Every finding on record at Tishomingo Manor

Based on resident interviews, staff interviews and resident representative interviews, record review, and facility policy review, the facility failed to safeguard and properly manage personal funds for two (2) of four (4) residents reviewed. The facility had withdrawn from residents personal-needs funds to pay past-due facility balances without demonstrating that the residents, or individuals possessing legal financial authority, specifically authorized the withdrawals before they occurred. Resident #2 and Resident #84 Findings include:Review of the facility policy titled General Resident Trust Fund Policies, revised 1/20, revealed under Basic Requirements: Residents have the right to manage their financial affairs. The facility must, upon written authorization by the resident, accept responsibility for holding, safeguarding and accounting for the resident's personal funds deposited with the facility .Resident #2Record review of Resident #2's Resident Statement revealed the facility made the following withdrawals from his trust-fund account, leaving him without his allotted $44.00 monthly personal-needs allowance after his room and board were paid:On 11/06/23, the facility withdrew $1,134.00, identified on the account statement as Care Cost Payment. The withdrawal reduced the resident's account balance to zero and did not leave Resident #2's $44.00 personal-needs allowance.On 09/04/24, the facility made two withdrawals totaling $2,767.09. The facility withdrew $1,470.09, identified as RM BRD PAST DUE BALANCE for August, and $1,297.00, identified as Care Cost Payment. The withdrawals reduced the resident's account balance to zero and did not leave Resident #2's $44.00 personal-needs allowance.On 10/03/24, the facility withdrew $1,340.00, identified as Care Cost Payment. The withdrawal reduced the resident's account balance to zero and did not leave Resident #2's $44.00 personal-needs allowance.On 11/05/24, the facility withdrew $1,340.00, identified as Care Cost Payment. The withdrawal reduced the resident's account balance to zero and did not leave Resident #2's $44.00 personal-needs allowance.Record review revealed an untitled letter with a signature date of 01/16/25 that read, l, (Resident #2) was denied Medicaid in August 2023 due to funds being deposited and withdrawn from my personal account. I owed the facility over $25,000 due to being penalized for 3 months. I agreed to have my Social Security check direct deposited in the resident trust fund at (proper name of the facility). I also agreed to (proper name of the facility) applying my $44.00 to the past due balance owed to the facility. The resident and the facility Accounts Manager signed the letter on 1/16/25, after the facility had made the identified withdrawals.An interview with the Administrator (ADM) on 7/21/26 at 4:04 PM revealed Resident #2 had a trust-fund account with the facility. The ADM stated she did not know whether the resident or the RR (resident representative) signed anything authorizing the facility to remove personal funds from the account. She revealed she thought the debt was written off by the corporate office.Record review of Resident #2's Transaction Report revealed the facility wrote off $22,633.14 in bad debt on 10/31/24.During an interview on 7/21/26 at 4:52 PM, the Regional [NAME] President (VP) was asked why the resident was asked to sign the 1/16/25 agreement after the debt had been withdrawn and after the debt had been written off by the corporate office. The VP stated, I get it, I understand, but I can't answer that.An interview with Resident #2 on 7/22/26 at 7:30 AM revealed he did not recall whether staff spoke with him about the debt or whether he signed an agreement allowing the facility to apply his personal funds to the facility balance.An interview with the Accounts Manager on 7/22/26 at 7:39 AM revealed the facility deducted the resident's $44.00 personal-needs allowance toward the outstanding balance before she assumed the position. The Accounts Manager stated a Medicaid auditor told the facility that they could not take the resident's $44.00 without his permission. She confirmed that she drafted the 1/16/25 agreement after the deductions occurred and after the debt was written off. The Accounts Manager stated, I got the resident to sign the agreement to cover the time that the facility was deducting the 44 dollars before I had the job.A telephone interview with Resident #2's RR on 7/23/26 at 12:01 PM revealed she did not recall the facility notifying her that it intended to collect money from Resident #2's trust-fund account to pay the past-due balance. She confirmed she never authorized the transactions and did not have legal authority to make his financial decisions.Record review of Resident #2's admission Agreement, dated 2/07/22, revealed under Section C. The resident and/or resident representative agree: .3. To be responsible for all other services/charges in relation to the resident's care, when these services/charges are not mandated as covered services to be provided by the Facility . The RR signed the agreement on 2/7/22. The agreement did not specifically authorize the facility to withdraw Resident #2's personal-needs funds to satisfy a past-due facility balance. Further review of the admission Agreement on page 9, indicated Resident #2 did not have a Power of Attorney, Conservator, or Health Care Surrogate.The facility did not provide an agreement, authorization, receipt, progress note, or other contemporaneous documentation showing Resident #2 authorized the facility to apply his $44.00 personal-needs allowance toward the outstanding facility balance before the withdrawals occurred.Record review of the Face Sheet revealed the facility admitted Resident #2 on 2/7/22 with medical diagnoses including Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/22/26, revealed a Brief Interview for Mental Status (BIMS) summary score of 15 in Section C, indicating Resident #2 was cognitively intact. Resident #84Record review of Resident #84's Medicaid liability notice dated 5/21/24 revealed that, effective 7/01/24, the resident's Medicaid-established monthly liability was $1,545.00.Record review of Resident #84's trust-fund Resident Statement revealed the facility reduced or eliminated the resident's available $44.00 personal-needs funds to pay a past-due facility balance, as follows:On 8/05/24, following an 8/02/24 SSA (Social Security Administration) deposit of $1,589.00 and an existing trust-fund balance of $4.40, the facility withdrew $234.94, identified as RM BRD JULY, and $1,358.46, identified as Care Cost Payment, totaling $1,593.40. The withdrawals reduced Resident #84's trust-fund account balance to $0.02.On 9/04/24, the facility withdrew Past Due Balance amounts of $186.54 and $1,402.47, totaling $1,589.01. The total withdrawn was $44.01 more than Resident #84's Medicaid-established monthly liability and reduced the resident's trust-fund account balance to $0.00.On 10/03/24, the facility withdrew $1,545.00, identified as Care Cost Payment, followed by $20.01, identified as Payment on Past Due. The additional $20.01 withdrawal reduced Resident #84's available personal-needs funds from $44.01 to $24.00.On 11/05/24, the facility withdrew $1,583.00, identified as Care Cost Payment. This amount exceeded the $1,545.00 monthly liability identified in the Medicaid notice by $38.00 and left $10.00 in the resident's trust-fund account.On 12/03/24, the facility withdrew $1,575.01, identified as Care Cost Payment. This amount exceeded the $1,545.00 monthly liability identified in the Medicaid notice by $30.01 and left $24.00 in the resident's trust-fund account.From 9/04/24 through 12/03/24, the facility withdrew at least $132.03 more than Resident #84's Medicaid-established monthly liability. The 9/04/24 and 10/03/24 ledger entries specifically identified additional withdrawals as payments toward the resident's Past Due Balance.Further review of Resident #84's trust-fund Resident Statement revealed the facility continued to withdraw personal-needs funds for past-due facility debt during 2025.On 2/03/25, the facility withdrew $1,584.00, identified as Care Costs Payment, leaving $44.00 in the resident's trust-fund account. The facility then withdrew an additional $20.00, identified as Towards Past Due, reducing the resident's available personal-needs funds to $24.00.On 3/03/25, the facility withdrew $18.96, identified as RM and BED [DATE], followed by $1,584.00, identified as Care Cost Payment. The separately identified RM and BED [DATE] withdrawal was applied to a prior-month facility bill and reduced the resident's available trust-fund balance to $29.05.Record review of Resident #84's General Notes Report revealed an entry dated 8/02/24 under Financial, which documented, Spoke with RP (responsible party) on 8/02/24. She said she has no money to pay the past due amount owed for May 2024, and for us to take the $44.00 each month until it is paid in full. A second entry dated 1/06/25 documented, Resident pays an extra $20.00 each month towards past due amount.During an interview on 7/23/26 at 11:00 AM, Resident #84 was asked whether he authorized the facility to withdraw funds from his trust-fund account to pay a past-due facility balance. Resident #84 stated, If they talked to me, I gave them permission but didn't sign anything. Resident #84 did not confirm that facility staff spoke with him and could not identify the amount, frequency, or duration of any withdrawals he authorized.During a telephone interview on 7/23/26 at 11:27 AM, Resident #84's Resident Representative (RR) stated the facility contacted her about an outstanding balance. She stated a staff member told her she could pay the balance or the facility could withdraw money from Resident #84's facility account. The RR stated she agreed to the withdrawals because she believed Resident #84 might lose his placement if the balance remained unpaid. She stated she was given two options: she could pay the bill, or the facility could deduct the money from Resident #84's account. The RR stated she was a stay-at-home mother and did not have the money to pay the bill. She stated Resident #84 was unhappy because the withdrawals left him without money to purchase personal items.Record review of Resident #84's admission Agreement, dated 6/01/23, revealed under admission Acknowledgements and Authorizations no documentation that Resident #84 had a power of attorney, conservatorship, or other individual with legal financial authority.During an interview on 7/23/26 at 2:28 PM, the Administrator (ADM) stated the facility never withdrew money from a resident's trust account without the resident's consent. The ADM confirmed the facility withdrew Resident #84's funds to pay past-due balances but stated the facility never took the full $44.00 and withdrew only $20.00.During an interview on 7/23/26 at 2:58 PM, the Accounts Manager stated she spoke with the RR and Resident #84's son in an effort to collect the resident's outstanding balance. The Accounts Manager stated she then contacted the RR, who said she could not afford to pay the balance and told her to take the resident's $44.00. The Accounts Manager stated, I only took out $20.00. When asked whether she obtained Resident #84's signature authorizing the facility to collect the outstanding balance from his trust-fund account, she stated, We could not find it; I'm not sure if he signed one or after our last Medicaid audit it got shredded. The Accounts Manager stated Resident #84 agreed to the withdrawals; however, the facility was unable to provide written documentation showing the resident authorized withdrawals from his trust-fund account to pay the past-due facility balance.Although the Administrator and Accounts Manager stated the facility withdrew only $20.00 monthly, the trust-fund statements showed withdrawals that reduced Resident #84's available personal-needs funds by as much as $44.01.The facility did not provide documentation showing Resident #84 authorized the withdrawals or that the RR had legal authority to authorize the use of the cognitively intact resident's personal funds.Record review of the Face Sheet revealed the facility admitted Resident #84 on 6/01/23 with medical diagnoses including Unilateral Primary Osteoarthritis, Left Knee.Record review of the MDS, with an ARD of 7/08/26, revealed in Section C a BIMS summary score of 15, indicating Resident #84 was cognitively intact.

