Every finding on record at Garden View Care Center

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) with a history of falls, in a review of five sampled residents, when staff did not routinely check on the resident at least every two hours per the facility's expectations throughout the night. On the morning of 5/30/26, staff found the resident on the floor in his/her room with the door closed for an undetermined amount of time with dried blood on his/her hair, face, and hands. The resident was admitted to the hospital following evaluation. The resident remained in the hospital for four days with discharge diagnoses of traumatic hematoma (collection of pooled, clotted blood that forms outside of a blood vessel, usually caused by injury or trauma) of head and traumatic rhabdomyolysis (a serious medical condition where severe physical injury causes skeletal muscles to rapidly breakdown). The facility census was 84. On 07/01/26 at 01:40 P.M., the Administrator was notified of the past noncompliance which occurred on 05/30/26. On 05/30/26, the Director of Nursing became aware of Resident #1's fall and the resident lay on the floor for an undetermined amount of time before staff found him/her on the floor. During the Director of Nursing's investigation, she determined Certified Nurse Assistant (CNA) H and CNA I did not check on the resident throughout the night. Licensed Practical Nurse (LPN) J did not ensure the staff conducted routine rounds on the resident every two hours. The Director of Nursing terminated CNA H and CNA I's employment, gave LPN J a warning, and provided one-on-one education to LPN J. The deficiency was corrected on 06/01/26. Review of the facility's policy, Safety and Supervision of Residents, revised 11/2025, showed the following:-The staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff);-Implementing interventions to reduce accident risks and hazards should include the following:Communicating specific interventions to all relevant staff;Assigning responsibility for carrying out interventions;Providing training, as necessary;Ensuring that interventions are implemented;Documenting interventions;-To ensure the safety and well-being of the residents, nursing staff should make routine resident checks throughout their shift and according to resident needs;-Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any changes in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 1. Review of Resident #1's admission summary, dated [DATE] at 3:31 P.M., showed the resident arrived at the facility on 5/28/26 at approximately 1:00 P.M. Review of the resident's care plan, dated 5/29/26, showed the following:-The resident was at risk for falls related to gait/balance problems, incontinence, psychoactive drug use and history of falls; -Anticipate and meet the resident's needs;-Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance;-The resident needed a safe environment with even floors, free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach. Review of the resident's health status note, dated 05/29/26 at 9:07 P.M., showed the following:-The resident walked around the hallway most of the shift;-He/She was very confused. Review of the resident's health status note, dated 05/30/26 at 08:41 A.M., showed the following:-Around 7:00 A.M., the certified nurse assistant (CNA) notified the nurse the resident was found on the floor in his/her room;-The resident was unable to say what happened;-The resident had a large hematoma the right side of his/her forehead. Review of the facility's investigation, dated 5/30/26, showed the following:-CNA H and CNA I left their shift without conducting walking rounds with CNA B (who worked the oncoming shift);-CNA B found the resident during his/her rounds at 6:45 A.M.;-The resident had a large hematoma on his/her forehead and was bleeding;-CNA B said when he/she found the resident, the resident was lucid (able to think clearly);-The resident said he/she was going to the bathroom and did not remember hitting the floor. He/She crawled around trying to get up and could not. The door was closed and he/she guessed no one heard him/her when he/she called for help. He/She pulled a pillow and a blanket off the bed and had it on the floor with him/her. He/She tried to clean up the blood with the blanket but smeared it everywhere. When staff asked the resident if he/she was okay, the resident responded, yes. Review of the resident's emergency room physician note, dated 05/30/26 at 10:34 A.M., showed the following:-Per the emergency medical services, the overnight staff did not see the resident;-The resident arrived with a large hematoma to his/her forehead;-The blood was completely dried in his/her hair and appeared to be there for a prolonged period of time;-Lab results caused concern for rhabdomyolysis for his/her prolonged downtime. Review of the resident's hospital history and physical, dated 05/30/26 at 10:48 A.M., showed for treatment of the rhabdomyolysis, the staff continued with intravenous hydration at 125 milliliters (ml) an hour and close monitoring of the resident's respiratory status while on the intravenous fluids. During an interview on 07/01/26 at 12:56 P.M., CNA B said the following:-CNA H and CNA I worked the night shift on 5/30/26 and left the facility without giving report to the oncoming staff;-While he/she was working on rounds, he/she found the resident's room door was closed;-The resident's door was not supposed to be closed when he/she was in his/her room, because the resident was at risk for falls; -He/She found the resident on the floor with dried blood on his/her hair, face and hands; -The resident said he/she yelled for help, but no one answered;-He/She thought the resident was headed to the restroom prior to the fall because the resident was holding an incontinence brief;-He/She stayed with the resident until emergency medical services (EMS) arrived;-He/She overheard the EMS staff say the resident had to be on the floor longer than two hours. During an interview on 07/01/26 at 10:00 A.M., LPN A said the following:-The day shift started at 6:45 A.M.;-At around 7:00 A.M., CNA B yelled to come quickly because the resident was on the floor;-The resident lay on his/her back with his/her feet pointing towards the door with dried blood on his/her face, hair, and hands;-LPN J did not report any problems with the resident during hand off report that morning;-The resident had a history of falls prior to being admitted , so the staff were supposed to check on him/her at least every two hours;-When the resident lay in bed, he/she usually stayed there, but the staff should have continued to check on him/her every two hours;-LPN A thought the resident's fall was related to him/her ambulating to the restroom without his/her walker. During an interview on 07/01/26 at 1:10 P.M., the Director of Nursing said the following:-She completed an investigation regarding the resident's fall;-The last time CNA H and CNA I checked on Resident #1 was at 12:00 A.M.;-The last time LPN J checked on the resident was at 4:00 A.M.;-She terminated CNA H's and CNA I's employment due to the incident;-She gave LPN J a warning and provided one-on-one education about ensuring the staff working with him/her completed checks every two hour and LPN J's responsibility of ensuring all residents' safety;-The facility provided monthly training for staff regarding checking on residents at least every two hours and would continue to do so;-She expected all nursing staff to complete a face check on every resident at least every two hours, especially the residents who could not physically use or remember to use the call light for assistance;-She also expected staff to know the interventions to reduce the risk of falls for all residents. During an interview on 07/01/26 at 1:20 P.M., the Administrator said the following:-She expected the staff to complete a face check for all residents at least every two hours;-She also expected the staff to know the interventions to reduce the risk of falls for residents. 3028697

Based on observation, interview and record review, the facility failed to ensure four residents (Resident #7, Resident #2, Resident #5 and Resident #10), in a review of eleven sampled residents, were free from sexual abuse. Resident #11 demonstrated a pattern of sexual behaviors with residents without the capacity to consent to sexual activity. Staff found Resident #11 in Resident #7's room with his/her hands down Resident #7's pants and in the resident's perineal area, Resident #11 touched and rubbed Resident #2's breasts, kissed Resident #5 on the mouth twice, and grabbed Resident #10 by his/her hands, pulled the resident to him/her and groped his/her breast. The facility census was 70. Review of the undated facility policy, Abuse Prevention Program, showed the following:-Policy Statement: Residents have the right to be free from abuse. This includes, but is not limited to, freedom from sexual abuse;-Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will:-Protect residents from abuse by anyone including, but not necessarily limited to other residents;-Develop and implement policies and procedures to aid our facility in preventing abuse;-Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, and handling verbally or physically aggressive resident behavior;-Identify and assess all possible incidents of abuse. Review of the facility policy, Abuse and Neglect, Clinical Protocol, revised November 2024, showed the following:-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish;-Sexual Abuse was defined as non-consensual sexual contact of any type with a resident;-Willful was defined and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the undated facility policy, Capacity to Consent, showed the following:-Purpose: To ensure residents are evaluated for the capacity to consent; -The residents have the right to, and the facility must promote and facilitate resident self-determination through support of resident choice;-Residents have the right to engage in consensual sexual activity; however, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity; the facility must ensure the resident is evaluated for capacity to consent;-Residents without the capacity to consent sexual activity may not engage in sexual activity;-Policy: If a resident expresses the desire to engage in consensual sexual activity, the facility must evaluate the resident for the capacity to consent; This can be done by the following:-Physician evaluation;-Completion of the Capacity to Consent Assessment Form;-Indications of potentially diminished capacity are:-Diagnosis of Dementia/Alzheimer's or other related cognitive impairment; -Documentation in the medical record from a family member or person well acquainted with the resident that resident has symptoms of cognitive impairment or dementia;-Other psychiatric diagnosis that could impair resident's decision making ability;-Noted confusion, forgetfulness or difficulty communicating. 1. Review of Resident #11's undated face sheet showed the following:-admission date of 08/18/25;-The resident's family member was his/her personal representative;-Diagnoses included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking reasoning, and problem-solving) with agitation (a behavioral symptom characterized by feelings of emotional distress, restlessness, and difficulty staying calm, which can manifest as verbal or physical aggression) and mood disturbance, major depressive disorder (MDD) with psychotic symptoms (a severe form of depression characterized by the presence of psychotic symptoms such as delusions and hallucinations, in addition to the classic symptoms of depression) and manic episodes (a period of abnormally elevated mood, energy, and activity levels that lasts for at least one week). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated10/26/25, showed the following: -Significantly impaired cognition;-No documentation the resident exhibited any physical behavior directed toward others (e.g. sexual behaviors;-Used a wheelchair for mobility. Review of the resident's care plan, revised on 09/04/25, showed the following:-He/She can be overly friendly and affectionate to staff and/or residents of the opposite sex;-He/She was able to change position in bed by self; may require supervision to moderate assist to get to the edge for transfer;-He/She required supervision to moderate assistance by one staff for transfers as requested and as necessary; up to wheelchair; -His/Her family reports that he/she was a very loving person with a history of behaviors of trying to kiss other residents/staff; he/she loved to blow kisses, hold hands and sweet talk; the resident reported his/her favorite hobby is chasing the opposite sex; -He/She has a history of wandering in/out of other residents' rooms;-Staff to provide reminders to keep his/her hands to himself/herself if he/she attempted to kiss them;-If reasonable, discuss any of his/her behaviors; explain/reinforce why behavior was inappropriate and/or unacceptable; -Intervene as necessary to protect the rights and safety of others; Approach/Speak in a calm manner; divert attention; remove from situation and take to alternate location as needed;-Psych consult as needed (PRN);-Cue, reorient, and supervise as needed;-Monitor/record/report to the Medical Director (MD), as needed (prn) risk for harming others. Review of the resident's progress notes, dated 09/13/25 at 8:53 A.M., showed Registered Nurse (RN) B documented the following:-While in the dining room, staff saw the resident put his/her hand up another resident's shirt;-The resident then put his/her hand between the other resident's legs;-The residents were separated to eat breakfast;-Family notified. During an interview on 11/17/25 at 1:46 P.M., RN B said the following:-He/She did not normally work the floor, so he/she was not very familiar with the residents;-He/She was made aware during a care plan meeting that Resident #11 was very friendly with residents of the opposite sex;-He/She could not recall who the resident was that he/she wrote the note about on 09/13/25;-He/She did not actually see the incident; it was reported to him/her by an aide, and he/she could not recall who the aide was that reported the incident to him/her;-He/She charted the behavioral note and made the Director of Nursing (DON) (who was also working in the building) aware of the incident. Review of the resident's electronic health record showed the following:-Physician order (verbal) for psych evaluation and treatment ordered on 09/15/25;-Psych consult as needed (PRN) was added as a Care Plan intervention on 09/16/25;-Physician order for sertraline hcl oral tablet (antidepressant medication); give 75 milligram (mg) by mouth one time a day for major depressive disorder (MDD)/anxiety; Start date 09/18/25. Review of the resident's progress notes, dated 09/24/25 at 11:30 A.M., showed LPN C documented the following:-The resident wheeled over to another resident saying Hi, touched the other resident's hand, then reached over and was rubbing the resident's chest;-Staff removed the other resident and redirected this resident. During an interview on 11/05/25 at 12:15 P.M. and 11/20/25 at 3:09 P.M., LPN C said the following:-The incident on 09/24/25 involved Resident #2-Resident #11 wheeled up to Resident #2 and was rubbing Resident #2's breasts. 2. Review of Resident #2's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease and generalized anxiety disorder (GAD) (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about everyday matters, which interferes with daily life.) Review of the resident's care plan, updated 03/27/24, showed the following:-He/She had impaired judgement/decision making abilities;-He/She had short term memory/recall deficits related to Alzheimer's. During an interview on 11/19/25 at 4:26 P.M., the resident's representative said the following:-The resident would not like another resident trying to touch, kiss, or hug him/her; he/she would find that behavior to be very inappropriate;-He/She could not recall signing anything or discussing anything regarding capacity to consent to sexual contact, nor would the resident be able to consent;-He/She has not been contacted regarding any incident with any other residents. Review of the resident's electronic health record showed no documentation of capacity to consent to sexual contact. 3. Review of Resident #11's Care Plan, revised 09/24/25, showed the following:-He/She had an unwitnessed fall on 09/21/25;-Ensure he/she is wearing proper footwear;-No new interventions regarding behaviors. Review of Resident #11's progress notes dated 09/25/25 at 12:58 P.M. showed the psych Nurse Practitioner (NP) was notified/contacted. Review of the resident's September 2025 Medication Administration Record (MAR) showed a new order for risperidone oral tablet (antipsychotic medication) 0.5 mg; give one tablet by mouth two times a day for behaviors; start date 09/25/25. Review of the resident's electronic health record showed no documentation staff implemented any new interventions to protect residents and prevent future sexual abuse following the incident on 9/24/25. Review of the resident's progress notes, dated 09/26/25 at 10:32 A.M., showed LPN C documented the following:-The CMT was approaching Resident #11 as he/she wheeled up to another resident (Resident #5) and kissed this resident on the lips twice;-Staff removed Resident #11 from the common area and took the resident to his/her room;-Social worker made aware. During an interview on 11/05/25 at 12:15 P.M., LPN C said the incident on 09/26/25 involved Resident #5. 4. Review of Resident #5's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease and major depressive disorder with psychotic symptoms. Review of Resident #5's care plan, updated 02/28/24, showed he/she had short term memory/recall and decision making deficits. During an interview on 11/18/25 at 1:02 P.M. and 11/20/25 at 8:12 A.M., the resident's representative said the following:-The resident would not like it if another resident would try to touch, kiss, or hold his/her hand;-He/She did not recall discussing or signing anything for capacity to consent to sexual activity. 5. Review of the Resident #11's electronic health record showed no documentation of any new interventions to protect residents and prevent future abuse from occurring after the incident on 9/26/25. Review of the resident's progress notes, dated 09/26/25 at 9:30 P.M., showed LPN A documented the following:-The resident was constantly coming out of his/her room seeking residents of the opposite sex;-Staff had to constantly remove the resident from multiple residents' rooms of the opposite sex. Review of the resident's October 2025 physician orders showed a new order for Depakote Sprinkles Oral Capsule Delayed release sprinkle; 125 mg.; Give 125 mg by mouth three times a day for behavior; Start date 10/04/25. Review of the resident's progress notes, dated 10/10/25 at 5:00 P.M., showed LPN A documented the following:-The resident had to be pulled off a resident of the opposite sex;-He/She was trying to kiss and hug the other resident. During an interview on 11/17/25 at 9:28 A.M., LPN A said that he/she could not recall who the residents were that he/she mentioned being involved with Resident #11 in his/her nursing progress notes 10/10/25. Review of the resident's electronic health record showed no documentation after the incident on 10/10/25 of any new interventions implemented to protect the residents and prevent future abuse from occurring. Review of the resident's progress notes, dated 10/17/25 at 6:00 P.M., showed LPN A documented Resident #11 stopped a resident as he/she was walking down the hall, grabbed this resident's hand, pulled the resident down to him/her and groped the resident's right breast. During an interview on 11/17/25 at 9:28 A.M., LPN A said the incident on 10/17/25 involved Resident # 11 and Resident #10. 6. Review of Resident #10's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease, dementia, major depressive disorder and anxiety disorder. Review of the resident's care plan, updated 05/22/24, showed he/she was dependent on staff for meeting intellectual needs related to cognitive deficits. During an interview on 11/19/25 at 9:31 A.M. and 11/20/25 at 8:31 A.M., the resident's representative said the following:-The resident would not want another resident touching his/her breast and would find that to be very aggressive;-The facility never discussed or had him/her sign for capacity to consent for any sexual activity. Review of the resident's electronic health record showed no documentation of capacity to consent to sexual contact. 7. Review of the Resident #11's electronic health record showed no documentation staff implemented any new interventions to protect the residents and prevent future abuse from occurring after the incident on 10/17/25. Review of the resident's Psychiatric Evaluation, dated 10/20/25, showed the following: -Chief complaint included still having inappropriate interactions with opposite sex residents, needs frequent redirection;-Content of thought: Hypersexual;-Memory: Alert, oriented to person, situation;-Insight and Judgement: Poor insight, poor judgement, poor decision-making skills, denial;-Assessment/Plan: mildly improved sexual behaviors/mania, increase Depakote Sprinkles to 250 mg twice a day, hold risperidone for now for family refusal continue psychosocial supportive care, discussed coping strategies and non-pharmacological interventions including deep breathing exercises and encouraged participating in activities. Review of the resident's physician order sheet, dated 10/21/25, showed Depakote Sprinkles oral capsule delayed release sprinkle 125 mg: Give two capsules by mouth two times a day for agitation. 8. Review of Resident #7's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included dementia with Lewy bodies (a progressive brain disorder characterized by a decline in thinking, reasoning, and independent function, with early and recurring symptoms including fluctuations in alertness, visual hallucinations, and movement problems like slowness and tremors) and major depressive disorder. Review of the resident's care plan, updated 03/10/25, showed he/she was dependent on staff for meeting intellectual needs related to deficits. Review of the resident's progress notes, dated 11/01/25 at 11:20 A.M., showed the Assistant Director of Nursing (ADON) documented the following:-The resident was brought to the nurse's station by CMT/Certified Nurse Assistant (CNA) who said that another resident was in his/her room with his/her hands down the resident's pants;-Reported to the DON and Administration (ADMIN);-Both residents on one on one supervision until further guidance. Review of the resident's care plan, updated 11/01/25, showed the following:-He/She may suffer from a history of trauma; on 11/01/25, a resident of the opposite sex put his/her hands down his/her pants in his/her room;-His/Her dignity autonomy will be maintained;-His/Her comfort will be maintained. During an interview on 11/05/25 at 3:40 P.M. and 11/20/25 at 8:23 A.M., the resident's representative said the following:-He/She did not recall discussing or signing anything regarding capacity to consent for any sexual activity;-He/She was made aware of the incident by a call from the facility;-He/She usually visited the resident every other day;-He/She spent a couple of hours with the resident yesterday;-If the resident was in his/her right state of mind, that incident would have made the resident feel violated and awful. 9. Review of the facility investigation, dated 11/01/25 at 12:24 P.M., showed the ADMIN documented the following:-She had a missed call from the DON at 12:14 P.M. and returned the call;-The DON reported that the CMT had gone to Resident # 7's room to bring him/her lunch and found Resident #11 in his/her room with his/her hands down Resident #7's pants;-The ADON joined the conversation and shared that Resident #11 had been disengaged from Resident #7, and Resident #7 had been brought to her for an assessment. 10. Review of the written statement, dated 11/01/25, showed CMT D documented the following:-While entering Resident #7's room to take him/her to the dining room for lunch, he/she found Resident #11 in the room with his/her right hand down Resident #7's pants;-He/She immediately separated the residents;-He/She took Resident #7 to the ADON and explained the situation;-He/She then returned to Resident #11 to attend to him/her. During an interview on 11/05/25 at 3:03 P.M., CMT D said the following:-He/She went to get Resident #7 for lunch and Resident #11 was in his/her wheelchair sitting next to Resident #7's Broda chair (a specialized wheelchair to provide comfort, support, and safety for individuals with limited mobility) with his/her hand in Resident #7's brief touching the resident's genitalia;-He/She would consider Resident #11's behavior toward Resident #7 sexual abuse. 11. During an interview on 11/17/25 at 9:28 A.M., LPN A said the following:-The incidents that occurred where Resident #11 kissed, touched or made inappropriate contact occurred on day shift; -He/She would consider grabbing, groping, and/or kissing sexual assault; -He/She watched the resident like a hawk, so he/she never had to report anything. During an interview on 11/05/25 at 2:35 P.M. and 11/21/25 at 1:13 P.M., the Social Services Director (SSD) said the following:-She was aware that Resident #11 had sexual behaviors upon admission; -If a resident would say No and not consent to those type of sexual behaviors, she would consider that sexual abuse;-For interventions, staff would make sure that Resident #11 made it back to his/her room and would redirect his/her behaviors;-There weren't many incidents that were reported to her; they were a long time ago;-She did not consider the incidents abuse; she would consider them more memory care behaviors. During an interview on 11/05/25 at 2:45 P.M., the ADON said the following:-She was aware of Resident #11's sexual behaviors prior to the incident on 11/01/25; -She would consider putting a hand up a shirt, going in and seeking the opposite sex in their rooms, and/or putting a hand down a resident's pants abuse;-She was unaware of any of the previous incidents prior to 11/01/25;-She had not yet done any in-servicing/education on abuse following any of these incidents. During an interview on 11/05/25 at 3:20 P.M., the DON said the following: -She started in the role of the DON in September and prior to that she was a charge nurse;-She was unaware of Resident #11's background;-She was not aware of any of the previous incidents prior to the incident on 11/01/25; -All the previous incidents (prior to the incident on 11/01/25), should have been reported to her and/or the Administrator;-The incident on 11/01/25 was reported because the ADON was in house at the time of the incident;-The last in-service/education on abuse was during their Occupational Safety and Health Administration (OSHA) fair in September where they had several different stations set up, one of which was on Abuse and reporting abuse;-Every employee gets abuse in-servicing during orientation;-With the incident occurring on the memory unit, it's a tough call to say if the incidents would be considered sexual abuse, but if the residents did not have dementia, she would consider it sexual abuse;-As soon as the situation occurred on 11/01/25, they put Resident #11 on one on one observation until he/she was transferred out;-She would expect the staff to follow facility policies. During an interview on 11/05/25 at 5:00 P.M. and 6:30 P.M. and 11/21/25 at 4:11 P.M., the Administrator said the following:-She knew that Resident #11 was handsy, but was not aware of all the incidents prior to the one on 11/01/25, -She was not aware of the incidents that occurred on 09/13/25, 09/24/25, 09/26/25 or 10/10/25;-Had she known about the incident on 09/13/25 when Resident #11 put his/her hand up another resident's shirt, she would have discharged Resident #11 at that time;-She was not aware of Resident #11's hypersexuality on admission;-She would not consider Resident #11's actions abuse, she considered it more of a behavior because of the resident's cognitive status. Review of an email communication from the administrator to the state agency on 11/20/25 at 8:44 A.M. and 8:55 A.M., showed she said the facility had a policy with a questionnaire that they would complete if they had two residents who wanted to engage or were attempting on multiple occasions to engage in sexual contact. The facility would first contact resident families to make them aware and discuss the next steps. Then, the facility would follow their capacity to consent policy, and the questionnaire would be completed by the social worker on both residents and would be scanned into the resident's electronic medical record. If both residents were deemed to have the capacity to consent, the facility would still call and speak with their power of attorney. If one or both residents were deemed incapable of consenting to sexual activity, then families would be notified, and interventions would be put into place to avoid those residents from attempting to do this. The questionnaire was put into place about five years ago. In the situation with Resident #11 and Resident #7, BIMS scores (brief interview for mental status, an assessment of cognition function rated from a 0 to 15, where 0 - 7 is severe impairment) were assessed (Resident #11 with a three and Resident #7 unable to assess) to determine if they had the capacity to consent and to determine if the assessment needed to be initiated. Since neither had the capacity to consent, the assessment form was not initiated, and an immediate discharge was determined as the remedy for Resident #11's inappropriate behaviors. The facility has not had the occasion to put it into practice because they had not had residents express interest in being sexually active. #2658020

