Every finding on record at Renaissance Care Center

Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in: 1. The facility failed to ensure refrigerator food items were dated when received, and freezer item were properly sealed on 06/02/26. 2. The Dietary Manager and Dietary [NAME] K failed to wear effective hair restraints during breakfast meal preparation on 06/04/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: 1. Observation of walk-in refrigerator on 06/02/26 at 8:59 AM revealed two packages of cabbage, were not dated when received, and two packages of carrots, were not dated when received. Observation of walk-in freezer on 06/02/26 at 9:02 AM revealed hamburger patties not sealed in the bag in an open box. Interview on 06/03/26 at 9:04 AM with the Dietary Manager revealed the carrots and cabbage must have been taken out of the original box last night, but it should have had a receive date on it. He stated the hamburger patties should be sealed and dietary staff must have forgotten to seal it when they got hamburger patties out last. 2. An observation on 06/04/26 at 7:20 AM revealed the Dietary Manager was wearing a hair restraint with 0.5 inches hair uncovered above both ears while taking hot food temperatures of eggs, gravy, mashed potatoes, grits, sausage, and oatmeal. At 7:38 AM, the Dietary Manager was covering the breakfast meal plates An observation on 06/04/26 at 7:36 AM revealed Dietary [NAME] K had a hair restraint not covering about 0.5 inches near both ears and 0.5 inches of back of hair while he was plating breakfast food for the resident meal trays. An interview on 06/04/26 9:03 AM with Dietary [NAME] K revealed he was not aware his hair restraint was not covering all of his hair. In an interview on 06/04/26 at 9:05 AM, the Dietary Manager stated he thought all of his hair was covered. He stated it was important for all hair to be covered to keep hair out of food and prevent cross contamination. Review of the facility's policy Food Storage last revised March 2019 reflected Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination.4. All food items should be dated with the received date, unless labeled with a readable label from the food vendor.18. Frozen foods.c. Foods must be covered, labeled and dated. Review of the facility's policy Nutrition Services Department Dress Code last revised December 2025 reflected The following are department specific standards:.g. Hair must be covered with a hairnet/bonnet, including bangs. Review of the Food and Drug Administration US Food Code 2022 reflected under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented and systematically organized for one of eight (Resident #61) reviewed for administration. The facility failed to ensure staff documented Resident # 61's wound care on the MAR/TAR, that was provided or declined on 05/05/26, 05/07/26, 05/08/26, 05/12/26, 05/13/26, 05/15/26, 05/19/26, 05/21/26, 05/22/26, 05/25/26, 05/27/26, 05/28,26, 05/29/26, 05/31/26, and 06/03/26. This failure could place residents at risk of not receiving treatments as ordered which could impact the residents' health and recovery. Findings included:Record review of Resident #61's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female admitted [DATE]. She had a BIMS of 7 which indicated she was severely cognitively impaired, had a urinary catheter, and was dependent for all ADLS. Diagnoses included multiple sclerosis (chronic neurological disorder) and pressure ulcer. Record review of Resident #61's care plan initiated 06/10/25 reflected, The resident has a stage 4 pressure ulcer to the right buttock.Interventions. Administer treatments as ordered and monitor for effectiveness. Record review of Resident #61's latest Wound Care physician assessment and orders dated 05/29/26 reflected, .Wound location: right ischium (buttocks).Pressure injury/ulcer-Wound stage: 4-pressure injury.Signs of infection: None.Wound Progress: Wound has decreased in size.clean wound with NS (normal Saline). Pat dry. Mix collagen powder (used in advanced wound care to manage complex, draining, or hard-to-heal wounds) with a few drops of saline, then apply to open wound. Cover with dry dressing. Change daily and prn.follow up at an interval of 1 week. Record review of Resident #61's Electronic Record reflected no evidence that wound care was provided or declined on 05/05/26, 05/07/26, 05/08/26, 05/12/26, 05/13/26, 05/15/26, 05/19/26, 05/21/26, 05/22/26, 05/25/26, 05/27/26, 05/28,26, 05/29/26, 05/31/26, and 06/03/26. During an interview and observation on 06/02/26 at 9:25 a.m. with Resident #61, she stated she was getting daily wound care and stated she thought her wounds were getting better. Resident #61 was observed to have a low air loss mattress and was offloaded with pillows. During an observation and interview on 06/03/26 at 11:09 a.m. of wound care with the Treatment Nurse revealed staff preparing the wound care supplies. The Treatment Nurse and CNA E performed hand hygiene and put on gowns and gloves and positioned Resident #61 on her left side, revealing a small dressing on her right hip dated 06/02/26. The Treatment Nurse stated the residents wound had made significant progress. He stated she originally had 2 wounds on her right ischium that were over a year old, and they had healed one and the other one was slowing healing. He stated the only other wound the resident had was an abrasion on her right kneecap which they were treating with skin prep. The Treatment Nurse removed the old dressing revealing slight amount of serous drainage, he performed hand hygiene and changed gloves and cleaned the wound with normal saline. He changed gloves and performed hand hygiene and applied collagen powder to the wound bed and covered with a dry dressing. Changed gloves, performed hand hygiene and applied triad paste to area surrounding the wound including the healed wound above the current wound. He changed gloves, performed hand hygiene and rolled resident back onto back, cleaned scabbed area on right kneecap and sprayed with skin prep. During an interview on 06/03/26 at 03:20 p.m. with the Treatment Nurse, he stated all of the missing documentation on the MAR/TAR were the days he provided the wound care treatments. He stated he did the treatments as ordered, but admitted his weakness was making sure he documented it on the MAR/TAR. He stated he knew it was important to document the administration of any treatment, otherwise, he had no proof the wound care had been completed. He stated he had worked very hard on the wound care progress, and he had just failed to complete the documentation. During an interview 06/04/26 at 11:25 a.m. with the DON, she stated it was the expectation that all treatments were documented at the time the treatment was provided. She stated the record was the only proof they had that care was provided, and it was the means of communications with the staff on what care had been provided or still needed to be provided. Record review of the facility's policy, Wound Treatment Management, dated December 2025, reflected, .Wound treatments will be provided in accordance with physician orders.Treatments will be documented on the Treatment Administration Record. Review of the facility's policy, Documentation in Medical Record, dated December 2025, reflected, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two of five Residents (Resident #58 and Resident #62) reviewed for quality of care. 1. The facility failed to implement interventions to prevent further decline of Resident #58's contracture to his left hand and arm. 2. The facility failed to implement interventions to prevent further decline of Resident #62's contracture to her right hand and arm. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included:1. Record review of Resident #58's Annual MDS assessment, dated 04/21/26, reflected a [AGE] year-old male with an admission date of 05/13/25. Resident #58 had BIMS score of 7 which indicated he was severely cognitively impaired. He required partial to moderate assistance for personal hygiene and had not refused care. He had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days prior to the assessment.Record review of Resident #58's care plan initiated 05/02/26 reflected, The resident had a cerebral vascular accident (CVA/Stroke) .Goal-The resident will be free from sign/symptoms of complications of CVA .contractures (a permanent tightening or shortening of muscles, tendons that cause joints to become rigid and stiff) .)-Interventions- Activity as tolerated. Out of Bed in chair if tolerated. The contracture to his left hand and arm had not been cared planned and did not address interventions to reduce worsening of the contractures. Record review of Resident #58's physician orders dated 06/04/26 reflected, Occupational Therapy Clarification Order - Skilled Occupational Therapy one time to include education and transfer to restorative care for control of Left upper extremity tone for Medical/Treatment. Verbal Pending confirmation. Order was discontinued on 09/30/25. There were no orders for splints to left hand and arm.Record review of Resident #58's Occupational Therapy Discharge summary dated [DATE] reflected, Diagnosis: Contracture, left hand- Long term goal-met on 05/08/26- Patient will tolerate wearing Left elbow extension and wrist extension splint for up to 4 hours with no adverse skin reactions or redness, demonstrating proper positioning and improved tone management with caregiver assistance as needed.Patient discharged to this long term care facility for continued skilled nurses supervision and care. During an observation and interview on 06/02/26 at 9:20 a.m., Resident # 58 was observed lying in bed. His left hand was contracted with his thumb pushing down toward his palm. No splint was in use. The nails on his left hand were clean, but all of the nail were approximately 1/4 inch in length. Two splints were observed on the resident's chest of drawers beside his bed. Resident #58 stated they used to put a splint on his left hand but stated he thinks they borrowed it for someone else. Resident stated he was not able to open his left hand. During an observation on 06/03/26 at 12:21 p.m. Resident #58 was observed in his wheelchair in the dining room eating lunch. The resident did not have a splint on his left hand or arm. 2. Record review of Resident #62's Annual MDS assessment, dated 03/17/26, reflected a [AGE] year-old female with an admission date of 07/28/22. Resident #62 had BIMS score of 9 which indicated she was moderately cognitively impaired. She required maximum assistance for personal hygiene and had not refused care. She had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). She had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days prior to the assessment.Record review of Resident #62's care plan initiated 09/10/25 reflected, The resident has an ADL self-care performance deficit related to hemiplegia. Has a splint to right arm but will refuse to wear it at times The contracture to her hand had not been cared planned and did not address interventions to reduce worsening of the contractures or who was responsible for splint placement.Record review of Resident #62's physician orders dated 06/04/26 did not reflect any orders for splints to right hand and arm.Record review of Resident #62's Occupational Therapy Discharge summary dated [DATE] reflected, Diagnosis: Contracture, right hand- Discharge reason-discharged per physician or Case manager.Progress and Response to treatment: Patient demonstrated less flexor tone (passive muscle tension in the flexor muscles) .Patient discharged to this long-term care facility for continued skilled nurses' supervision and care.During an observation and interview on 06/02/26 at 9:55 a.m. Resident #62 was observed sitting in her wheelchair at the sink in her room preparing to brush her teeth. Her right hand was drawn into a fist, and she was unable to open her hand. Two splints were observed on a chair by her bed. Resident #62 stated she had been asking for a splint for her arm and some therapy for over 5 months. She stated she wanted to get as much movement back as she could. During an interview on 06/03/26 at 12:20 p.m. with the DON she stated they do not have a restorative program and currently do not have anyone on restorative care. She stated at the moment therapy was placing splints and braces while residents were on therapy, either skilled or part B. She stated she was not aware of any residents that nursing staff were placing splints on. During an interview on 06/03/26 at 2:45 p.m. with LVN A, she stated she was not aware of the residents they were supposed to be putting daily splints on. She stated usually if a resident had splints, they had an order for how long the splint was to be applied and then they were required to assess the skin after removal of the splint. She stated she did not have any resident who currently had orders for splint placement. During an interview on 06/03/26 at 2:50 p.m. with LVN B, she stated she had not been instructed on splint placement on any of the residents. She stated she was not aware Resident #58 or Resident #62 had splints. During an interview on 06/03/26 at 2:55 p.m. with CNA E, she stated she mainly worked hall 100 and 200, but had worked all over the building. She stated she took care of Resident #58 and Resident #62. She stated she saw Resident #62 with a splint on her right arm in the past but had not seen it on her in over a month. She stated she was not aware Resident # 58 had a splint. She stated both of the residents had contracted hands from a stroke. She stated she assumed therapy was responsible for putting the splints on and taking them off the residents. She stated she had not been told they were responsible for putting on splints. She stated they used to have a restorative aide, but they had moved him to transportation. During an interview on 06/03/26 at 3:00 p.m. with CNA D, she stated she had worked at the facility for about 3 weeks. She stated she had not had any instruction or training on placing splints on any of the residents. During an interview on 06/04/26 at 12:20 p.m. with PTA H she stated they were told by the previous Administrator to stop writing restorative care plans for residents who were discharged from therapy because the facility was not providing restorative care. She stated they were not writing any orders for nursing to continue any form of restorative care since this is what they were told. During an interview on 06/04/26 at 12:25 p.m. with OT G she stated they had been instructed not to refer residents for restorative care once they were discharged from therapy since the facility no longer had a restorative aide. She stated Resident #58 and Resident #62 both needed elbow extension and hand splints to prevent further contractures and decline in tone and flexibility. She stated she had discharged Resident #62 from services around January 2026 and had discharged Resident #58 last month (May). She stated they were both tolerating the splints for 4 hours at time and stated that would be what she would have recommended for ongoing daily needs post discharge. She stated she had not been asked to teach any of the aides or nursing staff on splint placement. During an interview on 06/04/26 at 12:30 p.m. with the DON she stated they had a restorative aide but had not had one for several months. She stated therapy had not been letting them know of any needs for ongoing splint placement, and they were only told when a resident was being discharged . She stated all therapy had to do was let them know, and they would write an order for the splint and make sure the staff was trained on the splints. She stated they really did not have a good communication process in place between nursing and therapy. She stated she had recently requested a list of residents with contractures but stated she had not received it yet from therapy. She stated contractures needed to be care planned on any resident and interventions needed to be in place to improve or prevent further decline. During an interview with CNA F on 06/04/26 at 1:22 p.m. he said he used to provide restorative care at the facility. He said he would perform range of motion exercises, walk the residents, and put splints on if they had them, but they pulled him from that and placed him on transportation. He stated it had probably been about a year since he had done any restorative care. He stated he was never asked to train any of the CNAs on what restorative care any of the residents were getting or needed. During an interview on 06/04/26 at 1:40 p.m. with the Regional [NAME] President, she stated she believed there were a lot of miscommunications which resulted in the breakdown between therapy and nursing. She stated the facility no longer had a billable restorative program, but they were still required to provide functional restorative care for any resident who had ongoing needs once discharged from therapy. She stated the risk of not providing those services were decline in the resident mobility and quality of life. Record review of the facility's policy titled, Prevention of Decline in Range of Motion, dated December 2025, reflected, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motions is unavoidable.Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion.Based on the comprehensive assessment, the facility will provide interventions, exercises, and/or therapy to maintain or improve range of motion.This includes, but is not limited to.Specialized rehabilitation, restorative, maintenance.braces or splints.Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for five of 15 residents (Residents #58 , #62, #51, #8, and #4) reviewed for comprehensive care plans. 1. The facility failed to include, in the care plan for Resident #58, his left-hand contracture and interventions to prevent further decline. 2. The facility failed to include, in the care plan for Resident #62, her contracture to her right hand and arm and interventions to prevent further decline. 3. The facility failed to develop care plans for Resident #51's Activity of Daily Living assistance needs, and his antianxiety medication. 4. The facility failed to develop a care plan for Resident #8's contractures in both hands and left elbow contracture. 5. The facility failed to ensure Resident #4's dementia diagnosis was care planned. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and did not represent a person-centered coordination of care.1. Record review of Resident #58's Annual MDS assessment, dated 04/21/26, reflected a [AGE] year-old male with an admission date of 05/13/25. Resident #58 had a BIMS score of 7 which indicated he was severely cognitively impaired. He required partial to moderate assistance for personal hygiene and had not refused care. He had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days prior to the assessment. Record review of Resident #58's care plan initiated 05/02/26 reflected, The resident had a cerebral vascular accident (CVA/Stroke) .Goal-The resident will be free from sign/symptoms of complications of CVA .contractures (a permanent tightening or shortening of muscles, tendons that cause joints to become rigid and stiff) .) Interventions- Activity as tolerated. Out of Bed in chair if tolerated. The contracture to his left hand and arm had not been care planned and did not address interventions to reduce worsening of the contractures. Record review of Resident #58's physician orders dated 06/04/26 reflected, Occupational Therapy Clarification Order - Skilled Occupational Therapy one time to include education and transfer to restorative care for control of LUE tone for Medical/Treatment. Verbal Pending confirmation. Order was discontinued on 09/30/25. There were no orders for splints to left hand and arm. Record review of Resident #58's Occupational Therapy Discharge summary dated [DATE] reflected, Diagnosis: Contracture, left hand- Long term goal-met on 05/08/26- Patient will tolerate wearing Left elbow extension and wrist extension splint for up to 4 hours with no adverse skin reactions or redness, demonstrating proper positioning and improved tone management with caregiver assistance as needed.Patient discharged to this long term care facility for continued skilled nurses supervision and care. During an observation and interview on 06/02/26 at 9:20 a.m. Resident # 58 was observed lying in bed. His left hand was contracted with his thumb pushing down toward his palm. No splint was in use. The nails on his left hand were clean, but all of the nail were approximately 1/4 inch in length. Two splints were observed on the resident's chest of drawers beside his bed. Resident #58 stated they used to put a splint on his left hand, but he believed they borrowed it for someone else. Resident #58 stated he was not able to open his left hand. During an observation on 06/03/26 at 12:21 p.m., Resident #58 was observed in his wheelchair in the dining room eating lunch. The resident did not have a splint on his left hand or arm. 2. Record review of Resident #62's Annual MDS assessment, dated 03/17/26, reflected a [AGE] year-old female with an admission date of 07/28/22. Resident #62 had a BIMS score of 9 which indicated she was moderately cognitively impaired. She required maximum assistance for personal hygiene and had not refused care. She had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). She had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days prior to the assessment. Record review of Resident #62's care plan initiated 09/10/25 reflected, The resident has an ADL self-care performance deficit related to hemiplegia. Has a splint to right arm but will refuse to wear it at times The contracture to her hand had not been cared planned and did not address interventions to reduce worsening of the contractures or who was responsible for splint placement. Record review of Resident #62's physician orders dated 06/04/26 did not reflect any orders for splints to right hand and arm. Record review of Resident #62's Occupational Therapy Discharge summary dated [DATE] reflected, Diagnosis: Contracture, right hand- Discharge reason-discharged per physician or Case manager.Progress and Response to treatment: Patient demonstrated less flexor tone (passive muscle tension in the flexor muscles) .Patient discharged to this long-term care facility for continued skilled nurses' supervision and care. During an observation and interview on 06/02/26 at 9:55 a.m., Resident #62 was observed sitting in her wheelchair at the sink in her room preparing to brush her teeth. Her right hand was drawn into a fist, and she was unable to open her hand. Two splints were observed on a chair by her bed. Resident #62 stated she had been asking for a splint for her arm and some therapy for over 5 months. She stated she wanted to get as much movement back as she could. During an interview on 06/03/26 at 12:20 p.m. with the DON, she stated they did not have a restorative program and currently do not have anyone on restorative care. She stated, at the moment, therapy was placing splints and braces while residents were on therapy, either skilled or part B. She stated she was not aware of any residents that nursing staff were placing splints on. During an interview on 06/04/26 at 12:20 p.m. with PTA H, she stated they were told by the previous Administrator to stop writing restorative care plans for residents who were discharged from therapy, because the facility was not providing restorative care. She stated they were not writing any orders for nursing to continue any form of restorative care since this is what they were told. During an interview on 06/04/26 at 12:25 p.m. with OT G, she stated they had been instructed not to refer residents for restorative care once they were discharged from therapy since the facility no longer had a restorative aide. She stated Resident #58 and Resident #62 both needed elbow extension and hand splints to prevent further contractures and decline in tone and flexibility. She stated she had discharged Resident #62 from services around January 2026 and had discharged Resident #58 last month (May). She stated they were both tolerating the splints for 4 hours at time, and that would be what she would have recommended for ongoing daily needs post discharge. She stated she had not been asked to teach any of the aides or nursing staff on splint placement. During an interview on 06/04/26 at 12:30 p.m. with the DON, she stated she had recently requested a list of residents with contractures, but she had not received it yet from therapy. She stated contractures needed to be care planned on any resident and interventions needed to be in place to improve or prevent further decline. 3. Review of Resident #51's quarterly MDS dated [DATE] reflected Resident #51 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (progressive, inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (high blood pressure) and diabetes mellitus. Resident #51 had a BIMS score of 15 indicating he was cognitively intact. Resident #51 required partial to moderate assistance with most ADLs including showering, dressing and personal hygiene Review of Resident #51's Comprehensive Care plan last revised on 03/12/26 reflected no care plan for ADL assistance. An observation and interview on 06/02/2026 at 9:50 AM with Resident #51 revealed he stated he would like his fingernails trimmed. His nails were half an inch long on left hand, and half an inch on a couple of fingers on right hand. He stated it had been at least a week, but was not sure how long. He stated the podiatrist came out once to see him about 3 months ago. He stated he needed to have his toenails trimmed. An observation and interview on 06/02/2026 at 12:52 PM revealed Resident #51 was lying in bed. CNA J stated Resident #51 needed assistance with ADLs. Record review of Resident #51's consolidated current physician orders and June MAR revealed a physician order dated 03/12/26 of of Buspirone tablet 10 mg - Give 1 tablet orally two times a day for anxiety. An interview on 06/03/2026 at 2:45 PM with LVN I revealed Resident #51 did not have a care plan for his assistance with ADL needs. He stated the care plan helped staff know the resident assistance needs and baseline to know how residents perform their ADLs. He stated the MDS Coordinator was doing care plans, and no longer at facility for about 2 weeks. An interview on 06/04/26 at 10:50 AM with LVN I revealed he could not find the antianxiety medication care planned for Resident #51, and it should have been care planned to address the interventions in place for antianxiety medication management. 4. Record review of Resident #8's face sheet undated reflected Resident #8 was an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (chronic autoimmune disease that affects the brain and spinal cord), paraplegia (partial or complete paralysis of the lower half of the body) and congestive heart failure (condition when your heart can't pump blood well enough to give your body a normal supply). Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 15 indicating she was cognitively intact. Resident #8 was dependent with ADLs. Resident #8 had functional limitation in range of motion of her upper extremity on both sides and lower extremity on one side . Interview on 06/03/2026 at 11:25 AM with Occupational Therapist G revealed Resident #8 had contractures in both hands, and for her right hand, Resident # 8 not able to open 4 out of 5 fingers, and the Resident's left arm was contracted. She stated the last time she worked with Resident #8 was in February 2025 and attempted to encourage Resident #8 to wear splint in right hand and left elbow. She stated Resident #8 did not want to continue therapy, and refused the splints to help with contracture management. An observation and interview on 06/03/26 at 2:43 PM with LVN I revealed Resident #8 lying in bed. She had contracture on right hand with no splint in resident's hand and left elbow, and hand had contractures with no splints. Resident #8 stated she did not want therapy or any splint devices in her hands. An interview on 06/03/26 at 2:45 PM with LVN I revealed Resident #8 had contractures for both hands and a left elbow contracture since admission. He stated she refused therapy and contracture splint devices. He stated Resident #8's contractures and limited range of motion should be care planned. He stated Resident #8's refusal for therapy and contracture splints should be care planned to ensure staff were aware of resident's preferences and put interventions in place for resident preferences. An interview on 06/03/26 at 2:58 PM with CNA E revealed Resident #8 had contractures in both hands and was dependent on staff for ADLs. An interview on 06/04/2026 at 12:46 PM with the DON revealed Regional MDS Coordinators were responsible for completing comprehensive care plans like ADLs and medications based on the MDS assessment. She stated Resident #8 should have been care planned for contractures and limited range of motion. She was aware Resident #8 had refused therapy and contracture splints per her preferences. She stated it was important to care plan resident refusals so their preferences could be followed. She stated ADLs should be care planned to address resident assistance levels and interventions put in place for ADLs. She stated medications like antianxiety should be care planned to ensure interventions in place to monitor medications and their side effect monitoring. 