Based on resident representative (RR) and staff interview, record review, and facility policy review, the facility failed to ensure it did not request or require third-party guarantees of payment by holding RR's personally responsible for residents' facility charges for two (2) of 2 residents reviewed for admission and financial agreements. Resident #2 and Resident #84 Findings Include:Record Review of the facility policy titled A/R (Accounts Receivable) Type - Private Pay revised 9/24, Revealed under, Collection Policy: Payment is expected by the 5th of the month and the is considered past due on the 10th. If payment is not received by the 10th, the administrator should contact the resident representative by telephone or in person. If payment is not received by the 15th, a copy of this statement should be stamped Past Due and mailed to the resident representative. The administrator should contact the resident representative by phone or in person again. If payment is not received by the 20th, a final statement should be mailed to the resident representative. The need to continue collection efforts beyond this point will follow the bad debt procedure outlined in this manual.Resident #2Record review of a Debt Collection Letter dated 8/23/2024, addressed to Resident #2's RR revealed the facility sought payment from the RR. The letter stated, Despite our previous reminders, the amount due remains unpaid. As such, we would appreciate you making this payment as soon as possible. AMOUNT DUE: $27,989.85.We regret to advise that unless payment is received within 14 days of this letter this account will be turned over to an attorney for collection and the account is subject to interest and attorney fees.Record review of Resident #2's Debt Collection Letter, dated 9/16/24, and addressed to the RR revealed the facility sought payment of $25,054.05 from the RR.Record review of the Facility Bad Debt Declaration, dated 10/25/24, revealed Resident/Family refuses to pay was checked as the reason for the bad debt. The declaration stated Resident #2 was penalized for August, September, and October 2023 after Medicaid denied coverage.Record review of Resident #2's admission Agreement, dated 2/07/22, revealed under Section C. The resident and/or resident representative agree: .3. To be responsible for all other services/charges in relation to the resident's care, when these services/charges are not mandated as covered services to be provided by the Facility . The RP signed the agreement on 2/7/22 and had no legal authority to access the residents' funds. Record review of the Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/22/26, revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact.Resident #84Record review of Resident #84's Debt Collection Letter, dated 7/19/24 and mailed to the RR, revealed, We regret to advise that unless payment is received in 14 days of this letter this account will be turned over to an attorney for collection and the account is subject to interest fees. The Administrator signed the letter, which identified an outstanding balance of $234.94.Record review of Resident #84's admission Agreement, dated 6/01/23, revealed under Section C. The resident and/or resident representative agree: .3. To be responsible for all other services/charges in relation to the resident's care, when these services/charges are not mandated as covered services to be provided by the Facility . The RR signed the agreement on 6/1/23 and had no legal authority to access the residents' funds. On 7/23/26 at 11:27 AM, during a telephone interview with Resident #84's RR she stated the facility contacted her about an outstanding balance. She revealed that facility staff explained that Medicaid and Medicare paid a certain amount, and that Resident #84 had a remaining balance at the end of the year. She stated, They told me I was responsible for the bill. The RR stated the balance was more than $200.00 and a staff member told her she could either pay the balance or the facility would withdraw the money from Resident #84's facility account. She stated, I am a stay-at-home mother; It's just me and my sister and we do not have the extra money to pay his bills.Record review of Resident #84's General Notes Report revealed an entry dated 8/02/24 under Financial, which documented, Spoke with RP (responsible party) on 8/02/24. She said she has no money to pay the past due amount owed for May 2024, and for us to take the $44.00 each month until it is paid in full.An interview with the Accounts Manager on 7/22/26 at 7:39 AM stated that, when an RR signed the admission agreement, the RR assumed responsibility for charges incurred by the resident. When asked whether this depended on the RR having legal authority to access the resident's funds, she stated, It does not matter, it is part of their responsibility. She confirmed this was a facility practice of debt collection.During an interview on 7/23/26 at 1:44 PM, Social Services (SS) revealed she had a lot of family members who will not sign to be a RR because of verbiage in the admission agreement making them responsible for the residents' debts. She confirmed the agreement required the family to pay and did not state if they had legal authority and it must be from the resident's account. During an interview on 7/23/26 at 2:28 PM, the Administrator (ADM) stated the facility was a business and had to collect outstanding balances confirming the facility considered RR's responsible for resident's account balances.Record review of Resident #84's Face Sheet revealed the facility admitted him on 6/01/23 with a medical diagnosis of Unilateral Primary Osteoarthritis of the Left Knee.Record review of the MDS with an ARD of 7/08/26 revealed under section C a BIMS summary score of 15, indicating Resident #84 was cognitively intact.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) to reflect a State Level II Preadmission Screening and Resident Review (PASRR) determination of serious mental illness for one (1) of 23 residents reviewed for MDS accuracy. Resident #2 Findings include:Review of the facility policy titled MDS Charting Documentation Guidelines, revised 11/25, revealed, .To have an accurate assessment of the residents, information must be gathered on the residents while in the observation period for the MDS. This information must come from resident assessment and documented information in the residents' chart within the times frames set forth on the MDS .Record review of the Face Sheet revealed the facility admitted Resident #2 on 2/7/22 with a medical diagnosis of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular disease.Record review of the Preadmission Screening and Resident Review (PASRR), dated 2/17/22, revealed, Summary of Findings Report: The individual meets criteria for mental illness as defined by PASRR. The report identified schizophrenia as Resident #2's qualifying mental illness.Record review of the Significant Change MDS with an Assessment Reference Date (ARD) of 3/27/26 revealed that Section A1500 asked, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? The facility coded No.During an interview on 7/23/26 at 9:42 AM, the MDS Nurse confirmed Resident #2 had received a Level II PASRR determination. She stated she did not code the determination on the MDS because Resident #2 refused mental health services. The MDS Nurse acknowledged that the resident's refusal of services did not change the Level II PASRR determination and confirmed Section A1500 should have been coded to reflect the determination. She stated the assessment should be accurate so the plan of care could be developed.Record review of the MDS with an ARD of 6/22/26 revealed a Brief Interview for Mental Status (BIMS) summary score of 15 in Section C, indicating Resident #2 was cognitively intact.

Based on interview, record review, and facility policy review the facility failed to implement a comprehensive care plan for one (1) of 23 sampled residents, Resident #6. Findings Include: Review of the facility policy Care Plan Process with revision date of 12/24 revealed, .The facility must develop a comprehensive care plan for each resident The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being . The facility staff shall follow the care plan . Record review of Resident #6's care plan with an initiated date of 03/04/2025, revealed, Range of motion (ROM) (active and passive) with am/pm care daily as needed. Record review of Resident #6's Documentation Survey Report task revealed no order to perform range-of-motion exercises. On 07/22/26 at 9:45 AM an interview with Physical Therapy Assistant (PTA) #1, revealed that Resident #6 received Occupational Therapy (OT) Services and was discharged to the Restorative Nursing Program (RNP) on 12/30/25. On 07/22/26 at 11:15 AM during an interview and record review with the Restorative Nurse, she confirmed that Resident #6 was not enrolled in the Restorative Nursing Program despite being referred by the therapy department. She further acknowledged that active and passive ROM interventions had not been assigned under the restorative task tab nor under the task for any other Certified Nursing Aid (CNA) to complete. Restorative Nurse reviewed Resident #6's Task and confirmed that there was no documentation to reflect that ROM exercises were being completed, and she confirmed that a care plan for Restorative Nursing was not implemented. During this interview, Restorative Nurse also acknowledged that active and passive ROM daily interventions were included in the resident's care plan and stated, I agree 100% that since range of motion exercises were on the care plan, they should be completed. She further acknowledged that the facility was aware that therapy referrals continued to be generated while the restorative program was not fully operational and stated the referrals should have been reviewed to ensure the ordered interventions were implemented.An interview on 07/23/26 at 11:05 AM with Minimum Data Set (MDS) Nurse revealed that the purpose of the care plan is to make sure every resident receives the care they need based on their individual needs, goals, and preferences. She revealed that it tells the staff what care to provide and how to provide it. MDS Nurse reviewed Resident #6's Care Plan and confirmed that the intervention for range of motion was included in the care plan and should have been followed. Record review of Resident #6's Face Sheet revealed an admission date of 03/04/25 with diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Record review of Resident #6's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/02/26 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated she had severe cognitive deficits.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure range of motion services were implemented in accordance with therapy recommendations and resident care needs for two (2) of four (4) residents reviewed (Residents #2 and #6). Residents discharged from therapy to the Restorative Nursing Program were not enrolled, evaluated, assigned restorative tasks, or provided ordered active/passive range of motion interventions. Findings include: Review of the facility policy, Range of Motion with revision date of 01/24 revealed under the Purpose revealed To move the resident's joints through as full a range of motion as possible. To improve or maintain joint mobility and muscle strength. To prevent contractures. To increase strength and activity tolerance. To reduce pain. To prevent complications of mobility . Resident #2 An observation and interview on 7/20/26 at 1:46 PM revealed Resident #2 lying in bed. He stated he had left-sided hemiparesis and a contracture of the fingers on his left hand. He explained that he had been off therapy for a while and nobody performed exercises with his extremities. The resident stated he was supposed to have a hand device, but he could not keep track of it and did not know where it was. The fingers on his left hand were bent inward toward his palm. Record review of Resident #2's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/22/26, revealed that Section GG Functional Limitations in Range of Motion documented upper and lower extremity functional limitations on both sides. Record review of Resident #2's Occupation Therapy (OT) Discharge Summary dated 4/28/25 revealed, Pt (patient) discharging from skilled OT services to RNP (Restorative Nursing Program) and LTC (Long Term Care) Pt has left hand carrot to be used to continue to maintain joint motility and skin integrity. Also revealed under, Notes: Staff educated on wear schedule for up to 4 (four) hours at this time. To be removed and skin integrity checked every 2 hours for edema and redness. Record review of Resident #2's July 2026 Documentation Survey Report task revealed there was no order to perform range-of-motion exercises or apply a carrot splint to the resident's left hand. An interview with the Restorative Certified Nurse Aide (CNA) on 7/21/26 at 2:44 PM revealed passive range of motion was not included in the resident's tasks for the aides to perform. She stated only residents enrolled in the restorative program received range-of-motion exercises and that eight residents were currently enrolled. She confirmed Resident #2 did not have a carrot splint or have a task set up for them to apply the device. An interview with the Physical Therapy Assistant (PTA)#2 on 7/21/26 at 2:53 PM confirmed Resident #2 was discharged to the restorative nursing program on 4/28/25. The PTA stated the OT developed a restorative treatment plan that would have been provided to the staff development nurse for inclusion in the aides' daily care plan. An interview with Restorative Nurse on 7/21/26 at 3:04 PM revealed she had recently assumed the restorative nurse role. She stated that when a resident was referred to the restorative program, the restorative nurse would complete an evaluation. She confirmed she found no evidence that an evaluation was completed or that the OT recommendations were added to the resident's tasks for implementation. The Restorative Nurse acknowledged that failure to implement the services could cause the resident's contracture to worsen. Record review of the Restorative Nursing Program Plan dated 4/28/25, revealed under, Range of Motion . Pt (patient) to perform AROM (active range of motion) of RUE (right upper extremity) in all planes of movements for digits, wrist, elbow, and shoulder to maintain joint mobility and skin integrity .PROM (passive range of motion) to be performed before splinting of left and in all planes of movement for wrist, digits, elbow, and shoulder. Additionally revealed under Splinting and/or bracing: Resident to complete Upper Extremity (UE) splinting/bracing program as tolerated up to 5 (five) hours, splint to be checked every 2 hours for skin integrity, edema, and redness . Record review of the Face Sheet revealed the facility admitted Resident #2 on 2/7/22 with a medical diagnosis of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease. Record review of the MDS with an ARD of 6/22/26 revealed a Brief Interview for Mental Status (BIMS) summary score of 15 in Section C, indicating Resident #2 was cognitively intact. Resident #6 An interview on 07/22/26 at 9:45 AM with PTA #1, revealed that Resident #6 received OT Services and was discharged to the RNP on 12/30/25. During an interview on 07/22/26 at 11:15 AM with Restorative Nurse, she confirmed that Resident #6 was not enrolled in the Restorative Nursing Program despite being referred by the therapy department. She further acknowledged that active and passive Range of Motion (ROM) interventions had not been assigned under the restorative task tab nor under the task for any other Certified Nursing Assistant (CNA) to complete. She revealed that the Restorative Nursing Program was not fully operational when Resident #6 was last referred and stated that a custom task for range of motion exercises should have been created so that CNAs could identify, complete, and document the ordered care. Restorative Nurse reviewed Resident #6's Task and confirmed that there was no documentation to reflect that ROM exercises were being completed. She further revealed that therapy referrals continued to be generated while the Restorative Program was not fully operational and stated the referrals should have been reviewed to ensure the ordered care was provided. She also confirmed that failure to provide the prescribed ROM exercises could result in pain, decreased range of motion, and the development of contractures. An interview on 07/22/26 at 11:15 AM with Restorative CNA, revealed that residents discharged from therapy services to the Restorative Nursing Program were expected to receive the ordered services. She verified that Resident #6 was not enrolled in the Restorative Nursing Program and confirmed that active and/or passive range of motion exercises were not included in Resident #6's assigned CNA tasks for completion and documentation. Record review of Resident #6's OT Discharge summary dated [DATE] revealed that she was discharged from skilled OT services to LTC with RNP in place. Record review of Resident #6's Face Sheet revealed an admission date of 03/04/25 with diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Record review of Resident #6's MDS with ARD of 07/02/26 under Section C revealed a BIMS Score of 03 which indicated she had severe cognitive deficits. Record review of Resident #6's Comprehensive MDS under Section GG Functional Limitation in Range of Motion revealed that she had functional impairment to upper and lower extremities on one side. Record review of Resident #6's Care Plan Report revealed that she has right sided hemiplegia/hemiparesis stroke and had an intervention initiated on 03/04/25 to have range of motion (active or passive) with am/pm care daily as needed. Record review of Resident #6's July 2026 Documentation Survey Report task revealed there was no order to perform range-of-motion exercises.

Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure medication labeling was accurate for one (1) of 26 medication opportunities and failed to ensure medications were properly stored for one (1) of 101 residents. Resident #24 and Resident #71 Findings include: Review of facility policy titled Monitoring Medication Pass with review date 12/20, revealed, .11. No medications left at bedside . Review of the facility's Drug Administration and Documentation policy, with a revision date of 03/25, revealed .Read the medication label and compare it with the Medication Administration Record (MAR) . Resident #24 During an observation and interview on 7/20/2026 at 10:29 AM, it was revealed there were two (2) medication cups with topical medications left in Resident #24's room. One (1) medication cup was half filled with a white creamy substance sitting on his dresser. The second medication cup was one-fourth filled with a cream/white powdery substance on Resident #24's nightstand. Resident #24 stated that he used that cream and powder to rub underneath his breast and on his bottom. During an interview on 7/20/2026 at 10:36 AM, Restorative Certified Nursing Assistant (CNA) confirmed the two medication cups in the room with a white creamy substance in one and a powdery substance in the other. She stated, These are not supposed to be left in the room. Another resident could get it and possibly eat it. During an interview on 7/22/2026 at 3:45 PM and again on 7/23/2026 at 11:02 AM, the Director of Nursing (DON) confirmed that medication should not be left at the bedside and that any wandering resident could get it. She further stated, All nurses have access to the treatment cart, so any nurse could have left it. They know better and we will do retraining on that tomorrow. Record review of the Face Sheet indicated Resident #24 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Palsy, unspecified. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/15/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #24 was cognitively intact. Resident #71 During medication administration observation and record review on 07/22/2026 at 9:11 AM, an observation revealed a pharmacy label affixed to Resident #71's medication card identified the medication as Lasix 40 milligrams (mg). Record review of the electronic Medication Administration Record (eMAR) revealed the order dated 5/30/26 was entered as Lasix 20 mg, give 40 mg by mouth one time a day for edema of leg. The discrepancy between the medication label and the eMAR created the potential for a medication administration error. The resident refused the medication prior to administration; therefore, no medication was administered during the observation. On 07/22/2026 at 9:11 AM, during an interview with Licensed Practical Nurse (LPN) #4, she confirmed the medication label and the eMAR did not match and stated the order should have been changed in the computer to avoid a medication error and ensure the medication was labeled properly. She stated they did send two 20 mg tablets and started sending 40 mg tablets recently. During an interview with Medical Records on 07/22/2026 at 9:32 AM, she confirmed the order was changed on 5/29/2026 and should have been changed to accurately reflect the physician's order and avoid the potential for medication administration error. Record review confirmed the pharmacy label and the eMAR were inconsistent. The medication card reflected a new order that was given on 5/29/2026 of Lasix 40 mg, while the eMAR displayed Lasix 20 mg, give 40 mg, creating the potential for a medication administration error. During an interview on 07/22/2026 at 10:00 AM with the Director of Nursing (DON), she stated the nurse who entered the order works as needed and may not have experience entering the order correctly. Record review of the Face Sheet revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction. Record review of the MDS assessment with an ARD of 6/17/2026 revealed the resident had a BIMS score of 7, indicating severe cognitive impairment.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to maintain complete and accurate clinical records for one (1) of 23 sampled residents Resident #18. Findings Include: Review of the facility's Drug Administration and Documentation policy, with a revision date of 3/25, the policy revealed .The complete act of administration entails.promptly recording the time and dose given . Review of the facility's Procedure for Changing I.V. (Intravenous) Solution policy, with an original date of 10/16, the policy states, .8. Record in the resident's clinical record. Record review of the July 2026 Medication Administration Record (MAR) for Resident #18 revealed an order for Meropenem Solution Reconstituted 1 MG (gram) use one gram intravenously every 12 hours for bacterial infection. Documentation was missing for four (4) of 20 scheduled intravenous Meropenem 1 gram administrations. Documentation was absent for the scheduled doses due on 7/11/2026 at 0900 (9:00 AM), 7/16/2026 at 0600 (6:00 AM), 7/17/2026 at 1800 (6:00 PM), and 7/19/2026 at 0600. Further record review of the July 2026 Treatment Administration Record (TAR) for Resident #18 revealed an order dated 12/24/25 Clean suprapubic catheter site with NS (normal saline), pat dry, and apply split sponge daily. Multiple scheduled catheter care entries lacked documentation that the ordered care had been completed. The dates included 7/6/26, 7/8/26, 7/10/26, 7/13/26 through 7/16/26.During an interview with the Director of Nursing (DON) on 7/22/2026 at 10:10 AM, she revealed the nurse had forgotten to document the intravenous medication administrations due to the digital system rolling to the next shift. The DON confirmed intravenous medication administrations are to be documented on the Medication Administration Record (MAR) at the time they are administered as well as catheter care that was completed for Resident #18. During an interview with Resident #18 on 07/22/2026 at 3:30 PM, she revealed she believed she received every scheduled dose of her intravenous antibiotic and that staff routinely performed catheter care each shift. The resident did not recall staff skipping a day of her antibiotic therapy or catheter care. Record review of the Face Sheet revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease. Record review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of July 10, 2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on interview, record review, and facility policy review, the facility failed to implement their facility policy for reporting an alleged allegation of misappropriation of resident funds to the appropriate agencies for one (1) of four (4) residents reviewed for allegations of misappropriation. Resident #2 Findings Include:Record review of the facility policy titled Incident investigation & (and) Reporting revised 5/24, revealed under, Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to MSDH (Mississippi State Department of Health), Attorney General, local law enforcement, and others as required by state and federal requirements .An interview with the Regional [NAME] President (VP) on 7/20/26 at 4:27 PM revealed when Resident #2 came up for Medicaid redetermination his Resident Representative (RR) failed to take in the requested financial documents to the Medicaid office and he was penalized for three (3) months, September, October, and November 2023.Record review of the email communication regarding Resident #2 between the State Medicaid Agency and the Facility Accounts Manager, dated 9/19/24 revealed, He had someone giving him money and also someone was using his card and making large purchases and withdrawals.Follow up interview with the Regional VP on 7/21/26 at 4:52 PM revealed the facility did not notify any other outside agencies or notify the Attorney General (AG) office when they were made aware of the large money transfer in and out of Resident #2's bank account.An interview with Resident #2 on 7/22/26 at 7:30 AM revealed that he did not recall having a personal bank account and only recalls having an account with the facility.An interview with the Accounts Manager on 7/22/26 at 9:03 AM revealed that Resident #2 came up for Medicaid redetermination and during that time he was having thousands of dollars of money going in and out of his personal bank account. She revealed that the State Medicaid Agency notified her via email that someone had the residents debit card and was going haywire with it. She stated she knew what misappropriation was, but the account was his personal account, and the facility did not have access to it. The Accounts Manager confirmed she did notify the Administrator when she was made aware that someone was utilizing his personal funds, and he had been denied Medicaid during his recert period.An interview with the Administrator (ADM) on 7/22/26 at 10:00 AM revealed, I do remember the communication with the State Medicaid Agency that someone was using his debit card and making large transactions from his account. When inquired if the facility had an obligation and a duty to report misappropriation of any kind she stated, I probably should have. She revealed she was the abuse coordinator, but she thought the State Medicaid Agency would handle it. A follow up interview with the ADM on 7/23/26 at 8:02 AM revealed if someone was using Resident #2's debit card he had to have given it to them and gave permission. She stated the resident was cognitive and she acknowledged she never had a discussion with the resident regarding the transactions to ensure he authorized it. Record review of the Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/22/26, revealed under section C a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #2 was cognitively intact.

Based on observations, resident and staff interviews, record review, and a review of facility policy, the facility failed to ensure residents were treated with dignity and respect by providing adequate incontinent care supplies during the night shift for four (4) of five (5) residents sampled. Resident #1, #2, #3, and #4.Findings Include:Record review of the facility policy titled Resident's Rights Policy with a revision date of 12/23 revealed Every resident in this facility has the right to: 11.Receive adequate and appropriate health care, medical treatment and protective support services. 12. Be treated courteously, fairly, and with the fullest measure of dignity.Record review of the facility policy titled Dignity and Respect with a revision date of 07/22 revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility shall protect and promote the rights of the resident.3. All residents should have autonomy of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.On 12/30/2025 at 5:15 AM, Licensed Practical Nurse (LPN) #1 revealed we don't have access to the resident's incontinent briefs. If our residents run out of briefs, they tell the aides to bridge them, which is a pad underneath them and a couple of sheets, which is folded over them in the front and folded between their legs. She revealed that if they urinate or have a bowel movement, they will have it in the pad and the sheet. She revealed that many residents don't like that, especially the A hall residents, who are here for therapy.An interview on 12/30/2025 at 5:25 AM with Certified Nurse Aide (CNA) #1 revealed that we don't have access to the briefs if needed. The residents are given a certain amount of incontinence briefs in the morning and if they run out before the day is over then they have to wear a bed sheet. During an interview on 12/30/2025 at 5:30 AM, LPN #2 revealed that housekeeping passes out the briefs in the mornings. She revealed that a key is kept in the medication room, and the nurses will unlock the environmental room and retrieve the briefs for the aides. An observation of the environmental room alongside LPN #1 and LPN #2 revealed that no incontinent briefs were available in the locked room.In an interview on 12/30/25 at 5:35 AM, CNA #2 revealed it has been a big issue with not having briefs when we come on shift and we have complained about it. She revealed we have been told that we have to bridge the residents, we have to use a draw pad under them and then put a bedsheet between their legs and sheets across them. She revealed that if they have to urinate or have a bowel movement, they do it in those. She revealed that not all residents like that, and that Resident #4 has voiced her dislike, but there's not much we can do about it. She revealed that housekeeping comes in in the mornings and passes out the wipes and briefs for the whole day and night and if they run out then we don't have access to anymore.During an interview on 12/30/25 at 5:45 AM, laundry worker revealed that she passes the incontinent briefs and follows a list of residents' sizes provided by her housekeeping supervisor. She revealed we pass out six (6) briefs to the residents who are incontinent for a 24-hour period.In an interview on 12/30/25 at 5:50 AM, CNA #3 revealed there is a major shortage of briefs on the 11pm-7am shift. She revealed she used to work on the day shift, and it was nothing like this. We are told on night shift to Bridge the resident's meaning by putting a pad under them and a sheet over them when we run out of briefs.An interview on 12/30/25 at 6:05 AM, Housekeeper #1 stated that she Passes out briefs in the morning, and every resident gets 6 for the whole day and night and I personally didn't think that would be enough to last them, but that is what we're instructed to do. Everybody gets 6.During an interview on 12/30/25 at 8:05 AM, the Housekeeping Supervisor revealed that she is also a CNA but has been in the housekeeping supervisor role for about two (2) years. She revealed that they put out a certain number of adults briefs each morning, some residents get 6, some get eight (8), and some get 10. She revealed that when I took over this job, this was the way it was done. I don't fully understand it, but I do what the Director of Nursing (DON) has told me to do. I have questioned it in the past and was told that they wanted to Bridge the residents. She confirmed that the CNA's do not have access to the briefs, but that a key is hanging up in the medication room, and the nurse can go into the locked environmental room and get some extra briefs that she leaves for them. The Housekeeping Supervisor confirmed that there were not any extra briefs in the locked room this morning.In an interview on 12/30/25 at 10:35 AM, the DON confirmed that Resident #4 was incontinent, and she preferred to wear briefs. The DON stated, They have plenty of briefs at night, and they can access the environmental room for any additional supplies that they need although we try to do 'open air' during night shift, it's where we don't put briefs on them and just let them air out. She revealed all of our non-cognitive residents; we don't put on briefs at night. She revealed that she had never asked the residents what their preferences were and further confirmed that there were not any briefs this morning in the locked environmental room that the staff could access briefs for the incontinent residents.Resident #1An observation on 12/30/25 at 7:30 AM revealed Resident #1 lying in bed with only a shirt on, and his lower extremities from the waist down are exposed with just a white sheet lying across his lower abdomen and private area. An observation and interview on 12/30/25 at 7:35 AM, CNA #4 confirmed that Resident #1 was lying in bed with a sheet across his private area and no incontinent brief on. She revealed that the brief situation has been very interesting here. They are given a certain amount in the morning, and it has to last them through the next morning. She revealed it has really made it hard on us aides and we don't like it.Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease and Peripheral Vascular Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #1 is severely cognitively impaired. Section H- Bladder and Bowel revealed that Resident #1 is Frequently Incontinent of Urinary and Bowel Continence. Resident #2During an interview on 12/30/25 at 7:50 AM, Resident #2 revealed they had run out of diapers at night. She stated, They didn't ask if it would be okay with me not wearing one; they just took it upon themselves to put a sheet on me. I didn't say anything about it because I didn't feel like I had a say in what they were doing. I thought it strange, and I don't like it at all, but I have to go with what they do.Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Diastolic Congestive Heart Failure, and Hereditary and Idiopathic Neuropathy. Record review of the MDS with an ARD of 12/1/25, revealed under section C, a BIMS summary score of 11, indicating Resident #2 is moderately cognitively impaired. Section H- Bladder and Bowel revealed that Resident #2 has an indwelling catheter, and is always incontinent of bowel. Resident #3An interview on 12/30/25 at 9:30 AM, Resident #3 stated, The diaper issue is just totally ridiculous. I have a supra pubic catheter, but I wear a diaper for my bowel movements. They run out all the time, and they run around different rooms trying to find me one when I need to have a bowel movement. I prefer having a brief on at all times. I don't like it when they try to do the sheet between my legs.Record review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Polyneuropathy, Atherosclerotic Heart Disease, and Neuromuscular dysfunction of the bladder. Record review of the MDS with an ARD of 10/24/25, revealed under section C, a BIMS summary score of 13, indicating Resident #3 is cognitively intact. Section H- Bladder and Bowel revealed that Resident #3 has an indwelling catheter and is always incontinent of bowel. Resident #4During an interview on 12/30/25 at 9:40 AM, Resident #4 stated, I get nervous and stressed at night when I go to bed. I'm afraid to move and I try to lay as still as I can, so I don't urinate because I know they are always out of diapers. I say something to them, and they say, 'Well, they didn't give us anymore'. Resident #4 revealed that for what I'm paying to be in this facility, they should be providing my diapers. Resident #4 stated, Will you please do something about this? The resident further revealed that she hasn't gone to upper management because I try to get along, and I figured it wouldn't do any good anyway. Resident #4 confirmed that this causes her a lot of mental anguish, not having the incontinent supplies that she needs and the thought of having to urinate on a bedsheet. Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Spinal Stenosis, End Stage Heart Disease and Anxiety Disorder. Record review of the MDS with an ARD of 10/10/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #4 is cognitively intact. Section H- Bladder and Bowel revealed that Resident #4 is always incontinent of bowel and bladder.

