Every finding on record at Community Manor

Based on interview and record review, the facility failed to prevent the misappropriation of two gift cards from one resident (Resident #1) out of a sample of five residents when a staff member took possession of the resident's $200 Amazon gift card and $300 Visa gift card. The facility census was 98.The administration was notified on 06/04/26 of the Past Non-Compliance which occurred between 05/29/26 through 06/01/26. On 06/01/26, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 06/01/26, as the facility completed disciplinary action for CNA A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated.Review of the facility's policy titled, Abuse Prevention Program, revised April 2021, showed:-Misappropriation of resident property defined as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent;-Employees are educated on the Abuse Prevention Program upon hire and annually.1. Review of Resident #1's face sheet showed:- admitted on [DATE];- Diagnoses of Wernicke's encephalopathy (severe thiamine [vitamin B1] deficiency characterized by sudden confusion, abnormal eye movements and loss of muscle coordination), polyneuropathy (condition where multiple peripheral nerves throughout the body malfunction causing burning, tingling, numbness and weakness), morbid obesity, depression and anxiety.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 05/22/26, showed the resident's cognition to be intact.Review of the facility's investigation dated, 06/01/26, showed:-On 05/29/26, Resident #1 notified the facility he/she believed his/her gift cards had been stolen by CNA A. Resident #1 provided the facility with communication between himself/herself and Amazon customer service to verify CNA A had redeemed the $200 Amazon gift card. The facility immediately removed CNA A from the floor for questioning, as well as contacted the police per Resident #1's request. CNA A was questioned regarding the use of the gift cards and denied using them. CNA A was escorted from the facility pending the investigation. On 06/01/26, CNA A sent a text message to Social Services Director (SSD) admitting to taking the two gift cards. CNA A's employment with the facility was terminated. On 06/01/26, the facility reimbursed Resident #1 with $200 for the Amazon card and $300 for the Visa card. Review of CNA A's personnel file showed her signature, dated 04/27/26, on the Abuse Prevention Program Policy acknowledging she had read and understood the policy.During an interview on 06/04/26 at 11:00 A.M., Resident #1 said he/she never gave CNA A access or permission to use his/her gift cards. During an interview on 06/04/26 at 12:00 P.M., the Administrator said he/she would expect facility staff to follow the Abuse Prevention Program policy, which they are trained on upon hire and annually. The Administrator said facility staff should not take resident's personal items.During an interview on 06/04/26 at 12:22 P.M., the SSD said he/she received a text message from CNA A admitting to taking Resident #1's gift cards and using them for a total of $500. During a phone interview on 06/04/26 at 1:51 P.M., CNA A said he/she took the Amazon gift card and Visa gift card from Resident #1 approximately three to four weeks ago. CNA A said he/she did not know why he/she did it, but would be reimbursing the resident the money.

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds for the operating account in a timely manner for six residents (Residents #1, #2, #3, #4, #5 and #6). The facility census was 66.1. Record review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated [DATE], showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account#1 $241.00#2 $4,140.00#3 $18.00#4 $6,902.43#5 $4,420.00#6 $1,205.00Total $16,926.43 Record review of the facility-maintained paperwork showed Residents #1, #2, #3, #4 and #5 expired and Resident #6 discharged on the following dates:Number Discharge/ Expire Date#1 [DATE]#2 [DATE]#3 [DATE]#4 [DATE]#5 [DATE]#6 [DATE] Record review showed the facility did not provide the Personal Fund Account Balance Report (TPL) to the Missouri HealthNet Division, Third Party Liability Unit or complete the refund until the following dates:- [DATE], 62 days after Resident #1's credit was generated;- [DATE], 55 days after Resident #2 expired;- [DATE], 49 days after Resident #3 expired;- [DATE], 136 days after Resident #4 expired;- [DATE], 85 days after Resident #5 expired; - [DATE], 97 days after Resident #6 discharged . During an interview on [DATE] at 1:34 P.M., the Accounts Receivable Regional Manager said the funds should have been refunded timely but were not, due to the following:- A posting error on [DATE] created the credit balance for Resident #1;- The facility was waiting for insurance to pay before refunding Resident #2's money;- The credit balance for Resident #3 was moved forward each month;- The credit balance for Resident #4 was sent to the home office four times to be reviewed;- The credit for Resident #5 was not refunded until [DATE];- Resident #6 has not been refunded. Complaint #2793296

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents (Resident #25 and #77) out of three sampled residents who were discharged from Medicare Part A services with benefit days remaining. The facility's census was 97. The facility did not provide a policy for SNF ABN or NOMNC forms. 1. Review of Resident #25's medical record showed: - The resident discharged from Medicare Part A services on 02/28/25; - The resident remained in the facility; - The facility failed to issue a NOMNC to the resident. 2. Review of Resident #77's medical record showed: - The resident discharged from Medicare Part A services on 04/30/25; - The resident remained in the facility; - The facility failed to issue a SNF ABN to the resident. During an interview on 06/05/25 at 2:29 P.M., the Social Services Designee (SSD) said she hasn't gotten this process down to a science. She said she was told by corporate to use these two forms, and pointed to two ABN forms - one dated 09/2020 and one dated 2024. She said she does a NOMNC on everyone who comes off Med A whether they have days remaining or not and pointed to the ABN form when talking about completing the NOMNC. The NOMNC for Resident #77 was sent by the insurance company. During an interview on 06/06/25 at 7:35 P.M., the Administrator and Director of Nursing (DON) said they would expect the SNF ABN and NOMNC forms to be completed per regulation and provided to and signed by the resident and/or the resident's representative when a resident was discharged from therapy with days remaining.

Based on interview and record review, the facility failed to obtain and/or follow physician orders in a timely manner after the pharmacist made recommendations for specific medications for one resident (Resident #31) outside of the 20 sampled residents and failed to ensure a Certified Nursing Assistant (CNA) did not perform duties outside the scope of practice. The facility's census was 97. Review of the facility's Medication Regimen Reviews (MRR) policy, revised May 2019, showed: - The consultant pharmacist reviews the medication regimen of each resident, at least monthly; - The goal of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication; - The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities; - Within 24 hours of the MRR, the consultant pharmacist provides a written report to attending physicians for each resident identified as having a non-life threatening medication irregularity; - If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, the pharmacist contacts the medical director or Administrator; - The attending physician documents in the medical record that the irregularity has been reviewed and what, if any, action was taken to address it. The facility did not provide a policy regarding CNA scope of practice. 1. Review of Resident #31's medical record showed: - admitted on [DATE]; - Diagnoses of repeated falls, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow, making it difficult to breathe), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); - An order for bupropion ER 12 hour 150 mg tablet, give one tablet by mouth one time a day for other specified depressive episodes, with a start date of 02/22/23 and discontinued on 06/27/24; - An order for bupropion 75 mg tablet, give one tablet by mouth one time a day, with a start date of 06/28/24 and discontinued on 08/27/24; - An order for bupropion ER 24 hour tablet, give 100 mg by mouth one time a day, with a start date of 08/27/24 and discontinued on 08/29/24; - An order for bupropion 100 mg tablet, give one tablet by mouth one time a day, with a start date of 08/30/24 and discontinued on 03/21/25; - The resident received the incorrect dosage of bupropion 54 times from 06/28/24 to 08/27/24. Pharmacist review of the resident's bupropion (antidepressant medication) showed: - On 06/22/24, a recommendation to reduce bupropion ER (extended release) 12 hour 150 milligram (mg) daily to bupropion ER (extended release) 12 hour 100 mg daily; - On 07/29/24 and 08/26/24, documentation that an order was received on 06/28/24 per pharmacist request made on 06/22/24 to reduce bupropion ER (extended release) 12 hour 150 milligram (mg) daily to bupropion ER (extended release) 12 hour 100 mg daily. The new order was transcribed in the electronic charting system dated 06/28/24 as the immediate release formulation (bupropion 75 mg daily) instead of the extended release 12 hour formulation and also an incorrect dose (75 mg instead of 100 mg). Please clarify and update the order to reflect the correct dose and formulation: bupropion 100 mg ER 12 hour daily and notify the pharmacy of the changes. During an interview on 06/06/25 at 3:00 P.M., Assistant Director of Nursing (ADON) G said Resident #31's bupropion order was entered incorrectly. 2. Review of Resident #15's medical record showed: - admission date of 02/24/25; - Diagnoses of gastrostomy status (G-tube - a feeding tube inserted directly into the stomach through the skin and abdominal wall), tracheostomy status (a surgical procedure where an opening is created in the neck to directly access the trachea (windpipe) for breathing), and visual loss in both eyes. Observation on 06/05/25 at 10:14 A.M. of the resident showed: - Following the resident's shower, CNA P and CNA Q transferred the resident from the shower chair to the bed; - After transferring the resident to bed, CNA Q obtained the disconnected feeding tube from the IV pole (a medical device used to hold IV fluids or medications during administration), reattached the resident's feeding tube to the feeding tube port, turned the feeding pump on, and restarted the tube feed. During an interview on 06/06/25 at 4:41 P.M., the Director of Nursing (DON) said CNAs should not be hooking the tube feeding back up. They should tell the nurse and have them come do it. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they would expect new orders to be added correctly.

