Every finding on record at Transcendent Healthcare of Owensville

Based on observation, interview, and record review, the facility failed to maintain infection control practices for 1 of 2 resident's observed for catheter care and during 2 of 3 observations of care. A residents catheter tubing was left dragging the floor following care, staff failed to don (put on) required personal protection equipment (PPE) for a resident in enhanced barrier precautions (EBP), and staff failed to perform hand hygiene between glove changes. (Resident D, Resident K)Findings include:1. During an observation on 1/7/26 at 10:20 A.M., signage hanging outside of Resident D's room indicated a resident in the room required EBP. During an observation on 1/7/25 at 11:25 A.M., Resident D was up in a wheelchair in his room. Resident D's catheter drainage bag was clipped to the wheelchair with the catheter tubing resting on the floor. CNA 4 donned gloves, knelt next to the resident's wheelchair, and emptied the catheter bag into a urinal. CNA 4 closed the catheter bag and disposed of the urine in the resident's restroom. CNA 4 then exited the resident's room with the catheter tubing resting on the floor. During an observation on 1/7/25 at 2:00 P.M., Resident D was up in a wheelchair in the dining room. The resident's catheter tubing was resting on the dining room floor. A record review on 1/7/26 at 12:50 P.M. indicated Resident D's diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder and prostatic hyperplasia. Resident D's physician orders included but were not limited to catheter care every shift (started 9/19/25) and enhanced barrier precautions (EBP) due to a Foley catheter (started 9/22/25). On 1/8/25 at 10:20 A.M., RN 7 supplied facility policies titled, Catheter, Emptying Foley (dated 2/2/25) and Isolation - Initiating Transmission-Based Precautions (dated 11/11/21). The Catheter, Emptying Foley policy included, 1. Foley catheter drainage bags will be emptied using standard precautions and aseptic technique by trained staff at designated intervals or as clinically indicated . At least every shift . 4. As ordered by the physician . The Isolation - Initiating Transmission-Based Precautions policy included, 5. When Transmission-Based Precautions are implemented, the Infection Control Preventionist . shall: a. Ensure that protective equipment (i.e., gloves, gowns, goggle/eyewear masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need .During an interview on 1/8/25 at 10:30 A.M., the Infection Control Preventionist (ICP) indicated the resident's catheter tubing should be kept up off the floor whenever possible, and staff should donn gloves and a gown whenever providing catheter care for residents with EBP due to their Foley Catheter. 2. During an observation on 1/7/25 at 11:10 A.M., Resident K was being assisted to the restroom by CNA 8. CNA 8 removed and disposed of a soiled brief from the resident while the resident sat on the commode. CNA 8 removed the gloves and donned a new pair of gloves after retrieving them from a container without performing hand hygiene. On 1/8/25 at 10:00 A.M., the Facility Administrator supplied an undated facility policy titled, Handwashing/Hand Hygiene. The policy included, The facility considers hand hygiene the primary means to prevent the spread of infections.6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. after removing gloves; .Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves.During an interview on 1/8/25 at 10:30 A.M., the ICP indicated staff should perform hand hygiene before donning new gloves and in between glove changes. This citation relates to intake 2703214.3.1-18(b)3.1-18(j)3.1-18(l)

Based on interview and record review, the facility failed to ensure that annual influenza immunizations were offered to 2 of 5 residents reviewed for immunizations. Residents who had given consent to receive the influenza immunization had no record that they had received the immunization or that the immunization was medically contraindicated. (Resident D, Resident G)Findings include: 1. During record review on 1/7/26 at 12:50 P.M., Resident D's immunization consent form, signed and dated 7/16/25, indicated the resident gave consent to receive the influenza immunization.Resident D's immunization history indicated the resident's last influenza immunization was receivedon 10/27/21.Resident D's record contained no indication that the resident had received, refused, or was medically contraindicated to receive the influenza immunization during 2025.2. During record review on 1/7/26 at 10:30 A.M., Resident G's immunization consent form, signed and dated 10/30/25, indicated the resident gave consent to receive the influenza immunization.Resident G's immunization history indicated the resident's last influenza immunization was received on 10/7/19.Resident D's record contained no indication that the resident had received, refused, or was medically contraindicated from receiving the influenza immunization during 2025.On 1/8/26 at 10:00 A.M., the Facility Administrator provided an undated facility policy titled, Vaccination of Residents. The policy included, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. 7. Certain vaccines (e.g., influenza and pneumococcal vaccines) may be administered per the physician-approved facility protocol (standing orders) after the resident has been assessed by the physician for medical contraindications for each vaccine.During an interview on 1/8/26 at 10:30 A.M., the Infection Control Preventionist (ICP) indicated that after a resident has given consent to receive the influenza vaccine, a physician's order should be obtained, and the order would be filled and delivered by the pharmacy. The resident's record should contain documentation that the vaccine was administered or if the resident refused. The facility generally offered the annual influenza vaccine during September/October.During an interview on 1/8/26 at 11:00 A.M., RN 7 indicated the influenza vaccines were offered while the previous Director of Nursing (DON) was there and that they had no record that indicated the influenza vaccine was offered to Resident D or Resident G. This citation relates to intake 2703214.3.1-13(a)

Based on record review and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Food Services Director) Finding includes: During an interview on 5/5/25 at 9:30 A.M., the Food Services Director (FSD) provided a document that indicated she had been enrolled in a food service manager class from [Program Title] since September 2024 and had not completed it. On 5/7/26 at 10:27 A.M., the employee record for the FSD was reviewed. It indicated she started her role as the FSD on 6/30/24. During an interview on 5/8/25 at 9:11 A.M., the FSD indicated she did not start the management course until September because she did not know which course to be enrolled in. On 5/8/25 at 10:49 A.M., the Regional Consultant Nurse provided a current, non-dated job description for the Director of Food Services that indicated the director was to provide leadership training that includes the administrative and supervisory principles essential of the Food Services Department .

Based on observation, interview, and record review, the facility failed to ensure residents received consistent implementation of interventions to prevent falls for 4 of 4 residents reviewed for accidents related to falls. Fall interventions were observed out of place. (Resident 6, Resident 28, Resident 46, and Resident 45) Findings include: 1. On 5/5/25 at 1:26 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of the lower end of left radius. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/13/25, indicated Resident 6 was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) for transferring and toileting, and had one fall with major injury since the prior assessment. A current risk for falls care plan, last revised on 3/5/25, included the following interventions: Anticipate and meet the resident's needs, dated 9/9/19 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, dated 9/9/19 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, dated 9/9/19 Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, dated 9/9/19 Follow facility fall protocol, dated 9/9/19 Physical therapy (PT) evaluate and treat as ordered or as needed (PRN), dated 9/9/19 The resident needs a safe environment (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach), dated 9/9/19 Assure resident is centered in bed. Bed enablers to assist with bed mobility, dated 8/24/21 Encourage to rise slowly and wear shoes or gripper socks when ambulating in room, dated 1/18/22 Discussed eye sight and vision with glasses as relates to falls. Will see eye Dr for new glasses, dated 3/2/22 Use of nonskid shoes, encourage to not wear crocs, dated 1/19/24 Room rearranged, dated 12/6/24 Nonskid strips at bedside, dated 3/5/25 A fall risk assessment was completed on 1/8/25 and the resident was determined to be at risk for falls. On 3/5/25 at 3:30 A.M., Resident 6 had an unwitnessed fall while attempting to self-toilet. An abrasion to the left elbow was noted along with pain with flexing and edema below the elbow. An x-ray of the left humerus (upper arm bone) was ordered. Results were negative for fracture. On 3/5/25 at 3:19 P.M., the physician ordered an x-ray of the left wrist. On 3/6/25 at 2:45 P.M., Resident 6 returned from a visit to an orthopedic urgent care with a cast on her left wrist and a diagnosis of a wrist fracture. A fall risk assessment was completed on 3/5/25 and the resident was determined to be at risk for falls. The IDT met on 3/5/25 and determined the new intervention to be Nonskid strips at bedside. A social service progress note, dated 4/28/25 at 4:15 P.M., indicated that a care conference was held with the Interdisciplinary Team (IDT), resident, and responsible party, and resident care plans were adequate to resident care with no changes made. On 5/7/25 at 11:10 A.M., Resident 6's room was observed. There were no nonskid strips next to her bed. On 5/7/25 at 2:17 P.M., the Regional Consultant confirmed that there were no nonskid strips next to Resident 6's bed and there should have been. 46758 2. On 5/6/25 at 8:27 A.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and repeated falls. The current Quarterly Minimum Data Set (MDS) Assessment, dated 2/8/25, indicated Resident 28 was mildly cognitively impaired. The resident needed supervision for eating, dressing, and toileting. Physicians ordered included, but were not limited to: Up with one assist and wheelchair, dated 5/15/20. May participate in activities as tolerated, dated 5/15/20 A care plan conference was conducted on 4/28/25 with revisions to the care plan. The current fall risk care plan, dated 4/28/25, indicated the resident was at risk for falls due to unsteady gait, previous falls, and unaware of safety needs. Interventions included but were not limited to: Place motion sensor night light in room, dated 4/28/25 Encourage resident to ask for assistance for transfers before rising when dizzy, dated 9/6/23 When out with family encouraged to rest and sit when tired, dated 7/10/23 The nursing alert notes, dated 4/26/25 at 2:57 A.M., indicated the resident had an unwitnessed fall when she missed her bed and fell on the floor. The fall risk assessment done at the same time indicated the resident was at a high fall risk. An Interdisciplinary Team (IDT) note, dated 4/28/25 at 9:27 A.M., indicated the intervention that would be in place was the facility would provide a motion sensor night light in the resident's room to provide adequate lighting during nighttime so the resident could see her surroundings. On 5/6/25 at 8:55 A.M., there was no motion sensor night light observed in Resident 28's room. During an interview on 5/6/25 at 8:58 A.M., Qualified Medicine Aide (QMA) 7 indicated there was no motion detector night light located in the room. 3. On 5/6/25 at 10:31 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and idiopathic aseptic necrosis of the right toes. The current Quarterly Minimum Data Set (MDS) Assessment, dated 4/17/25, indicated Resident 46 was moderately cognitively impaired. Resident 46 needed supervision to eat, was dependent on staff for transferring, and needed partial assistance of staff (staff does less than half of the effort) for hygiene and toileting. Physician orders included but were not limited to: May use a mechanical lift as needed, dated 1/8/25. A care plan conference was conducted on 4/10/25 with revisions to the care plan. The current fall risk care plan, dated 4/10/25, indicated the resident was a fall risk related to decreased mobility, weakness, and history of falls. Interventions included, but were not limited to: Resident is not to be left in wheelchair unattended in room, dated 2/14/25 Re-educate resident on the use of call light, dated 9/17/24 An nursing alert note, dated 2/12/25 at 12:12 P.M., indicated Resident 46 had an unwitnessed fall. The resident was found sitting on his buttocks on the floor in his room while attempting to transfer himself and fell . The fall risk assessment indicated that the resident was a high fall risk. On 2/14/25 at 3:53 P.M., an Interdisciplinary Team (IDT) note indicated that an appropriate intervention for the resident was to not leave the resident in his wheelchair while in his room unattended and to remove his wheelchair from the room after assisting the resident to bed. On 5/6/25 at 12:08 P.M., Resident 46 was observed alone in his room sitting in his wheelchair waiting for a meal. On 5/7/25 at 9:00 A.M., Resident 46 was observed alone in his room sitting in his wheelchair after breakfast. During an interview on 5/7/25 at 9:46 A.M., Registered Nurse (RN) 5 indicated the resident should be in the dining room if up in the wheelchair and was not to be left in his room unattended. 