Every finding on record at Colonial Springs Healthcare Center

Based on interview and record review, the facility failed to ensure all residents were free from misappropriation of property when one staff (Certified Nurse Aide (CNA) A) received and cashed a $30,000 check from one resident (Resident #1) while the CNA was employed by the facility and provided care to the resident. The facility census was 117. On 07/23/26, the Administrator was notified of the Past Non-Compliance that occurred on 06/13/26, which involved staff misappropriation of one resident's (Resident #1) funds. The facility began an investigation into the allegations, completed audits of financial, resident, and facility records, and began in-servicing all staff regarding misappropriation and professional boundary requirements. The non-compliance was corrected on 07/27/26. Review of the facility's policy Patient Abuse/Neglect, Elder Abuse, and Person with Disability Abuse, dated 08/2021, showed the facility staff, employees, and physicians will follow regulations and standards in the identification of and procedure for handling alleged victims of abuse. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 08/12/25;-Diagnoses included congestive heart failure (CHF - a chronic condition where the heart muscle is too weak or stiff to pump blood effectively, causing fluid to back up into the lungs and body.) Review of the resident's care plan, dated 11/07/25, showed the following:-The resident had anxiety and depression;-At times the resident may be easily angered, agitated, and have behavior changes and sleep pattern during these times;-The resident has insomnia;-The resident has difficulty falling asleep and/or staying asleep;-The resident takes hypnotic medication to assist with managing his/her insomnia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/10/26, showed the following:-Cognitive skills intact-No behaviors. Review of the resident's care plan, dated 11/07/25, showed the following:-The resident had anxiety and depression;-At times the resident may be easily angered, agitated, and have behavior changes and sleep pattern during these times;-The resident has insomnia;-The resident has difficulty falling asleep and/or staying asleep;-The resident takes hypnotic medication to assist with managing his/her insomnia. Review of the facility's Financial Exploitation Investigation Report, dated 07/24/26, showed the following:-On 07/23/26, Financial/Service Staff (SS) C informed the Administrator that he/she received a phone call from a former employee that he/she heard Certified Nurse Aide (CAN) A allegedly bragged he/she obtained approximately $30,000 from a resident of the facility and had used the funds to purchase a vehicle for a business. The caller did not identify the resident involved and could not provide additional supporting details;-On 07/23/26, the Administrator conducted a phone interview with CNA A who denied taking money from any resident of the facility; -On 07/24/26, the Administrator conducted a follow-up phone conversation with the former employee who said he/she did not know the identity of the resident allegedly involved but would attempt to obtain additional information if possible;-On 07/24/26, at 2:30 P.M., Financial/SS C reported a carbon copy of a personal check in the resident's checkbook register payable to CNA A for the amount of $30,000 on 06/13/26. Copies of relevant records, interview notes, check register documentation, and reporting records were secured and preserved in accordance with the facility investigation procedures;-On 07/24/26, at 2:40 P.M., the Administrator and Financial/SS C interviewed the resident regarding the $30,000 check payable to former CNA A. The resident stated he/she did not know what staff referred to and was unable to provide an explanation regarding the check or the transfer of the funds;-On 07/24/26, with the resident's consent, the Administrator contacted the resident's bank who confirmed the check dated 06/13/26, in the amount of $30,000 payable to former CNA A, was negotiated and cleared the resident's account on 06/15/26;-On 07/24/26, at approximately 3:19 P.M., the Administrator contacted the Department of Health and Senior Services (DHSS) to report concerns possible to resident financial exploitation;-Based upon the information obtained during the investigation, the facility substantiated that a financial transaction in the amount of $30,000 occurred between the resident and former CNA A while employed as a direct care staff member at the facility;-The investigation further substantiated that former CNA A received $30,000 from the resident and engaged in a financial transaction prohibited by facility policy. Although former CNA A characterized the payment as a loan, the transaction constituted an impermissible financial relationship between a direct care employee and resident. Review of the Financial/SS C's statement, part of the facility investigation, showed the following:-On 07/24/26, at approximately 2:10 P.M., he/she received an email from the billing department regarding an outstanding balance owed by the resident;-The resident asked Financial/SS C to prepare a check on his/her behalf consistent with prior occasions;-Financial/SS C discovered a copy of a previously issued check payable to former CNA A in the amount of $30,000 in a prior check entry;-He/she recognized the last name of former CNA A from the information from the phone call on 07/23/26;-He/she asked the resident about the purpose of the check. The resident stated that it was an investment, but was unable to recall the identity of the recipient;-He/she asked the resident if former CNA A was employed at the facility, the resident confirmed that CNA A was. During an interview on 08/13/26, at 10:18 A.M. Financial/SS C said the following:-In July 2026, the resident asked him/her to write out the check for rent. The resident asked him/her to look at previous checks for his/her identifier number;-He/she saw the carbon copy check with CNA A's name and the amount of $30,000;-He/she reported this to the Administrator.;-The resident said he/she could call the bank;-The bank confirmed the $30,000 check was cashed to CNA A;-The resident at first denied who he/she wrote the check to and then said it was a loan transaction together for a business investment;-Misappropriation is defined as staff taking money from residents or other items; -He/she considered if a resident gives a large amount of money to a staff person, misappropriation;-Staff should not take any money from residents. Staff are at the facility to help them and care for them. During an interview on 08/13/26, at 9:30 A.M., the resident said the following:-He/she did not give former CNA A money; it was an investment/loan;-CNA A and the resident discussed dogs, dreams, and the CNA's future;-The resident offered to be a silent partner and invest in CNA A's business;-He/she was not aware it was wrong or informed that he/she could not give staff money;-The CNA told the resident he/she would repay the resident. The resident wrote the words, investment on the check to the CNA;-He/she did not have a contract with the CNA, but believes now they probably should have but just trusted people;-The CNA was terminated before any written contract could have been created; -He/she expected the money to be given back eventually over time;-He/she told CNA A to promise to work two days a week at the facility, but the facility took that away from CNA A, so the resident does not see her at all. During an interview on 08/13/26, at 12:37 P.M. CNA A said the following: -Staff bond with all the residents;-He/she was a business person and the resident was a business person;-He/she was a good aide and the resident latched on to him/her;-CNA A and the resident did not have anything in writing such as an agreement or contract of how the resident was to be paid back but did plan on paying the resident back;-It was a different situation to him/her and the resident;-CNA A was shocked the resident gave the money to him/her. CNA A told the resident he/she would have to quit, because CNA A knew it was crossing a line, approaching a border;-The resident said CNA A had to stay at the facility for two days a week to keep an eye on him/her;-CNA A knows the regulations and rules, he/she was going to need to quit because a resident gave him/her $30,000 for an investment. CNA A thought he/she needed to quit since it was a sticky situation;-CNA A said it will take at least a year to pay the resident back, since his/her business slows down. During an interview on 08/13/26, at 01:32 P.M., Licensed Practical Nurse (LPN) B said the following:-The resident said he/she was CNA A's business partner;- LPN B explained to the resident that staff and caregivers were not allowed to take anything from residents;- The resident was very upset that staff did not inform him/her of the rules and did not know CNA A could not take the money;-The resident said CNA A was going to pay him/her back;-CNA A came to his/her office on 07/23/26, at 6:10 P.M., at the Administrator's request. LPN B asked CNA A if he/she received any amount of money from any resident in this building, and CNA A said no and not that it is any of our business, but he/she received money from a couple for his/her business;-Misappropriation of property included staff should not take clothing, jewelry, furniture, or money from a resident;-If a resident knowingly and is alert and oriented and gives a large amount of money to a staff person and the staff person accepts it, he/she would consider it financial abuse;-He/she felt a staff receiving an investment from a resident was taking advantage of that resident;-The resident may interpret giving money to a staff person as getting better care which they should receive anyway. During an interview on 08/13/26, at 11:33 A.M., CNA E said types of misappropriation included taking things or money from a resident. During an interview on 08/13/26, at 11:38 A.M., CNA F said the following: -Misappropriation of property included taking money from residents;-He/she considered misappropriation of property if a resident gave a large amount of money to staff. It is financial abuse because that is the resident's money;-Staff are to care for residents. During an interview on 08/13/26, at 12:14 P.M. Registered Nurse (RN) G said the following: -Upon hire, staff have an orientation and are informed not to accept gifts or any money from residents; -He/she considered it misappropriation of property and financial abuse if a resident gave a large amount of money as a check to a staff member;-He/she heard a check was written to a staff member and they cashed it;-Staff should not take money from a resident, even if a resident says it is a loan/investment;-Staff should give the money or check back to the resident or the charge nurse or SS staff if a resident gives them money;-Staff should alert appropriate staff so they can talk with the resident about giving money to staff;-He/she considered this misappropriation of funds and financial abuse. During an interview on 08/13/26, at 1:11 P.M., SS D said the following:-Financial abuse included exploiting money from residents or families using the money for their own resources instead of the resident's care;-Staff should not take any type of gift, or monetary exchange from a resident because it is exploitation;-It is against facility policy whether the resident is ok with it or not to accept money from a resident. During an interview on 08/13/26, at 12:58 P.M., the Director of Nursing (DON) said the following:-Misappropriation of property includes taking money from a resident;-Staff should never accept any money from a resident, even if the resident is okay with it, alert and oriented, or says it is an investment;-Staff taking money from a resident can appear as providing that resident with special cares or treatment for payment;-Staff should attempt to refuse money and if the resident insists, should report to the Administrator. During an interview on 08/13/26, at 2:39 P.M., the Administrator said the following:-The residents are a protected group of individuals when they come into the facility's care;-The residents are susceptible to manipulation and dependent on staff;-The resident's story changed three times, first he/she did not know what the carbon copy referred to. The resident approved for the facility to call the bank. When staff went down for follow up, the resident was on the phone with CNA A, he believed. The resident did not tell him who he/she was on the phone with. The resident changed his/her story from 07/24/26;-The resident did not know who CNA A was as the first name written on the check but knew CNA A as another name;-After the resident was on the phone, the resident said it was an investment;-Financial exploitation includes taking gifts from residents, taking money from residents, or anything of value or any of their property;-It is financial exploitation if a resident gives a large amount of money or a $30,000 check to a staff knowingly and says it is an investment and the staff person accepts the money;-The facility had a vulnerable population, and staff are obligated not to do that;-He considered it to be misappropriation of property if a staff accepts money from a resident;-Staff should not accept a check from a resident;-Staff should report if a resident gives them a large amount of money immediately to their supervisor;-Staff should not accept money as an investment even if residents insist. Complaint 3111067

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible abuse made by one resident (Resident #1). The facility census was 118.Review of the facility's policy Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, reviewed August 2024, showed the following:-The facility designee will report or assist the person with direct knowledge of the concern to report immediately, within two hours of the allegation of mental, physical, verbal, or sexual abuse or if there has been bodily injury related to abuse. If not abuse and there is no injury, the designee should report within 24 hours of the observation or allegation, to the Department of Health and Senior Services (DHSS) at the hotline or in cases involving Long Term Care (LTC). The report shall be made first to the Regional DHSS (if during regular business hours) or the hotline if after hours;-The organization's designee, which is the facility Administrator, Administrator On-Call, Director of Nursing or Registered Nurse on-call, shall be responsible for reporting suspected abuse or neglect;-Any concern, complaint, or allegation of patient/resident abuse/neglect (sexual, physical, or verbal) by another patient, resident, employee, vendor or visitor shall be verbally reported immediately to department director, administrator on call or facility administrator;-If a substantiated concern, complaint, or allegation of patient/resident abuse or neglect involves the abuse or neglect by a staff member, employee, or physician of the facility the investigating party will determine, with consultation with their direct supervisor, whether the staff member, employee, or physician's employment will be suspended pending the investigation. 1.Review of Resident #1's face sheet (admission data) showed the following:-admission date of 08/24/22;-Diagnoses included displaced left femur (thigh bone) fracture.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/03/26, showed the resident had moderate cognitive impairment with no behaviors or hallucinations marked. Review of the resident's behavior monitoring note dated 06/30/26, at 6:00 P.M., showed the following:-Registered Nurse (RN) D documented distressing delusions. The resident experienced confusion early in the evening;-The resident said, three men raped me last night in my room. The resident asked the aide to stay in his/her room so the men couldn't get in tonight;-RN D redirected the resident, offered a snack, spoke to the resident in a calm voice, and the resident went to sleep.(Staff did not document reporting the allegation of possible abuse to management or DHSS.) Review of the facility's investigation, dated 7/01/26, showed the following:-The incident was reported to the Director of Nursing (DON) on 07/01/26, at 1:00 P.M.;-The Nurse Practitioner (NP) called and reported to the DON that she had read some concerning documentation in the resident's behavior documentation that needed investigation;-On 06/30/26, on the night shift, RN D marked behaviors for distressing delusions. The resident experienced confusion earlier in the evening and stated that three men raped him/her last night in his/her room. The resident asked the aide to stay in his/her room so the men could not get in tonight;-RN D completed an assessment of the resident.that night. Review of DHSS records showed the facility reported the allegation of possible abuse on 07/01/26, at 2:52 P.M. (The day following the allegation of possible abuse was documented by staff.) During an interview on 07/07/26, at 9:19 A.M., Licensed Practical Nurse (LPN) A said the following:-The DON notified him/her on 07/01/26 of the allegation of abuse;-Staff should report to the supervisor immediately any allegation of abuse;-The facility should notify the state immediately with any allegation of abuse. During an interview on 07/07/26, at 9:30 A.M, Certified Nurse Aide (CNA) B said the following: -On 06/30/26, the resident said the night before three men came in his/her room and raped him/her. He/she informed RN D right away of the resident's allegation;-Staff should report an allegation of abuse to the charge nurse immediately;-An allegation of abuse should be reported to the state within two hours. During interviews on 07/07/26, at 10:25 A.M. and 10:50 A.M., RN D said the following:-The resident told CNA B that three men came into his/her room the night before and raped him/her;-CNA B informed him/her of the resident's allegation of abuse on 06/30/26;-He/she talked to the resident who did not vocalize the allegation of abuse to him/her, and he/she also talked with CNA B of what the resident told him/her;-He/she assessed the resident for any type of injuries;-The resident had delusions in the past;-He/she did not report the allegation of abuse to appropriate staff, and he/she thought it was a delusion and figured it was not true;-Staff should talk to the resident and assess to make sure nothing happened if a resident has an allegation of abuse. During an interview on 7/07/26 at 11:24 A.M., the NP said the following:-On 07/01/26, in the morning meeting, a nurse stated nursing staff said the resident had delusions in the shift report;-NP wrote down the resident's name to visit him/her that day;-On 7/01/26, NP read the resident's behavior charting and saw the progress note of the allegation of abuse the resident made on 06/30/26;-NP asked the DON if she saw the note written on 06/30/26 and the DON was not aware of the note. During an interview on 07/07/26, at 12:25 P.M., the DON said the following:-The NP told the Administrator on 07/01/26, at 1:00 P.M., of the allegation of abuse;-Staff did not inform her of the progress note on 06/30/26;-RN D should have informed her immediately of the allegation of the abuse;-RN D said he/she documented a delusion in the resident's behavior note and thought the resident had an infection;-She considered it to be an allegation of abuse.-Staff should report to her immediately of an allegation of abuse;-Staff should report to the state within two hours of an allegation of abuse. During an interview on 07/07/26, at 12:47 P.M., the Administrator said the following: -He expected RN D to report the allegation of abuse to staff in a timely manner;-Staff should report immediately to the supervisor, DON or him of an allegation of abuse;-The facility should report to the state within two hours of an allegation of abuse. Complaint #3067083