Based on observations, resident/staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident's right to be free from involuntary seclusion for one (1) of three (3) residents on transmission-based precautions (TBP). Resident #40 Findings include: Review of facility policy titled, Incident Investigation & Reporting dated 11/09/2009, reviewed 1/14/2025, revealed, .Each resident residing in this facility has the right to be free from any type of abuse .includes but is not limited to free from .involuntary seclusion .Involuntary Seclusion: Separation of a resident from other residents or from his/her room or confinement to his/her room . Review of facility policy titled, Policy for Control of Multidrug-Resistant Organism (MDRO) Infection dated 6/14 reviewed 1/14/2025, revealed, It is the policy of this facility to place residents in contact .precautions if they are displaying symptoms of active multidrug-resistant organism (MDRO) infection. Conditions requiring isolation include: .If the resident has a draining wound that is infected with an MDRO, and the drainage cannot be contained . Review of facility policy titled, Resident's Rights Policy dated 6/94, revised 12/23, reviewed 1/14/2025, revealed, Every resident in this facility has the right to .Be free of .psychological .abuse . During an observation and interview on 3/30/2025 at 3:53 PM with Resident #40 it was revealed that the resident had a red biohazard barrel in her room. The resident reported being in isolation, stating she was informed by numerous staff that she could not leave her room until 4/3/25 after her antibiotics were finished. During the interview the resident expressed frustration and stated, I'm getting tired of it, I just want to go outside, I don't even care if it's raining. The resident acknowledged that isolation has increased her anxiety and depression, stating, Just from staying in for that long, anyone would have it! She emphasized, I like to go outside and be in the air. A record review of Resident #40's Order Summary Report for the month of 3/2025, revealed an order, dated 3/13/2025, for Contact Isolation Precautions due to Methicillin Resistant Staphylococcus aureus (MRSA) of Wound. A record review of a nursing Progress Note, dated 3/13/2025 at 6:52 PM for Resident #40, revealed, Dr (proper name) evaluated and reviewed labs .Doxycycline Monohydrate .related to MRSA infection .until 4/3/2025 .contact isolation precautions due to MRSA of wound. Observation on 3/31/2025 at 9:00 AM, Resident #40 was observed to be in her room lying in bed. Record review of Resident #40's Skilled Nursing Facility (SNF) Documentation Record dated 3/13/2025 through 3/25/2025, revealed no more than a scant amount of drainage to scabbed areas with no drainage observed to the surgical site wound to her back during that timeframe. On 3/31/2025 at 1:20 PM, Resident #40 was observed to be in her room lying in bed. A record review of a psychotherapy Progress Note dated 3/12/2025 at 11:59 PM for Resident #40, revealed, Reason for referral: [AGE] year old white female with follow up for insomnia, anxiety and depression .Resident's Statement: I've had my surgery. I had a brown spot come out on the bandages and they sent it (a specimen) off .Case Conceptualization .Endorses good sleep .Says she is not depressed and does not feel anxious and thinks medications are working well. Good mood. Laughing and talking freely . A record review of Resident #40's psychotherapy Progress Note dated 3/20/2025 at 11:59 PM, revealed, Diagnosis of Anxiety .Visit Summary .She shared she is frustrated as she is currently in isolation due to MRSA .She does report frustration related to isolation. She stated it has made her feel more disoriented . A record review of Resident #40's psychotherapy Progress Note dated 3/27/25 at 11:59 PM, revealed, She has now been isolated to her room for two weeks due to MRSA. She stated she is managing but is ready to get out of her room .She has 7 more days. She reported some anxiety and depression due to isolation and shared that her daughter is not supportive of her leaving the facility. During an interview on 4/1/2025 at 8:28 AM, with Certified Nursing Assistant (CNA) #3, she stated she was unsure of the type of isolation but confirmed that Resident #40 had not left her room in two (2) weeks. She confirmed that she has never seen any drainage on the residents' clothing or bed linen and stated there is always a small dressing covering the area. During an interview on 4/1/2025 at 8:31 AM, with the Treatment Nurse, she stated Resident #40 had MRSA to her lower left back surgical incision and that the resident has been in isolation for a couple of weeks under contact precautions and is on a 21-day antibiotic regimen. She confirmed that the treatment order included covering the incision with a dressing, and any drainage from the wound has only been a scant amount and contained by the dressings. She also noted that the resident was alert, oriented, and capable of making decisions. During an interview on 4/1/25 at 8:48 AM, with Infection Control (IC) Nurse, she confirmed the presence of MRSA in Resident #40's surgical incision. She confirmed that she was unaware that the resident has been confined to her room, and stated, Staff should have gotten her out of her room and allowed her to go out and get fresh air, maybe more staff education is warranted. During an interview on 4/1/2025 at 8:59 AM, with the Activities Director and Activities #1, confirmed that Resident #40 and other staff informed her that the resident could not come out of her room for 21 days due to being in isolation. Activities #1 went on to reveal that Resident #40 does not attend a lot of activities but enjoys walking around and going outside of the building daily. During an interview on 4/1/2025 at 9:11 AM, with Director of Nursing (DON) she stated, Residents are not supposed to come out of their room if they are on contact precautions. She stated we cannot force any residents to stay in their room but encourage them to do so. She confirmed her certification in infection control but admitted she did not review Resident #40's isolation status or continued need for isolation, as it is a facility practice for residents on isolation to remain in their rooms until the medication is completed. She acknowledged concerns that isolation could lead to depression and feelings of confinement. During an interview on 4/1/2025 at 9:16 AM, with the Social Services Director, she stated, I didn't know Resident #40 was in isolation until just now, I would have increased my visits with her if I had known. She further reported that isolation could lead to increased anxiety and depression. During an interview on 4/1/2025 at 9:33 AM, with Licensed Practical Nurse (LPN) #2, it was confirmed that Resident #40 was on contact isolation and must stay in her room to prevent contact with other surfaces or residents. She explained that residents placed in isolation are to remain on precautions until their antibiotic therapy is completed. During an interview on 4/1/2025 at 9:37 AM, with Housekeeping Staff #1, she confirmed she had recently completed in-service training that stated that a resident should remain in their room if they are on contact isolation. During a follow-up interview on 4/1/2025 at 9:40 AM, with the Infection Control Nurse, she acknowledged that the training was too broad, indicating that staff might interpret it to mean all residents on contact isolation should remain confined to their rooms. She said that she should have been more involved, but she had been teaching a CNA class for the past two (2) weeks, which limited her availability. She mentioned that had she been more present to review the infection log, she might have identified the situation sooner. She emphasized the need for treatment protocols for MDRO to be more personalized based on individual resident circumstances rather than applying a blanket policy of keeping residents in contact isolation until their medication regimen is completed. She confirmed that Resident #40 was alert, oriented, and able to follow directions. She noted that the residents' wound displayed only scant to zero drainage and remained covered. Furthermore, she stated that staff should have assisted the resident with hand hygiene and facilitated opportunities for her to go outside, acknowledging the importance of addressing the residents' emotional and mental well-being during isolation. The Administrator was interviewed on 4/1/2025 at 10:02 AM and confirmed that social isolation could lead to increased anxiety and depression among residents. An interview with CNA #1 and CNA #2 on 4/1/2025 at 2:10 PM, both verbalized they were trained to ensure that residents on isolation remain in their rooms to prevent the spread of infection. They confirmed that they had never observed any drainage from Resident #40's back as the affected areas were consistently covered. Additionally, they noted that the resident often leaves her room to approach the nurse's medication carts and frequently goes to the doorway, and requires redirection back to her room. During an interview with LPN #2 on 4/1/2025 at 2:20 PM, she also revealed that Resident #40 was alert, oriented and able to follow directions, additionally she confirmed the area to her back was always covered with a dressing and all drainage contained. She verbalized that the resident had never reported to her any increase in depression or anxiety, but stated she was not surprised as the resident has a history of both depression and anxiety. An interview with Medicare Nurse on 4/2/2025 at 8:00 AM, revealed she is the case manager for Resident #40. She stated she was aware that the resident was on contact precautions but confirmed that the surgical wound was approximately 1 (one) CM (centimeter) in diameter and only presented with scant drainage at times, but most of the time the surgical site was scabbed over and was always covered with a bandage and any drainage would have been contained. She confirmed that the resident should have been allowed to come out of her room for activities and socialization. A phone interview with Social Services #1 for on 4/2/2025 at 8:10 AM, she revealed she is a psychiatric social worker and has Resident #40 on case load. She confirmed that Resident #40 has a history of anxiety and depression. She confirmed that she saw the resident on several occasions in March and the resident voiced her frustration of being in isolation and confirmed that the resident also spoke of her increased anxiety and depression due to the isolation. She confirmed she gives a visit recap to the nursing staff after every visit and documented her notes in the medical record. An observation of Resident #40's surgical site on 4/2/2025 at 8:45 AM, with the DON revealed a secured dressing was removed, and revealed approximately a 0.1 CM open area noted with a scant amount of red drainage of the bandage. There was no drainage on the bed linens or the residents' clothing noted during this observation. A record review of an Admission Record indicated the facility admitted Resident #40 on 11/29/22 with medical diagnoses that included Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Encounter for Surgical Aftercare following Surgery on the Nervous System, Basal Cell Carcinoma of Skin of Other Part of Trunk, Anxiety Disorder, Depression, Mood disorder and MRSA Infection. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.

Based on staff interview, record review, and Payroll-Based Journal (PBJ) staffing data review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 1st Quarter, 2025 (October 1 through December 31, 2024) Findings Include: An interview with the Administrator on 4/02/25 at 10:02 AM revealed the facility did not have a policy for submitting Payroll-Based Journal. Record review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for excessively low weekend staffing for the 1st quarter, 2025 (October 1 through December 31, 2024). An interview with the Staff Development Nurse on 4/01/25 at 10:10 AM revealed the facility's staffing needs were based on the minimum hours PPD (per patient day) requirement and by determining the resident acuity for each hall. She revealed call-ins were the biggest concern for weekend staffing. She indicated if a staff member clocked in late for their shift, that would affect the PPD. The Staff Development Nurse indicated they had an on-call nurse that took call from Friday until 7 AM on Monday. She revealed the on-call nurse was responsible for calling staff and trying to find a replacement for call-ins and, if not, she must come in and work. An interview with the Administrative Assistant on 4/01/25 at 11:25 AM revealed she did the payroll for the facility, and their corporate office submitted the PBJ. A telephone interview with the Director of Special Projects on 4/01/25 at 11:39 AM revealed she worked with the corporate office and submitted the facility's PBJ. She indicated she had not received anything from CMS (Centers for Medicare and Medicaid Services), which indicated the facility had triggered for low weekend staffing. She revealed that the payroll data must be correct when it came over to her because she did not make any changes in the data. Furthermore, she confirmed her job duty was only to submit the data and indicated she did not go back into the system to check for any notifications or errors that might be reported from CMS and report back to the facility. An interview with the Administrative Assistant on 4/02/25 at 8:05 AM revealed when an administrative nurse came in to work on the weekend, she did not change their role in the payroll system to ensure the hours were captured under staff that provided direct care. She indicated those hours would have been included in the facility's PPD (patient per day) total but revealed if the role was not changed over to direct care staff, the PBJ information that was submitted to their corporate office would not be accurate. An interview with the Staff Development Nurse on 4/02/25 at 8:14 AM revealed that the administrative nurses who were on call were unable to clock in under regular nursing (direct care workers), and it had to be manually changed in the payroll system. An interview that included both the Regional Nursing Consultant and the Administrator on 4/02/25 at 10:04 AM revealed they did not have any dealings with PBJ and acknowledged this data should accurately reflect the facility's staffing. They confirmed the administrative staffing hours were not captured in the PBJ, which led to an inaccuracy with data submission.

