not Crush to medication administration record for diltiazem for hypertension (high blood pressure). Interview on 12/18/2024 at 3:32 p.m. the DON stated the facility did not add Do Not Crush on Resident #59's medication administration record per the pharmacist's recommendation, and the DON and all leadership group took over the facility on 12/16/2024 because the new company bought the facility, so they received the pharmacy review binder on 12/16/2024 from the previous leadership group. The DON did not know why the previous leadership group did not follow the pharmacist's recommendation. It was DON's responsibility to report all pharmacy recommendations to the physicians, and Resident #59 might have the wrong drug strength over time. Record review of the facility policy, titled Medication Regimen Review, dated 11/28/2022, indicated . 5. The pharmacist shall communicate any irregularities to the facility in the following ways: a. verbal communication to the attending physician, director of nursing, and/or staff of any urgent needs. b. written communication to the attending physician, the facility's medical director, and the director of nursing.f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and distributed properly for one of four nurse medication carts (Hall 200 nurse medication cart and Hall 300 medication cart) reviewed for drug storage and use, as evidenced by: 1. The nurse medication cart for the 300-hall contained 5 loose pills. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion. The findings included: 1. During an observation and interview on 12/17/24 at 9:15 AM of the nurse cart for the 300 hall with LVN F, revealed 5 loose pills in the bottom of the cart drawers that held the blister packs. When asked what could happen if loose pills are left in the cart, LVN F stated anything could happen if the pills were consumed by a resident for whom they were not prescribed. LVN F stated a resident could be allergic to one of the pills and the consequences could be horrific. During an interview on 12/18/24 at 10:16 AM with the acting DON, when asked what could happen if loose pills are found in the carts, the acting DON stated residents might not receive the medication they needed resulting in a delay in therapy, and if a resident consumed something that was not prescribed for them, the resident could experience adverse effects or an allergic reaction. The acting DON stated her expectation was for the staff to check carts per shift for loose pills. Review of the facility's policy titled Medication Carts and Supplies for Administering Meds dated 10/01/19, reflected the purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Review of the facility's policy titled Disposal of Medications and Medication-Related Supplies dated April 2019, reflected unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. 50760

Based on interview and record reviews, the facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility was not relieved of its obligation to provide this information to the individual once he or she was able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time for 1 of 1 (Resident #1) reviewed for Advanced Directives, in that: Resident #1's RP wished to have a DNR code status for Resident #1. Resident #1's OOHDNR was not valid, and Resident #1 was administered CPR by LVN A and RN B on [DATE]. This deficient practice could affect residents with an OOH-DNR and could result in residents not getting their Do Not Resuscitate wishes honored. The noncompliance was identified as PNC. The IJ (Immediate Jeopardy) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. The findings included: Record review of Resident #1's Admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses that included: ESRD (end stage renal disease, pulmonary edema, diabetes II (a chronic (long-lasting) health condition that affects how your body turns food into energy.), altered mental status, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen) in chronic kidney disease, vascular dialysis catheter, peripheral vascular disease (a slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel can cause PVD), acquired absence of right leg below the knee, dependence on renal dialysis, cognitive communication deficit disorder of brain. Further review revealed the resident expired on [DATE]. Record review of Resident #1's electronic chart revealed in red lettering (on the banner of the resident electronic chart on top)- DNR. Record review of Resident #1's consolidated physician orders for [DATE] revealed an order for a code status of DNR order date was [DATE]. Record review of Resident #1's OOHDNR, dated [DATE], revealed the document had no physician signature in the electronic chart. Record review of Resident #1's telephone order, dated [DATE], revealed an order for the resident's code status to be change to DNR was created by ADON/RN N. Further review revealed this order for DNR was not signed by the physician until [DATE]. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 2, which indicated the resident was severely cognitively impaired. Further review revealed MDS section I Active Diagnoses indicated the resident had diagnoses of: PVD (peripheral vascular disease), renal insufficiency renal failure, or end stage renal disease (ESRD), Diabetes, Alzheimer's disease, cerebrovascular accident (CVA)/transient ischemic attack (TIA) or stroke, non-Alzheimer's Dementia, asthma, and anemia in chronic kidney disease. Record review of Resident #1's care plan, dated [DATE], revealed the resident's care plan indicate a code status of DNR (dated [DATE]). Further review revealed interventions for the resident's DNR code status was: do not perform CPR, should resident be found without pulse, respiration. Record review of Resident #1 progress notes, dated [DATE], revealed it was documented Resident #1 was pronounced dead on [DATE] at 4:43 AM by EMS. Record review of Resident #1 progress note dated [DATE] at 5:30 PM by LVN A, revealed LVN A documented on [DATE] at approximately at 3:58 AM RN B came down the hall and asked if Resident #1 was a full code or DNR. LVN A looked it up on the computer and thought