Based on interview and record review, the facility failed to report allegations of sexual abuse to the state agency for three residents (Resident #2, Resident #5, and Resident #10), in a review of 11 sampled residents when staff witnessed and documented sexual abuse. Resident #11 demonstrated a pattern of sexual abuse behaviors with residents without the capacity to consent to sexual activity. Staff witnessed Resident #11 rub Resident #2's breasts, kiss Resident #5 on the mouth twice, and grab Resident #10 by his/her hands, pull the resident to him/her and grope the resident's breast. Further review showed the facility did not report these incidents to the resident representatives for Resident #2, #5 or #10 as facility policy directed. The facility census was 70. Review of the undated facility policy, Abuse Prevention Program, showed the following:-Report any allegations of abuse within timeframes as required by federal requirements;-The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. Review of the facility policy, Abuse and Neglect, Clinical Protocol, revised November 2024, showed the following:-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish;-Sexual Abuse was defined as non-consensual sexual contact of any type with a resident;-Willful was defined and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the undated facility policy, Freedom from Abuse, Neglect and Exploitation - Investigation and Reporting, showed the following:-At the facility, all reports of resident abuse shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported;-All personnel are to report any signs and symptoms of abuse to their supervisor or to the Director of Nursing Services immediately;-If the alleged abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident and that there may be restrictions on the accused resident's ability to visit other resident rooms unattended;-Should the results indicate that abuse occurred, appropriate authorities will be notified;Reporting:-All alleged violations involving abuse will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;c. The Resident's Representative of Record;-Suspected abuse will be reported within two hours;-Alleged abuse will be reported within two hours if the alleged events have resulted in serious bodily injury; a. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours;-Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone;-Notices will include, as appropriate: a. The name of the resident; b. The number of the room in which the resident resides;c. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.);d. The date and time the alleged incident occurred;e. The name(s) of all persons involved in the alleged incident; and f. What immediate action was taken by the facility. Review of the undated facility policy, Capacity to Consent, showed the following:-Purpose: -To ensure residents are evaluated for the capacity to consent; -The residents have the right to, and the facility must promote and facilitate resident self-determination through support of resident choice;-Residents have the right to engage in consensual sexual activity; however, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must ensure the resident is evaluated for capacity to consent;-Residents without the capacity to consent to sexual activity may not engage in sexual activity;-Policy: -If a resident expresses the desire to engage in consensual sexual activity, the facility must evaluate the resident for the capacity to consent; This can be done by the following:-Physician evaluation;-Completion of the Capacity to Consent Assessment Form;-Indications of potentially diminished capacity are:-Diagnosis of Dementia/Alzheimer's or other related cognitive impairment; -Documentation in the medical record from a family member or person well acquainted with the resident that resident has symptoms of cognitive impairment or dementia;-Other psychiatric diagnosis that could impair resident's decision making ability;-Noted confusion, forgetfulness or difficulty communicating. 1. Review of Resident #11's undated face sheet showed the following:-admission date of 08/18/25;-The resident's family member was his/her personal representative;-Diagnoses included: dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking reasoning, and problem-solving) with agitation (a behavioral symptom characterized by feelings of emotional distress, restlessness, and difficulty staying calm, which can manifest as verbal or physical aggression) and mood disturbance (significant changes in mood, such as: depression, anxiety, agitation, irritability and apathy), major depressive disorder (MDD) with psychotic symptoms (a severe form of depression characterized by the presence of psychotic symptoms such as delusions and hallucinations, in addition to the classic symptoms of depression), manic episodes (a period of abnormally elevated mood, energy, and activity levels that lasts for at least one week). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated10/26/25, showed the following:-Significantly impaired cognition;-No documentation of the resident exhibiting any physical behavior directed toward others (e.g.: grabbing, abusing others sexually);-Used wheelchair for mobility. Review of the resident's care plan, revised on 09/04/25, showed the following:-He/She can be overly friendly and affectionate to staff and/or residents of the opposite sex;-He/She was able to change position in bed by self; may require supervision to moderate assist to get to the edge for transfer;-He/She required supervision to moderate assistance by one staff for transfers as requested and as necessary; up to wheelchair; -His/Her family reports that he/she was a very loving person with a history of behaviors of trying to kiss other residents/staff; he/she loved to blow kisses, hold hands and sweet talk; the resident reported his/her favorite hobby is chasing the opposite sex; -He/She has a history of wandering in/out of other residents' rooms;-Staff to provide reminders to keep his/her hands to himself/herself if he/she attempts to kiss them;-If reasonable, discuss any of his/her behaviors; Explain/reinforce why behavior is inappropriate and/or unacceptable; -Intervene as necessary to protect the rights and safety of others; Approach/Speak in a calm manner; Divert attention; Remove from situation and take to alternate location as needed;-Psych consult as needed (PRN);-Cue, reorient, and supervise as needed;-Monitor/record/report to the Medical Director (MD), as needed (prn) risk for harming others. Review of the resident's progress notes, dated 09/13/25 at 8:53 A.M., showed Registered Nurse (RN) B documented the following:-While in the dining room, he/she was seen putting his/her hand up another resident's shirt;-He/She then put his/her hand between the other resident's legs;-He/She was blowing kisses;-The residents were separated to eat breakfast;-Family was notified. During an interview on 11/17/25 at 1:46 P.M., RN B said the following:-He/She doesn't normally work the floor, so he/she is not very familiar with the residents;-He/She was made aware during a care plan meeting that Resident #11 was very friendly with the opposite sex residents;-He/She could not recall who the resident was that he/she wrote the note about on 09/13/25;-He/She did not actually see the incident; it was reported to him/her by an aide, and he/she could not recall who the aide was that reported the incident to him/her;-He/She charted the behavioral note and made the Director of Nursing (DON) (who was also working in the building) aware of the incident;-He/She reported it to the DON and allowed them to decide if it was abuse;-He/She thought he/she notified both resident's family representatives. Review of the resident's progress notes, dated 09/24/25 at 11:30 A.M., showed Licensed Practical Nurse (LPN) C documented the following:-He/She wheeled over to a resident saying Hi, touched another resident's hand, then reached over and was rubbing that resident's chest;-Staff removed the other resident and redirected Resident #11. During an interview on 11/05/25 at 12:15 P.M. and 11/20/25 at 3:09 P.M., LPN C said the following:-The incident on 09/24/25 involved Resident #2;-Resident #11 wheeled up to Resident #2 and was rubbing Resident #2's breasts;-He/She reported to social work on a couple of incidents (he/she couldn't recall which ones) and on one of the incidents, the social worker advised him/her to report it to the Administrator;-He/She reported one of the incidents (couldn't recall which one) to the Administrator who advised him/her to contact psych. Review of Resident #11's electronic health record showed no documentation the incident on 09/24/25 was reported to a supervisor, Director of Nursing or the state agency as the facility policy directed. 2. Review of Resident #2's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease and generalized anxiety disorder (GAD) (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about everyday matters, which interferes with daily life.) Review of the resident's care plan, updated 03/27/24, showed the following:-He/She had impaired judgement/decision making abilities;-He/She had short term memory/recall deficits related to Alzheimer's. Review of the resident's electronic health record showed no documentation of the incident on 09/24/25 being reported to the resident's representative. During an interview on 11/19/25 at 4:26 P.M., the resident's representative said the following:-The resident would not be okay with another resident trying to touch, kiss, or hug him/her and would not like it; he/she would find that behavior to be very inappropriate;-He/She could not recall signing anything or discussing anything regarding capacity to consent to sexual contact, nor would the resident be able to consent;-He/She has not been contacted regarding any incident with any other residents. Review of the resident's electronic health record showed no documentation of capacity to consent to sexual contact. 3. Review of Resident #11's progress notes, dated 09/26/25 at 10:32 A.M., showed LPN C documented the following:-The CMT was approaching Resident #11 as he/she wheeled up to another resident (Resident #5) and kissed this resident on the lips twice;-Resident #11 was immediately removed from the common area and taken to his/her room;-Social worker made aware. During an interview on 11/05/25 at 12:15 P.M., LPN C said the incident on 09/26/25 involved Resident #5 and CMT D. Review of the Resident #11's electronic health record showed no documentation the incident on 09/26/25 was reported to a supervisor, Director of Nursing or the state agency as the facility policy directed. 4. Review of Resident #5's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease and major depressive disorder with psychotic symptoms. Review of the resident's care plan, updated 02/28/24, showed he/she had short term memory/recall and decision making deficits. Review of the resident's electronic health record showed no documentation of the incident on 09/26/25 being reported to the resident's representative. During an interview on 11/18/25 at 1:02 P.M. and 11/20/25 at 8:12 A.M., the resident's representative said the following:-The resident would not like it if another resident would try to touch, kiss, or hold his/her hand;-He/She did not recall discussing or signing anything for capacity to consent to sexual activity;-He/She had not been made aware of any incident involving another resident. 5. Review of Resident #11's progress notes, dated 10/17/25 at 6:00 P.M., showed LPN A documented Resident #11 stopped a resident as he/she was walking down the hall, grabbed his/her hand, and pulled the resident down to him/her and groped the resident's right breast. During an interview on 11/17/25 at 9:28 A.M., LPN A said the incident on 10/17/25 involved Resident # 11 and Resident #10.Review of the Resident #11's electronic health record showed no documentation the incident on 10/17/25 was reported to a supervisor, Director of Nursing or the state agency as the facility policy directed. 6. Review of Resident #10's undated face sheet showed the following:-The resident's family member was his/her personal representative;-Diagnoses included Alzheimer's disease, dementia, major depressive disorder and anxiety disorder (a group of mental health conditions characterized by persistent and excessive fear or worry that interferes with daily life.) Review of the resident's care plan, updated 05/22/24, showed he/she was dependent on staff for meeting intellectual needs related to cognitive deficits. Review of the resident's electronic health record showed no documentation of the incident on 10/17/25 being reported to the resident's representative. During an interview on 11/19/25 at 9:31 A.M. and 11/20/25 at 8:31 A.M., the resident's representative said the following:-The resident would not want another resident touching his/her breast and would find that to be very aggressive;-The facility never discussed or had him/her sign for capacity to consent for any sexual activity;-He/She had not been made aware of any incident involving another resident. Review of the resident's electronic health record showed no documentation of capacity to sexual contact. 7. During an interview on 11/05/25 at 12:45 P.M., Certified Nurse Aide (CNA) E said the following:-He/She would not sit Resident #11 with residents of the opposite sex; -Everyone was aware of Resident #11's behaviors; he/she had not reported them to anyone because he/she thought they knew. During an interview on 11/17/25 at 9:28 A.M., LPN A said the following:-The incidents that occurred where Resident #11 kissed, touched or made inappropriate contact occurred on day shift; day shift staff would've reported those incidents to the ADON or DON;-He/She would consider grabbing, groping, and/or kissing, sexual assault; -He/She watched the resident like a hawk, so he/she never had to report anything. During an interview on 11/05/25 at 2:35 P.M. and 11/21/25 at 1:13 P.M, the Social Services Director (SSD) said the following:-She was aware that Resident #11 had sexual behaviors upon admission; -There weren't many incidents reported to her, and for those that LPN C did report to her, those were a long time ago;-She did not think that the incidents were abuse; -She would consider it abuse if there was intent to harm;-She would consider the incidents more of a memory care behavior;-The incidents that LPN C reported to her she would have asked him/her if he/she had already reported to DON and/or Administrator and if he/she had not, she would have reported it to the DON and/or Administrator at that time;-She did not know why the incidents were not reported to the state agency. During an interview on 11/05/25 at 2:45 P.M., the ADON said the following:-She was aware of Resident #11's sexual behaviors prior to the incident on 11/01/25; -She would consider putting a hand up a shirt, going in and seeking the opposite sex in their rooms abuse;-She was unaware of any of the previous incidents prior to 11/01/25;-All these incidents should have been reported; She doesn't know why staff did not report the incidents;-She was working the floor at the time of the most recent incident on 11/01/25 and that is how/why it was reported. During an interview on 11/05/25 at 3:20 P.M., the DON said the following: -She started in the role of the DON in September and prior to that she was a charge nurse;-She was unaware of Resident #11's background;-She was not aware of any of the previous incidents prior to the incident on 11/01/25; -All the previous incidents (prior to the incident on 11/01/25), should have been reported to her and/or the Administrator;-She would expect the staff to follow facility policies. During an interview on 11/05/25 at 5:00 P.M. and 6:30 P.M. and 11/21/25 at 4:11 P.M., the Administrator said the following:-She knew that Resident #11 was handsy, but was not aware of all the incidents prior to the one on 11/01/25;-She was not aware of the incidents that occurred on 09/13/25, 09/24/25, 09/26/25 or 10/10/25;-She could not recall LPN C telling her about an incident on 9/25/25 or suggesting that he/she call psych;-Had she known about the incident on 09/13/25 when Resident #11 put his/her hand up another resident's blouse, she would have discharged Resident #11 at that time;-She would expect staff to notify the charge nurse, DON, and/or Administrator immediately because had she known about the previous incidents, Resident #11 would not be in the facility;-She would not consider Resident #11's actions abuse, she considers it more of a behavior because of his cognitive status. #2658020