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility's census was 97. Review of the facility's Food Receiving and Storage policy, revised November 2022, showed: - Food shall be received and stored in a manner that complies with safe food handling practices; - All foods stored in refrigerator or freezer are covered, labeled, and dated with a use by date; - Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. Review of the facility's Sanitation policy, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; - All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; - Kitchen wastes that are not disposed of by chemical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Observation on 06/03/25 at 10:55 A.M. of the kitchen showed: - Two flies buzzed around the dish washing area; - The floor with a black, sticky substance in front of the condiment storage area, the rest of the kitchen floor was covered with debris; - [NAME] top area on stove with a greasy, black grime, and food crumbs on the surface; - Ten ounces (oz) of dill relish, with a best if used by date of 10/07/23; - Four, five pound bags of refrigerated shredded cheese with no dates; - Large container of refrigerated fat free Italian dressing with opened on lid, and a manufactured date of January 2025; - Five pounds of unopened refrigerated pasteurized processed cheese slices with no date; - One unopened refrigerated head of iceberg lettuce, with brown and mushy edges, and no date. Observation of the freezer on 06/03/25 at 11:15 A.M., showed: - One large bag of unopened, diced ham, no weight on package and no date; - Six four-pound bags of corn, carrot and green bean trio, with no dates; - Two two-pound bags of carrots, with no dates; - Ten two-pound bags of broccoli with no dates; - Eleven 32 oz bags of sugar snap peas, with an expiration date of October 2024; - Four bags of unopened, mixed vegetables, with no weight on bag, and no dates. Observation on 06/05/25 at 9:45 A.M. of the kitchen showed: - A soiled knife on the prep counter, along with a serving bowl and spoon with a light brown substance dried on it; - Two used cups left on the prep area, along with a partially consumed bottle of soda; - Large white towel with a brown substance in the floor under the convection oven; - Three large trays of cherry dessert in serving dishes on cart and not covered; - Trash can lid on the floor beside the trash can; - Floor with sticky areas and debris all over; - Two wadded paper towels on the floor in front of the small trash can next to the sink; - Two soiled towels with a brown substance on the floor under the condiment storage area; - [NAME] top area on stove with a greasy, black grime, and crumbs on the surface. During an interview on 06/05/25 at 9:45 A.M., the Dietary Manager (DM) said he rotates the food out when received. The dates are on the shipping labels, and he tries to keep the food in boxes. However, the packages should be dated when removed. The snap peas had been ordered, but should have been pitched because the residents didn't like them. Observation of the kitchen on 06/06/25 at 5:10 P.M. showed: - Two plastic drinking mugs on the floor next to the stove; - Food crumbs and debris all over the floor. During an interview on 06/06/25 at 5:10 P.M., the DM said he would expect the floors, counters, and stove top to be clean and expired foods to be thrown out. He had been trying to get everyone to be better at cleaning up. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing, and both Assistant Directors of Nursing said they would expect the the kitchen work/prep areas and floors to be clean, expired foods to be discarded, and packages to be dated.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital for four residents (Resident #15, #23, #49, and #67) out of 20 sampled residents and failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #49, and #67) out of 20 sampled residents. The facility's census was 97. Review of the facility's policy, Bed-Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility did not provide a policy regarding notification of transfer. 1. Review of Resident #15's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 2. Review of Resident #23's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 3. Review of Resident #49's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 4. Review of Resident #67's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing, and both Assistant Directors of Nursing said they would expect transfer notifications and bed hold policies to be given in writing to the resident or resident's representative upon discharge to the hospital.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for one resident (Resident #23) out of 20 sampled residents and two residents (Resident #31 and #60) outside the sample. The facility's census was 97. Review of the facility's policy, Resident Assessments, revised October 2023, showed: - A comprehensive assessment of each resident is completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act of 1987 are comprehensive evaluations of a resident's needs and condition within a nursing home, conducted by the facility staff) regulations and PPS (Prospective Payment System-a method of healthcare reimbursement where the Centers for Medicare and Medicaid Services (CMS) pays a provider a fixed amount based on the type of service rendered) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES-cloud based application developed by CMS to help measure and evaluate the quality of care for Medicare and Medicaid beneficiaries) as required; - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments; - Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2024, showed: - N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period (or since admission/entry or reentry if less than seven days); - N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the seven-day observation period (or since admission/entry or reentry if less than seven days). 1. Review of Resident #23's medical record showed: - admission date of 05/09/23; - Diagnoses of stroke, overactive bladder, and hypertensive heart disease with heart failure (condition where the heart is affected by prolonged high blood pressure, potentially leading to heart failure). Review of the resident's Physician's Order Sheet (POS), dated 06/06/25, showed: - An order for Plavix (antiplatelet medication), 75 milligrams (mg), one tablet by mouth one time a day, dated 08/15/24; - No orders for an anticoagulant. Review of the resident's MDS assessments showed: - A significant change MDS assessment, dated 03/08/25, with Section N0415E coded yes for anticoagulant; - A quarterly MDS assessment, dated 02/23/25, with Section N0415E coded yes for anticoagulant; - A quarterly MDS assessment, dated 11/23/24, with Section N0415E coded yes for anticoagulant; - A quarterly MDS assessment, dated 08/23/24, with Section N0415E coded yes for anticoagulant. 2. Review of Resident #31's medical record showed: - admission date of 02/21/23; - Diagnoses of repeated falls, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow, making it difficult to breathe), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the resident's POS, dated 06/06/25, showed: - An order for clopidigrel (Plavix) 75 mg, one tablet by mouth one time a day, related to peripheral vascular disease, dated 02/21/23; - No orders for an anticoagulant. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 05/27/25, with Section N0415E coded yes for anticoagulant; - An annual MDS assessment, dated 02/24/25, with Section N0415E coded yes for anticoagulant. 3. Review of Resident #60's medical record showed: - admission date of 06/09/22; - Diagnoses of muscle weakness, history of pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), and atherosclerosis (buildup of fats, cholesterol and other substances in and on the artery walls). Review of the resident's POS, dated 06/06/25, showed: - An order for clopidigrel (Plavix), 75 mg, one tablet by mouth one time a day, related to presence of cerebrospinal fluid drainage device, dated 04/07/23; - No orders for an anticoagulant. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 03/09/25, with Section N0415E coded yes for anticoagulant; - A quarterly MDS assessment, dated 12/07/25, with Section N0415E coded yes for anticoagulant. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing (DON), and both Assistant Directors of Nursing said they would expect MDS assessments to be coded correctly to reflect the resident's current status and current condition. During an interview on 06/11/25 at 1:20 P.M., the MDS Coordinator said she was coding Plavix (clopidigrel) as an antiplatelet, and then she was told to code it as an anticoagulant. The person who trained her is not there anymore. The order in the electronic charting system says it is a hematological agent, so she just Googled the medication to find the drug class. When asked if she used the tool in their electronic charting system that provides a link to that particular section of the MDS assessment, she looked at Section N and said it showed clopidigrel as an antiplatelet and not an anticoagulant. She said she is going to have to go back and fix the MDS assessments where she had coded it wrong.

Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for three residents (Resident #6, #48, and #85) out of 20 sampled residents. The facility's census was 97. Review of the facility's Comprehensive Person-Centered Care Plan policy, revised March 2022, showed: - A comprehensive, person-centered plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial, and functional needs will be developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan is developed within seven days of completion of the required Minimum Data Set (MDS-a federally mandated assessment, completed by facility staff), and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; - Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his/her care plan; - The comprehensive, person-centered care plan includes measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, stated goals, and reflects currently recognized standards of practice for problem areas and conditions; - Assessment of residents are ongoing and care plans are revised as information about residents and residents' conditions change; - The IDT reviews and updates care plans when there has been a significant change in condition, when desired outcome is not met, when resident has been readmitted to facility from hospital stay and at least quarterly with the MDS assessment. 1. Review of Resident #6's medical record showed: - admission date of 05/26/22; - Diagnoses of Alzheimer's disease (a brain disorder that affects memory and thinking skills), dementia (a brain disorder that interferes with daily life and activities and causes memory loss, confusion and difficulty doing daily tasks), schizophrenia (a severe mental disorder that affects a person's ability to think, feel and behave clearly), and unsteadiness on feet (difficulty in maintaining balance and coordination while walking or standing). Review of the resident's progress notes, dated 03/22/25, showed discharge from hospice. Review of the resident's MDS, dated [DATE], showed: - Section O0110K1-hospice care unmarked; - Section GG0170-walk 10 feet, coded a 9- not applicable - not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Review of the resident's care plan, date initiated 01/16/24, showed the resident is ambulatory; however, requires use of a wheelchair for locomotion on the unit at times. Review of the resident's care plan, date initiated 08/02/24, showed: -The resident has the potential for impairment to skin integrity, the resident has poor nutritional intake and is on hospice care. During an interview on 06/06/25 at 10:40 A.M., Certified Medication Technician (CMT) H said the resident does not walk and is dependent on staff for wheelchair mobility, and the resident hasn't been on hospice for some time. 2. Review of Resident #48's medical record showed: - admitted on [DATE]; - Diagnoses of chronic kidney disease (a longstanding disease in which the kidneys fail to remove waste from the body appropriately), renal osteodystrophy (a disease that weakens bones in patients with chronic kidney disease), Type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy) and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's Physician's Order Sheet (POS), dated 06/06/25, showed: - On 01/31/25, an order that resident will require lunch to go for dialysis every Monday, Wednesday and Friday; - On 02/10/25, an order to assess, monitor and report concerns to Primary Care Physician (PCP) and dialysis center for bruit (whoosh sound heard through a stethoscope), thrill (purring vibration at access site), collateral vein distention (veins in arm close to fistula-a surgically created connection between the artery and vein, typically in the arm and used for hemodialysis access, which is when a machine is used to filter waste from the body when the kidneys are no longer able to do so), bruising, hematomas (a localized pooling of blood under the skin and outside of the blood vessel), significant changes in the extremity, every shift, shunt location in left upper arm; - On 04/25/25, an order to monitor for signs and symptoms of steal syndrome (condition where the fistula is taking too much blood away from the hand, causing pain, numbness or tingling) every shift, report signs and symptoms to dialysis physician for possible transfer; - On 05/12/25, an order to assess and monitor weight, blood pressure, respirations, pulse, temperature, oxygen saturation and access site, prior to dialysis, and document on dialysis communication slip, ensure that dialysis receives copy. Review of the resident's care plan, last reviewed 05/20/25, showed: - Resident needs dialysis related to kidney failure; check and change dressing daily at access site; - Do not draw blood or take blood pressure in arm with graft (a synthetic tube surgically placed between an artery and a vein to create an access point for dialysis); - Monitor for signs and symptoms of infection at access site; - Monitor for signs and symptoms of steal syndrome; - Resident will receive lunch to go on following days (no days listed). During an interview on 06/03/25 at 1:30 P.M., Resident #48 said staff would weigh him/her and send the paper work with him/her to dialysis. He/she eats breakfast and lunch at the facility (leaves after breakfast and is back before lunch) and has a port under the skin in the upper left chest that the dialysis center takes care of. During an interview on 06/06/25 at 1:43 P.M., the Assistant Director of Nurses (ADON) G said Resident #48 has a left chest catheter and has had that since he/she had been here on 02/07/25. Whoever put the orders in had hit dialysis and did not unclick certain areas. The fistula could have been unclicked, but wasn't. There are port specific orders, such as with flushes, but the dialysis center flushes, not us. It is a terribly written order, and the nurses are checking the other things listed in the order (weight, blood pressure, respiration, heart rate, temperature and oxygen saturation), however, the order should have been specifically written for the resident and his/her port, not just the template. We would of course call the doctor if there were any issues. During an interview on 06/06/25 at 2:45 P.M., ADON G said Resident #48's port was placed on 04/18/24. The orders from dialysis were to not do anything at all and report anything that could be an issue. 