Every finding on record at Washington Care Center

Based on observation, staff interviews and facility policy review the facility failed to ensure items in the kitchen refrigerator were dated and labeled and failed to discard food items by the expiration date for one (1) of three (3) dietary tour observations. Findings Include:Review of the facility policy titled, Food Storage Labeling, with a revision date of 08/12, revealed The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedures. 1. a. All temperature-controlled foods and ready to eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food, Date of storage. b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date .An observation and interview on the initial tour of the kitchen on 04/28/2026 at 10:15 AM, with the Dietary Manager (DM) revealed in refrigerator number two (#2) a plastic gallon-size bag with no date and no label, the DM identified the item as shredded carrots, and a 2-gallon bag of salad mix with no open date. The DM stated, I'm really not sure when these were opened. A five (5) pound white container with a manufacturer's label cottage cheese and dated 12/31/25, a one-gallon container with a manufacturer's label Lime Juice with an opened date of 6/25/25 and best by date of 9/17/25 by the manufacturer's label on the container. A plastic one-gallon container with a manufacturer's label of classic coleslaw with an open date of 10/22/25 and no expiration date. A gallon of manufactured 2% milk with approximately one-half remaining in the jug, with a best-by date of April 18 on the jug. The DM revealed that all foods should be labeled and dated, and that expired foods should be discarded.During an interview on 04/29/2026 at 11:10 AM, Dietary Worker #1 stated that it is everyone's responsibility to ensure the food is labeled and dated and that expired food is discarded. She stated, Food items that are opened and placed in the refrigerator are only supposed to be in there for four days. During an interview on 04/29/2026 at 11:25 AM, the Dietary Manager confirmed all foods should be labeled, dated, and discarded when expired to prevent spoilage and illness. The DM further confirmed that while all staff share responsibility for labeling, dating, and discarding expired foods, oversight of this process ultimately rests with her as the Dietary Manager.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the implementation of the resident's care plan for oral hygiene for one (1) of (16) care plans reviewed. Resident #4 Findings Include:Record review of the facility policy titled Care Plan Process, revised 12/24, revealed, The facility shall use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. The facility staff shall follow the care plan.Record review of Resident #4's Care Plan Report revealed under, Focus: Resident is dependent with oral hygiene. Further review revealed under, Interventions: Provide oral hygiene as needed. Provide X (times) 1 (one) staff with oral care at least two times a day & (and) or as indicated.On 4/29/26 at 12:58 PM, observation of Resident #4 revealed he was lying in bed and was non-verbal. The resident's lips were dry with dried particles of peeling skin noted on the lower lip. The lower teeth were covered in a light orangish-colored substance with yellowish-green secretions observed inside the oral cavity. The tongue was coated with a thick yellowish-white substance.An observation and interview with Licensed Practical Nurse (LPN) #2 on 4/29/26 at 1:11 PM, confirmed lack or oral care describing Resident #4's lips as dry and the tongue as coated with secretions.An interview with the Registered Nurse (RN) Case Manager on 4/29/26 at 2:59 PM revealed Resident #4's care plan was in place so that staff knew what care to perform. She confirmed the care plan for oral care should have been followed.Record review of the Face Sheet revealed the facility admitted Resident #4 on 1/23/26 with medical diagnoses including Encounter for Attention to Gastrostomy, Cough, and Cerebral Infarction.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #4 was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to accurately code Section A of the Minimum Data Set (MDS) for a resident identified with a serious mental illness (SMI) through the Preadmission Screening and Resident Review (PASRR) Level II process for one (1) of (16) MDS assessments reviewed. Resident #9Findings include:Review of the facility policy titled Resident MDS Assessment, revised 9/9, revealed, An assessment will be completed on each resident utilizing the MDS. The completed assessment guides staff in identifying key information about the resident and serves as a basis for identifying resident-specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental, and psychosocial well-being .Record review of Resident #9's Preadmission Screening and Resident Review Summary of Findings Report, dated 5/8/23, revealed under Mental Health, the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. The report further revealed diagnoses including Axis I Primary: Major Depressive Disorder, Axis I Secondary: Anxiety Disorder, and Axis I Tertiary: Bipolar Disorder.Record review of the MDS with an Assessment Reference Date (ARD) of 1/21/26 revealed under section A1500 that Resident #9 was not considered by the state Level II PASRR process to have a serious mental illness, which was coded inaccurately.An interview with the Registered Nurse (RN) Case Manager on 4/29/26 at 2:59 PM, revealed Resident #9 did have a serious mental illness requiring a Level II PASRR evaluation. The RN confirmed she made an error on the MDS and stated the MDS should be accurate to ensure Resident #9 receives the appropriate care and services for her mental health disorders.Record review of the Face Sheet revealed the facility admitted Resident #9 on 4/21/23 with medical diagnoses including bipolar disorder and anxiety disorder.Record review of the MDS with an ARD of 1/21/26 revealed under section C, a BIMS summary score of 15, indicating Resident #9 was cognitively intact.

Based on record review and staff interviews, the facility failed to ensure the administration of the influenza vaccine in accordance with facility policy to prevent the spread of infection for one (1) of five (5) residents reviewed for immunizations. Resident #10.Findings Include:Review of the facility policy titled Influenza Vaccination Program for Employees and Residents, revised 1/24, revealed, It is the policy of this facility to provide employees and residents with influenza vaccination every year between October and March. This is consistent with recommendations from the CDC (Center for Disease Control and Prevention) and state and local health departments.Record review of Resident #10's Vaccine Information and Consents revealed the Responsible Representative (RR) consented for the resident to receive the annual influenza vaccine on 2/3/26.Record review of Resident #10's Clinical Immunizations revealed that under Influenza Seasonal, the resident was documented as not eligible for the vaccine. The record also indicated the resident was admitted after flu season, with this entry dated 2/3/26.An interview with the Infection Preventionist (IP) on 4/30/26 at 9:52 AM, confirmed she did not administer the influenza vaccine to Resident #10. She stated she documented the vaccine as out of season, acknowledging that flu season usually peaks in February, which was when the resident was admitted . The IP further confirmed the resident should have been vaccinated, stating it was important to prevent the spread of infections and illness, particularly in elderly residents. An interview with the Director of Nursing on 4/30/26 at 10:02 AM, revealed the facility should have vaccinated Resident #10 for influenza, confirming it was not out of season and emphasizing the importance of preventing the spread of infection.Record review of the Face Sheet revealed the facility admitted Resident #10 on 2/5/26 with medical diagnoses including Type 2 Diabetes Mellitus without Complications and Unspecified Dementia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 3, indicating Resident #10 was severely cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide oral care to a resident dependent on staff for Activities of Daily Living (ADLs) care for one (1) of three (3) residents reviewed for ADLs. Resident #4 Findings Include:Review of the facility policy titled Oral Hygiene, revised 1/24, revealed under Purpose: To clean the mouth, teeth, and gums; To remove particles of food; To remove bacteria and odor; To provide comfort to the resident; To keep the mouth moist.Record review of Resident #4's Order Summary Report revealed an order dated 1/23/26 for NPO (nothing by mouth) diet.An observation on 4/28/26 at 10:38 AM revealed Resident #4 was lying in bed with upper and lower lips that were dry, with cracking and peeling skin on the lower lip. The resident's lower teeth were covered in a thick white substance.An observation on 4/29/26 at 12:58 PM revealed Resident #4 was lying in bed and was non-verbal. The resident's lips were dry with dried particles of peeling skin noted on the lower lip. The lower teeth were covered in a light orangish-colored substance with yellowish-green secretions observed inside the oral cavity. The tongue was coated with a thick yellowish-white substance.An observation and interview with Certified Nurse Aide (CNA) #1 on 4/29/26 at 1:06 PM, revealed the aides were responsible for providing oral care to Resident #4. She stated she had already performed oral care earlier that morning but indicated the secretions must have built back up.Record review of Resident #4's Personal Hygiene Task dated 4/29/26 revealed no documentation that oral care was provided during that shift.An observation and interview with Licensed Practical Nurse (LPN) #2 on 4/29/26 at 1:11 PM, described Resident #4's lips as dry and the tongue as coated with secretions. She confirmed that if oral care had been performed, it was not completed appropriately and stated the resident's lips should have been moisturized.An observation and interview with the Director of Nursing on 4/29/26 at 1:20 PM, revealed oral care was considered part of personal hygiene provided by the aides. She confirmed Resident #4's poor oral care could lead to tooth decay and other health concerns and stated it was the charge nurse's responsibility to follow behind the aides to ensure care was provided.Record review of the Face Sheet revealed the facility admitted Resident #4 on 1/23/26 with medical diagnoses including Encounter for Attention to Gastrostomy, Cough, and Cerebral Infarction.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 14, indicating Resident #4 was cognitively intact. Also revealed under section GG, the resident was dependent on staff for oral care.

