Nmmc Baldwyn Nursing Facility

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure skin care treatments were completed as ordered for one (1) of three (3) residents reviewed for wound and skin care. This deficient practice resulted in deterioration of a resident's wound, including a significant increase in wound size for Resident #1.Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided.Resident #1During an onsite complaint survey, an interview with Resident #1 on 11/3/25 at 10:30 AM revealed she had wounds to her legs. Resident #1 stated she often does not get her dressing changed to her leg at night and sometimes during the day. Observation revealed a dressing to the left posterior leg.Review of wound care orders for Resident #1's left lower leg ulcer revealed orders dated 9/20/25, 10/14/25, and 10/22/25, with treatment intervals of two (2) times daily.Review of Resident #1's October/November 2025 Treatment Flow Sheet for the left lower posterior leg ulcer revealed the treatment was not documented as completed as ordered thirty-five (35) times from 10/1/25 through 11/3/25 for the second dressing change daily.Review of the Weekly Skin Summary report dated 9/2/25 for Resident #1 revealed the left lower posterior leg ulcer measured 12 cm (centimeters) x 6.2 cm x 0.1 cm. State of healing: worsening.Review of the Weekly Skin Summary report dated 11/4/25 for Resident #1 revealed the left lower posterior leg ulcer measured 21.5 cm x 8 cm x 0.1 cm. State of healing: worsening. This represents a significant increase in wound size over the two-month period.An observation of Resident #1 on 11/4/25 at 8:54 AM with the treatment nurse revealed a saturated, intact dressing dated 11/3/25 at 9:25 AM, with a large area of dried drainage noted on the resident's pillowcase under the left leg dressing. The treatment nurse confirmed that was the dressing she applied on 11/3/25, verified by her initials. She stated the order was for the treatment to be completed twice daily and confirmed Resident #1's left leg ulcer had worsened over the last month. She also confirmed the dressing was soiled with drainage and the pillowcase as well.In a continued interview with the Treatment Nurse on 11/4/25 at 9:05 AM, she stated that she had recently found wound dressings on residents that had not been changed as ordered and had reported these findings to the Director of Nursing (DON). The Treatment Nurse explained that failure to perform wound care as ordered could cause wounds to worsen or become infected. She stated she performs treatments during the day, Monday through Friday, and that night shift and weekend nurses are responsible for completing their own wound treatments if a wound order dressing change is for more than one time a day. She further stated that when a treatment nurse is not scheduled, the assigned nurses are responsible for completing all wound treatments for their residents.Review of the demographic sheet for Resident #1 revealed the facility admitted the resident on 1/01/25 with a diagnosis of diabetic venous ulcers of both lower legs, lower extremity edema and Stage 3 chronic kidney disease. Record review of Resident #1's Section C of the Quarterly Minimum Data Set (MDS) revealed that on 10/1/25, the Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.Record review revealed a Medical Doctor progress note dated 08/19/25 that stated, Vascular surgery did not recommend revascularization due to bedbound and comorbidities. Patient will eventually require left (L) above the knee amputation (AKA). Record review of wound care center physician order dated 09/20/25 for an order to change dressing from once daily to twice daily (BID). Current treatment order is for left lower leg (LLL) cleanse with normal saline, pat dry with gauze, place Adaptic wound dressing to wound bed, cover with abdominal pad (ABD) and wrap with kerlix BID.An interview with the Assistant DON on 11/4/25 at 11:20 AM confirmed that staff failing to complete wound care as ordered could lead to worsening wounds.An interview with the DON on 11/5/25 at 11:30 AM confirmed she was aware the facility had concerns with treatments not being completed but not to the extent identified. She also stated she was unsure of the reason the wound care was not being completed.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure wound care treatments were completed as ordered for two (2) of three (3) residents reviewed for pressure ulcer wound care (Residents #2 and #3). Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided. Resident #2An interview with Resident #2 on 11/3/25 at 11:00 AM revealed she had a wound on the back of her right leg. She confirmed there had been a few times over the past month that her treatment had not been completed.Record review of wound care orders for Resident #2's right upper leg stage (4) pressure injury (PI) revealed orders dated 8/21/25 and 10/20/25, with treatment intervals of daily.Record review of Resident #2's October/November 2025 Treatment Flow Sheet for the right upper posterior leg revealed the treatment was not completed as ordered five (5) times from 10/1/25 through 11/3/25.Record review of the demographic sheet for Resident #2 revealed the facility admitted the resident on 2/3/25 with a diagnosis of paraplegia.Record review of Resident #2's Section C of the Minimum Data Set (MDS) revealed that on 8/6/25, the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact.Resident #3Record review of wound care orders for Resident #3's sacral stage (4) pressure injury revealed orders dated 9/20/25, 10/14/25, and 10/22/25, with treatment intervals of two (2) times daily.Record review of Resident #3's October/November 2025 Treatment Flow Sheet for the sacral stage (4) pressure injury revealed the treatment was not documented as completed as ordered nine (9) times from 10/1/25 through 11/3/25.Record review of the demographic sheet for Resident #3 revealed the facility admitted the resident on 5/14/25 with a diagnosis of metastatic disease in the pelvis and a stage (4) pressure ulcer of the coccygeal region.On 11/4/25 at 11:20 AM, in an interview with the Assistant Director of Nursing (ADON) confirmed that staff failing to complete wound care as ordered could lead to worsening wounds.On 11/5/25 at 11:30 AM, an interview with the Director of Nursing (DON) confirmed she was aware the facility had concerns with treatments not being completed but not to the extent identified. She also stated she was unsure of the reason the wound care was not being completed.

Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound for one (1) of three (3) residents reviewed for wound care. Resident #1.
Findings Include:
Review of the facility policy Negative Pressure Wound Therapy System, Single Use dated 03/03/2025 revealed The pump may be disconnected from the dressing if there is a requirement to disconnect - such as the need to have a shower
An interview on 04/29/25 at 10:00 AM with the complainant revealed that Resident #1, recently had an infected fistula removed from her left arm and she had a wound vac in place. The complainant revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. She revealed that Resident #1 went out to a doctor's appointment this morning and did not have the wound vac canister with her when she left. The complainant revealed that there had been several days that she observed that the wound vac was not hooked up to her, she told the nurse, and they sometimes hooked it up and sometimes they did not. She stated, How is her wound going to heal if they won't do their job and keep it hooked up? She revealed that she shouldn't have to remind them to do their job.
An observation on 04/29/25 at 3:15 PM in the Sunroom revealed Resident #1 reclined back in her wheelchair. Her wound vac tubing was attached to the dressing to her left upper arm and there was no negative pressure suction applied and no canister in place. The complainant revealed that Resident #1 returned from her doctor's appointment around 12:00 PM and went to the dining room and ate lunch. The complainant also revealed that Resident #1's wound vac was left off while she was out to her doctor's appointment, she returned to eat lunch and was now in the Sunroom with other residents and stated, Her wound vac has not been on all day. She revealed that the wound vac was supposed to be hooked to suction at all times and the staff knew that. She also revealed that several times last week, she noticed the wound vacuum was not on and she reported it to the nurse.
An observation on 04/29/25 at 3:30 PM in Resident #1's room, revealed the wound vac pump located in the corner of the room, it was attached to a pole and was not plugged in. Resident #1 was not in her room.
An observation on 04/29/25 at 4:40 PM in the dining room revealed Resident #1 sitting up in her wheelchair. The wound dressing to her left upper arm was intact with the wound vac tubing attached and there was no negative pressure suction hooked to it.
An interview on 04/30/25 at 9:02 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was supposed to have her wound vac in use and turned on to suction at all times. She revealed that the wound vac had a battery pack and was supposed to be taken with her to appointments as well. RN #1 revealed that not having the wound vac on and running yesterday was a failure. She revealed that not following the physician orders for continuous negative pressure could cause the fluid to pool, it could prevent the wound from healing and could lead to infection. RN #1 stated, It is doing her (Resident #1) a disservice by not having the wound vac in place as it is ordered. RN #1 confirmed that the wound vac canister should always be attached and hooked to suction unless a wet to dry dressing was applied. She revealed that Resident #1 never complained about discomfort with the wound vac and never refused to have it on, it was just not done.
An interview on 04/30/25 at 8:50 AM with Treatment Nurse, revealed that Resident #1's wound vac was supposed to be on at all times and hooked to suction. She revealed that a wet to dry dressing should be applied to the wound site if the wound vac was off and that the wound vac tubing and dressing should never be left on if not hooked to suction. She revealed that Resident #1 went to dialysis every Monday, Wednesday, and Friday and if the wound vac did not go with her, they should apply a wet to dry dressing until she returned. Treatment Nurse revealed that she had noticed the wound vac tubing and dressing on without being hooked to suction several times and had reported it to Interim Administrator herself. She revealed that the wound to Resident #1's left arm was much improved, and she could probably get the wound vac discontinued soon. Treatment Nurse revealed that Resident #1 had her dialysis fistula removed about a month ago, she received antibiotics, and the wound vac was placed.
An interview on 04/30/25 at 9:05 AM with Interim Director of Nursing, revealed that it had been brought to her attention by a family member before that the wound vac was not hooked up to suction. She revealed that the wound vac had a battery pack, was portable and there's no reason for it not to be hooked to suction. She revealed that it was the Floor Nurse's responsibility to ensure the wound vac was hooked to suction as ordered. Interim DON revealed that they had an order for continuous suction and an as needed order for a wet to dry dressing to be applied if wound vac was malfunctioning. Interim DON revealed that leaving the wound vac paused and not hooked up to suction all day was a big problem, she revealed that the wound could become infected and stated, the risk is there. Interim DON clarified the PRN (as needed) physician order for the wet to dry dressing and revealed that the wet to dry dressing was supposed to be applied to the surgical wound if the wound vac became dislodged, displaced, or if any problem occurred with the wound vac and she revealed that she would update the order.
An interview on 04/30/25 at 10:40 AM with Nurse Practitioner (NP), revealed that Resident #1's wound vac was supposed to be hooked to suction at all times with the exception of one to two hours. If needed. She revealed that if the wound vac was planned to be unhooked from suction for longer than two hours, a wet to dry dressing was supposed to be put on. NP revealed that not appropriately utilizing the wound vac for Resident #1 could cause worsening of the wound because without suction, the fluids would pool and not get suctioned off which could lead to infection or deterioration of the wound. She revealed that the nurses on the hall should be keeping a check on the wound vac's and ensuring they functioned properly and that they were hooked up to suction while in use.
An interview on 04/30/25 at 9:15 AM with complainant revealed that Resident #1 returned from her doctor's appointment yesterday between 11:30 AM and 12:00 PM and went straight to the dining room to eat lunch, and Resident #1's wound vac dressing and tubing was in place to her left arm but the wound vac canister with suction was left off. The complainant stated that Resident #1 participated in an activity at 2:00 PM yesterday, then went into the Sunroom with other residents and revealed that the wound vac was still not hooked to suction.
Record review of Resident #1's Nursing Orders revealed a wound care order with a start date of 03/31/25 for every Monday, Wednesday, and Friday. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, apply black foam to wound bed only, apply Tegaderm, apply wound vac at 120 mmHg continuous.
Record review of Resident #1's Nursing Orders revealed an unscheduled PRN (As Needed) wound care order with start date of 03/31/25. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, and apply NS (normal saline) wet to dry dressing.
Record review of Resident #1's Wound/Skin Care Plan dated 03/29/25, revealed that she had a surgical wound to her left upper forearm with interventions that included apply wound vac at 120 mmHg (millimeters of mercury) continuous.
Record review of Resident #1's Medical Record revealed the most recent admission date of 04/11/24 post hospitalization. She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity.
Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits.

