Every finding on record at Zachary Manor Nursing and Rehabilitation Center

Based on interviews and record reviews, the facility failed to ensure each resident remained free from accident hazards during a transfer for 1 (#3) of 3 residents reviewed for transfers. The facility failed to ensure staff transferred Resident #3 with two people to prevent a fall.Findings:Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, including Muscle Wasting and Atrophy, Right Lower Leg; Other Lack of Coordination; Other Abnormalities of Gait and Mobility; Muscle Wasting and Atrophy, Right Shoulder; Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; and Cognitive Communication Deficit. Review of Resident #3's current Physician Orders revealed an order with a start date of 11/04/2025 to transfer with two person assist. Review of Resident #3's current Care Plan revealed the following, in part:Problem date initiated 01/28/2025: Physical mobility impaired: bed mobility, transfers and locomotion related to diagnosis of CVA with Left Hemiplegia.Intervention: Manually transfer with 2 person assist.Problem: High risk for falls related to Gait/balance problems and poor safety awareness.Resident in on the Falling Star program. 8/6/26 lowered to floor.Intervention: 8/6/2026 nonskid socks applied. PT to eval and treat; Assist with transfers as needed. On 08/18/2026 at 11:23 a.m., an interview was conducted with Resident #3. She stated she fell on [DATE] when staff was transferring her to the bed. The stated the nurse came and assessed her after the fall. She stated she did not have any injuries from the fall. On 08/18/2026 at 2:50 p.m., an interview was conducted with S5CNA. She stated she followed Resident #3's care plan for how to transfer the resident. She stated she was with the resident during the fall on 08/06/2026. She stated at 8:00 a.m., she transferred Resident #3 to the bed independently. She stated during the transfer Resident # 3 began to slide forward and she lowered her to the ground. She stated Resident #3 did not sustain any injuries during the fall. She stated, after Resident #3's fall, S3DON provided training on how to transfer appropriately. On 08/18/2026 at 12:48 p.m., an interview was conducted with S4LPN. She confirmed she was assigned to Resident #3 on 08/06/2026 when she fell. She stated S5CNA lowered Resident #3 to the floor during a transfer. She stated after the fall she evaluated Resident #3 and Resident #3 sustained no injury from the fall. On 08/18/2026 at 2:35 p.m., an interview was conducted with S3DON. She stated, on 08/06/2026, Resident #3 had a fall. She stated S5CNA reported when S5CNA was assisting Resident #3 in bed she started sliding, so she eased her down to the floor. She stated when she responded to Resident #3's room, the resident was sitting on the floor facing the head of the bed. She stated the resident denied being hurt and sustained no injury. She stated after the fall she conducted an in-service with staff to remind them to utilize the buddy system when transferring residents, which consists of two person assist during transfers. She stated Resident #3 required two person assistance with transfers. She stated she was not doing any current monitoring of staff transfers.

Based on interviews and record review, the facility failed to develop a person centered care plan for 1 (#3) of 3 residents reviewed for transfers. The facility failed to ensure Resident #3's care plan reflected accurate transfer status.Findings:Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, including Muscle Wasting and Atrophy, Right Lower Leg; Other Lack of Coordination; Other Abnormalities of Gait and Mobility; Muscle Wasting and Atrophy, Right Shoulder; Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side; and Cognitive Communication Deficit. Review of Resident #3's current Physician Orders revealed an order with a start date of 11/04/2025 to transfer with two person assist. Review of Resident #3's current Care Plan revealed the following:Problem date initiated 01/28/2025: Physical mobility impaired: transfers related to diagnosis of CVA with Left Hemiplegia.Intervention: Manually transfer with 2 person assist. Problem date initiated 01/28/2025: Self-care ADL deficit: resident will receive person-centered care; Requires extensive x1 person assist with transfers related to Hemiplegia. On 08/18/2026 at 2:50 p.m., an interview was conducted with S5CNA. She stated she followed Resident #3's care plan for how to transfer the resident. She stated Resident #3 required one person assist with transfers. She stated she transferred Resident #3 independently. On 08/18/2026 at 3:24 p.m., an interview was conducted with S6LPN. She stated she was responsible for creating and updating Resident #3's care plan. She stated when creating a care plan, she confirmed the physician's orders, assessed the resident, and conferred with the CNAs to determine how many staff were needed to transfer a resident. She stated if there were any discrepancies between the orders and the care plan, she would obtain clarification, and update the resident's care plan accordingly. She reviewed the physician's orders which indicated Resident #3 was a 2 person assist with transfers. She reviewed Resident #3's current care plan and confirmed it indicated Resident #3 was both a 1 person assist and a 2 person assist with transfers. She confirmed the care plan was inaccurate. On 08/18/2026 at 2:35 p.m., an interview was conducted with S3DON. She reviewed the physician's orders which indicated Resident #3 was a 2 person assist with transfers. She reviewed Resident #3's current care plan and confirmed it indicated Resident #3 was both a 1 person assist and a 2 person assist with transfers. She stated Resident #3's care plan was inaccurate and should have reflected the most current care the resident required. She stated Resident #3 required two person assistance with transfers.