3. Review of Resident #85's medical record showed: - admission date of 06/07/24; - Diagnoses of metabolic encephalopathy (a condition where brain dysfunction occurs and causes mental status changes due to an underlying condition), senile degeneration of the brain (a brain disorder that leads to a decline in cognition, memory, reasoning and the ability to perform everyday activities), and dementia (a group of conditions that cause impairment to at least two brain functions, such as memory loss and judgment). Review of the resident's MDS, dated [DATE], showed: - Section GG Functional Abilities, GG0120. Mobility Devices, only marked for the use of a wheelchair, not marked for the use of a cane; Review of the resident's care plan, dated 06/19/24, showed: - The resident has a cane to maximize independence with transferring, but often forgets to use it; - The resident requires supervision/touching assistance by one staff to walk every two hours and as necessary; - The resident uses a cane for walking, clean weekly. Staff to remind him/her to use the cane. During an interview on 06/06/25 at 10:40 A.M., CMT H said that the resident does not use a cane and hasn't been ambulatory for some time, he/she is dependent on staff to push his/her wheelchair. During an interview on 06/06/25 at 10:45 A.M., the MDS Coordinator said there has been some new changes implemented over the last couple of months, the interdisciplinary team (IDT) updates care plans and care plans are updated weekly. He/She also said when a resident is discharged from hospice, then all things regarding hospice care should be removed from the care plan. During an interview on 06/06/25 at 7:35 P.M., the Administrator and Director of Nursing (DON) said they would expect care plans to be updated to reflect the current status, needs and/or issues of residents and care plans should be tailored to fit each individual.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to keep a urinary catheter drainage bag off the floor for one resident (Resident #15) out of 20 sampled residents. The facility failed to use enhanced barrier precautions (EBP) for one resident (Resident #39) out of 20 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection during peri (washing the genital and anal areas of the body) and urinary catheter (a flexible tube that is placed to drain urine from bladder) care for two residents (Resident #47 and #75) out of 20 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection during medication administration for two residents outside the sample (Resident #91 and #246). The facility failed to maintain infection control practices to prevent the development and transmission of infection when obtaining fingerstick blood sugar (FSBS) for one resident (Resident #43) out of 20 sampled residents and when obtaining FSBS and during insulin administration for one resident (Resident #29) out of 20 sampled residents and two residents (Resident #38 and #52) outside the sample. The facility failed to maintain infection control practices to prevent the development and transmission of infection during medication administration via a gastrostomy tube (G-tube - a surgically placed tube that provides direct access to the stomach for feeding, fluids, or medications) for one resident (Resident #39) out of 20 sampled residents. The facility's census was 97. Review of the facility's Enhanced Barrier Precaution policy, reviewed March 2024, showed: - EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs-bacteria resistant to multiple antibiotics) to residents; - Gloves and gowns are applied prior to performing the high contact resident care activity; - PPE is changed before caring for another resident; - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing or showering, transferring, providing hygiene, changing linens, changing briefs or assisting to toilet, device care (urinary catheter, feeding tube, tracheostomy, etc) or wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of indwelling medical device; - Staff are trained prior to caring for residents on EBP; - PPE is available outside of resident rooms. Review of the facility's Personal Protective Equipment-Using Gloves policy, revised September 2010, showed: - Gloves are used to prevent the spread of infection, protect wounds from contamination, protect hands from potentially infectious material and prevent exposure of viruses from blood or body fluids; - When gloves are indicated, use disposable, single-use gloves; - Discard used gloves into waste receptacle; - Wash hands after removing gloves as gloves do not replace handwashing. Review of the facility's Handwashing/Hand Hygiene policy, revised October 2023, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections; - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with body fluids, blood, or contaminated surfaces, after touching resident, before moving from work on soiled body site to clean-on same resident, immediately after glove removal; - Use an alcohol-based rub for most clinical situations; - Wash with soap and water when hands are visibly soiled and after contact with resident with infectious diarrhea; - The use of gloves does not replace hand washing/hand hygiene. 1. Observation on 06/03/25 at 11:43 A.M. of Resident #15 showed the resident lay in bed with his/her urinary catheter bag on the floor. 2. Observation on 06/05/25 at 10:14 A.M. of Resident #15's wound care showed: - Licensed Practical Nurse (LPN) I donned a mask and gown, then washed his/her hands in the resident's bathroom; - LPN I donned gloves, brought supplies in on a towel, placed on bedside table, moved the trash can with a gloved hand, then opened the supplies, including dressings, on the bedside table; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I repositioned the resident onto his/her side and, without performing hand hygiene, removed gloves and donned new gloves; - LPN I sprayed wound cleanser onto gauze and cleansed the upper wound on the resident's back; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I tore off a small piece of calcium alginate (a highly absorbent wound dressing) with a gloved hand, then placed it on the upper wound on the resident's back, then covered it with gauze and a bordered gauze dressing; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I sprayed wound cleanser onto gauze and cleansed the lower wound on the resident's back; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I laid calcium alginate and gauze on a bordered gauze dressing, then placed it on the lower wound on the resident's back; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I peeled the backing off the tape and laid it on the towel on the bedside table; - LPN I sprayed wound cleanser onto gauze and cleansed the wound on the resident's buttock; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I opened collagen powder (a wound treatment to support tissue repair and regeneration), sprinkled on wound on the resident's buttock, then applied gauze and tape; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I repositioned the resident, then threw dressing wrappers away; - LPN I removed PPE and washed hands in the resident's bathroom, then left the room; - LPN I returned to the room with scissors, Gentian violet (an antiseptic dye), and sanitizer, donned a mask and gown, and sanitized hands; - LPN I sanitized hands and donned new gloves and poured Gentian violet into a cup; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I sprayed wound cleanser onto gauze and cleansed the wound on the resident's fourth and fifth left toes; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I again sprayed wound cleanser onto gauze and cleansed the wound on the resident's fourth and fifth left toes; - LPN I cut calcium alginate with scissors, then applied between the resident's fourth and fifth toes; - LPN I removed gloves and, without performing hand hygiene, donned new gloves; - LPN I sprayed wound cleanser onto gauze and cleansed the wound on the resident's lateral calf, then applied an abdominal pad to calf, wrapped with Kerlix (a bulky gauze bandage roll used for wound care and bandaging), then taped; - LPN I threw trash away, then gathered trash bag with bare hands and threw away in the resident's bathroom trash barrel, and washed hands; - LPN I obtained a germicidal wipe and donned gloves, then cleaned scissors and wrapped them in the wipe. During an interview on 06/05/25 at 10:45 A.M., LPN I said he/she washes his/her hands when she changes the system as in going from one body system to another. He/She washes when going from one task to another, like going from a g-tube to a trach. He/She doesn't wash or sanitize when doing, for example, the two wounds on the resident's back. The reason is because they're both in the same location on the resident's body (on the back). He/she would wash or sanitize when going from the back wounds to the buttock wound, but he/she didn't do that today. He/She normally cleans his/her scissors in between residents. 3. Observation on 06/06/25 at 9:45 A.M. of Resident #39's gastrostomy tube dressing change showed: - LPN L entered room, washed hands, donned gloves, but did not don a gown; - G-Tube supplies were located in the resident's room on a small stand; - LPN L sprayed wound cleanser into a small cup with clean gauze pads; - LPN L removed dressing, removed gloves and donned clean gloves; - LPN L cleaned area with moistened gauze pads, removed gloves and washed hands; - LPN L donned new gloves, placed split sponge dressing around site and taped into place; - LPN L removed gloves and washed hands. During an interview on 06/06/25 at 12:55 P.M., LPN L said he/she should have put a gown on prior to cleaning the G-Tube. The supplies were kept in the hallway. 4. Observation on 06/06/25 at 9:00 A.M. of Resident #47's peri and urinary catheter care showed: - Certified Nurse Aide (CNA) M already in room wearing a gown and gloves; - CNA F entered room, washed hands, and donned gown; - CNA M and CNA F donned gloves and transferred the resident from wheelchair to bed via mechanical lift; - CNA M changed gloves, but did not wash or sanitize hands; - CNA F emptied urinary catheter bag into container and took into bathroom to empty; - CNA F rinsed container, removed soiled gloves and donned new gloves without washing hands; - Resident rolled toward CNA M and mechanical lift pad removed; - CNA M removed the resident's pants and CNA F removed the resident's wet brief; - CNA F changed gloves without washing or sanitizing; - CNA F cleaned the resident's peri area, using a clean wipe per side, then with a clean wipe, cleaned catheter from peri area, down a few inches of the tube; - CNA F changed gloves, cleaned buttock area, noticed a small bowel movement, and removed gloves; - CNA F donned new gloves, but did not wash or sanitize hands; - CNA M placed a small amount of barrier cream onto CNA F's gloved hand; - CNA F applied cream to buttocks, removed soiled gloves, and donned clean gloves; - CNA F and CNA M placed clean brief on the resident; - CNA F changed gloves, then fastened brief; - CNA F and CNA M did not wash hands prior to leaving room, then sanitized in the hallway. During an interview on 06/06/25 at 9:35 A.M., CNA F said he/she washes hands before going into the room and when leaving. If he/she sanitized in between glove changes, he/she wouldn't be able to get gloves on. During an interview on 06/06/25 at 9:40 A.M., CNA M said staff are supposed to sanitize between glove changes or when going from dirty to clean and he/she also tries to sanitize when walking by the dispensers in the hallway. 