Based on interview and record review, the facility failed to ensure one resident (Resident #1), with diagnosis of major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder and panic disorder, in a review of four sampled residents, who had a significant history of past trauma, received care planned interventions to address the resident's trauma to ensure the resident attained the highest practicable mental and psychosocial well-being, when the resident began to exhibit increased paranoia and saying someone had been hitting him/her. The facility census was 73 Review of the facility policy for Behavioral Assessment, Intervention and Monitoring with a revision date of ,d+[DATE] showed the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others; -The Interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm; -Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress; -The resident and family or representative will be involved in the development and implementation of the care plan. Review of the facility policy for Trauma Informed Care with a revision date of ,d+[DATE] showed the following: -Purpose: to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma; -As part of the admission process, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools; -Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma; -Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive; -Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.) 1. Review of Resident #1's undated face sheet showed the following: -An original admitted [DATE] with a readmission to the facility on [DATE]; -Diagnoses included adjustment disorder with anxiety and depressed mood; -A note made under special instructions to ensure no caregivers of a specified gender. Review of the resident's psychiatric notes dated [DATE] showed the following: -When the resident was five he/she lived with his/her parent who made friends with a young person (same gender as parent) who came to his/her home, took a gun and woke them up in the middle of the night. The resident said he/she told his/her parent and screamed, his/her parent got up and was shot by the friend, who then took his/her parent's car and left the resident by himself/herself and the floor was red (with blood). The resident's other parent died around the same time as well. Grandparents raised the resident with one grandparent sexually abusing the resident. The resident relayed many stories about how difficult his/her life was. Review of the resident's psychiatric progress notes dated [DATE] showed the following: -Chief complaint: Not doing well, seen about ten months ago. Resident reports multiple falls over the past ten months, he/she lost his/her significant other. Resident feels that facility was not been giving him/her therapy, feels he/she was on too many medications and had no connections with the people at the facility; -Now on Zoloft (an antidepressant medication), and Namenda ( indicated for the treatment of moderate to severe dementia of the Alzheimer's type); -He/She was witness to his/her parent's murder, grandparent sexually abused him/her over the years; -Strong family history of borderline personality disorder (BPD a mental health condition characterized by difficulties regulating emotions, maintaining stable relationships, and having a stable sense of self). Resident's child killed himself/herself due to BPD; -Resident had paranoia at times, displayed a anxious and sad mood, impaired attention and concentration; oriented to two of three of person, place and time, judgement was fair and thought association was concrete. Depressed affect, anxious and frustrated about being in the nursing home, paranoia noted by friend; -Problem: depression, anxiety and frustration was worsening; -Diagnostic impression: major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder and panic disorder without agoraphobia ( an anxiety disorder characterized by a persistent and intense fear of being in situations where escape may be difficult or help may not be available) -Treatment plan: Continue Zoloft 100 mg two times a day, add Remeron (a medication used for depression and appetite stimulant) 7.5 mg daily for sleep and appetite; Zyprexa (an antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder) 2.5 mg in the evening. Review of the resident's psychiatric progress notes dated [DATE] showed the following: -Chief complaint: disappointment about pain; -New medicine for arthritis, knee was better, careful while walking. Neck pain was present; -Mood was fair, not wonderful, pain affects how he/she felt; -Taking Zoloft for depression and anxiety; -Discussed treatment plan - ongoing depression and anxiety and continue with medication. Review of the resident's care plan for safety with a revision date of [DATE] showed the following: -Special Instructions: no caregivers of a specified gender; -The resident was unsafe and unable to care for self out in the community. The resident will remain in the facility for 24 hour supervision and care needs assistance he/she requires; -Goal: the resident will express satisfaction with care needs; -Interventions: Social Services offered as needed or requested by the resident. Review of the resident's care plan for Activities of Daily Living (ADLs) with a revision date of [DATE] showed the following: -The resident has an ADL self-care performance deficit related to history of left hip fracture, cognitive impairment with diagnosis of dementia, anxiety, some behavior issues, refused care, gets agitated and anxious. Preference of (Specified Gender) Caregiver; -Goal: Resident's needs will be met with staff assistance; -Interventions in part: assist with ADLs. No interventions to address the behavior issues. Review of the care plan for history/diagnosis of Anxiety and Depression with a revision date of [DATE] showed the following: -The resident has a diagnosis and history of anxiety and depression. He/She has needs for increased supervision/assistance with inability to return back to the community; he/she is at risk for mood changes; -Goal: the resident will demonstrate no signs or symptoms of depression, anxiety or sadness; -Interventions: administer medications as ordered; give the resident time and encourage him/her to express feelings of down, depressed, hopelessness, sadness or frustrations; monitor/record/report to nurse/physician as needed acute episodes feelings or sadness, loss of pleasure and interests in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patters, diminished ability to concentrate; psychiatric consult as needed. Review of the resident's care plan dated [DATE] showed no care plan with interventions to address history of abuse and past trauma experienced by the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated [DATE] showed the following: -The resident had the ability to make self understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 8 (moderate cognitive impairment); -Mood moderate risk, feeling down, hopeless marked yes nearly every day; trouble falling or staying asleep, no energy, poor appetite marked yes, feeling bad about self marked yes nearly every day; -No behaviors; -Diagnoses of dementia, anxiety, depression; -Takes antipsychotic medications, antianxiety medications and antidepressant medications. During an interview on [DATE] at 9:10 A.M. Resident #1 said the following: -There was a young person of a specified race that had stalked him/her and hit him/her in the back. He/She had not seen this person for a couple of weeks, then in the last couple of days, this person was back. He/She did not know this person's name, but this person will stalk him/her, and watch all of his/her movements like they were establishing his/her pattern. There was a time when this person came up behind him/her and grabbed him/her to take control of him/her and then hit him/her in the back. This person's family member also worked at the facility; -He/She did not feel safe at the facility; -He/She did not know when he/she would be attacked again; -The resident cried and sobbed as he/she told the story. During an interview on [DATE] at 1:55 P.M. Family Member (FM) A said the following: -The resident's significant other recently passed away and this has upset the resident tremendously. The resident took care of the significant other right up to his/her death. The resident had a child who committed suicide when the child was a young adult, and the resident had been sexually abused by family members. The resident had suffered a lot of trauma in his/her past and saw a psychiatrist. The facility received the psychiatric notes and should be aware of what the resident's past life was like. The resident had told him/her several months ago that he/she had been hit by a person of a specified gender. He/She reported this to the staff as this was very real to the resident and he/she was hurting from this. During an interview on [DATE] at 11:00 A.M. Licensed Practical Nurse/MDS coordinator D said the following: -He/She was responsible for the coordination of the resident assessment and care plans; -He/She was aware of the resident's past and the frequent psychiatric visits, but he/she has not read the psychiatric notes; -There should be a care plan to address the past trauma and interventions to help the resident with the affects of the trauma. During an interview on [DATE] at 11:10 A.M. the Social Services Director (SSD) said the following: -The resident has been upset lately and thinking that a person has been hitting him/her, the resident has said this multiple times and it has been reported to the Administrator and investigated; -The resident had experienced some trauma in his/her past life and saw a psychiatrist routinely. She had not read the psychiatric notes and had not thought about how the trauma in the resident's past might be influencing his/her thought process in the present; -The resident was assessed for trauma when he/she was first admitted to the facility over a year ago, and had not been assessed again; -The resident's significant other recently passed away. The resident took care of the significant other for some time and the resident had been more tearful and depressed since the significant other expired; -She has not thought about the possibility of the past trauma affecting the resident's thought process and if these thoughts could be influencing him/her saying that someone was hitting him/her. During an interview on [DATE] at 11:38 A.M. the Director of Therapy said the following: -The resident had received therapy in the past and considered the therapy department his/her safe place, so when the resident asked or was upset, they let the resident come to the therapy department; -A couple of days ago the resident was very upset and was crying so he/she took the resident to the therapy department which seemed to help him/her; -A couple of months ago, the resident did tell him/her that a person came into his/her room and this frightened the resident. During an interview on [DATE] at 9:45 A.M. the Director of Nursing (DON) said the following: -Resident #1 recently told her about a young person that he/she has to baby sit and he/she was tired of babysitting. The resident never said anything about being hit. She and the administrator talked to the resident recently because of a report the resident said something to them about being hit; -The resident always got emotional when you talked with him/her and will cry frequently; -She has been told that the resident had been attacked when he/she was younger; -The resident saw a psychiatrist several times a year for some trauma that occurred in his/her life; -She was not aware of what the trauma was, she has never read the resident's psychiatric notes. During an interview on [DATE] at 8:30 A.M. and [DATE] at 11:30 A.M. the Administrator said the following: -The resident had some delusions about having to care for a child that someone had left in his/her room; -He would expect staff to be aware of what the psychiatrist has documented in the resident's record and incorporate any interventions into the resident's care plan; -Staff would need to be educated on trauma and the potential for post traumatic stress syndrome (PTSD is a mental health condition that can develop after experiencing or witnessing a traumatic event, leading to persistent symptoms like intrusive memories, avoidance behaviors, and changes in mood and arousal); -He would expect all staff to be aware of the potential for PTSD and what interventions were needed to help the resident or any resident who had PTSD. During an interview on [DATE] at 3:30 P.M. Physician A said the following: -The resident has had a lot of trauma in his/her life and now is experiencing some paranoia, this past trauma could be playing a part in the paranoia; -The facility staff should recognize this and put interventions in place to help the resident with the paranoia and trauma. MO250845