Based on interview and record review, the facility failed to ensure timely notification of each resident's family/responsible party of changes in condition when staff failed to notify one resident's (Resident #1)'s x-ray results following a fall. A sample of four residents was reviewed in a facility with a census of 106.Review of the facility policy titled Changes in Patient/Resident Condition: Notification Guidelines, revised January 2025, showed the following:-Physicians, patients, residents, hospice when applicable, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the patient or resident;-Purpose to provide timely communication of condition and environmental changes to care providers, patients, residents, and families;-When patient/resident changes are noted nursing staff will notify the following: patient's or resident's attending provider, resident's legal representative (if patient/resident is incompetent), and/or interested family member;-Notification will occur as soon as possible when there is an accident or injury involving the patient/resident. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 02/10/25;-Diagnoses included fracture of unspecified part of neck of left femur (hip injury). Review of the resident's nursing progress note dated 11/19/25, at 1:10 P.M., documented as a late entry for 11/18/25, at 12:30 P.M. showed a nurse documented a fall communication form. A certified nurse aide (CNA) was in shared bathroom with another resident and heard a crash in the resident's room. Staff responded and noted the resident sat on the floor in front of his/her wheelchair. Staff notified the nurse. Staff assessed the resident for injury with none noted. The resident reported he/she attempted to transfer himself/herself to bed. Review of the resident's progress note dated 11/19/25, at 1:22 P.M. showed a late entry of 11/18/25 at 1:30 P.M., showed a nurse documented a verbal order received from the nurse practitioner for a STAT (as soon as possible) X-ray of the resident's right shoulder, humerus (upper arm bone), elbow, forearm and wrist. Staff notified the X-ray company and the X-ray completed as ordered. (Staff did not document family notification of the x-ray orders.)Review of the resident's X-ray report, dated 11/18/25 and reported on 11/18/25 at 4:08 P.M., showed the following:-Two views of the right elbow;-There was soft tissue swelling appreciated and suggestion of a fracture of the radial neck; -Impression of marked degenerative changes. Changes along the radial neck, which suggest a fracture of indeterminate age. Review of the resident's X-ray report dated, 11/18/25 date of service and reported on 11/18/25 at 4:11 P.M, showed the following:-Views of the right forearm;-Possible fracture involving the radial neck;-Impression of abnormal radial neck region.Review of the resident's progress note dated 11/22/25, at 10:29 P.M, the following: -Fall team meeting on 11/19/25;-The resident was found sitting on the floor and no injuries noted at the time of the assessment but afterwards had complaints of pain to his/her right arm;-Staff obtained an X-ray and noted a fracture to the radial neck with indeterminate age, may not be acute;-The medical director is aware, and the orthopedic physician is aware and ordered the resident to wear a sling;-Addendum entered by Licensed Practical Nurse (LPN) M on 11/22/25, at 10:44 P.M., noted at fall meeting therapy stated they would pick up the resident up for rehab.(Staff did not document family notification of the fall and x-ray results.)During an interview on 03/11/26, at approximately 1:30 P.M., LPN M said the resident had a fall on 11/18/25. The next day, on 11/19/25 the resident complained of pain. On 11/18/25, an X-ray was completed with results of a radial neck fracture. He/she did not see documentation of staff notifying the resident's responsible party of the X-ray results. Staff should document in the progress notes of notification of a resident's responsible party of an injury. During an interview on 03/11/26, at 2:25 P.M., Registered Nurse (RN C) said staff should document in the progress notes of X-ray results and notification of the resident and/or responsible party. During an interview on 03/11/26, at 3:47 P.M., the Director of Nursing (DON) said the following:-Nurses assess a resident following a fall;-The X-ray company comes to the facility to perform an X-ray on a resident or staff can send a resident to the hospital for the procedure;-Staff should document in the progress notes of notification of the resident and and/or responsible party of a fall;-Nurses call the physician for an X-ray order. Staff should notify the resident if own person or the resident's responsible party and document in the nurse's notes. During an interview on 03/11/26, at 5:36 P.M., the Administrator said he expected staff to notify a resident's family of X-ray results and injury and document in the progress notes. Complaint #2718595

Based on interview and record review, the facility failed to ensure residents received written notice before resident room changes when staff failed to provide and document room change notifications for one resident (Resident #1). The facility census was 106.Review of the facility's policy titled Changes in Patient/Resident Condition: Notification Guidelines, revised January 2025, showed the facility will promptly notify the resident and new roommate assignment in writing and the resident's legal representative or interested family member by phone if applicable when there is a change in room or roommate assignment. Review of the facility's policy titled Room and Roommate Transfers, revised 08/15/18, showed the following: -The facility reserved the right of room and roommate transfer at its discretion, so long as the transfer is not solely for the purpose of staff convenience;-The facility shall provide advance notice of a room or roommate transfer;-The facility agreed to allow resident to designate a roommate of his or her choice at any time, so long as accommodation of the resident's designation was practicable, both residents live at the facility, both residents consented to the arrangement, and the request did not infringe upon the rights of another resident;-In the event a room is not available at the time of resident's designation, accommodation of resident's roommate requests may be delayed until a room becomes available. 1.Review of Resident #1's face sheet (admission data) showed the following:-admission date of 02/10/25;-Diagnoses included fracture of unspecified part of neck of left femur (hip injury). Review of the resident's s Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/26/25, showed the resident's cognitive skills intact. Review of the facility's document titled Registration Events showed the following:-On 02/10/25, at 3:49 P.M., the resident admitted to a room on 100 hall; -On 02/19/25, at 3:13 P.M., the resident had change of room/bed to a room on the 200 hall.Review of the room/roommate change notice form, dated 04/18/25, showed for quality-of-care purposes, the resident will move to a room on 100 hall. Review of the facility's document titled Registration Events showed the following:-On 04/19/25, at 1:05 A.M. the resident changed rooms to one on 100 hall;-On 05/23/25, at 12:26 P.M, the resident changed rooms to one on 200 hall. Review of the resident's record showed staff did not document a room/roommate change notice provided to the resident or resident's representative. During interviews on 03/11/26, at 11:19 A.M. and 4:55 P.M., the Social Service Director (SSD) said the following:-Staff call the family or speak with the resident if they are their own person regarding a room change;-Reasons for room changes include a resident not getting along with a roommate or exit seeking behaviors;-Staff give the room/roommate change request card to the resident or representative of the room change;-Staff do not move a resident if they do not want to move;-On 04/18/25, she notified the resident's family member of the move to the more independent hall;-She did not find documentation of when the resident was moved back to the 200 hall; -She did not find documentation of the notifications for the resident's room change.During an interview on 03/11/26, at 12:18 P.M., Certified Nurse Aide (CNA) J said staff should tell the nurse if a resident wants a room change. The social service staff inform a resident of a room change. During an interview on 03/11/26, at 12:41 P.M., Licensed Practical Nurse (LPN) M said the following:-Staff should contact the social service department for any room changes;-Staff should document in the progress notes of any room changes consent from the family and discussion with the resident of the room change. During an interview on 03/11/26, at 3:47 P.M., the Director of Nursing (DON) said the following:-Social service staff talk to family and/or resident to get permission for a room change;-Weekend staff usually did not move residents unless there were safety issues. The nurse may call family to move into the locked unit;-Staff should document in the progress notes of a room change. During an interview on 03/11/26, at 5:36 P.M., the Administrator said he expected staff to document in the progress notes of a resident's room change and resident and/or family notification. Complaint 2718595

Based on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA F)) spoke in disrespectful tone and cursed when interacting with one resident (Resident #3). The facility census was 106.Review of the facility's policy titled Resident Rights, Rules and Regulations, revised 10/01/21, showed residents have the right to be treated with dignity and respect.1. Review of Resident #3's face sheet (admission data) showed the following:-admission date of0 5/01/19;-Diagnoses included dislocation of right ankle joint. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 02/20/26, showed the following:-Cognitive skills intact;-The resident had no behaviors;-The resident was dependent with toileting and personal hygiene;-The resident required substantial/maximal assistance with showering.Review of the resident's care plan, reviewed 02/26/26, showed the following:-The resident was admitted to the facility with a dislocation of his/her right ankle. The resident required extensive to total assistance with one to two staff assistance with all activities of daily living (ADL - dressing, grooming, etc.);-Use a calm reassuring approach.Review of the facility investigation, dated 02/17/26, showed the following:-The resident reported that he/she did not feel like CNA F's language in his/her room on 02/14/26, at approximately 9:30 P.M. were appropriate;-The resident reported CNA F got frustrated with the sit to stand lift that he/she utilized and cursed utilizing the f word at it;-The resident felt CNA F used inappropriate language. During an interview on 03/10/26, at 1:39 P.M., the resident said the following: -On 02/14/26, the sit stand was hard to turn;-CNA F took him/her to the bathroom and had trouble turning the lift;-The resident said he/she told Licensed Practical Nurse (LPN) G and the Social Service Director (SSD) of the incident with the lift and about CNA F cursing;-LPN G and SSD informed the resident to tell the Administrator;-The resident went to the Administrator's office and informed him of the incident with the lift and how mad CNA F was with the sit to stand lift and the CNA cursed.During an interview on 03/10/26, at 3:11 P.M., the Administrator said he received a delayed report something happening. The resident thought CNA F was unprofessional. CNA F cursed in the room with the resident, upset with some equipment. The resident said he/she did not appreciate the language. During an interview on 03/10/26, at 4:25 P.M., CNA F said he/she considered staff cursing around a resident not respectful and that is a form of abuse. During an interview on 03/11/26, at 9:28 A.M., CNA J said staff should not curse around a resident. CNA J considered it disrespectful if staff cursed around a resident. During an interview on 03/11/26, at 3:47 P.M., the Director of Nursing (DON) said staff should not curse around a resident. During an interview on 03/11/26, at 5:36 P.M., the Administrator he expected staff to be respectful with residents.Complaint 2718595