5. Observation on 06/06/25 at 2:40 PM of Resident #75's peri and catheter care showed: - CNA O gathered a basin, washcloths, peri wash, and wipes and placed on the bedside table; - CNA E and CNA O washed their hands in the resident's room and donned gloves and gowns; - CNA O lowered the resident's blankets, loosened the soiled brief, removed gloves and did not sanitize or wash hands; - CNA E obtained warm water in the basin, handed to CNA O and he/she placed it on the bedside table; - CNA O donned gloves and used a wet washcloth with peri wash to clean down each side of the resident's legs while lying on his/her back; - CNA E obtained two plastic liners, one for soiled linens and one for trash; - CNA O rolled the resident to his/her left side, tucked the soiled brief under the resident and cleaned stool from the resident's buttocks using five wipes, each time reaching into the wipes container with his/her soiled glove; - CNA O removed gloves and washed hands; - CNA O donned gloves, tucked the soiled pad and brief farther under the resident, tucked the clean pad and brief under the resident and rolled the resident onto his/her right side; - CNA O then removed the soiled brief and pad from under the resident and placed them in separate plastic liners; - CNA E obtained the wipes from the container and handed them to CNA O, who wiped stool from the resident's buttocks three times; - CNA O removed gloves and donned clean gloves without washing or sanitizing his/her hands; - CNA O wiped each side of the peri area with a clean side of the washcloth and placed in a plastic liner; - CNA O obtained a clean washcloth and washed around the insertion site of the indwelling foley catheter; - CNA O obtained another washcloth and cleaned down the indwelling foley catheter tubing; - CNA O removed gloves and donned clean gloves, without sanitizing or washing his/her hands; - CNA O pulled the blanket up around the resident's shoulders; - CNA E placed the catheter drainage bag on the side of the bed, and bagged the dirty linens and trash; - CNA O emptied basin of water in the resident's sink; - CNA E and CNA O removed gowns and gloves; - CNA E and CNA O both washed their hands in the resident's room; - CNA E and CNA O carried bags of soiled linens and trash to the soiled utility room and sanitized their hands after exiting the room. During an interview on 06/06/25 at 2:50 P.M., CNA O said he/she should probably not have used a soiled glove to get wipes out of the wipes container. Each resident has their own wipes container in their room. He/She should sanitize his/her hands in between glove changes. 6. Observation on 06/05/25 from 9:05 A.M. to 9:25 A.M. of Resident #91 and #246's medication administration showed: - Certified Medication Technician (CMT) K administered medications to Resident #91 at 9:05 A.M.; - CMT K did not wash or sanitize his/her hands prior to medication preparation or administration; - Resident #91 dropped a pill on the floor. CMT K picked the pill up off the floor, threw the pill away and did not wash or sanitize his/her hands; - CMT K did not wash his/her hands after administering the medications; - CMT K administered medications to Resident #246 at 9:15 A.M.; - CMT K did not wash or sanitize his/her hands prior to medication preparation, during administration, or after administration. During an interview on 06/05/25 at 12:40 P.M., CMT K said he/she should sanitize his/her hands in between residents and before and after administering medications. 7. Observation on 06/05/25 at 11:45 A.M. of Resident #43's FSBS showed: - LPN J obtained glucometer (a device to measure the amount of glucose (sugar) in a person's blood), lancet (a sharp medical device to make a small puncture), test strip and alcohol wipe from the cart and laid supplies on top of the cart with a paper towel barrier; -LPN J donned gloves, entered the resident's room and obtained the resident's FSBS; -LPN J exited the resident's room, threw away the trash in the trash can on the side of the cart and removed gloves; -LPN J did not perform hand hygiene prior to or after the FSBS. 8. Observation on 06/05/25 at 12:10 P.M. of Resident #29's FSBS and insulin administration showed: - LPN J obtained a clean glucometer, lancet, and test strip from the cart and laid the supplies on top of the cart without a barrier; - LPN J washed his/her hands in the resident's room, then exited the resident's room and donned gloves; - LPN J removed plastic end piece from lancet, lifted trash can lid on the side of the cart, threw away plastic end piece, and did not remove gloves or sanitize hands; - LPN J obtained the resident's FSBS and exited the resident's room; - LPN J obtained a disinfectant wipe from the container on top of the cart with a soiled glove and wrapped the glucometer; - LPN J removed gloves and sanitized hands; - LPN J obtained the insulin vial, alcohol wipe, and syringe from the cart; - LPN J opened the alcohol wipe and lifted the lid of the trash can on the side of the cart to throw away trash; - LPN J did not sanitize his/her hands, donned gloves, administered insulin to the resident, removed gloves, and sanitized hands. During an interview on 06/05/25 at 11:50 A.M., LPN J said he/she should wash or sanitize his/her hands prior to performing a blood glucose check, and soon as he/she is done, and should wash his/her hands after every third person. 9. Observation on 06/05/25 at 12:18 P.M. of Resident #52's FSBS and insulin administration showed: - LPN N did not wash or sanitize his/her hands prior to performing the FSBS; - LPN N obtained clean glucometer, lancet, and test strip from the cart and laid it on top of the cart without a barrier; - LPN N donned gloves, obtained the resident's FSBS and exited the room; - LPN N threw away trash in the trash can on the side of the cart; - LPN N removed gloves and did not sanitize his/her hands; - LPN N obtained the insulin pen from the cart, primed the pen, and dialed up ordered amount of insulin; - LPN N donned gloves, dropped alcohol wipe on the floor, picked up alcohol wipe off the floor and did not change gloves or wash or sanitize his/her hands; - LPN N, wearing the same gloves administered insulin to the resident; - LPN N threw away trash, removed gloves, and did not sanitize or wash his/her hands. 10. Observation on 06/05/25 at 12:25 P.M. of Resident #38's FSBS and insulin administration showed: - LPN N obtained the glucometer, lancet, and test strip from the cart and laid the supplies on top of the nurse cart without a barrier; - LPN N donned gloves and obtained the resident's FSBS; - LPN N removed gloves and did not wash or sanitize his/her hands; - LPN N obtained the insulin pen from the nurse cart, primed pen, dialed up ordered amount of insulin, donned gloves, and administered insulin to the resident; - LPN N removed gloves and did not sanitize or wash his/her hands. During an interview on 06/05/25 at 12:32 P.M., LPN N said he/she should sanitize his/her hands in between residents and in the beginning and after the fourth resident. 11. Observation on 06/05/25 at 2:15 P.M. of Resident #39's G-tube medication administration showed: - LPN J did not wash or sanitize his/her hands prior to medication preparation or administration; - LPN J obtained three small pill cups from the side of the nurse cart and touched the inside of the cups while pulling them apart; - LPN J obtained three medications from the nurse cart and placed each into the small medication cups; - LPN J obtained two pill pouches from the nurse cart and stuck his/her finger down in the pouch to open the pouches; - LPN J crushed each pill separately and then placed back into small medicine cups; - LPN J lifted the lid to the trash can on the side of the nurse cart to throw away pill pouches and sanitized his/her hands; - LPN J donned gloves and a gown; - LPN J entered the resident's room and administered each medication individually with flushes in between and at the end; - LPN J reconnected the tube feeding to the resident's G-tube; - LPN J removed his/her gown and gloves in the resident's room and washed his/her hands. During an interview on 06/05/25 at 2:30 P.M., LPN J said he/she should wash his/her hands before and after administering medications, that he/she should not touch the inside of medicine cups or pill pouches and should wash his/her hands after having contact with the trash can. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing (DON), and both Assistant Directors of Nursing (ADON) said they would expect during medication pass for staff to sanitize and/or wash hands before administering medications, between residents, after picking up trash or pills off of floor, and when touching the trash can lid on the side of medication cart. They would expect staff to wear a clean glove when retrieving wipes from wipe container during peri care. Proper PPE, such as gowns and gloves, should be worn with residents on EBP. They would not expect a urinary catheter drainage bag to be on the floor. During wound care, staff should perform hand hygiene before starting, between each wound, when going from dirty to clean, and with glove changes. Staff should not be moving a trash can with a gloved hand that they then use to open up wound supplies. Surveyor: [NAME], April

Based on record review and interview, the facility failed to obtain correct orders from the physician for dialysis (a process for removing waste and excess water from the blood) care, specifically for a port access (a medical device implanted for easy access to a vein), instead of a fistula (a surgically created connection between an artery and a vein, used for dialysis access) for one resident (Resident #48) out of one sampled resident. The facility's census was 97. Review of the facility's Care of a Resident With End-Stage Renal Disease (ESRD) policy, revised September 2010, showed: - Staff caring for residents with ESRD, including residents that receive dialysis care outside of the facility, shall be trained in the care and special needs of the resident; - Education and training of staff includes the nature and clinical management of ESRD, including infection prevention and nutritional needs, the type of assessment data that is to be gathered about resident's condition on a daily or per shift basis; - How to recognize and intervene in medical emergencies such as hemorrhage (uncontrolled bleeding) and septic infections (life-threatening complication of infection); - How to recognize and manage equipment failure or complications, timing and administration of medications, care for grafts and or fistulas and handling of waste; - Agreements between facility and contracted ESRD facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented and how information will be exchanged between facilities; - The resident's comprehensive care plan will reflect the resident's needs related to ESRD and dialysis care. 1. Review of Resident #48's medical record showed: - admitted on [DATE]; - Diagnoses of chronic kidney disease (a longstanding disease in which the kidneys fail to remove waste from the body appropriately), renal osteodystrophy (a disease that weakens bones in patients with chronic kidney disease), Type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's Physician's Order Sheet (POS), dated 06/06/25 showed: - On 01/31/25, an order that resident will require lunch to go for dialysis every Monday, Wednesday and Friday; - On 02/05/25, an order for a modified renal diet; - On 02/10/25, an order to assess, monitor and report concerns to Primary Care Physician (PCP) and dialysis center for bruit (whoosh sound heard through a stethoscope), thrill (purring vibration at access site), collateral vein distention (veins in arm close to fistula-a surgically created connection between the artery and vein, typically in the arm and used for hemodialysis access, which is when a machine is used to filter waste from the body when the kidneys are no longer able to do so), bruising, hematomas (a localized pooling of blood under the skin and outside of the blood vessel), significant changes in the extremity, every shift, shunt location in left upper arm; - On 02/18/25, an order to obtain daily weights, for daily weight purposes only; - On 04/25/25, an order to monitor for signs and symptoms of steal syndrome (condition where the fistula is taking too much blood away from the hand, causing pain, numbness or tingling) every shift, report signs and symptoms to dialysis physician for possible transfer; - On 05/12/25, an order to assess and monitor weight, blood pressure, respirations, pulse, temperature, oxygen saturation and access site, prior to dialysis, and document on dialysis communication slip, ensure that dialysis receives copy. Review of the resident's care plan, last reviewed 05/20/25, showed: - Resident needs dialysis related to kidney failure; check and change dressing daily at access site; - Do not draw blood or take blood pressure in arm with graft (a synthetic tube surgically placed between an artery and a vein to create an access point for dialysis); - Monitor intake and output; - Monitor for signs and symptoms of infection at access site; - Monitor for signs and symptoms of steal syndrome; - Resident will receive lunch to go on following days (no days listed); During an interview on 06/03/25 at 1:30 P.M., the resident said staff would weigh him/her and send the paperwork with him/her to dialysis. He/She eats breakfast and lunch at the facility (leaves after breakfast and is back before lunch) and has a port under the skin in the upper left chest that the dialysis center takes care of. During an interview on 06/06/25 at 1:43 P.M., the Assistant Director of Nurses (ADON) G said the resident has a left chest catheter and has had that since he/she had been here on 02/07/25. Whoever put the orders in had hit dialysis and did not unclick certain areas. The fistula could have been unclicked, but wasn't. There are port specific orders, such as with flushes, but the dialysis facility flushes it, not us. It is a terribly written order, and the nurses are checking the other things listed in the order. However, the order should have been specifically written for the resident and his/her port, not just the template. We would of course call the doctor if there were any issues. During an interview on 06/06/25 at 2:45 P.M., ADON G said the port was placed on 04/18/24. The orders from dialysis were to not do anything at all and report anything that could be an issue. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing (DON), and ADON G said they would expect orders to be accurate according to the resident's diagnoses and/or issues.

