Every finding on record at Life Care Center Of Yuma

Based on observations, interviews, and a review of facility policy and procedure, the facility failed to ensure that medications were stored in accordance with facility policy. The deficient practice could result in unauthorized persons having unrestricted access to the medications.Findings include: Regarding Resident #41: Resident #41 admitted to the facility on [DATE] with diagnoses that included hemiplegia, stage-3 chronic kidney disease, unspecified dementia. A review of the minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 3, which indicated that the resident is severely cognitively impaired. A review of physician orders revealed an order dated June 28, 2026 for the resident to receive wound care for a stage-2 pressure ulcer to his right heel that included instructions to cleanse the wound with 0.9% normal saline, pat dry, and apply foam dressing. The Director of Nursing (DON/Staff #64) stated that Resident #41 did not have an assessment on file to self-administer medications. An observation was conducted on August 3, 2026 at approximately 1:39 p.m. in the room of resident #41. A spray bottle of wound was observed to be present on the resident's bedside table. During an observation on August 3, 2026 a member of the environmental services team cleaned the resident's room at approximately 2:27 p.m. The environmental services team member wiped down the bedside table and moved the medication to a small open-topped container on top of the bedside table. LPN/Staff #75 2:32 p.m. removed the medication from the resident's room. Regarding Resident #70: Resident #70 admitted to the facility on [DATE] with diagnoses that included chronic systolic (congestive) heart failure, and memory deficit following cerebral infarction. A review of the MDS dated [DATE] revealed a BIMS score of 10, which indicated that the resident is moderately cognitively impaired. A Health Status Progress Note dated July 30, 2026 revealed the resident had redness in the groin area; provider notified and new orders received for Nystatin Powder twice daily to treat the redness. Review of physician orders revealed an order dated July 30, 2026 for the resident to be administered Nystatin Powder 100000 UNIT/GM and to apply per directions topically every shift for redness to groin. The DON stated that Resident #70 did not have an assessment on file to self-administer medications. An observation was conducted on August 3, 2026 at approximately 1:55 p.m. in the room of Resident #70. A tube of hydrophilic wound cream and a bottle of medicated powder were on the resident's bedside table. The prescribed name listed on the pharmacy label of the bottle of medicated powder was for Resident #65. Certified Nursing Assistant (CNA/Staff #140) was observed in the resident's room. LPN/Staff #75 at approximately 2:23 p.m. removed the medication from the resident's room. Regarding Resident #37: Resident #37 admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, anxiety disorder, and post-traumatic stress disorder. A review of the MDS dated [DATE] revealed a BIMS score of 15, which indicated that the resident was considered cognitively intact. Review of physician orders revealed an order dated June 18, 2025 for barrier cream to be applied to the resident's sacrum. The DON stated that Resident #37 did not have an assessment on file to self-administer medications. An observation was conducted on August 3, 2026 at approximately 2:41 p.m. in the room of Resident #37. A tube of tube of hydrophilic wound was observed on the resident's bedside table. The Assistant Director of Nursing (ADON/Staff #125) removed the medication from the bedside table. She asked Resident #37 if she had any more medications at her bedside and with the resident's agreement the ADON removed 2 tubes of medicated ointment and a bottle of cold/flu medication from the resident's bedside table. An observation was conducted on August 3, 2026 at approximately 3:46 p.m. in the hallway outside of resident #54's room. A clear plastic bag that listed the name of Resident #103 was observed to contain one full bottle of antimicrobial wound cleanser and 2 full bottles of normal saline and was discovered placed on top of a personal protective equipment (PPE) cart outside of the resident room in a common hallway of the facility. LPN/Staff #75 at 3:50 p.m. 5 proceeded to remove the medications from the PPE cart in the hallway outside of the resident's room. An interview was conducted with CNA/Staff #60 on August 5, 2026 at approximately 9:16 a.m., which revealed the CNA would notify nursing of medications left at a resident's bedside since a CNA is not authorized to handle medications. She stated that a medication left unattended at a resident's bedside is not compliant with facility policy and could result in another resident or visitor taking the medication which could cause them to become ill. The CNA stated the risks associated with leaving medications unattended at a resident's bedside are heightened for residents that are cognitively impaired An interview was conducted with Licensed Practical Nurse (LPN/Staff #75) at approximately 2:23 p.m. on August 3, 2026. The LPN verified that the medication found in Resident #70's room was prescribed for Resident # 65. He stated that Resident #70 did not have orders to self-administer the medication and that facility policy is for all medications to be secured on the med cart, wound cart, or medicine storage room. The LPN stated that the medications left unattended at a resident's bedside is not compliant with facility policy and could result in theft of the medication or someone else taking the wrong medication. During an interview was conducted with the ADON/Staff #125 on August 3, 2026, the ADON identified the medications found at the resident's bedside; which included triad hydrophilic wound cleanser, homeopathic ointment, pain relief gel, and cold and flu syrup. The ADON listed examples of medications that require an order which included normal saline, pain relief ointments, hydrophilic barrier cream, and cold and flu syrup. The ADON stated that an order is needed for the medications to determine if there are any potential drug interactions to monitor. The ADON stated that facility policy is for medications to be secured on the medication cart, treatment cart, or the medication storage room when not being administered to a resident. She stated potential adverse outcomes which included interactions with prescribed medications, especially with the homeopathic medications, and that the resident could use the medication incorrectly. The ADON stated that medications left unattended at a resident's bedside did not meet her or the facilities expectations and was not compliant with facility policy. An interview was conducted with LPN/Staff #65 at approximately 3:52 p.m. on August 3, 2026, The LPN identified the name listed on the medication bag on the PPE cart in the communal hallway outside of the room of Resident #54 as belonging to Resident #103. He identified the contents of the medication bag which included 2 full bottles of normal saline and 1 full bottle of antimicrobial wound cleanser. He stated that facility policy is for the medications to be securely stored in either the wound cart or medication storage room. The LPN stated adverse outcomes that could result from leaving the medication unattended in a common area of the facility could include theft of the medication or a resident or visitor could consume the medication and become ill. He further stated that the observed concern was not compliant with facility policy and did not meet his expectations. An interview was conducted with the Director of Nursing (DON/Staff #64) at approximately 9:03 a.m. on August 6, 2026, the DON stated that medication is defined as is a substance used to treat a condition. The DON stated the facility policy is for medications to be stored in the medication storage room, medication carts, wound carts, and at bedside for residents that have been assessed to self-administer medications. She stated that normal saline and triad paste are medications and that they can not be left at the bedside of a resident who is not assessed and approved to self-administer medications. The DON stated her expectation is that staff would follow facility policy regarding medication administration and storage. She stated potential adverse outcomes that included other residents taking the medication and a concern that a resident's medication administration record would not document the administration of the medication. The DON stated that medications discovered unattended at the bedside of multiple residents and in a communal hallway did not meet her expectations and was not compliant with facility policy. Review of the facility policy titled Administration of Medications - reviewed September 9, 2025, revealed the facility will ensure medications are administered safely and appropriately per physician orders to address residents' diagnoses and signs and symptoms. The policy revealed a physician order is required for medication to be administered that included the dosage, route, frequency, duration, and other required considerations that included the purpose, diagnosis, or indication for use. Review of the facility policy titled Self-Administration of Medication - reviewed September 15, 2025, revealed the facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications. The policy revealed if the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted.

Based on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure that Preadmission Screening and Resident Review (PASRR) was completed for one of twenty-two (#3) residents, with a diagnosis of a serious Mental Illness (MI) was referred to the appropriate state-designated authority for review. The deficient practice could result in residents not receiving the necessary specialized services that they require. The universe was 97. -Regarding Resident #3 Resident #3 was re-admitted to the facility on [DATE], with previous admission dates of April 17, 2024, June 3, 2024, July 18, 2024, February 12, 2025 with diagnoses that included post traumatic stress disorder (PTSD), generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, diabetes mellitus type two, asthma, and chronic kidney disease with heart failure. A care plan initiated on April 28, 2026 states the resident has an alteration in neurological status related to pain management. The resident uses antidepressant medication venlafaxine and fluoxetine related to depression. The resident has a behavior problem, obsessive thoughts, inability to sleep, and increased sadness, 3-5 times a week. An order summary revealed the following orders:Venlafaxine HCL Oral Tablet 25 MG, 1 tablet by mouth one time a day related to post-traumatic stress disorder, mixed obsessional thoughts, and acts as evidenced by verbalization of sadness. Active prescription date May 29, 2026 and resident consent signed on June 10, 2026.Hydroxyzine HCL 25 mg tablet, 1 tablet by mouth every 6 hours as needed for anxiety as evidenced by inability to relax. Active prescription date July 11, 2026 and resident consent signed on February 18, 2026.Hydroxyzine HCL 25mg/ml, 25 milligrams intramuscularly every 6 hours as needed for anxiety as evidenced by inability to relax. Active prescription date July 11, 2026 and resident consent signed on February 18, 2026.Pre-admission Screening and Resident Review (PASRR) documentation: A Pre-admission Screening and Resident Review (PASRR) Level 1, listed an admission date of April 17, 2024, for resident #3, revealed the section labeled mental illness listed no diagnoses and failed to list major depression, PTSD, and anxiety disorder. The screening was completed by the facility and dated October 31, 2024, with no results.A Pre-admission Screening and Resident Review (PASRR) Level 1, listed an admission date of June 3, 2024, for resident #3 revealed the section labeled mental illness listed no diagnoses and failed to list major depression, PTSD, and anxiety disorder. The screening was completed by the facility and dated June 3, 2024, with no results.A Pre-admission Screening and Resident Review (PASRR) Level 1, listed an admission date of July 18, 2024, for resident #3 revealed the section labeled mental illness listed no diagnoses and failed to list major depression, PTSD, and anxiety disorder. The facility completed the screening with no results.A Pre-admission Screening and Resident Review (PASRR) Level 1, listed an admission date of February 10, 2025, for resident #3 revealed the resident meets the admission criteria for 30-day convalescent care. The screening was completed by the hospital where resident #3 transferred from and was signed by a medical professional on February 12, 2024, with no results. Further review of the medical record revealed no evidence that a Level 1 PASRR was completed for resident #3 by the facility after the 30 days of convalescent care provided and the resident continued to reside at the facility. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitive function was intact. The resident was administered high-risk medications that included Venlafaxine HCL Oral Tablet 25 MG related to post-traumatic stress disorder and mixed obsessional thoughts, Hydroxyzine HCL 25mg/ml, inject 25 milligrams intramuscularly every 6 hours as needed for anxiety, and Hydroxyzine HCL 25 mg tablet, give 1 tablet by mouth every 6 hours as needed for anxiety.Further, the MDS revealed the resident's mood of little interest or pleasure in doing things and feeling down, depressed, or hopeless two to six days per week. An active diagnosis of PTSD is listed.An interview was conducted with the Regional Nurse Resource (staff #155) and the Director of Nursing (DON/staff #64) on August 4, 2026, at 3:00 P.M., who stated that the PASRR documents are located in the Documents or misc (miscellaneous) tabs on Point Click Care (PCC). When staff #155 was asked to look up resident #3 PASRR from last admission of November 17, 2025, it was not located in PCC, so she stated she will ask social services if they have a binder for PASRR's.An interview was conducted with staff #155 on August 4, 2026, at 3:40 P.M., as she presented a PASRR dated June 3, 2024, and she stated there was not a PASRR for admission on [DATE], and the new social service director noticed that it had not been completed. Staff #155 was not able to find a copy of the results from the authorized state agency. An interview was conducted with Social Service Director (Staff #2) on August 5, 2026, who stated that the process of PASRR is to receive one from the hospital they are coming from and/or, if that is not provided prior to admission, Staff #2 will complete it for the resident upon admission. Staff #2 stated depending on the level 1 results would determine next steps and if a Level II PASRR needed to be completed. He stated that if a resident stays longer than thirty days, he thought he would need to complete a PASRR and submit it to the PASRR portal for Arizona. Staff #2 stated the risk of not completing a Level 1 or Level 2 PASRR is that the behavioral health needs might not be met. Staff #2 stated that PTSD was a serious mental illness that would require a PASRR to determine the support needed for the resident prior to coming into the facility to make sure the facility is an adequate fit for the resident. Staff #2 stated that all new skilled residents or residents that have stayed longer than 40 days at the facility, or a significant change in condition, would complete a new PASRR Level 1. If a resident meets the qualifications, then he would submit to the portal for PASRR and he would receive a determination if a Level 2 PASRR is required. Staff #2 stated he is the one who tracks when PASRR's are due, and the determination letters are sent to his email. In review of resident #3's medical records in PCC, he stated that there was not a PASRR completed for the last admission of November 17, 2025. Also, the previous PASRR that was not dated was completed for admission on [DATE]; it revealed the day signed from the hospital was dated February 10, 2024, which he believed was to read February 10, 2024. Staff #2 stated that resident #3 did stay longer than 40 days and should have had a new PASRR Level 1 completed by the facility, but there was not one completed. The facility policy titled Pre-admission Screening and Resident Review (PASARR) was reviewed on September 26, 2025. The facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level 1, and is completed prior to admission to a nursing facility. A negative Level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation.