Based on interview and record review, the facility failed to have a complete grievance process in place when staff failed to consistently document in a timely manner grievances, steps taken to follow-up on the grievance, and resolution for one resident one resident (Resident #1). The facility census was 106.Review of the facility's policy titled Grievance Procedure, reviewed June 2024, showed the following:-Patients, residents, or their representatives may register a complaint or grievance regarding an aspect of the operation of a department or the care or treatment, abuse or neglect of a patient or resident without fear of reprisal;-Grievance is a formal or informal written or verbal complaint that is made to the facility by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the facility's compliance with the Centers for Medicare and Medicaid Services (CMS) conditions of participation, or a Medicare beneficiary billing compliant related to rights and limitations;-A staff member who receives a complaint should promptly take steps to resolve the concerns. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. If the concerns have not been resolved to the patient's /resident's satisfaction, the staff should notify their immediate supervisor. The supervisor should seek prompt action to resolve the complaint. If the supervisor cannot resolve the complaint, the Patient Advocate should be contacted to resolve the issue. In long term care facilities, the facility administrator should attempt to resolve the issue prior to contacting the Patient Advocate. If the concerns cannot be resolved by the Patient Advocate, the complaint will be elevated to a grievance;-Responses to relatively minor verbal requests shall be handled promptly and are not generally considered a grievance and do not require a written response. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for purposes of this policy. The Patient Advocate shall maintain a log of complaints and grievances through computerized Quality/risk Management module;-Whenever a patient or their representative requests that his or her complaint be handled as a grievance, or when the patient requests a response from facility staff, the complaint is considered a grievance. Upon request, provider must give a copy of the grievance policy to the patient, resident or representative;-The Patient Advocate shall contact the individual lodging the grievance, in writing, at the completion of the investigation. Written notice shall include the name of the contact person (Patient Advocate, administrator, or designee), the steps taken to investigate the grievance, the results of the grievance process, and the date of completion. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 02/10/25;-Diagnoses included fracture of unspecified part of neck of left femur (hip injury). Review of the resident's significant change Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/26/25, showed the following:-Cognitive skills intact;-Resident required partial/moderate assistance with toileting, shower, bathing and personal hygiene. Review of the resident's progress note dated 12/16/25, at 2:17 P.M., showed a nurse documented the resident's family member present and complained to a certified nurse aide (CNA) that resident had not had breathing treatment this day and he/she was reporting to social services, stating the resident requested breathing treatment two times this day. The resident's family member did not come to speak with this nurse and the resident refused breathing treatment two times this day. CNA reported the resident's family member complained of the resident wearing a brief rather than a pullup stating the resident did not like diapers. CNA attempted to explain to the resident's family member of the pullups. Management not in the building, and this nurse was unable to locate social service staff. The nurse entered the resident's room with another nurse and asked the resident's family member if there were any issues that needed resolved, the family member said no, everything is fine. Review of the resident's progress notes dated 12/17/25, at 12:30 P.M. (created on 12/18/25 at 12:30 P.M.), showed the Social Services Director (SSD) documented she received an email from the resident's family member on 12/17/25. The email stated he/she had concerns with the resident's care, from breathing treatments to wearing briefs. The resident's family member had concerns of several items being misplaced, lotion, Kleenex, turquoise ring, and watch. The SSD shared with the Administrator and Director of Nursing (DON) the content of the email. The staff member was addressed about the concerns and reported the resident's family member threw the wipes at him/her. The plan was to not have the staff member do any of the resident's care. The team will offer to move the resident to another hall. SSD called the resident's family member the same day and the family reported he/she did not throw the wipes. SSD reviewed the list of things missing. SSD will follow up with the resident's durable power of attorney. Review of the facility's complaint/concerns log showed the following:-Date: 12/17/25;-Person with complaint: The resident's family member;-Description of complaint: The resident's family member had concerns the resident's rings, lotion and watch were missing;-Date-response to complaint-signature: On 12/23/25 the facility brought the resident a new turquoise ring, three bottles of lotion and a new watch.(Staff did not document discussion with, or signature of, the resident or family member who filed the grievance.) Review of the resident's progress note dated 12/22/25, at 7:05 A.M. (created 01/14/26 at 7:05 A.M.) showed the SSD documented she responded to an email from the resident's family member. The family member stated several of the resident's things were missing. The facility replaced the turquoise rings with eight turquoise rings, two bottles of lotions and a watch on 12/22/25. The resident responded, why are you giving this to me? SSD stated to the resident it was brought to our attention you were missing these items. SSD informed the resident's family members of the items being replaced. Review of the resident's progress note dated 01/14/26, at 8:29 A.M., showed the DON documented she reached out to the resident's family member this morning and said she is understand there were some concerns regarding the night prior. The DON asked the family member if he/she would speak with her about any concerns he/she had. The family member stated that you can ask staff and read his/her formal grievance and hung up the phone on the DON.Review of the facility's grievance log showed staff did not document a grievance related to 01/14/26. During an interview on 03/11/26, at 9:28 A.M., Certified Nurse Aide (CNA) J said SSD was responsible for grievances. He/she would report to the charge nurse of any grievance from a resident or family. During an interview on 03/11/26, at 11:19 A.M., the SSD said the following:-She is the grievance officer;-If residents talk with staff of any complaints, staff should email or inform her of any complaints;-She reported to the Administrator/DON with a grievance. She spoke with the resident and should have a response immediately or within 24 hours;-If they were not able to resolve a grievance, she reports to the Administrator and DON;-She looked in the resident's room for the missing rings, lotions, and watch and did not locate the items;-The resident's family member emailed her 12/31/25 of an aide receiving $10.00 from the resident. SSD informed the Administrator who said he would take care of it;-She did not document the resolution on the grievance log. She did not know the results of the investigation regarding the $10.00;-She did not have a form with a resolution to return to the person who made a complaint or grievance.During an interview on 03/11/26, at 3:47 P.M., the DON said the following:-If a resident or family has a grievance, it is taken to social service staff;-Grievance forms are up front in a binder by the administrator office;-Staff should give the grievance form to the resident or family;-Staff try to figure out what the complaint was, talk to staff, residents and/or family and see what is their take on it;-Staff talk in the morning meetings of grievances;-Morning meetings involve the department heads, Administrator, staff coordinator, social services, Maintenance Supervisor, housekeeping;-She did not document resolutions of grievances but probably should. The SSD keeps the grievance log;-She expected staff to document notification of who filed a grievance and if resolved or not or a continued issue and needs to be readdressed;-She did not remember the concern of an aide accepting $10.00 from the resident.During an interview on 03/11/26, at 5:36 P.M., the Administrator said he was informed of the resident's missing items, and he instructed staff to replace the items. SSD should document who she talked with about a grievance and if the grievance was resolved and the date, the grievance should be on the complaint form. Staff should document the response to the person who filed a grievance and if resolved. He was not aware of the resident giving $10.00 to a staff member. Complaint #2718595

Based on interview and record review, the facility failed to develop a baseline care plan for all residents when staff failed to complete a baseline care plan within 48 hours of admission for one resident (Resident #2). The facility census was 106.Review of the facility's policy titled Assessments in Long Term Care, revised February 2026, showed the following:-Licensed nursing staff will begin to initiate an admission assessment of the patient when the patient presents to the nursing unit. The nursing assessments and screening assessments will be completed within 24 hours of admission. Additional assessments may be completed when there is a significant change in the patient's condition or diagnosis;-Purpose to provide an initial assessment to use as a baseline. To provide reassessments as needed if a change is indicated for the patient's response to care, condition changes, and/or diagnosis;-Initial admission assessments will be completed by a licensed nurse and will be documented on the admission assessment. Assessment will include the patient's physical, psychological, and social status;-The nursing assessment and other screening assessments will be completed within 24 hours of admission. The scope and intensity of further assessments will be based on the diagnosis, the specific nursing unit, the patient's desire for care, the consent to treatment, and the patient's response to previous care provided;-The nursing care plan will be initiated according to identified needs from the admission assessment by a licensed nurse. Licensed nursing personnel will update care plans as needs are assessed. Review of the facility's initial care plan upon admission form showed the following:-admission status;-Name the responsible party/resident that was offered/received a copy of Initial care plan and whether they accepted or declined;-Resident medications: Provide a copy of the medication list to resident or family (Staff can view in the electronic medical record). 1. Review of Resident #2 face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date 01/26/26;-admission diagnoses included multiple fractures of the pelvis. Review of the resident's progress notes dated 01/26/26, at 3:59 P.M., showed a nurse documented the resident arrived at the facility at 2:45 P.M. from the hospital. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment instrument completed by facility staff), dated 01/26/26, showed the following:-Cognitive skills intact;-The resident required partial/moderate assistance with toileting and personal hygiene. The resident required substantial/maximal assistance with showering, bathing, and lower body dressing. Review of the resident's medical record showed staff did not document completion of a baseline care plan.During an interview on 03/11/26, at 2:00 P.M., the MDS Coordinator/Registered Nurse (RN) N said the following:-The admitting charge nurse completes the initial baseline care plan upon admission;-The baseline care plan populates on a template in the computer. The nurse fills in the answers;-The admitting charge nurse should complete the baseline care plan within 24 hours and should be completed with admission notes;-The baseline care plan has admitted status, medicines, initial goals, the responsible party and resident section of offered to receive initial care plan and whether accepted or decline;-He/she did not see a baseline care plan for the resident. During an interview on 03/11/26, at 2:00 P.M., MDS Coordinator/Licensed Practical Nurse (LPN) O said the following:-He/she completes an admission audit within 48 hours after an admission;-He/she circles what the nurses did not complete on the admission paperwork and takes it back to the nurses' desk for them to complete;-Staff did not complete the baseline care plan for the resident;-The next nurse coming onto shift should complete anything the previous nurse did not complete;-He/she was under the impression the resident's baseline care plan had been completed. During an interview on 03/11/26, at 2:25 P.M. RN C said nursing staff should compete the baseline care plan upon admission. During an interview on 03/11/26, at 3:47 P.M., the Director of Nursing (DON) said the following:-The admitting nurse completes the new admission paperwork which include a head-to-toe assessment, falls, and skin assessments;-The admitting nurse completes the baseline care plan. The baseline care plan populates into the work list;-She expected the nurse to give a copy of the baseline care plan to the resident and/or family. During an interview on 03/11/26, at 5:36 P.M., the Administrator said the nurse on duty should complete the baseline care plan for a new admission. Staff should offer the resident and/or family to review the care plan.

Based on interviews and record review, the facility failed to keep residents free from accident hazards when one staff (Certified Nurse Aide (CNA) F) assisted one resident (Resident #3) in a unsafe manner while using a sit to stand lift (mechanical lift) and when staff (CNA I) did not utilize a gait belt (a 2-to-4-inch wide, sturdy belt, typically made of canvas or nylon, placed around a patient's waist to help caregivers safely assist with walking, standing, or transferring) during a transfer out of bed with one resident (Resident #5). The facility census was 106.Review of the facility's policy titled, Patient/Resident Handling, revised April 2025, showed the following:-Because patient/resident handling activities have been identified as a significant risk of injury to employees and others in the delivery and receipt of health care services within the organization, establishing and maintaining safe procedures for providing patient/resident care is a high priority;-Patient/resident handling incidents are analyzed for trends or patterns and appropriate follow up, changes in policy, staff education, or equipment maintenance initiated as required;-Employees are encouraged to report hazards, assert complaints, and/or make suggestions for improving the safety of patient/resident handling through the established procedures. 1.Review of Resident #3's face sheet (admission data) showed the following:-admission date of 05/01/19;-Diagnoses included dislocation of right ankle joint. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 02/20/26, showed the following:-Cognitive skills intact;-The resident had no behaviors;-The resident was dependent with toileting and personal hygiene;-The resident required substantial/maximal assistance with showering. Review of the resident's care plan, reviewed 02/26/26, showed the following: -The resident was admitted to the facility with a dislocation of his/her right ankle;-The resident required extensive to total assistance with one to two staff assistance with all activities of daily living (ADL – grooming, toileting, dressing, etc.);-Lifting/transfers in accordance with decision flow chart. The resident required one to two staff assistance for transfers;-The resident was alert and oriented and able to make his/her needs known;-Use a calm reassuring approach;-The resident had pain related to his/her previous fracture;-The resident was at risk for falls related to previous ankle injury with generalized weakness, dependence on staff for transfers, and use of psychoactive medications. Review of the facility's investigation, dated 02/17/26, showed the following:-The resident reported that he/she did not feel like CNA F's behaviors in his/her room on 02/14/26, at approximately 9:30 P.M., were appropriate;-The resident reported CNA F got frustrated with the sit-to-stand lift that he/she utilized. CNA F rocked the lift back and forth trying to get the wheels unstuck and the resident had to tell CNA F to calm down;-The resident reported that his/her upper chest was sore due to this incident. The resident was elevated in the sit to stand, and CNA F tried to get the wheels unstuck which resulted in him/her rocked back and forth in the lift which caused some discomfort in his/her chest region. During an interview on 03/10/26, at 1:39 P.M. and 3:56 P.M., the resident said on 02/14/26 the sit to stand lift was hard to turn. CNA F took him/her to the bathroom and had trouble turning the lift. CNA F could not get the sit to stand out of the bathroom. CNA F started raising the lift up in the air and letting the lift down which hit the floor, with him/her hanging up with his/her arms in the air and he/she swayed. The resident said he/she screamed at CNA F to calm down. The resident said he/she felt it could have been prevented if the floor was better. Other staff had difficulty getting the sit to stand lift in his/her bathroom. During an interview on 03/10/26, at 4:25 P.M., CNA F said he/she was with the resident in the bathroom and when he/she rolled the resident out of the bathroom, two of the wheels on the lift had locked up. He/she could not move the lift. The resident started swinging on the lift. He/she was worried the resident was going to fall out of the lift. During an interview on 03/11/26, at 10:06 A.M., CNA K said the lift was hard to move and the floor was horrible in the resident's room. The lift gets stuck. Staff should report any equipment issues to maintenance staff using the Quick Response (QR) code or verbally inform him. During an interview on 03/10/26, at 1:31 P.M., Licensed Practical Nurse (LPN) G said the following:-The resident said CNA F got angry with a transfer and could not get the sit to stand to work;-The resident said he/she had to yell at CNA F to stop. The resident said the incident scared him/her. CNA F was angry trying to move the sit to stand lift. During an interview on 03/10/26, at 2:18 P.M., LPN H said about three weeks ago, the resident said the night aide had jostled him/her in the sit to stand lift. The resident said CNA F appeared to be frustrated with the sit to stand lift. The resident said the sit to stand lift got stuck on an area to the bathroom where the lift gets stuck. The resident said CNA F got frustrated and went over the area of the bathroom to get him/her out of the bathroom, and CNA F was frustrated the lift was stuck. The resident said he/she felt scared. During an interview on 03/11/26, at 1:04 P.M. the Maintenance Supervisor said staff should put a work order in the computer and he checked for work orders every day and prioritizes them. Staff also inform him in person of any work orders. The maintenance department put in a new floor a year ago in the resident's room and staff needed to stay off of it for 24 hours. Staff put the sit to stand on it less than eight hours which caused it to sink. He did not have a work order or complaint with the sit to stand. After the resident's floor was ruined, staff would have to evacuate the room so they could strip out the floors. He asked staff if they had any issues with lifts awhile back, staff said it was useable and were transporting across the floor in the resident's bathroom. During interviews on 03/10/26, at 2:58 P.M., and on 03/11/26, at 3:47 P.M., the Director of Nursing (DON) said the following: -CNA F got frustrated with a sit to stand lift and it got stuck. CNA F shook the lift trying to get it unstuck from the little notch in the floor;-Staff place a maintenance request in the QR code posted around the building or the computer;-The Maintenance Supervisor reviewed at the work orders in the morning and reported them to the Administrator;-The Administrator informed her of the incident with the lift with the resident and CNA F. CNA F was rough getting the lift over the notch in the floor, CNA F shook the resident in the sit to stand lift;-She expected staff to report issues with floors and wheels locking up on a lift;-Staff rocking a lift back and forth causes safety issues with that lift. During an interview on 03/11/26, at 5:36 P.M., the Administrator said he expected staff to report if a sit to stand lift wheels locked up. He wanted things fixed, Staff should complete a work order, with a QR code to make it simple for the staff. He was not aware of the lift wheels locking up, or issues with the resident's floor. He expected staff to report any equipment issues and if flooring needs replaced. CNA F said the lift got stuck and he/she was concerned for the resident, trying to make sure the resident was safe. He was not aware the if the maintenance supervisor was made aware of the lift getting stuck during the incident with the resident. 2. Review of Resident #5's face sheet showed the following:-admission date of 05/26/19;-Diagnoses included dementia with behaviors. Review of the resident's quarterly MDS assessment, dated 02/12/26, showed the following:-Severely impaired cognitive skills;-Dependent on staff for toileting, personal hygiene and mobility. Review of the resident's care plan, revised 03/10/26, showed the following:-The resident required maximum staff assistance to total staff assistance with activities of daily living;-The resident required total assistance with all of his/her mobility needs;-The resident is at risk for falls related to advanced age, hearing and visual defects, opioid medication use, psychotropic medication use. Observation on 03/10/26, at 11:02 A.M. showed the following:-The resident lay in his/her bed;-CNA I rolled the resident to a sitting position and sat the resident up on the side of his/her bed;-Without using a gait belt, CNA I used both of his/her hands and placed them around the resident's back, stood the resident up, and pivoted to the right and sat the resident down in his/her wheelchair;-A gait belt hung on a hook on the wall beside the resident's bed. During an interview on 03/10/26, at 12:20 P.M., CNA I said the following:-He/she used a gait belt to transfer all residents;-The resident was care planned not to use a gait belt when getting resident up as he/she can fight getting up making it difficult to apply gait belt;-He/she did not use a gait belt to transfer resident this morning because he/she was worried resident might try and fight it;-The resident was not combative or resistant to care at that time. During an interview on 03/11/26, at 9:28 A.M., CNA J said staff should always use a gait belt with a one-person assistance transfer. During an interview on 03/11/26, at 10:06 A.M., CNA K said staff should always use a gait belt with the resident during transfers. During an interview on 03/11/26, at 12:21 P.M., Occupation Therapy Staff L said staff should use gait belts during transfers. Staff are trained on the use of the gait belt as the safest way to transfer. Staff should not lift on a resident's arms, which could cause injury. Staff should use a gait belt with getting a resident up and laying down a resident in bed if not using a lift. During an interview on 03/11/26, at 12:41 P.M., LPN M said staff should use a gait belt if the resident is not able to use the sit to stand. He/she had not heard of a gait belt not used getting up a resident. During an interview on 03/11/26, at 3:47 P.M., the DON said the following:-Staff should use a gait belt during transfers with a resident;-Gait belts use is for the resident and staff safety;-Gait belts make it easier for staff to control a resident and if they fall, it is a slow drop versus a hard hit;-The facility trains staff to use a gait belt with transfers;-Staff should use a gait belt during transfers with the resident. There is nothing in the resident's care plan or reason to not use a gait belt to get the resident up or lay the resident down with a gait. During an interview on 03/11/26, at 5:36 P.M., the Administrator said he expected staff to use a gait belt with the resident and there was no time the resident is care planned to not use a gait belt. Complaint #2718595