Based on interviews and record reviews, the facility failed to implement a person centered care plan by failing to ensure nursing staff followed the physician's order to notify the MD of an elevated blood glucose level for 1 (#2) of 3 residents reviewed with Type 2 Diabetes Mellitus.Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Other Hypoglycemia, Unspecified Severe Protein-Calorie Malnutrition, and Long-Term Use of Insulin. Review of Resident #2's Quarterly MDS with an ARD of 01/03/2026 revealed a BIMS assessment was not conducted related to the resident was rarely/never understood. Review of Resident #2's current Care Plan revealed the following, in part:Problem: MD orders - need to follow; andInterventions: Humalog KwikPen Subcutaneous Solution 100 unit/mL (Insulin Lispro).Problem: The resident has Diabetes Mellitus; andInterventions: Diabetes medication as ordered by doctor. Monitor/documents for side effects and effectiveness. Review of Resident #2's Physician Orders revealed the following, in part:Start date: 11/06/2025, Discontinued date: 02/24/2026 - Humalog KwikPen Subcutaneous Solution 100 unit/mL (Insulin Lispro) Inject as per sliding scale before meals and at bedtime: 351 - 400 mg/dL give 15 units and notify MD; andStart date: 03/09/2026, Active - Blood glucose monitoring four times a day related to Type 2 Diabetes Mellitus. Call MD if blood glucose level less than 70 mg/dL or greater than 350 mg/dL. Review of Resident #2's MAR dated February 2026 revealed the following, in part:Humalog KwikPen Subcutaneous Solution 100 unit/mL (Insulin Lispro) Inject as per sliding scale before meals and at bedtime: 351 - 400 give 15 units and notify MD. Further review revealed the following blood glucose levels documented by the following staff:02/22/2026 at 11:00 a.m. by S5LPN: 372 mg/dL;02/22/2026 at 4:45 p.m. by S5LPN: 374 mg/dL; and02/23/2026 at 4:45 p.m. by S4LPN: 391 mg/dL.Further review revealed no documentation Resident #2's physician was notified of the aforementioned blood glucose levels. Review of Resident #2's MAR dated March 2026 revealed the following, in part:Blood glucose monitoring four times a day related to Type 2 Diabetes Mellitus. Call MD if blood glucose level less than 70 or greater than 350. Further review revealed the following blood glucose levels documented by the following staff:03/09/2026 at 4:00 p.m. by S4LPN: 367 mg/dL; and03/09/2026 at 8:00 p.m. by S4LPN: 367 mg/dL.Further review revealed no documentation Resident #2's physician was notified of the aforementioned blood glucose levels. Review of Resident #2's Nurses Notes dated February 2026 through March 2026 revealed no documentation Resident #2's physician was notified of his blood glucose levels exceeding 351 mg/dL on 02/22/2026, 02/23/2026, and 02/24/2026 and 350 mg/dL on 03/09/2026. An interview was conducted with S4LPN on 03/10/2026 at 2:38 p.m. She explained physician notification should have been documented in the resident's nurses' notes. She reviewed Resident #2's MAR dated February 2026 and confirmed she documented Resident #2's blood glucose level as 391 mg/dL on 02/23/2026 at 4:45 p.m. She stated if she had notified the physician, she would have documented it in a nurses' note. She reviewed Resident #2's MAR dated March 2026 and confirmed she documented a blood glucose level of 367 mg/dL at 4:00 p.m. and 8:00 p.m. on 03/09/2026. She confirmed the order was to notify the physician if Resident #2's blood glucose level was above 350 mg/dL. She confirmed she did not notify the physician of the blood glucose levels on 03/09/2026. A telephone interview was conducted with S5LPN on 03/10/2026 at 3:06 p.m. She was made aware of Resident #2's documented blood glucose levels of 372 mg/dL on 02/22/2025 at 11:00 a.m. and 374 mg/dL on 02/22/2026 at 4:45 p.m. She confirmed she did not notify Resident #2's physician of the blood glucose levels. She stated she should have notified Resident #2's physician if the order was to notify the MD if blood glucose was above 351 mg/dL. An interview was conducted with S2ADON on 03/10/2026 at 3:39 p.m. She confirmed if Resident #2's physician order was to notify the physician if the blood glucose level was above 350 or 351 mg/dL, the nurse should have contacted the physician and documented a nurses' note including the blood glucose value, physician notification, and any new orders. An interview was conducted with S1DON on 03/10/2026 at 4:02 p.m. She confirmed she reviewed Resident #2's clinical record. She confirmed the above listed blood glucose values for Resident #2. She confirmed Resident #2's physician orders were to notify the MD if the blood glucose was above 350 mg/dL and 351 mg/dL. She confirmed Resident #2's physician should have been notified of the above blood glucose values and there was no documentation of physician notification. An interview was conducted with S3NP on 03/10/2026 at 1:02 p.m. She stated she expected the facility nurses to notify her or the on-call provider if Resident #2's blood glucose level was above 351 mg/dL. She stated it was the facility nurses' responsibility to document in Resident #2's record if the nurse notified her or the on call provider of a blood glucose value.

Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#3 and #4) of 4 sampled residents reviewed for accurate documentation. Review of the facility's undated policy titled Insulin Guidelines revealed the following, in part: Policy: Insulin is utilized to control blood sugar levels in residents with diabetes mellitus. Insulin therapy may include various regimens, which are carried out per doctor's orders. Insulin lowers the blood glucose by decreasing the release of glucose from the liver and increasing the utilization of glucose by muscle and fat cells.Guidelines: Whenever a physician orders Regular insulin on a sliding scale, care must be taken to document finger stick blood sugar and administration of insulin as ordered. Charting on MAR and/or nurses' notes should include the following:a. Date, time, and results of finger stick blood sugar testingb. Dose of insulin administration in accordance with sliding scale per MD order c. Site of injectiond. Identification of nurse administering the insulin Resident #3Review of Resident #3's Clinical Record revealed an admission date of 12/15/2020, with diagnoses which included, Obesity Due To Excess Calories, Cognitive Communication Deficit, Dysphagia Following Cerebral Infarction, and Type 2 Diabetes Mellitus. Review of Resident #3's Current Physician Orders revealed in part, the following:NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 60 - 130 = 0; 131 - 180 = 3; 181 - 240 = 6; 241 - 300 = 8; 301 - 350 = 10; 351 - 400 = 12; 401 - 999 = 14 Notify MD, Check blood glucose and document. Follow MD order, Review and Record administration site, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Start date: 11/06/2025 Review of Resident #3's February 2026 MAR revealed in part, the following:No documented evidence Resident #3 received or refused the above-mentioned medication on 02/18/2026, 02/26/2026, or 02/27/2026 at 11:00 a.m.No documentation of insulin administration or blood glucose check being completed or refused on 02/18/2026, 02/26/2026, or 02/27/2026 at 11:00 a.m. Review of Resident #3's March 2026 MAR revealed in part, the following:No documented evidence Resident #3 received or refused the above-mentioned medication on 03/02/2026 at 11:00 a.m.No documentation of insulin administration or blood glucose check being completed or refused on 03/02/2026 at 11:00 a.m. On 03/11/2026 at 1:56 p.m., an interview was conducted with S6LPN. She reviewed the February and March 2026 schedules and confirmed she provided care for Resident #3 on 02/18/2026, 02/26/2026, 02/27/2026, and 03/02/2026 from 7:00 a.m. to 3:00 p.m. She reviewed Resident #3's February and March 2026 MAR, and confirmed the aforementioned findings were blank and administrations or refusals were not documented. She stated she was responsible for the administration of Resident #3's 11:00 a.m. medications on her shift. She stated there should not be any blanks on a resident's MAR. S6LPN confirmed she did not document Resident #3's administration or refusal of sliding scale insulin and blood glucose checks on the MAR and should have. Resident #4Review of Resident #4s Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Mild Protein-Calorie Malnutrition, Gastrostomy Status, Long Term (current) Use of Insulin, and Cognitive Communication Deficit. Review of Resident #4's Current Physician Orders revealed in part, the following:NovoLog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 70 = 0 Give orange juice if alert or glucagon if unable to swallow. Notify provider for additional orders; 71 - 130 = 0; 131 - 180 = 3; 181 - 240 = 6; 241 - 300 = 8; 301 - 350 = 10; 351 - 400 = 12; 401 - 999 = 12 Call and notify physician, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Start date: 11/05/2025 Review of Resident #4's February 2026 MAR revealed in part, the following:No documented evidence Resident #4 received or refused the above-mentioned medication on 02/17/2026 at 4:45 p.m. or at 8:00 p.m.No documentation of insulin administration or blood glucose check being completed or refused on 02/17/2026 at 4:45 p.m. or at 8:00 p.m. Review of Resident #4's March 2026 MAR revealed in part, the following:No documented evidence Resident #4 received or refused the above-mentioned medication on 03/03/2026 at 4:45 p.m. or at 8:00 p.m.No documentation of insulin administration or blood glucose check being completed or refused on 03/03/2026 at 4:45 p.m. or at 8:00 p.m. On 03/11/2026 at 4:13 p.m., a telephone interview was conducted with S7LPN. She confirmed she provided care for Resident #4 on 02/17/2026 and 03/03/2026 from 3:00 p.m. to 11:00 p.m. She was notified the aforementioned findings were blank and administrations or refusals were not documented on Resident #4's February and March 2026 MAR for those dates. She stated she was responsible for the administration of Resident #4's 4:45 p.m. and 8:00 p.m. medications on her shift. She stated there should not be any blanks on a resident's MAR. S7LPN confirmed she did not document Resident #4's administration or refusal of sliding scale insulin and blood glucose checks on the MAR and should have. On 03/11/2026 at 4:05 p.m., an interview was conducted with S2ADON. She stated staff should accurately document medication administration during medication pass. She stated she expected all staff to accurately document medication administration on the MAR at the time of administration. S2ADON reviewed Resident #3 and #4's February and March 2026 MAR, and confirmed the aforementioned findings were blank and administrations or refusals were not documented. S2ADON confirmed all medication administered and glucose checks completed or refused should have been documented on the resident's MARs, and were not.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#37 and #71) out of 28 residents in the final sample. The facility failed to ensure Resident #37 and #71 were coded accurately on the Entry Minimum Data Set (MDS) assessment. Resident #37 Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis which included Schizoaffective Disorder, Bipolar Type, Dementia Psychotic Disturbance, Catatonic Disorder Depressive Disorders, and Mental Disorder. Review of Resident #37's Entry MDS with an ARD of 04/17/2025 revealed the following, in part: Section A1500 Preadmission Screen and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or a related condition was coded as no. Review of Resident #37's Behavioral Health State Form 142 with a date of 03/18/2025 revealed Resident #37 was approved for admission by Level II authority for a temporary period effective 03/18/2025 through 03/17/2026. An interview was conducted on 02/11/2026 at 2:50 p.m. with S3CCC. After reviewing Resident #37's Behavioral Health State Form 142 with a date of 03/18/2025, S3CCC confirmed Resident #37 was approved for admission by Level II authority for a temporary period effective 03/18/2025 through 03/17/2026. S3CCC further confirmed Resident #37's Entry MDS dated [DATE] Section A1500 was coded incorrectly. An interview was conducted on 02/11/2026 at 3:05 p.m. with S2DON. S2DON confirmed Resident #37 was approved for admission by Level II authority for a temporary period effective 03/18/2025 through 03/17/2026. S2DON further confirmed Resident #37's Entry MDS dated [DATE] Section A1500 was coded incorrectly. Resident #71 Review of Resident #71's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #71's Entry MDS with an Assessment Reference Date (ARD) of 01/30/2026 revealed Section A1805 Entered From: 08. Intermediate Care Facility. Review of Resident #71's Clinical Record revealed she entered from a Long Term Acute Care hospital on [DATE]. An interview was conducted on 02/11/2026 at 10:45 a.m. with S3CCC. She reviewed the aforementioned findings and confirmed Resident #71 entered from a Long Term Acute Care hospital on [DATE] and the entry MDS was coded incorrectly. An interview was conducted on 02/11/2026 at 10:47 a.m. with S2DON. She reviewed the aforementioned findings and confirmed Resident #71 entered from a Long Term Acute Care hospital on [DATE] and the entry MDS was coded incorrectly.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#68) of 5 residents reviewed on Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for Resident #68 who was on EBP.Findings: Review of the facility's policy titled, Enhanced Barrier Precautions Policy and Procedure, dated 08/12/2024, revealed the following, in part: Definitions: Precautions involve gown and glove use during high contact resident care activities for residents.at increased risk of multi drug resistant organism acquisition (for example residents with wounds or indwelling medical devices.)High-contact resident activities include:Device care or use: feeding tubeCare and use of indwelling medical devices would mean any dressing changes, injecting or infusing medication or tube feedings with indwelling medical device. Review of Resident #68's current Physician's Orders revealed the following:Start date - 11/06/2025 - Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to (feeding tube) every shift. On 02/10/2026 at 3:26 p.m., an observation was made of the Enhanced Barrier Precautions sign posted on Resident #68's door, which revealed the following, in part: Providers and staff must also:Wear gloves and a gown for the following high-contact resident care activities:Device care or use: feeding tube. On 02/10/2026 at 3:26 p.m., an observation was made of S5LPN performing PEG tube placement check, residual check, and a water flush. S5LPN did not wear a gown while performing high contact resident care. On 02/10/2026 at 3:33 p.m., an interview was conducted with S5LPN. S5LPN confirmed Resident #68 was on Enhanced Barrier Precautions, and she should have worn a gown while performing a PEG tube procedure and had not. On 02/11/2026 at 3:00 p.m., an interview was conducted with S2DON. S2DON confirmed staff should have worn a gown while performing Resident #68's PEG tube care.

Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#76) of 29 residents reviewed during the initial pool.Findings: Review of the facility's policy titled, Call Light Systems, undated, revealed the following, in part:Policy: To respond to resident's request and needs. Essential Points: Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times. when out of bed, call bell is to be pulled so it is accessible from wheelchair or bedside chair. Review of Resident #76's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unsteadiness On Feet, Parkinson's Disease, and Primary Generalized Osteoarthritis. Review of Resident #76's Entry MDS, with an ARD of 01/28/2026, indicated the resident was assessed by the facility and required substantial assistance for transfers. Review of Resident #76's current Care Plan revealed following, in part:Problem: Resident #76 is high risk for falls related to gait instability secondary to diagnosis of Parkinson's Disease and Osteoarthritis to knees. Interventions: Keep call light in reach and encourage Resident #76 to call for assist. On 02/09/2026 at 9:15 a.m., an observation was conducted of Resident #76 sitting in his wheelchair in his room. The call light was observed in the bed under the covers and out of Resident #76's reach. Resident #76 stated he needed assistance getting back in the bed but could not reach the call light. On 02/09/2026 at 9:40 a.m., an observation was conducted of Resident #76 sitting in his wheelchair in his room with his call light out of reach. An interview was conducted with S9PT at this time. S9PT confirmed Resident #76 could not reach his call light and required assistance to transfer to the bed. S9PT further confirmed Resident #76's call light should always be within reach and it was not. On 02/11/2026 at 3:01 p.m., an interview was conducted with S2DON. She confirmed the call light should be within reach at all times.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#24) of 2 residents reviewed for ADL's. The facility failed to trim and clean Resident #24's fingernails.Findings: Review of the facility's undated policy, Nail Management, revealed the following, in part:Policy: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails.It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Non diabetic residents may have nail care performed by Certified Nursing Assistants (CNA). Review of Resident #24's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Muscle Wasting and Atrophy of Right and Left Shoulder and Need for Assistance with Personal Care. Review of Resident #24's current Physician Orders revealed the following:Check, clean, and/or trim fingernails and toenails weekly by CNA every evening shift every Wednesday with a start date of 11/05/2025. Review of Resident #24's current Care Plan revealed the following:Problem: Self-care ADL deficit: resident will receive person-centered care.Interventions: Assist with hygiene, dressing, and grooming as needed. Fingernails cleaned and trimmed as needed. On 02/09/2026 at 9:05 a.m., an observation was made of Resident #24 with fingernails noted to be long and dirty. Fingernails observed to extend approximately 1 centimeter past the nailbeds of all 10 fingers. Fingernails noted to have a brown/red colored substance under each nail. On 02/10/2026 at 8:56 a.m., an observation was made of Resident #24. Resident #24's fingernails extended approximately 1 centimeter past the nailbeds on all 10 fingers. On 02/11/2026 at 1:08 p.m., an interview was conducted with Resident #24. Resident #24 stated his fingernails were too long. He stated staff had not cut his fingernails in a while. He stated he wanted his fingernails cut. On 02/11/2026 at 1:24 p.m., an interview was conducted with S4LPN. S4LPN stated CNAs were responsible for cleaning and trimming non-diabetic residents' nails. She confirmed Resident #24 was not diabetic. She stated nail care should have been performed during baths/showers. She stated Resident #24 did not refuse baths or nail trimming. On 02/11/2026 at 1:28 p.m., S4LPN observed and confirmed Resident #24's fingernails were long and dirty. On 02/11/2026 at 2:38 p.m., an interview was conducted with S6CNA. She stated if a resident did not have Diabetes, the CNAs were responsible for cleaning and trimming fingernails. On 02/11/2026 at 3:00 p.m., an interview was conducted with S2DON. S2DON stated CNAs were responsible for performing nail care for non-diabetic residents. She stated nail care should be performed weekly during the bath or shower. She confirmed resident's nails should be kept clean and trimmed.