Based on a review of clinical records, staff and resident interviews, and facility policies and procedures, the facility failed to ensure that pain medication for one (Resident #19) of twenty-two sampled residents were administered in accordance with physician orders. This deficient practice had the potential to result in overmedication, adverse drug effects, impaired pain management, and inaccurate assessment of the resident's pain status.The facility census was 97. Findings include:Resident #19 was admitted to the facility on [DATE], with diagnoses that included chronic pain, polyneuropathy, chronic kidney disease, acquired absence of left leg above knee, acquired absence of right leg below knee and peripheral vascular disease.Resident #19 care plan dated July 16, 2026, revealed no activity involvement due to her physical limitations and due to the amount of pain in her neck and lower back. She expresses pain and discomfort related to left polyneuropathy and chronic pain. Review of a physician's order dated June 17, 2026, revealed Oxycodone HCL 5mg 1 tablet was to be administered by mouth every six hours as needed for pain levels of 6-10 on a 0-10 pain scale.Review of the Medication Administration Record (MAR) for July 2026 revealed Oxycodone was administered one time when the documented pain level was below the physician-ordered parameter of 6-10. This administration included:July 26, 2026- pain level 4; Oxycodone administered at 4:12 P.M. Review of a physician's order dated April 24, 2026, revealed Oxycodone HCL 5mg 2 tablets were to be administered by mouth every six hours as needed for pain levels of 6-10 on a 0-10 pain scale.Review of the Medication Administration Record (MAR) for May 2026 revealed Oxycodone was administered five times when the documented pain level was below the physician-ordered parameter of 6-10. These administrations included:May 5, 2026- pain level 4; Oxycodone administered at 8:45 A.M.May 5, 2026- pain level 4; Oxycodone administered at 4:18 P.M. May 13, 2026- pain level 4; Oxycodone administered at 4:30 A.M. May 13, 2026- pain level 5; Oxycodone administered at 10:52 A.M. May 18, 2026- pain level 4; Oxycodone administered at 2:15 P.M.Review of a pain evaluation completed on April 8, 2026 listed a pain level of 1 for the locations of left above the knee amputation and right below the knee amputation. As needed, pain medication and repositioning makes the pain better. The effects of pain for quality of life are sleep and rest.Review of a pain evaluation completed on July 8, 2026, listed a pain level of 2 for the locations of left above the knee amputation and right below the knee amputation. As needed, pain medication and repositioning makes the pain better. The effects of pain for quality of life are sleep and rest.An interview was conducted with resident #19 on August 4, 2026 at 1:52 P.M. stated that she has pain most of the day in her lower back and neck. She also stated she has phantom pain in both legs from the amputations. She states she does not feel her pain is being controlled with the medication, and she has spoken to the nursing staff. Resident #19 stated they do prop pillows under her to help and she does request to be sitting upright in bed when awake.An interview with Registered Nurse (RN/Staff #48) on August 4, 2026 at 10:45 A.M. stated that when a resident has an as-needed order for pain medication, the nurse should ask the resident to rate their pain on a scale of 1 to 10 and attempt non-pharmacological interventions, such as repositioning. Staff #48 stated that pain medication should only be administered within the physician-ordered pain scale and time parameters. An interview with Director of Nursing (DON/RN/staff #64) on August 5, 2026 at 8:13 A.M. stated if a resident is in pain a nurse would be alerted to do a pain assessment. Pain is assessed every shift by the nursing staff. We use a pain scale of 0-10 with 10 being the worse pain and 0 being the least pain. She stated that all pain medications should have physician orders including pain parameters. If a resident's pain level falls below the ordered parameter of 6-10, then the pain medication would not be administered. If the resident is given pain medication not within the physician ordered parameters it could cause overmedicating the resident and could cause side effects like being sleepy. Staff #64 stated that the MAR's were recently audited by the home office staff and there were issues noted. The facility is working on a plan to audit the MAR's monthly going forward. The facility policy titled, Pain Management, reviewed on December 12, 2025 states it is to help residents attain or maintain their highest practicable level of well-being by proactively identifying, care planning, monitoring, and managing the residents pain indicators. Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and are in accordance with professional standards of proactive, the comprehensive care plan, and the resident's choices related to pain management. Assess pain every shift and record on eMAR. Always indicate which pain scale was used and document the type of pain the resident is experiencing. Residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. The facility policy titled, Administration of Medications, reviewed September 9, 2026 states the facility will ensure that medications are administered safely and appropriately per physician order to address resident's diagnosis and signs and symptoms. Residents are free of any significant medication errors. Note the resident's history and any parameters around drug administration.The facility policy titled, Pain Assessment and Management, revised November 11, 2025, states all residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. An individualized pain management care plan will be developed and initiated when pain indicators are identified. The care plan will be reviewed and revised by the interdisciplinary team upon completion of each Minimum Data Set (MDS) assessment and as needed. Monitoring appropriately for effectiveness and /or adverse consequences including defining how and when to monitor the resident symptoms and address of pain relief.