Based on record review, staff interview and facility policy review the facility failed to implement care plan interventions for a resident on a fluid restriction for one (1) of 24 care plans reviewed. Resident # 25. Findings Included: Record review of the facility policy Care Plan Process , revised 12/2024, revealed The overall care plan should be oriented towards .2. Managing risk factors to the extent possible .Interventions are actions that should promote meeting the established goal. A record review of the Care Plan Report for Resident #25 revealed, under Focus, Potential fluid volume overload related to Kidney failure. Under Interventions/Tasks it revealed 2,000-milliliter (ml) fluid restriction, with 120 ml allocated for four (4) medication passes, totaling 480 ml, and 500 ml with meals, totaling 1,500 ml, with a created date of 1/27/25. A record review of the electronic Medication Administration Record (MAR) for Resident #25 revealed no documentation of the resident's fluid intake. On 4/1/25 at 1:00 PM, during an interview Licensed Practical Nurse (LPN) #3 confirmed that Resident #25 was on a 2,000 ml per day fluid restriction. She revealed that Certified Nursing Assistants (CNAs) document the amount the resident drinks during meals on the meal ticket and give it to the nurse, who then records the total fluid intake for the shift under the task list. Record review of the oral intake task list documentation with LPN #3 for Resident #24 revealed no documentation of oral intake for the past 30 days. On 4/1/25 at 1:10 PM, an interview LPN # 3 confirmed that there was no documentation of the resident's fluid intake, making it impossible to determine if the resident was adhering to the prescribed fluid restriction. She stated the importance of monitoring fluid intake to prevent fluid overload. Interview with Medicare Nurse #1 on 4/1/25 at 2:38 PM, she stated that the purpose of the care plan was to let staff know how to care for the resident. She stated that the staff failed to implement the care plan when they did not ensure the resident was following the fluid restriction, by documenting intake. She stated that not following the fluid restriction could cause fluid overload. A record review of the Admission Record revealed that the facility admitted Resident #25 on 1/27/25, with diagnoses including End-Stage Renal Disease and Congestive Heart Failure.

Based on observation, staff interview, record review and facility policy review the facility failed to ensure the dignity of one (1) of four (4) residents observed during medication administration. Resident #12. Findings Include: Review of the facility policy titled Dignity and Respect with a revision date of 7/2022 revealed, 5. Residents will be examined and treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care. On 4/01/25 at 8:48 AM, an observation of Licensed Practical Nurse (LPN) #1 revealed, she administered Resident #12's, who was a female resident, Percutaneous Endoscopic Gastrostomy (PEG) tube medications without closing the resident's room door, blinds, or pulling the privacy curtain. The door of the resident's room remained open and anyone passing in the hallway could see that the resident's abdomen area was exposed. An interview with LPN #1 on 4/01/25 at 9:10 AM, confirmed she did not ensure the resident had privacy while administering medications through her PEG tube and revealed she should have provided privacy and maintained the dignity of the resident. During an interview with the Director of Nursing (DON) on 4/01/25 at 9:17 AM, she confirmed the nurse should have provided privacy for Resident #12 while administering medications through a PEG tube. Review of the Admission Record revealed that the facility admitted Resident #12 on 2/06/25, with a medical diagnosis that included Cerebral Infarction, Unspecified and Attention to Gastrostomy.

Based on record reviews, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of three (3) residents reviewed for hydration. Resident #25. Findings Include: A record review of the facility policy Physician Orders, revised 1/2025, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. A record review of the facility policy Fluid Restriction, revised 2/2022, revealed, Fluids will be restricted for residents as directed by physician orders . Nursing services will document intake and output. A record review of physician orders revealed that Resident #25 was placed on a 2,000-milliliter (ml) fluid restriction, with 120 ml allocated for four (4) medication passes, totaling 480 ml, and 500 ml with meals, totaling 1,500 ml. This order was initiated on 1/30/25. A record review of the electronic Medication Administration Record (MAR) for Resident #25 revealed no documentation of the resident's fluid intake. During an interview on 4/1/25, at 1:00 PM, Licensed Practical Nurse (LPN) #3 confirmed that Resident #25 was on a 2,000 ml per day fluid restriction. She explained that Certified Nursing Assistants (CNAs) document the amount the resident drinks during meals on the meal ticket and give it to the nurse, who then records the total fluid intake for the shift under the task list. A record review of the oral intake task list documentation, with LPN #3, for Resident #24 revealed no documentation of oral intake for over the past 30 days. During a further interview on 4/1/25 at 1:10 PM, LPN # 3 verified that there was no documentation of the resident's fluid intake, making it impossible to determine if the resident was adhering to the prescribed fluid restriction. She stated it was important to monitor fluid intake to prevent fluid overload. During an interview with the Director of Nursing (DON) on 4/1/25 at 2:00 PM, she confirmed that Resident #25 had a fluid restriction ordered by the physician upon admission. She acknowledged that there was no documentation of fluid intake monitoring and confirmed that it should have been recorded. During an interview with the Medical Records Nurse on 4/1/25 at 3:00 PM, she confirmed that she was responsible for triggering documentation tasks upon admission. She admitted that she had failed to initiate a task for the nursing staff to document Resident #25's intake upon admission. A record review of the Admission Record showed that the facility admitted Resident #25 on 1/27/25, with diagnoses including End-Stage Renal Disease and Congestive Heart Failure.

Based on observation, staff interview, and facility policy review the facility failed to follow Enhanced Barrier Precautions (EBP) for one (1) of three (3) resident care observations. Resident #12. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions with a revision date of 3/2024 revealed, Enhanced Barrier Precautions are indicated for residents with any of the following: . Wounds and/or indwelling medical devices . An observation outside Resident #12's room door on 4/1/25 at 8:42 AM, revealed a sign that read, Enhanced Barrier Precautions. On 4/01/25 at 9:01 AM, an observation during medication administration with Licensed Practical Nurse (LPN) #1 revealed, she administered medications to Resident #12 via (by) Percutaneous Endoscopic Gastrostomy (PEG) tube without using a gown for EBP. An interview on 4/01/25 at 9:11 AM, with LPN #1, confirmed she did not apply a gown to administer Resident #12's medications. She explained that the gowns were not hanging on the resident's door; therefore, she did not realize she was supposed to wear one. LPN #1 indicated the purpose of wearing a gown was to reduce infection risk to the resident who had an indwelling device. An interview with the Director of Nursing (DON) on 4/01/25 at 9:16 AM, confirmed LPN #1 should have worn a gown to administer medications to Resident #12 via PEG tube to protect the resident from infection. Record review of the Admission Record revealed the facility admitted Resident #12 on 2/06/25, with a medical diagnosis that included Cerebral Infarction and Attention to Gastrostomy.

Based on staff interview and record review the facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. First quarter 2024. Findings include: Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2024 (October 1-December 31), revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. During an interview on 5/21/24 at 9:53 AM, the Administrator (ADM) revealed the PBJ data is based on the hours entered in the time clock and goes directly to the corporate office. She revealed the agency staff that we utilize is manually entered into the system along with nursing administrative staff who occasionally work on the weekends doing patient care. The Administrator confirmed the hours worked by the nursing administrative staff were not captured correctly on the PBJ and were done so in error. She revealed the shifts for the first quarter of 2024 were covered, however, the data was entered incorrectly and did not capture the direct care on the PBJ. During an interview on 5/22/24 at 9:11 AM, the Administrative Assistant confirmed she was responsible for manually inputting the hours worked for the agency staff but had been unaware that the hours the nursing administrative staff worked on weekends doing direct patient care were also to be manually keyed in.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication administration error rate by less than 5% for four (4) of 25 medication administration opportunities. The medication error rate was 16%. Findings Include: Record review of the facility titled, Administration of Medications, dated 01/24, revealed, PURPOSE: To administer medications in accordance with best practice .ORAL MEDICATION ADMINISTRATION PROCEDURE . 7. If resident requires crushed medications Do not crush time release or enteric coated medications. Consult pharmacist for direction with questions . During a medication administration observation on 5/21/24 at 8:15 AM, with Licensed Practical Nurse (LPN) #1 on the C-Hall revealed the following: LPN #1 gathered medications for Resident #81 that included Coreg 12.5 mg (milligrams) (1) tablet, Potassium 20 meq (milliequivalents) CL (Chloride) ER (Extended Release) (1) tablet, Loratadine 10 mg (1) tablet and Citracel plus Vitamin D Maximum 250 units (1) tablet and placed the medications all in a bag and crushed together and mixed with a spoonful of yogurt to administer to the resident. Interview on 05/21/24 at 8:17 AM, with LPN #1 stated, It doesn't say that it is okay to crush them. I've just always done it because her cognitive ability is declined a lot and she will just hold them in her mouth if I don't. Interview on 05/21/24 at 9:00 AM, with the Pharmacy Consultant confirmed potassium extended release should not be crushed. He confirmed that he had recently completed an in-service with the nurses related to not crushing extended release potassium. The Pharmacy Consultant stated They have not told me that they were having to crush her medications or I could have reviewed her medications and notified the physician. Interview on 05/21/24 at 9:15 AM, with LPN #1 stated I do remember being in-serviced that we shouldn't crush potassium if it is extended release but I was thinking it was okay to crush it if if wasn't enteric coated. LPN #1 confirmed that these medications had not been approved to crush and administer all together like she had given them to the resident.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for a resident with a urinary catheter and for residents with Activities of Daily Living (ADL) that required oral care, nail care, bathing, and facial grooming for two (2) or twenty-one residents sampled. Resident #5 and Resident #85 Findings include: A review of the facility's Care Plan Process policy, dated 06/15 with a revision date of 08/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). Resident #5 Record review of care plan revealed a care plan that resident required extensive staff assistance for activities of daily living. Interventions included oral care two times a day and as needed. Interventions also included to brush teeth each night after eating, and to swab gums with peri guard mouth rinse. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/13/23. An observation and interview with the DON on 5/23/23 at 9:05 AM, revealed the resident had a broken tooth and was started on antibiotics for a mouth infection. She stated an x-ray was also done to ensure her tooth was not abscessed. The DON revealed the broken tooth on the right upper side and a decayed tooth on the lower right and one on the upper right side. Resident #5's teeth appear clean except for a small amount of food. She stated the physician ordered daily brushing of her teeth after the evening meal and a mouth rinse to ensure oral care was done. An interview with the DON on 5/24/23 at 11:15 AM, revealed that according to the documented care logs, the resident did not receive oral care each day as needed for the dependent resident's oral health. She confirmed the facility failed to ensure the resident received oral hygiene. During an interview with the DON on 5/24/23 at 1:55 PM, she confirmed that according to the documentation in the care log, the resident did not receive oral hygiene two times each day as directed in the care plan. She confirmed the care plan is a guide for the needed care for each resident and Resident #5's care plan was not followed. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered brushing of teeth or mouth rinse on 5/13/23. Record review of Physician's Progress Notes dated 4/25/23 revealed, Has Gingivitis. Has broken incisor tooth upper right. No pain to palpation. No lymphadenopathy in neck. Will give local treatment with chlorohexidine mouth rinse, tooth brushing, and PO (by mouth) antibiotics. 46013 Resident #85 A record review of Resident #85's Comprehensive Care Plan with Problem Onset: dated 08/12/2022 revealed, Problem: Resident needs extensive assistance with ADLS-Limited ROM, Weakness, Poor Safety Awareness . Approaches . Prefers to keep a shaved face, combed/brushed hair, and a haircut. Prefers to keep nails kept cut short . Observation on 05/22/23 at 11:39 AM, revealed Resident #85 sitting in his wheelchair with bilateral fingernails that were approximately (approx) one half (1/2) inch long and jagged past the tip of fingers, a brown substance under each nail. Facial hair to cheeks, chin and above the residents' lip was approximately 1/2 inch long. An observation and interview on 05/22/23 at 4:10 PM, Resident #85 sitting in the dining room in his wheelchair. The Director of Nurses (DON) confirmed that he needed to be shaved. She confirmed his nails were long and jagged with a brown substance underneath and stated he could cut himself and he could get an infection if his nails were not taken care of. An interview on 05/24/23 at 11:05 AM, the Minimum Data Set (MDS) nurse revealed she is responsible for developing the care plans. She revealed the care plans are developed so the staff will know how to take care of the resident and the care plan should be so clear that anyone would know exactly how to take care of that resident to include that resident's preferences. An interview on 05/24/23 at 2:40 PM, the DON confirmed that the ADL care plan was not followed on Monday 5/22/23 in reference to Resident #85 being shaved and his nails being clean and trimmed.