Based on interview and record review, the facility failed to immediately report allegations of physical abuse of one resident (Resident #1), to the state agency in a review of four sampled residents. The facility census was 73. Review of the facility policy for Freedom from Abuse, Neglect and Exploitation - Investigation and Reported dated 11/2024 showed the following: -At the facility all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -The facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Service immediately; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, the following persons or agencies: the State Licensing/certification agency responsible for surveying/licensing the facility; the Resident Representative (Sponsor) of Record; Law Enforcement offices; the resident's Attending Physician; and the facility Medical Director; -Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours if the alleged events have resulted in serious bodily injury; -If the events that cause the allegation do not involve abuse of not resulted in serious bodily injury, the report must be made within twenty-four hours; -The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. Review of Resident #1's face sheet showed original admitted [DATE] with a readmission to the facility on [DATE]. Review of the resident's care plan for safety with a revision dated of 3/2/25, showed the following: -Special Instructions: no (specified gender) caregivers; -The resident was unsafe and unable to care for self out in the community. The resident will remain in the facility for 24 hour supervision and care needs assistance he/she required. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/5/25 showed the following: -The resident had the ability to make self understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 8 (moderate cognitive impairment); -No behaviors; -Supervision with ADLs. During an interview on 3/12/25 at 8:30 A.M. the Administrator said the following: -He had not investigated any allegations of residents being hit; -There was a resident on the facility's locked memory care unit that was having some delusions about having to care for a child that someone had left in his/her room; -The administrator identified the memory care resident as Resident #1; -Yesterday, he/she specifically asked Resident #1 if anyone had hit him/her and the resident denied being hit; -He had gotten some strange reports of the resident making the allegations the week before; -He thought these were delusional allegations and no formal investigation was completed. During an interview on 3/12/25 at 9:10 A.M. Resident #1 said the following: -There was a young individual (specified gender and race), that had stalked him/her and hit him/her in the back. He/She had not seen this person for a couple of weeks, then in the last couple of days, this person was back. He/She did not know this person's name, but this person would stalk him/her and watch all of his/her movements like they were establishing his/her pattern. There was a time when this person came up behind him/her, grabbed him/her to take control of him/her and then hit him/her in the back. This person's family member worked at the facility too. He/She did not feel safe at the facility and did not know when he/she would be attacked again; -The resident cried as he/she told the story. During an interview on 3/12/25 at 9:45 A.M. the Director of Nursing (DON) said the following: -She and the administrator talked to the resident recently because an Activity staff member said the resident said something to them about being hit; -It had been reported by Activity Assistant C the resident did not like a particular aide (Certified Nurse Aide (CNA) A). CNA A was never investigated as potentially abusing the resident as she assumed that the resident was having delusions. During an interview on 3/12/25 at 11:00 A.M. Activity Assistant C said the following: -Over the weekend of 3/1/25, the resident wrote a note and put it on the door that said Do not enter, I will call the police ; -He/She asked the resident about the note and the resident said there was a person (specified gender) that would come and stalk and grab him/her, and then hit him/her; -He/She told the Activity Director and the Social Services Director a couple days later what the resident told him/her. During an interview on 3/12/25 at 11:10 A.M. the Social Services Director said the following: -Activity Assistant C came to her and the Activity Director on 3/5/24 and reported the note the resident left on his/her door and what the resident said about being hit; -She talked with Resident #1 and his/her story was consistent about a (specified gender person) hitting him/her on the back; -She reported this to the Administrator on 3/5/25. During an interview on 3/12/25 at 11:10 A.M. the Activity Director said the following: -She was with the Social Services Director when Activity Assistant C reported Resident #1 had a note on his/her door and about being hit; -On 3/10/25 as therapy was walking with the resident, the resident was very upset and said the person that hit him/her was back again, but now that person was (identified a different gender); -The DON was aware of this. During an interview on 3/12/25 at 11:50 A.M. the DON said the following: -She was not told anything about a young person (gender identified) hitting the resident; -She did talk with CNA A on 3/5/25 who told her that the resident thought CNA was (same identified gender young person) and did not like him/her; -CNA A worked on 3/8/25 and 3/9/25. During an interview on 3/12/25 at 12:22 P.M. the Administrator said the following: -He had gotten a lot of conflicting stories regarding the resident; -When he talked with the resident about being hit, the resident denied being hit and he did not notify the state agency due to the conflicting stories he had received; -He did not complete a formal investigation; -He should have investigated the allegation more thoroughly and reported the allegations to the state agency. MO250845

Based on interview and record review, the facility failed to conduct a timely and thorough investigation when one resident (Resident #1), in the review of four sampled residents, made an allegation of physical abuse. The resident said he/she was being hit by a young person (specified gender). The facility identified a staff member, Certified Nurse Aide (CNA) A, who met the general description that the resident provided. The facility failed to protect the resident when CNA A continued to work after the allegation of physical abuse was made. The facility census was 73 . Review of the facility policy for Freedom from Abuse, Neglect and Exploitation - Investigation and Reported dated 11/2024 showed the following: -At the facility all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source (abuse) shall be thoroughly investigated by facility management; -The facility will protect residents from harm, reprisal, discrimination or coercion during investigations of abuse allegations; -If an incident or suspected incident of resident abuse is reported, the Administrator will assign the investigation to an appropriate individual.; -The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation; -The Administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented.; -The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. -The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. Review of Resident #1's face sheet showed the resident's original admitted was 4/15/24 with a readmission to the facility on [DATE]. Review of the resident's care plan for safety with a revision dated of 3/2/25, showed the following: -Special Instructions: no (specified gender) caregivers; -The resident was unsafe and unable to care for self out in the community. The resident will remain in the facility for 24 hour supervision and care needs assistance he/she required. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/5/25 showed: -The resident has the ability to make self understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 8 (moderate cognitive impairment); -No behaviors; -Supervision with ADLs. During an interview on 3/12/25 at 9:10 A.M. Resident #1 said the following: -There was a young individual (specified gender and race), that had stalked him/her and hit him/her in the back. He/She had not seen this person for a couple of weeks, then in the last couple of days, this person was back. He/She did not know this person's name, but this person would stalk him/her and watch all of his/her movements like they were establishing his/her pattern. There was a time when this person came up behind him/her, grabbed him/her to take control of him/her and then hit him/her in the back. This person's family member worked at the facility too. He/She did not feel safe at the facility and did not know when he/she would be attacked again; -The resident cried as he/she told the story. During an interview on 3/12/25 at 11:00 A.M. Activity Assistant C said the following: -Over the weekend of 3/1/25, the resident wrote a note and put it on the door that said Do not enter, I will call the police ; -He/She asked the resident about the note and the resident said there was a person (specified gender) that would come and stalk and grab him/her, and then hit him/her; -He/She told the Activity Director and the Social Services Director a couple days later what the resident told him/her. During an interview on 3/12/25 at 11:10 A.M. the Social Services Director said the following: -Activity Assistant C came to her and the Activity Director on 3/5/24 and reported the note the resident left on his/her door and what the resident said about being hit; -She talked with Resident #1 and his/her story was consistent about a (specified gender person) hitting him/her on the back; -She reported this to the Administrator on 3/5/25. During an interview on 3/12/25 at 11:10 A.M. the Activity Director said the following: -She was with the Social Services Director when Activity Assistant C reported Resident #1 had a note on his/her door and about being hit; -On 3/10/25 as therapy was walking with the resident, the resident was very upset and said the person that hit him/her was back again, but now that person was (identified a different gender); -The DON was aware of this. During an interview on 3/12/25 at 9:45 A.M. and 11:50 A.M. the DON said the following: -She and the administrator talked to the resident recently because an Activity staff member said the resident said something to them about being hit; -It had been reported by Activity Assistant C the resident did not like a particular aide (Certified Nurse Aide (CNA) A). CNA A was never investigated as potentially abusing the resident as she assumed that the resident was having delusions. -She did talk with CNA A on 3/5/25 who told her that the resident thought CNA (same identified gender young person) did not like him/her; -CNA A worked on 3/8/25 and 3/9/25. During an interview on 3/12/25 at 1:00 P.M. CNA A said the following: -He/She had worked at the facility for a couple of months on the locked memory care unit; -Ever since he/she started, Resident #1 has accused him/her of stalking the resident and hitting the resident in the back; -Nurses have told him/her to just stay away from the resident; -He/she will try to stay away from the resident and not provide any care to Resident #1, but recently he/she had to go into Resident #1's room to care for the roommate; -He/She had not worked in a couple of weeks and just came back to work over the weekend; -The DON had talked to him/her about this a couple of days ago, when she got a report that the resident said he/she was hit. During an interview on 3/12/25 at 12:22 P.M. and 3/14/25 at 11:30 A.M., the Administrator said the following: -He had gotten some strange reports of the resident making the allegations the week before; -He thought these were delusional allegations and no formal investigation was done; -When he talked with the resident about being hit, the resident denied being hit so the investigation was not a formal investigation and did not notify the state agency due to the conflicting stories he had received. -He should have investigated the allegation more thoroughly and reported to the state licensing agency the allegations. MO250845

Based on observation, interview, and record review, the facility failed to ensure staff maintained areas throughout the kitchen in a clean and sanitary manner, failed to ensure ice machines in the kitchen and nourishment centers were clean and in good repair, failed to ensure staff properly wore hair and beard restraints while in the kitchen, and failed to cover food/drink items when transporting meal trays to residents' rooms. The facility census was 48. 1. Review of the facility policy, Sanitation, dated November 2024, showed the following: -All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair; -Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime; -The food services manager would be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Review of the facility policy, Food Receiving and Storage, dated July 2024, showed all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observations on 1/13/25 between 10:38 A.M. and 4:00 P.M., showed the following: -Eight opened, one-gallon containers of salad dressing, mayonnaise and slaw dressing were not marked with an expiration date and did not contain an opened or use by date; -The lids to the bulk flour and sugar bins were heavily soiled with dried debris; -The trash can, located next to the steamer and near the foot preparation counter and range, did not have a lid; -The power controls and the base of the blender were soiled with dried debris; -A one-half gallon bottle of stir fry sauce sat on a lower shelf by the range. The label on the bottle showed to refrigerate after opening; -Two large pans (24 inches by 12 inches) of gelatin were uncovered on a cart in the roll-in refrigerator; -The floors under the freezer and refrigerator in the hallway were soiled with debris; -The floor under the food preparation counter in the kitchen was soiled with food debris; -Black, mold-like debris was on the fan covers in the refrigerator located in the kitchen; -The lids, handles and sides of 14 five-pound spice containers, located on the top shelf above the sink and preparation counter, were soiled with dried debris; -The exterior surfaces of 22 16-ounce spice containers, located on the lower shelf above the sink and preparation counter, were soiled with dried debris. The lids to nine of the containers were open to air; -Splashes of food debris were located on the wall above the sink near the food processors; -The floor directly under the deep fat fryer and beside the range was heavily soiled with grease. 2. Observation on 1/13/24 between 1:15 P.M. and 2:00 P.M., showed the following: -A buildup of dust and debris on two plastic vent covers located in the ceiling above refrigerator in the kitchen; -A buildup of loose dusty debris on the ceiling vent and the ceiling tiles located in the hallway by the dry food storage room; -A buildup of dust and debris on the ceiling tiles, ceiling grid, and ceiling vents throughout the kitchen; Observation on 1/13/25 between 2:29 P.M. and 2:50 P.M. showed Dietary Staff N stood on a step ladder and used a cloth in his/her hand to clean the dust from the ceiling tiles in the kitchen while other dietary staff prepared a brownie mix in the mixer and filled beverage pitchers. Dietary Staff R made sandwiches at the preparation counter by the range. Dietary Staff N used a swinging motion with the cloth to wipe dust from the ceiling. Dust was visible in the air as Dietary Staff N cleaned the ceiling. Gray dust/debris was observed on preparation counters, the bulk flour and sugar bins, on the steamer, on the stack of clean dishes located next to the steamtable and on the steamtable. At 2:50 P.M., Dietary Staff N wiped a light fixture in the kitchen near the food preparation counter where a large bowl of a pudding dessert (staff was preparing to serve for the lunch meal) sat uncovered on the counter. He/She used a swinging motion with the cloth to wipe dust from the light fixture. Dust and debris fell from the ceiling/light fixture in the area of the open bowl. Dust and debris lay on the preparation counter by the bowl. 3. Review of the facility policy, Ice Machines and Ice Storage Chests, dated January 2024, showed the following: -To prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow precaution, including keeping the access door closed when not in use. -The facility policy has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. Observation on 1/13/25 at 12:30 P.M., showed the exterior of the ice machine, located in the kitchen, was soiled. The sides in the interior of the ice machine and the area along the edge where the access door closed were soiled with white debris. Observation on 1/13/25 at 12:21 P.M. and at 1:45 P.M. of the ice machine, located in the A Wing nourishment center, showed the following: -A heavy buildup of slimy yellow debris and crusty white debris along the ice-making components inside the machine. Water flowed over these areas within the machine; -A buildup of white debris along the sides inside the machine; -A white rubber drain pipe had a heavy buildup of white and yellow crusty debris at the end of the pipe. The end of the drain pipe was in direct contact with the floor funnel drain and was not equipped with an appropriately spaced air gap. During an interview on 1/13/25 at 12:23 P.M., the Maintenance Supervisor said he was unaware that an air gap was required on an ice machine. Observation on 1/13/25 at 4:55 P.M. of the ice machine located in the C Wing nourishment center, showed the following: -A heavy buildup of yellow and white debris along the ice-making components inside the machine. Water flowed over these areas in the machine; -A black, mold-like substance on the water filter, located inside the machine. -The door to the ice machine was completely open and would not close to protect the ice from contamination. Observation on 1/14/25 at 2:34 P.M., the door to the ice machine, located in the C Wing nourishment center, stood open and would not close. During an interview on 1/14/25 at 2:34 P.M., Certified Nurse Assistant (CNA) G said the ice machine door kept breaking for a couple of months. The staff fill out a paper to show it is broken and give to the receptionist who puts it in the computer system for the maintenance staff. Maintenance tried to fix the door and then it would break again. During an interview on 1/14/25 at 2:36 P.M., CNA Q said the door to the ice machine was open all the time. Maintenance staff tried to fix it and then it would break again. It had been like this for awhile. 4. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated October 2024, showed food service employees must wear hair nets or caps and/or beard restraints to keep hair from contacting exposed food, clean equipment, utensils and linens. Observation on 1/13/25 at 12:00 P.M.,showed Dietary Staff O served meals trays from the kitchen to residents in the dining room. He/She entered the kitchen, opened the refrigerator and obtained lettuce for a resident. Dietary Staff O's hair was approximately shoulder length. He/She wore a hat and did not wear a hair restraint that covered all of his/her hair. Dietary Staff O had facial hair and did not wear a beard restraint. Observation on 1/13/25 at 12:09 P.M., Dietary Staff N assisted with serving residents and was in the kitchen. Dietary Staff N had a bear and wore a beard restraint; however, the restraint did not cover all of the facial hair on the sides of his face. Observation on 1/14/25 at 10:09 A.M., showed Dietary Staff O placed apple cobbler into individual bowls for the residents. His/Her hair was approximately shoulder length. He/She wore a hat and did not wear a hair restraint to cover his/her hair that hung down below his/her hat. Dietary Staff O had facial hair and did not wear a beard restraint. A loose hair (the length of Dietary Staff O's hair) was visible on the left sleeve of his/her shirt. 5. Observations on 1/13/25 between 12:15 P.M. and 12:45 P.M., showed CNA staff served meal trays from an insulated cart on the A wing to residents in their rooms. Staff covered the plates on the meal trays with plate covers, however, the cake and the drinks were not covered as staff transported the trays down the hallways to the residents' rooms. Observations on 1/13/25 at 5:28 P.M., showed CNA staff served meal trays from the insulated cart on the A wing to residents in their rooms. Staff covered the plates on the meal trays with a plate cover, however, the dessert and drinks were not covered as staff transported the trays down the hallways to the residents' rooms. An unknown CNA carried two small, uncovered cups of salad dressing (prepared for a resident upon request) from the kitchen down the B wing hall to the A wing nurses station. 6. During interview on 1/15/25 at 10:50 A.M., the Dietary Manager said following: -Housekeeping staff were responsible for cleaning the ice machines in the nourishment centers; -He noticed the door to the ice machine in the C hallway nourishment center did not close and reported this to the Maintenance Supervisor on 1/14/25; -All food items in the refrigerators should be covered; -If there was no expiration date on items in the refrigerator, such as the salad dressing containers, then staff should label with the date they were opened and discard within two weeks of opening; -Staff were to deep clean (scrub) the floors weekly, sweep after each meal, and mop at least twice a day. Staff last deep cleaned the floors on 1/7/25; -Dietary staff were responsible for cleaning the ceilings in the kitchen. The dust builds up quickly on the ceilings. Staff are to clean the ceilings once a month. He expected staff to clean the ceilings after meals and not during meal preparation. He noticed dust particles around the kitchen after Dietary Staff N cleaned the ceilings on 1/13/25. -Staff should cover all items on the residents ' meal trays, including drinks and desserts, when transporting them from the hall cart to the residents ' rooms. -All dietary staff were to wear a hat or hair net. He expected any facial hair over 0.5 inch to be covered with a beard restraint. Dietary Staff O should wear a hair net to cover all of his/her hair and Dietary Staff N should wear a beard restraint that covers all of his facial hair.

