Every finding on record at NMMC Baldwyn Nursing Facility

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide sufficient nursing staff to ensure residents received necessary care as evidenced by failure to complete activities of daily living (ADL) care, including bathing, grooming, and nail care; failure to ensure call lights were answered in a timely manner; and failure to address repeated concerns voiced by residents during resident council meetings regarding delays in care and unmet needs for three (3) of four (4) survey days. Findings include: Review of the facility's policy titled, Scheduling of Nursing Staff with a revision date of 03/20, revealed under Policy: It is the policy of (Proper Name) to provide consistent expectations and standardized scheduling processes in staff schedules enabling appropriate staffing levels to ensure patient and staff safety. An observation and interview on 3/23/26 at 12:20 PM revealed Resident #10 with facial hair on the sides of his face, on his chin, and neck, approximately one (1) inch long. His fingernails on both hands were approximately one and a half (1 1/2) inches (in) long with a dark substance under the nails. The resident's hair was disheveled with a white, flaky substance noted throughout. Resident #10 stated, I really need to be shaved, and my fingernails are so long. It's been a long time since I've had them done. I really need them cut. An observation and interview on 3/24/26 at 10:00 AM, Resident #54 stated, I was supposed to get a bath last night, but the two Certified Nursing Assistants (CNAs) were so busy, and I guess they couldn't get to me. At that time, Resident #54 continued to present with disheveled, greasy hair, facial hair measuring approximately one (1) inch in length, and fingernails approximately one-half (1/2) inch long with debris present, with a noticeable body odor. An interview and observation on 3/24/26 at 11:05 AM, CNA #1 revealed that Resident #54 is scheduled to have his showers on the night shift. She confirmed that the resident required grooming, which includes a bath, shaving, and his hair washed. She stated, It looks like it's been a while since he was cleaned up to which Resident #54 stated, It's been two weeks. An interview on 3/24/26 at 11:10 AM, CNA #1 revealed that Resident #10 and Resident #54 were scheduled to receive baths or showers on the night shift on Monday, Wednesday, and Friday, and the bathing or showering includes complete head-to-toe hygiene care, including hair washing and shaving of facial hair as needed. CNA #1 confirmed that Resident #10 and Resident #54 were unkempt and dirty in appearance and stated, I'm not honestly sure when they were last shaved or when they last had their baths. CNA #1 additionally revealed that she had reported concerns to upper management on multiple occasions, stating that when the day shift staff arrived, several of the residents who were supposed to receive their baths or showers on the night shift appeared not to have been cleaned or groomed as required. An observation and interview on 3/24/2026 at 11:25 AM, the Director of Nurses (DON) confirmed that Resident #54 and Resident #10 were not adequately groomed and acknowledged that it appeared they had not been shaved in quite some time. Resident #54 stated, I guess the aides were just too busy to get to me last night. The DON revealed it is our expectation that all of our residents are kept clean and well-groomed. The DON confirmed that the facility failed to adequately meet the residents' ADL needs. During an interview on 3/25/26 at 8:25 AM, the DON revealed the facility primarily utilizes agency staff and confirmed there are frequent call-ins that they aren't able to replace. Although efforts are made to cover each shift, the facility may still operate short-staffed at times. The DON acknowledged that maintaining adequate staffing has been an ongoing struggle. An observation and interview on 3/25/26 at 10:12 AM, revealed a call light illuminated in the hallway for room A9. Upon entering the room, Resident #54 stated, I need to be changed. I turned my light on a while ago, and I'm just waiting. Further observation from the hallway revealed no staff present in the immediate area. Upon approaching the nurses' station at the end of the hallway, it was noted that the call light alarm was not sounding. The Unit Coordinator stated, I'm aware of his call light, and I've already paged overhead for his CNA, and it is silenced now. An observation of Registered Nurse (RN) #2 and the Unit Coordinator at the nurses' station. During continued observation from the hallway, the unit manager paged the assigned CNA twice more for room [ROOM NUMBER]. An observation and interview on 3/25/26 at 10:30 AM, Certified Nurse Aide (CNA) #3 and Nurse Aide in training (NA) #4 returned to the hall. CNA #3 stated, We finished our rounds earlier, and we went on our 15-minute break, and further indicated that another staff member should have responded to the call light in her absence. During the Resident Council meeting held on 3/25/26 at 2:00 PM, residents expressed that staffing was their primary concern. One resident reported that she had previously been told that she would have to wait until the following day to have certain care needs addressed. Although she was initially unable to specify the type of care referenced, when prompted about showers, she confirmed that this included bathing. Another resident further stated that she had experienced extended wait times for toileting assistance on approximately three (3) occasions, occurring at random times without a specific shift identified. During a phone interview on 3/25/26 at 2:05 PM, an anonymous nursing staff member reported that the facility is, at times, staffed with only four (4) to five (5) CNA's for the entire facility. An interview on 3/26/26 at 7:55 AM, CNA #6, revealed that staffing issues are frequent, with shifts often short due to call-ins. CNA #6 reported that staff turnover has occurred, stating some staff have left due to routinely working short-staffed. She confirmed that when staffing is insufficient, residents may miss scheduled baths as staff prioritize completing essential tasks. CNA #6 stated, The DON is aware of these concerns and attempts to provide incentives, but confirmed staffing challenges persist. During an interview on 3/26/26 at 8:05 AM, the Unit Coordinator revealed she holds multiple roles within the facility. She stated that today she was working in restorative care, and on the previous day she had served as the Unit Coordinator. She further revealed that she is also a CNA. In an interview on 3/26/26 at 8:45 AM, the DON confirmed that when a CNA is on break, another aide is expected to provide coverage; however, if staff are occupied, any available nursing staff are expected to respond to call lights and assist residents. The DON acknowledged the facility has experienced ongoing difficulty ensuring sufficient staffing to meet resident needs.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure the safe use, assessment, and ongoing evaluation of bed rails and failed to identify and remove a known entrapment hazard for one (1) of 25 sampled residents. Resident #65 Findings Include: Record review of the facility policy titled Bed Rails revised 9/18, revealed under, Policy: It is the policy of 'Proper name of the facility' that bed rails should be used appropriately. This failed practice was not in accordance with facility policy requiring appropriate use and assessment of bed rails. An observation of Resident #65 on 3/23/26 at 12:20 PM revealed he was lying in bed, awake and non-verbal. The left side of the bed was against the wall and one-half (1/2) upper side rails were observed to the left and right side of the bed with a fall mat on the floor. Record review of Resident #65's Significant Event Note dated 3/3/26 revealed, I heard residents peg (percutaneous endoscopic gastrostomy) pump going off, upon entering room Director of Nursing (DON) was standing next to resident, he was halfway on the bed. Legs and arms were in the floor on the protective mat. Resident was flipped face over into the mattress against the rail, his nose and mouth were not into the mattress but in between mattress and rail. Further review revealed the bed was against the wall to prevent falls with no indication the side rails were identified as a source for entrapment. Record review of Resident #65's Fall Care Plan revealed the resident flails/thrashes arms when providing care and at times when awake by self. An interview with Licensed Practical Nurse (LPN) #1 on 3/24/26 at 2:41 PM revealed the resident was a high risk for falls. She revealed the resident was contracted and he rocked his body side to side in the bed when he was wet or in pain which increased his safety risk. She revealed the resident could not use his side rails for bed mobility and confirmed he was totally dependent for care and could not reach out or grab the rails with turning and repositioning. Record review of Resident #65's Side Rail Evaluation dated 3/3/25 revealed the resident was currently using the side rails for positioning or support, did not have a history of falls, and expressed a desire to have the side rails raised while in bed. The side rail assessment was not updated when the resident fell on 3/3/26 despite a significant change in condition. Record review of Resident #65's Bed Rail Consent revealed the Responsible Party (RP) agreed to use bed rails on admit 3/3/25. An interview with the DON on 3/24/26 at 3:12 PM revealed the day of Resident #65's fall she responded to the room because she heard his feeding pump alarming. She observed the resident with his legs and arms on the protective mat and his head was face down in between the side rail and mattress. The DON confirmed the resident was at a greater risk of side rail entrapment and suffocation than from falls and acknowledged the bed rails should have been immediately removed. An interview with the Minimum Data Set (MDS) Nurse on 3/25/26 at 11:10 AM revealed MDS was responsible for updating the side rail assessment quarterly and confirmed this was not being done. She confirmed after reviewing the last fall note the resident was at risk for entrapment from his side rails and they should have been removed. Record review of the Demographics revealed the facility admitted Resident #65 on 3/3/25 with a medical diagnosis that included Anoxic Brain Injury. Record review of the MDS with an Assessment Reference Date (ARD) of 2/25/26 revealed under section C, a Staff Assessment for Mental Status was completed and indicated Resident #65's cognitive skills for daily decision making were severely impaired, which increased his inability to protect himself from harm.