48057 4. On 5/5/25 at 1:50 P.M., Resident 45's clinical record was reviewed. Resident 45 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/12/25, indicated Resident 45 was severely cognitively impaired, required partial assistance (staff does half of the effort) for toileting, bathing, and transfers, and two or more falls with injury occurred since the previous MDS assessment. Current care plans included, but were not limited to: I am at risk for falls related to impaired gait, balance, and weakness, dated 2/2/24. Interventions included, but were not limited to: Bed in lowest position while in bed, dated 2/12/24 Place call, don't fall sign in bathroom, dated 2/3/25 On 5/6/25 at 11:33 A.M., Resident 45 was resting in bed. The bed was not in the lowest position. The bathroom did not have a call don't fall sign. A progress note, dated 5/6/2025 at 1:05 P.M., indicated staff went into the resident's room and a call don't fall sign was not in place. On 5/7/25 at 11:21 A.M., Resident 45 was sitting on the side of the bed. The bed was not in the lowest position. At that time, Resident 45's wife indicated staff did not leave the bed in the lowest position because Resident 45 could not get out of bed when the bed was down that low. On 5/7/25 at 2:08 P.M., the Regional Consultant indicated that once IDT determined a new intervention, it went into place immediately. On 5/8/25 at 10:12 A.M., Registered Nurse (RN) 5 provided a current undated Falls - Clinical Protocol policy that indicated The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. On 5/8/25 at 10:12 A.M., RN 5 provided a current undated Care Plans, Comprehensive Person-Centered policy that indicated Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to .receive the services and/or items included in the plan of care . The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and dated properly in accordance with professional standards for food service for 1 of 2 kitchen observations. (Kitchen) Finding includes: On 5/4/25 at 9:23 A.M., an initial tour of the kitchen was conducted. The following items were observed: In the reach-in freezer: 1 container of butter oil with no open date 4 premade lunches with no preparation date or open date Spice Cabinet: 1 container of oil with no open date 1 container of pumpkin spice with no open date 1 container of ground mustard with no open date 1 container of white pepper with no open date 1 container of spray cooking oil with no open date 1 container of basil with no open date 1 container of garlic powder with no open date 2 containers of parsley flakes with no open date 1 container of thyme with no open date 1 container of mild chili powder with no open date 1 container of onion powder with no open date 1 container of dill weed with no open date 1 container of [NAME] with no open date 1 container of rosemary with no open dated Dry Storage: 1 bin of flour with no open date 1 bin of sugar with no open date 1 bag of panko breadcrumbs with no open date Walk-in Freezer: 1 bag of waffles open to air, not dated During an interview on 5/4/25 at 9:40 A.M., the [NAME] indicated that spices should be dated when opened. On 5/8/25 at 10:12 A.M., Registered Nurse (RN) 5 provided a current policy Food Receiving and Storage that was revised December 2008. The policy indicated .food shall be stored in a manner that complies with safe food handling practices .dry foods that are stored in bins will be removed from original packages, labeled and dated .all foods stored in the refrigerator or freezer will be covered, labeled, and dated . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to provide at least 80 square feet (sq ft) per resident in multiple resident occupancy rooms in 1 of 34 rooms reviewed. (room [ROOM NUMBER]) Finding includes: During the entrance conference interview on 5/4/25 at 9:50 A.M., the Administrator in Training (AIT) indicated that room [ROOM NUMBER] required a room variance waiver to have three residents in the room. A waiver had been applied for and not granted. On 5/5/25 at 2:10 P.M., Registered Nurse (RN) 5 provided a document that indicated Rooms that require a variance: room [ROOM NUMBER] measures 70.29 square feet per resident. On 5/8/25 at 9:47 A.M., the Regional Consultant indicated that the facility did not have a room variance policy and followed the federal regulations. 3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 1 of 5 residents reviewed for unnecessary medications (Resident 27) and 1 of 3 residents reviewed for wound care (Resident 14). Findings include: 1. On 5/6/25 at 9:14 A.M., Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/21/25, indicated Resident 27 was moderately cognitively impaired and required substantial assistance (staff does more than half of the work) for toileting, bathing, and transfers. On 5/6/25 at 9:14 A.M., the clinical record lacked a care plan conference held since 1/15/25. On 5/6/25 at 9:35 A.M., care plan conferences held in 2025 were requested. On 5/7/25 at 10:55 A.M., the Regional Consultant provided a Care Plan Conference Summary, with a completion date 5/6/25 at 12:20 P.M., that indicated a care plan conference was held on 4/15/25 and included Resident 27's POA (power of attorney). During an interview on 5/7/25 at 10:56 A.M., Resident 27's POA indicated she had not been invited to or included in a care plan conference since January 2025. 2. On 5/5/25 at 2:21 P.M., Resident 14's clinical record was reviewed. Resident 14 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident 14 was moderately cognitively impaired and required supervision from staff for eating, toileting, bathing, and transfers. On 5/5/25 at 2:21 P.M., the clinical record lacked a care plan conference held since 11/27/24. On 5/6/25 at 9:35 A.M., care plan conferences held in 2025 were requested. On 5/7/25 at 10:55 A.M., the Regional Consultant provided a Care Plan Conference Summary, with a completion date 5/6/25 at 12:25 P.M., that indicated a care plan conference was held on 2/27/25. During an interview on 5/7/25 at 11:14 A.M., the Social Services Director indicated care plan conferences should be held every three months, care plan conferences should be documented in the clinical record when completed, and that Resident 27 and Resident 14's care plan conferences had been backdated or documented late. On 5/8/25 at 10:12 A.M., the Regional Consultant provided an undated policy titled Care Plans Comprehensive Person-Centered, that indicated: The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: participate in the planning process; participate in establishing the expected goals and outcomes of care; see the care plan and sign it after significant changes are made. The resident is informed of his or her right to participate in his or her treatment, and provide advance notice of care planning conferences. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. 3.1-3(n)(3) 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed during wound treatment for 1 of 3 Residents reviewed for wound treatments. (Resident 14) Finding includes: On 5/4/25 at 11:02 A.M., Resident was observed with bilateral feet wrapped with brown bandages over white gauze, no shoes or socks on, and feet directly on the ground. On 5/5/25 at 2:21 P.M., Resident 14's clinical record was reviewed. Resident 14 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident 14 was moderately cognitively impaired and required supervision from staff for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: Cleanse bilateral lower extremities (BLE) with wound cleanser, pat dry, apply oil emulsion to top of foot, wrap with Kerlix (an absorbent gauze) from toes to below knees, secure with paper tape, initial and date, every day shift for wound care and as needed for soiled or dislodged dressing, start date 5/1/25. Enhanced barrier precautions related to wounds on bilateral lower extremities; start date 4/16/25 Current care plans included, but were not limited to: I have non-pressure wounds to my left foot and right foot. Treatment as ordered, medications as ordered, keep clean and dry; date initiated: 4/16/25 During a wound care observation on 5/7/25 at 11:39 A.M., the wound nurse removed Resident 14's dressings from the left and right feet that consisted of gauze wrapped in Coban. The wound nurse performed wound care on the right foot, removed the dressings from the left foot, and cleansed the left foot. While the wound nurse was performing hand hygiene, Resident 14 rested his left foot with no dressings directly on the floor. The wound nurse applied the dressings to Resident 14's left foot without cleansing the foot after it had made contact with the floor. During an interview on 5/8/25 at 8:57 A.M., the Infection Preventionist indicated that Resident 14's feet, only covered with absorbent dressings, directly on the floor was an infection control concern. On 5/8/25 at 10:12 A.M., the Regional Consultant provided an undated policy titled Wound Care that indicated: Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier . Wear sterile gloves when physically touching the wound . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for wound treatment, labs were obtained prior to antibiotic use, and antibiotics were administered for the duration ordered for 1 of 3 Residents reviewed for wound treatments. (Resident 14) Finding includes: On 5/4/25 at 11:02 A.M., Resident was observed with bilateral feet wrapped with brown bandages over white gauze, no shoes or socks on, and feet directly on the ground. On 5/5/25 at 2:21 P.M., Resident 14's clinical record was reviewed. Resident 14 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident 14 was moderately cognitively impaired and required supervision from staff for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: Cleanse bilateral lower extremities (BLE) with wound cleanser, pat dry, apply oil emulsion to top of foot, wrap with Kerlix (an absorbent gauze) from toes to below knees, secure with paper tape, initial and date, every day shift for wound care and as needed for soiled or dislodged dressing, start date 5/1/25. Cefdinir (an antibiotic medication) capsule 300 mg (milligrams) - Give one capsule by mouth two times a day for infection for seven days; start date 5/1/25 through 5/8/25 Enhanced barrier precautions related to wounds on bilateral lower extremities; start date 4/16/25 Current care plans included, but were not limited to: I have non-pressure wounds to my left foot and right foot. Treatment as ordered, medications as ordered, keep clean and dry; date initiated: 4/16/25 I am on an antibiotic related to bilateral lower extremities. Administer medication as ordered, monitor for adverse reactions, Notify physician of any concerns; date initiated: 5/1/25 A physician progress note signed by the physician on 5/8/25, indicated the physician assessed Resident 14 on 4/30/25 and ordered Omnicef (cefdinir) 300 mg twice a day for ten days. No additional documentation was in the record as to the changes in duration of the antibiotic with the above order from 10 days to seven days. A treatment order administration record indicated the following order was not administered on 4/30/25: Cleanse bilateral lower extremities with wound cleanser, pat dry, apply oil emulsion to top of foot, wrap with unna boot (a zinc oxide gauze wrap) from toes to below knees, secure with Coban (a compression bandage wrap), initial and date every day shift every Wednesday and Saturday for wound care, started on 4/19/25 and discontinued on 5/1/25. A progress note, dated 5/2/25 at 12:28 A.M., indicated the resident continued with unna boots bilateral legs and feet. A progress note, dated 5/2/25 at 3:13 P.M., indicated the resident continued with unna boots to bilateral legs and feet. A progress note, dated 5/3/25 at 12:51 A.M., indicated the resident continued unna boots to bilateral lower extremities. A progress note, dated 5/3/25 at 2:09 P.M., indicated the resident continued with unna boots to bilateral feet. During an interview on 5/8/25 at 8:57 A.M., the Infection Preventionist indicated the facility policy was typically to wait for cultures to come back prior to starting an antibiotic, but Resident 14 did not have a skin culture obtained prior to starting Cefdinir. On 5/8/25 at 10:12 A.M., the Regional Consultant provided a policy titled Medication Orders, dated 6/2008, that indicated: Medication orders will be accurate, timely, appropriate, and legible. 