Based on observation, staff, resident, and resident representative interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath nails, unshaven facial hair, unbathed, and poor oral hygiene for three (3) of 21 sampled residents. Resident #5, #39, #85 Findings included: Record review of facility policy titled, A.M. Care, dated 10/17, revealed, Purpose: to prepare the resident for their day, to maintain oral health and bodily hygiene, to provide for physical comfort, to maintain the resident's desired physical appearance, to observe the resident's physical and emotional state. Record review of facility policy titled, Activities of Daily Living, dated 12/20, revealed, Policy: An Activities of Daily Living flow sheet (ADL) will be utilized by the facilities and documented on a daily basis by the CNA (Certified Nursing Assistant) to reflect actual care rendered the resident. Record review of facility policy titled, Oral Hygiene, dated 10/17, revealed, Purpose: to clean the mouth, teeth and gums, to remove particles of food, to remove bacteria and odor, to provide comfort to the resident, to keep the mouth moist. The policy also revealed, inspect mouth and gums for irritation and open areas and observe the resident's mouth for dryness, redness, sores and general condition. Resident #5 An interview with Resident #5's daughter on 5/21/23 at 5:20 PM, revealed on the right upper side, the resident had a tooth that was broken off at the gum line and the tooth next to that one was decayed. She stated on the lower right side there was also a decayed tooth. She stated Resident #5 was not receiving adequate oral hygiene and that she had spoken with the Director of Nursing (DON), the Administrator, and the Physician about her concerns that the resident was not receiving adequate oral care since her teeth appeared unbrushed. She stated after speaking to several staff members, her mother was placed on a daily brushing and rinse schedule and was also given an antibiotic to treat gingivitis and this has improved the appearance of her mother's teeth. She stated her main concern was she wanted to know that her mother was comfortable and not in pain. An observation on 5/21/23 at 5:20 PM, of Resident #5's mouth revealed slight redness noted, but the daughter stated that this was much improved since the resident started on an antibiotic. An observation and interview with the DON on 5/23/23 at 9:05 AM, revealed the resident had a broken tooth and was started on antibiotics for a mouth infection. She stated an x-ray was also done to ensure her tooth was not abscessed. The DON revealed the broken tooth on the right upper side and a decayed tooth on the lower right and one on the upper right side. Resident #5's teeth appear clean except for a small amount of food. She stated the physician ordered daily brushing of her teeth after the evening meal and a mouth rinse to ensure oral care was done. An interview with the DON on 5/24/23 at 11:15 AM, revealed that according to the documented care logs, the resident did not receive oral care each day as needed for dependent residents' oral health. She confirmed the facility failed to ensure the resident received oral hygiene and this could have led to gingivitis. During an interview with the DON on 5/24/23 at 1:55 PM, she confirmed that according to the documentation in the care log, the resident did not receive oral hygiene two times each day as directed in the care plan. She confirmed that gingivitis is mainly caused by poor oral hygiene and the resident was diagnosed with gingivitis. She confirmed the facility failed to provide adequate oral hygiene which could have led to her gingivitis and teeth concerns. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/2/23, 5/3/23, 5/6/23, 5/9/23, 5/12/23, 5/13/23, 5/16/23, 5/19/23, 5/20/23, 5/21/23, and 5/22/23. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered teeth brushing or mouth rinse on 5/13/23. Record review of Departmental Note dated 4/25/23, revealed, physician saw resident at facility regarding tooth pain. New order for Doxycycline, to brush teeth each night after eating, and to swab gums with peri guard. Record review of Physician's Progress Notes dated 4/25/23 revealed, Has Gingivitis. Has broken incisor tooth upper right. No pain to palpation. No lymphadenopathy in neck. Will give local treatment with chlorohexidine mouth rinse, tooth brushing, and PO (by mouth) antibiotics. Record review of Physician's Progress Notes dated 5/2/23 revealed, Mouth Gingivitis much improved. Will continue daily mouth care and teeth brushing. Does have plaque. Not a candidate for deep cleaning. Right upper broken tooth. Not infected. No abscess noted on facial x-ray. Record review of Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dementia, Anxiety Disorder, and Depression. Record review of quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/28/23, revealed a Brief Interview for Mental Status (BIMS) of 99 which indicated severe cognitive impairment and inability to complete the interview. 46013 Resident #85 Observation on 05/22/23 at 11:39 AM, revealed Resident #85 sitting in his wheelchair, bilateral fingernails approximately one-half (1/2) inch long and jagged past the tip of fingers, and a brown substance was under each nail. Facial hair was approximately 1/2 inch long and was noted to cheeks, chin and above the residents' lip. Observation on 05/22/23 at 2:00 PM, Resident #85 sitting in the dining room at activities. A red stain was observed around his mouth and on his chin. His nails were long and jagged with a brown substance noted. Facial hair was approximately (approx) 1/2 inch long to his chin, above his lip and to the sides of his cheeks. Observation on 05/22/23 at 3:39 PM, Resident #85 sitting in the front foyer with other residents. Visitors observed entering and exiting facility. Resident was noted with a red stain around his mouth area and on his chin. His nails were long and jagged and had a brown substance noted under the nails. Facial hair approx. 1/2 inch long to his chin, above his lip and to the sides of his cheeks. An observation and interview on 05/22/23 at 4:00 PM, with CNA#1 confirmed Resident #85 had spaghetti on his face and that his nails were long and jagged, and had a brown substance under each nail. She stated it doesn't look like he has had a shower and been shaved in a while. She revealed she would make sure he got taken care of this evening. An observation and interview on 05/22/23 at 4:10 PM, with the DON revealed Resident #85 sitting in the dining room in his wheelchair. The DON confirmed that he needed to be shaved, and he had spaghetti on his face since that's what they had for lunch. She confirmed his nails were long and jagged with a brown substance underneath. She revealed he could cut himself and he could get an infection. She stated, Do you have any staff, and continued to state that the facility had some staffing problems lately and wasn't sure who got showers today but would make sure he got taken care of right away. An interview on 05/23/23 at 11:25 AM, with CNA #2 revealed she worked yesterday 7a-3p and the residents on her B-hall only got hygiene care which was a wipe down. She revealed Resident #85 only got a wipe down and didn't get a shower yesterday like he was supposed to. She stated none of the residents got a shower yesterday on her shift because there was only two aides on B-hall and it is a very busy hall with a lot of two people assist. She revealed one aide can't work the Hoyer-lift alone. She stated it is very frustrating and she has reported this several times to upper management. A record review of Resident #85's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy and Chronic obstructive pulmonary disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/2023 revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. 47874 Resident #39 An observation and interview on 5/22/23 at 4:00 PM, revealed Resident #39 sitting in a wheelchair in his room. Resident #39 revealed he has not had a shower today and that he needs to be shaved. He stated, I've been waiting all day and they told me they didn't have anybody to do it. Resident observed to have long facial hair. An observation and interview on 5/22/23 at 4:05 PM, with Certified Nurse Aide (CNA) # 7 revealed she works 3-11 shift. She revealed that the day shift was responsible for all the showers. She stated that today, all the odd rooms, which are located on the left side of the hall would have been scheduled for a shower. She confirmed that the resident was in an odd number room, so he should have got a shower on the 7-3 shift today. She confirmed that the facility doesn't have a shower team, but the day shift aide assigned to Resident #39 would have been responsible for his shower and she confirmed that Resident #39 did have long facial hair and that he needed shaved. She stated, He can tell you if he had a shower today, he knows. If he tells you that he didn't get a shower today, then he didn't. An observation and interview with the DON on 5/22/23 at 4:15 PM, confirmed that Resident #39 had not been showered or shaved and that today was the residents shower day. She revealed the resident should have been showered and shaved today. Record review of Resident #39's ADL's revealed under, Reason not bathed dated 5/22/23 and timed 11:45 AM documentation recorded, No. Record review of the Face Sheet revealed Resident #39 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and Unspecified Dementia. Record Review of Resident #39's MDS with an ARD of 5/19/23 revealed under section C a BIMS score of 9, which indicated resident is moderately cognitively impaired.