LVN A saw that Resident #1 was a full code. At that time, facility staff started CPR and LVN A came back the desk to call 911. EMS arrived approximately 10 minutes later and took ever CPR. LVN A stayed with Resident #1 to help and provide information as needed. Approximately 15 minutes later, RN N came to the room and stated Resident #1 was a DNR not a full code. By that time CPR had been in progress for approximately 30 minutes. So, EMS continued the CPR also the OOHDNR form EMS requested was not signed by a DR. So, they (EMS) continued the code until they called the local emergency room and spoke to the DR who called the code and time of death at 4:43 AM. LVN A then contacted [Resident #2's family member] and explained to them the Resident #1 had passed away. Resident #1's family member arrived at the facility soon afterwards. During an interview with LVN A on [DATE] at 4:55 PM, LVN A stated he was the night nurse who cared for Resident #1 on [DATE]. LVN A stated the last time he saw Resident #1 earlier that night Resident #1 had vomited (Mexican food brought in by the resident's family member), nurse cleaned Resident #1 up and changed the resident's clothes. LVN A stated Resident #1 seemed to be quiet and brought the resident his pain medications. LVN A stated the Resident #1's family member had brought the resident food that night and maybe it did not set well in his stomach. LVN A stated Resident #1 was normal for him not to eat too much. LVN A stated Resident #1 was in and out of the hospital and left home and then came back to the facility. LVN A stated Resident #1 was readmitted from home because the resident's family member could not care for him. LVN A stated he did CPR which entailed compressions, called 911, and EMS, and further stated when EMS had placed the AED pads-did not advise to shock the resident and continued to be unresponsive. LVN A stated RN B, who was working as a CNA that night, found Resident #1 and came to get him. LVN A stated Resident #1 was found unresponsive with no pulse, and when he looked at the resident's chart and he thought the resident was a full code. During an interview with RN B on [DATE] at 9:21 AM, RN B stated she worked as needed and was working in a CNA slot that night. RN B stated Resident #1's family member had brought Mexican food in and Resident #1 had vomited once that night. RN B stated the resident's vitals were normal and had been cleaned by her and LVN A around 11:30 PM. RN B stated Resident #1 had behaviors of yelling out for help and when staff went to check on him, the resident had forgotten what he needed. RN B stated she would check on Resident #1 every 30 minutes. RN B stated LVN A administered Resident #1 pain medications around 11:30 PM. RN B stated she found Resident #1 unresponsive about 3:55 AM and notified LVN A. RN B stated Resident #1 had no pulse, and he had not fallen. RN B stated LVN A checked the computer for Resident #1's code status, and replied the resident was a full code, so they got the crash cart, vital machine, compressions, and 911 was contacted. RN B stated they had started CPR compressions, then EMS arrived and took over- maybe around ,d+[DATE] AM. RN B stated another nurse brought Resident #1's OOHDNR form, and EMS stated it was not valid since the physician signature was missing. EMS preceded to do CPR on Resident #1, then she left the room. RN B stated LVN A was still in Resident #1's room with EMS. During an interview Resident #1's family member on [DATE] at 11:00 AM, Resident #1's family member stated she had signed the OOHDNR due to Resident #1 being in poor health and was too weak. During an interview with the Admission/Marketer on [DATE] at 11:50 AM, the Admission/Marketer stated Resident #1's family member had requested Resident #1 to have an OOHDNR form due the hospital physician stated Resident #1 was in poor health. The Admission/Marketer stated she let Resident #1 family member know the OOHDNR had to be completed before the resident was considered a DNR. The Admission/Marketer stated she gave the OOHDNR, that had two witnesses' signatures, and then gave the OOHDNR to one of the ADON/RN/Medical Records D. The Admission/Marketer stated she uploaded Resident #1's OOHDNR and in parentheses added OFS (out for signature). During an interview with ADON/RN/Medical Records D on [DATE] at 12:08 PM, ADON/RN/Medical Records D stated when the Admission/Marketer gave her a OOHDNR she would take it to the physician's office to have the physician sign the OOHDNR for residents and then would upload the OOHDNR form in the resident record. ADON/RN/Medical Records D stated she would notify the ADM, DON, and charge nurse of the OOHDNR was completed and in the resident's chart. ADON/RN/Medical Records D stated she did not remember receiving Resident #1's OOHDNR form or uploading it to the resident's chart in the computer. ADON/RN/Medical Records D stated, in Resident #1's chart, under Advanced Directive and initial OFS, ADON/RN/Medical Records D stated she was not sure what OFS initial meant. During an interview with the DON on [DATE] at 1:45 PM, the DON stated the staff had notified her of Resident #1's death and she had come to the facility. The DON stated nursing staff was responsible in making sure all residents had the correct code status in their charts. The DON stated Resident #1 did not have an OOHDNR form completed, so the resident would remain full code. The Administrator and DON were notified on [DATE] at 10:23 PM, that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to entrance included: PNC IJ verification: F578 During an interview with ADON/LVN C on at [DATE] at 5:33 PM, ADON/ LVN C stated she did the staff training with nursing staff on OODNR/CPR/change of conditions on [DATE]. Record review revealed 84 of 84 direct care staff were in serviced on [DATE] Code Status/change of condition with ADON/RN/Medical Records D and ADON C. Nurses, CNA, MA where to find the location of the code status. Non-clinical staff refer to charge nurse for assistance with code status, If you do not have access to matrix. If at any time these do not match you must notify the ADON, DON and Administrator