3.1-18(b) 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self-administer medications for 1 of 1 residents observed with medications in their room. (Resident 203) Finding includes: On 5/4/25 at 10:51 A.M., Resident 203 was observed in his recliner with a bottle of Tums on his bedside table. On 5/5/25 at 10:14 A.M., Resident 203 was observed in his recliner with a bottle of Tums on his bedside table. On 5/6/25 at 10:18 A.M., Resident 203's clinical record was reviewed. Diagnoses included, but were not limited to, cellulitis, diabetes mellitus, and obesity. Resident 6 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) Assessment was still in progress and indicated the resident was cognitively intact. Sections regarding medication and functional abilities had not been completed. Physician orders lacked an order for Tums and a self-administration of medication order. The comprehensive care plan lacked a care plan for self-administration of medications. A Self-Administration of Medication Assessment, dated 4/28/25, indicated that the resident did not wish to self-administer his own medications. On 5/7/25 at 11:12 A.M., the Director of Nursing (DON) indicated that no one in facility self-administered their own medications. On 5/8/25 at 10:12 A.M., Registered Nurse (RN) 5 provided a current undated Self-Administration of Medication policy that indicated If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . If the team determines that a resident cannot safety self-administer medications, the nursing staff administer the resident's medications . Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. 3.1-11(a)

Based on observation and record review, the facility failed to ensure staff promoted dignity by allowing a resident to use the bathroom when requested for 1 of 1 dining observations. (Resident 18) Finding includes: On 5/4/25 at 12:16 P.M., Resident 18 was observed in the dining room. Resident 18 told Certified Nurse Aide (CNA) 9 she needed to go pee. CNA 9 told Resident 18 she could not go to the bathroom because she had to eat. On 5/6/25 at 8:44 A.M., Resident 18's clinical record was reviewed. Resident 18 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/8/25, indicated Resident 18 was severely cognitively impaired, required supervision from staff while eating, and substantial assistance (staff does more than half of the work) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Lasix oral tablet (a diuretic medication) - Give 20 mg (milligrams) by mouth one time a day for edema; start date 7/29/23. Medication administration record for May recorded the administration of Lasix was scheduled for every morning. Current care plans included, but were not limited to: I have a history of bladder incontinence related to activity intolerance, impaired mobility, nocturia, urgency of urination; start date 1/5/21. On 5/8/25 at 10:12 A.M., the Regional Consultant provided an undated policy titled Dignity, that indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with this facility. When assisting with care, residents are supported in exercising their rights, for example, residents are: allowed to choose when to sleep, eat, and conduct activities of daily living. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance. 3.1-3(t)

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the state agency for 1 of 1 allegations of abuse reviewed. After being made aware of an allegation of abuse the facility failed to report the incident and findings to the state agency. (Resident D) Finding includes: During record review on 6/25/24 at 9:15 A.M., Resident D's diagnoses included, but was not limited to, anxiety, bipolar disorder, dementia with agitation, and senile degeneration of brain. Resident D's most recent Quarterly MDS (Minimum Data Set) assessment, dated 5/8/24, indicated the resident had severe cognitive impairment. Resident D's nurses' progress notes included the following: 6/3/24 at 5:08 A.M. - Resident took self to bathroom, CNA tried to help the resident and resident yelled and punched the CNA several times with fists. Resident has skin tears to bilateral hands, bandaged left hand to help stop bleeding. 6/3/24 at 4:09 P.M. - Residents family notified regarding incident during night shift. Residents alarm began to sound around 5:00 A.M., CNA entered room and found that Resident D was in the bathroom. CNA made her presents known to resident and when resident laid eyes on CNA he began yelling because he thought she was a man. Resident stated, I was going to fight that man, he was in my house. Resident D began thrashing and attempted to hit CNA. CNA told resident she was a woman and called for help. Another CNA and nurse on duty entered Resident D's room and noted resident thrashing and observed skin tears to bilateral hands. Resident stated to the nurse on duty that he was agitated due to thinking the CNA was a man but that he knows she is a woman because she showed her breast. During a review on 6/25/24 at 10:10 A.M. of the facility's investigation of the incident that occurred on 6/3/24, an Employee Warning Notice, dated 6/3/24 and signed as received by CNA 7 included that CNA 7 received a 3-day suspension due to an abuse complaint that included, Complaint of alleged abuse from a family member. During an interview on 6/25/24 at 10:30 A.M., the DON (Director of Nursing) indicated that Resident D's family thought that CNA 7 may have exposed her breasts to Resident D during the incident that occurred on 6/3/24 and that the allegation was found to be unfounded and was not reported to the state agency. On 6/25/24 at 11:00 P.M., the facility administrator supplied an undated facility policy, titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. The policy included, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management . This Federal tag relates to complaint allegation IN00435912. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to provide nutritional care and services including failure to identify significant weight loss, failure to notify the physician of poor intakes, and failure to be reviewed by the Registered Dietician, for 1 of 4 residents reviewed for nutrition (Resident 46). This deficient practice resulted in the resident experiencing a 20% weight loss in 35 days, developing a facility-acquired stage two pressure injury on the 12/28/23 that deteriorated to an infected unstageable pressure injury, and requiring a hospitalization for sepsis, dehydration, and malnutrition. Finding includes: On 3/27/24 at 1:46 P.M., Resident 46's family member indicated they had not been notified by the facility about Resident 46's weight loss. They indicated the resident was hospitalized in January 2024 and they found out about the weight loss then. They indicated that Resident 46 was able to feed herself when she was admitted to the facility but had since declined and required staff to help her eat. They indicated she was able to eat finger foods easily. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The Admission Minimum Data Set (MDS) Assessment, dated 9/15/23, indicated that Resident 46 had severe cognitive impairment, required extensive assistance of 2 (two) staff for bed mobility, transfer, toileting, and bathing, and required the supervision of 1 (one) staff for eating. The resident had no nutritional issues, swallowing disorders, and had no weight loss in the past 6 months. The resident weighed 150 pounds (lbs.) and was 61 inches (in) tall. A Dehydration Risk Assessment, dated 9/8/23, indicated Resident 46 was at high risk for dehydration. Admission physician orders included, but were not limited to: Regular diet, Regular texture, Regular consistency, dated 9/8/23. Weekly weights x4 weeks every Fri dated 9/15/23. A Nutritional Risk Assessment, dated 9/15/23, indicated Resident 46 was at high risk for malnutrition. A nutrition and dietary note, dated 9/15/23 at 11:49 A.M., indicated Initial nutrition risk assessment complete. High Risk. Dx. [diagnosis] of Alzheimer's. Current diet regimen is appropriate. Will continue to monitor weight, intake. RD [Registered Dietician] available as needed. The clinical record lacked a care plan related to a risk for weight loss or malnutrition. A facility weights and vitals summary report included the following measurements: 9/9/23 at 2:54 A.M. 150.4 lbs. (pounds) 9/11/23 at 2:56 P.M., 61 inches (in) length 9/15/23 at 3:08 P.M., 154.6 lbs. 10/9/23 at 11:30 A.M., 140 lbs. The weight warning indicated the resident had a 6.9% weight loss in a month. (The resident returned from the hospital on 10/10/23 and was weighed in the facility at 140 lbs. The facility entered the date 10/9/23 in error.) 11/3/23 at 8:08 A.M. 144.8 lbs. 12/1/23 at 8:44 A.M., 145 lbs. 1/4/24 at 10:31 A.M. 115.6 lbs., a 20.28% weight loss since 12/1/23. On 9/15/23, Resident 46 was transferred to a psychiatric hospital for treatment and evaluation of behaviors. The resident was transferred back to the facility on [DATE]. Hospital discharge records, dated 10/10/23, indicated Resident 46 was treated for aggression and paranoia. A re-admission Dehydration Risk Assessment, dated 10/10/23, indicated Resident 46 was at high risk for dehydration. The clinical record lacked a Nutritional Risk Assessment and a Clinical Readmission Assessment on re-admission to the facility. The clinical record lacked notification to the provider, RD (Registered Dietitian), or family of the 6.9% weight loss. The clinical record lacked an assessment by the RD following this weight loss. A Care Conference Summary, dated 10/16/23 at 1:00 P.M., lacked documentation of a review of Resident 46's significant weight loss. The Interdisciplinary Team (IDT) notes lacked documentation to show that the resident's weight loss was reviewed or effective interventions were implemented to prevent further weight loss. Progress notes, the plan of care, and doctor's orders, dated between 11/3/23 and 11/8/2023, did not include documentation to show an intervention was immediately implemented to prevent further weight loss. The nursing progress notes, dated from 11/8/2023 at 3:38 P.M. through 11/17/2023 at 6:21 P.M, indicated Resident 46 had a poor appetite and food intake, had extremely dark-colored skin in the area below the eyes, and slept most of the time. The notes indicated the facility staff notified the NP (Nurse Practitioner) of the significant changes on 11/15/2023 and the MD (Medical Doctor) on 11/16/23. The notes did not include documentation to show the NP responded to the notification or to show the facility followed-up with the NP between 11/15/2023 and 11/16/2023. A laboratory report, dated 11/18/2023, included, but was not limited to, the following blood level results: -Albumin (a blood test to determine liver and kidney function): 3.7 g/dL (grams/deciliter) therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 139 meQ/L (millequivalent/Liter) therapeutic range: 136-145 meQ/L The nursing progress notes, dated from 11/18/23 at 12:50 A.M. through 11/28/23 at 1:14 P.M., indicated Resident 46 had a poor appetite and food intake and slept most of the time. The notes did not include documentation to show notification to the provider or RD. The November 2023 Nutritional Intake form indicated the following: Breakfast consumption: 76-100% on 1 of 30 opportunities 51-75% on 7 of 30 opportunities 26-50% on 4 of 30 opportunities 0-25% on 4 of 30 opportunities 4 of 30 opportunities were documented as resident refused. 