Based on observation, staff and resident interviews, record review and facility policy review the facility failed to assure that there was sufficient qualified nursing staff available at all times to assist the residents in getting the care they needed for three (3) of 24 days of staffing reviewed. Findings include: Record review of the facility policy titled, Nursing Services-Staffing with the latest revision date of 11/17 revealed 1. Staffing-The facility will have sufficient nursing staff twenty-four hours every day to provide nursing and nursing related services to attain or help maintain the highest practicable, physical, mental, and psychosocial well-being of each resident as is determined in the comprehensive assessment and the resident care plan . An interview on 5/21/23 at 6:50 PM, with Certified Nurse Aide (CNA) #5, revealed she works the 3-11 shift and that they usually have two (2) aides per hall. She revealed it can be a struggle at times, but they (the aides) must use time management to get everything done. Record review revealed that the facility triggered low weekend staffing and the State Agency (SA) entered the facility on a Sunday 05/21/23 at 3:00 PM to observe for any weekend staffing concerns or care concerns related to low staffing. Staffing Data Report for Fiscal Year 2023 Payroll Based Journal, revealed, Excessively Low Weekend Staffing Triggered, Triggered = Submitted Weekend Staffing data is excessively low. An interview with the Director of Nursing (DON), on 5/22/23 at 3:30 PM, confirmed they have been experiencing staffing issues and stated they are actively looking for CNAs and have increased their pay rate as an incentive for new hires and included a shift differential as an extra incentive. She revealed they must use agency staffing because they do not have enough facility staff and that staffing has been increasingly difficult since Covid-19. She revealed that she does the nurse staffing schedule, and the Assistant Director of Nursing (ADON) does the aides. She revealed that she addresses call-ins by having a nurse on call during the weekend, so if someone should call in, the nurse will replace that shift, even working as an aide. The SA inquired whether the residents were receiving adequate care, she stated, We also have several office personnel that are CNA's and come out to assist. She stated, There have been many days that I have come out of the office and have given showers. She revealed that they staff two (2) aides to a hall, except for A hall that has a lower census. She confirmed that they do not have a shower team and the aides were responsible for giving their assigned halls/units showers. On 5/21/23 at 5:20 PM, an interview with Resident #5's daughter revealed on the right upper side, the resident had a tooth that was broken off at the gum line and the tooth next to that one was decayed. She stated on the lower right side there was also a decayed tooth. She stated Resident #5 was not receiving adequate oral hygiene and that she had spoken with the DON, the Administrator, and the Physician about her concerns that the resident was not receiving adequate oral care since her teeth appeared unbrushed. She stated after speaking to several staff members, her mother was placed on a daily brushing and rinse schedule and was also given an antibiotic to treat gingivitis, and this has improved the appearance of her mother's teeth. On 5/24/23 at 11:15 AM, an interview with the DON revealed that according to the documented care logs, the resident did not receive oral care each day as needed for dependent residents' oral health. She confirmed the facility failed to ensure the resident received daily oral hygiene and this could have led to the resident's gingivitis diagnosis. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/2/23, 5/3/23, 5/6/23, 5/9/23, 5/12/23, 5/13/23, 5/16/23, 5/19/23, 5/20/23, 5/21/23, and 5/22/23. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered teeth brushing or mouth rinse on 5/13/23. An observation on 5/22/23 at 5:45 PM, from C and D wing nurses' station, revealed three (3) call lights sounding on the call alert system behind the nurses' desk. SA observed call lights blink for approximately 13 minutes. One (1) aide was observed passing out supper trays on C hall with no other staff observed in the hallways. SA observed two (2) nurses seated behind the nurse's station with their heads down. SA inquired from Licensed Practical Nurse (LPN) # 5 as to what that sound was that was alarming. She stated, That's the call light system. SA inquired how the system worked and she stated, The residents push their call light when they need help or need something, and it will sound out here. SA inquired from LPN #5 whether she should go and answer the light. She replied, Yes. SA observed both nurses seated behind the desk get up to respond to the call lights after being cued. An interview with Licensed Practical Nurse (LPN) #3 on 5/23/23 at 9:10 AM, revealed that they have three (3) aides today on the D wing. She revealed that two (2) aides work the floor and one (1) will do the showers. She stated, I'm not going to lie to you; we are having staffing issues. She stated, Nobody wants to work right now, and I think everyone is having staffing issues. An interview on 5/23/23 at 9:45 AM, with Registered Nurse (RN) # 2, revealed that she works Monday-Friday as the charge nurse. She stated she usually works 9-10 hours a day and stated that the facility does not have enough staff to take care of the residents. She revealed that after Covid -19, the hospitals began sending more and more residents to the facility with higher acuity. She stated, They think we are the ICU step down. She revealed that the facility was having trouble finding and keeping staff and that they have a lot of high-level care residents that require one on one, and they do not have the staff to properly care for them. She revealed that the aides are overwhelmed with all that they have to do with the available staff and stated, It's frustrating. An interview on 5/23/23 at 4:10 PM, with the Assistant Director of Nursing (ADON), confirmed that the facility has been experiencing staffing concerns. She revealed that they've had trouble with staffing since Covid-19, but more so in the past year. She stated that they have just as many call-ins throughout the week as they do on the weekends. She revealed the facility has tried to discipline staff with excessive call-ins with verbal warnings, write-ups, and suspension but it doesn't work and stated, It doesn't do any good. Sometimes we struggle, especially with showers. Sometimes they (the residents) don't get a shower, or it may be the next day. It can be a struggle; We just need more staff. She revealed that they do use an agency, but those shifts must be scheduled ahead of time, and agency staff were only required to work two (2) weekends out of a month. She revealed that she often does shift trading with the aides to get a shift filled and stated that money doesn't work anymore, people still call in. She revealed the facility has increased the base pay for the aides and given a shift differential. She stated, We've done everything. We do have a lot of high-acuity residents here. When the SA inquired about the facility's willingness to hold off on admissions due to low staffing, she shook her head and stated, No, there is no way that they are going to do that. An interview on 5/24/23 at 10:20 AM, with Certified Nurse Aide (CNA) #6 revealed that the staffing has been a concern for a while. She revealed she had spoken with the administration, but they told her, We know, and that the facility was using agency staffing but stated, They are not reliable. She stated that the agency comes in late which makes it harder on them because they must cover the residents until agency arrives. She revealed the residents are not being cared for properly. She stated that this past Monday, 5/22/23 they had call-ins and none of the residents got a shower that day, just a wash-up in their bed. She revealed that the facility has a lot of high-level of care residents that must be transferred with lifts and must be fed. An interview with Resident # 3 on 5/24/23 at 10:35 AM, revealed the facility had a change in the administration about two (2) years ago and since then the care has gone down. She revealed that the aides work hard and provide good care, it's just not enough of them. She stated, They care for the residents, and they are doing all they can do. She stated when they have two (2) aides to a hall, they don't get everything they need. She revealed that when they are short it takes a long time to get assistance after pushing the call light and she also revealed there are days when she doesn't get a shower. She stated, It's not their fault, it's management's. She stated the two (2) aides usually have an entire hall and that's over twenty-something people to take care of. An interview on 5/24/23 at 3:35 PM, with the Corporate Nurse confirmed they were having staffing concerns and confirmed that the facility failed to have sufficient staff for three (3) of the 24 days reviewed on the staffing grid and the staff working schedule with the dates of 3/25/23, 5/20/23 and 5/22/23. She stated, We have done everything we can concerning staffing. She stated, I'm sure we're not the only ones like this. The Corporate Nurse confirmed that the facility had not held off on admissions due to low staffing. An interview on 5/24/23 at 3:40 PM, with the Director of Nursing (DON), revealed they are continuing to try and come up with ideas to help resolve the call-ins. She revealed some of the aides are now working sixteen hours on the weekend and taking the week off and that has helped. They've gotten a pay increase along with shift differential. She stated that money does not matter with the aides at this point. She acknowledges that the facility failed to meet the requirements for sufficient staff for three (3) of the 24 days reviewed on the staffing grid and working schedule with the dates of 3/25/23, 5/20/23 and 5/22/23. On 5/22/23 at 4:00 PM, an observation and interview revealed Resident #39 sitting in a wheelchair in his room. Resident #39 revealed he has not had a shower today and that he needs to be shaved. Resident stated, I've been waiting all day and they told me they didn't have anybody to do it. Resident observed to have long facial hair. On 5/22/23 at 4:05 PM, an observation and interview with CNA # 7 revealed she works 3-11 shift. She revealed that the day shift was responsible for all the showers. She stated that today, all the odd rooms, which are located on the left side of the hall would have been scheduled for a shower. She confirmed that the resident was in an odd number room, so he should have got a shower on the 7-3 shift today. She confirmed that the facility doesn't have a shower team. The day shift aide assigned to Resident #39 would have been responsible for his shower. She confirmed that Resident #39 did have long facial hair and that he needed to be shaved. She stated, He can tell you if he had a shower today, he knows. If he tells you that he didn't get a shower today, then he didn't. On 5/22/23 at 4:15 PM, an observation and interview with the DON confirmed that Resident #39 had not been showered or shaved and that today was the residents shower day. She revealed the resident should have been showered and shaved today. Record review of Resident #39's Activities of Daily Living (ADL's) revealed under, Reason not bathed dated 5/22/23 and timed 11:45 AM documentation recorded, No. Record review of Physician Orders revealed the facility had a total of 26 residents requiring the use of a total lift and two (2) staff members for transfers. The facility provided documentation on letterhead dated 5/24/23 with the attached census, highlighting a total number of 16 residents, which require two (2) person physical assistance for most of their activities of daily living (ADL's). The facility provided documentation on letterhead dated 5/24/23 with the attached census, highlighting a total number of 17 residents, which require staff assistance to be fed.

Based on observation, staff, family and resident interviews, record review and facility policy review the facility neglected to provide nursing services following a fall as evidenced by no shift change report, no progress note or incident report following the fall for one (1) of 10 residents reviewed. Resident #9. Findings include: Review of the facility policy titled, Resident Rights with a revision date of 11/17 revealed, All residents in a long-term care facility have rights guaranteed to them under Federal and State law. Residents residing at this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights include: . #23 A facility must immediately inform the resident; consult with the resident's physician; and notify, the resident representative, F-580, when there is- a. An accident involving the resident which results in injury and has the potential for requiring physician intervention .#31 To be free from abuse, neglect, misappropriation of resident property and exploitation . Review of the facility policy titled, Change in Resident Medical Status with a revision date of 09/17 revealed, A change in medical status is defined as any physical, psychological and /or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include: a fall and /or injury . These changes must be noted in a) clinical record, b) care plan if significant; c) accident/incident report (if due to fall or injury) . A facility must immediately inform the resident; consult with the residents physician; and notify, consistent with his or her authority, the resident representative(s), when there is-1. An accident involving the resident which results in injury and has the potential for requiring physician intervention; . Record review of the Administrator's investigation notes revealed the investigation began on 2/26/22 at 1:30 PM, with an interview Certified Nurse Assistant (CNA) # 5 and Nurse Assistant in Training (NAT) #1 which revealed on 2/25/22 at approximately 9:45 PM, they attempted to transfer Resident #9 from her wheelchair to her bed with a stand lift. The investigation notes revealed that as Resident # 9 was being lifted, she slid out of the lift sling and was assisted to the floor. Resident #9's nurse was notified, she assessed the resident, the resident denied an injury or any pain and was assisted to bed with a total lift. The Administrator interviewed Resident #9 on 2/26/22 at 3:50 PM, with the resident's RR present. The investigation notes revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 and confirmed that she started to fall while being put to bed with that stand-up thing, she told the CNA's she was falling, and they lowered her to the floor. The investigative notes revealed that Resident #9 confirmed she had no pain or known injury at the time of the fall but started hurting around 2:00 or 3:00 AM. The Administrator's investigation notes revealed that she interviewed Resident # 9's roommate -Unsampled Resident (C) on 2/28/22 at 10:00 AM, regarding Resident #9's fall with a lift on the night of 2/25/22, and the roommate confirmed well they was trying to put her to bed with that machine and she started slipping out of it and that girl got down in the floor and they set sis down in her lap, she didn't fall, they didn't let her fall and she told them she wouldn't hurt. An interview on 4/12/22 at 11:11 AM, with the Administrator and Director of Nurses (DON) revealed that the Administrator was notified of the resident's fall on 2/26/22 at 1:30 PM. The Administrator revealed that she had investigated the incident and discovered that RN #1 assessed the resident, and the resident had no complaints of pain. She revealed that Resident #9 started complaining of pain in her leg between 2 AM and 4 AM on 2/26/22. The Administrator revealed that Resident #9's Resident Representative (RR) was not notified until Saturday morning when the staff decided to send the resident to the emergency room (ER), because her pain was not being relieved. She revealed that Resident #9's leg was x-rayed in the ER and the facility was notified she had a Tib/Fib (tibia/fibula) fracture in her left leg. She confirmed that Resident #9's nurse that was on duty when the fall occurred should have completed an incident report but did not. She revealed that when the resident started complaining of pain during the next shift that nurse completed it and put the incident type as Other. The Administrator revealed that since that nurse put Other as the incident type then it did not show up on our Fall Incident Log She revealed that once the ER notified them that Resident #9's leg was fractured, then she notified the State Agency. She confirmed that the RR should have been notified before the next morning. An interview on 4/12/22 at 3:00 PM, with Certified Nurse Assistant (CNA) #5 revealed that Resident #9 was in her room on the night of 2/25/22 in her wheelchair and she pushed her light. She revealed that when she went in the resident ask to go to bed. She got NAT #1 to go get the stand lift which was the type of lift that was ordered for the resident. They put the sling vest on the resident and used the correct size sling vest, which was the largest one, they wrapped the sling around the residents back, Velcroed in the front of the resident, crossed the sling straps through the hole and then attached two (2) strings to each side of the lift hooks. She revealed the foot base has a rough texture and the resident was wearing gray gripper socks. She revealed this resident grabbed the handles on each side of the lift, they locked the wheels, the resident placed her feet up in the foot base before we started the lift. She revealed that she pushed the control button on the lift and NAT #1 guided the resident. She revealed that the back of the resident's legs was touching the bed and the vest started slipping up her back as we were lowering her to the bed. She revealed that NAT #1 got underneath her to break her fall and we lowered the resident until she was sitting in NAT #1's lap in the floor. She revealed it was all in slow motion and Resident #9's legs went straight out. She helped NAT #1 out from underneath the resident and went and told Registered Nurse (RN) #1 what had happened. She revealed they assisted the resident from the floor to the bed with a total lift. The resident had no complaint of pain after the fall, while using the total lift back to bed or while turning and changing her. RN #1 assessed the resident with us present and the resident denied any pain. She revealed the resident never pushed her call light before the end of their shift, but she knew the nurse went in to assess her several times before the end of shift. She revealed she had assisted with lifting this resident with a stand lift before. She revealed she had been in-serviced and used this lift before. An interview on 4/12/22 at 3:40 PM, with NAT #1 confirmed that she had been in serviced on how to use the stand lift and had used it before on this resident. She revealed this resident was yellow which was a lift assist, and this resident was supposed to use a stand lift. She revealed she is not sure if the sling has color codes, but she knows the resident used a large one. The resident had gray gripper socks on when they used the lift, and she could hold the handles on the lift with both hands. CNA #5 pushed the lift button and she guided the resident. She revealed she told CNA #5 to stop pushing the lift button when she realized the sling was slipping up the residents back. She confirmed the back of the resident's legs were touching the side of the bed at this point. She revealed the resident did not say anything and they tried to pull the vest down and try again to lower her, but she started to slowly fall because the sling slid back up again. She revealed she sat down on the bed and the resident sat in my lap and we went together to the floor. The resident legs went straight out and did not hit the legs of the lift because the lift legs were separated. CNA #5 went to get RN #1 and she came in and told us to get a total lift. She revealed that RN #1 helped CNA #5 get the total lift sling under the resident and then I slipped out. She revealed the resident did not holler out or complain of any pain. We used a total lift to get her back in bed, we turned her and changed her brief and got the sling off her and she still had no complaints of pain. An interview on 4/12/22 at 4:12 PM, with RN #1 revealed she remembers one of her aides coming to get her on the evening of 2/25/22 because Resident #9 had slid down on the floor while in the stand lift. She revealed she was doing the evening med pass and her med cart was in the hall between the resident's room and the next room. She did not hear anything that sounded like a fall. She went into the resident's room and the resident was lying on the floor with her legs stretched out and NAT #1 was sitting underneath her. She revealed she helped get the resident to a lying position with a pillow under her head while CNA #5 went to get the total lift. She assessed the resident while she was lying on the floor, had her move her arms and legs and confirmed she did not hit her head. The resident's roommate-Unsampled Resident (C) said she didn't even hit the floor. She revealed the resident confirmed that and said she had no pain and that she just wanted to go back to bed. They put the sling on the resident and lifted her back to bed with a total lift and she assessed her again. She checked her feet, legs and arms for any bruises and had her squeeze my hands. The resident still had no complaints of pain anywhere. She revealed CNA #5 and NAT #1 changed her and got her situated in bed and she came back and gave her evening medications. She stated that technically it wasn't a fall. She was lowered to the floor, and she knew the resident was fine. She revealed that CNA #5 and NAT #1 rolled her back and forth to get her out of the sling and she never complained of pain. When she came back in to give her meds, she asked her again if she was hurting and the resident still denied any pain. She revealed she went back in the resident's room seven (7) - eight (8) times before she got off that night at 11 PM. She stated she made the next shift aware. She stated she did not do a progress note, an incident report and did not notify the DON or the RR but should have. She revealed she was planning on calling the DON but forgot. She confirmed that not documenting this incident made it look suspicious. A telephone interview on 4/13/22 at 10:12 AM, with Licensed Practical Nurse (LPN) #3 revealed she came on shift 2/25/22 at 11 PM and her CNAs came and got her after they made their first round to check on the resident around 2 AM. She revealed they told her that Resident #9 was complaining of her leg hurting. She revealed she went to the resident's room and assessed her legs. She revealed the left foot was turned inward, but she compared it to her right foot, and they looked the same. She revealed she did not get a report of a fall or any incident with this resident, so I gave her some Tylenol and a couple of hours later she was still complaining of pain and requested to go to the ER. She revealed that she told the resident we could get a portable X-ray in the morning. She confirmed if she had known about the fall then she would have assessed her more frequently and when she started complaining of pain, she would have sent her out. She revealed she does not remember the CNAs saying that the CNAs from the previous shift mentioned a fall or an incident with the lift. An interview on 4/13/22 at 11:00 AM, with the Administrator revealed she was not aware that the 11-7 shift nurse on the night of the fall was not aware of the fall. She revealed she did reprimand RN #1 for not reporting it or calling the RR, did an in-service with everyone about reporting falls and when to do an incident report, but she did not do an audit of all falls. An interview on 4/13/22 at 1:33 PM with Unsampled Resident (C) roommate to Resident #9 at the time of the fall revealed she was in the bed in the room at the time of the fall with the curtain pulled open between us. She revealed she witnessed the fall and said the aide sat on the floor to break Resident #9's landing, she revealed Resident #9's legs went straight out and did not get bent. Record review of the BIMS score for Unsampled Resident (C) based on the facility assessment date range of 10-1-21 through 4-12-22 revealed it was 7, indicating severely impaired cognitive status, but the resident was able to tell me what day of the week it was, what she had for supper last night and what hall she was on when she was roommates with Resident #9 when this incident occurred. An interview with the RR on 4/14/22 at 10:58 PM, confirmed that she was not notified of her mother's fall from the lift until the next day. She stated her mother told her that she had severe pain in her leg all night. The RR stated, they let her lay there in pain all night. She revealed she spoke with the Administrator the day, she found out about the fall and insisted her mother be discharged . An interview on 4/23/22 at 3:15 PM, with the DON revealed that a nurse not reporting a fall of a resident to the next shift nurse is borderline neglect and confirmed that if an accurate report is not given to the oncoming shift, then any changes in care cannot be carried through. She revealed that the CNA's should walk down the hall and give a short report on each resident during shift change and she is not sure that occurred during this shift change. She confirmed the nurse on duty when Resident #9 had the lift fall should have completed an incident report, made the next shift nurse aware and notified the RR. Record review of a Departmental Note written by LPN #3 on 2/26/22 at 3:34 AM, revealed wake in bed with complaint of left leg/foot pain. Tylenol given PO (as needed) as ordered. Record review of a Departmental Note dated 2/26/22 at 3:07 PM, by RN #3, Late entry for 8:20 AM, revealed, called to resident room per medication nurse to assess resident's left foot and leg due to complaint of pain. Left foot has mild [CONDITION(S)] noted to outside of foot and ankle bone. She complained of pain that is shooting sharp and at a 10 on a scale of 0-10 when it is touched or moved. The resident described that three staff got her up in the stand lift and was performing her care and her foot slipped off the platform of the lift. The Responsible Person (RP) was called at this time and informed of the incident with residents' complaint of pain and need for an Xray. The RP chose to have the resident sent to the ER instead of waiting on a portable XRAY. Record review of the Departmental Note dated 2/26/22 at 3:40 PM, written by RN#3 revealed, Resident returned to facility at 2:05 PM via ambulance with RP present. Record review of a Departmental Note by a staff LPN, dated 2/26/22 at 3:57 PM-Late Entry for 7:30 AM Went to residents' room to assess her Bilateral Lower Extremities (BLE) due to resident had complaint of pain to leg. Observed for any bruising [CONDITION(S)], or pain to BLE's. Lower Left Extremity (LLE) tender to touch and resident yells when leg is moved. No [CONDITION(S)] or bruising noted. Reported this to charge nurse and for her to assess her LLE. Record review of Resident #9's Emergency Department Discharge Summary Report from 2/26/22 indicated an Computerized Tomography (CT) was obtained on the resident's left lower leg without contrast and the findings were noted as; Comminuted and impacted distal tibial fracture extends into the articular surface of the anterior medical distal tibia. Comminuted and impacted distal fibular shaft fracture with medial angulation of distal fragments. The review of this report indicated the resident received [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] in the emergency room and was discharged back to the facility on [DATE] in stable condition with a left leg splint and a follow up appointment with an orthopedic doctor on Monday 2/28/22. Record review of Resident #9's Face Sheet revealed the facility admitted the resident on 9/13/19 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged on [DATE]. Record review of Resident #9's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact.