Based on record reviews and interviews, the facility failed to report allegations of physical and verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for 1 (#33) of 29 residents reviewed for abuse in the initial pool. Findings: Review of facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025 revealed the following:6. Reporting and Response: it is the policy of the facility that abuse allegations are reported per Federal and State Law. Reports are to be no later than 2 hours to health standards if the incident or allegation involves abuse with or without serious bodily harm.Definitions:Verbal abuse is defined as the use of oral, written, or gestured communication, or sounds to residents within hearing distance, regardless of their age, ability to comprehend, or disability. Physical Abuse includes hitting, slapping, pinching, biting, and kicking. B. Alleged Violation: is the terminology used when a verbal allegation of resident abuse. has been made either by a resident, family member, visitor or employee. Resident #33 Review of Resident 33's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Dementia, Mood Disturbance, and Anxiety. Review of Resident #33's Annual MDS with an ARD of 01/28/2026 revealed she had a BIMS of 8, which indicated she was moderately cognitively impaired. Resident #11Review of Resident 11's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Schizophrenia, Generalized Anxiety Disorder, and Other Genetic Related Intellectual Disability. Review of Resident #11's Admit MDS with an ARD of 11/11/2025 revealed she had a BIMS of 9, which indicated she was moderately cognitively impaired. Review of the facility's incident report dated 12/26/2026 at 12:30 p.m. revealed the following:Name: Resident: #11Description: S7ADON called to Resident #11's room due to Resident #11 yelling, screaming, cursing staff and threw her meal tray across the room at the CNA. Staff removed resident's roommate from the room to allow her time to calm down. Resident #11 continued to yell, scream and curse. Resident #11 exited out of her door and cursed Resident #33. Resident #33 utilized her wheelchair for mobility and Resident #11 stood over Resident #33. Resident #11 then became aggressive, combative and hit Resident #33 on her lips. S8LPN immediately separated the residents and assessed Resident #33. Resident #11 currently experiencing symptoms related to mental history. MD notified and Resident #11 sent out for further evaluation and treatment. Review of the facility's State Agency Reported Incidents revealed none for Resident #11 or Resident #33. On 02/09/2026 at 9:00 a.m., an interview was conducted with S8LPN. She stated on 12/26/2025 at 12:30 p.m., Resident #11 exited her room and stood over Resident #33 yelling. She stated Resident #33 then stated Resident #11 hit her in the lips. She confirmed standing over someone, screaming and cursing was verbal abuse and hitting someone was physical abuse. She further confirmed she reported the incident to S7ADON. On 02/10/2026 at 9:52 a.m., an interview was conducted with S2DON. She stated on 12/26/2025 around 12:30 p.m., S7ADON reported Resident #11 screamed, yelled and cursed at Resident #33. She stated Resident #33 reported to her that Resident #11 hit her and called her a b****. She confirmed she immediately reported the incident to S1ADM. She confirmed screaming and cursing was verbal abuse and hitting someone was physical abuse. On 02/10/2026 at 10:11 a.m., an interview was conducted with S1ADM. She stated S2DON reported on 12/26/2025 Resident #11 was having behaviors and physically aggressive with Resident #33. She confirmed Resident #33 reported Resident #11 hit her but Resident #33 did not have any injuries. She stated she was responsible for reporting all allegations of abuse to the state agency. She stated a resident hitting another resident was abuse. She further stated screaming and cursing was Resident #11's behaviors and was not considered abuse. She confirmed the incident did not require reporting because Resident #33 did not have any injuries.

Based on interviews and record reviews, the facility failed to protect each residents' right to be free from verbal abuse for 1 (#33) of 29 residents reviewed for abuse in the initial pool. The facility failed to protect Resident #33 from verbal abuse by Resident #11.Findings: Review of facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025 revealed the following:II. Policy: It is the policy of the facility that each resident will be free from abuse.Each resident residing in this facility has the right to be free from verbal abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents.Definitions:Verbal abuse is defined as the use of oral, written, or gestured communication, or sounds to residents within hearing distance, regardless of their age, ability to comprehend, or disability. Resident #33 Review of Resident #33's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Dementia, Mood Disturbance, and Anxiety. Review of Resident #33's Admit MDS with an ARD of 01/28/2026 revealed she had a BIMS of 8, which indicated she was moderately cognitively impaired. Resident #11Review of Resident 11's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Schizophrenia, Generalized Anxiety Disorder, and Other Genetic Related Intellectual Disability. Review of Resident #11's Admit MDS with an ARD of 11/11/2025 revealed she had a BIMS of 9, which indicated she was moderately cognitively impaired. Review of Resident #11's most recent Care Plan revealed the following:Problem: Resident #11 has a behavior problem related to Schizophrenia12/26/2025-Resident #11 yelled, screamed, cursed at staff and threw her meal tray across the room. Resident #11 became aggressive with Resident #33. Interventions: 12/26/2025 Staff intervened immediately and separated Resident #11 and Resident #33. Resident #11 remained separated from others and was transferred for further evaluation and treatment. Review of the facility's incident report dated 12/26/2026 at 12:30 p.m. revealed the following:Name: Resident: #11Description: S7ADON called to Resident #11's room due to Resident #11 yelling, screaming, cursing staff and threw her meal tray across the room at the CNA. Staff removed resident's roommate from the room to allow her time to calm down. Resident #11 continued to yell, scream and curse. Resident #11 exited out of her door and cursed Resident #33. Resident #33 utilized her wheelchair for mobility and Resident #11 stood over Resident #33. Resident #11 then became aggressive, combative and hit Resident #33. S8LPN immediately separated the residents and assessed Resident #33. Resident #11 currently experiencing symptoms related to mental history. MD notified and Resident #11 sent out for further evaluation and treatment. An interview was not conducted with Resident #11 due to the resident remained at an inpatient behavior health facility. On 02/09/2026 at 3:20 p.m., an interview was conducted with Resident #33. Resident #33 could not recall the residents name or when the incident occurred but stated there was an incident where another resident was yelling and cursing. She stated she went to the doorway of another resident. She stated the resident yelled and swung her arms and hit her. She stated she was not scared of the resident, the resident was removed from the facility and she had not seen the resident since the incident occurred. On 02/09/2026 at 9:00 a.m., an interview was conducted with S8LPN. She stated Resident #11 was very active and had behaviors which included throwing things, screaming and yelling profanity. She stated on 12/26/2025 at 12:30 p.m., Resident #33 rolled to Resident #11's doorway to ask Resident #11 if she was ok. Resident #11 exited her room and stood over Resident #33's wheelchair yelling. She stated Resident #33 stated Resident #11 hit her in the lips. She stated she could not see if Resident #11 hit Resident #33 but Resident #11 stood over Resident #33's wheelchair and screamed and cursed at her. She stated she immediately separated Resident #11 and Resident #33. She stated she brought Resident #33 back to her room and assessed her. She stated Resident #33 did not have any visible markings on her face. She stated she did report the incident to S7ADON. She confirmed standing over someone, screaming and cursing was verbal abuse. She stated Resident #33 was upset in that moment but had not mentioned the incident again. On 02/10/2026 at 9:52 a.m., an interview was conducted with S2DON. She stated on 12/26/2025 around 12:30 p.m., S7ADON reported Resident #11 screamed, yelled and cursed at Resident #33. She stated when she arrived to Resident #11's doorway, Resident #33 had been removed. She stated the MD was notified and Resident #11 was transferred to an inpatient Behavior Health facility. She stated Resident #33 reported to her Resident #11 hit her and called her a b****. She confirmed she immediately reported the incident to S1ADM. She further confirmed screaming and cursing was verbal abuse. On 02/10/2026 at 10:11 a.m., an interview was conducted with S1ADM. She stated S2DON reported on 12/26/2025 Resident #11 was having behaviors and physically aggressive with Resident #33. She stated she immediately interviewed Resident #33. She stated Resident #33 reported she was fine and confirmed Resident #33 reported Resident #11 hit her but Resident #33 did not have any injuries. She further stated screaming and cursing was Resident #11's behaviors and not considered abuse.