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a dependent resident with a negative pressure wound therapy system (wound vac) in place and who required assistance with Activities of Daily Living for one (1) of four (4) residents sampled. Resident #1.
Findings Include:
Review of the facility policy, Care Plan Policy with reviewed date of 10/20 revealed, It is the policy of (Proper Name Facility) that care plans should be properly developed and implemented.
Record review of Resident #1's Care Plan updated 04/11/25 revealed that she required assistance with ADL's (activities of daily living) related to End Stage Renal Disease on dialysis, Decreased Mobility, and Generalized Weakness. Resident #1's Care Plan Approaches included, to provide appropriate level of assistance with ADL's as needed and this included limited to extensive need for one person assistance with dressing.
Record review of Resident #1's Wound/Skin Careplan dated 03/29/25, revealed that she had a surgical wound to her left upper forearm with interventions that included to apply wound vac at 120 mmHg (millimeters of mercury) continuous.
Record review of Resident #1's Nursing Orders revealed a wound care order with a start date of 03/31/25 for every Monday, Wednesday, and Friday. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, apply black foam to wound bed only, apply Tegaderm, apply wound vac at 120 mm continuous.
Record review of Resident #1's Nursing Orders revealed an unscheduled PRN (As Needed) wound care order with start date of 03/31/25. The order was to cleanse surgical incision to left upper arm with dermal wound cleanser, pat dry with 4x4 gauze, and apply NS (normal saline) wet to dry dressing.
On 04/29/25 at 9:47 AM, an interview with complainant revealed that Resident #1 had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. She revealed that on several occasions, Resident #1 had the same clothes on she had worn to dialysis the day before. The complainant revealed that Resident #1 slept in her clothes frequently and she had witnesses that also observed this. She revealed that Resident #1 didn't live like that, she didn't sleep in her clothes at night before she came to the facility, and she shouldn't have to now. The complainant revealed that Resident #1 had pajamas and gowns, and there was no reason she should have to sleep in her regular clothes. She stated, This is not comfortable for her. She revealed that she reported it to the previous administrator several times and it was never taken care of.
An interview on 04/29/25 at 10:00 AM with the complainant revealed Resident #1 recently had an infected fistula removed from her left arm and she had the wound vac in place. She revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. Complainant also revealed that Resident #1 had a wound vac (negative pressure wound therapy system) that was supposed to be hooked to suction at all times and the staff knew that. She also revealed that several times last week, she noticed the wound vac was not on and she reported it to the nurse.
An observation on 04/29/25 at 3:15 PM revealed Resident #1 reclined back in her wheelchair in the Sunroom with other residents present. She was dressed in a purple top, a brown cardigan sweater, a pair of pants and shoes. Her wound vac tubing was attached to the dressing to her left upper arm and there was no negative pressure suction applied and no canister in place.
An observation on 04/29/25 at 3:30 PM in Resident #1's room, revealed the wound vac pump located in the corner of the room, it was attached to a pole and was not plugged in. Resident #1 was not in her room.
An observation on 04/29/25 at 4:40 PM in the dining room revealed Resident #1 sitting up in her wheelchair. The wound dressing to her left upper arm was intact with the wound vac tubing attached and there was no negative pressure suction hooked to it.
On 04/30/25 at 9:15 AM, an interview with complainant, revealed that Resident #1 had the same clothes on this morning that she wore to her doctor's appointment yesterday, 04/29/25, a purple shirt and a brown cardigan sweater.
On 04/30/25 at 9:30 AM, an observation and interview with Resident #1, revealed her lying in her bed in her room. She had a purple top and a brown colored cardigan sweater on. Resident #1 confirmed that she had the same clothes on that she wore to her doctor's appointment the day before and revealed that the aides did not change her clothes before she went to bed last night. Resident #1 confirmed that she didn't like to sleep in her regular day clothes and that she would rather sleep in her bed clothes, her pajamas or gowns and stated, But I wasn't asked.
An interview on 04/30/25 at 10:40 AM with the Restorative Certified Nursing Assistant (CNA), revealed nearly every day she observed that Resident #1 was in the same clothes from the day before.
During an interview with Resident #1 on 04/30/25 at 10:45 AM with Interim Director of Nursing (DON) present, Resident #1 revealed that they did not change her clothes last night before putting her in bed. Resident #1 confirmed that regular clothes were not comfortable to sleep in and that she liked to sleep in her pajamas. Interim DON confirmed that the CNAs knew it was their responsibility to get the resident clothes changed for bed and to put appropriate bed clothes on them.
An interview on 04/30/25 at 9:02 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was supposed to have her wound vac in use and turned on to suction at all times. She revealed that the wound vac had a battery pack and was supposed to be taken with her to appointments as well. RN #1 revealed that not having the wound vac on and running yesterday was a failure on her part. She revealed that not following the physician orders for continuous negative pressure could cause the fluid to pool, it could prevent the wound from healing and could lead to infection. RN #1 stated, It is doing her (Resident #1) a disservice by not having the wound vac in place as it is ordered. RN #1 confirmed that the wound vac canister should always be attached and hooked to suction unless a wet to dry dressing was applied. She revealed that Resident #1 never complained about discomfort with the wound vac and never refused to have it on, it was just not done.
An interview on 04/30/25 at 8:50 AM with Treatment Nurse revealed that Resident #1's wound vac was supposed to be on at all times and hooked to suction. She revealed that a wet to dry dressing should be applied to the wound site if the wound vac was off and that the wound vac tubing and dressing should never be left on if not hooked to suction. She revealed that Resident #1 went to dialysis every Monday, Wednesday, and Friday and if the wound vac did not go with her, they should apply a wet to dry dressing until she returned. Treatment Nurse revealed that she had noticed the wound vac tubing and dressing on without being hooked to suction several times and had reported it to the Interim Administrator. She revealed that the wound to Resident #1's left arm was much improved, and she could probably get the wound vac discontinued soon. Treatment Nurse revealed that Resident #1 had her dialysis fistula removed about a month ago, she received antibiotics, and the wound vac was placed.
An interview on 04/30/25 at 9:05 AM with the Interim Director of Nursing, revealed that it had been brought to her attention by a family member before that the wound vac was not hooked up to suction. She revealed that the wound vac had a battery pack, was portable and there's no reason for it not to be hooked to suction. She revealed that it was the Floor Nurse's responsibility to ensure the wound vac was hooked to suction as ordered.
On 04/30/25 at 10:15 AM, an interview with the Minimum Data Set (MDS) Coordinator, revealed that the purpose of the care plan was to provide information on each individual resident for the nurses and cnas to relate back to in order to know how to take care of the specific needs of each resident. She revealed that the comprehensive care plan was a patient directed individualized care approach developed so the staff know how to take care of each resident. She confirmed that since Resident #1's wound vac was not hooked to suction and since the staff did not change her clothes for bed, and she was left in the same clothes from the day before, her care plans were not followed.
Record review of Resident #1's Medical Record revealed the most recent admission date of 04/11/24 post hospitalization. She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity.
Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits.
Record review of Resident #1's MDS with ARD of 04/17/25 revealed under Section GG-Functional Abilities that she was dependent on staff for care that included personal hygiene, dressing upper and lower body.

Based on observation, interview, record review and facility policy review the facility failed to provide a dependent resident with assistance to change clothes prior to going to bed for one (1) of four (4) residents reviewed. Resident #1.
Findings Include:
Review of the facility policy AM/PM Care dated March 2020 revealed, .Resident's clothing should be changed daily and when soiled.
On 04/29/25 at 9:47 AM, an interview with the complainant at the facility revealed that Resident #1, had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. Activities Director revealed that she came into the facility one Saturday morning and found that Resident #1 had the same clothes on she had worn to dialysis the day before. She revealed that Resident #1 slept in her regular clothes frequently and she had witnesses that also observed this. She revealed that Resident #1 didn't live like that, she didn't sleep in her clothes at night before she came to the facility, and she shouldn't have to now since Resident #1 had pajamas and gowns. She revealed that she reported it to the previous administrator several times and it was never taken care of. She revealed that the facility was Resident #1's home, and it wasn't right to be treated in this manner.
An observation on 04/29/25 at 3:15 PM of Resident #1, revealed Resident #1 reclined back in her wheelchair in the Sunroom with other residents present. She was dressed in a purple top, a brown cardigan sweater, a pair of pants and shoes.
On 04/30/25 at 9:15 AM, an interview with the complainant revealed that Resident #1 had the same clothes on this morning that she wore to her doctor's appointment yesterday, 04/29/25. She revealed that Resident #1 returned from her appointment yesterday between 11:30 AM and 12:00 PM and came to the dining room to eat with a purple shirt and a brown cardigan sweater.
On 04/30/25 at 9:25 AM, an observation revealed Resident #1 lying in bed in her room and she was being assisted with breakfast by a staff member.
On 04/30/25 at 9:30 AM, an observation and interview with Resident #1, revealed her lying in her bed in her room. She had a purple top and a brown colored cardigan sweater on. Resident #1 confirmed that she had the same clothes on that she wore to her doctor's appointment the day before and revealed that the aides did not change her clothes before she went to bed last night. Resident #1 confirmed that she didn't like to sleep in her regular day clothes and that she would rather sleep in her bed clothes, her pajamas or gowns and stated, But I wasn't asked.
On 04/30/25 at 10:35 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #1 was confused at times, had declined and she could no longer assist herself to bed. RN #1 revealed that Resident #1 required more help to get her clothes changed and ready for bed. She also revealed that she had told staff multiple times to change residents' clothes before helping them to bed. RN #1 revealed that the Certified Nursing Assistants (CNAs) knew they were responsible for getting the residents ready for bed at night and knew better than to make them sleep in their regular day clothes.
An interview on 04/30/25 at 10:40 AM with Restorative Certified Nursing Assistant (CNA), revealed that she came in early every morning and nearly every day she observed that Resident #1 was in the same clothes from the day before.
During an interview with Resident #1 on 04/30/25 at 10:45 AM with Interim Director of Nursing (DON) present, Resident #1 revealed that they did not change her clothes last night before putting her in bed and confirmed that the staff didn't offer to help her change into her bed clothes. Resident #1 confirmed that regular clothes were not comfortable to sleep in and that she liked to sleep in her pajamas. She revealed that lately she has had to sleep in her regular clothes every night and stated, We don't know no better, we just do it. The Interim DON reassured Resident #1 that she would take care of the issue with the staff. Interim DON revealed that this facility was the residents' home, and they should be able to choose what they wanted to sleep in, and their wishes should be granted. Interim DON confirmed that the CNAs knew it was their responsibility to get the resident clothes changed for bed and to put appropriate bed clothes on them.
Record review of Resident #1's Medical Record revealed the most recent admission date of 04/11/24 post hospitalization. She had diagnoses that included Type 2 Diabetes Mellitus with hypertension and ESRD (End Stage Renal Disease) on dialysis, Impaired mobility and ADLs (Activities of Daily Living), and Abscess of Left Upper Extremity.
Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/17/25 revealed under Section C a Brief Interview for Mental Status (BIMS) Score of 4 which indicated that she had severe cognitive deficits.
Record review of Resident #1's MDS with ARD of 04/17/25 revealed under Section GG-Functional Abilities that she was dependent on staff for care that included personal hygiene, dressing upper and lower body.