immediately. Interviews with nursing staff revealed they had received trainings for OOHDNR forms, resident code status location, and chance of condition - nursing staff were able to state what trained on: During an interview with the Administrator on [DATE] at 7:17 PM, the Administrator stated she was trained on where to locate a resident's code status on [the electronic medical records system] (face sheet, order, care plan, OOHDNR). The Administrator stated if the code status's does not match, then let the charge nurse know. During an interview with RN D on [DATE] at 7:58 PM, RN D stated she worked here for about one month and had worked here in the past. RN D stated she was trained on where they could find the code status for residents in different locations in chart, could find in orders, could find in the POC for aides, make sure the OODNR was completed. RN D stated staff were to notify the Administrator, DON, or ADON if a resident's code status did not match. During an interview with CNA E on [DATE] at 8:01 PM with CNA E had worked here for 1 year. Yes, she was trained was on residents POC [the electronic medical records system] (residents care plan on the POC). CNA E stated she would notify the charge nurse if change in resident. During an interview with on [DATE] at 8:08 PM with ADON/ LVN F worked here for 7 months. Yes, she was trained was about advanced directives, where to find the code status for residents [the electronic medical records system] and how to access it. If the code status does not match, she would look for the OODNR in documents. The OODNR was valid with Resident/RP signature, 2 witnesses' signatures and physician signature. If missing a signature, it would not be valid. Notify Admin, DON, ADON if do not match. During an interview with on [DATE] at 8:15 PM with MA G had worked here for 4 yrs. Yes, she was trained on code status, [the electronic medical records system] (resident on banner at top of chart, face sheet) Also, trained on notifying charge nurse if the code status does not match. During an interview with on [DATE] at 8:18 PM with CNA H worked here for 2 weeks. Yes, she was trained on OODNR. CNA H sated she would check the residents POC [the electronic medical records system] for the code status. Also, CNA H would ask nurse about a resident code status. CNA H would notify the charge nurse for change in resident condition. During an interview with on [DATE] at 8:25 PM with ADON/LVN I had worked here for 5 months. Yes, she was trained on where to find code status [the electronic medical records system]. ADON/LVN I was trained on where to find who initiated the code status in residents' chart. For OODNR's when admitting she would view the OODNR form to make sure all signatures were completed. ADON/LVN I stated until the OODNR was completed, staff should not create the order. If the code status does not match look at OODNR form and verify its valid. If not validated she would let the floor manager know and correct the code status with DON/ADON and Resident/family. If OODNR form not valid then resident was still considered a full code. During an interview on [DATE] at 8:31 PM with LVN J had been working here for 2 years. Yes, she was trained on advanced directives and mock CPR. This entailed staff check resident code status, [the electronic medical records system] staff brought crash cart, who would call 911, and ADON's monitored. LVN J stated she was trained on advanced directives where to find in the resident chart, the definition, how the OODNR form needs to be filled out completely and where to go to access it. If transferring print out the OODNR form, so it will go with resident. If code status does not match in the resident chart, you have to perform CPR if resident was not responsive. LVN J stated she would notify the ADM, DON, ADON if the resident code status did not match and change of resident condition. During an interview on [DATE] at 8:36 PM with LVN K stated she had worked here for 3.5 yrs. Yes, she was trained on computer. LVN K stated she was trained on where to find the code status, [the electronic medical records system] (on top banner of resident chart, face sheet, and in documents-advanced directive). Also, trained on where to find crash cart and mock CPR. If the OODNR form had to have all signatures to be competed. If the OODNR form was not completed the resident remained full code. If code status does not match, LVN K would double check the OODNR. Resident remains full code until DNR status was completed/valid. LVN K she was trained on who to notify for resident change of conditions. During an interview on [DATE] at 8:48 PM with CNA L had worked here for 4 yrs. Yes, she was trained on where to find code status on residents POC [the electronic medical records system]. CNA L stated she was trained on who can do CPR or not. CNA L stated she was trained to talk to nurse about any change in the resident. During an interview on [DATE] at 8:51 PM with CNA M had worked here for 1.5 yrs. Yes, she was trained on resident code status where to find on POC [the electronic medical records system]. CNA M stated if resident was a DNR, it would be in red and had resident picture. If she sees something wrong with resident, she alerts a nurse. If resident had a change of condition, she would get the nurse. During an interview on [DATE] on 9 AM DON had worked here for 2 weeks. Yes, she was trained on code status, where to find it. The DON stated she could find the resident code status on [the electronic medical records system] (top of banner in resident chart, face sheet, order, OODNR). If the residents code status did not match and when she would follow the OODNR form. The DON stated, if the OODNR form was missing signatures the resident was a full code. The DON stated she was trained on change of condition of a resident- she would complete the SBAR and prompt nurse. Record review of the facility's policy titled, Emergency Procedure- Cardiopulmonary Resuscitation, dated ,d+[DATE], revealed, 6. If an individual is found unresponsive and not breathing normally, a license staff member who is certified in CPR/BLS shall initiate CPR unless: a. is known that a DNR order that specifically prohibits CPR and/or external defibration exist for that individual: 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a valid OOHDNR. The noncompliance was identified as PNC. The IJ began on [DATE] and corrected on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE].