Based on clinical record review, staff interviews, facility documentation, policies and procedures the facility failed to protect one (#15) of 20 sampled resident's rights to be free from neglect by staff. The deficient practice could lead to other residents not receiving the care and services needed to maintain their health. The census was 97. Findings include:Resident #15 was readmitted on [DATE] with diagnoses that include type 2 diabetes mellitus, vascular dementia and colostomy. A care plan focus area of ADL (activities of daily living) assistance had an intervention initiated on May 18, 2026 that staff will assist with foley and colostomy care as needed.A quarterly MDS (minimum data set) dated July 22, 2026 revealed a BIMS (brief interview mental status) score of 15, meaning the resident was cognitively intact.A progress note dated June 22, 2026 by Social Services Director (Staff #2) revealed that Resident #15's daughter reported concerns of neglect. The progress note then revealed that Resident #15 noticed the colostomy bag was leaking at approximately 02:00 a.m. and asked for assistance from the night shift staff. Around 06:00 a.m. assistance was asked from the day shift certified nursing assistant (CNA). That CNA informed the resident that she had not been trained on how to perform ostomy care. CNA then reported to the hall nurse, of Resident #15's request of changing the ostomy bag. Resident #15 requested a second time with the CNA, to notify the nurse again. The nurse stated she was completing the medication pass and would attend to the resident afterward. Resident #15 activated the call light later to request assistance again. CNA informed the nurse again and was instructed by the nurse to seek assistance from another CNA for help that knew how to do ostomy care. That CNA informed Resident #15 of the plan and when returned with assistance of another CNA, the hall nurse was already performing the care.During the initial pool process on August 3, 2026 at 4:14 p.m. An attempt was made to talk with Resident #15, and Resident #15 did not want to speak and turned their head away.A review of the facility's 5 day report was reviewed.An attempt to interview Licensed Practical Nurse (LPN/Staff #200), who was the hall nurse that had been taking care of Resident #15 was made on August 4, 2026 at 2:56 p.m.,. A message was left for a request to return the call.An interview was conducted on August 4, 2026 at 3:05 p.m. with CNA/staff #70 and revealed that everybody (all CNAs) are trained with colostomy care.An interview was conducted on August 4, 2026 at 3:15 p.m. with LPN/Staff #151 and revealed that colostomy care is done when needed and a resident in the building does have the care scheduled. Care includes making sure the clip is on and sealed and observing the skin around the ostomy site.An interview was conducted on August 5, 2026 at 09:21 a.m. with Social Services Director/Staff #2 and revealed that there are different kinds of abuse and examples include neglect, physical, emotional and psychological. Abuse training is conducted in the facility. Staff #2 stated the Resident was followed up for a few days after the incident and Resident #15 felt that it was neglect because she had asked for assistance multiple times before the care was provided.An interview was conducted on August 5, 2026 at 09:32 a.m. with Director of Nursing (DON)/Staff #64 revealed that ostomy care should be done and timely. DON Staff # 64 continued the interview by stating that there are different kinds of abuse and training is done annually and as needed. The expectation regarding abuse/neglect is that it does not happen. During the interview it was brought to the DON Staff #64's attention that the nurse involved with the situation was not on the staff list. Staff #64 responded that the nurse caring for Resident #15 was terminated due to not documenting and it was for neglect, for knowing to do the care and not doing it.An interview was conducted on August 5, 2026 at 10:29 a.m. with Ombudsman/Staff # 201 and revealed that the nurse involved (Staff #200) was placed on the national registry for neglect.Another attempt was conducted on August 5, 2025 at 10:50 a.m. to contact LPN Staff #200 and was unsuccessful. A review of the policy Abuse- Identification of Types issued October 4, 2022 and reviewed: April 1, 2026 revealed the definition of neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on clinical record reviews, staff and resident interviews, review of facility documentation, and policy and procedures, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of the four sampled residents (#2 and #3). The deficient practice could result in the resident being in an unsafe environment.Findings Include:- Regarding Resident #2:Resident #2 was admitted on [DATE], with a diagnosis of cerebral edema, dysphagia, aphasia, dysarthria, restlessness and agitation, stimulant abuse, hypertension, anemia, and repeated falls. An annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #2 was cognitively intact with no physical or verbal behaviors.A psychosocial note dated May 28, 2026, at 4:29 PM revealed that an assessment was conducted due to a physical altercation between Resident #2 and another female resident in the facility activity room. During the assessment, Resident #2 stated bumping into the wheelchair of another resident while in the activity room watching a film on television (TV), and the other resident was already upset with her and unsure of the reason and then other resident grabbed her hair and pulled it twice and she used her left arm to reach the back of head to get the Resident to let go her hair. This caused her finger to get hurt. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Executive Director (ED) were made aware of the incident in a timely manner.A weekly skin integrity Data Collection dated May 28, 2026, at 5:45 PM revealed that Resident #2's left hand index finger nails were separated from the nail bed. A care plan was initiated on May 29, 2026, with a focus area for Resident #2 for mood problems related to an altercation with another resident. Interventions included that if the resident was noted to be in an altercation with Resident #3, staff would supervise, the resident would need time to talk, and the resident would be encouraged to express their feelings. An interview was conducted on July 07, 2026, at 2:47 AM with Resident #2, who stated that the other resident was mad and pulled on her hair twice and caused her pain. She also stated that at that time someone came to stop her from pulling the hair. - Regarding Resident #3:Resident #3 was admitted on [DATE], with a diagnosis of non-Hodgkin lymphoma, panlobular emphysema, hemiplegia and hemiparesis, anemia, hyperlipidemia, chronic viral hepatitis C, scoliosis, hypertension, chronic pain, and osteoarthritis.An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #3 was cognitively intact, with no physical or verbal behaviors.A psychosocial Note dated May 28, 2026, at 4:00 PM revealed that an assessment was conducted due to a physical altercation between Resident #3 and another female resident (Resident #2) in the activity room. Resident #3 explained that Resident #2 was in front of her wheelchair while watching the movie in the activity room. Resident #2 kept rolling back, hitting her leg, and was asked to move to the other side of the room, away from her. Resident #2 declined to move, touched her leg, and then she grabbed Resident #2's hair for 3-5 seconds until Resident #2 smacked her hand away. Further, Resident #3 explained that Resident #2 continued to taunt her with laughing and sticking her tongue out. Resident #3 stated that she pulled Resident #2's hair again outside of the activity room. Resident #3 had pain in her leg; the nurse was notified, and medication was provided. A weekly skin integrity Data Collection dated May 28, 2026, at 08:49 PM revealed that Resident #3 had new skin findings: Resident #3's skin was normal, warm, and turgor was good; however, dry skin was noted on the left hand. A review of the facility investigation of the 5-day report dated May 28, 2025, revealed Resident #3's statement confirming that she pulled Resident #2's hair because the Resident was mocking her and her wheelchair was bumping into her feet after asking her to stop. Electronic health record (EHR) review revealed Resident #3 was discharged on June 10, 2026. A Call attempt interview was conducted on July 7, 2026, at 3:21 PM with Resident #3, who refused to answer any questions and ended the call, which resulted in an unsuccessful interview. An interview was conducted on July 8, 2026, at 08:21 AM with the Witness (Volunteer/Staff #4), who stated that she does small tasks for residents, like helping with activities. She stated that there are different types of abuse, such as physical, mental, and sexual. She stated that if she witnesses a resident-to-resident altercation, she will find help right away and separate the residents. She stated that she did work on May 28, 2026, and witnessed a resident-to-resident altercation. She stated that she was helping with activities, and Resident #2 and Resident #3 were there, and there were two other volunteers (Staff #1 and Staff #5) with her. She stated that Resident #2 kept rolling back and forth with her wheelchair and kept hitting Resident #3, and Resident #3 told her to stop because it was hitting her, but Resident #2 did not understand Resident #3 because she mostly spoke Spanish. Staff #4 stated that as she was properly trying to translate that to Resident #2 to stop, Resident #3 pulled her hair hard. She stated that she and staff #1 stayed with the resident until staff showed up and separated the resident from each other. Multiple call attempts were made on July 8, 2026, at 08:43 AM, 09:38 AM, and 09:40 AM to Volunteer (Staff #5), but was unreachable. An interview was conducted on July 8, 2026, at 10:27 AM with the Witness (Volunteer/Staff #1), who stated that her role at the facility is to help residents with activities, make beds for the residents, help answer call lights, and pass out trays in the dining room. She stated that Resident #2 and Resident #3 were sitting in the activities room and watching a movie on TV, and Resident #2 kept bumping into Resident #3's wheelchair. She stated that Resident #3 told Resident #2 to stop in rudely manner, and Resident #2 said she was trying to, then Resident #3 pulled her hair. She stated that then a staff member came to stop, but does not remember the name of the staff member. An interview was conducted on July 8, 2026 at 12:25 PM with ADON (Staff #9), who stated that the different types of abuse are sexual, financial, physical, and emotional. She stated the expectation of staff members when they witness a resident-to-resident altercation is to report abuse immediately to the ADON, abuse coordinator, or the DON. She stated that the expectation of staff members to ensure safety during this incident is to separate the residents, implement a 15-minute check, and have the social services director conduct a well-being assessment for the residents. She stated that she does not remember the exact time or date of the incident that occurred between Resident #2 and Resident #3, but she was made aware that Resident #3 pulled Resident #2's hair in the activities room and they were separated by staff #10. She stated that at that time they were assessed and family was called for Resident #2, and Resident #3 did not want her family to be notified as she was her responsible party. She further stated that Resident #2 complained about having pain in her head and her nail was broken. Resident #3 had pain in the foot, and exams were done for her, but there were no injuries noted. She stated that the ADON stated that that was physical abuse because it was not appropriate when a resident pulled another resident's hair. A call attempt was made on July 8, 2026 at 12:49 PM to Infection Preventionist (IP/Staff #10), but she was unreachable.An interview was conducted on July 08, 2025 at 1:15 PM with the ED (Abuse Coordinator/Staff #12), who stated that her role as abuse coordinator is that staff and residents know who she is, prevent abuse, investigate abuse, and report. She stated her number is posted at the nurses' station so anyone had access to her. She stated that when resident-to-resident abuse is reported to her, she would speak to the resident if they were able to be interviewed to get the story from them regarding what happened. She stated that if she was present on scene, she would separate them. She stated that the expectation of staff members when resident to resident alteration occurs is to separate the residents from each other, then they assess for any injuries, pain, psychosocial issues, and do a full assessment for both residents. She stated that the last time she received reporting on a physical resident-to-resident altercation was for Resident #2 and Resident #3 via phone. She stated that it was reported to her that Resident #2 accidentally bumped into Resident #3's chair or foot; it upset Resident #3, and then she pulled Resident #2's hair, and they were separated immediately. She further stated that a resident pulling another resident's hair would not meet facility expectations because it is physical abuse and all the residents' hands should be on themselves.A Policy titled Abuse & Neglect was revised November 19, 2024, revealing that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on observation, clinical record review, interviews, and facility policy and procedures, the facility failed to ensure the care plan regarding anticoagulant therapy was established for one resident (Resident #9). The deficient practice may result in absence of person-centered goals or safeguarding against adverse events related to medication therapy.Findings include:Resident # 9 was initially admitted to the facility on [DATE], readmitted on [DATE], and had a medical history that included a history of falling, unspecified dementia, and unspecified anemia.Review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 02, which indicated that Resident #9 was severely cognitively impaired. Section N titled, Medications - High-Risk Drug Classes, revealed Resident #9 was taking an anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin).A physician order dated December 28, 2023, revealed an order for Sodium Injection Solution Prefilled Syringe 40 milligram/0.4 milliliter of Enoxaparin Sodium to be given subcutaneously daily for deep vein thrombosis (DVT) prevention for 19 days. The start date was December 29, 2023 and end date were January 17, 2024.Despite Enoxaparin administered in the month of January, clinical records revealed no evidence of an anticoagulant therapy focus area in Resident #9's care plan report.Review of the medication administration records dated January 01, 2024 through January 31, 2024, revealed Enoxaparin was administered daily January 01 through 04, 2024 and January 09 through 22, 2024, in the abdomen subcutaneously.Review of the facility reported incident, dated January 5, 2024, the report described Resident #9 as highly impulsive, and sustained an unwitnessed fall while attempting to get out of bed. She was transferred to the hospital, where evaluation revealed a left hip fracture. The report indicated that the resident hit her head, and was receiving Enoxaparin Sodium therapy, which increased her risk of bleeding.An interview was conducted on January 28, 2026, at 10:10 a.m. with Certified Nurse Assistant (CNA/Staff #22). The CNA stated that staff refer to the resident's care plan to determine specific needs and interventions, when unfamiliar with a resident, the CNA will review the care plan to obtain additional information. The CNA stated staff must be extra careful with cares, because of prolonged bleeding blood thinners can cause. The CNA stated that residents on blood thinners may bruise easily, and should be monitored closely for things like urine in the blood. The CNA continued that checking a resident for bruising, and prolonged bleeding, is of utmost importance for residents on blood thinners.An interview was conducted on January 28, 2026, at 10:40 a.m. with Registered Nurse (Staff #54). The RN stated that fall-prevention education was provided during orientation and annually; and that, staff rely on the resident's care plan to identify resident-specific risks and interventions. The RN reviewed the clinical record and identified the resident's use of Enoxaparin Sodium to prevent DVT's, and stated that anticoagulant therapy required individualized care planning. The RN confirmed no care planning in the resident's record for anticoagulant therapy, and stated the absence of anticoagulant-specific care planning could limited staff communication regarding monitoring and prevention of potential bleeding complications.An interview was conducted with a member of the Rehab Services team (Staff #10) on January 28, 2026, at 11:09 a.m. Staff # 10 stated that residents on anticoagulants are at higher risk for bleeding and bruising; and that, care plans should include monitoring for vital signs, symptoms, and blood loss, and departments working together to minimize fall risks.An interview was conducted with the Director of Nursing (DON/Staff #99) on January 6, 2026, at 11:34 a.m. The DON stated that care plans guide staff in implementing fall prevention interventions and educating staff on resident-specific risks, including anticoagulant therapy. The DON reported that staff obtain resident information through care plans, physician orders, and shift reports. The DON stated that care plans are expected to be reviewed and revised following any incident. The DON stated that review of the resident's clinical record did not identify care plan interventions addressing anticoagulant therapy for the resident who experienced a fall. The DON indicated this did not meet facility expectations because residents who are both fall risks and receiving anticoagulants are at increased risk for internal injury or bleeding following a fall.The policy titled, Area of Focus: Care Planning - Baseline, Comprehensive, and Routine Updates (Issued: 01/04/2022; Reviewed 12/04/2025), revealed Federal Regulation S483.21(b) requires the facility to develop and implement a comprehensive person-centered care plan for each resident. that includes measurable objectives and time frames to meet a residents medical nursing, and mental and psychosocial needs that are identified in the comprehensive assessment (MDS).The National Library of Medicine (updated October 26, 2022), revealed Enoxaparin is used to prevent and treat deep vein thrombosis (DVT; blood clots that form in the veins, typically in the legs). Enoxaparin is in a class of medications called low molecular weight heparins. It works by stopping the formation of substances that cause clots.The policy titled, Area of Focus: Anticoagulation Management (Issued: 01/03/2022; Reviewed 12/01/2025), revealed staff should ensure the care plan reflects anticoagulant use and is updated as needed.