Based on interview, record review and facility policy review, the facility failed to properly store medications needing refrigeration in one (1) of two (2) medication storage rooms. Station one (1) Medication Storage Room.
Findings Include:
Review of the facility policy, Medication Storage with last modified date of 03/14/2024, revealed, It is the policy of (proper name) that all medications should be appropriately delivered and stored. The policy also revealed under Security and Storage that Once the medications are removed from the designated storage area, the medications should remain with the licensed designated individual at all times and should not be left unattended
An interview on 04/29/25 at 10:55 AM with Interim Director of Nursing (DON), revealed that they had a small refrigerator in each medication room with a lock box inside where they kept their narcotics that required refrigeration. She revealed that on 04/03/25, Licensed Practical Nurse (LPN) #1 was defrosting one of the medication refrigerators and realized that there was a problem with it. Interim DON revealed that the nurses normally emptied their refrigerators of any medications and locked the medications in the medication carts until the defrosting process was completed. Interim DON revealed that LPN #2 went and retrieved one of the vials of Ativan injectable out of the refrigerator for one of her residents, and left four vials in the locked box inside the refrigerator. Interim DON revealed that LPN # 1 was under the impression that LPN #2 removed all five vials of the Ativan from the refrigerator. She revealed that when the charge nurse realized that the refrigerator was not working properly, she took it out back to have maintenance check it out to see if it needed parts to repair or if it needed to be replaced. The Interim DON revealed that when LPN #2 came back to work, she realized that the refrigerator was gone and then remembered the four vials of Ativan that were left in there. The Interim DON revealed that when they realized the situation, they contacted her (Interim DON) and Interim Administrator, and they wondered where the refrigerator went. Interim DON revealed that they investigated the situation and found that the refrigerator had been transported as scrap to the landfill, and they were not allowed to retrieve it. She revealed that each lock box they kept in the refrigerators had a key that the nurses kept and were not easily accessed. She revealed that on the night this occurred, LPN #2 should have removed all of the Ativan from the refrigerator and locked it up in the medication cart until LPN #1 finished defrosting it. Interim DON revealed that the vials of Ativan were accounted for at end of shift, and it was the next day, they discovered that they were gone.
An interview on 04/29/25 at 11:20 AM with Interim Administrator, revealed that they had a refrigerator in one of the medication rooms that malfunctioned, and it was placed on the back dock to be disposed of. Interim Administrator revealed that due to failed communication on the nurses' part, four vials of Ativan were left inside the locked box in the refrigerator, and it was taken as scrap to a landfill and there was no way to get it back. He confirmed that the four vials of Ativan should have been removed from the refrigerator and locked up prior to placing the refrigerator outside to ensure no one else had access to the medication.
A phone interview on 04/29/25 at 5:12 PM with LPN #1, revealed that she was working on the night shift of 04/03/25. She revealed that she noticed some water leakage onto the insulin labels and some ice buildup in the refrigerator that was located in the medication storage room at Nursing Station 1. LPN #1 revealed that she took the refrigerator to the shower room to defrost it. She revealed that she knocked the ice off of it and when she plugged it back up, she heard a hissing sound, and she smelled some kind of chemical. LPN #1 revealed that she took the refrigerator out on the back dock to be checked out by maintenance to see if it needed parts ordered or if it needed to be replaced. LPN #1 revealed that the refrigerator in the medication storage room at Nursing Station 1 held lock boxes for halls A, B, and C. She revealed that she had removed the Hall C locked box, and the nurse locked it up in the medication cart. She revealed that there were no medications in the Hall A locked box and that LPN #2 came in while she was defrosting the refrigerator to get Ativan from the Hall B locked box. LPN #1 revealed that this was where the miscommunication came in. LPN #1 revealed that she thought LPN #2 removed all of the Ativan from the refrigerator from Hall C locked box, but she only got one vial of the Ativan for a resident who needed it right then. LPN #1 revealed that they found out the next day that the maintenance guy took the refrigerator off before the narcotic boxes (A and B) were removed. She revealed that the maintenance man didn't know they were in there either. LPN #1 revealed that she should have made sure that all locked boxes and narcotics were removed from the refrigerator before taking it outside and she should not have assumed that LPN #2 had removed them. She confirmed that the medications were not properly stored during that time, and she agreed that leaving the Ativan in the unattended refrigerator was a risk for someone else taking the medications.
A phone interview on 04/29/25 at 5:30 PM with LPN #2, revealed that she worked on April 3, 2025, on the night shift. She revealed that on that night, she needed to get a dose of Ativan out of the refrigerator for one of her residents. She revealed that LPN #1 had the refrigerator in the shower room defrosting it, LPN #2 got one vial of Ativan out and left the other four vials of Ativan in there. LPN #2 revealed that LPN #1 said something about the refrigerator, but she thought LPN #1 would put it back in the medication storage room when she finished defrosting it until maintenance could check it out. LPN #2 revealed that it was miscommunication and if she had known that there was a problem with the refrigerator or that it was going to be taken out back, she would have removed all narcotics and locked them up in the medication cart to make sure they were secure. LPN #2 revealed that keeping up with the narcotics was a serious issue and she hated that it happened and agreed that all medications should be properly secured and locked up to prevent them from falling in the wrong hands.
Record review of LPN #1's Statement revealed, I was defrosting refrigerator due to ice buildup and when I plugged it back in, I heard a hissing noise that smelled like chemicals. I was transporting the refrigerator outside for ventilation and I gave C hall their narcotics from narcotic box, then B hall nurse (proper name) (LPN #2) came up and said she needed to get hers out for B hall. I was not aware that nurse only got 1 dose out. I took refrigerator to back door and sat outside .The next I heard about it was when (proper name of LPN #2) came to me Saturday night and asked where the fridge was. I looked where I put it and it was gone. DON made aware at this time. Statement was signed by LPN #1 on 04/08/25.
Record review of LPN #2's Statement revealed, On April third, 2025 I needed to retrieve an Ativan vial from the Station 1 refrigerator, the charge nurse (proper name for LPN #1) was defrosting the refrigerator in the Station 1 shower room, I retrieved the needed vial and replaced the remaining vials back into the refrigerator narcotic lockbox. During April third shift change I had not been informed that the Station 1 refrigerator had been moved from Station 1 med room and believed that it was still on the premises. The statement was signed by LPN #2 on 04/08/25.
Record review of the Controlled Substance Record form revealed there were five vials of Ativan 2 mg/ml in the refrigerator for a resident on B Hall. The record revealed documentation of one vial of Ativan 2 mg/ml signed out on 04/03/25 at 02:58 by LPN #2 with four vials left.
Record review of LPN #1 and LPN #2's Time Card Report revealed that they worked on the night shift of 04/02/25 to the morning of 04/03/25. Record review revealed that LPN #1 clocked in on 04/02/25 at 18:36 and clocked out on 04/03/25 at 07:29.
LPN #2 clocked in on 04/02/25 at 18:42 and clocked out on 04/03/25 at 07:10
The misplaced 4 vials of Ativan 2 mg/ml for resident on B Hall were credited to the resident's account.

Based on staff interview and record review, the facility failed to accurately complete section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for two (2) of 26 MDS reviewed. Resident #2 and #76
Findings Include:
The facility provided a statement on letterhead dated 1/8/25 and signed by the Administrator that read, We follow the CMS (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) version 3.0 for policy information regarding MDS (Minimum Data Set) accuracy.
Resident #2
Record review of Resident #2's PASRR (Preadmission Screening and Resident Review) Summary Findings dated 6/25/24 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed.
Record review of the admission MDS with an Assessment Reference Date (ARD) of 8/5/24 revealed under section A 1500, Is the resident considered by state level II PASRR process to have serious mental illness and /or intellectual disability or a related condition? No was answered.
Resident #76
Record review of Resident #76's PASRR Summary Findings dated 2/27/24, revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Bipolar Disorder, Axis I secondary: Mood Disorder, Axis I tertiary: Post Traumatic Stress Disorder was listed.
Record review of Resident #76's Annual MDS with an ARD of 6/5/24 revealed, under section A 1500, Is the resident considered by state level II PASRR process to have serious mental illness and /or intellectual disability or a related condition? No was answered.
An interview with the MDS Nurse on 1/8/25 at 2:50 PM revealed, she was informed by Social Services (SS) that they did not have any residents that was considered by the state PASRR process to have a serious mental illness and required a level II. She confirmed Resident #2 and #72's MDS was coded inaccurately and revealed the purpose of having correct information was to ensure the residents' plan of care was created and for billing purposes.
An interview with SS on 1/8/25 at 3:10 PM revealed, she was aware Resident #2 and #76 received a level II PASRR and confirmed she did not relay the information to the MDS department.
Record review of the Patient Demographics revealed the facility admitted Resident #2 on 7/29/24.
Record review of the Patient Demographics revealed the facility admitted Resident #76 on 6/20/23.