Based on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Residents #1, #4, #6, and #11), in a review of 14 sampled residents. The facility failed to complete Tuberculin Skin Tests (TST) and/or annual evaluations as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for three of ten new employees reviewed (Registered Nurse I, Laundry Staff J and Dietary Staff K). The facility failed to monitor cold water temperatures as part of their water management program to prevent the growth of water borne pathogens including Legionella. The facility census was 48. Review of the facility policy, Handwashing/Hand Hygiene, last revised in November 2024, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of healthcare associated infections; -All personnel were trained and in-serviced on the importance of hand hygiene to prevent the transmission of healthcare associated infections; -All staff were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections; -Hand hygiene is indicated: -Before and after direct contact with residents; -After contact with blood or bodily fluids, or contaminated surfaces; -After touching a resident; -After touching a resident's environment; -Before moving from work on a soiled body site to a clean body site on the same resident; -After removing gloves; -Use an alcohol-based rub containing at least 60% alcohol for most clinical situations; -Wash hands 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. Review of the facility's Tuberculosis, Employee Screening policy, last revised in July 2024, showed the following: -All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classifi cation or as per State regulations; -Each newly hired employee will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment. -Tuberculin Skin Testing: -The facility's Employee Health Coordinator will administer a TST to all newly hired employees except those who have documented positive TST or BAMT results, and those who provide doc umented verification of having had a negative TST or BAMT within the preceding 12 months; -The initial TB testing will be a two-step TST performed by injecting 0.1 ml (5 tuberculin units) of purified protein derivative (PPD) intradermally; -If the reaction to the first skin test is negative, the facility will administer a second skin test 1 to 2 weeks after the first test. The employee may begin duty assignments after the first skin test (if negative) unless prohibited by state regulations. Review of the facility policy Water Management Program dated 11/2018, showed the facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. Water management programs identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Seven key activities are routinely performed in a Legionella water management program: In general, the principles of effective water management include maintaining water temperatures outside the ideal range for Legionella growth. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/24, showed the following: -His/Her cognition was severely impaired; -He/She was dependent on staff for oral hygiene, toilet hygiene, and bathing; -He/She was always incontinent of bowel and bladder. Review of the resident's Care Plan, last updated on 11/21/24, showed the following: -He/She had an activities of daily living (ADL) self-care performance deficit related to dementia; -He/She was totally dependent on staff for personal hygiene and oral care; -He/She was totally dependent on one to two staff for toilet use; -He/She was incontinent of bladder and bowel related to dementia; -Staff were to check for incontinence every two hours and provide peri-care after each incontinent episode. Observation of the resident on 01/15/25 at 6:45 A.M. showed the following: -The resident was incontinent of bowel and bladder; -While wearing gloves, CNA E cleaned urine from the resident's perineum, assisted the resident onto his/her side and used a perineal wipe to remove feces from the resident's rectal area; -Without removing gloves, CNA E put a clean incontinence brief on the resident, assisted the resident to dress, and transferred the resident to his/her chair. During interview on 1/15/25 at 7:17 A.M., CNA E said staff should wash their hands between glove changes. Staff should change their gloves and wash hands when going from a dirty task to a clean task. Staff should not touch clean supplies/items with soiled gloves. 2. Review of Resident #4's admission MDS, dated [DATE] showed the following: -Cognitively intact; -Partial to moderate assist with bed mobility; -Substantial to maximum assist with personal hygiene; -Dependent with toileting; -Always incontinent of bladder and bowel. Review of the resident's care plan dated 10/17/24, showed the following: -Incontinence related to impaired mobility, use of diuretics and BPH (benign prostatic hyperplasia-gland enlargement making urinating difficult); -Clean peri-area with each incontinent episode. Observation on 1/15/25 at 11:21 A.M. showed the following: -The resident lay in bed on his/her back; -CNA C entered the room to perform morning cares and without washing his/her hands, donned gloves, removed tape fasteners from the urine soiled incontinent brief and using wipes, cleaned the front perineal area; -CNA C, wearing the same soiled gloves, assisted the resident to his/her left side with the cloth pad located under the resident; -CNA C removed formed feces from the resident's anal area and tucked it in the soiled brief. With the same soiled gloved hands, he/she cleaned the resident's anal area and buttocks. He/She tucked the soiled brief and pad, placed a clean brief under the resident, and assisted the resident to his/her right side; -Wearing the same soiled gloves, CNA C pulled the soiled items and the clean brief through. He/She picked up a tube of barrier cream and without changing gloves, applied barrier cream to the resident's perineal and groin areas; -CNA C degloved and without washing hands, pulled the incontinence brief up, fastened it and covered the resident with a sheet. During an interview on 1/23/25 at 10:17 A.M. CNA C said the following: -Hands should be washed before cares, with glove changes, when soiled and after the completion of cares; -Gloves should be removed and hands washed after perineal care and clean gloves applied, before moving to a clean area or touching clean items. 3. Review of Resident #6's care plan dated 6/13/23 showed the following: -Bladder incontinence related to impaired mobility and lack of bladder control; -Provide peri-care with episodes of incontinence. Review of the resident's annual MDS, dated [DATE] showed the following: -Cognitively intact; -Dependent for toileting hygiene and transfers; -Substantial to maximum assist with bed mobility and dressing; -Always incontinent of bladder and frequently incontinent of bowel. Observation on 1/15/25 at 7:09 A.M. showed the following: -The resident lay on his/her back in bed; -CNA B entered the room and without washing his/her hands, donned gloves; -CNA B cleaned the resident's front perineal area with wipes and tucked the urine soiled pad under the resident. Without washing hands or changing gloves, CNA B touched the resident's back and hip and assisted the resident to roll to his/her right side; -CNA B cleaned the resident's buttocks and with the same soiled gloves picked up and placed a clean brief under the resident, rolled the resident back to his/her left side, pulled the urine soiled pad out, placed it in a bag, and pulled the clean brief through; -He/She picked up barrier cream with the same soiled gloves, applied the cream to the resident's bilateral inner thighs, pulled up and attached the clean brief and applied the resident's clean pants; -He/She rolled the resident back to his/her right side and placed a mechanical lift sling under the resident, pulled the resident's pants up and placed a cloth pad between the resident and the sling; -He/She rolled the resident back to his/her left side and pulled the sling and pad through, pulled the resident's pants up and assisted the resident to his/her back; -Wearing the same soiled gloves, CNA B removed the resident's gown and applied a clean top; -He/She removed his/her gloves and without washing hands exited the room to get assistance. 4. Review of Resident #11's significant change MDS, dated [DATE], showed the following: -Intact cognition; -Dependent on staff for toileting; -Always incontinent of bladder and occasionally incontinent of bowel. Review of the resident's care plan, revised 12/05/24, showed the following: -The resident had and ADL self-care performance deficit related to impaired balance, advanced age, and episodes of incontinence; -The resident required extensive assist by one staff to dress; -The resident required extensive to total assist by one staff for toileting. Observation on 01/15/25 at 7:36 A.M., showed the following: -The resident lay on his/her back in bed; -CNA B entered the room and without washing hands donned gloves; -CNA B provided peri care cleansing the resident's front perineal area with wipes. Without washing hands and changing gloves, he/she touched the resident's back and hip and assisted the resident to roll to his/her right side; -He/She then cleaned the resident's buttocks with cleansing wipes removing brown fecal matter from the resident's rectal area; -He/She picked up a container of barrier cream with the same soiled gloves and applied it to the resident's buttocks and pulled up a clean brief; -CNA B then changed gloves without washing his/her hands with soap and water and donned gloves; -He/She dressed the resident and applied a gait belt assisting the resident to stand. He/She then pulled up the resident's shorts; -CNA B then removed his/her gloves and applied hand sanitizer to his/her hands. During an interview on 01/15/25 at 7:49 A.M., CNA B said the following: -He/She should wash his/her hands when entering a resident's room and then apply gloves; -He/She should change gloves after cleaning a resident's peri area; -He/She should have changed gloves and washed his/her hands with soap and water after cleaning fecal matter from the resident's rectal area; -He/She should not have picked up barrier cream with dirty gloves; -He/She thought hand sanitizer was sufficient to use after completing morning cares. During an interview on 01/16/25 at 3:15 P.M., the Director of Nursing (DON) said she expected staff to change their gloves and perform hand hygiene any time they were contaminated. Hands were to be sanitized every time gloves were removed. Staff should not be touching any clean surfaces with contaminated gloves and/or hands. 5. Review of the facility employee list, provided by the facility, showed Registered Nurse (RN) I's date of hire was 02/08/23. Review of RN I's employee file showed the following: -No documentation of a first-step TB test or a second-step TB test completed or provided at the time of hire; -No documentation of a TB test completed at one year of employment in February 2024; -No documentation of an annual evaluation to rule out signs and symptoms of TB. During an interview on 01/15/25 at 11:51 A.M., the DON/Infection Preventionist (IP) said she did not know if RN I had any TB testing completed when he/she was hired. She did not know if RN I had a TB test in February 2024. During a telephone interview on 01/24/25 at 5:37 P.M., RN I said the following: -He/She had worked at the facility for almost two years; -He/She thought she had a one-step TB test when hired; -He/She did not have a two-step TB test when hired; -He/She thought she had a TB test after one year of employment; -He/She did not have any records of the test. 6. Review of the facility employee list, provided by the facility, showed Laundry Staff J's date of hire was 10/29/24. Review of Laundry Staff J's employee file showed the following: -Documentation of a first-step TB test administered on 10/24/24 with results read on 10/29/24; -No documentation a second-step TB test was administered. 7. Review of the facility employee list, provided by the facility, showed Dietary Staff K's date of hire was 11/05/24. Review of Dietary Staff K's employee file showed the following: -Documentation of a first-step TB test administered on 10/31/24 with results read on 11/04/24; -No documentation a second-step TB test was administered. During an interview on at 01/15/25 at 11:27 A.M. the DON/Infection Preventionist (IP) said all new employees should have a TB test prior to starting employment and a second TB test in three weeks. The employee should have a TB test annually thereafter. She started employment at the facility in August 2024. She had asked the departments to send her the laundry staff and the dietary staff to get their second TB test, but the employees had not come to her for their second TB test. She would have to start both the laundry staff and the dietary staff testing over from the beginning. 8. Review of the facility's Legionella binder on 1/15/24 at 12:00 P.M. showed the following: -Hot water temperatures documented along with room numbers and dates; -No cold water temperatures documented. During an interview on 1/15/25 at 1:00 P.M. the maintenance director said the following: -He had been in his position for three months; -They were working to get the water management program going; -He had not been directed to and had not measured cold water temperatures; -He was vaguely aware of the danger zone of cool water for optimal Legionella growth. During an interview on 01/23/25 at 10:32 A.M. the administrator said he did not expect cold water temperatures to be measured as the cold water cames off the main line. The facility would have to have a chiller added to control the cold water temperatures. 47008

Based on observation, interview and record review, the facility failed to properly store, change and date respiratory equipment (oxygen tubing) for two residents (Residents #4 and #39), in a review of 14 sampled residents. The facility census was 48. During an interview on 01/23/25 at 10:59 A.M., the administrator said the facility did not have a policy for changing and dating oxygen (O2) tubing. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/10/24, showed the following: -Cognitively intact; -Used oxygen. Review of the resident's care plan, dated 10/17/24 showed the following: -Oxygen for for chronic obstructive pulmonary disease (COPD) (lung disorder that blocks airflow), history of pneumonia and respiratory failure; -Oxygen via nasal prongs (nasal cannula (NC) (prongs that are inserted into the nares to deliver oxygen) at one-two liters (L) as needed (PRN); -The care plan did not direct staff to change or date the O2 tubing. Review of the resident progress notes dated 11/10/24, showed the resident admitted to the hospital with pneumonia (lung infection). Review of the resident's Physician Order Sheet (POS), dated 01/2025 showed the following: -Diagnoses included COPD, respiratory failure and history of pneumonia; -Oxygen at 1-2 L per NC as needed for shortness of breath (SOB); order date of 10/04/24; -No order indicating when to change O2 tubing. Review of the resident's Treatment Administration Record (TAR) dated 01/2025, showed O2 at 1-2 L per NC as needed for shortness of breath (SOB); order date of 10/04/24. The TAR did not address when to change the O2 tubing. Observation on 01/13/25 at 3:00 P.M., 01/14/25 9:00 A.M., and 01/15/25 at 6:50 A.M. and 11:21 A.M., showed the resident lay in his/her bed and wore O2 per NC that was attached to a concentrator. There was no date or initials on the oxygen tubing. During an interview on 01/15/25 at 11:45 A.M. the resident said he/she could not recall the last time staff changed his/her oxygen tubing. 2. Review of Resident #39's care plan, dated 11/07/24, showed the following: -Diagnoses included COPD; -Resident will be free of signs/symptoms of respiratory infections through review date; -O2 via NC 2-3 L continuous. Review of the resident's progress notes, dated 11/21/24 showed resident chest x-ray results show mild left lower lobe pneumonia. Review of the resident's POS, dated 01/2025, showed the following: -O2 at 2-3 L per NC every shift; order date of 10/29/24; -No order indicating when to change O2 tubing. Observation on 01/13/25 at 11:45 A.M. showed the resident propelled him/herself in the hallway and wore O2 per NC attached to an O2 cylinder strapped to the back of the chair. There was no date or initials on the oxygen tubing. Observation on 01/14/25 at 8:45 A.M. showed the resident sat in his/her wheelchair in his/her room and wore O2 per NC attached to the cylinder on the back of the chair. There was no date or initials on the oxygen tubing. Observation on 01/15/25 at 6:10 A.M. showed the resident lay in his/her bed and wore O2 per NC attached to an O2 concentrator. There was no date or initials on the oxygen tubing. During an interview on 01/28/25 at 10:27 A.M., Licensed Practical Nurse (LPN) M said the following: -It was the licensed nurses responsibility to change O2 tubing; -Tubing should be changed weekly on night shift; -Tubing should be initialed and dated; -Staff should document changing the oxygen tubing on the TAR. During an interview on 01/29/25 at 10:58 P.M. LPN P said the following: -He/She worked night shift at the facility; -If a task (changing O2 tubing) showed up on the night shift TAR, then night shift would be responsible for that task; -He/She was not aware that it was a night shift duty to change the O2 tubing; -Oxygen tubing should be tagged with a piece of tape with the initials of who changed it and the date. During an interview on 01/16/25 at 3:10 P.M., the Director of Nursing (DON) said the following: -Nursing (not specific as to what nursing or what shift) was responsible for changing the O2 tubing weekly; -Tubing should be initialed an dated when it is changed weekly; -Staff should document on the TAR when the tubing is changed. During an interview on 01/23/25 at 10:59 A.M., the administrator said he expected oxygen tubing be changed and dated weekly.