Based on record review and interview the facility failed to have sufficient Certified Nursing Assistant (CNA) staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. This deficiency had the potential to affect the facility's total census of 68 residents. Findings: Review of the facility's Minimum Staffing Requirements assessment revealed the following: Hall A Days: 1-2 CNA Evenings: 1 CNA Nights: 1 CNA Hall B Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Hall C Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Review of the facility's Staffing Pattern dated 03/04/2025 revealed the following: Staff assigned: Day shift - 7 CNA; Evening shift- 2-CNA; Night shift- 2 CNA On 04/06/2025 at 9:16 a.m. an interview was conducted with S8CNA. She revealed the facility was often short staffed. She further stated it was most often Hall B and Hall C that was short staffed. On 04/06/2025 at 9:35 a.m. an interview was conducted with S7CNA. She revealed the facility was often short staffed on the weekends. On 04/06/2025 at 10:00 a.m. an interview was conducted with S10CNA. She revealed she was often asked to pick up shifts. She stated the facility could use more staff. On 4/07/2025 at 8:26 a.m. an interview was conducted with S9LPN. She revealed the number of CNA staff for Hall B and Hall C was not sufficient at times. On 04/07/2025 at 3:51 p.m. an interview was conducted with S11CNA. She revealed she had to work Hall C by herself on more than one occasion. On 04/08/2025 at 12:20 p.m. An interview was conducted with S12CNA. She revealed she has worked the evening shift by herself and it was too much for one person. On 04/08/2025 at 3:30 p.m. an interview was conducted with S1ADM. She stated she would look at the facility assessment to determine the facility's staffing procedure and based on the facility's census and resident acuity she was able to determine the minimum staffing requirements. On 04/08/2025 at 3:50 p.m. an interview was conducted with S6CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 2 p.m.-10 p.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 3:51 p.m. an interview was conducted with S5CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 2 p.m.-10 p.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 4:05 p.m. an interview was conducted with S4CNA. She confirmed on 03/04/2025 she was one of two CNAs for the entire facility on the 10 p.m.-6 a.m. shift. She stated it was not enough CNA staff to be able to complete her tasks on time. On 04/08/2025 at 4:25 p.m. an interview was conducted with S1ADM. She confirmed on 03/04/2025 on the evening and night shifts there were only 2 CNAs for the entire facility. She confirmed 2 CNAs was not sufficient.

Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#R1) of 7 (#1, #2, #3, #4, #5, #6, and #R1 ) residents reviewed. Findings: A review of the facility's undated policy titled Call Light System, revealed, in part: Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. A review of the medical record for Resident #R1 revealed she was admitted to the facility on [DATE] with diagnoses which included, Muscle Wasting and Atrophy right shoulder, Chronic Pain Syndrome, Unsteadiness on feet, History of falling, Dementia, Lack of Coordination, and Alzheimer's Disease. A review of the current Care Plan for Resident #R1 revealed the resident was at risk for falls related to Gait/balance problems. Interventions included encourage resident to call for assist. On 04/06/2025 at 8:51 a.m., an observation was made of Resident #R1 lying in bed with her call light noted to be on the table at the foot of her bed. When Resident #R1 was asked where her call light was, she searched her bed and could not find it. Resident #R1 was unable to reach her call light. On 04/06/2025 at 10:56 a.m., an observation was made of Resident #R1 lying in bed with her call light on the table at the foot of her bed. Resident #R1 was unable to reach her call light. On 04/07/2025 at 10:57 a.m., an interview was conducted with S3CNAS. She confirmed Resident #R1's call light was on the table at the foot of her bed. She further confirmed Resident #R1's call light was out of reach and should have been within reach. On 04/08/2025 at 4:32 p.m., an interview was conducted with S2ADON. She stated she expected staff to ensure resident call lights were kept within reach.

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024 Quarter 4 (July 1- September 30) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, triggered. -No Registered Nurse hours, triggered. -Failed to have licensed nursing coverage 24 hours/day, triggered. An interview was conducted on 01/08/2025 at 10:40 a.m. with S10CHR. She stated she was responsible for submitting payroll data to a contract company who was hired to submit the facility's payroll data. She stated on 01/08/2025, the contract company identified inaccurately submitted September 2024 payroll data for direct care staffing. She stated all quarters for payroll data submission for direct care staffing should be complete and accurate. An interview was conducted on 01/08/2025 at 10:52 a.m. with S1ADM. She stated all quarters for payroll data submission for direct care staffing should be complete and accurate. 47732