Based on observation, staff interviews, and facility policy review, the facility failed to provide a clean, safe, and homelike environment as evidenced by bugs in ceiling lights, walls and ceiling in disrepair, blind slats broken and bent, broken wood molding, unclean air/heating unit and floors for six (6) of 67 rooms in facility.
Findings include:
Record review of facility policy titled, Resident Rights: Dignity and Respect, dated 2/12/24, revealed, To provide the kind of care to our residents that should maintain and enhance their dignity, individuality, and quality of life by the following treatment. a living environment that is safe, clean, and comfortable.
During an initial observation on 1/6/25 at 12:10 PM, room A-12 was noted to be in disrepair and had multiple areas of the room that had paint missing on the walls. Several areas of the room were observed that included an area by door measuring approximately eight (8) inches x 6 inches, an area near the bathroom counter measuring approximately four (4) inches x five (5) inches, and other smaller areas scattered around the room that were all missing paint. Approximately 15 dead bugs were observed in the ceiling light fixture and multiple water stains were covering most of the ceiling tiles. The wood molding on the center of the wall approximately shoulder high behind the resident's headboard was broken with a sharp point protruding from the wall surface. The window blinds were noted to be in disrepair with multiple bent and broken slats, along with dust and debris that was noted in the corners of the room and on edges of the floor around the floor molding.
On 1/8/25 at 9:30 AM, during an interview and observation of room A-12, the Environmental Service (EVS) Manager confirmed the areas of concern in this room which included missing paint, water stains on ceiling tiles, bugs in light fixture, blind slats bent and broken, floor with dust and debris, and broken wood molding with sharp point that could cause an injury. She stated their process for repairs was for staff to note these concerns and notify her and she would put in a work order for maintenance and this process was not followed for this room. She confirmed the facility failed to maintain the room in good repair and to ensure each resident had a safe, clean, comfortable, and homelike environment.
During an interview on 1/8/25 at 11:20 AM, the Assistant Administrator confirmed the environmental and maintenance concerns for this room. He confirmed the facility failed to ensure each resident had a clean, safe, and homelike environment.
ROOM #C-14
An observation in room C-14 bathroom on 01/06/25 at 9:55 AM and on 01/07/25 at 8:30 AM revealed a foul odor was noted. Further observations revealed there was an area measuring approximately one foot by one foot of yellow dried substance on the floor to the right of the commode in the resident's bathroom.
An observation and interview with the Assistant Administrator on 01/07/25 at 3:35 PM in Room C-14, revealed that resident rooms and bathrooms were supposed to be cleaned every day. He agreed that the bathroom in room C-14 had an odor and confirmed that there was a dried yellow substance on the floor to the right of the commode. He revealed that he would get housekeeping in to mop it now.
An interview with EVS Manager on 01/08/25 at 9:08 AM revealed that all resident rooms and bathrooms were supposed to be cleaned and mopped every day. She revealed that she wasn't sure why the floor in Room C-14 bathroom was missed and stated, That's an issue with me. The EVS Manager confirmed that not mopping the bathroom in Room C-14 was not acceptable and she agreed that the room was not a clean, homelike environment for the resident. She also revealed that she would address this issue with her staff.
ROOM #E-3
An observation in Room E-3 on 01/06/25 at 11:45 AM revealed an area approximately two feet by three feet on the wall behind the resident's bed with paint scraped off, sheet rock peeling and an electrical wall outlet cover broken off with the left half missing.
An interview with Maintenance on 01/08/25 at 9:00 AM revealed that if staff noticed anything needing his attention in the facility, they put in a work order, and he got to it as soon as he could. He revealed that when he received work orders, he prioritized their needs and addressed the issues as soon as he could. Maintenance revealed that with the age of the building, it was hard to keep up. Maintenance confirmed that the wall behind the bed in Room E-3 was in disrepair and confirmed that the electrical wall socket cover was broken. He revealed that he had not received a work order on that room and would get it taken care of. He also agreed that room E-3 was not a homelike environment for the resident.
An observation in Room E-3 and interview with the EVS Manager on 01/08/25 at 9:15 AM, confirmed that the wall behind the head of the bed was in disrepair and in need of painting. She also confirmed that the electrical socket behind the bed was broken and needed to be replaced and revealed that she would put in a work order now. The EVS Manager revealed that any concerns with the building in need of repair were supposed to be reported to Maintenance and if he couldn't fix the problem, he contacted someone from the main unit. EVS Manager stated, This should have been noticed and reported and we'll take care of it.
An interview with the Administrator on 01/08/25 at 10:45 AM, revealed that it was the responsibility of anyone who noticed a problem to put a work order in to maintenance. He revealed that this was an older building with challenges and stated, We need to put work orders in and follow up.
ROOM B-7, B-9 AND B-15
An observation of room B-7 on 1/06/25 at 9:30 AM revealed a clear rectangular ceiling light covering with 12 dead brown insects inside.
An observation of room B-9 on 1/06/25 at 9:46 AM revealed the outer plastic airflow vent on the air/heat unit was covered in a black and white substance that was in a droplet pattern.
An observation of room B-15 on 1/06/25 at 11:51 AM revealed two clear rectangular ceiling light coverings with 15-20 dead brown insects inside.
An observation and interview with EVS Manager on 1/8/25 at 9:30 AM revealed housekeeping was responsible for cleaning all the resident rooms every day. She explained that cleaning involved sweeping, mopping, dusting, emptying the garbage and whatever else that was needed. She revealed that the rooms were deep cleaned once weekly, which was a more in-depth cleaning such as wiping down the mattresses. The EVS Manager revealed the facility just started doing angel rounds a couple of weeks ago, which entailed an assigned staff member to every room to do a daily walkthrough and to look for any environmental concerns. She revealed if the residents had a complaint about their room or an issue was identified, a work order must be completed for maintenance to be fixed. She revealed after maintenance resolved the issue, he was required to sign off on the work order to show completion. During a walkthrough of rooms B-7 and B-15, the EVS Manager confirmed the dead insects in the ceiling light covers and stated, That's some kind of bug. She revealed maintenance would be responsible for cleaning the light covers. She explained that any staff member who noticed a concern could have reported the issue. During a walkthrough of room B-9, the EVS Manager confirmed the air/heat unit vents were covered in a black and white substance. She explained it could be coming from a dirty filter. She revealed housekeeping was responsible for cleaning the vents daily with a Swiffer duster, and maintenance was responsible for changing and cleaning the filter. The EVS Manager confirmed her expectations were for the residents to have a clean, safe environment.

Based on staff interview and record review, the facility failed to submit accurate information into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fourth Quarter 2024
Findings include:
Record review of facility policy titled, Staffing Guidelines, undated, revealed, Guidelines for Payroll Based Journal submission: 1. The facility shall submit staffing data to the Centers for Medicare and Medicaid Services (CMS) via CMS's Payroll Based Journal electronic data submission portal. 2. The facility shall submit staffing data in a uniform format according to specifications established by CMS.
Record review of PBJ Staffing Data Report revealed the facility had Excessively Low Weekend Staffing for the fourth quarter of 2024.
Upon entry into the facility on 1/6/25 at 9:10 AM, an interview with the Assistant Administrator revealed the facility had not been short staffed during the weekends or the week and he was uncertain why the PBJ report reflected that. He stated he would gather the necessary information for this concern.
During an interview on 1/8/25 at 10:35 AM, the Managerial Assistant revealed she was the person responsible for entering the information into the PBJ system. She stated she began this job on 6/3/24, so during the fourth quarter she was new to the position. She revealed the clocking system automatically entered the hourly staff working into the system, but when a salary staff member works outside their normal hours, their time had to be entered manually. She stated the shifts were sufficiently covered during the fourth quarter and she confirmed that since she was new to the position it was likely that the data was not entered accurately. She stated she now had a better system of entering the salary employees' time, but at that time it was very likely it was entered inaccurately.
An interview with the Assistant Administrator on 1/8/25 at 10:55 AM, revealed each shift was sufficiently staffed during the fourth quarter. He acknowledged the employee responsible for entering the information into the PBJ system was new to that position. He confirmed that since the facility was adequately staffed, the concern had to be due to the salary employees' time not entered into the system accurately. He confirmed the data entered should reflect the accurate staffing information in the facility.