Based on observation, interview, and record review, the facility failed to ensure expired testing supplies and medications not in use by two residents including one current resident Resident #10) and one discharged resident (Residents #100), were destroyed or returned as directed by facility policy. The facility census was 48. Review of the facility's policy, Storage of Medications, last revised [DATE], showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. Review of Resident #100's physician orders, dated [DATE], showed an order for fluticasone-salmeterol (a combination of two medicines that are used to help control the symptoms of asthma and improve breathing) aerosol powder breath activated ,d+[DATE] microgram (mcg)/dose, one inhalation - inhale orally every 12 hours (original order dated [DATE]). Review of the facility clinical census showed the resident discharged from the facility on [DATE]. Observation on [DATE] at 10:37 A.M. of the medication storage room for the 100, 200 and 300 halls showed the following: -Fluticasone propionate/salmeterol metered diskus inhalation powder 250 mcg/50 mcg located in the upper middle cabinet by the door; -The medication was labeled for Resident #100 and was labeled as opened on ,d+[DATE]. (The medication remained in the facility 182 days after the resident was discharged .) 2. Observation on [DATE] at 10:37 A.M. of the medication storage room for 100, 200 and 300 halls, in a cabinet above the sink on the far right side, showed the following: -One BinaNow COVID-19 Ag Self Test, lot number 226882, with an FDA extended expiration date of [DATE]. (The test kits had not been pulled for destruction or destroyed per facility policy and remained in the facility for 132 days after expiration); -Eleven unopened boxes of Access Bio, Inc. CareStart COVID-19 Antigen Home Test and On/Go Antigen Self Test, lot number CP23B10, with an expiration date of [DATE]. (The test kits had not been pulled for destruction or destroyed per facility policy and remained in the facility for 74 days after expiration); -One unopened box of Access Bio, Inc. CareStart COVID-19 Antigen Home Test and On/Go Antigen Self Test, Lot Number CP23B16, with an expiration date of [DATE]. (The test kits had not been pulled for destruction or destroyed per facility policy and remained in the facility for 71 days after expiration); -Four unopened boxes of Access Bio, Inc. CareStart COVID-19 Antigen Home Test and On/Go Antigen Self Test, Lot Number CP23B36, with an expiration date of [DATE]. (The test kits had not been pulled for destruction or destroyed per facility policy and remained in the facility for 66 days after expiration); -Twenty-on unopened boxes of OHC COVID-19 Antigen Self Test, lot number SHK2901-XL,d+[DATE]AF, with an FDA extended expiration date of [DATE]. (The test kits had not been pulled for destruction or destroyed per facility policy and remained in the facility for 42 days after expiration.) During an interview on [DATE] at 11:08 A.M., Licensed Practical Nurse (LPN) L said the COVID-19 tests were used for employees and residents who had symptoms of COVID-19. 3. Review of Resident #10's face sheet showed the resident admitted to the facility on [DATE]. Observation on [DATE] at 10:37 A.M., of the medication storage room for 100, 200 and 300 halls in the cabinet by the door, showed the following medications labeled for the resident and not in use: -Sixteen atorvastatin (a medication used to treat high cholesterol) 20 mg tablets; -Thirty cyclobenzaprine (a muscle relaxant) 10 mg tablets; -Fourteen digoxin (a medication to treat heart failure) 0.125 mg tablets; -One diltiazem ER (a medication used to treat high blood pressure and chest pain) 180 mg tablet; -Three gabapentin (a medication used to treat seizures and nerve pain)100 mg tablets; -Eleven ropinirol (a medication used to treat symptoms of Parkinson's disease and restless leg syndrome) 1 mg tablets; -Thirty sertraline (an antidepressant/antianxiety medication)100 mg tablets; -Thirteen one-half tablets of spironolactone (a diuretic medication used to treat high blood pressure) 25 mg; -Seventeen montelukast (an anti-inflammatory medication used to treat allergies and prevent asthma attacks) 10 mg tablets. (Review of the resident's physician orders showed no orders for this medication since admission to the facility); -Nineteen prednisone (a steroid medication) 5 mg tablets. (Review of the resident's physician orders showed no orders for this medication since admission to the facility); -Four quetiapine (an antipsychotic medication) 400 mg tablets. (Review of the resident's physician orders showed no orders for this medication since admission to the facility); -Twenty-two sertraline 200 mg tablets. (Review of the resident's physician orders showed no orders for this medication since admission to the facility.) During an interview on [DATE] at 11:08 A.M., LPN L said the following: -He/She did not know why the medication cards labeled for the resident were in the cabinet; -He/She did not know how long the medications had been in the cabinet; -He/She did not know who put the medications in the cabinet; -Sometimes family brought in medications from home, and the facility cannot use them. The medications were stored in the cabinet because family was supposed to take them home; -If the medications were not narcotics, he/she could destroy them without another staff member present. During an interview on [DATE] at 11:22 A.M., the Director of Nursing (DON) said the following: -She was responsible for checking the medication storage room; -She tried to check it weekly, but the last time she checked the storage room was two weeks ago; -If there were any medications that needed to be destroyed, she destroyed them at that time; -The COVID-19 tests were normally stored in the supply room not in the medication storage room; -She did not know why the COVID-19 tests were in the medication storage room; -The last time she checked the medication storage room, she had not remembered seeing the COVID-19 tests in the cabinet, Resident #10's medication or Resident #100's medication cards in the cabinet; -The night nurse should check the COVID-19 tests and destroy them if they were expired; -Anyone who sees outdated COVID-19 tests could get rid of them; -Medications that needed to be destroyed were to be placed in the destroyed container on the counter with the medication destruction book; -She normally destroyed any medication that should not be in the medication storage room.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure staff responded timely to reports of pests in the building. The facility census was 48. Review of the facility's policy, Pest Control, revised May 2024, showed the following: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services are provided by the pest control service/vendor; -Maintenance services assist, when appropriate and necessary, in providing pest control services. Review of the facility's policy, Sanitation, revised November 2024, showed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 1. Review of the pest control company's service summary report, dated 12/31/24, showed the company treated the exterior of the facility for rodents and ants. Observation on 1/13/25 at 2:30 P.M. showed a light brown insect crawled along the wall by the heated carts, located in the kitchen near the dishwashing area. The insect crawled around the wall into the dishwashing room and went through a gap between the wall and the metal backsplash in the dishwashing area. Three light brown insects crawled on the floor in the dishwashing area near and under the trash can on the dirty side of the dishwashing room. A light brown insect crawled on the floor under the clean side of the dishwashing room under the dishwashing area. Observation on 1/13/25 at 3:41 P.M., showed a light brown insect crawled on the floor in the kitchen by the convection ovens and deep fat fryer. During interview on 1/13/25 at 3:56 P.M. and 1/15/25 at 10:50 A.M., the Dietary Supervisor said a pest control company came to the facility to spray for insects when needed. The pest control company last sprayed at the facility a month or month and a half ago. Staff reported on 1/11/25 they saw a roach in the service hallway where they received deliveries. He didn't think about it since it wasn't located in the kitchen. He called the pest control company on 1/13/25 and was told there was an issue with payment. On 1/15/25, he talked to the Maintenance Supervisor, who said the billing issue had been resolved, so he called the pest control company again this morning and they responded. Observation on 1/14/25 at 10:38 A.M., showed technicians from the pest control company placed insect bait in the dining room. During interview on 1/15/25 at 10:38 A.M., the pest control technician said the insects in the kitchen were roaches. The pest control company came to the facility on ce a month. They conducted an inspection and sprayed/baited inside one month and then treated the exterior of the facility the next month. If the facility sees insects, they are to contact the pest control company. He/She received a call this morning to go to the facility to spray. Health care facilities were a priority, so they get to the facilities as soon as they receive a report of pests. The facility had an ongoing issue with roaches, however, the volume had been down. During an interview on 1/13/25 at 3:52 P.M., the Administrator said the pest control company came to the facility monthly. They haven't needed the pest control company to come since their last visit. If staff see insects, they are supposed to report them to him or to their supervisor. The Dietary Supervisor just told him about the insects in the kitchen. He was not aware of any current issues with insects in the kitchen until now.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for incontinence care for one resident (Resident #1) and failed to provide oral care for one resident (Resident #29), in a review of 14 sampled residents, who required assistance to perform activities of daily living. The facility census was 48. Review of the facility's policy, Oral Care, dated October 2024, showed the purpose of the procedure was to clean and freshen the resident's mouth, to prevent infections of the mouth, to maintain the teeth and gums in a healthy condition, to stimulate the gums, and to remove food particles from between the teeth. (The policy did not include documentation to show when staff were to assist with oral care.) Review of the facility's policy, Perineal Care, dated November 2024, showed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. (The policy did not include documentation to show when staff were to assist residents with perineal care.) 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/24, showed the following: -His/Her cognition was severely impaired; -Dependent on staff for oral hygiene, toilet hygiene, and bathing; -Always incontinent of bowel and bladder. Review of the resident's Care Plan, last updated on 11/21/24, showed the following: -He/She had an activities of daily living (ADL) self-care performance deficit related to dementia; -He/She was totally dependent on staff for personal hygiene and oral care, but would often refuse to have his/her teeth cleaned; -Totally dependent on one to two staff for toilet use; -Incontinent of bladder and bowel related to dementia; -Staff were to check for incontinence every two hours and provide peri-care after each incontinent episode. Observation on 01/14/25 at 11:46 A.M., showed the following: -The resident sat in the dining room waiting for lunch service; -He/She became agitated as evidenced by facial expressions and cursing, increased fidgeting in his/her chair, and banging hands on the chair arm rests. Observation on 01/14/25 at 1:25 P.M. showed the following: -The resident sat in his/her broda chair (a specialized positioning chair) in his/her room with his/her eyes closed; -There was a strong urine odor noted in room. Observation on 01/14/25 at 2:40 P.M. showed the following: -The resident sat in his/her broda chair in his/her room with his/her eyes closed; -There was a strong urine odor noted in room. Observation on 01/14/25 at 4:48 P.M. showed the following: -The resident sat in his/her broda chair in his/her room with his/her eyes closed; -There was a strong urine odor noted in room; -No evidence staff checked the resident for incontinence. Observation of the resident on 01/14/25 at 5:07 P.M. showed the following: -The resident had a strong odor of urine and feces; -Without first checking for incontinence and/or providing perineal care, CNA D assisted the resident from his/her room to the dining room for supper. Observation on 01/15/25 at 6:06 A.M. showed the resident lay in his/her bed. A stale urine odor was present in the resident's room. Observation on 01/15/25 at 6:45 A.M. showed the following: -The resident was incontinent of bowel and bladder; -The resident had debris noted around his/her mouth; -Certified Nurse Aide (CNA) E and CNA F provided incontinence care for the resident, dressed the resident and transferred him/her to the broda chair; -Staff took the resident to the dining room without offering to provide oral care for the resident. During an interview on 01/15/25 at 7:05 A.M., CNA E said the following: -He/She was too pressed for time to complete oral care on any of the residents, but would if he/she had more time; -More often than not, he/she did not have time to perform oral care as part of morning care; -He/She hoped the day shift staff would provide the care, but didn't know if they did or not; -Staff should check the resident for incontinence every two hours and as needed when staff noted odors. Observation on 01/15/25 at 11:23 A.M. showed the resident sat in his/her room in the broda chair and had a strong urine odor. During an interview on 01/15/24 at 11:44 A.M., CNA G said the following: -The resident was usually incontinent; -Staff were supposed to check the resident for incontinence and change the resident every two hours. -He/She did not notice the resident had urine/fecal odors. Observation on 01/15/25 at 11:55 A.M. showed the following: -The resident sat in his/her broda chair in his/her room with strong urine and fecal odors; -His/Her pants were visibly soiled; -CNA G transported the resident with soiled pants and strong urine/fecal odors from his/her room to the dining room for lunch. Observation on 01/15/25 at 12:42 P.M., showed the following: -CNA H assisted the resident from the dining room to his/her room; -The resident yelled, was agitated and hit the chair rail; -His/Her pants were soiled; -CNA H prepared to take the resident to the shower. Observation on 01/15/25 at 12:50 A.M., showed the following: -The resident yelled out and had facial grimacing; -CNA H took the resident to the shower room; -The resident's pants and incontinence brief were heavily soiled with urine and feces; -CNA H cleaned the resident in the shower room and transported him/her back to his/her room; -CNA H did not attempt to provide oral hygiene for the resident. During an interview on 01/15/25 at 1:37 P.M., CNA H said the following: -This was not the resident's normal shower day. The Director of Nurses (DON) told him/her the resident needed a shower so he/she showered the resident; -The resident had continuous diarrhea, which was usual for the resident; -Staff should check the resident for incontinence every two hours and as needed, and should provide incontinence care after each incontinence episode; -He/She tried to complete oral care for the residents after meals when he/she had time and when the residents cooperated. 2. Review of Resident #29's significant change MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She required substantial/maximum assistance with oral hygiene; -He/She had no abnormalities with dental assessment. Review of the resident's Care Plan, last reviewed on 10/31/24, showed the resident required extensive/total assistance with oral care. During an interview on 01/15/25 at 8:15 A.M., the resident said he/she did not have any top teeth, but had a few teeth on the bottom. Staff did not assist him/her with oral care. Observation on 01/15/25 at 8:15 A.M. showed there were no oral care supplies in the resident's room. The resident had no upper teeth, but had a few teeth on the bottom. The resident's mouth was dry and he/she had debris on his/her teeth. Review of the resident's electronic health record on 01/16/25 showed there was no documentation staff provided oral hygiene as it was not part of the resident's activity of daily living (ADL) tasks documentation. During an interview, on 01/16/25 at 3:15 P.M., the DON said the following: -She noted Resident #1 had strong urine/fecal odors on 01/15/25 and instructed the CNA to bathe the resident; -Staff should ensure the residents were clean and odor free at all times; -Staff should not have taken the resident to the dining room with soiled clothing; -CNAs, who assists residents out of bed, were expected to provide/assist with oral care; -Staff should also provide oral care at bedtime and as needed.