Based on record review and staff interviews, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of two (2) residents reviewed for unnecessary medications. Resident #2 Findings include:Record review revealed the facility had no policy requiring psychotropic consent forms to be obtained prior to initiation of a psychotropic medication.Record review of Resident #2's Active Order Sets revealed an order dated 2/25/26 for Seroquel oral tablet 50 milligrams (mg) to be given by mouth at bedtime for non-Alzheimer's dementia and an order dated 2/25/26 for Buspar oral tablet 10 mg to be given three times daily for depression.Record review revealed the Psychotropic Medication Informed Consent Form was not signed until 3/23/26.On 3/26/2026 at 8:37 AM, during an interview with the Minimum Data Set (MDS) Consultant, she stated there should have been signed consent for Seroquel and Buspar prior to initiation; however, the facility did not obtain consents until approximately one month later.During an interview with the Director of Nursing (DON) on 3/26/2026 at 9:00 AM, she confirmed that the facility had not obtained consents prior to initiation of the psychotropic.Record review of Resident #2's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Heart Failure, Dementia, Mood Disorder, Anxiety and Depression.Record review of the MDS with an Assessment Reference Date (ARD) of 3/04/2026 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) was provided to residents requiring assistance with personal hygiene for four (4) of the twenty-five sampled residents. (Residents #7, # 10, #46, and #54) Findings include: Record review of facility policy titled, AM/PM Care dated 10/24 revealed, Rationale: to provide guidelines to help promote resident cleanliness. Residents should be shaved per preference. Resident #7 During an observation with Resident #7 on 3/23/26 at 11:40 AM, the resident revealed she would like for her fingernails to be trimmed. Observation revealed the resident's fingernails were approximately one-half (1/2) inch in length. The resident was also observed to have dark chin hair approximately one-fourth (1/4) inch in length. During an observation with Resident #7 on 3/24/26 at 8:39 AM, the resident continued to request that her fingernails be trimmed. Observation revealed long fingernails and visible chin hair that had not been addressed. On 3/26/26 at 8:50 AM, the Director of Nursing (DON), observed and confirmed the resident's fingernails and facial hair. During an interview following the observation, the DON confirmed that the resident should have had her fingernails trimmed and facial hair removed. She stated it is the expectation of the facility that residents' facial hair be groomed, and fingernails be clean and trimmed. Record review of Resident #7's admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #7's Medical Problems list revealed diagnoses including functional quadriplegia, muscle spasticity, and ataxia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #10 An observation on 3/23/26 at 10:45 AM revealed Resident #10 lying in bed asleep. The resident was unshaven, and his fingernails were long, with a dark substance under them. The resident was unkempt in appearance. Observation and interview on 3/23/26 at 12:20 PM revealed Resident #10 with facial hair on the sides of his face, on his chin, and neck, approximately one (1) inch long. His fingernails on both hands were approximately one and a half (1 1/2) inches (in) long with a dark substance under the nails. The resident's hair was disheveled with a white, flaky substance noted throughout. Resident #10 stated, I really need to be shaved, and my fingernails are so long. It's been a long time since I've had them done. I really need them cut. During an observation and interview on 3/24/26 at 8:25 AM, Resident #10's appearance was unchanged from the prior day. Resident #10 stated, I still haven't been shaved and cleaned up, and these fingernails are so long. Resident #10 stated, I bet you wouldn't want your fingernails to look like this. I really need to be shaved, and my fingernails cleaned and trimmed. During an interview and observation on 3/24/26 at 11:00 AM, Certified Nurse Aide (CNA) #1 revealed that Resident #10 is scheduled to have his showers on the night shift. She confirmed that the resident required grooming, including shaving and hair washing. During an observation and interview on 3/24/26 at 11:20 AM, the DON confirmed Resident #10 was not adequately groomed. The DON stated, it's primarily the treatment nurse's responsibility to ensure the fingernails are trimmed. During an interview on 3/24/2026 at 11:35 AM, Registered Nurse (RN) #1 confirmed that both residents' fingernails were long and required trimming and stated she was unsure when they had last been addressed. RN #1 further revealed that staff routinely assume she is the only individual responsible for trimming residents' fingernails. She stated that she has voiced concerns to management that, in addition to her other job duties, she is unable to complete nail care for all residents in the facility. Record review of the Demographics page revealed Resident #10 was admitted to the facility on [DATE]. Record review of Resident #10's Medical Problems list revealed the resident has diagnoses which include Hemiparesis affecting left side as late effect of cerebrovascular accident (CVA), Peripheral Artery Disease, and Type 2 Diabetes Mellitus. Record review of Resident #10's MDS with ARD of 12/24/25 revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #46 During an observation and interview with Resident #46 on 3/23/26 at 4:30 PM, the resident revealed she would like for her facial hair to be removed. The observation revealed facial hair under her chin on upper front part of neck. An observation and interview with Resident #46 on 3/24/26 at 8:20 AM revealed resident requested hair to be removed. Observation of light-colored, fine, but thick hair covering the area under her neck on the front portion of upper neck and appeared to be about 1/3 - 1/2 inch long. On 3/24/26 at 8:30 AM, the DON observed and confirmed the resident for her facial hair. During an interview after the observation, the DON acknowledged that each resident should have their ADL care needs met. She confirmed the facility failed to meet this need by not addressing a lady resident with facial care and her preference to have this removed. Record review of the Demographics page revealed Resident was admitted to the facility on [DATE]. Record review of Resident #46's Medical Problems list revealed the resident had a diagnosis of Cerebral Infarction. Record review of Resident #46's MDS with ARD of 2/25/26 revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #54 During an observation and interview on 3/23/26 at 10:50 AM, Resident #54 was observed with approximately one (1) inch of facial hair and fingernails measuring approximately one-half (1/2) inch in length with a dark substance noted underneath. The resident's hair appeared greasy and disheveled, and a noticeable body odor was present. Resident #54 revealed it's been a while since I have been shaved and had my fingernails trimmed. I'm supposed to get my bath tonight. During a follow-up observation and interview on 3/24/26 at 10:00 AM, Resident #54 revealed I was supposed to get a bath last night, but the two CNAs were so busy, and I guess they couldn't get to me. At that time, Resident #54 continued to present with disheveled, greasy hair, facial hair measuring approximately one (1) inch in length, and fingernails approximately one-half (1/2) inch long with debris present. A noticeable body odor remained. During an interview and observation on 3/24/26 at 11:05 AM, CNA #1 revealed that Resident #54 is scheduled to have his showers on the night shift. She confirmed that the resident required grooming, which includes a bath, shaving, and his hair washed. She revealed it looks like it's been a while since he was cleaned up to which Resident #54 stated, It's been two weeks. During an interview on 3/24/26 at 11:10 AM, CNA #1 revealed that Resident #10 and Resident #54 were scheduled to receive baths or showers on the night shift on Monday, Wednesday, and Friday, and the bathing or showering includes complete head-to-toe hygiene care, including hair washing and shaving of facial hair as needed. CNA #1 confirmed that Resident #10 and Resident #54 were unkempt and dirty in appearance and stated, I'm not honestly sure when they were last shaved or when they last had their baths. CNA #1 additionally revealed that she had reported concerns to upper management on multiple occasions, stating that when the day shift staff arrived, several of the residents who were supposed to receive their baths or showers on the night shift appeared not to have been cleaned or groomed as required. During an observation and interview on 3/24/2026 at 11:25 AM, the DON confirmed that Resident #54 was not adequately groomed and acknowledged that it appeared he had not been shaved in quite some time. Resident #54 stated, I guess the aides were just too busy to get to me last night. The DON revealed it is our expectation that all of our residents are kept clean and well-groomed. The DON confirmed that the facility failed to adequately meet the resident's ADL needs. Record review of the Demographics page revealed Resident #54 was admitted to the facility on [DATE]. Record review of Resident #54's Medical Problems list revealed the resident has diagnoses which include Chronic Obstructive Pulmonary disease, Total self-care deficit, and Traumatic Brain Injury. Record review of Resident #54's MDS with ARD of 2/18/26 revealed a BIMS of 14, which indicated the resident was cognitively intact.

Based on record review, facility policy review, and resident and staff interviews, the facility failed to ensure necessary treatment and care were provided to promote healing and prevent worsening of pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers (Resident #7). Findings include: Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided. Resident #7 An interview with Resident #7 on 3/25/26 at 2:00 PM revealed the resident was admitted with two wounds, one on the buttock and one on the sacrum. The resident stated one wound had healed and the sacral wound remained present. Record review of wound care orders for Resident #7's sacral stage four (4) pressure ulcer with physician orders dated 2/10/2026 with treatment intervals of two (2) times daily. Record review of the Treatment Administration Record (TAR) for March 2025 Flow Sheet for the sacral pressure ulcer revealed the wound care treatments were not completed as ordered on 3/11/26, 3/14/26, and 3/24/26 on the PM shift. On 3/26/26 at 10:25 AM, during an interview and interview with Registered Nurse (RN) #1, she confirmed the night shift nurse did not complete the wound treatments on the identified dates. Observation and interview with the treatment nurse revealed that the wound care dressing to the sacral on the morning of 03/26/26 was dated the previous day of 03/25/26 and the physician's order had not been completed for the PM wound care dressing change. Record review of wound documentation revealed the resident was admitted with two wounds, the left buttock wound had resolved, and the sacral wound remained present and was healing. On 3/26/26 at 11:05 AM, an interview Director of Nursing confirmed it is the facility's expectation that ordered treatments are completed as prescribed and it could delay the wound care healing process. Record review of Resident #7's admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #7's Medical Problems list revealed diagnoses including functional quadriplegia, muscle spasticity, and ataxia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a catheter securement device for a resident with an indwelling catheter for one (1) or four (4) catheters observed. Resident #4 Findings include: Resident #4 Record review of facility letterhead titled Catheter Care (if present) dated 3/25/26, revealed 5A. The catheter tubing should be secured with securement device to resident's upper portion of lower extremity (ex. Adhesive securement device, leg securement strap, or other approved device provided by [local hospital]). During an interview and observation of catheter care by Certified Nursing Assistant (CNA) #2 on 3/24/26 at 2:10 PM, it was noted that Resident #4 had an indwelling catheter. It was observed that no securing device was in place for the securement of the catheter. CNA #2 revealed that use of the device was required to secure the catheter in place and this must have fallen off. An interview on 3/24/26 at 2:20 PM with the Director of Nursing (DON) revealed the catheter securing device should be in place for each resident with an indwelling catheter. She confirmed the facility failed to have a securing device in place for the protection of Resident #4's catheter placement. Record review of Demographics page for Resident #4 revealed resident was admitted to the facility on [DATE]. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/11/26 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated a moderate cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to ensure adequate nutritional support and implementation of physician-ordered interventions to prevent significant weight loss for one (1) of six (6) residents reviewed for nutrition. Resident #1 Findings Include: Review of the facility policy titled Weight Loss: Monitoring of unrevised, revealed under, Policy: It is the policy of 'Proper name of the facility 'that the weight and the nutritional status of residents be monitored. Also revealed under, Procedure: If a resident has a weight loss greater than 5 (five) percent of body weight in one month or 10 percent of body weight in a six month period, the dietician should be consulted and recommendations of dietician should be followed. Record review of Resident #1's Flowsheet History revealed the following weights: Record review of Resident #1's weights revealed on 9/17/2025, the resident weighed 135 pounds (lbs.). On 02/05/2026, the resident weighed 119 lbs., which was a significant weight loss of -11.85% (percent) in 6 months. On 12/11/2025, the resident weighed 132 lbs. On 2/05/2026, the resident weighed 119 lbs., which was a significant weight loss of -9.85% (Percent) in three (3) months. Record review of Resident #1's meal intake Flowsheet History from 2/23/26 through 3/24/26 revealed a consistent pattern of poor oral intake, with the resident consuming 25% (percent) or less of meals, including multiple documented entries of 0% intake, less than 25% intake, and refusals of meals. Further review revealed under, Does the resident take their supplement? No - activity did not occur was documented. Record review of Resident #1's Registered Dietician (RD) Progress Note dated 2/24/26 revealed the residents documented PO (by mouth) intake average was 50-100 % (percent) for the majority of meals. On this day, the Registered Dietician (RD) spoke with the resident and documented his willingness to try chocolate Glucerna in the afternoon. An interview with the RD on 3/25/26 at 8:56 AM revealed Resident #1 was on a pureed diet in February and was receiving Glucerna three times daily with meals. She revealed the resident did not like the pureed diet or the Glucerna. The RD stated the resident's intake was averaging between 50-100% of meals, and on 2/24 he requested to change the Glucerna to once daily in the evening. She stated the recommendation was made on that day to change Glucerna to once daily. She revealed that she goes into the flowsheets to check and see if the resident was drinking it, but a lot of the time it was not documented, so she must go ask the nurse. After reviewing Resident #1's supplement flowsheet, she confirmed there was no documentation to show the resident was receiving a supplement. After reviewing the physician orders with RD, the Glucerna order was entered into the system for only three (3) days and then stopped. She confirmed the resident did not get the recommended nutrients and protein that was ordered, which placed him at further risk for weight loss and malnutrition. Record review of Resident #1's Flowsheet History revealed a monthly weight was obtained on 3/24/26 and was 115 lbs., which was down four (4) pounds from the last monthly weight in February, which was documented at 119. Record review of the Canceled Orders for Resident #1 revealed an order dated 2/24/26, Glucerna; Chocolate chilled daily at risk for malnutrition, PO (by mouth) intake < (less than) 50% (percent) daily with a duration of 3 days, confirming the resident was not receiving. Record review of the Demographics revealed the facility admitted Resident #1 on 4/28/25 with medical diagnoses that included Acute Stroke due to Ischemia, at risk for Malnutrition, Dysphagia due to recent Stroke, and Vascular Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #1 was severely cognitively impaired.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and treatment solutions were secured and not accessible to the resident for three (3) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Administration revised 3/11/24 revealed, 3. No medications should be left in the resident's room [ROOM NUMBER]. Storage of medications and several other associated products should be secure, i.e., in a locked drawer/cabinet, or under constant surveillance. An observation inside room C3 on 3/23/26 at 11:12 AM and again on 3/24/26 at 8:14 AM revealed four (4) bottles of Dakin's solution quarter-strength (1/4), 16 fluid ounce bottles; two (2) bottles sitting on a table beside the bed and the other two (2) in a pink pail by the sink. Other items stored on the counter by the sink included a bottle of ethyl alcohol, 16-ounce bottle 70% (percent), and hydrogen peroxide 3% (percent). An observation and interview with Licensed Practical Nurse (LPN) #1 on 3/24/26 at 2:42 PM confirmed treatment solutions were left in the room and were readily accessible. She stated these items should not be stored in the room due to the safety risk of a confused resident ingesting or misusing them. An interview with the Director of Nursing on 3/25/26 at 10:42 AM confirmed treatment solutions should not be left at the bedside due to resident safety risk. Observation and interview on 3/26/2026 at 8:09 AM, while walking down the hallway, observed medication cart for Halls E and F unlocked and unattended. Registered Nurse (RN) #4 confirmed that the medication cart was unlocked and unattended. The assigned cart nurse, Licensed Practical Nurse (LPN) #2, returned to the medication cart and acknowledged that she had walked away, leaving the cart unlocked. LPN #2 verbalized awareness of the risks associated with leaving the cart unsecured, stating, Anyone could come to the cart and have access to anything in the cart. LPN #2 further stated, I just walked away for a minute, but I should not have left it unlocked. On 03/26/2026 at 8:57 AM, an interview was conducted with the Director of Nursing (DON). The DON stated her expectation is that all medication carts remain locked at all times unless the nurse is actively obtaining medications. She further stated that an unlocked and unattended medication cart could lead to medication diversion by staff, residents, visitors, or others.

Based on observation, staff interview, and facility policy review, the facility failed to maintain effective infection control practices as evidenced by uncovered clean utility cart, staff not wearing gowns for enhanced barrier precautions, and handling soiled linens without a barrier bag, increasing the risk of cross-contamination and infection transmission for one (1) of four (4) survey days. Findings Include: Review of the facility's policy titled, EVS-Residential Laundry with an issued date of 4/1/18, revealed under Policy: All potentially contaminated linen should be handled with appropriate measures to prevent cross-transmission . Linen should be carried away from the body and clothing.Clean linens and residential laundry should be stored on clean, covered carts. Review of the facility's policy titled, Enhanced Barriers in Nursing Homes with an approved date of 4/5/24, revealed under Policy: It is the policy of Proper Name long term care facilities that appropriate infection control precautions be observed by personnel caring for residents in needed precautions. Under procedure: Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease the transmission of certain MDRO's (multidrug-resistant organisms) when contact precautions do not apply. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities On 3/25/26 at 10:15 AM, a clean utility cart on A Hall, between rooms A9-A11, was observed uncovered with clean supplies exposed. Resident gowns on the bottom shelf with the tie strings and gowns touching the floor. During an observation and interview on 3/25/26 at 10:30 AM, Certified Nurse Aide (CNA) #3 confirmed that the clean utility cart was uncovered, exposing the clean utilities on the cart. She further confirmed that the resident gowns on the bottom shelf with the fabric ties touching the floor were now dirty. CNA #3 confirmed the cart should always be covered and that the residents' gowns touching the floor were unsanitary and could contribute to infection transmission. Further observation outside room [ROOM NUMBER]A on 3/25/26 at 10:32 AM revealed Enhanced Barrier Precautions (EBP) and Contact Isolation signage on the door. CNA #3 and Nurse Aide in training (NA) #4 entered room [ROOM NUMBER]A and did not don personal protective equipment (PPE), which included a gown. When CNA #3 opened the door to exit the room, it was observed that the NA #4 was holding soiled linen against her body that was not contained in a barrier bag and neither CNA #3 nor the NA #4 had on a gown. CNA #3 confirmed that both residents in the room were under precautions and confirmed that they both had provided care for the resident in B bed, which was under enhanced barrier precautions, and they did not wear a gown. She confirmed that there was contact-isolation signage on the door for the resident in bed A. She confirmed that without wearing the appropriate PPE and taking precautions, they could spread infection. During an interview on 3/25/26 at 10:55 AM, the Infection Preventionist confirmed that clean linen carts must always be kept covered to reduce the risk of cross-contamination. She revealed that when a resident is on Enhanced Barrier Precautions (EBP) or any type of isolation, staff are required to wear the appropriate PPE, which always includes a gown. She further confirmed that when aides provided care to the resident in the B bed in room [ROOM NUMBER]A they should have worn a gown and should not have carried soiled linen against their body into the hallway without containing it in a blue barrier bag for proper placement in a soiled linen container. In an interview on 3/25/26 at 3:00 PM, the Director of Nurses (DON) revealed that staff should wear the appropriate PPE when providing care to residents under enhanced barrier or contact precautions. She confirmed by not adhering to these practices it increases the risk of infection transmission among residents and staff.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure adequate supervision and implementation of interventions to prevent accidents for one (1) of four (4) falls reviewed. Resident #65.Findings Include:Review of the facility policy titled Fall Prevention and Post Fall Assessment & (and) Follow-up revealed under, Rational: To provide guidelines for the identification of residents at risk for falls. To provide assessments, interventions, and documentation after a resident fall. Also revealed under, Policy: It is the policy of 'Proper name of the facility' to identify residents at risk for falls in the attempt to help prevent falls and resident falls should be handled appropriately. An observation outside Resident #65's room on 3/23/26 at 12:20 PM revealed that the door was closed. The resident was located on the window side of the room, and the center privacy curtain was pulled. Resident #65 was lying in bed, awake and non-verbal. The left side of the bed was against the wall and one-half (1/2) side rails were located on the right and left side of the bed. A fall mat was located on the floor.Record review of Resident #65's Fall Event dated 2/17/26 revealed the resident was found on the floor with his head near the feeding pump pole.Record review of Resident #65's Fall Event dated 2/25/26 revealed, Called to room per staff. Upon entering room, observed resident lying in the floor on side of bed. CNA (certified nurse aide) in room and reported resident rolled off bed while she was providing care.An interview with Licensed Practical Nurse (LPN) #1 on 3/24/26 at 2:41 PM revealed Resident #65 was a high risk for falls. She stated on her shift she ensured the bed was in the lowest position and the fall mat was in place. She stated the aides made rounds every 2 hours and the nurses made rounds opposite the aides, resulting in hourly rounding. LPN #1 explained the resident's roommate would not allow the room door to remain open so that he was visible to staff from the hallway. She revealed the resident bilateral arms and legs were contracted and he rocked his body side to side in the bed when he was wet or in pain, which increased his safety risk. Record review of Resident #65's activities of daily living (ADL) Task revealed the resident was total dependence for bed mobility and total dependence with toileting assistance without reference to a number of staff required. An interview with the Registered Nurse (RN) #3 on 3/25/26 at 1:36 PM confirmed that Resident #65's ADL task indicated he was totally dependent for bed mobility and toileting care but did not specify how many staff were required to perform the task safely. She explained it was a flaw with the charting system, stating that the task could only be set up to indicate total dependence. RN #3 confirmed staff should be aware of how many staff were required to perform the task safely. Record review of Resident #65's Fall Care Plan revealed, Resident flails/thrashes arms when providing care and at times when awake by self. A telephone interview with Certified Nurse Aide (CNA) #5 on 3/25/26 at 2:57 PM revealed the day of Resident #65's fall she was providing care to the resident. She explained that he was clinching up, combative, and fighting back. CNA #5 stated she had raised his bed up and locked the bed and revealed she was holding onto him when he jerked and rolled off the bed and fell onto his buttocks. She stated staff were to check the care plan that was left in a binder at the desk to determine how much assistance a resident required. CNA #5 confirmed she had not checked his care plan to determine how much assistance was needed and stated, We've always used one. She acknowledged having two (2) staff with the resident would have been appropriate due to his combative behaviors. An interview with the Director of Nursing (DON) on 3/25/26 at 3:42 PM confirmed that after Resident #65's fall, there was not a review of the fall to determine the root cause, and no interventions were put into place to prevent a recurrence. She confirmed that if the resident fell out of bed while one aide was providing care, the number of staff assistance should have been increased to two (2). Record review of the Demographics revealed the facility admitted Resident #65 on 3/3/25 with a medical diagnosis that included Anoxic Brain Injury. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/26 revealed under section C, a Staff Assessment for Mental Status was completed and indicated Resident #65's cognitive skills for daily decision making were severely impaired.