1 of 30 opportunities was documented as not applicable. 9 of 30 opportunities were not documented. Lunch consumption: 76-100% on 1 of 30 opportunities 51-75% on 3 of 30 opportunities 26-50% on 4 of 30 opportunities 0-25% on 5 of 30 opportunities 5 of 30 opportunities were documented as resident refused. 12 of 30 opportunities were not documented. Dinner consumption: 76-100% on 1 of 30 opportunities 51-75% on 2 of 30 opportunities 26-50% on 2 of 30 opportunities 0-25% on 4 of 30 opportunities 2 of 30 opportunities were documented as resident refused. 19 of 30 opportunities were not documented. The clinical record lacked documentation of notification to the physician or dietitian related to the refusal of meals and poor food intake. The nursing progress notes, dated from 12/1/23 at 1:57 P.M. through 12/14/23 at 2:23 P.M., indicated Resident 46 had a poor appetite and food intake and slept most of the time. The notes did not include documentation to show notification to the provider or RD. A Quarterly MDS assessment, dated 12/16/23, indicated Resident 46 had severe cognitive impairment, required supervision or touch assistance for eating, had no weight loss, no swallowing disorder, and weighed 148 lbs. A Quarterly Dehydration Risk Assessment, dated 12/16/23, indicated Resident 46 was at high risk for dehydration. Nursing progress notes from 12/16/23 to 1/16/24 lacked documentation related to loss of appetite, weight loss, nutritional status, or notification of poor appetite or intake to the physician, RD, or family. The December 2023 Nutritional Intake form indicated the following: Breakfast consumption: 76-100% on 0 of 31 opportunities 51-75% on 1 of 31 opportunities 26-50% on 3 of 31 opportunities 0-25% on 13 of 31 opportunities 3 of 31 opportunities were documented as resident refused. 11 of 31 opportunities were not documented. Lunch consumption: 76-100% on 0 of 31 opportunities 51-75% on 2 of 31 opportunities 26-50% on 0 of 31 opportunities 0-25% on 6 of 31 opportunities 2 of 31 opportunities were documented as resident refused. 21 of 31 opportunities were not documented. Dinner consumption: 76-100% on 0 of 31 opportunities 51-75% on 2 of 31 opportunities 26-50% on 1 of 31 opportunities 0-25% on 1 of 31 opportunities 1 of 31 opportunities were documented as resident refused. 26 of 31 opportunities were not documented. A care plan, dated 12/22/23, indicated the resident was at risk for weight loss due to dementia. Interventions included diet as ordered, record intake, labs as ordered, and notify Dr and family of changes. The clinical record lacked a care plan related to the resident's refusal of food or poor intake. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer on the intergluteal cleft that measured 2.2 cm (centimeters) length by 0.5 cm width by 0.2 cm depth. A Quarterly Braden Scale Assessment, dated 12/16/23, indicated the resident was at risk for pressure ulcers. The clinical record lacked referral to the RD for assessment and review. A Pressure Wound Weekly assessment, dated 1/4/24, indicated the stage 2 pressure ulcer was worsening and measured 2.5 cm length by 2 cm width by 0 cm depth. Nursing progress notes and the weight change alert lacked notification to the RD or the family regarding this significant weight loss. The clinical record lacked an assessment by the RD following this weight loss. The Interdisciplinary Team (IDT) notes between 1/4/24 and 1/6/24 lacked documentation to show that the resident's weight loss was reviewed or effective interventions were implemented to prevent further weight loss. A nursing progress note, dated 1/4/24 at 10:36 A.M., indicated the resident was lethargic and not eating, and the NP saw the resident and gave new orders to obtain labs for CBC (complete blood count), CMP (comprehensive metabolic panel), TSH (thyroid-stimulating hormone), and T4 (thyroxine) the next morning. A nursing progress note, dated 1/6/24 at 4:23 P.M., indicated the resident had vomited on her gown and was observed having shallow breathes with blood pressure at 60/40 mm/Hg (millimeters/Mercury) and a thready pulse of 26 beats per minute. The doctor was notified, and new orders were given to send the resident to [name of hospital] for treatment and evaluation. A hospital admission summary, dated 1/6/24, indicated Resident 46 was admitted to the hospital for treatment of dehydration, acute hypernatremia (high sodium), acute kidney injury, altered mental status, and sepsis. It was noted that the resident had a large decubitus ulcer (pressure ulcer) on the coccyx with eschar (dead tissue) that was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). A physical exam also indicated the resident had pressure areas on the left shoulder, left ear, and right hip. The resident was admitted to the general medical floor to await transfer to another hospital and was started on IV (intravenous) Zosyn (an antibiotic medication) and given IV fluids for hydration. A second set of labs, dated 1/7/24, included lactic acid at 2.3, troponin at 231, sodium at 157, and albumin at 2.8. A laboratory report, dated 1/6/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 3.0 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 203 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A laboratory report, dated 1/7/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 2.8 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 231 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A hospital admission summary, date 1/7/24, indicated Resident 46 was transferred to another hospital and admitted to the ICU (intensive care unit) with diagnoses of severe sepsis with the source of decubitus wound, severe hypernatremia, notable dehydration, acute kidney injury, elevated troponin, and decubitus ulcer. A hospital discharge summary, dated 1/13/24, indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer, severe hypernatremia due to notable dehydration, decubitus ulcer present on admission, and severe malnutrition present on admission. The resident had a temporary weighted feeding tube placed on 1/11/24 for comfort feedings. The feeding tube was removed prior to discharge. The resident also had a surgical debridement of the ulcer on 1/8/24. The resident was discharged back to the facility and was admitted to hospice services on 1/13/24. A clinical readmission assessment, dated 1/13/23 at 12:31 P.M., indicated the resident had a stage 4 pressure ulcer on the coccyx and was taking nutrition and hydration orally. The clinical record lacked a Nutritional Risk Assessment on re-admission to the facility. Re-admission physician orders related to nutrition included: Mechanical Soft diet, Mechanical Soft texture, Regular consistency for comfort feeding, dated 1/13/23. On 3/28/24 at 12:23 P.M., Resident 46 was observed sitting in a Broda chair (high backed wheelchair) in her room with a lunch tray on the bedside table in front of her. No bites had been taken of the meal. There were no staff present. 75% of the supplementary shake was gone. At 12:30 P.M., Registered Nurse (RN) 5 entered the room and asked if the resident was done. The resident indicated she was not done yet. RN 5 offered the resident the dessert cup and left the room. The resident picked up the dessert cup and attempted to dump it out onto her plate. The dessert did not come out and the resident put the cup aside. The resident picked up her plastic fork, stabbed the potatoes and salmon onto the fork, attempted to get the fork to her mouth, but was unable, and put the fork down. The resident closed her eyes. In an interview on 4/1/24 at 12:13 P.M., the DON indicated that residents were weighed weekly for four weeks upon admission and then monthly with vitals. Weight reports were generated and reviewed on Tuesdays following completion of weekly weight measurement to determine who had significant weight loss. If a resident had unplanned weight loss, they were referred to the dietician. For residents who were weighed monthly, weekly weights would be started if staff noticed the resident appeared to be losing weight. Families were notified if a resident experienced significant weight loss and those notifications were charted in the weight change note. Significant weight loss would be added to the care plan once it was identified. At that time, she indicated Resident 46 should have been triggered for significant weight loss upon her return from the hospital on 10/10/23 but didn't see where she was and was not sure how she got missed. She indicated that the weight on 10/9/23 was a data entry error and was intended to read 10/10/23. She indicated that staff in December consistently charted the resident had a poor appetite, but could not find notification to the provider, the RD, or the family. The resident liked to be left alone to eat and often refused meals, but sometimes ate better if staff encouraged her. The resident really liked her supplements, soda, orange juice, and was able to pick up cups on her own. The DON was unable to find a care plan related to the refusal of food or risk of malnutrition and weight loss, prior to 12/22/23. On 4/2/24 at 10:55 A.M., RN 5 indicated that Resident 46 needed setup assistance and encouragement to eat. She liked her shakes and used plastic utensils because they were lighter, and she did not have difficulty using them. She preferred to eat in her room. On 4/2/24 at 9:55 A.M., the DON provided a current Nutritional Assessment policy, undated, that indicated The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition . The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition . Increased need for calories and/or protein - onset of exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g., .wounds)[sic] . A comprehensive nutritional assessment was requested on 4/2/24 at 9:57 A.M., and the Director of Nursing (DON) indicated a nutritional risk assessment was conducted on 9/15/2023, and no documentation could be provided to show further nutritional risk assessments were performed. On 4/2/24 at 12:28 P.M., the DON provided a current Weight Assessment and Intervention policy, undated, that indicated Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant weight unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; great than 5% is severe . Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes . the resident's calorie, protein, and other nutrient needs compared with resident's current intake . Care planning for weight loss or impaired nutrition .includes the physician, nursing staff, the dietitian .and the resident's legal surrogate. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent the development of a facility-acquired stage two pressure injuries for Resident 46 and Resident 9, who were admitted to the facility without pressure injuries, and were identified by the facility upon admission to be at risk to develop pressure injuries. This deficient practice resulted in Resident 46 developing a facility-acquired stage two pressure injury on the coccyx that deteriorated to an unstageable pressure injury with infection and required hospitalization for intravenous antibiotic therapy of wound-based sepsis, and surgical debridement of the facility-acquired unstageable pressure injury to a stage four pressure injury. This deficient practice resulted in Resident 9 developing a facility-acquired stage two pressure injury on the left heel that deteriorated to a stage three pressure injury. Findings include: 1. On 3/27/24 at 1:46 P.M., Resident 46's family member indicated Resident 46 was hospitalized in January 2024 for a pressure ulcer. They indicated they were not told about the pressure ulcer until the resident was transferred to the hospital and they weren't sure how the resident got the pressure ulcer. At the hospital the resident received antibiotics and treatment, and the pressure ulcer started to heal. They indicated that prior to the hospitalization the resident was giving staff a hard time and thought it was because the resident was in pain due to the pressure ulcer. They indicated that the resident was mobile when admitted to the facility but was no longer able to get around on her own. On 3/28/24 at 9:06 A.M., a Hospice Nurse was observed changing the dressing for Resident 46's pressure ulcer on her coccyx. The hospice nurse cleansed and packed the wound with a half sheet of calcium alginate dressing (a highly absorbent dressing). At that time, the Hospice Nurse indicated the resident was admitted to Hospice upon return from the hospital in January. She further indicated the pressure injury was healing nicely. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region, onset date 1/13/24. The Admission Minimum Data Set (MDS) Assessment, dated 9/15/23, indicated that Resident 46 had severe cognitive impairment, required extensive assistance of 2 staff for bed mobility, transfers, toileting, and bathing, and supervision of 1 staff for eating. The resident was frequently incontinent of bowel and bladder. No pressure ulcers were present. A formal assessment scale was used that indicated the resident was at high risk for pressure ulcers. The resident had no nutritional or swallowing issues. An Admission Braden Scale Assessment (a tool used to assess the resident's risk to develop pressure injuries), dated 9/8/23, indicated the resident was at high risk to develop a pressure injury. The tool did not include documentation related to turning and repositioning interventions. The admission physician orders, dated 09/08/2023, included, but were not limited to, the following orders: Turn and reposition approximately every 2 hours per Braden Scale. Pressure relieving/reducing mattress and device for chair. A late loss ADLs (Activities of Daily Living) care plan, initiated 9/8/23, included an intervention to inspect the resident's skin weekly, observe for redness, open areas, scratches, cuts, and bruises, and report any concerns to the nurse. The comprehensive care plan lacked documentation related to the resident's risk for pressure ulcers. Weekly Skin Assessment every day shift every Friday, dated 9/15/23. Tylenol (a pain reliever) Oral Tablet 325 mg (milligrams) - Give 2 tablets by mouth every 6 hours as needed for pain or temperature, dated 11/15/23. A re-admission Physician's Note, dated 10/10/23, indicated the resident did not have any skin impairments. The Quarterly MDS Assessment, dated 12/16/23, indicated Resident 46 had severe cognitive impairment, was dependent (staff does everything) on staff for toileting and shower, required substantial/maximal assistance (staff does more than half) for bed mobility and transfers, and required supervision/touch assistance for eating. The resident was always incontinent of bowel and bladder. No pressure ulcers were present. A formal assessment scale was used that indicated the resident was not at risk for pressure ulcers. The resident had no nutritional or swallowing issues. A Quarterly Braden Scale Assessment, dated 12/16/23, indicated the resident was at risk for pressure ulcers. The Nursing Skilled evaluation reports, dated 12/16/23 through 01/03/2024, indicated skin assessments were completed by nursing staff twice daily and no skin impairment was observed. A partially-completed resident shower sheet/skin concern document, dated 12/26/23, did not include documentation to indicate skin issues were present. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister) on the coccyx (the area that articulates with the sacrum at the top of the buttocks) that measured 2.2 cm (centimeters) in L (length) by 0.5 cm W (width) by 0.2 cm D (depth). The assessment indicated the wound bed contained no epithelial tissue, no granulation, no slough, no necrotic tissue, no drainage, no odor, and normal per-wound tissue. The Nurse Practitioner (NP) and the facility's wound nurse were notified on 12/28/23, and orders were received to cleanse the wound with Anasept (an antimicrobial skin and wound cleanser) and apply a foam dressing. The December 2023 TAR (treatment administration record) indicated that a weekly skin assessment was conducted on 12/1, 12/8, 12/15, 12/22, and 12/29 and that the resident's skin was intact with no new or existing skin issues. The December 2023 TAR indicated that the pressure wound was cleansed with Anasept and a foam dressing was applied once daily on day shift from 12/28/23 to 12/31/23. The December TAR did not include sufficient documentation to show the facility-acquired stage two pressure ulcer was effectively assessed by nursing staff daily between 12/28/23 and 01/03/24. The IDT (Interdisciplinary Team) progress notes, the plan of care, the nursing progress notes, and the wound nurse progress notes dated from 12/29/23 through 1/3/24, did not include documentation of the facility-acquired stage two pressure injury on the coccyx. On 4/2/24 at 12:28 P.M., assessments of the specific characteristics of the facility-acquired stage two pressure injury on the coccyx between 12/29/23 and 1/03/24 were requested. The facility was unable to provide documentation to determine that staff assessed the facility-acquired stage two pressure injury on the coccyx between 12/29/23 and 1/3/24. The January 2024 TAR indicated that a weekly skin assessment was conducted on 1/5/24 and that the resident's skin was intact with no new or existing skin issues. The record did not include documentation related to the specific characteristics facility-acquired stage two pressure injury on the coccyx initially identified on 12/28/23. The January 2024 TAR indicated that the facility-acquired stage two pressure wound was cleansed with Anasept and a foam dressing was applied once daily on day shift from 1/1/24 to 1/4/24. It did not include an assessment of the wound. A resident shower sheet/skin concern document, dated 1/2/24, indicated the resident had an open area, but did not include a nurse assessment related to the open area. The nursing progress notes did not include sufficient documentation to show the facility-acquired stage two pressure ulcer was effectively assessed by nursing staff daily between 12/28/23 and 01/03/24. A Pressure Wound Weekly assessment, dated 1/4/24, indicated the pressure ulcer on the coccyx was worsening and measured 2.5 cm in length, 2 cm in width, and 0 cm in depth. The assessment indicated the wound bed contained 100% epithelial tissue, no granulation, no slough, no necrotic tissue, no drainage, no odor, and normal per-wound tissue. The NP was notified and orders were given to cleanse the wound with wound cleanser, pat dry, apply Medihoney (a gel used to treat wounds), and apply a bordered foam dressing A care plan, initiated 1/4/24, indicated the resident had a facility-acquired stage 2 pressure ulceration to inner buttocks with interventions to implement treatment as ordered, update the facility wound nurse, PCP (primary care physician), or NP of benefit of treatment plan or worsening with routine treatments, and weekly skin assessments. A Nursing Skilled Evaluation, dated 1/4/24 at 2:03 A.M., indicated Moisture Associated Skin Damage (MASD) was newly identified on the coccyx above the buttocks measuring 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/4/24 at 10:36 A.M., indicated the resident was lethargic and not eating, and the NP saw the resident and gave new orders to obtain labs for CBC (complete blood count), CMP (complete metabolic panel), TSH (thyroid-stimulating hormone), and T4 (thyroxine) the next morning. A Nursing Skilled Evaluation, dated 1/5/24 at 1:27 A.M., indicated the MASD on the coccyx above the buttocks measured 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/5/24 at 2:15 A.M., indicated the dressing on the coccyx was intact and there were no signs of discomfort. A resident shower sheet/skin concern document, dated 1/5/24, indicated the resident had an open area, but did not include a nursing assessment related to the open area. A nursing progress note, dated 1/6/24 at 12:48 A.M., indicated the wound was cleaned, and the dressing was changed and was intact. A Nursing Skilled Evaluation, dated 1/6/24 at 12:52 A.M., indicated the MASD on the coccyx above the buttocks measured 2 cm in length and 20 cm in width with slough in the wound bed and minimal bloody drainage on the dressing. The assessment indicated the resident experienced episodic pain. Pain relieving interventions were not given at that time. A nursing progress note, dated 1/6/24 at 3:17 P.M., indicated the dressing to the coccyx was clean, dry, and intact. The nursing progress notes and skilled nursing evaluation reports, dated from 01/05/2024 at 1:28 A.M. through 01/06/2024 at 4:22 P.M., did not include sufficient documentation to determine the specific characteristics of the facility- acquired stage two pressure injury that deteriorated to an unstageable pressure injury. A nursing progress note, dated 1/6/24 at 4:23 P.M., indicated the resident had vomited on her gown and was observed having shallow breathes with a low blood pressure of 60/40 and a thready slow pulse at 26 beats per minute. The doctor was notified, and new orders were given to send the resident to the hospital for treatment and evaluation of the significant change in condition. A hospital admission summary, dated 1/6/24, indicated Resident 46 was admitted to the hospital for treatment of dehydration, acute hypernatremia (high sodium), acute kidney injury, altered mental status, and sepsis. It was noted that the resident had a large decubitus ulcer (pressure ulcer) with eschar (dead tissue) that was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.) The summary indicated new areas of pressure-related skin impairment, on the left shoulder, left ear, and right hip, were identified by hospital staff during a physical exam. The resident was admitted to the general medical floor to await transfer to another hospital and was started on IV (intravenous) Zosyn (an antibiotic medication). A laboratory report, dated 1/6/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L (millimoles/Liter) therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 3.0 g/dL (grams/deciliter) therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L (milliequivalent/liter) therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 203 ng/L (nanogram/Liter) therapeutic range: 0-13 ng/L A laboratory report, dated 1/7/23, included, but was not limited to, the following blood level results: -Lactic Acid (a blood test to determine sepsis): 2.3 mmol/L therapeutic range: 0.5-2.0 mmol/L -Albumin (a blood test to determine liver and kidney function): 2.8 g/dL therapeutic range: 3.4-4.8 g/dL -Sodium (a blood test to determine fluid and electrolyte balance): 157 meQ/L therapeutic range: 136-145 meQ/L -Troponin (a blood test to determine heart damage): 231 ng/L therapeutic range: 0-13 ng/L A hospital admission summary, dated 1/7/24, indicated Resident 46 was transferred to another hospital and admitted to the ICU (intensive care unit) with diagnoses of severe sepsis with the source of decubitus wound and decubitus ulcer. A hospital discharge summary, dated 1/13/24, indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer and decubitus ulcer present on admission. The resident had a surgical debridement of the ulcer on 1/8/24 with a wound vac placed that was removed prior to discharge. The resident was discharged back to the facility and was admitted to hospice on 1/13/24. During an interview on 4/1/24 at 12:13 P.M., the Director of Nursing (DON) indicated Resident 46 developed a pressure ulcer on 12/28/23 that continued to worsen until she was transferred to the hospital on 1/6/24. She indicated that pressure ulcers were measured weekly but assessed daily during the dressing change and should be documented in the progress notes or the TAR. She indicated that the assessment in the Skilled Nursing Evaluations between 12/28/23 and 1/3/24 were not correct and most likely copied and pasted. At that time, she indicated that care plans were updated each morning during Interdisciplinary Team (IDT) meetings and when new orders were added. 