Based on record review, staff interviews, facility documentation and policy review, the facility failed to ensure controlled medications were recorded, stored, and reconciled accurately for one Resident (#1). The deficient practice could result in the inability to establishes a system of records of receipt and disposition of controlled drugs.Findings include:Resident #1 was admitted to the facility, with a last admission date of September 13, 2025, with diagnoses that included hypothyroidism, type 2 diabetes mellitus, anxiety disorder, chronic pain, acute on chronic systolic heart failure, and unspecified dementia.Review of the minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 08, which revealed Resident #1 had moderate cognitive impairment.A review of the care plan dated December 11, 2025 revealed that anxiety was addressed as a focus area. Interventions included administer anti-anxiety medications as ordered by physician.Review of the facility's 5-day investigation report submitted December 15, 2025, revealed that Licensed Practical Nurse (LPN) Staff #3 had a recollection of receiving the medication and placing it in the medication cart on September 16, 2025.An interview was conducted on December 16, 2025 at 10:04 pm with hospice registered nurse (RN) Staff #10 who revealed that the medications were delivered to the facility and the person accepting medication had signed a receipt for the controlled medication.A review of hospice documents was conducted on December 16, 2025 at 10:26 a.m. and revealed a receipt for Medication/Narcotic Delivery Receipt. Review of handwritten receipt revealed Staff #10 as person delivering medication: the name was printed, signature included, and there was a date, but no time. The persons who received the medication had Staff #3 printed, a signature, a time at 1735, and a date of September 16, 2025 at the bottom. Further, the receipts revealed the medications were Lorazepam 0.5 mg tablet with quantity of 60; Morphine: Solution 100/5 milliliter quantity 30.An interview was conducted on December 16, 2025 at 11:05 a.m. with LPN Staff #3 who revealed that on September 16, 2025, had singed for the medications. Staff #3 stated that the medication delivery had happened at the shift change and therefore the count verification was completed with the incoming nurse. Staff #3 stated that on September documented everything, however did not know when the Lorazepam went missing afterwards due to going on different hall after a few days. Staff #3 stated that both nurses and medication aids have access to the facility medication carts.An interview was conducted on December 16, 2025 at 11:33 a.m. with DON Staff #2 who revealed that a nurse may accept medications, however medication aides cannot sign for medications in the state of Arizona. Staff #2 stated that the process for medication orders from hospice was that hospice will fax over the orders to the facility's nursing station, and the nurse who is responsible for that hall, documents the medications. Staff #2 confirmed receiving a copy of the medication receipt by hospice after requesting the copy which was available for review. Staff #2 stated there was no order for the Lorazepam for Resident #1, prior to December 10, 2025 - despite the Lorazepam being added to the shift count on September 16, 2025. Staff #2 stated that everything was missing for the medication including the medication administration record (MAR) sheet. Staff #2 stated that a lot of staff members had access to the medications. Staff #2 stated that Approximately 10-15 nurses and medication aides had access to the medication cart since September 16, 2025. Staff #2 stated that policy required staff to count at the end of every shift; and that, it showed on September 16, 2025 that staff documented the addition correctly at the bottom Lorazepam and Morphine which noted to be added for Resident #1 on September 16.A review of documents from the facility was conducted on December 17, 2025 at 8:30 a.m. The Shift Change Controlled Substance Inventory Count Sheet. The first date was September 15, 2025 and the last was December 16, 0600. The first page was filled out with blank spaces, numbers written on top of other numbers. No second signatures. There are pages without a second signature for either On-Coming or Off-Going nurses. This occurred approximately 21 times. There were instances where both On-Coming and Off-Going had no signatures. A signature had a line drawn through it on December 1, Shift/Time 1800. The last page did not have the top portion filled out with Facility name. Unit had 600. The Date, # Containers/Cards and # Count Sheets were all blank. Change of Shift had the date of December 16 with Shift/Time 0600. Off-Going Signature noted and no On-Coming Signature, Start of Shift: Total # Cards/Cont. 20, Total # Count Sheets 22. There was a gap in the dates for the sheets. November 20 with Shift/Time 0600 on one page with signatures, Total # Cards/Cont. 18 and Total # Count Sheets 20. No additions or subtractions of medications was the last entry. The next page started on November 23, 2025 with Shift/Time 0600. The Off-Going had no signature and the On-Coming had a signature filled in. Total # Cards/Cont. 20 Total # Count Sheets 22.A phone interview was conducted with DON Staff #2 on December 17, 2025 at 12:55 p.m. who revealed that at the beginning and end of each shift the On-Coming staff count with the Off-Going Staff the form was supposed to be filled out, but the staff are not filling it out completely; and that date with December 9, looked confusing and was unable to be explained. DON stated that a page was missing, and could not be found. DON stated that since finding out about the missing Lorazepam, education with the nursing staff has been conducted, the policy is that the count is done at shift change, and that the risk for not keeping accurate records is missing medications for residents and potential drug diversion situations.Review of facility's policy titled, Management of Controlled Substances, last revised: March 4, 2025 revealed the facility will maintain a system to account for controlled medications; receipt and disposition in sufficient detail to enable an accurate reconciliation, and that the facility conducts a periodic reconciliation. This system includes but is not limited to a record of receipt of all controlled medications with sufficient detail to allow reconciliation (e.g., specifying the name and strength of the medication, the quantity and date received, and the resident's name). Procedures 5. The facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift and whenever control of the controlled substances changes from one qualified individual to another (e.g., associate leaves facility for lunch break), using the Shift Change Controlled Substance Inventory Count Sheet.

Based on record review, staff interviews, facility documentation and policy review, the facility failed to ensure medication records were completed, or safeguarded against loss or destruction. The deficient practice could lead to incomplete medical records in accordance to professional standards. Findings include:Resident #1 was admitted to the facility, with a last admission date of September 13, 2025, with diagnoses that included hypothyroidism, type 2 diabetes mellitus, anxiety disorder, chronic pain, acute on chronic systolic heart failure, and unspecified dementia.Review of the minimum data set (MDS) dated [DATE] revealed a brief interview mental status (BIMS) score of 08, which revealed Resident #1 had moderate cognitive impairment.A review of the care plan dated December 11, 2025 revealed that anxiety was addressed as a focus area. Interventions included administer anti-anxiety medications as ordered by physician.Review of the facility's 5-day investigation report submitted December 15, 2025, revealed that Licensed Practical Nurse (LPN) Staff #3 had a recollection of receiving the medication and placing it in the medication cart on September 16, 2025.An interview was conducted on December 16, 2025 at 10:04 pm with hospice registered nurse (RN) Staff #10 who revealed that the medications were delivered to the facility and the person accepting medication had signed a receipt for the controlled medication.A review of hospice documents was conducted on December 16, 2025 at 10:26 a.m. and revealed a receipt for Medication/Narcotic Delivery Receipt. Review of handwritten receipt revealed Staff #10 as person delivering medication: the name was printed, signature included, and there was a date, but no time. The persons who received the medication had Staff #3 printed, a signature, a time at 1735, and a date of September 16, 2025 at the bottom. Further, the receipts revealed the medications were Lorazepam 0.5 mg tablet with quantity of 60; Morphine: Solution 100/5 milliliter quantity 30.An interview was conducted on December 16, 2025 at 11:05 a.m. with LPN Staff #3 who revealed that on September 16, 2025, had signed for the medications. Staff #3 stated that the medication delivery had happened at the shift change and therefore the count verification was completed with the incoming nurse. Staff #3 stated that on September documented everything and had created the medication administration record (MAR) sheet, however did not know when the Lorazepam went missing afterwards due to going on different hall after a few days. An interview was conducted on December 16, 2025 at 11:33 a.m. with DON Staff #2 who revealed that a nurse may accept medications, however medication aides cannot sign for medications in the state of Arizona. Staff #2 stated that the process for medication orders from hospice was that hospice will fax over the orders to the facility's nursing station, and the nurse who is responsible for that hall, documents the medications. Staff #2 confirmed receiving a copy of the medication receipt by hospice after requesting the copy which was available for review. Staff #2 stated there was no order for the Lorazepam for Resident #1, prior to December 10, 2025 - despite the Lorazepam being added to the shift count on September 16, 2025. Staff #2 stated that everything was missing for the medication including the medication administration record (MAR) sheet. Staff #2 stated that a lot of staff members had access to the medications. Staff #2 stated that Approximately 10-15 nurses and medication aides had access to the medication cart since September 16, 2025. Staff #2 stated that policy required staff to count at the end of every shift; and that, it showed on September 16, 2025 that staff documented the addition correctly at the bottom Lorazepam and Morphine which noted to be added for Resident #1 on September 16.A review of documents from the facility was conducted on December 17, 2025 at 8:30 a.m. The Shift Change Controlled Substance Inventory Count Sheet. The first date was September 15, 2025 and the last was December 16, 0600. The first page was filled out with blank spaces, numbers written on top of other numbers. No second signatures. There are pages without a second signature for either On-Coming or Off-Going nurses. This occurred approximately 21 times. There were instances where both On-Coming and Off-Going had no signatures. A signature had a line drawn through it on December 1, Shift/Time 1800. The last page did not have the top portion filled out with Facility name. Unit had 600. The Date, # Containers/Cards and # Count Sheets were all blank. Change of Shift had the date of December 16 with Shift/Time 0600. Off-Going Signature noted and no On-Coming Signature, Start of Shift: Total # Cards/Cont. 20, Total # Count Sheets 22. There was a gap in the dates for the sheets. November 20 with Shift/Time 0600 on one page with signatures, Total # Cards/Cont. 18 and Total # Count Sheets 20. No additions or subtractions of medications was the last entry. The next page started on November 23, 2025 with Shift/Time 0600. The Off-Going had no signature and the On-Coming had a signature filled in. Total # Cards/Cont. 20 Total # Count Sheets 22.A second interview was conducted with DON Staff #2 on December 17, 2025 at 12:55 p.m. and revealed that misappropriation would be considered and was the reason for reporting the missing Lorazepam. Since being notified of the missing Lorazepam, audits have been conducted to see the policy is that the count is done at shift change; and that the risk for not keeping accurate records is missing medications and potential drug diversion situations. if staff are completing the controlled substance sheets correctly. DON stated thatA review of the Abuse & Neglect policy issued January 3, 2022 revealed in the category Why, the resident has the right to be free from abuse, neglect, misappropriation of resident property. In the Policies and Procedures category: The facility must develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.

Based on record review, staff interviews, facility documentation and policy review, the facility failed to ensure safe and secure storage of controlled medication for one Resident (#1). The deficient practice could result in unsafe handling of controlled medication.Findings include:Review of the facility's 5-day investigation report submitted December 15, 2025, revealed that Licensed Practical Nurse (LPN) Staff #3 had a recollection of receiving the medication and placing it in the medication cart on September 16, 2025.An interview was conducted on December 16, 2025 at 10:04 pm with hospice registered nurse (RN) Staff #10 who revealed that the medications were delivered to the facility and the person accepting medication had signed a receipt for the controlled medication.A review of hospice documents was conducted on December 16, 2025 at 10:26 a.m. and revealed a receipt for Medication/Narcotic Delivery Receipt. Review of handwritten receipt revealed Staff #10 as person delivering medication: the name was printed, signature included, and there was a date, but no time. The persons who received the medication had Staff #3 printed, a signature, a time at 1735, and a date of September 16, 2025 at the bottom. Further, the receipts revealed the medications were Lorazepam 0.5 mg tablet with quantity of 60; Morphine: Solution 100/5 milliliter quantity 30.An interview was conducted on December 16, 2025 at 11:05 a.m. with LPN Staff #3 who revealed that on September 16, 2025, had singed for the medications. Staff #3 stated that the medication delivery had happened at the shift change and therefore the count verification was completed with the incoming nurse. Staff #3 stated that on September documented everything, however did not know when the Lorazepam went missing afterwards due to going on different hall after a few days. Staff #3 stated that both nurses and medication aids have access to the facility medication carts.An interview was conducted on December 16, 2025 at 11:33 a.m. with DON Staff #2 who revealed that a nurse may accept medications, however medication aides cannot sign for medications in the state of Arizona. Staff #2 stated that the process for medication orders from hospice was that hospice will fax over the orders to the facility's nursing station, and the nurse who is responsible for that hall, documents the medications. Staff #2 confirmed receiving a copy of the medication receipt by hospice after requesting the copy which was available for review. Staff #2 stated there was no order for the Lorazepam for Resident #1, prior to December 10, 2025 - despite the Lorazepam being added to the shift count on September 16, 2025. Staff #2 stated that everything was missing for the medication including the medication administration record (MAR) sheet. Staff #2 stated that a lot of staff members had access to the medications. Staff #2 stated that Approximately 10-15 nurses and medication aides had access to the medication cart since September 16, 2025. Staff #2 stated that policy required staff to count at the end of every shift; and that, it showed on September 16, 2025 that staff documented the addition correctly at the bottom Lorazepam and Morphine which noted to be added for Resident #1 on September 16.A phone interview was conducted with DON Staff #2 on December 17, 2025 at 12:55 p.m. who revealed that at the beginning and end of each shift the On-Coming staff count with the Off-Going Staff the form was supposed to be filled out, but the staff are not filling it out completely; and that date with December 9, looked confusing and was unable to be explained. DON stated that a page was missing, and could not be found. DON stated that since finding out about the missing Lorazepam, education with the nursing staff has been conducted, the policy is that the count is done at shift change, and that the risk for not keeping accurate records is missing medications for residents and potential drug diversion situations.Review of facility's policy titled, Management of Controlled Substances, last revised: March 4, 2025 revealed the facility will maintain a system to account for controlled medications; receipt and disposition in sufficient detail to enable an accurate reconciliation, and that the facility conducts a periodic reconciliation. This system includes but is not limited to a record of receipt of all controlled medications with sufficient detail to allow reconciliation (e.g., specifying the name and strength of the medication, the quantity and date received, and the resident's name). Procedures 5. The facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift and whenever control of the controlled substances changes from one qualified individual to another (e.g., associate leaves facility for lunch break), using the Shift Change Controlled Substance Inventory Count Sheet.