5. Record review of Resident #4's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Cachexia (severe, involuntary weight loss), dementia (decline in thinking and memory skills), Alzheimer's disease (brain disorder slowly destroys memory, thinking skills), and cerebrovascular disease (condition affecting blood flow and the blood vessel in the brain). Record review of Resident #4's MDS assessment, dated 03/11/2026, reflected a BIMS score of 04, which indicated severe cognitive impairment. Section I-Active Diagnoses revealed a diagnosis of Non-Alzheimer's Dementia. Record review of Resident #4's Comprehensive Care Plan reviewed 06/04/2026 revealed no measurable goals and interventions addressed for the care and treatment for Resident #4's dementia diagnosis. During an interview on 06/04/26 at 9:10 a.m., LVN I stated Resident #4's dementia diagnosis was not addressed in the care plan. He stated he was unsure why. He stated there was no Social Worker nor MDS Coordinator that worked at the facility. He stated he addressed changes to the care plan as they arose since taking over the care plan duties three weeks ago. He stated he was not trained on care plans. He stated measurable goals and interventions, pertaining to Resident #4's dementia diagnosis, were important, for staff to know the needs and care of the resident. He stated the MDS Coordinator was responsible for addressing Resident #4's diagnosis in the care plan. Record review of the facility's policy titled, Prevention of Decline in Range of Motion, dated December 2025, reflected, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motions is unavoidable.Based on the comprehensive assessment, the facility will provide interventions, exercises, and/or therapy to maintain or improve range of motion.Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner.A Nurse with the responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercised will be documented in the medical record. Modification to the plan of care will be made as needed. Review of facility's policy Comprehensive Care Plans dated 10/01/25 reflected policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for two of five residents (Resident #58 and Resident #51) reviewed for quality of life. The facility failed to ensure Resident #58 had his nails cut and cleaned. The facility failed to ensure Resident #51's fingernails were trimmed. These failures could place residents, who were dependent on staff for ADL care, at a loss of dignity and a decreased quality of life. Findings include: 1. Record review of Resident #58's Annual MDS assessment, dated 04/21/26, reflected a [AGE] year-old male with an admission date of 05/13/25. Resident #58 had BIMS score of 7 which indicated he was severely cognitively impaired. He required partial to moderate assistance for personal hygiene and had not refused care. He had functional limitation in range of motion both upper and lower extremities on one side. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focus on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days prior to the assessment. Record review of Resident #58's care plan initiated 05/02/26 reflected, The resident had a cerebral vascular accident (CVA/Stroke) .Goal-The resident will be free from sign/symptoms of complications of CVA .contractures.) Interventions- Activity as tolerated. Out of Bed in chair if tolerated. There were no interventions listed for resident's Activity of Daily needs. During an observation and interview on 06/02/26 at 9:20 a.m., Resident # 58 was observed lying in bed. The nails on his right hand had a black/brown substance under all the nails. His left hand was contracted with his thumb pushing down toward his palm. The nails on his left hand were clean, but all of the nail were approximately 1/4 inch in length. Resident #58 stated he was not sure when his nails were last cut. During an observation on 06/03/26 at 12:21 p.m. Resident #58 was observed in his wheelchair in the dining room eating lunch. The nails on his right hand still had black/brown substance under them and had not been trimmed. Resident #58 was observed feeding himself. During an observation and interview on 06/03/26 at 3:00 p.m. with LVN B, Resident #58's fingernails were observed to still have black/brown substance under his nails on his right hand. LVN B stated having dirty nails posed the risk for infections. She stated the nurses were responsible for trimming the diabetic resident's nails, but the CNAs should make sure the nails were clean. She stated they would be cleaned and trimmed today. 2. Review of Resident #51's quarterly MDS dated [DATE] reflected Resident #51 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (progressive, inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (high blood pressure) and diabetes mellitus. Resident #51 had a BIMS score of 15 indicating he was cognitively intact. Resident #51 required partial to moderate assistance with ADLs of personal hygiene. Review of Resident #51's Comprehensive Care plan last revised on 03/12/26 reflected no care plan for ADL assistance. Observation on 06/02/2026 at 9:50 AM with Resident #51 revealed he would like his fingernails trimmed - 1/2 inch long on left hand, 1/2 inch on a couple of fingers on right hand. He stated it had been at least a week not sure how long. He stated podiatrist came out once to see him about 3 months ago. He stated he needed to have his toenails trimmed. An observation and Interview on 06/02/2026 at 12:52 PM, with CNA J revealed Resident #51 stated he would like his fingernails trimmed. CNA J stated she ensured fingernails were cleaned during showers but she did not look at the fingernails to see if the fingernails needed trimming. She could not recall the last time she asked about Resident #51's fingernails trimmed. She stated CNAs were responsible for trimming resident fingernails. CNA J stated nurses were responsible for trimming the nails for resident with diabetes. An interview on 06/04/26 at 9:38 AM with RN C revealed she trimmed fingernails for Resident #51 yesterday after it was brought to her attention by CNA J. She stated charge nurse was responsible for trimming fingernails of diabetic residents, like Resident #51. She stated she did not know the specific policy on how often to check to ensure fingernails were trimmed. She stated she did not know the last time Resident #51's fingernails were trimmed. During an interview with the DON on 06/04/26 at 3:42 p.m., she stated the CNAs should be checking all the residents' nails to ensure they were clean. She stated diabetic residents required the nurse to trim the nails, and the CNAs should be getting the nurse to trim them on the resident's shower days since the nails were softer and easier to trim. The DON stated they should be checking for cleanliness daily to prevent the risk of infections. Review of the facility's policy titled Activities of Daily Living dated 12/01/25 reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices.Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good.grooming, and personal.hygiene.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of eight residents (Resident #39) reviewed for pharmacy services. The facility failed to ensure RN C followed the manufacturer's instructions to keep the needle in Resident #39's skin for 5 seconds to ensure complete administration of the Humalog insulin on 06/06/26. This failure placed residents at risk of not receiving the full dosage of medication. Findings included: Record review of Resident #39's, Face sheet, dated 06/04/26 reflected a [AGE] year-old female with an admission date of 02/01/22. Resident #39 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) Record review of Resident #39's Physician's Orders for June 2026, reflected, Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: .150- 199 = 2u; 200 - 249 = 4u; 250 - 299 = 6u; 300 - 349= 8u; 350 - 399 = 10u;.subcutaneously before meals and at bedtime. with a start date of 12/08/25. During an observation on 06/02/26 at 11:42 a.m. revealed RN C put on gloves and entered Resident #39's room to obtain the resident's blood sugar readings. RN C checked the resident's continuous glucose monitor which revealed a blood sugar reading of 389. RN C returned to the medication cart, reviewed the orders, and stated Resident #39 would get 10 units of Humalog. She pulled the resident's vial of Humalog (lispro insulin) insulin and a U-100 insulin syringe and drew up 10 units of insulin. RN C then sanitized her hands, put on gloves, and entered Resident #39's room. She cleaned the resident's lower left abdomen and inserted the needled, pushed down the plunger and immediately pulled the needle away from the skin without waiting 5 seconds. During an interview on 06/02/26 at 11:55 a.m. with RN C, she stated she was not aware she had to keep the needle in the resident's skin for 5 seconds. She stated she was aware they had to hold the insulin pen for 5 seconds, but she was not aware it was required with the use of an insulin syringe. She stated going forward she would make sure she was holding the needle against the skin for the required amount of time. During an interview on 06/03/26 at 12:55 p.m. with the DON, she stated she was not aware of the guidelines on the amount of time needed to hold the insulin needle in the skin to ensure the resident received the full dose of insulin. She stated she was aware of the insulin pen requiring 5 seconds, but she was not aware it was required with the syringe and needle. She stated the expectation was to follow the manufacture guidelines and stated she would in-service the staff on the proper procedure. She stated she was not sure if they had a policy on Insulin administration. Review of the manufacturer's instructions for Humalog insulin obtained from https://uspl.lilly.com/humalog/humalog.html#u searched on 06/02/26 reflected, .Supplies needed to give your injectiona multiple-dose HUMALOG viala U-100 insulin syringe and needleStep 3:Remove the Needle Shield from the syringe by pulling the Needle Shield straight off. Hold the syringe with the needle pointing up. Pull down on the Plunger until the Plunger Tip reaches the line for the number of units for your prescribed dose.Step 6:Turn the vial and syringe upside down and slowly pull the Plunger down until the Plunger Tip is a few units past the line for your prescribed dose.Step 7:Slowly push the Plunger up until the Plunger Tip reaches the line for your prescribed dose.Check the syringe to make sure that you have the right dose.Do not inject where the skin has pits, is thickened, or has lumpsDo not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skinStep 10:Insert the needle into your skin.Step 11:Push down on the Plunger to inject your dose.The needle should stay in your skin for at least 5 seconds to make sure you have injected all of your insulin dose.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) and 1 of 2 shower rooms observed for infection control. 1. The facility failed to ensure CNA A and CNA B performed hand hygiene between gloves changes while providing incontinence care to Resident #1 and failed to ensure CNA A used the required PPE for Resident #1, who was on enhanced barrier precautions due to a wound on her toe on her right foot, during incontinence care on 08/20/25. 2. The facility failed to ensure staff did not place soiled linens on the floor on the hall 500 shower room on 08/20/25. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record review of Resident #1's face sheet dated 08/20/25 reflected a [AGE] year-old female with an admission date of 07/03/24. Diagnoses included hemiplegia effecting right dominant side (paralysis) and dementia. An observation on 08/20/25 at 09:00 a.m. revealed CNA A and CNA B entering Resident #1's room to provided incontinence care. There was a sign posted outside of the door which indicated Resident was on Enhanced Barrier Precautions. Both staff washed their hands and put on gloves and gown. CNA A uncovered resident and unfastened the resident brief. CNA A then cleaned the resident's front pubic area with several wipes, changing the surface of the wipe with each stroke. Both staff rolled the resident on her side revealing urine had soaked through her brief onto the bottom sheet. CNA A stated she needed to get more linens, removed her gown and gloves, left the room and used the hand sanitizer outside of the room, and went to retrieve linens. CNA B covered the resident while waiting for CNA A to return. CNA A returned to the room with clean linens placed in a plastic bag. CNA A then washed her hands and put on gloves but did not put on a gown. CNA A returned to the bedside, removed the top sheet and blanket, held the soiled linens against her uniform while CNA B opened a plastic bag for her to place the linens in. CNA A then removed the resident brief, revealing she had a large bowel movement. CNA A cleaned the resident's anal area from front to back, removing her gloves with each wipe, retrieving new gloves from the wall container and returning to the bedside to continue with care. After the 3rd trip to retrieve gloves, CNA A then put on a gown. CNA A continued to clean the resident until all the feces had been removed, but stated they would have to clean her front again because she had not been able to get her clean. CNA A removed the soiled brief and rolled the soiled sheet under the resident, revealing the mattress was wet with urine. CNA A took a peri-wipe and wiped down the mattress. CNA A then removed the glove from her right and put on a clean glove with performing hand hygiene. CNA A the placed the clean bottom sheet, draw sheet and a clean brief under the resident and both staff rolled the resident over to her other side while CNA B removed the soiled linen from under the resident, revealing the mattress was wet from urine on that side of the bed. CNA B removed the soiled linens and placed them in a plastic bag. CNA B then removed her gloves, washed her hands and put on clean gloves. CNA B then returned to the bedside and used a peri-wipe to wipe the urine off the mattress, and with the same soiled gloves, pulled the clean sheet and clean brief under the resident. Both staff then rolled the resident onto her back and CNA B provided peri- care, going from front to back and downward toward the clean brief, while still wearing soiled gloves. Both staff then closed the resident's brief. Both staff removed their PPE, gathered the trash, and soiled linens, performed hand hygiene and left the room. In an interview on 08/20/25 at 09:45 a.m. with CBA A and CNA B, CNA A stated she was supposed to do hand hygiene before and after care and stated she should have washed her hands before going from dirty to the clean portion of the resident's care. CNA B stated they were to sanitize their hands between glove changes. CNA B stated she thought she had done that, but then realized after she had cleaned the mattress she now had on soiled gloves. CNA A stated she realized she had forgot to put her gown back on when she returned to the room. Both staff stated anyone who was on Enhance Barrier Precautions required them use a gown and gloves for all direct care to the resident. Both staff stated failing to perform hand hygiene after gloves changes and failing to utilize proper PPE exposed the resident to infections. 2. An observation and interview on 08/20/25 at 11:15 a.m. of the Hall 500 shower room revealed CNA A in the shower room with Resident #2. A sheet, towel and blanket were observed laying on the shower room floor under the sink area. CNA A stated it did not belong to Resident #1. She stated it was laying on the floor when she entered the shower room with Resident #1. CNA A stated they were not supposed to place dirty linen on the floors, but instead were to place them in a plastic bag. She stated putting dirty linen on the floor caused the risk of spreading germs throughout the building. In an interview with ADON C who was also the facility's infection preventionist on 08/20/25 at 03:00 p.m. stated staff were to always perform hand hygiene between gloves changes. She stated they had to perform hand hygiene when going from dirty to clean. She stated any resident who had a wound or any implanted medical device required the use of enhanced barrier precautions to prevent the potential spread of drug-resistant infections. She stated she had just completed an in service on hand hygiene and infection control on 08/08/25 because she had started to see an increase in urinary tract infections. She stated she does spot checks on her daily rounds and will watch the staff provide direct care. In an interview with the DON on 08/20/25 at 4:54 p.m. she stated staff were to change their gloves and sanitize their hands when going from dirty to clean. She stated staff were always required to perform hand hygiene before care and after care and to wear a gown and gloves for direct care for any resident who was on enhanced barrier precautions. She stated the staff had been taught to never place soiled linens on the floor. She stated they do train on infection control during their skills checks and anytime they had any issues with infections in the building. She stated the risk of not adhering to the protocol was increased risk of infections. Record review of the Facility's policy titled, Enhanced Barrier Precautions, dated August 2022, reflected, Enhanced Barrier Precautions (EHPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.EBP employ targeted gown and glove use during high contact resident care activities when contact precautions no not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include.changing linens.changing briefs.EBPs remain in place for the duration of the residents stay or until resolution of the wound.Staff are trained prior to caring for resident on EBPs.Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019, reflected, This facility considers hand hygiene the primary means to prevent the spread of infection.Wash hands with soap(antimicrobial or non-antimicrobial) and water for the following.When hands are visibly soiled.After contact with a resident with infectious diarrhea.Use an alcohol-based hand rub.Soap.and water for the following.Before and after direct contact with residents.Before moving from a contaminated body site to a clean body site during resident care.After removing gloves.Hand hygiene is the final step after removing and disposing of personal protective equipment.The use of gloves done replace hand washing/hand hygiene.Record review of the facility's policy titled, Laundry and Bedding, Soiled, dated September 2022, reflected, Soiled laundry/bedding shall be handled, transported and process according to best practices for infection prevention and control.All used laundry is handled a potentially contaminated using standard precautions.Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used).Contaminated line and laundry bags/containers are not held close to the body or squeezed during transport.

Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 2 (Resident #61 and Resident #23) of 24 residents reviewed for staffing concerns. 1. The facility failed to ensure Residents #61 and #23 received consistent showers/bed baths on their shower days for the evenings of 6 pm to 6 am shift due to staffing issues. 2. The facility failed to ensure sufficient staff to meet resident needs in April 2025. These failures placed residents at risk of not getting needed care and services, a decrease in quality of care and quality of life and/or injury. Findings include: 1. Record review of Resident #61's quarterly MDS assessment, dated 03/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 13, which indicated she was cognitively intact. She had not rejected care and required supervision and touch assistance with showers and baths. Her active diagnoses included diabetes and dementia. Record review of Resident #61's care plan, dated 04/30/25, reflected, [Resident #61] ADL Function (current) .Goals .Will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days .Interventions . set-up, assist, give shower, shave, oral, hair, nail care scheduled and prn . Record review of the facility's undated shower schedule reflected Resident #61 was scheduled for showers on Monday, Wednesday, Friday on the 6:00 PM to 06:00 AM shift. Record review of Resident #61's ADL documentation survey report for March 2025 reflected no showers were provided. No days marked as offered and refused. Record Review of Resident #61's ADL documentation survey report for April 2025 reflected she had received a shower on 04/16/25. No other days were marked as offered and refused. Record review of Resident #61's shower sheets for April 2025 reflected Resident #61 received a shower on 04/11/25 (Friday), 04/14/25 (Monday), 04/16/25 (Wednesday), 04/23/25 (Wednesday). Notation on 04/16/25, reflected, Needs to be moved to AM shower,. There were no shower sheets for March 2025. In an interview and observation with Resident #61 on 04/29/25 she stated she was not getting her showers. She stated they don't come get her for showers. She stated she cannot remember the last time she had her shower and was not sure what her shower days were. Resident was observed to have very oily hair. In an interview on 04/29/25 at 10:35 a.m. with CNA H she stated she just finished giving Resident #61 a shower. She stated she really needed a shower. She stated the resident was a 06:00 p.m. to 06:00 a.m. shower. She stated she thought the resident had been refusing her showers on the PM shift. In an interview with LVN A on 04/29/25 at 04:00 p.m. she stated the CNAs were supposed to complete a shower sheet on every resident who was scheduled for a shower and turn it into them and then they turned the shower sheets into the staffing coordinator. She stated if a resident refused a shower, then the aide and the Nurse had to co-sign off that the shower was reattempted and note the ongoing refusal. She stated she cannot recall any refusal of showers for Resident #61. In an interview with CNA F on 04/29/25 at 05:04 p.m. she stated she worked the 06:00 p.m. to 06:00 a.m. shift. She stated to be honest, they have not been able to get to their assigned showers since they had been so short handed in the last several weeks. She stated by the time they get their first rounds made and people back to bed it is almost 10:00 p.m. and the residents were not wanting their showers that late. She stated in the past 3 weeks they had been working with only 2 aides on the 6:00 p.m. to 06:00 a.m. shift. She stated when they had 3 aides, they were able to get most of their assigned showers done, but they were not able with just 2 aides. She stated CNA G was usually assigned to Resident #61. She stated the resident frequently asked to get her shower. In an interview with CNA G on 04/30/25 at 09:12 a.m. she stated she works the 06:00 p.m. to 06:00 a.m. shift. She stated she had offered Resident #61 a shower, but it was usually after 10:00 p.m. when she had offered, and the resident would refuse because it was too late. She stated this was the time they usually got around to getting to showers since they had been so shorthanded. She stated she had not been turning in a shower sheet or logging it into the computer system when she offered, and the resident refused. Record Review of Resident #23's face sheet undated reflected Resident #23 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (Lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated blood sugar), paraplegia (paralysis of the legs and lower body), parkinsonism (neurological disorders characterized by slowed movements, stiffness and tremors) and peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record Review of Resident #23's Quarterly MDS dated [DATE] reflected Resident #23 had a BIMS of 14 indicating she was cognitively intact. Resident #23 required substantial/maximal assistance with showering/bathing. Record Review of Resident #23's comprehensive care plan undated reflected the following: Resident #23 required extensive to total assistance required with bathing . Frequency of bath/shower was 3 times weekly. Resident #23 will allow bed bath given at times. Record Review of Resident #23's Daily Care Guide printed 04/30/25 reflected Resident #23 required assist x 1 for bath/shower evening shift Tuesday, Thursday, and Saturday. Record Review of facility's shower schedule reflected Resident #23 was a Tuesday, Thursday and Saturday shower from 6 pm to 6 am shift. Record Review of Resident #23's electronic ADL documentation for CNAs from 04/01/25 to 04/25/25 reflected no documentation of bathing for Resident #23. It was blank for bathing, but other ADLs for Resident #23 were captured. Record Review of 100 hall shower sheets for March to April 2025 reflected the following: -dated 03/04/25 by CNA G reflected Resident #23 received a shower. dated 04/02/25 by CNA G reflected Resident #23 refused because it was too late and did not want a shower at night. -dated 04/10/25 by CNA H reflected Resident #23 refused shower. No reason given. -dated 04/17/25 (day shift) reflected Resident #23 received a shower. -dated 04/22/25 (day shift) reflected Resident #23 received a shower. There was no other shower documentation found for Resident #23 for March to April 2025. Observation and Interview on 04/29/25 at 9:13 a.m. revealed Resident #23 was lying in bed with oily hair. Resident #23 stated she was dependent on staff for bathing. She stated she preferred bed baths on her shower days which were Tuesdays, Thursdays and Saturdays in the evenings. Resident #23 stated she did not like getting bed baths at 10 pm because she liked to go to bed early. She stated she recently had talked to the facility staff about changing her showers times so they were not so late and she was told it cannot be changed. She stated she did not refuse bed baths unless it was too late in the evening. She could not recall the last time she was given a bed bath thought it had been a week or two. She stated she was not offered a bed bath at times due to short of staff in the evenings. She stated CNAs tell her they do not have time to give her a bed bath. In an interview on 04/29/25 at 2:18 p.m. CNA N revealed Resident #23 preferred bed baths. She was scheduled for bed baths on Tuesdays, Thursdays and Saturdays on the 6 pm to 6 am shift. She stated Resident #23 received a bed bath twice on day shift last week due to staffing issues on the evening shifts. She cannot recall what date last week she bathed Resident #23. She stated the staffing coordinator, LVN A and LVN I knew about Resident #23 complaints of not getting bed baths on the evening shifts on her scheduled bath days. In an interview on 04/29/25 at 2:29 p.m. with CNA H revealed Resident #23 preferred bed baths and was on the 6 pm to 6 am shift for bed baths on Tuesdays, Thursdays and Saturdays. She stated Resident #23 complained on Sunday (04/27/25) of not getting a bed bath on Saturday (04/26/25). She stated she reported this to LVN I of Resident #23 not getting a bed bath. She stated the ADON and Staffing Coordinator were aware of residents not getting showers on the 6 pm to 6 am shifts. In an interview on 04/29/25 at 2:55 p.m. with the ADON revealed Resident #23 did prefer bed baths. He stated it had not been reported to him that Resident #23 was not getting bed baths on evening shift. The ADON stated he had been the ADON for last 5 days only. He stated he was having to work the floor as a charge nurse to assist with staffing needs. In an interview on 04/29/25 at 3:32 p.m. with CNA C revealed Resident #23 allowed them to give her bed baths. She was not aware of Resident #23 refusing bed baths recently but she worked the day shift. She stated last week on Thursday she gave Resident #23 a bed bath on day shift since they were short staff on evening shifts. She stated for the last month there had been difficulty on evening shifts for residents to get baths and showers due to short staffed. In an interview on 04/29/25 at 3:52 p.m. with LVN A revealed last time Resident #23 was given a bed bath last week but cannot recall which day. She stated Resident #23 preferred bed baths and was unaware of resident refusing bed baths. She stated the 6 pm to 6 am shift had been short staff recently. In an interview on 04/29/25 at 05:03 p.m. with CNA F revealed when they had 3 CNAs from 6 pm to 6 am shift they were able to get all the showers/bed baths completed unless a resident refused. She stated CNA G worked with Resident #23 so she was not sure when Resident #23 received a bed bath or shower. She stated she was not able to get all showers completed on her shift and did not know she should document why showers were not given to residents. In an interview on 04/30/25 at 08:48 a.m. with LVN B revealed she was aware Resident #23 preferred bed baths