Based on observation, interview and record review, the facility failed to ensure resident safety by failure to transfer one resident (Resident #1) as directed in his/her plan of care and failed to follow facility fall policy and procedure following one resident's fall (Resident #12) or implement interventions in the resident's plan of care to prevent further falls in a review of 15 sampled residents. The facility census was 48. Review of the facility's policy, Gait Belt Use/Transfers, dated November 2024, showed the following: -The facility will take all measures to ensure resident safety; -Transfers are performed based upon resident transfer status and the facility's policy; -Gait belts should be placed around the resident's waist, above the pelvic bone and below the rib cage over top of clothing; -A gait belt should be adjusted so that it is snug, without being uncomfortable for the resident; -Verify proper closure of buckle before use; -Grasp/transfer belt from underneath; -Remove/loosen gait belt when not in use; -No direction to show when a gait belt should be used. Review of the facility policy Fall Risk Assessment and Management dated 11/2024 showed the following: -Based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -Assessment data should be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis) (a condition in which the bones become weak and brittle); -Staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence and cognition; -Identify environmental factors that may contribute to falling, such as lighting and room layout; -Staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable; -Staff, with the input of the attending physician would identify appropriate interventions to reduce the risk of falls; -If underlying causes cannot be readily identified or corrected, staff should try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling was identified as unavoidable; -In conjunction with the attending physician, staff should identify and implement relevant interventions to try to minimize serious consequences of falling; Staff should monitor and document each resident's response to interventions intended to reduce falling or risks of falling. Review of an undated facility document/policy titled, Falls, showed the following: -Must complete RISK (risk management), including pain and signing last page, progress note, 72 hour charting started, Certified Nurse Assistant (CNA) post fall summary tool; -Assessments that need to be completed: Fall risk, pain, skin, neuro focused evaluation, neuro checks started if unwitnessed; -Progress note needs to include time of fall, location, activity prior to fall (walking, transfer, bed, chair, etc.), injury description, treatment if needed, put in order for treatment, notification of physician, family and Director of Nursing (DON), neuro checks started, send to hospital. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by the facility, dated 11/20/24, showed the following: -His/Her cognition was severely impaired; -He/She was dependent on staff for bathing; -He/She was dependent on staff for assistance with tub/shower transfers. Review of the resident's Care Plan, last updated on 11/21/24, showed the following: -He/She was a high risk for falls related to confusion, poor communication/comprehension, unaware of safety needs, jerky movements, and unpredictable with transfers and ambulation; -He/She required extensive assistance from two staff to move between surfaces; -Staff were to make sure he/she was properly positioned in the shower chair and to get help if he/she started to slide down; -On 10/11/24, the resident fell out of the shower chair and was taken to the emergency room with a head laceration; -If he/she becomes agitated, return him/her to his/her to room, assist him/her back to bed, and play music; -The resident was a two-person transfer; he/she no longer transferred to the bathroom. Observation on 01/15/25 at 12:42 P.M., showed CNA H assisted the resident from the dining room to his/her room in his/her broda chair (tilt in space chair) as the resident yelled and hit the arm rest. Observation on 01/15/25 at 12:50 P.M. showed the following: -CNA H took the resident to the shower room in his/her broda chair; -Without using a gait belt, CNA H instructed the resident to grab the assist bar next to the shower; -The resident grabbed the assist bar and stood from the broda chair. The resident was unsteady with jerky movements; -The resident transferred to the shower chair for the shower; -The resident was agitated, yelled and attempted to stand from the shower chair during the entire shower; -Once the shower was completed, CNA H assisted the resident with dressing, but did not put socks on the resident's feet; -CNA H placed a bath blanket on the floor, and instructed the resident to grab the assist bar and stand; -The resident began to lean backwards; -CNA H placed his/her left leg behind the resident, the resident leaned on CNA H's leg for support and to prevent the resident from falling backwards as the resident continued to hold onto the assist bar; - As the resident continued to lean on the CNA's leg, CNA H pivoted the resident and assisted him/her to sit in the broda chair. During an interview on 01/15/25 at 1:37 P.M., CNA H said the following: -He/She did not use a gait belt because he/she did not want to harm the resident's skin and make him/her more agitated; -He/She normally did not have any problems transferring the resident by himself/herself; -The resident could stand and grip onto the assist rail and wouldn't let go; -He/She should have had a second person for increased safety because of the resident's increased agitation, but no other staff was available to assist him/her; -The resident did not have socks in his/her room because they were in the laundry, but he/she should have obtained grip socks from the supply room prior to the shower and made sure he/she had all supplies available before she started the shower. Review of resident's undated care card located in the resident's closet on 01/15/25 at 1:37 P.M. showed the resident required two person assist with a stand/pivot transfer. 2. Review of Resident #12's fall risk assessment, dated 04/11/24, showed the resident was at risk for falls. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent for transfers; -Substantial to maximum assist for bed mobility; -No falls since admission or last assessment. Review of the resident's care plan, last revised 11/12/24, showed the following: -At risk for falls related to gait/balance problems/ dependent on a mechanical lift device for transfers; -History of falls; -Follow facility fall protocol (fall policy); -Provide safe environment, low bed at night (06/23/23). Review of the resident's Physician Order Sheet (POS), dated 01/2025, showed the following: -Diagnoses included age related osteoporosis, abnormal gait and mobility, and dementia; -Low air loss (LAL) mattress (a specialized mattress designed to prevent and treat pressure wounds composed of multiple inflatable air tubes that alternately inflate and deflate); -Mechanical lift for transfers. Review of the resident's progress notes showed the following: -Staff documented on 01/11/25 at 11:20 A.M., the resident returned from hospital with no new orders. X-rays negative for fractures. Tramadol (narcotic pain medication) for pain, hematoma (bruise) to right shin area. Continues on observation for rolling out of bed; -There was no documentation in the progress notes regarding the time of the resident's fall, location, activity prior to the fall, injury description, treatment needed if any, notifications of the physician, family or DON or that neuro checks had been started, all of which was directed by the facility policy to documented in the progress notes. Review of the resident's 72 hour neuro checklist paper document showed the following: -Fall: 01/11/25; -Time: 4:00 A.M.; -RISK completed and signed by nurse; -Neuros started: yes; -Assessments completed: fall risk, pain and neuro focused assessment; -Notification: medical director (MD), family and DON; -72 hour charting, each shift and nurse initial when completed: started 01/11/25 (unable to read time) and last entry 01/14/25 at 7:00 A.M. Review of the resident's medical record showed no documentation of the location of the resident's fall, the activity prior to the fall, injury description and treatment or that the facility had completed a root cause of the fall, all of which was directed by the facility policies. Observation on 01/13/25 at 12:10 P.M. showed the resident lay in his/her bed on a LAL mattress with partial bolstered sides (air-filled sides that are meant to prevent residents from falling out of bed). The bed was at waist height and not in a low position. During an interview on 01/13/25 at 12:10 P.M., the resident said he/she rolled out of bed recently, maybe Saturday the 11th, and was transferred to the hospital for x-rays. Review of the resident's undated care plan, posted in the resident's closet, on 01/15/25 at 3:40 P.M., showed the following: -Resident at risk for falls; -Lock bed and chair; -No documentation to show the resident was supposed to have his/her bed in the lowest position. Observation on 01/16/25 at 8:16 A.M. showed the resident lay in his/her bed. The bed was not in the lowest position. During an interview on 01/16/25 at 9:33 A.M., CNA G said he/she was aware of the resident's fall. He/She had not been informed of any new interventions put in place to prevent falls for the resident. During an interview on 01/15/25 at 3:45 P.M., Licensed Practical Nurse (LPN) A said the following: -He/She knew the resident fell out of bed recently; -He/She was not informed of any new interventions to prevent falls for the resident following his/her recent fall. During an interview on 01/29/25 at 10:58 A.M., LPN P said the following: -He/She was working the night/morning the resident fell out of bed; -The resident said he/she rolled out of bed and landed between the bed and the bedside table with his/her leg lying on the wheels of the table; -A resident's fall should be documented in the progress notes, on the paper incident report and under the risk management section of assessments in the electronic record; -He/She had only completed the paper neuro check list with cover sheet but failed to document in the resident's progress notes; -When a resident falls, the nurse should assess and care for the resident, interview the resident and any witnesses, notify the physician and family and document in the necessary areas which would include the date, time, incident, resident interview, assessment, treatment and notifications. All should be completed prior to the end of staff's shift; -He/She believed the resident's bed had been in the medium to low height at the time of the fall; -The resident could use his/her remote to move the bed him/herself; -He/She had not added any new interventions after the resident's fall and was not made aware of any new interventions being added after the resident fell out of bed; -He/She had not investigated further how the resident fell out of bed. During an interview on 01/16/25 at 1:50 P.M. and 3:15 P.M., the DON said the following: -She could not find a fall report or documentation for Resident #12's fall in the progress notes, which occurred on 01/11/25, in the electronic health record; -Resident #12 was on the LAL mattress and was a mechanical lift transfer prior to the fall; -She had spoken with the nurse when notified of Resident #12's fall and instructed him/her to make sure he/she completed the fall protocol; -She expected staff to follow resident's care plan guidance for all transfers; -Resident #1 required assistance of two staff for transfers; -Staff should use gait belts for transfers unless directed otherwise with mechanical lift transfers; -CNA H should not have attempted to complete the shower alone when Resident #1 was agitated; -It was not appropriate for the CNA to place his/her leg behind Resident #1 for support; he/she should have had assistance; -Staff should be prepared and have all supplies available before starting the shower; -She would expect staff to follow the facility fall protocol/policy following a resident fall; -She would expect the charge nurse (who worked when the fall occurred), to document the incident in the progress notes, investigate to find the root cause, fill out the fall report and implement new interventions when possible.; -No new interventions had been put in place after Resident #12's fall; she did not feel they needed to add any as the resident had not fallen before.

Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment prior to placement of bed rails, document alternatives attempted prior to bed rail placement, complete entrapment zone measurements, or obtain written consent from the residents and/or their guardians prior to use for one resident (Residents #11), who used side rails, in a review of 14 sampled residents. The census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary: -The resident's sleeping environment should be assessed by the Nursing Supervisor/ Administrator/ DON (interdisciplinary team), considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -The facility will attempt to utilize appropriate alternatives to bed rails prior to initiating the use of a bed rail; -The facility will identify specific medical reasons to justify the use of a bed rail such as functional ability, bed mobility, etc. and will provide rationale for why the use of bed rail is necessary and why the alternatives to bed rails did not meet the resident's needs; -To try to prevent injuries from the use of bed rails and related equipment, the facility should promote the following approaches: -Assess resident for risk of entrapment from bed rails prior to installation of a bed rail; -Consult with attending physician and resident/resident representative regarding the risks and benefits of the use of a bed rail and why other alternatives attempted failed to meet resident's needs; -Obtain informed consent from resident and/or resident representative for the install and use of bed rail prior to installing; -Ensure the beds dimensions are appropriate for the resident's size and weight; -Ensure that bed rails are properly installed and used following the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); -The facility's education and training activities would include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. -Ongoing evaluation of resident and bed rails will occur to assess the ongoing need for use of bed rails and resident's safety. Review of the facility's Proper Use of Side Rails policy, last revised in November 2023 showed the following: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints and prevent entrapment; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the residents symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed or chair, and to stand and toilet; -Risk of entrapment from the use of side rails; and -The bed's dimensions are appropriate for the resident's size and weight; -If the use of a side rail is as an assistive device this will be addressed in the resident care plan; -Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol; -Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails; -The risks and benefits of side rails will be considered for each resident; -Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks; -Manufacturer instructions for the operation of side rails will be adhered to; -The resident will be checked periodically for safety relative to side rail use; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used); -Facility staff, in conjunction with the attending physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. 1. Review of Resident #11's undated face sheet showed the following: -His/Her family member was his/her responsible party; -Diagnoses included fracture of upper end of the right humerus (bone in the arm), unsteadiness on feet, abnormalities of gait and mobility, history of falling, generalized muscle weakness and repeated falls. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/03/24, showed the following: -Intact cognition; -Limited range of motion on the upper and lower extremities on one side of his/her body; -Substantial/Maximum assistance required for rolling left and right and for lying to sit on side of bed transfers; -The resident was dependent on staff for sit to stand transfers and chair/bed-to-chair transfers. Review of the resident's care plan, revised 12/05/24, showed the following: -The resident returned from the hospital after a fall and fractured shoulder with non-weight bearing and sling requiring more assistance; -The resident used half side rails to maximize independence with turning and repositioning in bed. He/She requires extensive assist at this time; -The resident is at high risk for falls related to gait and balance problems, medication use and incontinence; -The resident needs a safe environment with side rails as ordered; -The resident requires assist with bed mobility; may assist with use of bed rails. Review of the resident's January 2025 Physician's Orders showed no order for bed rails. Observation on 01/15/25 at 7:29 A.M., showed the resident lay in bed. The resident had a half bed rail in the raised position on the left side of his/her bed. The resident used the bed rail to assist himself/herself to sit on the side of the bed. The right side of the resident's bed was up against the wall. During an interview on 01/16/24 at 8:45 A.M., the resident said he/she used the bed rail to turn in bed and help him/her get out of bed. He/She felt safer in bed with the half bed rail. Review of the resident's medical record showed no bed rail assessment, no bed rail entrapment assessment or informed consent from the resident for the use of the bed rail. During an interview on 01/15/2025 at 3:50 P.M., the Director of Nursing (DON) said the facility had no orders, assessments, consents or entrapment zone measurements for the resident's bed rail. The facility had thought about taking all the bed rails down, but after talking to the resident in question, the resident and the facility thought it was in the best interest of the resident to keep the bed rail. 47008

Based on observation, interview and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment for one resident (Resident #11), in a review of 14 sampled who used bed rails/assist bars. The facility census was 48. Review of the facility's Bed Safety /Bed Rails policy, last revised in July, 2024, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident and after evaluation, if need be, appropriate bed rails will be used for bed mobility as necessary; -To try to prevent injuries from the use of bed rails and related equipment, the facility should promote the following approaches: -The maintenance department will complete an inspection on bed rail and bed components routinely and should provide a copy of inspections to the Administrator. These inspections will be incorporated into Safety Committee; -Ongoing evaluation of resident and bed rails will occur to assess the ongoing need for use of bed rails and resident's safety. Review of the facility's Proper Use of Side Rails policy, last revised in November, 2023, showed the following: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints and prevent entrapment; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -When used for mobility or transfer, an assessment will include a review of the resident's risk of entrapment from the use of side rails and the bed's dimensions are appropriate for the resident's size and weight; -When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 1. Review of Resident #11's undated face sheet showed the following: -His/Her family member was his/her responsible party; -Diagnoses included fracture of upper end of right humerus (long bone in the upper arm that runs from the shoulder to the elbow), unsteadiness on feet, abnormalities of gait and mobility, history of falling, generalized muscle weakness and repeated falls. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/03/24, showed the following: -Intact cognition; -Limited range of motion on the upper and lower extremities on one side of his/her body; -Substantial/ Maximum assistance required for rolling left and right and lying to sitting on side of bed; -The resident was dependent on staff for sit to stand transfers and chair/bed-to-chair transfers; -Used a walker and a wheelchair. Review of the resident's care plan, revised 12/05/24, showed the following: -The resident returned from the hospital after a fall; fractured his/her shoulder; is non-weight bearing and has sling; requiring more assistance; -The resident used half side rails to maximize independence with turning and repositioning in bed; requires extensive assist at this time; -The resident is high risk for falls related to gait and balance problems, medication use and incontinence; -The resident needs a safe environment with side rails as ordered; -The resident requires assist with bed mobility, may assist with use of bed rails. Observation on 01/15/25 at 7:29 A.M., showed the resident lay in bed. The resident had a half bed rail in the raised position on the left side of his/her bed. The resident used the bed rail to assist himself/herself to a sitting position on the side of the bed. The right side of the resident's bed was up against the wall. Review of the resident's Physician Order Summary Report, dated 01/15/25, showed no order for bed rails. During an interview on 01/16/24 at 8:45 A.M., the resident said he/she used the half bed rail to turn in bed and help him/her get out of bed. He/She felt safer in bed with the half bed rail. Review of the resident's medical record showed no bed rail assessment, no bed rail entrapment assessment or informed consent from the resident or the resident's representative for the use of the bed rail. During a telephone interview on 01/23/25 at 9:58 A.M. , the Maintenance Director said he did not realized it was his responsibility to measure bed rails for entrapment zones. He had only worked at the facility for three months and in that time he had never installed any bed rails or measured any existing bed rails for entrapment zones. During an interview on 01/15/2025 at 3:50 P.M., the Director of Nursing (DON) said the facility had no orders, assessments, consents or entrapment zone measurements for the resident's bed rails. During a telephone interview on 01/23/25 at 10:32 A.M., the Administrator said the maintenance director was responsible for measuring for bed rail entrapment zones and checking all current bed rails every quarter. The maintenance director had only worked at the facility for one quarter. He did not realize there were so many bed rails in the facility, He did not realize the bed rails were not being measured for entrapment zones or no quarterly checks were being completed for all the current bed rails. 47008