Based on staff interview and record review, the facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Second (2nd) Quarter 2024. Findings include: Review of the facility PBJ (Payroll-Based Journal) Instructions with a revision date of February 3, 2020 revealed, PBJ = Payroll-Based Journal - Mandated by CMS (Centers for Medicare and Medicaid Services). Each location must collect time worked by contract workers. The corporate office will submit at regular intervals Review of the PBJ (Payroll-Based Journal) Staffing Data Report revealed the facility triggered for excessively low weekend staffing data for the 2nd Quarter 2024 [NAME] report from CMS.Triggered=Submitted Weekend Staffing data is excessively low. An interview with the Administrator on 8/20/2024 at 9:25 AM, revealed, she was not aware of the facility triggering on the [NAME] report for low weekend staffing data and stated the corporate office was responsible for submitting the PBJ. She revealed the facility had been using agency staff and to her knowledge the agency hours were added by the Business Office. A telephone interview with Corporate Special Projects on 8/20/2024 at 3:36 PM, revealed, she was responsible for submitting the PBJ. She revealed she was not aware the facility triggered for low weekend staffing data and stated she had not received any kind of notification. She explained that she did not have contact with anyone at the facility to ensure contract/agency hours were being captured in the PBJ. She revealed the facility was responsible for adding the agency hours into the (proper name of system) and the system would automatically do a payroll interfaced sweep over every night to capture those hours. She confirmed if the agency hours were not entered manually at the facility, they would not be captured. Review of the PBJ total daily staffing hours submitted to CMS for the 2nd Quarter 2024 did not match the facility's staffing grid hours, which indicated inaccurate information was submitted in the PBJ. An interview with the Regional Supervisor on 8/21/2024 at 2:25 PM revealed, she had not received any information that the facility was triggering for low weekend staffing. She stated she was unsure how contract hours were handled, but she knew the Business Office added the agency hours into the (proper name of system) after receiving the information from the shift worked. She confirmed there could be a breakdown and revealed that was something they would have to look into.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident on a PRN (as needed) psychotropic medication had a stop date for one (1) of five (5) medication reviews. Resident #40 Findings Include: Review of the facility policy titled, Psychotropic Medication, revised 10/22, revealed Residents do not receive psychotropic drugs pursuant to a PRN (as needed) order unless that medication is necessary to treat a diagnosed a specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days. Review of the Order Summary Report with active orders as of 8/21/24 for Resident #40 revealed an order dated 7/5/2024, Xanax oral tablet 0.5 mg (milligram) (Alprazolam) give (1) tablet by mouth every 6 (six) hours as needed for agitation . There was no stop date for the order. Review of the August 2024 Medication Administration Record (MAR) for Resident #40 revealed the resident received Xanax 0.5 mg on the following dates: 8/3, 8/4, 8/8, 8/9, 8/10, 8/13, 8/14, 8/15, 8/16, 8/18, 8/19, 8/20, 8/21. An interview with the Director of Nursing (DON) on 8/21/2024 at 12:08 PM confirmed Resident #40's PRN Xanax order did not have a stop date. She revealed the resident was on hospice and should have been re-evaluated by hospice within the 14 days to ensure the medication was needed and it could have been continued at that point. Review of the Admission Record revealed the facility admitted Resident #40 on 3/14/24 with a medical diagnosis of Aftercare following joint replacement surgery.

Based on resident and staff interview, record review, and facility policy review, the facility failed to accurately code a quarterly Minimum Data Set Assessment (MDS) for one (1) of 16 resident assessments reviewed. (Resident # 11) Findings include: Review of the facility policy titled, Resident Assessment, with the latest revision 09/19 revealed, .The completed assessment guides the staff in identifying key information about the resident's specific issues and objectives to develop a care plan . Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed . In an interview with Resident #11 on 8/20/24 at 11:00 AM, she revealed she was not on or receiving Hospice services. Record review of Resident #11's Section C of the Quarterly MDS revealed on 7/08/24 a Brief Interview for Mental Status (BIMS) score was 13 indicating the resident was cognitively intact. Section: O- Special Treatments, Procedures, and Programs was coded Hospice services while a resident. In an interview with Licensed Practical Nurse (LPN)/MDS Nurse on 8/21/24 at 9:04 AM, she revealed after review of Resident #11's quarterly MDS that she accidentally coded that the resident was on Hospice and confirmed that Resident #11 had never been on Hospice. She then revealed the purpose of accurate coding is to get an accurate picture of the resident's needs and services required. In an interview with the MDS Registered Nurse (RN) Coordinator on 8/21/24 at 12:19 PM, she revealed that Resident #11 has not ever been on Hospice services and confirmed the resident's MDS assessment was coded incorrectly. She stated the purpose of accurately coding the resident assessments is to ensure the facility receives proper payment for care and to ensure the resident receives the individualized care required. Review of the Admission Record revealed the facility admitted Resident #11 on 4/21/23 with diagnoses that included End-stage renal disease.

Based on resident representative and staff interview, record review and facility policy review the facility failed to honor a resident's right to return to the facility following a hospitalization for one (1) of three (3) residents reviewed for discharge. Resident #1. Findings Include: Record review of facility policy titled, Discharge Transfer and Planning , revised 9/23, revealed The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility .Before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .The Discharge/Transfer notice shall be made by the facility at least 30 days before the resident is transferred or discharged . Record review of the Face Sheet for Resident #1 revealed that the facility admitted him on 12/24/2013 with diagnoses that included Cerebral Infarction and Alzheimer's Disease. The facility discharged Resident #1 on 6/7/2024. A telephone interview with Resident Representative #2 on 7/1/24 at 11:15 AM, she stated that on 6/7/24 she was notified by the hospital social worker that Resident #1 was being discharged from the hospital on that day but that the facility refused to take him back because he had exceeded his bed hold and that the family had fired the attending physician. Resident Representative #2 stated that the family never fired the resident's attending physician. She stated that at the hospital another physician was filling in for the attending physician there and they thought the attending physician would resume care when Resident #1 returned to the facility. Resident Representative #2 stated that after the initial call they received on 5/23/24 when the resident was being sent to the hospital, they received no other communication from the facility until 6/10/24 when she and Resident Representative #1 initiated contact. Resident Representative #2 stated that they were never notified by the facility that the attending physician would no longer be Resident #1's physician in the nursing home or that Resident #1 was being discharged from the facility. She stated they never received a discharge notification or the opportunity to appeal the discharge. Resident Representative #2 stated that on 6/10/24 she asked Resident Representative #1 to go to the facility to find out what the issue was. She stated that a conference was held on 6/10/24 between Resident Representative #1, Resident Representative #2, the Administrator and the Director of Nursing (DON). She stated that at that time they were told by the facility that the resident exceeded his bed hold days, so he had to be discharged and he did not have a physician to readmit him. She reported that the facility did not offer to help them find an alternative physician telling them that the other physicians were not accepting new residents. She stated that the resident was discharged from the hospital to an alternative nursing home on 6/14/24 after he had lived in the nursing home for over [AGE] years. During an interview with the DON on 7/1/24 at 11:05 AM, she stated on 6/3/24, while the resident was still in the hospital, the facility received a call from the receptionist at Resident #1's attending physician's office notifying them that he would no longer be Resident #1's physician. She stated that she did not know what prompted this change. She verified that she did not reach out to the family to notify them or to attempt to find out what prompted this change. The DON stated on 6/5/24 she called another physician to see if he would be willing to accept Resident #1, but the physician was not accepting new residents. She stated she did not contact the two (2) physicians to inquire if they would be willing to admit Resident #1. She stated on 6/6/24 or 6/7/24 the hospital called regarding Resident #1's readmission to the nursing facility, and she informed them at that time that the resident did not have a physician so they would not be taking him back. An interview and record review on 7/1/24 at 11:15 AM, with the Administrator, of an untitled document, on facility letter head, addressed to Resident Representative #1 revealed This letter is to inform you of the facility-initiated discharge to hospital on 6/7/24 . we are no longer able to meet your needs in this facility and the transfer is necessary for your welfare. Additional comments: Resident exhausted his bed hold days. Discharge to Proper Name of Hospital effective date 6/7/24. The Administrator stated that the notification was mailed on 6/7/24 but was unable to provide documentation that the document had been delivered to the Resident Representative. An interview on 7/1/24 at 11:20 AM, with the Administrator verified that the facility did not contact Resident #1's family regarding the resident not having an attending physician or to notify them that he would be discharged and not readmitted to the facility. She also verified that the facility did not reach out to any of their other physicians to determine if they would accept the resident for admission.