and was not aware of Resident #23 refusing bed baths. She stated she was an evening shower and if evening shift was not short of staff then residents were able to get shower/baths. She stated she knew day shift would provide Resident #23 her bed baths doing the day sometimes if Resident #23 complained of not getting her bed baths. In an interview on 04/30/25 at 09:15 a.m. with CNA G revealed Resident #23 preferred bed baths on her shift but she could not recall the last time she was given bed bath. She stated the last 3 weeks they have been short on CNAs and have had one less CNA. She stated the charge nurse was aware of residents not getting showered or bathed due to short staff. In an interview with the Staffing Coordinator on 04/30/25 at 10:05 a.m. she stated when a resident was admitted to the facility, they were assigned a shower day and assigned AM or PM showers. She stated the aides work 12 hours shift. She stated they were getting ready to go to 8 hours shifts, but then had several aides quit. She stated when they had 3-4 aides on the 06:00 p.m. to 06:00 a.m. shift they do not have any issues getting showers done. She stated the aides were supposed sign off when the shower had been completed and turn the shower sheets into the nurse. She stated if a resident refused a shower they were supposed to have the nurse co-sign with them. She stated the nurse was supposed to attempt to see if the resident wanted their shower at another time or was simply refusing the shower and document the refusal. She stated she had only been keeping the shower sheets for a month at a time and was not aware until today she was supposed to keep them for a year. She stated Resident #61 had told her yesterday (04/29/25) she was not getting her showers and wanted a shower. She stated she told the aides she needed a shower. She stated she had not been notified Resident #61 was refusing her showers after 10:00 p.m. She stated she had since moved Resident #61 to the day shift shower schedule. She stated on Monday (04/28/25) Resident #23 reported she did not get her bed baths on Saturday. She stated she talked to LVN I of Resident #23's complaint of not getting showers, but she had not followed up with evening night shift nurse LVN A about Resident #23's complaint of not getting her bed bath in the evening shift. She stated she had difficulty getting the shower sheets from night shift. She stated residents not getting showers or baths can lead to skin issues. She stated inadequate staffing could lead to increase in residents' falls and not getting their ADL care. She stated the 6 pm to 6 am shift she stated there were times only 1 CNA was working the night shift. She was not aware if the facility could use agency staffing but she had reached out to Administrator of issues with staffing and assisted in helping her find staff to work from other facilities in the corporation. She stated she did not have consistent CNAs on the evening shifts and tried to have at least 2 CNAs on evening shifts. She stated based on resident census and resident needs she could have 3 full-time CNAs on the 6 pm to 6 am with 2 nurses on the 6 pm to 6 am shift. She stated she reaches out to prn staff and staff who work other shifts to assist with their staffing needs. She stated on 2 pm to 10 pm shift she has 3 nurses. She stated they had hired new staff for 6 pm to 6 am shift, but some have already quit. She stated she had not asked the Administrator about agency staff as an option to assist with staffing. In an interview with CNA E on 04/30/25 at 10:10 a.m. she stated she worked the 06:00 p.m. to 06:00 a.m. shift. She stated she had not been giving any showers on her shift, and stated she was not aware they were supposed to provide showers on the evening shift. In an interview on 04/30/25 at 11:50 a.m. with the Director of Operations stated the Administrator was working on addressing staffing concerns by calling other staff members from other facilities within the corporation to assist with CNAs and nurses. He stated agency was a contingency plan if needed but they had not used agency staff at this facility. He stated he was not aware of resident showers/baths not getting done on the evening shifts due to staffing. He stated the Administrator had hired more staff and the staffing concerns had gotten better than the Administrator first took over. He stated he was covering the facility this week since the Administrator was on leave. In an interview on 04/30/25 at 12:01 p.m. with LVN I revealed Resident #23 preferred bed baths and had voiced to her about not getting her bed baths on evening shift. She stated the facility tried to accommodate and provide bed baths on day shift if they could but this is not always possible with the residents they need to get showered on their shifts. LVN I stated she had reported her concerns to Staffing Coordinator about Resident #23 not getting bed baths on her shower/bath days. In an Interview on 04/30/25 at 12:05 p.m. with the Regional Nurse Consultant reflected she took over the facility about 3 weeks ago and had only been able to come to facility about once a week. She stated the risk to residents not getting showers could place residents at risk of body odor and it was a dignity issue. She stated the previous DON gave her notice on 04/17/25 and did not come back after this date. She stated the facility was in process of hiring a new DON to start in May 2025. She stated she was unaware of any residents not getting their showers or bed baths on their shower days. She stated inadequate staffing concerns could affect the residents' quality of care and quality of life. In an interview on 04/30/25 at 3:55 p.m. with the ADON revealed he worked the 2 pm to 10 pm and 10 pm to 6 am shifts to assist with staffing as a floor nurse. He stated one of the 6 pm to 6 am shifts he worked they were down to only 1 CNA with 2 nurses on the evening shift 6 pm to 6 am shift but could not recall the date. He stated he was the CNA and nurse on his hall. He stated the day shift did not have any issues with staffing. He stated he had to work the floor as a nurse to assist with staffing needs since he was hired in February 2025. In an interview on 04/30/25 at 04:51 PM with the Director of Operations revealed the Administrator was ultimately responsible to ensure adequate staffing to meet resident needs. Record Review of timesheets for Nurses and CNAs for April 2025 reflected the following for 6 pm to 6 am shifts: - 04/01/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 1 CNA until 7:35 PM and 1 CNA from 7:33 pm until 6 AM - 04/03/25 - 2 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/06/25 - 4 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 3 CNAs from 6 pm to 10 pm, 2 CNAs until 11 pm, 1 CNA from 11:00 PM to 6 AM - 04/07/25 - 2 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 3 CNAs from 6 PM to 11:20 PM, 2 CNAs from 11:20 PM to 6 AM - 04/08/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/11/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 11:28 PM, 1 Nurse until 6 AM, 2 CNAs from 6 PM to 8:53 PM, 3 CNAs from 8:53 PM to 9:48 PM, 2 CNAs from 9:48 PM to 6 AM. - 04/12/25 - 3 Nurses from 6 PM to 10 PM, 1 nurse from 10 PM to 6 AM, 3 CNAs from 6 PM to 11 PM, 2 CNAs from 11 PM to 6 AM - 04/15/25 - 2 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/16/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/17/25 - 2 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 10 PM, 1 CNA from 10 PM to 6 AM - 04/18/25 - 1 Nurse from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/19/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/20/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/21/25 - 1 Nurse from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/22/25 - 3 Nurses from 6 PM to 10 PM, 1 Nurse from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/23/25 - 3 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/24/25 - 2 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/26/25 - 4 Nurses from 6 PM to 10 PM, 2 Nurses from 10 PM to 6 AM, 2 CNAs from 6 PM to 6 AM - 04/27/25 - 4 Nurses from 6 PM to 10:00 PM, 2 Nurses from 10 PM to 10:28 PM, 1 Nurse from 10:28 PM to 6 AM, 2 CNAs from 6 PM to 3:08 AM, 1 CNAs from 3:08 AM to 6:00 AM Review of staff sign in sheets for April 2025 reflected the ADON worked on 04/07/25, 04/08/25 and 04/18/25 the 2 PM to 10 PM shift as a nurse. It reflected on 04/11/25, 04/14/25 and 04/17/25 ADON worked the 10 pm to 6 am shift as a nurse. Review of facility's policy Staffing last revised April 2007 reflected Our facility provides adequate staffing to meet needed care and services for our resident population. 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and service are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan .Inquires or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure stove grease trap was cleaned and emptied. 2. The facility failed to ensure cold food temperatures were at or below 40 degrees F for 3 menu items for lunch on 04/28/25. 3. The facility failed to ensure hot food temperatures were taken and were above 135 F for menu items for lunch on 04/28/25. 4. The facility failed to ensure Dietary Manager wore a facial restraint for his mustache during lunch meal preparation on 04/28/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings include: 1. Observation on 04/28/25 at 9:32 AM revealed the stove grease trap had black sticky substances covering the bottom about 1 inch thick and had with food debris. Interview on 04/28/25 at 9:33 AM with the Dietary Manager revealed he had last emptied and cleaned out stove grease trap 2 days ago. He stated he emptied it every 2 days or more often if it gets full before then. Review of facility's policy Cleaning Ranges dated 11/03/04 reflected The cook on each shift is responsible for keeping the range as clean as possible during the meal preparation. The range will be cleaned after each use. Spills and food particles will be wipes as they occur. 2. Observation on 04/28/25 at 12:06 PM revealed the Dietary Consultant used the thermometer to take the food temperature of pico de gallo which was 52 F while the pico de gallo was on the steam table in a container with ice under it. Observation and Interview with the Dietary Consultant revealed she put more ice under the pico de gallo and lettuce containers to cool them down. At 12:27 PM, Dietary Consultant re-temped the pico de gallo which was on the steam table in container with ice under it, the food temperature was at 49 F degrees. Observation on 04/28/25 at 12:14 PM revealed the Dietary Consultant used the thermometer to take food temperature of pureed pico de gallo which was on steam table in container with ice under it, the food temperature was 43 F degrees . The Dietary Consultant did not take the food temperature of the pureed pico de gallo prior to serving for lunch meals. Observation on 04/28/25 at 12:28 PM revealed the Dietary Consultant used the thermometer to take food temperature of lettuce which was on steam table in a container with ice under, it was 48 F degrees. Interview on 04/28/25 at 12:29 PM with the Dietary Consultant revealed the lettuce and pico de gallo should be served at 40 F or below. She stated she had ice under the containers to keep them cool. Observation on 04/28/25 at 12:31 PM revealed the Dietary Consultant started plating food for lunch including pico de gallo. At 12:33 PM, lettuce was put on resident plate for lunch. The Dietary Consultant did not take any food temperatures of the lettuce and pico de gallo which were both on the steam table with ice under their containers to ensure temperatures were below 41 for serving. Record Review of the facility's production recipe Pico de Gallo from US Food/Blue Print Menu Management System undated reflected to hold or serve cold food at or above 40 degree F. Record Review of the facility's production recipe Lettuce Shredded and Diced Tomato from US Food/Blue Print Menu Management System undated reflected to hold or serve cold food at or above 40 degree F. 3. Observation on 04/28/25 at 12:57 PM revealed a 2nd batch of enchiladas came out of the stove. The Dietary staff failed to take food temperature of the enchiladas prior to serving. The Dietary Consultant started scooping the enchiladas and placing it on residents lunch plates. Observation on 04/28/25 at 1:10 PM revealed a 2nd batch of beans was cooked on oven stove. The Dietary staff failed to take food temp of beans. The Dietary Consultant used a scoop to place beans in bowl and then placed the bowl of beans on resident meal trays. Observation on 04/28/25 at 1:35 PM of lunch test tray revealed the lettuce was warm. The beans were lukewarm. Interview on 04/28/25 at 1:46 PM with the Dietary Consultant revealed she was aware the food temperature of the beans should be served at 135 degrees F or higher, enchiladas at 135 degrees F or higher. She stated the pico de gallo and lettuce should have had the food temperatures taken and be within proper temperatures prior to serving for cold foods. She stated she did not obtain the food temperatures of enchiladas and beans prior to serving and should have taken the food temperatures. Record Review of the facility's production recipe Enchilada Beef from US Food/Blue Print Menu Management System undated reflected to hold or serve hot food at or above 140 degree F. Record Review of the facility's production recipe Beans Seasoned from US Food/Blue Print Menu Management System undated reflected to hold or serve hot food at or above 140 degree F. Record Review of the facility's policy Food Temperatures dated September 2010 reflected The Dining Services Director/designee shall check food temperatures routinely. PROCEDURE: 1. All hot and cold food items must be served to the Resident at a palatable temperature. All hot food must be held at a minimum of 145 degrees Fahrenheit. 2. All cold food items must be held at 40 (degrees) F or below .Food temperatures must be taken prior to placing on the steamtable/trayline .8. Temperatures should be taken periodically to ensure hot foods stay above 145 (degrees) F and cold foods stay below 40 (degrees) F all during the trayline period. Record Review of Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-501.19 Time as a Public Health Control. (A) Except as specified under (D) of this section, if time without temperature control is used as the public health control for a working supply of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD before cooking, or for READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is displayed or held for sale or service . (B) If time without temperature control is used as the public health control up to a maximum of 4 hours: (1) Except as specified in (B)(2), the FOOD shall have an initial temperature of 5 C (41 F) or less when removed from cold holding temperature control, or 57 C (135 F) or greater when removed from hot holding temperature control. 4. Observation on 04/28/25 at 12:52 PM the Dietary Manager was cutting up onions with no facial restraint for mustache. At 1:03 PM, the Dietary Manager put fruit in a cup for resident lunch with no facial restraint to cover the mustache. Interview on 04/28/25 at 01:48 PM with the Dietary Manager revealed he was not aware he needed to wear a facial hair restraint for his mustache. He stated he was only aware he needed a beard restraint if he had a beard. He was not aware of facility's specific policy on facial restraints. Follow-up interview on 04/30/25 at 2:43 PM with the Dietary Manager revealed he had only been working at facility about 1.5 months. He stated the importance of effective hair and facial restraints were to keep hair out of food. Review of the facility's policy Nutrition Services Department Dress Code last revised April 2019 reflected All employees will be require to abide by [corporate] minimum dress code standards, as detailed in the Staff Guidelines-Dress Code/Uniform Policy. The following are department specific standards: .j. Facial hair must be covered by a beard restraint. Review of the Food and Drug Administration Food Code, dated 2022, reflected, 2-402.11 Effectiveness. (Hair Restraints) .1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.

Based on observation, interview and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for two of seven residents (Resident #171 and Resident #21) reviewed for quality of care. 1. The facility failed to ensure LVN A followed physician ordered water flushes between each medication administration given via the G-Tube for Resident #171 on 04/28/25. 2. The facility failed to ensure LVN J followed physician ordered water flushes between each medication administration given via the G-Tube for Resident #21 on 04/28/25. These failures could place residents at risk of nausea, shortness of breath and a decrease potential fluid overload. Findings include: 1. Record review of Resident #171's face sheet dated 04/30/25 reflected a [AGE] year-old male with and admitted [DATE]. Diagnoses included dysphagia (difficulty swallowing), cerebral vascular accident (stroke), atrial fibrillation (irregular, rapid heartbeat) and gastroesophageal reflux (condition where stomach contents back up into the esophagus. Record review of Resident #171's Nurse Admission assessment dated [DATE] did not address Resident #171' g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #171's base line care plan with an effective date of 04/23/25 did not address Resident 171's g-tube status. Record review of Resident #171's April 2025 Physician order sheet report reflected, .Flush G-tube with 50 cc water before and after medication administration .Medication water Mix-May mis and flush each med with 5-10 ml of water . with a start date of 04/23/25. Record review of Resident #171's Medication administration record for April 2025 reflected, Flush G-tube with 50 cc water before and after medication administration .Medication water Mix-May mis and flush each med with 5-10 ml of water . with a start date of 04/23/25. An observation on 04/28/25 at 01:30 p.m. of G-Tube medication administration revealed LVN A prepared medication for Resident #171. LVN A placed 1/2 tablet Baclofen 10 mg (muscle relaxant), 1 tablet of Hydrocodone-acetaminophen 10-325 mg (opioid for pain), and Sucralfate 1 gram tablet (used to treat/prevent ulcers) and placed them in and individual cup and crushed each tablet. LVN A placed the 3 medication cups and a cup filled with approximately 8 ounces of water on a tray and entered the resident's room. LVN A poured approximately 10 cc of water into each medication cup and the then retrieved a 60-cc piston syringe and placed the piston syringe into the G-tube connector and checked for residual. LVN A then flushed the G-tube with 50 ccs of water and then administered the first medication by gravity and flushed with 50 cc of water after the first medication. LVN A then capped the G-Tube and went to the sink to retrieve another full glass of water. LVN A reconnected the piston syringe to the G-Tube and flushed the tube again with another 50 cc of water and then administered the second medication followed by another 50 cc of water. LVN A then administered the last medication and flushed again with 50 cc of water. LVN A then reconnected the feeding tube and turned the pump back on. In an interview with LVN A on 04/28/25 at 01:45 p.m. she stated she was required to flush the G-tube with 50 cc of water before and after each med pass. When LVN A looked at the medication administration record, she stated oh it was supposed to be 10 ml of water after each medication. She stated she misread the orders when she saw the order for flush with 50 cc of water before and after mediation administration, she assumed it meant after each individual medication, not the beginning and end of the medication administration. She stated she should not have assumed and was required to review with physicians' orders prior to giving any medication and clarify if it was not clear. She stated not flushing with the prescribed amount of water could result in possible fluid overload. 2. Record review of Resident #21's quarterly MDS assessment, dated 04/15/25, reflected a [AGE] year-old female with an admitted [DATE]. Resident #21 had BIMs score of 15 which indicated she was cognitively intact. She was totally depended on all ADL and always incontinent of bowel and bladder and she received 25% or more of total calories through a feeding tube. Diagnoses included dysphagia (difficulty swallowing), cerebral vascular accident (stroke), and diabetes. Record review of Resident #21's Care Plan, with an effective date of 09/20/21 to present, reflected, . [Resident #21] has g-tube due to past problems with dysphagia. She refused to swallow her pills and request all medications to be given via G-tube but does not take feeding. Eats orally .Goals .will be free from complications with G-tube and will remain free from signs and symptoms of infection or breakdown . Record review of Resident #21's April 2025 Physician order sheet report reflected, .Flush G-tube with 50 cc water before and after medication administration .Medication water Mix-May mis and flush each med with 5-10 ml of water . with a start date of 10/25/21. Record review of Resident #21's Medication administration record for April 2025 reflected, Flush G-tube with 50 cc water before and after medication administration .Medication water Mix-May mis and flush each med with 5-10 ml of water . with a start date of 10/25/21. An observation on 04/28/25 at 04:40 p.m. of G-Tube medication administration revealed LVN J prepared medication for Resident #21. LVN J placed Atorvastatin 40 mg 1 tab (used to treat high cholesterol), Metformin 850 mg 1 tab (treats diabetes), and placed them in and individual cup and crushed each tablet. She then poured 6 ml of Gabapentin 250 mg/ 5 ml in a medication cup. LVN J then diluted each medication with 10 ml of water and placed the 3 medication cups and a cup filled with approximately 8 ounces of water on a tray and entered the resident's room. LVN J then retrieved a 60-cc piston syringe and placed the piston syringe into the G-tube connector and checked for residual. LVN J then flushed the G-tube with 50 ccs of water and then administered the first medication by gravity and flushed with 20 cc of water. LVN J repeated the process with the next 2 medications, flushing each time with 20 cc after each medication. In an interview with LVN J on 04/28/25 at 04:40 p.m. she stated she was required to flush the G-tube with 50 cc of water before and after each med pass and then 20 cc of water between each medication. When LVN J looked at the medication administration record, she stated oh it was supposed to be 10 ml of water after each medication. She stated she misread the orders and swore it was 20 ccs. She stated she was required to review with physicians' orders prior to giving any medication. She stated not flushing with the prescribed amount of water could result in possible fluid overload if someone was on fluid restrictions. In an interview with the Regional Nurse Consultant/DON on 04/28/25 at 4:55 p.m., she stated staff were to always to follow the docts' orders on the amount of fluid to flush before and after medications. She stated failing to follow the orders could result in complication with the G-tube and discomfort to the resident. She stated flushing with the too much water could cause fluid overload. She stated all nurses were skills checked prior to G-tube medications administration and were expected to follow the physician ordered flushes. She stated any time a nurse questioned an order it was their responsibility to clarify the order. She stated they would be doing follow up monitoring to ensure staff were following proper procedures. Record review of the facility's policy, Medication Administration through a Feeding Tube, dated May 2012, reflected, .Dilute liquid medications with 10 -30 cc of water (or as ordered by the physician) and dissolve or suspend crushed medications in 5-10 cc (or as ordered by the physician) .Flush feeding tube with at least 30 cc of water. Pour medication into 60 cc syringe. Allow mediation to flow from syringe into tube. Flush the tube with 5-10 cc of water (or as ordered by physician) between each medication. After all medications have been administered, flush syringe with at least 30 cc of water to assure complete dose of medication will be administered. Clamp tubing and detach syringe .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for two of three (Resident #170, and Resident #52) reviewed for respiratory care. 1. The facility failed to have Physician orders for the use of Oxygen and the amount to be administered to Resident #170 upon her admission to the facility on [DATE]. 2. The facility failed to have Physician orders for the use of Oxygen and the amount to be administered to Resident #52 upon his re-admission to the facility on [DATE]. These failures could place residents at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity (occurs when the body inhales too much supplemental oxygen which can damage the lungs and affect the central nervous system). Findings include: 1. Record review of Resident #170's face sheet, dated 04/30/25, reflected a [AGE] year-old female with an admitted [DATE]. Resident #170 had diagnoses which included acute cystitis with hematuria (bladder infection accompanied by blood in the urine, pneumonia (infection that inflames the air sacs of the lungs) and chronic respiratory failure with hypoxia (condition where the body's respiratory system is unable to effectively provide enough oxygen to the blood, leading to low blood oxygen levels). Record review of Resident #170's Nursing Admission Assessment, dated 04/21/25 completed by RN L and LVN K, reflected, Primary Admission diagnosis- Acute cystitis .Orientation .Alert and oriented x 4 .had non-labored shortness of breath with exertion .diminished breath sounds bilateral lungs and was on continuous oxygen Record review of Resident #170's hospital discharge orders dated 04/21/25, reflected, .Portable oxygen .Nasal Cannula with Activity at 2 L/Min . Record review of Resident #170 Nurse progress note, dated 04/21/25 by LVN K, reflected Resident arrived with family to facility after being discharged from the hospital in [city name]. Resident is A&O x 4. Able to make needs and want known .Respirations even and unlabored. O2 @ 92 % on 3L. Resident does use a CPAP (continuous positive airway pressure used to deliver a steady stream of pressurized air through a mask worn over the nose or mouth during sleep). Machine set up for resident to use this evening Record review of nurse progress note, dated 04/22/25 by LVN A, reflected Skilled nursing Respiration even non-labored O2 at 3 lpm via NC . Record review of Resident #170's base line care plan completed by LVN A on 04/24/25 did not reflect the resident needed for continuous oxygen. Record review of Resident #170's Physician Order Summary for April 2025 on 04/28/25 reflected no orders for Oxygen. An observation and interview with Resident #170 on 04/28/25 at 09:55 a.m. revealed the resident lying in bed. Resident #170 was receiving oxygen at 3 liters per minute via a nasal cannula. The resident stated she had recently discharged from the hospital and was on antibiotics for about 2 weeks. She stated she was on oxygen since admission to the facility and used oxygen prior to her hospital stay. She stated she was using 3 lpm at home. Observation and interview of Resident #170 on 04/29/25 at 10:15 a.m. revealed the resident was up in her wheelchair with O2 via nasal cannula. A portable oxygen tank was attached to the back of the wheelchair and was set to deliver 3 liters per minute. In an interview on 04/29/25 at 10:20. a.m., LVN I stated any resident who received oxygen had to have a physician's order for oxygen and the amount to administer. She stated she had not noticed there were no orders for the Oxygen for Resident #170. She stated she had been on oxygen since her admission. She stated the admitting nurse (LVN A) was responsible for obtaining the admission orders when a new resident came into the facility. She stated Oxygen was considered a medication and a nurse could not provide it without an order. She stated giving to much oxygen or providing oxygen that was not needed could make the residents breathing worse. She stated 2 nurses reviewed admission orders to make sure they did not miss any orders at the time of admission, and then the DON or ADON reviewed the admission orders the next day. She stated she would add the oxygen orders today. In an interview with LVN A on 04/29/25 at 11:00 a.m., she stated she started the admission on Resident #170 and put the medications in the system but had not seen the order for the oxygen. She stated the resident came in right around the end of her shift and the oncoming nurse (LVN K) was from a sister facility. She stated she assumed they completed the admission. She stated she had not noticed the resident did not have an order for oxygen. She stated all residents who had oxygen had to have an order for the amount to be delivered. Interview with the ADON on 04/29/25 at 11:30 a.m., he stated they were reviewing new admits in the morning stand up meetings but had not gone line by line on reviewing hospital discharge orders to ensure all the orders were captured. He stated if the hospital discharge orders did not address how much Oxygen a resident required, they had to clarify it with the physician to determine the amount and frequency the Oxygen was to be delivered. He stated giving to much Oxygen could be toxic to a resident. Record review of Resident #170's updated Physician Order Summary for April 2025 reflected, Oxygen (O2) at 2 L/min per nasal canula. With a start date of 04/29/25. 