2. During record review on 4/1/24 at 11:45 A.M., Resident 9 diagnoses included, but were not limited, to type II diabetes, dementia, heart failure, and chronic kidney disease. Resident 9's most recent Quarterly MDS (Minimum Data Set) assessment, dated 1/19/24, indicated that the resident had severe cognitive impairment, required extensive assistance with ADL's (activities of daily living) and mobility, was always incontinent of bowel and bladder, and had an unhealed stage III pressure area. A nurse's note dated 10/12/23 at 9:56 A.M., indicated that Resident 9 had arrived at the facility in a wheelchair. Resident 9 was taken to her room and transferred to her bed. A skin assessment was completed, and no open areas were noted. An admission Braden scale completed on 10/12/23 indicated that Resident 9 was at risk for pressure. Resident 9's physician orders included, but were not limited to: Cleanse area on left heel with wound cleanser and apply Medi-honey to wound bed. Cover with dry dressing daily, one time a day for wound (started 10/20/23). Float heels at all times, every shift for wound (started 10/20/23). House supplement 4 ounces three times a day, with meals (started 1/11/24). Left Heel: Cleanse with wound cleanser, pat dry. Pack wound bed with collagen sheet moistened with normal saline. Apply bordered gauze dressing. Secure with Kerlix (gauze bandage) as needed. Initial and date every day shift for wound care and as needed for soiled or dislodged dressing (started 3/13/24). Resident 9's care plan included, but was not limited to: I am at risk for impairment to skin integrity due to fragile skin, incontinence. I will maintain or develop clean and intact skin by the review date (revised 10/19/23). I have a stage 3 pressure area to left heel (initiated 10/20/23). Interventions included weekly skin assessments. A weekly wound assessment dated [DATE] at 1:41 P.M., indicated a facility-acquired stage two pressure ulcer on Resident 9's left heel that measured 3 cm (centimeters) L (length) x 4 cm W (width) x 0.3 cm D(depth) (Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present). The assessment indicated the wound bed contained 100% granulation tissue with no odor and well-defined edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 3 cm L x 3.5 cm W x 0.1 cm D (Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed). The assessment indicated the wound bed contained 10% granulation tissue and 90% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2.4 cm L x 2.4 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2.2 cm L x 2 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 2 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% granulation tissue and 75% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. Weekly wound assessment records, dated between 11/21/23 and 12/26/23 did not contain wound documentation including, but not limited to, measurements and specific wound characteristics to show staff effectively assessed the facility-acquired stage three pressure injury to Resident 9's left heel. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.2 cm W x 0.3 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.5 cm W x 0.5 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.5 cm L x 1.3 cm W x 0.3 cm D. The assessment indicated the wound bed contained 90% granulation tissue and 10% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.4 cm L x 1 cm W x 0.4 cm D. The assessment indicated the wound bed contained 50% granulation tissue and 50% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 1.5 cm W x 0.6 cm D. The assessment indicated the wound bed contained 50% granulation tissue and 50% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 2 cm L x 1.6 cm W x 0.4 cm D. The assessment indicated the wound bed contained 75% granulation tissue and 25% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 1.8 cm L x 0.6 cm W x 0.2 cm D. The assessment indicated the wound bed contained 75% granulation tissue and 25% slough with no odor and a moderate amount of serosanguinous drainage with rounded wound edges. Weekly wound assessment records, dated between 2/6/24 and 2/20/24 did not contain wound documentation including, but not limited to, measurements and specific wound characteristics to show staff effectively assessed the facility-acquired stage three pressure injury to Resident 9's left heel. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.3 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.2 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.5 cm L x 0.5 cm W x 0.2 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. A wound assessment dated [DATE] indicated a facility-acquired stage 3 pressure ulcer on Resident 9's left heel that measured 0.3 cm L x 0.3 cm W x 0.1 cm D. The assessment indicated the wound bed contained 100% granulation tissue with no odor and no drainage and well-defined wound edges. On 4/2/24 at 12:28 P.M., the DON provided a current Pressure Ulcer Treatment policy, revised 11/1/17, that indicated The pressure ulcer treatment program should focus on the following strategies: Assessing the resident and the pressure ulcer(s). Managing tissue loads. Pressure ulcer care. Managing bacterial colonization and infection. Operative repair of the pressure ulcer(s). Education and quality improvement. The following information should be recorded in the resident's medical record: . Any change in the resident's condition. All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound. On 4/2/24 at 3:04 P.M., the DON provided a current Charting and Documentation policy, undated, that indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 3.1-40(a)(1) 3.1-40(a)(2) 39130

Based on record review and interview, the facility failed to electronically submit to CMS (Center for Medicare and Medicaid Services) required information regarding direct care staffing for the first Fiscal Quarter from 10/1/23 thru 12/31/23. Finding Includes: During a review of the facility's PBJ (Payroll Based Journal) Staffing Data Report [NAME] Report 1705D on 3/25/24 at 11:15 A.M., the staffing data report included, Failed to Submit Data for the Quarter 10/1/23 thru 12/31/23. During an interview on 3/28/24 at 12:20 P.M., the BOM (business office manager) indicated the payroll based journal information is automatically generated and is the responsibility of outside staff to ensure the information is submitted to CMS timely. On 3/28/24 at 1:24 P.M., the BOM supplied an undated facility policy titled Reporting Direct Care Staffing Information (Payroll-Based Journal). The policy included, .9. Direct care staffing is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter .

Based on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 4 of 17 residents reviewed for resident assessment. (Resident 46, Resident 22, Resident 5, Resident 45) Findings include: 1. On 3/28/24 at 9:06 A.M., Resident 46 was observed in her room. She appeared to be around 5 feet tall. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. A Quarterly MDS (Minimum Data Set) Assessment, dated 12/16/23, indicated that Resident 46 had severe cognitive impairment, a formal assessment scale was used that indicated the resident was not at risk for pressure ulcers, and the resident was 74 inches (in) tall. A Significant Change MDS Assessment, dated 1/20/24, indicated Resident 46 had severe cognitive impairment, a formal assessment scale was not used to assess for risk of pressure ulcers, the resident was at high risk for pressure ulcers, and the resident was 74 in tall. The most recent Quarterly MDS Assessment, dated 2/3/24, indicated Resident 46 had severe cognitive impairment, did not have any pressure injuries, had a surgical wound, had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, had a weight gain of 5% or more in the last month or gain of 10% or more in last 6 months, and was 74 in tall. A facility weights and vitals summary indicated Resident 46 was measured on the following dates: 9/11/23 at 2:56 P.M., Resident 46 measured 61 in tall. 10/10/23 at 3:56 P.M., Resident 46 measured 74 in tall. A facility weights and vitals summary indicated Resident 46 was weighed on the following dates: 9/9/23 at 2:54 A.M. Resident 46 weighed 150.4 pounds (lbs). 9/15/23 at 3:08 P.M. Resident 46 weighed 154.6 lbs. 9/25/23 at 11:30 A.M. Resident 46 weighed 154 lbs. 10/9/23 at 11:30 A.M. Resident 46 weighed 140 lbs. 11/3/23 at 8:08 A.M. Resident 46 weighed 144.8 lbs. 12/1/23 at 8:44 A.M. Resident 46 weighed 145 lbs. 1/4/24 at 10:31 A.M. Resident 46 weighed 115.6 lbs. 1/16/24 at 11:28 A.M. Resident 46 weighed 128 lbs. 2/26/24 at 10:00 A.M. Resident 46 weighed 114.2 lbs. A Quarterly Braden Scale Assessment, dated 12/16/23, indicated the resident was at risk for pressure ulcers. An Admission Braden Scale Assessment, dated 1/13/24, indicated the resident was at very high risk for pressure ulcers. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer on the buttocks measuring 2.2 cm (centimeters) in length, 0.5 cm in width, and 0.2 cm in depth. A Pressure Wound Weekly Assessment, dated 1/4/24, indicated the pressure ulcer was worsening and measured 2.5 cm in length, 2 cm in width, and 0 cm in depth. The resident was sent to the hospital for treatment and evaluation on 1/6/24. A hospital discharge summary, dated 1/13/24, indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer (pressure ulcer) and decubitus ulcer present on admission. The resident had a surgical debridement of the ulcer on 1/8/24. A clinical readmission assessment, dated 1/13/23 at 12:31 P.M., indicated the resident had a stage 4 pressure ulcer on the coccyx above the buttocks measuring 10 cm in length, 10 cm in width, and 3 cm in depth with slough in the wound bed and heavy bloody drainage on the dressing. A care plan, initiated 1/13/24, indicated the resident had a stage 4 pressure ulceration to the sacral region following a surgical debridement. A skin/wound note, dated 2/7/24 at 10:58 A.M., indicated After reviewing RAI [Resident Assessment Instrument] for MDS it was determined that wound to resident's coccyx should be documented as a surgical wound present upon re-admit on 1/13/24. Resident went out to hospital with SDTI [Soft Damage Tissue Injury] at which time hospital debrided and wound had significantly changed upon readmission. Prior assessments struck-out and corrected to be nonpressure. Correct assessment completed 2/6/24. During an interview on 4/2/24 at 10:20 A.M., the MDS Coordinator indicated the following MDS assessment items were marked in error: Quarterly 12/16/23 - should indicate the resident was at risk for pressure ulcers. The resident was not 74 inches tall. The resident should be closer to 61 or 62 inches tall, but the clinical record was wrong and she was unsure exactly how tall the resident was. Significant Change 1/20/24 - should indicate a formal assessment was completed. The resident was not 74 inches tall. Quarterly 2/3/24 - should indicate the resident had 1 stage 4 pressure injury and no surgical wounds. Should indicate the resident only had a weight loss. Weight gain was marked in error. The resident was not 74 inches tall. At that time, the MDS Coordinator indicated the facility followed the RAI User Manual. 48057 2. On 4/1/24 at 11:32 A.M., Resident 22's clinical record was reviewed. Resident 22's diagnoses included, but were not limited to, type 2 diabetes mellitus, major depressive disorder, and hypertension. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/5/24, indicated Resident 22 was cognitively intact and required limited assistance of 1 staff for mobility and transfers. The MDS Assessment indicated Resident 22 had received tube feedings while at the facility. During an interview on 4/2/24 at 10:41 A.M., the MDS Coordinator stated Resident 22 was not receiving tube feedings, and that MDS Assessment was marked in error. 3. On 3/27/24 at 01:53 P.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, aphasia. The most recent Annual MDS Assessment, dated 1/16/24, indicated Resident 5 had moderate cognitive impairment, and required extensive assistance of 2 staff for mobility, transfers, and toileting, and required supervision of 1 staff while eating. The MDS Assessment indicated Resident 5 was receiving a mechanically altered diet and was not edentulous. During an interview on 3/25/24 at 12:54 P.M., Resident 5 was observed having no teeth. During an interview on 4/2/24 at 11:22 A.M., the MDS Coordinator confirmed Resident 5 was edentulous, and the MDS Assessment was marked in error. 4. On 3/28/24 at 9:11 A.M., Resident 45's clinical record was reviewed. Resident 45 diagnoses included, but were not limited to, dysphagia and hemiplegia. The most recent Quarterly MDS Assessment was completed on 3/6/24, and indicated Resident 45 was moderately cognitively impaired, and was total dependent on assistance from staff with eating, mobility, transfers, and toileting. The MDS Assessment indicated Resident 45 had not experienced hallucinations. Current care plans included, but were not limited to: Resident has Hallucinations at times, sees snakes in her bed. Dated 1/22/24. During an interview on 4/2/24 at 11:50 A.M., the MDS Coordinator stated that Resident 45 does experience hallucinations and that it is documented in progress notes as well as updated in the care plan, and the MDS Assessment was marked in error. The RAI User Manual 3.0 indicated surgical debridement of a pressure ulcer does not create a surgical wound. Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing. A pressure ulcer that has been surgically debrided should continue to be coded as a pressure ulcer.