Based on resident and staff interviews, and facility policy review, the facility failed to honor a resident right to vote in the 2024 election for one (1) of 23 sampled residents. Resident #72
Findings Include:
Review of the facility policy titled Resident Rights: Participation in Groups and Activities of Choice with a review date of 2/12/24 revealed under, Procedure: . Residents should be encouraged to exercise their rights to vote in local, state, and national elections.
An interview with Resident #72 on 1/8/24 at 8:11 AM revealed she had lived at the facility for over a year and did not get to vote this past election. She explained that she was registered to vote in a different county and had waited for the staff to bring her the necessary forms to complete, but no-one ever did. She revealed she always voted in the past, and it was important for her to continue to do so.
An interview with Social Services (SS) on 1/8/24 at 10:10 AM revealed she did not go room to room and speak with the residents individually regarding their desire to vote in the past election. She explained that she spoke with some residents in a resident council meeting and told them, if they wanted to vote, they needed to come talk to her. She revealed Resident #72 did not tell her that she wanted to vote and confirmed that she should have directly spoke with the resident regarding her wishes and acknowledged this was the resident's right to participate and cast her vote.
An interview with the Administrator (ADM) on 1/8/24 at 10:43 AM confirmed the facility should have spoken with Resident #72 regarding her desire to vote and ensured she was able to vote.
Record review of the Face Sheet revealed the facility admitted Resident #72 on 11/29/23.
Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/24, revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #72 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and facility policy review the facility failed to develop and implement a comprehensive care plan for a resident requiring nail care Resident #71 and for a resident with limited range of motion (ROM) Resident #26 and Resident #45 for three (3) of 23 resident care plans reviewed.
Findings include:
A record review of the facility Policy, Titled, Care Plan Policy with a revision date of October 2012, revealed, .Procedure .In accordance with each resident's plan of care, all services provided or arranged by the facility should meet professional standards of quality and should be provided by qualified persons.
A record review of the facility handout titled Facility Specific Handout with no revision date revealed under the title Providing Excellent Resident Care . 6. Nail care: clean nails every shift/PRN (as needed) and file as needed. RN/LPN (Registered Nurse/Licensed Practical Nurse.
Resident #71
A record review of Resident #71's Care plan, Problem/Need dated 02/09/2022 revealed, ADL's (Activities of Daily Living): Resident requires assist with ADL's r/t (related to): TBI (Traumatic Brain Injury) and Left hemiplegia and under approaches: Provide appropriate level of assistance with ADLs, as needed. Personal hygiene and bathing total dependent.
Observations on 09/05/23 at 11:05 AM and 4:36 PM revealed Resident #71's fingernails were approximately one-half (1/2) inch long and jagged past the tips of his fingers with a brown substance underneath his fingernails bilaterally.
An interview on 09/06/23 at 10:05 AM, Certified Nurse Aide (CNA) #1 confirmed that Resident #71's nails were long and had a brown substance underneath them.
An observation and interview on 09/06/23 at 10:21 AM, with the Director of Nurses (DON) confirmed Resident #71's nails were long and needed to be cleaned.
An interview on 09/06/23 at 1:16 PM with the DON confirmed that on Resident #71's ADL care plan that nail care was not specifically listed. He revealed that he thinks it may just fall under personal hygiene but confirmed that regardless the care plan was not being followed regarding his nails and it should have been.
An interview on 09/06/23 at 1:32 PM with the Minimum Data Set (MDS) Nurse revealed when a resident is admitted the admitting nurse does the baseline care plan, and the comprehensive care plan is developed by her or the other MDS nurse. She revealed the care plan is developed individually for each resident so the staff will know how to care for them, and that nail care is part of their bathing care plan. She confirmed if the residents' nails were long and not cleaned then the plan of care was not being followed.
An interview and record review on 09/06/23 at 1:48 PM of the facility handout titled Facility Specific Handout with the DON revealed under Providing Excellent Resident Care .#6. Nail care: clean nails every shift/prn (as needed) and file as needed. He stated this is part of the care plan for all the residents. He once again confirmed that it was not being followed for Resident #71.
A record review of Resident #71's Face Sheet revealed he was admitted to the facility on [DATE] with medical diagnoses that include Unspecified Intracranial Injury, Hemiplegia, Dysphagia, Neuralgia, and Neuritis. Review of the MDS with an Assessment Reference Date (ARD) of 8/9/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had a severe cognitive impairment.
Resident #26
Record review of Resident # 26's Care Plans revealed under, Problem onset 9/15/2020, Risk for new skin breakdown r/t (related to): . Cast/Brace . and Problem onset 7/14/2020, ADL's (activities of daily living): . contractures .
An observation on 9/05/23 at 10:45 AM, of Resident # 26 revealed the resident lying in bed with eyes closed and a right-hand contracture without a device in place.
An observation and interview on 9/06/23 at 10:48 AM, with the DON confirmed that Resident # 26 did not have a palm protector to his right hand. The DON revealed that the resident could develop worsening contracture by not applying the palm protector as ordered.
An interview with MDS Nurse #1 on 9/07/23 at 8:30 AM, confirmed that the staff did not follow the care plan for applying the palm protector for Resident # 26. She revealed the purpose of the care plan was to inform the staff of the resident care and needs.
An interview with the DON on 9/07/23 at 9:45 AM, confirmed that the facility was not following Resident # 26's care plan for applying the palm protector daily and revealed the purpose of the care plan was to provide individualized care for the resident to meet their needs.
Record review of the Face Sheet revealed that Resident # 26 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia, Type 2 Diabetes Mellitus, Seizures, Gastrostomy Status, Contracture Right Hand, and Contracture Unspecified Knee. Review of the MDS with an ARD of 8/01/23 revealed under Section C a BIMS score of 99, which indicated that the resident is severely cognitively impaired and in Section G under functional limitation in range of motion an impairment on both sides (Upper and Lower) extremity.
Resident #45
A record review of Resident # 45's Care Plan with an onset date of 4/28/21, revealed Approaches: Make sure range of motion exercises are done when resident goes to bed-report when done to hall nurses.
A record review of Resident # 45's Instant Care Plan, with an onset date of 2/21/22, revealed Problem/Risk: Risk for contractures, Goal: prevent contractures, new order/other: ROM to be done every morning Monday through Friday.
During an interview and record review with the Assistant Director of Nursing (ADON) on 9/7/23 at 8:32 AM revealed she was unable to locate documentation that the range of motion exercises were performed on Resident # 45 during the months of July, August, or September 2023.
A record review and interview with the DON and ADON on 9/7/23 at 8:45 AM, of Resident # 45's Care Plan and Instant Care plan they verified that Resident # 45 was at risk for contractures and t the care plan indicated that ROM was to be performed daily, and both agreed that the care plan was not being followed.
Record review of Resident # 45's MDS, with an ARD of 6/27/23, revealed a BIMS score of 15, indicating that the resident is cognitively intact. Section G Functional Limitation in Range of Motion revealed that the resident had impairment on both sides of lower extremities.
A record review of Resident # 45 Face Sheet revealed he was admitted to the facility on [DATE] with a diagnosis of Paraplegia at T9 level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide range of motion (ROM) exercise for a resident at risk for contractures Resident #45, and a splint for a resident with contractures Resident #26 for two (2) of 44 residents reviewed with limited ROM.
Findings include:
Record review of the facility policy titled Restorative Care Program with a revision date of 08/18 revealed under, Policy: It is the policy of (proper facility name) that residents' maximum functional potential and independent living should be promoted. Also revealed under, a. Range of Motion . These exercises should be planned, scheduled, and documented in the clinical record. Also revealed under, Splint or Brace Assistance: . 2) where staff have a scheduled program of applying and removing a splint or brace, assess the resident's skin and circulation under the device, and reposition the limb in correct alignment. These sessions are planned, scheduled, and documented in the clinical record.
Resident #26
Record review of Resident # 26's Active Orders Report revealed an order dated 11/17/20, Frequency: < User Schedule > (every 1 day: 08:00, 20:00) -Wash right hand with soap and water. Apply palm protector/rolled wash cloth to right palm daily.
An observation on 9/05/23 at 10:45 AM, of Resident # 26 revealed the resident lying in bed and a right-hand contracture without a device in place.
An observation on 9/06/23 at 10:00 AM, of Resident #26 revealed the resident lying in bed and a right-hand contracture without a device in place.
An observation and interview on 9/06/23 at 10:40 AM, with Registered Nurse (RN) # 1 confirmed that Resident #26 did not have a palm protector inside his right hand. She confirmed that the resident had a physician order to apply a palm protector/rolled wash cloth daily, scheduled for 08:00 (8:00 AM) and 20:00 (8:00 PM).
An observation and interview on 9/06/23 at 10:48 AM, with the Director of Nursing (DON) confirmed that Resident # 26 did not have a palm protector or a washcloth inside his right hand. The DON revealed that the resident could develop worsening of the contracture by not applying the palm protector as ordered.
An observation and interview on 9/06/23 at 10:53 AM, with Licensed Practical Nurse (LPN) # 1, with the DON in attendance, revealed that she was the nurse for Resident # 26, and stated that the resident's right hand was supposed to have a palm protector/rolled washcloth applied inside the hand. She confirmed that she did not apply the palm protector yesterday or today. She revealed that the resident could develop worsening contracture by not performing the care.
Record review of the Face Sheet revealed that Resident # 26 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia, Contracture Right Hand, and Contracture Unspecified Knee.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/01/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely cognitively impaired and in Section G under functional limitation in range of motion an impairment on both sides (Upper and Lower) extremity.
Resident #45
During an interview with Resident #45 on 9/5/23 at 10:55 AM, he stated that he did not consistently receive his ROM exercises.
A record review of Resident #45's care plan revealed Approaches: Make sure range of motion exercises are done when resident goes to bed-report when done to hall nurses. Problem/Risk: Risk for contractures, Goal: prevent contractures, new order/other: ROM to be done every morning Monday through Friday.
A record review of the monthly ROM schedule for July, August and September 2023 revealed that there are specific staff members listed on the schedule to perform ROM exercises Monday through Friday for Resident #45.
Record review of Certified Nursing Assistant (CNA) #2's weekly schedule revealed that she was scheduled to perform ROM exercises for Resident #45 on Monday, Wednesday, and Friday at 0800.
During an interview with CNA #2 on 9/5/23 at 1:23 PM, she stated that she performs ROM for Resident #45 on Monday, Wednesday and Friday and documents it on the calendar that hangs on Resident #45's wall. She stated she has provided ROM exercises on all the days she was scheduled unless the resident refuses the ROM. CNA#2 confirmed that she does not document the completed ROM in the computer.
During an interview with the Assistant Director of Nursing (ADON) on 9/6/23 at 3:20 PM she stated that the monthly ROM schedule is posted on the resident's wall so he will know who is going to perform his ROM exercises. She stated that it is divided up among the staff that assists with providing ROM for the resident. The ADON stated that the exercises are documented under the CNA tasks in the computer and that the staff initials the calendar hanging in his room.
During an interview with Licensed Practical Nurse #2 (LPN) on 9/7/23 at 8:02 AM, revealed she was assigned to Resident # 45 today, but was unfamiliar with his ROM schedule.
An interview with CNA #4 on 9/7/23 at 8:20 AM, stated that she provided ROM exercises to Resident #45's legs on the days she is scheduled. She stated that she documents the care provided on the schedule posted on the resident's wall. CNA #4 stated that she has only missed providing ROM exercises for Resident # 45 if he refused but confirmed that she is not documenting it in the computer.
During an interview and record review with the ADON on 9/7/23 at 8:32 AM, confirmed that she was unable to locate documentation that the ROM exercises were performed on Resident #45 during the months of July, August, or September 2023. She stated that usually it could be pulled up under completed care, but no documentation was showing up. She stated she no longer had the July or August calendars that staff initialed the care had been provided as they had been shredded. She verified that there was no documentation to prove that Resident #45 had received ROM exercise for July, August, or September of 2023.
During an interview with the DON and ADON on 9/7/23 at 8:40 AM, they agreed that failure to perform range of motion could cause contractures.
During an interview with the ADON on 9/7/23 at 10:09 AM, she verified that they did not have a Restorative Program, but they would follow the Restorative Care Program policy when providing range of motion and splinting or brace assistance.
Record review of Resident # 45's MDS, with an ARD of 6/27/23, revealed a BIMS score of 15, indicating that the resident is cognitively intact, Section G, Functional Limitation in Range of Motion revealed that the resident has impairment on both sides of lower extremities. Review of the Clinical Summary Report revealed he was admitted to the facility on [DATE] with a Diagnosis of Paraplegia at T9 level.

Based on observation, staff interview and facility policy review the facility failed to safely secure medications as evidenced by an unlocked and unattended medication cart on one (1) of three (3) survey days.
Findings include:
Review of the facility policy titled, Medication Administration with a revision date of 03/18 revealed under Medication Administration . #4. Storage of medications and several other associated products should be secure, i.e., in a locked med room, in a locked drawer/cabinet, or under constant surveillance. Any product used in a therapeutic manner should be treated and administered as a medication .
An observation and interview on 09/05/23 at 11:50 AM, revealed the medication cart on the B Hall was unlocked and unattended. This observation revealed Licensed Practical Nurse (LPN) #1 walked away from the medication cart and went two doors down to administer medications and left the medication cart unlocked and unattended. An interview with LPN #1 confirmed that the medication cart was unlocked and unattended. She stated that the purpose of locking the medication cart is for patient safety and to prevent others from getting into the medication cart.
An interview on 9/5/23 at 2:20 PM, with the Director of Nurses (DON) confirmed that a medication cart needs to be locked when the nurse leaves the cart to prevent anyone from getting into the medication cart and confirmed that it is a patient safety issue.
Record review of LPN #1's in-services revealed she completed an in-service on 7/11/23 regarding when to lock a medication cart.