Based on observation, interview, and record review, the facility failed to ensure proper tracheostomy (trach - incision in the windpipe to relieve an obstruction to breathing) care for one resident (Resident #15) out of one sampled resident. The facility's census was 97. Review of the facility's policy, Suctioning the Trachestomy Tube, revised October 2023, showed: - The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract; - Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning; Review the resident's care plan to assess for any special needs of the resident; Obtain baseline vital signs and oxygen saturation; Obtain information about the resident's medical history, including date of tracheostomy, respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive Pulmonary Disease [COPD], chest trauma, abdominal surgery, and smoking); Determine the need for suctioning: Visible secretions in the artificial airway; or Respiratory sounds heard when auscultating over the trachea; Assemble the equipment and supplies as needed; Test equipment before use. Determine if suction equipment is generating appropriate negative pressure; Portable suction devices should have negative pressure set at -10 to -15 millimeters (mm) mercury (Hg); - Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia (tissues and organs in the body do not receive enough oxygen to function properly), hypoxemia (abnormally low levels of oxygen in the blood), and cardiac dysrhythmias (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines: Suction only as needed, based on assessment of the resident's level of respiratory distress; Pre-oxygenate the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning; Suctioning of the lower airway is a sterile procedure; Set suction pressure as low as possible while effectively clearing secretions; Suction catheters should occlude less than 50% of the lumen for adults; Keep the suctioning procedure as brief as possible and no longer than 15 seconds; and Use a shallow suctioning technique; - Monitor the resident's pulse and oxygen saturation during suctioning. If pulse decreases more than 20 beats per minute (BPM) or increases more than 40 BPM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re-oxygenate the resident; - The following equipment and supplies will be necessary when performing this procedure: Sterile suction catheter kit; or Sterile drape; Sterile cup; Sterile gloves; #10 to #16 French catheter (catheter outer diameter should not exceed one-half the internal diameter of the tube); Sterile gauze; Towel or Chux pad; 100 cc sterile saline or sterile water; Wall or portable suction unit; Tubing (approximately 6 feet); and Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed); - Identify the following risk factors for impaired airway clearance or aspiration: Impaired cough or gag reflex; Dysphagia; Weak respiratory muscles (from injury, abdominal surgery, etc.); COPD; Pulmonary infection; Presence of feeding tube; Smoking; and/or Decreased level of consciousness; - Assess for the following signs and symptoms of respiratory distress/hypoxia/hypoxemia: Diminished breath sounds; Tachypnea; Dyspnea; Gurgling, crackling or wheezing upon inspiration; Cyanosis; Decreased oxygen saturation (SpO2); Restlessness; and/or Drooling, secretions or vomitus in mouth; - Steps in the Procedure: Provide for resident privacy. Explain the procedure to the resident. Perform hand hygiene. Put on gloves. Put on mask and protective eyewear (goggles or face shield), as indicated. Assist the resident to semi-Fowler's position with head turned toward you. Pre-oxygenate the resident by increasing supplemental oxygen flow for 30 seconds to one minute. Connect one end of suction tubing to suction unit and place the other end near the resident. Turn on suction unit and adjust to appropriate negative pressure (-100 to -120 mmHg for wall unit or -10 to -15 mmHg for portable unit). Remove gloves. Open suction catheter kit. Place sterile drape across the resident's chest. Remove sterile cup, touching only the outside. Fill cup with sterile saline or sterile water. Apply sterile gloves. The dominant hand will remain sterile. Holding the suction catheter in dominant hand and the suction tubing in the non-dominant hand, connect the catheter to the tubing. Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit). Remove oxygen or humidity delivery device using non-dominant hand. Insert the catheter into tracheostomy tube without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME]). Pull back one to two cm. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than 15 seconds. Re-oxygenate the resident for 30 seconds to one minute between suctions. Dip catheter tip in sterile saline or sterile water and apply suction. Rinse catheter and tubing until clear. Assess cardio-pulmonary status. Repeat steps 19 through 23, if necessary. Limit suction passes to a maximum of three. Replace oxygen or humidity delivery device. If the resident's physical or medical condition permits, assist the resident to a position that promotes deep breathing and coughing. Turn off suction. Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle. Remove drape and discard in designated receptacle. Discard water or saline in commode. Dispose of cup in designated receptacle. Empty and rinse collection container if necessary or as indicated by facility protocol. Discard personal protective equipment in designated receptacles. Perform hand hygiene. Apply clean gloves and provide oral hygiene for the comfort of the resident, if indicated. Perform hand hygiene. Review of the facility's policy, Trachestomy Care, revised October 2023, showed: - Preparation and Assessment: Check physician order. Explain procedure to resident. Perform hand hygiene. Apply clean gloves. Remove supplemental oxygen from tracheostomy. Inspect skin and stoma site for signs or symptoms of infection, leakage, subcutaneous crepitus, or dislodged tube. Assess resident for respiratory distress. Measure resident's oxygen saturation with pulse oximeter. Listen to lung sounds with a stethoscope. Observe for asymmetrical chest expansion. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle. Perform hand hygiene; - Clean the Stoma and Surrounding Site: Apply clean gloves. Clean the stoma: With the moistened gauze starting at the 12 o'clock position of the stoma, wipe toward the three o'clock position. Begin again with a new gauze square at 12 o'clock and clean toward 9 o'clock. To clean the lower half of the site, start at the three o'clock position and clean toward six o'clock; then wipe from nine o'clock to six o'clock, using a clean moistened gauze square for each wipe. Continue this pattern on the surrounding skin and tube flange. Wipe with dry gauze. Apply a fenestrated gauze pad around the insertion site, touching only the outer edges; - Replace neck ties: A two-person technique is recommended, with one person holding the tracheostomy tube in place while the other person secures the ties. If the resident's condition is unstable, or if the stoma is less than two weeks old, apply new ties before removing old ones. Replace supplemental oxygen mask over tracheostomy. Remove gloves and discard into appropriate receptacle. Perform hand hygiene. The facility did not provide a policy regarding Certified Nursing Assistants' scope of practice. Review of Resident #15's medical record showed: - admission date of 02/24/25; - Diagnoses of respiratory failure with hypoxia (a condition where the lungs are unable to deliver adequate oxygen to the bloodstream, leading to low blood oxygen levels), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow, making it difficult to breathe), and trachestomy status. Review of the resident's Physician Order Sheet, dated June 2025, showed: - An order to change trach collar every Thursday day shift, dated 05/16/25; - An order for oxygen at five liters per minute via trach continuously. Humidified air at 28% via compressor. Obtain oxygen saturation and record every day and night shift, dated 05/16/25; - An order for trach care every day and night shift, dated 05/16/25; - No order to obtain baseline vital signs and oxygen saturation, pre-oxygenate, suction trach, or monitor vital signs and oxygen saturation during suctioning. Observation on 06/05/25 at 10:14 A.M. of Resident #15 showed: - Certified Nursing Assistant (CNA) P and CNA Q donned gloves, gown, and mask, and transferred the resident from the chair to bed; - CNA P then placed supplemental oxygen back on the resident's trach. Observation on 06/05/25 at 3:34 P.M. of Resident #15's trachestomy care showed: - Resident coughing and attempting to clear airway. He/She had copious amounts of thick yellow sputum in trach and on his/her neck area; - Licensed Practical Nurse (LPN) I donned a mask and gown, washed hands in the resident's bathroom sink, then donned clean gloves; - Without pre-oxygenating, obtaining vital signs or oxygen saturation, LPN I suctioned the resident's trach two passes with the suction catheter lying on the shelf in the opened packaging and already connected to the suction pump, rinsing the suction catheter in water container sitting on shelf to clean the catheter in between passes; - LPN I then disconnected the suction catheter and threw it in the trash with his/her gloves; - The resident continued to cough and attempt to clear his/her airway and had copious amounts of thick yellow sputum in trach and pooled on his/her neck area; - LPN I removed mask, gown, and gloves, and left the room to get another suction catheter; - LPN I donned a new mask and gown, washed hands, then donned clean gloves; - LPN I opened a trach kit and poured 1/2 hydrogen peroxide and 1/2 water in trach kit tray, dipped a 4 inch by 4 inch gauze in it and wiped the resident's secretions from his trach and neck; - LPN I removed gloves and, without performing hand hygiene, put on new clean gloves and unfastened the resident's trach collar, removed the gloves, then moved the trash can to the side of the bed with a bare hand; - LPN I washed hands, donned sterile gloves, removed the old trach collar and put the new one on; - LPN I removed sterile gloves and, without washing or sanitizing, put on clean gloves, and attached new suction catheter to pump; - Without pre-oxygenating, obtaining vital signs or oxygen saturation, LPN I suctioned the resident's trach, then suctioned secretions on the resident's chest, then suctioned the resident's trach again; - LPN I then rinsed out the suction catheter, curled it up and put it back in its opened package and laid it on the shelf; - LPN I washed hands, donned clean gloves, put split gauze dressing around the resident's trach and, without washing or sanitizing, changes gloves and gathered trash; - LPN I realized the oxygen concentrator wasn't running and turned on the concentrator. During an interview on 06/05/25 at 4:00 P.M., LPN I said they typically change suction catheter sets out daily, but he/she has worked other places and they change them after each suction, but they don't do that here. He/She doesn't know how long the oxygen concentrator had been off. He/She apologized that the care wasn't very good as he/she had a lot going on right now. During an interview on 06/06/25 at 4:41 P.M., the Director of Nursing (DON) said everyone who has a trach in the building has a Bivona (a specialized tracheostomy tube designed for long-term airway management), and they don't have an inner cannula that would need to be taken out. There should be an order to suction. A trach care order would mean cleaning. CNAs should not be placing the oxygen back on the resident's trach. They should tell the nurse and have them come do it. During an interview on 06/06/25 at 7:35 P.M., the Administrator, DON, and both Assistant Directors of Nursing (ADONs) said they would expect a resident with a trach to have orders to be suctioned and for staff to follow facility policy on suctioning. The suction catheter should only be used once and not reused.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent or less. There were four medication errors out of 30 opportunities for errors, resulting in an error rate of 13.33%. This practice affected resident (Resident #39) out of 20 sampled residents and one resident (Resident #91) outside the sample. The facility's census was 97. Review of the facility's policy, Administering Medications, revised April 2019, showed: - Medications are administered in accordance with prescriber orders, including any required time frame; - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication, preventing potential medication or food interactions, and honoring resident choices and preferences, consistent with his or her care plan; - Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. Review of the facility's policy, Administering Medications through an Enteral Tube (a feeding tube that allows liquid food to enter your stomach or intestine through a tube), revised November 2018, showed: - Purpose: to provide guidelines for the safe administration of medications through an enteral tube; - Steps: Wash your hands, retrieve medication(s), prepare the medication(s), prepare the resident, check compatibility with feeding tube formula, verify placement of the feeding tube, stop feeding and flush tubing with at least 15 ml (milliliters-a unit of volume, one-thousandth of a liter) warm purified water (or prescribed amount), remove syringe and clamp tubing, dilute medication(s): remove plunger from syringe, add medication and appropriate amount of water to dilute, dilute crushed medication with at least 30 ml purified water (or prescribed) amount, dilute liquid medication with 30 ml or more (depending on viscosity-a measure of a fluid's resistance to flow), purified water, administer each medication separately, reattach syringe (without the plunger) to the end of the tubing, administer medication by gravity flow, if administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications, when the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount), quickly clamp the tubing when the flush is complete and remove the syringe, wash your hands. 