Based on clinical record review, interviews, and review of facility documentation and policies, the facility failed to ensure that the facility policy was implemented regarding restricting access to residents following an allegation of abuse by a staff. This deficient practice placed the resident at risk and has the potential to violate the resident's right to safety and prevent further harm.Findings include:Resident #684 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD), dementia, depression unspecified, and chronic diastolic (congestive) heart failure (CHF). A review of the Constipation related to decreased mobility care plan, initiated on November 10, 2023, revealed an intervention directing staff to encourage the resident to sit on the toilet to evacuate bowels, if possible.A review of the care plan focus area for Activity of Daily Living (ADL) Self-Care Performance Deficit, related to activity intolerance, fatigue, and impaired balance secondary to Chronic Obstructive Pulmonary Disease (COPD), emphysema, and Congestive Heart Failure (CHF), initiated on February 1, 2024, revealed that the resident was totally dependent on one staff member for personal hygiene and two staff members for toilet use.A review of the Risk for Bowel and Bladder Incontinence due to decreased mobility, decreased awareness of need, and overactive bladder care plan, initiated on March 26, 2024, revealed interventions directing staff to assist the resident with toileting as needed and to provide perineal care after each incontinent episode.A review of the hospice report, dated August 26, 2025, revealed that the resident requires maximum assistance with activities of daily living (ADLs), including bathing, dressing, and continence, and is incontinent of both bowel and bladder.A review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Further review of the MDS revealed that resident #684 was usually understood when communicating, but not without some difficulty.A review of the facility's Abuse, Neglect, Exploitation (ANE) Allegation Investigation Checklist, revealed the event date was October 3, 2025. The checklist also revealed the Staff # 05 was placed on suspension October 4, 2025, at 8:39 a.m.A review of the staff assignment schedule dated October 3, 2025, revealed staff #05 was assigned to work the 400 hall 6p-6:15a, but was re-assigned to work the 500 hall after 10 pm. Further review of the assigned staff schedule sign-in sheet revealed staff #05's initials under the signature line on October 3, 2025.Review of the facility's staff #05's time card revealed a check-in time of 6:06 p.m. on October 3, 2025. The time card records Staff # 5'sbreak time of October 3, 2025, at 11:44 pm through October 4, 2025, at 12:16 a.m. Staff # 5 ended scheduled shift on October 4, 2025, at 6:02 a.m.A review of the alleged abuse incident report for October 3, 2025, at 11:00 p.m., revealed that the resident refused medical attention and that the accused staff member was removed from the resident's assignment and reassigned elsewhere. The report further indicated that Staff #05 was placed on suspension on October 4, 2025, at 8:30 a.m.A review of a provider progress note dated October 5, 2025, indicated that the provider was informed of the allegation by the resident, who described the incident as very painful. The provider noted no evidence of rectal or anal trauma, with no bleeding or erythema observed.A review of the Suspension Pending Investigation Form dated October 7, 2025, revealed that the abuse allegation was unsubstantiated and that the staff suspension was communicated via phone on October 4, 2025 (time not documented). Despite the unsubstantiated finding, the form indicated that Staff #05 was terminated due to quality of care concerns.A review of Staff # 5's Termination Form, dated October 7, 2025, revealed that upon interviewing multiple residents under the care of Staff # 5, there was a quality of care concern brought to the DON's attention. Many residents complained that Staff # 5 was rough when providing care and reported pain while he was performing peri-care. The reason for determination was for not upholding the facility's standards of care. The 5-day incident report revealed the CNA (Staff #07) contacted the Director of Nursing (DON) on October 3, 2025 at 11:15 p.m. to report the allegation. The report also supported that the DON gave instruction to have Staff # 05 removed from the hall, and have another staff member take care of resident #684 for the rest of the night.Further review of the 5-day incident report revealed the DON received a follow-up call from the LPN (Staff #20) at 8:20 a.m., and made the decision to suspend Staff #05 pending investigation.An interview was conducted on October 7, 2025 at 11:28 a.m. with the Staff Coordinator (RN/Staff #52) after review of this allegation, the coordinator revealed the correct course of action, was for the nurse to report the allegation to the abuse coordinator immediately, and for the alleged perpetrator to be immediately placed on suspension and sent home. The coordinator explained that the reason to immediately suspending the alleged perpetrator was to prevent any further interaction between the alleged victim and the alleged perpetrator until the conclusion of the investigation. The Coordinator revealed that immediate action is of utmost importance to ensure the safety and protection of the resident. Staff #52 expressed facility expectation that suspension of the AP was not met in a timely manner. An interview was conducted with the Director of Nursing (DON/Staff #01) on October 7, 2025 at 12:30 p.m. The DON stated that she is leaving for a road trip, but can still be accessible by phone if needed. The DON was alerted to the incident on October 3, 2025, but did not call the incident in until the day after. The DON stated that she was aware that allegations of sexual abuse were to be reported within a two-hour time frame, but was unsure why she did not proceed to do so in this case.An interview was conducted with CNA (Staff #07) on October 8, 2025, at 9:40 a.m. The CNA reported that two CNAs are assigned to the 400 hall as a team rather than being assigned specific residents. On the night of the incident, the CNA stated that her partner was Staff #05, who worked the 6:00 p.m. to 6:00 a.m. shift. The CNA reported that she informed the Licensed Practical Nurse (LPN, Staff #99) at approximately 9:30 p.m. about the allegation. Later during the shift, she observed that Staff #05 had not been removed from the hall and could potentially have access to resident #684. The CNA returned to Staff #99 to express her concern regarding the resident's safety. She reported that it was at that time the decision was made to notify the abuse coordinator.An interview was conducted with the resident on October 8, 2025, at 10:59 a.m. The resident revealed feeling better and safer since learning that Staff #5 was no longer working at the facility. The resident stated having that Staff #5 hurts her when providing peri-care. An interview was conducted with Staff #05 on October 8, 2025, at 12:10 p.m. The CNA reported that during his rounds, he learned of the allegation from the nurse (Staff #99). He stated that he and the nurse reviewed the resident's mental capacity and decided at that time not to pursue further investigation but to no longer provide care for resident #684. Staff #05 recalled completing the 6:00 p.m. to 10:00 p.m. shift on the 400 hall, specifically excluding resident #684 from his care. At 10:00 p.m., he was directed to take over the 500-hall due to a no-show by another CNA. He stated that he remained at work until 6:10 a.m.Staff #05 indicated that he understood that if a situation were severe enough, management would send him home. He assumed everything was acceptable because he was allowed to continue working. He recalled receiving a call from the DON notifying him of his suspension the following day. Upon reviewing his call log, he confirmed that he was notified by the DON of his suspension on Saturday, October 4, 2025, at 8:30 a.m.An interview was conducted with LPN (Staff #99) on October 8, 2025, at 12:42 p.m. The LPN reported hearing the resident call out for her parents during medication pass between approximately 8:30 p.m. and 9:00 p.m. Upon checking on the resident, the resident asked the LPN to check her rectum, stating that that man poked a hole in her rectum. Approximately ten minutes later, the reporting CNA (Staff #07) informed the LPN of the same allegation that Staff #05 had penetrated the resident's rectum with a finger. Following this discussion, the LPN had the CNA contact the Director of Nursing DON to report the allegation. The LPN reported that the DON gave the directive for Staff #05 to continue his shift on the 500 hall. An interview was conducted with the Social Services Director (SSD/Staff #31) on October 8, 2025 at 1:30 p.m. The SSD reported that it did not meet facility expectations that allowed Staff # 5 to continue working on the same floor as the resident, as this would still provide potential access to the resident, placing the resident at risk. The SSD stated that the policy was to remove an alleged perpetrator for resident protection. Staff #31 further reinforced that even if Staff # 5 was reassigned to a different hall, there remains a possibility that the CNA could still have access to the resident.An interview was conducted with the facility's Resource Director (Staff #100) on October 8, 2025, at 2:03 p.m. The Assistant Director of Nursing (Staff #500) and the Interim Executive Director (Staff #28) were present during the interview. An interview with the Director of Nursing (DON/Staff #1) was requested; however, Staff #100 served as the DON's proxy, as the DON was traveling and unavailable. The DON's proxy revealed that once the CNA informed the nurse of the allegation of sexual abuse, the expectation was for Staff #05 to be immediately suspended and sent home. The proxy further stated that allowing Staff #05 to complete his shift did not meet facility expectations, as protocol requires suspension of the alleged perpetrator pending the investigation.Review of the facility's Abuse-Identification of Types policy, reviewed May 6, 2025, defined sexual abuse includes unwanted intimate touching of any kind, especially of the beasts or perineal area. Review of the facility's Incident and Reportable Event Management policy, reviewed September 25, 2024, revealed that in response to allegations of abuse, the facility must prevent further potential abuse while the investigation is in progress. Review of the facility's Resident Rights policy, reviewed November 19, 2024, revealed that the facility must protect and promote the rights of the resident.