Based on observations, staff interviews, and facility policy review the facility failed to ensure food items in the refrigerator/freezer were labeled and dated or discarded by expiration date and failed to ensure a dietary cook was wearing a beard restraint while prepping foods, for one (1) of two (2) kitchen tours.
Findings Include
Record review of the facility policy titled, Food and Supply Storage with a revision date of 1/23 revealed Policies: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Procedures: . Cover, label and date unused portions and open packages .Discard food past the use-by or expiration date .
Record review of facility policy titled, Uniform Dress Code with a revision date of 1/23, Policy #E006 revealed .Procedures: Associates Working with Food .Restrain all facial hair with a beard net/restraint .
An observation and interview during the initial tour of the kitchen on 09/05/23 at 10:10 AM, revealed the pass-through refrigerator had a metal container with no date and no label. Dietary worker #1 identified the food item in the metal container as coleslaw, and stated, I'm guessing they had it yesterday but I'm not sure. A large zip-lock bag which Dietary Worker #1 identified as lettuce and eleven cups were identified as prunes with no label and no date. A 12-pound (lb.) container with a manufacturing label of mustard potato salad with a label that indicated an open date of 8/30 and good through 9/2. Dietary worker #1 revealed that the potato salad was supposed to be thrown out and food that was old could possibly make a resident sick. An observation of the prep cooler revealed a large zip lock bag that the Dietary Manager (DM) identified as spinach, an opened 15 lb box which the DM revealed was bacon and a 12 lb box that the DM identified as sausage with no label and date on the items. The DM confirmed all foods are supposed to be labeled and dated and confirmed the items found were not labeled and dated. An observation of the walk-in freezer #7 revealed multiple open food items in their original bags not dated or labeled. The DM identified the food items as a bag of chopped onions, a bag of tater tots, a bag of chicken nuggets, and a bag of English peas. The DM stated that it was a failure on their part to make sure the items were labeled, dated and discarded on expiration dates.
An observation and interview on 09/05/23 at 10:35 AM, revealed a dietary worker that had approximately one and one- half inches of facial hair on his chin and side of his face with no covering over his beard and was observed prepping food. The DM revealed all hair including beards are supposed to be kept covered. She revealed with hair not being covered the hair could possibly fall into the food.
An interview on 09/06/23 at 4:35 PM, with the Assistant Administrator revealed we do make sure that all our foods are labeled and dated. He stated he was surprised to hear that there were food items found yesterday not labeled and dated. He revealed the purpose of labeling and dating foods is to ensure the foods are not expired. He revealed the worker with the long facial hair not covered could have caused an issue with hair being in the food. It's our policy that facial hair is supposed to be covered as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to promptly address and provide a follow up to grievances for four (4) of 32 residents reviewed. Resident #45, Resident #47, Resident #62, and Resident #64.
Findings Include
Record review of facility policy titled, Resident Rights: Complaint/Grievance Policy and Procedure dated 10/17, revealed, Policy: To provide a timely mechanism for receiving, responding, resolving, and documenting the outcome of patient complaints and grievances that is in compliance with current Resident Rights guidelines. The policy also revealed, 5. Response to a grievance is expected to take place within five business days of receipt of grievance and acknowledged in writing appropriately to the resident council, resident, or his/her representative.
Record review of facility policy titled, Electronic Device Guidelines, undated, revealed, The use of electronic devices and social media has become a part of many employees' daily lives, but is not appropriate activity during work time If electronic devices are allowed to be brought into the workplace, responsible use is expected and required. The following are examples of minimum expectations . 3. Employees should not use personal electronic devices in patient areas or in halls where patients or family members are present, except for common eating areas.
On 9/6/23 at 3:00 PM, a Resident Council meeting was held with nine (9) residents attending. During this meeting, Resident #47, Resident #62, and Resident #64 revealed they had a concern with the staff's use of personal cell phones while providing care in the residents' rooms. They revealed this was an ongoing concern that had been mentioned in multiple Resident Council meetings, yet the issue had not been resolved. Resident #62 and Resident #64 revealed the staff did not respond and give follow-ups to their grievances. Resident #47 who is the Resident Council President revealed he had gone to the Administrator on several occasions and asked if a grievance were addressed and the follow-up to the grievance, but he felt this information should be provided without the residents having to ask.
An interview with the Licensed Social Worker (LSW) on 9/7/23 at 9:00 AM, revealed she attended the Resident Council meetings and would take the minutes for the meeting. She revealed the concern with staff using their cell phones in resident care areas had been a concern for several months now. She stated when a nursing concern was discussed in the Resident Council meeting, she provided the information to the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Administrator. She confirmed that the staff received in-services, but she was unaware of other measures that were put in place to resolve this issue. She confirmed when a grievance is filed, it is the staff's responsibility to address the grievance and to notify the residents with a follow-up to their grievance and she confirmed that this was not done.
An interview with the DON on 9/7/23 at 9:15 AM, revealed he was aware of the residents' ongoing concern of employees using personal cell phones in resident care areas. He confirmed the facility had in-serviced the staff, but they continued to use their phones during care of the residents and that the facility failed to resolve the residents' grievances and provide follow-ups to the residents timely.
An interview with the Administrator on 9/7/23 at 9:40 AM, revealed cell phone use by staff was a concern of the residents and had been voiced in several Resident Council meetings. He confirmed the facility failed to find a solution to the grievance and failed to notify the residents with a response to the grievance timely. He confirmed this was an unresolved grievance from multiple Resident Council meetings and the facility failed to resolve this grievance.
Record review of Resident Council Minutes, dated 1/25/23, revealed, All residents feel as they are ignored by staff and that staff are coming into their rooms with earphones in their ears and talking on the phone.
Record review of Resident Council Minutes, dated 2/22/23, revealed, Resident on B and C halls mentioned Certified Nursing Assistants (CNAs) are still on their cellphones via (by) earbud.
Record review of Resident Council Minutes, dated 3/30/23, revealed, Several residents reported that some CNAs are still talking on their cellphone while in the rooms.
Record review of Resident Council Minutes, dated 4/21/23, revealed, Resident stated, when staff give her care, they are always on the phone.
Record review of Resident Council Minutes, dated 6/27/23, revealed, Several residents mentioned that staff continue to talk on their phones via earbuds while entering their rooms.
Record review of Resident Council Minutes, dated 7/26/23, revealed, It was mentioned that CNAs continue using cellphones in the rooms.
Record review of Resident Council Minutes, dated 8/24/23, revealed, It was mentioned CNAs are lazy, sit at the desk all the time, stay on the work phone and their cellphones.
Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/13/23, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident was cognitively intact.
Review of Resident #62's MDS with ARD of 7/28/23, revealed a BIMS score of 15 which indicated the resident was cognitively intact.
Review of Resident #64's MDS with ARD of 6/21/23, revealed a BIMS score of 15 which indicated the resident was cognitively intact.
Resident #45
During an interview on 9/5/23 at 10:55 AM, with Resident #45 he stated that the facility does not notify him of what has been done about issues that he reports or follow up with him to find out if the issue has been resolved.
Record review of the facility Resident Grievance Form, dated 5/16/23, filed by Resident # 45, revealed that the resident reported he was not receiving range of motion (ROM) exercises, he was not being turned, staff did not assist him to bed when he requested, his bed is not always made up after he gets up, his dirty clothing is left in his room, his hair is not getting washed, and staff have been on their cell phones. A record review of the response provided by the ADON revealed a formal schedule was put in place for ROM exercises, staff was provided in-service education regarding, turning, making beds, assisting residents, answering call lights, and cell phone usage.
During an interview on 9/6/23 at 9:15 AM, with the DON stated he was aware of the grievance and that the staff was provided an in-service. The DON confirmed that the resident grievances were not resolved with the in-service.
During an interview on 9/6/23 at 1:58 PM, with LSW, verified she forwards grievances to the DON, ADON and Administrator but does not follow up with residents to ensure grievances are resolved. She stated she was not aware that she needed to do the follow up. She assumed that the DON, ADON and the Administrator took care of the issues.
During an interview on 9/6/23 at 2:00 PM, with the DON he agreed that there is no evidence that Resident #45's grievance was resolved.
During an interview on 9/6/23 at 3:30 PM, with the Assistant Administrator he agreed that there is no evidence that Resident # 45's grievance was resolved.
Record review of Resident #45's Clinical Summary revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Compression of the Spinal Cord with Myelopathy and Paraplegia at T9 level.
Record review of the MDS, with an ARD of 6/27/23, revealed a BIMS score of 15, indicating that the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long dirty jagged nails for one (1) of 23 residents reviewed. Resident #71
Findings include:
A record review of the facility policy titled, Nails, Care of with a revised date of 07/17, revealed under Policy .It is the policy of (facilities proper name) that nails should be properly cared for.
A record review of the facility handout titled Facility Specific Handout revealed under the title Providing Excellent Resident Care . 6. Nail care: clean nails every shift/PRN (as needed) and file as needed. RN/LPN (Registered Nurse/Licensed Practical Nurse)
Observations on 09/05/23 at 11:05 AM and 4:36 PM, of Resident #71 revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged past the tips of his fingers with a brown substance underneath his fingernails.
An observation on 09/06/23 at 10:00 AM, of Resident #71 revealed bilateral fingernails to be approximately 1/2 inches past the tips of his nails with a brown substance underneath his fingernails.
An interview on 09/06/23 at 10:05 AM, with Certified Nurse Aide (CNA) #1 revealed she is assigned to the resident today and revealed they are not allowed to cut the nails only clean them. She confirmed that she did clean underneath them as best as she could this morning and confirmed that the nails were long and still had some brown stuff underneath them.
An observation and interview on 09/06/23 at 10:21 AM, the Director of Nurses (DON) confirmed that Resident #71's nails were long and needed to be cleaned. He revealed with his nails being that long he could scratch himself and create a skin tear and that it was the responsibility of the treatment nurse to cut the nails and he wasn't sure when the last time they were done.
An interview on 09/06/23 at 11:35 AM, with the Treatment Nurse revealed, I try to keep the nails trimmed but the schedule has changed for doing the nails, she revealed his fingernails are to be done on the 19th of this month and honestly the nail care for the residents has been sporadic. She stated, I try to do them every week. I don't always document when nail care is done and honestly, I'm not sure when he last had them done.
A record review of Resident #71's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses that include Unspecified intracranial injury, Hemiplegia, Dysphagia, Neuralgia, and Neuritis.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/23 revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident has a severe cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide dignity to a resident with a urinary catheter bag for one (1) of six (6) residents with a urinary catheter. Resident #52
Findings Include:
Review of the facility policy titled Resident Rights: Dignity and Respect with a revision date of July 2012 revealed under, Policy: It is the policy of (proper name of facility) that residents should be treated with dignity and respect.
The facility provided documentation titled Facility Specific Handout that revealed under, Providing Excellent Resident Care: . 5. Catheters: Use privacy bag or pillowcase .
An observation on 9/06/23 at 10:25 AM, revealed the resident lying in bed with a urinary catheter drainage bag containing light yellow urine that was uncovered and visible from the hallway.
An observation and interview on 9/06/23 at 10:42 AM, with Registered Nurse (RN) # 2 confirmed that Resident #52 had a urinary drainage bag that was uncovered and in view from the hallway and stated that the bag should be covered to maintain the resident's dignity.
An interview with RN # 1 on 9/6/23 at 10:44 AM, confirmed that urinary drainage bags should be covered and on the other side of the bed out of sight from the doorway for dignity.
An observation and interview with the Director of Nursing (DON) on 9/06/23 at 10:45 AM, confirmed that Resident # 52's urinary drainage bag did not have a privacy cover and was visible from the hallway and confirmed that it should have a cover for dignity.
Record review of the Face Sheet revealed Resident # 52 was admitted to the facility on [DATE] with medical diagnoses that included Dysphagia, Gastrostomy Status, Cerebral Palsy and Fetal Alcohol Syndrome.
Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident was severely cognitively impaired and in Section H that the resident had an indwelling catheter.