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#12, #54 and #66) residents out of a total of 21 sampled residents. The facility failed to ensure: 1. Resident #12 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #54 was coded correctly for vision; and 3. Resident #66 was coded correctly for discharge. Findings: Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #12's OBH-Level II Evaluation Summary & Determination Notice dated 08/02/2024 revealed under recommendations: The individual has a serious mental illness and nursing home admission was recommended. Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024 revealed Section A1500 PASRR: Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0. No. On 01/07/2025 at 1:02 p.m., an interview was conducted with S4MDS. She stated she was responsible for completing resident's MDS assessments. She reviewed Resident #12's PASRR Level II dated 08/02/2024 indicating she had a serious mental illness. She reviewed Resident #12's Annual MDS with an ARD of 09/04/2024. She confirmed Resident #12 was not coded accurately for having a serious mental illness and should have been. On 01/07/2025 at 1:13 p.m., an interview was conducted with S2DON. She reviewed Resident #12's information listed above. She confirmed Resident #12 was not coded accurately for having a serious mental illness and should have been. Resident #54 Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Legal Blindness. Review of Resident #54's Quarterly MDS with an ARD of 12/09/2024 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed Section B1000 Vision was coded as Adequate. On 01/08/2025 at 9:00 a.m., an interview was conducted with Resident #54. She stated she was legally blind. On 01/08/2025 at 10:00 a.m., an interview was conducted with S4MDS. S4MDS reviewed Resident #54's Quarterly MDS with an ADR of 12/09/2024 and verified Section B1000 was coded for Adequate Vision. S4MDS confirmed Resident #54 was legally blind, which made the entry incorrect. On 01/08/2025 at 11:30 a.m., an interview was conducted with S2DON. She confirmed Resident #54 had a diagnosis of legal blindness. She reviewed the Quarterly MDS with an ADR 12/09/2024 and confirmed Section B1000 Vision was coded as Adequate, which was not correct. Resident #66 Review of Resident #66's Clinical Record revealed she was admitted to the facility on [DATE] and transferred to a local hospital for shortness of breath on 11/02/2024. Review of Resident #66's Discharge MDS with an ARD of 11/02/2024 revealed Section A2105 Discharge Status: Inpatient Rehabilitation Facility. Review of Resident #66's Nurse's Note dated 11/02/2024 at 2:49 p.m. revealed the following, in part: Resident was complaining of shortness of breath and coughing up mucous, wheezing was heard upon auscultation, contacted doctor. Order given to send to emergency room for evaluation and treatment. Signed, S9LPN. Review of Resident #66's Physician Order dated 11/02/2024 revealed the following, in part: Send to ER. On 01/08/2025 at 2:00 p.m., an interview was conducted with S5MDS and S2DON. They reviewed the above documentation and confirmed Resident #66 should have been coded as having a discharge location for a Short Term General Hospital and not an Inpatient Rehabilitation Facility. 47732

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#14 and #65 ) of 2 (#14 and #65 ) residents reviewed for accurate documentation. The facility failed to ensure: 1. The medical record of Resident #65 contained accurate documentation of Coroner Notification with Permission to Release the Body; and 2. The medical record of Resident #14 contained a documented nurse assessment upon return from dialysis. This deficient practice had the potential to affect a current census of 67 residents. Findings: Review of the facility's undated policy, titled Documentation Guidelines: General, revealed the following: Nursing Service documentation will include, but shall not be limited to the following: 4. Baseline data such as weight, vital signs, etc. 5. Follow up care of resident's incidents and accidents Documentation in the nursing record will be made when a change in resident condition occurs. This includes all nursing interventions and follow up. Documenting information on the resident in the medical record provides: 1. A means of communication between the physician and other professionals contributing to the resident's care. 4. A way to record the care received by the resident. Review of the facility's undated policy, titled Fistula Maintenance: Post Dialysis Care, revealed the following: B. Documentation: 1. Documentation in the medical record regarding the fistula site may occur on the MAR, flowsheets, in the nurses' notes or any other part of the medical record. The following are examples of items to include in the documentation: b. condition of site; c. Presence/absence of bleeding and/or any other abnormalities noted; and d. Complaints from resident regarding the site. 1. A review of Resident #65's Clinical Record revealed he was admitted to the facility on [DATE], with diagnosis, which included Chronic Obstructive Pulmonary Disease and Neoplasm of the Digestive System. Further review revealed he expired in the facility on [DATE]. A review of Resident #65's Physician Orders revealed the following: [DATE] at 11:00 a.m. by S3ADON - Ok to call Coroner, [DATE] at 10:30 a.m. by S3ADON - Ok to release body to a local funeral home. A review of Resident #65's MDS, with an ARD of [DATE], revealed the following: Section F: Entry/Discharge Reporting: 12. Death in Facility; and A2105: Discharge Status: 13. deceased A review of Resident #65's Nurse's Note revealed in part, [DATE] at 12:15 p.m. by S7LPN - Resident found at 8:12 a.m. in his wheelchair unresponsive, skin cold to touch, and had no pulse or respiration. Cardiopulmonary Resuscitation (CPR) was started at 8:15 a.m. and continued until 8:58 a.m. Local paramedics were called and arrived at 8:26 a.m. and placed a call to the Emergency Physician at 8:56 a.m. obtaining permission to stop CPR. On [DATE] at 9:00 a.m., an interview was conducted with S7LPN. S7LPN confirmed she was working day shift on [DATE]. S7LPN stated Resident #65 was found unresponsive in his wheel chair in the dining room, and CPR was started. She stated she was the scribe for the incident, and did not place any of the notification phone calls following his death. On [DATE] at 9:30 a.m., an interview was conducted with S3ADON. S3ADON confirmed she was working on [DATE]. S3ADON stated when the paramedics arrived, they worked on Resident #65 until they called the local emergency department physician and received an order for OK to stop CPR. S3ADON stated the facility's procedure for notification of the coroner was for a nurse to call. S3ADON stated she initiated a medical order, ok to call the coroner at [DATE] at 11:00 a.m. S3ADON stated she called the Coroner's Office to notify them Resident #65 had expired. S3ADON stated she spoke to a female on the phone, but was unable to recall her name. S3ADON stated the female on the phone said OK. She stated the Coroner's Office did not come to the facility prior to the body being released to the funeral home. S3ADON confirmed she did not document the time she called the coroner, who she spoke with, and permission to release the body was obtained. On [DATE] at 11:00 a.m., an interview was conducted with the Chief of Investigations for the local Coroner's office. He confirmed when a resident expired in a nursing home, even if EMS was present on the scene at the time of death, the funeral home was required to contact the coroner's office to report the death. He confirmed his office was open on [DATE] and if the nursing home had called to report a death, a staff member would have taken the call, written a report, and due to the circumstances of a sudden unexpected death in the facility, an investigator would have been sent out to the facility. He confirmed the Coroner's office did not receive a phone call regarding Resident #65's death until the funeral home called to request permission to cremate his body. He confirmed when the funeral home called, there was no active case for Resident #65 because they were never made aware of his passing and should have been. On [DATE] at 1:00 p.m., an interview was conducted with S2DON. S2DON confirmed she was present in the building on [DATE] when Resident #65 expired. S2DON confirmed the facility was responsible for notifying the coroner's office when a resident expired in the facility. S2DON confirmed an order to call the coroner was initiated by S3ADON on [DATE] at 11:00 a.m., and there was no further documentation regarding his death notification to the coroner or obtaining permission to release the body present in Resident #65's medical record and should be. 2. A review of Resident #14's Clinical Record revealed he was admitted on [DATE] with diagnoses, which included Dependence of Renal Dialysis. A review of Resident #14's current Physician Orders revealed the following: 11//2024- Dialysis Schedule: Resident #14 to have dialysis 3 times a week on Tuesday, Thursday and Saturday at local Dialysis Center. A review of Resident #14's Nurse's Notes, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. A review of Resident #14's Dialysis Communication Binder, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. A review of Resident #14's MAR/TAR, dated [DATE] through [DATE], revealed no documented evidence of his nurse conducting an assessment upon his return to the facility from the local Dialysis Clinic on Tuesday [DATE], Thursday [DATE], and Saturday [DATE]. On [DATE] at 3:40 p.m., an interview was conducted with S16LPN. She stated she conducted an assessment of Resident #14 upon his return to the facility from the Dialysis Clinic and it should have been documented in her nurse's notes. She confirmed it was not documented in the nurse's notes. On [DATE] at 4:01 p.m., an interview was conducted with S5MDS. She stated it was a standard practice to assess a resident upon their return to the facility from the Dialysis Clinic and the assessment should be documented in the resident's medical record. She confirmed Resident #14 attended dialysis three times per week and the medical record did not have any documented evidence of his nurse conducting an assessment upon his return to the facility from the Dialysis Clinic. On [DATE] at 4:31 p.m., an interview was conducted with the S2DON. She stated the nurse should complete a resident assessment upon return to the facility from dialysis, which included an assessment of their dialysis access site. She stated the assessment should be documented on the resident's MAR/TAR. She confirmed there was no documented evidence of a completed assessment upon return from the Dialysis Clinic in Resident #14's medical record. 47732