Based on observation, staff and resident interviews, record reviews, and facility policy reviews, the facility failed to implement a Catheter and Activities of Daily Living (ADL) care plan for five (5) of 25 resident care plans reviewed. (Resident #4, Resident #7, Resident #10, Resident #46, and Resident #54) Findings include: Record review of facility policy titled, Care Plan Policy with most recent revision date of 10/24, revealed, .In accordance with each resident's plan of care, all services provided or arranged by the facility should meet professional standards of quality and should be provided by qualified persons Resident #4 Record review of the Care Plan revealed, Requires a foley catheter related to neurogenic bladder.Approaches.Secure catheter to prevent trauma. On 3/24/26 at 2:10 PM during an interview and observation of catheter care by Certified Nursing Assistant (CNA) #2, it was noted that Resident #4 had an indwelling catheter. It was observed that no securing device was in place for the securement of the catheter. CNA #2 revealed that use of the device was required to secure the catheter in place and this must have fallen off. On 3/24/26 at 2:20 PM an interview with the Director of Nursing (DON) revealed the catheter securing device should be in place for each resident with an indwelling catheter. She confirmed the facility failed to have a securing device in place for the protection of Resident #4's catheter placement which was a part of the care plan for catheter care. During an interview on 3/24/26 at 3:20 PM, the Minimum Data Set (MDS) Coordinator acknowledged that each resident with an indwelling catheter should have a bowel and bladder care plan which included care for the catheter. She confirmed the facility failed to implement the care plan for catheter care which included usage of a securing device. Record review of Demographics page for Resident #4 revealed resident was admitted to the facility on [DATE]. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated a moderate cognitive impairment. Resident #7 Record review of Resident #7's care plan revealed the resident required assistance with activities of daily living, including personal hygiene and grooming needs such as nail care and shaving. On 3/23/26 at 11:40 AM during an observation with Resident #7 the resident revealed she would like for her fingernails to be trimmed. Observation revealed the resident's fingernails were approximately one-half (1/2) inch in length. The resident was also observed to have chin hair approximately one-fourth (1/4) inch in length. During an observation on 3/26/26 at 8:50 AM, the DON observed the resident's fingernails and facial hair. During an interview following the observation, the DON confirmed that the resident should have had her fingernails trimmed and facial hair removed. During an interview on 3/26/26 at 9:00 AM, the MDS Coordinator stated that the care plan provides guidance for each resident's care needs. She confirmed that Resident #7's care plan included activities of daily living interventions such as grooming and hygiene; however, the care plan was not implemented for this resident. Record review of Resident #7's admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #7's Medical Problems list revealed diagnoses including functional quadriplegia, muscle spasticity, and ataxia. Record review of the MDS with an ARD of 12/24/2025 revealed a BIMS score of 13, indicating the resident was cognitively intact. Resident #10 Record review of Resident #10's care plan revealed the resident required assistance with activities of daily living, related to a diagnosis of Cerebral Vascular Disease (CVA) and left side hemiplegia. Personal hygiene and grooming include bathing, nail care, and shaving. An observation and interview on 3/23/26 at 12:20 PM revealed Resident #10 with facial hair on the sides of his face, on his chin, and neck, approximately one (1) inch long. His fingernails on both hands were approximately one and a half (1 1/2) inches (in) long with a dark substance under the nails. The resident's hair was disheveled with a white, flaky substance noted throughout. Resident #10 stated, I really need to be shaved, and my fingernails are so long. It's been a long time since I've had them done. I really need them cut. On 3/24/26 at 11:20 AM during an observation and interview, the DON confirmed Resident #10 was not adequately groomed. and further acknowledged the resident's personal hygiene plan of care was not followed. During an interview on 3/24/26 at 2:30 PM, the MDS Coordinator stated the purpose of the care plan is to guide staff in providing individualized care to each resident. She confirmed the ADL care plan for Resident #10 was not being implemented with regard to his personal hygiene and acknowledged it should have been followed. Record review of the Demographics page revealed Resident #10 was admitted to the facility on [DATE]. Record review of Resident #10's Medical Problems list revealed the resident has diagnoses which include Hemiparesis affecting left side as late effect of cerebrovascular accident (CVA), Peripheral Artery Disease, and Type 2 Diabetes Mellitus. Record review of Resident #10's MDS with ARD of 12/24/25 revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #46 Record review of Resident #46's Care Plan revealed, Resident requires assist with ADL's related to CVA and weakness. On 3/23/26 at 4:30 PM during an observation and interview with Resident #46, the resident revealed she would like for her facial hair to be removed. The observation revealed facial hair under her chin on upper front part of neck. During an observation on 3/24/26 at 8:30 AM, the DON observed the resident for her facial hair. During an interview after the observation, the DON acknowledged that each resident should have their ADL care needs met. She confirmed the facility failed to meet this need by not addressing a lady resident with facial care and her preference to have this removed met. She confirmed that shaving was part of the ADL care plan and for this resident, the care plan was not implemented. During an interview on 3/24/26 at 2:30 PM, the MDS Coordinator revealed the care plan provided a guide for the care needs of each resident. She stated this resident had an activity of daily living care plan which would include shaving, but this was not implemented for the resident. Record review of the Demographics page revealed the resident was admitted to the facility on [DATE]. Record review of Resident #46's Medical Problems list revealed the resident had a diagnosis of Cerebral Infarction. Record review of Resident #46's MDS with ARD of 2/25/26 revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #54 Record review of Resident #54's care plan revealed the resident required assistance with activities of daily living, related to weakness, history of Traumatic Brain Injury (TBI) and Chronic pain. Personal hygiene and grooming include bathing, nail care, and shaving. On 3/23/26 at 10:50 AM during an observation and interview, Resident #54 was observed with approximately one (1) inch of facial hair and fingernails measuring approximately one-half (1/2) inch in length with a dark substance noted underneath. The resident's hair appeared greasy and disheveled, and a noticeable body odor was present. Resident #54 revealed it's been a while since I have been shaved and had my fingernails trimmed. I'm supposed to get my bath tonight. On 3/24/2026 at 11:25 AM during an observation and interview, the DON confirmed that Resident #54 was not adequately groomed and acknowledged that it appeared he had not been shaved in quite some time. Resident #54 stated, I guess the aides were just too busy to get to me last night. The DON revealed it is our expectation that all of our residents are kept clean and well-groomed. The DON confirmed that the facility failed to adequately meet the resident's ADL needs and the resident's plan of care was not being followed regarding his personal hygiene. During an interview on 3/24/26 at 2:30 PM, the MDS Coordinator stated the purpose of the care plan is to guide staff in providing individualized care to each resident. She confirmed that the Activities of Daily Living (ADL) care plan for Resident #54 was not being implemented regarding his personal hygiene and acknowledged that it should have been followed. Record review of the Demographics page revealed Resident #54 was admitted to the facility on [DATE]. Record review of Resident #54's Medical Problems list revealed the resident has diagnoses which include Chronic Obstructive Pulmonary disease, Total self-care deficit, and Traumatic Brain Injury. Record review of Resident #54's MDS with ARD of 2/18/26 revealed a BIMS of 14, which indicated the resident was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure skin care treatments were completed as ordered for one (1) of three (3) residents reviewed for wound and skin care. This deficient practice resulted in deterioration of a resident's wound, including a significant increase in wound size for Resident #1.Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided.Resident #1During an onsite complaint survey, an interview with Resident #1 on 11/3/25 at 10:30 AM revealed she had wounds to her legs. Resident #1 stated she often does not get her dressing changed to her leg at night and sometimes during the day. Observation revealed a dressing to the left posterior leg.Review of wound care orders for Resident #1's left lower leg ulcer revealed orders dated 9/20/25, 10/14/25, and 10/22/25, with treatment intervals of two (2) times daily.Review of Resident #1's October/November 2025 Treatment Flow Sheet for the left lower posterior leg ulcer revealed the treatment was not documented as completed as ordered thirty-five (35) times from 10/1/25 through 11/3/25 for the second dressing change daily.Review of the Weekly Skin Summary report dated 9/2/25 for Resident #1 revealed the left lower posterior leg ulcer measured 12 cm (centimeters) x 6.2 cm x 0.1 cm. State of healing: worsening.Review of the Weekly Skin Summary report dated 11/4/25 for Resident #1 revealed the left lower posterior leg ulcer measured 21.5 cm x 8 cm x 0.1 cm. State of healing: worsening. This represents a significant increase in wound size over the two-month period.An observation of Resident #1 on 11/4/25 at 8:54 AM with the treatment nurse revealed a saturated, intact dressing dated 11/3/25 at 9:25 AM, with a large area of dried drainage noted on the resident's pillowcase under the left leg dressing. The treatment nurse confirmed that was the dressing she applied on 11/3/25, verified by her initials. She stated the order was for the treatment to be completed twice daily and confirmed Resident #1's left leg ulcer had worsened over the last month. She also confirmed the dressing was soiled with drainage and the pillowcase as well.In a continued interview with the Treatment Nurse on 11/4/25 at 9:05 AM, she stated that she had recently found wound dressings on residents that had not been changed as ordered and had reported these findings to the Director of Nursing (DON). The Treatment Nurse explained that failure to perform wound care as ordered could cause wounds to worsen or become infected. She stated she performs treatments during the day, Monday through Friday, and that night shift and weekend nurses are responsible for completing their own wound treatments if a wound order dressing change is for more than one time a day. She further stated that when a treatment nurse is not scheduled, the assigned nurses are responsible for completing all wound treatments for their residents.Review of the demographic sheet for Resident #1 revealed the facility admitted the resident on 1/01/25 with a diagnosis of diabetic venous ulcers of both lower legs, lower extremity edema and Stage 3 chronic kidney disease. Record review of Resident #1's Section C of the Quarterly Minimum Data Set (MDS) revealed that on 10/1/25, the Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.Record review revealed a Medical Doctor progress note dated 08/19/25 that stated, Vascular surgery did not recommend revascularization due to bedbound and comorbidities. Patient will eventually require left (L) above the knee amputation (AKA). Record review of wound care center physician order dated 09/20/25 for an order to change dressing from once daily to twice daily (BID). Current treatment order is for left lower leg (LLL) cleanse with normal saline, pat dry with gauze, place Adaptic wound dressing to wound bed, cover with abdominal pad (ABD) and wrap with kerlix BID.An interview with the Assistant DON on 11/4/25 at 11:20 AM confirmed that staff failing to complete wound care as ordered could lead to worsening wounds.An interview with the DON on 11/5/25 at 11:30 AM confirmed she was aware the facility had concerns with treatments not being completed but not to the extent identified. She also stated she was unsure of the reason the wound care was not being completed.