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of all residents when staff failed to provide medications as ordered by the prescriber to meet the needs of each resident when the facility failed to administer medications within the time frame specified by the provider for two residents (Resident #2 and Resident #6) out of four residents sampled . The census was 106.Review of the facility's policy titled Medication Administration and Documentation, dated 11/01/26, showed the following:-Medications not eligible for scheduled dosing times will have a time specified by the provider:-Medications eligible for scheduled dosing times include daily (QD), twice a day (BID), three times a day (TID), and hourly intervals such as every 6 hours (Q6SCH);-Standard administration times used include daily (9:00 A.M.), BID (9:00 A.M., 9:00 P.M.), TID (9:00 A.M., 3:00 P.M., 9:00 P.M.), and Q12HSCH (9:00 A.M., 9:00 P.M.);-Standard administration times may be adjusted by pharmacy staff due to drug or food incompatibilities;-The medication administration window in LTC has been extended to three hours before and after scheduled administration times for oral medications;-This liberalized medication pass allows for a more home like environment for residents;-LTC providers may exclude certain patients or medications from liberalized medication pass;-Oral agents with narrow therapeutic index such as anticoagulants (slows or prevents blood clotting) and anticonvulsants (used to treat seizures) should not be liberalized if ordered at a specific time on the Medication Administration Record (MAR);-If a scheduled dose is missed for reasons such as patient availability or patient refused the provider will be consulted for directions concerning the missed dose;-In long-term care facilities (LTC) medications are considered late if they are given more than 3 hours after their scheduled administration time.1. Review of Resident #2 face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 01/26/26;-admission diagnoses included multiple fractures of the pelvis.Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 1/30/26, showed the following:-Cognitive skills intact;-On anticoagulant medication.Review of the resident's care plan, reviewed 03/10/26, showed the resident at risk for bleeding due to taking anticoagulant medications.Review of resident's current physician orders showed the following:-An order, dated 01/26/26, for apixaban (an anticoagulant medication) 5 milligrams (mg) PO (by mouth) BID;-An order, dated 01/26/26, for flecainide (antiarrhythmic medication used to prevent and treat serious, often, or sustained, fast, and irregular heartbeats) 25 mg PO Q12hrs.Review of resident's MAR, dated 03/01/26 to 3/10/26, showed the following for apixaban:-On 03/01/26, staff administered a dose at 7:00 A.M. Staff did not document administration of the P.M. dose;-On 03/02/26, Staff did not document administration of the A.M. dose. Staff administered a dose at 8:01 P.M.;-On 03/03/26, staff administered the medication at 10:17 A.M. and 6:29 P.M.;-On 03/08/26, staff administered the medication at 12:14 P.M. and 7:10 P.M.;-On 03/09/26, staff administered the medication at 10:00 A.M. and 6:58 P.M.;-On0 3/10/26, staff administered the medication at 10:55 A.M., and 7:15 P.M.Review of resident's MAR, dated 03/01/26 to 03/10/26, showed the following for flecainide:-On 03/01/26, staff administered a dose at 7:00 A.M. Staff did not document administration of the P.M. dose;-On 03/02/26, staff did not document the A.M. dose administered. Staff administered the medication at 8:01 P.M.;-On 03/03/26, staff administered the medication at 10:17 A.M. and 6:29 P.M.;-On 03/08/26, staff administered the medication at 12:14 P.M. and 7:10 P.M.;-On 03/09/26, staff administered the medication at 10:00 A.M., and 6:58 P.M.;-On 03/10/26, staff administered the medication at 10:55 A.M. and 7:15 P.M.Review of the resident's nurses' notes, dated 03/01/26 to 03/10/26, showed staff did not document related to medication missed or given outside of the ordered time frame. During an interview on 03/11/26, at 12:15 P.M., the Nurse Practitioner (NP) said apixaban should be given 8 hours between doses. If given earlier then that, it would be a medication error.During an interview on 03/11/26, at 1:32 P.M., the Pharmacist said apixaban was typically scheduled at 9:00 A.M. and 9:00 P.M., due to the medication's half-life. Occasionally it would be okay to give six hours apart as not missing a dose was more important.2. Review of Resident #6 face sheet showed the following:-admission date of 05/28/25;-Admissions diagnoses included pressure ulcer of the sacral region (a wound near the end of the spine in-between the buttocks caused from pressure).Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitive skills intact;-On anticoagulant medication.Review of resident's care plan, reviewed 03/11/26, showed the resident was at risk for bleeding due to taking anticoagulant medications.Review of resident's current physician orders showed an order, dated 05/28/25, for metoprolol succinate (a beta-blocker used to treat high blood pressure, angina, and heart failure) 12.5 mg give daily at 6:00 A.M. Review of residents' MAR, dated 03/01/26 to 03/10/26, showed the following for metoprolol succinate;-On 03/01/26, staff administered the medication at 9:20 A.M.;-On 03/02/26, staff administered the medication at 9:27 A.M.;-On 03/03/26, staff administered the medication at 10:27 A.M.;-On 03/04/26, staff administered the medication at 9:45 A.M.;-On 03/05/26, staff administered the medication at 9:36 A.M.;-On 03/06/26, staff administered the medication at 10:22 A.M.;-On 03/08/26, staff administered the medication at 11:10 A.M.;-On 03/09/26, staff administered the medication at 10:19 A.M.;-On 03/10/26. staff administered the medication at 11:01 A.M.Review of resident's nurses' notes, dated 03/01/26 to 03/10/26, showed staff did not document related to medication administration outside of accepted time frames. 3. During an interview on 03/10/26, at 10:36 A.M., Certified Medication Technician (CMT) A said the following:-Liberal medication pass gives staff a three-hour window to give daily medication;-Medication with a specific time should be given as close to that time as possible.During an interview on 03/10/26, at 12:20 P.M., Registered Nuse (RN) B said the following;-Liberal medication pass gives staff a three-hour window to give some medication;-Scheduled medications and BID medications were given at a specific time;-Medication given too early or too late can be an error.During an interview on 03/11/26, at 10:00 A.M., RN C said the following:-Liberal medication pass gives staff a 3-hour window to give certain medications;-If a medication was scheduled for 6:00 A.M., staff have one hour before and one hour after to give that medication;-Staff have one hour before and one hour after to give scheduled BID medications.During an interview on 03/11/26, at 10:20 A.M., CMT E said the following;-Liberalized medication pass gives a three-hour window to pass some medications;-One time a day at a certain time, BID, TID, QID medications need to be given as close to their scheduled times as possible.During an interview on 03/11/26, at 12:15 P.M., the NP said the following:-Liberal medication pass allowed staff to adjust the time a medication was given;-Medications that staff can adjust times are routine medication;-If a medication is scheduled at 6:00 A.M., it should be given at that time;-BID medication is given at 8:00 A.M., and 8:00 P.M., or 9:00 A.M., and 09:00 P.M.During an interview on 03/11/26, at 1:32 P.M., the Pharmacist said the following:-Liberal medication pass was to allow for a more home like environment and gives staff a three-hour window to administer certain medications;-Exceptions to the liberal medication pass would be scheduled medications, those would be time specific.During an interview on 03/11/26, at 4:18 P.M., the Director of Nursing (DON) said the following:-He/she expected staff to give medications to resident when they are due;-Liberal medication pass gives staff a three-hour window for daily medications;-He/she expects BID medications to be given 8 to 10 hours apart.During an interview on 03/11/26, at 5:41 P.M., the Administrator said the following:-He/she expected staff to administer all medication within the policy of the facility;-Liberal medication pass gives staff a three-hour window to give daily medications;-Scheduled medications, it depends on the medication and the order how long between doses.Complaint 2794617 and 2718595

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevent possible contamination when the ice machine has a black substance on the deflector shield, a dented can was on the shelf for use, and scoops were left in the sugar and cornstarch. This has the potential to affect all residents who consumed food from the facility kitchen. The facility census was 109. 1. Review of the 2013 Missouri Food Code showed equipment food-contact surfaces and utensils shall be clean to sight and touch. Review of the facility's policy Ice Machines, dated 2024, showed the following: -Ice machine bins shall be cleaned on a quarterly schedule by departments utilizing cubers with bins; -Ice machines shall be cleaned using the wash, rinse, and sanitize process by removing all ice and water from the bin; -Using a cleaning solution or a solution with detergent and sanitizer combined wash interior of ice bin, rinse with clear water and town dry; -Inspect the ice chute for microbial growth, and clean as needed. Review of the preventative maintenance work order shows the ice machine was cleaned last on 07/31/24. Observation on 12/02/24, beginning at 9:27 A.M., of the ice machine showed the deflector shield, located over the ice, had multiple black spots over the entire shield. Observation on 12/04/24, beginning at 9:37 A.M., of the ice machine showed the deflector shield, located over the ice, had multiple black spots over the entire shield. During an interview on 12/04/24, at 2:14 P.M., Dietary Aide (DA) D said maintenance was responsible for cleaning the inside of the ice machine. The ice machine shouldn't have a black substance in it. During an interview on 12/04/24, at 2:19 P.M., DA E said he/she didn't know who was responsible for cleaning the inside of the ice machine. It should not have black spots on the inside. During an interview on 12/04/24, at 2:23 P.M., the Assistant Dietary Manager said they have a company that takes care of the ice machine, but they don't do anything with the inside. He/she wasn't sure who cleans the inside, but it shouldn't have black spots on the inside. During an interview on 12/04/24, at 3:50 P.M., Maintenance Director said the following: -He/she cleaned the inside of the ice machine; -He/she had a program called preventative maintenance and the program told him/her when to clean the ice machine; -He/she was not aware the deflector shield had black spots. There shouldn't be black spots in the ice machine. During an interview on 12/04/24, at 2:50 P.M., the Administrator said the following: -Maintenance cleans the inside of the ice machine; -The system generates preventative maintenance schedules and the tasks are completed as scheduled; -He/she was not aware there were black spots on the deflector shield. 2. Review of the Food and Drug Administration (FDA) 2022 Food Code FDA showed the following: -Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard. -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. Observation on 12/02/24, beginning at 9:27 A.M., showed a 105 ounce can of pumpkin, with a large dent on the side, located by several other cans of pumpkin on the shelf. Observation on 12/04/24, beginning at 9:37 A.M., showed a 105 ounce can of pumpkin, with a large dent on the side, located by several other cans of pumpkin on the shelf. During an interview on 12/04/24, at 2:14 P.M., DA D said they do not use cans with dents on them. They put them away from the other cans. During an interview on 12/04/24, at 2:19 P.M., DA E said they do not use cans with dents. They put them in a bucket. During an interview on 12/04/24, at 2:23 P.M., Assistant Dietary Manager said the following: -They have two cans of pumpkins with dents; -If the dents are minor, or if the staff sometimes drop them and they have a dented rim they will use them; -If the cans come in with dents they will send them back. During an interview on 12/04/24, at 2:50 P.M., the Administrator said if dented cans come in from the truck dented, they should be returned. If staff cause the dent, they should be disposed of and not used. 3. Observation on 12/02/24, beginning at 9:27 A.M., showed the following: -Large plastic container of sugar with a scoop halfway in the sugar; -Large plastic container of cornstarch with the scoop partially in the cornstarch. (The scoop handles could come in contact with the sugar or cornstarch causing potential contamination.) Observation on 12/04/24, beginning at 9:37 A.M., showed the following: -Large plastic container of sugar with a scoop halfway in the sugar; -Large plastic container of cornstarch with the scoop partially in the cornstarch. During an interview on 12/04/24, at 2:14 P.M., DA D said as far as he/she knew the scoops are okay to be down inside of the containers of sugar and cornstarch. During an interview on 12/04/24, at 2:19 P.M., DA E said scoops should not be left in the plastic containers. They should be stored elsewhere. During an interview on 12/04/24, at 2:23P.M., the Assistant Dietary Manager said he/she didn't know if scoops could be left down in the containers of food. During an interview on 12/04/24, at 2:50 P.M., the Administrator said scoops should not be left in containers with food such as sugar and cornstarch.