Based on an observation, interviews, and record review, the facility failed to ensure there was a system in place for facility residents to receive routine dental care by an outside dentist as requested for 1 of 1 (#16) resident reviewed for dental services. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: A review of Resident #16's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Mild Protein-Calorie Malnutrition. A review of Resident #16's Quarterly MDS with an ARD of 12/26/2024 revealed he had a BIMS of 11, which indicated he was moderate cognitively impaired. A review of the In House Facility Dental notes revealed the following: 05/29/2024 Resident #16 refused dental services today. Resident #16 told S11MR he only wants to see an outside dentist. 08/29/2024 Resident #16 refused dental services today. On 01/07/2025 at 2:25 p.m., an observation and interview was conducted with Resident #16. He was observed in the dining room with multiple broken bottom teeth noted. Resident #16 stated he only wanted to see an outside dentist and did not want to see the dentist which came to the facility. On 01/08/2025 at 8:14 a.m., an interview was conducted with S12ST. She stated Resident #16 liked to attend appointments at his normal places where he was from. She stated Resident #16's last appointment with his outside dentist was on 02/07/2022. She confirmed she made all outside facility appointments and was not made aware of 05/29/2024's dental note where Resident #16 requested an appointment with the outside dentist; therefore, she did not schedule Resident #16 an appointment. On 01/08/2025 at 8:35 a.m., an interview was conducted with a representative at Resident #16's outside dental office. She confirmed Resident #16's last scheduled appointment was on 02/07/2022. On 01/08/2025 at 8:59 a.m., an interview was conducted with S11MR. She stated on 05/29/2024, Resident #16 told her he only wanted to see his outside dentist. She confirmed she did not tell the nurse because she thought S3ADON reviewed the dental notes. On 01/08/2025 at 9:06 a.m., an interview was conducted with S3ADON. She stated residents had the option to see an outside dentist if requested. She stated S13RN and S14SW reviewed the onsite dental notes when the dentist came to the facility. She confirmed S12ST was responsible for scheduling outside appointments. She reviewed the dental note dated 05/29/2024, and confirmed Resident #16 should have had an outside dental appointment scheduled. A review of Resident #16's Nurses Note, dated 06/04/2024 revealed the following: Resident #16 was to be seen by in house dentist, Resident #16 refused and stated he wanted to be seen by an outside dentist. Signed by S13RN On 01/08/2025 at 9:11 a.m., an interview was conducted with S14SW. She stated she thought she reviewed the note on 05/29/2024, an appointment was made, and Resident #16 refused to go. She was unable to provide documentation of the scheduled appointment or Resident #16's refusal. On 01/08/2025 at 4:31 p.m., an interview was conducted with S2DON. She stated she thought Resident #16 was scheduled for an appointment and refused to go. She was unable to provide documentation of the scheduled appointment or Resident #16's refusal.

Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update vision interventions for 1 (#54) of 19 residents reviewed in the final sample for Care Plans. Findings: Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Legally Blind. Review of Resident #54's Quarterly MDS, with ARD of 12/09/2024, revealed a BIMS of 12, which indicated she was moderately cognitive impaired. Further review revealed Section B: Hearing, Speech, and Vision, line B100-Vision was coded as Adequate, and Corrective Lenses was coded as No. Review of Resident #54's Care Plan dated 12/22/2023 revealed: Care Plan Description: Visual deficit related to Blindness to Bilateral Eyes Interventions: Assist resident to maintain eyeglasses. Encourage to wear glasses. Ensure adequate lighting for tasks. Keep eyeglasses within reach. Keep pathways clear. Provide assistance with ambulation as needed. On 01/08/2025 at 9:00 a.m., an interview was conducted with Resident #54. She stated she was legally blind, unable to distinguish light from dark, and does not wear corrective lenses. She confirmed she was non-ambulatory and bed bound. On 01/08/2025 at 9:10 a.m., an interview was conducted with S15CNA. She confirmed Resident # 54 is blind, does not ambulate, requires lift with 2 people, and does not have corrective glasses. On 01/08/2025 at 9:15 a.m., an interview was conducted with S6LPN. She stated Resident #54 has diagnosis of Legally Blind. She stated Resident #54 is unable to ambulate and transferred to the Geri chair daily using lift. On 01/08/2025 at 11:00 a.m., an interview was conducted with S4MDS. S4MDS reviewed the Care Plan dated 12/22/2023 for Resident #54. S4MDS confirmed the current interventions for Resident #54 related to Visual Deficit Blindness Bilateral Eyes included intervention for eye glasses, adequate lighting, glare free environment, clear pathways, and ambulation assistance did not reflect the status of Resident #54 on admission, or currently. She stated that care plan revisions should be updated as often as needed, and with 3 month assessments done by the MDS Staff and was not. 01/08/2025 at 11:30 a.m., an interview was conducted with S2DON. She confirmed Resident #54 had a diagnosis of Legal Blindness. She reviewed the Care Plan dated 12/22/2023 for Resident #54. S2DON confirmed the interventions listed for Resident #54 related to Visual Deficit Blindness Bilateral Eyes did not reflect the status of Resident #54. S2DON confirmed the care plan should be updated with each assessment conducted by MDS staff, and was not.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection for 1 (#167) of 19 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while providing catheter care; and 2. Staff performed proper hand hygiene while providing catheter care. Findings: Review of Resident #167's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Urinary Tract Infection. Review of Resident #167's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to Urinary Catheter; and Catheter care with soap and water. One time every shift. On 01/07/2025 at 9:20 a.m., an observation of the Enhanced Barrier Precautions sign posted on Resident #167's door revealed the following, in part: Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Providing hygiene, changing briefs, device care or use: urinary catheter. On 01/07/2025 at 9:24 a.m., an observation was made of S8CNA performing catheter care for Resident #167 with no gown in use. S8CNA cleansed Resident #167's genitalia and catheter tubing, then applied a clean brief without changing gloves or performing hand hygiene. On 01/07/2025 at 9:42 a.m., an interview was conducted with S8CNA. She confirmed she did not wear a gown while performing catheter care for Resident #167. She confirmed she did not change gloves or perform hand hygiene between cleansing Resident #167's genitalia, catheter tubing, and applying a new, clean brief. On 01/07/2025 at 11:12 a.m., an interview was conducted with S2DON. She confirmed S8CNA should have worn a gown during catheter care. She confirmed S8CNA should have changed gloves and performed hand hygiene after cleansing the resident's genitalia and catheter tubing.