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure wound care treatments were completed as ordered for two (2) of three (3) residents reviewed for pressure ulcer wound care (Residents #2 and #3). Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided. Resident #2An interview with Resident #2 on 11/3/25 at 11:00 AM revealed she had a wound on the back of her right leg. She confirmed there had been a few times over the past month that her treatment had not been completed.Record review of wound care orders for Resident #2's right upper leg stage (4) pressure injury (PI) revealed orders dated 8/21/25 and 10/20/25, with treatment intervals of daily.Record review of Resident #2's October/November 2025 Treatment Flow Sheet for the right upper posterior leg revealed the treatment was not completed as ordered five (5) times from 10/1/25 through 11/3/25.Record review of the demographic sheet for Resident #2 revealed the facility admitted the resident on 2/3/25 with a diagnosis of paraplegia.Record review of Resident #2's Section C of the Minimum Data Set (MDS) revealed that on 8/6/25, the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact.Resident #3Record review of wound care orders for Resident #3's sacral stage (4) pressure injury revealed orders dated 9/20/25, 10/14/25, and 10/22/25, with treatment intervals of two (2) times daily.Record review of Resident #3's October/November 2025 Treatment Flow Sheet for the sacral stage (4) pressure injury revealed the treatment was not documented as completed as ordered nine (9) times from 10/1/25 through 11/3/25.Record review of the demographic sheet for Resident #3 revealed the facility admitted the resident on 5/14/25 with a diagnosis of metastatic disease in the pelvis and a stage (4) pressure ulcer of the coccygeal region.On 11/4/25 at 11:20 AM, in an interview with the Assistant Director of Nursing (ADON) confirmed that staff failing to complete wound care as ordered could lead to worsening wounds.On 11/5/25 at 11:30 AM, an interview with the Director of Nursing (DON) confirmed she was aware the facility had concerns with treatments not being completed but not to the extent identified. She also stated she was unsure of the reason the wound care was not being completed.

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a dependent resident with a negative pressure wound therapy system (wound vac) in place and who required assistance with Activities of Daily Living for one (1) of four (4) residents sampled. Resident #1. Findings Include: Review of the facility policy, Care Plan Policy with reviewed date of 10/20 revealed, It is the policy of (Proper Name Facility) that care plans should be properly developed and implemented. Record review of Resident #1's Care Plan updated 04/11/25 revealed that she required assistance with ADL's (activities of daily living) related to End Stage Renal Disease on dialysis, Decreased Mobility, and Generalized Weakness. Resident #1's Care Plan Approaches included, to provide appropriate level of assistance with ADL's as needed and this included limited to extensive need for one person assistance with dressing. Record review of Resident #1's Wound/Skin Careplan dated 03/29/25, revealed that she had a surgical wound to her left upper forearm with interventions that included to apply wound vac at 120 mmHg (millimeters of mercury) continuous. Record review of Resident #1's Nursing Orders revealed a wound care order with a start date of 03/31/25 for every Monday, Wednesday, and Friday. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, apply black foam to wound bed only, apply Tegaderm, apply wound vac at 120 mm continuous. Record review of Resident #1's Nursing Orders revealed an unscheduled PRN (As Needed) wound care order with start date of 03/31/25. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, and apply NS (normal saline) wet to dry dressing. On 04/29/25 at 9:47 AM, an interview with complainant revealed that Resident #1 had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. She revealed that on several occasions, Resident #1 had the same clothes on she had worn to dialysis the day before. The complainant revealed that Resident #1 slept in her clothes frequently and she had witnesses that also observed this. She revealed that Resident #1 didn't live like that, she didn't sleep in her clothes at night before she came to the facility, and she shouldn't have to now. The complainant revealed that Resident #1 had pajamas and gowns, and there was no reason she should have to sleep in her regular clothes. She stated, This is not comfortable for her. She revealed that she reported it to the previous administrator several times and it was never taken care of. An interview on 04/29/25 at 10:00 AM with the complainant revealed Resident #1 recently had an infected fistula removed from her left arm and she had the wound vac in place. She revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. Complainant also revealed that Resident #1 had a wound vac (negative pressure wound therapy system) that was supposed to be hooked to suction at all times and the staff knew that. She also revealed that several times last week, she noticed the wound vac was not on and she reported it to the nurse. An observation on 04/29/25 at 3:15 PM revealed Resident #1 reclined back in her wheelchair in the Sunroom with other residents present. She was dressed in a purple top, a brown cardigan sweater, a pair of pants and shoes. Her wound vac tubing was attached to the dressing to her left upper arm and there was no negative pressure suction applied and no canister in place. An observation on 04/29/25 at 3:30 PM in Resident #1's room, revealed the wound vac pump located in the corner of the room, it was attached to a pole and was not plugged in. Resident #1 was not in her room. An observation on 04/29/25 at 4:40 PM in the dining room revealed Resident #1 sitting up in her wheelchair. The wound dressing to her left upper arm was intact with the wound vac tubing attached and there was no negative pressure suction hooked to it. On 04/30/25 at 9:15 AM, an interview with complainant, revealed that Resident #1 had the same clothes on this morning that she wore to her doctor's appointment yesterday, 04/29/25, a purple shirt and a brown cardigan sweater. On 04/30/25 at 9:30 AM, an observation and interview with Resident #1, revealed her lying in her bed in her room. She had a purple top and a brown colored cardigan sweater on. Resident #1 confirmed that she had the same clothes on that she wore to her doctor's appointment the day before and revealed that the aides did not change her clothes before she went to bed last night. Resident #1 confirmed that she didn't like to sleep in her regular day clothes and that she would rather sleep in her bed clothes, her pajamas or gowns and stated, But I wasn't asked. An interview on 04/30/25 at 10:40 AM with the Restorative Certified Nursing Assistant (CNA), revealed nearly every day she observed that Resident #1 was in the same clothes from the day before. During an interview with Resident #1 on 04/30/25 at 10:45 AM with Interim Director of Nursing (DON) present, Resident #1 revealed that they did not change her clothes last night before putting her in bed. Resident #1 confirmed that regular clothes were not comfortable to sleep in and that she liked to sleep in her pajamas. Interim DON confirmed that the CNAs knew it was their responsibility to get the resident clothes changed for bed and to put appropriate bed clothes on them. An interview on 04/30/25 at 9:02 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was supposed to have her wound vac in use and turned on to suction at all times. She revealed that the wound vac had a battery pack and was supposed to be taken with her to appointments as well. RN #1 revealed that not having the wound vac on and running yesterday was a failure on her part. She revealed that not following the physician orders for continuous negative pressure could cause the fluid to pool, it could prevent the wound from healing and could lead to infection. RN #1 stated, It is doing her (Resident #1) a disservice by not having the wound vac in place as it is ordered. RN #1 confirmed that the wound vac canister should always be attached and hooked to suction unless a wet to dry dressing was applied. She revealed that Resident #1 never complained about discomfort with the wound vac and never refused to have it on, it was just not done. An interview on 04/30/25 at 8:50 AM with Treatment Nurse revealed that Resident #1's wound vac was supposed to be on at all times and hooked to suction. She revealed that a wet to dry dressing should be applied to the wound site if the wound vac was off and that the wound vac tubing and dressing should never be left on if not hooked to suction. She revealed that Resident #1 went to dialysis every Monday, Wednesday, and Friday and if the wound vac did not go with her, they should apply a wet to dry dressing until she returned. Treatment Nurse revealed that she had noticed the wound vac tubing and dressing on without being hooked to suction several times and had reported it to the Interim Administrator. She revealed that the wound to Resident #1's left arm was much improved, and she could probably get the wound vac discontinued soon. Treatment Nurse revealed that Resident #1 had her dialysis fistula removed about a month ago, she received antibiotics, and the wound vac was placed. An interview on 04/30/25 at 9:05 AM with the Interim Director of Nursing, revealed that it had been brought to her attention by a family member before that the wound vac was not hooked up to suction. She revealed that the wound vac had a battery pack, was portable and there's no reason for it not to be hooked to suction. She revealed that it was the Floor Nurse's responsibility to ensure the wound vac was hooked to suction as ordered. On 04/30/25 at 10:15 AM, an interview with the Minimum Data Set (MDS) Coordinator, revealed that the purpose of the care plan was to provide information on each individual resident for the nurses and cnas to relate back to in order to know how to take care of the specific needs of each resident. She revealed that the comprehensive care plan was a patient directed individualized care approach developed so the staff know how to take care of each resident. She confirmed that since Resident #1's wound vac was not hooked to suction and since the staff did not change her clothes for bed, and she was left in the same clothes from the day before, her care plans were not followed. Record review of Resident #1's Medical Record revealed the most recent admitted [DATE] post hospitalization . She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits. Record review of Resident #1's MDS with ARD of 04/17/25 revealed under Section GG-Functional Abilities that she was dependent on staff for care that included personal hygiene, dressing upper and lower body.