Based on observation and interview, the facility failed to maintain a sanitary environment for all residents and staff when staff failed to ensure the fans located in the walk-in refrigerator and walk in freezer were kept clean. The facility census was 109. Review showed the facility did not provide a policy that addressed maintenance of the refrigerator or freezer fans. 1. Review of the facility's weekly cleaning schedule showed the staff responsible for cleaning the fans in the freezer or refrigerator was not listed. Observation on 12/02/24, beginning at 9:27 A.M., showed the following: -Black and brown substances on the plastic casing on the refrigerator fans; -Black and brown substance on the plastic casing covering the fans in the freezer. Observation on 12/04/24, beginning at 9:37 A.M., showed the following: -Black and brown substances on the plastic casing on the refrigerator fans; -Black and brown substance on the plastic casing covering the fans in the freezer. During an interview on 12/04/24, at 2:14 P.M., Dietary Aide (DA) D said maintenance is responsible for cleaning the fans in the refrigerator and freezer. He/she hasn't noticed them being dirty or he/she would have told maintenance. During an interview on 12/04/24, at 2:19 P.M., DA E said he/she had not been at this facility long, but in other facilities the maintenance person has been responsible for cleaning the fans in the walk in freezer and refrigerator. He/she had not noticed them being dirty. During an interview on 12/04/24, at 2:23 P.M., the Assistant Dietary Manager said he/she didn't know how to turn the fans off to clean them. He/she wasn't sure if maintenance or dietary staff were supposed to be cleaning the fans. He/she had not noticed the fans being dirty. During an interview on 12/04/24, at 3:50 P.M., the Maintenance Director said the following: -Normally the task of cleaning the fans inside of the freezer and refrigerator would generate on the preventative maintenance; -He/she didn't know when they were cleaned last, but he/she should be getting reminders; -The fans shouldn't' have black or brown substances on them. During an interview on 12/04/24, at 2:50 P.M., the Administrator said maintenance is responsible for cleaning the fans in the walk in refrigerator and freezers.

Based on interview and record review, the facility failed to give ensure all residents received bed hold information upon transfer when staff failed to provide the facility's bed hold policy to the resident and/or resident's representative for five residents (Residents #32, #35, #261, #31, and #68) who were transferred out to the hospital. The facility census was 109. Review of the facility's policy entitled Bed Hold and Re-Admission, dated 2024, showed the following information: -Residents and their family members or legal representatives will be informed of the bed hold policy in writing upon admission as part of the admission contract; -In the case of an emergency, a written notification will be made within 24 hours of the transfer. Review of the facility's bed hold policy card showed the following: -The facility is required by Centers for Medicare and Medicaid Services (CMS) to notify residents of the bed hold policy upon any transfer or discharge from the facility. 1. Review of Resident #32's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included vitamin D deficiency, renal failure (when the kidneys are no longer able to filter waste and toxins from the blood), diabetes (the body doesn't produce enough insulin or use the insulin properly), and dementia (decline in thinking, memory and reasoning skills). Review of the resident's nurses' notes, dated 11/21/24, showed the following: -Resident found on floor next to bed in resident's room; -Resident sent to the emergency room (ER) for multiple head lacerations. Review of the resident's medical record showed the facility did not have a copy of the bed hold policy sent, or document sending a bed hold policy, with the resident or to the resident's representative. 31464 2. Review of Resident #35's face sheet showed the following: -admitted [DATE]; -Diagnoses included sepsis (infection in the bloodstream), deficiency of vitamins B12 and D, low thyroid function, obesity, high cholesterol, low magnesium level, dementia, major depressive disorder, anxiety disorder, restless legs syndrome, degenerative disease of the nervous system, insomnia, chronic pain, metabolic encephalopathy (brain dysfunction due to a chemical imbalance elsewhere in the body), chronic kidney disease, atrial fibrillation (irregular heart function), history of mini-stroke, low blood pressure, and osteoarthritis. Review of the resident's nurse's notes, dated 08/14/24, at 1:11 P.M., showed the resident's roommate used his/her call light. On entry to the room, staff found the resident on the floor next to his/her bed. The resident said his/her head hurt and a laceration was noted to the side of his/her head. Review of the Emergency Medical Service (EMS) Transfer Report, dated 08/14/24, showed the following information: -Reason for ER visit: recent fall, decreasing blood pressure, episode of bleeding with three golf ball sized blood clots; -Facility checklist indicated: med list printed, face sheet printed, resident elected a status of Do Not Resuscitate (DNR), Staff did not indicate bed hold Information provided. Review of a transfer letter, dated 08/14/24, showed staff did not document information regarding a bed hold policy given to the resident or mailed to his/her responsible party. 3. Review of Resident #261's face sheet showed the following: -admitted [DATE]; -Diagnoses included prostate cancer, iron deficiency, deficiency of vitamins B group and D, high cholesterol, high potassium, major depressive disorder, anxiety disorder, insomnia, chronic pain, metabolic encephalopathy, high blood pressure, heart disease, history of stroke, circulatory disease, and gastro-esophageal reflux disease (GERD - stomach acid backs up into the chest and throat). Review of nurses' notes, dated 10/30/24, showed the resident left the facility via emergency medical services (EMS). Review of the EMS Transfer Report, dated 10/30/24, showed the following information: -Reason for ER visit: low blood pressure, high pulse, low oxygen saturation level, positive for COVID-19, and lethargy; -Facility checklist did not show indication of med list printed, face sheet printed, or bed hold Information given. Review of a Transfer Letter, dated 10/30/24, showed staff did not document information pertaining to a copy of the bed hold policy given or sent to the responsible party. 41787 4. Review of Resident #31's face sheet showed the following information: -admitted [DATE]; -Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) , and chronic anxiety; -Resident was not self-responsible. Review of the resident's EMS Transfer Report, dated 11/06/24, showed the following: -Resident transferred to emergency room via ambulance with complaints of right wrist pain, back pain, and left side of head pain; -Phone message was left for family member; -Medication list and face sheet sent with resident; -Bed hold was not checked as provided. Review of the resident's medical record showed the facility did not send a bed hold policy with the resident, or to the resident's representative. 5. Record review of Resident #68 face sheet showed the following information: -admitted [DATE]; -Diagnoses included coronary artery disease (CAD - common heart disease in which there is narrowing or blockage of the coronary arteries), hypertension (high blood pressure), peripheral vascular disease (PVD - a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions); -Resident was not self-responsible. Review of the resident's nurses' notes showed staff documented the following: -On 11/10/24, at 1:28 P.M., staff called the nurse to the resident's room after lunch. The resident complained of pain to right chest that radiated to the back with breathing. Vital signs obtained. Contacted on-call physician and received order to send to emergency room . EMS arrived and the resident was transferred to the gurney. Family notified by phone. Review of the facility transfer letter showed the resident was sent to the emergency department on 11/10/24. Review of the resident's medical record shows the facility did not send a bed hold policy with the resident, or to the resident's representative. 6. During an interview on 12/05/24, at 8:22 A.M., the Business Office Manager (BOM) said the following: -He/she sends out hospital transfer letters when a resident goes to the hospital; -He/she doesn't know anything about bed hold policies. During interviews on 12/05/24, at 11:25 A.M. and 11:40 A.M., the Social Services Director (SSD) said the following: -The nursing staff notify resident families of bed hold by phone and ask if they want to hold the bed when transferred to the hospital. There was no written notification of the bed hold policy sent to the resident or resident's representative. -He/she was responsible for completing the admissions paperwork and it included the bed hold policy; -He/she didn't have anything to do with sending out bed hold policies when a resident is sent out on therapeutic leave; -There is a section in the medical record where therapeutic leaves of absence are documented, but He/she doesn't know about a form to send with the resident or the resident's representative. During an interview on 12/05/24, at 3:00 P.M., Registered Nurse (RN) A said bed holds are done up to 30 days on admission and up to 30 days after readmission. He/she doesn't do anything with bed holds or give residents a form when they go out on a hospital leave. During an interview on 12/05/24, at 3:12 P.M., RN C said the following: -When a resident was transferred to the hospital, he/she sent a message to leadership and they put a bed hold in the record; -If it's in the middle of the night when a resident is sent out, he/she goes in the computer and puts in the medical record a bed hold; -He/she didn't know anything about a form that is sent out with the resident or to the resident's representative. During an interview on 12/06/24, at 9:28 A.M., the Assistant Director of Nursing (ADON) said the following: -When a resident goes out to the hospital, the bed hold is included in the other paperwork sent with the resident; -The BOM sends out a hospital transfer letter that also includes the bed hold. During an interview on 12/06/24, at 11:40 A.M., the Director of Nursing (DON) said -Staff send a bed hold policy with the residents upon transfer to the hospital; -The policy is also mailed to the resident's representative, power of attorney or guardian. During an interview on 12/06/24, at 1:05 P.M., the Administrator said they have bed hold cards that are supposed to go out with the residents when they're transferred to the hospital. The BOM sends out the bed hold policy to the family.

Based on observation, interview, and record review, the facility failed to ensure catheter (sterile tube inserted into the bladder to drain urine) usage and care per standards of practice when staff failed to obtain physician's orders regarding placement of a catheter and catheter care for two residents (Resident #29 and Resident #33) in a sample of size of 3. The facility census was 109. Review of a facility's policy entitled Urinary Catheterization, dated 2024, showed urinary catheters should be placed only under the direction of a physician's order. 1. Review of Resident #29's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included obstructive and reflux uropathy (condition in which the flow of urine is blocked), retention of urine (condition that makes it difficult to empty the bladder, either partially or completely), and acute kidney failure (condition where the kidneys suddenly lose their ability to filter waste from the blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 10/15/24, showed the following: -Severe cognitive impairment; -Resident had an indwelling catheter; -Resident dependent on staff for toileting hygiene and personal hygiene. Review of the resident's care plan, last reviewed 12/02/24, showed the following: -Due to urethral stricture (narrowing of the urethra (tube through which urine leaves the body) caused by scar tissue) the resident had a long term foley catheter (thin, flexible tube that drains urine from the bladder into a collection bag when a person is unable to urinate on their own). The catheter was to be changed by urology (medical and surgical specialty that treats conditions of the urinary tract) as it had to be surgically placed; -Staff should assess indwelling urinary catheter; -Staff should provide urinary catheter care; -No longer seeing urology, may change catheter every month. Review of the physician's order sheet, dated 12/02/24, showed no orders for indwelling catheter or catheter care. Observation on 12/02/24 showed the following: -At 10:00 A.M., the resident was seated in a wheelchair in the common area near the nursing desk with a catheter bag in a dignity bag located under his/her wheelchair; -At 12:00 P.M., the resident was seated in the dining room with a catheter bag located under his/her wheelchair. 2. Review of Resident # 32's face sheet, showed the following: -admitted [DATE]; -Diagnoses included renal failure (when the kidneys are no longer able to filter waste and toxins from the blood). Review of the resident's quarterly MDS, dated [DATE], showed staff did not indicate the resident had an indwelling catheter. Review of the resident's family nurse practitioners's note, dated 11/25/24, showed the following: -Resident was hospitalized due to a fall on 11/21/24; -Resident was found to have urinary retention, a foley catheter was placed and returned thick, purulent (containing puss) discharge. Observation on 12/02/24, at 11:44 A.M., showed the resident in the dining room eating with catheter bag attached to the bottom of his/her wheelchair. Review of the resident's physician orders showed staff did not document orders for a catheter placed or catheter care prior to 12/03/24. Review of the resident's care plan, updated of 12/03/24, showed staff to manage urinary catheter and continue foley catheter care. Review of the resident's December 2024 Physician Order Sheets showed the following: -An order, dated 12/03/24, to insert urinary catheter; -An order, dated 12/03/24, to continue foley catheter care. During an interview on 12/05/24, at 3:00 P.M., Registered Nurse (RN) A said the following: -The resident came back from the hospital with a catheter; -Orders for a catheter would come from the hospital; -Usually facility staff ask for a catheter to be removed after a resident is admitted from the hospital, but the resident has acute urinary retention; -He/she pulled up the resident's record and it showed on his/her work list the resident has a catheter; -He/she looked at the resident's online medical record and saw an order for a catheter on 12/03/24. During an interview on 12/05/24, at 3:12 P.M., Certified Nurse Aide (CNA) B said the resident came from the hospital with a catheter. During an interview on 12/05/24, at 3:12 P.M., RN C said he/she looked at the resident #32's orders and he/she had an order for a catheter beginning 12/03/24. 3. During an interview on 12/05/24, at 3:00 P.M., RN A said the following: -Orders are usually put in by the nurse or the doctor; -Aides have work lists and the catheter care comes up on the list; -Aides also document urine output; -He/she said all residents with a catheter should have an order. During an interview on 12/05/24, at 3:12 P.M., CNA B said the following: -He/she knew which residents had catheters as he/she learned about each resident; -He/she documents catheter cares in the medical record; -He/she also documents output of urine. During an interview on 12/05/24, at 2:45 P.M., Licensed Practical Nurse (LPN) J said the following: -Catheter care would show on the nursing staff work list interventions in the computer. The information would include when the catheter change was due and the pertinent size information. -He/she did not know what the care plan said. -He/she said that facility policy was to change any catheters every 30 days. -The information would not populate the due date, the nurses just were aware to check that 30 days had occurred. During an interview on 12/05/24, at 3:12 P.M., RN C said the following: -Staff know which residents have catheters as the work order pops up on the status board; -The aides have different work orders for documenting cares and urine output; -Every resident with a catheter should have an order; -Nurse's are responsible for putting in the orders. During an interview on 12/06/24, at 9:28 A.M., the Assistant Director of Nursing (ADON) said residents with catheters should have an order to insert, insert/remove, and manage or continue. He/she wasn't sure if the orders would say all of this, but it would be on the staff's work list. During an interview on 12/06/24, at 11:40 A.M., the Director of Nursing (DON) said any resident with a catheter should have an order and the admitting nurse was responsible for putting in the order. During an interview on 12/06/24, at 1:05 P.M., the Administrator said nurses should be putting in orders for catheters, and all residents should have an order. 41787