2. Record review of Resident #52's face sheet, dated 4/30/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included acute respiratory failure with hypoxia (a condition in which the body doesn't receive enough oxygen), Chronic Obstructive Pulmonary Disease (lung disease involving long-term poor air flow), and Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Record review of Resident #52's electronic medical record reflected he had no MDS completed as of 04/30/25. Record review of Resident #52's care plan, with an effective date of 02/07/25, did not indicate the resident had a need for oxygen. Record review of Resident #52's hospital discharge orders, dated of 4/24/25, reflected .Discharge Instructions .Diagnosis: Hypoxia - Chronic .Special Notes: Patient is to have 2 L nasal cannula oxygen as needed for low pulse ox Record review of Resident #52's April 2025 Physician Order Sheet on 04/29/25, reflected no physician orders for continuous and/or as needed oxygen supplement. Record review of Resident #52's Nurse progress note, dated 04/23/25 by LVN A, reflected Resident #52 was sent to the hospital. Record review of Resident #52's electronic medical record reflected there was no Nurse Admission Assessment for Resident #52 or Nurse's admission note for 4/24/25. Record review of Resident #52's progress note, dated 4/25/25 at 9:00 a.m., by LVN A, reflected Resident lying in bed took all medications this morning, pleasant, cooperative. No behaviors at this time. Resident O2 sat 76% RA (room air) SN applied O2 sat increased to 95% Observation and interview of Resident # 52, in his bedroom, on 4/28/25 at 9:44 a.m. revealed an oxygen concentrator running. The nasal cannula was laying on the bed. Resident #52 stated a nurse had turned on the oxygen for him. Resident #52 proceeded to grab the cannula and put it on his face. Observation of the oxygen tubing revealed a date of 4/26/25. In an interview with LVN A on 4/29/25 at 12:32 p.m. she revealed Resident #52 had not normally used oxygen but after his last hospitalization it was recommended due to him having been diagnosed with Hypoxia. Resident #52 had not kept his oxygen on when she administered it to him. When asked to provide an order for the oxygen, LVN A was unable to locate one. She stated the risk of the resident receiving oxygen without an order could be an increase in carbon monoxide, which could cause him more damage. Interview with the ADON on 4/29/25 at 1:04 p.m. revealed the resident had not required oxygen initially but had come back from this last hospitalization with oxygen. Interview with LVN B on 4/30/25 at 9:03 a.m. revealed if a resident was discharged from the hospital with an order for oxygen the order needed to be in the electronic system. The risk to the resident of not having had an order was the resident may not receive the required treatment they needed which in turn could result in O2 saturation dropping and they could become disoriented and possibly die. In an interview with the Regional Nurse Consultant/DON on 04/30/25 at 11:50 a.m., she stated any resident who required oxygen had to have an order from the physician which stated the number of liters to be delivered. She stated it was a requirement that the physician determined how much supplemental oxygen someone needed. She stated the nurses were supposed to assess the resident's respiratory status, which included ensuring the Oxygen was delivered at the prescribed rate. She stated giving to much oxygen could lead to Co2 build up and respiratory decline. Record review of the facility's policy titled, Oxygen Administration, dated October 2010, reflected Verify that there is a physician order for this procedure .Before administering oxygen, and while the resident is receiving oxygen therapy, asses for the following .Signs or symptoms of hypoxia .Signs or symptoms of oxygen toxicity .lung sounds .After completing the oxygen setup or adjustment, the following information should be recorded .The date and time that the procedure was performed. The name and title of the individual who performed the procedure. The rate of oxygen flow, route, and rationale, the frequency and duration of the treatment

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of seven residents (Resident #55) reviewed for pharmacy services. The facility failed to ensure Resident # 55's discontinued Lorazepam 2mg/ml was removed from the Refrigerator in the Medication room. These failures could place residents at risk of nausea, shortness of breath and a decrease potential fluid overload. Findings include: During an observation of the facility's one Medication room on 04/30/25 at 11:41 a.m. with the ADON, revealed one medication was observed in the locked compartment of the medication rooms refrigerator. The lock box contained a vial of Lorazepam 2mg/ml for Resident #55. The fill date of the prescription was 07/19/25 with an expiration date 07/19/25. Record review of the Narcotic count sheet for Resident #55's Lorazepam 2mg/ml revealed the last time the medication was administered was on 01/25/24 with remaining amount of 29ml which matched the amount in bottle. In a follow up interview on 04/30/25 at 11:50 a.m. with the ADON, he stated Resident #55's Lorazepam 2mg/ ml was discontinued on 09/09/24. He stated he had pulled the medication and would place it in the DON locked area for drug destruction. He stated all discontinued medication was to be pulled from the stock as soon as it was stopped to prevent staff from inadvertently giving a medication that was no longer needed. He stated the risk of not pulling medication was possibly giving duplicate medications. In an interview on 04/30/25 at 12:04 p.m. with LVN I she stated they were expected to pull any discontinued medication as soon as it was discontinued. She stated the risk of not pulling discontinued medication was someone could give something that had been discontinued or the risk of drug diversion. She stated they had been counting Resident #55's Lorazepam every shift change but never thought to question if it was discontinued. In an interview on 04/30/25 at 12:30 p.m. with the Regional Nurse Consultant/DON she stated discontinued medication should be removed from the cart or medication room immediately, or if it was a narcotic as soon as it could be handed off to the DON for it to be logged and locked up for destruction. She stated the risk of having discontinued medication would be administering medication without an order or the potential for drug diversion. Record review of the facility's policy titled Storage of Medications, dated April 2007, reflected, . The nursing staff shall be responsible for maintaining medication storage The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (Resident #171 and Resident #55) observed for infection control. 1. The facility failed to ensure LVN A used the required PPE for Resident #171, who was on enhanced barrier precautions due to his g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), while administering residents' medication through the g-tube on 04/28/25. The facility failed to ensure Resident #171's room had a sign reflecting she was on enhanced barrier precautions. 2. The facility failed to ensure CNA K performed hand hygiene while providing incontinence care to Resident #55 on 04/28/25 and failed to ensure CNA K and Hospitality Aide D performed hand hygiene before leaving the resident's room. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #171's face sheet dated 04/30/25 reflected a [AGE] year-old male with an admitted [DATE]. Diagnoses included dysphagia (difficulty swallowing), cerebral vascular accident (stroke), atrial fibrillation (irregular, rapid heartbeat) and gastroesophageal reflux (condition where stomach contents back up into the esophagus. Record review of Resident #171's April 2025 Physician order sheet report reflected, .G-tube site care-Check GT site daily for s/s of infection . with a start date of 04/23/25. An observation on 04/28/25 at 01:30 p.m. of G-Tube medication administration revealed LVN A prepared medication for Resident #171. LVN A placed the 3 medication cups and a cup filled with approximately 8 ounces of water on a tray and entered the resident's room. There was no sign posted outside of the door which indicated Resident was on EBP. LVN A performed hand hygiene and put on gloves but did not put on a gown. LVN A turned off the feeding pump, checked for residual and then administered the medication and reconnected the feeding tube and turned the pump back on. LVN A removed her gloves and performed hand hygiene and left the room. In an interview with LVN A on 04/28/25 at 01:45 p.m. she stated any resident with a G-tube was required to be in enhanced barrier precautions. She stated she should have worn a gown and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. In an interview with the Regional Nurse Consultant/DON on 04/28/25 at 02: 45 p.m. she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was supposed to be posted outside to the door, which explains what PPE was to be worn and for what task the PPE is to be worn for. She stated any contact with a resident with a g-tube required the use of gown and gloves. She stated the staff had received numerous trainings on the use of Enhanced Barrier Precautions. Record review of the Facility's policy titled, Enhanced Barrier Precautions, dated August 2022, reflected, Enhanced Barrier Precautions (EHPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBP employ targeted gown and glove use during high contact resident care activities when contact precautions no not otherwise apply .Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include .device care or use ( .feeding tube .)EBPs remain in place for the duration of the residents stay or until resolution .or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for resident on EBPs .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . 2. In an observation on 04/28/25 at 10:29 a.m. CNA C and Hospitality Aide D entered Resident #55's room to provide peri-care and get her up for the day. Both staff washed their hands and put on gloves and gown. CNA C uncovered resident and unfastened the resident brief. CNA C provided catheter care, cleaning down the tube away from the body. CNA C then cleaned the resident's front pubic area with several wipes, changing the surface of the wipe with each stroke. Both staff rolled the resident on her side revealing resident had a small bowel movement. CNA C cleaned the resident's anal area from front to back, removed the soiled brief and her gloves. CNA C then put on new gloves without performing hand hygiene. CNA C placed the clean brief under the resident and both staff rolled the resident over and closed the resident's brief. Both staff rolled the resident onto the mechanical sling and transferred the resident to her wheelchair. Both staff removed their PPE, gathered the trash, and soiled linens and left the room without performing hand hygiene. In an interview on 04/28/25 at 11:10 a.m. CNA C stated she was supposed to change her gloves and perform hand hygiene when she went from dirty to clean. CNA C stated she should sanitize her hands between change of gloves. She stated failing to provide proper care exposed the resident to infections. CNA C and Hospitality aide D stated they were supposed to wash their hands after they finished providing care to the resident and before leaving the room and both stated they had forgot to do that. Both stated the risk for not washing their hands was the spread of germs. In an interview on 04/28/25 at 02:25 p.m. with the Regional Nurse Consultant /DON stated staff were to change their gloves and sanitize their hands when going from dirty to clean. She stated staff were always required to perform hand hygiene before care and after care. She stated they do train on infection control during their skills checks and anytime they had any issues with infections in the building. She stated the risk of not adhering to the protocol was increased risk of infections. Record Review of the Facility's policy titled, Perineal Care, dated October 2010, reflected, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Wash and dry your hands .put on gloves .For female resident .Wash perineal area, wiping from font to back .Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Remove gloves .Wash and dry your hands . Record review of the facility's policy titled, Hand Washing, dated August 2012, reflected, .Hand washing is the single most important means of preventing the spread of infection .After Patient contact .Wash hands with soap and running water .May use Hand sanitizing gel in place of soap and water .

Based on interview and record review, the facility failed to ensure prompt efforts to resolve grievances for 6 (confidential residents) of 13 residents reviewed for grievances. The facility failed to provide a written response to the Resident Council addressing the grievances reported from their meetings on February 2025 and March 2025 which included ongoing issues with call light response times. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Record review of the Resident council meeting notes from February 19, 2025 reflected, .New Business .b. New Concerns: Aids do not answer call lights in timely manner , nurses need to help answer lights, especially emergency lights Record review of the Resident council meeting minutes from March 19, 2025 reflected, .New Business: a. Facility Updates, call lights are no being answered in a timely manner The minutes had no response to the same concern from February 19, 2025. Record review of the Grievance logs for February 2025, March 2025 and April 2025 did not reflect any Grievance filed on behalf of the Resident Council. In an interview with the Lifestyles Director on 4/29/25 at 3:46 PM revealed she recently found out she needed to file a grievance for complaints and concerns at the Resident Council meetings. She stated she had been providing the concerns at the next stand-up meeting after the Resident Council Meeting and would give the Resident Council an update the next time they convened but never filed any grievances on their behalf. She stated as of April's meeting she started to file grievances with the Administrator. The risk to the Resident of not filing a grievance would be that issues would not be resolved timely and could impact their care. An anonymous interview with a resident revealed she attended all the Resident Council meetings since she was admitted to the facility, which had been several years, and staff never provided any feedback on their concerns from previous meetings. She stated they had not gotten a response to their concerns for the call light response times from the last two meetings. She stated she knew the minutes were provided to the Administrator. She stated that the delayed call light had not been resolved and delayed resident care. In an interview with Director of Operations on 4/30/25 at 3:43 PM revealed whenever there was a complaint, a grievance should have been filled out by the staff who received the complaint. That staff should have provided the complaint to the Department Heads who the complaint pertained to. Any complaints at a Resident Council meeting, a grievance should have been filed. Once the grievance was investigated, the staff member who facilitated the next Resident Council Meeting should provide the update on the grievances filed from the previous meeting and what was being done about them. He stated he did not believe there was any risk to the resident of their complaints at the Resident Council Meeting not being filed as a grievance, as residents had multiple opportunities to file a grievance and complaint outside of the Resident Council meetings. Record review of the facility's Grievances, updated on November 2017, reflected Policy .Grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients .Guidelines: 1. The facility must make prompt efforts to resolve grievances and must make information on how to file a grievance or complaint available to the patient. 2. The facility must make information on how to file a grievance policy if requested. 3. When the facility is made aware of a problem or concern voiced by a patient or on behalf of the patient, the facility must make every effort for prompt resolution of all grievance regarding the residents' rights .c. the right to obtain a written decision regarding his or her grievance .4. The following steps should be taken for concern resolution: a. Attempt to solve the problem yourself and check back with the patient to see if they are satisfied with the outcome. B. involve your Executive Director or Director of Nursing Services .&. The executive Director is the designated grievance official for the facility with the Director of Nursing as the designee who is responsible for overseeing: A. The grievance process to include initiation of resolutions within 72 hours of received the grievance. B. the receiving and tracking grievances to their conclusion. C. leading any necessary investigations by the facility .e. issuing written grievance decisions to the Patient/Resident if requested. F. Coordinating with state and federal agencies as necessary in light of specific allegations .8. Any grievance which arises to the level of abuse, mistreatment, or neglect, or injuries of unknown source, and/or misappropriation of resident property shall be reported to the state agency immediately

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Resident #61 and Resident #23) reviewed for ADLs. 1. The facility failed to ensure staff provided consistent showers/baths for Resident #61. 2. The facility failed to ensure staff provided consistent bed baths on 6 p.m. to 6 a.m. shift on Tuesdays, Thursdays and Saturdays for Resident #23. These failures could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: 1. Record review of Resident #61's quarterly MDS assessment, dated 03/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 13, which indicated she was cognitively intact. She had not rejected care and required supervision and touch assistance with showers and baths. Her active diagnoses included diabetes and dementia. Record review of Resident #61's care plan, dated 04/30/25, reflected [Resident #61] ADL Function (current) .Goals .Will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over the next 90 days .Interventions . set-up, assist, give shower, shave, oral, hair, nail care scheduled and prn Record review of the facility's, undated, shower schedule reflected Resident #61 was scheduled for showers on Monday, Wednesday, Friday on the 6:00 p.m. to 06:00 a.m. shift. Record review of Resident #61s ADL documentation survey report for March 2025 reflected no showers were provided. No days marked as offered and refused. Record review of Resident #61's ADL documentation survey report for April 2025 reflected she received a shower on 04/16/25. No other days were marked as offered and refused. Record review of Resident #61's shower sheets for April 2025 reflected Resident #61 received a shower on 04/11/25 (Friday), 04/14/25 (Monday), 04/16/25 (Wednesday), 04/23/25 (Wednesday). Notation on 04/16/25, reflected Needs to be moved to AM shower,. There were no shower sheets for March 2025. In an interview and observation with Resident #61 on 04/29/25 at 08:25 a.m., she stated she was not getting her showers. She stated they didn't come get her for showers. She stated she could not remember the last time she had her shower and was not sure what her shower days were. The resident was observed to have very oily hair. In an interview on 04/29/25 at 10:35 a.m. with CNA H, she stated she just finished giving Resident #61 a shower. She stated she really needed a shower. She stated the resident was a 06:00 p.m. to 06:00 a.m. shower. She stated she thought the resident had been refusing her showers on the PM shift. In an interview with LVN A on 04/29/25 at 04:00 p.m., she stated the CNAs were supposed to complete a shower sheet on every resident who was scheduled for a shower and turn it into them and then they turned the shower sheets into the staffing coordinator. She stated if a resident refused a shower, then the aide and the Nurse had to co-sign off that the shower was reattempted and note the ongoing refusal. She stated she could not recall any refusal of showers for Resident #61. In an interview with CNA F on 04/29/25 at 05:04 p.m., she stated she worked the 06:00 p.m. to 06:00 a.m. shift. She stated they had not been able to get to their assigned showers since they had been so short-handed in the last several weeks. She stated by the time they got their first rounds made and people back to bed it was almost 10:00 p.m. and the residents were not wanting their showers that late. She stated in the past 3 weeks they had been working with only 2 aides on the 6:00 p.m. to 06:00 a.m. shift. She stated when they had 3 aides, they were able to get most of their assigned showers done, but they were not able with just 2 aides. She stated CNA G was usually assigned to Resident #61. She stated the resident frequently asked to get her shower. In an interview with LVN B on 04/30/25 at 08:45 a.m., she stated she was one of the 10 p.m. to 6 a.m. Charge nurses. She stated she had very few residents who were willing to take their showers after 10:00 p.m. She stated if the aides did provide the resident a shower they were supposed to turn in a shower sheet to the Nurse, who signed off and then put the shower sheet under the door of the Staffing Coordinator. In an interview with CNA G on 04/30/25 at 09:12 a.m., she stated she worked the 06:00 p.m. to 06:00 a.m. shift. She stated she had offered Resident #61 a shower, but it was usually after 10:00 p.m. when she had offered, and the resident would refuse because it was too late. She stated this was the time they usually got around to getting to showers since they had been so shorthanded. She stated she had not been turning in a shower sheet or logging it into the computer system when she offered, and the resident refused. In an interview with the Staffing Coordinator on 04/30/25 at 10:05 a.m., she stated when a resident was admitted to the facility, they were assigned a shower day and assigned AM or PM showers. She stated the aides worked 12 hour shift. She stated they were getting ready to go to 8 hours shifts, but then had several aides quit. She stated when they had 3-4 aides on the 06:00 p.m. to 06:00 a.m. shift they did not have any issues getting showers done. She stated the aides were supposed to sign off when the shower was completed and turn the shower sheets into the nurse. She stated if a resident refused a shower they were supposed to have the nurse co-sign with them. She stated the nurse was supposed to attempt to see if the resident wanted their shower at another time or was simply refusing the shower and document the refusal. She stated she had only been keeping the shower sheets for a month at a time and was not aware until today she was supposed to keep them for a year. She stated Resident #61 told her yesterday (04/29/25) she was not getting her showers and wanted a shower. She stated she told the aides she needed a shower. She stated she had not been notified Resident #61 was refusing her showers after 10:00 p.m. She stated she had since moved the resident to the day shift shower schedule. In an interview with CNA E on 04/30/25 at 10:10 a.m., she stated she worked the 06:00 p.m. to 06:00 a.m. shift. She stated she had not been giving any showers on her shift, and she was not aware they were supposed to provide showers on the evening shift. 2. Record Review of Resident #23's face sheet undated reflected Resident #23 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #23 had diagnoses which included chronic obstructive pulmonary disease (Lung disease causing restricted airflow and breathing problems), type 2 diabetes (elevated blood sugar), paraplegia (paralysis of the legs and lower body), parkinsonism (neurological disorders characterized by slowed movements, stiffness and tremors) and peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #23's Quarterly MDS, dated [DATE], reflected Resident #23 had a BIMS of 14, which indicated she was cognitively intact. Resident #23 required substantial/maximal assistance with showering/bathing. Record review of Resident #23's, undated, comprehensive care plan reflected the following: Resident #23 required extensive to total assistance required with bathing . Frequency of bath/shower was 3 times weekly. [Resident #23] will allow bed bath given at times. Record review of Resident #23's Daily Care Guide, printed 04/30/25, reflected Resident #23 required assist x 1 for bath/shower evening shift Tuesday, Thursday, and Saturday. Record review of facility's shower schedule reflected Resident #23 was a Tuesday, Thursday and Saturday shower from 6 pm to 6 am shift. Record review of Resident #23's electronic ADL documentation for CNAs from 04/01/25 to 04/25/25 reflected no documentation of bathing for Resident #23. Record review of 100 hall shower sheets for March to April 2025 reflected the following: -dated 03/04/25 by CNA G reflected Resident #23 received a shower. -dated 04/02/25 by CNA G reflected Resident #23 refused because it was too late and did not want a shower at night. -dated 04/10/25 by CNA H reflected Resident #23 refused shower. No reason given. -dated 04/17/25 (day shift) reflected Resident #23 received a shower. -dated 04/22/25 (day shift) reflected Resident #23 received a shower. There was no other shower documentation found for Resident #23 for March to April 2025. Observation and interview on 04/29/25 at 9:13 a.m. revealed Resident #23 was lying in bed with oily hair. Resident #23 stated she was dependent on staff for bathing. She stated she preferred bed baths on her shower days which were Tuesdays, Thursdays and Saturdays in the evenings. Resident #23 stated she did not like getting bed baths at 10 pm because she liked to go to bed early. She stated she recently talked to the facility staff about changing her showers times so they were not so late and she was told it could not be changed. She stated she did not refuse bed baths. She could not recall the last time she was given a bed bath and thought it had been a week or two. She stated she was not offered a bed bath at times due to short of staff in the evenings . In an interview on 04/29/25 at 2:18 p.m., CNA N revealed Resident #23 preferred bed baths. She was scheduled for bed baths on Tuesdays, Thursdays and Saturdays on the 6 p.m. to 6 a.m. shift. She stated Resident #23 received a bed bath twice last week due to staffing issues on the evening shifts. She could not recall what date last week she bathed Resident #23. She stated the staffing coordinator, LVN A and LVN I knew about Resident #23 complaints of not getting bed baths on the evening shifts on her scheduled bath days. In an interview on 04/29/25 at 2:29 p.m. with CNA H revealed Resident #23 preferred bed baths and was on the evening and night shift for bed baths on Tuesdays, Thursdays and Saturdays. She stated Resident #23 complained on Sunday (April 27) of not getting a bed bath on Saturday. She stated she reported this to LVN I of Resident #23 not getting a bed bath. She stated the ADON was aware of the residents not getting showers on the evening and night shifts. In an interview on 04/29/25 at 2:55 p.m. with the ADON revealed Resident #23 preferred bed baths. He stated it had not been reported to him that Resident #23 was not getting showers on the evening shift. He was not aware Resident #23 was not getting showers. The ADON stated he had been the ADON for last 5 days only. In an interview on 04/29/25 at 3:32 p.m. with CNA C revealed Resident #23 allowed staff to give her bed baths. She was not aware of Resident #23 refusing bed baths recently, but she worked the day shift. She stated last week on Thursday (04/24/25) she gave Resident #23 a bed bath on the day shift since they were short staff on evening shifts. She stated for the last month there was difficulty on evening shifts for residents to get baths and showers due to short staff. In an interview on 04/29/25 at 3:52 p.m. with LVN A revealed the last time Resident #23 was given a bed bath was last week but could not recall which day. She stated Resident #23 preferred bed baths and was not aware of the resident refusing bed baths. She stated the 6 p.m. to 6 a.m. shift had been short staff recently. In an interview on 04/29/25 at 05:03 p.m. with CNA F revealed when they had 3 CNAs in the evening and nights, they were able to get all the showers/bed baths. She stated CNA G worked with Resident #23. She stated she was not able to get all showers completed on her shift and did not know she should document why showers were not given to residents if they were unable to get to them due to staffing. In an interview on 04/30/25 at 08:48 a.m. with LVN B revealed she was aware Resident #23 preferred bed baths and was not aware of Resident #23 refusing bed baths. She stated she was an evening shower and if evening shift was not short of staff, then residents were able to get shower/baths. She stated she knew day shift would provide Resident #23 her bed baths doing the day sometimes if Resident #23 complained of not getting her bed baths. In an interview on 04/30/25 at 09:15 a.m. with CNA G revealed Resident #23 preferred bed baths on her shift, but she could not recall the last time she was given bed bath. She stated the last 3 weeks they were short on CNAs and had one less CNA on evening shifts. She stated the charge nurse was aware of residents not getting showered or bathed due to short staff. In an interview on 04/30/25 at 10:04 a.m. with the Staffing Coordinator revealed on Monday (04/28/25) Resident #23 reported she did not get her bed baths on Saturday. She stated she talked to LVN I of Resident #23's complaint of not getting showers, but she had not followed up with the evening night shift nurse, LVN A, about Resident #23's complaint of not getting her bed bath. She stated she had difficulty getting the shower sheets from the night shift and was not aware she should be keeping them. She stated residents not getting showers or baths could lead to skin issues. She stated inadequate staffing could lead to increase in residents' falls and not getting their ADL care. She stated the 6 p.m. to 6 a.m. shift stated there were times only 1 CNA was working the night shift. She stated she did not have consistent CNAs on the evening shifts and tried to have at least 2 CNAs on evening shifts. She stated based on the resident census and resident needs, she could have 3 full-time CNAs on the 6 p.m. to 6 a.m She stated when she had at least 3 CNAs on the 6 p.m. to 6 a.m. shift showers were getting done and shower sheets were turned in to her. In an interview on 04/30/25 at 12:01 p.m. with LVN I revealed Resident #23 preferred bed baths and had voiced to her about not getting her bed baths on the evening shift. She stated the facility tried to accommodate and provide bed baths on day shift if they could. LVN I stated she reported her concerns to the Staffing Coordinator about Resident #23 not getting bed baths on her shower/bath days. In an interview on 04/30/25 at 12:05 PM with the Regional Nurse Consultant reflected she took over the facility about 3 weeks ago and had only been able to come to the facility about once a week. She stated the risk to residents not getting showers could place residents at risk of body odor and it was a dignity issue. She stated the previous DON gave her notice on 04/17/25 and did not come back after this date. She stated the facility was in process of hiring a new DON to start in May 2025. She stated she was unaware of any residents not getting their showers or bed baths on their shower days. Record review of the facility's policy Activities of Daily Living, dated May 2016, reflected 2. A Daily Care Guide must be prepared from the electronic medical record (EMR) to assist direct care staff in providing assistance to Patients in their activities of daily living .5. CNA ADL Tracking Record must be maintained in accordance with the MDS coding guidelines and specific to the Patient's needs. CNA ADL Tracking Records must be regularly monitored by the DON or the designee to ensure that tasks are being performed as scheduled. 34918