Based on observation, staff interviews, resident interview, facility policy review and record review, the facility failed to provide Activities of Daily Living (ADLs) as evidenced by long and jagged nails, and unshaven facial hair for two (2) of eighteen residents observed. Resident #24 and Resident #42 Findings include: A record review of the facility policy titled, A.M. Care policy' with a revision date of 10/17 revealed, Purpose: To prepare the resident for their day, to maintain oral health and bodily hygiene, and to maintain the resident's desired physical appearance . Procedure: 12. Assist the resident with grooming according to their preferences (makeup application, shaving, hair removal, hair care, and styling, etc.) . A record review of the facility policy titled, Nail Care Policy, with a revision date of 10/17 revealed, Purpose: To promote cleanliness, safety, and a neat appearance. To observe skin condition on fingers and toes .Procedure: 8. Trim the nails straight across, and even with the end of the finger or toe. For fingers, remove any sharp edges with the file or emery board . Resident #24 During an observation on 02/06/23 at 11:20 AM, revealed Resident #24 sitting in his wheelchair with long fingernails that were approximately 1/2 inch past the end of his fingertips. Resident #24 stated that he had asked staff to cut his nails, but they told him they didn't have any clippers. Resident #24 stated that he knew somebody here should have nail clippers. During an observation on 02/07/23 at 9:44 AM, revealed Resident #24 sitting up in wheelchair. His fingernails had been trimmed but had sharp edges and his left thumbnail was jagged. Resident #24 stated they (staff) came in yesterday afternoon and cut them. He confirmed they were rough but stated that it was a start. On 02/07/23 at 1:00 PM, during an interview with the Activity Trainer revealed that she cut Resident #24's fingernails yesterday. She stated that they were long, but they were clean. An interview on 2/7/23 at 2:10 PM, with Certified Nursing Assistant (CNA) #3 revealed that she felt like Resident #24's fingernails were kind of long today, but not as long as they were yesterday. She confirmed that they needed trimming. An observation and interview, on 2/7/23 at 3:20 PM, with the Director of Nursing (DON) confirmed Resident #24's fingernails were trimmed yesterday. She confirmed they had sharp uneven corners. She stated that long nails and rough nails could cause skin tears and harbor debris. The DON stated the Certified Nursing Assistants are responsible for maintaining nails or reporting to the nurse if they are unable to cut them. Review of the facility Face Sheet revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Anxiety. Record review of Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/04/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #24 was cognitively intact. 46013 Resident #42 During an interview and observation on 2/06/23 at 11:54 AM, revealed Resident #42 sitting on the side of the bed with facial hair noted to the sides of his cheeks, above his lip, and on his chin with approximately. 1-inch growth. Resident #42 revealed the last time he was shaved was a week ago, but he likes to be shaved every two days. He revealed he has mentioned it to staff before, but they say they'll get to it but never do. Resident #42's fingernails on bilateral hands were approximately 1/2-inch past the end of the finger, were jagged, and dirty with a brown substance under each nail. The resident revealed he doesn't like them this long and would like them to be cut but they haven't cut them since he's been here. An observation on 2/06/23 at 2:30 PM, revealed, Resident # 42 lying in bed. Resident #42 was unshaven and nails on bilateral fingers jagged and approximately 1/2 inch long with a brown substance under the nails. The resident revealed he hasn't been shaved or his nails cut yet. An observation and interview on 2/07/23 at 08:10 AM, revealed Resident #42 sitting on the side of the bed. The resident was unshaven, and his nails were long, with a brown substance underneath. An observation on 2/07/23 at 9:55 AM, revealed Resident #42 sitting in the dining room, unshaven and the fingernails on bilateral hands are dirty, jagged, and approximately 1/2 inch long. An interview and observation on 2/07/23 at 11:05 AM, with CNA #1 confirmed that Resident # 42's nails were long and dirty and needs to be cut. She revealed that if a resident isn't diabetic that the aides can cut their nails, but she was unsure if the resident was diabetic or not. She revealed that she hasn't cut his fingernails and wasn't sure if he was supposed to get that done when he went to the shower. She revealed his shower days are Monday, Wednesday, and Friday and that he gets shaved by CNA #2 because she gives him his showers. She revealed that she can shave him as well if he needs it. She confirmed that he hasn't been shaved in a while and that he should have been. She revealed we don't have assignment sheets with the exact task we are supposed to do and wished the facility had them. An interview and observation on 2/07/23 at 11:30 AM, the DON confirmed Resident #42's fingernails were long, jagged, and dirty. She revealed she would get his nails done right away. She confirmed that the resident was unshaven with hair on his chin and the sides of his face. Resident #42 revealed to the DON that he likes to be shaven every other day. The DON revealed the residents usually get shaved when they go to the shower and confirmed that the resident was unshaven and looked like he hadn't been shaved in a while. On 2/07/23 at 1:30 PM, during an interview with CNA #2 revealed she does the showers, and it is basically her responsibility to shave a resident when they come to the shower unless they can shave by themselves. She revealed Resident # 42 was unable to shave on his own. She revealed she can't remember when the last time he was shaven, but it might have been last Friday. She confirmed that she had noticed his long fingernails before but hadn't cut them and any aide can cut the resident's nails unless they are diabetic, but there is no one specifically assigned. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Hemiplegia, unspecified affecting left nondominated side, Personal history of Transient Ischemic Attack (TIA), and Cerebral Infarction. A record review of the MDS with an ARD of 1/30/2023 revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident has moderate cognitive impairment.