Based on observation, interview, and record review, the facility failed to have pharmacy services in place to ensure a consistent counting, reconciliation, and destruction of controlled substances when staff failed to consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log and failed document administration on individual resident controlled drug record logs for three residents (Resident #13, #34, and #35) located in one of four medication carts in the facility. The facility census was 109. Review of the facility's policy titled Controlled Substances, PHA04-02, revised 09/24, showed the following: -Pharmacy services is responsible for the proper safeguarding of controlled substances throughout all the hospital and facilities connected to the facility; -The purchase, storage, distribution and accounting of controlled medications will be done in accordance with all federal and state laws and standards of professional practice; -Nursing units are responsible for routine inventories of controlled substances kept in their automated dispensing cabinets (ADCs); -Nursing units will conduct narcotic counts at least weekly or per department guidelines; -Controlled substance discrepancies will be reported to the charge nurse immediately; -If the count is incorrect, licensed nursing personnel from the off-going shift will stay until the discrepancy has been resolved; -Resolution of the discrepancy must be documented in the ADC and witnessed by a second nurse; -Any controlled substances not stored in the ADC will be counted at the change of shift by both the licensed nurse leaving the shift and the nurse coming on duty. Both nurses must sign the narcotic inventory sheet thereby verifying that the count is correct; -Narcotic prescriptions are secured in a designated medication cart in each long term care facility; -Long term care facilities much establish a resident specific control sheet for each narcotic prescription delivered for resident use; -Directors of Nursing (DONs) are provided a daily report for all narcotics pulled from the e-kit. DONs are responsible for confirming all dispensing, administration, and waste records align; -Waste/destruction of controlled substances shall be done in the presence of two licensed individuals who are authorized to handle and control these drugs. 1. Review of the Control Medication Shift Count Sheet and Continuous Package Count: Cart/Cabinet log, dated 11/27/24 to 12/05/24, for the 100 hall/small unit medication cart, showed the following: -On 11/27/24, at 10:00 P.M., one staff signed the shift count sheet; -On 11/28/24, at 6:00 A. M., one staff signed the shift count sheet; -On 11/28/24, at 2:00 P.M., one staff signed the shift count sheet; -On 11/30/24, at 2:00 P.M., one staff signed the shift count sheet; -On 11/30/24, at 10:00 P.M., one staff signed the shift count sheet; -On 12/2/24, at 10:00 P.M., one staff signed the shift count sheet; -On 12/3/24, at 2:00 P.M., one staff signed the shift count sheet when four controlled medication packages were removed/destroyed; -On 12/04/24, at 6:00 A.M., one staff signed the shift count sheet; -On 12/04/24, at 2:00 P.M., one staff signed the shift count sheet; -On 12/05/24, at 6:00 A.M., one staff signed the shift count sheet and no further counts were documented for the day; -On 12/06/24 staff did not document narcotic counts. During an interview on 12/06/24, at 10:30 A.M., Registered Nurse (RN) C said the following: -The last count documented on the List for Narcotics sheet showed 12/04/24 for the 7:00 A.M. to 3:00 P.M. shift signed by Registered Medication Technician (RMT) F. -Staff did not document a count for 12/05/2024, but RMT G should have counted and documented. -RMT F also did not count or document on the List for Narcotics sheet when he/she left the facility during his/her shift at 8:00 A.M. on 12/06/24 to attend an appointment. During an interview on 12/06/24, at 11:25 A.M., RMT F said this morning Licensed Practical Nurse (LPN) I left the night shift, gave him/her the narcotic keys and left without counting. He/she has two medication carts to manage during his/her shift. 2. Observation on 12/06/24, at 10:30 A.M., of the narcotics and the controlled drug record documents located on the 100 hall/small unit medication cart showed the following: -Resident #13's oxycodone HCL (a controlled pain medication used to treat moderate to severe pain) 5 milligram (mg) tablet package contained 61 tablets. The controlled drug record showed 62 tablets available. -Resident #34's tramadol HCL (a controlled pain medication used to treat moderate to severe pain and chronic pain) 50 mg tablet package contained 68 tablets. The controlled drug record showed 69 tablets available. -Resident #35's oxycodone IR 5 mg tablet package contained 26 doses. The controlled drug record showed 27 tablets available. During an interview on 12/06/24, at 12:56 A.M., RMT F said the following: -Resident #13's oxycodone HCL 5 mg package had 61 tablets. -Resident #35's oxycodone IR 5 mg package had 26 tablets. -Resident #'34's tramadol HCL 5 mg package had 68 tablets. During an interview on 12/06/24, at 12:50 P.M., RN C said he/she administered tramadol to Resident #34 at 9:24 A.M. and oxycodone to Resident #35 at 9:46 A.M. He/she did not document the medication on either resident's controlled drug record at the time administered. He/she wrote the date and time administered on a sticky note. During an interview on 12/06/24, at 1:01 P.M., the Director of Nursing (DON) reviewed the electronic narcotic administration record at the nurses' station with RN C for Resident #13 , Resident #35, and Resident #34. The DON said RMT G documented that he/she administered tramadol to Resident #34 on 12/05/24, at 6:39 P.M., but did not document the dose on Resident #34's controlled drug record. On 12/04/24, RMT G documented administering oxycodone to Resident #13 at 8:52 A.M., but he/she did not document the dose on Resident #13's controlled drug record. 2. During an interview on 12/06/24, at 11:17 A.M., RMT H said he/she completed narcotic counts with a nurse in the morning, with another RMT when he/she leaves for the evening, and with any medication cart changes. During an interview on 12/06/24, at 11:19 A. M., RN A. said he/she would not accept responsibility for administering narcotics without counting with other staff first. For discrepancies, he/she checked to see if the discrepancy was something he/she did not document, then he/she checked with other staff that recently passed narcotics. With unresolved discrepancies, he/she contacted the DON. During an interview on 12/06/24, at 11:25 A.M., RMT F said he/she occasionally completed narcotic counts with other staff. He/she has two medication carts to manage during his/her shift. If he/she does not get to count the narcotics, he/she goes ahead and passes the narcotics, but tries to count them and sign the narcotic sheet as the medications are passed even though he/she is the only one counting and signing. With discrepancies, he/she talks with the staff that narcotic keys were obtained from or to the DON. He/she counted narcotics with a RMT or nurse when they were available. He/she documented on a shift sheet and a narcotic card count sheet. During an interview on 12/06/24, at 10:45 A.M., the DON said his/her expectation was for the nurses and RMTs to do narcotic counts at shift change and with every exchange of narcotic keys. If narcotics are missing or there is a discrepancy, he/she would expect staff to notify him/her and he/she would investigate it and report to the Administrator. When staff that administer narcotics leave the building even for a temporary amount of time, the expectation was for the narcotic count to be completed prior to the staff leaving. If there was a narcotic discrepancy that he/she cannot rectify, the staff would be held in the facility until the issue is resolved. During an interview on 12/06/24, at 10:55 A.M., the Administrator said he/she expected staff to complete narcotic counts with each shift change, any change of staff and if staff leave the facility during their shift. He/she would hold staff in the facility until discrepancies are resolved. At 1:43 P.M., the Administrator said the narcotic count should be completed every shift with two staff and every time the narcotic passing role changes hands. Discrepancies in narcotics need to be taken care of immediately. 41787

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #49) of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 109. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. Review shoed the facility did not provide a policy pertaining to the issuance of Advance Beneficiary Notices. 1. Review of Resident #49's electronic medical record (EMR) summary page showed admitted [DATE]. Record review of the resident's Skilled Nursing Facility Beneficiary Notification Review, completed by facility staff on 12/05/24, showed the following: -Medicare Part A skilled services episode start date 10/14/24; -Last covered day of Medicare Part A service as 12/06/24. -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. (Facility staff did not provide the resident or his/her legal representative the required SNFABN form CMS-10055 or alternative denial letter.) During an interview on 12/06/24, at 10:55 A.M., the resident said he/she signed the Notice of Medicare Non-Coverage (CMS-10123-NOMNC), but the facility did not provide anything showing an estimated cost of services that would not be covered after that day. The resident said he/she did his/her own research to find out the daily cost of room/board and therapy. He/she would need to stay in the facility until he/she was able to bear weight on his/her affected leg and transfer independently. During an interview on 12/06/24, at 1:30 P.M., the Social Services Director (SSD) said he/she was responsible for issuing the resident or their responsible party the Medicare Part A discharge forms. He/she was told during his/her training to only issue the SNFABN for CMS-10055 if a resident was going to stay in the facility for long-term care. The SSD did not issue the form to the resident prior to the last covered day of Medicare Part A skilled services. During an interview on 12/06/24, at 1:05 P.M., the Administrator said if a resident might potentially stay in the facility past their last covered date of Medicare Part A services, the facility should issue a CMS-10055 to show the potential cost of services not covered.

Based on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment for two residents (Residents #18 and #77) within 92 days of the prior assessment. The facility had a census of 109. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; and -The ARD must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Review showed the facility did not provide a policy pertaining to the completion of MDS assessments. 1. Review of Resident #18's MDS submitted reports showed the last MDS assessment ARD date was 07/24/24. Staff did not document an assessment completed since 07/24/24 (over 129 days prior). 2. Record review of Resident #77's MDS submitted reports showed the last MDS assessment ARD date was 07/29/24. Staff did not document an assessment completed since 07/24/24 (over 124 days prior). 3. During interviews on 12/05/24, at 1:40 P.M. and 1:55 P.M., the MDS Coordinator said the following: -Until recently, he/she has been the only one doing MDS assessments; -The facility had a tracking system, but there was a glitch and a couple of residents didn't have their quarterly assessments completed timely; -Resident #18 had his/her last assessment on 07/24/24; -Resident #77 had a quarterly assessment on 07/29/24; -The assessments are due every 92 days. During an interview on 12/06/24, at 11:50 A.M., the Assistant MDS Coordinator said the following: -Quarterly assessments completed every 92 days, repeat the cycle until the fourth and that's the annual; -Resident #18's quarterly was due 92 days after 07/24/24. The report omitted the next one due so it wasn't done timely; -Resident #77's quarterly was due 92 days after 07/29/24. The report omitted this resident's next assessment time so it wasn't completed timely; -He/she recently began assisting with MDS assessments and helps a couple days per week. During an interview on 12/06/24, at 1:05 P.M., the Administrator said the following: -MDS assessments are done every 90 days and have a 10 day window; -He/she isn't aware of a system the MDS Coordinator uses to track assessments; -He/she isn't aware of any MDS assessments not completed timely; -He/she expected the assessment to be completed timely.