1. Review of Resident #39's medical record showed: - admission date of 07/18/23; - Diagnoses of cerebral palsy (a group of conditions that affect movement and posture, cause by damage that occurs to the developing brain, most often before birth), depression (a persistent feeling of sadness and loss of interest, significantly impacts daily functioning), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). Review of the resident's Physician's Order Sheet (POS), dated 10/18/24, showed: - An order for clonazepam (medication to treat seizures, panic disorder, or anxiety) oral tablet, 0.5 milligram (mg-a unit of mass or weight, one thousandth of a gram), one tablet per g-tube (a feeding tube that provides direct access to the stomach for delivery of nutrition, fluids and medications) three times a day (TID), dated 02/18/25; - An order for trazodone (antidepressant medication) HCl oral tablet 50 mg, one tab per g-tube TID, dated 05/27/25; - An order for Depakene (anticonvulsant medication) oral solution 250mg/5ml, give 8 ml per g-tube TID, dated 04/01/25. Observation of the resident's medication pass on 06/05/25 at 2:15 P.M. showed: - Licensed Practical Nurse (LPN) J did not verify placement of the g-tube; - LPN J administered the crushed clonazepam 0.5 mg tab, mixed with water, and used a syringe to push the medication through the g-tube; - LPN J administered the crushed trazodone HCl 50 mg tab, mixed with water, and used a syringe to push the medication through the g-tube; - LPN J administered the Depakene oral solution, 8 ml mixed with water, and used a syringe to push the medication through the g-tube. 2. Review of Resident #91's medical record showed: - admission date of 03/25/25; - Diagnoses of cancer, diabetes mellitus (DM-a chronic disease characterized by high blood sugar, occurs when your body does not produce enough insulin, does not use insulin effectively, or both) with polyneuropathy (a common complication from DM, characterized by nerve damage, particularly in the feet and legs), low back pain, and artificial shoulder joint. Review of the resident's POS, dated 06/11/25, showed an order for diclofenac (anti-inflammatory medication) 75 mg, one tab by mouth twice daily (BID), dated 03/25/25. Observation of the resident's medication pass on 06/05/25 at 9:05 A.M. showed: - Certified Medication Technician (CMT) CMT K prepared fourteen medications for administration for Resident #91 and placed into a medication cup; - CMT K gave medications to the resident, and the resident dropped the diclofenac 75 mg pill on the floor; - CMT K picked up the medication up off the floor and threw it away; - CMT documented in the eMAR (electronic medication administration record) the pill was dropped in the floor; - CMT K closed out of the resident's eMAR and pulled up the next resident's name he/she had to administer medications to and started to move the medication cart; - CMT K, when questioned as to why he/she didn't give the resident a replacement pill for the one that was dropped, gave the resident a replacement pill, the last pill remaining in the card. During an interview on 06/05/25 at 9:10 A.M., CMT K said that usually when a pill is dropped, he/she will give a replacement pill, but it is cycle fill day (when the medication carts get stocked with medications) and typically there are no pills left on those days. During an interview on 06/06/25 at 7:35 P.M., the Administrator and Director of Nursing (DON) said they would expect the medication error rate to be less than five percent. During an interview on 06/11/25 at 12:08 P. M, the Director of Nursing (DON) said he/she would expect g-tube administered medications to be given using gravity. During an interview on 06/11/25 at 4:05 P.M., LPN J said she typically checks g-tube placement prior to administering medications, but he/she was nervous and forgot. Typically he/she would give g-tube medications per gravity flow, but Resident #39 likes to bear down and the medications won't go down unless pushed with a syringe.

Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in five rooms. Storing items on the overbed light creates a hazard of the items falling on resident below and does not utilize the light fixture as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility's census was 97. The facility did not provide a policy regarding overbed light safety. Observation on 06/06/25 showed: - At 6:00 P.M., room W12 with a decorative Blessed sign stretching across the light fixture; - At 6:05 P.M., room W16 with a decorative Welcome sign and paper picture of a horse on top of the light fixture; - At 6:06 P.M., room W20 with a sound bar for the television on top of the light fixture; - At 6:08 P.M., room W22 with two small decorative Christmas trees, a stuffed animal, and another small decoration on the light fixture; - At 6:30 P.M., room E11 with eight small, decorative items on the light fixture. During an interview on 06/06/25 at 7:35 P.M., the Administrator, Director of Nursing, and both Assistant Directors of Nursing said they would expect light fixtures in rooms to be free from decorations and objects.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 96. Review of the facility policy, Refrigerators and Freezers, revised November 2022, showed: - Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 F and freezers keep frozen foods frozen solid; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken. The last column will be completed only if temperatures are not acceptable; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening; - The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted; - Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference; - All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened; - Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy; - Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging; - Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed; - Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. 1. Observation on 06/18/24 at 11:40 A.M. of the walk-in refrigerator showed: - Numerous items in plastic storage bags, some of which were opened, that were not labeled or dated; - An opened energy drink sat on the top right shelf. Dietary Staff I took a drink from the can and then put it back on the shelf. 2. Observation on 06/18/24 at 11:40 A.M. of the walk-in freezer showed: - Ice build up on the inside of the door; - A pie sat on the top right self, uncovered and not labeled or dated; 3. Observation on 06/18/24 at 11:40 A.M. and 06/19/24 at 12:54 P.M., of the dry food storage room showed: - A bottle of opened lemon juice which said refrigerate after opening; - Open bags of shake mix in an opened and undated plastic storage bag; - An opened, undated bag of muffin mix; - Instant pudding/pie filling in a sealed plastic storage bag with no date or label; - Large opened bag of cheesecake mix, not dated; - Two large, unopened jars of French dressing sat on the floor of the storage area; - A 25 pound opened bag of catfish breading with a delivery date of 8/22/23. No best or used by date; - An opened box of pasta, not dated; - A 25 pound bag of opened biscuit mix not dated, with a delivery date of 10/27/23. No best by or use by date; - An opened bag of dry milk with scoop inside, not sealed or dated. 4. Observation on 06/18/24 at 11:40 A.M. and on 06/19/24 at 12:45 P.M. of the kitchen showed: - Debris on the shelves and counters throughout the kitchen; - Debris on the floors throughout the kitchen; - A buildup of a brown substance in the fryer; - Debris on the front and back of the fryer, around the knobs and down the sides of the fryer; - Carbon buildup on the convection oven and stove; - A black substance buildup on the stove; - A black substance buildup on skillets, pots, and cooking sheets. Review of the temperature logs indicated daily temperatures were not being taken for the following: - Food cooking temperatures; - Steam table temperatures; - Walk-in freezer; - Walk in refrigerator; - Double door refrigerator; - Water; - Dishwasher - High temp sanitizing; - Dishwasher PPM sanitizer. During an interview on 06/19/24 at 12:45 P.M. the Dietary Manager (DM) said the cook is responsible for completing the temp logs for the refrigerators, freezer, and steam table. He/she said anyone can check the water and dishwasher temps. During an interview on 06/21/24 at 9:26 A.M., the DM said he/she would expect food to be stored off the floor, opened packages wrapped or put into appropriate storage containers and to be labeled and dated. The DM said he/she would expect kitchen equipment, cookware and bakeware to be free from grease, debris and carbon buildup. The DM said he/she would expect temperature logs to be kept for the freezer, refrigerator, steamtable, dishwasher, and water. He/she said staff are not supposed to keep their personal drinks in the walk-in refrigerator, because they have an employee break room where they are to be kept. During an interview on 06/21/24 at 12:00 P.M., the Administrator and DON said they would expect food to be stored off the floor, opened packages wrapped or put into appropriate storage containers and to be labeled and dated. They said they would expect kitchen equipment, cookware and bakeware to be free from grease, debris and carbon buildup. They said they would expect temperature logs to be maintained for the freezer, refrigerator, steamtable, dishwasher, and water. They said they would expect staff to keep their personal drinks out of the kitchen and in the employee break room.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices while providing care for two residents (Resident #1 and #36) out of 20 sampled residents and failed to provide appropriate documentation of tuberculosis (TB-an infectious bacterial disease that affects the lungs) testing for five residents (Resident #12, #24, #28, #30 and #76) out of five sampled residents. The facility census was 96. Review of the facility's policy, Personal Protective Equipment-Using Gloves, last revised September 2010, showed: - Use gloves when touching excretions, secretions, blood, body fluids, or non-intact skin; - To prevent spread of infection; - To protect hands from potentially infectious material; - Wash hands after removing gloves. Review of the facility's policy, Screening Residents for Tuberculosis, last revised August 2019, showed: - The facility shall screen all residents for tuberculosis infection and disease; - Individuals identified with active TB shall be isolated from other residents and ancillary staff and transported to an appropriate care facility as soon as possible; - The admitting nurse will screen referrals for admission and readmission; - Signs and symptoms of TB include cough, loss of appetite, fatigue, weight loss, night sweats, bloody sputum, fever and chest pain; - Did not address exact measures in testing for TB. 1. Observation of Resident #1 on 06/18/24 at 12:50 P.M. showed: - Certified Nursing Assistant (CNA) C and CNA D provided perineal care for the resident; - CNA D cleaned the resident while CNA C positioned the resident on his/her side; - Resident repositioned to back. CNA D cleaned the front perineal area and did not change gloves; - With the same gloves, CNA D placed a brief on the resident; - With the same gloves, CNA D touched the mechanical lift pad, controls and hand bars to transfer the resident with the assistance of CNA C; - CNA C and CNA D removed gloves, but did not wash or sanitize hands before leaving the room. During an interview on 06/20/24 at 9:05 A.M., the Director of Nursing (DON) said he/she would expect staff to use proper infection control practices while giving peri care. During an interview on 06/20/24 at 9:09 A.M., Licensed Practical Nurse (LPN) E said he/she would expect staff to use proper infection control practices while giving peri care. 2. Observation for Resident #36 on 06/21/24 at 9:00 A.M. showed: - CNA A and CNA B provided perineal care for the resident; - CNA B cleaned the resident while CNA A positioned the Resident on his/her side; - The resident had a bowel movement during care. CNA B did not change gloves after cleaning; - Resident repositioned to back. CNA A cleaned the front perineal area and did not change gloves; - With the same gloves, CNA B touched sheets and pulled them over the resident; - With the same gloves, CNA B touched the door knob to push chair out of the room before removing gloves and washing hands; - With the same gloves, CNA A touched the resident's call light and clean sheets before removing gloves and washing hands. During an interview on 06/21/24 at 9:16 A.M., CNA A and CNA B said gloves should have been changed between dirty and clean and before they touched resident's sheets, call lights, door knobs and other items. 3. Review of Resident #12's medical record showed: - admitted on [DATE]; - A first step TB test given on 9/05/23, with no date for a reading of 0 millimeters (mm); - A second step given on 9/19/23, with no date for a reading of 0 mm. 4. Review of Resident #24's medical record showed: - admitted on [DATE]; - A first step TB test given on 5/21/24, with no date for a reading of 0 mm; - A second step given on 06/07/24, with no date for a reading of 0 mm. 5. Review of Resident #28's medical records showed; - admitted on [DATE]; - A first step TB test administered on 8/24/23, with no date for a reading of 0 mm; - A second step given on 9/07/23, with no date for a reading of 0 mm. 6. Review of Resident #30's medical record showed: - admitted on [DATE]; - A one time readmission screen given on 4/03/24, with no date for a reading of 0 mm. 7. Review of Resident #76's medical record showed: - admitted on [DATE]; - A yearly screen, dated 10/14/23, with no documentation of signs or symptoms. During an interview on 06/20/24 at 09:45 A.M., the DON said he would expect the signs and symptoms to be marked yes or no. During an interview on 06/20/24 at 11:55 A.M., the DON said they have contacted the electronic medical record company and they will be having the read date of the PPD(s) added to the system. During an interview on 06/21/24 at 12:00 P.M., the Administrator and DON said they would expect staff to change gloves, once contaminated, before touching a clean surface or resident and TB results should have correct read dates. 49150