Based on observation, resident and staff interviews, facility policy review and record review, the facility failed to develop a comprehensive care plan for a resident requiring shaving and failed to implement the care plan for residents requiring nail care for two (2) of 18 residents reviewed. Resident #24 and Resident #42 Findings include: Resident #24 A record review of the facility policy titled, Care Plan Process Policy , with a revision date of 08/17, revealed regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence. The facility shall develop and implement a Baseline Careplan and Summary NS 813 for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. An observation on 02/06/23 at 11:20 AM, revealed Resident #24 sitting up in his wheelchair. His fingernails were long on both hands approximately 1/2 inch past the end of fingertips. Resident #24 stated that he had asked staff to cut his nails, but they told him they didn't have any clippers. Resident #24 stated that he knew somebody here should have nail clippers. An observation on 02/07/23 at 9:44 AM, revealed Resident #24's fingernails are trimmed but have sharp edges and the left thumbnail is jagged. The resident stated they came in yesterday afternoon and cut them. He confirmed they were rough but stated that it was a start. An interview on 2/7/23 at 1:00 PM, with the Activity Trainer revealed that she had cut Resident #24's fingernails yesterday. She stated that they were long but they were clean. An interview on 2/7/23 at 2:10 PM, with Certified Nursing Assistant (CNA) #3 stated that she felt like Resident #24's fingernails were kind of long today, but not as long as they were yesterday. She stated that they needed trimming. An observation and interview on 2/7/23 at 3:20 PM, with the Director of Nursing (DON) confirmed Resident #24's fingernails were trimmed yesterday. She confirmed they had sharp uneven corners. She stated that long nails and rough nails could case skin tears and harbor debris. An interview on 2/09/23 at 8:40 AM, with the DON confirmed Resident #24's care plan was not implemented because his nails were long and needed cutting. Record review of Resident #24's Care Plan with a problem onset date of 11/18/2020, revealed, (Formal Name of Resident) needs assist with ADL's .Approaches .Nursing staff to provide nail care as needed . Record review of the facility Face Sheet revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease and Anxiety. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/04/23, Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #24 was cognitively intact. 46013 Resident #42 An interview and observation on 02/06/23 at 11:54 AM, revealed Resident #42 sitting on the side of the bed with facial hair noted to his cheeks, above his lip, and on his chin approximately one (1) inch long. Resident #42 revealed the last time he was shaved was a week ago, but he likes to be shaved every two days. He revealed he has mentioned it to staff before, but they say they'll get to it but never do. Resident #42's fingernails on both hands were approximately 1/2-inch past the end of the fingers and were jagged and dirty. There was a brown substance under each nail. The resident revealed he doesn't like his fingernails this long and would like for them to be cut. He stated that they haven't been cut since he's been at the facility. An observation on 2/06/23 at 2:30 PM, revealed Resident #42 lying in bed unshaven and nails on bilateral fingers jagged and approximately 1/2 inch long with a brown substance under the nails. The resident revealed he hasn't been shaved or his nails cut yet. An observation and interview on 2/07/23 at 8:10 AM, revealed Resident #42 sitting on the side of the bed. The resident was unshaven and his nails were long with a brown substance underneath the nails. An observation on 2/07/23 at 9:55 AM, revealed Resident #42 sitting in the dining room. The resident was unshaven and the fingernails on both hands were dirty, jagged, and approximately 1/2 inch long. An interview and observation on 2/07/23 at 11:05 AM, with CNA #1 confirmed that Resident # 42 nails were long and dirty and needed to be cut. She revealed that if a resident isn't diabetic the aides can cut their nails, but she was unsure if the resident was diabetic or not. She revealed that she hasn't cut his fingernails and wasn't sure if he was supposed to get that done when he went to the shower. CNA #1 revealed Resident #42's shower days are Monday, Wednesday, and Friday and that he gets shaved by CNA #2 because she gives him his showers. CNA #1 revealed that she can shave him as well if he needs it. She confirmed that he hasn't been shaved in a while and that he should have been. She revealed the CNA's don't have assignment sheets with the exact task we are supposed to do. An interview and observation on 2/07/23 at 11:30 AM, the DON confirmed Resident # 42's fingernails were long, jagged, and dirty. She revealed she would get his nails done right away. She confirmed that the resident was unshaven with hair on his chin and the sides of his face. Resident #42 revealed to the DON that he likes to be shaved every other day. The DON revealed the residents usually get shaved when they go to the shower and confirmed that the resident was unshaven and looked like he hasn't been shaved in a while. An interview on 2/07/23 at 2:31 PM, with the MDS nurse revealed she is the one that develops the plan of care, and the care plan is developed to help us specifically know how to take care of the resident. She revealed she is responsible for updating the plan of care and that the care plan is updated as needed and/or when the resident has an MDS due. She revealed each resident's Activities of Daily Living (ADL) care plan should be reflective of nail care, baths, and if they are to be shaven or not. She revealed she wasn't sure if all ADL care plans addressed that or not. An interview on 2/08/23 at 11:00 AM, the Corporate Consultant revealed each resident is supposed to have an individualized care plan which should include nail care, shaving, and any specific preferences so the staff will know how to take care of them. An interview on 2/08/23 at 11:24 AM, with the MDS nurse confirmed that Resident # 42 did not have a care plan that addressed shaving and his preference of shaving every other day and he should have. An interview and ADL care plan review on 02/08/23 at 05:26 PM, with the DON confirmed that Resident #42 did not have an ADL care plan that was individualized to his preference of shaving and confirmed his nail care was not being implemented and it should have been. Record review of Resident #42's care plan, with a problem onset date of 10/24/2022 revealed (Formal Name of Resident) need assist with ADLs .Approaches . Nursing staff to eval (evaluate) or nail care as needed . Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Hemiplegia, unspecified affecting left nondominated side, Personal history of Transient Ischemic Attack (TIA), and Cerebral Infarction. Record review of the MDS with an ARD of 1/30/2023 revealed Resident #42 had a BIMS score of 10, which indicated the resident has moderate cognitive impairment.

F565- S/S=D Based on record reviews, staff interviews, resident interviews, reviews of the resident council meeting minutes, and facility policy and procedures reviews, the facility failed to provide evidence of their responses to the resident council concerns and requests for Resident #6. Resident #6 was one (1) of eight (8) residents reviewed for the facility's response to grievances voiced by the resident council. Findings: The facility policy and procedure titled Grievances - Residents (F-565 & F-585) dated 03/93 with revision dates of 02/03; 06/11; 1/12; 12/16; 02/17; 04/17 read: All resident are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other resident's and other concerns regarding their facility stay, in the event that they have a need to make a concern known. Minutes of each Resident Council Meeting are recorded and made available to each member of the council, and a copy is maintained by the Administrator. Future meetings will indicate progress made on each suggestion/recommendation, and/or the reason (s) for rejection if changes suggested cannot be implemented. The Social Worker of Social Service Designee has been appointed by the Administrator to work with the Resident Council in obtaining services that assist the residents in voting, marriage, divorce, executing legal documents (i.e., wills, etc.), acquiring and disposing of property, choosing to practice a religion, etc., and to receive grievances and recommendations by residents, or any group or individual designated by the resident and his/her representative. These grievances shall be directed to the appropriate Department Head and/or Administrator for investigation and follow-up. The facility policy and procedure titled Resident Council (F-565) dated 03/93 with revision dates of 02/03; 01/12; 02/17 read: All residents constitute the governing body of the Resident Council; all meetings are open to each resident residing in the facility. Meetings will be held on a regular basis and not less than quarterly. Staff liaison to the Resident Council will be the Social Services Designee/Social Worker or the Resident Activity Director, as approved by the group. This staff member is responsible for providing assistance and responding to written requests that result from group meetings. Other departmental staff will attend the meeting by invitation only. Meetings will at a minimum address the following: Review of minutes, Old/new Business, Open forum for questions/concerns, staff reports. The facility must consider the views of the group and act promptly upon recommendations regarding issues of resident care and life in the facility. The Grievances-Residents process shall be followed. The grievance report shall reflect the rationale of facility response. In review of the facility's policies and procedures for the facility's responses to Resident Council Meetings, the facility did not follow the guidance outlined in the policies for Resident Council Meetings with responses and action taken for the voiced resident concerns. Record review of the Resident Council Meeting minutes for the past year, January 2021 through December 2021, revealed that the facility had no documented responses to the monthly voiced group concerns as evidenced by : Review of the 01/20/1921 Resident Council Meeting minutes revealed that Resident #6 and Resident #7 were two (2) of six (6) residents that attended the Resident Council Meeting in which there were concerns voiced that money had been taken from a resident. The minutes did not identify the resident that had money taken and there was no dollar amount identified in the resident council minutes of January 20, 2021. The minutes also contained dietary requests for eggs, and nursing concerns that the food trays were being left in resident rooms, and housekeeping concerns that deep cleaning was still not being done. The January 2021 minutes did not contain responses and follow up actions taken by the facility to resolve the residents' voiced concerns. The facility did not follow their policies and procedures for responding to the voiced concerns from the Resident Council Meeting. The review of the February 23, 2021, Resident Council Meeting minutes did not contain comments and responses to the concerns issued during the January 20, 2021, group meeting. The section of the minutes titled Old Business was blank as was the section of the minutes titled New Business. The February 23, 2021, Resident Council Meeting minutes did document Housekeeping rooms not being deep cleaned. Resident #6 and Resident #7 were two (2) of five (5) residents that attended the February 2021 group meeting. The same housekeeping concerns that the residents' rooms were not being deep cleaned were unresolved in group meeting of February 23, 2021, that had also been unresolved during the group meeting of January 20, 2021. Review of the March 24, 2021, Resident Council Meeting minutes revealed that Resident #6 and Resident #7 were in attendance and that they were two (2) of ten (10) residents that attended the March 24, 2021, group meeting. The March 24, 2021, minutes contained no documentation for Old Business and no Old Business discussions were documented. There was no evidence documented that the facility had addressed the Resident Council group concerns that were voiced in the February 23, 2021, group meeting. Resident #6 voiced to the Administrator that