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and hazards, in that: CNA A did not request assistance from a second staff when providing incontinent care and changing bed linens for Resident #1, resulting in the resident falling out of bed on 09/05/2023 and fracturing her right leg. An Immediate Jeopardy (IJ) was identified on 9/9/23 at 5:05 p.m. While the IJ was removed on 9/11/23, the facility remained out of compliance at a scope of isolated and and a severity level of no actual harm with potential for more than minimal harm because of residents' safety. This deficient practice could place the residents at risk for serious injury. The findings included: Record review of Resident #1's face sheet, dated 11/8/22, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other mental functions), Muscle Wasting, Abnormalities of Gait and Mobility, and Morbid Obesity (being more than 80-100 pounds above ideal body weight). Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 10, signifying moderate cognitive impairment, extensive assistance with two+ physical assistance for bed mobility, total dependence with two+ physical assistance for transfers, substantial/maximal assistance (helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene and was always incontinent of bowel and bladder. Record review of Resident #1's annual MDS, dated [DATE], revealed Resident #1 had a BIMS score of 10, signifying moderate cognitive impairment, total dependence with two+ physical assistance for bed mobility/transfers and dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene and was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #1's care plan, dated 12/1/22, revealed the following Focus area: [Resident #1], have an ADL self-care performance and mobility deficit related to intrinsic and extrinsic factors such as: limited mobility, impaired cognition, depression, heart failure, anxiety, pain, contracture of left ankle/foot. This Focus area had the following interventions: The resident requires extensive assistance by 2 staff to turn and reposition in bed and in chair at least every 2 hours and as necessary . Resident requires total assistance by 2 staff .The resident requires extensive assistance by 2 staff with personal hygiene .The resident requires extensive assistance by 2 staff for toileting Record review of Resident #1's Kardex, dated 11/8/22, revealed the following: Bathing - Resident requires total assistance by 2 staff; Bed Mobility - The resident requires extensive assistance by 2 staff to turn and reposition in bed and in chair at least every 2 hours and as necessary; The resident requires extensive assistance by 2 staff for toileting. Record review of Resident #1's incident report, dated 9/5/23 at 4:25 a.m. and written by LVN O, revealed the following verbiage: CNA called [sic] me to residents [sic] room, upon entering residents [sic] room I observed resident lying on the floor on her right side. The CNA said that as she was changing residents [sic] bed linens resident was holding onto her bedside dresser for support and her legs were hanging off the bed then she slid off the bed. I observed resident for any injuries and resident has redness to her right cheek and bridge of nose. Resident c/o pain to right knee. Residents [sic] right leg appears to be turned inward. I called [DON's name], DON . I notified .administrator. MD and called [county] EMS (911) for Transport to ER. Residents [sic] RP notified as well. Record review of Resident #1's progress note, dated 9/5/23 at 5:20 a.m. and written by LVN O, revealed the following verbiage: CNA called [sic] me to residents [sic] room, upon entering residents [sic] room I observed resident lying on the floor on her right side. The CNA said that as she was changing residents [sic] bed linens resident was holding onto her bedside dresser for support and her legs were hanging off the bed then she slid off the bed. I observed resident for any injuries and resident has redness to her right cheek and bridge of nose. Resident c/o pain to right knee. Residents [sic] right leg appears to be turned inward. I called [DON's name], DON . I notified .administrator. MD and called [county] EMS (911) for Transport to ER. Residents [sic] RP notified as well. Record review of facility's electronic medical record system's 24-hour communication bulletin revealed: 9/5/23 [Resident #1] - witnessed fall out of bed, sent to ER for evaluation and treatment. During an attempted interview and observation on 9/8/23 at 3:26 p.m., Resident #1 was observed in ICU of Hospital A with family at bedside. Resident #1 was observed to have bruising to right hand and arm, swelling and bruising to the left hand, and bruising to the left elbow. Resident #1 was unable to respond to surveyor's questions. During an interview with Hospital Representative T on 9/8/23 at 3:26 p.m., Hospital Representative T stated Resident #1 was extubated (removal of breathing tube) at 11:30 a.m., placed on a face mask with oxygen at 40%. Hospital Representative T further stated the resident's wrists were restrained due to confusion and to avoid pulling of tubes and IV. Record review of Resident #1's radiology report of right femur (the bone that runs from the hip to the knee), dated 9/5/23 at 6:32 am, revealed the following: CLINICAL HISTORY: Trauma/Injury . IMPRESSION: 1. Comminuted [fragmented], displaced and angulated fracture involving the right distal femoral metaphysis [neck portion of a long bone]. 