Based on observations, record review, and interview, the facility failed to provide enteral nutrition per standards of practice when staff failed to administer tube feeding consistently as ordered and failed to ensure the orders were clear and accurate for one resident (Resident #102), out of a sample of one resident. The facility census was 109. Review of the facility policy, titled Tube Feedings, dated 11/2023, showed the following: -Tube feeding shall be administered by licensed nursing personnel upon recommendation of registered dietician and/or order by physician; -For continuous method of administration, staff should assure tubing is connected, fill the chamber one-half full and prime tubing, hang the container from the infusion pump pole, thread the tubing through the infusion pump, head of bed elevated 30 to 45 degrees at all times; -Connect the tubing to the feeding tube. Secure the connection with tape; -Set the rate as ordered and begin the infusion; -Staff should document the feeding and water flush; -Record intake and output; -Document residuals; -Document area of concern and notify physician. 1. Review of Resident #102's face sheet showed the following: -admitted [DATE]; -Diagnoses included nontraumatic subarachnoid hemorrhage from anterior communicating artery (a type of intracranial (inside the skull) bleeding that occurs when an aneurysm (bulge or ballooning in a blood vessel wall that's caused by a weakened area ) in the anterior communicating artery (short blood vessel that connects the left and right anterior cerebral arteries in the brain) ruptures and leaks blood into the subarachnoid space (surrounds the brain)), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), personal history of aneurysm rupture, and craniotomy (surgical opening into the skull). Review of the resident's care plan, last reviewed on 12/06/24, showed the following: -As of 08/06/24, due to the resident's poor oral intake and frequent changes in condition, the resident had restarted tube feeding; -As of 08/06/24, the resident had a pureed diet with thickened liquids; -As of 08/06/24, the resident was on a regular diet with thin liquids and tube feeding supplementation if less than 50% of oral meal is consumed; -Staff should refer to the current order for tube feeding instructions. Review of the resident's physician note, dated 11/22/24, showed the following: -Staff sent a message to the physician stating the resident was currently getting jevity (therapeutic nutrition product that provides complete, balanced nutrition for people who are unable to get enough calories and nutrients by mouth) 1.5 calories every 8 hours, sometimes did not tolerate it well, and was having residual emesis (vomiting). Speech therapy (ST) and nurse discussed continuous feeding. Could staff receive an order for continuous feeding jevity 1.5 calorie at 30 milliliter (ml) per hour for 18 hours for mostly during the night and off for 6 hours to promote eating during the day and working with speech ST and can staff continue with the flushes every 8 hours; -The physician responded let's try this and continue to observe the resident for nausea and/or vomiting and make changes if necessary. The resident is an aspiration risk, so staff need to be monitoring him/her. Review of the physician orders. dated 12/06/24, showed the following: -An order, dated 11/13/24, for tube feeding flush of 250 ml water three times per day at 5:00 A.M., 1:00 P.M., and 9:00 P.M.; -An order, dated 11/22/24, jevity 1.5 calorie, to run at 30 ml/hr every 18 hours, for duration of 33 hours and 20 minutes, with a total volume of 1,000 ml. Observations showed the following: -On 12/02/24, at 11:00 A.M., the resident was in bed with his/her eyes closed. Tube feeding attached to infusion pump running at 30 ml/hr; -On 12/03/24, at 8:58 A.M., the tube feeding was not attached to the resident or the infusion pump and not turned on. The resident was in bed with his/her eyes closed; -On 12/03/24, at 11:15 A.M., the resident was in the dining room. His/her meal included pureed meat, spinach, and mashed potatoes. The resident only ate one bite of mashed potatoes. -On 12/04/24, at 2:40 P.M., the nurse checked the resident's blood pressure. The tube feeding was running at 30 ml/hr, the nurse prepared to administer medications; -On 12/05/24, at 12:00 P.M., the resident was in the dining room, with a pureed meal. The resident was not eating and had not taken any bites; -On 12/05/24, at 12:50 P.M., the resident was in bed. The head of bed was elevated, there was no tube feeding attached or running; -On 12/05/24, at 2:54 P.M., the resident was in bed with head of bed elevated and his/her eyes closed. There was no tube feeding running or attached; -On 12/05/24, at 9:05 P.M., the resident in bed with eyes closed, the tube feeding was attached and running at 30 ml/hr. During an interview on 12/04/24, at 2:50 P.M., Registered Nurse (RN) A said the resident's tube feeding was continuous. He/she said that every 18 hours the nursing staff change the tube feeding bag and add more jevity. During an interview on 12/05/24, at 2:45 P.M., Licensed Practical Nurse (LPN) J said the tube feeding was scheduled for every 18 hours on and 6 hours off. The order did not say 6 hours off. He/she said it was a rotating schedule and there was not a set time to put on and take off. The night shift would turn on the feeding and it was turned off at 11:35 A.M. During an interview on 12/05/24, at 9:10 P.M., RN K said the tube feeding order was a little confusing. It stated to be every 18 hours and off for 8 hours. He/she said the day staff turned off the feeding at about 11:00 A.M. this day and he/she connected and turned on at 9:00 P.M. this night. During an interview on 12/06/24, at 9:27 A.M., the Assistant Director of Nursing (ADON) said staff should follow the physician orders for tube feeding and administer every 18 hours. He/she was not familiar with the resident's orders. During an interview on 12/06/24, at 11:40 A.M., Director of Nursing (DON) said staff should give tube feeding according to physician orders and if the orders were unclear, staff should obtain clarification. During an interview on 12/06/24, at 12:11 P.M., the Pharmacist said the computer system should put in the times for staff to complete tube feeding. The physician order should be correct and it should cue up every 18 hours. During an interview on 12/06/24, at 1:45 P.M., Administrator said that staff should follow physician orders and if the orders were not clear the staff should get clarification. He was made aware of tube feeding orders being unclear.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 28 opportunities resulting in an error rate of 7.14% when facility staff failed to administer medication at the specified scheduled dosing time, before a meal and separate from other medications, for two residents (Resident # 98 and Resident # 101). The facility census was 109. Review of the facility's policy titled Medication Administration and Documentation, NUR09-09, revised 12/24, showed the following: -Medications are administered in accordance with prescriber orders; -Standard administration times may be adjusted by pharmacy staff due to drug/food incompatibilities with the following agents: Thyroid preparations 6:00 A.M.; -Long Term Care (LTC) providers may exclude certain patients or medications from liberalized medication pass: Dietary and drug-drug interactions should be avoided where specifically noted in the electronic Medication Administration Record (eMAR); -Administration of medications outside their scheduled dosing times and windows will be tracked in routine reporting by the facility. 1. Review of Resident # 98's face sheet (brief resident profile sheet) showed diagnoses included Alzheimer's disease, unspecified. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/07/24, showed the following: -The resident entered the facility on 12/21/23; -The resident had severe cognitive impairment; -Diagnoses included thyroid disorder. Review of the resident's current physician orders showed an order, dated 12/22/23, for the following: -Administer levothyroxine (medication used for treatment of hypothyroidism (a condition in which the thyroid doesn't produce enough thyroid hormone) 75 micrograms (mcg) PO (by mouth) daily at 6:00 A.M. -Dose instructions included take on an empty stomach, 30 to 60 minutes before breakfast. -Label insturctions to administer consistently in the morning on an empty stomach, at least 30 minutes before food or other medications. Observation on 12/04/24, at 9:05 A.M., showed Registered Medication Technician (RMT) F prepared and administered levothyroxine 75 mcg tablet for the resident. RMT F administered other medications the same time as the levothyroxine. During an interview on 12/05/24, at 10:25 A.M., RMT G said breakfast is typically served between 7:00 A.M. and 8:00 A.M. and he/she normally administered the resident's thyroid medication between 8:00 A.M. to 9:00 A.M. He/she administered all of resident's medications at the same time (including levothyroxine). RMT G was aware that he/she was administering the levothyroxine to the resident at the wrong time, after breakfast, and with additional medications. He/she should have administered the medication at 6:00 A.M., before breakfast, and separate from other medications. During an interview on 12/05/24, at 1:33 P.M., Registered Nurse (RN) C said the resident's thyroid medication should be administered as ordered at 6:00 A.M., before the breakfast meal on an empty stomach and separate from other medications. 2. Review of Resident # 101's face sheet showed diagnoses included of right femur (thigh bone) fracture. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident entered the facility on 6/20/24; -Moderate cognitive impairment; -Diagnosis of hypothyroidism. Review of the resident's current physician orders showed the following: -Order, dated 05/03/24, for levothyroxine 88 mcg daily by mouth scheduled at 6:00 A.M. -Dose instructions included take on an empty stomach, 30 to 60 minutes before breakfast. -Label instructions to administer consistently in the morning on an empty stomach, at least 30 minutes before food or other medications. Observation on 12/05/24, at 8:57 A.M., showed RMT G prepared and administered levothyroxine 88 mcg one tablet to the resident. RMT G administered other medications at the same time. During an interview on 12/05/24, at 10:25 A.M., RMT G said he/she administered levothyroxine to the resident on 12/05/24 after he/she ate breakfast and all other medications were administered at the same time as the levothyroxine. It was impossible to administer the 6:00 A.M. medications before meals due to the number of residents receiving medications. He/she knew that levothyroxine was supposed to be administered on an empty stomach and separate from other medications. The resident received his/her breakfast between 7:00 A.M. to 8:00 A.M. on 12/05/24 and he/she administered all the resident's morning medications (including levothyroxine) around 9:00 A.M. this morning. During an interview on 12/05/24, at 1:33 P.M., RN C said the resident's levothyroxine should be administered before the breakfast meal and on an empty stomach. 3. During an interview on 12/05/24, at 10:25 A.M., RMT G said breakfast was typically served between 7:00 A.M. and 8:00 A.M. and he/she normally administered the morning medications between 8:00 A.M. and 9:00 A.M. All the morning medications for each resident are administered at the same time (including levothyroxine) because there is not enough time to administer medications separately due to the number of residents he/she was responsible for administering medications to. RMT's start their shift at 6:00 A.M. and finish their medication pass for all residents between 10:00 A.M. to 11:00 A.M. He/she was aware that he/she was administering levothyroxine to residents at the wrong time and it should be administered at 6:00 A.M., before breakfast, and separate from other medications. 4. During an interview on 12/05/24, at 1:33 P.M. RN C said the facility policy allowed staff a liberal three hour window to pass medications from the time they are due. He/she did not know of any specific medications per facility policy that needed to be administered at a specific time except medications ordered with a status to be given now. The levothyroxine should be given before the meal, on an empty stomach, and he/she would expect the night shift staff to administer the levothyroxine at 5:00 A.M., but that had not been happening. 5. During an interview on 12/06/24, at 9:23 A.M. the Director of Nursing (DON) said staff have time allowances of 30 minutes to two hours to pass medications beyond the time they are due. Some medications have exact times that they should be administered. The DON said staff should not be administering a medication after breakfast that has been ordered to be administered before breakfast. Medications that are required to be administered on an empty stomach should be administered on an empty stomach. If medications are ordered to be given without other medications they should be administered separately. The facility has a liberalized three hour window of time to give medications that are ordered in the A.M. or P.M. without a specific time listed. Staff are expected to follow parameters for medications ordered with specific instructions. It was brought to his/her attention that levothyroxine was not being administered prior to breakfast per physician orders. The DON said the medication technicians are scheduled from 6:00 A.M. to 2:00 P.M. and 2:00 P.M. to 10:00 P.M. or until all evening medications are passed. The facility has 42 residents diagnosed with hypothyroidism and his/her expectation is for staff to administer thyroid medication as ordered at 6:00 A.M. per physician orders, prior to breakfast and separate from other medications. 6. During an interview on 12/06/24, at 1:43 P.M., the Administrator said staff are expected to administer medications within the window they are ordered to be administered in. He/she is aware of the medication timing issue with the thyroid medication.

Based on interview and record review, the facility failed implement an abuse/neglect policy that ensured all reported allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours when staff failed to reported a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -Staff, employees, and physicians will follow regulations and standards in identification of and procedures for handling alleged victims of abuse; -In the event a person with responsibility for care of a person sixty years of age or older or adults with disabilities ages 18-59 has reasonable cause to suspect that an individual has been subjected to abuse or neglect, receives an allegation of abuse or neglect, or observes this individual being subjected to conditions or circumstances which would reasonably result in abuse or neglect, that individual shall immediately make a report to the DHSS or the appropriate facility designee; -The designee will report or assist the person with direct knowledge of the concern to report immediately, within two hours of the allegation is for mental, physical, verbal, or sexual abuse or there has been bodily injury related to abuse. If not abuse and there is no injury, the designee should report within 24 hours of the observation or allegation, to DHSS at the hotline or in cases involving LTC (Long Term Care), the report shall be made first to the regional DHSS office during business hours or the hotline after hours. A fax notice or email to the regional DHSS during hours the hotline is closed is acceptable for the two-hour notice, but a follow up call is required; -In LTC, the designee is the facility Administrator, Administrator On-Call, Director of Nursing (DON) or registered nurse (RN) that shall be responsible for reporting suspected abuse or neglect; -Any concern, complaint, or allegation of patient/resident abuse/neglect (sexual, physical, or verbal) by another resident, employee, vendor or visitor shall be verbally reported immediately to the facility Administrator. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Resident had a guardian; -Diagnoses included bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 07/02/24, showed the following: -Cognitively intact; -Resident had a guardian; -No behaviors exhibited. Review of the resident's care plan, last revised 09/25/24, showed the following: -Resident had a history of bi-polar disorder, unspecified mood disorder, conversation disorder with motor symptoms and deficits, insomnia, altered mental status, and Parkinson's disease; -Mood interventions included to encourage expression of feelings, acknowledge/validate feelings, assist with coping skills, maintain a non-defensive stance, implement diversional activity, and assess for trigger situation such as pain, personal loss, relocation, conflict or prior history; Review of the resident's nursing note dated 08/08/24, at 9:51 P.M., showed the following: -The resident was found outside in courtyard with another resident. Resident #1 was touching the Resident #2's genitalia with his/her hand; -Residents were separated and put on 15-minute checks; -Resident was educated that his/her actions were inappropriate; -Staff notified the resident's guardian. The guardian advised he/she did not know what to do about the situation, but would be at the facility the following day to talk to the resident and the Administrator; -Staff notified the DON and who gave direction to place residents on 15-minute checks. During an interview on 09/26/24, at 10:52 A.M., the resident said the following: -He/she had been in a relationship with Resident #2 for over a year; -He/she touched Resident #2's genitalia and rubbing it in the courtyard. During an interview on 09/26/24, at 1:15 P.M., the resident's guardian said the following: -A nurse notified him/her the resident was playing with Resident #2's genitalia on the back patio; -He/she advised the nurse to separate the residents and he/she would be at the facility the following day to speak to the Administrator; -The Administrator told the resident during the meeting the next day it is not appropriate for him/her to touch residents' in the private parts. Review of the resident's record showed staff did not document reporting the allegation abuse to DHSS. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Resident had a Durable Power of Attorney (DPOA); -Diagnoses included major depressive disorder (persistently depressed mood or loss of interest in activities) and a history of stroke. Review of the resident's care plan, last reviewed on 02/27/24, showed the following: -Resident had a history of combat experience and has received professional treatment in the past, but does not wish to receive counseling or professional services; -Resident will not be exposed to triggers that may cause re-traumatization; -Observe for signs of adjustment difficulties such as inability to pursue interests or activities, sad or anxious mood, behavioral symptoms, impaired communication, sleep problems, and spiritual distress. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors exhibited. Review of the resident's nursing note dated 08/08/24, at 11:23 P.M., showed the nurse was informed by aide that resident was outside in the courtyard receiving stimulation to his/her private area by another resident's hand. Residents were brought back into the building and remained in the dining room. Around 7:50 P.M., nurse called the resident's DPOA to notify of the incident. This nurse explained that the resident was found outside in the courtyard with another resident engaging in adult activity. The residents were separated and placed on 15-minute checks. Staff notified the DON of the situation. During an interview on 09/26/24, at 11:59 A.M., the resident said the following: -He/she does not remember traumatic events at times and would consider someone touching his/her genitalia to be a traumatic event because he/she would not want another resident to be doing that to him/her at the facility. Review of the resident's record showed staff did not document reporting the allegation abuse to DHSS. 3. Review of facility records showed staff did not provide documentation of reporting the allegation of possible abuse to DHSS. Review of DHSS records show DHSS did not have record of the facility reporting the allegation of sexual contact between Resident #1 and Resident #2. 4. During interviews on 09/26/24, at 12:15 P.M. and 2:03 P.M., Certified Nurse Assistant (CNA) A said the following: -Staff should separate residents engaging in sexual touching and report to the Administrator immediately because staff may not know what the guardian's expectations are if the resident has a guardian; -The facility has 24 hours to report any abuse allegations to the state; -He/she would consider the incident of touching between Resident #1 and Resident #2 to be potential abuse and would have reported to the charge nurse. 5. During interviews on 09/26/24, at 12:19 P.M. and 2:10 P.M., License Practical Nurse (LPN) B said the following: -Staff should separate residents with guardians engaging in sexual activity and contact the guardian and DON for further guidance; -Staff would not necessarily report residents with guardians engaging in sexual activity to the state agency if no harm or force was involved. 6. During an interview on 09/26/24, at 12:31 P.M., CNA C said the following: -The guardian of a resident makes decisions regarding sexual activity with another resident, and staff should follow the guardian's decisions; -Resident #1's guardian did not want him/her engaging in sexual activity; -He/she did not know if Resident #2 consented; -Staff should have reported to the state agency because it could have been considered abuse. 7. During interviews on 09/26/24, at 12:48 P.M., and 1:48 P.M., Licensed Practical Nurse (LPN) D said the following: -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If a guard of a resident does give permission to engage in sexual activity, the facility should provide a safe and private setting; -Staff should consider residents engaging in sexual activity without the permission of the guardian to be abuse and should report immediately to the guardian, DON, Administrator, and the state agency within 24 hours; -An aide reported observing Resident #1's hand on Resident #2's genitalia to another charge nurse who then reported to her/him; -He/she ensured the residents were separated; -He/she reported the incident to the guardian and the DON; -The guardian wanted the residents completely separated; -The DON advised to separate the residents and start 15-minute checks; -He/she did not report the incident to the state agency. 8. During an interview on 09/26/24, at 2:17 P.M., the DON said the following: -Staff should immediately separate residents engaged in abusive behavior and report the incident to the charge nurse. The charge nurse reports to management; -Staff should immediately notify the responsible party and physician of any abuse allegation and the state agency within two hours; -Guardians and DPOA's make decisions regarding residents engaging in sexual relations with other residents; -The facility should take steps to honor decisions to now allow residents to engage in sexual relations by providing monitoring; -An aide reported observing Resident #1 touching Resident #2's genitalia while outside in the courtyard; -He did not feel this incident needed to be reported to the state agency as there was no allegation of abuse or neglect; -The facility did not have prior permission from Resident #1's guardian or Resident #'2 DPOA to engage in sexual relations; -Residents should not be engaging in sexual relations outside at the facility; -Staff should have treated the incident as an abuse situation if Resident #2 had said he/she did not consent, but to his knowledge, no staff had this conversation with either resident. 9. During an interview on 09/26/24, at 3:22 P.M., the Administrator said the following: -Staff should separate residents following a resident-to-resident abuse allegation; -Staff should immediately report any abuse allegation to the charge nurse, DON, Administrator, and state agency within two hours; -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If staff are unsure of a guardian's wishes regarding a resident engaging in sexual relations, staff should separate until a determination is made; -Staff found the residents outside and Resident #1 was touching Resident #2's genitalia; -Residents should not be touching one another's private parts outside at the facility; -The guardian of Resident #1 and DPOA of Resident #2 were contacted almost immediately; -The guardian of Resident #1 did not want him/her engaging in sexual behavior and the DPOA of Resident #2 did not have a preference; -He did not ask Resident #2 if he/she wanted to be touch and is unsure if any other staff asked; -Staff did not report to the state agency because they believed this was a mutual issue. MO00242275