she would like a new chair during the March 24, 2021, group meeting. The group voiced numerous food concerns and requests during the March group meeting. Review of the April 21, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of ten (10) residents that attended the April 2021 group meeting. The April 21, 2021, group meeting contained no documentation of the facility's follow-up and/or actions taken to resolve and respond to the previous resident group concerns. There was no response documented to in the minutes of April 21, 2021, concerning Resident #6's request for a new chair that she made in March 2021. Review of the May 24, 2021, Resident Council Meeting minutes revealed that Resident #7 was one (1) of eight (8) residents that attended the group meeting. There were no responses and or resolutions documented in the May 2021 minutes of the facility's action taken to address the previous voiced resident group concerns. The residents voiced in the May 24, 2021, group meeting that the beds were not being made by the Certified Nursing Assistance's (CNA's); and that the residents were not gotten up and out of bed before 10:00 A.M. Review of the June 23, 2021, Resident Council Meeting minutes revealed that Resident #6 and Resident #7 were two (2) of ten (10) residents that attended the group meeting. The residents voiced concerns about the food, not getting baths, noise in the hallways, beds not being made, not enough activities and no social worker. The facility did not document what had been done to address the previous group concerns. The minutes contained previously voiced concerns that were on-going and had been documented each month in the Resident Council Meeting minutes. Review of the July 12, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of 12 residents that attended the July group meeting. Previous voiced concerns with food, noise in the hallways, activities, beds not being made and hollering up and down the hall. The same group issues remained unresolved and un-responded to by the facility in the July 12, 2021, group meeting. Review of the August 25, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of 14 residents that attended the group meeting in August 2021. Resident #6 reported that she was not gotten up before 10:00 A.M. Some of the ongoing voiced concerns that had been documented in prior group meeting were reported by the group such as: noise in the hallways, food, no weekend activities, want more games, and want more snacks. There were no responses to the group concerns documented in the group minutes for August 2021 and/or for the previous voiced group concerns. Review of the September 28, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of ten (10) residents that attended the group meeting in September. The minutes contained voiced concerns about the food, want more activities and board games, CNAs in hallways being loud at night, trays being left in the rooms, and want more snacks. The facility did not document the resolutions to previous voiced group concerns and did not document any responses to the voiced requests of the resident group. Review of the October 21, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of ten (10) residents that attended the group meeting. The residents voiced concerns about not having Sunday activities and not having Church services, food trays left in rooms, noise in the hallways, residents requested more board games, and one resident reported a blanket with her name on it was missing. The October 2021 group meeting did not contain documentation of responses to the voiced resident concerns. Previously voiced group concerns were voiced in the October 2021 group meeting with no facility resolutions and responses documented. Review of the November 3, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of three (3) residents that attended the group meeting. Residents voiced in the group meeting that there was noise in their hallways at night, food trays were left in the rooms all day, snack cart doesn't come to the rooms on the 200 hall, food concerns, and want more activities on the weekends and want more outside of facility activities. There were no facility responses documented in the group minutes for November 3, 2021, and the voiced group concerns were the same as from previous group meetings with no facility response to the resident group. Review of the November 16, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two (2) of ten (10) residents that attended the group meeting. The group voiced that there was noise in the hallways, not knocking on room doors, food concerns, not enough meat servings with meals, and one (1) resident needed a new chair. The facility did not document in the minutes the facility resolutions and/or responses to the November 16, 2021, voiced group concerns. Review of December 9, 2021, Resident Council Meeting minutes revealed that Residents #6 and #7 were two of the 17 resident that attended the group meeting. The resident's voiced concerns were Sunday activities, residents ar3e not being allowed enough time to finish their food before the aides take up the trays, residents are not aware of who the new administrator is and they think that she should walk around and introduce herself, food requests, and residents made suggestions of several activities that they would like to see in the facility. There was no facility documented responses to the residents group concerns and requests and no resolutions were documented by the facility for the previously issued group concerns. In an interview on 2/21/2021 at 2:50 P.M. with the facility administrator, ADM, she confirmed that she had been newly licensed as an Administrator (ADM) and had begun her first job as an ADM on 11/2/2021 at the facility. Interview on 2/21/22 at 4:10 P.M. with the Activities Director (AD) revealed that she had been newly employed as the AD and that she had just completed the BIMS scores on all 44 of the residents in the facility. The AD presented the SA with a copy of the BIMS scores for all 44 residents. The AD stated that they had on Friday 2/18/22 met with the resident council and had elected a new resident council president, (Res #5) a new recording secretary, (Res #6) and had elected a new vice president (Res #7). The AD stated that she had no idea what the prior AD had done in relation to the resident council meeting minutes. The AD stated that she would make sure that all the concerns and requests that the residents had in Resident Council Meeting would be responded to and attempts would be made toward resolution and response. The AD confirmed that Res #6 and Res #7 had no cognitive deficits and were interviewable residents. Interview on 2/22/22 at 12:00 P.M. with the Dietary Manager (DM) revealed that she had never been given the Resident Council Meeting food concerns and she had never been to a Resident Council Meeting to speak with the residents about their food concerns. The DM stated that the residents did not want her at the Resident Council Meetings. The DM stated that the cooperate office provided the menus to the facility. The DM stated that she was given a tight budget for the food purchases and that it was hard to provide quality choices in foods on such a tight budget. Interview and observation on 2/22/22 at 1:30 P.M. with the new resident council president (Res #5) revealed that he had never attended a resident council meeting since he had been in the facility. Res #5 stated that he had been admitted to the facility in May of 2021. Res #5 stated that he had had a stroke and was not able to care for himself alone. Res #5 had good eye contact and was appropriately dressed in season appropriate clothes. Res #5 was pleasant in mood and had good command of language and his affect was pleasant. Res #5 was very interviewable and engaging in conversation. Res #5 stated that he felt that the facility did not let him know what was going on in the facility with things like menu changes and foods that would be served in the dining room. Resident #5 also stated that he had been placed on the Covid isolation unit when he was positive with Covid 19. He stated that when he would ask for information and wanted to know what to expect the facility did not answer his questions and did not communicate with him. Res #5 stated that today (2/22/22) was the first time since his admission to the facility in May of 2021, that he had received a menu for the foods that would be served. Res #5 wanted the daily menu to be posted in an area of the dining room where they have meals that could be reviewed by the residents. Res #5 stated that he used to be a tennis pro and ran tennis [NAME] across the State. Res #5 stated that he liked to go outside and get fresh air, but the facility had not allowed him to go outside and sit on the patio with the group that smokes, because he was not a smoker, he felt that he did not get the same privileges as the smokers. Res #5 gave permission to the SA to relay his concerns to the facility. Record review of Resident #5's Minimum Data Set (MDS) section C dated 02/02/22 revealed that Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that he had no cognitive deficits. Record review of Res #5's face sheet revealed that Resident #5 was admitted to the facility on [DATE] and had a date of birth of 08/29/2957. Interview and Observation on 2/22/22 at 2:00 P.M. with Res #6 revealed that she was sitting in a wheelchair in her private room alone watching television. Res #6 stated that she had reported in resident council meetings that she needed a new wheelchair because her chair was hard to roll. Res #6 stated that this had been the case for several months and her chair had not been replaced. Res #6 stated that the previous ADM had told her that the facility had no money in the budget to replace her wheelchair. Res #6 stated that her wheelchair was too small and would not roll and that it was very hard to push. Res #6 also had a broken remote control on her automatic bed that was broken, and the bed would not let down and up and the wheels on the bed would not lock. Resident #6 stated that she had reported the broken bed to the facility's Director of Maintenance, and he had told her that he would have to order a part to repair the remote control. Resident #6 stated that her bed had been broken for several weeks. Resident #6 stated that the facility had not resolved her concerns from the resident council meeting. Res #6 gave permission to rely on her concerns to the facility. Record review of Res #6's face sheet revealed that Res #6 had been admitted to the facility on [DATE] and had a date of birth of 05/30/1940. Res #6's MDS dated [DATE] contained a BIMS score of 13 indicating that Res #6 had mild cognitive impairment. Interview on 2/22/22 at 2:15 P.M. with the Director of Maintenance, revealed that he was told, by Res #6 that her bed was broken, and he stated that he would have to order a new part for the remote control. SA asked the Maintenance Director for a copy of the invoice of the part ordered and when would it be repaired. The Maintenance Director confirmed that he had no invoice. He stated that he would have to see if he could order the part. Interview on 2/22/22 at 2:30 with the DON and ADM revealed that Res #5 had not mentioned any concerns and that they had seen Res #5 out on the patio with the smoking residents several times per day sitting in the fresh air. DON stated that she would talk to Res #5 and find out his concerns. Neither the ADM nor the DON were aware of Res #5's concerns. ADM stated that they started today, 2/22/22, giving the residents a daily menu of the meals to be served. The DON will talk to Res #5. DON stated that she will have Res #6's bed repaired, DON did not know that Res #6's bed was broken. The DON stated that she would have a new wheelchair fitted and ordered for Res #6. The ADM and the DON assured the SA that the concerns of Res #5 and Res #6 would be resolved. Interview on 2/23/22 at 11:00 A.M. with Resident #6 revealed that the facility had been to her room and had begun to switch the bed out for another bed in the facility that was working properly and that was not occupied. Res #6 stated that she was very much looking forward to her new wheelchair and that the DON had come to talk to her about the ordering of a new wheelchair. Interview on 2/23/22 at 11:15 A.M. with Res #5 revealed that he had been told that he could go outside any time with the group of smokers and/or with the staff. Res #5 stated that the facility had followed up on his requests for menus.