2. Marked soft tissue swelling. Record review of Resident #1's hospital Physician's Order Sheet, dated 9/5/23 at 9:01 a.m., revealed the following: Admit Status: ICU .Diagnosis: Right femoral fracture. Record review of Resident #1's radiology report of right femur (the bone that runs from the hip to the knee), dated 9/6/23 at 4:10 p.m., revealed the following: . IMPRESSION: Intraoperative open reduction internal fixation [operation to repair broken bones] involving the right femur . During a telephone interview on 9/8/23 at 11:32 a.m. Resident #1's RP stated the resident arrived at the hospital with swelling of the right leg and was diagnosed with a fracture, Resident #1 subsequently had surgery to repair the fracture and is now in the ICU and on a ventilator. Resident #1's RP stated the resident was able to follow directions but was 100% bedridden, and further stated the resident did not move or get up. Resident #1's RP stated Resident #1 needed extensive assistance and during the incident there was only one person in the room and the resident was holding on to the dresser. Observation on 9/9/23 at 12:13 p.m. of Resident #1's room revealed there was a side table located to the side of Resident #1's bed at the head of the bed, which placed the side table to the right side of the resident when in the bed. Phone interviews were attempted with CNA R on 9/8/23 at 4:52 p.m. and 9/9/23 at 4:17 p.m. but no return call was received prior to the end of the investigation. During an interview with the DON on 9/8/23 at 5:04 p.m., the DON stated CNA A was suspended immediately following the incident with Resident #1's injury. The DON stated the facility had begun in-servicing regarding ADLs, specifically two-person assistance. During a telephone interview with LVN O on 9/8/23 at 5:40 p.m., LVN O stated she was not in the room when the incident involving Resident #1 on 9/5/23 happened. LVN O stated CNA A called her to the resident's room and LVN O found Resident #1 lying on the floor on her right side. LVN O stated CNA A had said she had been changing the linens on Resident #1's bed when CNA A rolled the resident over and the resident used the dresser for support. LVN O further stated CNA A had said that Resident #1 rolled off the bed and fell . LVN O stated Resident #1 was unable to sit up on her own, was unable to ambulate, and was unable to turn on her side without assistance. LVN O stated staff were expected to follow the individual care plans. During an interview with CNA A on 9/9/23 at 10:35 a.m., CNA A stated that on 9/5/23 she was scheduled to work in the facility's memory care unit, but around 9:45 p.m. she was asked to help on the skilled unit. CNA A stated she asked if there had been any changes in resident conditions and was told no by CNA R. CNA A stated that during the shift Resident #1 voided and she provided incontinent care for the resident and proceeded to change the bed linens because they were soiled. CNA A stated she asked Resident #1 to turn and hold on to the dresser drawer next to the resident's bed, which was opened. CNA A stated Resident #1 was laying on right side holding to the dresser draw, the resident slightly moved her leg, the bed shifted, and Resident #1 rolled off the bed with her leg hitting the floor first. CNA A further stated that Resident #1 was kneeling on the floor while she (CNA A) was on the opposite side of the bed. CNA A stated she ran around to the other side, moved the bed, put her hands under the resident's head and right shoulder, laid her down on the floor and called for the nurse. CNA A stated Resident #1's bed was in a low position due to the resident's short stature and the bed's wheels were locked. CNA A stated she was providing care to Resident #1 alone, and further stated she did not know that Resident #1 required two-person assist for transfers. CNA A stated she always asked for help when providing care to residents that required two-person assistance. CNA A stated she was not trained on how to access the Kardex (a system used to provide a brief overview of each resident and was updated as needed) in the facility's electronic medical records system. CNA A further stated she was informed on 9/9/23, by the DON and Administrator, that the Kardex included everything staff needed to know to care for the residents. CNA A stated she thought the Kardex was for the nurses and repeated that she was never trained how to access it or how to use. CNA A stated had she known how to access the Kardex, she would have reviewed all the residents' plans to know what type of care they required. CNA A stated CNAs reported changes and the care residents required to each other verbally. CNA A stated she had worked at the facility for three years and received one week of training when she was hired and then shadowed another CNA. CNA A further stated that initial training included becoming familiar with the residents, how to provide individual resident care, resident preferences and ADL training, which included scenarios. CNA A stated she also received training regarding ANE and fall prevention. CNA A stated hat abuse was when someone verbally abused a person and neglect was when proper care was not provided to residents, like not changing them or not showering them. CNA A further stated that not following a resident's plan was considered neglect. CNA A stated she was upset because the incident resulting in Resident #1's fall could have been prevented had she known Resident #1 required two-person assistance. CNA A stated there were three other residents she cared for on the night of 9/5/23 that she knew required two-person assistance from having worked with them in the past; and further stated she had asked for assistance when providing care for those three residents and received help, but she stated she was not aware that Resident #1 required more assistance. CNA A stated that otherwise she would have asked for help. During an interview on 9/9/23 at 1:12 p.m., the DON, who started working at the facility on 9/6/23, stated the residents' needs assessments were completed admission and quarterly. The DON stated each residents' needs were included in the individual care plans and that information was then transferred onto the Kardex. The DON stated after the IDT met, agreed and finalized the care plans, the MDS nurse, herself, and the nurse managers were responsible for updating the resident care plans. The DON stated changes/updates to the care plans were relayed to the charge nurse, added to the 24-hour communication bulletin