Based on clinical record review, interviews, and facility policy and procedure, the facility failed to ensure that an allegation of sexual abuse was reported to the State Agency within the required time frame for one resident (# 684). This deficient practice can result in allegations of abuse not being reported. Findings include:Resident #684 was admitted to the facility on [DATE], with diagnoses that include unspecified dementia, depression, unspecified, and paroxysmal atrial fibrillation. A review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Further review of the MDS revealed that resident #684 was usually understood when communicating, but not without some difficulty.A review of the facility's Class Attendance Record, dated June 9, 2025, at 9:00 a.m., revealed that Incident and Reportable Event Management was presented to staff by the Director of Nursing (DON/Staff # 01).A review of the facility's Class Attendance Record, dated October 4, 2025, at 11:00 a.m., revealed that Abuse Identification Training was presented to staff by Staff # 01.Review of the facility's Abuse, Neglect, Exploitation (ANE) Allegation Investigation Checklist, revealed the event date was October 3, 2025, and the State Agency was notified October 4, 2025 at 8:43 a.m. An interview was conducted on October 7, 2025, at 11:28 a.m. with the Staff Development Coordinator (Staff #39). Staff #39 stated that staff are educated to report allegations of abuse to the designated abuse coordinator, who is expected to contact the appropriate authorities within two hours. Staff #39 further stated that the Director of Nursing (DON/Staff #1) was the designated abuse coordinator on October 3, 2025. Staff #39 revealed that the delay in reporting the allegation of abuse on that date was not in accordance with facility expectations or annual training.An interview was conducted with the Director of Nursing (DON/Staff #01) on October 7, 2025, at 12:30 p.m. During the interview, the DON stated that she was preparing to leave for a road trip but would remain accessible by phone if needed. The DON reported that she was alerted to the incident involving the allegation of sexual abuse on October 3, 2025, but did not report the incident until the following day. The DON acknowledged that she was aware that allegations of sexual abuse must be reported within a two-hour time frame but stated that she was not sure why she didn't call it in.An interview was conducted on October 8, 2025, at 9:40 a.m. with a Certified Nursing Assistant (CNA/Staff #7). The CNA stated that the allegation was initially reported to a Licensed Practical Nurse (LPN/Staff #20) at approximately 9:30 p.m. The CNA further stated that after reporting the allegation, Staff #5 was observed remaining on the hall with Resident #684. The CNA reported returning to the nurse around 10:00 p.m. to inquire why Staff #5 (the alleged perpetrator) was still in the facility and had not been removed from resident care areas.An interview was conducted on October 8, 2025, at 12:10 p.m. with Certified Nursing Assistant (CNA/Staff #5). The CNA stated that during his rounds, he was informed by the nurse (Staff #20) of an allegation of sexual abuse against him, prior to switching hall assignments on October 3, 2025, at 10:00 p.m. The CNA reported that he and Staff #20 discussed the resident's mental capacity and decided at that time not to move forward with reporting the allegation. Staff #5 and Staff #20 agreed that Staff #5 would no longer provide care to the resident. Staff #5 further stated that he felt nothing was wrong, as he was permitted to continue working for the remainder of his shift. Staff #5 also stated that he did not recall much about the facility's abuse prevention training but believed that the facility had 24 hours to report an allegation of abuse.An interview was conducted on October 8, 2025, at 12:42 p.m. with Licensed Practical Nurse (LPN/Staff #20). Staff #20 stated that she continuously heard the resident calling out for her parents during medication pass between 8:30 p.m. and 9:00 p.m. Staff #20 reported that while administering medications to Resident #684, the resident requested that she check her rectum because that man poked a hole in [my] rectum. Staff #20 stated that after calming the resident, she spoke with CNA/Staff #5 regarding the accusation and instructed him not to return to the resident's room for the remainder of the night. Approximately ten minutes later, Staff #7 informed Staff #20 of the same allegation of sexual abuse against Staff #5. Staff #20 stated that she directed CNA/Staff #7 to notify the Director of Nursing (DON/Staff #1) of the allegation. Staff #20 acknowledged that she was aware allegations of abuse are to be reported immediately to the DON but stated that she delayed making contact because she believed the accusation was a result of the resident's confused state.An interview was conducted on October 8, 2025, at 1:00 p.m. with Licensed Practical Nurse (LPN/Staff #34). Staff #34 stated that if there is an accusation of abuse, the facility's procedure is to immediately inform the Director of Nursing (DON) and ensure the resident's safety. The LPN also stated that abuse training is provided annually, and that allegations of abuse are required to be reported to the appropriate authorities within two hours.An interview was conducted on October 8, 2025, at 1:30 p.m. with the Social Services Director (SSD/Staff #46). Staff #46 stated that he learned the alleged incident occurred on October 3, 2025, and that the Director of Nursing (DON/Staff #01) did not follow up on the allegation until the following day. Staff #46 stated that facility training and policy require reporting allegations of abuse within two hours. Staff #46 further stated that a delay beyond the two-hour window could be detrimental to an abuse investigation, as the resident may require immediate follow-up, and there is an increased risk of lost or compromised evidence.An interview was conducted on October 8, 2025, at 2:03 p.m. with the facility's Resource Director (Staff #100). The Assistant Director of Nursing (Staff #500), and the Interim Executive Director (Staff #28), were present during the interaction. An interview with Staff #1 (DON) was requested; however, Staff #100 stated she would serve as the DON's proxy because the DON was traveling and unavailable. The proxy stated that once the CNA informed the nurse, the expectation was for the abuse coordinator (Staff #1) to be contacted immediately. The proxy further stated that the abuse coordinator was expected to notify the state agency within the two-hour window, and that following the facility's abuse policy was required to ensure resident safety.An interview was conducted on October 8, 2025, at approximately 2:10 p.m. with the Interim Executive Director (Staff #28). Staff #500 and Staff #100 were both present during the interaction. Staff #28 stated that the facility had immediately initiated in-services on the proper handling of allegations of abuse and that the topic will also be discussed at the next Quality Assurance Performance Improvement (QAPI) meeting. Staff #28 emphasized that following the facility's abuse policy is critical for resident protection and preservation of evidence. Staff #28 further stated that she conducted in-service on the policy with department heads. Staff #28 revealed that Staff #01 is scheduled for re-education on the policy upon return, prior to starting her next shift.Review of the facility's Abuse-Identification of Types policy, reviewed May 6, 2025, defined sexual abuse includes unwanted intimate touching of any kind, especially of the beasts or perineal area.Review of the facility's Incident and Reportable Event Management policy, reviewed September 25, 2024, ensures that all violations involving abuse, neglect, exploitation, or mistreatment of a resident are reported immediately, but not later than two hours after the allegations is made, if the events of the allegation involve abuse or result in serious bodily injury.Review of the facility's Resident Rights policy, reviewed November 19, 2024, revealed that the facility must protect and promote the rights of the resident.

Based on clinical record review, interviews and facility policy review, the facility failed to ensure accurate medical documentation was completed on four residents (#72, #54, #66 and #89). The deficient practice could result in the medical records not being complete and accurate. Findings include: Resident #72 was admitted to the facility on [DATE], from an out of state medical facility, with a diagnosis of chronic pain and chronic pain syndrome. Review of the resident Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. This indicates that the resident is cognitive. An interview was conducted on March 13, 2025 at 12:10 PM with resident #72. She stated she had been admitted to the out of state medical facility with chronic pain. It was explained to her from the staff at the out of state medical facility, that the receiving facility would have the resident's controlled substances for her upon admission. Before discharge, the medical facility administered the resident a controlled substance so the resident would not experience pain during transport. A few hours after arrival to the receiving facility, the resident began to have pain. The staff offered Tylenol to the resident but the resident declined and requested to go to the emergency room (ER). An interview was conducted on March 13, 2025 at 12:42 PM with the Director of Nursing (DON, staff #100). She stated when a resident is admitting, they receive the discharge orders from the discharging facility and send any prescriptions to the pharmacy. If a resident has an order for a controlled substance, the pharmacy requires a handwritten prescription. Resident #72 did not have that prescription with her. Tylenol was offered but the resident refused and requested to go to the emergency room . The doctor in the ER wrote a prescription for the controlled substance and the resident returned with it. An interview was conducted on March 13, 2025 at 1:11 PM with Admissions Assistant (staff #25). She stated when a resident is accepted for admission she obtains the authorization from the insurance company and requests that the orders be faxed from the discharging facility. She states I spoke with the case manager from the discharging facility in the early morning of March 1, 2025 and asked for the orders to be faxed to me. I did not receive the orders until 3:13 PM that day and the resident arrived at 7:00 PM. Once I received the orders, I put them on our system called Tiger Text and the DON and the Medical Director see them. I was notified that there was an issue with some of the resident's medications and a handwritten prescription was required for some of those. I called the case manager at the discharging facility again, and told her we would need handwritten prescriptions for these particular medications. Her response to me was she couldn't send a handwritten one because the resident was going across a state line and that is prohibited for controlled substance medications. I relayed that information to the DON. Review of the medical record does not reveal any documentation regarding any of this. Resident #54 admitted to the facility on [DATE], with a diagnosis of dementia. Review of the MDS dated [DATE] revealed a BIMS score of 03, which indicates severe cognitive impairment. Resident #66 admitted to the facility on [DATE] with a readmitted [DATE] and a diagnosis of sepsis and chronic pain. Review of the BIMS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident is cognitive. The facility reported to the State Agency that a resident to resident altercation occurred between resident #66 and resident #54 on December 16, 2023. The allegation stated that resident #54 punched resident #66 in the back. Investigation of this allegation showed no documentation in the clinic record of this. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. Resident #89 admitted to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic left knee joint and Alzheimer's disease. Review of the MDS dated [DATE] reveals a BIMS score of 05, indicating severe cognitive impairment. The facility reported to the State Agency an allegation of neglect for resident #89 for an incident dated November 20, 2023. The complaint stated that at 10:00 AM a therapist entered her room and the resident stated she had left hip and groin pain. The therapist pulled the blanket back to look at the resident's leg and noticed there was a length discrepancy. It was then reported to the Director of Rehabilitation, who then reported to the Assistant Director of Nursing. Investigation of the allegation revealed there was no documentation in the clinical record. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. The facility's policy on Abuse, Neglect and Exploitation, Chapter 3 dated October 13, 2023 page 2 states the facility must conduct record review for pertinent information related to the alleged violation, as appropriate, such as progress notes (Nurse, social services, physician, therapist, consultants as appropriate, etc), financial records, incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies.

Based on clinical record review, interviews and facility policy review, the facility failed to ensure residents care plans were updated and revised on four residents (#15, #66, #54 and #89). The deficient practice could result in the medical records not being complete and accurate, resulting in the resident not receiving the proper care or interventions. Findings include: Resident #15 admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease, repeated falls, tremors, difficulty walking and a history of falling. Review of the Minimum Date Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident is cognitive. It was reported to the State Agency that resident #15 sustained a fall that was witnessed by her roommate on December 17, 2023. It was reported to staff by the roommate, that resident #15 was standing by her bed and fell . Resident #15 told staff she had vertigo and fell . Review of the clinical record showed the care plan had not been updated after this incident. Resident # 54 admitted to the facility on [DATE], with a diagnosis of dementia. Review of the MDS dated [DATE] revealed a BIMS score of 03, which indicates severe cognitive impairment. Resident #66 admitted to the facility on [DATE] with a readmitted [DATE] and a diagnosis of sepsis and chronic pain. Review of the BIMS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident is cognitive. The facility reported to the State Agency that a resident to resident altercation occurred between resident #66 and resident #54 on December 16, 2023. The allegation stated that resident #54 punched resident #66 in the back. Investigation of this allegation showed no documentation in the clinic record of this. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. Resident #89 admitted to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic left knee joint and Alzheimer's disease. Review of the MDS dated [DATE] reveals a BIMS score of 05, indicating severe cognitive impairment. The facility reported to the State Agency an allegation of neglect for resident #89 for an incident dated November 20, 2023. The complaint stated that at 10:00 AM a therapist entered her room and the resident stated she had left hip and groin pain. The therapist pulled the blanket back to look at the resident's leg and noticed there was a length discrepancy. It was then reported to the Director of Rehabilitation, who then reported to the Assistant Director of Nursing. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. Review of the care plans for residents #15, #66, #54 and #89 reveal the care plans were not updated after each incident. An interview was conducted on March 13, 2025 at 3:42 PM with the Director of Nursing (DON, staff #100) and the Assistant Director of Nursing (ADON, staff #50). They stated that if an incident occurred current practice would be to interview all parties involved, complete a skin assessment if needed, notify the responsible parties and the providers, update the care plan and have social services follow-up. This author had staff #100 to look over resident #66 and #54's care plans. She stated that neither care plan had been updated but since she was not DON at that time she could not answer why it wasn't updated.