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to the other officials, including to the State Survey Agency, in accordance with State law through the established procedures for one of 7 residents (Resident #66) reviewed for abuse and neglect . The facility failed to report allegations of neglect and abuse which involved Resident #66 to the Administrator and appropriate State Agency immediately on 04/26/25. This failure could place residents at risk of abuse and neglect. Findings Include: Record review of Resident #66's Admission MDS assessment, dated 4/26/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had little to no cognitive impairment and had a BIMs of 15 . Her active diagnoses included coronary artery disease (a heart condition where plaque builds up inside the coronary arteries), Hypertension (elevated blood pressure), Ulcer (the break or erosion in the lining of an organ or tissue), Diabetes (a disease that results in too much sugar in the blood), Thyroid Disorder(a condition that prevents your thyroid from making the right amount of hormones , and wedge compression fracture of first lumbar vertebra, she required some help with self-care to include moderate assistance with toileting and substantial help with bathing. Record review of Resident #66's Admission Assessment, dated 4/25/25, reflected the resident had a catheter, was continent, a high fall risk, and required a retraining program for bowel and bladder. Record review of Resident #66's Daily Care Guide, dated 4/30/25, reflected Resident #66 needed assistance with bathroom, was a fall risk, voiding method was toilet and was continent for urine and bowel. Her transfer needs were 1 person Gait Belt assist and partial lift 1 person assist for sit to stand. Record review of facility's incident logs for April 2025 did not reflect an incident had been documented for Resident #66. Record review of progress notes for Resident #66 on 4/26/25 did not reflect the allegation of abuse and neglect were reported or documented. In an interview with Resident #66's family member on 4/29/25 at 9:43 AM revealed Resident #66 was admitted to the facility on [DATE] for therapy. She reported the night of admission, Resident #66 called for help to go to the restroom and LVN B responded but did not help her. It was reported LVN B laughed at her because Resident #66 had a bowel movement in her pull-up . The family member stated she talked to the weekend supervisor the morning of 4/26/25, and weekend supervisor apologized for the nurse's behavior. The family member reported she decided to discharge Resident #66 from the facility that day due to the incident. In an interview with RN M on 4/29/25 at 3:19 PM revealed she was the weekend supervisor. She spoke to Resident #66 and her relative on 4/26/25 and was told during the night shift, Resident #66 had requested help getting up to go to the restroom. She stated no one helped her and when staff went in they didn't help her and laughed. The resident identified LVN B as the nurse who laughed instead of helping Resident #66. The relative stated Resident #66 had been lying in her poop for over any hour when she arrived. RN M stated when they brought the incident to her attention LVN B had already left. She had not interviewed LVN B or questioned her about the incident. Resident #66 had requested to go home, and she assisted them with Home Health to discharge with the appropriate supports. RN M stated she told the Manager on Duty of the incident and assumed she would take care of reporting it to the Administrator. RN M stated the incident should have been reported to the Administrator. In an interview with the Lifestyle Director on 4/29/25 at 3:46 PM revealed she was the MOD on 4/26/25. She reported RN M provided the complaint from Resident #66 and her relative and she talked to the family and assisted with the discharge. She stated she provided the update on this resident at the stand-up meeting Monday morning. The Lifestyle Director stated she did not know she needed to report it to their abuse coordinator and assumed RN M would have reported it since she was the one who had told her about the complaint. She stated it could have been abuse and therefore should have been investigated . She was not aware that she needed to ensure it was reported as the MOD for the weekend. She stated she believed an email by another staff member was sent to the Administrator about the incident because Resident #66's relative wanted to speak to Administrator. In an interview with Director of Operations on 4/29/25 at 4:03 PM revealed he was covering for the Administrator while he was on vacation. He stated if there was an allegation of abuse or neglect, they would have needed to report it to the abuse coordinator immediately, which would be him while the Administrator is on leave. He stated staff should have been aware of reporting it to him. He stated he did not know about the incident and was barely being made aware of it during this interview. Now that it had been brought up, he would call the family and see if they felt it was abuse and would report it to the state survey agency immediately or within 2 hours and would have taken the following steps: conducted an assessment of the resident, investigated the incident, suspend the alleged perpetrator until the investigation was complete, in-service with staff and completed safe surveys. In an interview with the Regional Nurse Consultant on 4/30/25 at 11:55 AM revealed whoever received a complaint or witnessed the alleged abuse or neglect should have reported it to the abuse coordinator, the Administrator. RN M should have reported the complaint to the Administrator when is happened on 4/26/25. In an interview with the Director of Operations on 4/30/25 at 12:47 PM revealed he contacted Resident #66's relative and received the complaint earlier on 4/30/25. He initiated the abuse/neglect protocol immediately, called in the report to the state survey agency and suspended LVN B until he completed his investigation . He started to in-service staff and conducted safe surveys with residents. Record review of the facility's Abuse and Neglect Policy, updated August 2024, reflected .8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse .9. The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical, or sexual abuse . 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to the State agency and other appropriate authorities' incidents of Patient Abuse as required under applicable regulations and regulatory guidance

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's one medication room reviewed for storage. The facility failed to ensure a vial of TB PPD, that was opened and used, was not dated in the medication room refrigerator. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings included: An observation on 04/30/25 at 11:35 a.m. of the medication room refrigerator with the ADON revealed an undated open vial of Tuberculin Purified protein derivative. The ADON stated it appeared one dose might have been used out of the multi dose vial. In an interview with the ADON on 04/30/25 at 11:41a.m. he stated the TB PPD had to be dated when opened. He stated once it was open it would only be good for 30 days. He stated the risk of not dating it once opened was the potential for false positive or an inaccurate test, which could lead to a missed infection. He stated all the nurses perform the TB skin test on any new admission and whoever opened the vial was responsible for dating it. He stated going forward he would most likely be responsible for checking the medication room for expired medications. In an interview with the Regional Nurse Consultant/DON on 04/30/25 at 11:50 a.m. she stated once a multi-use vial of medication was opened the staff were required to date it. She stated when they open of vial of TB PPD it had to be dated to prevent the risk of using an expired medication which would render it ineffective and could give a false positive reading of the PPD. The Regional Nurse Consultant/DON said all nurses were responsible to check the medication carts and the medication rooms for expiration and labeling of medication. Record review of the facility's policy titled Storage of Medications, dated April 2007, reflected, .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed The nursing staff shall be responsible for maintaining medication storage

Based on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one of 7 residents (Resident #66) reviewed for abuse and neglect. The facility failed to ensure allegations of abuse and neglect were investigated when Resident #66 reported an allegation of abuse and neglect to the facility. This failure could place residents at risk for abuse and neglect . Findings Include: Record review of Resident #66's Admission MDS assessment, dated 4/26/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had little to no cognitive impairment and had a BIMs of 15 . Her active diagnoses included coronary artery disease (a heart condition where plaque builds up inside the coronary arteries), Hypertension (elevated blood pressure), Ulcer (the break or erosion in the lining of an organ or tissue), Diabetes (a disease that results in too much sugar in the blood), Thyroid Disorder(a condition that prevents your thyroid from making the right amount of hormones , and wedge compression fracture of first lumbar vertebra, she required some help with self-care to include moderate assistance with toileting and substantial help with bathing. Record review of Resident #66's Admission Assessment, dated 4/25/25, reflected the resident had a catheter, was continent, a high fall risk, and required a retraining program for bowel and bladder. Record review of Resident #66's Daily Care Guide, dated 4/30/25, reflected Resident #66 needed assistance with bathroom, was a fall risk, voiding method was toilet and was continent for urine and bowel. Her transfer needs were 1 person Gait Belt assist and partial lift 1 person assist for sit to stand. In an interview with RN M on 4/29/25 at 3:19 PM revealed she was the weekend supervisor. She spoke to Resident #66 and her relative on 4/26/25 and was told during the night shift, Resident #66 had requested help getting up to go to the restroom. She stated no one helped her and when staff went in they didn't help her and laughed. The resident identified LVN B as the nurse who laughed instead of helping Resident #66. The relative stated Resident #66 had been lying in her poop for over any hour when she arrived. RN M stated when they brought the incident to her attention LVN B had already left. She had not interviewed LVN B or questioned her about the incident. Resident #66 had requested to go home, and she assisted them with Home Health to discharge with the appropriate supports. RN M stated she told the Manager on Duty of the incident and assumed she would take care of reporting it to the Administrator. RN M stated the incident should have been reported to the Administrator. In an interview with the Lifestyle Director on 4/29/25 at 3:46 PM revealed she was the MOD on 4/26/25. She reported RN M provided the complaint from Resident #66 and her relative and she talked to the family and assisted with the discharge. She stated she provided the update on this resident at the stand-up meeting Monday morning. The Lifestyle Director stated she did not know she needed to report it to their abuse coordinator and assumed RN M would have reported it since she was the one who had told her about the complaint. She stated it could have been abuse and therefore should have been investigated . She was not aware that she needed to ensure it was reported as the MOD for the weekend. She stated she believed an email by another staff member was sent to the Administrator about the incident because Resident #66's relative wanted to speak to Administrator. In an interview with the Director of Operations on 4/29/25 at 4:03 PM revealed that he was covering for the Administrator while he was on vacation. He stated if there was an allegation of abuse or neglect, they would have needed to report it to the abuse coordinator, which would be him, while the Administrator was on leave. He stated he did not know about the incident and was barely being made aware of it during this interview. Now that it was brought up, he would call the family and see if they felt it was abuse and would report it to the state and take the appropriate steps. He stated it would be investigated if the family felt it was abuse . In an interview with the Regional Nurse Consultant on 4/30/25 at 11:55 AM revealed RN M should have reported the complaint to the Administrator when it happened so that it could be investigated and the abuse protocol could be followed. Record review of the facility's Abuse and Neglect Policy, updated August 2024, reflected . immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. C. conduct and document on a Patient Abuse Investigation (see form 3-5) a thorough investigation of each incident or patient abuse, neglect, exploitation or mistreatment to include: observation, interviews and reviews of all patients involved, interviews of all witnesses, including Patients, staff and family members, notify physicians, notify families and responsible parties of the involved patients, recording all relevant physical findings

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three of eight residents (Residents #4, #5, and #6) reviewed for medications and for 1 (nurses cart hall ,d+[DATE]) of 2 medication carts reviewed for pharmacy services in that: 1. The Nurses Cart Hall ,d+[DATE] had 1 insulin pen for Resident #5 with an expired open date of [DATE] and 1 insulin pen for Resident #6 with no open date . Observation of the pen reflected it was not full and it was used. 2. The facility failed to administer Resident #4's Phenobarbital (treats seizures) according to doctor's orders on [DATE] and [DATE]. These failures placed residents at risk of not receiving the therapeutic benefits of the medications. The Findings included: 1. Observation on [DATE] at 09:40 AM of nurses cart hall ,d+[DATE], with LVN F revealed: - The pen of insulin humalog 100 unit /ml for Resident #5 with an expired opened date of [DATE]. - The pen of insulin lantus 100 unit/ml for Resident #6 with no open date . Observation of the pen reflected it was not full and it was used. Interview on [DATE] at 09:35 AM, LVN F stated she did not give insulin to Resident #5 and Resident #6 and she did not check the pen for the open date. LVN F stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective. Interview on [DATE] at 01:42 PM, the DON stated the insulin flex pens and vial, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and she stated she was supposed to do random checks of the medication carts for monitoring. 2. Record review of Resident #4's face sheet, dated printed [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of traumatic brain injury and epilepsy. Record review of Resident #4's Comprehensive MDS, dated [DATE], reflected he had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #4's care plan, undated, reflected he had a history of seizures and was on levetiracetam divalproex with an intervention of give meds per order . Record review of Resident #4's physician orders revealed an order with a start date of [DATE] for Phenobarbital 30 mg tablet, orally, 3 times daily. Record review of Resident #4's nurses progress notes revealed a note, dated [DATE], written by LVN F at 1:28 PM: Medication Phenobarbital did not arrive last night as pharmacy had said, Called pharmacy again spoke with [Pharmacist K] and said it would be delivered tonight. Record review of Resident #4's electronic Medication Administration Record for [DATE], reflected Phenobarbital 30 mg tablet (2 tablets) orally 3 times a day were not administered on: [DATE] at 2 PM, signed by LVN F and 10 PM signed by LVN G [DATE] at 7 AM and 2 PM signed by LVN F In an interview on [DATE] at 9:06 AM with Resident #4, he was seated in his wheelchair in his room, he was a poor historian and stated he had no concerns with medications. In an interview on [DATE] at 3 PM with LVN F she reviewed [DATE]'s medication administration record for Resident #4 and stated she remembered that she was unable to give the medication (2 tablets of Phenobarbital 30 mg) to Resident #4 on [DATE], and [DATE]. She said the seizure medication had not been refilled and it was not in the emergency kit. She stated that Resident #4 had no negative effects, and no break through seizures. She stated she could not remember when she contacted the pharmacy and when she did, they said it would be sent to the facility, and they usually delivered in the middle of the night. She stated that the following day she saw the medication had not been filled and called the pharmacy again and spoke with Pharmacist K who said they would be delivered that evening. She stated she most likely would have mentioned it to the physician but could not remember and did not remember if she told the Interim Director of Nursing. She stated that there was not a local company to get the medications from in these situations. She stated that the cut off time for medications to come in at midnight was 3 PM. In an interview on [DATE] at 4:08 PM with LVN G she reviewed Resident #4's [DATE] Medication Administration Record (MAR) and stated she remembered that the resident was out of the medication Phenobarbital and she was unable to administer the medication. She stated it was not a medication that they kept in the emergency kit. She stated she was unable to recall if she contacted the pharmacy but knew they had been notified and there was not a local pharmacy they could contact. She stated that usually medication refills are ordered a week in advance through fax and they received deliveries at midnight on Tuesdays or Thursdays. She stated refill requests needed to be completed by noon on Tuesdays to receive them Tuesday at midnight or they would not receive the medication until Thursday. In an interview on [DATE] at 12:34 PM with Interim Administrator he said if a resident missed a dose of medication, because it was not available then he expected nurses to check the emergency kit and if it was not available then they would notify the physician and follow whatever orders the physician gave and document in the progress notes. He stated he was unaware any residents missed a seizure medication in [DATE] and the risk to a resident could be break through seizures. In a phone interview on [DATE] at 1:03 PM with Interim DON he said he was unaware that Resident #4 had missed any doses of a seizure medication in November of 2024 and did not remember if nurses informed him that the facility had run out of a seizure medication. He stated he would have expected the nurse to check the emergency kit and if there was not any medication there then inform the DON and he would have called the pharmacy directly and the physician. He stated that the medication should have been ordered ahead of time. He stated the risk to the resident could be break through seizures. In an interview on [DATE] at 1:46 PM with LVN H she said she was the charge nurse and was not aware of any resident missing seizure medications in [DATE]. She stated that they send refill requests on Tuesdays and Thursday by noon to the pharmacy by printing the labels and faxing them to the pharmacy. She stated that if a resident is out of a medication they should notify the physician and follow any new orders. She stated a resident missing 4 doses of a seizure medication like Phenobarbital placed them at risk for breakthrough seizures. In an interview on [DATE] at 2:50 PM with the DON she said medications refill requests are sent via fax to the pharmacy and they receive fax confirmations. She stated it would be concerning if a resident did not receive 4 doses of Keppra because it would put them at risk for break through seizures. She stated she expected nurses to notify the pharmacy of refill requests timely and notify the physician and the DON if the medication was not available and document it in the progress notes. On [DATE] at 3:38 PM, an attempt to interview Pharmacist K via phone revealed he was not available and in interview with Pharmacist L she stated the Phenobarbital was dispensed on [DATE] with a quantity of 120 pills. She stated that it was important to not miss doses because a resident who took Phenobarbital to control seizures could experience break through seizures if they missed several doses. She stated the facility faxes the prescription labels with a refill request and had the ability to call them. Record review of the facility's medication reordering policy, titled Medication Ordering Procedures, dated revised [DATE], reflected Purpose: To ensure that medications are ordered appropriately and to assist both the Facility and Pharmacy in maintain a timely medication re-ordering schedule . Procedure 3) .Check each medication card/container/package and ensure there is enough medication on hand to meet the needs of the Patient. Reorder as needed . 4) Medications should not be reordered until there is a ,d+[DATE] day supply remaining. Compare the directions and quantity carefully to determine the appropriate time to reorder. 5) If a medication refill is needed, remove the small re-order sticker from the prescription label and affix to an appropriate re-order form. Scan or fax this form to [Pharmacy]. Keep all fax confirmation sheets. Note: Do not attempt to fax the original reorder sheet as the prescription labels may jam the fax machine. Instead, make a copy of this form and fax the copy to [Pharmacy] . 7) If a medication refill was overlooked during the twice weekly review process and is needed prior to the Facility's next assigned refill day, please call [Pharmacy] and make arrangements for the processing of a refill outside your normal schedule . Record review of the facility's policy titled Medication Labeling and Storage, revised February 2023, revealed in part .5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 49427