Based on observation, interview, record review and facility policy review the facility failed to provide a dependent resident with assistance to change clothes prior to going to bed for one (1) of four (4) residents reviewed. Resident #1. Findings Include: Review of the facility policy AM/PM Care dated March 2020 revealed, .Resident's clothing should be changed daily and when soiled. On 04/29/25 at 9:47 AM, an interview with the complainant at the facility revealed that Resident #1, had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. Activities Director revealed that she came into the facility on e Saturday morning and found that Resident #1 had the same clothes on she had worn to dialysis the day before. She revealed that Resident #1 slept in her regular clothes frequently and she had witnesses that also observed this. She revealed that Resident #1 didn't live like that, she didn't sleep in her clothes at night before she came to the facility, and she shouldn't have to now since Resident #1 had pajamas and gowns. She revealed that she reported it to the previous administrator several times and it was never taken care of. She revealed that the facility was Resident #1's home, and it wasn't right to be treated in this manner. An observation on 04/29/25 at 3:15 PM of Resident #1, revealed Resident #1 reclined back in her wheelchair in the Sunroom with other residents present. She was dressed in a purple top, a brown cardigan sweater, a pair of pants and shoes. On 04/30/25 at 9:15 AM, an interview with the complainant revealed that Resident #1 had the same clothes on this morning that she wore to her doctor's appointment yesterday, 04/29/25. She revealed that Resident #1 returned from her appointment yesterday between 11:30 AM and 12:00 PM and came to the dining room to eat with a purple shirt and a brown cardigan sweater. On 04/30/25 at 9:25 AM, an observation revealed Resident #1 lying in bed in her room and she was being assisted with breakfast by a staff member. On 04/30/25 at 9:30 AM, an observation and interview with Resident #1, revealed her lying in her bed in her room. She had a purple top and a brown colored cardigan sweater on. Resident #1 confirmed that she had the same clothes on that she wore to her doctor's appointment the day before and revealed that the aides did not change her clothes before she went to bed last night. Resident #1 confirmed that she didn't like to sleep in her regular day clothes and that she would rather sleep in her bed clothes, her pajamas or gowns and stated, But I wasn't asked. On 04/30/25 at 10:35 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was confused at times, had declined and she could no longer assist herself to bed. RN #1 revealed that Resident #1 required more help to get her clothes changed and ready for bed. She also revealed that she had told staff multiple times to change residents' clothes before helping them to bed. RN #1 revealed that the Certified Nursing Assistants (CNAs) knew they were responsible for getting the residents ready for bed at night and knew better than to make them sleep in their regular day clothes. An interview on 04/30/25 at 10:40 AM with Restorative Certified Nursing Assistant (CNA), revealed that she came in early every morning and nearly every day she observed that Resident #1 was in the same clothes from the day before. During an interview with Resident #1 on 04/30/25 at 10:45 AM with Interim Director of Nursing (DON) present, Resident #1 revealed that they did not change her clothes last night before putting her in bed and confirmed that the staff didn't offer to help her change into her bed clothes. Resident #1 confirmed that regular clothes were not comfortable to sleep in and that she liked to sleep in her pajamas. She revealed that lately she has had to sleep in her regular clothes every night and stated, We don't know no better, we just do it. The Interim DON reassured Resident #1 that she would take care of the issue with the staff. Interim DON revealed that this facility was the residents' home, and they should be able to choose what they wanted to sleep in, and their wishes should be granted. Interim DON confirmed that the CNAs knew it was their responsibility to get the resident clothes changed for bed and to put appropriate bed clothes on them. Record review of Resident #1's Medical Record revealed the most recent admitted [DATE] post hospitalization . She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits. Record review of Resident #1's MDS with ARD of 04/17/25 revealed under Section GG-Functional Abilities that she was dependent on staff for care that included personal hygiene, dressing upper and lower body.

Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound for one (1) of three (3) residents reviewed for wound care. Resident #1. Findings Include: Review of the facility policy Negative Pressure Wound Therapy System, Single Use dated 03/03/2025 revealed The pump may be disconnected from the dressing if there is a requirement to disconnect - such as the need to have a shower An interview on 04/29/25 at 10:00 AM with the complainant revealed that Resident #1, recently had an infected fistula removed from her left arm and she had a wound vac in place. The complainant revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. She revealed that Resident #1 went out to a doctor's appointment this morning and did not have the wound vac canister with her when she left. The complainant revealed that there had been several days that she observed that the wound vac was not hooked up to her, she told the nurse, and they sometimes hooked it up and sometimes they did not. She stated, How is her wound going to heal if they won't do their job and keep it hooked up? She revealed that she shouldn't have to remind them to do their job. An observation on 04/29/25 at 3:15 PM in the Sunroom revealed Resident #1 reclined back in her wheelchair. Her wound vac tubing was attached to the dressing to her left upper arm and there was no negative pressure suction applied and no canister in place. The complainant revealed that Resident #1 returned from her doctor's appointment around 12:00 PM and went to the dining room and ate lunch. The complainant also revealed that Resident #1's wound vac was left off while she was out to her doctor's appointment, she returned to eat lunch and was now in the Sunroom with other residents and stated, Her wound vac has not been on all day. She revealed that the wound vac was supposed to be hooked to suction at all times and the staff knew that. She also revealed that several times last week, she noticed the wound vacuum was not on and she reported it to the nurse. An observation on 04/29/25 at 3:30 PM in Resident #1's room, revealed the wound vac pump located in the corner of the room, it was attached to a pole and was not plugged in. Resident #1 was not in her room. An observation on 04/29/25 at 4:40 PM in the dining room revealed Resident #1 sitting up in her wheelchair. The wound dressing to her left upper arm was intact with the wound vac tubing attached and there was no negative pressure suction hooked to it. An interview on 04/30/25 at 9:02 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was supposed to have her wound vac in use and turned on to suction at all times. She revealed that the wound vac had a battery pack and was supposed to be taken with her to appointments as well. RN #1 revealed that not having the wound vac on and running yesterday was a failure. She revealed that not following the physician orders for continuous negative pressure could cause the fluid to pool, it could prevent the wound from healing and could lead to infection. RN #1 stated, It is doing her (Resident #1) a disservice by not having the wound vac in place as it is ordered. RN #1 confirmed that the wound vac canister should always be attached and hooked to suction unless a wet to dry dressing was applied. She revealed that Resident #1 never complained about discomfort with the wound vac and never refused to have it on, it was just not done. An interview on 04/30/25 at 8:50 AM with Treatment Nurse, revealed that Resident #1's wound vac was supposed to be on at all times and hooked to suction. She revealed that a wet to dry dressing should be applied to the wound site if the wound vac was off and that the wound vac tubing and dressing should never be left on if not hooked to suction. She revealed that Resident #1 went to dialysis every Monday, Wednesday, and Friday and if the wound vac did not go with her, they should apply a wet to dry dressing until she returned. Treatment Nurse revealed that she had noticed the wound vac tubing and dressing on without being hooked to suction several times and had reported it to Interim Administrator herself. She revealed that the wound to Resident #1's left arm was much improved, and she could probably get the wound vac discontinued soon. Treatment Nurse revealed that Resident #1 had her dialysis fistula removed about a month ago, she received antibiotics, and the wound vac was placed. An interview on 04/30/25 at 9:05 AM with Interim Director of Nursing, revealed that it had been brought to her attention by a family member before that the wound vac was not hooked up to suction. She revealed that the wound vac had a battery pack, was portable and there's no reason for it not to be hooked to suction. She revealed that it was the Floor Nurse's responsibility to ensure the wound vac was hooked to suction as ordered. Interim DON revealed that they had an order for continuous suction and an as needed order for a wet to dry dressing to be applied if wound vac was malfunctioning. Interim DON revealed that leaving the wound vac paused and not hooked up to suction all day was a big problem, she revealed that the wound could become infected and stated, the risk is there. Interim DON clarified the PRN (as needed) physician order for the wet to dry dressing and revealed that the wet to dry dressing was supposed to be applied to the surgical wound if the wound vac became dislodged, displaced, or if any problem occurred with the wound vac and she revealed that she would update the order. An interview on 04/30/25 at 10:40 AM with Nurse Practitioner (NP), revealed that Resident #1's wound vac was supposed to be hooked to suction at all times with the exception of one to two hours. If needed. She revealed that if the wound vac was planned to be unhooked from suction for longer than two hours, a wet to dry dressing was supposed to be put on. NP revealed that not appropriately utilizing the wound vac for Resident #1 could cause worsening of the wound because without suction, the fluids would pool and not get suctioned off which could lead to infection or deterioration of the wound. She revealed that the nurses on the hall should be keeping a check on the wound vac's and ensuring they functioned properly and that they were hooked up to suction while in use. An interview on 04/30/25 at 9:15 AM with complainant revealed that Resident #1 returned from her doctor's appointment yesterday between 11:30 AM and 12:00 PM and went straight to the dining room to eat lunch, and Resident #1's wound vac dressing and tubing was in place to her left arm but the wound vac canister with suction was left off. The complainant stated that Resident #1 participated in an activity at 2:00 PM yesterday, then went into the Sunroom with other residents and revealed that the wound vac was still not hooked to suction. Record review of Resident #1's Nursing Orders revealed a wound care order with a start date of 03/31/25 for every Monday, Wednesday, and Friday. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, apply black foam to wound bed only, apply Tegaderm, apply wound vac at 120 mmHg continuous. Record review of Resident #1's Nursing Orders revealed an unscheduled PRN (As Needed) wound care order with start date of 03/31/25. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, and apply NS (normal saline) wet to dry dressing. Record review of Resident #1's Wound/Skin Care Plan dated 03/29/25, revealed that she had a surgical wound to her left upper forearm with interventions that included apply wound vac at 120 mmHg (millimeters of mercury) continuous. Record review of Resident #1's Medical Record revealed the most recent admitted [DATE] post hospitalization . She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits.