Based on clinical record review, interviews and facility policy review, the facility failed to thoroughly investigate an injury of unknown origin and a resident to resident altercation for three residents (#66, #54 and #89). The deficient practice could lead to thorough investigations not being completed and sent to the State Agency potentially placing residents at harm. Findings include: Resident #54 admitted to the facility on [DATE], with a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS)score of 03, which indicates severe cognitive impairment. Resident #66 admitted to the facility on [DATE] with a readmitted [DATE] and a diagnosis of sepsis and chronic pain. Review of the BIMS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident is cognitive. The facility reported to the State Agency that a resident to resident altercation occurred between resident #66 and resident #54 on December 16, 2023. The allegation stated that resident #54 punched resident #66 in the back. Investigation by the state agency surveyor revealed that a thorough five day investigation from the facility had not been completed, residents clinical record had not been updated and the facility did not follow their own policy. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. Resident #89 admitted to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic left knee joint and Alzheimer's disease. Review of the MDS dated [DATE] reveals a BIMS score of 05, indicating severe cognitive impairment. The facility reported to the State Agency an allegation of neglect for resident #89 for an incident dated November 20, 2023. The complaint stated that at 10:00 AM a therapist entered her room and the resident stated she had left hip and groin pain. The therapist pulled the blanket back to look at the resident's leg and noticed there was a length discrepancy. It was then reported to the Director of Rehabilitation, who then reported to the Assistant Director of Nursing. Investigation by the state agency surveyor revealed that a thorough five day investigation from the facility had not been completed, residents clinical record had not been updated and the facility did not follow their own policy. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. The facility's policy on Abuse, Neglect, and Exploitation, Chapter 3 page 1 has listed the Federal Regulations on 483.12 (c)(2) have evidence that all alleged violations are thoroughly investigated. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State Law, including he State Survey Agency, within 5 workings days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on clinical record review, interviews and facility policy review, the facility failed to ensure their policy was followed for abuse and injury of unknown origin for three residents (#66, #54 and #89). The deficient practice could lead to other policies not being followed potentially placing residents at harm. Findings include: Resident #54 admitted to the facility on [DATE], with a diagnosis of dementia. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS)score of 03, which indicates severe cognitive impairment. Resident #66 admitted to the facility on [DATE] with a readmitted [DATE] and a diagnosis of sepsis and chronic pain. Review of the BIMS assessment dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitive. The facility reported to the State Agency that a resident to resident altercation occurred between resident #66 and resident #54 on December 16, 2023. The allegation stated that resident #54 punched resident #66 in the back. Investigation by the state agency surveyor revealed that a thorough five day investigation from the facility had not been completed, residents clinical record had not been updated and the facility did not follow their own policy. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. Resident #89 admitted to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic left knee joint and Alzheimer's disease. Review of the MDS dated [DATE] reveals a BIMS score of 05, indicating severe cognitive impairment. The facility reported to the State Agency an allegation of neglect for resident #89 for an incident dated November 20, 2023. The complaint stated that at 10:00 AM a therapist entered her room and the resident stated she had left hip and groin pain. The therapist pulled the blanket back to look at the resident's leg and noticed there was a length discrepancy. It was then reported to the Director of Rehabilitation, who then reported to the Assistant Director of Nursing. Investigation by the state agency surveyor revealed that a thorough five day investigation from the facility had not been completed, residents clinical record had not been updated and the facility did not follow their own policy. There was no evidence to know what happened to this resident. Attempts were made for interviews but either no one remembered the incident, were no longer employed or no documentation could be provided. The facility's policy on Abuse, Neglect, and Exploitation, Chapter 3 page 1 has listed the Federal Regulations on 483.12 (c)(2) have evidence that all alleged violations are thoroughly investigated. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State Law, including he State Survey Agency, within 5 workings days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#27) was not neglected and her basic needs were being met regarding assistance with bathing, nail clipping, hair washing, and monitoring the condition of her skin. The facility also failed to assess the resident's needs after falls and update the care plan with new interventions as needed. The deficient practice could result in further incidents of resident neglect. Findings include: Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, depression, and osteoporosis. The functional goal care-plan initiated April 27, 2022 with a revision date of September 4, 2024 revealed that the resident has limited physical mobility related to Alzheimer's disease, dementia, osteoporosis, osteoarthritis, and weakness. Interventions included that staff will assist with activities of daily living (ADL's) with a 1-2 assist as needed. Review of a shower list dated June 29, 2024 revealed that the resident #27 was bathed and had no new skin issues. It was also observed that the shower list consisted of a list of residents' names and if the residents were bathed. Nail clipping and hair washing was not documented on the shower sheet for any of the residents. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had a severe cognitive impairment. It also included that the resident had skin problems related to skin tear(s). Review of the functional abilities and goals assessment revealed that the resident was dependent on the assistance of helpers for showering, personal hygiene, rolling left to right, and transfers. Review of a shower list dated July 20, 2024 revealed that the resident did not receive a shower and did not refuse. It was observed that the shower list consisted of a list of residents' names and if the residents were bathed. Nail clipping, hair washing and condition of skin was not documented on the shower sheet for any of the residents. Review of a shower list dated July 27, 2024 revealed that the resident received a shower and there was no documentation regarding the condition of the resident's skin. It was observed that the shower list consisted of a list of residents' names and if the residents were bathed. Nail clipping and hair washing was not documented on the shower sheet for any of the residents. Review of the electronic record for shower documentation dated July 2024 revealed that the resident was bathed July 2, July 16, July 23, and July 30, 2024. Review of the shower list dated August 3, 2024 revealed that the resident received a shower, but did not include the condition of skin. It was observed that the shower list consisted of a list of residents and if the residents were bathed. Nail clipping, hair washing, and condition of skin was not documented on the shower sheet for any of the residents. Review of the shower list dated August 24, 2024 revealed that the resident received a shower, but did not include the condition of skin. It was observed that the shower list consisted of a list of residents and if the residents were bathed. Nail clipping, hair washing, and condition of skin was not documented on the shower sheet for any of the residents. Review of the electronic record for shower documentation dated August 2024 revealed that the resident was bathed August 3 and August 10, 2024. The shower documentation revealed that resident #27 did not received assistance with bathing from July 2, 2024 to July 16, 2024, which was a total of 13 days, and August 3, 2024 to August 10, 2024, which is a total of 6 days. The shower documentation did not reveal that the resident received any assistance with hair washing or nail clipping. Review of the progress notes did not reveal that the resident refused assistance with bathing. An interview was conducted on October 18, 2024 at approximately 11:22 a.m. with the Director of Nursing (DON/staff #1) and the Assistant Director of Nursing (ADON/staff #3). The DON stated that residents should be getting showers twice a week. The ADON/staff # stated that staff track the residents' showers on a shower sheet form and there is an area where staff can document any concerns. She stated that the shower sheet form consists of a list of residents that are supposed to receive a shower on a specific day. An interview was conducted with a Certified Nursing Assistant (CNA/staff #12) on October 18, 2024 at 11:41 a.m., who stated that residents are supposed to be showered at least twice a week, nails clipped, hair washed, lets the nurse know if the resident refused, and should be documented on the shower list. She stated that the resident could be combative at times, so she would give her a bed bath instead of a shower. An interview was conducted with a Licensed Practical Nurse (LPN/staff #20) on October 18, 2024 at 12:02 p.m., who stated that residents are showered twice a week, and that CNA's should report skin issues to the nurse so that they can report it to the Director of Nursing (DON). It is also her expectation that that CNA's also report if the resident refuses care like showers, hair washing, and nail clipping, and that it would be documented in a progress note. The facility policy, Activities of Daily Living dated February 12, 2024 states that A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. It also states to ensure that fingernails are clean and trimmed to avoid injury and infection. -The care-plan initiated May 4, 2021 and a revision date of September 4, 2024 revealed that the resident was at risk for injury from a fall related to weakness, pain, and a history of a fall with a lumber spine fracture. The resident has poor safety awareness. With noted interventions of assist with activities of daily living (ADL's) as needed, call-light within reach, complete fall risk assessment, move resident to common areas for more eyes on supervision, provide medications as ordered, and anticipate and meet the resident's needs. Review of the medication order summary revealed active orders as of February 1, 2024, which included Quetiapine Fumarate tablet 50 mg give one tablet by mouth two times a day related to Alzheimer's disease with a start date of December 28, 2023. Review of a shower list for resident #27 dated June 29, 2024 revealed that the resident was bathed and had no new skin issues. Review of weekly skin assessment dated [DATE] revealed a scab to the left shin. A progress note dated July 8, 2024 revealed a skin tear to the right thumb from bumping the bed table. A new order for foam dressing to right thumb area every three days and as needed until healed. Review of the weekly skin assessment dated [DATE] included a scab to the left shin. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had a severe cognitive impairment. It also included that the resident had skin problems related to skin tear(s). Review of the functional abilities and goals assessment revealed that the resident was dependent on the assistance of helpers for rolling left to right, and transfers. Review of the weekly skin assessment dated [DATE] included a scab to the left shin. Review of progress note dated July 22, 2024 revealed that the resident was found sitting on the floor leaning against her bed. She had pushed the border pillows off the bed and tried to get up on her own. The nurse checked for injuries and none were noted. The physician and guardian were notified. Review of a Fall Risk assessment dated [DATE] revealed that the resident had fallen more than three times in the last 90 days with a score of 24. Review of a shower list dated July 27, 2024 revealed that the resident received a shower and no documentation regarding the condition of the resident's skin. A progress note dated July 28, 2024 revealed that the resident was found on the floor in front of her chair. The resident was unable to tell staff how she ended up on the floor. An assessment was completed, and there were no obvious signs of injury and no pain indicators present. The resident was transferred to her chair by two staff and neuros were started. Review of a Fall Risk assessment dated [DATE] revealed that the resident had fallen 1-2 times in the last 90 days with a score of 20. Review of the progress notes July through August 2024 did not reveal documentation of a fall on August 3, 2024. The medication administration record (MAR) dated July 2024 revealed: -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth two times a day related to Alzheimer's disease dated April 24, 2024 and discontinued July 2, 2024 was administered July 1 and 2, 2024. -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth one time a day dated July 2, 2024 and discontinued July 3, 2024 was administered on July 3, 2024. -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth one time a day dated July 3, 2024 for six days was administered July 4, 2024 through July 9, 2024. -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth one time a day related to Alzheimer's disease dated July 30, 2024 for 6 days, and was administered July 3, 2024. -Also, the MAR revealed that Quetiapine was not administered from July 10, 2024 through July 30, 2024. Review of a Fall Risk assessment dated [DATE] revealed that the resident had fallen 1-2 times in the last 90 days with a score of 16. Review of the shower list dated August 3, 2024 revealed that the resident received a shower, but did not include the condition of skin. A progress note by the Social Services Director dated August 8, 2024 revealed that the resident was visited by the case manager from the public fiduciary office. The case manager expressed concerns regarding reoccurring falls and skin tears/bruising. She requested an explanation for the skin tears and bruising. The Social Services Director explained that some falls are unwitnessed and nursing are unable to record when some skin tears and bruising happened. The case manager requested that she be contacted when the resident has a fall or is sent out to hospital. The Social Services Director will update the Director of Nursing, Assistant Director of Nursing, and nursing staff. A care conference will be scheduled soon. A progress note by the (ADON/staff #3) dated August 9, 2024 revealed that the resident's Seroquel was discontinued on a trial basis leading to agitation, falls and behaviors this last month; Seroquel was reinitiated. The weekly skin assessment date August 21, 2024 revealed bruises on the bilateral lower legs and on top of the left foot; skin tear(s) to the right forearm; and scab to the left shin. Review of the shower list dated August 24, 2024 revealed that the resident received a shower, but did not include the condition of skin. The minimum data set (MDS) dated [DATE] revealed one fall, which included an injury. The medication administration record (MAR) dated August 2024 revealed: -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth one time a day related to Alzheimer's disease dated July 30, 2024 for 6 days, and was administered August 1, 2024 through August 5, 2024 -Quetiapine Fumarate tablet 50 mg give 25 mg by mouth one time a day dated August 23, 2024 and discontinued August 29, 2024 was administered. -Also, the MAR revealed that Quetiapine was not administered August 6, 2024 through August 23, 2024, or from August 29, 2024 through August 31, 2024. An email dated November 13, 2024 from the Director of Nursing (DON/staff #1) included that she was unable to find any interdisciplinary team meeting (IDT) notes regarding falls that occurred on July 22, 2024, July 28, 2024, and August 2, 2024; and she is not sure that the previous DON was getting these done. They have since started IDT meetings and notes on all incidents. An interview was conducted on October 18, 2024 at approximately 11:22 a.m. with the Director of Nursing (DON/staff #1) and the Assistant Director of Nursing (ADON/staff #3). The DON stated that nurses and CNAs are required to complete training on fall prevention. If a resident falls, staff are to take vitals, contact the physician for instructions, start neuros and document if the event is witnessed or unwitnessed. The DON stated that when falls occur, they discuss the cause and preventions that can be implemented the next morning during the standup meeting, but she doesn't know if the meeting is documented. She stated that it is her expectation that new interventions are implemented and the care plan is updated and the purpose of the care plan is so all staff know what interventions are to be implemented. She stated that a Fall Risk Assessment is completed after every fall and a score above ten requires a care plan with interventions to be developed and updated as after each fall. The details regarding each fall should be documented in a progress note. She stated that resident #27 fell on [DATE], July 28, 2024, and August 2, 2024; she reviewed the progress notes and stated that there was no documentation of an IDT meeting occurring after each fall and the care plan was not updated with any new interventions. The ADON stated that there was not an intervention for non-skid socks in the fall care plan. She also stated that a skin assessment should have been completed after each fall and it was not done. At 10:18 a.m., the MDS Coordinator (MDS/staff #27) joined the meeting and stated that she has never attended an IDT meeting after a resident has fallen. She stated that she completes the care plan when the resident is admitted and it is her expectation that the care plan is updated with new interventions when a resident has fallen. An interview was conducted with a Certified Nursing Assistant (CNA/staff #12) on October 18, 2024 at 11:41 a.m., who stated that she has been trained on falls and the resident is for assessed for bruising, skin tears, and other injuries when a fall occurs. She stated that if a resident is found on the floor, staff are to assume there was a fall and go get the nurse, so the nurse can assess for injuries. She stated that that resident #27 falls a lot, and that the resident has slipped out of out of her chair. She stated that residents are supposed to get showers twice a week and staff should look for bruises and skin tears during this time. An interview was conducted with a Licensed Practical Nurse (LPN/staff #20) on October 18, 2024 at 12:02 p.m., who stated that she was trained on falls and when a resident falls, she is supposed to take the vitals, assess the skin, start neuros, notify the physician and document everything in a progress note. She also stated that residents are showered twice a week, and that CNA's should report skin issues to the nurse so that they can report it to the DON. She stated that she has not attended an interdisciplinary meeting (IDT) after a resident falls or updated a care plan with new interventions after a resident has fallen. The facility policy, Area of Focus: Fall Management dated December 4, 2023 states the facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated.