in the facility's electronic medical records system, and the Kardex updated to reflect the care plan; changes were then communicated verbally to the CNAs. The DON stated all staff had access to the information included in the Kardex, and further stated that her expectation was for CNAs to communicate verbally at shift change; however, they were still responsible for checking the Kardex at the start of their shift, before providing care. The DON stated she was told on 9/9/23 by CNA A, that CNA A had not received education regarding access and use of the Kardex. The DON stated she was now responsible for nursing education and verifying competency. During an interview with the Administrator on 9/9/23 at 1:55 p.m., the Administrator stated the expectation was that the DON reviewed the competency of the staff. The Administrator stated competency was reviewed when staff were hired but after that he did not know how often staff competencies was evaluated. During an interview with the OT on 9/9/23 at 2:42 p.m., the OT stated Resident #1 was totally dependent on staff for mobility. During an interview with the Administrator on 9/9/23 at 3:45 p.m., the Administrator stated the care plans were available for the staff to review in the facility's electronic medical records system and it was everyone's responsibility to report any changes in residents' condition. The Administrator stated, with regard to the Kardex, staff were expected to review the Kardex at the start of their shift at a minimum. The Administrator stated the facility did not have a policy, but this was the expectation. The Administrator further stated he did not think this expectation had been relayed to the staff by previous management. With regards to the incident, the Administrator stated that per the documentation, CNA A was changing Resident #1 and the resident was holding on to the nightstand when the resident slid down off the bed. The Administrator stated the facility did not use bedrails. The Administrator stated CNA A was immediately suspended, and CNA A was asked to report to the facility and the DON reviewed the Kardex with her. During a telephone interview on 9/10/23 at 1:01 p.m., CNA A stated she had received training on how to regarding how to turn and reposition residents. CNA A stated that when Resident #1 resided in the memory care unit the resident was able to turn on her own and was told that Resident #1 was a one-person assist because the resident was able to turn herself in the bed. CNA A further stated she was familiar with Resident #1 when she resided in the memory care unit. CNA A stated that changes were communicated verbally and that she had asked on 9/5/23 if there were any changes in resident condition and was told by CNA R there were not any. CNA A stated she was asked to work on the skilled unit around 10:00 p.m. on 9/5/23, further stated that she did not work on the skilled unit. CNA A stated she knew how to care for the memory care residents and what their needs were because she had worked with them for almost one year and was familiar with the residents. CNA A stated she was not made aware that she could access the Kardex for all residents in the facility (both memory care and skilled) until 9/9/23. CNA A stated that prior to this she was only able to access the ADLs section. CNA A stated when she worked the night of 9/9/23 she reviewed the Kardex for all her residents, and further stated the Kardex included exactly what was supposed to be done when providing care to the residents and repeated that if she had known about the Kardex, the incident with Resident #1 on 9/5/23 could have been prevented. CNA A stated on 9/9/23, she was asked, by the DON and Administrator, about the Kardex and she told them she had seen it but had been told it was only used by nurses. CNA A stated she was unable to recall when this was or who gave her this information. CNA A stated she did not ask the LVN or other staff on duty on 9/5/23 how to access the Kardex because she thought they were for nurses only. When asked by the surveyor about the training she signed in for in April and November 2022, which included the Kardex, CNA A stated she did not remember that training. During an interview with the DON on 9/10/23 at 1:17 p.m., when asked who monitors whether a staff member was properly trained on how to care for residents, the DON stated she was now responsible for ensuring that staff were properly trained on how to care for the residents. The DON stated that Prior to her starting employment at the facility it was the previous DON's responsibility. During a telephone interview with LVN S on 9/10/23 at 1:23 p.m., LVN S stated she had frequently conducted in-services regarding use of the Kardex. LVN S stated the Kardex in-services included showing staff how to access the Kardex in the facility's electronic medical records system and POC. LVN S stated everyone had access to the Kardex. LVN S stated during the in-service she demonstrated how the nurses accessed the Kardex versus how CNAs accessed the Kardex. LVN S further stated during the in-service she also explained to the staff what the Kardex was used for. LVN S stated these in-services were always in-person and were provided for new employees and as needed. LVN S stated she could not recall when she provided this training to CNA A, but stated if CNA A had signed in that meant she had definitely received the training. During an interview with the ADON on 9/10/23 at 3:21 p.m., the ADON stated staff should never provide care to residents who required two-person assist alone, and further stated there were always other staff in the facility and there was no excuse for not asking for help from a second person. The ADON stated special needs of the residents were found in the Kardex and training regarding the Kardex was provided to staff upon hire. Record review of the facility's Education Bundle in-service, provided by LVN Q on 9/8/23, revealed: .Purpose: staff will follow Kardex for all care given to residents if you are needing 2 people for any task ensure that you find assistance prior to going to do any care. Goal: ensure that resident receive proper care