F609 S/S=D Based on record reviews, staff interviews, and policy and procedures reviews, the facility failed to timely report alleged staff to resident abuse within two (2) hours of the alleged occurrence for Resident #1. Resident #1 was one (1) of eight (8) residents reviewed for timely reporting of alleged occurrences of abuse and neglect. Findings: The review of the facility policy and procedure titled: Incident Investigation & Reporting (MS only) dated 04/06; latest revision: 05/18; read: Abuse, neglect, misappropriation of resident property and exploitation are crimes and shall be reported to proper authorities as such. The facility administrator shall ensure that any incident involving an allegation or suspicion of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported not later than 2 hours after allegation is made to local law enforcement and the state agency, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency and adult protective services. Initial Report must be called in to Mississippi State Department of Health Certification and Licensure. Attorney General Office; Local Law Enforcement. Final Report must be submitted within 72 hours to MSDH Certification and Licensure and Attorney General's Office. In an interview on 2/21/2021 at 2:50 P.M. with the facility Administrator (ADM) stated that she had mailed via US mail the investigation that the facility had conducted concerning the alleged abuse of Resident #1 (Res #1) by a Certified Nursing Assistant (CNA#1). The ADM was not able to provide documentation that the alleged abuse was timely reported immediately after the alleged occurrence on 12/10/2021 at 2:00 A.M. The ADM stated that she mailed the facility's report and investigation of the alleged abuse to the State Agency (SA). The ADM confirmed that she did not fax or email the report to the SA. The ADM confirmed that she did not have any email or fax confirmations of the alleged abuse of Resident #1 that occurred on 12/09/21 or 12/10/21. The ADM verified that her investigation report was mailed to the Survey Agency on 12/15/2021. The ADM stated that CNA #1 and CNA #2 had both been placed out on leave pending the conclusion of the facility investigation. CNA #2 resigned due to the stress of the investigation and CNA #1 was terminated out of an abundance of caution. There was no substantiated abuse or neglect of Resident #1. Interview with the Director of Nursing (DON) on 2/21/2021 at 3:00 P.M. revealed that she received the call from the third shift nurse, Licensed Practical Nurse (LPN) #1, sometime after midnight on Saturday 12/11/2021 reporting that CNA #2 told her that she witnessed CNA #1 curse and grab the wrist of Resident #1 and say F****r, I am stronger than you are. You can't hurt me. The DON stated that she came to the facility on the first shift on Saturday 12/11/2021 and at approximately 10:30 A.M. the DON began the assessments of all of the residents in the facility. The DON completed the accident and incident report for resident #1 on 12/11/2021. The DON called the ADM, and she called the local police department to report alleged abuse of resident #1 by the CNA #1. The DON stated that she called the hotline at Mississippi State Department of Health (MSDH) at approximately 11:00 A.M. on 12/11/2021 to report the alleged abuse. The DON confirmed that she was not able to provide documentation that the alleged abuse was timely reported immediately after the occurrence on 12/10/2021 at 2:00 A.M. The DON stated that she had looked through her personal cell phone and was not able to locate the date and time that she called the alleged abuse of resident #1 into the State agencies. There was no record of the notification of the SA with in two (2) hours of the alleged occurrence of abuse. The DON confirmed that the incident of alleged abuse occurred during the third shift on 12/09/2022-12/10/2022. The DON confirmed that the facility did not substantiate any abuse or neglect of Res #1. The SA attempted to interview and observe Resident #1 during the investigation of 2/21/22-2/23/22. No observations and/or interviews were made since resident #1 was in the hospital for complications with Covid 19. The record review of Resident #1's Minimum Data Set (MDS) section C-Cognitive Patterns dated 02/04/2022 revealed that Res #1 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated he had severe cognitive deficits. Review of Resident #1's face sheet revealed that he had a documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The SA confirmed that the first notification the facility made to the SA of the alleged occurrence was on 1/6/2022 via US mail. The SA had no record of the facility reporting the alleged abuse in a timely manner within two (2) hours of occurrence that took place on 12/09/2021 during the third shift. The facility did not timely report the incident of alleged abuse of Resident #1 by CNA #1.

Based on record review, staff and resident interview, and facility policy and procedure review the facility failed to ensure residents were free from theft of personal property (cash) for one (1) of (15) sampled residents reviewed, Resident #1. Findings include: Review of the facility policy/procedure titled Employee Corporate Compliance Code of Conduct, last updated 5/18, defined Misappropriation of Resident Property as The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident belongings or money without the resident's consent. On 3/9/21, at 10:35 AM, an interview with the Director of Nursing (DON) revealed Resident #1 was upset and reported that she had $60.00 stolen. The facility began an investigation and replaced the $60.00. Resident #1 insisted on keeping the replaced money with her and not keeping it in her trust fund. On 1/24/21, Resident #1 reported that the $60.00 had been stolen again from her room. Resident #1 said Nursing Assistant ( NA) #1 took her money. An investigation was begun again, and the resident's money was refunded again. NA #1 was suspended pending the outcome of the investigation. Resident #4 reported to the DON that she saw NA #1 going through Resident #1's things. The facility reported the incidents to the appropriate State Agencies and the Local Police Department. A receipt was made for the money replaced to Resident #1 dated 12/24/2020. On 3/10/21 at 2:00 PM, an interview with Resident #4 revealed she saw NA #1 going through Resident #1's things and Resident #1 told her about her money missing. An interview on 3/12/2021, at 12:40 PM, with the Attorney General (AG) investigator, revealed he did get an admission from NA #1 and she admitted to taking $50.00 from Resident #1 on either 12/23/20 or 12/24/20. The AG investigator stated NA #1 would be charged with a misdemeanor. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/20 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated severely impaired cognition. Review of the Face Sheet for Resident #1 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of NA#1's personnel file revealed she signed the Employee Corporate Compliance Code of Conduct on 8/3/2020. She was hired as a temporary nurse aide. Review of the Quarterly MDS with an ARD of 12/10/20 for Resident #4 revealed a BIMS score of 13 indicating she was cognitively intact. Review of the Face Sheet for Resident #4 revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].