Based on observations, staff interviews, and facility policy review and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure infection control standards related to enhanced barrier precautions were followed for one resident (#78) with catheter and wound. The deficient practice could result in transmission of multi-drug resistant organisms. Findings include: Resident #78 was admitted on [DATE] with diagnoses of obstructive and reflux uropathy, type 2 diabetes mellitus, emphysema, dementia, anxiety, and benign prostatic hyperplasia with lower urinary tract symptom. The care plan dated May 28, 2024 revealed that an indwelling catheter was in place for uropathy. Interventions included enhanced barrier precautions (EBP), catheter care per shift, change catheter as needed a 16FR (French) 10cc (cubic centimeter) and checking tube for kinks each shift. A physician order dated May 29, 2024 revealed an order for an indwelling catheter size 16 French with a 10cc bulb. The minimum data set (MDS) assessment dated [DATE] revealed the resident had a diagnosis of obstructive uropathy and a Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderate cognitive impairment. The MDS also included that the resident had an indwelling catheter in place and had open lesion(s) skin condition. A review of the care plan dated June 23, 2024 revealed the resident had an open area on coccyx, left and right buttocks. Intervention included to treat per facility protocol. A progress note dated June 23, 2024 included that the resident had open areas to coccyx, left and right buttocks, and a deep tissue injury (DTI) on the right heel. A physician order dated June 25, 2024 revealed stage 2 pressure ulcer to coccyx. An observation was conducted on June 25, 2024 at 1:59 p.m. revealed that there were no EBP signs posted outside of the resident room and there were no PPE (personal protective equipment) readily available for use. An interview with resident #78 and family was conducted immediately following the observation. The family stated that the resident had sacral wound. A second observation was conducted on June 26, 2024 at 9:06 a.m. There continued to be no signs posted outside of the resident's room the use of enhanced barrier precautions and continued to have no PPE (personal protective equipment) readily available for use. An interview with director of nursing (DON/staff #108) was conducted on June 27, 2024. The DON stated that the criteria for putting residents on EBP included residents with an indwelling catheter, chronic wound, and multi-drug resistant organisms. She stated that she misinterpreted the CMS guidelines regarding EBP; and that, resident #78 should be placed on EBP and was not. Further, the DON said that the facility also needed to update their policy on this. A review of the policy titled Enhanced Barrier Precautions with a revision date of June 12, 2024 included that enhanced barrier precautions are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organisms). The CDC website updated on July 12, 2022 on healthcare acquired infections revealed that the enhanced barrier precautions are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. The CDC further stated that nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's (multi-drug resistant organisms). The CDC website further stated that the use of gown and glove for high-contact resident care activities is indicated when contact precautions do not otherwise apply.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to maintain a clean kitchen; and failed to ensure food items were dated when opened. The deficient practice could result in residents having food-borne illness. Findings include: An observation of the kitchen was conducted on June 24, 2024 at 11:25 a.m. with the cook (staff #92). The large walk-in refrigerator had a 5lb opened and undated bag of green leaf lettuce that was exposed; and, the lettuce heads were wilted and discolored. Inside the bag of lettuce was a white plate with food covered by a plastic film. Staff #92 stated that the food items on the white plate were turkey, chicken and potato salad; and, she did not know how the plate got in the lettuce bag or why the bag of lettuce was left open. There was also an opened and exposed three-pound box of cream cheese; and the end of the cream cheese had dried out and was left open in the box. The refrigerator floor had spilled milk. The walk-in freezer area had approximately two cups of frozen corn kernels on the freezer floor and an opened 12-quart bucket of frozen mashed potatoes. Further observation of the kitchen revealed there were opened two loaves of bread that were open and exposed to air but did not have a use by or open dates. There was a package of open dinner rolls with no open or use by date on the packaging. The area above the cooking area over the stove had three lamps had stringy particles hanging and were covered with dust and dark brown grease/grime. The observation continued at 12:45 p.m. of the area next to the stove that had an open two-quart container of butter with no open or use by date. Staff #92 stated she had taken the container of butter from the refrigerator at approximately 11:00 a.m. to prepared the grilled cheese sandwiches. There was also an open gallon zip lock bag with shredded cheese and a package of sliced cheese that were now melting found on this cooking area. Further, the shredded cheese had no open or use by date. Another observation of the kitchen was conducted on June 26, 2024 at 8:30 a.m. with another cook (staff #128). The walk-in refrigerator had a five quart container of strawberries that was partially open with no open or use by date. There was a container with 9 visibly wilted and shriveled cucumbers; and, a container with 14 lemons mixed in a container with three large tomatoes that were soft and wilted. The large 5-lb bag of green leaf lettuce that was found on June 24 continued to be in the refrigerator; and, the three light lamps over the cooking range continued to have stringy particles hanging and covered with dust and dark brown grease. Staff #128 stated it was the cook's responsibility to wipe down the lamps to prevent the dust and grease from falling into the food while cooking; and that, there was a risk of food contamination associated with this. Staff #128 further stated that having open exposed foods in the refrigerator had the risk for airborne contamination and should these opened exposed foods should have been discarded. An interview was conducted on June 26, 2024 at 12:45 p.m. with the Administrator (staff #160), who stated that he supervised the Nutrition Director (Staff #90) who was on vacation. However, the administrator stated that it was his expectation that the nutrition director ensured that quality checks were done daily to ensure that the food was fresh; and that, any foods that were no longer of use were also discarded. Review of the facility policy titled Food Safety states food is stored in a clean and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth.

Based on personnel file review, staff interviews, facility assessment and policy review, the facility failed to ensure one Certified Nursing Assistant (CNA /staff #64) had the cardiopulmonary resuscitation (CPR) certification to provide nursing and related services. The deficient practice could result in staff not able to to safely meet resident needs during an emergency. Sample size was one. Facility census was 81. Findings include: The Facility assessment dated [DATE] revealed the staffing plan included 13 licensed nurses, and 27 CNA's to provide direct care for an average of 86 residents every day including emergencies. The assessment also revealed the resources the facilities needed to provide competent support and care for their resident population every day and during emergencies. A review of the personnel record for CNA (staff #64) revealed a hire date of [DATE] and had no evidence of current CPR certification. An interview was conducted on [DATE] at approximately 8:35 AM with the business office manager (BOM/staff #12), who stated that it was the facility's responsibility to ensure that staff and individuals under contract have the necessary licenses and certifications to fulfill their job roles as outlined in the job description. The facility's policy titled, License and CPR Certification Verifications revealed that the facility has the responsibility to ensure that all associates that require a license or certification as part of their delivery and management of health services as well as provide necessary information to comply with all application statutes, laws, and regulatory licensing board/agencies. The policy also included that it is their responsibility to ensure that the associates and persons under contract have the necessary licenses and certifications needed to fulfill their job role as outlined in the job description for that role. The Compliance department assist the facility with monitoring professional licensure, they monitor the licenses and certifications of nurses, and CNA's who are employed by the facility.

Based on observation, staff interviews, and policy review, and review of current facility practice, the facility failed to ensure care plan was developed and implemented to meet the assessed need for one resident (#78). The deficient practice could result in the resident receiving the care they need. Findings include: Resident #78 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, dysphagia, and unspecified protein-calorie malnutrition. The mini nutritional assessment signed and dated 05/29/2024 revealed that the resident had a score of 6 indicating the resident was malnourished. The Residents at Risk meeting notes dated 05/29/2024 revealed that resident was a new admission and was on a mechanically altered diet on 05/29/2024. The weight record on 05/29/2024 was 221.5 lbs. (pounds). A nutritional assessment dated on 05/31/2024 revealed the resident had a diet of regular mechanically altered texture and thin liquid consistency; and had an overweight status for age. The documentation also included that the resident was at risk for malnutrition or was currently diagnosed with malnutrition related to age and diagnosis of dysphagia. Further, the documentation included that the care plan was reviewed/revised or implemented. The physician order dated 06/03/2024 included for a regular diet, mechanically altered texture, thin consistency, with no added salt. It also included an order for 1:1 supervision for all meals and for fortified foods three times a day. The Residents at Risk meeting notes dated 06/13/2024 revealed that the resident triggered for weight loss and had varied oral intake. Per the documentation, the resident was still overweight; and had a mechanically altered diet and was on an assisted diet. Further, the not included that the resident had an extremely strict diet per family request. The weight record for 6/19/2024 was 201.4 lbs. which was approximately 20 lbs. weight loss since admission. Despite documentation of the resident's nutritional risk, there was no evidence found that a care plan with interventions put in place was developed and implemented until 6/26/2024. The care plan dated 6/26/2024 included that the resident had an unplanned/unexpected weight loss related to an acute illness, poor intake and recent hospitalization . The goal was that the resident will maintain weight at 197 lbs. +/- 5%. Interventions included to evaluate weight loss, determine percentage lost, follow facility protocol for weight loss, give supplements as ordered and alert dietician if consumption was por for more than 48 hours. In an interview with the registered dietitian (RD/staff #144) conducted on 6/26/24 at 4:22 p.m., the RD stated she would expect that the resident's nutritional status be in the care plan for any residents with or was experiencing significant weight loss. Regarding resident #78, the RD stated that resident #78 triggered for weight loss on 06/19/24; and that, she missed this. An interview was conducted with the director of nursing (DON/staff #108) and assistant DON (ADON/staff #116) was conducted on 6/27/24 at 9:16 a.m. Bothe the DON and the ADON stated that that nutritional risk/issues should be care-planned; and that, the nutritional status of resident #78 was not care planned until 6/26/2024.