Based on interview, record review and facility policy review, the facility failed to properly store medications needing refrigeration in one (1) of two (2) medication storage rooms. Station one (1) Medication Storage Room. Findings Include: Review of the facility policy, Medication Storage with last modified date of 03/14/2024, revealed, It is the policy of (proper name) that all medications should be appropriately delivered and stored. The policy also revealed under Security and Storage that Once the medications are removed from the designated storage area, the medications should remain with the licensed designated individual at all times and should not be left unattended An interview on 04/29/25 at 10:55 AM with Interim Director of Nursing (DON), revealed that they had a small refrigerator in each medication room with a lock box inside where they kept their narcotics that required refrigeration. She revealed that on 04/03/25, Licensed Practical Nurse (LPN) #1 was defrosting one of the medication refrigerators and realized that there was a problem with it. Interim DON revealed that the nurses normally emptied their refrigerators of any medications and locked the medications in the medication carts until the defrosting process was completed. Interim DON revealed that LPN #2 went and retrieved one of the vials of Ativan injectable out of the refrigerator for one of her residents, and left four vials in the locked box inside the refrigerator. Interim DON revealed that LPN # 1 was under the impression that LPN #2 removed all five vials of the Ativan from the refrigerator. She revealed that when the charge nurse realized that the refrigerator was not working properly, she took it out back to have maintenance check it out to see if it needed parts to repair or if it needed to be replaced. The Interim DON revealed that when LPN #2 came back to work, she realized that the refrigerator was gone and then remembered the four vials of Ativan that were left in there. The Interim DON revealed that when they realized the situation, they contacted her (Interim DON) and Interim Administrator, and they wondered where the refrigerator went. Interim DON revealed that they investigated the situation and found that the refrigerator had been transported as scrap to the landfill, and they were not allowed to retrieve it. She revealed that each lock box they kept in the refrigerators had a key that the nurses kept and were not easily accessed. She revealed that on the night this occurred, LPN #2 should have removed all of the Ativan from the refrigerator and locked it up in the medication cart until LPN #1 finished defrosting it. Interim DON revealed that the vials of Ativan were accounted for at end of shift, and it was the next day, they discovered that they were gone. An interview on 04/29/25 at 11:20 AM with Interim Administrator, revealed that they had a refrigerator in one of the medication rooms that malfunctioned, and it was placed on the back dock to be disposed of. Interim Administrator revealed that due to failed communication on the nurses' part, four vials of Ativan were left inside the locked box in the refrigerator, and it was taken as scrap to a landfill and there was no way to get it back. He confirmed that the four vials of Ativan should have been removed from the refrigerator and locked up prior to placing the refrigerator outside to ensure no one else had access to the medication. A phone interview on 04/29/25 at 5:12 PM with LPN #1, revealed that she was working on the night shift of 04/03/25. She revealed that she noticed some water leakage onto the insulin labels and some ice buildup in the refrigerator that was located in the medication storage room at Nursing Station 1. LPN #1 revealed that she took the refrigerator to the shower room to defrost it. She revealed that she knocked the ice off of it and when she plugged it back up, she heard a hissing sound, and she smelled some kind of chemical. LPN #1 revealed that she took the refrigerator out on the back dock to be checked out by maintenance to see if it needed parts ordered or if it needed to be replaced. LPN #1 revealed that the refrigerator in the medication storage room at Nursing Station 1 held lock boxes for halls A, B, and C. She revealed that she had removed the Hall C locked box, and the nurse locked it up in the medication cart. She revealed that there were no medications in the Hall A locked box and that LPN #2 came in while she was defrosting the refrigerator to get Ativan from the Hall B locked box. LPN #1 revealed that this was where the miscommunication came in. LPN #1 revealed that she thought LPN #2 removed all of the Ativan from the refrigerator from Hall C locked box, but she only got one vial of the Ativan for a resident who needed it right then. LPN #1 revealed that they found out the next day that the maintenance guy took the refrigerator off before the narcotic boxes (A and B) were removed. She revealed that the maintenance man didn't know they were in there either. LPN #1 revealed that she should have made sure that all locked boxes and narcotics were removed from the refrigerator before taking it outside and she should not have assumed that LPN #2 had removed them. She confirmed that the medications were not properly stored during that time, and she agreed that leaving the Ativan in the unattended refrigerator was a risk for someone else taking the medications. A phone interview on 04/29/25 at 5:30 PM with LPN #2, revealed that she worked on April 3, 2025, on the night shift. She revealed that on that night, she needed to get a dose of Ativan out of the refrigerator for one of her residents. She revealed that LPN #1 had the refrigerator in the shower room defrosting it, LPN #2 got one vial of Ativan out and left the other four vials of Ativan in there. LPN #2 revealed that LPN #1 said something about the refrigerator, but she thought LPN #1 would put it back in the medication storage room when she finished defrosting it until maintenance could check it out. LPN #2 revealed that it was miscommunication and if she had known that there was a problem with the refrigerator or that it was going to be taken out back, she would have removed all narcotics and locked them up in the medication cart to make sure they were secure. LPN #2 revealed that keeping up with the narcotics was a serious issue and she hated that it happened and agreed that all medications should be properly secured and locked up to prevent them from falling in the wrong hands. Record review of LPN #1's Statement revealed, I was defrosting refrigerator due to ice buildup and when I plugged it back in, I heard a hissing noise that smelled like chemicals. I was transporting the refrigerator outside for ventilation and I gave C hall their narcotics from narcotic box, then B hall nurse (proper name) (LPN #2) came up and said she needed to get hers out for B hall. I was not aware that nurse only got 1 dose out. I took refrigerator to back door and sat outside .The next I heard about it was when (proper name of LPN #2) came to me Saturday night and asked where the fridge was. I looked where I put it and it was gone. DON made aware at this time. Statement was signed by LPN #1 on 04/08/25. Record review of LPN #2's Statement revealed, On April third, 2025 I needed to retrieve an Ativan vial from the Station 1 refrigerator, the charge nurse (proper name for LPN #1) was defrosting the refrigerator in the Station 1 shower room, I retrieved the needed vial and replaced the remaining vials back into the refrigerator narcotic lockbox. During April third shift change I had not been informed that the Station 1 refrigerator had been moved from Station 1 med room and believed that it was still on the premises. The statement was signed by LPN #2 on 04/08/25. Record review of the Controlled Substance Record form revealed there were five vials of Ativan 2 mg/ml in the refrigerator for a resident on B Hall. The record revealed documentation of one vial of Ativan 2 mg/ml signed out on 04/03/25 at 02:58 by LPN #2 with four vials left. Record review of LPN #1 and LPN #2's Time Card Report revealed that they worked on the night shift of 04/02/25 to the morning of 04/03/25. Record review revealed that LPN #1 clocked in on 04/02/25 at 18:36 and clocked out on 04/03/25 at 07:29. LPN #2 clocked in on 04/02/25 at 18:42 and clocked out on 04/03/25 at 07:10 The misplaced 4 vials of Ativan 2 mg/ml for resident on B Hall were credited to the resident's account.

Based on staff interview and record review, the facility failed to submit accurate information into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fourth Quarter 2024 Findings include: Record review of facility policy titled, Staffing Guidelines, undated, revealed, Guidelines for Payroll Based Journal submission: 1. The facility shall submit staffing data to the Centers for Medicare and Medicaid Services (CMS) via CMS's Payroll Based Journal electronic data submission portal. 2. The facility shall submit staffing data in a uniform format according to specifications established by CMS. Record review of PBJ Staffing Data Report revealed the facility had Excessively Low Weekend Staffing for the fourth quarter of 2024. Upon entry into the facility on [DATE] at 9:10 AM, an interview with the Assistant Administrator revealed the facility had not been short staffed during the weekends or the week and he was uncertain why the PBJ report reflected that. He stated he would gather the necessary information for this concern. During an interview on 1/8/25 at 10:35 AM, the Managerial Assistant revealed she was the person responsible for entering the information into the PBJ system. She stated she began this job on 6/3/24, so during the fourth quarter she was new to the position. She revealed the clocking system automatically entered the hourly staff working into the system, but when a salary staff member works outside their normal hours, their time had to be entered manually. She stated the shifts were sufficiently covered during the fourth quarter and she confirmed that since she was new to the position it was likely that the data was not entered accurately. She stated she now had a better system of entering the salary employees' time, but at that time it was very likely it was entered inaccurately. An interview with the Assistant Administrator on 1/8/25 at 10:55 AM, revealed each shift was sufficiently staffed during the fourth quarter. He acknowledged the employee responsible for entering the information into the PBJ system was new to that position. He confirmed that since the facility was adequately staffed, the concern had to be due to the salary employees' time not entered into the system accurately. He confirmed the data entered should reflect the accurate staffing information in the facility.

Based on resident and staff interviews, and facility policy review, the facility failed to honor a resident right to vote in the 2024 election for one (1) of 23 sampled residents. Resident #72 Findings Include: Review of the facility policy titled Resident Rights: Participation in Groups and Activities of Choice with a review date of 2/12/24 revealed under, Procedure: . Residents should be encouraged to exercise their rights to vote in local, state, and national elections. An interview with Resident #72 on 1/8/24 at 8:11 AM revealed she had lived at the facility for over a year and did not get to vote this past election. She explained that she was registered to vote in a different county and had waited for the staff to bring her the necessary forms to complete, but no-one ever did. She revealed she always voted in the past, and it was important for her to continue to do so. An interview with Social Services (SS) on 1/8/24 at 10:10 AM revealed she did not go room to room and speak with the residents individually regarding their desire to vote in the past election. She explained that she spoke with some residents in a resident council meeting and told them, if they wanted to vote, they needed to come talk to her. She revealed Resident #72 did not tell her that she wanted to vote and confirmed that she should have directly spoke with the resident regarding her wishes and acknowledged this was the resident's right to participate and cast her vote. An interview with the Administrator (ADM) on 1/8/24 at 10:43 AM confirmed the facility should have spoken with Resident #72 regarding her desire to vote and ensured she was able to vote. Record review of the Face Sheet revealed the facility admitted Resident #72 on 11/29/23. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/24, revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #72 is cognitively intact.