Based on observation, interview, and record review, the facility failed to ensure proper handling of tableware and hand hygiene during 1 of 2 observations of dining. Staff handled a resident's coffee mug by placing their thumb on the inside rim of the mug when refilling the mug, and staff failed to perform hand hygiene after coming in contact with residents while providing dining services. (Resident 16, Resident 6, Resident 42, Resident 21) Finding includes: During a dining observation on 3/25/24 at 11:56 A.M., Activities 4 was placing a clothing protector on Resident 16. Activities 4 then pulled Resident 16's hair through the back of the clothing protector, patted the resident's arm, then per Resident 16's request, Activities 4 took the resident's coffee mug and carried it by placing a thumb inside the rim of the mug. Activities 4 filled the mug with coffee and returned it to Resident 16's table. At 12:05 P.M., Activities 4 was changing the television channel with a remote control next to Resident 6 and Resident 42's table. Activities 4 then placed one hand on the shoulder of Resident 6 and another hand on Resident 42's shoulder. Without performing hand hygiene, Activities 4 served Resident 21 their meal, and per Resident 21's added tarter sauce to Resident 21's plate and placed a napkin on Resident 21's lap. Then without performing hand hygiene, went back to Resident 6 and adjusted the oxygen tubing on the resident's face. During an interview on 3/28/24 at 1:03 P.M., RN 5 indicated when assisting in the dining room to pass food trays, staff should not touch utensils or cups where a resident's mouth may come in contact, and that staff should perform hand hygiene after coming in direct contact with a resident or after passing every third tray. On 3/28/24 at 1:45 P.M., the BOM (Business Office Manager) supplied an undated facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices. The policy included, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . Gloves and Direct Food Contact . 9.hands are washed (and gloves are replaced:) a. after direct contact with residents . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure care plan conferences were conducted in a timely manner every 3 months and revised with changes for 9 of 12 residents and revised reviewed for care plans. (Resident 8, Resident 4, Resident 34, Resident 46, Resident 49, Resident 11, Resident 5, Resident 45, Resident 4) Findings include: 1. On 3/23/24 at 8:43 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, major depressive disorder, and unspecified mood (affective) disorder. The current Quarterly MDS(Minimum Data Set) assessment dated [DATE]. Indicated Resident 8 was mildly cognitively impaired and required extensive assistance with transfer and mobility. Care plan conferences were documented for 11/3/23 but lacked a care plan conference for the next 3 months due in January of 2024. During an interview on 4/2/24 at 11:09 A.M. the MDS coordinator indicated a care conference should have been done in January 2024, but was missed. During an interview on 4/01/24 at 9:25 A.M., the DON (Director of Nursing) indicated there should be a care plan conference upon admission and with quarterly assessments. On 4/2/24 at 3:02 P.M., BOM (Business Office Manager) provided a current nondated policy Care Planning- Interdisciplinary Team. The policy indicated resident care plans are developed to timeframes . based on resident assessments . 48057 2. On 3/27/24 at 1:21 P.M., Resident 41's clinical record was reviewed. Resident 41 was admitted on [DATE]. Diagnoses included, but were not limited to, anoxic brain damage, rheumatoid arthritis, and multiple sclerosis. The most recent Quarterly MDS Assessment was completed on 1/27/24, and indicated Resident 41 had total dependency on 2 staff for transfers, mobility, eating, and toileting, and was unable to assess cognitive function. Care conferences for the past year were held on 4/12/23, 1/22/24, and 3/27/24. 3. On 3/27/24 at 01:53 P.M., Resident 5's clinical record was reviewed. Resident 5 was admitted on [DATE]. Diagnoses included, but were not limited to, aphasia. The most recent Annual MDS Assessment, dated 1/16/24, indicated Resident 5 had moderate cognitive impairment, and required extensive assistance of 2 staff for mobility, transfers, and toileting. Care conferences for the past year were held on 3/15/23. 4. On 3/28/24 at 9:11 A.M., Resident 45's clinical record was reviewed. Resident 45 was admitted on [DATE]. Resident 45 diagnoses included, but were not limited to, dysphagia and hemiplegia. The most recent Quarterly MDS (Minimum Data Set) Assessment was completed on 3/6/24, and indicated Resident 45 was moderately cognitively impaired, and was total dependent on assistance from staff with eating, mobility, transfers, and toileting. Care conferences for the past year were held on 12/6/23. 5. On 4/1/24 at 11:32 A.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, major depressive disorder, and hypertension. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/5/24, indicated Resident 22 was cognitively intact and required limited assistance of 1 staff for mobility and transfers. Care conferences for the last year were held on 4/3/23, 10/20/23, and 3/27/24. 48147 6. On 3/27/24 at 12:23 P.M., Resident 4's clinical record was reviewed. Resident 4 was admitted to the facility on [DATE]. Diagnosis included, but was not limited to, dementia. The most recent Quarterly MDS Assessment, dated 2/16/24, indicated Resident 4 had moderate cognitive impairment. The clinical record lacked documented care plan conferences after 11/15/23. 7. On 4/1/24 at 10:14 A.M., Resident 34's clinical record was reviewed. Resident 34 was admitted to the facility on [DATE]. Diagnosis included, but was not limited to, dementia. The most recent Quarterly MDS Assessment, dated 12/18/23, indicated Resident 34 had severe cognitive impairment. The clinical record lacked documented care plan conferences between 9/26/23 and 3/20/24. 8. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Resident 46 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The most recent Quarterly MDS Assessment, dated 2/3/24, indicated Resident 46 had severe cognitive impairment. The clinical record lacked documented care plan conferences after 10/16/23. 9. On 4/1/24 at 10:45 A.M., Resident 49's clinical record was reviewed. Resident 49 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia and diverticulitis of the intestine. The most recent Admission MDS Assessment, dated 2/8/24, indicated Resident 49 had severe cognitive impairment, required substantial/maximal assistance (helper does more than half) with eating, had no weight loss prior to admission, was 68 inches (in) tall, and weighed 142 pounds (lbs). Current physician orders included, but weren't limited to: Regular diet, Regular texture, Regular consistency, dated 2/2/24 Weekly weights for 4 weeks, dated 2/5/24 and discontinued on 3/4/24 Weekly weights for 4 weeks, dated 3/11/24 Monthly weight, dated 2/3/24 mirtazapine (an antidepressant that causes appetite stimulation) tablet 7.5 MG (milligrams) - Give 1 tablet by mouth one time a day for appetite, dated 3/8/24 A nutrition care plan, dated 2/2/24, indicated the resident would take his diet as ordered with supplements and vitamins as needed. A facility weights and vitals summary for Resident 49 indicated the following weights: 2/2/24 at 12:55 P.M. - 143.2 lbs 2/5/24 at 10:58 A.M. - 143.0 lbs 2/12/24 at 7:28 A.M. - 142.0 lbs 3/5/24 at 2:31 P.M. - 133.0 lbs, a 6.34% weight loss since 2/12/24 3/11/24 at 8:19 A.M. - 133.0 lbs 3/19/24 at 11:19 A.M. - 132.8 lbs 3/25/24 at 2:16 P.M. - 132.0 lbs A weight change note, dated 3/6/24 at 1:19 P.M., indicated Down 9 pounds 1 month. Added house supplement bid [twice a day], weekly weight x 4. Wife here and aware of weight loss. Will encourage to go to dining room for meals and staff will assist with eating as he will allow. A weight change note, dated 3/27/24 at 7:55 A.M., indicated Weight at 132 # [lbs] has been stable 4 [sic] last 4 weeks. Remains on Remeron [brand name for mirtazapine] to increase appetite. Encouraged to be out of room for meals. Will feed self with set up staff assists as needed. The care plan was not revised related to Resident 49's weight loss or new orders. In an interview on 4/1/24 at 12:13 P.M., the Director of Nursing (DON) indicated that significant weight loss would be added to the care plan once it was identified. On 4/2/24 at 12:28 P.M., the DON provided a current Weight Assessment and Intervention policy, undated, that indicated The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; great than 5% is severe . Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plans shall address .the identified cause of weight loss. On 4/2/24 at 12:28 P.M., the DON provided a current Care Plans, Comprehensive Person-Centered policy, undated, that indicated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. On 4/2/24 at 3:02 P.M., BOM ( Business Office Manager) provided a current nondated policy Care Planning- Interdisciplinary Team. The policy indicated resident care plans are developed to timeframes . based on resident assessments . 3.1-35(d)(2)(B) 3.1-35(e)