Based on observation, record reviews, interviews and facility policy review, the facility failed to store drugs and biologicals appropriately as evidenced by a facility reported investigation of medications for the residents on A hall were found prepared and stored in medication cups for 20 residents in a night shift nurse's unlocked locker in the employee breakroom for one (1) of five (5) medication carts observed.
Findings include:
Record review of the facility's policy Medication Administration last modified 6/10/2020, revealed Title: Medication Administration 4. Storage of medications and several other associated products should be secure, i.e., in a locked med room in a locked drawer/cabinet, or under constant surveillance. Any product used in a therapeutic manner should be treated and administered as a medication .10. All medication removed from a medications storage area should be removed just prior to administration and only for one patient at a time .
Record review of a facility reported incident revealed that the incident was reported to the Administrator and the Director of Nursing (DON) on 05/15/23 around 1:15 PM. The incident revealed that Registered Nurse (RN) #1 had prepared medications for residents, in medication cups with the name of the resident on the outside of the medication cup and stored these medications in his locker inside a locked staff break room. This was investigated by the facility Administrator and Assistant Administrator and was reported to the State Agency (SA) and the Attorney General (AG) office at the time of the incident.
Interview on 5/25/23 with the DON 10:00 AM, revealed that there had been an audit of the medication cups found in RN #1's locker and there were no narcotics found. The medications were either prescribed medications or over-the-counter medications that were ordered. Each medication cup had the last name of the resident written on the outside of the cup. The Medication Administration Records (MAR)'s were reviewed with no issues found. When he interviewed RN #1, he said that He would preset meds for the next night he would come in. He would check for new orders. He did not say how long he had done this exactly. There were 20 separate cups.
Interview with the Assistant Administrator on 5/24/23 at 10:15 AM, revealed that the stored medications in the locker was seen by a staff member,while on her lunch break in the break room. The staff member reported it to the Assistant Administrator and the Administrator. He said they immediately went to the staff break room and the locker door was open. There was no lock present on the employee locker. The medication cups were in two stacks and were stacked on top of each other with medical tape holding the cups together. He stated they immediately suspended RN #1 and began their investigation.
Observation by SA on 5/24/23 at 10:20 AM, of the staff break room revealed that the door required the staff member's identification card (ID) to open the door entering the breakroom. There was a wall with small staff lockers located in the breakroom, some are locked, and some are not locked, but it was observed that there was not a lock on RN #1's locker.
Review of the facility's investigation revealed an email written by RN #1 dated 5/16/2023 regarding the incident revealed he had Done this for many months and that he Thought it was ok since the meds were locked in the locker and the lounge door is also locked. He stated that he locks his locker and was worried someone may have tampered with the medications. He wrote that the medications found were to be administered to residents the next time he worked.
Review of RN #1's personnel file revealed RN #1 had received training and testing on medication administration. There were no discipline actions in his file until this incident. He had worked for the facility since 2009. Currently, he is still suspended. The facility's Human Resources (HR) has the completed the investigation and will be following through with termination of this employment.
The SA attempted to call RN#1 twice with no return phone calls on 5/24/23 and 5/25/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff, resident, and resident family interviews, record review and facility policy review, the facility failed to identify and report an incident of alleged verbal abuse for one (1) of five (5) residents reviewed. Resident #1.
Findings include:
Record review of facility policy with revision date of 03/20 titled: Abuse: Investigation and Reporting revealed, . Rationale: To provide guidelines to help protect, report, and investigate abuse allegations. Policy: It is the policy of (Proper Name) Nursing Facility that all reports of suspected resident abuse, neglect and injuries should be properly reported and investigated .Procedure: When investigating reports of suspected resident abuse, neglect and injury, the guidelines below should be followed: 3. The individual conducting the investigation should, as a minimum .j. Report allegations to the State Licensure and Certification and to the Attorney General within 24 hours of report and in writing within 72 hours of the report.
On 05/01/23 at 9:20 AM, a phone interview with, Resident #1's granddaughter revealed that on 03/02/23 Resident #1 had called her daughter and was on the phone when Registered Nurse (RN) #1 came into Resident #1's room and yelled at her saying, You are killing yourself'.RN #1 then Resident #1's phone. The resident's daughter heard the conversation and was upset that this nurse would speak to her mom in this manner.
On 05/01/23 at 4:15 PM, during a phone interview with Resident #1's daughter revealed that Resident #1 doesn't sleep much. Resident #1 enjoyed playing games on her phone that she bought for her and revealed that Resident #1 had called her early one morning by accident and while on the phone, the daughter overheard RN #1 yelling at her mom. RN#1 said, You need to go to sleep, you're gonna kill yourself! Resident #1's daughter revealed that she could hear her mom crying and she immediately hung up the phone and called the facility and talked to RN #1. The resident's daughter stated, RN #1 said, 'Yes, I bawled your mama out' and then commenced to bawl me out. She revealed that this nurse was removed from her mom's care and that they had moved Resident #1 to a different nursing home.
On 05/02/23 at 8:30 AM, an interview with RN #1 revealed that on the night of 03/02/23, Resident #1 was up wandering, going in and out of other resident rooms, was sluggish, staggering, confused and disoriented. RN #1 revealed that Resident #1 had been up for nearly 72 hours without sleep. She was concerned about her and tried to talk her into going to sleep. She said, She couldn't keep going like this without no sleep. RN #1 revealed that the facility didn't use alarms or bedrails and that Resident #1 had already had a couple of falls, so she was worried about her. RN #1 also revealed that she did talk loudly because she was hard of hearing, and she could see why it might come across that she was fussing at the resident but wasn't meant that way. RN #1 said, I was just trying to get her to lie down in her bed and get some sleep.
On 05/02/23 at 9:15 AM, an interview with Assistant Director of Nursing (ADON) revealed that when the incident between Resident #1 and RN #1 was reported to her she didn't realize that it was a reportable incident. The ADON revealed that she and the Director of Nursing (DON) talked to the resident, the resident's daughter, the resident's roommate and that they did not feel that it was abuse. The ADON said that the daughter seemed to be okay with it when RN #1 was no longer allowed to care for her mother. The ADON revealed that she understood and could see now why it should have been reported and would make sure it was handled differently in the future.
On 05/02/23 at 10:00 AM, a phone interview with RN #2 revealed that around 6:30 AM or 7:00 AM on the morning of 03/03/23 that Resident #1's daughter reported to her that RN #1 had yelled at her mom. The daughter told her that her mom had accidentally called her and while listening, she heard RN #1 chastising her mom and that her mom was upset and crying. RN #2 revealed that she immediately reported this to the DON and the ADON. RN #2 also revealed that the incident was immediately investigated.
On 05/02/23 at 10:40 AM, an interview with ADON revealed that when an abuse situation was suspected, they would make sure that the residents were safe and then they would report it. The ADON revealed that she did know that an alleged abuse situation was supposed to be reported within 24 hours but usually they tried to report anything within 2 hours to err on the side of caution. She revealed that she was not sure if this incident had been reported or not. The ADON revealed that they did an investigation, interviewed the daughter and other residents, intervened, and completed in-services with all employees. The ADON said that they removed RN #1 from Resident #1's care and the family were good with everything.
On 05/02/23 at 11:00 AM, an interview with the Administrator revealed that they did not report the incident between Resident #1 and RN #1 because they had investigated it and had determined that it was not abuse. He revealed that he did not think that this situation should have been reported.
On 05/02/23 at 12:30 PM, an interview with Director of Nursing (DON) revealed that on the morning of 03/03/23, RN #2 reported the occurrence between Resident #1 and RN #1 to him and the ADON. The DON revealed that he went straight to the resident's room and the daughter was still present and voiced her concerns to him as well. The DON said that he pulled RN #1 into his office to find out from her what occurred and that they immediately removed RN #1 from the care of the Resident #1. Since this seemed to appease the family, he thought that the problem was solved. The DON confirmed that he did not report this incident to the State Agency and that he now realized that this should have been done.
Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Acute Metabolic Encephalopathy, Cerebrovascular Accident with cognitive deficits, and Dementia in Alzheimer's Disease with depression.
Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) score of 09 which indicated that resident had severe cognitive impairment.