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #2, Resident #4, and Resident #8) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA A and CNA B maintained the foley catheter drainage bag below Resident #2's bladder while they transferred the resident with a mechanical lift on 02/04/25 2. The facility failed to ensure CNA C provided Resident #4 timely and appropriate perineal care after an incontinent episode when she failed to check and change the resident from 06:00 a.m. to 10:30 a.m. and failed to clean the resident's penis and scrotum from front to back on 02/05/24. 3. The facility failed to ensure CNA C provided timely incontinence care for Resident #8 on 02/05/25. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #2's quarterly MDS assessment, dated 01/20/25, reflected an [AGE] year-old female with an admitted [DATE]. She had a BIMS of 15, which indicated she was cognitively intact. Resident #2 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers. She had an indwelling catheter and was always incontinent of bowel. Resident #2 had diagnoses which included neurogenic bladder (condition caused by nerve problems affecting the bladder), diabetes and hypertension. Record review of Resident #2's care plan, dated 02/04/25, reflected, At risk of infection related to indwelling catheter .Goal . [Resident #2] will remain free of urinary tract infection during period of catheterization .Interventions .Keep tubing below the level of bladder and free of kinks or twist Record review of Resident #2's February 2025 Physician Order Sheet, dated 02/04/25, reflected .Foley catheter: Check for patency (unobstructed) and placement every shift . with a start date of 06/18/24. In an observation on 02/04/25 at 11:30 a.m. CNA A and CNA B entered Resident #2's room to transfer her from her bed to the wheelchair with a mechanical lift. CNA A unhooked the urinary drainage bag from the bed rail and hooked it onto the lower pocket on her pants. Both staff positioned the resident onto the mechanical lift sling and hooked the sling to the mechanical lift. Once the sling was attached, CNA B instructed CNA A to attach the urinary drainage bag to the top bar of the mechanical lift, well above the resident's bladder. CNA A attached the urinary drainage bag to the top bar of the lift while CNA B began to lift the resident from the bed. Once the lift went up the urinary drainage bag was above her head. The resident was positioned over the chair and lowered onto the chair. Urine was observed in the tube flowing up and down. CNA A then unhooked the drainage bag and placed it on the wheelchair. In an interview with CNA B on 02/04/25 at 11:35 a.m. she stated they had been taught the urinary drainage bag was to be kept below the bladder. She stated she knew they were not supposed to hook it to their clothing which is why she instructed CNA B to hook it to the lift. She stated she was not sure how they were supposed to position the drainage bag during a mechanical lift. In an interview with CNA A on 02/04/25 at 11:40 a.m. she stated she had started at the facility about 3 weeks ago. She stated she was assigned with another CNA who had showed her how to do transfers. She stated she knew they were supposed to keep the urinary bag below the bladder and was not sure why CNA B had her hook it to the bar of the mechanical lift. She stated this was her first time working in a facility and she was still learning. In an interview with the ADON on 02/04/25 at 12:45 p.m. she stated staff were taught to keep the urinary drainage bag below the bladder to ensure proper drainage and prevent urine from backing up into the bladder. She stated she and the Interim DON had performed skills checks a few weeks ago and the staff knew they were to keep the drainage bag below the bladder. In an interview with the Interim DON on 02/05/25 at 11:25 a.m., he stated the staff were taught to keep the urinary drainage bag below the bladder to ensure proper drainage and prevent urine from backing up into the bladder. He stated he and the ADON did the competency checks on all the CNA staff a few weeks ago. He stated proper placement of the foley catheter bag during a mechanical lift transfer was not part of their current check off skills, but stated the staff should know how to place it on the sling where it was below the bladder. He stated it was not appropriate to hook it on the top bar of the sling. Record Review of CNA A's Nurse Aide Proficiency skills check off dated 02/03/25 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record Review of CNA B's Nurse Aide Proficiency skills check off dated 02/03/25 reflected she was competent in the care of indwelling catheters which included keeping the drainage below the bladder. Record review of the facility's policy, Catheter Care, dated March 2019, did not reflect the placement of the urinary drainage bag. 2. Record review of Resident #4's quarterly MDS assessment, dated 11/21/24, reflected a [AGE] year-old male with an admitted [DATE]. He had a BIMS of 10, which indicated he was moderately cognitively impaired. Resident #4 required substantial/maximum assist with ADLs and was dependent of 2 persons assist with transfers and toileting hygiene. He was always incontinent of bladder and bowel. Resident #4 had diagnoses which included Parkinson's disease (disorder of the central nervous system that affects movement) and seizure disorder. Record review of Resident #4's care plan dated 02/05/25 reflected, Urinary and Bowel incontinence: [Resident #4] is always incontinent .Goal .Incontinence will be managed by staff without evidence of skin breakdown .Interventions .Patients who are incontinent of bladder and/or bowel will have incontinent care provided every 2 hours as needed In an interview and observation with Resident #4 on 02/05/25 at 09:55 a.m. Resident #4 was observed sitting up in his wheelchair in his room watching TV. Resident #4 stated he needed to be changed and stated he was soaked through his pants. Resident #4 stated no one had changed him this morning. He stated he had been up since the butt crack of dawn. Resident's call light was pushed to obtain assistance. In an observation on 02/05/25 at 10:00 a.m. CNA C entered Resident #4's room in response to his call light. Resident #4 told CNA C he needed to be changed, and stated I am soaked. CNA C stated she would have to get help to transfer the resident to bed. CNA C re-entered Resident #4's room with the mechanical lift at 10:25 a.m. with the ADON. CNA C put on gloves without performing hand hygiene while the ADON washed her hands and put on gloves. Both staff hooked the mechanical sling to the lift and transferred the resident from his wheelchair to the bed. The wheelchair cushions exuded a very strong urine smell when the resident was lifted. The resident's pants were observed to be wet. Staff lowered the resident onto the bed and unhooked the sling. ADON then left the room with the mechanical lift. CNA C assisted the resident to roll from side to side to remove the sling and then removed his wet pants and saturated brief. CNA C rolled the resident onto his left side and wiped his buttocks a few times with a peri-wipe. She then placed a clean brief under the resident with soiled gloves and had him roll onto his back. CNA C then took a peri-wipe and wipe down his groin one time on each side and wiped the top of his penile shaft from his body down toward the head of his penis. She did not clean the resident's scrotum, the underside of his penis, or his inner thighs. CNA C then fastened the brief, removed her gloves, and went to the resident's closet without performing hand hygiene, and retrieved a clean shirt. CNA C removed his dirty shirt and assisted him with putting on the clean shirt. CNA C then gathered the trash and dirty clothes and left the room without performing hand hygiene. In an interview with CNA C on 02/05/25 at 10:50 a.m. she stated they were required to check and change any resident with incontinence every 2 hours, but stated it was just not possible with only 4 of them covering 6 halls. She stated she was not sure how long Resident #4 had been up since the night shift had gotten him up. She stated she was supposed to clean the resident from front to back and stated she did not realize she had not adequately cleaned the resident. She stated failing to clean the resident properly or timely placed him at risk of infections and skin breakdown. In an interview with the current DON on 02/05/25 at 12:45 p.m. she stated she had worked the night shift on 02/03/25 and knew the night shift got a few residents up. She stated the residents were gotten up around 4:30 a.m. She stated she was not sure if they had gotten Resident #4 up or not. She stated any resident the night shift got up needed to be checked and changed no later than a few hours after the start of the day shift at 6:00 a.m. She stated any resident who was incontinent of bowel and bladder needed to be checked for incontinence every 2 hours and changed as needed. She stated staff were to clean the peri area including penis and scrotum for male residents then move toward the buttocks. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. 3. Record review of Resident #8's Comprehensive MDS assessment, dated 12/06/24, reflected a [AGE] year-old female with an admitted [DATE]. Resident #8 was unable to participate in the interview for cognition and was assessed by the staff to be severely impaired. She was dependent for ADL care and was always incontinent of urine and bowel. Her active diagnoses included respiratory failure with hypoxia (not enough oxygen in the blood), and dementia. Record review of Resident #8's care plan, reviewed on 08/12/2019, reflected, .is always incontinent . Interventions: check for incontinence; change if wet/soiled. Clean skin with mild soap and water . Check skin for areas of redness . Observation on 02/05/25 at 08:30 AM, 10:30 AM, and 11:50 a.m. revealed Resident #8 was laying in the Geri-chair (specialized wheelchair) in the activity room. Resident was unable to answer questions. An observation on 02/05/25 at 12:00 p.m. revealed CNA C and CNA I entered Resident #8's room to transfer her back to bed. Both staff washed their hands and put on gloves and transferred the resident via a mechanical lift from her Geri-chair to the bed. Both staff removed their gloves, without performing hand hygiene they re-gloved to provide peri-care. CNA C opened the resident's brief to reveal a strong smell of urine. CNA C provided peri care and with assistance from CNA I turned the resident over on her side to reveal she had saturated through the brief. Resident #8's buttocks was red with creases noted in skin, but no skin breakdown. CNA I provided peri-care and applied barrier cream to the resident's buttocks. In an interview with CNA C on 02/05/25 at 12:30 p.m., she stated she was assigned to Resident #8 today (02/05/25) and did not provide incontinence care to her because she assumed the hospice nurse did because Resident #8 was on hospice. She stated her procedure was to check each resident every two hours or more often depending on the individual. She stated the risk for not changing Resident #8 for a long time would be skin break down and urinary infection. In an interview with CNA I on 02/05/25 at 1:35 p.m., she stated she was not assigned to Resident #8 today (02/05/25), and she would help CNA C when she called for assistance with total care residents. In an interview on 02/05/25 at 01:42 p.m., the DON stated it was her expectation the CNAs provide incontinence care in a timely manner at least every two hours. She stated the risk factor for not performing timely incontinence care was skin rash, infection, and skin breakdown. She stated she felt there was enough staff to care for the current resident census. She stated it was the expectation for the CNAs to come and ask the nurse, medication aide, or herself if they needed assistance with a resident. Record review of the facility's policy titled, Perineal Care Protocol, dated September 2023, reflected, Purpose: to provide care of the external genitalia and anal are which promotes cleanliness and prevents infections .Perform hand hygiene and apply gloves .Assist patient to supine position and remove soiled brief .Remove gloves and perform hand hygiene, and apply new gloves .Perform perineal care (as directed below) .For male patient .Gently hold the shaft of the penis, cleanse the head of the penis from urethral meatus outward in circular motion .Cleanse the shaft of the penis from the head of the penis toward the body .Using the downward one stroke method. Gently cleanse one groin fold and the scrotum, use a new cleansing wipe to cleanse the other groin fold and other side of the scrotum .Cleanse across the lower abdomen and inner thighs using a downward stroke method. Use a separate cleaning wipe for the lower abdomen and inner thighs .Turn the patient to his side to expose the anal area .Cleanse the anal area, wiping in one stroke method from the front toward the rectum .Cleanse the entire buttock and hip area using a separate cleaning wipe for each area .Remove gloves, perform hand hygiene, and apply new gloves .Apply brief .Assist patient to comfortable position .Remove gloves, sanitize hands, and remove sealed plastic bag(s) . Record review of the facility's policy titled, Activities of Daily Living, dated May 2016, reflected, Every effort must be made to assure that assignments of nurses and nurse aides to Patients are as consistent as possible .CNA ADL Tracking Records must be regularly monitored by the DON or designee to ensure that tasks are being performed as scheduled 42971

Based on observations, interview and record review revealed the facility failed to, in response to allegations of abuse, thoroughly investigate the alleged violation for two (Residents #1 and #2) of nine residents reviewed for resident abuse. 1. The facility failed to immediately investigate two incidents which occurred on 02/20/23 after allegations of verbal and physical abuse for Resident #1 were reported to the Abuse Coordinator. Abuse Coordinator/Administrator was made aware on 02/22/23 and failed to thoroughly investigate the allegations of abuse. PT B was not suspended pending investigation. 2. The facility failed to investigate after allegation of verbal abuse for Resident #2 by PT B. OT A and Director of Rehab failed to report an allegation of verbal abuse by PT B for Resident #2 which occurred in December 2022. On 02/22/23 Administrator was made aware of an allegation of verbal abuse for Resident #2 but failed to investigate alleged abuse for Resident #2. PT B continued to work at the facility since Administrator did not look into or investigate the allegation of abuse for Resident #2. PT B was not suspended pending investigation into abuse allegations for Residents #1, #2, and #3 and was allowed to continue working despite allegations of abuse. On 04/19/23 and 04/20/23, PT B was in facility and providing PT services to residents. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/21/23 at 11:15 AM, . While the IJ was removed on 04/24/23 at 4:15 PM, the facility remained out of compliance at a scope of pattern and a no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place the residents at risk for further potential abuse due to uninvestigated allegations of abuse. Findings included: 1. Observation on 04/19/23 at 10:35 AM, revealed PT B was in therapy room. Observation on 04/19/23 revealed PT B was in therapy room while Resident #4 was in therapy room on the exercise bike. Observation on 04/19/23 at 1:05 PM revealed PT B was pushing Resident #4 in her wheelchair from therapy to common area near nurse's station. Observation on 04/19/23 at 2:46 PM, revealed PT B was pushing a resident in wheelchair down the hall. Observations on 04/20/23 at 9:15 AM and 12:35 PM PT B was in therapy room. Review of Resident #1's face sheet dated 04/19/23 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cellulitis (bacterial skin infection) of left lower limb, Chronic Kidney Disease, Heart Failure, Respiratory Failure and Diabetes. Resident #1 was his own responsible party. Resident #1 was discharged on [DATE]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required extensive assistance with ADLs except eating supervision assistance only. Resident #1 was occasionally urinary incontinent and frequently bowel incontinent. Resident #1 was on OT and PT services. Review of Resident #1's undated comprehensive care plan reflected Resident #1's ADL functions. Interventions included to assist with ADL's as needed. Review of OT A's email to Regional Director of Rehab dated 02/22/23 at 2:51 PM, reflected the following about Resident #1: On Monday, February 20th, 2023, around approximately 11:45 A.M., another incident occurred that I personally witnessed. I had a patient to see, [Resident #1]. [PT B] also had this patient on her schedule and asked me if she could come with me so that we could see him together. We went into the patient's room. The patient was still in bed and reported that he needed to be cleaned up. [Resident #1] had a BM (bowel movement) in his brief. [PT B] immediately became upset and stated, A grown man, laying there, pooping in his diaper, that's just great. [Resident #1] immediately got upset and told [PT B] that she did not need to be so mean. [PT B] started arguing with the patient. This went on for a few minutes. [PT B] and resident were arguing back and forth. The patient was telling [PT B] that he didn't appreciate her being rude, and [PT B] was telling the patient that he needed to stop being lazy, and that he needed to use the toilet instead of his diaper. Finally, after a few minutes of this, [PT B] told the patient we would clean him up. The patient had a sore/wound on his bottom. [PT B] took some wet wipes and began cleaning the patient; however, she was being very aggressive and ruff. The patient asked her multiple times to be more gentle, and he also told her multiple times that she was hurting him. She continued on anyways, with the same aggression and the same roughness. We helped the patient get transferred into his wheelchair and get ready for lunch. I asked the patient if he would come down, after lunch, to do a little more therapy. He agreed to do so. After lunch, [Resident #1] came down to the therapy room where he did some more therapy. At the end of the session, patient wanted to walk. I walked with the patient, with a gait-belt, while [PT B] walked behind us, following us with the wheelchair. The patient walked approximately 100 feet when he asked to sit down to take a rest break. Patient started to sit down in his wheelchair. [PT B] started telling the patient in an aggressive raised tone, Reach back for your chair before you sit. The patient was holding onto the hallway railing that he was standing next to, so he did not listen to [PT B] and continued to sit on down in the wheelchair. [PT B] stuck her hand underneath the patient's bottom, pushing on him, in an upward motion, trying to keep him from sitting. She started yelling at him, stating, No! No! I told you to reach back for your chair and that's what you're going to do. [PT B] was being so loud that the social worker heard her from across the way, in her office, approximately 150 feet away. She came out of her office and down the hallway toward us, to see what was happening. I stayed with the patient to help him get back to his room. [PT B] was speaking to the social worker, telling a different version of the story, blaming everything on the patient, stating that he was just not listening today, and that he was being difficult. I attempted to locate the building administrator and the building DON/ADON multiple times throughout the day, so that I could report this incident, however, I was never able to locate any of them. The administrator's office was also locked. I also attempted to locate them the next day as well, with no luck. That is why I am reaching out to you about this. [Director of Rehab] stated that she spoke to [PT B], however, [PT B] continues to act inappropriately and unprofessional. I'm afraid if this continues on, she will not only continue to act inappropriately and unprofessionally with the residents, but I am afraid this will also affect outsiders view of the facility as a whole. Review of PT B's statement dated 02/23/23 signed by PT B reflected I know an allegation has been made against me concerning the treatment of my patients, and my professionalism as a therapist. I would like to take this time to rebut some of these accusations. Monday 02/20/2023 with [Resident #1]: when I went to ask [Resident #1] that morning what time he would prefer to participate in his therapy services, he stated he would like to after lunch. I then asked if he would like to practice his transfers by getting up in his chair right before lunch so he could eat in the dining room. He agreed and said yes that would be good. I responded OK I will see you a little before lunch, and maybe after lunch we can practice our gait training? He was also agreeable to this plan. When it was time to practice transferring to his w/c I noticed his call light was on and [OT A] was here so I asked her if she would like to be part of his treatment list too. [Resident #1 was on her treatment list too. [Resident #1] had been a patient at OT A and OT I facility several times. OT A and OT I had made several comments about how difficult and self-limiting [Resident #1] could be. When we entered [Resident #1's] room I asked if he was ready to get up, if that was the reason he had turned on his call light. He proceeded to tell us he was waiting to be cleaned up he had a bowel movement in his brief. I had already had a conversation with [Resident #1] the week before about being independent with his toileting because his plan was to return to an assisted living facility. When he told us had had soiled himself I felt it was my responsibility to re-iterate the conversation from earlier regarding toileting, and reminded him it may take a few minutes for staff to respond to his call light and he should turn it on as early as possible to get to the bathroom in time to avoid an accident. I said well, let's get clean up and go to lunch. As I was cleaning his bottom he said Oh one time, I thought it was because the wipes were cold (I saw no sores, or skin break-down I checked with the wound nurse who stated he had none. I then told [Resident #1] I'm sorry I've got to get you clean. Nothing else was said by [Resident #1] during the cleaning process. [Resident #1] got out of bed SBA for safety purposes and took himself to lunch. After lunch [Resident #1] came to the gym as promised to practice his gait training. We walked about 100 feet with a [two wheeled walker] and [side bend/contact guard assist] for safety, I was [NAME] the w/c behind [Resident #1] as OT A walked beside him so when he required a rest break all he had to do was reach back for the w/c, but [Resident #1] just started sitting he did not reach to make sure the w/c was in the proper position to prevent a fall. Again I was concerned for my patients safety, and it frightened me that he would not reach back to not only make sure the chair was there but to prevent him from causing trauma to his spine by sitting down too hard in the chair. [Resident #1] was not following proper safety protocol that was given and stated I'm holding onto the rail I told him that was not safe, he need to reach back for the chair for safety. He raised his voice to me so loud the Social Worker came to investigate the disturbance. I took her aside and explained what was going on, she was very concerned about [Resident #1's] safety. OT A and I continued walking with [Resident #1] after his rest break back to his room, When he arrived in his room he made the comment Let me reach back before I sit down I praised him for his safe practice and we laughed. [Resident #1] wanted to know how far he had walked, I left his room to measure the footage. I came back a few minutes later to let him know the results, OT A had already left his room. I told [Resident #1] how far he had walked and what a great job he had done, he then apologized for yelling at me and not following the safety precautions/instructions while involved in gait training. If I was being at all abusive to my patient at any time would it not be the responsibility of anyone hearing the conversation to intervene, especially if this was an ongoing occurrence? I feel that my assertiveness has been misconstrued because abuse is totally different from assertiveness. I feel that my personality has been attacked and my character has been defamed. I feel like I am being unfairly scrutinized for my treatment practices and the way I educate my patients to keep them safe. Each of my patients is different, what may work for one does not necessarily work with another. I have to be more assertive with some patients, it is my job to keep them as safe as possible when they are in my care. Review of facility's investigation completed by Administrator, provided on 04/19/23 at 5:56 PM reflected the following: - Email dated 02/22/23 at 5:53 PM from [NAME] President of Operations to the Administrator reflected I'm forwarding you an exchange regarding potential allegation. - Email dated 02/22/23 at 7:22 PM from Administrator to [NAME] President of Operations reflected I am reading this now and I will get right on it. I was not contacted by the community nor was the DON as I spoke to her this evening and I am sure she would have told me. I will get right on this as there is a window of time to get information. I will contact [Director of Rehab] now and go from there. Thank you and I will have a full report as I found out more information. - Administrator wrote down Resident #1's statement dated 02/23/23 about PT B 1. We are like oil and water, she never compliments me, she always says I do not do the things that she said for you to do. 2. How many times, did I tell you, and then you can stabilize the chair and make sure that it won't slide behind you. 3. It comes off as her being concerned that I am going to hurt myself in a motherly way. I have a bad temper and I asked the other girls later if I used profanity when I yelled back to her. They stated no. 4. I do truly believe that [PT B] has best interest at heart and she is trying to ensure that I understand how to make myself the most independent. 5. Did she get on my nerves telling me, yes, but I never felt unsafe or uncomfortable with any care or treatment that she gave me. - There was no provider investigation report. There were no staff witness statements or resident safe surveys to alleged incident. There was no summary of facility's investigation findings for alleged abuse. Review of Resident #1's progress notes including nurse notes for February to March 2023 reflected no documentation of resident abuse/neglect allegations. Review of February 2023 Incident/Accident Reports reflected no incident/accident reports for Resident #1. Review of PT Treatment Notes reflected Resident #1 received PT services by PT B on 02/14/23, 02/16/23, 02/17/23, 02/20/23 and 02/22/23. Review of OT Treatment Notes reflected Resident #1 received OT services by OT A on 02/20/23 and 02/21/23. Review of Resident #1's discharge summary dated 03/03/23 reflected he was discharged on [DATE] at 10:30 AM to an assisted living facility with home health services. Interview on 04/19/23 at 11:27 AM with OT A revealed she was cotreating with PT B when she witnessed the morning of 02/20/23 PT B being verbally abusive with Resident #1 when he had soiled on himself and needed to be changed. She stated PT B told Resident #1 he was a lazy and a grown man should not poop on himself. She stated PT B was physically abusive by being rough when wiping Resident #1's butt during incontinent care and Resident #1 told her she did have to mean and hateful to him. She stated Resident #1 told PT B she was hurting him but continued providing incontinent care. She stated she did not report to the Charge Nurse about Resident #1 complaining of pain and allegation of abuse by PT B. She stated she tried to find the Administrator, who is the abuse coordinator, and was unable to find her so she did not report the allegation of abuse to the Abuse Coordinator. She stated she witnessed another incident the same day after lunch when she was walking with Resident #1 using gait belt and PT B was behind Resident #1 pushing the wheelchair. She stated she was to the side of Resident #1 and Resident #1 wanted to sit down but PT B yelled at Resident #1 telling him No, No and placed her hand under his bottom smacking him on bottom not allowing him to sit down. She stated PT B continued yelling at Resident #1 and other staff overheard her yelling including LVN D and CNA E. She stated social worker came out of her office and started She stated she did not report it to the Administrator about incident and did not speak to the social worker about what happened either. OT A stated she did not know she needed to report abuse allegation to the charge nurse for Resident #1 as per the facility policy. She stated she did not report the allegation of verbal/physical abuse to the Director of Rehab due to a past allegation of abuse by PT B was reported to the Director of Rehab and nothing happened. She stated she could not find the Administrator or DON so she did not report the abuse allegations by PT B. She stated on 02/22/23 she reported it to Regional Director of Rehab Services the allegations of witnessed verbal and physical abuse by PT B. She stated the next morning (02/23/23) the Administrator talked to her about what she witnessed and said she had gotten a report from Resident #1 who denied any abuse. She stated PT B was not suspended during investigation but was taken off Resident #1's services after the abuse allegation. Interview 04/19/23 at 1:20 PM with CNA E revealed she witnessed PT B being verbally abusive to Resident # 1. CNA E stated PT B threatened and yelled at Resident #1 saying I told you to lock the wheelchair when Resident #1 tried to sit down and told Resident #1 what would you do if I had taken the wheelchair away. She stated LVN D witnessed it along with another therapist. CNA E stated she did not immediately report it to the Administrator. She stated Administrator knew about alleged abuse incident she thought by Resident #1 or by other staff. CNA E stated she did not witness any physical abuse by PT B. She stated she was not asked by Administrator about what she witnessed on Resident #1's incident and did not complete a witness statement. Surveyor attempted to contact Resident #1 on 04/19/23 at 2:43 PM via telephone leaving a voicemail but Resident #1 did not call surveyor back. Interview on 04/20/23 at 10:15 AM with LVN D revealed she witnessed PT B being verbally abusive towards Resident #1. LVN D stated PT B was behind Resident #1 pushing the wheelchair. She stated PT G was hateful and yelling at Resident #1 saying You have to lock brakes when Resident #1 wanted to sit down. She stated PT B and Resident #1 continued arguing back and forth. She stated another therapist and CNA E also witnessed the incident. She stated LVN H was aware of the incident she thought. She stated she did not remember the exact date it happened but was about a week to a few days or so before Resident #1 was discharged . LVN D did not report it to the Administrator immediately. She stated she thought she talked with the Administrator about the incident the next day but did not fill out witness statement or an incident report. Interview on 04/20/23 at 10:27 AM with LVN H revealed she was unaware of any allegations of abuse in regards to Resident #1. She was not aware of any incident involving a therapist yelling at a resident. She stated the facility had in-serviced on abuse/neglect but was not sure how recent it was. She stated the Administrator was the abuse coordinator who she would need to report any abuse allegations to immediately. Interviews on 04/19/23 at 5:50 PM and 04/20/23 at 1:15 PM, the Social Worker revealed she did not witness any verbal abuse by PT B towards Resident #1. She stated PT B was talking loudly to Resident #1 in the 600 hallway but she did not hear exactly what was said. She stated PT B and Resident #1 were arguing but did not know the specifics about what happened. She stated no one came