and to prevent any incidents. Subject: kardex and adl care. Further review revealed the sign-in sheet was signed by 7 out of 97 nursing employees. Record review of the facility's In-Service Training Report, dated 4/11/22 and conducted by LVN S, revealed: TOPIC: Kardex/Patient Care .SUMMARY OF TRAINING SESSION .When completing patient care, please ensure to read through Kardex to ensure appropriate patient care is provided. Further review revealed the sign-in sheet for the above-mentioned training included CNA A's signature. Record review of the facility's CNA Orientation Skills Checklist for CNA A, dated 11/22/22 and signed by LVN S, revealed the checklist included Kardex. Further review revealed the checklist also included a statement that read: I certify that the above employee has demonstrated proficiency and/or verbalized an understanding of the skills listed on this form. Record review of the facility's procedure titled, Turning a Resident on His/Her Side Away From You, dated 10/2010, revealed: .Preparation: Review the resident's care plan to assess for any special needs of the resident. The Administrator and the DON were notified of an IJ on 9/9/23 at 5:05 p.m. and were given a copy of the IJ Template and a Plan of Removal (POR) was requested. The facility provided a POR and it was accepted on 9/10/23 at 3:29 p.m. The POR was documented as follows: Plan of Removal: All direct care nursing staff will be in-serviced on the following- - The expectation for all direct care nursing staff is to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. - All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. Specifically, the Kardex is located in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right hand side of their screen. This will then display any special needs of the resident as directed in their care plan. - DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the Kardex. - The training regarding identification and utilization of the Kardex in order to allow direct care nursing staff to review the resident's care plan to assess for any special needs of the resident will be an ongoing continuous training to be conducted quarterly with first training completed 9/9/2023. Training will also be included in new hire process for all direct care nursing staff. - The utilization of [the facility's electronic medical records system] in the facility does not differ from unit to unit, it is displayed in the same format for all direct care nursing staff. - The facility DON/ADON/Designee notified all direct care nursing staff of facility's policy regarding Turning a Resident on His/Her Side Away From You to educate staff on promoting good body alignment. The policy directs the direct care nursing staff to review the resident's care plan to assess for any special needs of the resident. In addition to the policy direct care nursing staff have been made aware that if assistance is needed to provide resident ADL care they should seek assistance prior to providing care. - The training confirmations will be stored with their employee file in the Human Resources department. - On 9/6/23, the Director of Nursing initiated an addendum to the original in-service initiated on 9/5/2023 by Administrator to include visual aids to assist staff with identification of the Kardex location, this is to include all direct care nursing staff to cover the topics of: - Importance of and expectation that all direct care nursing staff will be able to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. - Importance of and expectation that all licensed nurse staff will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to assess for any special needs of the resident. Demonstration of and acknowledgement that all direct care nursing staff are aware of the above- - DON/ DON Designee will contact all direct care nursing staff to obtain signature and return demonstration on site or via [video conference] with demonstration and acknowledgment, however, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by DON/DON Designee to serve as a return demonstration of understanding that- - Kardex is to be utilized to review resident's care plan to assess for any special needs of the resident prior to providing care. Effective 9/9/23 the DON/ADON/designee will randomly observe direct care nursing staff demonstrate how to locate and utilize the Kardex. - The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to locate the Kardex and review to assess for any special needs of the resident. - All direct care nursing staff were contacted in person or by phone and verbally in-serviced. - All direct care nursing staff in-services will be completed by 7:30 pm 9/9/23. - All direct care nursing staff will be made aware and provided with a copy of the facility's policy regarding Turning a Resident on His/Her Side Away From You and to also include specific direction that if assistance is needed they should seek assistance prior to providing ADL care by 10:30 pm 9/9/2023. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. This will be reviewed monthly in QAPI until compliance is met. Validation of the POR: On 09/10/2023 at 3:30 p.m., Administrator provided in-service sign-in sheets for all nursing staff, in-service was completed on 9/9/23. Record review of facility Education Bundle in-service on 9/10/23, revealed the following: .Purpose: staff will follow Kardex for all care given to residents if you are needing 2 people for any task ensure that you find assistance prior to going to do any care. Goal: ensure that resident receive proper care and to prevent any incidents. Subject: kardex and adl care. The sign-in sheet was signed by 97 out of 97 nursing employees. In-service documentation included a handout of the POC Shift Dashboard, which includes tabs for the Kardex and Care Plan, as well as an example of a Kardex and information included in the resident Kardex (this included: Bed Mobility, Toileting and Transferring). Record review of facility In-Service Training Report on 9/10/23, revealed the following: TOPIC: Facility Policy re: repositioning, assessing resident care plan, assistance with ADL care .SUMMARY OF TRAINING