Based on facility policy review, record review, and staff interviews, the facility failed to submit a Change in Status Request Form for evaluation of need for a Preadmission Screening and Resident Review (PASRR), Level Two (II) Screening, for a resident with new major mental illness diagnoses and new physician's orders for psychiatric medications, as evidenced by, a Change in Status Request form not being submitted for one (1) of two (2) residents reviewed for no PASRR II with diagnosis. Resident #63
Review of the facility policy titled, Coordination with PASARR Program, with a last review date of 05/05/2020, revealed, Rationale: To ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level two II resident review. b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.
Findings include:
Record review was attempted for review of the Change in Status Request Form submission, for Resident #63, for evaluation of need for a Preadmission and Resident Review (PASRR), Level Two (II) Screening, due to the new major mental illness diagnoses and new psychiatric medications, that were ordered after completion of the initial Pre-admission Screening (PAS), revealed there was not a Change in Status Request Form in Resident #63's medical record.
An interview, on 3/1/22 at 04:06 PM, with the Social Worker (SW), confirmed that the Change in Status Request Form was not submitted to evaluate for the need of a PASRR, Level II Screening, for Resident #63. The SW revealed she had no knowledge of the Change in Status Request Form submission process for an evaluation for the need of a PASRR, Level II Screening, when new major mental illness diagnoses are added to a resident's medical record, and when new psychiatric medications are ordered, by a physician, for a resident after the initial PAS had been completed for admission.
An interview, on 3/2/22 at 08:54 AM, with the Director of Nursing (DON), revealed he had no knowledge of the Change in Status Request Form submission process needed to be done when new major mental illness diagnoses are added to the medical record and/or new psychiatric medications are ordered, by a physician, after the original PAS was completed for admission.
An interview, on 3/2/22 at 03:00 PM, with the Administrator, revealed he was not aware of a Change in Status Form needed to be submitted for residents, with new major mental illness diagnoses and new orders for psychiatric medications, from a physician, to ensure the appropriate mental health treatment is provided to residents by the facility. The Administrator confirmed Resident #63 should have had a Change in Status Form completed to ensure all psychiatric care needed for Resident #63 was provided.
Record review, of the diagnosis list, for Resident #63, revealed chronic diagnoses of Impulsive Personality Disorder, with an entry date of 10/9/19, Emotional Instability (excessive), with an entry date of 12/9/20, and Bipolar Disorder, with a an entry date of 3/3/22. Initial review of the diagnosis list did not reveal the Bipolar Disorder diagnosis.
Record review, of the Minimum Data Set (MDS) Quarterly Assessment's Active Diagnosis List, with an Assessment Reference Date (ARD) of 1/4/22, revealed Resident # 63's diagnosis of Bipolar Disorder.
Record review, of the PAS Summary and Physician Certification, dated 3/4/2016, revealed the answer, no, to the questions that asked, Person has a diagnosis of a major mental illness; Person has a recent history of a mental illness?
Record review, of the Active Orders Report, for Resident #63, revealed a physician's order for Prozac 80 MG daily, that was prescribed for Borderline Personality Disorder, with a start date of 6/18/2021, for Seroquel 100 MG daily, that was prescribed for Idealization and Emotional Instability and Bipolar Disorder, with a start date of 9/13/21, and Depakote 500 MG daily, that was prescribed for Bipolar Disorder, with a start date 11/25/21.
Resident #63 was admitted to this facility on 2/5/16 with a diagnosis of Borderline Personality Disorder. Record review, of the most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/4/22, for Resident #63, revealed a Brief Interview for Mental Status, (BIMS), score of 12, indicating Resident #63 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review the facility failed to revise care plans for pressure ulcers and tracheostomy care for residents #29 and #45 for two (2) of twenty six resident's care plans reviewed.
Resident #29
Respiratory Care
[DATE] 9:30am observed trach care with Respiratory Therapist (RT) suctioned resident and monitored the resident oxygen level while providing care.
Record review of the facility care plan for Risk for Respiratory complications and SOB (shortness of breath), dated Problem onset [DATE], with a goal and target date of [DATE].
Interview with the DON on [DATE] at 2:10 PM confirmed that the care plan for resident was expired and that the facility has quarterly care plan meetings but that he would have to ask the MDS nurse why she had not updated the resident's care plan.
Interview with the MDS nurse, CLPN on [DATE] at 2:30 PM confirmed that the resident's care plan have expired and stated, The care plans should have been updated on [DATE] when the resident's quarterly assessment was done but I haven't had any help and we had the care plan meeting but I never went back and updated the care plans I guess.
Record review of the facility policy titled, Care Plan Policy, dated [DATE], stated, When developing a comprehensive care plan, the guidelines below should be followed: Review and revise after each comprehensive assessment.
Findings include:
Record review of Resident #45's care plan revealed a Pressure Ulcer Care Plan dated [DATE] with a goal and target date of [DATE] for new skin breakdown/Stage II to coccyx.
An interview with the Director of Nursing (DON) on [DATE] at 2:10 PM confirmed that they do have monthly and quarterly care plan meetings and verified that the care plans for Resident #45 expired on [DATE] and should have been updated with the residents quarterly assessment review in [DATE].
An interview, on [DATE] at 2:30 PM with the Minimum Data Set (MDS) Nurse revealed that they do conduct quarterly meetings and as needed for significant changes and stated, Yes, the care plans should have been updated but I have been back there by myself and guess I failed to do so. The MDS Nurse confirmed that she does not bring the actual care plans to the quarterly meetings and she should have so they could have updated them at that time.
Record review revealed resident was admitted to the facility on [DATE] with diagnoses including Paraplegia, Spinal Stenosis, Type II Diabetes, Morbid Obesity, Osteoporosis and Pressure Ulcer. Record review of the most recent Brief Interview for Mental Status score (BIMS) on [DATE] revealed a BIMS Score of 15 indicating resident had full cognitive ability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review the facility failed to provide facial hair removal for a female resident who was dependent for her activities of daily living as evidenced by visible patches of shiny white hairs on a female resident's chin for one (1) of twenty residents observed. Resident #81.
Record review of the facility policy titled, AM/PM Care revealed under Policy: It is the policy of (Facility Name) to promote resident cleanliness by assisting with AM/PM care as appropriate. This policy revealed under Procedure: Residents should be shaved per preference
Findings include:
An observation on 02/28/22 at 11:27 AM revealed Resident #81 lying in bed with a patch of shiny long white hairs on both sides of her chin.
An interview, on 3/1/22 at 3:30 PM with Certified Nurse's Assistant (CNA) #1 revealed the CNAs are responsible for the residents' baths and shaving. CNA #1 revealed the bath schedule for B Hall was Monday, Wednesday and Friday (M, W, F) with odd rooms and Tuesday, Thursday and Saturday (T, TH, SA) for even rooms. CNA #1 revealed that if someone needs shaved and it is not their bath day then she will go ahead and shave them even if it is a woman.
An interview, on 3/1/22 at 3:40 PM with Licensed Practical Nurse (LPN) #2 revealed baths and shaving are the responsibility of the CNAs, but if I need to help them I do.
An observation and interview, on 3/1/22 at 3:50 PM with CNA #1 and LPN #2 confirmed that the resident was lying in bed with a patch of long shiny white hair on both sides of her chin. LPN #2 revealed the resident was combative at times during care and when she provides care for the resident she always carries someone with her. CNA #1 and LPN #2 confirmed the resident had hair on her chin and needed to be shaved.
An interview, on 3/22/22 at 9:15 AM with Registered Nurse (RN #2 ) revealed that residents are supposed to be shaved with AM/PM care if they need it, even if it is not their bath day and this is the responsibility of the CNA's.
An interview, on 3/3/22 at 10:40 AM with the DON revealed that an in-service is completed on hire and annually regarding AM/PM care that includes shaving.
An interview, on 3/3/22 at 11:30 AM with the DON revealed that a female resident that had chin hair would probably make them feel bad and if they want shaved, they need to be.
An interview, on 3/3/22 at 11:40 AM with the Administrator revealed that staff may forget about women needing to be shaved and maybe that could be taken care of in a beauty shop visit if they can go. The Administrator revealed shaving women when they need it is something we are going to have to be sure and work on remembering.
Review of the resident's face sheet revealed the resident was admitted [DATE] with medical diagnoses that included: Other Reduced Mobility, Dementia with Lewy bodies, Age Related Physical Debility, Muscle weakness.
Review or the residents care plan revealed a care plan for ADL's: Unable to independently perform basic self-care due to hx fall with lt femur fx, dementia, muscle weakness, debility. Review of this care plan revealed the interventions included Assist daily with hygiene, bathing, toileting, dressing, grooming, and feeding which indicated the responsibility of this intervention is the CNAs.
Record review of the bath roster for the resident from 2/2/22 thru 3/2/22 revealed the resident had 10 partial or complete bed bath's during this time frame.
Record review of the residents AM/PM Care Roster for 2/2/22 thru 3/2/22 revealed the resident had not been shaved.
Record review of the residents Minimum Data Set with an Assessment Reference Date of 01/04/22 revealed under Sectional G-Functional Status Personal hygiene: support provided; Two+ persons physical assist.
Record review revealed that the Minimum Data Set with an Assessment Reference Date of 01/04/22 revealed a Brief Interview of Mental Status of 99 which indicated the resident was severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review the facility failed to provide the activities to meet the resident's needs for one (1) of twenty-six residents. Resident #70.
Findings Include:
Record review of the facility policy titled, Resident Activities with a revision date of October 2015 revealed under, Policy: It is the policy of (Facility Name) that activities designed to meet the interests and physical, mental, and psycho-social well-being of the resident should be provided. The policy revealed under, Procedure: #4-Activities should be planned for both individual and group according to the resident level of functioning. Activities should be planned for inside and outside the facility
An observation on 2/28/22 at 10:15 AM revealed the resident lying in bed, eyes closed, lights off and blinds closed.
An interview on 02/28/22 at 10:55 AM with the resident revealed he is blind. The resident stated, I can see shadows When asked if the staff provides any activities for him, he stated, They don't do a damn thing, the resident revealed they do not bring activities to my room, no music or anything.
An observation on 3/1/22 at 9:00 AM revealed the resident lying in bed, lights off and blinds closed, no TV was observed on the resident's side of the room and no radio. The observation revealed the resident does not have a roommate and the TV on the other side of the room was off.
An interview on 3/1/22 at 4:00 PM with Activities staff #1 revealed she has been with the facility as activities director for 3 years. The Activities staff #1 revealed that she develops a monthly calendar of activities and those that cannot attend group activities get in room visits 2-3 times per week. The Activities staff #1 revealed that her assistants usually completes the in room visits based on the resident's interest, they document it on an activities log and she reviews it quarterly. The Activities staff #1 revealed that she could not find the activity log for December 2021.
An observation on 3/1/22 at 4:05 PM of the activity log revealed that the resident had not attended any group activities since admission on [DATE] and had six (6) in room visits. The observation revealed the residents in room visits were on 11/16/21, 11/18/21, 11/20/21, 1/21/22, 1/26/22 and 2/21/22.
An interview on 3/1/22 at 4:12 PM with the Activities staff #1 revealed she stated, We could do better by him.
An observation on 3/1/22 at 4:15 PM of the resident's activity assessment on admission [DATE] revealed under current activity preference and interest survey that the resident was interested in any type of TV, western movies, gospel, and blues music, enjoys sitting outside, van rides, music club, Bible, church services, church specials and gospel singings.
An interview on 3/1/22 at 4:20 PM with the Activities staff #1 revealed that the resident needed a TV, and we could get him some music. The activities staff #1 stated, The nurses could turn the TV on in his room to the music channel. The activities staff #1 confirmed that activities are to help residents to maintain their quality of life and makes them feel at home, but when they do not have activities they could feel depressed.
An interview on 3/3/22 at 11:59 AM with the Administrator revealed that each resident should have activities based on their interest to help with their quality of life. He revealed that the resident could use a radio.
Record review of the resident's face sheet revealed an admission date of 10/11/21 with medical diagnoses that included Alzheimer's disease with late onset.
Record review of the residents History and Physical with a date of service 10/11/21 indicated the resident was legally blind under Chief Complaints.
Record review of the Minimum Data Set with an Assessment Reference Date of revealed a Brief Interview Status (BIMS) of 03 indicating the resident is severely cognitively impaired.

Based on facility policy review, observations, staff interviews, and record reviews, the facility failed to protect the dignity of a resident which was evident when a privacy bag was not placed over a foley catheter bag for one (1) of six (6) residents reviewed with a foley catheter. Resident #90.
Resident #90
Dignity
Review of the facility policy titled, Urinary Procedures, with an approval date of 09/2019, an issued date of 12/9/2000, and a last modified date of 04/01/2021, revealed It is the Policy of (Facility Name) to ensure that urinary procedures are performed appropriately.
An observation, on 02/28/22 at 11:24 AM, revealed that Resident #90 did not have a privacy bag that covered her foley catheter bag. Resident #90's foley catheter bag hung on the side of her hospital bed that faced the entry door to Resident #90's room, with the clear side of the foley catheter bag facing the entry door, that allowed the urine drainage to be visible to all other residents, staff, and visitors, that passed Resident #90's room when the door was opened, and was visible to everyone who entered Resident #90's room.
An observation on 03/1/22 at 03:32 PM, revealed Resident #90 did not have a privacy bag over the foley catheter bag. Resident #90's foley catheter bag was hung on the side of the hospital bed that faced the entry door to Resident #90's room. The clear side of the bag faced the entry door to Resident #90's room and the urine drainage was visible to everyone who passed Resident #90's room, when the door was opened, and was visible to everyone who entered Resident #90's room.
An interview and observation, on 03/1/2022 at 03:41 PM, with the Licensed Practical Nurse (LPN)#1, confirmed Resident #90's foley catheter bag did not have a privacy bag covering it. LPN #1 confirmed that Resident #90's foley catheter bag was visible to everyone that passed Resident #90's entry door, when the door the was opened, and was visible to everyone that entered Resident #90's room. LPN #1 confirmed that there should have been a privacy bag over the foley catheter bag and a privacy bag not being placed over the foley catheter bag could have caused a dignity issue for Resident #90.
An interview, on 3/2/2022 at 08:54 AM, with the Director of Nursing (DON), revealed privacy bags are only placed over a foley catheter bag when a resident was taken out of the room. The DON stated the facility policy did not state that a privacy bag had to be placed over a foley catheter bag when a resident remained in their room, but confirmed he understood how Resident #90 could have had dignity issues, due to the foley catheter bag being hung on the side of the bed facing the entry door to Resident #90's room and was visible to everyone that passed, when the door was opened, and was visible to everyone that visited the room. The DON confirmed Resident #90 should have had a privacy bag placed over the foley catheter bag.
An interview, on 3/3/22 at 09:30 AM, with the DON, revealed the in-service with staff regarding usage of a privacy bag over a foley catheter bag was done with each individual employee, at time of hire and the in-service was done again yearly. DON revealed these in-services are not done in a group setting.
Record review, of the individual employee in-service titled, Facility Specific Handout Every Resident - Every Time, dated 12/11/2018, revealed, Providing Excellent Resident Care, 5. Catheters: Use privacy bag to cover drainage bag while resident is out of room.
Record review, of the Active Orders Report, revealed a physician's order for an indwelling urinary catheter, dated 10/22/2021.
Resident #90 was admitted to this facility on 10/22/21, with a diagnosis of Other Cystostomy Status. Record review, of the most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/25/2022, for Resident #90, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #90 had moderately impaired cognition.

Based on staff interview, facility policy review, and record review the facility failed to develop and implement an activity care plan for one (1) of twenty six care plans reviewed. Resident # 70
Findings Include:
Review of the facility policy titled, Care Plan Policy revealed under Procedure When developing a comprehensive care plan, the guide lines below should be followed: A comprehensive care plan should be developed for each resident using the results of a comprehensive assessment. All assessment and care plan documentation should be completed as required by both state and federal regulations.
An interview on 3/1/22 at 4:20 AM with the activities staff #1 confirmed that activities help residents to maintain their quality of life and makes them feel at home and that we should have care planned for activities.
An interview on 3/2/22 at 2:12 PM with the Director of Nurses (DON) confirmed the resident did not have a care plan relating to his activities, but should have had a care plan.
Record review of the facility policy titled, Resident Activities with a revision date of October 2015 revealed under, Policy: It is the policy of (Facility Proper Name) that activities designed to meet the interests and physical, mental, and psycho-social well-being of the resident should be provided. The policy revealed under, Procedure: #4-Activities should be planned for both individual and group according to the resident level of functioning. Activities should be planned for inside and outside the facility
Record review of the residents face sheet revealed an admission date of 10/11/21 with medical diagnoses that included Alzheimer's disease with late onset.
Record review of the Minimum Data Set with an Assessment Reference Date of 01/11/22 revealed a Brief Interview Status of 03 indicating the resident is severely cognitively impaired.