Based on interview and record review, the facility failed to provide a written notice of the bed hold policy with required information to the resident and/or resident representative within 24 hours of transfer to the hospital for four residents (Residents #11, #16, #35, and #251), in a review of 14 sampled residents. The facility census was 48. Review of the facility's undated policy, Bed Hold, showed the following: -If the resident is discharged to the hospital, the bed is considered empty. The facility can do one of two things: -1. Hold the bed for the resident who is in the hospital or on leave from the facility for any reason; -2. Release the bed, allowing the facility to admit a new resident; -During the absence of resident for any reason, the regular charge herein shall apply until the room is released and all belongings are removed. Resident and/or responsible party shall notify the facility's social services department regarding whether resident's bed should be held, or whether resident shall be discharged . If notice is nor received, the resident's bed will automatically be held and charges will continue to accrue; -When the bed is held, the responsible party agrees to pay the current room rate as a bed hold fee. The bed hold fee is a private chare, no matter what the resident's pay source is. The plan specified in this record will immediately go into effect when hospitalization is warranted. The responsible party should contact admissions or social services within 24 hours following hospitalization or on a weekend or holiday the next business day if the family wishes to make changes in the plan for bed hold. The facility must issue notification within 24 hours of transfer to hospital details of bed hold policy. 1. Review of Resident #16's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 12/07/24 at 4:04 P.M., showed the following: -The resident had elevated fever, decreased oxygen saturation, and increased respiratory effort; -Physician notified of the resident's symptoms and nursing assessment; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident transferred to the hospital on 12/07/24. Review of the resident's Nurse's Notes, dated 12/07/24, showed the resident was admitted to the hospital with a pulmonary embolism (blood clot in the lung). Review of the resident's medical record showed no evidence staff provided a copy of the facility's bed hold policy to the resident's representative when the resident was transferred to the hospital on 12/07/24. Review of the resident's nurse's notes, dated 12/10/24, showed the resident returned to the facility on [DATE]. 2. Review of Resident #11's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 11/19/24 at 7:02 P.M., showed the following: -The resident fell and was found lying on the floor on his/her right side; -The resident could not move his/her right shoulder due to the increased pain; -Physician notified of the resident's symptoms and nursing assessment; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident was transferred to the hospital on 11/19/24. Review of the resident's Nurse's Notes, dated 11/19/24 at 7:49 P.M., showed the resident was admitted to the hospital with a right shoulder fracture (break in bone). Review of the resident's medical record showed no evidence staff provided a copy of the facility's bed hold policy to the resident's representative when the resident was transferred to the hospital on 11/19/24. Review of the resident's nurse's notes, dated 11/21/24, showed the resident returned to the facility on [DATE]. 3. Review of Resident #35's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 08/26/24 at 9:20 A.M., showed the following: -The resident had moderate periorbital edema (swelling around the eyes) and moderate swelling in upper and lower extremities, confusion, wheezing, and shortness of breath; -The physician gave an order to send the resident to the emergency room ; -An ambulance transported the resident to the hospital. Review of the resident's medical record showed no evidence staff provided a copy of the facility's bed hold policy to the resident's representative when the resident was transferred to the hospital on 08/26/24. Review of the resident's Nurse's Notes, dated 08/26/24 at 1:37 P.M., showed the resident was admitted to the hospital. Review of the resident's nurse's notes, dated 09/05/24, showed the resident returned to the facility (from the hospital) on 09/05/24. 4. Review of Resident #251's face sheet showed he/she was his/her own responsible party. Review of the resident's progress notes, dated 1/15/25, showed the resident complained of having a hard time breathing and suspected he/she had gained weight. Lung sounds revealed crackles in the left lower lobe. Resident transferred to hospital per emergency medical services. Review of the resident's census sheet showed he/she was discharged from the facility on 1/15/25 and readmitted to the facility on [DATE]. Review of the resident's medical record on 1/16/25 showed no evidence the facility provided the resident with a copy of the facility's bed hold policy when the resident was transferred to the hospital on 1/15/25. 5. During an interview on 01/16/25 at 9:05 A.M., the Admission Director said she contacted the residents and/or the residents' representatives to go over the bed hold policy via phone but did not document the discussion. She was unaware of a paper trail for this. During an interview on 01/16/25 at 12:30 P.M., the Administrator said the nurses were to send the bed hold policy with the resident and/or provide the policy to the resident's representative upon transfer to the hospital. After visiting with the nurses, he identified this was not being done. 32899 47008

Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative when six residents (Residents #11, #12, #16, #29, #35, and #251), in a review of 14 sampled residents, were transferred to the hospital. The facility census was 48. Review of the facility's Transfer or Discharge Notice policy, last revised December 2024, showed the following: -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge when an immediate transfer or discharge is required by the resident's urgent medical needs; -The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: -The name, address, email and telephone number of the entity which receives such requests; -Information about how to obtain, complete and submit an appeal form; -How to get assistance completing the appeal process; -The facility bed-hold policy; -The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; -The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); -The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); -The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices; -A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman; -The reasons for the transfer or discharge will be documented in the resident's medical record; -If the information in the notice changes prior to the transfer or discharge, the recipients of the notice will be updated as soon as practicable. 1. Review of Resident #29's Face Sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 10/09/24 at 1:08 P.M., showed the following: -The resident complained of not feeling well and wanted to be transferred to the hospital; -Physician notified of the resident's complaint and request; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident transferred to the hospital on 10/09/24. Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident transferred to the hospital on 10/09/24. Review of the resident's Nurses Notes, dated 10/25/24 at 1:08 P.M., showed the following: -The resident complained of increased respiratory effort and not feeling well and wanted to be transferred to the hospital; -Physician notified of the resident's complaint and request; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident transferred to the hospital on 10/25/24 Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident transferred to the hospital on 10/25/24. 2. Review of Resident #16's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 12/07/24 at 4:04 P.M., showed the following: -The resident had elevated fever, decreased oxygen saturation, and increased respiratory effort; -Physician notified of the resident's symptoms and nursing assessment; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident transferred to the hospital on 12/07/24. Review of the resident's Nurse's Notes, dated 12/07/24, showed the resident was admitted to the hospital with a pulmonary embolism (blood clot in the lung). Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident transferred to the hospital on 12/07/24. 3. Review of Resident #11's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 11/19/24 at 7:02 P.M., showed the following: -The resident fell and was found lying on the floor on his/her right side; -The resident could not move his/her right shoulder due to the increased pain; -Physician notified of the resident's symptoms and nursing assessment; -Orders received to send the resident to the emergency room for evaluation via ambulance. Review of the resident's census sheet showed the resident transferred to the hospital on 11/19/24. Review of the resident's Nurse's Notes, dated 11/19/24 at 7:49 P.M., showed the resident was admitted to the hospital with a right shoulder fracture (break in bone). Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident transferred to the hospital on 11/19/24. Review of the resident's nurse's notes, dated 11/21/24, showed the resident returned to the facility on [DATE]. 4. Review of Resident #35's face sheet showed the resident's family member was his/her responsible party. Review of the resident's Nurses Notes, dated 08/26/24 at 9:20 A.M., showed the following: -The resident had moderate periorbital edema (swelling around the eyes) and moderate swelling in upper and lower extremities, confusion, wheezing, and shortness of breath; -The physician gave an order to send the resident to the emergency room ; -An ambulance transported the resident to the hospital; -Staff notified the resident's family member by telephone. Review of the resident's Nurse's Notes, dated 08/26/24 at 1:37 P.M., showed the resident was admitted to the hospital. Review of the resident's medical record showed no evidence staff provided the resident's representative with a written notice of transfer when the resident transferred to the hospital on 08/26/24. Review of the resident's nurse's notes, dated 09/05/24, showed the resident returned to the facility on [DATE]. 5. Review of Resident #251's face sheet showed he/she was his/her own responsible person. Review of the resident's progress notes dated 1/15/25 showed the resident complained of having a hard time breathing and suspected he/she had gained weight. Lung sounds revealed crackles in the left lower lobe. Resident transferred to hospital per emergency medical services. During an interview on 1/16/25 at 9:07 A.M., Licensed Practical Nurse (LPN) A said the resident was sent to the hospital last evening due to weight gain and shortness of breath related to his/her congestive heart failure (CHF; heart does not pump blood sufficiently). Review of the resident's census sheet showed he/she was discharged on [DATE] and readmitted on [DATE]. Review of the resident's medical record showed no evidence the facility provided the resident or his/her representative with a written notice of transfer when the resident transferred to the hospital on 1/15/25. 6. Review of Resident #12's face sheet showed he/she had a responsible party. Review of the resident's progress notes, dated 1/11/25 at 11:20 A.M., showed the resident returned from the hospital. Continues on observation for rolling out of bed. (Review of the resident's medical record showed no documentation when the resident went to the hospital.) Review of the resident's medical record showed no evidence the facility provided the resident's representative with a written notice of transfer to the hospital on 1/11/25. 7. During an interview on 01/16/25 at 12:30 P.M., the Administrator said the nurses should send transfer notices with the resident and/or provide the notice to the resident's representative upon transfer to the hospital. After he visited with the nurses, he identified this was not being done. 32899 47008

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #22), in a review of fifteen sampled residents, remained free from verbal abuse, when Certified Nurse Aide (CNA) U used curse words directed toward and within hearing distance of the resident. CNA U's language made the resident feel hurt and abused. The resident was tearful after the incident. The facility census was 29. The facility learned of the allegation of staff to resident abuse when staff reported the concern on 06/14/23. Administration suspended CNA U pending the investigation. The facility reported the incident to DHSS timely and conducted a thorough investigation, speaking with residents and staff and later terminated CNA U's employment. All staff were in-serviced regarding abuse, neglect and professionalism on 06/14/23. Interviews with staff confirmed the in-service education provided. The noncompliance was corrected on 06/14/23. Review of facility policy, Freedom from Abuse, Neglect, and Exploitation-Reporting & Response, revised, November 2018, showed residents have the right to be free from abuse. This includes but is not limited to freedom from verbal abuse. 1. Review of the facility's daily assignment sheet, dated 06/14/23, showed CNA U worked day shift as well as part of the evening shift and was assigned to take care of residents on the 100 hall. 2. Review of the resident roster, provided by the facility, showed Resident #22 resided on the 100 hall. 3. Review of Resident #22's care plan, last reviewed 03/09/23, showed the following: -The resident at times may have inappropriate verbal conversation trying to be funny with staff and other residents; -Do not engage/encourage the resident in inappropriate conversation topics; -Refocus conversation when the resident becomes too inappropriate. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 06/07/23, showed the following: -Cognitively intact; -Adequate hearing - no difficulty in normal conversation or social interaction; -Made himself/herself understood. Review of the facility's investigation and summary, dated 06/14/23, showed the following: -At approximately 5:30 P.M., the resident was waiting for CNA U to assist him/her with toileting; -Licensed Practical Nurse (LPN) T completed the resident's blood sugar check (a finger stick procedure to determine the amount of sugar in the blood) and let the resident know CNA U was assisting another resident with a shower and another CNA was coming to help him/her; -LPN T attempted to tell CNA U to avoid the resident's room for now as another CNA was assisting the resident, and to avoid the resident's room because the resident was already upset with CNA U; -CNA U went into the resident's room anyway and assisted CNA Y with the resident's care; -CNA U argued with the resident because the resident told CNA U he/she should not be spending so much time with another resident; -CNA U said, Fuck you, to the resident when he/she left the room; -CNA U was asked to leave the community pending investigation; -The resident was alert and oriented and able to make all of his/her needs known; -The resident said he/she felt abused; -The resident was visibly upset and crying to the Administrator; During an interview on 06/22/23 at 1:53 P.M., the resident said the following: -Around 5:00 P.M., the night of the incident, CNA U was giving a shower; -He/She waited on his/her call light for one hour to be changed due to being incontinent; -He/She got snappy with CNA U and they started arguing back and forth like kids; -When CNA U went to leave, he/she was in the doorway and said, Fuck you; -LPN T was outside of the doorway and overheard CNA U's remark; -CNA U hurt his/her feelings and made him/her cry; -CNA U used the F word a lot; -He/She would call CNA U out on using the F word, and told him/her that he/she as going to have to stop using the F word or he/she was going to get into trouble; -A resident should never be treated like that. Review of LPN T's written statement regarding the incident, signed and dated 06/14/23, provided by the facility, showed the following: -At approximately 5:30 P.M., he/she went into the resident's room to check his/her blood sugar; -The resident was very upset that his/her call light had been going off and no one had responded; -He/She explained the caregiver, CNA U, was in the shower with another resident; -The resident said CNA U should not be doing showers at this time; -CNA U came down the hall and LPN T asked him/her to avoid the resident because the resident was upset; -CNA U continued into the room and was heard shouting at the resident asking him/her what him/her problem was; -LPN T asked CNA U to leave the resident's room; -CNA U continued to argue back and forth with the resident; -CNA U walked out into the hall and told the resident to Fuck off; -The resident shouted Don't tell me to fuck off, come back here!; -CNA U continued to yell, Fuck you as he/she walked down the hall. During an interview on 06/22/23 at 2:58 P.M., LPN T said the following: -He/She was in the room next to the resident; -CNA U was in the shower with another resident; -The resident's call light had been going off for approximately 30 minutes; -He/She went into the resident's room and the resident asked where his/her aide was and why was he/she was in the shower with another resident; -The resident seemed jealous CNA U was assisting another resident with a shower and not attending to the resident's own needs; -CNA Y showed up to perform incontinence care for the resident; -He/She saw CNA U walking down the hall saying he/she was going to check his/her (the resident's) ass, and saying he/she was tired of his/her shit; -He/She tried to stop CNA U from going into the resident's room; -He/She heard the resident and CNA U start arguing with each other; -He/She heard CNA U say, I'm tired of your shit. You do this all of the time. It is not all about you. We have other residents to take care of; -He/She heard the resident say, Don't talk to me like that; -He/She heard the resident say, Did you just say fuck you?; -He/She heard CNA U say, Yes, I said fuck you. During an interview on 06/30/23 at 1:38 P.M., the Assistant Director of Nursing (ADON) said the following: -LPN T came down the hallway toward him/her and said he/she needed help and filled him/her in on what had happened, referring to the incident between Resident #22 and CNA U; -The resident was taken back by how CNA U had talked to him/her, more shocked than anything; -The resident did tear up; -The resident said CNA U said Fuck you; -CNA Y thought the resident and CNA U were arguing like a married couple and tried to stop them. During an interview on 06/29/23 at 2:05 P.M., the Administrator said the following: -Staff reported CNA U and the resident had an argument and the resident heard CNA U say, Fuck you; -She expected staff to never use abusive language toward a resident. MO 220020

Based on interview and record review, the facility failed to ensure individuals employed by the facility did not have a federal indicator for misconduct. Review of Licensed Practical Nurse (LPN) B's employee file showed he/she had a federal indicator for misconduct. LPN B was employed by the facility as a charge nurse with access to all residents. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees; -For the purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program; -The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct access employee, as stated above. Such investigation will be initiated within two days of an offer of employment or contract agreement; 1. Review of LPN B's employee file showed the following: -Date of hire 03/23/23; -Nurse aide registry check dated 03/10/2023 showed misconduct history: Federal Indicator verified 02/06/2009; -No documentation of a Good Cause Waiver (a finding that it is reasonable to believe that the restrictions imposed by section 660.317,RSMo, on the employment of an applicant may be waived after an examination of the applicant's prior work history and other relevant factors is conducted and demonstrates that such applicant does not present a risk to the health or safety of residents, patients or clients if employed by a provider.) Review of LPN B's timecard for June 2023 showed the following: -On 06/05/23 he/she worked 7:28 A.M. to 8:09 P.M.; -On 06/06/23 he/she worked 7:20 A.M. to 3:44 P.M.; -On 06/08/23 he/she worked 8:07 A.M. to 7:45 P.M.; -On 06/21/23 he/she worked 7:24 A.M. to 3:21 P.M.; -On 06/22/23 he/she worked 7:05 A.M. to 8:48 A.M. During an interview on 06/22/23 at 11:20 A.M., the Office Manager said he/she missed LPN B's federal indicator for misconduct. During an interview on 6/23/23 at 3:45 P.M. the Director of Nursing (DON) said the following: -She was not aware LPN B had a federal indicator for misconduct; -LPN B told her the federal indicator was probably regarding an allegation of abuse against him/her years ago when he/she worked as an aide. During an interview on 06/29/23 at 2:05 P.M. the Administrator said the following: -She would expect to be notified if a staff member was noted to have a federal indicator for misconduct on their background check; -It is not appropriate for a staff member with a federal indicator for misconduct to be present and working in the facility.

Based on interview and record review, the facility failed to develop a policy and procedure to address reviewing the state Certified Nurse Aide (CNA) Registry for all new employees. This has the potential to affect all residents of the facility. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -For any individual applying for a position as a Certified Nursing Assistant (CNA), the state nurse aide registry will be contract to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of the facility policy showed it did not include that all individuals employed by the facility will be checked against the state nurse aide registry. During an interview on 07/11/23 at 11:26 A.M., the Administrator said she was aware that the policy did not instruct for the CNA registry check to be completed on all new hires, including any potential non-CNA staff.