Based on staff and resident interviews, record review and facility policy review the facility failed to ensure a resident remained pain free following an incident of a fall with a fracture for one (1) of 10 residents reviewed. Resident #9 experienced a pain level of 7 - 10 on a pain scale of 1 - 10, with 10 being the highest level, following the fall. An incident report was not completed immediately following the incident resulting in a delay in receiving treatment until the resident began complaining of pain several hours later. Findings include: Record review of the facility policy titled Pain Screen and Management with a revision date of 9/19, revealed, All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pain Screen is completed when a resident has a new onset of pain, or when a resident has not experienced an acceptable level of pain relief . Review of the Administrator Investigation Notes revealed her investigation began on 2/26/22 at 1:30 PM, with an interview Certified Nurse Assistant (CNA) # 5 and Nurse Assistant in Training (NAT) #1 which revealed they attempted to transfer Resident #9 from her wheelchair to her bed with a stand lift. The investigation notes revealed that as Resident # 9 was being lifted, she slid out of the lift sling and was assisted to the floor. Resident #9's nurse was notified, she assessed the resident, the resident denied an injury or any pain and was assisted to bed with a total lift. The Administrator interviewed Resident #9 on 2/26/22 at 3:50 PM, with the resident's Resident Representative (RR) present. The investigation notes revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 and confirmed that she started to fall while being put to bed with that stand-up thing, she told the CNA's she was falling, and they lowered her to the floor. The investigative notes revealed that Resident #9 confirmed she had no pain or known injury at the time of the fall but started hurting around 2:00 or 3:00 AM. The Administrator's investigation notes revealed that she interviewed Resident # 9's roommate -Unsampled Resident (C) on 2/28/22 at 10:00 AM, regarding Resident #9's fall with a lift on the night of 2/25/22, and the roommate confirmed well they was trying to put her to bed with that machine and she started slipping out of it and that girl got down in the floor and they set sis down in her lap, she didn't fall, they didn't let her fall and she told them she wouldn't hurt. An interview with the Administrator and Director of Nurses (DON) on 4/12/22 at 11:11 AM, revealed that the Administrator was notified of the residents fall on 2/26/22 at 1:30 PM. The Administrator revealed that she had investigated the incident and discovered that RN #1 assessed the resident, and the resident had no complaints of pain. She revealed that Resident #9 started complaining of pain in her leg between 2 AM and 4 AM on 2/26/22. Saturday morning the resident was sent to the emergency room (ER), because her pain was not being relieved. Resident #9's leg was x-rayed in the ER and the facility was notified she had a Tib/Fib (tibia/fibula) fracture of her left leg. She confirmed that Resident #9's nurse that was on duty when the fall occurred should have completed an incident report, but she did not. She revealed that when the resident started complaining of pain during the next shift that the nurse completed it and put the incident type as Other. The Administrator revealed that since that nurse put Other as the Incident type then it did not show up on our Fall Incident Log On 4/13/22 at 10:12 AM, a phone interview with Licensed Practical Nurse (LPN) #3 revealed she came on shift 2/25/22 at 11 PM, the CNAs reported around 2 AM that Resident #9 was complaining of her leg hurting. She revealed she went to the resident's room and assessed her legs and the left foot was turned inward. She compared it to her right foot, and they looked the same. She revealed she did not get a report of a fall or any incident with this resident, so I gave her some Tylenol and a couple of hours later she continued to complain of pain and requested to go to the ER. She revealed that she told the resident we could get a portable X-ray in the morning. She confirmed if she had known about the fall then she would have assessed her more frequently and when she started complaining of pain, she would have sent her out. She confirmed that if she had known about the fall then when the Tylenol had not relieved her pain, she would not have put her off for transfer until the morning. An interview on 4/23/22 at 3:15 PM, with the DON revealed that a nurse not reporting a fall of a resident to the next shift nurse is borderline neglect and confirmed that if an accurate report is not given to the oncoming shift, then any changes in care cannot be carried through. She confirmed the nurse on duty when Resident #9 had the lift fall should have completed an incident report, made the next shift nurse aware and notified the RR. An interview on 4/14/22 at 10:58 PM, with the resident's RR confirmed she was not notified of her mother's fall from a lift until the next day. She revealed her mother told her that she had severe pain in her leg all night. The RR stated, they let her lay there in pain all night. She revealed she spoke with the Administrator the day she found out about the fall and insisted her mother be discharged . Record review of Resident #9's Face Sheet revealed the facility admitted the resident on 9/13/19 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged on [DATE]. Record review of a Departmental Note written by LPN #3 on 2/26/22 at 3:34 AM, revealed wake in bed with complaint of left leg/foot pain. Tylenol given PO (as needed) as ordered. Record review of a Departmental Note dated 2/26/22 at 3:07 PM, by RN #3, Late entry for 8:20 AM, revealed, called to resident room per medication nurse to assess resident's left foot and leg due to complaint of pain. Left foot has mild [CONDITION(S)] noted to outside of foot and ankle bone. She complained of pain that is shooting sharp and at a 10 on a scale of 0-10 when it is touched or moved. The resident described that three staff got her up in the stand lift and was performing her care and her foot slipped off the platform of the lift. The Responsible Person (RP) was called at this time and informed of the incident with residents' complaint of pain and need for an Xray. The RP chose to have the resident sent to the ER instead of waiting on a portable XRAY. Record review of the Departmental Note dated 2/26/22 at 3:40 PM, written by RN#3 revealed, Resident returned to facility at 2:05 PM via ambulance with RP present. Record review of a Departmental Note by a staff LPN, dated 2/26/22 at 3:57 PM-Late Entry for 7:30 AM Went to residents' room to assess her Bilateral Lower Extremities (BLE) due to resident had complaint of pain to leg. Observed for any bruising [CONDITION(S)], or pain to BLE's. Lower Left Extremity (LLE) tender to touch and resident yells when leg is moved. No [CONDITION(S)] or bruising noted. Reported this to charge nurse and for her to assess her LLE. Record review of Resident #9's Physician's Orders revealed an order dated 9/13/19 for Acetaminophen 500 mg (milligrams) tablet give two by mouth every 4 hours for pain AS NEEDED FOR MILD PAIN. Record review of Resident #9's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Emergency Department Discharge Summary Report from 2/26/22 indicated a Computerized Tomography (CT) was obtained on the resident's left lower leg without contrast and the findings were noted as; Comminuted and impacted distal tibial fracture extends into the articular surface of the anterior medical distal tibia. Comminuted and impacted distal fibular shaft fracture with medial angulation of distal fragments. The review of this report indicated the resident received [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] in the emergency room and was discharged back to the facility on [DATE] in stable condition with a left leg splint and a follow up appointment with an orthopedic doctor on Monday 2/28/22. Record review of Resident #9's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/21 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates the resident was cognitively intact.