Based on interview, record review and facility policy review, the facility failed to ensure the privacy for residents as related to a video and a picture that was posted on a personal social media for two (2) of 43 residents (Residents #1 and #2). Findings include: Record review of the facility policy titled Cell Phone/Electronic Communication Devices Policy (Facility Personnel), dated 7/19, revealed under the section titled Prohibited Actions revealed any use of Cell Phones to record or take still or video pictures of the facility, employees, residents, or property is strictly prohibited, and such activity may subject an employee to disciplinary action up to and including termination. Uploading resident PHI (personal/protected health information), videos, photos, or other private information to social media including but not limited to Facebook, Snapchat, Instagram, Twitter, etc. shall subject employee to disciplinary action up to and including termination. Noted signature of Certified Nursing Assistant (CNA) #1 at the bottom of the policy with the date of 3/12/20, also signed by the facility representative signature. On 12/22/20 at 8:30 AM an interview with the Administrator revealed the facility was called by Resident #1's niece on 10/20/20 and made aware of the video that was posted on a personal Facebook account of her uncle. The Administrator revealed CNA #1 was hired in March 2020 and terminated in May 2020, the video was not known of until 10/20/20 so the facility has no idea when the video was taken. The Administrator was also made aware on 10/21/20 a selfie picture taken by CNA #1 of Resident #2. The Administrator revealed it is against facility policy to take pictures or videos of any residents and new hires are educated on this policy. The Administrator revealed CNA #1 was terminated on 5/14/20 for an unrelated incident of leaving during a shift and not returning. On 12/22/20 at 9:30 AM an interview with Resident #2 revealed he could not recall ever having his picture taken. On 12/22/20 at 11:15 AM an interview with the Director of Nursing (DON) revealed she did not know about the video or picture that was posted on Facebook by CNA #1's boyfriend until Resident #1's family called to report to the Administrator. The DON questioned staff, and no one knew of the video or picture taken of Resident #1 or Resident #2. As soon as she was aware of the posting to Facebook, she in-serviced all staff on privacy policies and cell phone use. CNA #1 was terminated in May (2020) and they have no idea when the video was taken. All new hires are educated on the policy of privacy and cell phone use. The facility tried to reach CNA #1 but without success. On 12/22/20 at 1:49 PM an phone interview with Resident #1's responsible party (RP) revealed she was notified by friends and family that a video of her uncle was on Facebook. She called her sister that was working near the nursing home and told her to go to the nursing home and make sure he was okay. The Administrator brought her uncle to the front lobby so her sister could see that he was fine. The RP revealed she was told CNA #1 and her boyfriend had a confrontation, and he was the one that posted the video CNA #1 made. The RP revealed she and her family did not know CNA #1 or her boyfriend. On 12/22/20 at 2:08 PM an interview with the Attorney General agent revealed he had been unable to contact CNA #1 and had been told she was working as a travel CNA and was last in Texas. The Attorney General agent revealed he had a copy of a short clip of the video and stated he saw and heard Resident #1 being asked why he was on the floor by CNA #1. Review of the Cell Phone/Electronic Communication Devices Policy, under the heading of Prohibited Actions, revealed any use of Cell Phones to record or take still or video pictures of the facility, employees, residents, or property is strictly prohibited, and such activity may subject an employee to disciplinary action up to and including termination. Uploading resident PHI, videos, photos, or other private information to social media including but not limited to Facebook, Snapchat, Instagram, Twitter, etc. shall subject employee to disciplinary action up to and including termination. CNA #1's signature is on the bottom of the page with the date of 3/11/20. The DON's signature is on the bottom of the page as the Facility Representative Signature. Review of the Search Results Mississippi Nurse Aides revealed CNA #1 has been certified since 2/26/20. Record review of the Employee Warning Report revealed CNA #1 was terminated on 5/14/20. CNA #1 worked on 5/13/20 and left the facility between 5:30 PM and 6:00 PM and was never seen again. On 5/14/20 a phone call to CNA #1 revealed she was not coming back to work. Review of the Termination Report for CNA #1, dated 5/14/20, noted it was because the employee walked out of building and stated that she was not coming back. Review of the signed statement related to The Mississippi Vulnerable Adults Act revealed CNA #1 was given the information on the Vulnerable Adults Act and in-serviced on this information. CNA #1 noted she understood the steps to be taken if she suspects or witnesses an incidence of resident rights violation. The signature of CNA #1, with the date of 3/12/20, was noted. Review of a statement presented by the DON revealed she watched the video on Facebook on 10/20/20 of Resident #1 and a picture of Resident #2. The DON identified CNA #1 as the person taking the picture and talking in the video. Review of the Greenville Police incident report (# 196) revealed a report was made by the Administrator on 10/20/20 a post on Facebook about Resident #1 was sent to a boyfriend of one of the ex-employees. The Administrator stated CNA #1 was fired months ago. Review of the Employee Acknowledgements and Authorizations revealed CNA #1's signature and initials confirming she had read, received, understood and agreed to abide by the stipulations included in the following policies, procedures, and forms. Included in the list of policies are resident rights and cell phone/electronic communication devices.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store oxygen equipment in a manner to prevent cross contamination for two (2) of 20 residents receiving oxygen therapy, Residents #2 and #39. Findings include: A review of the facility's Infection Control Oxygen Equipment Cleaning policy, revised 03/18, revealed: Tubing should be replaced every seven (7) days. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Resident #2 During an observation, on 01/06/20 at 11:30 AM, Resident #2's oxygen concentrator had a cannula bag on it, dated 12/25/19. There was no nasal cannula attached to the concentrator. During an observation, on 01/06/20 at 4:32 PM, Resident #2's oxygen concentrator was observed with a cannula bag on it dated 12/25/19. There was no nasal cannula attached to the concentrator. During an observation and interview, on 01/07/20 at 8:30 AM, Resident #2's nasal cannula was observed to be laying across the resident's bed, uncovered, and dated 12/25/19. The cannula cover bag was dated 12/25/19. The Director of Nursing (DON) was brought to Resident #2's room to observe the placement of the cannula and the dates on the cannula and cover bag. The DON confirmed they were both dated 12/25/19. The DON stated the oxygen tubing was to be changed one time a week and should have been changed on 01/01/20. Review of Resident #2's care plan revealed a problem, with an onset date of 06/10/19, to address the resident receives oxygen therapy as ordered for shortness of breath (SOB) with exertion and sitting at rest. Interventions included to Change O2 (oxygen) tubing and nasal cannula/mask weekly on Wednesday. Flag with date and initials. Store in plastic bag when not in use with residents name and date. Resident #39 An observation, on 01/06/20 at 12:42 PM, revealed Resident #39's oxygen concentrator was turned on and running at 2 liters per minute (LPM), with the nasal cannula and tubing draped over the head of the bed, uncovered and touching the floor, and dated for 01/01/20. During an observation, on 01/06/20 at 3:30 PM, Resident #39's concentrator was turned on and running at 2 LPM. The nasal cannula, dated 01/01/20, was uncovered, draped over the head of the bed. and lying on the floor, behind the head of the bed. On 01/07/20 at 8:30 AM, Resident #39 was observed in bed, with a nasal cannula on, and dated 01/01/20. During an observation and interview, on 01/07/20 at 8:33 AM, the DON was informed, by the surveyor, of the observations made on 01/06/20, where Resident #39's nasal cannula was uncovered, draped over the head of the bed, touching the floor and dated 01/01/20. Resident #39 was wearing the same cannula when observed by the DON. The DON stated she would replace the nasal cannula.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the care plan related to storage of oxygen equipment, for two (2) of 19 resident care plans reviewed, Resident #2 and #39. Findings include: Review of the facility's Care Plan Process policy, revised 08/17, revealed: The comprehensive care plan is an interdisciplinary communication tool. The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility staff shall follow the care plan. Resident #2 Review of Resident #2's care plan, revealed a problem to address oxygen therapy related to shortness of breath (SOB), with an onset date of 06/10/19. Interventions included to change oxygen (O2) tubing and nasal cannula/mask weekly on Wednesday and flag with date and initials. Store in plastic bag, when not in use, with residents name and date. During an observation, on 01/06/20 at 11:30 AM, Resident #2's oxygen concentrator had a cannula cover bag laying on it, dated 12/25/19. There was no nasal cannula attached to the concentrator. During an observation, on 01/06/20 at 4:32 PM, Resident #2's oxygen concentrator was observed with a cannula cover bag laying on it, with a date of 12/25/19. There was no nasal cannula attached to the concentrator. During an observation and interview, on 01/07/20 at 8:30 AM, Resident #2's nasal cannula was observed to be laying across the resident's bed, uncovered, and dated 12/25/19. The cannula cover bag was dated 12/25/19. The Director of Nursing (DON) was brought to Resident #2's room to observe the placement of the cannula, and the dates on the cannula and cover bag. The DON confirmed they were both dated 12/25/19. The DON stated the oxygen tubing was to be changed one time a week, and should have been changed on 01/01/20. Resident #39 An observation, on 01/06/20 at 12:42 PM, revealed Resident #39's oxygen concentrator was turned on and running at 2 liters per minute (LPM). The nasal cannula and tubing was draped over the head of the bed, uncovered, and touching the floor behind the bed, and dated for 01/01/20. During an observation, on 01/06/20 at 3:30 PM, Resident #39's concentrator was turned on and running at 2 LPM. The nasal cannula, dated 01/01/20, was uncovered, draped over the head of the bed. and lying on the floor, behind the head of the bed. On 01/07/20 at 8:30 AM, Resident #39 was observed in bed, with a nasal cannula on, and dated 01/01/20. During an observation and interview, on 01/07/20 at 8:33 AM, the DON was informed of the observations made on 01/06/20, where Resident #39's nasal cannula was uncovered, draped over the head of the bed, touching the floor and dated 01/01/20. Resident #39 was wearing the same cannula when observed by the DON. The DON stated she would replace the nasal cannula. Review of Resident #39's care plan, revealed a problem for occasional shortness of breath (SOB)/wheezing, with an onset date of 01/25/18.