to her after incident to allege any allegations of abuse by PT B towards Resident #1. She stated any resident abuse allegations should be reported to the Administrator who is the abuse coordinator immediately and Administrator was responsible for reporting allegations to the state. She stated she completed the resident safe surveys when an allegation of abuse/neglect was suspected for the investigation but she did not complete any resident safe surveys about allegations of abuse in regards to therapist. Interview on 04/20/23 at 10:58 AM with Regional Director of Rehab revealed he received a phone call from OT I and OT A about concerns of PT B allegedly being rude and having a tone with Resident #1 during a therapy session and said she had not told the Director of Rehab due to a past incident where nothing was done about PT B. Regional Director of Rehab stated OT A told him she had not informed the Administrator. Regional Director of Rehab asked OT A to email him her statement. He stated he received the email the same day OT A called him. He stated he tried to call the facility to get hold of Administrator but Administrator was not at facility nor was the DON so he reached out to his boss. He forwarded the email to the [NAME] President of Operations and Administrator about the allegations of abuse for Resident #1. He stated the email from OT A revealed suspected allegations of abuse and required the Administrator who is the abuse coordinator to investigate these alleged abuse allegations. He stated PT B was not suspended and did not know if Resident #1 was taken off her caseload. Interviews on 04/19/23 at 3:16 PM and 04/20/23 at 12:20 PM the Director of Rehab revealed she was not made aware of OT A reporting abuse by PT B for Resident #1 until after Administrator contacted her. She stated the Administrator was the abuse coordinator who was responsible for investigating the allegation of abuse. She stated she was not aware if this allegation of abuse was reported to the state. She stated Administrator investigated the alleged incident and Resident #1 reported he felt safe. She stated PT B was not suspended but was taken off Resident #1's treatment caseload. She stated Administrator inserviced the staff on abuse/neglect and reporting guidelines. Interview with OT F on 04/20/23 at 11:14 AM revealed she became aware of allegation of abuse for Resident #1 by PT B when OT A reported it to her either face to face or via telephone. She could not recall when she specifically became aware of the alleged incident. She stated OT A reported she and PT B had gone into Resident #1's room who told them he was waiting to be changed and had a bowel movement. She stated it was reported to her that PT B told Resident #1 Grown man should not be shitting upon himself and this upset Resident #1. She stated OT A stated when PT B was doing incontinent care on Resident #1 he reported she was hurting him. OT F stated OT A stated later same day when walking Resident #1 when he wanted to sit down PT B yelled at him saying If you try to sit down we will pull this chair from underneath you. She stated when she became aware it was after the Administrator was already made aware of the allegations of abuse. She did not report the allegation of abuse to the Administrator. Interview on 04/19/23 at 3:35 PM with PT B revealed Administrator reported there was a complaint about my treatment and allegation of abuse for Resident #1 on 02/20/23. She was told by Administrator Resident #1 did not have any issues with it. She stated she talked with Administrator the same day as her statement (02/23/23) about two incidents with Resident #1. She stated first incident OT A and her went into Resident #1's room. PT B stated Resident #1 had a bowel movement and was waiting to be changed. She stated she provided incontinent care to him and when he rolled over said Oh. She stated he was not complaining of pain during incontinent care. She denied any verbal abuse or physical abuse to Resident #1. She stated after she provided incontinent care she assisted in in transfer to go to dining room for lunch. She stated after lunch the same day she was doing gait belt training with Resident #1 with OT A. PT B stated she was holding the wheelchair while OT A was beside Resident #1 when walking down the hall. She stated Resident #1 was holding until rail and not reaching back for wheelchair when wanting to rest. She stated she did raise her voice because she was concerned about his safety and him falling. PT B stated she told him to reach for wheelchair before trying to sit down because he was not reaching back. PT B stated she sometimes had to raise her voice to get resident's attention or if concerned about their safety but she denied any verbal abuse. She stated social worker overheard it and checked on incident. She stated LVN D was standing at her cart when the incident happened on 02/20/23. She stated she was not sent home nor was suspended pending investigation by Administrator due to allegation of abuse for Resident #1. She stated she was in-serviced on abuse/neglect. She stated Resident #1 was taken off of her caseload after she talked with Administrator as a precaution but no disciplinary action was taken. Interview with Administrator on 04/19/23 at 4:07 PM revealed she did not report the allegation of verbal and physical abuse by PT B for Resident #1 to the state agency within 2 hours. She stated she was at a corporate meeting on 02/22/23. She stated OT A should have reported the allegation of abuse to her immediately on 02/20/23 when alleged incidents occurred. She stated OT A reported the alleged allegation of abuse by PT B to Regional Director of Rehab on 02/22/23 and she was informed by an email of OT A's statement on the evening of 02/22/23. She stated she contacted Director of Rehab on 02/22/23 to get her a statement from PT B. Administrator stated she would immediately notify the state if a resident or family member reported an alleged allegation of abuse/neglect, suspend alleged perpetrator pending investigation and investigate the incident. She stated at first stated this alleged allegation of abuse was hearsay by staff member. She stated she would report the allegation if the resident when interviewed stated an allegation of abuse/neglect occurred to the state. She stated she interviewed Resident #1 the next day on 02/23/23 who denied any abuse and felt safe at facility. She stated PT B provided a witness statement on 02/23/23. She stated since Resident #1 denied any abuse occurred so she did not report it and PT B denied any abuse occurred. She stated PT B was not suspended but Resident #1 was taken off her caseload just to be safe. She stated staff were in-serviced on abuse/neglect and reporting after incident. She stated OT A alleged the first incident that PT B was rude to Resident #1 by stating grown man laying there pooping in his diaper and wiping aggressive and rough during incontinent care provided by PT B. Interview on 04/20/23 at 1:44 PM with Administrator revealed she did contact LVN G on 02/22/23 in the evening to have him talk to Resident #1 about allegation of abuse. She stated she talked with Resident #1 in the morning on 02/23/23 about the alleged incident and he denied any abuse by PT B. She stated she was not aware of any other staff being witnesses to the second alleged allegation of abuse. She stated she did not interview facility staff to determine if there were any witnesses to the alleged allegations of abuse for Resident #1. She stated not reporting allegations of resident abuse immediately to abuse coordinator can place residents at risk of further abuse if they do not report it. She stated PT B was currently in the facility providing therapy services. She was not aware the facility policy stated to report suspected abuse to Charge Nurse. Interview on 04/21/23 at 11:47 AM with LVN G revealed he was not the charge nurse for Resident #1. He stated the Administrator did not contact him about allegation of abuse for Resident #1. LVN G stated he did not speak with Resident #1 about allegation of abuse or therapy issues. He was unaware of any alleged abuse concerns for Resident #1. 2. Review of Resident #2's face sheet dated 04/19/23 reflected Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of gout, myocardial infarction, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease and osteoarthritis. She was discharged on [DATE]. Review of Resident #2's Admission MDS assessment dated [DATE] reflected Resident #2 had a BIMS of 12 indicating she was moderately cognitively impaired. Resident #2 required limited assistance with ADLs except extensive for bathing and supervision with eating. Resident #2 was on OT and PT services. Review of Resident #2's Grievance Report dated 01/02/23 reflected Resident #2's responsible party reported family was upset with therapist as the patient currently has an order to wear back brace at all times while up. This order is in the patients medical record and the family stated the patient should only have to wear it when she is comfortable. The nurses will be getting an intervention to clarify the order with the MD and either keep the brace when up or make it prn for comfort. The grievance was resolved on 01/05/23. It did not mention about an issues with therapist yelling at Resident #2. Review of OT A's email to the Regional Director of Rehab dated 02/22/23 at 2:51 PM reflected the following about Resident #2: A few months ago, approximately sometime toward the end of December, I was in a resident's room working with her. Her name was [Resident #2]. We were in the middle of some seated exercises and it was me, [Resident #2], and [Resident #2's family member] in the room. [PT B] opened the door and came into the room. She saw a walker, in the room, that had been left by the OT. [PT B] immediately became upset and started raising her voice, with a hateful tone, and stated, Well, I see you got your way, and you got the walker that you were wanting. [PT B] did not want the resident to have the walker, in her room, and was angry that the OT had left one for her. [PT B] then noticed that the patient was not wearing her back brace while she was seated upright in a chair. [PT B] started becoming more and more agitated and aggressive with her tone and speaking. She began getting onto the resident for not having her back brace on. The patient stated that she did not have to have the brace on. The patient stated that the brace was for comfort only, to help reduce back pain with support and compression. The son also stated that the brace was only for comfort purposes and was not a requirement. [PT B] continued to raise her voice and argue with the patient, stating that this information wasn't true, and that the patient was supposed to wear the brace at all times when out of bed. [PT B] finally left the room because things were getting too heated. Shortly after [PT B] left the room, the son's wife arrived, [Resident #2's] daughter-in-law. The son shared with her what had just happened. He was upset with the way that [PT B] had handled the whole situation, and with how she had spoken to his mother. The daughter-in-law was also very angry and upset. The daughter-in-law immediately went and found [PT B] and confronted her about what had happened, telling her that she had not right to speak to her mother with that tone and in that manner. This was the first incident that occurred that I had personally witnessed myself. I contacted [OT F] and told her about what had happened. I also notified the [Director of Rehab]. [Director of Rehab] stated that she would talk to [PT B] about it. Review of Resident #2's PT Treatment Notes dated 12/22/22, 12/23/23 and 01/05/23 reflected PT B worked with Resident #2. Review of Resident #2's December 2022 and January 2023 Progress notes including nurse notes reflected no concerns with therapy or abuse/neglect. Review of facility's incident reports for December 2022 and January 2023 reflected no incident reports for Resident #2. Review of Resident #2's Discharge Plan of Care date 01/12/23 reflected Resident #2 was discharged home with family with home health services. Interview on 04/19/23 at 11:27 AM with OT A revealed this was the first time she had worked with PT B before with Resident #2. She stated end of December 2022 she witnessed PT B being verbally abusive towards Resident # 2 when she walked into her room noticed a walker in room left by another therapist. OT A stated PT B was upset about walker being in Resident #2's room and was hateful and raised her voice telling he Well I see you got your way, and you got walker you were wanting. She then stated PT B noticed she was not wearing her back brace like she should while sitting in a chair. PT B was yelling at Resident #2 for not wearing a back brace that she had to wear per doctor's orders. OT A

Based on observations, interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse for three (Residents #1, #2 and #3) of nine residents reviewed for resident abuse. 1.OT A, LVN D and CNA E failed to follow their policy to report two abuse allegations(02/20/23) involving Resident #1 to the Administrator, who is the abuse coordinator, on 02/20/23. The Administrator failed to immediately report the allegations of verbal and physical abuse of Resident #1, by alleged prepurator PT B after becoming aware of the incident on 02/22/23. Administrator failed to follow their policy to thoroughly investigate the alleged abuse allegations. 2. OT A and the Director of Rehab failed to report an allegation of verbal abuse (end of December 2022) of Resident #2 by alleged perpetrator PT B. The Administrator was made aware of an allegation of verbal abuse for Resident #2 by alleged perpetrator PT B on 02/22/23 but failed to report to HHSC immediately. The Administrator failed to investigate alleged abuse for Resident #2. 3.ST C and OT F failed report verbal and physical abuse allegations of Resident #3 by alleged perpetrator PT B to the charge nurse and immediately to the Administrator. PT B was not suspended pending investigation into abuse allegations and was allowed to continue working despite allegations of abuse. On 04/19/23 and 04/20/23, PT B was in facility and providing PT services to residents. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/21/23 at 11:15 AM, . While the IJ was removed on 04/24/23 at 4:15 PM, the facility remained out of compliance at a scope of pattern and a no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk for further abuse due to unreported and uninvestigated allegations of abuse. Findings included: Review of facility's policy Abuse Protocol dated November 2016 reflected Resident has the right to be free from Abuse .4. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. 5. The Abuse Prevention Coordinator will assure that all facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment .6. Our facility will not retaliate against any person who in good faith reports an allegation. Accidents and Incidents must be reported internally and externally in accordance with Reportable Incident Protocol .a. Staff will be made aware of the name and contact phone number for the Abuse Prevention Coordinator. b. All persons who report an allegation of Abuse or Neglect will be kept confidential by the Abuse Prevention Coordinator. c. A person who believes he or she has been subjected to retaliation as a result of reporting an allegation or who believes an allegation has been ignored, may contact the Abuse Prevention Coordinator, the DADS office or the Office of the Attorney General .7. The following definitions are provided to assist our facility's staff members in recognizing incidents of patient/resident abuse; a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all patient/resident, irrespective of any physical or mental condition cause physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .d. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to patient/residents or their families, or within their hearing distance to describe Patient/Residents, regardless of their age, ability to comprehend, or disability .f. Physical abuse is defined as hitting, slapping, pinching, kicking etc. It also includes controlling behavior through corporal punishment .h. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services .8. Any person observing an incident of Patient/Resident Abuse or suspecting Patient/Resident Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse: a. The name of the Patient/Resident involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed (i.e. verbal, physical, sexual, etc); and g. Other information that may be requested by the Charge Nurse. 9. The Charge Nurse will immediately examine the Patient/Resident and notify the Abuse Prevention Coordinator upon receiving report of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient/Resident's medical record. 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities of Patient/Resident Abuse as required under applicable regulations and regulatory guidance .b. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. c. Conduct and document on a Patient/Resident Abuse Investigation a thorough investigation of each incident of Patient/Resident abuse .to include: observations, interviews and reviews of all patient/residents involved -interviews of all witnesses, including patient/residents, staff and family members -notifying physician -notifying families and responsible parties of the involved Patients/Residents -recording all relevant physical findings. d. Complete an appropriate assessment of all patient/residents involved e. Take all steps necessary to protect the Facility's patient/residents form further incidents of patient/resident abuse .while the investigation is in process .g. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse .(Investigation) 11. The Patient/Resident abuse questionnaire must be completed on a sampling of Patient/Residents and/or family members during an investigation of an abuse allegation to determine their awareness of abuse that may have occurred inside the facility. 12. An employee abuse investigation questionnaire must be completed on a sampling of employees during an investigation of an abuse allegation to determine their awareness of abuse that may have occurred inside the facility. 13. When an incident of Patient/Resident Abuse is suspected or determined, the incident must be reported to the Charge Nurse regardless of the time lapse since the incident occurred .20. The Abuse Prevention Coordinator will (a) report all alleged incidents of Patient/resident abuse to DADS .In addition, the results of all investigations will reported to the State Agency within 5 working days of the incident if the alleged violations are verified are appropriate, corrective action will be taken. 1. Observation on 04/19/23 at 10:35 AM, revealed PT B was in therapy room. Observation on 04/19/23 revealed PT B was in therapy room while Resident #4 was in therapy room on the exercise bike. Observation on 04/19/23 at 1:05 PM revealed PT B was pushing Resident #4 in her wheelchair from therapy to common area near nurse's station. Observation on 04/19/23 at 2:46 PM, revealed PT B was pushing a resident in wheelchair down the hall. Observations on 04/20/23 at 9:15 AM and 12:35 PM PT B was in therapy room. Review of Resident #1's face sheet dated 04/19/23 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cellulitis (bacterial skin infection) of left lower limb, Chronic Kidney Disease, Heart Failure, Respiratory Failure and Diabetes. Resident #1 was his own responsible party. Resident #1 was discharged on [DATE]. Review of Resident #1's Admission MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required extensive assistance with ADLs except eating supervision assistance only. Resident #1 was occasionally urinary incontinent and frequently bowel incontinent. Resident #1 was on OT and PT services. Review of Resident #1's undated comprehensive care plan reflected Resident #1's ADL functions. Interventions included to assist with ADL's as needed. Review of OT A's email to Regional Director of Rehab dated 02/22/23 at 2:51 PM, reflected the following about Resident #1: On Monday, February 20th, 2023, around approximately 11:45 A.M., another incident occurred that I personally witnessed. I had a patient to see, [Resident #1]. [PT B] also had this patient on her schedule and asked me if she could come with me so that we could see him together. We went into the patient's room. The patient was still in bed and reported that he needed to be cleaned up. [Resident #1] had a BM (bowel movement) in his brief. [PT B] immediately became upset and stated, A grown man, laying there, pooping in his diaper, that's just great. [Resident #1] immediately got upset and told [PT B] that she did not need to be so mean. [PT B] started arguing with the patient. This went on for a few minutes. [PT B] and resident were arguing back and forth. The patient was telling [PT B] that he didn't appreciate her being rude, and [PT B] was telling the patient that he needed to stop being lazy, and that he needed to use the toilet instead of his diaper. Finally, after a few minutes of this, [PT B] told the patient we would clean him up. The patient had a sore/wound on his bottom. [PT B] took some wet wipes and began cleaning the patient; however, she was being very aggressive and ruff. The patient asked her multiple times to be more gentle, and he also told her multiple times that she was hurting him. She continued on anyways, with the same aggression and the same roughness. We helped the patient get transferred into his wheelchair and get ready for lunch. I asked the patient if he would come down, after lunch, to do a little more therapy. He agreed to do so. After lunch, [Resident #1] came down to the therapy room where he did some more therapy. At the end of the session, patient wanted to walk. I walked with the patient, with a gait-belt, while [PT B] walked behind us, following us with the wheelchair. The patient walked approximately 100 feet when he asked to sit down to take a rest break. Patient started to sit down in his wheelchair. [PT B] started telling the patient in an aggressive raised tone, Reach back for your chair before you sit. The patient was holding onto the hallway railing that he was standing next to, so he did not listen to [PT B] and continued to sit on down in the wheelchair. [PT B] stuck her hand underneath the patient's bottom, pushing on him, in an upward motion, trying to keep him from sitting. She started yelling at him, stating, No! No! I told you to reach back for your chair and that's what you're going to do. [PT B] was being so loud that the social worker heard her from across the way, in her office, approximately 150 feet away. She came out of her office and down the hallway toward us, to see what was happening. I stayed with the patient to help him get back to his room. [PT B] was speaking to the social worker, telling a different version of the story, blaming everything on the patient, stating that he was just not listening today, and that he was being difficult. I attempted to locate the building administrator and the building DON/ADON multiple times throughout the day, so that I could report this incident, however, I was never able to locate any of them. The administrator's office was also locked. I also attempted to locate them the next day as well, with no luck. That is why I am reaching out to you about this. [Director of Rehab] stated that she spoke to [PT B], however, [PT B] continues to act inappropriately and unprofessional. I'm afraid if this continues on, she will not only continue to act inappropriately and unprofessionally with the residents, but I am afraid this will also affect outsiders view of the facility as a whole. Review of PT B's statement dated 02/23/23 signed by PT B reflected I know an allegation has been made against me concerning the treatment of my patients, and my professionalism as a therapist. I would like to take this time to rebut some of these accusations. Monday 02/20/2023 with [Resident #1]: when I went to ask [Resident #1] that morning what time he would prefer to participate in his therapy services, he stated he would like to after lunch. I then asked if he would like to practice his transfers by getting up in his chair right before lunch so he could eat in the dining room. He agreed and said yes that would be good. I responded OK I will see you a little before lunch, and maybe after lunch we can practice our gait training? He was also agreeable to this plan. When it was time to practice transferring to his w/c I noticed his call light was on and [OT A] was here so I asked her if she would like to be part of his treatment list too. [Resident #1 was on her treatment list too. [Resident #1] had been a patient at OT A and OT I facility several times. OT A and OT I had made several comments about how difficult and self-limiting [Resident #1] could be. When we entered [Resident #1's] room I asked if he was ready to get up, if that was the reason he had turned on his call light. He proceeded to tell us he was waiting to be cleaned up he had a bowel movement in his brief. I had already had a conversation with [Resident #1] the week before about being independent with his toileting because his plan was to return to an assisted living facility. When he told us had had soiled himself I felt it was my responsibility to re-iterate the conversation from earlier regarding toileting, and reminded him it may take a few minutes for staff to respond to his call light and he should turn it on as early as possible to get to the bathroom in time to avoid an accident. I said well, let's get clean up and go to lunch. As I was cleaning his bottom he said Oh one time, I thought it was because the wipes were cold (I saw no sores, or skin break-down I checked with the wound nurse who stated he had none. I then told [Resident #1] I'm sorry I've got to get you clean. Nothing else was said by [Resident #1] during the cleaning process. [Resident #1] got out of bed SBA for safety purposes and took himself to lunch. After lunch [Resident #1] came to the gym as promised to practice his gait training. We walked about 100 feet with a [two wheeled walker] and [side bend/contact guard assist] for safety, I was [NAME] the w/c behind [Resident #1] as OT A walked beside him so when he required a rest break all he had to do was reach back for the w/c, but [Resident #1] just started sitting he did not reach to make sure the w/c was in the proper position to prevent a fall. Again I was concerned for my patients safety, and it frightened me that he would not reach back to not only make sure the chair was there but to prevent him from causing trauma to his spine by sitting down too hard in the chair. [Resident #1] was not following proper safety protocol that was given and stated I'm holding onto the rail I told him that was not safe, he need to reach back for the chair for safety. He raised his voice to me so loud the Social Worker came to investigate the disturbance. I took her aside and explained what was going on, she was very concerned about [Resident #1's] safety. OT A and I continued walking with [Resident #1] after his rest break back to his room, When he arrived in his room he made the comment Let me reach back before I sit down I praised him for his safe practice and we laughed. [Resident #1] wanted to know how far he had walked, I left his room to measure the footage. I came back a few minutes later to let him know the results, OT A had already left his room. I told [Resident #1] how far he had walked and what a great job he had done, he then apologized for yelling at me and not following the safety precautions/instructions while involved in gait training. If I was being at all abusive to my patient at any time would it not be the responsibility of anyone hearing the conversation to intervene, especially if this was an ongoing occurrence? I feel that my assertiveness has been misconstrued because abuse is totally different from assertiveness. I feel that my personality has been attacked and my character has been defamed. I feel like I am being unfairly scrutinized for my treatment practices and the way I educate my patients to keep them safe. Each of my patients is different, what may work for one does not necessarily work with another. I have to be more assertive with some patients, it is my job to keep them as safe as possible when they are in my care. Review of facility's investigation completed by Administrator, provided on 04/19/23 at 5:56 PM reflected the following: - Email dated 02/22/23 at 5:53 PM from [NAME] President of Operations to the Administrator reflected I'm forwarding you an exchange regarding potential allegation. - Email dated 02/22/23 at 7:22 PM from Administrator to [NAME] President of Operations reflected I am reading this now and I will get right on it. I was not contacted by the community nor was the DON as I spoke to her this evening and I am sure she would have told me. I will get right on this as there is a window of time to get information. I will contact [Director of Rehab] now and go from there. Thank you and I will have a full report as I found out more information. - Administrator wrote down Resident #1's statement dated 02/23/23 about PT B 1. We are like oil and water, she never compliments me, she always says I do not do the things that she said for you to do. 2. How many times, did I tell you, and then you can stabilize the chair and make sure that it won't slide behind you. 3. It comes off as her being concerned that I am going to hurt myself in a motherly way. I have a bad temper and I asked the other girls later if I used profanity when I yelled back to her. They stated no. 4. I do truly believe that [PT B] has best interest at heart and she is trying to ensure that I understand how to make myself the most independent. 