Based on interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for two residents (Resident #7 and #30) out of two sampled residents. The facility census was 96. 1. Review of Resident #7's medical record showed: - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other import mental functions), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), other bilateral secondary osteoarthritis of first carpametacarpal joint (breakdown of cartilage in the joint.) Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 05/10/24, showed: - Moderately impaired cognition; - Dependent with activities of daily living (ADLs) and self care; - Impairment on one side of lower extremities; - Restorative Nursing Program for active (when an outside force, such as another person, causes movement of a joint) range of motion. Review of the resident's care plan, dated 05/13/24, showed: - Dependent on staff for toileting and transferring; - At risk for falls due to gait and balance problems. Review of the resident's Physician's Order Sheet (POS), dated 05/31/24, showed an order for Restorative Nursing Services to be provided 1-5 days a week, dated 05/07/24. Review of the resident's restorative nursing documentation showed no documentation that restorative therapy occurred. 2. Review of Resident #30's medical record showed: - Diagnoses of congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), hyperlipidemia, and chronic kidney disease, stage 4 (loss of kidney function). Review of the resident's Physician's Order Sheet (POS), dated 06/19/24, showed an order for Restorative Nursing Services to be provided 1-5 days a week, dated 05/07/24. Review of the resident's restorative nursing documentation showed restorative therapy occurred on 05/09/24, 05/24/24, 05/31/24, and 06/21/24. During an interview on 06/21/24 at 9:36 A.M., Restorative Aide H said Resident #7 isn't on his list of residents he/she sees for restorative. He/She hasn't done any documentation on Resident #7. During an interview on 06/21/24 at 10:22 A.M., Restorative Aide H said they normally will have residents complete twelve weeks of restorative services and then therapy will re-evaluate and determine if they if they need to stay on services. They normally complete their notes for each resident in the electronic medical record at the end of each week. When they first started doing restorative therapy, they were not good about completing the notes, but they are doing better about it now and try to get them put in at the end of each week. During an interview on 06/21/24 at 12:00 P.M., the Administrator and Director of Nursing (DON) said they would expect restorative services to be completed as ordered and appropriate documentation to be completed regarding the services.

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center for one resident (Resident #33) out of one sampled resident receiving dialysis. The facility census was 96. Review of the facility's policy titled, Hemodialysis Catheters-Access and Care of, dated 02/2023, showed: Care of the AVF's and AVGs: - Do not use access arm to take blood pressure; - Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals; - Check patency of the site at regular intervals. Palpate the site to feel the thrill,or use a stethoscope to hear the whoosh or bruit of blood flow through the access; - The nurse should document in the resident's medical record every shift as follows: location of catheter, condition of dressing, If dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, observations post dialysis. Review of the Dialysis Critical Element Pathway Form CMS 20071, dated 5/2017, provided by the Director of Nursing (DON), showed: - Physician Orders: dialysis access care, dialysis schedule, individualized dialysis prescription such as number of treatments per week; length of treatment time, type of dialyzer, fluid restrictions, target weight, blood pressure monitoring; - Care Plan: Has staff evaluated the resident's response to dialysis and developed/revised the care plan in collaboration with the dialysis facility: - Monitoring vital signs, weights nutritional, and fluid needs or any restrictions, lab results, and who to notify with concerns; - Specific type and location of dialysis services, transportation arrangements, and the interventions and goals based upon the type of dialysis; - For hemodialysis (HD), which arm to use for blood pressure; - Who to contact such as the attending practitioner, nephrologist, and dialysis staff, for dialysis related emergencies, concerns or complications; - Monitoring for risk factors and managing complications such as hemorrhage, access site infection, hypotension, and to whom to report concerns; - Approach to administering medications before, during, or after dialysis according to the practitioner's orders. Review of Resident #33's Physician's Order Sheet (POS), dated 06/01/24-06/30/24, showed: - admitted to the facility on [DATE] and readmitted on [DATE]; - Diagnosis of end stage renal disease (chronic irreversible kidney failure), congestive heart failure (heart is unable to push enough blood into circulation), diabetes mellitus type II (body is unable to control the amount of sugar in the blood), and chronic respiratory failure (lungs cannot get enough oxygen in the blood or eliminate carbon dioxide from the blood); - 2000 cc Fluid Restriction over 24 hours; - No documentation of dialysis days, times or transportation; - No documentation of dialysis Facility with demographics; - No orders to assess and monitor the dialysis access site; - No orders to assess and monitor the resident before and after a dialysis treatment. Review of the resident's medical record, dated 04/28/24 through 06/21/24, showed: - No documentation of the resident's condition being assessed and monitored before and after dialysis treatments; - No documentation of the resident's dialysis access site being assessed and monitored from 04/28/24-06/21/24; - No documentation of any communication between the facility and the dialysis staff. Review of the resident's Medication Administration Record (MAR) and the Treatment Administration Record (TAR), dated 4/28/24 through 06/21/24, showed: - No documentation of the resident's condition being assessed and monitored before and after dialysis treatments; - 2000 ml fluid restriction not documented in the electronic medical record or monitored each shift and totaled daily; - No documentation of pre or post dialysis weights or vital signs; - No documentation of the resident's dialysis access site being assessed and monitored daily or before and after dialysis treatments. Record review of the resident's care plan, dated 3/18/24, showed: - Potential for fluid deficit related to presence of foot infection, goes to dialysis 3x week, he/she is on fluid restriction; - No interventions for the assessment and monitoring of the resident before and after dialysis; - No monitoring of fluid limits or amounts per shift or per day. Record review of the resident's progress notes, dated 03/05/24 to 06/20/24, showed: - No documentation of ongoing assessments and/or monitoring of the resident's condition; - No documentation of assessment or monitoring resident before or after dialysis on Monday, Wednesday, and Friday. During an interview on 06/18/24 at 1:30 P.M., Licensed Practical Nurse (LPN) G said the facility does not have dialysis communication sheets. Dialysis calls us or the nurses call them if we have questions. The resident has early morning dialysis, so he/she does not take medication prior to dialysis. The resident comes back from dialysis and immediately lays down. LPN G said he/she looks at the pressure dressing and checks bruit and thrill, but doesn't usually record it. During an interview on 06/20/24 at 11:20 A.M., the DON said dialysis is mentioned in the fluid dehydration care plan and there was an order under other 3/8/24 for dialysis (no documentation required). During an interview on 06/20/24 at 11:20 A.M., the Minimum Data Set (MDS - a mandatory assessment completed by the facility) Coordinator said dialysis is mentioned in the fluid dehydration care plan. During an interview on 06/21/24 at 12:00 P.M., the Administrator and DON said they would expect staff to assess a resident before and after dialysis. They would expect the resident to have a care plan for dialysis and would expect a resident with fluid restriction to be monitored for fluid intake.

Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #48) outside of the sample. The facility census was 96. Review of the facility policy titled, Medication and Treatment Orders, last revised 2016, showed: - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; - Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis; - All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order; - The signing of orders shall be by signature or a personal computer key. Signature stamps may not be used; - The staff and practitioner shall use only approved abbreviations and symbols when ordering and/or charting medications; - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, and the date and the time of the order; - Verbal orders must be signed by the prescriber at his or her next visit; - Orders for medications must include: a. name and strength of the drug; b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration; d. route of administration; e. clinical condition or symptoms for which the medication is prescribed; f. any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). - Only authorized personnel shall call in orders for prescribed medications to the pharmacy. - Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. Review of Resident #48's medical record showed: - admitted [DATE]; - Diagnoses of Alzheimer's disease (type of dementia that affects memory, thinking, and behavior), traumatic subdural hemorrhage with loss of consciousness, (head injury, such as a blow to the head or a fall that develops when tiny veins that are located between the membranes covering the brain leak blood after an injury to the head), dysphagia (swallowing difficulties), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), major depressive disorder, recurrent, severe with psychotic symptoms (disorder in which a person has depression along with loss of touch with reality (psychosis); - An order dated 05/14/24 for Tramadol HCI oral tablet 50 mg, give 1 tablet by mouth in the morning for back pain. Review of Resident #48's Medication Administration Record (MAR), dated May 2024, showed the resident did not receive the medication from 05/14/24 through 06/20/24. During an interview on 06/20/24 at 9:00 A.M., Certified Medication Technician (CMT) J said the Tramadol has not been delivered from pharmacy and unsure of the reason. CMT J said he/she would expect all medications prescribed to be available and given. During an interview on 06/20/24 at 9:10 A.M., Licensed Practical Nurse (LPN) F said he/she would expect all prescribed medications to be delivered from the pharmacy and given to residents. LPN F would expect nurses and CMTs to notify the pharmacy, physician's office, and supervisor, if medications were not delivered and available for residents. During an interview on 06/21/24 at 12:00 P.M., the Administrator and Director of Nursing said they would expect all prescribed medications to be ordered and delivered from the pharmacy to be available to residents as physician ordered.

Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician's (RD) recommendations for weight loss were provided to the physician which affected one resident (Resident #7) out of 20 sampled residents. The facility census was 96. Review of the facility policy, Weight Assessment and Intervention, revised March 2022, showed: - Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month - 5% weight loss is significant; greater than 5% is severe. Three months - 7.5% weight loss is significant; greater than 7.5% is severe; Six months - 10% weight loss is significant; greater than 10% is severe. Review of the facility policy, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, showed the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), gastroesophageal reflux disease (GERD - a digestive disease in which stomach acid or bile irritates the food pipe lining), and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues); - At risk of malnutrition, per the Mini Nutrition Evaluation, dated 02/09/24. Review of the resident's weights showed: - On 12/11/23, the resident weighed 207.4 pounds (#); - On 01/09/24, the resident weighed 206.4#; - On 02/05/24, the resident weighed 207.0#; - On 03/05/24, the resident weighed 194.0#; - On 04/04/24, the resident weighed 187.6#; - On 05/06/24, the resident weighed 175.9#; - On 05/24/24, the resident weighed 193.8#; - On 06/03/24, the resident weighed 181.2#; - On 06/7/24, the resident weighed 181.0#; - On 06/14/24, the resident weighed 177.3#, which is a 14.51% loss over six months. Review of the resident's care plan, revised on 05/16/24, showed: - Resident has an activities of daily living (ADL) self-care performance and mobility deficit related to Alzheimer's and requires supervision/touching assist of one staff with eating; - Cue, reorient, and supervise as needed; - Dietary consult for nutritional regimen and ongoing monitoring; - Resident has a nutritional problem and has had a recent weight loss and is on an appetite stimulant and supplement; - Administer medications as ordered. Monitor/Document for side effects and effectiveness; - Provide and serve diet as ordered; - Provide and serve supplements as ordered; - RD to evaluate and make diet change recommendations as needed; - Weights to be monitored monthly and as needed/ordered. Review of the RD note, dated 03/12/24, showed: - Resident continues to receive a regular diet for meals, eats independently in the dining room after meal set up. - Current weight 194#, reflecting 6.3% loss in 30 days. - Will request re-weigh to ensure accuracy. Will continue to monitor and follow as needed. Review of the RD note, dated 04/09/24, showed: - Weight: 187.6# indicative of 3.3% loss past month and 9.1% loss past three months; - Resident receives a regular diet and eats meals usually in the dining room, though has refused at times; - Staff have placed resident at the assist table for encouragement, but has not been responding well to this per staff. Resident has changed from taking food from other resident at times to no longer doing this and refusing to eat at times. Resident will not respond to assistance efforts either; - Cognition is altered such that he/she will smile or laugh at times, but then does not follow through with eating, etc. No skin breakdown, though redness to groin and buttocks noted 04/03/24; - Cause for weight loss evaluated due to variable intake related to decline in mental status. Continued rapid loss not desired. To support stability, recommend 1) Assure kcal drinks offered every meal and encouraged. 2) Offer high kcal snacks between meals 3) Monitor meal intake for 30 days. Will notify nursing of recommendations. RD to follow as needed. Review of the resident's May 2024 physician orders showed: - Regular diet, regular consistency, dated 07/28/22; - Weight check and record weekly every day shift every Friday for weight loss, dated 05/17/24; - Two Cal (a calorie and protein dense nutrition supplement) (90 milliliters) two times a day with meals, dated 05/15/24; - Megestrol Acetate Suspension 400 milligrams (mg)/10 milliliters (mL), give 5 mL by mouth one time a day for anorexia, dated 04/12/24; - No order for Assure kcal drinks every meal; - No order to offer high kcal snacks between meals; - No order to monitor meal intake for 30 days. Review of the resident's Nutrition - Amount Eaten task showed no documentation of the resident's meal intake per dietician recommendation. Observations of the resident showed: - On 06/18/24 at 1:18 P.M., the resident fed self a few bites with spoon, set spoon down and moved the plate away. Staff approached and fed the resident a bite of dessert and then walked away to assist another resident. After a few minutes, the resident ate another bite of dessert. Resident very slow to feed self and was still feeding self at 1:56 P.M. At 2:09 P.M., resident had eaten approximately 25%. No observation of Assure kcal drinks per dietician recommendation; - On 06/19/24 from 1:05 P.M. to 1:28 P.M., the resident ate independently and ate approximately 25%. No observation of Assure kcal drink per dietician recommendation; - On 06/20/24 from 1:36 P.M. to 1:56 P.M., the resident fed self slowly and ate almost 100%. No observation of Assure kcal drink per dietician recommendation. During an interview on 06/20/24 at 2:54 P.M., the Director of Nursing (DON) said they have a new dietician and she comes every couple weeks. She will typically focus on new admissions and hospitalization s or if someone has had a significant weight loss. The RD will send an email to the DON and Administrator and they give it to the unit managers, who put recommendations in as orders. If someone has a low intake, they try them in the assisted dining room. Monthly weights have been inconsistent in the past with some of the CNA's weighing, so now the unit managers do the weights. If they are off, they will weigh again and/or find out why the resident has a weight loss or gain. They try to do a weekly risk meeting where they discuss residents with weight loss. The DON would expect the dietician to see a resident with weight loss at least monthly. During an interview on 06/21/24 at 10:00 A.M., the Director of Nursing said staff should have been recording the resident's intake in the chart per the dietician's recommendation, but the task is not showing up in the medical record for them to chart. He will go reactivate that so they can begin charting. During an interview on 06/21/24 at 12:00 P.M., the Administrator and Director of Nursing said they would expect the dietician recommendations to be relayed to the physician for appropriate orders to be completed and they would expect residents with weight loss to be seen monthly by the dietician.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #36) out of 20 sampled residents. The facility's census was 96. Review of the facility policy, Certifying Accuracy of Resident Assessment, revised November 2019, showed: - Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge; - Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment; - The information captured on the assessment reflects the status of the resident during the observation (lookback) period for that assessment. Different items on the MDS may have different observation periods; - The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse; - Inquiries concerning the signing of the MDS should be referred to the assessment coordinator, director of nursing services, or to the administrator; - Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action. 1. Review of Resident #36's medical record showed: - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other import mental functions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood.); - Resident discharged from hospice services on 04/09/23. Review of the resident's annual MDS, dated [DATE], showed: - Hospice care; - The facility did not code the resident's MDS accurately. Review of the resident's quarterly MDS, dated [DATE], showed: - Hospice care; - The facility did not code the resident's MDS accurately. During an interview on 06/20/24 at 10:25 A.M., LPN F said the resident was on hospice services at one time but started doing better so hospice services were discontinued. During an interview on 06/21/24 at 12:00 P.M., the Administrator and DON said they would expect the MDS to accurately reflect the resident's status.

Based on observation, interview and record review the facility failed to protect a cognitively impaired resident from mental abuse and humiliation when staff took an unauthorized nude photo of one resident (Resident #1) out of three sampled residents. The facility census was 82. Review of facility's policy in the employee handbook, undated, titled Computer, Electronic Mail, Telephone, Electronic Devices and Personal Business showed: -Cell phones are prohibited in the facility. Only administrative staff are authorized to have cell phone, which must be silenced. If employees must use their cell phones, it must be during rest periods; - No audio or video devices are allowed to be used during work hours. Observations on 5/16/19 at 3:30 P.M. of a picture taken by Certified Medication Tech (CMT) A showed: - Resident #1 standing in an unidentified bed room; - Resident #1 had a sock on each hand, with his/her hands up in the air; - The resident had on black pants; - The resident was nude from the waist up with his/her breasts exposed. Review of Resident#1's physician order [REDACTED]. Review of Resident #1's Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility) showed: - Moderately impaired cognitive status and poor decision making skills; - Cues and supervision required; - Signs and symptoms of [MEDICAL CONDITION]: - Experienced inattention and disorganized thinking; - Behaviors include delusions, hallucinations and wandering; - Requires one person assistance and oversight with activities of daily living. During an interview on 5/15/19 at 12:15 P.M., the Administrator said: - During a care plan meeting for Resident #1, just a few hours before interview, Significant Other (SO) A informed facility staff that CMT A had a picture on his/her phone (CMT A's) where Resident #1 was nude from the waist up, with his/her breasts exposed; - SO A informed them that CMT A mentioned while he/she was visiting Resident #1 on 5/1/19 that he/she (CMT A) had a funny picture of Resident #1 on his/her personal phone; - SO A asked to see those pictures. CMT A showed him/her multiple pictures of Resident #1 and other residents on his/her personal phone. SO A said he/she saw the one where Resident #1 was exposed and asked if CMT A would send it to his/her phone (SO A's) via multimedia message; - The photo depicted Resident #1, nude from the waist up, breasts exposed with socks on his/her hands; - CMT A was immediately brought off the floor for an interview, admitted to taking the pictures and was terminated at that same time. The administrator described the photo as Resident #1 standing in a room with a pair of socks on his/her hands, nude from the waist up. Review of facility's Employee Counseling Summary, dated 5/15/19, showed CMT A admitted taking the nude photo of Resident #1 on his/her cell phone. During an interview on 5/16/19 at 10:12 A.M., SO A said: - He/she came to visit Resident #1 on 5/1/19; - CMT A said Resident #1 had been doing some funny things. CMT A said he/she had pictures on his/her personal phone of Resident #1 and other residents; - CMT A showed SO A the pictures by pulling them up on his/her phone and swiping through multiple pictures of Resident #1 and other residents; - While CMT A showed pictures, SO A saw one of Resident #1 nude from the waist up, exposing his/her breasts; - SO A said he/she was appalled and knew Resident #1 would be as well because he/she had always been a very modest person; - SO A asked CMT A to send him/her a copy of the picture; - CMT A sent the photo of Resident #1 with her breasts exposed to SO A. Complaint #MO 6