Based on record review, staff interview, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one (1) of 19 MDS assessments reviewed, Resident #42. Findings include: Review of the facility's Resident MDS Assessment policy, revised 09/19, revealed: Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed. Review of Resident #42's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 12/13/19, revealed Section N (Medications), Item N0410E, was answered to indicate the resident had received an anticoagulant medication for seven (7) days, during the look back period. Review of Resident #42's Medication Administration Record [REDACTED]. During an interview, on 01/08/20, at 12:02 PM, the Director of Nursing (DON) stated Resident #42 did not receive an anticoagulant medication. The DON stated [MEDICATION NAME], which is an antiplatelet, was mistakenly coded as an anticoagulant, and that made the MDS inaccurate.

Based on record review, observation, staff interview, and facility policy review, the facility failed to revise the care plan related to Nutrition for Resident #27 for one (1) of 19 resident care plans reviewed. Findings include: Review of the facility's Care Plan Process policy, dated 08/17, revealed: The comprehensive care plan is an interdisciplinary communication tool. The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the residents's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with each resident's written plan of care. Review of Resident #27's Care Plan, revealed a problem to address Nutritional Approaches Therapeutic diet: Carbohydrate Controlled Diet/Limited Concentrated Sweets (CCD/LCS), onset date of 11/26/19, and Goal and Target date, to follow therapeutic diet by 03/17/20. Interventions included to provide diet as ordered. A review of Resident #27's Physician order [REDACTED]. an order for [REDACTED].#27 has a current order, dated 01/08/20, for [MEDICATION NAME] AC tube feeding via Percutaneous Gastrostomy (PEG) Tube at 55 cubic centimeters (cc) per hour for 22 hours. Observations on 01/06/20 - 01/09/20 (dates of survey), revealed Resident #27 had a PEG tube in place, with [MEDICATION NAME] AC infusing at 55 cc per hour. No meal tray was observed in the resident's room at any time. During an interview, on 01/08/20 at 12:10 PM, the Director of Nursing (DON) revealed the Dietary Supervisor completes the initial Nutrition care plan. The DON stated, If this care plan was followed, something bad could happen. During an interview, with the Dietary Manager (DM), on 01/08/20 at 2:20 PM, she stated It (care plan) should have been updated. I haven't had time. The DM stated, I must have missed it in reference to initiation of care plan upon admission. Review of the Face Sheet, revealed, Resident #27 was admitted by the facility, on 11/26/2019, with [DIAGNOSES REDACTED].

Based on observation, interview, and review of facility grievances, it was determined the facility failed to ensure efforts were made to resolve grievances with the facility incontinent brief practice for nine (9) of 13 Residents (R), R #6, #8, #9, #14, #20 #26, #29, #33, and #34, attending the resident group meeting; and two (2) of 19 sample residents, R #22 and R #47, also reviewed. This deficient practice had the potential to affect the other 46 residents identified by the facility with incontinence out of total census of 50 residents. Findings include: The facility's Grievances policy, revised (MONTH) (YEAR), documented, . Minutes of each Resident Council meeting are recorded . Future meetings will indicate progress made on each suggestion/recommendation and/or the reasons(s) for rejection . The policy documented the facility would make prompt efforts to resolve grievances, and document follow through with the complainant. On 3/26/19, the administrator provided a signed statement that the facility did not have a policy on daily brief usage. Resident #47: On 3/25/19 at 2:44 PM, during a resident interview, R #47 pointed to a stack of three (3) adult briefs laying on top of his dresser and stated, This is something I don't like. They bring you four (4) diapers a day. That's all you get, and if you ask them to leave more, they won't. I thought Medicaid paid for them, but I guess they just pay for four (4) a day, R #47 stated if he required more than four (4) briefs per day, My wife must go out and buy them. I try to wait as long as I can before I ask to be changed, because it seems like such a hassle. R #47 stated he and his wife had complained to the facility about this issue, but it was still not resolved. Review of the facility's Grievance File documented a 02/20/19, grievance from R #47's family member, upset due to the facility's diaper shortage, and because she had to buy additional briefs for the resident. The facility's response was documented, Administrator educated (family member's name) on how the diapers work and the facility also has cloth diapers that can be used as well. The Grievance Form documented the family member was still upset, so they offered a secure storage area for any additional briefs she purchased. No further resolution was documented for the concern. Resident #22: On 3/25/19 at 3:50 PM, R #22's representative stated, during a family interview, that the facility only supplied four (4) adult briefs per day. R #22's representative stated R #22 usually tried not to void in the afternoons, so she had plenty of briefs for the evening and night. R #22's representative stated she was not aware of a time when the resident had been denied an extra brief if she needed it but stated, It's a terrible thing to have to worry about all day. And I know she does worry, because when I visit that's one of the things she always talks about. Resident Group: On 3/26/19 at 10:05 AM, nine (9) of the residents in the resident group stated incontinent residents were given only four (4) adult briefs per day. The residents stated they had never been denied additional briefs if they needed them, but had repeatedly asked the facility to adapt their brief distribution system to reduce resident worry over brief usage. The residents stated the facility had not made any changes, and they felt it had been made clear that no changes would be forthcoming, so they had stopped complaining and made their own adaptations to cope with the lack of response by the facility. The residents reported that staff often chose to borrow briefs from another resident for them. Three (3) residents, who wanted to remain anonymous, stated they started asking for their allotment of four (4) briefs per day, so they could share them with other residents. Two (2) residents, who wanted to remain anonymous, stated they paid privately to stay at the facility, and bought their own briefs, but asked their families to supply additional briefs so they could share with others. Two (2) residents, who wanted to remain anonymous, stated they required extra large briefs stated the facility often did not have that size available, so staff would use a large size instead. R #6 stated the briefs had to be pulled so tight to fasten them that he sometimes sustained bruises, and the other stated she frequently stayed in her room when extra large briefs were not available so as not to become embarrassed if she became incontinent in a public setting and her waste leaked out of the smaller brief. R #12 stated when she saw she received extra large briefs for that day, she quickly stuffed them under her mattress, so staff did not see them there and take them for another resident. Seven (7) members of the group stated they started thinking about how to procure additional briefs from the moment staff left their allotment of four (4) briefs each morning and did not stop thinking about it all day. Review of the Resident Council meeting minutes revealed on 01/23/19, Residents were confused about diaper policy . Administrator explained the policy on diapers. The facility provides four (4) diapers per day for each resident and we encourage residents to be 'open to air' at night to promote skin integrity. Administrator explained that we would not let residents go without diapers, but that he would work with families to provide extra diapers if the residents/families preferred more than four (4) a day. The Resident Council Minutes for 02/25/19, and 03/21/19, did not document follow-up discussion to confirm the issue had been resolved. On 3/26/19 at 4:26 PM, the Administrator stated when he first started working in the facility a few months prior, he was informed that residents were allotted four (4) adult briefs per day, although there was no formal policy to that effect. The Administrator stated the facility requested resident families to provide additional briefs if a resident preferred more than four (4) briefs per day, regardless of payer source. The Administrator stated he had assured residents that if their family members refused to supply extra briefs, the facility could obtain one (1) for them. The Administrator stated the State Agency had recently been in the facility for a complaint investigation, became aware of the resident concerns, and told him the facility could be cited if the practice continued. The Administrator stated after that, he received permission to provide up to six (6) briefs per day if a resident needed them. The administrator stated, I know it's a problem, and it embarrasses me that it's an issue, but the decision is made far above me or my boss. On 3/28/19 at 12:47 PM, Housekeeper (H) #1 stated she had worked at the facility for years and one (1) of her job duties was to distribute briefs to residents each morning. H #1 stated she had been instructed to give each resident four (4) briefs even if they requested more, and she had never questioned it. H #1 stated she could give four (4) briefs per day to any resident who requested them, and did not know who was continent or incontinent, so if a resident asked she left them four (4)briefs. H #1 stated many residents had requested more than four (4) briefs from time to time, but she just told them no. H #1 stated she had not been informed she could leave up to six (6) briefs per day after the recent complaint survey.