5. Did she get on my nerves telling me, yes, but I never felt unsafe or uncomfortable with any care or treatment that she gave me. - There was no provider investigation report. There were no staff witness statements or resident safe surveys to alleged incident. There was no summary of facility's investigation findings for alleged abuse. Review of Resident #1's progress notes including nurse notes for February to March 2023 reflected no documentation of resident abuse/neglect allegations. Review of February 2023 Incident/Accident Reports reflected no incident/accident reports for Resident #1. Review of PT Treatment Notes reflected Resident #1 received PT services by PT B on 02/14/23, 02/16/23, 02/17/23, 02/20/23 and 02/22/23. Review of OT Treatment Notes reflected Resident #1 received OT services by OT A on 02/20/23 and 02/21/23. Review of Resident #1's discharge summary dated 03/03/23 reflected he was discharged on [DATE] at 10:30 AM to an assisted living facility with home health services. Interview on 04/19/23 at 11:27 AM with OT A revealed she was cotreating with PT B when she witnessed the morning of 02/20/23 PT B being verbally abusive with Resident #1 when he had soiled on himself and needed to be changed. She stated PT B told Resident #1 he was a lazy and a grown man should not poop on himself. She stated PT B was physically abusive by being rough when wiping Resident #1's butt during incontinent care and Resident #1 told her she did have to mean and hateful to him. She stated Resident #1 told PT B she was hurting him but continued providing incontinent care. She stated she did not report to the Charge Nurse about Resident #1 complaining of pain and allegation of abuse by PT B. She stated she tried to find the Administrator, who is the abuse coordinator, and was unable to find her so she did not report the allegation of abuse to the Abuse Coordinator. She stated she witnessed another incident the same day after lunch when she was walking with Resident #1 using gait belt and PT B was behind Resident #1 pushing the wheelchair. She stated she was to the side of Resident #1 and Resident #1 wanted to sit down but PT B yelled at Resident #1 telling him No, No and placed her hand under his bottom smacking him on bottom not allowing him to sit down. She stated PT B continued yelling at Resident #1 and other staff overheard her yelling including LVN D and CNA E. She stated social worker came out of her office and started She stated she did not report it to the Administrator about incident and did not speak to the social worker about what happened either. OT A stated she did not know she needed to report abuse allegation to the charge nurse for Resident #1 as per the facility policy. She stated she did not report the allegation of verbal/physical abuse to the Director of Rehab due to a past allegation of abuse by PT B was reported to the Director of Rehab and nothing happened. She stated she could not find the Administrator or DON so she did not report the abuse allegations by PT B. She stated on 02/22/23 she reported it to Regional Director of Rehab Services the allegations of witnessed verbal and physical abuse by PT B. She stated the next morning (02/23/23) the Administrator talked to her about what she witnessed and said she had gotten a report from Resident #1 who denied any abuse. She stated PT B was not suspended during investigation but was taken off Resident #1's services after the abuse allegation. Interview 04/19/23 at 1:20 PM with CNA E revealed she witnessed PT B being verbally abusive to Resident # 1. CNA E stated PT B threatened and yelled at Resident #1 saying I told you to lock the wheelchair when Resident #1 tried to sit down and told Resident #1 what would you do if I had taken the wheelchair away. She stated LVN D witnessed it along with another therapist. CNA E stated she did not immediately report it to the Administrator. She stated Administrator knew about alleged abuse incident she thought by Resident #1 or by other staff. CNA E stated she did not witness any physical abuse by PT B. She stated she was not asked by Administrator about what she witnessed on Resident #1's incident and did not complete a witness statement. Surveyor attempted to contact Resident #1 on 04/19/23 at 2:43 PM via telephone leaving a voicemail but Resident #1 did not call surveyor back. Interview on 04/20/23 at 10:15 AM with LVN D revealed she witnessed PT B being verbally abusive towards Resident #1. LVN D stated PT B was behind Resident #1 pushing the wheelchair. She stated PT G was hateful and yelling at Resident #1 saying You have to lock brakes when Resident #1 wanted to sit down. She stated PT B and Resident #1 continued arguing back and forth. She stated another therapist and CNA E also witnessed the incident. She stated LVN H was aware of the incident she thought. She stated she did not remember the exact date it happened but was about a week to a few days or so before Resident #1 was discharged . LVN D did not report it to the Administrator immediately. She stated she thought she talked with the Administrator about the incident the next day but did not fill out witness statement or an incident report. Interview on 04/20/23 at 10:27 AM with LVN H revealed she was unaware of any allegations of abuse in regards to Resident #1. She was not aware of any incident involving a therapist yelling at a resident. She stated the facility had in-serviced on abuse/neglect but was not sure how recent it was. She stated the Administrator was the abuse coordinator who she would need to report any abuse allegations to immediately. Interviews on 04/19/23 at 5:50 PM and 04/20/23 at 1:15 PM, the Social Worker revealed she did not witness any verbal abuse by PT B towards Resident #1. She stated PT B was talking loudly to Resident #1 in the 600 hallway but she did not hear exactly what was said. She stated PT B and Resident #1 were arguing but did not know the specifics about what happened. She stated no one came to her after incident to allege any allegations of abuse by PT B towards Resident #1. She stated any resident abuse allegations should be reported to the Administrator who is the abuse coordinator immediately and Administrator was responsible for reporting allegations to the state. She stated she completed the resident safe surveys when an allegation of abuse/neglect was suspected for the investigation but she did not complete any resident safe surveys about allegations of abuse in regards to therapist. Interview on 04/20/23 at 10:58 AM with Regional Director of Rehab revealed he received a phone call from OT I and OT A about concerns of PT B allegedly being rude and having a tone with Resident #1 during a therapy session and said she had not told the Director of Rehab due to a past incident where nothing was done about PT B. Regional Director of Rehab stated OT A told him she had not informed the Administrator. Regional Director of Rehab asked OT A to email him her statement. He stated he received the email the same day OT A called him. He stated he tried to call the facility to get hold of Administrator but Administrator was not at facility nor was the DON so he reached out to his boss. He forwarded the email to the [NAME] President of Operations and Administrator about the allegations of abuse for Resident #1. He stated the email from OT A revealed suspected allegations of abuse and required the Administrator who is the abuse coordinator to investigate these alleged abuse allegations. He stated PT B was not suspended and did not know if Resident #1 was taken off her caseload. Interviews on 04/19/23 at 3:16 PM and 04/20/23 at 12:20 PM the Director of Rehab revealed she was not made aware of OT A reporting abuse by PT B for Resident #1 until after Administrator contacted her. She stated the Administrator was the abuse coordinator who was responsible for investigating the allegation of abuse. She stated she was not aware if this allegation of abuse was reported to the state. She stated Administrator investigated the alleged incident and Resident #1 reported he felt safe. She stated PT B was not suspended but was taken off Resident #1's treatment caseload. She stated Administrator inserviced the staff on abuse/neglect and reporting guidelines. Interview with OT F on 04/20/23 at 11:14 AM revealed she became aware of allegation of abuse for Resident #1 by PT B when OT A reported it to her either face to face or via telephone. She could not recall when she specifically became aware of the alleged incident. She stated OT A reported she and PT B had gone into Resident #1's room who told them he was waiting to be changed and had a bowel movement. She stated it was reported to her that PT B told Resident #1 Grown man should not be shitting upon himself and this upset Resident #1. She stated OT A stated when PT B was doing incontinent care on Resident #1 he reported she was hurting him. OT F stated OT A stated later same day when walking Resident #1 when he wanted to sit down PT B yelled at him saying If you try to sit down we will pull this chair from underneath you. She stated when she became aware it was after the Administrator was already made aware of the allegations of abuse. She did not report the allegation of abuse to the Administrator. Interview on 04/19/23 at 3:35 PM with PT B revealed Administrator reported there was a complaint about my treatment and allegation of abuse for Resident #1 on 02/20/23. She was told by Administrator Resident #1 did not have any issues with it. She stated she talked with Administrator the same day as her statement (02/23/23) about two incidents with Resident #1. She stated first incident OT A and her went into Resident #1's room. PT B stated Resident #1 had a bowel movement and was waiting to be changed. She stated she provided incontinent care to him and when he rolled over said Oh. She stated he was not complaining of pain during incontinent care. She denied any verbal abuse or physical abuse to Resident #1. She stated after she provided incontinent care she assisted in in transfer to go to dining room for lunch. She stated after lunch the same day she was doing gait belt training with Resident #1 with OT A. PT B stated she was holding the wheelchair while OT A was beside Resident #1 when walking down the hall. She stated Resident #1 was holding until rail and not reaching back for wheelchair when wanting to rest. She stated she did raise her voice because she was concerned about his safety and him falling. PT B stated she told him to reach for wheelchair before trying to sit down because he was not reaching back. PT B stated she sometimes had to raise her voice to get resident's attention or if concerned about their safety but she denied any verbal abuse. She stated social worker overheard it and checked on incident. She stated LVN D was standing at her cart when the incident happened on 02/20/23. She stated she was not sent home nor was suspended pending investigation by Administrator due to allegation of abuse for Resident #1. She stated she was in-serviced on abuse/neglect. She stated Resident #1 was taken off of her caseload after she talked with Administrator as a precaution but no disciplinary action was taken. Interview with Administrator on 04/19/23 at 4:07 PM revealed she did not report the allegation of verbal and physical abuse by PT B for Resident #1 to the state agency within 2 hours. She stated she was at a corporate meeting on 02/22/23. She stated OT A should have reported the allegation of abuse to her immediately on 02/20/23 when alleged incidents occurred. She stated OT A reported the alleged allegation of abuse by PT B to Regional Director of Rehab on 02/22/23 and she was informed by an email of OT A's statement on the evening of 02/22/23. She stated she contacted Director of Rehab on 02/22/23 to get her a statement from PT B. Administrator stated she would immediately notify the state if a resident or family member reported an alleged allegation of abuse/neglect, suspend alleged perpetrator pending investigation and investigate the incident. She stated at first stated this alleged allegation of abuse was hearsay by staff member. She stated she would report the allegation if the resident when interviewed stated an allegation of abuse/neglect occurred to the state. She stated she interviewed Resident #1 the next day on 02/23/23 who denied any abuse and felt safe at facility. She stated PT B provided a witness statement on 02/23/23. She stated since Resident #1 denied any abuse occurred so she did not report it and PT B denied any abuse occurred. She stated PT B was not suspended but Resident #1 was taken off her caseload just to be safe. She stated staff were in-serviced on abuse/neglect and reporting after incident. She stated OT A alleged the first incident that PT B was rude to Resident #1 by stating grown man laying there pooping in his diaper and wiping aggressive and rough during incontinent care provided by PT B. Interview on 04/20/23 at 1:44 PM with Administrator revealed she did contact LVN G on 02/22/23 in the evening to have him talk to Resident #1 about allegation of abuse. She stated she talked with Resident #1 in the morning on 02/23/23 about the alleged incident and he denied any abuse by PT B. She stated she was not aware of any

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to treat pressure ulcers on Resident #1's toes. The facility failed to assess for pressure ulcer development on Resident #1's sacrum and buttocks after identifying the resident was uncomfortable after receiving incontinent care. The facility failed to off load Resident #1's left heel per his care plan to treat a pressure ulcer on Resident #1's left heel. These failures caused Resident #1 to have a pressure ulcer on his left great toe which increased in size and he developed new pressure ulcers on his sacrum and buttocks. These failures placed the 53 residents who required assistance with incontinence care at risk for the development and/or worsening of wounds, infection, and delayed healing. Findings included: Review of Resident #1's Face Sheet, dated 06/28/17, revealed the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, dated 06/17/17, revealed the resident had a care plan to address his behavior of removing his clothing, brief, and linens. The facility goal was to maintain the resident in a clean and dry state and prevent complications of incontinence care by maintaining and providing incontinent care to the resident at regular intervals. The resident also had a care plan for activities of daily living with the facility interventions including to set-up, and assist with ADLs as needed. Review of the Skin Report, provided by the DON and completed by RN H, dated 06/15/17-06/22/17, revealed Resident #1 was admitted on [DATE] with a wound (non-pressure/other) on his left great toe measuring 0.1 cm x 0.1 cm x 0.1 cm and a wound (non-pressure/other) on his left second toe measuring 0.1 cm x 0.1 cm x 0.1 cm. Review of Resident #1's Wound Assessment Sheets, dated 06/17/17, revealed the resident was admitted with a wound (non-pressure/other) on his left great toe measuring 0.1 cm x 0.1 cm x 0.1 cm and a wound (non-pressure/other) on his left second toe measuring 0.1 cm x 0.1 cm x 0.1 cm. The Wound Assessment reflected the ordered treatment was skin prep, and the physician notification was done on 06/17/17. The resident also had a right hip-surgical incision. Review of Resident #1's Physician's Orders for 06/17/17 revealed the resident did not have orders to treat the wounds on his toes. Review of Resident #1's Wound Assessment Sheets, dated 06/24/17, revealed the resident developed pressure ulcers (deep tissue injuries) on his bilateral heels in-house measuring 6.0 cm x 6.0 cm on his right heel and 2.0 cm x 3.0 cm on his left heel. The ordered treatment was skin prep with a physician notification on 06/24/17. Review of Resident #1's Physician's Orders for 06/24/17 revealed: Apply Skin Prep to each heel every shift. Review of Resident #1's Treatment Administration Records for June 2017 revealed the resident did not have a treatment for [REDACTED]. Review of Resident #1's Treatment Administration Records for June 2017 revealed the resident was being treated with skin prep to each heel every shift. An observation on 06/27/17 at 9:30 a.m. revealed Resident #1 was not in his room. The room had a foul and pungent odor of urine and feces. The resident's bed was low to the ground and had soiled bed linens on it and on the carpeted floor. The bed linens were soiled with dried, brown, urine stains. There was a soiled brief on the floor containing feces and wipes covered with feces. There were pieces of a shredded brief on the floor. An interview with CNA A on 06/27/17 at 10:40 am revealed his assignment had changed that morning because an aide was sick, and that he was helping on all of the halls. He stated he was assigned to Resident #1, but had not provided peri-care to the resident because therapy already did. He stated the last time he saw the resident, he was still lying in bed. An interview with the SLP on 06/27/17 at 11:10 a.m. revealed she assisted COTA E to provide incontinence care to Resident #1 between 7:15 a.m. and 7:30 a.m. She stated she had not been trained by the facility to provide incontinence care to residents. She stated when she left the room it was disheveled and they had stripped part of the bed. She stated she did not remove anything from his room. She stated she did not see any open areas on the resident. An interview with COTA E on 06/27/17 at 11:30 a.m. revealed she provided incontinence care to Resident #1 sometime between 7:00 a.m. - 7:30 a.m. She stated she and the SLP changed his brief and cleaned him of bowel movement because his bed and clothes were soaked from his chest to upper thighs and his brief was brown and yucky. She stated she told CNA A the resident needed to be showered because she was only able to get him so clean with wipes and they had cleaned him the best they could. She stated she had not received any facility training to provide incontinent care, but did receive training in school. She stated they left the soiled linens and soiled brief in the resident's room. She stated she did not see any open areas on the resident. An observation and interview for Resident #1 on 06/27/17 at 12:05 p.m. revealed the resident lying in bed with CNA A, CNA B, and DON C preparing to do incontinent care. DON C was at the head of the bed holding the resident's hand. CNA B washed her hands and applied gloves. The resident was lying on his back. CNA B folded the resident's brief down and cleansed the fold beneath the abdomen, the top of the right thigh, the top of the left thigh, the shaft of the penis and the meatus. One wipe was used for each area. The resident was then rolled partially to his left side. Urine had soaked through the brief and onto the bottom sheet. The resident was rolled to his right side. CNA A pulled out the soiled brief which had feces, urine, and a moderate amount of serosanguinous (drainage that consists of blood and clear fluid) on it. A large, red, open area with sera-sanguineous drainage was visible to his sacrum. The resident was rolled onto his back without having his buttocks cleansed. The surveyor asked CNA A, CNA B, and DON C how long the wound on the resident's bottom had been present. They stated they were not aware he had a wound and started to turn the resident back onto his right side to look for it. DON C asked staff to bring in the ADON to assess and measure the wound. DON D and the ADON entered the room and the resident was turned to his right side. The resident had a Stage II pressure ulcer on his sacrum that was red, raw, open, and draining serosanguinous drainage. The edges of the skin of the wound were rolled up. It was approximately 5.0 cm x 5.0 cm circular area. The resident also had three other Stage II pressure ulcers on his inner buttocks. They were opened with no visible drainage. The largest was approximately 1.5 cm x 1.5 cm with two smaller areas approximately 0.8 cm x 0.8 cm. They were circular round areas. His buttocks were red and the area directly beneath the sacral wound was a darkened purplish color. The darkened area looked like a deep tissue injury. A subsequent interview with CNA A on 06/27/17 at 12:15 p.m. revealed he had not provided incontinent care to the resident that shift and stated therapy had provided incontinent care to the resident at approximately 7:00 a.m. and 10:00 a.m. CNA A stated he did not see the wounds when he provided peri-care on 06/26/17, but he was unsure if they had been present or not because he was not able to see the resident's buttocks clearly when he had changed him. CNA A stated he hoped the wounds had not occurred due to the shower chair because he had showered the resident on 06/26/17. An interview with CNA F on 06/27/17 at 12:50 p.m. revealed he assisted with peri-care for Resident #1 on 06/26/17 and he did not see any pressure ulcers on the resident. An interview with the ADON on 06/27/17 at 1:45 p.m. revealed she was not previously aware the resident had pressure ulcers on his sacrum and buttocks and she was the nurse who made weekly rounds with the wound care physician. She stated the Stage II pressure ulcer on the resident's sacrum was 4.5 cm x 4.0 cm. The other Stage II pressure ulcers measured 3.5 cm x 1.5 cm on the left inner buttock wound and .1 cm x .1 cm and .1 cm x .1 cm on his right inner buttock. She stated the pressure ulcers were not there when she completed his skin assessment on 06/23/17 and she did not know how long they had been present. She stated she had not assisted with his peri-care on 06/27/17 but she did assist therapy to transfer him to bed at about 10:00 a.m. and therapy had completed his peri-care at that time. An interview with the Administrator on 06/27/17 at 2:45 p.m. revealed she saw Resident #1 prior to his wound care and he was shifting in his seat and trying to remove his brief. She instructed DON C to go see the resident and stated she saw her walk in his room. An interview with OTA G and the PTA on 06/28/17 at 1:30 p.m. revealed they put Resident #1 in bed sometime between 10:00 a.m. - 10:30 a.m. on 06/27/17 and his brief was not wet at that time so they did not provide him with peri-care. An interview with the therapy director on 06/28/17 at 9:45 a.m. revealed the therapy department did not receive facility or specialized training to provide incontinent care. She stated the function of the department was to increase the ability of a resident to be continent again, and COTAs were taught in school to assist residents who were not able to clean themselves if they became incontinent during therapy. She stated the facility had instructed the therapy department to take a resident who had an incontinent episode in therapy to their room and ask the CNA or nurse to clean the resident. An observation of Resident #1 on 06/27/17 at 3:25 p.m. revealed he was in bed lying on his back in an upright position. His left heel was not off-loaded and was lying directly on the bed mattress. His right foot was in a soft pillow boot. LVN I removed the resident's socks and revealed his left great toe and his left second toe each had a raised blood blister. The size of the blisters were approximately 0.3 cm x 0.3 cm in diameter and they were on the bony prominences of the toes. LVN I stated she had never observed the wounds on his toes before and did not know how long they had been there. She stated she would ask about getting a canopy on his bed to keep the sheets off of his toes. The resident's left heel had a large, fluid- filled blister covering approximately ¾ of the heel and was a dark black-purple color. The resident's right heel had a large, fluid- filled blister covering approximately all of the heel and was a dark black-purple color. LVN I stated they were treating the heels with skin prep and off-loading them with pillows, but the resident was often kicking off the pillows. There were no pillows observed on or off the foot of the bed. A subsequent interview with the ADON on 06/27/17 at 3:40 p.m. revealed she assessed Resident #1's feet that morning and the pressure ulcers on his toes were not there. She stated she was getting an order to treat the toes with skin prep and a soft boot pillow for the resident's left heel. An interview with CNA J on 06/27/17 at 4:20 p.m. revealed she provided care, including a bed bath, to Resident #1 on 06/26/17 and the pressure ulcers on his sacrum, buttocks, and toes were not there. An interview with RN H on 06/28/17 at 2:00 p.m. revealed she had admitted Resident #1 to the facility on [DATE] and during his admission assessment she found the wounds on his toes. She stated the wounds on his toes had been present since admission, but that staff probably did not see them because they did not remove his socks. An observation of Resident #1 on 06/28/17 at 11:50 a.m. revealed he had just returned from a doctor's appointment and was in bed. His toes were visible. The wound on his left big toe was no longer a blister and was approximately 0.5 cm x 0.3 cm in size with eschar and surrounding redness. The wound on his left second toe was no longer a blister and was approximately 0.3 cm x 0.3 cm in size with eschar and surrounding redness. The wounds were no longer raised. DON C was in the room with the resident and stated the wounds on his toes were unstageable. An interview with DON C and DON D on 06/28/17 at 3:35 p.m. revealed Resident #1 had not been assessed by the wound care physician since his admission to the facility on [DATE]. They stated the ADON and nurses were responsible for ensuring follow-up was completed when pressure ulcers were identified on residents. DON C stated that going forward, she would review the skin assessment daily to make sure resident wounds had appropriate orders to treat. DON C and DON D were not able to provide any documentation to indicate assessment or treatment had been provided to Resident #1 for the pressure ulcers on his toes prior to orders received on 06/27/17 after the surveyor brought the pressure ulcers to the attention of the facility. An interview on 06/28/17 at 4:25 p.m. with DON C and DON D revealed the pressure ulcers on Resident #1's toes were eschar and measured 0.3 cm X 0.2 cm on his left great toe and 0.1 cm x 0.1 cm on his left 2nd toe. An interview on 06/28/17 at 5:30 p.m. with the Administrator revealed she had observed wounds on Resident #1's left big toe and left second toe on 06/26/17 and 06/27/17. An interview on 06/29/17 at 9:45 a.m. with the Regional Wound Care Physician of the facility revealed Resident #1 had not been assessed by a wound care physician since his admission to the facility. An interview with the Primary Care Physician for Resident #1 on 06/29/17 at 10:05 a.m. revealed he remembered getting a fax about the resident on admit regarding abrasions on his toes and he said it was ok to use skin prep on the wounds. He stated he did not see the resident. He stated he saw the resident at the facility but did not inspect his feet that closely. He saw him because he was congested. The Primary Care Physician stated he going to the hospital on [DATE] to see the resident. He stated he spoke to the son who stated the resident had large areas on his heels that sounded like eschar and the facility should have had him see the patient instead of just sending faxes to his office to request orders. Review of the Facility Policy and Procedure, Patient Care Management System 1, dated May 2016, reflected, 1. The admitting nurse must notify the physician and responsible party of any identified areas and must implement treatment and interventions . 6. A wound assessment must be completed and a narrative of each site must be documented weekly for any pressure injury and non-pressure skin condition including arterial ulcers, diabetic [MEDICAL CONDITION] ulcers, [MEDICAL CONDITION] ulcers, bruises, skin tears, and surgical wounds .11. Timely and appropriate incontinent care will be consistently provided to all incontinent patients. The facility must ensure that all licensed staff and nurse aides are consistently in-serviced on the provision of proper incontinent care. Review of the facility Resident Census and Conditions of Residents Form CMS-672, signed and dated by the LVN/Patient Care Coordinator on 06/27/17, revealed 53 residents required assistance with incontinent care.