Based on observation, staff interviews, and facility policy review, the facility failed to provide a clean, safe, and homelike environment as evidenced by bugs in ceiling lights, walls and ceiling in disrepair, blind slats broken and bent, broken wood molding, unclean air/heating unit and floors for six (6) of 67 rooms in facility. Findings include: Record review of facility policy titled, Resident Rights: Dignity and Respect, dated 2/12/24, revealed, To provide the kind of care to our residents that should maintain and enhance their dignity, individuality, and quality of life by the following treatment. a living environment that is safe, clean, and comfortable. During an initial observation on 1/6/25 at 12:10 PM, room A-12 was noted to be in disrepair and had multiple areas of the room that had paint missing on the walls. Several areas of the room were observed that included an area by door measuring approximately eight (8) inches x 6 inches, an area near the bathroom counter measuring approximately four (4) inches x five (5) inches, and other smaller areas scattered around the room that were all missing paint. Approximately 15 dead bugs were observed in the ceiling light fixture and multiple water stains were covering most of the ceiling tiles. The wood molding on the center of the wall approximately shoulder high behind the resident's headboard was broken with a sharp point protruding from the wall surface. The window blinds were noted to be in disrepair with multiple bent and broken slats, along with dust and debris that was noted in the corners of the room and on edges of the floor around the floor molding. On 1/8/25 at 9:30 AM, during an interview and observation of room A-12, the Environmental Service (EVS) Manager confirmed the areas of concern in this room which included missing paint, water stains on ceiling tiles, bugs in light fixture, blind slats bent and broken, floor with dust and debris, and broken wood molding with sharp point that could cause an injury. She stated their process for repairs was for staff to note these concerns and notify her and she would put in a work order for maintenance and this process was not followed for this room. She confirmed the facility failed to maintain the room in good repair and to ensure each resident had a safe, clean, comfortable, and homelike environment. During an interview on 1/8/25 at 11:20 AM, the Assistant Administrator confirmed the environmental and maintenance concerns for this room. He confirmed the facility failed to ensure each resident had a clean, safe, and homelike environment. 45598 ROOM #C-14 An observation in room C-14 bathroom on 01/06/25 at 9:55 AM and on 01/07/25 at 8:30 AM revealed a foul odor was noted. Further observations revealed there was an area measuring approximately one foot by one foot of yellow dried substance on the floor to the right of the commode in the resident's bathroom. An observation and interview with the Assistant Administrator on 01/07/25 at 3:35 PM in Room C-14, revealed that resident rooms and bathrooms were supposed to be cleaned every day. He agreed that the bathroom in room C-14 had an odor and confirmed that there was a dried yellow substance on the floor to the right of the commode. He revealed that he would get housekeeping in to mop it now. An interview with EVS Manager on 01/08/25 at 9:08 AM revealed that all resident rooms and bathrooms were supposed to be cleaned and mopped every day. She revealed that she wasn't sure why the floor in Room C-14 bathroom was missed and stated, That's an issue with me. The EVS Manager confirmed that not mopping the bathroom in Room C-14 was not acceptable and she agreed that the room was not a clean, homelike environment for the resident. She also revealed that she would address this issue with her staff. ROOM #E-3 An observation in Room E-3 on 01/06/25 at 11:45 AM revealed an area approximately two feet by three feet on the wall behind the resident's bed with paint scraped off, sheet rock peeling and an electrical wall outlet cover broken off with the left half missing. An interview with Maintenance on 01/08/25 at 9:00 AM revealed that if staff noticed anything needing his attention in the facility, they put in a work order, and he got to it as soon as he could. He revealed that when he received work orders, he prioritized their needs and addressed the issues as soon as he could. Maintenance revealed that with the age of the building, it was hard to keep up. Maintenance confirmed that the wall behind the bed in Room E-3 was in disrepair and confirmed that the electrical wall socket cover was broken. He revealed that he had not received a work order on that room and would get it taken care of. He also agreed that room E-3 was not a homelike environment for the resident. An observation in Room E-3 and interview with the EVS Manager on 01/08/25 at 9:15 AM, confirmed that the wall behind the head of the bed was in disrepair and in need of painting. She also confirmed that the electrical socket behind the bed was broken and needed to be replaced and revealed that she would put in a work order now. The EVS Manager revealed that any concerns with the building in need of repair were supposed to be reported to Maintenance and if he couldn't fix the problem, he contacted someone from the main unit. EVS Manager stated, This should have been noticed and reported and we'll take care of it. An interview with the Administrator on 01/08/25 at 10:45 AM, revealed that it was the responsibility of anyone who noticed a problem to put a work order in to maintenance. He revealed that this was an older building with challenges and stated, We need to put work orders in and follow up. 47874 ROOM B-7, B-9 AND B-15 An observation of room B-7 on 1/06/25 at 9:30 AM revealed a clear rectangular ceiling light covering with 12 dead brown insects inside. An observation of room B-9 on 1/06/25 at 9:46 AM revealed the outer plastic airflow vent on the air/heat unit was covered in a black and white substance that was in a droplet pattern. An observation of room B-15 on 1/06/25 at 11:51 AM revealed two clear rectangular ceiling light coverings with 15-20 dead brown insects inside. An observation and interview with EVS Manager on 1/8/25 at 9:30 AM revealed housekeeping was responsible for cleaning all the resident rooms every day. She explained that cleaning involved sweeping, mopping, dusting, emptying the garbage and whatever else that was needed. She revealed that the rooms were deep cleaned once weekly, which was a more in-depth cleaning such as wiping down the mattresses. The EVS Manager revealed the facility just started doing angel rounds a couple of weeks ago, which entailed an assigned staff member to every room to do a daily walkthrough and to look for any environmental concerns. She revealed if the residents had a complaint about their room or an issue was identified, a work order must be completed for maintenance to be fixed. She revealed after maintenance resolved the issue, he was required to sign off on the work order to show completion. During a walkthrough of rooms B-7 and B-15, the EVS Manager confirmed the dead insects in the ceiling light covers and stated, That's some kind of bug. She revealed maintenance would be responsible for cleaning the light covers. She explained that any staff member who noticed a concern could have reported the issue. During a walkthrough of room B-9, the EVS Manager confirmed the air/heat unit vents were covered in a black and white substance. She explained it could be coming from a dirty filter. She revealed housekeeping was responsible for cleaning the vents daily with a Swiffer duster, and maintenance was responsible for changing and cleaning the filter. The EVS Manager confirmed her expectations were for the residents to have a clean, safe environment.

Based on record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #1 was free from accident/hazards for (1) one of four (4) residents reviewed, Resident #1, as evidenced by Certified Nurses Assistants transferring Resident #1 from bed to chair without the use of a gait belt resulting in the resident's injury. Findings Include: Review of the facility policy and procedure entitled "Transfer Techniques/Positioning the Patient" revealed, to assist patient from edge of bed to chair, "c. Apply a gait belt. Gait belt should be low and tight." The quarterly Minimum Data Set (MDS) assessment with a reference date of 12/18/2014 revealed extensive assist of two (2) for bed mobility, and total dependence, two (2) person physical assist for transfers. Resident #1 had a BIMS (Brief Interview Mental Status) score of zero (0) indicating severe cognitive impairment. Review of a written statement from CNA #1, dated 2/11/15, confirmed she and CNA #2 were transferring Resident #1 on 2/11/15 from the bed to the wheelchair. The statement read after attempting the transfer three times, Resident #1 almost fell and hit her foot on the side of the chair. An interview on 3/9/15 at 2:30 PM with CNA #1 confirmed a gait belt was not used while transferring Resident #1 from the bed to the wheelchair on 2/11/15. "We didn't use a gait belt that day. We used a pillow case under her knees and lifted up under her arms." CNA #1 confirmed Resident #1 hit her foot on the chair and had a purple-like a bruise. Review of Nurses Notes for Resident #1, dated 2/11/2015 10:15 AM, revealed, "The patient has a skin tear and hematoma to the left metatarsal. The skin tear measures 2.5 x 0.3 cm with a superficial depth. There is a hematoma beneath the skin tear with bruising that radiates on the underside of the lateral left foot. The wound bed is a moist pink tissue with no drainage and a small amount of inflammation. The patient is having a large amount of pain to the site. A dressing was applied." An interview on 3/9/15 at 1:50 PM with Therapy Employee #1 confirmed transferring a resident using a pillow case or towel was not recommended and had not been recommended. Review of Resident #1's face sheet revealed the facility admitted Resident #1 on 09/08/09. [DIAGNOSES REDACTED].

Based on record review, staff interview, and facility policy and procedure review the facility failed to develop a comprehensive care plan for transfer needs for one (1) of four (4) residents reviewed, Resident #1. Findings Include: Record review of Resident #1's Comprehensive Care Plan revealed a problem area addressing the resident's inability to independently perform basic self care due to compression fracture, back hip pain, unsteady gait, [MEDICAL CONDITION]. The approaches included total care with bed mobility, transfers, locomotion, dressing, eating, toileting, hygiene, and bathing. The Care Plan failed to include a plan for the two person transfer technique needed by the resident. An interview with Registered Nurse (RN) #1 on 3/9/15 at 2:10 PM confirmed the Comprehensive Care Plan did not include specific transfer needs for Resident #1. Review of the policy and procedure entitled "Care Plan Policy" revealed, "It is the policy of Baldwyn Nursing Facility that care plans should be properly developed". Review of Resident #1's face sheet revealed the facility admitted Resident #1 on 9/08/09. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) reference date of 12/18/2014 revealed a BIMS (Brief Interview of Mental Status) score of 0 indicating severe cognitive impairment. Extensive assist of Two (2), for bed mobility. Total dependent, two (2) person physical assist for transfers.