Based on interview and record review, the facility failed implement an abuse/neglect policy that ensured staff completed and documented a timely investigation of all reported allegations of possible abuse when staff failed to complete a documented investigation of a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -All complaints will be reviewed by the department director or facility administrator to determine the need for investigation; -The investigation party will determine the protocol for presenting the results of individual investigations to the Department of Health and Senior Services (DHSS) and may recommend changes to preclude recurrence of non-complaint activity; -The organization's designee will be responsible for immediately initiation and conducting an investigation of the alleged abuse/neglect; -During the investigation, residents will be protected from harm by interrupting the source of activity relating to the suspected abuse or neglect, providing education on appropriate behavior, and redirecting the resident as appropriate; -Residents will be removed from the area or distanced from the individual suspected of abuse/neglect; -In long-term care (LTC), the investigation will be completed by the administrator or designee and a summary submitted to the DHSS within five working days. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Resident had a guardian; -Diagnoses included bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 07/02/24, showed the following: -Cognitively intact; -Resident had a guardian; -No behaviors exhibited. Review of the resident's care plan, last revised 09/25/24, showed the following: -Resident had a history of bi-polar disorder, unspecified mood disorder, conversation disorder with motor symptoms and deficits, insomnia, altered mental status, and Parkinson's disease; -Mood interventions included to encourage expression of feelings, acknowledge/validate feelings, assist with coping skills, maintain a non-defensive stance, implement diversional activity, and assess for trigger situation such as pain, personal loss, relocation, conflict or prior history. Review of the resident's nursing note dated 08/08/24, at 9:51 P.M., showed the following: -The resident was found outside in courtyard with another resident. Resident #1 was touching the Resident #2 genitalia with his/her hand; -Residents were separated and put on 15-minute checks; -Resident was educated his/her actions were inappropriate; -Staff notified resident's guardian and the guardian advised he/she did not know what to do about the situation, but would be at the facility the following day to talk to the resident and the Administrator; -Staff notified the Director of Nursing (DON) who gave direction to place residents on 15-minute checks. During an interview on 09/26/24, at 10:52 A.M., the resident said the following: -He/she had been in a with Resident #2 for over a year; -He/she touched Resident #2's genitalia and was rubbing it in the courtyard. and Resident #2 are only allowed to hold hands now and can only go outside together during the day; During an interview on 09/26/24, at 1:15 P.M., the resident's guardian said the following: -A nurse notified him/her the resident was playing with Resident #2's genitalia on the back patio; -He/she advised the nurse to separate the residents and he/she would be at the facility the following day to speak to the Administrator; -The Administrator told the resident during the meeting the next day it is not appropriate for him/her to touch residents in the private parts. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Resident had a Durable Power of Attorney (DPOA); -Diagnoses included major depressive disorder (persistently depressed mood or loss of interest in activities) and a history of stroke. Review of the resident's care plan, last reviewed on 02/27/24, showed the following: -Resident had a history of combat experience and has received professional treatment in the past, but does not wish to receive counseling or professional services; -Resident will not be exposed to triggers that may cause re-traumatization; -Observe for signs of adjustment difficulties such as inability to pursue interests or activities, sad or anxious mood, behavioral symptoms, impaired communication, sleep problems, and spiritual distress. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors exhibited. Review of the resident's nursing note dated 08/08/24, at 11:23 P.M., showed the nurse was informed by aide that resident was outside in the courtyard receiving stimulation to his/her private area by another resident's hand. Residents were brought back into the building and remained in the dining room. Around 7:50 P.M., nurse called the resident's DPOA to notify of the incident. This nurse explained that the resident was found outside in the courtyard with another resident engaging in adult activity. The residents were separated and placed on 15-minute checks. Staff notified the DON of the situation. During an interview on 09/26/24, at 11:59 A.M., the resident said the following: -He/she does not remember traumatic events at times and would consider someone touching his/her genitalia to be a traumatic event because he/she would not want another resident to be doing that to him/her at the facility. 3. Review showed the facility did not provide a written investigation into the allegation of possible abuse. Review of DHSS records showed a written investigation into the allegation of possible abuse was not received. 4. During interviews on 09/26/24, at 12:15 P.M. and 2:03 P.M., Certified Nurse Assistant (CNA) A said the following: -Staff should separate residents engaging in sexual touching and report to the Administrator immediately because staff may not know what the guardian's expectations are if the resident has a guardian; -He/she would consider the incident between Resident #1 and Resident #2 to be potential abuse. 5. During interviews on 09/26/24, at 12:19 P.M. and 2:10 P.M., License Practical Nurse (LPN) B said staff should separate residents with guardians engaging in sexual activity and contact guardian and DON for further guidance. 6. During an interview on 09/26/24, at 12:31 P.M., CNA C said the following: -The guardian of a resident makes decisions regarding sexual activity with another resident, and staff should follow the guardian's decisions; -Resident #1's guardian did not want him/her engaging in sexual activity; -He/she did not know if Resident #2 consented. 7. During interviews on 09/26/24, at 12:48 P.M. and 1:48 P.M., LPN D said the following: -The guardian of a resident makes decision regarding sexual activity with another resident and staff should follow the guardian's decision; -If a guard of a resident does give permission to engage in sexual activity, the facility should provide a safe and private setting; -Staff should consider residents engaging in sexual activity without the permission of the guardian to be abuse and should report immediately to the guardian, DON, Administrator, and the state agency within 24 hours; -An aide reported observing Resident #1's hand on Resident #2's genitalia to another charge nurse who then reported to her/him; -He/she ensured the residents were separated; -He/she reported the incident to the guardian and the DON; -The guardian wanted the residents completely separated; -The DON advised to separate the residents and start 15-minute checks. 8. During an interview on 09/26/24, at 2:17 P.M., the DON said the following: -Staff should immediately separate residents engaged in abusive behavior and report the incident to the charge nurse. The charge nurse reports to management; -Staff should place residents on 15-minute checks; -Management completes investigations regarding abuse allegation, which includes resident and staff interviews and resident assessments; -Guardians and DPOA's make decisions regarding residents engaging in sexual relations with other residents; -The facility should take steps to honor decisions to now allow residents to engage in sexual relations by providing monitoring; -An aide reported observing Resident #1 touching Resident #2's genitalia while outside in the courtyard; -He did not know if staff asked Resident #2 if he/she consented to being touched; -The facility did not complete an investigation regarding the incident because there was no allegation of abuse or neglect; -The facility did not have prior permission from Resident #1's guardian or Resident #'2 DPOA to engage in sexual relations. -Staff should have treated the incident as an abuse situation if Resident #2 had said he/she did not consent, but to his knowledge, no staff had this conversation with either resident. 9. During an interview on 09/26/24, at 3:22 P.M., the Administrator said the following: -Staff should separate residents following a resident-to-resident abuse allegation; -The facility should complete an investigation with any abuse allegation, including interviewing residents and staff and completing resident assessments; -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If staff are unsure of a guardian's wishes regarding a resident engaging in sexual relations, staff should separate until a determination is made; -Staff found the residents outside and Resident #1 was touching Resident #2's genitalia; -Residents should not be touching one another's private parts outside at the facility; -The guardian of Resident #1 did not want him/her engaging in sexual behavior and the DPOA of Resident #2 did not have a preference; -He did not ask Resident #2 if he/she wanted to be touch and is unsure if any other staff asked; -An investigation was not completed. MO00242275

Based on observation, record review, and interview, the facility failed to protect all residents from abuse when one staff member (Certified Nurse Aide (CNA) A) used a walker to place and hold one resident (Resident #1) in the corner in response to his/her behaviors which resulted in the resident striking out while being held in the corner. The facility census was 106. The administrator was notified on 2/16/2022, at 12:30 P.M., of an Immediate Jeopardy (IJ) which began on 2/11/2022. The IJ was removed on 2/16/2022, as confirmed by surveyor onsite verification. Record review of the facility's policy titled Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, dated 8/2021, showed the purpose of the policy is to keep residents free from abuse, mistreatment, and neglect. Record review of the facility's policy titled Abuse Appendices, revised 5/2021, showed abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, including deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, pain, or mental anguish. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -Readmitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 1/12/2022, showed the following: -Severely cognitively impaired; -Experienced hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there) and delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Physical behaviors toward others, such as hitting, kicking, or scratching on one to three days of the look back period (the period of time when the assessment was done); -Verbal behaviors toward others, such as threatening others, screaming at others, and cursing at others on four to six days of the look back period; -Wandered daily and put others at risk for harm or injury. Record review of the resident's current care plan showed the following: -On 1/13/2022, staff documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/17/2022, staff documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included reinforce positive behaviors; if agitated and it is safe to do so, leave and re-approach later; reduce excessive stimuli; use a calm, reassuring approach; maintain a non-defensive stance; and monitor for wandering behaviors and redirect the resident if he/she attempts to go in other resident's rooms. Record review of the facility's investigation of a resident-to-resident incident, dated 2/12/2022, showed the following: -On 2/12/2022, at 10:40 A.M., as part of the investigative process, staff began to review camera footage of the resident-to-resident incident. On camera, the Social Services Director (SSD) and Director of Nursing (DON) viewed CNA A, use a walker to move the resident from the doorway of a resident room several feet into the hallway, past the exit door on that side of the Memory Care Unit (MCU), until the CNA used the walker to hold the resident against the wall. The resident began to hit CNA A at that time. CNA A was then seen tripping and/or being pushed by the resident away from him/her. CNA A then walked away from the situation, set the walker down, and headed towards the area of the nurses' station. Observation of the facility's video on 2/16/2022, at 11:55 A.M., showed the following: -On 2/11/2022, at approximately 7:50 A.M., CNA A wheeled a resident into his/her room; -Resident #1 was in the room and then exited the room; -Resident #1 then went back in the room for 11 seconds; -CNA A came out of the room with the open end of a walker held to Resident #1's waist and quickly backed him/her six steps across the hallway into the corner. The resident's pants were down around his/her ankles; -CNA A held the resident for eight seconds in the corner of the hallway with the walker at the resident's chest level; -After four seconds, the resident began to hit the CNA; -After eight seconds, CNA A stumbled back, walked up the hallway, and put the walker down on the way. During an interview on 2/16/2022, at 8:30 A.M., CNA A (agency staff) said Resident #1 was in another resident's room and grabbed the walker. Resident #1 was swinging it with another resident next to him/her. The CNA said he/she got a hold of the walker, backed Resident #1 into the corner while the aide screamed for help. The CNA said he/she used the walker as a safety barrier. The resident started swinging his/her fists at the CNA. The CNA said his/her intent was to hold the resident in the corner to protect him/herself with the walker. During an interview on 2/15/2022, at 1:00 P.M., Licensed Practical Nurse (LPN) C said he/she worked on the MCU the past weekend when the incident occurred with the resident. The LPN had asked staff not to push cares with the resident because he/she was so easily agitated. During interviews on 2/16/2022, at 2:05 P.M., and 2/18/2022, at 11:50 A.M., Care Plan Coordinator D said the resident care plans contain what the staff needs to care for a resident. If something needs to be added to the care plan, the information is usually told to the care plan coordinator and it is added. Agency staff do not have access to the care plan, but they get the resident information needed in the verbal report from off-going staff. He/she said it is never appropriate to restrain a resident with a walker and he/she would consider that abuse. During an interview on 2/15/2022, at 9:55 A.M., CNA B said he/she is an agency staff member and gets no abuse and neglect training through the facility or through the agency. He/she gets no additional training on how to properly care for an aggressive or agitated resident. During an interview on 2/17/2022, at 10:30 A.M., Nurse Practitioner (NP) E said the resident has dementia and at times some agitation and aggressive behaviors. During those times, staff should approach him/her in a calm, soothing manner, and if needed, back off. It would never be appropriate to entrap him/her, or restrain him/her with a walker. It would never be appropriate to entrap or restrain any resident with a walker. During an interview on 2/18/2022, at 9:40 A.M., the SSD said she watched the video of the incident on 2/11/2022 with the DON and was immediately concerned. She saw CNA A push the resident across the hall of the MCU with a walker and hold him/her. It is never appropriate to hold any resident with a walker. She does consider this abuse. During an interview on 2/22/2022, at 2:00 P.M., the DON said on 2/11/2022, she watched the video and saw CNA A move the resident across the MCU hallway with a walker and held him/her in the corner. The DON said it is not appropriate for staff to hold a resident in the corner. It would be construed as abuse if the aide had intent for abuse. During an interview on 2/18/2022, at 11:54 A.M., the Administrator said she expects staff to ensure resident safety, and if a resident is agitated or aggressive, staff should step away if able and if needed ask another staff member to assist. Staff should use soft, calm voices. It is never appropriate for staff members to hold residents in the corner with a walker. She would consider that abuse. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 114 & MO 144