Based on interviews and record review, the facility failed to ensure residents remained free of accident hazards by failing to ensure residents were transferred with proper transfer assistance and devices for 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed for transfer assistance. The facility failed to ensure: 1. Resident #2 was transferred with 2 person assistance; and 2. Resident #3 was transferred with a mechanical lift. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff. The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type) and size of sling, if lift is used). It is the responsibility of the CNA to read and follow the wall care plan instructions to care for each resident. Review of the undated policy titled, Transfer: Wheelchair or Geri Chair Policy, revealed the following, in part: The procedures involve various degrees of assistance depending on the strength and capabilities of the resident. Conditions in which assistance is usually necessary are paralysis or weakness of one or both sides. The techniques involved in transfer to and from bed and chair require that the nurse obtain extra staff to assist, if needed, and use correct body mechanics to prevent injury. Essential Points to Remember: 2. Obtain assistance from another staff member if resident is unable to assist. Resident #2 Review of Resident #2's clinical record revealed an admitted [DATE]. Resident #3 had diagnoses which included Lack of Coordination; Muscle Wasting and Atrophy; Hemiplegia and Hemiparesis. Review of Resident #2's MDS with an ARD dated 06/12/2024, revealed Resident #2 had a BIMS of 13, which indicated intact cognition. Resident #2 required extensive Two + persons physical assistance with bed mobility, toileting, and transfers. Review of Resident #2's Care Plan revealed the following, in part: High Risk for falls related to left sided hemiplegia secondary to Cerebral Vascular Accident on 05/31/2024 fall no injury. Required 2 person assistance for transfers. Review of Resident #2's wall care plan sheet revealed the following, in part: Transfer x2 person assist Review of Resident #2's current Physician Orders revealed the following, in part: 05/26/2021 Resident requires 2 person assistance with transfer Review of the Resident #2's Incident Report dated 05/31/2024 revealed the following, in part: Incident Type- lying on floor Date/time: 05/31/2024 6:15 p.m. Incident reported by S3CNA Narrative: Resident lying on floor in supine position. Aide states while trying to transfer from WC to bed resident's foot got caught and they both began to fall to the floor. On 07/29/2024 at 2:07 p.m., an interview was conducted with Resident #2. Resident #2 stated they normally transferred her with 2 people. Resident #2 stated S3CNA transferred her by herself. On 07/30/2024 at 10:02 a.m., an interview was conducted with S3CNA. S3CNA stated they were educated to review communication sheets on the wall to know what care and assistance the residents need. S3CNA confirmed she did not check the communication sheet on the wall for Resident #2. S3CNA stated she transferred Resident #2 by herself and should have had another CNA assist her. Resident #3 Review of Resident #3's clinical record revealed an admitted [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Muscle Wasting and Atrophy, History of Falling, and Other Lack of Coordination. Review Resident #3's Care Plan revealed the following, in part: At high risk for falls related to diagnoses of hemiplegia, osteoarthritis, Cerebral Vascular Accident and debility 07/18/2024 lowered to floor; no injuries Self-Care Deficit: resident requires Extensive x2 person assist with bed mobility, transfers, toilet use, locomotion. Transfer x2 with mechanical lift A review of the current Physician's Orders revealed the following, in part: 12/05/2023 Transfer assist x2 with mechanical lift Review of the resident's Wall Care Plan Sheet revealed the following in part: Transfer x2 person assist with mechanical lift Review of Resident #3's Incident Report dated 07/18/2024 at 7:00 a.m. revealed the following, in part: Incident Type: Lowered to the floor Narrative: CNA staff stated Resident #3 was being transferred with staff assistance x 2 when his legs began to give out. CNA stated we lowered Resident #3 to the floor so the resident did not fall. Resident #3 did not hit his head. There were no apparent injuries upon assessment. On 07/29/2024 at 3:34 p.m., an interview was conducted with S6CNA. S6CNA stated she and S5CNA were transferring Resident #3 from the bed to chair and he started sliding down. S6CNA stated she and S5CNA were lifting Resident #3 under his arms. S6CNA confirmed a mechanical lift was not being used during the transfer. S6CNA confirmed she did not check the wall communication sheet for the resident's transfer status before transferring Resident #3. On 07/30/2024 at 9:14 a.m., an interview was conducted with S5CNA. S5CNA stated Resident #3 is dependent and requires 2 aides with a mechanical lift for transfers. S5CNA confirmed a mechanical lift was not used for Resident #3 during the transfer on 07/18/2024. On 07/30/2024 at 12:25 p.m., an interview was conducted with S2DON. S2DON stated CNAs are trained to look at the wall care plans for the resident's transfer needs. S2DON confirmed Resident #2 was a 2 person assistance with transfers. S2DON confirmed S3CNA transferred Resident #2 by herself on 05/31/2024. S2DON confirmed Resident #3 required two person mechanical lift for transfers. S2DON confirmed S5CNA and S6CNA transferred Resident #3 without a mechanical lift. S2DON confirmed if Residents #2 and #3 had received the transfer assistance as listed on the wall care plan both incidents could have been prevented. On 07/30/2024 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM confirmed the wall communication sheet contains information from the resident's care plan and transfers and care should be followed in accordance with the care plan.

Based on observation, record review and interview, the provider failed to ensure the care plan was implemented for 1 ( #2) of 3 (#1, #2, and #3) residents sampled for ADL care had incontinence care provided with the required amount of staff assistance. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff . The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type) and size of sling, if lift is used) . It is the responsibility of the CNA to read and follow the wall care plan instructions to care for each resident. Review of the undated policy titled, Positioning (Movement in Bed), revealed the following, in part: Procedure: 3. Obtain assistance needed based on assessment of resident's ability to move in bed and type of positioning required. Review of Resident #2's clinical record revealed an admitted [DATE]. Resident #3 had diagnoses which included Lack of Coordination, Muscle Wasting and Atrophy, and Hemiplegia and Hemiparesis. Review of Resident #2's Optional State Assessment MDS with an ARD revealed Resident #2 had a BIMS of 13 which indicated intact cognition. Resident #2 required extensive Two + persons physical assistance with bed mobility, toileting, and transfers. Review of Resident #2's Care Plan revealed the following in part: Self-Care ADL deficit: resident will receive person centered care. Resident is extensive 2 person assistance for transfers, bed mobility and toileting. Review of the Resident's wall care plan sheet revealed the following, in part: Bed mobility x2 person assist. On 07/29/2024 at 1:51 p.m., an observation was made of S4CNA performing incontinence care to Resident #2. S4CNA did not have assistance from another staff member. S4CNA was observed to roll Resident #2 from one side to the other during the removal of the wet brief, incontinence care and the placement of the new brief. On 07/29/2024 at 2:02 p.m., an interview was conducted with S4CNA. S4CNA reviewed Resident #2's wall care plan and confirmed Resident #2 was a 2 person assistance. S4CNA confirmed she had performed incontinence care on Resident #2 by herself. S4CNA confirmed she should have had another staff member present during Resident #2's incontinence care. On 07/30/2024 at 12:25 p.m., an interview was conducted with S2DON. S2DON was made aware of the aforementioned findings for Residents #2. S2DON confirmed peri-care/incontinence care was included in bed mobility. S2DON confirmed Resident #2 should have had two staff present during incontinence care. On 07/30/2024 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM was made aware of the aforementioned findings. S1ADM confirmed peri-care/incontinence care is encompassed in bed mobility. S1ADM confirmed the wall communication sheet contains information from the resident's care plan and transfers and care should be followed in accordance with the care plan.