SESSION: Facility policy regarding Turning a Resident on His/Her Side Away From You discusses how to promote good body alignment and for the direct care nursing staff to review the resident's care plan to assess for any special needs of the resident. If staff needs assistance to provide ADL care, they must seek help prior to providing the resident care. Please review attached policy for Turning a Resident on His/Her Side Away From You for the detailed purpose, preparation and steps in the Procedure, Documentation and Reporting. During interview on 9/9/23 at 3:45 p.m., the DON stated that in-service was completed for all staff, those that were not available in person were called via video conference to conduct the ADL, Kardex and Turning/Repositioning in-service. During an interview on 9/10/23 at 4:49 p.m., LVN B stated she had received training that included transfers, Kardex and Care Plans. LVN B stated during the in-service she was told to check the Kardex for any special needs the residents might have and was shown how to access the Kardex in the facility's electronic medical records system. LVN B further stated she had access all records, both SNF and Memory Care. Following the interview LVN B demonstrated how to access the Kardex and Care Plans in the facility's electronic medical records system. During an interview on 9/10/23 at 4:51 p.m., CNA C stated she received an in-service on 9/9/23 that included where to find and how to read the Kardex, transfers and bed mobility which included using proper technique and the right amount of assistance when provided care to the residents. Following the interview CNA C demonstrated how to access the Kardex and Care Plans in the facility's electronic medical records system. During an interview on 9/10/23 at 4:56 p.m. CNA D stated she did receive in-service regarding ADLs, Kardex and transfers. CNA D stated the ADL in-service included resident diets, incontinent and incontinent care, the Kardex in-service included ensuring that it was reviewed every morning before providing care and the transfers in-service included using proper techniques, equipment, and level of resident assistance. Following the interview CNA D demonstrated how to access the Kardex. During an interview on 9/10/23 at 5:00 p.m. CNA E stated she received training on 9/9/23 which included fall prevention, notifying nurses of changes in resident condition, what the Kardex was for and how to access it and following special needs of the residents. CNA E stated she had also received training regarding abuse, neglect and exploitation. Following the interview CNA E demonstrated how to access the Kardex. During an interview on 9/10/23 at 5:04 p.m. LVN F stated she recently received training which included how to access the Kardex to check for updates on resident needs and accessing resident care plans. Following the interview LVN F demonstrated how to access the Kardex and care plans. During an interview on 9/10/23 at 5:07 p.m. CNA G stated she had not received training recently. During a demonstration, CNA G was able to locate the Kardex and stated the Kardex was used to review residents' special needs. CNA G stated she accessed the Kardex weekly and when there were new admits. CNA G stated if a resident has a change in condition the nurses would communicate with the CNAs. CNA G stated the expectation was that she accessed the Kardex every other day, and the DON clarified that her expectation were that the Kardex be accessed every shift before providing patient care. Record review of the in-service training records revealed CNA G had received in-services regarding the Kardex, ADLs, and turning residents on 9/9/23. During an interview on 9/10/23 at 5:13 p.m. CNA H stated she received an in-service this week but could not remember what day. CNA H stated the in-service included Kardex, which includes information regarding the residents, transfers, ADLs, level of assistance, turning, repositioning and level of assistance. CNA H stated she usually accessed the Kardex at least twice during her shift. During an interview on 9/10/23 at 6:50 p.m. LVN I stated she recently received an in-service regarding Kardex, transfers, repositioning, asking for assistance when needed and ANE. Following the interview LVN I demonstrated how to access the Kardex. During an interview on 9/10/23 at 6:56 p.m. CNA J stated she did received training recently which included Kardex, falls, and ANE. CNA J stated the Kardex included resident history, special needs and any changes in condition. CNA J stated during the ANE in-service she was told to report any ANE to the Administrator and if she saw anything she considered ANE to report it. CNA J stated she was required to access the Kardex daily when providing care to residents. Following the interview CNA J was able to demonstrate how to access the Kardex. During an interview on 9/10/23 at 6:58 p.m. CNA K stated she received training regarding ANE, ADLs, turning the resident, fall prevention and protecting the residents. CNA K stated the Kardex included resident history, changes in condition, assistive devices, bowel/bladder status and assistance level. CNA K stated she accessed the Kardex daily when providing care because anything can change. CNA K stated she was able to access all resident records in the facility. CNA K stated that in her opinion they should always have two staff when providing care for the residents' safety. Following the interview CNA K was able to demonstrate how to access the Kardex. During an interview on 9/10/23 at 7:05 p.m. CNA L stated she received training on 9/9/23 which included Kardex, transfers and fall prevention. CNA L stated the Kardex included information regarding resident needs to help provide care. CNA L stated she accessed the Kardex every shift and as needed when she was not sure how to care for a resident. Following the interview CNA L was able to demonstrate how to access the Kardex. During an interview with the DON on 9/10/23 at 7:03 p.m., the DON stated the facility started posting signs next to the kiosks for the facility's electronic medical records system as a reminder of how to access the [TRUNCATED]