Based on interview and record review, the facility failed to notify the physician and resident representative of changes in a resident's medical status for 2 of 4 residents reviewed for weight loss. The physician was not notified of a resident's refusal of food and the resident's representative was not notified of significant weight loss or a newly identified pressure injury. (Resident 46, Resident 45) Findings include: 1. On 3/27/24 at 1:46 P.M., Resident 46's Power of Attorney (POA) indicated Resident 46 was hospitalized in January for a pressure ulcer. They indicated they were not told about the pressure ulcer or that the resident had a weight loss until the resident was transferred to the hospital. On 3/28/24 at 10:25 A.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and stage 4 pressure ulcer of sacral region. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/3/24, indicated Resident 46 had severe cognitive impairment, had no pressure injuries, had a surgical wound, and had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. A facility weights and vitals summary indicated Resident 46 was weighed on the following dates: 9/9/23 at 2:54 A.M. Resident 46 weighed 150.4 pounds (lbs). 10/9/23 at 11:30 A.M. Resident 46 weighed 140 lbs., a 6.9% weight loss since 9/9/23 11/3/23 at 8:08 A.M. Resident 46 weighed 144.8 lbs. 12/1/23 at 8:44 A.M. Resident 46 weighed 145 lbs. 1/4/24 at 10:31 A.M. Resident 46 weighed 115.6 lbs., a 20.28% weight loss since 12/1/23 The clinical record lacked notification to the physician, Registered Dietitian (RD), or family of the 6.9% weight loss on 10/9/23. The clinical record lacked notification to the RD or the family regarding the 20.28% weight loss on 1/4/24 The following nursing progress notes, dated 11/18/23 through 12/14/23, indicated the resident had poor appetite and food intakes: 11/18/23 12:50 A.M. - Refused snack tonight. 11/20/23 7:03 P.M. - Resident did not eat breakfast but ate lunch and supper. Resident up in her recliner watching TV. 11/21/23 2:43 P.M. - Has not been out of bed today. Appetite remains poor. Offer snacks between meals. Fluids encouraged. No behaviors this shift. 11/22/23 12:22 A.M. - Resident has not been out of her bed so far this shift. No snacks this evening but did drink some water with her medications. 11/22/23 12:50 P.M. - Resident ate 75% of breakfast, and 0% of lunch. Resident continues to sleep most of the day. Snacks offered between meals, and staff continues to encourage resident to increase her intake of fluids. 11/24/23 2:05 P.M. - Resident has been awake off and on all throughout this shift so far. Resident ate 25% of breakfast and 100% of lunch. No behaviors noted. Staff continues to encourage resident to increase her intake of fluids. 11/28/23 1:14 P.M. - Resident continues with decreased appetite. Resident ate 0% of breakfast and 50% of lunch. Staff continues to encourage resident to increase her intake of fluids, and snacks offered between meals. 12/1/23 1:57 P.M. - Residents appetite continues to remain poor. Ate 25% of breakfast and lunch. Staff continues to encourage resident to increase her intake of fluids. Snacks offered. Resident continues to sleep throughout most of the day. 12/3/23 11:57 A.M. - Residents appetite continues to remain poor. Staff continues to encourage resident to increase her intake of fluids. Snacks offered. Resident continues to sleep throughout most of the day. 12/4/23 11:18 A.M. - In bed at this time appetite remains unchanged. 12/6/23 1:42 P.M. - Up in chair at bedside transferred with 2 assist. Gait unsteady. Appetitei [sic] remains unchanged. 12/7/23 1:51 P.M. - Resident up in recliner earlier this shift with 2 assist. Appetite remains unchanged. Resident took medications. 12/8/23 12:31 A.M. - Refused PM (night) meds. Appetite poor. 12/9/23 1:30 P.M. Resident continues with poor appetite. 12/10/23 1:48 P.M. Resident has been sleeping in bed most of the morning. Did wake up to eat lunch. 12/11/23 12:53 P.M. - Resident is resting in recliner at this time. Resident did eat 50% of breakfast and lunch. No complaints of pain noted. Staff continues to encourage fluids. 12/12/23 11:59 A.M. - Up in recliner for meal at this time. Staff encouraging and cuing her to eat. 12/13/23 2:18 P.M. - Resident continues with poor appetite. Is bedridden most of the time. No behaviors noted. 12/14/23 2:23 P.M. - Resident continues with poor appetite. Is bedridden most of the time. No behaviors noted. The clinical record lacked any progress notes from 12/16/23 to 1/16/24 related to loss of appetite, weight loss, nutritional status, or notification of poor appetite or food intake to the physician, RD, or family. A Pressure Wound Weekly assessment, dated 12/28/23, identified a new stage 2 pressure ulcer on the buttocks measuring 2.2 cm (centimeters) in length, 0.5 cm in width, and 0.2 cm in depth. The note indicated the facility left a message for the POA. A nursing progress note, dated 1/4/24 at 10:36 A.M., indicated the resident was lethargic and not eating, and the NP saw the resident and gave new orders to obtain labs for CBC, CMP, TSH (thyroid-simulating hormone), and T4 (thyroxine) the next morning. A review of the census indicated the resident was hospitalized from 1/6/24 to 1/13/24. A hospital history of present illness note, dated 1/6/24, indicated Resident 46 was evaluated for sepsis due to a large, unstageable decubitus ulcer (pressure ulcer) that was acquired at the facility. It was noted that family was present during the evaluation and stated they were not aware the ulcer was present. A hospital discharge summary, dated 1/13/24, indicated the resident's discharge diagnoses included, but were not limited to, sepsis due to decubitus ulcer, severe hypernatremia due to notable dehydration, decubitus ulcer present on admission, and severe malnutrition present on admission. The resident was discharged back to the facility and was admitted to hospice on 1/13/24. 48057 2. On 3/28/24 at 9:11 A.M., Resident 45's clinical record was reviewed. Resident 45 diagnoses included, but were not limited to, dysphagia and hemiplegia. The most recent Quarterly MDS Assessment was completed on 3/6/24, and indicated Resident 45 was moderately cognitively impaired, and was total dependent on assistance from staff with eating, mobility, transfers, and toileting. Current active physician orders included, but were not limited to: Enteral Feed four times a day; Give 240 cc (equivalent of ml) (milliliter) of Jevity 1.5 after meals if consumes < 50% and at bedtime. Start date 6/14/23. Current care plans included, but were not limited to: I will take diet as ordered; Peg tube enteral feedings as ordered. Start date 2/26/24 Diet as ordered; Weight as ordered; Registered dietician evaluation as needed; Notify MD of any concerns. Start date 6/13/23. The most recent recorded weight in 3/18/24 indicated Resident 45 weighted 72 pounds. Weight recorded six months prior on 9/21/23 indicated a weight of 85.6 pounds. The total weight loss for the past 6 months indicated Resident 45 had a weight loss of 15.89%. The following dates, during the 6 month weight loss period of 15.89%, indicated Resident 45 did not receive the full amount of Jevity feeding ordered, or did not receive it at all, with no notification documented between the facility and the dietician, or the facility and the physician. 1/31/24 8 A.M. no feeding administered; 1/31/24 5 P.M. 100 ml 2/1/24 8 P.M. 60 ml 2/2/24 1 P.M. 100 ml; 2/2/24 5 P.M. 100 ml; 2/2/24 8 P.M. 100 ml 2/5/24 1 P.M. 200 ml 2/10/24 8 P.M. 120 ml 2/14/24 8 P.M. 120 ml 2/15/24 8 A.M. 120 ml; 2/15/24 1 P.M. 120 ml 3/4/24 5 P.M. no feeding administered 3/13/24 8 P.M. 120 ml 3/19/24 8 A.M. 120 ml, 3/19/24 1 P.M. 120 ml; 3/19/24 5 P.M. 120 ml 3/20/24 8 A.M. 120 ml, 3/20/24 1 P.M. 120 ml; 3/20/24 5 P.M. 120 ml; 3/20/24 8 P.M. 60 ml 3/21/24 8 A.M. 120 ml, 3/21/24 1 P.M. 120 ml; 3/21/24 5 P.M. 120 ml; 3/21/24 8 P.M. 120 ml 3/24/24 1 P.M. 120 ml; 3/24/24 5 P.M. 120 ml During an interview on 4/1/24 at 1:47 P.M., the Director of Nursing stated sometimes Resident 45 will tell staff she is full before a feeding is complete and if the full amount of feeding is not administered, it should be documented why the full amount was not administered. In an interview on 4/1/24 at 12:13 P.M., the Director of Nursing (DON) indicated that families were notified if a resident experienced significant weight loss and those notifications were charted in the weight change note. On 4/2/24 at 12:28 P.M., the DON provided a current Weight Assessment and Intervention policy, undated, that indicated Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant weight unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; great than 5% is severe . Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes . the resident's calorie, protein, and other nutrient needs compared with resident's current intake . Care planning for weight loss or impaired nutrition .includes the physician, nursing staff, the dietitian .and the resident's legal surrogate. On 4/2/24 at 12:28 P.M., the DON provided a current Change in a Resident's Condition or Status policy, undated, that indicated Our facility promptly notifies the resident, his or her attending, physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a . significant change in the resident's physical/emotional/mental condition; . refusal of treatment or medications two (2) or more consecutive times; . A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff .requires interdisciplinary review and/or revision to the care plan . Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a Resident was provided restorative therapy services to prevent avoidable decline in range of motion and progression of muscle atrophy for 1 of 1 residents reviewed for mobility. (Resident 41) Findings include: On 3/27/24 at 1:21 P.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, anoxic brain damage, rheumatoid arthritis, and multiple sclerosis. The most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident 41 had total dependency on 2 staff for transfers, mobility, eating, and toileting, and was unable to assess cognitive function. The MDS Assessment indicated Resident 45 had limitation in range of motion and impairment on both sides of upper and lower extremities but received zero minutes of restorative therapy. Current active physician orders included, but were not limited to: Up with assist and mechanical lift, dated 3/15/24. Turn and reposition approximately every 2 hours per Braden Scale every shift, dated 1/20/24. Current care plans included, but were not limited to: Potential for contracture r/t (related to) anoxic brain injury causing persistent vegetative state. PROM (passive range of motion) as tolerated. Refer to therapy/restorative as needed. Observe for increase in contractures. Notify Dr. as needed, revised 3/15/24. The clinical record lacked documentation of restorative nursing services or range of motion exercised provided to Resident 41 during the current year. During an observation on 03/27/24 at 1:44 P.M., Resident 41 was observed laying in bed with the bed in a high position; both hands contracted; both feet contracted and were resting on pillow with heels touching. During an interview on 03/28/24 at 1:38 PM, RN (Registered Nurse) 5 indicated Resident 41 should be receiving restorative nursing for range of motion in her upper and lower extremities, and that the restorative aid provides services Monday through Friday. During an interview on 04/02/24 at 11:25 A.M., CNA (Certified Nurses Aide) 3 stated Resident 41 was removed from restorative nursing in December due to COPD (chronic obstructive pulmonary disorder) but that she had not witnessed Resident 41 experiencing shortness of breath drop during range of motion exercises. On 4/2/24 at 9:55 A.M., the DON (Director of Nursing) provided a policy titled Restorative Nursing Services, that did not include a date, and indicated: Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: maintaining physiological resources, and maintaining dignity. 3.1-42(a)(2)